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Patientsikkerhedstyrelsen

Patientklagenævnet

I subsequently reflected on the experience using Gibbs' Reflective Cycle. It became apparent that stress and pressure were the main contributors to the unfortunate outcome. The challenge lies in identifying precursors to critical stress states. Gibbs’ model assisted me in re-establishing structure in clinical processes to maintain control and perspective throughout treatment sessions. Specifically, I found that setting aside unresolved clinical problems until a solution is found was essential. Additionally, maintaining focus on the most relevant aspects from the patient’s perspective—without prematurely excluding other concerns—was extremely helpful.

Problem deconstruction also enabled the treatment to stay within the allocated time, with the added benefit that the patient was not subjected to over-treatment, and the volume of input remained manageable. I realised that I sometimes risk overwhelming the patient with excessive intervention, potentially undermining their ability to absorb and benefit from treatment.

Furthermore, I have become more aware of the importance of involving the patient. This is achieved by openly discussing emerging clinical challenges and sharing my reflections and proposed strategies. I occasionally refrain from performing aspects of treatment with which I am not yet sufficiently confident, instead committing to resolving such dilemmas—especially where patient safety could be at risk. It is essential to establish agreements with patients on how to proceed in such situations. These agreements must be made on a fully informed basis. When the available information is deemed insufficient, the appropriate course of action may be to offer the patient provisional options or recommendations.

My experience has shown that patients respond positively when I share my reasoning and considerations. Sincerity is rewarded with honest and open dialogue from patients, which enhances collaboration and improves the likelihood of successful outcomes. The ongoing challenge remains: to establish and maintain structure in one’s clinical practice.

Such conversations frequently allow for the exploration of patients’ beliefs and expectations regarding treatment and prognosis—especially when addressing misconceptions or treatment-related myths. Commonly used patient questionnaires in my clinical practice include:

• STarT Back Screening Tool – for identifying the risk of chronicity in patients with low back pain.
  https://startback.hfac.keele.ac.uk

• SF-36 Health Survey and EQ-5D (EuroQol-5 Dimension) – for assessing general health and quality of life.

  • SF-36: https://www.rand.org/health-care/surveys_tools/mos/36-item-short-form.html

  • EQ-5D: https://euroqol.org/eq-5d-instruments/

• PROMs such as the:

  • Roland-Morris Disability Questionnaire (RMDQ): https://www.rmdq.org

  • Oswestry Disability Index (ODI): https://www.physio-pedia.com/Oswestry_Disability_Index

  • Functional Rating Index (FRI) or other condition-specific functional status forms.

These tools assist not only in clinical assessment but also in building patient rapport, tailoring communication, and supporting shared decision-making processes.

Over the years, I have learned to be attentive to encouraging patient reflection. More specifically, this involves not only gaining insight into the patient's overall well-being from session to session, but also actively inquiring about their experiences with specific techniques, exercises, and daily life challenges.

These reflections often take place during treatment sessions—for example, I may ask the patient whether a particular technique feels appropriate, helpful, or comfortable for them. I also learn from unexpected patient reactions, such as discomfort during techniques like IVM or BLT, which can provide valuable clinical insight. A dynamic and open dialogue with the patient contributes to a deeper understanding of their reactions and perceptions—both of the treatment itself and of the underlying rationale for receiving it. The patient’s beliefs and myths, particularly in relation to conditions such as low back pain, influence how treatment is structured and delivered. Ultimately, my ability to understand the patient is essential for fostering a strong therapeutic relationship, which in turn has a significant impact on the outcome of the treatment.

The systematic review by Morton, de Bruin et al. (2018), https://pmc.ncbi.nlm.nih.gov/articles/PMC6492285/, found that beliefs about the negative consequences of back pain are widespread across countries and populations. In contrast, fear-avoidance beliefs are less commonly held among most groups.

Importantly, belief in the negative consequences of back pain is associated with higher levels of pain intensity and diminished functional capacity. These beliefs are particularly prevalent among older individuals and those with poorer self-rated health.

However, the review also highlights a notable gap in the literature: few studies have explored how such beliefs influence long-term pain management behaviours and outcomes.

It is important to maintain the integrity of your intervention without compromising patient safety, while simultaneously establishing a shared understanding of the treatment goals and what can be expected from the intervention. This is best achieved by obtaining a clear overview of the patient and their presenting complaint(s).

Be mindful to prioritise the patient's main concerns without neglecting clinically relevant issues that must also be addressed. Communicate your clinical reasoning clearly and ensure that the patient acknowledges your understanding of their situation. Collaboratively structure a treatment plan for the session, recognising the potential need for one or more follow-up sessions before a treatment prognosis can be reasonably established.

Keep in mind that patients are more likely to commit to a treatment plan that makes sense to them and feels worthwhile. Avoid rushing into diagnostic conclusions at the expense of developing rapport. Taking time to engage with and understand your patient is often essential for effective care. Pausing treatment to allow for reflection and deeper case understanding can be both educational and instrumental in ensuring patient safety.

• Informed Consent
  Before sharing patient information, it's essential to obtain explicit, informed consent. Patients should be made aware of what information will be shared, with whom, and for what purpose. This transparency upholds patient autonomy and trust.

• Minimum Necessary Disclosure
  Only the information necessary for the intended purpose should be shared. This principle minimizes potential breaches of privacy and aligns with data protection regulations.

• Need-to-Know Basis
  Access to patient information should be limited to individuals directly involved in the patient's care. This approach ensures that sensitive information isn't unnecessarily disseminated.

• Secure Communication Channels
  When transmitting patient information, use secure and encrypted methods to prevent unauthorized access. This includes secure email systems, encrypted messaging platforms, and protected electronic health record systems.

Moreover, inadequate assessment and management can compromise patient safety, particularly if contraindications to OMT are overlooked. Ensuring that osteopathic care is delivered competently requires continuous education and adherence to established clinical guidelines. Neglecting these responsibilities not only affects patient health but may also undermine the credibility and effectiveness of osteopathic practice as a whole.

The vast majority of successful cases are associated with patients whose records are well-structured and thoroughly documented. Discussions with colleagues about what constitutes a comprehensive journal often highlight the importance of clear communication, mutual respect, and a shared motivation to collaborate. My colleagues frequently express that they felt they truly understood their patients—and, most importantly, that they had established a strong and constructive therapeutic relationship.

The main challenge was maintaining consistency in producing records that were accurate, clearly articulated, and completed in a timely manner. Delays often arose when treatment sessions were interrupted or when time was limited. I also became aware that a lack of understanding on my part regarding the patient’s presentation or clinical dilemma could lead to fragmented and vague documentation.

This insight prompted me to introduce structure both in clinical assessment and in the way I documented findings. A structured approach supported a systematic method for data collection and helped establish a rational examination plan. This in turn created an overview of the patient’s condition and clinical dilemma, forming the basis of an effective treatment plan.

I found that structured treatment sessions helped to manage time more effectively and reduce the risk of important elements being overlooked. It also became apparent that the patient’s core presentation and concerns were not always fully revealed during the first session. However, there were always elements that could be meaningfully addressed from the outset. In such cases, it became essential to maintain well-organised notes from the initial consultation that could be revisited in future sessions.

I found the self-audit model particularly useful in ensuring that at least a minimum standard of data was consistently captured—allowing for later revision if necessary. The SOAP model also proved valuable, as it helped integrate the patient’s own perspectives, concerns, and expectations into my clinical reasoning alongside objective clinical findings. This approach had the added benefit of enhancing the quality of referral documentation and supported professional discussions with colleagues regarding patient cases.

Example of a Model Patient Note (SOAP Format)

Patient ID: 0413-22M
Date: 13 May 2025
Clinician: Jane Doe, M.Ost

S – Subjective:
Patient reports insidious onset of mid-thoracic discomfort, worse on deep inspiration and during seated work. Denies trauma. No red flags. Pain rated 5/10.

O – Objective:
Posture: mild kyphosis. Palpation: T4-T6 hypomobility. Muscle tone increased paraspinally. Respiratory excursion reduced. No neurological deficit.

A – Assessment:
Mechanical thoracic dysfunction with associated myofascial restriction. No contraindications to OMT.

P – Plan:
Applied soft tissue release and articulation to T4-T6. Instructed on thoracic mobility exercises. Plan to review in one week. Patient tolerated treatment well.

Patient management includes preventive efforts aimed at avoiding relapse, as well as measures to anticipate and address potential recurrences.

Health Promotion

The patient is actively considered within the broader context of health promotion.

Patient Education

Patient education is a crucial part of treatment, enabling the patient to understand their condition and the underlying causes of the complaint for which they are seeking care. In a clinical setting, it is important to assess the patient’s level of knowledge regarding their condition, including their understanding of potential causes and contributing factors.

In addition, patients often hold their own beliefs, assumptions, and myths about their symptoms. It is important that the practitioner is aware of these perspectives in order to engage the patient in the appropriate context. This requires curiosity, openness, and reflective dialogue from the clinician. This can pose a pedagogical challenge for the practitioner.

Creating an environment where the patient feels heard and understood—through the practitioner’s empathy and responsiveness—can promote mutual learning and enhance the patient’s receptiveness to educational input.

Patient Information

Providing patients with information serves as a foundation for the clinical process by helping them feel secure and guided through their course of care. Information about what the process involves—including examinations and treatment planning—gives patients a well-informed basis for giving consent to treatment and participation in the course of care.

It is essential that the practitioner ensures the patient has truly understood the information. This is achieved by cross-checking the patient’s responses and confirmations. In some cases, patients may consent to an intervention without fully understanding what they have agreed to. The practitioner must therefore be attentive to the patient’s behavior and reactions during treatment, and must clearly explain what will happen, how it will be carried out, and the purpose of the intervention.

This applies both to individual components of treatment and to the overall structuring and conclusion of a treatment session. The latter is important for establishing a baseline for the next session or concluding the course of care.

An informed patient will understand—and have consented to—what the treatment involves, how the process is structured in relation to that, what the prognosis is, and what the goals of the intervention are, including how progress will be monitored to ensure alignment with agreed outcomes.

This information can serve as a form of contract between practitioner and patient, supporting active patient participation and fostering a therapeutic partnership. In this way, the patient becomes a co-owner of the process.

Such a relationship creates the foundation for open dialogue and mutual commitment toward achieving shared objectives. Gail Sowden from the University of Leeds has contributed to a deeper understanding of the value of truly understanding one's patients.

I have always been fascinated by the connections and underlying causes of the problems my patients present to me. I am particularly intrigued by situations where patients exhibit similar symptoms and behaviour, yet respond differently to treatment—despite an apparently “identical presentation” of their symptom profile.

This was also one of the reasons I chose to pursue training in osteopathy. I came to realise that, even with many years of clinical experience and a wide range of postgraduate education and courses, I am not always able to achieve the desired outcome in treatment.

Continuing Education & Courses:

• Acupuncture

• McKenzie Method – Lumbar Spine Therapy

• Cervical and Thoracic Spine Manipulation

• Advanced Assessment of the Lumbar Spine

• Exercise on Prescription

• Medical Exercise Therapy (MET)

• Management of Chronic Pain

• Specialist Training in Foot Injuries

• Differential Diagnosis and Red Flags

• The Motivational Back School

• Multiple Sclerosis – Clinical Course

• The Complex Back Patient – A Communicative and Cognitive Approach

• Rehabilitation after Acquired Brain Injury

• Analysis and Treatment of Shoulder Dysfunction

• Medical Exercise Therapy (MET)

• Post-Mastectomy Rehabilitation – Kirsten Tørsleff’s Method

 https://journals.lww.com/ijsoncology/fulltext/2017/07000/how_to_study_effectively.10.aspx

Therapy is enhanced by respect, dignity, and cooperation between clinician and patient. You need to establish a base where the patient finds value and faith in the treatment as well as the patient acknowledges they have an interest in getting better through active participation in the treatment. This can be done by an understanding of mutual responsibility in the treatment, where the patient is aware of you being independent of their feedback and reactions to treatment. Success in partnership can arise from setting achievable goals, that are important for the patient and give good meaning in the context of the patient's daily life living.

