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Paul Evans DO, FAAFP, FACOFP Vice President and Dean OMT In a Busy Office Practice.

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Presentation on theme: "Paul Evans DO, FAAFP, FACOFP Vice President and Dean OMT In a Busy Office Practice."— Presentation transcript:

1 Paul Evans DO, FAAFP, FACOFP Vice President and Dean OMT In a Busy Office Practice

2 Introduction OMT is evidence based for improving clinical outcomes but not used by osteopathic physicians OMT is evidence based for improving clinical outcomes but not used by osteopathic physicians Obstacles to doing OMT including: Obstacles to doing OMT including: time for competent assessment and treatment time for competent assessment and treatment documentation concerns documentation concerns concerns about safety and effectiveness if not a specialist concerns about safety and effectiveness if not a specialist

3 Introduction “How can I use OMT in an efficient manner to increase my utilization of this important treatment option?”

4 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

5 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.

6 --------------------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.

7 --------------------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

8 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.

9 --------------------Manipulation and Low Back Pain---------------- ---- High dose Low dose

10 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.

11 --------------------Manipulation and Low Back Pain------------------- - Goals Of Manipulation  Restore maximum pain- free movement of the musculoskeletal system in postural balance

12 Low Back Pain Office Visit Checklist Using OMT

13 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 50, Cancer Hx, constitutional sx, pain supine or at night)  Previous OMT treatment – better, worse, same

14 --------------------Manipulation and Low Back Pain---------------- ---- GU and GI All Back Pain Is NOT Back Disease

15 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

16 Physical Examination Screening nerve root exam Hoppenfeld S. Physical examination of the spine and extremities. Appleton Century Crofts 1976 Norwalk CT. L4L5S1 ReflexPatellarNoneAchilles MotorTibialis anterior Ext. Hallicus Longus Peroneus longus/brevis SensoryMedial foot Dorsal foot Lateral foot/heel


18 --------------------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)


20 * Find Dysfunction, Fix Dysfunction * Muscle Energy - Rule of 3 * Assess, Treat, Reassess Motion Important Concepts

21 --------------------Manipulation and Low Back Pain---------------- ----



24 Assessment - Sacroiliac  Pain  SLR  PSIS  ASIS  Leg length  Foot eversion PosteriorAnterior Pinpoint Diffuse Less+ / - LowerHigher HigherLower Shorter+ / - YesNo Evans P. Sacroiliac strain. American Family Physician 1993; 48,8:1388-1389 (letter).

25 --------------------Manipulation and Low Back Pain---------------- ----



28 Posterior View- PSIS Assessment Right

29 --------------------Manipulation and Low Back Pain---------------- ---- Ischial Tuberosity Iliac Crest

30 --------------------Manipulation and Low Back Pain---------------- ---- Posterior SI Rotation – Force on Iliac Crest, Toward Umbilicus

31 --------------------Manipulation and Low Back Pain---------------- ---- Anterior SI Rotation – Force on Ischial Tuberosity, Down Femur

32 Assessment - Lumbar  Most common dysfunction = lumbo sacral junction L5-S1  Use “pelvic rock” motion test  Least motion = dysfunctional “bad” side

33 --------------------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

34 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

35 --------------------Manipulation and Low Back Pain---------------- ---- Iliac Crest Ischial Tuberosity

36 Conclusion of Visit  Describe diagnosis and treatment to patient in 5 th 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

37 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.

38 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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