Shared Decision Making
Below is an analysis to help you provide informed consent regarding any proposed investigations and treatment, provided by Mr Gerry Gajadharsingh DO at The Health Equation.
Benefits of Examination & Treatment
Clinical Examination
To perform a clinical examination, it is usual to need the patient to undress, usually to their underwear, for a standing, sitting and an examination on the treatment/examination table. As an Osteopath I need to perform a detailed examination of the body, even though the patient may only report symptoms affecting one part of their body. The vast majority of patients are comfortable with this, if you are not please let us know and we will accommodate your preferences. You are also welcome to have a chaperone present and to bring a trusted person to the consultation with you.
Clinical Examination is ongoing each time I see the patient to re-evaluate what has changed since the last treatment.
It aids the evaluation and diagnosis, one of the main purposes of clinical examination as an Osteopath is the use of palpation, feeling, to get a sense of your body and how you might/are responding to OMT. Some of the clinical examination may include other more standard clinical tests exploring for example your Cardiovascular (BP, Pulse, Auscultation etc), Respiratory (Spirometry, Capnography O2 sats etc) and Neurological systems (power, sensory, reflexes etc).
Laboratory Investigations
Blood, Urine and Stool Tests, to help make a more accurate diagnosis and to have a functional interpretation of the tested parameters and to help with onward medical referral where necessary.
Imaging, to help make a more accurate diagnosis and to help with onward medical referral where necessary.
Treatment/Management
Osteopathic Manual Treatment (OMT)
To perform OMT, it is usual to need the patient to undress, usually to their underwear, towels are provided for modesty.
The aim of OMT is to improve physical function of the neuromusculoskeletal system, visceral systems and the autonomic nervous system.
Exercise & Rehabilitation
The right sort of exercise prescribed for individuals can be an important part of any health strategy. I will often suggest various exercise approaches to patients during the consultation as part of their rehabilitation/recovery.
Biochemistry/Nutrition
Improving diet/nutrition to support the normal physiological processes of the body and the mind, sometimes supported with a short-term use of nutritional supplementation.
Breathing Re-Education
70% patients do not breathe optimally, and this can have a significant impact on our physiology. Adopting a more relaxed patent breathing does numerous things including optimising the delivery of oxygen on a cellular level, managing pH and achieving better balance within the autonomic nervous system. This has profound effects on many different systems of the body.
Mind/Psychology
I’m not a trained psychotherapist, however many of my patients find my counselling and advice very helpful. My undergraduate and postgraduate training having incorporated a very detailed understanding of how the mind impacts on the physiology of the body and vice versa. Helping the patient understand the impact of what is going on in their life and how their physiology responds to it (positively and negatively) can often be very helpful. I tend to also advise reading around the subjects and often provide links to various blogs and books to help people understand the impact of their mind, thoughts and feelings on their physiology and the impact can have on their symptoms.
I adopt a comprehensive integrated approach to evaluation diagnosis and treatment/management. Sometimes I may recommend additional clinical help and have a large network of medical specialists, other clinicians and practitioners who I can refer to for more expert support.
Risks of Examination & Treatment
The BMJ (British Medical Journal) define risk of an adverse event into the following categories:
| Risk description | Percentage | Fraction |
| High | 1 | More than 1 in 100 |
| Moderate | 0.1 | 1 in 100 to 1 in 1000 |
| Low | 0.01 | 1 in 1000 to 1 in 10,000 |
| Very Low | 0.001 | 1 in 10,000 to 1 in 100,000 |
| Minimal | 0.0001 | 1 in 100,000 to 1 in 1,000,000 |
| Negligible | 0.00001 | Less than 1 in 1,000,000 |
Clinical Examination
Risk- Negligible
Laboratory Investigations
Blood, Urine and Stool Tests, urine and stool tests carry negligible risk to the patient when providing samples. Samples for blood tests (venesection/phlebotomy) carry minimal risk of adverse events, although statistics suggest that approximately 10% of patients may have some bruising or haematoma at the needle entry site, although in my experience, this is rare. I am an NHS certified phlebotomist and I tend to use single use vacutainer venesection kits provided by the laboratory we use, The Doctors Laboratory (TDL), to take samples or refer the patient to TDL reception for venesection. I have up to date Hepatitis B vaccination status, as required by UK regulations.
Risk- Negligible for urine and stool samples/Minimal for blood samples
Imaging
X-ray and CT scans involve a small amount of ionising radiation, as an Osteopath who regularly refers for Imaging, it is a legal requirement for me to periodically complete certification in Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER). In younger age group patients, we keep these types of Imaging to an absolute minimum.
The main adverse risk regarding ionising radiation is cancer.
