Osteopathic Manual Manipulation W. Joshua Cox, D.O., FACOFP Chair, Department of Primary Care KCUMB This document may not be copied or shared without prior written consent of the AAFP.
Disclosure Statement It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME session. All faculty and staff in a position to control content for this session have indicated they have no relevant financial relationships to disclose. This document may not be copied or shared without prior written consent of the AAFP.
Learning Objectives 1. Describe use of manipulative medicine techniques in treatment of musculoskeletal problems through a case-based approach. 2. Demonstrate manipulative techniques to assist patients in recovering from injuries or enhancing their performance. 3. Describe physical therapy approaches/modalities for common musculoskeletal problems and how to prescribe specific treatment regimens. 4. Become familiar with basic manipulation techniques, their application, and contraindications. This document may not be copied or shared without prior written consent of the AAFP.
Osteopathic Medicine AT Still, MD, DO 4 Principles of Osteopathy – Body is a dynamic unit of function – Body possesses self-regulating mechanisms – Structure and function are inter-related at all levels – Treatment is based on understanding of these 3 principles This document may not be copied or shared without prior written consent of the AAFP.
Osteopathic Approach “ To find health should be the object of the doctor. Anyone can find disease.” A.T. Still, M.D.,D.O. This document may not be copied or shared without prior written consent of the AAFP.
Osteopathic Manipulative Treatment (OMT) Somatic Dysfunction: Altered or impaired function of the related components of the somatic system, including skeletal, arthroidal, and myofascial structures and the related vascular, neural, and lymphatic components Osteopathic Manipulative Treatment: Therapeutic application of manual forces used to improve physiologic function and support homeostasis Variety of techniques/modalities Treat “somatic dysfunction” Communicate while treating Applied to more than just spine Head, Cervical, Thoracic, Lumbar, Rib, Abdomen, Upper Ext, Lower Ext, Innominate (Pelvis), Sacrum This document may not be copied or shared without prior written consent of the AAFP.
Somatic Dysfunction TART • Tissue texture changes/abnormalities (acute, chronic) • Asymmetry (static, dynamic/motion) • Restriction of motion (active/passive ROM) • Tenderness to palpation This document may not be copied or shared without prior written consent of the AAFP.
American Osteopathic Association Guidelines for OMT for Patients with Low Back Pain – (July 2009) • Recommends that osteopathic physicians use OMT in the care of patients with low back pain • Evidence: systematic reviews and meta-analyses of randomized clinical trials (Evidence Level 1a) • OMT for somatic dysfunction has not demonstrated harm in any clinical trials to date • Licciardone JC, Brimhall AK, King LN. Osteopathic manipulative treatment for low back • pain: a systematic review and meta-analysis of randomized controlled trials. BMC Musculoskeletal Disorders 2005, 6:43. This document may not be copied or shared without prior written consent of the AAFP.
Clinical Guideline – OMT in Low Back Pain The patient population – Low back pain patients of MS origin • LBP referred from visceral origin is excluded from these guidelines • Other exclusions – Vertebral fracture/dislocation, muscle tears/lacerations, spinal ligament rupture, discitis, sacroiliitis, ankylosing spondylitis, masses, inflammation of facets/muscles/fascia – This does not imply that OMT is contraindicated in all of these conditions This document may not be copied or shared without prior written consent of the AAFP.
Clinical Guideline – OMT in Low Back Pain 7 trials met criteria for inclusion Each trail was independently evaluated by 2 reviewers to abstract data – Methodological characteristics – OMT & control treatments – Low back pain outcomes • Significant reduction in pain • Analgesic effect comparable to NSAIDs • Less referral, imaging, and rx This document may not be copied or shared without prior written consent of the AAFP.
