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Clinical integration class - this module is where we bring all elements of the course together and begin our journey to clinical competence. I am amazed at the depth of patient care and back ground a case history involves.
SOCRATES is an abbreviation for: Site, Onset, Characteristics, Radiations, Associations, Time (when), Exacerbating factors/alleviation factors and Scale (1-10 pain).
An incredibly useful tool to note the history of the patient complaint.
My prior studies looked into diseases, research and focused of this above the patient themselves, osteopathy is the opposite, which is an adjustment for me.
During the case history we also note the medical history of the patient, any health issues they have, their general health (CV, GIT, RESP etc), their prior surgeries, accidents, family history (diabetes RA, OA etc), medications they take and their concerns, expectations and goals. It really is an in depth thorough medical examination, asking so many questions about the patient allows them to discuss any concerns they have and we can gain their trust. It's important to explain to the patient why we ask these questions should they be curious. When moving onto the next stage of the evaluation process - clinical tests (muscular, neurological, active) it's important to explain in laymans terms to the patient WHY we are performing these tests, if they ask. Keeping the patient informed throughout the appointment will not only build a trusting patient practitioner partnership but also hopefully encourage patient compliance with any extra exercises given following the treatment. If a patient knows why they're doing something it will hopefully keep them motivated. Help the patient help themselves.

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Disappointed with my mark, silly errors made with referencing.  I think I did not follow ESO referencing guidelines as well as i should have. Given I have done 4 years of referencing at Edinburgh University, I automatically used Harvard referencing style, as it's what I am overly familiar with. For CW2 I really ensured I followed the ESO guidelines strictly.

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The mock went well, my only let down was in communication. My failure to fully ask patient for consent. "Let me know if you feel any discomfort" is not enough. Good lesson learnt and I won't forget it again.

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I initially really struggled with the side-lying techniques - side bending and rotation of the lumbar spine. I found the movements difficult and the positioning and handling of the patients legs frustrating. Practice practice practice has allowed me to be much more comfortable with this technique by the end of year 1.

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I attended my first appointment as a patient at the ESO clinic. My first experience of the clinic. My Osteopath was very professional. Daunting to think this will be me in 2 years.

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I am fortunate enough to have two ESO alumni parents whom can help me through the course and allow me to observe in private clinic. My father practices in Newcastle at a clinic established by Grandfather in the 1950s. This is an incredibly fortunate position to be in, as I can call on extra help if it's needed. However, both my parents graduated prior 1992, the key date in which osteopathy became recognised as an allied health profession. So the course has changed since their day.

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A particularly interesting and memorable case. The patient had been diagnosed by the osteopath with spinal canal stenosis. In 2015 the patient had had surgery to remove the excess bone which was narrowing the spinal canal (which crushed the spinal cord slightly). Initial symptoms were back pain, leg weakness and pain/cramp in both legs when stood or walking. Alleviated by siting down/bending forward. It's been 5 years since the patients surgery, so the SC stenosis symptoms are beginning to worsen again.

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14/04/21 Lack of in clinic observation at ESO

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14/04/21 Lack of in clinic observation at ESO

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Covid has unfortunately prevented me being able to observe so far this year physically in the ESO clinic. Hopefully in second year I will have ample opportunity to observe and learn from the 3rd and 4th years. I have attended the ESO clinic as a patient as regularly as possible (7 sessions) in order to gain as much experience as possible from being a patient.

