Paul Evans DO, FAAFP, FACOFPVice President and Dean

OMT In a Busy Office Practice

Introduction

• OMT is evidence based for improving clinical outcomes but not used by osteopathic physicians• Obstacles to doing OMT including:

• time for competent assessment and treatment

• documentation concerns• concerns about safety and effectiveness if not a specialist

Introduction

“How can I use OMT in an efficient manner to increase

my utilization of this important treatment option?”

Objectives of Presentation

Review a time - efficient method using OMT for common low back pain syndrome using a checklist approach

HistoryPhysical ExamStructural examOMT (long restrictors, SI, lumbar)Coding

Reference

Basic Musculoskeletal Manipulation Skills: The 15 Minute Office Encounter. Rowane, MP, Evans P. 2012 (in press).

Based on over 20 years of teaching novices (MD, DO, PA, others) basic skills in manipulation.

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Does Workshop Training In Manipulation Work? Short workshop - primary care MD’s Confidence in managing low back pain

pre course = 15%, post = 70% Felt that effective skills had been

obtained pre course= 39%, post 58%

Used manipulation in practice = 100% Curtis P, Evans P, Rowane MP et al. Training generalist

physicians in manual therapy for low back pain: development of a continuing education model. J Continuing Ed in the Health Professions 1997:17;148-158.

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Manipulation By Novices: Does It Work?

U. North Carolina Study (AHCPR / AHRQ) 31 primary care MD’s (17-FP and 14-IM) Passed course, randomized office LBP

patients Manipulation plus “Enhanced Care” (guidelines) “Enhanced Care” only

Compared Roland-Morris Functional Disability scores, time to functional & complete recovery

Manipulation By Novices: Does It Work?

Overall similar outcomes both groups “Intense manipulation” in 3 regions (long

restrictors, SI, lumbar) showed: faster initial recovery after first visit

9% no manip vs. 19% any manip (p=0.05) faster functional recovery

7.6 days high vs. 11.8 no manip (p=0.02)

Curtis P, Carey TS, Evans P, Rowane MP, Garrett JM, Jackman A. Training conventional doctors to give unconventional care: a randomized trial of

manual therapy. Spine 2000;25:2954-2961.

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High dose

Low dose

Manipulation By Novices: Is It Safe?

Over 1600 OMT procedures done* No complications reported on 295 patients

most with multiple procedures / visits * Complication rate lowest in low back for OMT OMT appears much safer than NSAID’s

GI perforation risk for aspirin = 3.7:1 NSAID plus smoking plus any etoh = 10.7:1

(Van Tulder MW et al. Spine 2000;2501-2513) Recent MI risks for NSAIDs?

Curtis P, Carey TS, Evans P, Rowane MP, Garrett JM, Jackman A. Spine 2000;25:2954-2961.

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Goals Of Manipulation

Restore maximum pain-free movement of the musculoskeletal system in postural balance

Low Back Pain Office

Visit Checklist

Using OMT

History- Low Back Pain HPI PMX, PSX Red Flags - screening

Radiculopathy (weakness, sensory loss, cauda equina, GU symptoms)

Infection (immuno-compromised, fever, chills, weight loss)

Fracture (trauma, fall, heavy lifting) Tumor (age <20, >50, Cancer Hx,

constitutional sx, pain supine or at night) Previous OMT treatment – better, worse, same

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GU and GI

All Back Pain Is NOT Back Disease

Physical Exam - Low Back Pain

General observations Do all maneuvers in each position to save

time, then move to next position (sitting, supine, prone, standing, other)

Neurological (sitting) Screen using L4, L5, S1 nerve root

evaluation to rule out neuropathydeep tendon reflexes, motor, sensory

Physical ExaminationScreening nerve root exam

Hoppenfeld S. Physical examination of the spine and extremities.Appleton Century Crofts 1976 Norwalk CT.

L4 L5 S1Reflex Patellar None AchillesMotor Tibialis

anteriorExt. Hallicus Longus

Peroneus longus/brevis

Sensory Medial foot

Dorsal foot

Lateral foot/heel

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Assessment - Piriformis

Measure internal rotation of femur using feet

Compare one side to other (ART) Check tenderness at sciatic notch

thumb on ischial tuberosity middle finger on greater trochanter notch in middle (under piriformis)

* Find Dysfunction, Fix Dysfunction

* Muscle Energy - Rule of 3

* Assess, Treat, Reassess Motion

Important Concepts

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Assessment - Sacroiliac

Pain SLR PSIS ASIS Leg length Foot eversion

Posterior Anterior

Pinpoint DiffuseLess + / -Lower HigherHigher LowerShorter + / -Yes No

Evans P. Sacroiliac strain. American Family Physician 1993; 48,8:1388-1389 (letter).

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Posterior View- PSIS Assessment

Right

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Ischial Tuberosity

Iliac Crest

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Posterior SI Rotation – Force on Iliac Crest, Toward Umbilicus

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Anterior SI Rotation – Force on Ischial Tuberosity, Down Femur

Assessment - Lumbar Most common dysfunction = lumbo

sacral junction L5-S1 Use “pelvic rock” motion test Least motion = dysfunctional “bad” side

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Techniques - Lumbar Spine

Soft tissue technique patient in prone position use thenar and hypothenar

eminence to push para-lumbar muscles away from midline

can also use in thoraco-lumbars

Techniques - Lumbar Spine

Lumbar roll - patient lateral recumbent bad side UP shoulders parallel to table

“dishrag” roll knee down to “barrier” Force mid-pelvis (no wheel) use ME or HVLA

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Iliac Crest

Ischial Tuberosity

Conclusion of Visit

Describe diagnosis and treatment to patient in 5th grade terms

Recommend non Rx treatments Exercise, stretching, nutrition/weight

loss, ice, heat, activity alteration, posture change, PT/OT

RX if needed Indicate referrals, follow up, other Handout for OMT and low back pain

Documentation

Code Sites of pain/condition Code Sites of somatic dysfunction treated

(body regions) CPT codes (use 25 modifier)

Psoas = 4 regions - lumbar, sacrum, pelvis, lower extremity

Plan documentation OMT, exercise and rehabilitation, physical

modalities, medications, images, referrals, return to clinic date etc.

Summary

OMT can be used effectively in a short office visit

Focus on defined history “red flags” Focus assessment and treatment on

common dysfunctions Assess, treat, reassess Use checklist for efficiency and

reminders Coding with 25 modifier important