OMT in Low Back Pain John C. Licciardone, DO, MS, MBA; Dennis E. Minotti, DO; Robert J. Gatchel, PhD; Cathleen M. Kearns, BA; Karan P. Singh, PhD. Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial . ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 11, NO. 2 ✦ MARCH/APRIL 2013 OMT regimen met or exceeded the Cochrane Back Review Group criterion for medium size effect in relieving chronic low back pain. It was safe and well accepted by patients. Improvement in LBP Patient satisfaction Less prescription drug use This document may not be copied or shared without prior written consent of the AAFP.
OMT Considerations • When to Consider Osteopathic Manipulation – Sarah Cole, DO; Jeremy Reed, DO – Patients with low back pain, headache, and neck pain can benefit from this approach – Vol 59, No 5 | MAY 2010 | The Journal of Family Practice This document may not be copied or shared without prior written consent of the AAFP.
Discussion Barriers to the application of the recommendations – Poor reimbursement for OMT • Medicare has reimbursed DOs for OMT >30 years – ICD-9 code 98926-9 with a 25 modifier attached to the E&M code – Time constraints – Lack of confidence or loss in skills – Inadequate office space – Some specialties This document may not be copied or shared without prior written consent of the AAFP.
Clinical Case 1 A 26 y/o male professional indoor soccer player is “walled” by an opponent as he is striking the ball for a defensive clear/pass. The patient’s posterior gluteal region makes contact with first the wall then the floor. When he tries to get up from the incident, he notices pain in the post and lat hip region, as well as pain with ambulation. Exam reveals no motor/sensory/reflex deficit, or specific point tenderness. Good stability, but he does have diffuse mild tenderness around the SI, altered gait, and global hip ROM reduction. Which of the following is the most likely diagnosis: A. Gluteus medius disruption B. Somatic dysfunction of the lumbar C. Abductor spasm D. Somatic dysfunction of the pelvis E. Labral tear of the hip This document may not be copied or shared without prior written consent of the AAFP.
Clinical Case 1 • Other considerations – contusion, fracture, soft tissue disruption…… • Complete evaluation performed • Somatic Dysfunction of Pelvis – Innominate, sacrum SI restriction – treated with gentle articulation/ROM OMT • Restoration of motion, resolution of discomfort • Immediate return to play Side note - he scored a goal 15 seconds after returning to play This document may not be copied or shared without prior written consent of the AAFP.
Clinical Case 2 A 25 y/o female runner presents with progressive left hip region pain since beginning a marathon training program several weeks ago. Exam reveals a negative scour and labral loading test, but a weakly positive jump sign and a + ober’s test. Which of the following is the most likely diagnosis for this patient? A. Labral tear of the hip B. Hip flexion somatic dysfunction C. Hip extension somatic dysfunction D. Hip adduction somatic dysfunction E. Hip abduction somatic dysfunction This document may not be copied or shared without prior written consent of the AAFP.
Clinical Case 2 • Other considerations – fracture, overuse stress reaction, CAM/pincer deformity, soft tissue injury….. • Complete evaluation performed • Somatic Dysfunction: Named for position of ease/freedom, “where it likes to live” • IT band syndrome • Mild greater trochanteric bursitis • Hip Abduction Somatic Dysfunction – treated with Myofascial Release, Muscle Energy. Home stretches, roller recommended • Pt able to complete marathon This document may not be copied or shared without prior written consent of the AAFP.
Clinical Case 3 A 21 y/o male college basketball player presents with L shoulder pain and tightness the day after the game. He feels that his shot has been affected. He reports getting tangled up with an opponent while going for a lay-up and having his shot blocked. Exam shows ROM restriction in multiple planes of the L shoulder, most notable with internal rotation. He has no motor/sensory/reflex deficits. Drop arm, empty can, apprehension, Yergason tests were all negative. Which of the following is the most likely diagnosis? A. Glenohumeral instability B. Biceps tendonitis with subluxation C. Shoulder external rotation somatic dysfunction D. Shoulder internal rotation somatic dysfunction E. Shoulder abduction somatic dysfunction This document may not be copied or shared without prior written consent of the AAFP.
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