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Paul Evans DO, FAAFP, FACOFP Vice President and Dean

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

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Paul Evans DO, FAAFP, FACOFP Vice President and Dean

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

  2. 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

  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. 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--------------------

  7. 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--------------------

  8. Manipulation By Novices: Does It Work? • Overall similar outcomes both groups • “Intense manipulation” in 3 regions (long restrictors, SI, lumbar) showed: • faster initial recoveryafter 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. Low dose High dose --------------------Manipulation and Low Back Pain--------------------

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

  12. Low Back Pain Office Visit Checklist Using OMT

  13. History- Low Back Pain • HPI • PMX, PSX • Red Flags - screening • Radiculopathy (weakness, sensory loss, caudaequina, 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

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

  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.

  17. Assessment - Piriformis • Measure internal rotation of femur using feet • Compare one side to other (ART) • Check tenderness at sciatic notch • thumb on ischialtuberosity • middle finger on greater trochanter • notch in middle (under piriformis) --------------------Manipulation and Low Back Pain--------------------

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

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  21. Assessment - Sacroiliac • Pain • SLR • PSIS • ASIS • Leg length • Foot eversion Posterior Anterior Pinpoint Diffuse Less + / - Lower Higher Higher Lower Shorter + / - Yes No Evans P. Sacroiliac strain. American Family Physician 1993; 48,8:1388-1389 (letter).

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  25. Posterior View- PSIS Assessment Right --------------------Manipulation and Low Back Pain--------------------

  26. Ischial Tuberosity Iliac Crest --------------------Manipulation and Low Back Pain--------------------

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

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

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

  30. 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--------------------

  31. 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

  32. Ischial Tuberosity Iliac Crest --------------------Manipulation and Low Back Pain--------------------

  33. 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

  34. 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.

  35. 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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