Manipulation By Novices

Report
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
• 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
 History
 Physical Exam
 Structural exam
 OMT (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.
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.
--------------------Manipulation and Low Back Pain--------------------
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 and Low Back Pain--------------------
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.
Low dose
High dose
--------------------Manipulation
and Low Back Pain-------------------
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.
Goals Of Manipulation
 Restore maximum pain-
free movement of the
musculoskeletal system
in postural balance
--------------------Manipulation and Low Back Pain-------------------
Musculoskeletal/Osteopathic Manipulation Form
Name: _____________________________
Patient #: __________________________
Date: ____ / ____ / ____
Age: _____
HISTORY: Chief Complaint: _______________________________________________________ _________
HPI: ______________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
PMHx / PSHx: _______________________________________________________________________
Low Back
Pain Office
Visit
Checklist
Using OMT
Review of Systems: “Red Flags” [RIFT]
___ Radiculopathy (Weakness, sensory change, Cauda Equina Syndrome-saddle anesthesia & GU Symptoms)
___ Infection (Immunosupression, IV drug abuse, elderly, ect.)
___ Fracture (Trauma, Fall or Lifting)
___ Tumor (< 20 yrs or > 50 yrs, CA Hx, Constitutional Symptoms, Pain worse: Supine / Night)
? PREVIOULSY TREATED: Y N
IMPROVED
SAME
WORSE
Comments:
PHYSICAL EXAM: (Circle / Check / Write In)
IMPRESSION: (Circle)
General: _____________________________________
1.
Sites of Pain/Condition: Neck/Cervicalgia [723.1]
NEURO: Muscle strength:
/5(R)
/5(L)
Sensory: __ Intact B/L ________________
DTR’s: (R) /4 (L) /4 ________________
Cerebellar: ____ Intact ________________
STRUCTURAL EXAM:
Posture/Gait: ______________________
Structural Curvature (Lordosis / Kyphosis / Scoliolsis)
___________________________________________
Leg Length: (Longer) R L Arm Length: (Longer) R L
Straight Leg Test: R ___ o L ___ o
Radiculopathy(Lasegue’s test): R + -- L + -Patrick Fabre R + -L + -Cervical Compression (Spurling) Tx + --
Thoracic Spine [724.1]
LBP [724.2]
UE [729.5]
LE [729.5]
Sacroiliitis [720.2]
Headache [784.0]
Fibromyalgia/myofascl pain [729.1] Weakness [780.79]
Cervical Radiculopathy [723.4]
Lumbar Radic [724.4]
2.
SITES OF SOMATIC DYSFUNCTION (BODY
REGIONS):
Head
Cervical
Thoracic
Rib Cage
Lumbar
Pelvis
Sacrum (Sacroiliac Joint)
Lower Extremity Upper Extremity Abdomen/Viscera
3.
CPT CODES PROCEDURE DESCRIPTION
___
___
___
___
___
[Procedure requiring modifier 25]
98925 OMT one to two body regions
98926 OMT three to four body regions
98927 OMT five to six body regions
98928 OMT seven to eight body regions
98929 OMT nine to ten body regions
Lower Extremity: ______________________________
Long Restrictors: ( Circle decreased ROM)
Piriformis R
L
Psoas R
L
4. ________________________________________
5. ________________________________________
6. ________________________________ ________
Pelvis: S.I. Joint (Tender) R
Innominates:
Ant/Inf: R L
PLAN: (Circle)
1. Osteopathic Manipulative Treatment:
L
Post/Sup: R L
Lumbar Spine: (L-S) (Rotates easier) R
L
Paravertebral Tenderness/Tender Points:
Soft Tissue
Myofascial Release
Muscle Energy
HVLA
Other
Comments: _______________________________
L1 ____ L2 ____ L3 ____ L4 ____ L5 ____
2. Exercises / Stretching / Rehabilitation
Thoracic Spine: (Note level/side of prominent /tender T.P.)
T1 ____ T2 ____ T3 ____ T4 ____ T5 ____ T6 ____
T7 ____ T8 ____ T9 ____ T10 ____ T11 ____ T12 ____
3. Physical Modalities: Cold-Ice
Warmth-Heat
Other _____________________________________
st
*Cervicothoracic Junction: (T1/1 rib)
RRSR (1st rib elevated L/ T.P. T-1 Prominent R) RLSL
Thoracic Cage: Inspiratory ribs __ Expiratory ribs __
4. Medication:
·
·
·
·
Tylenol 325/500/650 mg one-two QID/TID / PRN
Ibuprofen 200/400/600/800 mg (#
) q 6-8 hrs / PRN
Glucosamine 1500/2000 mg/day
Calcium [with Vitamin D] supplementation
Other: __________________________________
Sites of Tenderness/Tender Points:
·
Cervical Spine: Upper C-spine (Rotates easier) R L
5. Other recommendations:
Paravertebral Tenderness/Tender Points:
C1 ___ C2 ___ C3 ___ C4 ___ C5 ___ C6 ____ C7___
Upper Extremity: ( Circle decreased ROM)
Clavicle: R
L
Scapula: R L
Cranial/Visceral: ______________________________
Nutritional changes
Maintain Ideal Weight
Improve Posture
Lifestyle Change
Activity Alteration
PT/OT Exercises
PT/OT Referral
Other: _________________________________
6. Return to Office / Musculoskeletal Clinic:
_____ Days ____ Wks ____ Mo ____ PRN
© 2010 Paul Evans, DO, FAAFP, FACOFP-Michael P. Rowane, DO, MS, FAAFP, FAAP
Reviewing Physician's Initial's _____
_________________________________ DO/MD
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
All Back Pain Is NOT Back Disease
GU and GI
--------------------Manipulation
and Low Back Pain-------------------
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 neuropathy
 deep tendon reflexes, motor,
sensory
Physical Examination
Screening nerve root exam
L4
Reflex
Motor
Patellar
Tibialis
anterior
Sensory Medial
foot
L5
S1
None
Ext.
Hallicus
Longus
Dorsal
foot
Achilles
Peroneus
longus/brevis
Lateral
foot/heel
Hoppenfeld S. Physical examination of the spine and extremities.
Appleton Century Crofts 1976 Norwalk CT.
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)
--------------------Manipulation and Low Back Pain--------------------
Important Concepts
* Find Dysfunction, Fix Dysfunction
* Muscle Energy - Rule of 3
* Assess, Treat, Reassess Motion
--------------------Manipulation
and Low Back Pain-------------------
--------------------Manipulation
and Low Back Pain-------------------
Assessment - Sacroiliac






