# data[].attributes.body
A brief summary on how I entered in contact with osteopathy and why I choose to commit to this course.

# data[].attributes.body
Yesterday I’ve got my interview with the school Director and today I’ve received this email communicating me that I am accepted into the course.

The lectures start in less than 3 weeks, I am thrilled to enter a new chapter of my life.

I finished what corresponds to the A Level in the UK at the end of June. It has been a rough path ending in a rough way. The evening before my last written exam I assisted our old cat passing away on her own, few hours later a friend called me and announced me that another friend died, falling from a 9th floor, not 21 years old yet. I passed my exam with a couple of points more than the minimum and with a heavy heart I left the place where I spent most of my time in the last 6 years, the teachers that have done so hard to try and communicate with me and all these students and some friends with the ones I shared a troubled adolescence.

This summer my dad cheered me up bringing me on a road trip in France and I finally made up my choice to get into Osteopathy. I discovered this discipline less than a year ago at a congress where I went with the school. The symposium presented many universities, all private, expensive, and thereby rather selective. Definitely, not my cup of tea. Until I’ve been given a leaflet worth 3 osteopathic treatments by a student from the university of osteopathy in my city. A couple of months before I broke my 5th digit, since then I could not extend properly my 5th and 4th digits of my dominant hand. So I went and after two treatments I had my full hand function back.

This and the acknowledgement that an osteopath relies mainly on his/her own hands and knowledges led me to make this choice, dreaming a work that I enjoy and that allows me to travel. Only later, during my second of third year I finally understood that it is not that easy to set in a place and have patients straight forward and that insurances, treatment room rent and professional registration are not given for granted and might reach substantial fees. OPS B4

# data[].attributes.body
I finished Y1 with some quite outstanding marks. Unfortunately it seemed I was not doing very well in practical skills and my overall average mark accounted for barely 25/30. I also reckon that many exams were structured as questions with the choice between multiple answers to cross. No further explanation was required and no feedback was given. It must be hard to give a feedback on an answer that might have been guessed.

Evaluation criteria and outcomes feedback were missing for oral and practical exams as well, although it would have been highly beneficial for first year students to receive a clear feedback on why they received a mark instead of another. This process might raise consc to questions such as “Is my method of study effective?”, “Have I retained enough reliable information?”, “Have I understood what I was meant to understand?” and “Do I apply reliable reasoning on the information transmitted?”.

A posteriori I recognize I probably did not understand a lot about the connection and importance of all these subjects and the huge amount of information that I was meant to assimilate.

At that time, unaware of this, I was happy about my choice, established good relationships with old and new friends and ready to dive head first in a continuous new adventure: go and study one year in France. OPS B4

# data[].attributes.body
During my first year of osteopathy course I had the opportunity to observe different practitioners in their practice and I could join a sport event for observational training. OPS B1, B3, C1

# data[].attributes.body
Luckily French and Italian are both Latin languages, this allowed me to understand the technical vocabulary used by the teachers – except for that one speaking that quickly that after each sentence my brain needed 5 minutes to understand what he has just said. However the slang talked by the students, goodness, this was difficult to understand ! Therefore, bond friendship looked as a hard mission.

I soon noticed how the lectures were structured differently than in Italy and how the students study method differed as well. Or maybe it was just different from mine?

If my understanding of osteopathy and the importance of the different topics studied was low at the end of my first year in Italy I cannot say it improved while I was concentrated in learning and understanding a new language and integrate information from two different languages and two slightly different way of teaching. So I continued to assimilate notions in an automatic way without make sense of any of them, or at least not much. I also went on spending a huge amount of type re writing my notes until aesthetics approved without getting the meaning of what I was writing. Not many things did make sense to me at that time, not even I knew what was my origin any more, why do we identify ourselves with political bordered Nations instead of areas of the same globe?

In despite of moving in three houses in the first three months, the inexistent social life and the absolutely oblivion in which all my knowledges resided, I found a reliable coping strategy spending up to 10hrs per week at the gym, discovering pole dance as an amazing complete sport and gaining in flexibility in both a physical and psychological way. I bonded kind relationships with my very original, barely present and very different flatmates and raise love and caring with a stray kitten. I started spending more time outside, studying, revising or following her in her urban adventures around the den of two hedgehogs. She gave birth to an only child and finally both of them ended up living with me, spayed this time. I still wonder about the two hedgehogs.

No one should be refused love and care, awareness will raise. Wildness is great and rough, city life is only rough.

With all this thoughts in my head I started counting in French and understood it was the moment the language started to be mine.

Study wise, exams were mainly close questions with multiple choice or open questions with short answers. Far from the some outstanding marks I achieved in Italy, I only had to resit one exam: visceral osteopathic techniques. The teacher did not get fun with me as I did not understand his jokes, which were some sort of bad humour as a friend told me.

