Coding case study - OMT Codes for use by DOs and MDs

Article by Angelia Halaja-Henriques, PAFP Communications Director

Credit: Note this article was directly taken from the Pennsylvania Academy of Family Physicians website at www.pafp.com/MMS/coding and the material posted below and even more information can be obtained by visiting the PAFP website at http://www.pafp.com/.

Pennsylvania Academy of Family Physicians

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OMT has value for patients & docs. Positive outcomes helped to establish Osteopathic Manipulative Treatment (OMT) within the federal codes and eventually to become recognized in the CPT Manual 11 years ago.

Reasons why osteopathic family physicians with training in OMT should make it part of their practice today include the offer of holistic treatment, more satisfying patient encounters and an economic boost. Family physicians who practice manipulation say it is rewarding, effective and tout the value of the “laying on of hands.”

Note that OMT is not therapy; OMT is a treatment option by definition and in practice and is reimbursable as such. OMT also is not the same as chiropractic therapy; there are distinct codes for OMT vs. chiropractic manipulative therapy (CMT). Note too that the AMA CPT coding manual clearly states that code descriptions are in no way intended to be specialty- or profession-limiting. Therefore, an MD or DO can do CMT.

Modifier –25 & bundling

The economic incentive comes from the CPT guideline that a patient visit and OMT can both be billed at the same visit using modifier –25. This is not to say that all payors honor the guideline.

It’s a gray zone,” said Dr. Williams, who maintains a private practice while serving as a medical director for Capital Blue Cross in the midstate. Many payors like Capital Blue Cross take a hard line on the usage of modifier –25, referring to its original definition as a “significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.” They mistakenly see the office visit as preservice work for the procedure.
These payors are missing the clarifications made over the years, including one in CPT 1999 that “the E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.” The clarification was published specifically because private payors were and are bundling E/M and OMT codes. The separate nature of E/M from OMT also was supported within recommendations implemented in 2004.

When asked about bundling, PAFP General Counsel Charles Artz, Esq. took an equally hard line. He wrote that the opinion of the AMA CPT Assistant is that “it’s absolutely NOT PART OF THE PRESERVICE WORK.

“The E/M code always may be billed separately with a -25 modifier,” he continues, “Is there any wonder there’re class action lawsuits?”Artz cites the HIPAA Transaction and Code Set standard as the statutory framework requiring payors to honor the CPT codes, code descriptors and modifiers. He has successfully employed his argument in court. “Under federal law,” says Artz, “[CPT codes] are the exclusive coding rules, to the exclusion of all other rules and interpretive guidelines.” Additionally, he says, “official comments make clear that modifiers are included in the code set, but that code sets do not include all operational guidelines or instructions.”

Further evidence against bundling is the minimal relative value unit (RVU) assigned to OMT which sets the Medicare physician fee for the procedure. The work RVU for OMT code 98925 is 0.45. According to the AOA, the OMT codes are valued only for the actual work of the procedure. “This is the same work value as code 99212,” says AAFP Coding & Compliance Specialist Cindy Hughes, CPC. “Obviously when payors say that there is preservice work included in the OMT codes, they are not accounting for much.”

The issue of pre- and postservice work being included in the code can be confusing for payors. Many other procedures and services include pre- and postservice work, and CMT specifically includes” pre-manipulation patient assessment.”

While bundling is prevalent across the country and is an advocacy issue of the American Medical Association and AOA, some family physicians are getting paid for both the E/M and OMT. Sam Schrack, DO, (Williamsport) provides manipulative treatment about once or twice a week and has not had trouble getting reimbursed using the –25 modifier. A family physician with an emphasis in sports medicine, Michael Cordas, DO, (Harrisburg) also reports no OMT reimbursement problems. Dr. Cordas qualified his statement by adding that he uses OMT as an “adjunct treatment and then very selectively.”

The AOA suggests physicians negotiate to add the following language into their payor contracts: “MCO agrees to adhere to the CPT codes, including notes, guidelines and instructions printed within the codebook and agrees not to bundle payment codes unless the edit conforms to the attached fee schedule and CPT. (Attach a fee schedule for the OMT and E/M codes- use the fees the physician expects to be paid.) In addition, MCO agrees to respect the CPT modifier –25 when used with an office visit and a procedure such as OMT when performed on the same day. (or in the alternative, “MCO agrees to pay E/M and OMT as Medicare does.”) Also, MCO warrants that each payor subject to this agreement conform to the fee schedule and these provision.”

OMT as a capitated service

Including OMT in capitation is another one of the primary reimbursement problems physicians may encounter.

“OMT should not be subject to capitation. It’s a separate procedure, separately payable,” says Artz.

Careful review of managed care contracts will tell physicians whether OMT is capitated with other services. Physicians are encouraged to read the contract themselves or ask a health law attorney to do so as some payors do not properly interpret or communicate the exact nature of the capitation agreement.

Physicians and their attorneys are encouraged to renegotiate contracts to exclude OMT from capitation or increase the per patient fee over what is being offered physicians who do not perform OMT. If a physician can carve out OMT from capitation, the AOA suggests including a list of OMT codes that will be paid fee for service.

Studies show the efficacy and efficiency of OMT, so it is worth the time of both the payor and physician to renegotiate for fee for service.

Covered treatment?

Dr. Schrack warns that patients’ policies might not cover OMT. If OMT is not covered, he suggests asking payers about billing the patient for the service. Dr. Williams also suggests encouraging patients to check caps on manipulation visits.

Appeal denials of correctly coded OMT visits

Similarly, it is worth a physician’s time and effort to resubmit denials and educate payors on correctly applying CPT codes related to OMT. One PAFP member found that payers started approving codes previously denied after his practice called to question denials.

CPT & ICD codes

The procedure codes for OMT relate to the number of regions affected and the diagnosis codes to the specific region(s) affected.

OMT CPT codes [inpatient & 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

Body region codes:

head
sacral
rib cage area
cervical
pelvis
abdomen
thoracic
lower extremities
viscera region
lumbar
upper extremities

ICD Codes Descriptors

739._
Somatic dysfunction
739.0
Head region
739.1
Cervical region
739.2
Thoracic region
739.3
Lumbar region
739.4
Sacral region
739.5
Pelvic region
739.6
Lower extremities
739.7
Upper extremities
739.8
Rib cage
739.9

Abdomen and other
Be sure to thoroughly document the history, examination and medical decision making (MDM) to support an appropriate E/M code. While all physicians know not to supplement documentation to upcode, neither should they omit information from the history or exam that supplements the diagnosis process.

Physicians should document the history using CPT and their own clinical judgment. The note might include the chief complaint, history of present illness, a review of systems and any family, social and/or medical histories. The note also should use federal guidelines to detail the physical exam. The structural exam supports medical necessity for OMT, and the assessment and plan (A/P) can serve as procedure note and justify other interventions, such as pharmaceutical treatments.