A recurring challenge with manual techniques in everyday practice is that no two patients are alike. There is significant morphological variation among patients, which requires constant clinical adaptability. To address this, I have developed a structured approach in the form of an annual rotation plan that allocates time for revisiting and refining various techniques on a cyclical basis. Additionally, I have established an agreement with my colleagues to regularly dedicate time to reviewing clinical challenges, discussing manual techniques, and addressing other professional concerns arising in the clinic. This includes conducting random peer assessments to evaluate our osteopathic knowledge and practical skills.

The overall aim is to achieve the highest possible level of general professional competence while leveraging our diverse skill sets in a collaborative network. This serves to strengthen both patient safety and the overall quality of care we provide.

It’s important to be aware that general practitioners and medical specialists—my main professional collaborators—often receive over 80 electronic messages per day. Therefore, communication must be concise and precise, with a clear indication of the intended action. The clinical rationale for the request should be well-founded and explicitly stated in the documentation.

Obtaining relevant data presents its own challenges. In Denmark, clinicians can access test results, imaging, and biochemical data via the national digital health platform, provided the patient consents. However, access to patients’ medication lists is limited, and many patients do not know the names of their medications. Information regarding medications or hospitalisations can usually be obtained from the patient’s GP.

A third challenge in handling written material arises when the patient’s reason for consultation involves insurance or public benefits. In such cases, it is crucial to maintain a critical perspective from the outset. Gathering documentation, case histories, and factual information about the patient’s condition and circumstances can be helpful—but must be done with care.

Written communication may also touch on areas the patient finds private or sensitive. Therefore, it is essential to be transparent about what information you are responding on or requesting, from a third part and, and why. This supports obtaining informed consent and demonstrates respect for the patient. Always inform the patient that the data will be used only within a specified timeframe and reassure them that all information will be treated with strict confidentiality.

I often reflect on whether this stems from a tendency toward routine-based practice, which may lead to a lack of critical thinking about my clinical approach—and, as a result, limit my ability to absorb new knowledge and deliver safe, high-quality care. In addition to compromising the quality of treatment, there is a risk that the patient's confidence in the intervention and their trust in me may be affected. Both outcomes are detrimental to the therapeutic relationship as well as to the safety and quality of care provided.

It is essential that the roles within the clinical interaction are clearly delineated—specifically, that I maintain the role of healthcare professional, while the patient serves as the primary source of subjective information. Patients may feel unsettled if they sense that I am unable to respond or act as expected within the scope of professional competence. This is particularly relevant when clinical scenarios extend beyond my current expertise.

In such situations, it is critical to end the session in a respectful and appropriate manner, while informing the patient that I will either return with a well-considered management plan or facilitate a referral to another qualified healthcare provider with the necessary expertise. In doing so, I aim to safeguard the patient from undue distress and simultaneously uphold a standard of professional responsibility and ethical care.

I have found that encounters like these strengthen the therapeutic alliance. Patients are more likely to take shared responsibility in their care journey, and the process evolves into a collaborative project rather than a one-sided treatment plan. This encourages a more balanced and equal relationship between clinician and patient. An open dialogue, coupled with a sincere invitation to co-create the therapeutic direction, nurtures trust, respect, honesty, and dignity—elements that underpin a constructive and potentially more effective course of treatment.

references:

https://bmcpsychology.biomedcentral.com/articles/10.1186/s40359-019-0347-3

When a patient seeks your help—often without any prior knowledge of you—it is an act of trust that should be reciprocated only with sincerity and honesty. This is especially vital, as the success of any treatment process is contingent upon the trust established between the patient and the practitioner.

In clinical practice, unforeseen events or situations may occur, leading to inconvenience or, in the worst cases, harm to the patient. These incidents can be procedural in nature, such as unintended events arising during the patient’s use of clinical equipment, either independently or under supervision, as well as during manual treatment or patient handling in the context of group sessions.

Procedural errors may include referral based on an incorrect diagnosis, incomplete or missing prerequisite clinical information, or failure to identify relevant comorbidities that are crucial for determining the appropriate intervention. Unintended incidents related to the use of clinic equipment or movement within the clinical environment can also pose risks or cause inconvenience to the patient.

Furthermore, misunderstandings between the patient and the clinician, or mishandling of the patient and the techniques applied, may result in physical or emotional harm, be perceived as overly invasive, or generate a sense of insecurity—and in the worst case, cause injury.

The practitioner must always remain observant and attuned to the patient, particularly with regard to any burdens they may be carrying or any potential risks to their safety and well-being.

reference:

https://www.surgeryjournal.co.uk/article/S0263-9319(20)30175-7/fulltext

1. Description – What happened?
   A patient was referred by a rheumatologist due to pain in both Achilles tendons and had been diagnosed with tendinopathy based on an ultrasound scan. Upon conducting my own clinical assessment, I found that the symptoms were more likely related to lumbar spinal stenosis. Following the first consultation, I attempted to contact the rheumatologist both electronically and by phone but was unsuccessful.

At the second consultation, I informed the patient that I had not received a response. The patient accepted my assessment and agreed to pursue the lumbar stenosis hypothesis. However, he later expressed concern that this approach might put him at odds with the referring rheumatologist, who was also managing his psoriatic arthritis treatment. The patient feared that challenging the rheumatologist’s diagnosis might provoke a negative response and jeopardize his ongoing care.

Although the treatment I provided was effective, it further added to the patient’s concern about conflicting care plans. The main challenge was to create reassurance and address the uncertainty without undermining the rheumatologist’s authority. Ideally, this could have been resolved through dialogue between myself and the rheumatologist. As this did not occur, I decided to contact the regional quality centre, an institution responsible for handling adverse events with the aim of system improvement and learning. In this case, my concern was rooted in protecting the patient’s well-being, as I did not find it acceptable for the patient to be left feeling insecure.

2. Feelings – What were you thinking and feeling?
   I felt professionally confident in my clinical reasoning but was uncertain about how best to navigate a disagreement in findings. I felt responsible for the patient’s comfort and progress, yet also concerned about being perceived as disloyal to a fellow clinician. I hoped to encourage interdisciplinary dialogue but was unsure whether my outreach would be received openly.

3. Evaluation – What was good and bad?
   Positively, the patient experienced symptom relief and felt heard and understood, which strengthened our therapeutic alliance. However, it was problematic that the patient was caught in an informational crossfire between two healthcare professionals. This created insecurity that could have undermined trust in the treatment process. I considered involving the rheumatologist essential to developing a shared care plan, but unfortunately, that dialogue did not materialize.

4. Analysis – Why did it happen, and what was the learning?
   This situation underscored the importance of clear and open communication with both patients and colleagues. It illustrated that patients can experience loyalty conflicts when faced with differing professional opinions, leading to confusion and anxiety. Clinically, I learned the value of thorough documentation and respectful communication with other healthcare professionals, even in the presence of disagreement. I also came to better appreciate that a patient’s need for safety and confidence is often more about trust and shared understanding than about any single "correct" diagnosis.

5. Conclusion – What could I have done differently?
   I could have contacted the rheumatologist earlier, presenting my clinical findings in a professional and collegial manner. This might have reduced the patient’s sense of being caught between two providers and enabled a shared explanation that included both imaging and clinical findings. Additionally, I could have spent more time exploring the patient’s concerns and clarifying how different diagnoses can sometimes coexist.

6. Action Plan – What will I do next time?
   In the future, I will take a more proactive approach to contacting referring physicians when diagnostic discrepancies arise. I aim to strengthen interdisciplinary communication while ensuring that patients feel informed and safe. I also intend to use written summaries for both patients and colleagues to clarify clinical reasoning and treatment plans.

This became particularly evident in the feedback I received during practical exams at ESO, where I often felt I did not recognize myself in the role I was perceived to play as a practitioner. Discussions with fellow students and tutors in relation to patient cases and treatments highlighted a discrepancy between my own perception of a clinical situation and how the patient experienced my actions.

This realization was unsettling, as I consider it essential to establish a partnership with the patient in order to create the foundation for a successful course of treatment.

The Guidelines on Informed Consent for Osteopaths have helped me navigate and address patients’ personal beliefs and misconceptions about osteopathy—many of which can be overwhelming or misleading. These beliefs must be taken into account during both examination and treatment. It is essential to clarify such myths and establish a mutual understanding of the purpose and nature of assessment and intervention.

This clarification may not always be achieved through verbal explanation alone, as some patients may struggle to fully understand spoken information. Their body language and behavior can often reveal anxiety or discomfort, even when verbal consent has been given. True consent must be grounded in the patient feeling safe, respected, and secure throughout the entire session.

In cases where patients have mental health challenges or complex conditions, the presence of a chaperone may be necessary. The chaperone should be someone the patient trusts and who is capable of recognizing situations that may be distressing or sensitive for the patient. The clinician must be able to use the chaperone’s presence to help interpret and respect the patient’s boundaries without crossing them.

Patient limitations—whether physical, psychological, or cognitive—may affect the ambition or scope of the treatment. As a clinician, it is crucial to be mindful of your approach, including the pace and intensity of both examination and treatment. The patient must experience the treatment as safe, considerate, and appropriate to their individual needs.

Treatment should be carefully tailored to the patient, avoiding a directive or authoritarian approach. Instead, the clinician should adopt a curious, supportive, and responsive attitude. Ethical considerations, cultural background, and patient preferences must always be respected when obtaining informed consent and designing a treatment plan.

I have experienced this myself, particularly in situations where I struggle to navigate a clinical problem or feel under pressure during treatment—whether due to not achieving the intended outcome or simply running out of time.

In daily practice, I rely on patient responses during treatment by actively engaging the patient in conversation and continuously observing their non-verbal reactions to both assessment and treatment. Additionally, I have found that patients benefit from recording parts of the session on their phone, as this enhances their ability to revisit and reflect on the information shared. Patients have expressed that having video clips or written information, as well as references to websites or relevant literature, increases their sense of security and supports their understanding of their condition and the treatment they receive from me.

It is crucial that consent is obtained on a well-informed basis. This can be achieved by inquiring about the patient’s understanding of the purpose of the treatment and the intended outcomes, based on their individual situation and preferences. Informed consent can also foster a sense of shared responsibility, encouraging the patient to actively collaborate in the course of care. Finally, I discovered that I could prompt myself to remember to obtain patient consent by placing it as the first item in my clinical note template, under the anamnesis section. In addition, I have practiced documenting in the patient record during treatment whenever the patient has not expressed a preference for specific examinations or treatment techniques.

The challenge of this approach lies in the need for structure and clarity. However, the advantage is that treatment tends to proceed more smoothly when the patient is well-informed from the outset and has provided clear consent. This clarity reduces unnecessary interruptions and promotes a shared direction between practitioner and patient.

As a practitioner, it is always easier to focus objectively on the specific area the patient is complaining about. However, the risk of this approach is that treatment outcomes are rarely successful when attention is limited solely to the body region or symptom location identified by the patient—especially without critically reflecting on the patient’s narrative. It is also important to be able to explain to the patient, for example, why you intend to address the lower back, even though the pain is located in the leg.

What is even more difficult, however, is explaining the connection between bodily pain and factors such as dietary habits.

