WCSO – 12th November 2011Osteopathic Evaluation – A new look,

revisiting the picture of the neuro-muscular- skeletal system in the context of the bigger picture of bio-psycho-social issues.

Tools for decision making The evidence base and how it fits with

practiceManaging acute and chronic pain

Changing Landscape of Healthcare

Drivers for change Evidence base Safety and risk Consent Maturing professions New expectations from patients regarding

choice and involvement in decision making Greater information available on the

internet

Personal drivers for change

Boredom Awareness of habits Automatic working Unconscious incompetence Recognition of areas for professional

development

Today’s undergraduate OE programme Emphasis on greater criticality Engagement with wider evidence base Integration of quantitative and

qualitative research Shared decision making between

osteopath and patient Use of guidelines and algorithms

Skills for change

Self awareness – being critical of assumptions we make and perceptions we form

Making and changing perceptions

Skills for change

Critical reflection/thinking – challenges us to move away from automatic practice and unconscious unreliable decision making. It requires the confidence to question received wisdoms and to recognize clearly the positive effects of professionalism and the negative effects of habit.

Skills for change

An understanding of quantitative and qualitative research Qualitative methods provide indepth studies of subjects

but produce information only on the particular cases studied, and any more general conclusions are only propositions (informed assertions).

Quantitative research refers to systematic empirical investigation via statistical, mathematical or computational techniques. The process of measurement is central to quantitative research and it aims to find an answer to a precise question. This means the data acquired only relates to that particular question.

Konwing which one you are using at a particular time makes you more critically aware.

Osteopathic Evaluation

Can be seen as a way of understanding a patients symptoms, loss of function/personal agency (the NMS picture) in the context of their life and bio-psycho-social picture.

It should inform a route to help that patient become comfortable and regain function.

It should be a critical, justifiable process integrating qualitative and quantitative data.

OE – The Big Picture

A full picture of the patient at that moment in time, integrating NMS (the little picture) with the bigger picture of the patients bio-psycho-social status.

Engages evidence based clinical reasoning to integrate with osteopathic thought to move towards an initial hypothesis and early treatment plan.

OE – The Little Picture

The “little picture” represents NMS the primary area of symptoms or failure (the tissue causing symptoms – TCS) and/or failure in other areas creating load on the primary area (TCS) How important is the “little picture” in each case?How important are the TCS in each case?

OE should involve…

Finding out if the patient is safe and appropriate for us to treat

Developing a therapeutic relationship Engagement of qualitative and

quantitative reasoning processes Use of clinical temporal profiling Developing assembly for dysfunction

(NMS), assembly for pain and disability Creating first treatment plan and prognosis

Questions

Is this a mechanical problem? Is the patient with the right practitioner? Is the patient safe to treat – red flags? Are there other flags? Is the patient distressed? How can I integrate all this info? What shall I tell the patient? How do I form a plan and measure it’s

progress?

Decision Making - algorithms

What is the dysfunction due to? (Have I got the right guidance?)

A problem elsewhere

Yes

Are there any Red Flags?

No

What is this an example of?

A local issue

Local / Regional / System Triage

Is the patient distressed?

Are any Yellow / Blue (Orange / Black) Flags present?

No

Yes

Yes

Motivational Interviewing

No

What explanation and education is appropriate? What are the patients and your expectations? (Continue with expected outcome for pathway.)

Where to start treatment?

How do I approach and respect the tissues to support change?

What changes are we anticipating and how do we evaluate change?

Non Specific… ? ? ? Specific Condition (see separate guidance)

An Approach to Decision Making(Focus on decision making, rather than the nature of a condition)

Objectives1. More appropriate and timely referral and multi-

professional care.2. To provide an environment in which the patient

is more likely to take up the opportunity for health.

© Tim Oxbrow / Stowmarket Osteopaths September 2009

TOOLS FOR EVALUATION

Communication NMS and Evidence based practice BPS and the evidence

Communication – GOsC review Osteopathic Practice Standards warns….“that poor communication is at the root of

most complaints made by patients against osteopaths”

“It is easy for a practitioner to slip into a known treatment without explanation and for social conversation to replace the professional dynamic of the consultation”

Communication – GOsC review

"The osteopath needs to give the patient information about what their problem is, what the treatment will do, and what to expect after treatment such as transient stiffness and soreness.”

