To refer or not to refer?
When is something not normal? When do you concern and inconvenience your patient by asking them to go to see their GP? Do you risk making yourself look a fool?
Much of the training to be an osteopath is about conditions we don't treat. Why is that? Well, many systemic conditions present with symptoms that mimic musculoskeletal problems. Fibroids that refer to the low back, deep vein thrombosis which the patient thinks is a torn calf muscle, prostate cancer metastasised to the low back and causing back ache there. That's why we ask so many questions to try and differentiate between something which is probably musculokeletal in nature from something that may have a systemic and possibly sinister origin and requires further investigation.
We have a duty to maintain our continuous professional development through a mix of self-study, talks and courses and recently I have been on a couple that were specifically about spotting people who needed to be referred. The first was a course on neurological and intracranial anatomy and pathology. This was part lecture, part looking at preserved specimens of intracranial pathologies and part handling of dissected human neurological and intracranial anatomy. It was fascinating and a little daunting and I am very grateful to the people who expressed a wish that their mortal remains should be used in this way...I didn't just do it so I had something interesting to write about here, by seeing and handling the structures in 3D and as near to their natural state as possible it is much easier to picture, to understand how, for example, different types of intracranial bleed progress and how they effect the patient. A more common pathology I am likely to spot is skin cancer. I attended a talk on skin cancer and the strongest message I took home from it was that they aren't always easy to spot. Skin cancers can look benign and equally there are many benign lesions which often show features associated with skin cancers. I suggest everyone brush up on their ABCDE of Melanomas but remember that it's only a guide...the only one of the 5 criteria that is a very strong warning is E - evolving. Anything that looks like a melanoma and is changing faster than anything else on the back, needs urgent investigation. I only attended the course 3 weeks ago and have already referred one patient on for further investigation, her GP has made an appointment to use a dermatoscope to look further into it (pun intended) - so that probably gives you the answer to the questions I posed at the beginning.
When is something not normal? - Most of the time I am unsure
When do you concern and inconvenience your patient by asking them to go to see their GP? - When something may not be normal and leaving it may be deleterious to their health
Do you risk making yourself look a fool? - Every time there is anything above the lowest suspicion of something not being musculoskeletal, better to look a fool than risk a patient's health - but bear in mind I have trained for 4 years, kept up to date on courses and asked the patient a lot of questions so it is required less than you'd think
Last week I was treating a patient with whom I share a sense of humour. we were chatting away as I do, when it is appropriate (don't worry I won't force you to chat if you would rather not!) and I kept making her laugh. At the time I was setting her up for a series of 'lumbar rolls', these are 'manipulations' where we lie the patient on the side and twist and flex them so that the point of tension lies at the segment we wish to manipulate. I always think of it like a ribbon, if you put one twist in a ribbon you can twist it from the top or bottom and move the point where it twists round itself up and down the length of the ribbon. Now imagine I can also flex your back in such a way that in that direction of motion the forces are focused at the same point. I can then compress through the area and further focus the forces to the one joint. At this point the normal technique would be for me to drop slightly and use gravity to deliver a small impulse which would be enough to manipulate the joint and achieve the desired outcome, resetting local muscle tone so the joint moves more normally and often with the pop or click of cavitation and any potential benefits that may confer. Except in this case, every time I set the joint, either before or after I added the compression, Ms X would laugh and the joint would release and cavitate. The involuntary tightening of the abdominal muscles and the movement associated with that, coupled with the increased intra-abdominal pressure were working to act as extra levers and were enough to initiate the process in a gentle and enjoyable way. Sadly I don't think I can be reliably funny enough to make this a part of my everyday practice but it does go to show how effectively some techniques minimise the force required to perform a manoeuvre and how a good set up can increase the probability of success.
Damian is the principal osteopath at Vauxhall Village Osteopathy and Oval Osteopathy