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A1. You must listen to patients and respect their individuality, concerns and preferences. you must be polite and considerate with patients and treat them with dignity and courtesy. (GOsC 2018, p.6)

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A1. You must listen to patients and respect their individuality, concerns and preferences. you must be polite and considerate with patients and treat them with dignity and courtesy. (GOsC 2018, p.6)

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Reflection Using Jasper's Reflective Model

Experience

In year 4 I had a transgender patient that also is neurodivergent. They kept changing gender and, because of my neurodiversity and learning disability, I kept using the pronoun ‘her’ with my clinic tutor and colleagues when presenting the case, as their assigned gender at birth was ‘female’.

My neurodivergence and learning disability predisposed me to make mistakes like that.

Reflection

I was aware instantly that I needed more training regarding LGBTQ+ in healthcare.

Moreover, I was surprised by my research that there is still stigma in healthcare regarding LGBTQ+, because of the religious background of the medical staff.

According to Lapinski et al. (2018) the individuality and preferences of patients, especially in terms of gender identity and neurodiversity, is crucial in healthcare to ensure appropriate care and reduce potential biases.

There has been training offered by a fellow osteopath at the ESO regarding the subject, however, I was not able to attend that day. I also realised how much I didn’t know about the transgender patient, the hormonal treatment involved, plus the physical struggle to reassemble the desired gender. The biopsychological involvement is nevertheless very important, especially when the transition is not fully accomplished, and the patient is possibly continuously feeling unhappy with themselves. This self-awareness and unhappiness leads to further anxiety and depression, use of antidepressants, leading to further health struggles.

Action

I have decided to assign my patient to my colleague, also member of the LGBTQ+ community, as she understands more the patient’s situation. I have also looked up online for a course that will educate me on the subject and help listen to patients and respect their individuality, concerns and preferences without having the stress of possibly misunderstanding symptoms, signs or expectations. My colleague has been keeping me updated on the patient and also has offered guidance on the subject.

Lapinski, J., Covas, T., Perkins, J.M., Russell, K., Adkins, D., Coffigny, M.C. and Hull, S., 2018. Best practices in transgender health: a clinician’s guide. Primary Care: Clinics in Office Practice, 45(4), pp.687-703.

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A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them. (GOsC 2018, p.6)

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A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them. (GOsC 2018, p.6)

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Reflection Using Jasper's Reflective Model

Experience

Having a child as patient is not easy, especially if the child is a preteen and communication is not easy for them at this stage.

X is a 7 year old diagnosed with celiac disease 1 year ago, after a stressful episode of sickness at school. The school did not ring the parents, therefore X developed a fear of being sick and had trust issues towards the school, but also towards medical staff in general, as he had to endure many investigations and procedures in the past year.

His mum brought him to the ESO clinic for serious acid reflux symptoms that were affecting X’s life, especially at school, as he was continuously living with the anxiety that he would be sick again and the school wouldn’t not call  his parents.

X’s mum did a great job explaining the situation, however, I felt that I had to adapt my communication style so I could have more relevant information from the patient. I needed to understand if his symptoms were present both at school and home, or less present in the calmer environment of the house.

I made sure that X understood that I was on his side, being both friendly but also treating him as an adult, a person that knows exactly what he wants and needs. X opened up about some symptoms that the mother wasn’t aware of, like daily headaches, but also he started describing what I believe it is body dysmorphia.

I quickly understood that there was some pressure on him to look and be in a particular way, which is unnatural for a boy his age. Having a closer look, X was wearing designer sports clothes as his mother and little sister. I wondered in that moment if there was a certain pattern in the family, to look and be in a certain way. X’s symptoms were aggravated by his anxiety, which, in turn, aggravated his symptoms.

Reflection

As a mother and osteopath, I could see that X’s symptoms could have been less present if he would have had a much laid back and grounded attitude about himself and the world around him.