Because "osteopathic consultation involves...being undressed in front of a stranger, touching, holding...it is vital that osteopaths do not forget how strange the experience can be for patients who are new to it."

Communication – GOsC review

"Lack of consistency between practitioners may alarm patients and represents a risk for complaint. Patients expect consistency in quality of service, treatment and diagnosis."

Communication and Consent – GOsC review Consent is an ongoing process during

treatment. The emphasis for consent has shifted

from disclosing information to sharing information with patients.

Patients generally want more information than they receive.

Consent should be sought when the patient does not feel vulnerable, possibly when they are dressed and seated to enable eye contact.

Communication and Consent – GOsC review Obtaining valid consent will involve

explaining the benefits of the treatment you propose and any significant risks associated with the treatment.

Currently risks for osteopathic treatment are not well understood. The GOsC has commissioned NCOR to conduct research in this area which should be published shortly.

Communication and Consent – GOsC review The validity of your patients consent does not

depend on the form in which it is given. Your patient may imply their consent, by for example removing their clothes and getting ready for assessment or by saying "yes" or "okay" to your treatment or by signing a form.

Validity depends on providing clear information about evaluation and proposed examination and treatment that the patient understands.

Further detail on P6 of The Osteopath Oct/Nov 2011 - Vol 14 - Issue 5

Communication Summary

Reflect on current practice....

When do we explain our thoughts about evaluation?

When do we seek consent? Are we always aware of personal

boundaries? Should we always leave the room for

patients to undress?

Communication Summary

Perhaps a full discussion should occur at the end of the CH, before examination. After examination clarification can be offered and further explanation and consent can occur through the rest of the consultation.

Communication skills – the case history

Case history taking is a largely qualitative exercise, making sense of the patients story with them, developing a picture of their problems and expectations in the context of their current way of life.

Communication should show understanding and empathy

Patient centered approaches are part of understanding more fully the patient's expectations.

Communication skills - Tools

Narrative Reasoning This can be seen as the comprehension

and understanding of a patients' illness experience integrated with their beliefs and culture. This process involves the patient in the case history taking process as the practitioner and the patient work to construct knowledge together and bind truth and meaning within that context in a story like manner. It has value for that individual person at that time.

Narrative Reasoning

This helps you and the patient explore their cognition (thoughts, beliefs, fears etc) and any unpleasant emotions associated with where they are now and how they got there. It may highlight triggers of negative thoughts and avoidance tactics. It can develop understanding of barriers and opportunities to address and suggest alternatives in order to facilitate patients' own understanding and recognition of their current situation and encourage the patient to regain autonomy.

Narrative Reasoning

It can help in collaborative goal setting, developing specific coping strategies ( such as graded exposure and set-back planning) and selective reinforcement in the form of encouragement and providing positive reinforcement to limit catastrophising.

It may involve the use of propositional reasoning where the therapeutic story becomes a meaningful short story in the patient's larger life story.

it should explore the expectations that a patient has of their consultation and treatment with you.

Tools for narrative reasoningDirect Questions "How can I help you?" This is a common

question used to start the case history and offers an open forum for the patient to develop their narrative. This may be supplemented later with an exploration of the patients aims, aspirations and goals for their recovery and may include direct questions about what they expect to achieve through treatment such as the

Tools for narrative reasoningDirect Questions "What are you hoping for

from this consultation?" question. This considers what the patient wants from the osteopath rather than what the osteopath wants to offer the patient. It allows the patient to rank their issues rather than receiving our ranking of their issues. It engages the patient in ownership of the evaluation and hence possibly a solution and can form part of the negotiation of the management plan.

Tools for narrative reasoningIndirect questions. Level of function questions. These questions

frequently revolve around the agency of the patient. What they can and can't do and what they want/need to be able to do. They may arise out of the aggravating/relieving factor questions or as part of the patients responses to direct questions. Their loss of function is likely to be affecting their lives in individual and specific ways and this may or may not be directly related to pain.

NMS and Evidence based practice

Three big changes have happened here….

The move away from TCS

The introduction of the non-specific mechanical diagnosis

Greater evidence base for practice

The Move Away from TCS

Although many osteopaths make a local TCS diagnosis this is rarely consistent with the treatment given.

