Manual Manipulation for the Adaptive Sports Athlete

Shounuck I. Patel, DOSamuel A. Yoakum, DO

Gina M. Benaquista DeSipio, DOJulie Lanphere, DO

Arthur J. De Luigi, DO

Disclosures

none

Outline

BackgroundDefinitionsDiagnosisTechniquesBilling

Manual Therapy in Adaptive Sports

Valuable complementary treatment for injury in the adaptive sports athlete

Adaptive sports athletes can have musculoskeletal pain directly related to their condition, or secondary to injuries to which they are more susceptible

Adaptive sports

● Primary conditionso Spasticityo Lumbosacral/sacroiliac dysfunction due to

limb length inequality, hemiparesis, etc.

● Secondary injurieso Neck & Shoulder pain

Myofascial thoracic outlet syndrome Scapular dyskinesia

o Overuse syndromes Tendinopathies/enthesopathies Carpal tunnel syndrome

Definitions

Manual manipulation/therapyHands-on mobilization, manipulation, and balancingn techniques involving articulations and/or soft tissues in order to improve range of motion, biomechanics, and function.

Manual therapy● Acupressure● Bodywork● Bowen technique● Chiropractic● Cranial Osteopathy● Craniosacral therapy● Indian head massage● Lomilomi● Manual lymphatic drainage● Massage therapy● Naprapathy● Osteopathic medicine● Physical therapy● Rolfing structural integration● Shiatsu● Thai massage● Tui na● Watsu

Osteopathic Medicine

Definitions:

•Osteopathy = Osteopathic medicine

•Osteopathic manipulative medicine = OMM

•Osteopathic manipulative treatment/techniques = OMT

•Doctor of Osteopathy = DO

According to the World Osteopathic Health Organization, Osteopathy is a“…system of healthcare which relies on manual contact for diagnosis and treatment. It respects the relationship of body, mind and spirit in health and disease; it lays emphasis on the structural and functional integrity of the body and the body's intrinsic tendency for self-healing.”

Tenets of Osteopathy

● The body is a unito Understanding this concept allows the treatment of patients as

a functional whole.

● Structure and Function are interrelatedo According to AT Still, the founder of Osteopathy, “Disease is

the result of anatomical abnormalities followed by physiologic discord”

● The body possesses self-regulatory and self-healing mechanisms

● Rational treatment is based on applying these principles

Case Example

40 yo F with T4 complete paraplegia

CC: sharp pain at posterior mid thoracic region

HPI: Pain began the day after hand cycling dozens of miles in a benefit race, and is band-like in upper-mid thoracic region Rt>Lt, stabbing in nature. No motor, sensory, bowel or bladder changes.

Diagnosis

Somatic Dysfunction● Tissue Texture Changes

o Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed, atrophied, rigid, moist, dry

● Asymmetryo ‘Inspection’

● Restriction of motion = a deeper look at A/PROMo Named for FREEDOM Of MOTION

o Restricted motion is the BARRIER

● Tendernesso Tenderpoints vs. Triggerpoints

Diagnosis

Physiatric Exam <-> Osteopathic Exam

Inspection <-> AsymmetryPalpation <-> Tissue texture and tendernessROM <-> Restriction of motionMotor, Sensory, ReflexesSpecial tests

Tissue Texture Changes

● Acuteo Edematous

o Erythematous

o Boggy

o Increased moisture

● Chronico No edema/erythema

o Cool dry skin

o Decreased muscle tone

o Flaccid, ropy, fibrotic

● Acute○ Acute MSK injuries○ OA exacerbation

● Chronic○ Atrophy in SCI/TBI/CVA○ Old OA

Asymmetry

● Posture● Scoliosis (kyphosis/lordosis,

levo-/dextro-) ● Side-to-side

● Mastoid

● Acromion

● Lower ribs

● Iliac crests

● Greater trochanters

● Lateral femoral condyles

● Lateral malleoli

Restriction of motion

● Orthopedic o Very Loose

● Rheumatologic o Very Restricted

● Somatic Dysfunction o Free in one direction + restricted in the other

Restriction of motion

● BARRIER stops motion

● FREEDOM Of MOTION is opposite the barrier

● Barriers

o Anatomical

o Physiological

o Restrictive

Anatomical & Physiological Barriers

Restrictive Barrier

Case - Osteopathic exam

● Tissue texture change:o Fullness and tenderness at suboccipital region o No skin changes