If during MDM a physician sees a need for injections in addition to OMT, list these codes first as they are more complex. Typically, the procedure and ICD code are listed first followed by the E/M with –25 modifier. Practices should consult payors for their specific preference.
Physicians are not limited in the number of dysfunctions that may be diagnosed, treated and/or billed. Physicians should include their notes and be specific about physical findings to limit misunderstanding by the payor. Submitting detailed notes also supports coding when there is not enough room on the payor form for what are often many ICD codes.
Physicians trained in OMT also may do consults.

AOA coding case study

A 42-year old male with confusion and pain in the neck and upper back presents to a neurosurgeon. Patient also complains of exacerbation of previous lumbar disc herniation with radiculitis following a motorcycle accident. After evaluation of the patient, the diagnosis is: (1) closed head injury and (2) somatic dysfunction of the head, cervical, lumbar, sacral and rib region. The physician then utilizes osteopathic manipulative treatment to treat the patient’s head, cervical, lumbar, sacral and rib regions.

Diagnosis Coding
Somatic dysfunction, head 739.0
Somatic dysfunction, cervical 739.1
Somatic dysfunction, lumbar 739.3
Somatic dysfunction, sacral 739.4
Somatic dysfunction, rib 739.8

Procedure Coding
Osteopathic manipulative treatment (OMT); five to seven body regions involved 98927
Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components:
a detailed history
a detailed examination
medical decision making of moderate complexity 99214-25

Explanation of Code Selection

For the diagnosis coding of somatic dysfunction it is necessary to code to the fourth digit (e.g. 739.1) as one should code to the most specific ICD-9 code. Not coding to the fourth digit could cause the payor to reject this claim. Code 98927 was selected for the OMT provided as five regions were treated. In selecting the E/M code, since the patient had been seen by the physician within the past three years, this was an established patient. A detailed history and examination were performed and medical decision making of moderate complexity was provided, hence the selection of CPT code 99214. The –25 modifier was added as this indicates to the payor that a significant, separate identifiable evaluation and management service was provided in addition to the OMT.

Expert Q & A

Cindy Hughes, CPC, is a Coding & Compliance Specialist with AAFP.

Q: How would a physician code injections in addition to OMT? Are there specific codes and/or modifiers?

A: Ms. Hughes: The National Correct Coding Initiative (NCCI) edits from CMS bundle injections including lumbar epidurals into the OMT codes. If an injection is a distinct procedural service such as an unrelated joint injection or trigger point injection, a –59 modifier should be appended to the code for the lesser procedure.

Chapter 11 of the NCCI for Medicare Part B Carriers states: “Osteopathic Manipulative Treatment is subject to Global Surgery Rules. Per Medicare Anesthesia Rules a provider performing OMT cannot separately report anesthesia services such as nerve blocks or epidural injections for OMT. In addition, per Medicare Global Surgery Rules, postoperative pain management after OMT (e.g., nerve block, epidural injection) is not separately reportable. Epidural or nerve block injections performed on the same date of service as OMT and unrelated to the OMT may be reported with OMT using modifier –59.”

Q: What’s the difference between the –51 and –59 modifiers? Can you give an example of how to use each related to OMT?

A: Ms. Hughes: The –59 modifier is used to show that two codes which are listed in the NCCI edits as being bundled or exclusive are being appropriately billed due to a distinct procedural service. The –51 modifier is used to indicate multiple procedures. A patient might come to the office for scheduled procedures such as lesion removals and ask for an osteopathic treatment before the surgical procedures. For instance, the patient is scheduled for excision of benign lesions of the arm and leg but has back pain and requests an OMT service as well: codes could be 11403, 11402-59-51 and 98925-51.

Sources

All contents © 2000 Pennsylvania Academy of Family Physicians. All Rights Reserved.
OMT Coding Strategies To Boost Your Bottom Line; Implement these strategies for better OMT reimbursement. Douglas J. Jorgensen, DO, CPC. Osteopathic Family Physician News. Osteopathic Principles and Procedures - April, 2004. http://www.acofp.org/member_publications/0404_1.html
Consistency Counts for OMT Coding; Osteopathic family physicians need to be both highly skilled in medicine and practice management. Douglas J. Jorgensen, DO, CPC. Osteopathic Family Physician News. April, 2003. http://www.acofp.org/member_publications/0403_coding.html
Osteopathy: OMT Codes. http://www.drfeely.com/doctors/osteo_coding_1.htm
Osteopathic Physicians, Bundling And Modifier -25, Issue Paper: Reimbursement of Osteopathic Manipulative Treatment, Osteopathic Coding, American Osteopathic Association, Division of Socioeconomic Affairs

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OMT and Ear Infection In Children

A "HANDS-ON" APPROACH:

Researchers from Oklahoma State University are studying how osteopathic manipulation treatment (OMT) affects children with ear infections. OMT is a hands-on technique that allows fluids to drain from the head and neck, so bacteria and viruses are less likely to grow. Researchers studied 57 children. Twenty-five patients received routine pediatric care plus OMT, while 32 patients received only routine care. The patients ranged in age from 6 months to 6 years old and all had, had three ear infections in the previous six months. Researchers found those who underwent OMT had fewer recurrent ear infections, fewer surgical procedures, and more time before they opted for surgery than those who only received standard care. Researchers say results of this study suggest a potential benefit of OMT as additional therapy for children with recurrent middle ear infections. Marian Mills, who uses OMT, says, "I think my criteria for using antibiotics or for sending someone for surgery are the same as they always were. I just don't seem to have the same need to do these things."

Improved Lung Function in Children

Source:Journal of the American Osteopathic Association Vol 105 Jan 2005, 7-12.
New Research Links Osteopathic Manipulative Treatment with Improved Lung Function in Children.

While pharmaceutical treatments have significantly improved the symptoms of asthma and the inflammation associated with wheezing, very few doctors recognize the importance of proper movement of the chest, ribs, and diaphragm.

Osteopathic physicians are uniquely trained to treat the whole person, emphasizing the importance of the structure of the body influencing the function of the body. This is most easily seen with the act of breathing.

Crack a rib and one has a lot of pain and restricted motion of the thoracic rib cage. Break three or four ribs and it becomes a life-threatening situation. This is not because there is anything wrong with the lungs- quite the opposite. But, the restriction of the thorax, rib cage, and diaphragm muscle underneath the lungs cause the lungs to under-inflate. Then there is less oxygen to the tissues and toxic waste products build up in the body along with carbon dioxide. This results in more muscle spasm, inflammation, and mucous development. Now there is a vicious cycle to break.