I felt that I had to make sure I knew how to empower him and help with reducing his anxiety, so his acid reflux symptoms would resolve. However, I also felt in that moment that I wasn’t the right person to offer the help with this, as the patient seemed vulnerable and I didn’t have the right skills. I considered this in my futher reading also where Hallman and Bellury (2020) write, that effective communication in healthcare involves adapting communication strategies to meet the individual needs of patients, which is especially important when dealing with pediatric patients with specific anxieties or conditions.

Action

Although osteopathy can help with the gastro intestinal issues, in this case I believe the patient needed more support with coping with anxiety and also some temporary medicine that would help with acid reflux, so the vicious cycle of symptoms would break.

I decided to read more about juvenile anxiety and also bought some books on the topic.

Knowing how to empower young children and patients of every age, but also knowing how to communicate with patients of any age is very important, therefore improving my communication skills is mandatory, especially because of the language barrier.

I have suggested the mother to speak to X's school and ask for more support regarding his needs and also overcoming breaking X's trust in the past; but also to book an appointment with the family doctor and ask for medication that would help with his symptoms temporarily, to help reduce his anxiety too.

Hallman, M.L. and Bellury, L.M., 2020. Communication in pediatric critical care units: a review of the literature. Critical care nurse, 40(2), pp.e1-e15.

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A3. You must give patients the information they want or need to know in a way they can understand. (GOsC 2018, p. 7)

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A3. You must give patients the information they want or need to know in a way they can understand. (GOsC 2018, p. 7)

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Reflection Using Jasper's Reflective Model

Experience

A 78 year old male patient with spinal stenosis affecting his L LEX because of neurogenic atrophy I have covered for my colleague. Mr X used a stick to help with his walking for 12 years and his daily life was affected, as he is caring for his chronically ill wife, doing the house work and family shopping too (also described as a more social and pleasant activity outside the house).

I decided to opt for a different approach to my colleague that has treated mainly the lumbar spine, and explained the patient I wanted to work on his LEX to help with his muscular strength and give his muscular, vascular and neurological tissue a tiny ‘boost’. The patient was interested in my approach, as he was weaker and weaker as the years passed by and his struggles were increasing.

I have spent 40 minutes doing isometrics on all muscles groups in his lower limbs and the patient has put all the effort in.

At the next appointment in 1 week, the patient reported he could walk ‘normally’ for 2 days after 12 years. He was also pain free for a few days and this brought him some happiness. On this occasion the treatment included isometrics and weight bearing exercises, like calf rises and chair assisted squats. The patient was very adamant to work hard and get better. He even said he will come back as a stronger, better man. At the next appointment he reported 4 days of pain free movement.

Reflection

I realised at the time of the 3rd appointment that the patient had some hope that he could get better, but his lumbar stenosis was only getting worse and I felt I had to have a discussion about the severity of his condition and my professional limitations. I did not want to give him false expectations at any given point in time, my communication had to be spot on, and I needed to remember that providing clear and accurate information is essential for enabling patients to make informed decisions, particularly when managing chronic conditions (Epstein & Street, 2007).

Action

I decided to discuss again with the patient his home and health situation, emphasising that his condition was only advancing and that he had to start planning for the future and also looking into applying for caring staff for his wife and maybe get help with cleaning the house, which was affecting his back pain the most. I explained him there were limitations to my treatment and that there was no miracle cure, but if my treatment was helping with the symptoms enough, he could book more appointments as needed.

Unfortunately I haven’t seen him since that discussion, so I can only understand that the patient weighted the situation and decided a different action plan.

Epstein, R.M. and Street Jr, R.L., 2007. Patient-centered communication in cancer care: promoting healing and reducing suffering.

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate. (GOsC 2018, p. 7-9

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate. (GOsC 2018, p. 7-9

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Reflection Using Jasper's Reflective Model

Experience

Miss Y is a 23 year old female diagnosed with epilepsy, autism and dyspraxia. She uses the jumping on the trampoline for around 2 hours per day to deal with her frustrations, since she was 7 years old. This has caused a few injuries, over the years and she is coming to the ESO for regular help. Miss Y is always accompanied by her mother, as communication can be a bit challenging at times.