Pain
SLR
PSIS
ASIS
Leg length
Foot
eversion
Posterior
Anterior
Pinpoint
Less
Lower
Higher
Shorter
Yes
Diffuse
+/Higher
Lower
+/No
Evans P. Sacroiliac strain. American Family Physician
1993; 48,8:1388-1389 (letter).
--------------------Manipulation
and Low Back Pain-------------------
--------------------Manipulation
and Low Back Pain-------------------
--------------------Manipulation
and Low Back Pain-------------------
Posterior View- PSIS Assessment
Right
--------------------Manipulation
and Low Back Pain-------------------
Ischial Tuberosity
Iliac Crest
--------------------Manipulation
and Low Back Pain-------------------
Posterior SI Rotation – Force on Iliac Crest, Toward Umbilicus
--------------------Manipulation
and Low Back Pain-------------------
Anterior SI Rotation – Force on Ischial
Tuberosity, Down Femur
--------------------Manipulation
and Low Back Pain-------------------
Assessment - Lumbar
 Most common dysfunction = lumbo
sacral junction L5-S1
 Use “pelvic rock” motion test
 Least motion = dysfunctional “bad” side
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
--------------------Manipulation
and Low Back Pain-------------------
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
Ischial Tuberosity
Iliac Crest
--------------------Manipulation
and Low Back Pain-------------------
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

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