The aim of this assignment is to critically report on the assessment and communication of risk for a 65year old male patient presenting with low back (lumbar vertebral level 4/5) (L4/5) and neck pain (cervical vertebral level 2/3) (C2/3). He has hypertension and suffers from headaches and occasional dizziness. He is overweight and has to walk with the aid of stick. The osteopath is considering performing a cervical spine manipulation (cSM).

Being an osteopath carries an inherent risk due to the nature of dealing with patients in a primary and secondary care setting. cSM is especially controversial. It’s been associated to vertebrobasilar stroke (VBS) as stated by Reggars et al (2003) it could result with serious neurological complications or even death.

A clinical risk can be defined as “the chance of an adverse outcome resulting from clinical investigation, treatment or patient care.” (Healthcare risk assessment made easy.2007.pp 4). Assessing and managing this risk is important for patient safety, which must be at the core of clinical practice. This includes following guidelines for best practice, clinical assessment and reasoning so that the patient receives the most relevant treatment.

All aspects of patient care must be addressed. This could include professionalism of the osteopath and the way he administers treatment to the way he communicates with other health professionals on the patient’s behalf. Communication of the risk is important not only for the patient’s welfare but also for the collaboration between other healthcare professionals.

There is the aspect of risk assessment with regards to meeting the legal requirements of the UK Health and Safety Executive as stated in the Osteopathic Practice Standards (OPS) (2012) D.13. This would require identifying and reducing the risk of potential hazards to patients and staff.

A general risk assessment of the clinic for this patient would include assessing access to and from the building. Are their steps leading up to the clinic doors, if so is their a strong handrail to prevent people falling over or a ramp for those who cannot climb steps? It would be pertinent to assess door handles for those who have upper limb injuries or have less dexterity caused by the degeneration of aging.

During a systematic case history the osteopath has built a picture of the patients complaints, overall systemic health and lifestyle. All of this must be recorded within the patient’s notes and be in line with OPS C.8.

The first part of managing clinical risk with this patient is to gain consent for examination. “The patient needs to understand the nature and purpose of the examination” (OPS. A2.5.). It ensures good communication and increases the validity of consent as it is informed. Consent is both an “ethical and legal requirement.” (OPS. A4.3.). For consent to be valid the osteopath make certain that it’s volunteered and the patient has sufficient capacity to make that decision in accordance with OPS. A4.7. If the osteopath proceeded to

examine or treat without consent then he could find himself in disrepute with the General Osteopathic Council (GOsC) or face criminal or civil proceedings.

To further minimise clinical risk the osteopath needs to ensure he is working within the framework of current guidelines. The National Institute for Care Excellence (NICE) publishes guidelines for the early management of persistent non-specific back pain. NICE guidelines CG88 1.4 (2009) views spinal manipulation, mobilisation and massage as valid techniques to employ. What the osteopath must determine is which modality will have the best outcome with the least risk.

While this criteria would satisfy manipulation to the patients lower back we are concerned with the cervical area. The mechanism of cSM contains cervical extension and rotation. Haynes et al (2012) state ordinary daily movements involving these movements play a role in instigating stroke. Taking into account the patients age, his predisposition to vascular disease, dizziness and the pain in C2/3 the osteopath decides it contraindicates a cSM. This is further enforced by Reggars et al (2003) who state that most VBS symptoms occur from events within Section 3 of the artery. Section 3 is where the vertebral artery leaves C2 superiorly.

OPS.A3.2. States “You should inform your patient of any material or significant risks associated with the treatment you are proposing.” How does the osteopath communicate the risk involved in treatment to the patient? Firstly it should take place in an environment where the patient is comfortable as recommended by NCOR Final Report (2011). This should be when the patient is sat down and fully dressed so he can be relaxed and not worry about his modesty. It is also recommended that the osteopath use language and terms relevant to the patient. (NCOR Final Report (2011). Not only is this satisfying the OPS guidelines, it’s enforcing the patient’s autonomy and forming a shared decision making partnership.

Assessing and communicating risk takes time and planning. There is both a professional and legal framework to adhere to. This can be implemented through following OPS. B2. 1. 11. 1-4. Which is concerned with critically appraising the osteopathic practice. This can be carried out looking selectively at either communication or risk. It is recommended to do this on four levels. Firstly by drawing upon their own experience through self-reflection. A case such as this one may encourage the osteopath to do more research into VBS and related disorders. Secondly there is asking for feedback from patients. This can give an invaluable insight into how the patient perceives everything about the treatment experience. Thirdly is speaking with colleagues however this may not be practical if it is a sole practice. Lastly there is performing a clinical audit.

If the osteopath has carried out a clinical audit then they will have critically appraised the way they plan, communicate and practice to eradicate known risk from their clinic. It will provide insights into areas of strength and weakness. This will improve patient standard of treatment and care by identifying best practice guidelines. If an audit is carried out periodically it

ensures clinical practice standards are constantly evolving and staying within legal and professional boundaries.

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