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OMT In a Busy Office Practice. Paul Evans DO, FAAFP, FACOFP Vice President and Dean. 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 - PowerPoint PPT Presentation
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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.
--------------------Manipulation and Low Back Pain--------------------
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.
--------------------Manipulation and Low Back Pain--------------------
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.
--------------------Manipulation and Low Back Pain--------------------
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
--------------------Manipulation and Low Back Pain--------------------
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
--------------------Manipulation and Low Back Pain--------------------
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
--------------------Manipulation and Low Back Pain--------------------
--------------------Manipulation and Low Back Pain--------------------
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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--------------------Manipulation and Low Back Pain--------------------
--------------------Manipulation and Low Back Pain--------------------
--------------------Manipulation and Low Back Pain--------------------
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
--------------------Manipulation and Low Back Pain--------------------
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
--------------------Manipulation and Low Back Pain--------------------
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