Risk Low for CT, angiography, interventional radiography
Risk Very Low for X-Ray spine, abdomen, pelvis
Risk Minimal for X-Ray head, neck, joints
Risk Negligible for X-Ray chest, limbs, teeth
Context
There is a 1 in 2 lifetime risk of cancer development in the general population, 1 in 4 die of cancer in the UK, other risks in life such as the proverbial being run over by a bus.
MRI and Ultrasound, involve no ionising radiation
Risk- Negligible
Osteopathic Manual Treatment (OMT)
There are a range of OMT techniques, from very gentle cranio-sacral techniques, functional techniques, soft tissue techniques, articular techniques and HVT (high velocity low amplitude thrust techniques). There are several absolute and relative indications to using any particular technique and I will discuss this with the patient verbally when appropriate.
There are some short-term transient symptoms that patients can experience after receiving OMT. They can include increased pain and stiffness, headaches, dizziness, fatigue, nausea, flu-like symptoms and extremity tingling but in the majority of patients they last less than 24-48 hours. Many patients do not experience any of these short-term symptoms.
All medical interventions carry some risk. I have lectured on the subject of Osteopathic Manual Treatment (OMT), especially high velocity low amplitude thrust techniques (HVT) for over 37 years at both undergraduate and postgraduate level, as well as obviously providing OMT, including cervical manipulation (HVT) to many thousands of my patients. I mostly use and teach minimal leverage, multiple component HVT, considered to be gentler and safer than classical combined leverage HVT (it’s technical).
HVT is the joint manipulation that often results in a “click” when the joint is momentarily gapped or separated.
Statistically any medical intervention can carry a risk of an adverse reaction. Research has been carried out into the use of “manipulation” or HVT and the risk of adverse reactions.
For example, Cervical (neck) HVT, carries some risk of potential arterial dissection leading to stroke. However, the latest research comparing chiropractic manipulation versus GP consultations (where manipulation was not used) suggests a similar risk of 1.72 per 100,000 individuals.
Risk- Very Low
For lumbar spine HVT, the main risk is potential disc herniation. Serious adverse events are much rarer. These could include conditions like cauda equina syndrome, fractures, or serious neurological damage. The risk of such serious complications is estimated to be between 1 in 1 million (0.000001%) to 1 in 2 million (0.000002%) manipulations. Some studies estimate even lower rates.
Risk- Minimal
For thoracic spine and the ribcage HVT, the main risk is potential vertebral fracture in undiagnosed osteoporosis (if osteoporosis is a known diagnosis, this is a contraindication to using HVT in the thoracic spine and ribcage). In individuals without osteoporosis, the risk of fracture due to spinal manipulation is extremely low, estimated at less than 1 in 1 million manipulations (0.000001%).
Risk- Minimal
For comparison, for short-term users of Ibuprofen (another treatment for neck pain and headache) at standard doses, the risk of GI bleeding is Risk Moderate, likely less than 0.1% (1
in 100 to 1 in 1,000 individuals). However, this risk increases with dose and duration. The risk of a heart attack or stroke with long-term use at high doses is estimated to increase by about 30-50%, but the absolute risk remains small. For example, an increase from 1% to 1.3%-1.5% over a year Risk- High (1in 100 individuals).
Exercise & Rehabilitation
I gave an interview for Timeout magazine a few years ago when they wanted to know the incident of injury after exercise. In 37 years, I’ve seen three Pilates injuries, (however, with the recent move into large classes provided by inexperienced teachers this is increasing), I see around two yoga injuries a month and probably two gym/personal training injuries per week.The generic term “exercise” is obviously beneficial for health, but the devil is in the detail. We tend to start patients off with specific exercises and then a graduated return to their normal exercise regime. The exercises are initially mostly about releasing, gentle stretching, gentle resistance and core work, targeted at different parts of the body. Then encouraging patients into more formal exercise with Pilates teachers etc as part of that recovery and rehabilitation is often important. One of the challenges with cardiovascular health complications, is with intense exercise such as cardiovascular exercise or high interval intensity training (HIIT) which can be beneficial, however depending on the patient’s age group and medical history it’s often important to give them a maximum heart exercise rate.
Risk- Very Low
Breathing re-education
I have assessed and treated over 4 ½ thousand patients in relation to breathing pattern disorder and I lecture in the subject. Sometimes focusing on breathing can make patients a little anxious short term, but apart from that, I’ve not noted any other adverse reaction.
Risk- Negligible
Nutritional and Nutritional Supplementation
Nutrition was part of my undergraduate osteopathic training and I trained at postgraduate level both in nutrition and applied pathophysiology. I am the UK lecturer for Metabolic Balance which is the science based nutritional philosophy that I tend to follow. I have a big interest in nutritional and medical research and there are over 450 blogs on my website, many of them in relation to nutrition.
Risk- Negligible
Alternatives
I am very happy to discuss alternatives to any of my suggestions. It is your right to take up any or all of my suggestions.
No Treatment
You also of course have an option of not following any of my advice or taking me up on any of my treatment/management suggestions.