Paul Evans DO, FAAFP, FACOFP Vice President and Dean

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.

18. 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--------------------

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

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

23. --------------------Manipulation and Low Back Pain--------------------

24. 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).

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

26. --------------------Manipulation and Low Back Pain--------------------

27. --------------------Manipulation and Low Back Pain--------------------

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

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

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

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

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

33. 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--------------------

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

36. 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

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