I also got a 20/20 for my handling of the shoulder girdle, this time the teacher appreciated me a lot for the country I come from. Favoritism? In all his magnificence. OPS A2, B1, B3, B4

# data[].attributes.body
The CEESO Lyon had an agreement with a hospital in Paris and organised the observation of a dissection each year. This year was upper and lower limbs. Absolutely wonderful. Shining nerves floating within bloody muscle fibers and yellow fat tissue, whitish bright tendons melted from the muscle belly into the perioste, ligaments and articular capsule so stiff to protect these important joints and so adaptable to allow them free movement. Someone opined the smell was gross, personally I thought I entered a butchery with human bodies instead of cows and pigs. The difference is that these human bodies were died for disease or elderly age, some of them given to science by themselves or with the family approval and not born and raised in a cage and killed by electrocution in the sake of a cancerous diet. I swallow a bitter bite for the ones, humans, who died in a below zero night under a bridge or in the outside corner of a museum doors and for the one no one recalled.

The things that most impressed me was the elasticity and the thickness of the nerves. OPS B1, B3

# data[].attributes.body
Some students of the school I attended in France formed an association in order to provide us the possibility to join sport event as training observer or training practitioner. OPS B1, B3, C1

# data[].attributes.body
One day a friend turned up at a pole dance class reporting pain on the fibular head, unilater, with sudden onset during a movement at the previous pole dance class or falling from the slackline, I can’t quite remember. One of the toughest women I know: she overcame the pain and did some fine moves during the class. However during a break I asked her if I could test it and due to the nature of the pain I started with some gentle palpation to then percuss from the distal portion of the involved fibula going up. At the lateral malleola the pain was not much, however as I started percussing along the diaphysis the pain was excruciating. To me it was a fracture and I suggested her to go get an x-Ray within the same day. She did and she showed as a small fracture of the proximal portion of the fibula, just below the head. She got a brace for 30 days.

I have to confess that I was quite proud of my work.

I don't find the course of the knee clinical assessment that I received in France, so I hyperlink a site reporting quite precise information. OPS B2, C1, C6

# data[].attributes.attachment_link.readable_text
The Ottawa Knee Rules determine the need for radiographs in acute knee injuries. This screening tool was developed because of the need for a rapid and accurate way to avoid unnecessary imaging.

"Plain radiographs of the knee are among the most commonly ordered radiographs in U.S. emergency departments; 60% to 80% of patients with knee pain have a knee film at an estimated annual cost of $1 billion." 92% will not have a fracture.

An estimated 1.3 million patients are seen annually in US emergency departments due to acute knee trauma. Although only 6% of these patients have sustained a fracture, the vast majority undergo plain radiography of the knee. More than 92% of these radiographic results are negative for fractures and exemplify the many low cost, but high volume tests, that add to health care costs.The Ottawa Knee Rules were developed in an attempt to allow physicians to be more selective with radiography, without missing fractures.

A prospective study by Stiell et al found the rules to be 100% sensitive for identifying fractures of the knee with the potential relative reduction in the use of radiography to be estimated at 28%.

Ottawa Knee Rules in Adults

Several studies have examined the effectiveness of the Ottawa Knee Rules, with each reporting the Rules leading to a decrease in the use of knee radiography. The Rules were also associated with a reduction in waiting times and costs. Application of the Ottawa Knee Rules worldwide would be very important and advantageous in decreasing health care costs and unnecessary exposure to radiography without risking the quality of patient care.

Ottawa Knee Rules in Children

With regards to applying the Rules in children, the evidence is conflicting. In the past, several studies have been performed but all have reported varying results. Some have shown the use of the Ottawa Knee Rules in children as being accurate and efficient, but many have reported the opposite as being true. Therefore, it is safer that the Ottawa Knee Rules be not used in children under the age of 18.

As such, there is an important need for more concise studies to investigate the effectiveness of the Rules in children. Only when the results become consistent should a clear and general conclusion be made. Until then, the consensus is that under the age of 18 years is considered an exclusion criteria.

If one of the following is present, radiographs are indicated:

1. Age >55 years

2. Isolated patellar tenderness without other bone tenderness

3. Tenderness of the fibular head

4. Inability to flex the knee to 90°

5. Inability to bear weight immediately after injury and in the emergency department (4 steps) regardless of limping

If any of the following are present, the Ottawa Knee Rules may be contraindicated:

1. younger then 18 years old

2. injuries greater then 7 days old

3. re-evaluation of recent injuries

4. altered levels of consciousness

5. paraplegia (an impairment in motor or sensory function) of the lower extremities

6. multiple injuries or other fractures

7. pregnancy

8. isolated injuries of the skin without underlying soft tissue or bone involvement:
a. superficial lacerations or skin injuries
b. abrasions
c. puncture wounds
d. burns

9. referred from outside the hospital with radiographs

When the Ottawa Knee Rules are executed, the following assessments will be performed:

1. Check for sensitivity of the proximal fibula

2. Check for sensitivity of the patella - only examine the patella, not the surrounding tissues

3. Determine if the patient is able to flex his/her knee to 90° - this will be measured with a goniometer as follows:
a. the axis of the goniometer is placed on the lateral epicondyle of the femur
b. the stationary arm is placed on the femur and points towards the greater trochanter
c. the moving arm is placed on the fibula and points towards the lateral malleolus

4. Examine if the patient is able to bear weight on the affected leg. First, ask the patient if he/she was able to weight bear and be able to take four steps immediately after the injury. Then ask the patient to take four steps. If the patient is unable to do this due to pain, it can be concluded that this part of the examination is positive. If the patient is able to take at least four steps on the affected leg (without a limp), we can conclude that this part of the examination is negative.

