0. Manual Manipulation for Common Exercise Injuries and the Muscle Energy Home Exercise Prescription
Shounuck I. Patel, DO
Samuel A. Yoakum, DO
Julie Lanphere, DO
Arthur J. De Luigi, DO

1. Disclosures
none

2. Outline
Background
Definitions
Diagnosis
Techniques
Billing

3. Common Exercise Injuries
Anecdotal increase in exercise-induced injuries with extreme exercise activities
Obstacle races
High-intensity interval workouts
Box-jumps, olympic-style lifts
Injuries associated with exercise can be acute or insidious

4. Common Exercise Injuries
Acute
Upper & Lower Limb Strains & Sprains
Chronic
Tendinopathies
Enthesopathies
Joint instability
Distal clavicular osteolysis

5. Kinetic chain
Exercise injuries can be a result of or can result in abnormalities along the kinetic chain

6. Manual Manipulation
Manual manipulation can treat the whole kinetic chain
Techniques can be taught to your patients to improve the quality and focus of their home exercise programs

7. Definitions Manual manipulation/therapy
Hands-on manipulation, mobilization or massage techniques involving articulations and/or soft tissues in order to modulate pain, alter range of motion, facilitate movement, and improve function.

8. Manual therapy Acupressure Bodywork Bowen technique Chiropractic
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

9. 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.”

10. Tenets of Osteopathy The body is a unit
Understanding this concept allows the treatment of patients as a functional whole.
Structure and Function are interrelated
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

11. Diagnosis Somatic Dysfunction Tissue Texture Changes Asymmetry
Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed, atrophied, rigid, moist, dry
Asymmetry
‘Inspection’
Restriction of motion = a deeper look at A/PROM
Named for FREEDOM Of MOTION
Restricted motion is the BARRIER
tenderness
Tenderpoints vs. Triggerpoints

12. Diagnosis Physiatric Exam <-> Osteopathic Exam
Inspection <-> Asymmetry
Palpation <-> Tissue texture and tenderness ROM <-> Restriction of motion
Motor, Sensory, Reflexes
Special tests

14. Tissue Texture Changes
Acute
Edematous
Erythematous
Boggy
Increased moisture
Chronic
No edema/erythema
Cool dry skin
Decreased muscle tone
Flaccid, ropy, fibrotic
Acute
Acute MSK injuries
OA exacerbation
Chronic
Atrophy in SCI/TBI/CVA
Old OA

15. Asymmetry Posture Scoliosis (kyphosis/lordosis, levo-/dextro-)
Side-to-side
Mastoid
Acromion
Lower ribs
Iliac crests
Greater trochanters
Lateral femoral condyles
Lateral malleoli

16. Restriction of motion Orthopedic Rheumatologic Somatic Dysfunction
Very Loose
Rheumatologic
Very Restricted
Somatic Dysfunction
Free in one direction + restricted in the other

17. Restriction of motion BARRIER stops motion
FREEDOM Of MOTION is opposite the barrier
Barriers
Anatomical
Physiological
Restrictive

18. Anatomical & Physiological Barriers

19. Restrictive Barrier

20. Osteopathic Manipulative Techniques
Direct Techniques
Engage (go into) the dysfunctional barrier
Goal is moving through the barrier to restore normal motion
Indirect Techniques
Disengage (go away from) the barrier
Using the path of least resistance
Combined Techniques
Begin indirect, then go direct

21. OMT Soft tissue mobilization / Articulatory Techniques
Direct
Myofascial Release (MFR)
Direct or Indirect
Muscle Energy (contract-relax)
Jones Counterstrain & FPR
Indirect
High Velocity Low Amplitude (HVLA)
Craniosacral

22. Counterstrain Jones Counterstrain = passive indirect technique
Muscle being treated is positioned at a point of balance or ease, away from the restrictive barrier.
“Fold and hold” for 90 sec
This is a neurosensory approach to the treatment of tenderpoints.
Mimicking the original strain position -> reducing aberrant afferent flow from the muscle spindle -> relaxes the muscle “spasm” associated with a tenderpoint

23. 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

24. 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.
Physician engages a barrier and holds
Patient is instructed to contract the muscle against your holding force (Activating force)
Relax
Engage a new barrier
Repeat

25. Billing
AMA CPT coding manual clearly states manipulation codes are NOT specialty- or profession-limiting
OMT not the same as Chiropractic Tx (CMT)
Separate and distinct codes
MDs & DOs can bill for OMT or CMT
CMT codes will not be covered here

26. Billing Perform & document thorough H&P
Perform & document diagnostic & therapeutic intervention
List ‘Somatic Dysfunction’ & the OMT code
List secondary diagnoses
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

27. CPT: Osteopathic procedure codes
Used for both inpatient and outpatient
98925 = 1-2 body regions
98926 = 3-4 body regions
98927 = 5-6 body regions
98928 = 7-8 body regions
98929 = 9-10 body regions

28. ICD-9: Osteopathic
739 = Nonallopathic lesions, not elsewhere classified
Includes Segmental Dysfunction & Somatic Dysfunction
739.0 = Head & Occipitocervical regions
739.1 = Cervical & Cervicothoracic regions
739.2 = Thoracic & Thoracolumbar regions
739.3 = Lumbosacral region
739.4 = Sacral and sacrococcygeal regions
739.5 = Pelvic region
739.6 = Lower extremities
739.7 = Upper extremities, AC and SC regions
739.8 = Rib cage, costochondral and costovertebral regions
739.9 = Abdomen and other

29. ICD-10-CM (2015) M99.0 = Segmental & Somatic Dysfunction
M99.00 = Head region
M99.01 = Cervical region
M99.02 = Thoracic region
M99.03 = Lumbar region
M99.04 = Sacral region
M99.05 = Pelvic region
M99.06 = Upper extremities
M99.07 = Lower extremities
M99.08 = Rib cage
M99.09 = Abdomen and other regions

30. ICD-10-PCS: Future procedure codes
7W0 = Osteopathic, Anatomical Regions, Treatment
7W00 = Head & Occipitocervical regions
7W01 = Cervical & Cervicothoracic regions
7W02 = Thoracic & Thoracolumbar regions
7W03 = Lumbosacral region
7W04 = Sacral and sacrococcygeal regions
7W05 = Pelvic region
7W06 = Lower extremities
7W07 = Upper extremities, AC and SC regions
7W08 = Rib cage, costochondral and costovertebral regions
7W09 = Abdomen and other

31. 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 forces
7W01X1Z = using Fascial Release
7W01X2Z = using General Mobilization
7W01X3Z = using High Velocity-Low Amplitude Forces
7W01X4Z = using Indirect Forces
7W01X5Z = using Low Velocity-High Amplitude Forces
7W01X6Z = using Lymphatic Pump
7W01X7Z = using Muscle Energy-Isometric Forces
7W01X8Z = using Muscle Energy-Isotonic Forces
7W01X9Z = using Other Method