Basics of Manual Manipulation in Physiatry: START HERE! Samuel A. Yoakum, DO Shounuck I. Patel, DO Gina M. Benaquista DeSipio, DO Arthur J. De Luigi, DO Amir Mahajer, DO Kristen Garlanger, DO

Disclosures none

Outline Background Definitions Diagnosis Techniques Billing

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

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

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.”

Osteopathic Medicine Andrew Taylor Still • Founded Osteopathy 1870’s • Previously trained as an MD • Lost entire family to meningitis • Devoted to the study of anatomy and physiology • Early Hipster

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 Still’s philosophy: “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

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

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

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

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

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

The Barrier Concept BARRIER stops motion FREEDOM Of MOTION is opposite the barrier Barriers Anatomical Physiological Restrictive

Anatomical & Physiological Barriers

Restrictive Barrier

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

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

Physical Therapy Contract-Relax Muscle Energy Joint Mobilizations = “Mobs” = direct technique with a range of force and velocity (Grade I-V) Deep articulation

Chiropractic “Adjustment” of subluxations Direct “thrust” maneuvers Similarities with HVLA

High Velocity, low amplitude Some of the earliest osteopathic techniques Confronting restricted motion of segments and articulations “head on” Requires skill for safety and appropriate application The barrier is rested against, isolated in multiple planes to minute specificity Final thrust in nearly ALL cases should be quick (high velocity) but short (low amplitude) “shotgun” techniques are discouraged

Soft Tissue Mobilization Soft tissue tensions affect function of the soft tissues and the joints to which they attach. Allows treatment to other parts of the body to be more effective. Gently and directly applying pressure as to separate the origin and insertion of muscle fibers from each other. Deep articulation, in contrast, is the repeated engagement of the barrier or endpoint of joint motion in order to increase mobility and ROM.

Myofascial Release (MFR) MFR is an umbrella term encompassing several types of osteopathic manipulative techniques (OMT) that stretch and release muscle and fascia restrictions. MFR first involves palpating a restriction in the fascia/soft tissue. Direct MFR = practitioner engages the restrictive barrier and holds until a release is felt in the tissue. Indirect MFR = practitioner moves the myofascial structures away from the restrictive barrier.

Counterstrain Used to treat Tenderpoints Tenderpoints are small tense edematous areas of tenderness typically located near tendon attachments, ligaments, or in the belly of some muscles. Tenderpoints, unlike trigger points, do not radiate pain when compressed.

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

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

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

Still Technique A combination of indirect technique, moving to direct technique following the release The patient is completely passive The lever is placed in a position of ease Holding force (compression/distraction) is applied The joint, or body part is then taken through a range of motion while attempting to hold the activating force as long as possible The range of motion is taken to (and through if reasonably possible) the barrier

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

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

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

ICD-9 739 = 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

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

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

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

References