A positive test results when one or more of the following occur:

the patient indicates pain during palpation

there is an increased sensitivity of the fibula

the patient is unable to bring the knee in 90° flexion

the patient in unable to carry his/her own bodyweight (stepping is not possible)

acute blunt injuries of the knee are present, regardless of mechanism of injury

Steill et al reported a 26.4% reduction in the number of adult patients referred for radiographs and lower medical charges when the Ottawa Knee Rules were applied.

Although there is conflicting evidence, Khine et al noted 46% of patients aged 3-18 years would not require radiographs with 92% of fractures being identified.

A systematic review by Buchmann et al found a negative result on the Ottawa Knee Rules as being associated with a fracture probability of less than 1.5% in the adult population.

Ottawa Knee Card

1. Stiel I, Wells G, Hoag R, Sivilotti M, Cacciotti T, Verbeek R, Greenway K, McDowell I, Cwinn A, Greenberg G, Nichol G, Michael J. Implementation of the Ottawa knee rule for the use of radiography in acute knee injuries. JAMA; 1997; 278: 2075 - 2079

2. National Center for Health Statistics. National Hospital Ambulatory Medical Care Survey 1992. Hyattsville, MD:National Center for Health Statistics; 1994.

3. Stiell IG, McKnight RD, Greenberg GH, McDowell I, Nair RC, Wells GA, Johns C, Worthington JR. Implementation of the Ottawa Ankle Rules. Journal of the American Medical Association 1994; 271:827-832.

4. Glynn P, Weisbach C. Clinical prediction rules: a physical therapy reference manual. Jones Barlett Learning; 2009: 248 pg 36-43

# data[].attributes.attachment_link.description
The Ottawa Knee Rules determine the need for radiographs in acute knee injuries. This screening tool was developed because of the need for a rapid and accurate way to avoid unnecessary imaging. "Plain radiographs of the knee are among the most commonly ordered radiographs in U.S.

# data[].attributes.body
Few weeks before the starting of the lectures I decided to give France another chance, called the school and stayed at a classmate’s less than 15 mt square flat for one week before finding the home for me and my cats: a flat shared with two funny and lovely people with a sunny balcony and a green common courtyard downstairs.

This time I was determined: more quality time spent efficaciously.

Newbie skilful climber, attentive cats’ mama and socially active.

In average a good student: always present at lectures, almost always awake and able to take notes in a tidy and understandable way, at least for who could decode my writing, I also invested 350€ of my season salary in a microscopic, 11 inches, laptop with the feature of disconnecting the screen from the keyboard. Characteristics that I have never used.

Nevertheless, still tiny was the amount of information I was understanding from my studies. The concept of differential diagnosis and medical testing completely blown out my mind and even if I was living with a final year student who spent the most of his time gaming and partying and still was above average good in clinical and hands on skills, I did not overcome my fear in express questions and doubts. Fear that I reckon I bring with me since I was a child and that prevent me for asking questions even when my head overflown.

I was also doubting in having done the right choice for my future. Would I have rather preferred get engaged in a circus academy?  OPS B2, B4

# data[].attributes.body
In third year we started get engaged in the clinic process: we took the case history for the 4th year students, observe the assessment and after the consultation they showed us how to update the record. OPS A1, A2, A4, C2

# data[].attributes.body
This year dissection covered abdomen and skull. I remember it a bit as a high speed overview: we covered it in one morning and one afternoon. OPS B1, B3

# data[].attributes.body
The teacher of cardiophysiology in my first year of university was a cardiologist. One day she brought us the lungs and the heart of a pig to dissect. She let us try and fill the lungs in blowing in a straw.

I also get very interested in dissecting chicken hearts and rabbit kidneys that my mum bought to feed our cats and dogs. OPS B1, B3

# data[].attributes.body
The program of the 3rd year required to attend several internships in specialistic units:

- Rheumatology consultations at the hospital

- Rheumatology consultations in a clinic

- Pain management service

- Orthopaedics surgery, pre-surgery consultation and orthopaedics management

- Sport medicine consultations
OPS B1, B2, B3, C6, D10

# data[].attributes.body
During the third year I also had the opportunity to join a sport event and to observe how the clinic of another school works. OPS B1, B3, C1

# data[].attributes.body
Physiopedia, 2021. Ottawa Knee Rules | Physiopedia, Available at: https://www.physio-pedia.com/Ottawa_Knee_Rules [Accessed May 14, 2021]

# data[].attributes.body
In the university I attended in Europe students started to practice in clinic in the last two years, that represented the 4th and 5th ones. It is the case that also subjects covering clinical practice standards were planned over the 4th year and not before.

# data[].attributes.body
The curriculum of the school I attended before join the ESO planned to go through a business course across the 4th year. Topic as professionalism were covered by this course, This is the reason why I have not encountered any of these standards during the first three years.