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I finally had the opportunity to observe a new patient, the osteopath-patient interaction for the first meeting, it was a very interesting case. This patient was extremely nervous, she wasn't sure what an osteopath was, so it was great to see how her nerves and concerns were professionally handled by the osteopath. She was extremely reluctant to have any HVT's done due to a past negative experience with a manual therapist.   In the patients case, the osteopath advised to attain the best outcome he would need to perform HVT's if possible explaining the benefits in laymans terms to the patient. Highlighting how key communication is in this job. I was also astounded at how thoroughly yet quickly the case history was taken. In 45 minutes the osteopath took the case history, performed the relevant neurological and muscle and active tests and had plenty of time for treatment. The practitioner and patient decided together to wait until the next treatment session to do HVTs if they were still needed following the lower grade treatments. I see how important it is to let the patient make the informed decision on whether to receive manipulation or not - this builds trust between the patient and practitioner. I myself have seen an osteopath in the past for neck pain and you do feel slight situational dis-empowerment when advised a certain treatment is the best one by a medical professional. Great paper regarding this topic:
Reed, M. B., & Thomson, O. P., 2021. “Who am I to disagree?” A qualitative study of how patients interpret the consent process prior to manual therapy of the cervical spine. International journal of osteopathic medicine, 39.

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Each patient has different beliefs/ financial circumstances, upbringing, expectations etc. Some religions involve a very conservative dress code and/or forbid contact outside of wedlock. I observed in clinic a female muslim patient (pt) who was uncomfortable undressing. The Pr made the Pt feel at ease and performed the observation and treatment to the best of his ability with her fully clothed. (i find this hands on skill level, on a separate note, so admirable - as a 1st year i am just learning my palpatory skills and for the Pr to be able to perform tests etc with the patient fully clothed is amazing, to me). Pts will have different beliefs on undressing, some will not feel uncomfortable in their underwear, others will prefer to be clothed for the treatment. As a Pr one must be accepting of this, leaving the room while the Pt undresses is essential to allow them to feel as comfortable as possible. The Pr was very adaptable and empathetic. KEY traits for an osteopath. It's important to be clued up on the various religions in UK and their beliefs but not be stereotypical if the pt is of a certain religion. COMMUNICATION is absolutely key, the interaction between the pr and pt. What a patient believes will affect their willingness to consent. It is important the Pr is skillful in explaining in laymans terms the reasoning for the tests they perform, or the treatment advised, if the patient questions WHY we do something.

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Jan 2021 - OSPE A O.T Exam communication

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Jan 2021 - OSPE A O.T Exam communication

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Following the failure in the mock O.T exam in the communication section, I attained 10/10 in the exam for my communication skills. I'm thrilled with this.

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Dec patho exam: 78%
March patho exam: 82%
March anatomy exam: 94.5%
June patho exam: 70%
June anatomy exam: 73%

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All lecturers inform me that osteopathy is a constant learning curve. You're never bored, you never know what/who will walk through the door into your practice. In a society and world of constant instant media, we as medical professionals must keep up with the latest real, evidence based medical information to safely advise patients. New Scientist magazine and MIMS free healthcare professional subscription magazines. It's key to remain up to date.

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Following a lecture on inflammation i investigated the effectiveness of anti-inflammatories in the healing process of the body. Clue being in the name, ‘anti-inflammation’, intrigued me, as inflammation is a necessary healing process of the body (Lisowska et al. 2018). I further researched anti-inflammatories. Liao et al investigated ibuprofen use on skeletal muscle cell migration (Liao et al. 2019). As health care professionals we must keep up to date with the latest medical breakthroughs and news, so as to correctly inform our patients.
(Liao CH, Lin LP, Yu TY, Hsu CC, Pang JS, Tsai WC. Ibuprofen inhibited migration of skeletal muscle cells in association with downregulation of p130cas and CrkII expressions. Skelet Muscle. 2019 Aug 29;9(1):23)
(Lisowska, B., Kosson, D., & Domaracka, K. (2018). Positives and negatives of nonsteroidal anti-inflammatory drugs in bone healing: the effects of these drugs on bone repair. Drug design, development and therapy, 12, 1809–1814.)

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I observed a patient with lumbar spinal canal stenosis (LSCS). The practicing osteopath had diagnosed the patient over 5 years ago due to concerning neurological symptoms. Some of the symptoms - Bilateral numbness in the lower extremities from walking a few hundred meters. The neurological symptoms were alleviated by the patient sitting down. This patient was returning with similar symptoms. The osteopath knew the limits of his training and advised the patient it is time for a repeat operation sadly, as the bone spurs in the spinal canal were always going to grow back.

