reakout 3 Visceral Somatic OMM › acofpimis › IR15 › Handouts › Breakout 3 Mason...reakout 3 -Visceral Somatic OMM David . Mason, DO, FA OFP Title “5 minute OMT: Integrating

Breakout 3 - Visceral Somatic OMM

David C. Mason, DO, FACOFP

8/6/2015

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“Integrating OPP into Your

Family Medicine Encounter:

Common Cases”

David C. Mason, D.O., FACOFP

ACOFP Intensive OMT review

August 2015

Learning Objectives:

• By the end of the workshop the attendee will be able to:

• Recognize new opportunities to apply osteopathic concepts and treatment techniques.

• Apply osteopathic manipulative techniques learned in the session.

• Document findings, treatment, billing and coding for each case.

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These work shops will allow the busy family practitioner to include Osteopathic Principles and Practices in their office visits. The presenter will offer case based learning experiences using the familiar SOAP note format to integrate OMT into the thought process, documentation, and coding of the office encounter. The attendee will leave with ability to apply the knowledge and techniques clinically. The session will be primarily hands on treatment sessions focused by an interactive didactic session. A rational approach to each office encounter will be proposed, incorporating the basic tenets of osteopathic medicine. Application of functional anatomy, biomechanics and knowledge of the autonomic nervous systems physiological effects will be incorporated.

Tenets of Osteopathy

1) The Human body is a functional unit. Mind, Body, and Spirit are interconnected.

2) Form and Function are inter-dependant.

3) The Human body has the innate ability to heal itself.

4) Osteopathic Manipulative Treatment is based upon individualized rational application of the above tenets.

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TART

• Tissue texture changes upon palpation.

• Asymmetry on inspection.

• Range of motion deficits.

• Tenderness to palpation.

Case 1:

New Patient to your office. 32 yo female

executive cc: Frequent headaches.

Photophobia, phonophobia, band-like at

base of skull wraps to temples B/L. No

aura, 3-4 per week for months, worse with

stress, better with naprosyn OTC and rest.

Currently 6/10 on VAS. Not worst HA of

life. Reviewed PMHx,PSHx, Family Hx,

Meds/NKDA, Social Hx, Dietary Hx.

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Physical Exam

• 120/72 HR 76 RR 16 T 98.4 F

• HEENT: NL TM, turbs, pharynx clear

• COR: reg at 76 no murmur or ectopy

• Pulm: CTA B/L no W/R/R

• Abd: NL BS, soft ,NT, No Masses

• Biomech: Myospasm at OA and cervical paraspinal muscles. OA FRrSl. Occiptomastoid suture compressed right >left.

• Ext: NL pulses, no edema, cyanosis

• Neuro: CN II-XII intact, neg Rhomberg, 5/5 MS ULE B/L 2/4, DTR ULE B/L

A/P

• Diagnoses– Headache: Muscle tension type

– Head (739.0), and Cervical (739.1) somatic dysfunctions

• Treatment– NSAID?

– MRI?

– OA direct myofascial release

– Cervical direct myofascial stretching

– V-Spread

– Home exercise stretches

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• Headache

• Pain in the head that is localized to the cranial vault although it may include the region of the eyes or the back of the upper neck.

• Physiology and Common Somatic Dysfunctions

• Parasympathetics increased tone= contracts pupil, significantly increased secretions of nasal, lacrimal and submandibular glands, senses aortic blood pressure

• Facial (CN VII), Glossopharyngeal (CN IX)- Cranial dysfunction

• Vagus nerve-

• OA, AA, C2-

• -Tenderpoints

• -Tissue texture changes over cervical pillars

• -Rotated vertebrae

• Compression of occipitomastoid sutures as well as occipito-atlanto joint

•

• Sympathetics increased tone= vasoconstriction and slight secretions of nasal, lacrimal and submandibular glands, increased blood flow to skeletal muscle

• T1-5

• Tenderpoints

• Tissue texture changes over transverse processes

• Rotated vertebrae

• Motor

• C2-8 (levator scapulae, scalene; irritation associated with anxiety/stress)