A new study on children done at the Peninsula Hospital Center in Far Rockaway, N.Y. measured improved amounts of air forced out of the lungs during an asthma attack after osteopathic manipulation (OMT). A common method to calculate this is often used by the children at home with a peak flow meter. In asthma there is difficulty getting air forced out of the lungs quickly from the small airways. A hand-held device called a peak flow meter can tell the child if the asthma is worsening as the total volume of air pushed out of the lungs in one breath will be less.

Those children who received OMT, hands on treatment involving the ribs, back muscles, and diaphragm markedly reduced their asthma symptoms.

• They expended less energy breathing and were more comfortable
• Easier breathing reduced the child's anxiety level
• Small airways opened up increasing oxygen in the blood
• Chest wall motion improved making the lungs expand more
  

So why haven't these simple techniques of rib raising and thoracic myofascial release been used? Nine out of ten doctors in the U.S. are allopathic physicians or MDs and have no training or first hand knowledge of osteopathy. The old adage “if all you can do is hammer than everything is a nail” applies. Unfortunately, traditional medicine is not even referring to osteopathic physicians to provide care for the musculoskeletal system. DOs understand integrating forms of complementary medicine with standard medical care in treating the whole person.

As more parents become aware of alternative medicine they will demand more choices in treatment of their children. Osteopathic medicine and its 150,000 physicians offer a blend of holistic medicine and Western medicine. With asthma this includes mobilizing the ribs, chest wall, and diaphragm to improve the body's healing response.References

How safe is OMT anyways?

In short, research shows that Osteopathic Manipulation is extremely safe.

In more than 15 controlled trials of manipulation, there were no adverse effects from manipulation. A review of 128 articles published between 1925 and 1993 revealed that there were only 185 specific cases of major complications out of millions of manipulative treatments. Approximately 66% were cerebrovascular accidents, 12% disk herniations, 8% pathologic fractures or dislocations, and 3% general increase in pain. Of these, only 2 cases involved osteopathic physicians. Ladermann reviewed the world literature and discovered only 135 case reports of serious complications from manipulation. Most involved chiropractic cervical treatments and were due to misdiagnosis or the unrecognized presence of neoplastic disease. The most common complication was a delay in diagnosis and treatment, and the most serious was paraplegia from manipulating a patient with a bleeding disorder who developed a meningeal hematoma.

Source:Department of Osteopathic Manipulative MedicineUniversity of North Texas Health Science Center at Fort Worth

Myofascial Release

Myofascial Release: Also referred to as MFR, this procedure to designed to stretch and reflexly release patterned soft tissue and joint-related restrictions.

Example of Technique:
Physician twists, shears, and compresses joints while simultaneously feeling tissue and joints for shifting tightness and looseness.

Reason for Applying:
Applied to patients suffering from muscle tightness.

Effect of Treatment:
Joint-related movements are assessed and treated simultaneously. Joint and muscle movements are improved and pain is decreased.

Key Benefits

• Reduced pain
• Improved mobility
• Sense of wholeness
• Understanding MFR

Some examples:

Source: Carol J. Manheim, MS, PT, LPC

BACK STRAIN, chronic back pain, low back pain, thoracic back pain
Persistent, recurrent back pain can cause or be the result of asymmetrical soft tissue tension that does not respond to active stretching by the patient. Active myofascial trigger points can be the stimuli for continued muscle spasm. The pain–spasm cycle further distorts the patient’s posture and causes additional soft tissue injury. Using Focused Myofascial Stretching, the physical therapist can neutralize the trigger points and equalize the soft tissue tension, decreasing the postural asymmetries.

CARPAL TUNNEL SYMPTOMS
Anterior chest wall tightness, forward head posture and active myofascial trigger points can cause carpal tunnel symptoms. Myofascial Stretching of the anterior chest wall decreases the asymmetrical pull that causes protraction of the scapulae and contributes to the forward head posture. Myofascial Trigger Points in the pectoralis minor and the forearm can be neutralized at the same time. A home exercise program using Myofascial Release techniques is given as soon as the initial symptoms decrease by 50%. Focused Myofascial Stretching can also break the adhesions that form between irritated and inflamed tendons.

CHRONIC CERVICAL STRAIN, chronic cervical pain

Persistent cervical pain can cause or be the result of asymmetrical soft tissue tension that does not respond to active stretching by the patient. Active myofascial trigger points can cause radiating pain into the face, jaw, skull, shoulders, upper back and down the arms. Chronic cervical strain and forward head posture can cause vertigo and balance dysfunction. All of these problems must be addressed in a comprehensive physical therapy treatment program.

COMPLEX PAIN COMPLAINTS

When a patient does not completely recover from an initial injury, inefficient accommodation to the residual restriction of movement causes additional asymmetrical soft tissue stresses. Chronically irritated and inflamed tissues develop adhesions that further limit efficient movement. As this feedback loop continues, the patient’s pain complaint becomes diffuse and global. Pain causes fatigue, depression and impaired sleep.

Myofascial Release can address all of these problems as part of a comprehensive physical therapy treatment program. As a direct, "hands-on" treatment, Myofascial Release reverses the physical withdrawal behavior of many patients who are in chronic pain. As the asymmetrical soft tissue stresses decrease, the feedback loop is interrupted. Sleep patterns improve and overall pain decreases. Gradually, the layers of injury are peeled away like an onion until only the sequelae from the original injury are present and can be treated.

More about MFR

Myofascial release (MFR) and soft tissue techniques are similar to deep massage, but the hands of the manipulator do not slide along the skin surface. The goal is to stretch muscles and fascia to reduce tension. Most commonly, traction is applied to the long and transverse axis of muscles during soft tissue stretching and kneading. Deep tissue inhibition can also be used in conjunction to reduce somatic dysfunctions. More involved MFR techniques entail operator monitoring and adjusting tension along fascial and muscular planes. Soft tissue and myofascial techniques can also be adapted to promote venous and lymphatic drainage.

Source: Carol J. Manheim, MS, PT, LPC

How change occurs in our body and how we heal.

Myofascial Release is a whole body treatment method that recognizes that tightness and restrictions in one area of the body affects the entire body. Restrictions cause uneven stresses in the body and inefficient movement patterns. Our bodies maintain the most energy-efficient posture and movement patterns available to us. When a more efficient posture can be achieved using Myofascial Release, energy increases and pain decreases.

Our brains recognize our current posture, muscle tension, and movement patterns as being "normal" -- not necessarily as efficient or pain free. Myofascial Release requires re-education of the central nervous system to accept the new posture and muscle tension as better and less painful.