Gail Sowden’s methodology also demonstrated its potential to support health promotion by uncovering the patient’s own resources. This was achieved by focusing on activities and functions that the patient either missed or expressed a desire to regain. In this way, health promotion and self-care were not imposed on the patient, but instead perceived as a path out of pain and dysfunction—driven by the patient’s own awareness and motivation.

The osteopathic approach has contributed significantly to my understanding of the relationship between structure and function in the body, thereby supporting a patient-specific and holistic model of care. Furthermore, one of the strengths of osteopathy lies in the fact that patients often feel genuinely cared for through the use of manual techniques. These hands-on techniques can promote a sense of well-being, enhance the patient’s motivation for health-promoting behavior, and encourage them to pursue the life they wish to lead.

I have particularly benefited from using fascial and cranial-sacral techniques in osteopathy to create a constructive environment for working from a broader, holistic perspective in patient care.

During my time in the military, undressing individuals was sometimes used as a means of humiliation and degradation, intended to control and dominate a person. Because of that, I have always been extremely cautious and sensitive about placing a patient in a similar situation.

In osteopathic practice, it makes clinical sense for the patient to be minimally dressed during examination, as this allows the practitioner to observe skin changes and detect possible structural abnormalities that might otherwise be concealed by clothing. The challenge, however, lies in helping the patient feel at ease in situations where some degree of undressing is required for assessment purposes.

Additionally, engaging the patient in dialogue during observation and during standing palpation contributed to building trust. In the case of palpation, it was also essential to explain exactly where I intended to touch and to obtain the patient’s consent beforehand. I found that this approach prevented the patient from feeling objectified or inappropriately touched.

Patients were always offered the option to wear whatever clothing made them feel most comfortable during the treatment that followed. My ongoing priority is to create a safe and welcoming environment for the patient, using a polite and respectful tone and always respecting the patient’s preferences, regardless of their reason for seeking care.

Patients with mental health conditions or cognitive challenges can be more complex to manage than those with whom verbal communication is straightforward. In such cases, it is particularly important to be attentive to subtle signs of discomfort or uncertainty and to consider the presence of a chaperone during sessions.

It may be helpful to seek prior knowledge of any special considerations that need to be taken into account before the initial appointment. This information can typically be obtained from the person who referred the patient or from someone familiar with the patient’s circumstances.

A chaperone can be valuable in several roles: as an interpreter, as a guide to highlight potential concerns that might otherwise go unnoticed, and as a witness in the event of an unintended incident during treatment. Finally, the chaperone can help ensure that important information related to the care process is communicated and managed as intended, in the best interest of the patient.

Unfortunately, some patients interpret this openness, empathy, and concern for their well-being as an invitation to involve the practitioner in their personal opinions and views about life or society. This is rarely ill-intentioned, but rather a reflection of the fact that the patient feels they are in a safe environment. A sense of safety is, in fact, desirable from a therapeutic standpoint, and it is therefore important that the practitioner fosters a safe space that supports dialogue related to the patient's presenting issue.

The challenge for the practitioner is to avoid being drawn into discussions that could disrupt this therapeutic environment and potentially jeopardize the course of treatment. Emotional or sensitive topics are often the ones that trigger confrontation or cause the practitioner to inadvertently become involved in a debate that leads nowhere constructive.

This broad treatment perspective, while enriching, also carries a significant responsibility. As a practitioner, one must be capable of managing and integrating multiple clinical dimensions simultaneously. At the same time, osteopathy offers a deeper insight into the patient and the complexity of their presenting concerns.

I have found particular value in Littlejohn’s model, which provides a clear and structured overview of the patient. It effectively serves as a map that highlights areas for potential attention, which can then be interpreted through biomechanical, neurological, circulatory, respiratory, metabolic, and biopsychosocial lenses.

My introduction to Barral’s work offered a welcome explanation as to why a strictly musculoskeletal approach was insufficient for certain patients, such as those presenting with chronic low back pain. I gained an appreciation for the interrelationship between the viscera, fascia, nervous system, and musculoskeletal system—connections that had not previously been part of my clinical repertoire.

The IVM model posed the greatest initial challenge for me. It was not until I began witnessing patient-reported improvements that I could accept the method’s clinical value, even if I did not fully understand the underlying mechanisms. Patient satisfaction became, in this case, a form of experiential evidence justifying the use of the technique. Since then, IVM has become an integrated component of my practice, and it represents an area of osteopathy in which I seek to deepen my theoretical knowledge and clinical competence.

As my scope of practice has expanded, so too has the responsibility that comes with treating patients. This underscores the importance of maintaining critical self-awareness in clinical work. In particular, it is vital to ensure that treatment choices are driven by patient needs and preferences, rather than practitioner habit or bias. Avoiding routine-based care and upholding a reflective, evidence-informed approach are essential to safeguarding the patient-centred ethos of osteopathic practice

Key Themes in Clinical Supervision for Osteopaths

• Reflective practice: Encouraging critical reflection on clinical encounters to enhance reasoning, self-awareness, and learning.

• Boundary setting & scope of practice: Ensuring practitioners remain within professional limits and refer appropriately.

• Support & wellbeing: Addressing emotional demands of practice, burnout prevention, and ethical dilemmas.

• Competency development: Fostering advanced skills through guided feedback, especially for early-career osteopaths or complex cases.

I consider patient record audits, collegial consultations, in-clinic supervision, and case studies to be low-hanging fruits for monitoring and reflecting on my clinical interventions. Additionally, I have participated in separate annual audits focused on neck and low back pain in collaboration with other clinicians and hospitals. These initiatives facilitate critical monitoring of my clinical practice, inspire knowledge-seeking in areas where I may lack expertise, and help build a professional network that provides mutual support in areas where individual competencies may be limited.

I have completed a dedicated course on "Red Flags" and comorbidities within the General Medical Services (GMS) framework, in addition to profession-specific courses and continued education in physiotherapy.

In the clinic, I find it important to avoid relying solely on rote memory when structuring clinical reasoning. Therefore, the clinic is equipped with multiple anatomical illustrations and models, and I have access to reference materials on anatomical structures and their interrelations, as well as medical terminology and the treatment of various conditions with comorbidities in mind. The advantage of using such visual aids is that they significantly enhance patient education and understanding. However, the key lies in selecting models and illustrations carefully, so as not to appear intimidating to children or too detailed in ways that could alienate adults from different ethnic or religious backgrounds.

Within osteopathic practice, the range of potential interrelations and etiological explanations for bodily complaints is extensive. When combined with a naturally inquisitive approach to patient care, this can, at times, lead to a loss of clinical focus. In my own practice, I have occasionally found myself so absorbed in the search for underlying causes that I failed to maintain a clear thread of reasoning and, importantly, to cross-check information across clinical findings.

I found the use of an analytical reasoning model, SOAP, to be an invaluable aid. It enabled me to structure my diagnostic process, triangulate findings, and apply a critical lens to the interpretation of results. A lack of clinical competence became evident when my choice of tests yielded ambiguous results, which—when considered alongside the patient's overall presentation—did not cohere into a meaningful clinical picture.

In such situations, the ambiguity may stem from clinician bias, but it may also point toward systemic or multisystemic changes requiring further investigation by another healthcare professional. In some cases, conditions are identified that warrant referral without necessarily preventing the continuation of osteopathic treatment. What matters most is maintaining awareness of such findings and ensuring that the patient is sufficiently informed to make an autonomous decision about how to proceed.

During the therapeutic process, the patient disclosed a longstanding history of poorly regulated hypertension, despite numerous medical interventions. Encouraged by the immediate improvements experienced after osteopathic treatment, the patient expressed a wish for me to assume responsibility for the management of his blood pressure. I made it explicitly clear that, due to my limited expertise in pharmacological hypertension management, I was not competent to oversee such care.

Nonetheless, I recognised and acknowledged his concerns, which centred on the perceived ineffectiveness of antihypertensive medication, fear of adverse effects, and general anxiety regarding long-term prognosis. As a clinician, it felt natural and ethically appropriate to engage with his concerns on a human level, while remaining focused on the ischemic back pain. Given his motivation and the symptomatic improvement—including reduced back pain and enhanced wellbeing in the lower limbs—we explored the potential association between vascular function and musculoskeletal symptoms.

Through open dialogue, the patient and I reached a shared understanding of the limitations of my role, while also acknowledging the therapeutic progress. It was agreed that his general practitioner (GP) should be involved. I therefore drafted a clinical letter to the GP, outlining my observations regarding ischemia-related back pain, the patient’s subjective improvements, and his concerns about ongoing medical management and prognosis.

The outcome was a collaborative care agreement, whereby the patient would self-monitor his blood pressure according to the GP’s instructions while continuing osteopathic sessions. The overarching goal was to stabilise his blood pressure and, if clinically appropriate, gradually reduce pharmacological dependency in favour of lifestyle and behavioural adaptations—contingent on his ongoing improvement.

This case exemplifies the transition from condition-focused treatment to a patient-centred approach. The involvement of the GP ensured I remained within my professional remit, while reinforcing safety, shared decision-making, and holistic care. The patient subsequently reported a renewed sense of self-efficacy and motivation to engage in his health management—outcomes that extended far beyond the original presenting complaint.

We also collect cost-related data from both public authorities and internal financial records, allowing us to evaluate treatment costs per patient. On the quality side, we independently assess patient-perceived treatment quality through anonymised patient surveys. The anonymised data is analysed with the aim of identifying areas for improvement and promoting learning among clinicians, particularly with regard to self-reflection on clinical practice.

Furthermore, patients were asked to evaluate practical aspects of the clinic such as parking availability, ease of contact, the facilities, and hygiene standards. Overall, patients expressed high satisfaction with the clinic's service, the physical environment, and the care they received. The majority of respondents indicated they would recommend the clinic to others, which we consider the strongest possible endorsement.

Additionally, the clinic participates in a collaborative quality improvement network, based on data-driven benchmarking. This includes the comparison of anonymised treatment data with that of other clinics to support collective learning and ongoing clinical development.

Our starting point is the existing literature, which indicates promising outcomes when diaphragm-focused breathing techniques are integrated into low back pain treatment. As a result, we have implemented both patient education initiatives and group-based sessions that incorporate breathing exercises. In addition, we offer manual treatment of the diaphragm and aim to integrate its function into both lumbar stabilisation and mobilisation strategies.

To my astonishment, I received negative feedback on my patient interaction during my neurology examination in year two.

It was perceived that I had not demonstrated politeness, care, or consideration according to good clinical standards. This surprised me, as I have always taken great pride in these values throughout my clinical practice.

Admittedly, I felt challenged and under pressure during the exam, especially because I didn’t feel I delivered a sufficiently strong academic performance. I was genuinely embarrassed by the feedback and felt uncomfortable being perceived as inconsiderate or lacking in empathy.

For me, the foundation of any successful course of treatment lies in demonstrating politeness, compassion, humility, and dignity in how one interacts with the patient. The patient deserves nothing less when they place their trust in you by seeking your help. Maintaining dignity—even under pressure—is, in my view, the most important principle of all.

The patient requires a safe and supportive environment, and such an atmosphere also enables openness and honesty, which are essential for establishing an effective therapeutic relationship. One key area of attention should be to avoid exposing the patient to danger, discomfort, inconvenience, or harm. The practitioner’s focus must remain on the patient’s wellbeing, ensuring that care is delivered within safe and respectful boundaries.

The practitioner should continuously inform the patient to ensure they are sufficiently well-informed to engage in open dialogue and respond rationally to the intended plan for assessment and treatment. In addition, the practitioner must remain observant of non-verbal signs—such as facial redness or unusual perspiration—that may indicate patient distress during the session.