• Tenderpoints

• Tissue texture changes over cervical pillars


• Other Somatic Dysfunctions

• Levator scapulae hypertonicity

• Sternocleidomastoid hypertonicity

• OA dysfunction

• Any cervical dysfunction

• TMJ dysfunction- medial pterygoid, posterior digastric mm, glossal muscles, hyoid muscles and fascial restrictions

•

•

• Treatment

• The 2 minute treatment

• Head- Vagus: OA release 739.0

• Cervical- FPR 739.1


• Cervical spine: MFR,ME and or HVLA 739.1

• Thoracic spine-Seated ME 739.2

•

• The Extended treatment

• Head- Decreased CRI- CV4 hold 739.0

• Head- TMJ – direct inhibition to medial pterygoid and/or posterior digastric muscle 7390

• Cervical- Anterior cervicals-MFR 739.1

• Thoracic- MFR and or HVLA 739.3

• Head, Cervical- PINS technique to the head 739.0 and neck 739.1

• Abd/Other/Visceral somatic- Chapman’s reflex for any corresponding illness of the head ex sinusitis, otitis media 739.9

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Techniques

• OA Decompression

• Cervical soft tissue direct stretching

– Longitudinal stretch

– Perpendicular stretch

• V spread

– Osteopathy in the Cranial Field

– or Direct MFR

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Coding and Billing

• ICD-9

• E&M

– 99204.25

• Procedure

– 98925

Case 2

• 45 yo seen for the first time with complaint

of “heart burn” especially after lying down

with a full stomach. Associated with

belching and bloating. Denies

hematemisis N/V/D/C or hematochesia.

OTC cimetadine offers short lived relief.

FamHX: neg Past Med Hx: HTN Meds:

Atenolol, NKDA, Smokes 1ppd, 4 cups

Coffee daily.

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Physical Exam

• 138/88 HR 68 RR 16 T 98.4

• HEENT:nl TM, Pharynx clear, midline uvula and trachea, no lymphadenopathy.

• Cor: Reg 68 no murmurs


• Abd: nl BS soft, mild mid epigastric tenderness, no rebound or rigidity.

• Biomech: AA Rr, Chapman’s reflexes on sternum(esophagus) and anterior 5th

intercostal space(Stomach), T5-7 SrRl.

A/P

• Diagnoses

– GERD

– Cervical(739.1), Thoracic(739.2), Rib(739.8) Somatic dysfunction.

• Treatment

– Proton pump inhibitor

– AA muscle energy

– Seated Thoracic muscle energy

– Inhibitory technique for Chapman’s

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• Gastroesophageal Reflux Disease

• A disorder in which the gastric contents enter the esophagus because of transient or chronic relaxation of the lower esophageal sphincter.

• Physiology and Associated Somatic Dysfunctions

• Vagus nerve-

• OA, AA, C2-

• -Tenderpoints




•

• Sympathetics increased tone= decreased acid production and peristalsis

• T5-10-Tenderpoints



• Celiac, superior mesenteric ganglion restriction

• Motor

• C3-5 (Phrenic nerve to the diaphragm. Irritation due to proximity to diaphragm)

• Tenderpoints




• Diaphragm restriction and at all attachments

• Celiac ganglion restriction

• Treatment


• Thoracic- Seated ME 739.2


• Abdomen/other- Celiac ganglion: MFR 739.9

• Abd/Other/Visceral somatic- Chapman’s reflex for stomach and esophagus: 739.9

• Left 5th and 6th ICS near sternum and midline body of sternum

•


• Head- Vagus: OA release 739.0

• Head, Cervical: MFR, FPR and/or HVLA 739.1

• Thoracic- MFR and/or HVLA 739.2

• Abdomen other- Diaphragm-– Doming technique 739.9

– Thoraco-lumbar junction – ME, MFR, HVLA 739.2,

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Techniques

• AA Muscle Energy

• Seated Thoracic Muscle Energy

• Chapman Reflexes for Acidity and Motility

Intercostal space 5-6 and 6-7, progressive

inhibition.

Coding and Billing

• ICD-9

• E&M

– 99204.25

• Procedure

– 98926

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Case 3:

• Consulted by OB/GYN for medical

management of a 24 yo G2P0101 with a

history of Asthma in her 30th week. She

states she is using her albuteral at least

twice a day for the past week. This has

been increasing since her 26th week of

gestation.

