O.M.T. Demystified

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O.M.T.Demystified

• Rocco Caveng, D.O., M.B.A.
• Resident Lecture
• Aug 24, 2004

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OMT

• Goals
• What is O.M.T?
• Who should be referred?
• What happens during O.M.T.?
• Benefits of OMT (to office/to patient)

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OMT Definitions

• What is O.M.T.?
• Osteopathic Manipulative Treatment
• aka OMM, OPP or a manipulation
• What is that?
• Its 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.

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OMT Definitions

• 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

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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

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OMT Clinic?

• Ok great, I can sendm to OMT clinic
• Well, who are you sending to OMT clinic? And for
  what reason or complaint?
• Bread Butter
• Back pain
• Neck pain
• Sciatica
• Joint pain

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OMT

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

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OMT

• So what happens, what do you do, specifically to
  patients?

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OMT Techniques

• 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.
• High velocity, low amplitude (HVLA)
• Yeah, thats the crack the back one
• Muscle Energy patient assisted
• Counterstrain position of comfort

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Live Demo

• Hows your back feelin?
• Treatment of sinusitis
• Treatment of Sciatica (piriformis spasm)
• Treatment of spine (cervical, thoracic, lumbar)
• Treatment of anything else mentioned?

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OMT

• Goals of the Treatment
• Improve/Fix the Somatic dysfunction
• Decrease pain
• Improve function (ROM, use of painful part)
• 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 ?

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For the D.O.s

• Some obstacles to using OMT
• Not enough time?
• True sometimes, but use it often enough, you will
  become very efficient. Not too different from
  your level 4 visit that hasnt seen a doctor in
  1-2 years and you are given 15-30 minutes for,
  you make it work.
• Lost my touch during my 3rd 4th year med
  school, now Im 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.

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OMT

• So, do we get paid for this?
• Yes!
• 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

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Reimbursement Summary

• 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)
• This can be above beyond what we get paid for
  the EM 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.

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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 LgtR
• Lumbar ROM FB 75, BB 10, SBL 30, SBR 20

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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

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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 LgtR
• Cervical ROM FB 70, BB 50, SBL 45, SBR 30, Rot L
  80, Rot R 65

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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

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Questions?

• Thats all folks
• Questions/comments
• Examples?

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Resources

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