Finally, it is essential for the practitioner to regularly check in with the patient regarding their comfort and wellbeing throughout the course of care. This open dialogue not only fosters safety and trust but also helps to verify whether the patient has understood the treatment intentions and plan, thereby ensuring that informed consent is genuine and ongoing.

Occasionally, an adverse event may occur unintentionally, without necessarily leading to conflict, yet the patient may still have been exposed to potential harm or, in the worst-case scenario, sustained an injury. In Denmark, there is a national authority where such incidents—referred to as utilsigtede hændelser (unintended events)—can be reported by the patient, their relatives, the healthcare provider, or others involved.

The purpose of reporting unintended events is to support learning and prevent recurrence. Reports are submitted digitally, and practitioners are encouraged to initiate the report where appropriate. Alternatively, patients may be guided to do so themselves if they feel more comfortable taking the initiative.

To ensure transparency in our clinic, we have made information about unintended events accessible to our patients on our website:

For both myself and my clinic, it is a source of continuous learning to engage in open and constructive dialogue about unintended events. Such conversations contribute not only to safer care, but also to trust and professional development.

The central challenge lies in protecting our wider patient population from potential infection risks—both during individual treatment sessions and in group-based rehabilitation programmes. Hygiene therefore plays a substantial role in my daily clinical practice and requires a high degree of vigilance from both myself and my colleagues.

The worst-case scenario would be to become a source of infection, which would not only pose a direct risk to patients but also reflect a negligent attitude toward the responsibility we hold for the health and safety of others.

·       Ensuring that both patients and practitioners have access to hand sanitiser immediately upon entering the clinic.

·       Displaying signage throughout the clinic reminding patients and staff to disinfect equipment and hands after contact.

·       Facilitating dynamic entry and exit procedures to avoid patient congestion and minimise the risk of airborne transmission.

·       Conducting screening prior to treatment for symptoms of influenza, cold, or gastrointestinal illness. If a patient appears unwell, further questioning may result in postponement of treatment until full recovery. Masks are available for both practitioner and patient where deemed necessary for infection control.

·       Group sessions are held with a minimum of one metre between participants, and patients are directed immediately to the exercise studio upon arrival to avoid crowding in the waiting area.

·       A cleaning and ventilation routine is implemented after each treatment, group session, or patient encounter.

·       For patients diagnosed with Multi-Drug Resistant Staphylococcus aureus (MDRSA), appointments are scheduled at the end of the day. An extended hygiene protocol is followed, including disinfection of the waiting area and universal cleaning of treatment spaces before the next patient enters.

·       Hygiene performance is reviewed monthly through spot checks, alongside ongoing reporting of any deviations that could impact infection control or compliance with accreditation standards.

·       Dedicated bathroom and shower facilities are provided for staff, along with separate areas for storing personal belongings not used during treatment. Practitioners are mindful of not bringing potential contaminants into the workplace. Gloves, face shields, and masks are readily available in the clinic to protect both patients and staff.

 References:

·       Statens Serum Institut. (2023). National Infection Control Guidelines – General Precautions (NIR). Available at: https://hygiejne.ssi.dk/NIRgenerelle [Accessed 15 May 2025].

·       Danish Institute for Quality and Accreditation in Healthcare (IKAS). (2022). Accreditation Standards for Primary Healthcare Clinics. Available at: https://ikas.dk [Accessed 15 May 2025].

·       World Health Organization. (2020). Infection Prevention and Control During Health Care When COVID-19 is Suspected. Geneva: WHO.

·       European Centre for Disease Prevention and Control (ECDC). (2018). Guidelines for the Prevention and Control of MDR Organisms. Stockholm: ECDC.

We acknowledge that patients may not always feel comfortable addressing concerns directly with us. Therefore, our website provides information on how to file a formal complaint with the relevant authorities if a patient feels they have been treated improperly and wishes to pursue compensation or legal action against the clinic, https://www.stpk.dk/

Our website also offers guidance on how to report adverse events, https://aarslevfysioterapi.dk/utilsigtede-haendelser/.

All clinic staff are required to inform the management immediately of any cases involving disagreement, adverse events, or complaints from patients or external collaborators.

Accessible, well-organised, and precise patient records are an invaluable resource in managing clinical care. Conversely, negligent handling of patient records or sensitive personal information demonstrates a lack of respect and dignity towards our patients and may constitute a breach of privacy and criminal offence if such data falls into the hands of unauthorised third parties.

Key Legal Frameworks That Must Be Observed

1. The Danish Health Act (Sundhedsloven)

Chapter 9: Patient Records

• Requires all authorised healthcare professionals to maintain and store patient records.

• Records must be kept concurrently with, or as soon as possible after, patient consultations.

• Patient records must be retained for a minimum of 10 years after the last entry.

• Relevant Sections: §§ 15–21.

The Health Act on retsinformation.dk

2. The Authorisation Act (Autorisationsloven)

• Obligates authorised healthcare professionals to keep records in accordance with good clinical practice.

• Failure to maintain or properly manage records may result in disciplinary sanctions.

  The Authorisation Act

3. The General Data Protection Regulation (GDPR) and the Danish Data Protection Act

• Sensitive personal data (including health data) must be securely stored.

• Includes requirements for:

  • Clear information to patients about how their data is processed.

  • Consent in certain cases (e.g., for marketing or data sharing).

  • Data processing agreements when using external IT providers.

  • The right to access, correct, and delete data (where applicable).

The Danish Data Protection Agency – Health Data & GDPR

4. Executive Order on Patient Records for Authorised Healthcare Professionals

(Executive Order No. 1225 of 24/10/2007)

• Provides specific guidance on how records should be created, what they must include, and how they must be stored.

• Covers both paper-based and electronic record keeping.

Journal Executive Order

Practical Requirements for Record Keeping

Requirement

Legal Basis

Record retention for a minimum of 10 years

Health Act § 21

Protection against unauthorised access

GDPR, Data Protection Act

Clear data processing agreement

GDPR Article 28

Right to access and file complaints

GDPR Articles 15 and 77

Records must be easily legible

Journal Executive Order § 4

Any breach of these protocols would not only constitute a serious violation of patient trust but also be subject to:

• Supervision and sanctions by:

• The Danish Patient Safety Authority (for breaches of record-keeping obligations)

• The Danish Data Protection Agency (for data protection violations)

• Potential consequences:

• Official orders or injunctions

• Police reporting

• Fines

• Revocation of professional authorisation (in severe cases)

References: Danish standards for digital kommunication: https://medcom.dk/

Key Legal Frameworks Against Discrimination in Healthcare

1. The Danish Health Act

• Section 2(2): The healthcare system must "… provide the population with easy and equal access to healthcare services."

• Equality in access to healthcare is a core principle: Discrimination based on ethnicity, gender, age, religion, disability, sexual orientation, etc., is prohibited.

Health Act – retsinformation.dk

2. Executive Order on the Duties of Authorised Healthcare Professionals (Ethical Rules)

• Requires healthcare professionals to show respect and uphold patient dignity in all interactions.

• They must not act in conflict with the patient’s rights or integrity, including actions based on prejudice.

Executive Order No. 1240 of 27/10/2008

3. Equal Treatment and Anti-Discrimination Legislation

• The Act on Ethnic Equal Treatment and the Act on Prohibition of Discrimination in the Labour Market also apply within the healthcare sector.

• These laws prohibit discrimination on the basis of race, skin colour, national or ethnic origin, gender, religion, disability, age, sexual orientation, and more.

  Act on Ethnic Equal Treatment – retsinformation.dk

4. The European Convention on Human Rights & the Danish Constitution

• Denmark is bound by the European Convention on Human Rights, which prohibits discrimination (Article 14).

• Section 70 of the Danish Constitution guarantees freedom from discrimination on the basis of religion and belief.

Ethical Guidelines from Professional Bodies

• Ethical Guidelines for Physicians (Danish Medical Association)

"The physician must show respect for the patient’s integrity and dignity and must not be influenced by prejudice."

• Danish Physiotherapists: Code of Ethics

"The physiotherapist acts loyally and fairly and respects the patient’s cultural, religious, and personal values."

Code of Ethics – Danish Physiotherapists

Examples of Prohibited Forms of Discrimination

Category

Example

Race or ethnicity

Refusing treatment to individuals based on skin colour

Religion or belief

Avoiding treatment of patients wearing religious head coverings

Sexual orientation

Making derogatory remarks to LGBTQ+ individuals

Disability

Failing to accommodate physical or cognitive disabilities

Language/nationality

Denying treatment to non-Danish speakers without offering interpreter support

According to both Danish healthcare legislation and ethical guidelines, clinic owners and managers have a duty to intervene if colleagues behave in a discriminatory manner—failure to act can also be deemed unethical.

Who can sanction healthcare professionals?

1. The Danish Patient Safety Authority (STPS)

Role: Supervisory authority for authorised healthcare professionals.
Powers:

·       Investigates misconduct and breaches of the Authorisation Act, including:

o   Unprofessional behaviour

o   Unethical or discriminatory treatment

·       May issue decisions such as:

o   Formal reprimands

o   Orders for professional or ethical remediation

o   Temporary or permanent revocation of authorisation
https://stps.dk

2. The Danish Agency for Patient Complaints (STPK)

Role: Handles complaints from patients concerning the conduct or treatment by healthcare professionals.
Sanctions:

·       Criticism of the healthcare provider

·       Referral to STPS in serious cases

·       Does not impose direct disciplinary sanctions but plays a key role in case development
https://stpk.dk

3. The Equal Treatment Board (Ligebehandlingsnævnet)

Role: Reviews cases of discrimination, including those based on race, religion, disability, age, gender, and sexual orientation.
Sanctions:

·       Compensation or damages awarded to the patient

·       Publication of decisions with named individuals in certain cases
https://naevneneshus.dk

4. The Danish Data Protection Agency (Datatilsynet)

Role: Sanctions unlawful or degrading handling of sensitive personal data, which may also constitute discriminatory behaviour.

Types of Sanctions

Sanction Type

Authority

Description

Professional criticism

Danish Agency for Patient Complaints

Formal statement declaring the behaviour unacceptable

Official orders/remediation

Danish Patient Safety Authority

E.g. supervision, continuing education, or mandatory changes in practice

Temporary revocation of authorisation

Danish Patient Safety Authority

In cases of severe or repeated unethical conduct

Permanent revocation of authorisation

Danish Patient Safety Authority

For gross incompetence or posing danger to patient safety

Compensation/damages

Equal Treatment Board

Typically in cases of proven discrimination

Criminal charges and court proceedings

Police and courts

In serious cases (e.g. hate crimes, assault, or severe discriminatory conduct)

In my case, I live near my clinic, and the majority of my patients encounter me in the local community or see me during my runs. Furthermore, my social interactions often include people who are currently in treatment or who know someone receiving care at the clinic. I am more exposed to public scrutiny than colleagues who live several kilometres away from their practice.

This exposure, both professionally and personally, places an additional responsibility on me to avoid creating any adverse perceptions. This applies not only to the reputation of my clinic but also to the standing of the osteopathic profession as a whole. My focus is on proactively identifying and mitigating factors that could discredit either.

Unfortunately, discredit and rumours may arise from misunderstandings, which is why it is essential to be attentive to how patients perceive and experience care provided by myself and my clinical staff. The more proactive we are in addressing concerns that may affect reputation, the better positioned we are to manage and resolve potential issues.

Advantages of Patient Payment

Cost-effectiveness:
A systematic review from the United States showed that patients with back pain who received chiropractic care generally had lower healthcare expenses compared to those treated by other healthcare professionals. In 92% of the studies reviewed, the costs were lower for patients who were treated by chiropractors.
(Source: BioMed Central)

Reduction in opioid use and surgery:
Several studies indicate that patients who initially consult chiropractors or physiotherapists are less likely to be prescribed opioids or referred for surgery. This can lead to both lower costs and better patient outcomes.