Physical Exam

• 124/78 HR 80 RR 24 T 98.8

• HEENT: NL TM, turbs, pharynx clear

• COR: reg at 80 2/5 systolic murmur, no ectopy.

• Pulm: Tachypnic wheezing reduced diaphragm excursion.

• Abd: NL BS, soft ,NT, Gravid uterus nearly to xyphoid process.

• Ext: good pulses, minimal pitting edema B/L.

• Biomech: OA myospasm, C3-5 RSl, T1-8 paraspinal myospasm, Tenderpoint at anterior scalene left and myospasm of pec minor B/L.

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A/P

• Diagnoses

– Asthma (RAD)

– Cervical(739.1), Thoracic(739.2), Rib(739.8) somatic dysfunctions

• Treatment

– Beta Agonist

– Inhaled steroids

– Accessory Muscles of Respiration Assessment and Myofascial Treatment

– Cervical Muscle Energy C3-5

– Rib Raising Ribs 1-8

• Asthma

• A disorder of the tracheobronchial tree characterized by mild to severe obstruction to airflow. The clinical hallmark is wheezing, but cough may be the predominant symptom.


• Parasympathetics increased tone = increased volume of secretions and relative bronchiole constriction

• Vagus nerve-

• OA, AA, C2-

• -Tenderpoints




• Sympathetics increased tone = decreased secretions and bronchiole dilation

• T1-5

• Tenderpoints

• Tissue texture changes over

• transverse processes


• Motor

• C3-5 (Phrenic nerve to the diaphragm. Dysfunction due to decreased excursion and overuse)

• Tenderpoints




• Cranial extension dysfunction

• Scalenes- tenderpoints and hypertonicity

• Sternocleidomastoid- tenderpoints and hypertonicity

• Inhalation or exhalation dysfunction of ribs

• Flattened diaphragm

• Thoraco-lumbar dysfunction (diaphragm attachment)

•

• Treatment


• Thoracic- Seated ME 739.2

• Abd/Other/Visceral-somatic-Chapman’s reflex for lung 739.9

• 3rd (upper lung) and 4th (lower lung) ICS near sternal border


• Upper Extremity- Pectoralis minor- CS, MFR and/or pectoralis traction (for lymphatic treatment) 739.7

• Thoracic- HVLA 739.2



• Head –Vagus: OA release 739.0

• Head- Sphenopalatine ganglion stimulation 739.0

• Cervical-C2, C3-5: MFR, FPR and/or HVLA 739.0

• Cervical-Scalenes: CS and/or ME 739.1

• Thoracic- MFR 739.2

• Rib dysfunction- ME 739.8

• Rib raising 739.8

• Abdomen- Diaphragm-– Doming technique 739.9

– Thoracolumbar junction: ME, MFR, HVLA 739.2, 739.3

•

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Techniques

• Accessory Muscles of Respiration Assessment and Myofascial Treatment

• Cervical Muscle Energy C3-5

• Rib Raising Ribs 1-8

Coding and Billing

• ICD 9

-Asthma (RAD)

-Cervical(739.1), Thoracic(739.2),

Rib(739.8) somatic dysfunctions

• E&M

– 99204.25

• Procedure

– 98926

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Case 4:

• A previous patient of yours. 25 year old

school teacher with 10 day hx of

mucopurulent nasal discharge. Sore

throat, bad taste, OTC sinus tablets prn

little relief for head and sinus pressure.

Physical Exam

• 110/64 HR 80 RR 20 T 99.8

• HEENT:TM cloudy, bulging, tenderness over maxillary and frontal sinuses, purulent nasal discharge on erythematous turbinates, pharyngeal erythema and post nasal drip, anterior cervical lymphadenopathy.

• Cor: Reg at 80 no murmur or ectopy

• Pulm: CTA, no W/R/R

• Biomech: OA ERrSl, OA myospasm, T1-4 myospasm r>l., Chapman’s reflex infraclavicular.

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A/P

• Diagnoses

– Acute Rhinosinusitis

– Head (739.0), Cervical (739.1), and Thoracic (739.2)

somatic dysfunctions

• Treatment

– Abx

– Nasal Steroid?