All tissues work together so can any one really be the cause of symptoms

We can predict common areas of failure yet every patient is unique, the sum of tissues leading to failure is usually different.

The Non-specific Mechanical Diagnosis

The current evidence very simply suggests that manual therapy is effective for non specific mechanical problems. Guidelines and algorithms can help us be sure of that evaluation.

Non specific means no clear tissue is primarily responsible

Mechanical means influenced by movement

The Non-specific Mechanical Diagnosis Most algorithms aim to categorize the

type of dysfunction/pathology offering known pathologies, for example a route leading to a diagnosis of discal prolapse with nerve root compression or a route that leads to a diagnosis of non specific mechanical low back pain. These diagnoses are separated because evidence suggests that they require different management .

The Non-specific Mechanical Diagnosis Using an algorithm provides integration

of current guidelines and best practice and leads to a simple initial diagnosis of a non specific mechanical dysfunction that we can then explore further to make a full osteopathic evaluation, safe to consider that particular patients little picture (NMS) within the context of the bigger picture (their life and BPS factors).

The Non-specific Mechanical Diagnosis Various different guidelines for different areas

exist to help provide clear pathways for patients for evaluation/diagnosis and offer evidence for treatment rationales. These provide limited help for osteopaths however they are in frequent use by doctors, physios etc and using them provides a common path for communication and a degree of safety as procedure is followed.

These guidelines are based on various studies that have been peer reviewed and collated support evidence based practice. NICE and cks.

Decision Making - algorithms

What is the dysfunction due to? (Have I got the right guidance?)

A problem elsewhere

Yes

Are there any Red Flags?

No

What is this an example of?

A local issue

Local / Regional / System Triage

Is the patient distressed?

Are any Yellow / Blue (Orange / Black) Flags present?

No

Yes

Yes

Motivational Interviewing

No

What explanation and education is appropriate? What are the patients and your expectations? (Continue with expected outcome for pathway.)

Where to start treatment?

How do I approach and respect the tissues to support change?

What changes are we anticipating and how do we evaluate change?

Non Specific… ? ? ? Specific Condition (see separate guidance)

An Approach to Decision Making(Focus on decision making, rather than the nature of a condition)

Objectives1. More appropriate and timely referral and multi-

professional care.2. To provide an environment in which the patient

is more likely to take up the opportunity for health.

© Tim Oxbrow / Stowmarket Osteopaths September 2009

The Non-specific Mechanical Diagnosis So if we follow guidelines or assess our

patient problems as mechanical and non-specific then we know we are treating a group of people who should respond to manual therapy - we are working in an evidence based way.

Evidence based reasoning and prognosis Much evidence available today has

looked at signs that indicate good or poor prognoses. This evidence is very useful for us in practice.

In summary patients presenting in the first 12 weeks after onset are likely to have a better prognosis than those presenting after that time.

Evidence based reasoning and prognosis Waddell identified predictors for chronicity in

lumbar spine patients seen within the first 6-8 weeks, including:-

Nerve root pain or specific spinal pathology eg AS

Severe pain at the acute stage Beliefs about pain being work related Psychological distress Compensation claim Time off work The post 12 week group can be further

explored by recent concepts in pain which we will look at a little later.

Evidence based reasoning and decision making – C.Sp. Age - Spondylosis can be found in those aged 25

and above - occurs in 60% of those over the age of 45 and 85% of those over 60, though symptoms do not normally present before 60yoa.

Mechanism of onset - a) Whiplash or whiplash associated disorders often involve speed of injury that leads to neurological involvement often affecting the brachial plexus. Delayed symptom onset in whiplash usually suggests ligamentous damage. Sympathetic involvement may show as tinnitus, dizziness, blurred vision, photophobia, sweating and lacrimation.

b) Delayed insidious symptoms in the over 55's supports the possibility of spondylotic change

Evidence based reasoning and decision making – C.Sp. Sites, boundaries and radiations of pain -

these can help establish level of problem - symptoms do not go down the arm for nerve root injuries at C4 or above. They can also help clarify nature of pain as referred or radicular. Disc herniations in the cervical spine most commonly involve neck pain radiating into the shoulders, scapular and/or arm - they also tend to limit ranges of movement and are worse on coughing or sneezing.

