1. O.M.T. Demystified… Rocco Caveng, D.O., M.B.A. Resident Lecture Aug 24, 2004

2. OMT Goals: 1. What is O.M.T? 2. Who should be referred? 3. What happens during O.M.T.? 4. Benefits of OMT (to office/to patient)

3. OMT Definitions What is O.M.T.? Osteopathic Manipulative Treatment Osteopathic Manipulative Treatment –aka: OMM, OPP or “a manipulation” What is that? What is that? –It’s a lot of what you already know, and MORE… In order to use O.M.T., you need to find something to “treat,” we call that Somatic Dysfunction. In order to use O.M.T., you need to find something to “treat,” we call that Somatic Dysfunction.

4. OMT Definitions Somatic Dysfunction: Somatic Dysfunction: –Impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic and neural elements –“Spinal Somatic Dysfunction” occurs when the spine becomes restricted within the normal range of motion of one or more of its planes of motion and fails to return to its normal or neutral position when its activity is over

5. Somatic Dysfunction How to Diagnose Somatic Dysfunction Tenderness: produced during palpation Asymmetry: bones, muscles, or joints Restriction of motion: motion barrier (ie. Rotates neck to left 80 degrees and to the right 45 degrees) Barrier to right rotation Tissue Texture Changes: edematous, tender, fibrosed, atrophied, rigid, hypertonic

6. OMT Clinic? Ok great, I can send’m to OMT clinic Ok great, I can send’m to OMT clinic Well, who are you sending to OMT clinic? And for what reason or complaint? Well, who are you sending to OMT clinic? And for what reason or complaint? Bread & Butter: Bread & Butter: –Back pain –Neck pain –Sciatica –Joint pain

7. OMT Others diagnoses or complaints: Headaches (migraine, tension) Headaches (migraine, tension) Carpal Tunnel Syndrome Carpal Tunnel Syndrome Sinusitis (chronic/acute) Sinusitis (chronic/acute) Otitis media (chronic/acute) Otitis media (chronic/acute) Allergies (chronic nasal congestion) Allergies (chronic nasal congestion) Pregnancy (back/hip complaints) Pregnancy (back/hip complaints) Chronic Edema (leg, arm) Chronic Edema (leg, arm) Asthma/COPD Asthma/COPD Bowel changes (chronic constipation) Bowel changes (chronic constipation) Non-cardiac Chest Pain (costochondritis) Non-cardiac Chest Pain (costochondritis) Joint pain (acute/chronic, shoulder, elbow, wrist, hip, knee, ankle) Joint pain (acute/chronic, shoulder, elbow, wrist, hip, knee, ankle) Foot/Hand Pain, Plantar fasciitis Foot/Hand Pain, Plantar fasciitis Shin splints Shin splints Fibromyalgia, Generalized chronic pain Fibromyalgia, Generalized chronic pain TMJ TMJ And more… And more…

8. OMT So what happens, what do you do, specifically to patients? So what happens, what do you do, specifically to patients?

9. OMT Techniques Not all “snap, crackle & pop” Not all “snap, crackle & pop” –Although that is what we are mostly known for as part of the “difference” Each treatment is tailored to patient build, risk factors, request, response to previous treatment, etc. Each treatment is tailored to patient build, risk factors, request, response to previous treatment, etc. High velocity, low amplitude (HVLA) High velocity, low amplitude (HVLA) –Yeah, that’s the crack the back one Muscle Energy – patient assisted Muscle Energy – patient assisted Counterstrain – “position of comfort” Counterstrain – “position of comfort”

10. Live Demo How’s your back feelin’? How’s your back feelin’? Treatment of sinusitis Treatment of sinusitis Treatment of Sciatica (piriformis spasm) Treatment of Sciatica (piriformis spasm) Treatment of spine (cervical, thoracic, lumbar) Treatment of spine (cervical, thoracic, lumbar) Treatment of anything else mentioned? Treatment of anything else mentioned?

11. OMT Goals of the Treatment Goals of the Treatment –Improve/Fix the Somatic dysfunction –Decrease pain –Improve function (ROM, use of painful part) Bonus features Bonus features –Improve doctor/patient relationship –Often immediate improvement that visit –Possibly decrease use of unnecessary tests –Possibly delay need for invasive procedures –Repeat business, referrals from happy patients –Repeat business, referrals from happy patients

12. For the D.O.’s Some obstacles to using OMT: Not enough time? Not enough time? –True sometimes, but use it often enough, you will become very efficient. Not too different from your level 4 visit that hasn’t seen a doctor in 1-2 years and you are given 15-30 minutes for, you make it work. Lost my touch during my 3 rd + 4 th year med school, now I’m not too confident in my skills Lost my touch during my 3 rd + 4 th year med school, now I’m not too confident in my skills –Yup, welcome to the club, but if you stop using it you will definitely lose it. Literally “practice” on your patients, no different than practicing other office procedures, except these procedures you have quite a bit of experience at already! Your patients will appreciate it regardless. Literally “practice” on your patients, no different than practicing other office procedures, except these procedures you have quite a bit of experience at already! Your patients will appreciate it regardless.