High patient satisfaction:
Patients often report high satisfaction with treatments provided by chiropractors and physiotherapists, especially for musculoskeletal disorders such as low back pain. This may be attributed to a more holistic approach and longer consultation times.

Disadvantages of Patient Payment

Increased financial burden for patients:
User fees can place a financial strain on patients, particularly those with low income, potentially resulting in delayed or avoided treatment. This may worsen health outcomes and lead to higher long-term costs.

Inequality in access to care:
Studies have shown that higher patient fees can lead to disparities in access to care, with patients of higher socioeconomic status more likely to access necessary health services compared to those with lower income.

Potential overuse of services:
In some cases, direct payment may result in the overuse of healthcare services, where patients request or are offered unnecessary treatments. This can increase overall healthcare costs without corresponding improvements in patient outcomes.

It is inappropriate for clinical quality to be sacrificed for financial gain, and the situation is further exacerbated when practitioners speak negatively about one another. Such behaviour undermines patient trust—both in the practitioner and in the intervention being offered.
Finally, the patient's safety and quality of care may be jeopardised if their condition is not addressed promptly and in accordance with established clinical guidelines.

Research highlights the substantial benefits of Interprofessional Collaboration (IPC) in primary care. In particular, it enhances patient safety, treatment outcomes, and patient-reported satisfaction. Furthermore, studies show that patients appreciate the expansion of the healthcare team when it leads to coordinated efforts across disciplines. Additional evidence suggests that IPC fosters a more holistic approach to care and contributes to greater professional satisfaction among practitioners.

It is evident that no single clinician possesses the full competence or knowledge to manage every condition presented in clinical practice. I find it essential to acknowledge this limitation and remain vigilant in identifying when the involvement of other professionals is necessary in a patient’s care journey.

Models Supporting Collaborative Practice

I find both Tuckman’s team development model and Elwyn et al.’s shared decision-making model (BMJ, 2012) to be excellent tools for fostering healthy and effective collaboration. While each can be applied independently, their combination is particularly powerful. Elwyn’s model stands out by introducing structured and accountable interactions between professionals, including scheduling and shared responsibilities. This contrasts with Tuckman’s model, which, although foundational in team dynamics, lacks a structured approach to ongoing collaboration. Moreover, shared decision-making facilitates documentation sharing, enhancing mutual learning among professionals.

Tuckman’s Team Development Model
(Tuckman, B. W., 1965)
Purpose: To understand and navigate the stages of health team development.

• Forming: Establishing introductions and setting expectations

• Storming: Managing conflict and clarifying roles

• Norming: Developing shared frameworks and operational standards

• Performing: Engaging in effective, synergistic collaboration

Shared Decision-Making and Care Pathway Mapping
(Elwyn et al., 2012, BMJ)
Purpose: To establish collaborative treatment strategies with the patient at the centre.

Key Elements:

• Defining professional roles and responsibilities

• Sharing documentation and ensuring follow-up

• Clarifying communication pathways (e.g., secure IT systems, discharge summaries, and teleconferencing)

Scientific References Supporting IPC:

1. Systematic Review – BMC Primary Care (2023)
   A review of 65 studies revealed:

• 82% of cardiovascular patient studies reported better clinical outcomes (e.g., blood pressure and glucose control).

• 92% of studies involving patients with mental or physical conditions demonstrated positive effects.

• Mixed results were noted in elderly and multimorbid populations.
  Source

2. Overview of Systematic Reviews – IJIC (2021)
   An umbrella review of 34 systematic reviews concluded:

• IPC enhances care delivery and patient satisfaction.

• Impact on clinical outcomes and healthcare usage varies by implementation.
  Source

3. Patient Experiences – BMC Primary Care (2022)
   An integrative review of 48 studies (>3,800 patients) found:

• Generally positive patient experiences, especially in chronic care.

• Patients appreciated coordinated efforts and expanded care teams.
  Source

4. Professional Benefits – Journal of Interprofessional Care (2015)

• IPC reduces medication errors and improves outcomes.

• It enhances job satisfaction among healthcare professionals.
  Source

Global Trends in Communicable Diseases

• Rising disease outbreaks: The number of infectious disease outbreaks has increased significantly since 1980. An analysis of more than 12,000 outbreaks from 1980 to 2013 showed that both the number of outbreaks and the variety of diseases have grown markedly. Although outbreaks are on the rise, data suggest that the incidence per capita is decreasing, which indicates that global improvements in prevention, early detection, control, and treatment are becoming more effective in reducing the number of infections.
  Source: The Journalist’s Ressource: https://journalistsresource.org/economics/global-rise-human-infectious-disease-outbreaks

• Impact of climate change: Climate change contributes to the spread of vector-borne diseases such as dengue and malaria into new areas, including parts of Europe. Warmer temperatures and altered precipitation patterns create favourable conditions for disease-carrying insects, increasing the risk of outbreaks in previously unaffected regions.
  Sources: Financial Times, The Guardian: https://www.ft.com/content/599c87da-7920-4832-87de-98934cb5cbc4

• Declining vaccination rates: One of the most concerning trends is the reduction in vaccination rates, which has led to the resurgence of previously controlled diseases such as measles. In 2025, a significant rise in measles cases has been reported in the USA and Canada, primarily due to falling vaccination coverage.
  Source: The Times of India: https://timesofindia.indiatimes.com/life-style/health-fitness/health-news/not-just-covid-these-5-diseases-are-spreading-fast-globally-in-2025/articleshow/121193953.cms?utm_source=chatgpt.com

Zoonotic Diseases and Human Behaviour

• Increased human–animal interaction: Human encroachment into wildlife habitats and intensive farming increases the risk of zoonotic diseases, where pathogens are transmitted from animals to humans. This has been a major factor in previous pandemics such as COVID-19 and continues to pose a global health threat.
  Source: Financial Times: https://www.ft.com/content/a7148663-dd17-4334-b423-b92204ed56cd?utm_source=chatgpt.com

• Antimicrobial resistance (AMR): AMR is a growing concern, with bacteria and other microorganisms becoming resistant to existing treatments. This makes infections harder to treat and raises the risk of spreading resistant strains.
  Sources: CDC, The Guardian, World Health Organization: https://wwwnc.cdc.gov/eid/

Conclusion

The increasing global incidence of infections and communicable diseases is a complex issue that requires a multidisciplinary approach. Prevention, early detection, and control measures are essential to address this challenge. It is vital to strengthen vaccination programmes, monitor the impact of climate change on disease transmission, and reduce high-risk human behaviour that increases contact with potential zoonotic sources.

Professional Reflection (Acupuncture and Infection Control)

In my clinical practice, I provide acupuncture either as a standalone treatment or in combination with osteopathy. Our clientele consists primarily of individuals aged 40 and above, many of whom present with comorbidities and a health profile that renders them particularly vulnerable to infection. Therefore, in addition to maintaining high hygiene standards in the clinic, I must be vigilant regarding my own potential to pose a risk of infection to patients.

One challenge is the tendency to attend work while mildly unwell, in an effort not to disrupt the patient’s treatment progression. This seems contradictory when we advise patients to cancel appointments if they are ill. Consequently, I question whether we consistently follow the same sick leave standards that we expect from our patients.

Acupuncture requires heightened attention to hygiene due to the obvious tissue penetration involved. The key challenge lies in maintaining the same level of awareness toward potentially harmful factors that are less invasive—technically speaking—than acupuncture, yet equally capable of transmitting infection.

The concentration of individuals in one place—up to more than 60 per day in our clinic—constitutes an infection risk in itself. In light of this, we are obliged to implement measures that mitigate the risk of transmission. We aim to achieve this by ensuring that patients spend as little time as possible in the waiting area to avoid crowding. Appointment schedules are arranged to reduce wait times, and clinicians escort patients in and out of the clinic to minimise unnecessary contact with others.

Treatment rooms are ventilated and disinfected after each session—whether individual or group-based. Multiple hand sanitiser stations and paper towel dispensers are available for patients using clinic equipment independently or participating in group sessions. Clinicians have access to changing facilities, separate bathrooms, and hand hygiene products. Additionally, gloves, masks, and face shields are available as protective equipment to prevent cross-infection between practitioner and patient.

Patients presenting with symptoms of fever, flu, or gastrointestinal illness are not to be seen. If there is any uncertainty, the patient is advised to cancel their appointment. Beyond hygiene, there are also psychological and physical conditions that can compromise the ability to deliver safe and responsible treatment.

Mental health conditions such as depression or anxiety may impair a clinician’s ability to maintain adequate focus on the patient and their situation. In such cases, the clinician may be unable to process patient data effectively or respond to patient needs cognitively or emotionally, potentially resulting in unintended incidents.

Similarly, physical impairments—such as fractures or sprains—can hinder the clinician’s ability to react swiftly in emergencies (e.g., supporting a fainting patient) or to execute manual techniques accurately and safely, increasing the risk of patient discomfort or harm.

In Denmark, provisions exist to arrange occupational accommodations with both employers and public authorities. These accommodations allow for a gradual return to work for those on long-term sick leave, enabling a progressive increase in working hours. This supports a balance between recovery and continued workforce participation.

Crucially, such arrangements ensure that patient safety and care quality are maintained while allowing clinicians the time and support they need to recover fully.

For osteopaths educated outside the EU/EEA, recognition is generally based on Executive Order No. 478 of 10/05/2013 on the authorisation of certain healthcare professionals who are citizens of and/or trained in countries outside the EU/EEA.

Application must be submitted to the Danish Patient Safety Authority (Styrelsen for Patientsikkerhed) together with the following documentation:

• Proof of completed education in osteopathy (diploma and curriculum)

• CV outlining relevant professional experience

• Copy of any other relevant health professional authorisations (e.g. physiotherapist, chiropractor)

• Certificate of good standing from the health authorities in the country of education

• Criminal record certificate

• Proof of language proficiency (typically Danish at B2 level if the education was completed abroad)

Reference:

https://stps.dk/sundhedsfaglig/autorisation/soeg-autorisation/osteopat

Unfortunately, I occasionally receive extensive information lacking clinical reasoning from the referring provider. Simply listing findings and observations is insufficient unless a clear clinical perspective has been established.

The literature highlights the following consequences of poor patient handovers:

1. Increased Risk of Medical Errors
   Miscommunication during care transitions is a leading cause of adverse events in hospitals and primary care. A systematic review by Starmer et al. (2014) found that implementing standardized handoff procedures reduced medical errors by 23% and preventable adverse events by 30% (Starmer et al., New England Journal of Medicine, 2014).

2. Delayed or Inappropriate Treatment
   When essential clinical information is not effectively communicated, patients may receive incorrect or delayed treatment, especially during provider handovers or interprofessional transitions.

3. Patient Dissatisfaction and Readmission
   Poor communication leads to fragmented care, contributing to increased patient dissatisfaction and higher rates of unplanned readmissions (Kripalani et al., JAMA, 2007).

4. Compromised Patient Safety
   The World Health Organization (WHO) identifies communication failures as one of the top root causes of sentinel events worldwide. Effective handovers are essential for ensuring patient safety and continuity of care.

Suggested References:

• Starmer AJ, et al. (2014). Changes in medical errors after implementation of a handoff program. New England Journal of Medicine, 371(19), 1803–1812. https://doi.org/10.1056/NEJMsa1405556

• World Health Organization (2007). Communication during patient hand-overs: WHO High 5s Project.