Evidence based reasoning and decision making – L.Sp Unilateral pain with no referral below the

knee that is aggravated by movement or a prolonged posture is usually referred to as mechanical low back pain. This generally makes up over 95% of LBP.

Evidence based reasoning and decision making – L.Sp Mechanical low back pain usually has the

following characteristics: 1. Usually cyclical 2. Often radiates to the buttocks and thighs 3. Commonly associated with morning

stiffness/pain and often gets worse over the course of the day.

4. There is commonly start pain, pain on forward flexion and on returning to the erect position.

5. Pain is aggravated by movement or prolonged posture and relieved by change of position and lying down.

The Thoracic Spine IVDWood, K.B. et al. MRI of the thoracic spine. J.B.J.S. vol 77-A. No 11. Nov 1995Review of MRI’s of asymptomatic individuals of

which 73% had anatomical findings. 37% IVD Herniation 53% IVD Bulging 58% IVD Annular tear 29% Deformation of the spinal cord 38% Scheuermann end-plate irregularities –

dystrophic spondylosis.Conclusion: High prevalence of false-positive

findings – need to re-consider if thoracic PID findings are related to symptoms.

NMS Concepts

NMS ideas have been tidied up and responded to the evidence base but still include qualitative judgements

Consider acute and chronic pain patterns

NMS CONCEPTS 1

Structure function relationships – Shape, muscle balance, health.

Developmental and ageing changes – is development within normal limits, what changes have been acquired, how are ageing changes manifesting?

Adaptability – individual reflexivity

NMS CONCEPTS 2

Other compensatory demands – effect of developmental and acquired changes

Timelines – frequency of injury, diseases Domain theory – relationship between

NMS tissues, chemical health (eg diabetes), and emotional state (e.g. effect of stress on tissue health)

Why now? What influenced the onset? Why are they presenting now for treatment?

NMS CONCEPTS 3

Acute pain is…Peripherally mediated – local

change/damageEasily localisedResponds to NSAID’sUsually mechanicalHas a patternUsually less than 12 – 26 weeks duration

NMS CONCEPTS 3

Chronic pain is…Centrally mediatedHard to localise/diffuseDoes not respond to NSAID’sNot always mechanicalCan be very intense out of proportion to

mechanical stimulusUsually greater than 12-26 weeks duration

NMS CONCEPTS 3

How does this information influence prognosis and treatment?

BPS and the evidence

Osteopaths usually engage in some consideration of the psycho-social aspects (primarily the effects of these on NMS tissues). This deepens our NMS understanding into an Osteopathic evaluation and lead towards a management plan specific to the individual patient, their loss of function and agency and reflexive to changes in the patients needs.

BPS and the evidence

Evidence exists to show that understanding the BPS picture may Identify drivers for chronicity and allow us to make more accurate prognoses. It may also help prevent complaints as certain factors highlight patients more likely to react unpredictably feel pain more acutely and complain eg those displaying nervous body language, with histories of emotional crisis/psychological problems/ dependence.

BPS and the evidence

Much BPS is about identifying information that informs management, often through identifying barriers to treatment through thoughts, perceptions and beliefs. These are often called yellow flags today and may also highlight those patients likely to catastrophise which may require positive communication to help explore and change these beliefs reducing the barriers to recovery.

e.g. patient with surgically induced pelvic pain. "I will do exercises when you take the pain away."

Flags

Yellow, blue or black flags indicate obstacles or barriers to being active and able to function normally. They are a convenient way to group psycho-social obstacles to recovery and help select individuals who may need additional help to recover and overcome obstacles to recovery.

They indicate issues that need recognition and that may need to be overcome or bypassed.

Frequently managing flags means a multi-disciplinary approach involving patient, practitioners, workplace as well as friends and family.

Flags

Failure to make a full recovery can be due to psycho-social obstacles which can be more important than bio-medical factors and may require an action plan involving:-

Appreciation of the problem. Reminding patients that symptoms are common and

usually short term. Emphasizing that activity is helpful and prolonged rest is

not. Encourage people to stay at work, even if they need to

adjust their tasks or schedules. Encourage an early return to a normal routine. Address psycho-social factors where possible (e.g.

isolation) and bio-medical factors at the same time.

Yellow Flags

These highlight beliefs, signs and symptoms of distress and the person's approach to change that may influence management. Identified in a patient who:

1. Catastrophizes (focuses on the worst possible outcome) - this can be aggravated by partner/spouse worrying and taking over tasks or becoming frustrated with the person.