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Red flags are specific signs and symptoms derived from a patient's medical history and the clinical exam that are usually linked with a high  risk of having a serious (contra-indicative) disorder like a serious infection, cancer, or a fracture. They have been mentioned weekly in our classes as identification of these is imperative. During a clinical observation at the ESO clinic, there was an appointment gap due to a last minute cancellation. The clinic tutor gave me a tutor session with the 4th year i was due to observe, on what to look for with red flags and contraindications. Contraindications are reasons to not manually treat a patient. This to me is daunting, it's a scary thought missing a red flag/contraindication and causing further injury to a patient. Highlighting how important it is to be up to date with our anatomical and clinical methods knowledge.
I see now how essential it is to know when to refer a patient onwards to another medical professional. And to know when it is safe or importantly unsafe to treat a pateint especially using HVTs.
RED FLAGS & CONTRAINDICATIONS -
"Absolute contraindications to performing cervical spine manipulation (CSM)

Acute fracture | Acute soft tissue injury
Dislocation | Osteoporosis
Ligamentous rupture | Ankylosing spondylitis
Instability | Rheumatoid arthritis
Tumor | Vascular disease
Infection | Vertebral artery abnormalities
Acute myelopathy | Connective tissue disease
Recent surgery | Anticoagulant therapy"
"Red flags

Previous diagnosis of vertebrobasilar insufficiency
Facial/intra-oral anesthesia or paresthesia
Visual disturbances
Dizziness/vertigo
Blurred vision
Diplopia
Nausea
Tinnitus
Drop attacks
Dysarthria
Dysphagia
Any symptom listed above aggravated by position or movement of the neck
No change or worsening of symptoms after multiple manipulations"

Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports

Puentedura, Emilio J ; March, Jessica ; Anders, Joe ; Perez, Amber ; Landers, Merrill R ; Wallmann, Harvey W ; Cleland, Joshua A

England: Taylor & Francis

The Journal of manual & manipulative therapy, 2012-05-01, Vol.20 (2), p.66-74

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Fascinating model of health - "At the practical level, it is a way of understanding the patient’s subjective experience as an essential contributor to accurate diagnosis, health outcomes, and humane care." This model brings more empathy than the biomedical model of health. Looking at the patient as a whole not just a list of symptoms and signs.
Great papers:
Original Engel, G. L. 1980. The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137(5), p. 535-544.
Borrell-Carrió, F., Suchman, A. L., & Epstein, R. M. 2004. The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Annals of family medicine, 2(6), p. 576–582.
Epstein, R. M., Alper, B. S., Quill, T. E,. Communicating evidence for participatory decision making. 2004. JAMA, 291(19), p. 2359-2366.

Fahlgren, E., Nima, A. A., Archer, T., & Garcia, D., 2015. Person-centered osteopathic practice: patients' personality (body, mind, and soul) and health (ill-being and well-being). PeerJ, 3, p. 1349.

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I was modelling for a fellow student in an exam. I was lying prone for the treatment. I have a plate and 8 screws in my shoulder/clavicle which the practitioner had noted and was aware of.  However their confusion meant they muddled their lefts and rights and when performing the prone shoulder GOT routine really hurt my injured shoulder and caused pins and needles symptoms for the rest of the day. If the practitioner had checked in with me more effectively, and asked simple questions of are you ok, I would not have been so injured. It is a really essential part of our training to experience all treatments as a patient. And also link back to an important part of treatment - PATIENT COMFORT.