Because of her dyspraxia, Miss Y has some issues with her posture and also understanding movement, vectors, and directions. Every physical assessment element and treatment method has to be explained in detail to her and also every contact with her body, so nothing catches her by surprise. I have been given feedback in my exams that I ask for too much consent, however, this has served me well with neurodivergent patients like her.

Reflection

The research we had to do in third year regarding the neurodivergent population revealed that it is estimated that 1:7 people in the UK have some form of neurodiversity (The Farrant et al., 2022). These patients might have difficulties describing symptoms, situations, or even being touched by another person. Language and communication, consent is very important with this type of patients.

Moreover, I have been noticing that my neurodivergence is being affected by the patient’s one. I find it more difficult to focus sometimes and clinical case history takes longer. The fact that Miss Y is not able to follow instructions to perform osteopathic/ orthopaedic tests is slowing even more my performance.

Action

I understand that sometimes I ask for continuous consent with the rest of the patients, however, I believe it is important and I will improve my performance by practicing more direct questions and continuously learning about neurodiversity. As Axson et al., (2019) write, obtaining valid consent, especially from neurodivergent patients, is critical to ensuring ethical standards in healthcare and protecting patient autonomy, which aligns principally with GOsC.

I have explored online for learning and certification courses and came across a few mentioned on the NHS page, including:

Autism Awareness e-learning Programme: This course, developed by Health Education England, provides insight into autism and how healthcare professionals can make their services more accessible to autistic individuals.

Disabilities & Neurodiversity Courses: Skills for Health offers a variety of courses on disabilities and neurodiversity.

Axson, S.A., Giordano, N.A., Hermann, R.M. and Ulrich, C.M., 2019. Evaluating nurse understanding and participation in the informed consent process. Nursing Ethics, 26(4), pp.1050-1061.

Farrant, F., Owen, E., Hunkins-Beckford, F.L., and Jacksa, M., 2022. Celebrating neurodiversity in higher education. The Psychologist. Available at: https://www.bps.org.uk/psychologist/celebrating-neurodiversity-higher-education [Accessed 11 August 2024].

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They have also developed a Disability Passport, 'About Me', that aims to support disabled claimants to safely disclose their disability or health condition to their Jobcentre Plus Work-Coach / Adviser with the aim of improving communication and ensuring appropriate, reasonable adjustments are identified and put in place at the earliest opportunity

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing. (GOsC 2018, p.10)

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing. (GOsC 2018, p.10)

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Reflection Using Jasper's Reflective Model

Experience

I saw Mr X 2 weeks ago for the first time, a 77 year old retired man, suffering with psoriasis(since 16 years old) and gout and receiving STELARA® (ustekinumab) injections for 18 years for psoriasis  and on Allopurinol for gout for 5 years.

Mr X complained of general stiffness since early age and did not exercise much, but worked hard all his life and had aches and pains everywhere, mainly tendons and small joints. Following R biceps tenotomy and an R subacromial decompression surgery in 2022, Mr X developed pain in the R lateral epicondyle area and, on examination I noticed reduced ROM BIL shoulders, and the patient couldn’t make a fist properly. The patient told me he had no interest in movement and mobility, however his daily functional skills were deteriorating.

Reflection

I reflected on how to explain Mr X and other patients the importance of movement and mobility at any age, even more at his age, and especially if he didn’t exercise all his life.

I have noticed that the majority of patients with inflammatory conditions and higher rates of flare-ups have a sedentary lifestyle and their diet is not great. Giving the right advice without creating shame and guilt is very important, we need to find ways how to inspire the patients to desire to make the first step towards health improvement. Supporting self-care is vital in being able to managechronic conditions, as it enhances patient autonomy and leads to better health outcomes (Elissen et al., 2021).

Action

As I always keep a grip strength trainer in my clinic bag, I thought I would show Mr X how movement improves ROM and also how moving the muscles massages the vascular and neural tissue, helping the heart and also with the neural tissue, tendons, ligaments glide and strengthening. Mrs X was intrigued to see how veins were enlarging in the forearm when he was contracting the flexors to squeeze the grip trainer. I advised that exercise should not be seen as a chore, instead as a great tool to obtain better health. After one minute of using the grip strenghtener, the patient could make a perfect fist and he was very happy about the accomplishment. I gave him some gentle exercises involving the shoulders/arms and also performed isometric exercises during the treatment.

