Protocols For Osteopathic Manipulative Treatment (OMT)

Source: Notes Contributors
The development of this document by the American Osteopathic Association was prompted by the growing need among non-osteopathic peer reviewers and entities for guidance in the appropriate frequency and uses of osteopathic manipulative treatment (OMT). While these materials provide a framework, they are not absolute rules and should not be used to set absolute restrictions or other restrictions criteria that would override an osteopathic physician's professional judgment on case management. As with all medical treatments, patients may present with a broad variety of complicating factors and physicians should be afforded sufficient latitude to apply varying treatment styles and approaches to patient care.
The use or omission of any of the techniques described herein for the purposes indicated herein should not be construed as adherence to the standard of care or failure to adhere to the standard of care. Finally, these materials are only a basic reference and can not substitute for the education and training of an osteopathic physician.
Use of the enclosed guidelines, accompanied by proper documentation from the physician, should provide the reviewer with the information necessary to make an accurate determination. For further information please consult the osteopathic profession’s standard textbook: Foundations for Osteopathic Medicine, Robert C. Ward, DO, FAAO, Executive Editor, (Copyright 1997, Williams and Wilkins)

Osteopathic physicians utilize all recognized medical procedures and available technologies to provide comprehensive health care to their patients. The osteopathic profession is recognized by its distinctive philosophical approach. 1,2,19,33,34,39 This approach led to unique contributions by the osteopathic profession in the development of techniques used in osteopathic manipulative treatment, and by their integration into a physician-directed management of the total patient. 3.4 Osteopathic manipulative treatment involves the use by the physician of manual procedures to optimize patient health and function. 5,6,32 It should be emphasized that osteopathic manipulative treatment is a distinctive medical procedure and should not be confused with services provided by non-physicians. 7 Osteopathic manipulative treatment is a general term currently encompassing approximately twenty-five different types of physician-performed manipulative treatment. 19 Osteopathic manipulative treatment (OMT) is defined in the "Glossary of Osteopathic Terminology", the profession-wide accepted resource for osteopathic terminology, which is published by the American Osteopathic Association.


Structural Dysfunction
Structural diagnosis involves the use of expanded observation and palpatory examination of the neuro-musculoskeletal system with its venous, lymphatic and pulmonary interactions, 8, 9, 10,11, 12, 13, 14, 15, 25 as part of evaluation of the entire patient. The goal is to identify the presence of significant impediments to health and well being in the entire patient through an understanding of the interrelationships between the musculoskeletal system and all other systems of the body. 16,17 This includes but is not limited to the identification of somatic dysfunction and related visceral disease/dysfunction. 10,32, 38, 35 The performance of the history and physical examination of a patient should not be viewed as an isolated examination of the musculoskeletal system since many organ systems are examined. 18 The definition of somatic dysfunction is correlated with the entire patient as follows:
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. 19 21, 25, 36, 37, 38
During the process of diagnosis of altered structural function, somatic dysfunction is identified by one or more of the following physical findings: asymmetry of related parts of the musculoskeletal system, range of motion abnormalities, tenderness and/or tissue texture abnormalities.20, 21 Alteration in the range of motion may be exhibited by either restricted or increased motion. Alterations in quality and range of motion are the most common and often most significant findings indicating the presence of somatic dysfunction. 33, 39 Pain or tenderness or their provocation can be of assistance in the diagnosis but their provocation is not diagnostic in and of itself. Somatic dysfunction is also made clinically relevant by interpreting the effects of personal injury history 19, 22, 23, 24, 25, 33, 39

OMT Case Management
Osteopathic manipulative treatment involves the same principles utilized in diagnosing and treating any disease. This diagnosis must be specific. Once an accurate diagnosis is made, the physician will determine the appropriate techniques and treatment. It is not usually appropriate to create a "treatment plan" for OMT. Several different treatment techniques may be integrated for use in the same patient. Adjunctive modalities may be employed in the total case management of the patient's condition.
The choice of osteopathic manipulative technique is based on multiple factors. These include the age and physical condition of the patient, and the effectiveness of previous forms of treatment. The physician must also keep in mind his or her own experience and expertise in each of the treatment methods, and must choose those that can be performed effectively. Due to the complex interrelations of body systems, and the body's innate ability to make compensatory changes during each treatment, tissues both adjacent to and remote from the area of primary involvement may require concomitant treatment.
The three key components of an E/M service: history, examination and medical decision making are essential in the decision making process and management of the patient prior to the performance of subsequent OMT. Therefore it is appropriate for an E/M service to be performed at each follow-up patient encounter. An appropriate significant, separately identifiable E/M service, documented according to the E/M Documentation Guidelines should be provided and reported. This is all necessary in determining: If additional OMT needs to be provided and if so, 1) What body regions need to be treated, 2) What OMT technique(s) should be utilized, and 3) If OMT needs to be augmented with other medical services/ procedures.