During the initial phase of treatment, the patient's brain says, "This isn't me! This feels weird. I'm not going to do this," and the changes achieved in a treatment session do not last. As treatment progresses, however, the patient's brain begins to recognize the new posture and lessened muscle tension as being less energy expensive and less painful. At that point, the changes achieved during treatment last longer. At the end stage of treatment, the brain recognizes the new posture and muscle tension as better, less painful and more energy efficient. When that occurs, change is maintained, the old posture is recognized as inefficient and painful while the new posture is more efficient and not (or less) painful

Anatomy of Fascia
Fascia (also called “connective tissue”) is a body system to which little attention has been paid to in the past. It is the tough, white membrane which we sometimes remove from meat before cooking. It is very strong, being able to withstand and exert a force of 2000 pounds per square inch.The fascial system extends from the toes to the top of the head, throughout the body, in a continuous spider web-like fashion. It surrounds all the tissues and organs of the body right down to a cellular level. Without the fascia, our body would crumple up into a pile on the floor.

The majority of the body’s fascia is oriented vertically. There are however four major crosswise (or transverse) planes which are extremely dense. These are the pelvic diaphragm, respiratory diaphragm, thoracic inlet and the cranial base. Sometimes all four planes can become effected over time as restrictions entwine themselves through the body, gradually torquing and twisting outwards. The dura mater (the connective tissue surrounding the brain and spinal cord) is also fascia. All of these regions can be treated with MFR techniques to free restrictions and restore equilibrium.

"Fascia Man"
A problem in the back can pull on all the connected fascia and cause symptoms in distant areas.



When Fascia is Injured
Because our entire body is interconnected, when the fascia becomes compromised following any injury (such as surgery, birth, trauma, disease, inflammation, etc.) it can put tension on adjacent pain-sensitive structures, as well as creating a drag on distant areas. Long after the original complaint, some patients have bizarre symptoms that we can now identify as being caused by the fascial system—symptoms like burning, tingling, pulling, cramping, poor posture, difficulty breathing, and cranial symptoms. A visual analogy may be when you pull on your sweater at the bottom you can feel it “dragging” and tightening up around your neck and shoulders.




The “Sweater Effect”: any pulling in one place can create drag in distant areas.

We slowly tighten, losing our flexibility and spontaneity of motion, and setting ourselves up for more trauma and pain as we are pulled out of our three-dimensional orientation with gravity.

References
ACOFP website

Does Osteopathic Manipulative Treatment Work?

Does OMT Work?


Consider the results of a study published in a 2003 issue of Archives of Pediatrics & Adolescent Medicine.

Researchers observed the effects of OMT as an added treatment for children suffering from frequent ear infections. Patients were divided into two groups. One group received routine care for the infections while the other received routine care plus OMT. The results found a potential benefit of using OMT as an added treatment by possibly preventing or decreasing the need for surgical interventions or the overuse of antibiotics.

In addition, The New England Journal of Medicine published a study in November 1999. In the study, researchers looked at how well OMT works to treat low-back pain. Patients were divided into two groups. One group got standard treatments, such as hot and cold packs, physical therapy, and drugs. The other group received standard care plus OMT. Twelve weeks later, patients in both groups felt better. But those in the OMT group used less medication and less physical therapy. That meant they had fewer side effects and lower health care costs.

OMT Technique: Cervical Soft Tissue

Source: ACOFP website http://www.acofp.org/member_publications/print/0904_1_6.html

Dysfunction: Cervical soft tissue tension.

Objective: To decrease cervical tissue tension.Patient

Position: Supine.Physician Position: Seated at the head of the table.

Procedure:

• Start at C7 and work your way up.
• Place the pads of your fingers over the cervical paraspinal tissues bilaterally.
• With both hands, apply an anterior and superior pressure until you sense the stretch of the cervical paraspinal muscles.
• Hold this position until you feel the inherent release, then slowly release your force, being careful to not allow the muscles to "snap back.”
• Repeat the procedure several times working up and down the cervical spine, until you palpate a decrease in tissue tension.

OMT for ENT: Upper Respiratory Infections

Source: www.acofp.org/member_publications/0904_1.html

MUSCLE ENERGY, UPPER THORACIC SPINE
Standing Structural Examination Step-by-Step Technique Directions


Dysfunction: T3 extended, side bent left, and rotated left. This technique may be used on the upper thoracics either flexed or extended.

Objective: Increase the flexion, side bending right and rotation right of T3 on T4.

Patient Position: Seated

Physician Position: Standing behind the patient.


Procedure:

Place the middle finger of your left hand between the spinous processes of T3-T4; index finger is between T2 and T3, and the third finger is between T4 and T5.

Place your right hand on top of the patient’s head to passively produce flexion, right side bending, and right rotation of T3 to engage the barrier.

Direct the patient to extend the lower cervical and upper thoracic areas to include T3. Offer a counter force equal to the patient’s force.

Maintain the forces long enough to sense the patient’s contractile force at the localized segment

Direct the patient to gently cease the directive force while simultaneously ceasing your counter force.

Wait 2 seconds for the tissues to relax, and then take up the slack to engage the new barrier.

Repeat until the best possible increase of motion is obtained.

For flexed dysfunctions, passively extend the patient’s head and neck down to the segment you are treating.

With your hand on the patient’s forehead, instruct the patient to flex against your holding force.

Yet Another Individual OMT Technique:Facial Effleurage

Source: http://www.acofp.org/member_publications/print/0904_1_13.html



Dysfunction: Congestion of the superficial soft tissues of the face.
Objective: Enhance lymphatic drainage.
Physician Position: Seated at the head of the table.
Patient Position: Supine.

Procedure:
Place the pads of your index fingers bilaterally over the patient's forehead.

Apply medial to lateral pressured stroking. This is intended to moves interstitial fluid of the soft tissues of the face into the superficial lymphatic drainage.

Repeat steps one and two over the cheeks and chin.

OMT Technique: Submandibular Percussion

Source: http://www.acofp.org/member_publications/print/0904_1_14.html

Dysfunction: Congestion of the superficial soft tissues of the face.
Objective: Enhance lymphatic drainage.
Physician Position: Seated at the head of the table.
Patient Position: Supine.


Procedure:

• Place the tips of the fingers of your right hand so they contact the skin over the submental region just medial to the body of the mandible on the right.
• Apply a rapid oscillating percussive force in an upward direction.
• Note: Be sure that the patient's upper and lower teeth are in contact to avoid possibly chipping them.
• Repeat steps 1 and 2 on the left side.

Correctly Coding for OMT: Consistency Counts for OMT Coding

Summarized from this source: Consistency Counts for OMT Coding by Douglas J. Jorgensen, DO, CPC , ACOFP website.

Five Steps to Correctly Coding for OMT visits:

1. Perform and document a thorough history and examination.
2.Determine, perform and document theraputic and diagnostic intervention.
3. Put Somatic Dysfunction and the OMT Code first on encounter forms "Somatic Dysfunction as noted above" in your dictation.
4. List secondary diagnosis on encounter forms and in dictation.
5. Use the -25 Modifier on the E&M Code for your secondary diagnosis.

OMT codes are Current Procedural Terminology (CPT) codes designed to reimburse us for performing manipulative medicine on our patients. See Table 1 below for codes:

They are broken down by numbers of regions and are intended to correlate with the somatic dysfunctions ICD-9-CM codes regarding the specific regions treated. See table 2 below.