Elissen, A., Nolte, E., Knai, C., Brunn, M., Chevreul, K., Conklin, A., Durand-Zaleski, I., Erler, A., Flamm, M., Frølich, A. and Fullerton, B., 2013. Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches. BMC health services research, 13, pp.1-9.

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Key facts

Regular physical activity provides significant physical and mental health benefits.

In adults, physical activity contributes to prevention and management of noncommunicable diseases such as cardiovascular diseases, cancer and diabetes and reduces symptoms of depression and anxiety, enhances brain health, and can improve overall well-being.

In children and adolescents, physical activity promotes bone health, encourages healthy growth and development of muscle, and improves motor and cognitive development.

31% of adults and 80% of adolescents do not meet the recommended levels of physical activity.

The global target set to reduce levels of physical inactivity in adults and adolescents is a 10% relative reduction by 2025 and 15% by 2030, from the 2010 baseline.

The global estimate of the cost of physical inactivity to public health care systems between 2020 and 2030 is about US$ 300 billion (approximately US$ 27 billion per year) if levels of physical inactivity are not reduced.

Overview

WHO defines physical activity as any bodily movement produced by skeletal muscles that requires energy expenditure. Physical activity refers to all movement including during leisure time, for transport to get to and from places, or as part of a person's work or domestic activities. Both moderate- and vigorous-intensity physical activity improve health. Popular ways to be active include walking, cycling, wheeling, sports, active recreation and play, and can be done at any level of skill and for enjoyment by everybody.

Physical activity is beneficial to health and well-being and conversely, physical inactivity increases risk for noncommunicable diseases (NCDs) and other poor health outcomes. Together, physical inactivity and sedentary behaviours are contributing to the rise in NCDs and placing a burden on healthcare systems.

Improving levels of physical activity will benefit health and well-being and contribute to attainment of global NCD targets and a number of the Sustainable Development Goals. However, this will require increased commitments and investments by Member States; innovation and contributions from non-state actors; cross sector coordination and collaboration; and ongoing guidance and monitoring from WHO.

Benefits of physical activity and risks of sedentary behaviour and inactivity

Physical inactivity is one of the leading risk factors for noncommunicable diseases mortality. People who are insufficiently active have a 20% to 30% increased risk of death compared to people who are sufficiently active. Regular physical activity is associated with:

in children and adolescents, improvedphysical fitness, cardiometabolic health, bone health, cognitive outcomes, mental health and reduced body fat;

in adults and older adults, reducedrisk of all-cause mortality, risk of cardiovascular disease mortality, incident hypertension, incident site-specific cancers, incident type-2 diabetes, and falls and improved mental health, cognitive health, sleep and measures of body fat; and

for pregnant and post-partum women, decreased risk of pre-eclampsia, gestational hypertension, gestational diabetes, excessive gestational weight gain, delivery complications, postpartum depression and newborn complications. Physical activity has no adverse effects on birthweight or increased risk of stillbirth.

Sedentary behaviour is any period of low-energy expenditure while awake such as sitting, reclining or lying. Lives are becoming increasingly sedentary through the use of motorized transport and the increased use of screens for work, education and recreation. Evidence shows higher amounts of sedentary behaviour are associated with the following poor health outcomes:

in children and adolescents, increased adiposity, poorer cardiometabolic health, fitness, and behavioural conduct/pro-social behaviour, and reduced sleep duration; and

in adults, increasedall-cause mortality, cardiovascular disease mortality and cancer mortality and incidence of cardiovascular disease, cancer and type-2 diabetes.

How much physical activity is recommended?