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New patient #3 - Menieres disease 7.10.22

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New patient #3 - Menieres disease 7.10.22

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My patient presented in clinic with an over the phone diagnosis by GP of menieres disease, and was looking for some alternative treatment.
I briefly remember this being touched on in clinical methods last year and therefore due to lack of background knowledge of the disease my case history was not as fluid as it could have been. The case ended in a referral to ENT specialist for confirmation of menieres by exclusion of other brain pathologies, as her disabling attacks and symptoms had worsened in the last month. This was a great learning experience for me as it was the first time I had to write a referral letter. However my main take home from this patient interaction was my lack of knowledge of the disease this patient had. Therefore I came away and read around menieres disease to improve my knowledge.

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👂 Ménière’s Disease | Presentation, Pathophysiology, Diagnosis & Treatment

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I recently purchased Terry Rutlens book on case history taking for osteopaths - in the systemics section, he mentions 59 COMMON pathologies of various systems in the body. I have tasked myself to read into each one of these, their common signs and symptoms, cause if known and demographic of this disease. This is to prepare for most common pathologies that my patients could have, known or unknown to them.

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New patients are challenging, you're meeting this person for the first time, and they're in pain, you have to do some detective work.
Coming up with DDx is a challenge for me. I've missed some blinders that I won't forget again, clinic is a steep learning curve, so much information and knowledge is needed at all times. 2 new patient DDx's that I will not forget again are:
- somatic referred pain from the neck - referral pain with neck movement !
- sacroiliac dysfunction - transitional movements, point to the pain.
In hindsight missing these DDx's for both cases in discussion with the tutor was frustrating as they seem obvious once they were said. Perhaps its the pressure of being put on the spot. I won't forget those DDx's again.

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July 2021 Professionalism CW2 reflective writing fail

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July 2021 Professionalism CW2 reflective writing fail

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Really gutted, I failed this coursework by 2%. The hardest thing is this summer I am working 2 jobs and they have given us under 2 weeks until the re-sit deadline to re-write a whole new one. I'm really devastated not only to not pass but also I work every day, I don't know how i'll find the time to rewrite this at short notice. This makes me want to give up the course, it's the first thing i've ever failed academically even in high school and i've taken it hard. How could the essay be so bad it's under 40%, more wrong than right.
After writing this, I did find the time to re-write the essay with late nights and early mornings and a cancelled trip to see my boyfriend. The course is worth it to carry on, must not give up now.
The resit I got 56%, still not great grade but everything happens for a reason and my reflective writing is a weak area of mine, so having to resit was good practice for me.
A picture to help with future reflective pieces and thought structure.

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Literature review ideas:
- Low impact exercise on pain levels in people with LBP

- Stroke rehab
- LBP and pregnancy: sys review in 2015 https://pubmed.ncbi.nlm.nih.gov/26422811/

Quantitative research ideas:

- Core stabilising exercises

- Active exercises – increase in flexion / extension ROM of LSP

Questionnaire ideas:

- EBP?

- Osteopathic students population

- WFH since covid 19 and correlation to back pain? Ask general public?
-Telehealth use in osteopathy

The Impact of the COVID-19 Lockdown on Physical Therapy Undergraduates and Their Families. A Qualitative Study from the United Arab Emirates”

https://pubmed.ncbi.nlm.nih.gov/35935101/

“The Impact of the COVID-19 Lockdown on Osteopathy Undergraduates vs Other student populations. A Qualitative Study from the U.K” = My idea?

“Relationships between the physical work environment, postures and musculoskeletal pain during COVID-19: A survey of frequent computer users.”

https://pubmed.ncbi.nlm.nih.gov/36075375/

“Relationships between the physical work environment, postures and musculoskeletal pain during and after COVID-19. A survey of desk-based workers”

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Polo vs white tunic? The debate at the start of clinic. The college pushing towards white tunics, students wanting to wear blue polos that have already been purchased.
I personally wear my white tunic for patients as it makes me feel more professional and medical. Patients have commented on this, and the smartness of the white.