13. OMT So, do we get paid for this? Yes! Yes! Even if not, you still get the warm & fuzzy treatment goals and bonus features Even if not, you still get the warm & fuzzy treatment goals and bonus features Summary of actual reimbursement at FMC July 1, 2003 to July 1, 2004 Summary of actual reimbursement at FMC July 1, 2003 to July 1, 2004

16. Reimbursement Summary Some insurances pay better than others. Some insurances pay better than others. On average, we get paid 50% of what we bill for OMT. (apparently still learning the “appropriate” way to bill for this) On average, we get paid 50% of what we bill for OMT. (apparently still learning the “appropriate” way to bill for this) –This can be above & beyond what we get paid for the E&M visit. So bill $75 for office visit (back pain), get paid $40, add on OMT, get an additional $20-$75 for that same visit. So bill $75 for office visit (back pain), get paid $40, add on OMT, get an additional $20-$75 for that same visit. Plus you can have patient return for repeat sessions as indicated. This is billed just as a procedure visit. Plus you can have patient return for repeat sessions as indicated. This is billed just as a procedure visit.

17. Example Case #1 New Patient Subjective A 30 year old male complains of low back pain. It started 2 days ago when lifting some heavy furniture. The patient reports having a sharp pain in his left lower back at the time of lifting. The next morning he was unable to stand straight due to significant pain in low back. Denies numbness/tingling or weakness of lower extremities. He took ibuprofen with mild relief of pain. He has no prior history of back pain/injury. Denies and medical or surgical history. No Allergies to medications. Objective Vitals BP-130/80, P-72, R-18, Temp 98.8 Ext: no edema. Dec ROM Lower Ext due to pain in lower back. Neuro: DTR's +2/4 = b/L, Strength +5/5 = b/L, sensation intact. CN II-XII grossly intact Osteopathic Exam - focussed L5 Flexed, Rotated Left, Sidebent Left Lumbar paraspinal muscle spasm, tenderness to palpation L>R Lumbar ROM: FB 75, BB 10, SBL 30, SBR 20

18. Example Case #1 Assessment 1. Lumbosacral sprain 846.0 2. Lumbar Somatic Dysfunction 739.3 Plan 1. OMT, Myofascial, HVLA to Lumbar spine with improvement of pain and range of motion. 2. Continue ibuprofen as needed for pain 3. Exercise and stretching instruction given 4. Follow up in 1 week E/M: 99204-25 OMT x1 region 98925

19. Example Case #2 Established Patient Subjective 35 year old male presents to your office for an OMT treatment of his neck pain of 5 years. Reports sometimes starts to get a headache from the tension in the back of his neck. (his history is a car accident 5 years ago with negative imaging results). Mild improvement with alleve. Occasional stretches and heating pad help. Denies numbness/tingling/weakness of upper extremities. No recent trauma. Objective Vitals BP-120/75, P-68, R-18, Temp 97.8 Physical Exam - focussed HEENT/neck: NC/AT, pharynx - benign, Neck supple, No nodes CV: RRR s1 + s2, no murmurs Neuro: DTR's +2/4 = b/L, Strength +5/5 = b/L, CN II-XII grossly intact Osteopathic Exam: Cervical Exam: C3-5 Extended, Rotated Left, Sidebent Left Tenderness over articular pillars L>R Cervical ROM: FB 70, BB 50, SBL 45, SBR 30, Rot L 80, Rot R 65

20. Example Case #2 Assessment 1. Cervical Strain 2. Cervical Somatic Dysfunction 739.1 Plan 1. OMT, myofascial, HVLA to cervical spine with improvement of pain and ROM 2. Continue Naprosyn 500mg PRN for pain 3. Stretching exercises given 4. Return to office PRN E/M: 99211-25 OMT x1 region 98925

21. Questions? That’s all folks… That’s all folks… Questions/comments Questions/comments Examples? Examples?

22. Resources Savarese, D.O., Robert. OMT Review, 2 nd ed. 1999. Kimberly, D.O., Paul. The Kimberly Manual. Revised edition 1999, KCOM class edition. Ward, Robert. Foundations of Osteopathic Medicine. 1 st ed. 1997 Williams & Wilkins. Online Resources: www.aoa-net.orgwww.aoa-net.org – AOA Website www.aoa-net.org www.do-online.comwww.do-online.com – AOA Website www.do-online.com Omt4fp.tripod.com - OMT for Family Practice (my personal design) www.acofp.comwww.acofp.com - Amer Academy Osteopathic Family Physicians www.acofp.com