Documentation

When documenting OMT, use the documentation guidelines three key components of history, examination and medical decision making (MDM).

The history should have a chief complaint, history of present illness, review of systems and a past medical, family and/or social history. Your physical examination would include your musculoskeletal structural examination and any germane body area or organ systems. The history and physical examination should contain information germane to the complaint or be part of a workup to rule out specific pathology. One should not add components to the history or physical simply to enhance the documentation.

The MDM must evaluate the number of diagnoses, the amount of data to be reviewed and the level of risk involved depending on the type of problems found as well as medical and/or therapeutic intervention needed. Once the history, examination and MDM are scored an E&M code is assigned.

Evaluation &Management Codes

Consults come in two types: outpatient consults (99241-99245) and confirmatory consults (99271-99275). The first type (99241-99245) is used when another provider sends someone to be evaluated and treated. The confirmatory consult is for a new patient with a specific complaint, but you could use the outpatient codes for a new patient (99201-99205) also.Confirmatory consults are acceptable and are assigned a more optimal RVU designation than new patient codes. If you use the consult codes you must send a letter to the referring provider. A ‘cc’ or photocopy of your note is unacceptable unless you send a letter or fax stating you saw the patient and that your note is en route. This can be a form letter (see Figure 1), but even if the referring doctor is within your group practice, a written response from the consultant is still required. Lastly, dictating your office visit into letter format provides another option.

25 Modifier

Modifiers are designed to better describe a code or how that code is being used in conjunction with another code or modifier. Typically it is used for two unrelated problems such as a treating a UTI at the time of an excisional biopsy.

With OMT, the diagnosis somatic dysfunction is listed first with the correlating ICD code(s) and CPT code without a modifier. The second, third and/or fourth diagnoses are listed and these justify or create medical necessity for the E&M service billed (your consult, in or outpatient codes). The E&M code gets a modifier here just like the UTI example, but the E&M code need not be for a separate problem and can in fact be what prompted the OMT.

A Final Example:

Is managed care dooming osteopathic manipulative treatment?

Source: www.physweekly.com/archive/97/04_14_97/pc.html
Source: Physician Weekly, 1997 article.


Ray Stowers, D.O., FACOFPFP, Medford, Okla.; Consultant, American Osteopathic Association Payer Relations Department; Commissioner, Physician Payment Review Commission

Opinion: NO

Some osteopathic physicians have run up against the obstacle of a single capitation rate for FPs, be they DO or MD. These managed-care firms don’t take into account the additional time and service OMT represents. Some managed-care groups won’t pay for an office visit and OMT on the same day. But osteopathic physicians across the country are winning most of the battles to have OMT-already recognized in CPT and by HCFA as a freestanding and separate procedure-approved by managed care as a covered service. Managed-care groups in general are starting to become aware that OMT and other aspects of osteopathic medicine are not only excellent care, but cost-effective. Over the past year, AOA payer relations has seen a dramatic reduction in physician complaints about managed-care reimbursement or access to managed-care panels.
I am not a fan of managed care. But its basic philosophy is usually in step with osteopathic medicine in paying for services uniquely provided by DOs. Managed care can build OMT and other special osteopathic medical services into the capitation rate. The osteopathic profession only rarely has difficulty resolving problems with managed-care organizations once we bring them up to speed on the cost-effectiveness of osteopathic medicine and OMT.
Mature managed-care plans appreciate this. DOs practicing where there are newer managed-care plans-mainly interested in discounting and restricting services-will face more difficulties. But even though there may be some up-front reimbursement problems, the future of osteopathic medicine and OMT is bright.




Judith O’Connell, D.O., FAAOPrivate Practitioner, Dayton, Ohio; Trustee and Past President, American Academy of Osteopathy

Opinion: YES

Managed-care entities consider me a specialist because my practice is entirely osteopathic manipulative treatment. As long as I have prior authorization, they generally are happy to reimburse for my services. But managed-care organizations are less enthusiastic about OMT as an integrated service in family practice. HMOs like a profession that does only one thing, or a specialist who does only one thing, because it makes it easier for them to restrict services and to predict expenditures. So HMOs look askance at GPs and OMT. As a result, practitioners are inhibited from using these techniques that have served osteopathic medicine well. At best, OMT is being forced into being a back-room procedure, or one for which osteopathic FPs are afraid to bill managed care. At worst, OMT is being abandoned. Insurance carriers are telling DOs that OMT is just an extra procedure done to earn extra money. Sadly, one cannot stay in business by providing a service and not charging for it. FPs are phasing out OMT for their managed-care patients in fear of being singled out as “overutilizers.” HMOs are prejudiced against preventive medicine as well as continuing maintenance care. And, indeed, some practitioners of manual medicine have overused it, which has tainted the procedure. But there is mounting evidence from workers’ compensation that osteopathic care, even when medical and surgical care is factored in, is the most cost-effective manual medicine compared with practices by allopathic physicians, chiropractors, and physical therapists. Managed care is penny-wise and pound-foolish when it comes to OMT.

Statistical Usage of OMT by Osteopathic Physicians in Different Specialties

Source: JAOA

Please visit the JAOA website today for more articles.

Journal of the American Osteopathic AssociationWeb site for Journal of the American Osteopathic Association.www.jaoa.org/

Note: Click on the Image below to see a bigger image.

In Her Own Words

Source: www.osteopathiccenter.org/whatis.html

What is Osteopathic Manipulation?
by Viola Frymann, D.O., F.A.A.O., F.C.A.

The human body is a living machine which is supremely adaptable to changes within and around it. For example, if you shift your weight from two feet to one, a series of complex changes will occur within the muscular and bony systems of the body from head to foot to enable you to establish balance under the new circumstances.

A similar complex adaptation mechanism goes into operation in response to an injury. However, if the injury produced a local change which passed beyond the limit of spontaneous resolution, the various adaptations made in all other parts of the body structure persist as new demands are made upon this living mechanism.

In response to these numerous structural changes, changes in circulation and nerve impulses also occur which in turn produce areas of greater susceptibility to infection, or hypertrophy or degeneration. The whole range of these later changes makes up the diverse and complex array of human disease.

This is the osteopathic concept of disease- an effect, which is the climax to a whole series of changes in response to the various stresses of life superimposed on an original cause.

In the treatment of the patient - attention is given to the total patient and not just to this manifested effect. The osteopathic physician searches for these fundamental causes while he is also alleviating the local, presenting complaint. Through the use of his trained, perceptive, discriminating fingers he will search for, find, and endeavor to correct the fundamental causes thus producing a more enduring and complete change within the body which will permit a reversal of those adaptive changes and restoration of health. At the same time he many employ in addition any of the modern methods of treatment, medicinal or surgical , as indicated, to
alleviate the local distress, but the need for these is reduced because of his attention to first causes.