2. Demonstrates dysfunctional beliefs and expectations about pain, work and healthcare.

3. Presents with negative expectations of recovery and a preoccupation with health.

Yellow Flags

Identified in a patient who:

4. Reports extreme symptoms relative to onset

5. Shows poor or passive coping strategies 6. Has experienced serial ineffective

therapy. 7. Shows worry, distress and a low mood 8. Demonstrate a fear of movement and

uncertainty about their future.

Blue Flags

These are about the workplace and usually mark socio-economic issues that can affect outcome, including conditions in the workplace that may inhibit recovery such as perceived time pressures.

They include fear of re-injury, high physical job demands, low expectation of resuming work, low job satisfaction, low social support and perception of high job demand.

Black Flags

These relate to the context in which the person functions and include occupational factors that may inhibit recovery such as issues of compensation - the patient generally has no control over these.

They include misunderstandings and disagreements between employee and employer, financial or compensation issues. This may be aggravated by unhelpful company policies and procedures.

Black flags may also include spouse or family member with negative expectations, fears or beliefs and the person may be feeling socially isolated.

Current Phase of Recovery 1 The acute or initial phase post onset is

the first 2-6 weeks. Patients usually make good progress in this phase and can be supported by evidence based advice such as keeping active, trying to cope and using symptom control.

Current Phase of Recovery 2 The sub-acute or early phase is generally

perceived as the next 6 to 12 weeks. The focus here is on early return to work, maintaining as much of normal life pattern as is possible. This is the optimal time to prevent long term consequences

Current Phase of Recovery 3 The chronic or persistent phase

approximately follows 12 weeks. Patients who reach this stage frequently find it hard to recover and return to purposeful activity. It may be necessary to shift goals and involve other therapies to approach ongoing obstacles.

Current Phase of Recovery 4 From 26 weeks social solutions may be

needed including goal oriented job retraining, community support should be engaged and unnecessary medical intervention avoided. Levels of independence and self-efficacy should be supported. Develop appropriate signposting

Improving our evaluation

Using…. The flag system (it’s role in evaluation of

BPS issues) The clinical time line (it’s role in decision

making) Current best practice (clinical guidelines and

algorithms - how they inform evaluation and management, patient education and advice).

Valuation of acute and chronic pain patients.

Improving our evaluation

Exploring the personal factors that have moved patients from being asymptomatic (normal) individuals to being symptomatic (abnormal) individuals to help us develop a management plan to help them become asymptomatic again.

This process may involve decision making regarding cause of the dysfunction, red flags, suitability for osteopathic treatment, level of distress, willingness to change and other flags. Understanding these factors may also influence our prognosis and offer explanations for slow recovery or failing to feel better.

Improving our evaluation

Integrating evidence based diagnostic clinical reasoning with osteopathic models of evaluation. This should encourage an integration of quantitative data with qualitative reasoning in the process of evaluation.

Examining clinical uncertainty, learning to make decisions within grey areas and exploration of integrating case history information with academic knowledge to inform planning of clinical management.

References

A Textbook of Osteopathic Diagnosis. Hawkins PJ. (Editor) Tamor Pierston Publishers 1985.

Osteopathic Diagnosis. Sammut EA. & Searle-Barnes PJ. Stanley Thornes Publishers 1998.

An Osteopathic approach to diagnosis and treatment. DiGiovanna EL. Schiowitz S. & Dowling DJ. 3rd Edition. Lippincott Williams & Wilkins 2005.

Osteopathy: Models for diagnosis, treatment and practice. Parsons J & Marcer N. Churchill Livingstone 2006.

Science in the art of osteopathy: osteopathic principles and practice. Stone C. Stanley Thorne 1999.

References

Red Flags: a guide to identifying serious pathology of the spine. Greenhalgh S. & Selfe J. Churchill Livingstone 2006.

Tackling musculoskeletal problems: a guide for clinic and workplace. Kendall & Burton. TSO 2009.

Orthopaedic Physical Assessment by David J. Magee (5th edition) - Saunders Elsevier

9. Waddell G 1998 The Back Pain Revolution. Churchill Livingstone, pp241-258

www.nice.org.uk www.cks.nhs.uk