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

3. 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.

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

10. 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. Flexion: Right thumb rides up but left remains down & more prominent. Indicates failure of left facet joint to open. Extension: thumbs ride down & back equally. Pelvis: The right thumb is higher than the left, indicating stiffness of the right side of the pelvis. Diagram to show movement of the facets & Annotation used Neutral FlexionExtension Restriction of flexion at left facet joint, causing left sidebending & left rotation of upper vertebra on lower. Normal opening on flexion, but right facet fails to close. Annotation T3 ˄ ˅ 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 4 th 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.