● Asymmetryo R downward scapular rotation

● Restriction of motion:o Cervical ROM decreased in left sidebending

and rotation ● Tenderness:

o Point ttp Rt T4-T7 paraspinal region, Rt levator and Rt supraclavicular space resulting in band-like radiation of pain, concordant with chief complaint

Osteopathic Manipulative Techniques

● Direct Techniqueso Engage (go into) the dysfunctional barrier

o Goal is moving through the barrier to restore normal motion

● Indirect Techniqueso Disengage (go away from) the barrier

o Using the path of least resistance

● Combined Techniqueso Begin indirect, then go direct

OMT

● Soft tissue mobilization / Articulatory Techniqueso Direct

● Myofascial Release (MFR)o Direct or Indirect

● Muscle Energy (contract-relax)o Direct

● Jones Counterstrain & FPRo Indirect

● High Velocity Low Amplitude (HVLA)o Direct

● Low Velocity High Amplitude (LVHA)o Direct

● Craniosacralo Direct or Indirect

Massage techniques

● Similarities with soft tissue mobilization/articulatory techniques and myofascial release

● Effleurage = stroking and gliding (effortlessly)● Petrissage = kneading (pinching)● Tapotement = percussion (tapping)● Deep friction = deep linear/circular rubbing to prevent

adhesions in subacute/chronic injuries● Acupressure = sustained deep pressure over

acupuncture points OR Travell trigger points

Physical Therapy

● Contract-Relax o Muscle Energy

● Joint Mobilizations = “Mobs” = direct technique with a range of force and velocity (Grade I-V)o Deep articulation

Chiropractic

● “Adjustment” of subluxationso Direct “thrust” maneuverso Similarities with HVLA

Soft Tissue Mobilization

● Soft tissue tensions affect function of the soft tissues and the joints to which they attach.

● Allows treatment to other parts of the body to be more effective.

● Gently and directly applying pressure as to separate the origin and insertion of muscle fibers from each other.

● Deep articulation, in contrast, is the repeated engagement of the barrier or endpoint of joint motion in order to increase mobility and ROM.

Myofascial Release (MFR)

● MFR is an umbrella term encompassing several types of osteopathic manipulative techniques (OMT) that stretch and release muscle and fascia restrictions.

● MFR first involves palpating a restriction in the fascia/soft tissue.

● Direct MFR = practitioner engages the restrictive barrier and holds until a release is felt in the tissue.

● Indirect MFR = practitioner moves the myofascial structures away from the restrictive barrier.

Counterstrain

Used to treat Tenderpoints● Tenderpoints are small tense edematous areas of

tenderness typically located near tendon attachments, ligaments, or in the belly of some muscles.

● Tenderpoints, unlike trigger points, do not radiate pain when compressed.

Counterstrain

● Jones Counterstrain = passive indirect techniqueo Muscle being treated is positioned at a point of balance or

ease, away from the restrictive barrier.o “Fold and hold” for 90 sec

● This is a neurosensory approach to the treatment of tenderpoints.o Mimicking the original strain position -> reducing

aberrant afferent flow from the muscle spindle -> relaxes the muscle “spasm” associated with a tenderpoint

Facilitated Positional Release (FPR)

● Indirect technique● Place tissue in neutral position to diminish tissue/joint

tension in all planes● Add activating force (compression or distraction)● Takes 3-4 seconds to induce a release● Good for superficial muscles or deep intervertebral

muscles

Muscle Energy

● Muscle energy, also known as “contract-relax,” is a direct technique used to improve range of motion.