The injuries sustained at birth ranging from the imperceptible which can only be detected by trained skillful fingers, to the gross which are immediately obvious to the naked eye may provide the first cause on which numerous adaptive effects are superimposed. A car accident in which a whiplash type of injury was sustained is another of these often obscure primary
causes which through the years accumulates adaptive changes until the time comes
when the accumulation of effects manifests as a gastric ulcer, a heart condition, an arthritis, a colitis, or any other named disease.

Numerous less well-defined complaints such as nervousness, fatigue, insomnia, indigestion,
backache, headache, etc. may have persisted so long that they have been taken for granted. But when the structural disturbances produced by that original injury are corrected, the patient is surprised to find that those persistent, habitual complaints have gone.

These are but two examples of the influence of causes in the production of effects namely early injuries and second disease. Their number can be multiplied indefinitely by the multitude of diverse mishaps that occur to human beings and the unlimited range of combinations and variations which may accumulate as the body strives to adapt and accommodate to the stresses and needs of daily life. These effects may be further complicated by nutritional deficiencies, toxic influences such as smog, disinfectants, pesticides, drugs and so on, and by emotional and mental circumstances. Such factors as these must all be considered, by those primary causes need to be found and eliminated if a state of positive health rather than a mere absence of disease is to be achieved.

This is the purpose of osteopathic manipulation, namely the diagnosis and treatment of the structural and functional changes within the body by the trained, perceptive, discriminating skillful hands of the physician- the mechanic of the human machine.

OMT treatment techniques : High Velocity-Low Amplitude (HVLA)

Source: www.acofp.org/member_publications/omt_6.html
Note: This blog author feels that www.acofp.org/member_publications is the best website today for OMT techniques.

The goal of Osteopathic Manipulative Treatment (OMT) is to restore motion and balance to affected areas of the musculoskeletal system. With balance, fluid and healing elements can return to the area and the toxic byproducts of injury can be drained away. To do this we use a variety of techniques:

Note: Picture taken from ACOFP website.

Thrust Technique
In this form of manipulation, the physician applies a high velocity/low amplitude force to restore specific joint motion. With such a technique, the joint regains its normal range of motion and resets neural reflexes. The procedure reduces and/or completely nullifies the physical signs of somatic dysfunction tissue changes, asymmetry, restriction of motion and tenderness.

Example:

High Velocity-Low Amplitude (HVLA): In this technique the physician uses his or her hands to find joints that are not moving as well as or symmetrically with other joints. He or she then engages the barrier to motion in the joint and uses a quick but short thrust to overcome that barrier. Often a popping noise will ensue as motion is restored to the joint.

HVLA is a general type of manipulative treatment that involves a quick thrust over a short distance through what is termed a pathologic barrier. The movement is within a joint's normal range of motion and does not exceed the anatomic barrier or range of motion. With proper positioning of the patient, high-velocity-low-amplitude requires very little force and can be specifically targeted to spinal segments. The goal of the treatment is restoration of joint play or a desirable gap between articulating surfaces.

Of all the osteopathic techniques, high-velocity-low-amplitude most closely resembles the chiropractic technique and has the greatest number of contraindications, including rheumatoid arthritic involvement of the cervical spine, carotid or vertebrobasilar vascular disease, the presence or possibility of bony metastasis or severe osteopenia, and a history of pathological fractures. One difference between osteopathic manipulative therapy and chiropractic therapy is that chiropractors may manipulate an affected joint beyond its physiologic and anatomic range of motion. Doctors of osteopathy look for restrictions within the normal or physiologic range of motion of the joint and attempt to correct them by moving the joint through the abnormal pathologic barrier, usually not beyond the physiologic range. This may explain the low incidence of adverse effects from OMM.

Modified Upper Thoracic HVLA Techniques in Action:

Source: ACOFP Website

Procedure:

Using chest as Fulcrum, as she breathes in, she’ll fall back on you. At end of expiration, take hands over elbows and thrust toward your head using your chest. Take hands and thrust up through the hands and use the chest to push forward.

What is it like to get an osteopathic manipulative treatment?

Source: www.andrewtaylorstill.com/omm.htm

For a runner who is experiencing foot pain following routine training, OMM could be very appropriate. A D.O. would begin by examining your foot and by comparing the painful foot with the non-painful foot. The D.O. would identify the various bumps and grooves in the bones of the foot, that are common to all people, via palpation or touch. The D.O. would most likely also examine the Knee, and your lower back as well as the foot. After thoroughly explaining their findings to you, the D.O. would then begin the treatment. This treatment could consist of turning your foot in such a way as to allow a particular bone of the foot to be pushed back into it's proper position to relieve nerves, or could consist of a similar technique performed at the back or knee. In explaining how a disorder of the lower back would result in foot pain it was Dr. Still who said it best by saying "If your foot stepped on a cat's tail, you would hear the noise at the other end of the cat, wouldn't you?" However it is the simple relocation of the bone or other body structure (such as muscle or fascia) by the physician's hands that is formally referred to as OMM.



How does OMM work?
The structures that you can feel within beneath your skin are not just limited to bone and muscle however, as there are several thick fibrous sheets of soft connective tissue that basically keep your body parts from traveling around like toys in a big bathtub. (If you have ever wondered why your veins, arteries, and nerves of your shoulder never fell down into your abdomen...it is partly because of these sheets of tissue formally called fascia) Interestingly enough, these sheets of connective tissue can in many cases toughen limiting circulation and irritating nerves.
There are many disorders that are the result of a lack of circulation and local nerve irritation. Your circulation plays a greater role in muscular pain than one might normally believe. Pain in many cases is the result of chemicals released in the body following injury. These chemicals travel via your circulatory system and thus any change in flow of that system can result in a delay in the removal of those chemicals. Persistent pain can be the result of this decrease in circulation...and thus often any procedure that increases local circulation (like removing the "kink in the hose" of the artery or vein) will reduce the pain. Restoring local circulation is one area in which OMM has had much success.

Lower back pain is very common complaint of many patients and can be the result of local nerve irritation. The problem itself can be very complicated, but simply put it is basically a matter of space within your body. Which is to say that there is limited space within your body and that movement of the intricate arrangement of parts within your back can cause direct contact with those parts and the complex network of nerves that radiate down into the legs from the spinal column. This direct contact of any body part with these nerves caused pain and can result in painful spasms that last for hours or even days. OMM consists of placing these body parts back into their original place so that the pressure on those nerves can be relieved reducing spasm and correcting the problem. In this oversimplified example, OMM can quickly resolve a problem that would ordinarily be treated with a $1,000 MRI and some pain killers. Again it is important to emphasize that today the osteopathic manipulative technique exists only to augment and not to replace modern medical therapies.