The WHO Global guidelines on physical activity and sedentary behaviour provide recommendations for children (age 5 and up), adolescents, adults, older adults, pregnant and post-partum women, and people living with chronic conditions and disabilities. The recommendations detail the amount of physical activity (frequency, intensity and duration) required to offer significant health benefits and to reduce health risks. The guidelines highlight that any amount of physical activity is better than none; all physical activity counts; all age groups should limit the amount of time being sedentary; and muscle strengthening benefits everyone.

The WHO Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age provide recommendations on the amount of time in a 24-hour day that young children, under 5 years of age, should spend being physically active or sleeping for their health and well-being, and the maximum recommended time these children should spend on screen-based sedentary activities or time restrained.

An infographic summarizes the current WHO guidelines on physical activity and sedentary behaviour for all age groups. WHO develops guidelines through an arduous process of reviewing scientific evidence and expert consultations. Preparations are already underway for the next guidelines, anticipated for publication in 2030.

Levels of physical inactivity globally

WHO regularly monitors trends in physical inactivity. A recent study (1) found that nearly one third (31%) of the world's adult population, 1.8 billion adults, are physically inactive. That is, they do not meet the global recommendations of at least 150 minutes of moderate-intensity physical activity per week. This is an increase of 5 percentage points between 2010 and 2022. If this trend continues, the proportion of adults not meeting recommended levels of physical activity is projected to rise to 35% by 2030.

Globally, there are notable age and gender differences in levels of physical inactivity.

Women are less active than men by an average of 5 percentage points. This has not changed since 2000.

After 60 years of age physical inactivity levels increase in both men and women.

81% of adolescents (aged 11-17 years) were physically inactive (2).

Adolescent girls were less active than adolescent boys, with 85% vs. 78%, not meeting WHO guidelines.

Many different factors can determine how active people are and the overall levels of physical activity in different population groups. These factors can be related to the individual or wider social, cultural, environmental and economic determinants that influence access and opportunities to be active in safe and enjoyable ways.

How Member States can increase levels of physical activity

The WHO Global action plan on physical activity provides policy recommendations for countries and communities to promote physical activity and ensure everyone has more opportunities to be regularly active. Examples of these recommendations include policies that ensure access to walking, cycling and non-motorized transport; that increase physical activity opportunities in schools, workplaces, childcare centres and in healthcare service delivery; and that increase accessibility and availability of community sports and public open spaces.

Implementing effective policies to increase levels of physical activity requires a collective effort, coordinated across multiple government departments at all levels, including health, transport, education, employment, sport and recreation, and urban planning. It also demands national and local engagement from nongovernmental organizations, various sectors, stakeholders and disciplines to support the implementation of policies and solutions that are appropriate to a country's cultural and social environment. Priority should be given to policy actions that address disparities in levels of physical activity, promoting, enabling and encouraging physical activity for all.

WHO response

WHOsupports countries and stakeholders to implement the recommended actions by:

1. developing global policy guidance and guidelines, underpinned by latest evidence and consensus;

2. supporting countries to develop appropriate policies that promote physical activity and multisectoral collaborations;

3. conducting advocacy to raise awareness of the multiple benefits of increasing physical activity and support the development of economic analysis of the impact of increasing physical activity and return on investment of different policy interventions;

4. developing technical tools and training packages to help countries build capacity in the implementation of policy and programmes across key settings and innovations using digital platforms including through WHO Academy courses, multi-country workshops and other knowledge exchange activities;

5. convening, coordinating, and collaborating to strengthen partnerships across sectors and between policy makers, practitioners and researcher communities; and

6. undertaking global monitoring and reporting of progress on implementation of the Global action plan on physical activity, global levels of physical inactivity and progress towards a 15% relative reduction in the prevalence of physical inactivity by 2030.

WHOsupports countries and stakeholders to implement the recommended actions by developing global policy guidance and guidelines, underpinned by latest evidence and consensus, to help countries develop appropriate policies, investment cases and financing mechanisms.
References

1. Strain, T., Flaxman, S., et al. National, regional, and global trends in insufficient physical activity among adults from 2000 to 2022: a pooled analysis of 507 population-based surveys with 5·7 million participants. The Lancet Global Health (2024).

