Osteopathy Studies - Osteoarthritis of the hip

The normal trabecular structure of the bone of the femur ensures the best transmission of forces through the joint. Osteoarthritis can alter the trabecular structure and increase propensity for fracture.
http://www.palmm.org

Adhesive Capsulitis - Frozen Shoulder

In adhesive-capsulitis (frozen shoulder) as the gleno-huneral joint loses its range of movement the accessory joints, including the sterno-claviclular joint compensate. Examination must include active and passive examination of the joint.
For more on-line videos on how to treat the shoulder:
http://www.palmm.org/copy-of-palmm-manual-medicine-studi

Answers to questions on the cervico-thoracic junction:

1) What is the nerve root that exits the cervico-thoracic junction? Answer: C8
2) What are the parameters where paresthesia is felt when the nerve-root that exits the cervico-thoracic junction is aggravated?  All the skin on little finger and slightly past the wrist into the forearm.

3) Which movement is most affected by compression of the cervico-thoracic nerve root? Shaking hands as gripping is the movement most affected due to the loss of power to the small muscles of the hand.

4) Which of the following tissues attach to the C7 vertebra?  All except Levator Scapulae

https://youtu.be/_1G102Elqis

Confessions of an osteopath

After qualifying as an osteopath, my inexperience and idealism led me to believe that osteopathy was the cure for all ills, everything from back-pain to eczema to bed-wetting.  

I felt reasonably confident with orthopaedic conditions but less so with the other stuff. However, I still accepted into my clinic most of what came my way. A part of me felt that to be an osteopath, I had to treat all the conditions that fall under the osteopathic umbrella, anything else would disqualify me. Also, I had unconsciously imbibed the belief that osteopathy is the solution to most medical problems. It was a belief that I had not checked, but had come to believe.

With time I felt disingenuous and worried that it was affecting my reputation. It was even harder to admit defeat once the treatment had started and instead I would carry on treating indefinitely till it petered out.

I am sure that some osteopaths treat eczema and bed-wetting successfully but my omnipotent, hubristic attitude led me to think I was one of them simply by qualifying from an osteopathic college.

The affect of my osteopathic hubris may have been an initial increase in my patient list but ultimately it reflected badly.  

Nowadays I am more honest with myself and my patients.  I am careful on the phone to discuss the condition.  I ask if others have treated them, and how chronic the problem is. If they have been to see other practitioners without relief I put the question to them why they think another manual therapy may help. I discuss a mutually satisfactory approach that meets realistic expectations. From the start I try to set boundaries.

One could argue that it is experience that has helped me to evaluate what I do as an osteopath in more realistic terms. Perhaps it is not possible for educational institutions to teach these skills. However, to self-question and be critical is something the profession must encourage. Helping students and new graduates realize the limitations of osteopathy doesn’t weaken the profession, it strengthens it and it will ultimately help graduates enhance their professional identity and sense of achievement.

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The 3 boundaries a practitioner must not break.

Why do I get anxious before I see a new patient? If my patient list includes new patients I get more anxious than other days. I arrive at the clinic early, open up my computer and settle down awaiting the appearance of the first patient. New encounters are loaded with a degree of anxiety and I assume patients experience similar feelings especially when in pain.

Therefore, it is important for the osteopath to keep unnecessary anxiety, such as unexpected events or surprises, to a minimum. Anxiety is reduced however, in a safe, therapeutic environment or put another way, when clear boundaries are set.

"Clear boundaries" is a term often used in the adult-child relationship where they are considered important for the child's development. Boundaries help the child know that the parent won't let behavior get out of hand, making the child feel safe, even if they frustrate and inhibit.

Boundaries in the osteopathic/therapeutic sense can be considered factors which define clearly the consultation as... a consultation.

The 3 most important boundaries are:

1) Space. The space is defined as the room in which the consultation takes place. At the risk of stating the obvious, it's a room, not a corridor, not a field nor a person's home. In the patient's mind (and in the osteopath's mind too), it is a room which is dedicated to the osteopathic treatment. Anything inappropriate that permeates the "therapeutic membrane" increases anxiety. Examples might be people walking into the room without proper warning (receptionists, other practitioners, or students), or telephones ringing etc.