OMM therefore is most simply described as identifying and correcting the day to day shifts in position of our body parts that can cause symptoms such as pain. These changes in position can be the result of trauma as well, such as from a fall or from a collision. It is also important to note that pain is not the only symptom that can result from nerve irritation as there are nerves that carry the other sensations, such as nausea, that can be irritated anywhere along the path that the nerve travels within the body up to the central nervous system. (The various nerve sensations and how they are influenced is currently being researched by scientists and osteopathic physicians alike) These structural abnormalities are then corrected via simple massage, touch, and other release techniques all aimed at restoring normal motion and position.

The ABC’s of OMT and How It Can Work for You

Source: www.healthynj.org/health-wellness/omt/main.htm

OMT is predicated upon your D.O.’s knowledge of medicine. Once your D.O. has ruled out mechanical causes for your illness or injury (through blood and urine testing, X-rays, etc.), and based upon physical and mechanical findings, your D.O. may decide to utilize OMT. While it is commonly associated with physical ailments such as low back pain, this modality can also be used to relieve the discomfort or musculoskeletal abnormality associated with a number of disorders, including: asthma, sinus disorder, carpal tunnel, migraines and menstrual pain.
The osteopathic approach to treating many diseases includes medication and/or surgical intervention, plus OMT. OMT can relieve muscle pain associated with a disease and can hasten your recovery from illness by promoting blood flow through tissues.

Your Structural Exam
Diagnosis
Your structural exam will begin with an assessment of your posture, spine and balance. Your D.O. will then use his fingers to palpate your back and extremities. Your D.O. will then use his fingers to palpate your back and extremities. He will also check your joints for restriction and/or pain during motion as well as check your muscles, tendons and ligaments where tenderness can signal a problem. Through extensive osteopathic training in manipulative medicine, D.O.s can detect changes in tissue, however small, that signal injury or impairment.
Once the structural exam is complete, your D.O. will integrate this information with your medical history and a complete physical exam. After that point, a treatment plan can be established.

Treatment
Using a variety of OMT techniques, your D.O. will apply manual forces to your body’s affected areas to treat structural abnormalities and will then apply specific corrective forces to relieve joint restrictions and misalignments. Based upon the severity of your problem, you may require more than one treatment.

A History of Hands-On Healing
The earliest medical writings from centuries past describe the efficacy of manual medicine. In 1874, osteopathic medicine’s founder, Dr. A.T. Still, recognized the power of hands-on care and incorporated it into his philosophy of medicine. Dr. Still identified the musculoskeletal system as a key element of health; he recognized the body’s self-healing capacity; he emphasized prevention, exercise and keeping fit; and he identified palpation and human touch as vital and less intrusive elements of diagnosis and treatment. As the impressive growth of osteopathic medicine demonstrates, Dr. Still’s founding tenets have withstood the test of time and scientific scrutiny.

Osteopathic Medical Education
D.O.s complete four years of medical training at one of the nation’s fully accredited colleges of osteopathic medicine. The osteopathic curriculum is intensive and broad-based. It includes comprehensive training in the musculoskeletal system and the use of OMT. Manipulation combined with the osteopathic principles of holistic care, prevention and primary care makes osteopathic medicine unique. Upon graduation from medical school, D.O.s complete a one-year rotating internship through all the areas of primary care. Afterwards, they may complete a residency in any of more than 120 specialty and subspecialty areas of medicine. However, sixty-four percent of all D.O.s remain in primary care practices.

OMT and Lower Back Pain

Source: www.jaoa.org/cgi/content/full/104/11_suppl/13S

Low back pain is a common and costly condition in industrialized nations. Consequently, a variety of treatment modalities and providers are available. A widely recognized clinical practice guideline states that spinal manipulation, as potentially provided by various types of practitioners, can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms. The underlying principles of osteopathic manipulative treatment (OMT) suggest the potential utility of OMT in both acute and chronic low back pain.

This philosophy suggests that OMT may be useful in treating patients with low back pain. Ideally, OMT should be used in the acute stage of low back pain, early in its natural history, to prevent progression. This ideal is consistent with guidelines regarding the use of spinal manipulation for acute low back pain. Nevertheless, the potential interactions between structure, function, environmental demands, and the patient's psychosocial response that may lead to chronicity suggest that an integrative osteopathic approach also may be useful at this stage in the natural history of low back pain.

Benefits of Osteopathic Manipulative Treatment for Hospitalized Elderly Patients With Pneumonia

Source: http://www.jaoa.org/cgi/reprint/100/12/776

Physicians today are under constant pressure to discharge patients early from the hospital, because of the current prospective payment system and the influence of managed care. As soon as clinical improvement warrants, patients are empirically changed to oral antibiotic therapy in preparation for hospital discharge.

An interesting clinical trial found that osteopathic manipulative treatment (OMT) is thought to be beneficial for patients with pneumonia by showing that the treatment group had a significantly shorter duration of intravenous antibiotic treatment and a shorter hospital stay.
Most participants received one visit from the OMT specialist within the first 48 hours of diagnosis and another visit before discharge. The OMT seemed to be well tolerated in this elderly, acutely ill, frail population. It has been theorized that OMT may improve the immune response to infection, as evidenced by a more robust fever and WBC response, and this study found some evidence to support the idea.

See the full article on JAOA.

Sports and OMT

Source:
Osteopathic Manipulative Treatment Helps Olympic Speed Skater to Compete Despite Injury
From: Mary Ann M. Pagaduan of the American Osteopathic Association, 800-621-1773, ext. 8040, or 312-202-8040

CHICAGO, March 1 -- Olympic speed skater, Apolo Anton Ohno received osteopathic manipulative treatment (OMT) prior to last week's 1,500 meter Short Track race in which he won the gold medal. After Ohno suffered a gash on his leg requiring stitches during a collision in a previous race, Lawrence Lavine, D.O., an osteopathic physician (D.O.) and Ohno's personal physician from Tacoma, Wash., flew to Salt Lake City to assist U.S. team physicians in treating him.

Dr. Lavine, who is board certified in osteopathic manipulative medicine, explains that he used advanced forms of OMT to treat Ohno. "Basically, I used osteopathic manipulative medicine to release the injury pattern," asserts Dr. Lavine. "By relieving structure and tissue restrictions, you allow the body to begin healing itself more rapidly."

Developed by Dr. Andrew Taylor Still in 1874, osteopathic medicine is based on a philosophy that focuses on the unity of all body parts. He identified the muskuloskeletal system as a key element of health. The type of care Dr. Lavine provides strongly reflects these principles. "When I treated Apolo, it was not a matter of dealing with just the leg, it was a matter of going through his entire body and cleaning out every bit of strain pattern," contends Dr. Lavine. "The whole purpose of what we do is to restore the health, remove the strain and let the body heal itself."
A study published in the Nov. 4, 1999 issue of the New England Journal of Medicine shows OMT to be an effective form of medical treatment. Patients who participated in the study, who received OMT, required significantly less medication and used less therapy, resulting in lower costs and fewer side effects.