2. Guthold, R., Stevens, G., et al. Global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1.6 million participants. The Lancet Child & Adolescent Health Vol. 4 Iss. 1 (2019).

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WHO fact sheet on physical activity provides key facts and information on benefits, risks of inactivity, reasons for physical inactivity and how to increase physical activity, WHO response.

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A6. You must respect your patients’ dignity and modesty. (GOsC 2018, p.10)

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A6. You must respect your patients’ dignity and modesty. (GOsC 2018, p.10)

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Reflection Using Jasper's Reflective Model

Experience

In the years I have been observing and treating at the ESO clinic, I have noticed that female patients have higher preference for not accepting observers or removing trousers/skirts. I have not come across a male patient that has declined observers/ clothing removal. Elderly patients are very confident in removing clothing, even they do not have the patience for the practitioner to leave the room during the process.

Reflection

As female practitioner, I understand the importance of respecting the patient’s dignity and modesty, I have been a patient myself over the years and I have been disrespected by a male GP that has made inappropriate remarks while using his authority and asking that he would need to examine me first and then refer me to a gynaecologist. I have left his office straight away and moved surgery, however, looking back, I should have complained, as other female patients, more vulnerable than myself, could have been exposed to even more inappropriate behaviour.

Respecting the patients’ dignity goes hand in hand with respecting mine as practitioner as well. We all need to feel safe in a professional environment and, if a chaperone is not available, it’s ok to postpone the appointment. Furthermore, respecting the dignity and modesty of patients is a fundamental aspect of patient-centered care, ensuring that patients feel safe and respected during clinical encounters (Baillie, 2009).

Action

I have attended a workshop, led by Claire Cheetham, designed to enable osteopaths to directly apply what they learn during the day to their own practice, as well as having a better understanding of their patients’ expectations and possible concerns. I have learned so much in those 3 hours, as Claire has presented many situations that led to serious complaints because the patients were not treated with respect. Claire Cheetham served as a Registrant member of the General Osteopathic Council (GOsC) from 2005 to 2008 and was a member of the GOsC’s Investigating Committee for 8 years. In 2014, she was also appointed as a Professional Conduct Panel Member for the Health and Care Professions Council (HCPC), and since 2017, she has chaired HCPC panels for its Investigating, Conduct and Competence, and Health Committees. In 2017 she was appointed to be a Registrant Panel Member on the GOsC’s Professional Conduct Committee, and in recent years has also been appointed to similar roles in other UK health and social care regulators.

Baillie, L., 2009. Patient dignity in an acute hospital setting: a case study. International journal of nursing studies, 46(1), pp.23-37.

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A7. You must make sure your beliefs and values do not prejudice your patients’ care. (GOsC 2018, p.11)

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A7. You must make sure your beliefs and values do not prejudice your patients’ care. (GOsC 2018, p.11)

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Reflection Using Jasper's Reflective Model

Experience

Mr J, a 56 year old male came to the ESO clinic requiring treatment for the neck, complaining of stiffness and muscle tension.

I have seen Mr J for a course of 5 treatments, and, although my treatment was aiming working with increasing ROM, mobility, reducing muscle tightness and strengthening the long, weak ones in the neck and upper thoracic area and shoulders, Mr J would not do his part and perform at home the given strength and mobility exercises. After every treatment he would feel better for a while, but he kept coming back for appointments, although he wasn’t doing the exercises.

Reflection

This situation became a bit frustrating for me because I could not see progress if the patient wasn’t doing his exercises, only straight after treatment while retesting against baseline. The patient also had a very vague attitude towards my questions and made things a bit difficult and awkward at times. I was not being judgmental for the fact that he kept finding excuses for his lack of involvement in the healing process, but I felt that he was interested more in the appointments with myself, rather than getting better.

Action

I explained Mr J that I wasn’t seeing the progress in his case and I offered him to do 4 weeks of daily home exercise, as it was those who were instantly improving symptoms during treatment, or see another practitioner.

Mr J did not rebook an appointment with myself, possibly he realised exercises were improving his neck problems, or possibly opted for another practitioner.

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Cl case history taking feedback