2) Time. It should should be made clear before the consultation the start and finish time of the session and how long the session will last. Changes in scheduling can increase a patient's anxiety. Even when the reason for rescheduling may be benign. Regular schedule changes made by the osteopath may elicit the patient's fantasies (other patient's are more important and take preference). Running late for a session also arouses feelings such as anger or jealousy. Similarly, giving patients more time than agreed. This is also considered breaking a boundary as it may arouse feelings of favoritism. 

Which brings me on to my 3rd boundary.

3) Role. The role of an osteopath has many sides to it. We are medical practitioners but we are given permission to touch. Patients offer emotional information about themselves but we are not strictly speaking "talking-therapists". With some patients we may become friendly but they pay us for our services. It is a constant struggle to stay in role. Sometimes we may find ourselves being pulled out of role. In one of the sessions in the series "What is the patient really telling me?" (The Osteopath, Nov 2006, Page 24), an osteopath told the group that she occasionally shopped for one of her elderly patients. This became increasingly tiring for the osteopath.  The group was able to help the osteopath recognize that her behaviour related to the osteopath's feelings of guilt for not helping her own elderly parents who lived far away. The example reflects the way an osteopath can get pulled out of role.

One of the most fascinating aspects of keeping boundaries is the positive therapeutic affect on the patient.  As a parent, as well as taking care of the child's physical needs, maintaining safe boundaries for the child is 90% of the work. Similarly I believe is true of the osteopathic consultation. As osteopaths we need to attend to the patient's medical needs, but maintaining clear boundaries will affect to what extent the patient will internalize the osteopathic therapy.

"I'm not well.... JUST DO SOMETHING"

You have come to this blog expecting good content haven't you?  You want me, as an osteopath/blogger to provide value that will satisfy your desire to learn.

By providing good content I hope that you return to my blog and build up my readership.  If the post does not interest you, you'll read a few lines and go elsewhere. If it is good, you might share it.  What a wonderful feeling of success that would be!!

Similar feelings occur in the patient-practitioner encounter.

If I am successful, this patient will return and possibly recommend a friend. That will do wonders for my confidence. However, what if I fail? What will that do to my reputation?  To my business? These are feelings that may be familiar to you.

A patient-practitioner relationship has a giving-receiving dynamic.  The osteopath gives treatment and the patient receives relief. The osteopath is concerned not to disappoint the patient, to meet their expectations. As a result the osteopath manages the consultation in the way he perceives is the wish of the patient. This is understandable, we behave this way socially too, but problems  occur when the patient, consciously or unconsciously, mobilizes the osteopath to behave outside of the patient's best interests. 

An example of this was a patient who, after expressing dissatisfaction with a previous practitioner said she only wanted me to treat her shoulder and not waste time on the rest of the body. Do I stick my clinical judgment and risk losing the patient or do I do as the patient asks and treat ineffectively?

One of the strongest feelings that can be aroused during the consultation is the need to act, by that I mean, to be active, to do something for the patient, even when doing nothing might be the best. The fear is that by not acting, one makes oneself redundant. 

My guess is that many practitioners experience this, not just osteopaths, all practitioners. Physiotherapists, chiropractors, acupuncturists and doctors.  We feel mobilized by the patient to "JUST DO SOMETHING"... and we do!

Understanding this dynamic which I refer to as "mobilized" can be helpful to us.  Next time you are with a patient ask yourself  "How is this patient making me feel?" and thus "How am I acting?". This may help you to stop acting outside the patient's and perhaps your best interests.

So I have reached the end of my blog. I wonder whether you liked it or not.  Will I be criticized for it? Are these feelings mine alone and not experienced by others? On the other-hand, perhaps I'll be regaled and applauded. Still, at least I've satisfied my urge to act.

PALMM - Program for Advanced Learning of Manual Medicine