• The Joint Commission (2017). Sentinel Event Data – Root Causes by Event Type.

• Arora V. & Johnson J. (2006). A model for building a standardized hand-off protocol. Quality and Safety in Health Care, 15(6), 401–406.

One of the most helpful guiding principles in my clinical practice has been to envision how I myself would prefer to receive a patient from a colleague. Patient records that focus clearly on the main complaint and include reasoned arguments with a coherent narrative across the case history, physical findings, and treatment response provide an ideal starting point for the receiving clinician.

When referring a patient whose condition remains unresolved, it is valuable to include the referring clinician’s clinical reasoning based on their observations, tests, and attempted interventions. This helps the next provider avoid repeating ineffective approaches and enables a more targeted and timely continuation of care. For the patient, such a handover supports continuity, avoids redundant procedures, and strengthens trust in a multidisciplinary care approach.

Moreover, clinicians often prefer handover notes and discharge letters that are concise, structured, and clinically meaningful. Avoiding unnecessary filler text and instead emphasizing clear reasoning ensures that critical information is not lost. The primary objective must always be to safeguard the patient’s well-being, which sometimes requires striking a balance between brevity and the inclusion of essential clinical details. In my experience, the better I understand a patient, the easier it is to be succinct and precise.

Scientific References Supporting the Importance of Effective Handover:

1. World Health Organization (2007)
   Poor communication during handovers is a major risk factor for patient safety. WHO recommends standardized tools such as SBAR (Situation, Background, Assessment, Recommendation) to reduce errors and miscommunication.
   World Health Organization. (2007). Communication during patient hand-overs. Patient Safety Solutions.

2. Starmer et al., NEJM (2014)
   A multicentre study found that the implementation of a structured handoff program led to a 23% reduction in medical errors and a 30% reduction in serious medication-related errors.
   Starmer AJ et al. Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine, 2014. DOI: 10.1056/NEJMsa1405556

3. Holly & Poletick, Journal of Clinical Nursing (2014)
   This systematic review concluded that effective handovers are essential for care continuity and result in better patient outcomes and satisfaction.
   Holly C, Poletick E. A systematic review on the transfer of patient care from one caregiver to another. J Clin Nurs. 2014. DOI: 10.1111/jocn.12362

4. The Joint Commission (2017)
   Inadequate handoff communication remains one of the leading causes of serious adverse events. The Commission emphasizes the need for formal, standardized communication protocols as part of safe clinical practice.
   Joint Commission. Sentinel Event Alert, Issue 58.

5. Greenstein & Arora, Academic Medicine (2009)
   Highlights the importance of structured handoff training during medical education to reduce errors and foster interprofessional collaboration.
   Greenstein EA, Arora VM. Improving patient handoffs through standardized training. Acad Med. 2009.

Why it Matters

• Patient Safety: Incomplete handovers are associated with medication errors, misdiagnoses, and treatment delays.

• Improved Clinical Continuity: Structured handovers facilitate a clearer understanding of the patient's journey.

• Better Collaboration: Standardized procedures enhance mutual trust and communication across disciplines.

Gender Bias in Health Research and Its Clinical Implications

There is increasing awareness that women's health is underrepresented in medical research, which may lead to disparities in diagnosis and treatment. While there has been progress towards more balanced gender representation in clinical trials, key gaps persist.

An analysis by the Danish Medicines Agency and the Danish Health Authority found that, overall, gender representation in clinical research is well-balanced. However, women remain underrepresented in specific areas, such as cardiovascular diseases and certain cancers. This may result in women receiving less effective treatment, as sex-specific physiological differences are often not adequately addressed in the research design (Lægemiddelstyrelsen, 2025).
Source: https://laegemiddelstyrelsen.dk/da/nyheder/2025/ny-analyse-generelt-god-balance-i-baade-kvinders-og-maends-repraesentation-i-klinisk-forskning

A report discussed in Dagens Medicin noted that although the findings are not dramatic, they are significant and highlight a need for more equity in representation:
Source: https://dagensmedicin.dk/rapport-undersoeger-koensrepraesentation-det-er-ikke-et-dramatisk-fund-men-det-er-et-ret-vigtigt-fund

Feminist scholars have criticised research design for being influenced by "neurosexism"—the tendency to exaggerate or misinterpret gender differences—leading to stereotypical assumptions and exclusion of women in trial designs and data analysis. A more inclusive research model that accounts for both biological and social differences is needed.
Source: kvinderogsundhed.dk

A 2019 study by Harvard Medical School found that women comprised only around 40% of participants in clinical trials related to cancer, cardiovascular disease, and psychiatric conditions—despite making up 51% of the general population (AAMC, 2020).
Source: https://www.aamc.org/news/why-we-know-so-little-about-women-s-health

In early-phase industry-sponsored clinical trials, women made up less than 30% of participants, often due to concerns about hormonal fluctuations and pregnancy.
Reference: Singh, K., & Swarup, R. (2025). Women are poorly represented in clinical trials. That’s problematic. Nature India. https://doi.org/10.1038/d44151-025-00036-y

Furthermore, when women are included, data are often not analysed separately by sex, potentially obscuring important differences in disease manifestation and treatment effectiveness.

Consequences of Underrepresentation:

• Misdiagnosis and delayed treatment: Women often present with different symptoms than men—particularly in cardiovascular disease—and may be misdiagnosed or diagnosed too late.

• Increased risk of side effects: Medication dosages are frequently based on male physiology, which can lead to more severe or frequent side effects in women.
  Source: Adelaide Now – Article on Overmedication in Women

• Insufficient treatment for female-specific conditions: Conditions such as endometriosis and menopause remain under-researched, resulting in limited clinical knowledge and fewer treatment options.

• Health outcome inequality: The lack of female inclusion in trials contributes to broader gender-based disparities in health outcomes.

Clinical Perspective:

The national clinical guidelines we follow in my clinic do not take gender differences into account. This may appear negligent, especially when research from the U.S. has shown that cardiovascular conditions in women were often detected too late because screening models were based on male populations. This delay in diagnosis hindered timely intervention.
Reference:
Sun, T. Y., Walk IV, O. J., Chen, J. L., Nieva, H. R., & Elhadad, N. (2020). Exploring Gender Disparities in Time to Diagnosis. ArXiv. https://arxiv.org/abs/2011.06100

In my clinical practice, the guidelines used for managing low back pain are not sex-specific. The assumption that all patients can be treated the same way can lead to suboptimal outcomes and inappropriate care for some individuals. For instance, research from the U.S. has shown that cardiovascular conditions in women were often detected too late because screening models were based on male populations. This delay in diagnosis hindered timely intervention.
Reference:
Sun, T. Y., Walk IV, O. J., Chen, J. L., Nieva, H. R., & Elhadad, N. (2020). Exploring Gender Disparities in Time to Diagnosis. ArXiv. https://arxiv.org/abs/2011.06100

Evidence and Gender-Based Differences in Pain Perception

In everyday clinical practice, it is essential to be aware that symptoms of the same disease may present differently in men and women. This awareness enables timely recognition of potentially dangerous comorbidities and competing conditions.

Biological Differences in Pain

• Hormonal influences: Women’s experience of pain is significantly affected by hormonal fluctuations, particularly oestrogen and progesterone. These hormones can increase pain sensitivity and influence the body’s production of endogenous opioids such as endorphins.

  • Reference: LiveScience (2022). Oestrogen may spur the body to make opioids after injury. Available at: https://www.livescience.com/health/neuroscience/estrogen-may-spur-the-body-to-make-opioids-after-injury

• Nociceptor activation: Research indicates that certain compounds activate pain receptors differently in men and women. For example, prolactin sensitises pain receptors in women, while orexin B has a similar effect in men.

  • Reference: Fysio.dk (2011). Hvorfor har kvinder flere smerter end mænd. Available at: https://www.fysio.dk/fysioterapeuten/arkiv/nr.-1-2011/Hvorfor-har-kvinder-flere-smerter-end-mand

Psychosocial Factors

• Pain perception and reporting: Women tend to report higher pain intensity and have lower pain thresholds than men. This is influenced by both biological and societal norms, which may make it more socially acceptable for women to express pain.

  • Reference: International Association for the Study of Pain. Fact Sheet on Gender Differences in Pain. Available at: https://www.iasp-pain.org/resources/fact-sheets/156455

• Bias and stereotyping: Women's pain is more likely to be dismissed or attributed to psychosomatic causes by healthcare professionals, often resulting in suboptimal treatment.

  • Reference: Fysio.dk (2011). Hvorfor har kvinder flere smerter end mænd

Clinical Implications

• Under-treatment: Women are more frequently prescribed sedatives rather than analgesics compared to men, even when reporting similar levels of pain.

• Delayed diagnosis: Women often experience longer diagnostic delays for several conditions, which can result in symptom worsening and chronic pain development.

  • Reference: Sun, T. Y., Walk IV, O. J., Chen, J. L., Nieva, H. R., & Elhadad, N. (2020). Exploring Gender Disparities in Time to Diagnosis. arXiv. Available at: https://arxiv.org/abs/2011.06100

Summary Table: Gender Differences in Pain

Aspect

Women

Pain threshold = Lower

Reported pain intensity = Higher

Prevalance of Chronic Pain = Higher

Common Treatment approach = Sedatives

Common Time to diagnosis = Longer

Men

Pain threshold = Higher

Reported pain intensity = Lower

Prevalance of Chronic Pain = Lower

Common Treatment approach = Analgesics

Common Time to diagnosis = Shorter

These differences underscore the importance of gender-specific considerations in pain research and management to ensure fair and effective treatment for all patients.

• Reference: Mosca, L. et al. (1999). Guide to Preventive Cardiology for Women. Circulation, 99(18), 2480. https://doi.org/10.1161/01.cir.99.18.2480

Clinical Reflections

In my clinical practice, pain is the most common complaint among patients. Understanding sex-related differences in pain physiology is vital for tailoring treatment strategies appropriately. Even when patients present with similar symptoms, consideration must be given to the biological, physiological, and biopsychosocial differences between the sexes.

For instance, when managing back pain, I adapt my choice of techniques, treatment intensity and frequency, and even consider whether individual or group therapy is more appropriate. Broadly, I observe that women are more receptive to theoretical explanations and educational input, while men often prefer manual interventions and respond well to technical modalities such as TENS or acupuncture.

In group settings, women tend to value shared discussions and mutual support, whereas men often focus on "fixing" the problem and prefer physically intensive approaches.

Despite these trends, individualised treatment remains essential. Recognising gender-related differences aids not only in symptom interpretation but also in guiding clinical decision-making.

As a healthcare professional, you have an active duty to take appropriate action if your health or personal circumstances pose a potential risk to patient safety, professional competence, or public trust. Doubt should always lead to reflection and ideally consultation—not to inaction.

In Denmark, healthcare professionals—including doctors, osteopaths, physiotherapists, and others—have both a legal and ethical responsibility to act if their ability to deliver safe and competent patient care is compromised. This applies in cases of health-related issues as well as legal proceedings, criminal convictions, or any event that may raise concerns about professional suitability.