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Mrs B (age 77) initially came to the clinic (April 2023) using a stick to walk, with 11/10 buttock and leg pain, following 5 weeks of sitting at the bedside of her husband who died 2 weeks prior to the appointment. Over 6 treatments, Mrs B got back to playing bowls which was her initial goal of treatment. However I did not discharge Mrs B, she just stopped coming. After 1 month of not seeing her, I called the patient to enquire that she was ok. Mrs B advised that she was going for a private MRI scan of her low back/pelvic area as she was not overly happy she is not 100% better. I wished her well. Reflecting on this made me question the patient partnership and communication with this patient. Older patients can take longer to heal and this expectation was managed over the course of treatments, and her progress was going well, enabling her to walk without a stick and get back to bowls. However in future I need to offer other treatment and investigation options to patients in follow-up appointments, to ensure the patient is satisfied with their progress and if not what other actions we can take to appropriately manage their complaint.

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Randomised pilot study distributed on 6/7/23 to 10 students from class 3A at ESO.

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B2. You must recognise and work within the limits of your training and competence.

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B2. You must recognise and work within the limits of your training and competence.

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B2 2.1 seeking advice or assistance from an appropriate source to support your care for the patient.
22/8/23 14.10 appointment new patient 76 M, Uex area. As usual with new patients, i begin forming DDx's in my head given the patients demographics which in the case history I narrow down to the most of least likely.
I collected the patient and his wife from reception to walk upstairs. On the walk to the treatment room, the patient described he felt "wobbly today". A small alarm rang in my head. I sat the patient down and he explained he was in for help with 3-month old right shoulder pain that came on after some home painting and decorating (mechanical onset, my mind was at ease about the shoulder pain). Any radiations down the arm, pins/needles? Numbness? Yes the patient replied, in all 5 finger tips of my right hand. However, "this came one yesterday with this feeling of being drunk, I just woke up with it". Thinking about dermatomal and cutaneous nerve distribution, the patients description of the symptoms did not fit either of these, again a small alarm bell rang. The patient also described he was unable to pick anything up with his right hand either, but again this symptom had come on yesterday (sunday morning). The patient reassured me his daughter is a nurse and she monitored the symptoms yesterday. Infact, this morning the patient had been at the GPs, he had asked the GP if these new symptoms could be as a result of him halving his blood pressure medication dosage 2 weeks ago. The GP said no regarding the medication changes, assured the patient that "if the osteopath can't help the shoulder they can refer him to orthopedics". The GP also did a Rhombergs test, but still send the patient out the door and to the ESO clinic.
I took the patients blood pressure which was high at 145/90, with a pulse of 108 bpm. I could have trusted the GP had checked the patient and that he was safe to treat. However, on further questioning the patient had tingling around the lips and right leg weakness too. Adding up these symptoms below:
- Right hand weakness
- Right leg weakness
- Dizziness
- Tingling in non dermatomal / cutaneous nerve distribution
- Tingling around the lips
I considered the patient had had a stroke. As it had been over 24 hours, it couldn't be a T.I.A. Along with the cardiovascular signs if HBP and pulse, i wrote an emergency referral note and send the patient and his wife to A&E, explaining to them that I hope I was being a hypochondriac, but to please call the clinic and let us know how they got on.
A few hours later the wife called the clinic and thanked us, as the patient had had a stroke and was not in the stroke unit.

Reflecting on this case, although it's a sad story as the symptoms had been missed for 40 hours, it re-assured me in that when something is not right you feel it in your gut, and act appropriately, in this case seeking emergency advice to ensure the patient got the appropriate care.

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DEC 2023. Patient - Master I - is almost 3 years old and a takeover from a collegue. Patient has resolving night terrors has been a patient for over 6 months at ESO clinic. Patient is awaiting a referral for behavioural and psychological assessment. Patient is aware of and uses language and curse words and when his mothers attention is not on him he gets aggressive and throws items in the room and slams his fists on the treatment couch. It can be challenging to remain professional in this scenario. Patient does not comply or sit still, making it very hard to examine and treat the patient.

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https://youtu.be/WGBVeSS9Dvo - youtube upload of psychology presentation