– Sinus Drainage

– Anterior Cervical Lymphatic Drainage

– Direct Myofascial Release T1-4

• Sinusitis

• Infection (viral, bacterial or fungal etiology) of the sinuses of the head.


• Parasympathetics

• Facial nerve (CN VII) via Sphenopalentine ganglion

• Vagus nerve-

• OA, AA, C2-

• -Tenderpoints




•

• Sympathetics

• T1-4-Tenderpoints

• -Tissue texture changes over transverse processes


•

• Sensory-Motor

• Trigeminal nerve (CN V)

• -Tenderness/fascial restriction at supraorbital and infraorbital notch and over frontal and maxillary sinuses.


• Eustachian tube dysfunction

• Cranial dysfunction

• Lymphatic congestion of lymph nodes: pre/post auricular, submaxillary and submental, supraclavicular, and anterior cervical chain.

•

• Treatment


• Head- Supraorbital and infraorbital (CNV) massage 739.0

• Head- Frontal and maxillary efflurage 739.0


• Head- Periauricular drainage technique 739.0

• Cervical- Lymphatic drainage of anterior cervical lymphatics 739.1

• Abd/Other/Visceral somatic- Chapman’s reflexes Mid-maxillary line above the clavicle for ear and below the clavicle for sinuses 739.9


• Head- OA MFR 739.0


• Cervical- C2: MFR, FPR and/or HVLA 739.1

• Thoracic ME, MFR and/or HVLA 739.2

• Rib raising 739.8

• Head- Muncie technique 739.0

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Techniques

– Sinus Drainage

– Anterior Cervical Lymphatic Drainage

– Direct Myofascial Release T1-4

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Coding and Billing

• ICD-9

– Acute Rhinosinusitis

– Head (739.0), Cervical (739.1), and Thoracic

(739.2) somatic dysfunctions

• E&M

– 99213.25

• Procedure

– 98926

Case 5:

• 7 yo patient of your FM practice with a 4

day hx of right ear pain.

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Physical Exam

• 88/48 HR 90 RR18 T 101.4

• HEENT: Bulging injected erythematous right TM, no perforations. Tender Pina. Anterior cervical and periauricular lymphadenopathy. Pharynx clear.

• Cor: Reg at 90, no murmur

• Pulm: CTA B/L no W/R/R.

• Biomech: OA congestion, Chapman’s at OA on right, T1-3 SrRl, T4FRSl with tenderness and myospasm.

A/P

• Diagnoses

– Otitis Media

– Head(739.0), Cervical(739.1), Thoracic(739.2)


• Treatment

– ABX?

– Acetaminophen prn?

– Auricular Drainage

– Mandibular Drainage

– Muscle Energy T1-4

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• Otitis media

• Inflammation of the middle ear, usually associated with a viral or bacterial infection


• Parasympathetics increased tone= copious secretions of nasal, lacrimal and submandibular glands

• Facial nerve (CNVII)- Cranial dysfunction

•

• Sympathetics increased tone= vasoconstriction and slight secretions of nasal, lacrimal and submandibular glands

• T1-5

• Tenderpoints



• Motor

• Tensor veli palatine- CN V3

• Tensor tympani- medial pterygoid branch of the CN V3

• Levator veli palatine- CN X

• Salpingopharyngeus- CN X

• OA, AA, C2 -Tenderpoints

• -Tissue texture changes over

• cervical pillars




• Eustachian tube dysfunction

• Digastric mm tenderpoint and hypertonicity

• Cranial dysfunction

• Lymphatic congestion of lymph nodes: pre/post auricular, submaxillary and submental, supraclavicular.

•Treatment


• Head- Muncie technique 739.0

• Head- Periauricular drainage technique 739.0


• Head- Supraorbital and infraorbital nn massage 739.0


• Cervical: MFR, FPR and/or HVLA 739.1


• Head- Nasion gapping 739.0

• Head- Gallbreath technique (mandibular drainage) 739.0


• Head- Digastric- CS and/or MFR 739.0

• Head- Vagus- OA release 739.0

• Abd/Other/Visceral somatic- Chapman’s reflex for ear and/or sinuses 739.9

• Mid-maxillary line above the clavicle

•

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Techniques

–Auricular Drainage

–Mandibular Drainage

–Muscle Energy T1-4

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Coding and Billing

• ICD-9

– Otitis Media

– Head(739.0), Cervical(739.1), Thoracic(739.2)


• E&M

– 99213.25

• Procedure

– 98925

Case 6

• Consulted by OB/GYN for medical

management of a 31 yo G3P2002 for LBP.

