September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom nspine.co.uk

1. September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

2. Welcome to NSpine

3. Introduction Introduction to the CSSS The thinking behind the program The speakers – surgical, osteopathic & research Interactive and forum for discussion Networking Exposure for the profession Highlighting the work in the CSSS

4. The Centre for Spinal Studies and Surgery • QMC one of Europe’s largest teaching hospitals. • Recognised National and International referral centre for complex spinal pathologies. • 8 Consultant Spinal Surgeons. • 5 Senior Spinal Fellows. • >8200 outpatient consultations pa. • >80% referrals are not offered/choose not to have surgery.

5. The Programme • Common spinal conditions managed in CSSS. • Surgical management vs. osteopathic. • Sharing experience. • Supported by data.

6. The Speakers • Surgical colleagues • Osteopathic team • Guest speakers • Key note speakers • Panel discussions • Interactive

7. And what’s more… • Opportunity to network with osteopaths and other healthcare professionals. • Opportunity for osteopathy is be present and represented at a large spinal conference. • Opportunity to raise awareness of what osteopaths are doing in CSSS.

8. Introduction to Examination Techniques & Treatment Strategies used by the Osteopathic Team at the QMC

9. Osteopathic Assessment & Treatment • Background • Case history • Examination • Special tests • Imaging • Treatment strategies • Exercises • Management

10. Patient Types All patients are chronic. All referrals are tertiary. Majority of patients investigated. Majority of patients have mostly had multiple interventions. Many patients have co-morbidities. Many patients take substantial amounts of medication. Patients are often ‘fed up’.

11. Case History • Referral letters and medical notes. • Take osteopathic case history. • Often little background information. • MOI. • Lifestyle/occupational factors particularly important in chronic patients.

12. Examination • Many patients will comment that this is the first time they have been physically examined. • Visual assessment. • Standing, sitting & supine examination. • Flexion and extension – gross & segmental. • Sacrum to OAJ. • Palpation.

13. Examination • Aim for a consistency in examination throughout the osteopathic team at QMC. • Pictorial format for recording findings. • Keep it universal and quick glance annotations.

14. Spinal Examination Used Thumbs placed on transverse processes in neutral. Pelvis: The right thumb is higher than the left, indicating stiffness of the right side of the pelvis. Flexion: Right thumb rides up but left remains down & more prominent. Indicates failure of left facet joint to open. Diagram to show movement of the facets & Annotation used Annotation Flexion Extension Neutral Restriction of flexion at left facet joint, causing left sidebending & left rotation of upper vertebra on lower. T3˄ ˅ T3 ˄ ˅ Normal opening on flexion, but right facet fails to close. Extension: thumbs ride down & back equally. Ref: Bourdillon, JF & Day, EA; Spinal Manipulation; 1987; pp. 46, 86, 87.

15. Specific Tests often used • Neurological examinations where necessary • Gillets • Fabers • Laguere’s • Piedallu’s • Gaenslens • Femoral shear • Adsons • Allens

16. Imaging • Vast majority have imaging. • MRI, CT, X-Ray, DEXA. • Not all imaging is reported. • Advantages and disadvantages. • Treat the man, not the scan…

17. Treatment strategies • 12 treatment sessions are allocated in addition to assessment appointments. • By using a universal examination procedure, same diagnosis & treatment strategy should be reached across the team. • Treatment plan is unaffected if different practitioner treats. • Consistency – one aim. • Maintains robust data.

18. Treatment Strategies • Generally work from the base upwards. • First 2-3 sessions involve general mobilisation and soft tissue techniques. • Usually see a change by 4th treatment. • Techniques used include articulation, mobilisation, manipulation, MET, passive stretching, inhibition. • Treat identified flexion and extension restrictions. • Once segmental restrictions have been addressed, focus moves to global movements. • Long levers used on pelvic and shoulder girdles. • Strong techniques to change things mechanically – not just symptom chasing.

19. Treatment Strategies • Manage patient expectations. • Re-examine & treat according to findings at each session. • Adhere to the treatment plan – no deviation according to patient complaining of new symptoms. • Aim towards stable and neutral at all spinal segments. • If mechanically stable & neutral, symptoms should diminish. • Let nature take its course. • May not – we have failed!

20. Exercise Strategies • Many patients have tried and failed physiotherapy. • Avoid exercises early on. • Introduce exercises at week 6. • Repetitive isometric and isotonic stretches. • Keep regime short. • Physio referral post-treatment if appropriate.

21. Long term management • Follow up assessment at 3, 6 & 12 months. • Further treatment prescribed where necessary. • Certain conditions will need follow up.