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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. Its 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 patients behalf.
Communication of the risk is important not only for the patients 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 patients 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 its 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, its enforcing the patients 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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