The patient is in her 32nd week of this

pregnancy. She complains of right SI joint

pain and right buttock pain both are worse

with standing and walking. This has been

increasing since her 24th week of

gestation.

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Physical Exam

• B/P 122/78 HR 64 T 98.8 RR 18

• Ext: Good 2/4 pulses in all extremities, 2+ pitting edema in legs.

• Neuro: 5/5 muscle strength, 2/4 DTR

• Ortho: SLR neg.

• Biomech: Posterior Innominate on Right, Right lumbar paraspinal muscle hypertonicity, L2FRSr, T10-L1 SblRr, Hypertonic right piriformis with a tenderpoint and pelvic and thoracolumbar diaphragm restrictions.

A/P

• Diagnoses– Acute Mechanical LBP

– Pregnancy (V22.2)

– Thoracic(739.2), Lumbar(739.3), Sacrum(739.4), Innominate(739.5), Lower Extremity(739.6), and Abdomen/other(739.9) somatic dysfunctions.

• Treatment– Exercises

– ME for PIR

– Myofascial stretching for Lumbar

– HVLA lumbar

– HVLA thoracic

– Counterstrain piriformis tenderpoint

– MFR LS and SI joints

– Diaphragm doming.

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• Pregnancy

• The duration between conception and the end of gestation.


• Parasympathetics increased tone= uterine body relaxation, constriction of the cervix

• Pelvic splanchnic nerves

• S2-4

• Sacral torsions

• Decreased sacral motion

• Sacro-iliac joint pain

•

• Sympathetics increased tone= constriction of uterine body relaxation of the cervix,

• T12-L2

• Tenderpoints



• Motor

• Psoas L1-4

• Piriformis S1-2

• Quadratus Lumborum subcostal nerve, L1-4

• Tenderpoints




• Innominate dysfunction

• Pubic shears

• Restriction and congestion of the ischial rectal fossa

• Thoracic outlet syndrome

• Dependent edema especially of the lower extremities

• Increased lumbar lordosis

• Increased thoracic kyphosis

• Diaphragm restrictions

• somatic- Chapman’s reflexes for ovaries and uterus 739.9

•Treatment


• Sacral inhibition 739.4

• Head- OA release 739.0


• Innominate dysfunction- ME 739.5

• Sacral torsions- ME 739.4


• Innominate- Pubic shears- ME 739.5

• Lower extremity- Psoas- CS 739.6

• Lower extremity- Piriformis- CS, ME 739.6

• Innominate- Ischial rectal fossa- MFR 739.5

• Cervical- MFR, FPR and/or HVLA 739.1

• Thoracic outlet syndrome

• Thoracic 739.3 and lumbar 739.4: ME, MFR and/or HVLA

• Lower extremity- Pedal pump 739.6

• Abdomen/Other- Diaphragm doming 739.9

• Thoracic duct lymphatic tx 739.8

• Lower extremities- Mild, slow effleurage/pettrisage of lower extremities 739.6

• Head- cranial strain pattern (corresponding to sacrum):– Vault hold 739.0

– CV4 hold 739.0

• Sacral rocking 739.4

• Abd/Other/Visceral

Pregnancy Video Clip

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Coding and Billing

• ICD-9 – Acute mechanical LBP

– Pregnancy (V22.2)

– Thoracic(739.2), Lumbar(739.3), Sacrum(739.4), Innominate(739.5), Lower Extremity(739.6), and Abdomen/other(739.9) somatic dysfunctions

• E&M– Consult 99243.25

• Procedure– OMT to 5-6 regions 98927

Case 7

• 27 yo female seen for the first time with

complaint of intermittent diarrhea

especially during stressful situations.

Associated with bloating. Denies

hematochesia.

• Fam HX: neg

• Past Med Hx: neg

• Smokes 1ppd, 4 cups Coffee daily.