Basic Treatment Concepts
A. Patients who present with a dysfunctional somatic component to their condition may benefit from OMT.
B. The primary goal of using OMT is to enable the patient to return to health and optimize function.
C. OMT should be performed at the appropriate effective frequency as determined through the on-going process of medical evaluation and management.
D. OMT should be performed for the minimum appropriate duration. This can be defined as that duration of time from the initiation of treatment which will result in continued improvement, and where additional treatment will not further benefit the patient.
E. Subsequent treatments may be an appropriate response to unstable or recurrent conditions as part of the overall management of the patient's condition. Every attempt is made to reach maximum improvement of the patient and OMT should be coupled with other appropriate medical and/or surgical interventions. Occasionally, less frequent, periodic treatment may be utilized effectively to help continue maximum medical improvement. The frequency of such treatment should be consistent with the phase of the patient's disease or dysfunctional process as determined by on-going evaluation and management of the patient's condition. 26
Some stabilized conditions that acutely decompensate may require reinstitution of OMT. 27
Subsequent evaluation and management in conjunction with OMT is appropriate for patients with long term conditions. 28, 29
Passive physical medicine modalities should be combined with an active treatment program which emphasizes progressive exercises with a decreasing frequency of passive treatments. The modalities provided should be appropriate to the individual patient's presenting problem and their response to prior treatment. Prolonged application of physical rnedicine modalities beyond the acute phase of treatment should be limited in frequency and number of modalities utilized and should not be utilized as the sole form of treatment.



OMT Parameters
The guidelines below are meant to be used as a basic reference for appropriate osteopathic manipulative treatment. They are not intended to set restrictive criteria that would override an osteopathic physician's good judgment in comprehensive case management. Most patients should fall within the parameters below and there should be sufficient latitude for physicians with varying treatment styles and approaches. Some patients have additional factors which complicate successful completion of treatment. Among these factors are the severity of the illness, duration or chronicity of the condition, as well as the existence and extent of comorbidities. 30
Acute, Post-acute and Chronic refer to the phase of illness determined by the time elapsed from the onset of symptoms. Date of injury, diagnosis, acute exacerbation or surgery must be taken into consideration. 31
Initial refers to the interval during which OMT is first utilized by a particular physician in the treatment process regardless of the phase. The initial use of OMT may occur through its use by the primary treating physician in the acute illness, or it may be first used in subsequent phases of the illness through appropriate referral. Patients are treated more frequently during the first several encounters regardless of the phase of the illness, with a subsequent decrease in treatment as appropriate.
Subsequent refers to the treatment period following the initial interval of treatment by a particular physician within an illness phase, and as continuing treatment through subsequent phases patient's progress to recovery or maximum medical improvement.
Treatment of Recurrent Problems: If a patient has multiple recurrent episodes related to their original complaint within one year, it should not be classified or treated as an acute problem. In this circumstance, it would be classified as a recurrent problem and secondary assessment and treatment methods should be used with an emphasis on active therapy and prevention strategies. Additional treatment may be necessary if repeated efforts to withdraw from treatment results in significant deterioration of clinical status. Patients with recurrent problems may require additional evaluation and interventions for psychosocial and ergonomic factors which may be contributing to the recurrent nature of the problem. A history of previous episodes of similar complaints should be considered as well as possible contributory factors such as chronic pain, depression, alcohol/substance abuse, smoking and extreme obesity. Supervised changes in physical activity and lifestyle should also he considered.
The routine scheduled provision of osteopathic manipulative treatment (OMT) would not be considered appropriate in the absence of acute or chronic problems.