● This is a form of OMT in which the patient actively uses his/her muscles against the practitioner’s resistance.o Physician engages a barrier and holdso Patient is instructed to contract the muscle against

your holding force (Activating force)o Relaxo Engage a new barriero Repeat

Case

Dx:- Somatic dysfunction- Levator Scapulae spasm / strain versus

zone of injury neuropathic pain- “Band-like” radiating pain is not typical of

levator scapula referral patterns but this can present differently in the setting of neurological injury

Case - Diagnosis

● Myofascial pain syndrome● Levator spasm / strain● Somatic dysfunction of Rib: elevated

1st rib (inhaled)● Somatic dysfunction of Cervical spine:

C2 rotated right ● Somatic dysfunction of Thoracic spine:

right paraspinal muscles ropey and hypertonic

DDx includes neuropathic pain, fracture

Case - Treatment

C2: muscle energy1st rib: facilitated positional releaseThoracic paraspinal muscles: myofascial releaseLevator muscle spasm: myofascial release or counterstrain

*in thoracic region, passive techniques because pt may not be able to provide enough force for active technique due to neurological level of injury

Billing

● OMT is a procedure● AMA CPT coding manual clearly states

manipulation codes are NOT specialty- or profession-limiting● OMT not the same as Chiropractic Tx

(CMT)o Separate and distinct codes

● MDs & DOs can bill for OMT or CMT● CMT codes will not be covered here

Billing

1.Perform & document thorough H&P2.Perform & document diagnostic &

therapeutic intervention3.List ‘Somatic Dysfunction’ & the OMT

codes4.List secondary diagnoses5.Use the -25 modifier on the E&M code

● This may only be possible if E&M is for a distinctly separate issue than what is being treated by manipulation

CPT: Osteopathic procedure codes

Used for both inpatient and outpatient

98925 = 1-2 body regions98926 = 3-4 body regions98927 = 5-6 body regions98928 = 7-8 body regions98929 = 9-10 body regions

ICD-9

739 = Nonallopathic lesions, not elsewhere classifiedIncludes Segmental Dysfunction & Somatic Dysfunction

739.0 = Head & Occipitocervical regions739.1 = Cervical & Cervicothoracic regions739.2 = Thoracic & Thoracolumbar regions739.3 = Lumbosacral region739.4 = Sacral and sacrococcygeal regions739.5 = Pelvic region739.6 = Lower extremities739.7 = Upper extremities, AC and SC regions739.8 = Rib cage, costochondral and costovertebral regions739.9 = Abdomen and other

Case Example - Billing

ICD-9: 344.1 = paraplegia728.85 = Spasm of muscle739.1 = Somatic dysfunction Cervical regions739.2 = Somatic dysfunction Thoracic regions39.8 = Somatic dysfunction Rib cage

CPT:99213 = level 3 outpt follow up-25 = another separate service offered 98926 = OMT 3 body regions

ICD-10-CM (2015)

M99.0 = Segmental & Somatic DysfunctionM99.00 = Head regionM99.01 = Cervical regionM99.02 = Thoracic regionM99.03 = Lumbar regionM99.04 = Sacral regionM99.05 = Pelvic regionM99.06 = Upper extremitiesM99.07 = Lower extremitiesM99.08 = Rib cageM99.09 = Abdomen and other regions

ICD-10-PCS: Future procedure codes

7W0 = Osteopathic, Anatomical Regions, Treatment7W00 = Head & Occipitocervical regions7W01 = Cervical & Cervicothoracic regions7W02 = Thoracic & Thoracolumbar regions7W03 = Lumbosacral region7W04 = Sacral and sacrococcygeal regions7W05 = Pelvic region7W06 = Lower extremities7W07 = Upper extremities, AC and SC regions7W08 = Rib cage, costochondral and costovertebral regions7W09 = Abdomen and other

ICD-10-PCS: continued...

Each anatomical region is further subdivided by technique: 7W0_X_Z = Osteopathic treatment of ____ Region using ____7W01X0Z = Cervical region using Articulatory-Raising forces7W01X1Z = using Fascial Release7W01X2Z = using General Mobilization7W01X3Z = using High Velocity-Low Amplitude Forces7W01X4Z = using Indirect Forces7W01X5Z = using Low Velocity-High Amplitude Forces7W01X6Z = using Lymphatic Pump7W01X7Z = using Muscle Energy-Isometric Forces7W01X8Z = using Muscle Energy-Isotonic Forces7W01X9Z = using Other Method