Dr. Lavine points out that if you can enable the body to heal itself, there is less need for medication, which is beneficial to athletes like Ohno. "What I did was enable Ohno not to take anti-inflammatory drugs," explains Dr. Lavine, "which was important in this case because any drug you put into an athlete at his level is going to slow him down."

Ohno's father, Yuki Ohno, describes his son's recovery. "Sunday, when the treatment started, his leg was swollen and sore. On Monday he was still experiencing some pain," he recalls, "but then by Tuesday, the pain was gone, there was no swelling and he started practice again."
During the months leading up to the Games, Dr. Lavine worked intensively with Ohno. "Ohno originally came to me so I could relieve discomfort he was experiencing in his back and restore normal function," recalls Dr. Lavine. Utilizing a variety of osteopathic manipulative treatments, Dr. Lavine focused on removing restrictions across Ohno's entire body to help relieve his discomfort and restore normal function. "I don't make him a great skater." Dr. Lavine clarifies, "He makes himself a great skater. I just help to relieve the restrictions that block the full expression of his talent."

Steven Karageanes, D.O., team physician for the Detroit Tigers, also recognizes the benefits that OMT offers athletes. "Manipulation is extremely beneficial to athletes because of the time constraints they have when healing," says Dr. Karageanes, a sports medicine and orthopedic osteopathic specialist. "OMT helps to speed up recovery by restoring function faster, and also aids in diagnosis, as well."

Per Gunnar Brolinson, D.O., a team physician for the U.S. Ski Team and a volunteer physician for the U.S. Olympic Committee, points out that athletes who do not suffer from specific injuries can also benefit from OMT. "An athlete having performance problems may have structural imbalances," says Dr. Brolinson. "OMT can fix that. I've used it on skiers literally in between runs."

Just as Dr. Brolinson treats skiers between runs, Dr. Lavine and the U.S. team physicians treated Ohno between races. As an osteopathic physician, Dr. Lavine stresses the importance of meeting the needs of the patient. "It's definitely a team effort," he recognizes. "It's all of us working together in the best interest of the patient."

Flu and OMT...maybe for Bird Flu??

Source: www.acofp.org/member_publications/ca1_nov_02.html

Flu is a killer, despite the fact that many dismiss it as a mild ailment, attributed with killing 500,000 Americans in 19181. Flu, the colloquialism for influenza (ICDM code 487.1) is defined in Dorland’s Medical Dictionary, as an acute viral infection of the respiratory tract occurring in isolated cases, epidemics, and pandemics, with infections of the nasal mucosa, pharynx, and conjunctiva, headache, and severe, often generalized myalgia.3 Synonyms include “grip” and acute catarrhal fever. Influenza viruses are orthomyxoviruses4, classified as types “A,” “B,” or “C” depending on reaction of complement fixing antibodies to the virus’s nucleoprotein, and matrix proteins. The virus’s genetic make up is a single-stranded RNA virus.Frequently dismissed as minor or misdiagnosed as other respiratory infections, this illness affects 10 to 20 percent of Americans yearly, resulting in about 110,000 hospitalizations, and causing about 20,000 deaths.

Osteopathic Manipulative Therapy

Specifically the thoracic lymphatic pump and rib elevation OMT techniques, can be beneficial by encouraging proper tissue activity and metabolism, and providing a proper immunologic environment. OMT has been shown to improve motion, enhance blood and lymph flow associated with thoracic cage motion, more rapid clearing of airway secretions, and maintaining proper lung function, ultimately enhancing healing. Treatment should be directed to the entire body in a holistic approach, and should not be limited to the cervical, upper and lower thoracic regions, lumbar, and sacral regions in addition to the thoracic cage. These modalities should be offered to individuals suffering from chronic respiratory disease, a population susceptible to influenza. Naturally, appropriate hygienic procedures and prophylactic measures should be taken by the manipulator. Magoun demonstrates osteopathic techniques specific for influenza, noting the benefits and giving pictorial demonstration again of the lymphatic pump, as well as fourth ventricle compression using one hand on the forehead and one on the mastoid region with upward motion. The importance for craniocervical junction release was stressed. And a technique assisting postnasal drip where the osteopathic physician using one hand occludes one nostril, while applying force on the contralateral temple was described. This reference indicates that treatment once to thrice daily is appropriate for 20 to 30 minutes at a time.

Carpal Tunnel Syndrome and OMT

Source: The Journal of the American Osteopathic Association 1994 Aug;94(8):673
Maria T. Gentile, D.O. website.

Osteopathic manipulation for patients with confirmed mild, modest and moderate carpal tunnel syndrome can help reduce pain and do much more.

This study was to show that patients who received traditional conservative therapy (TCT) plus osteopathic manipulative treatment (OMT) for their carpal tunnel syndrome (CTS) would have decreased signs and symptoms of CTS as compared to patients who received TCT alone.

The OMT group received TCT plus systemic OMT every 2 weeks for two months. Pre-and post-treatment EMG/NCS, positive provocative tests, and pain surveys were compared between these groups. By EMG/NCS, 38% of Group II improved in their CTS classification compared to only 20% Group I improvement. These findings suggest that TCT plus OMT can improve patients' mild, modest and moderate CTS compared to traditional therapy alone.

OMT and Alzheimer’s disease (AD)

Source: Alzheimer's: A Family AffairAnd Growing Social Problem By Mohammed A. Jayber, DO

Alzheimer’s disease (AD) is one of the most difficult conditions that osteopathic physicians are asked to diagnose and treat. Its toll on patients, families, and society has been enormous. Although dementia in general is common, it is often overlooked. Unfortunately, most cases of AD are only diagnosed when the dementia is fully apparent. Typically, the early stages go undetected until AD has progressed to a severe, disrupting disorder. This is because specific biological markers for AD do not exist. The caregivers drive themselves to physical and emotional exhaustion. However, patients with AD are not beyond help as researchers struggle to understand the disease. They are looking for treatments that will prevent it, slow its progress, or treat it outright.

Role of OMT in treating AD.

Osteopathic physicians can play an important role in AD management. At their disposal, they have numerous OMT techniques that can help nurture and maybe repair the visceral damage done by AD.

Somatic adjustments can restore the balance in the neuro-hormonal-lymphatic axis. Some techniques that can be employed include muscle energy, HVLA, strain/counterstrain, lymphatic pump and cranio-sacral.

Areas that can be adjusted include the OA joint, AA joint, cervical spine and cranio-sacral. These techniques usually work best in the mild to moderate AD patient for obvious reasons. The osteopathic physician must take care to explain his clinical intent to the patient and the patient’s family. Again, the art of medicine may come into play here.