1. In Cases of Health-Related Limitations

Duty of Self-Evaluation and Action

According to the Health Act and most professional authorisation laws (e.g., for physiotherapists and physicians), healthcare professionals are obligated to:

• Refrain from working if their condition poses a risk to patient safety

• Seek relevant medical treatment and support

• Consider informing their employer, supervisory authority (e.g., the Danish Patient Safety Authority), or clinical partners, if deemed necessary

National Health Authority Guidance:

“Healthcare professionals must not continue working under conditions where illness or functional impairment makes them unfit to provide safe and appropriate patient care.”
(Source: Danish Health Authority – Guidance on Duties and Responsibilities)

Relevant legislation: Authorisation Act (Autorisationsloven)

2. In Cases of Legal Proceedings or Criminal Conviction

Duty to Notify the Danish Patient Safety Authority (STPS)

You are required to report to STPS if:

• You are convicted of an offence that may affect your trustworthiness, ethics, or professional suitability (e.g., violence, fraud, sexual offences, gross negligence)

• Your professional judgment is likely to be compromised due to ongoing legal proceedings—even without a conviction

STPS will assess whether further actions are needed, such as:

• Supervision

• Temporary suspension

• Restriction of professional activities

• Revocation of authorisation (in severe cases)

Legislative source: Authorisation Act – danskelove.dk

 Examples of Appropriate Actions

Situation

Recommended Action

You suffer from a physical or mental illness that affects clinical judgment

Step back temporarily, seek treatment, and notify your employer if appropriate

You are under criminal charge or conviction for an issue affecting patient safety or ethics

Notify the Danish Patient Safety Authority

You are unsure whether you can still deliver safe and competent care

Consult a peer, professional association, or STPS

 Guidance and Support

• Professional associations (e.g., Danish Physiotherapists, medical unions) offer legal advice and counselling

• STPS provides guidance in cases of fitness to practise and disciplinary matters
  Read more at stps.dk

• Work environment support and psychological counselling may be relevant, especially in cases involving stress or burnout
  Mental Health for Healthcare Professionals – patientsikkerhed.dk

In response to this perspective, I chose to undergo supervision both professionally and in my personal life. The aim was to gather observations and feedback regarding potential signs of burnout, stress, depression, or similar reactions that might pose a risk to patient safety, affect their sense of well-being during treatment, or compromise the quality of my clinical practice.

The process is ongoing. So far, stress assessments have been positive, with the explanation being that I currently have a high level of engagement across several domains—running a clinic, working as a consultant, pursuing studies, and maintaining an ambition to continue long-distance running. Overall, the goal is to improve my ability to prioritise time and tasks, particularly by focusing on those aspects that are most important for sustaining personal health and well-being.

In the clinic, my efforts are directed toward ensuring that patients feel comfortable, safe, and genuinely cared for—not only in regard to their health concerns but also as individuals. Being received with courtesy, respect, dignity, and an empathetic approach contributes greatly to a positive treatment experience.

Younger colleagues have also played a valuable role by introducing me to contemporary concepts such as the notion of being "woke" and other evolving social issues that I may not have previously been attuned to.

References:

https://www.decent.com/blog/effective-strategies-for-setting-boundaries-in-healthcare

Reflections on Infant Treatment and Professional Development

The osteopathic training has greatly inspired me to work with infants. Until now, I have refrained from doing so in my clinical practice, as I have not felt competent in handling children who cannot communicate verbally. In short, I worry about unintentionally causing harm due to an inability to detect signs of overload or distress during treatment. Mr. Kok Weng Lim was an extraordinary example of how treatment can be delivered without words, relying instead on brief communication with the parents. It was remarkable to observe how Mr. Lim created calm around the infant, allowing him to manage and treat with precision. His mastery of non-verbal communication, and the harmony between him and the infant, formed a compelling unity.

My impression of Mr. Lim's approach was that he led not by assertiveness, but with distance and curiosity, asking insightful questions about the child’s daily behaviour and wellbeing, and observing with careful, non-invasive attention. Palpation was gentle and unhurried, and the treatment followed naturally from the findings. At the end of the session, the infant appeared peacefully tired in a healthy and balanced way. The only thing I missed was feedback from the parents on how the infant fared after the session.

As uplifting as it was to witness Mr. Lim in action, it was equally humbling to realise how much I still need to learn to treat infants with such professionalism and safety. I left the seminar with a sense of awe, questioning whether I could ever develop the same level of expertise.

Scientific Perspective on Communication with Infants and Families

Research highlights several essential findings for effective communication between healthcare professionals, infants/young children, and their caregivers:

1. NICE Guideline 204 – "Communication by Healthcare Staff" (2021)
   This comprehensive UK guideline from the National Institute for Health and Care Excellence (NICE) outlines how healthcare staff should interact with infants, children, and young people, including their parents or guardians. Recommendations include:

• Using the child’s name and creating a personal connection

• Adapting communication to the child’s developmental level

• Active listening and acknowledging the child’s emotions

• Using visual aids and playful methods to aid understanding

• Involving parents as partners in the process These approaches aim to establish a safe and supportive environment that fosters the child’s wellbeing and cooperation during treatment.

2. "Paediatric Patient Perceptions of Healthcare Professionals" (2024)
   This study explored perspectives from children aged 3–18, identifying what they value in communication with healthcare staff. Children preferred:

• Friendly and patient professionals who show genuine interest

• Clear and age-appropriate information

• Being involved in discussions and decisions

• The use of play and visual tools to explain complex topics The findings emphasise tailoring communication to the child's developmental needs to enhance their healthcare experience.

3. "Communication Between Mothers and Health Workers in Neonatal Units" (2019)
   A qualitative South African study highlighted how effective communication with mothers of newborns enhances neonatal care quality. Key findings include:

• Good communication builds trust and maternal engagement

• Poor communication leads to misunderstandings and lower care quality

• Involving mothers in decision-making improves infant health outcomes Training healthcare professionals in communication techniques that promote parental collaboration and understanding is recommended.

Practical Recommendations for Health Professionals:

• Early engagement: Initiate communication with both the child and parents early to build trust

• Age-appropriate communication: Adapt language and explanations to suit the child’s developmental level

• Use of playful and visual methods: Incorporate images, toys or roleplay to explain procedures

• Parental involvement: Treat parents as partners and involve them actively in decision-making

• Empathic listening: Pay attention to the concerns of both child and parent and respond with understanding

References:

• https://pubmed.ncbi.nlm.nih.gov/39663230/

• https://healthmanagement.org/c/hospital/Health/nice-published-positive-experience-guidelines-for-baby-child-and-adolescent-healthcare

• Wreesmann, W. W., Lorié, E. S., Van Veenendaal, N. R., Van Kempen, A. A., Ket, J. C., & Labrie, N. H. (2021). The functions of adequate communication in the neonatal care unit: A systematic review and meta-synthesis of qualitative research. Patient Education and Counseling, 104(7), 1505-1517. https://doi.org/10.1016/j.pec.2020.11.029

Inspired by Mr. Lim’s teaching, I have become acutely aware of the importance of non-invasive care and the need to avoid forcing hypotheses during treatment. Instead, I strive to approach each child with openness and curiosity. While I have not yet treated infants in my clinic, I have applied this mindful approach when treating older children and adolescents.

In addition to Mr. Lim’s teachings, the NICE guidelines have also been valuable, even though I have yet to begin my osteopathic work with infants. Moving forward, my intention is to become more confident and competent in this field. My clinical framework will be based on the following principles:

1. A holistic view of the child:

• Assess the child as a whole, including birth history, nutrition, sleep, breathing, and motor development

• Observe the interaction between cranium, spine, pelvis, connective tissue, nervous system, and organ function

2. Gentle manual techniques:

• Use non-manipulative and non-invasive techniques suited to the infant's delicate tissue

• Develop skills in craniosacral and functional techniques (e.g., indirect techniques) to support intrinsic motion and release restrictions

3. Focus on birth trauma and biomechanics:

• Learn techniques for infants born via C-section, assisted delivery (forceps/vacuum), or traumatic labour

• Apply cranial and cervical techniques targeting, for example, the vagus nerve to support digestion, sleep, and crying

4. Common infant conditions to address:

• Colic and digestive issues

• Asymmetry (e.g., head flattening, preference for one side)

• Sleep disturbances

• Excessive crying

• Breastfeeding difficulties due to jaw, neck, or tongue restrictions

• Motor restlessness or developmental delay

5. Collaboration and safety:

• Collaborate with health visitors, midwives, physicians, and physiotherapists

• All treatment will be based on the infant's response and only proceed in the absence of contraindications

Scientific Evidence While the evidence base for osteopathic treatment of infants is limited, it is growing:

• Hayden et al. (2019) found osteopathy may reduce colic symptoms in some cases, though evidence remains weak

• Posadzki et al. (2010) highlighted the need for larger, controlled trials

• Guillaud et al. (2016) conducted a systematic review suggesting osteopathy shows promise for functional disorders, though study quality varies: https://doi.org/10.1186/s12887-016-0670-4

·      Avoid having prejudices to e.g. obesity and be open minded when discussing issues concerning health and well-being.

·      Keeping adequate attention and making notes of key information.  

·      Make sure to keep your questioning open

·      Challenge your hypothesis through patient reaction and treatment outcome

·      Understand connectivity between structure and function

·      Patients are motivated as long as they feel you listen to them, understand them and their issues.

·      Assessments can be preferred from treatment if necessary and as long as the patient can see the point of it and believes the aim of assessing is constructive.

·      IVM can benefit from being introduced through demonstration/ patient experiencing it  prior an oral explanation.

References:

•​​(Still, n.d.)​ 

•Sports:​(EVIDENCE-INFORMED PRIMARY CARE MANAGEMENT OF LOW BACK PAIN Clinical Practice Guideline |, 2015; Geneen et al., 2017; Hackney & Walz, 2013; Raya-González et al., 2020)​​(Raya-González et al., 2020)​​(Tori Stone, 2021)​ 

•​​(Effects of the Central Tendon Osteopathic Treatment on the Cardiorespiratory Function in Healthy Subjects · Osteopathic Research Web · Osteopathic Research Web, n.d.; Geneen et al., 2017)​ 

•Digestive/ Endokrine: 

•​​(Hackney & Walz, 2013; Tennant, 2013)​​(Itriyeva, 2022)​ 

•Menstrual-Related Headache: 

•​​(Dysmenorrhea: Menstrual Cramps, Causes & Treatments, n.d.; Itriyeva, 2022; Moy & Gupta, 2022; Wallner et al., 2006)​ 

•Neurological​(Basbaum et al., 2009; Fitzcharles et al., 2021; Lorimer Mosely, n.d.; Tennant, 2013; Wallner et al., 2006)​: 

• 

•​​Basbaum, A. I., Bautista, D. M., Scherrer, G., & Julius, D. (2009). Cellular and Molecular Mechanisms of Pain. Cell, 139(2), 267. https://doi.org/10.1016/J.CELL.2009.09.028 

•​Dysmenorrhea: Menstrual Cramps, Causes & Treatments. (n.d.). Retrieved August 6, 2024, from https://my.clevelandclinic.org/health/diseases/4148-dysmenorrhea 

•​Effects of the central tendon osteopathic treatment on the cardiorespiratory function in healthy subjects · Osteopathic Research Web · Osteopathic Research Web. (n.d.). Retrieved July 31, 2024, from https://www.osteopathic-research.com/s/orw/item/2390 

•​EVIDENCE-INFORMED PRIMARY CARE MANAGEMENT OF LOW BACK PAIN Clinical Practice Guideline |. (2015). 

•​Fitzcharles, M.-A., Cohen, S. P., Clauw, D. J., Littlejohn, G., Usui, C., & Häuser, W. (2021). Nociplastic pain: towards an understanding of prevalent pain conditions. The Lancet, 397(10289), 2098–2110. https://doi.org/10.1016/S0140-6736(21)00392-5 

•​Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. In L. J. Geneen (Ed.), Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858.CD011279.pub2 

•​Hackney, A. C., & Walz, E. A. (2013). Hormonal adaptation and the stress of exercise training: the role of glucocorticoids. Trends in Sport Sciences, 20(4), 165–171. 