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Physical Exam

• 110/64 HR 80 RR 16 T 98.4

• Gen: Thin anxious appearing

• HEENT:nl TM, Pharynx clear, midline uvula and trachea, no lymphadenopathy.

• Cor: Reg 68 no murmurs


• Abd: nl BS soft, mild mid epigastric tenderness, no rebound or rigidity.

• Biomech:Diaphragm restriction, Superior mesenteric ganglion dysfunction, T10-12 SbrRl, Chapman’s reflexes on anterior ITB, iliocecal valve sphincter hypertonicity.

A/P

• Diagnoses– IBS

– Thoracic(739.2), Abdomen/other(739.9), Sacrum(739.4) Somatic dysfunctions.

• Treatment – Medication

– Dietary

– Counseling

– Exercise

– Doming diaphragm

– Collateral ganglion release

– HVLA Thoracic

– Inhibitory technique for Chapman’s

– Iliocecal valve MFR

– Mesenteric lift

– Sacral rocking.

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• Irritable Bowel Syndrome

• Disease of the gastrointestinal system characterized by abdominal pain, bloating, cramping and mixed predominance of diarrhea or constipation

• Physiology and Common Somatic Dysfunctions

• Parasympathetics increased tone = increased peristalsis

• Vagus nerve-

• OA, AA, C2-

• -Tenderpoints




•

• Pelvic splanchnic-

• Sacral dysfunctions

• Sympathetics increased tone = decreased peristalsis

• T10-L2

• Tenderpoints



• Celiac, Superior, and Inferior mesenteric Ganglia-Fascial restrictions

•


• Thoraco-abdominal diaphragm dysfunction

• Pelvic diaphragm dysfunction

•

• Treatment


• Thoracic- ME 739.2

• Lumbar- ME 739.3


• Head- OA release 739.0

• Abdomen/other- Collateral Ganglia release 739.9


• Thoracic- MFR and/or HVLA 739.2

• Lumbar- MFR and/or HVLA 739.3

• Sacral rocking 739.4

• Head- V-Spread 739.0

• Cervical: FPR and/or HVLA 739.1

• Rib raising- 739.8

• Sacrum- ME 739.4

• Innominates- ME 739.5

• Innominates- Ischial rectal fossa release- 739.5

• Abd/Other/Visceral somatic- Chapmans for GI 739.9

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Coding and Billing

• ICD-9

– IBS

– Thoracic(739.2), Sacrum(739.4), Abdomen other(739.9) Somatic dysfunctions.

• E&M

– New patient sick 99204.25

• Procedure

– OMT to 3-4 regions 98926

Current Procedural Terminology

• E&M Codes CPT Book

• OV codes

– NP Sick Established sick

– 99201 - 99211

– 99202 -99212

– 99203 -99213

– 99204 -99214

– 99205 -99215

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OMT Codes

• 1-2 areas treated 98925

• 3-4 areas 98926

• 5-6 areas 98927

• 7-8 areas 98928

• 9-10 areas 98929

• 10 areas are Cranial, Cervical,Thoracic, Lumbar, Sacral, Innominate, Upper Extremity, Lower

Extremity,Rib cage, Visceral.

Modifiers

• .25 separate identifiable service on same

day (Patient seen for “Headache”

diagnosis muscle tension type HA,

Cervical Somatic Dysfunction E&M

99213.25 98925 ICD-9 codes 307.81

739.1)

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ICD-9 codes

• 739.0 Head/ Cranial Somatic dysfunction

• 739.1 Cervical Somatic dysfunction

• 739.2 Thoracic Somatic dysfuction

• 739.3 Lumbar Somatic dysfunction

• 739.4 Sacral Somatic dysfunction

• 739.5 Innominate Somatic dysfunction

• 739.6 Lower extremity Somatic dysfunction

• 739.7 Upper extremity Somatic dysfunction

• 739.8 Rib Somatic dysfunction

• 739.9 Abdominal/ Visceral somatic Dysfunction

Documents

reakout 3 Visceral Somatic OMM › acofpimis › IR15 › Handouts › Breakout 3 Mason...reakout 3 -Visceral Somatic OMM David . Mason, DO, FA OFP Title “5 minute OMT: Integrating