Transcript Manual Manipulation for Common Exercise Injuries and the Muscle

Manual Manipulation for
Common Exercise Injuries
and the Muscle Energy
Home Exercise Prescription
Shounuck I. Patel, DO
Samuel A. Yoakum, DO
Julie Lanphere, DO
Arthur J. De Luigi, DO
Disclosures
none
Outline
Background
Definitions
Diagnosis
Techniques
Billing
Common Exercise Injuries
● Anecdotal increase in exercise-induced
injuries with extreme exercise activities
o
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Obstacle races
High-intensity interval workouts
 Box-jumps, olympic-style lifts
● Injuries associated with exercise can be
acute or insidious
Common Exercise Injuries
● Acute
o
Upper & Lower Limb Strains & Sprains
● Chronic
o
o
o
o
Tendinopathies
Enthesopathies
Joint instability
Distal clavicular osteolysis
Kinetic chain
Exercise injuries can be a
result of or can result in
abnormalities along the
kinetic chain
Manual Manipulation
● Manual manipulation can treat the whole
kinetic chain
● Techniques can be taught to your patients
to improve the quality and focus of their
home exercise programs
Definitions
Manual manipulation/therapy
Hands-on manipulation, mobilization or
massage techniques involving articulations
and/or soft tissues in order to modulate
pain, alter range of motion, facilitate
movement, and improve function.
Manual therapy
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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.”
Tenets of Osteopathy
● The body is a unit
o Understanding this concept allows the treatment of patients as
a functional whole.
● Structure and Function are interrelated
o According to AT Still, the founder of Osteopathy, “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
o Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed,
atrophied, rigid, moist, dry
● Asymmetry
o ‘Inspection’
● Restriction of motion = a deeper look at A/PROM
o Named for FREEDOM Of MOTION
o Restricted motion is the BARRIER
● tenderness
o 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
o Edematous
o Erythematous
● Acute
○ Acute MSK injuries
○ OA exacerbation
o Boggy
o Increased moisture
● Chronic
o No edema/erythema
o Cool dry skin
o Decreased muscle tone
o Flaccid, ropy, fibrotic
● 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
o
Very Loose
● Rheumatologic
o
Very Restricted
● Somatic Dysfunction
o
Free in one direction + restricted in the other
Restriction of motion
● BARRIER stops motion
● FREEDOM Of MOTION is opposite the barrier
● Barriers
o Anatomical
o Physiological
o Restrictive
Anatomical & Physiological Barriers
Restrictive Barrier
Osteopathic Manipulative Techniques
● Direct Techniques
o Engage (go into) the dysfunctional barrier
o Goal is moving through the barrier to restore normal motion
● Indirect Techniques
o Disengage (go away from) the barrier
o Using the path of least resistance
● Combined Techniques
o Begin indirect, then go direct
OMT
● Soft tissue mobilization / Articulatory Techniques
o Direct
● Myofascial Release (MFR)
o Direct or Indirect
● Muscle Energy (contract-relax)
o Direct
● Jones Counterstrain & FPR
o Indirect
● High Velocity Low Amplitude (HVLA)
o Direct
● Craniosacral
o Direct or Indirect
Counterstrain
● Jones Counterstrain = passive indirect
technique
o Muscle being treated is positioned at a point of balance or
ease, away from the restrictive barrier.
o “Fold and hold” for 90 sec
● This is a neurosensory approach to the
treatment of tenderpoints.
o 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.
o Physician engages a barrier and holds
o Patient is instructed to contract the muscle against
your holding force (Activating force)
o Relax
o Engage a new barrier
o Repeat
Billing
● AMA CPT coding manual clearly states
manipulation codes are NOT specialty- or
profession-limiting
● OMT not the same as Chiropractic Tx (CMT)
o Separate and distinct codes
● MDs & DOs can bill for OMT or CMT
● CMT codes will not be covered here
Billing
1. Perform & document thorough H&P
2. Perform & document diagnostic &
therapeutic intervention
3. List ‘Somatic Dysfunction’ & the OMT code
4. List secondary diagnoses
5. 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
98926
98927
98928
98929
= 1-2 body regions
= 3-4 body regions
= 5-6 body regions
= 7-8 body regions
= 9-10 body regions
ICD-9: Osteopathic
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