•​Itriyeva, K. (2022). The effects of obesity on the menstrual cycle. Current Problems in Pediatric and Adolescent Health Care, 52(8), 101241. https://doi.org/10.1016/j.cppeds.2022.101241 

•​Lorimer Mosely. (n.d.). Explain Pain, second edition. 

•​Moy, G., & Gupta, V. (2022). Menstrual-Related Headache. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK557451/ 

•​Raya-González, J., Clemente, F. M., Beato, M., & Castillo, D. (2020). Injury Profile of Male and Female Senior and Youth Handball Players: A Systematic Review. International Journal of Environmental Research and Public Health, 17(11), 3925. https://doi.org/10.3390/ijerph17113925 

•​Still, A. T. (n.d.). PHILOSOPHY OF OSTEOPATHY. http://www.osteopathie-france.net/Information/livresapprof_philo.htm 

•​Tennant, F. (2013). The Physiologic Effects of Pain on the Endocrine System. Pain and Therapy, 2(2), 75. https://doi.org/10.1007/S40122-013-0015-X 

•​Tori Stone, P. L. D. P. M. and N. S. S. PhD. (2021). Exercise Treatment of Obesity. National Libary of Medicine. 

•​Wallner, C., Maas, C. P., Dabhoiwala, N. F., Lamers, W. H., & DeRuiter, M. C. (2006). Innervation of the pelvic floor muscles: A reappraisal for the levator ani nerve. Obstetrics and Gynecology, 108(3), 529–534. https://doi.org/10.1097/01.AOG.0000228510.08019.77 

·      Avoid autonomy in your clinical performance by evaluating journals and be critical in not approaching patients in the same way even though they express same symptoms and beliefs to their problem

·      Enhance working with structure in praxis

·      Take time in sessions to make immediate reflection from the treatment.

·      Enhance patients to give feedback on experience from former treatment to reap information that could be beneficial for the treatment and avoid  composing assessments and treatments the patient hasn’t found favourable.

References:

•​​(Still, n.d.)​ 

•Sports:​(EVIDENCE-INFORMED PRIMARY CARE MANAGEMENT OF LOW BACK PAIN Clinical Practice Guideline |, 2015; Geneen et al., 2017; Hackney & Walz, 2013; Raya-González et al., 2020)​​(Raya-González et al., 2020)​​(Tori Stone, 2021)​ 

•​​(Effects of the Central Tendon Osteopathic Treatment on the Cardiorespiratory Function in Healthy Subjects · Osteopathic Research Web · Osteopathic Research Web, n.d.; Geneen et al., 2017)​ 

•Digestive/ Endokrine: 

•​​(Hackney & Walz, 2013; Tennant, 2013)​​(Itriyeva, 2022)​ 

•Menstrual-Related Headache: 

•​​(Dysmenorrhea: Menstrual Cramps, Causes & Treatments, n.d.; Itriyeva, 2022; Moy & Gupta, 2022; Wallner et al., 2006)​ 

•Neurological​(Basbaum et al., 2009; Fitzcharles et al., 2021; Lorimer Mosely, n.d.; Tennant, 2013; Wallner et al., 2006)​: 

• 

•​​Basbaum, A. I., Bautista, D. M., Scherrer, G., & Julius, D. (2009). Cellular and Molecular Mechanisms of Pain. Cell, 139(2), 267. https://doi.org/10.1016/J.CELL.2009.09.028 

•​Dysmenorrhea: Menstrual Cramps, Causes & Treatments. (n.d.). Retrieved August 6, 2024, from https://my.clevelandclinic.org/health/diseases/4148-dysmenorrhea 

•​Effects of the central tendon osteopathic treatment on the cardiorespiratory function in healthy subjects · Osteopathic Research Web · Osteopathic Research Web. (n.d.). Retrieved July 31, 2024, from https://www.osteopathic-research.com/s/orw/item/2390 

•​EVIDENCE-INFORMED PRIMARY CARE MANAGEMENT OF LOW BACK PAIN Clinical Practice Guideline |. (2015). 

•​Fitzcharles, M.-A., Cohen, S. P., Clauw, D. J., Littlejohn, G., Usui, C., & Häuser, W. (2021). Nociplastic pain: towards an understanding of prevalent pain conditions. The Lancet, 397(10289), 2098–2110. https://doi.org/10.1016/S0140-6736(21)00392-5 

•​Geneen, L. J., Moore, R. A., Clarke, C., Martin, D., Colvin, L. A., & Smith, B. H. (2017). Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. In L. J. Geneen (Ed.), Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. https://doi.org/10.1002/14651858.CD011279.pub2 

•​Hackney, A. C., & Walz, E. A. (2013). Hormonal adaptation and the stress of exercise training: the role of glucocorticoids. Trends in Sport Sciences, 20(4), 165–171. 

•​Itriyeva, K. (2022). The effects of obesity on the menstrual cycle. Current Problems in Pediatric and Adolescent Health Care, 52(8), 101241. https://doi.org/10.1016/j.cppeds.2022.101241 

•​Lorimer Mosely. (n.d.). Explain Pain, second edition. 

•​Moy, G., & Gupta, V. (2022). Menstrual-Related Headache. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK557451/ 

•​Raya-González, J., Clemente, F. M., Beato, M., & Castillo, D. (2020). Injury Profile of Male and Female Senior and Youth Handball Players: A Systematic Review. International Journal of Environmental Research and Public Health, 17(11), 3925. https://doi.org/10.3390/ijerph17113925 

•​Still, A. T. (n.d.). PHILOSOPHY OF OSTEOPATHY. http://www.osteopathie-france.net/Information/livresapprof_philo.htm 

•​Tennant, F. (2013). The Physiologic Effects of Pain on the Endocrine System. Pain and Therapy, 2(2), 75. https://doi.org/10.1007/S40122-013-0015-X 

•​Tori Stone, P. L. D. P. M. and N. S. S. PhD. (2021). Exercise Treatment of Obesity. National Libary of Medicine. 

•​Wallner, C., Maas, C. P., Dabhoiwala, N. F., Lamers, W. H., & DeRuiter, M. C. (2006). Innervation of the pelvic floor muscles: A reappraisal for the levator ani nerve. Obstetrics and Gynecology, 108(3), 529–534. https://doi.org/10.1097/01.AOG.0000228510.08019.77 

In Denmark, this observation is recognised by acknowledging recurrent low back pain as a potentially chronic condition. Long-term use of medical, manual, or surgical interventions is discouraged, as there is no conclusive evidence that any one treatment approach is superior for managing CLBP. Imaging diagnostics are no longer routine but are instead reserved for cases where surgery is being considered or where red flags suggest conditions like fractures, malignancy, or rheumatological disease. The WHO supports this approach.(Who Guidelines on Chronic Low Back Pain, n.d.)

My osteopathic training has opened my eyes to the complexity of low back pain and its relationship to bodily function, psychosocial context, and patient behaviour. My education and clinical experience have primarily focused on musculoskeletal, neurological, and psychosomatic perspectives. I have also explored acupuncture, particularly the meridian concept, which to the uninitiated may resemble Integrated Visceral Manipulation (IVM) in osteopathy. I never fully connected with the meridian concept, even though it closely mirrors major nerve pathways. In contrast, osteopathy has offered a much more grounded and structured understanding of bodily interconnections.

This shift in perspective made me realise that my earlier approach to treating spinal and musculoskeletal conditions was too simplistic. I became increasingly intrigued by the interaction between bodily systems and how that influences CLBP. This led to my decision to write a dissertation exploring whether breathing techniques could be an effective addition to the treatment of patients with chronic low back pain.

Back Pain Medication: What Medicines Help Lower Back Pain? (n.d.). Retrieved June 3, 2024, from https://www.webmd.com/back-pain/what-medicines-help-with-low-back-pain

Fatoye, F., Gebrye, T., Mbada, C. E., & Useh, U. (2023). Clinical and economic burden of low back pain in low-and middle-income countries: a systematic review. BMJ Open, 13, 64119. https://doi.org/10.1136/bmjopen-2022-064119

Kolář, P., Šulc, J., Kynčl, M., Šanda, J., Čakrt, O., Andel, R., Kumagai, K., & Kobesová, A. (2012). Postural function of the diaphragm in persons with and without chronic low back pain. The Journal of Orthopaedic and Sports Physical Therapy, 42(4), 352–362. https://doi.org/10.2519/JOSPT.2012.3830

Menezes Costa, L. D. C., Maher, C. G., Hancock, M. J., McAuley, J. H., Herbert, R. D., & Costa, L. O. P. (2012). The prognosis of acute and persistent low-back pain: A meta-analysis. CMAJ. Canadian Medical Association Journal, 184(11). https://doi.org/10.1503/CMAJ.111271

Who guidelines on Chronic Low Back Pain. (n.d.). Https://Www.Who.Int/News/Item/07-12-2023-Who-Releases-Guidelines-on-Chronic-Low-Back-Pain.

Wideman, J., & Winchester, B. (2013). Literature Review: Core Stabilization From The Inside Out: The Role Of The Diaphragm And Intra-Abdominal Pressure.

In light of these insights, I have actively sought to apply my osteopathic knowledge to better manage CLBP. I became particularly interested in the relationship between the diaphragm and back pain. Anatomically and biomechanically, the diaphragm is deeply connected to the lumbar spine. Literature indicates that the diaphragm plays a significant role in trunk stabilisation during peripheral limb movement.(Kolář et al., 2012)

It is often the first structure activated during upper limb motion. In addition, the diaphragm is the body’s largest active circulatory pump and significantly influences intra-abdominal pressure.

In clinical practice, I now consciously incorporate the diaphragm in my evaluation and treatment of patients with CLBP with inspiration from J.Wdeman et Winchester B (2013). (Wideman & Winchester, 2013). I specifically treat the diaphragm and have, together with colleagues, developed group-based rehabilitation programs focusing on dysfunctional breathing. These include patient education on the connection between breathing patterns and back health. Treating the diaphragm, along with targeted breathing education in group settings, has proven beneficial to the patients who participate.

A striking observation is how quickly many patients report improvement or a sense of relief in the back through breathing-focused exercises. Additionally, patients appreciate how accessible and convenient these techniques are—they require no equipment, can be done at home or work, and don’t require physical exertion or a change of clothes.

We have also observed that patients with respiratory issues such as asthma or COPD, who join our breathing classes due to dysfunctional breathing patterns, often experience relief in their longstanding back pain. For this group, breathing techniques may offer a useful alternative, especially since they may struggle with conventional back exercise programs that require greater physical capacity.

I hope that this work will encourage others to look more deeply into causes and contributing factors for CLBP. People with back pain are at risk of being overlooked or even stigmatised. The commonly used term "non-specific low back pain" is a clear example of this. I prefer the WHO’s term "primary low back pain," which is more respectful and validating.

To me, the goal is not to become dogmatic about a new approach, but rather to integrate what I have learned—particularly about the diaphragm—into a more nuanced and holistic understanding of the causes and contributing factors to back pain.

Back Pain Medication: What Medicines Help Lower Back Pain? (n.d.). Retrieved June 3, 2024, from https://www.webmd.com/back-pain/what-medicines-help-with-low-back-pain

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Kolář, P., Šulc, J., Kynčl, M., Šanda, J., Čakrt, O., Andel, R., Kumagai, K., & Kobesová, A. (2012). Postural function of the diaphragm in persons with and without chronic low back pain. The Journal of Orthopaedic and Sports Physical Therapy, 42(4), 352–362. https://doi.org/10.2519/JOSPT.2012.3830

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Wideman, J., & Winchester, B. (2013). Literature Review: Core Stabilization From The Inside Out: The Role Of The Diaphragm And Intra-Abdominal Pressure.