JESSICA KELNER, DO BRIAN BROWNING, DO FAMILY MEDICINE NEUROMUSCULAR MEDICINE Cracking the Case: Quick, Easy OMT in a Nutshell.

JESSICA KELNER, DOBRIAN BROWNING, DO

FAMILY MEDICINE NEUROMUSCULAR MEDICINE

Cracking the Case: Quick, Easy OMT in a Nutshell

Today’s lecture

3 musculoskeletal casesDifferential DiagnosisDocumentation and Billing for OMT Pertinent anatomy and special tests3 OMT treatments for each caseLab after each case

Case 1 - HPI

35 year old female c/o intermittent progressively worsening headaches x 1 month.

3-4x a week, worse when she is stressed, better with lying down and closing her eyes

Headaches start in the back of her head on the right and radiate around toward the back of her right eye.

Pain is “achy” and “sharp” behind her eye, rates them as a 7/10.

Associated discomfort on right side of her neck. Tried taking ibuprofen and Excedrin which helps

for an hour or two.

Case 1

She denies recent head trauma. No association with menstruationROS: +headache, +right sided neck pain,

denies numbness or tingling, denies blurry vision,+ Light sensitivity when she gets the headaches. denies N/V/D/F, denies weakness, denies fatigue

All other ROS are negative

Medical History

Medical History: seasonal allergies, no past history of headaches or motion sickness as a child.

Surgical History: noneMedications: zyrtec 10mg during allergy

season, ibuprofen 600mg every 6 hours as needed for headache

Family History: Mom – headaches, HTN Social History: works as a secretary, drinks 2

cups of coffee/day, processed food diet, no exercise, non smoker, lives with husband

Physical Exam

Temp: 98.8 deg F BP: 128/75 Pulse: 70 Ht: 66inches Wt: 160lbsGEN: Well-nourish, well-hydrated. NADHEAD: normocephalic, atraumaticORO-PARYNX: mucus membranes mildly

dehydrated, clear, no exudates EYE: PERLA, EOMILUNGS: CTA B/L, no wheezing or rhonchiCV: RRR, no M/R/GAbd: Soft, NT/ND, no organomegalyNEURO: sensation in b/l upper extremities in-tact to

light touchPSYCH: A&O x 3, judgment, memory and insight intact

Physical Exam

MSK hypertonic paraspinal muscles in thoracic spine

and cervical spine B/Lhypertonic trapezius B/Lhypertonic levator scapula B/Ldecreased cervical lordosishypertonic anterior and middle scalenes B/L TTP over right occipital condyle with reproduction

of symptomsROM of head: decreased rotation to the right

compared to the left, otherwise full ROM of neck, neck is supple

Negative Spurling’s test

Osteopathic Exam

Patient was found to have tenderness, asymmetry, restriction of ROM, and tissue texture changes in the following areas: HEAD: OA compression on the right, with

TTP over occipital condyle CERVICAL SPINE: C2 Flexed RRSR

anterior and middle scalenes restriction Right, Right SCM restriction

THORACIC SPINE: T2 Flexed SLRL B/L trigger points in upper trapezius

Differential Diagnosis

Tension headacheMigraine headacheDehydration Cerebral aneurysmMeningitis Viral syndrome Trigeminal neuralgiaPseudotumor cerebriGiant Cell Arteritis

Diagnosis

Allopathic Assessment and Plan Tension headache (G44.209) Muscle spasm of paraspinal muscles (M62.838)

Heating pad Stretching exercises for upper back and neck Increase oral fluid intake Diclofenac PRN

Osteopathic Assessment and Plan Somatic Dysfunction of Head Region (M99.00) Somatic Dysfunction of Cervical Region (M99.01) Somatic Dysfunction of Thoracic Region (M99.02)

OMT to 3 Body Regions (98926)

Billing for this Visit

99213 (E/M level 3 establish patient office visit)

- 25 modifier on E/M code for other separate procedure (OMT)

98926 (3-4 Body Regions Treated)

Billing Tips

Evaluation and Management Codes: 99202, 99203, 99204 most often used for new patients 99212, 99213, 99214 most often used for established

patientsModifier

25 for “separate and identifiable procedure done the same day”

CPT codes 98925 (OMT to 1-2 body regions) 98926 (OMT to 3-4 body regions) 98927 (OMT to 5-6 body regions) 98928 (OMT to 7-8 body regions) 98929 (OMT to 9-10 body regions)

Greater Occipital Nerve

Originates from C2 spinal

Between C1 and C2, along with the lesser occipital nerve

Emerges inferior to the suboccipital triangle  (obliquus capitis inferior) muscle

Passes through the trapezius muscle and ascends to innervate the skin along the posterior scalp to the vertex of the head

Greater Occipital Nerve

OMT Techniques

OA decompression Muscle Energy for Cervical SpineMuscle Energy for the shoulder girdle Upper Thoracic Soft Tissue

OA Decompression

Used for abnormal tension, hypertonicity or spasm of the cranial base that can interfere with cranial-sacral functioning

Releases tissues around the jugular foramen thus enhancing fluid drainage from the cranial vault and reducing intracranial fluid congestion.

Restores normal vagal tone.Can also benefit the

glossopharyngeal nerve, and the spinal accessory nerve.

OA Decompression

Physician: seated at the head of patient Patient: supine Place fingers vertically (pointing toward ceiling) so that the

patient’s sub-occipital area is balanced on the physicians fingertips. The pads of the fingers should maintain contact with this area.

The weight of the patient’s head is the only therapeutic force applied.

As tissues relax, maintain pressure, until you can palpate the posterior arch of the atlas (C1).

Continue pressure to slowly disengage the atlas from the occiput. Disengagement will be noted by a “floating sensation” of the atlas

As the atlas floats, balance it, support it with the tips of your ring finger while moving the occiput gently in a cephalad direction with the tips of your middle fingers. This will further disengage the occiput from the atlas and decompress the condylar region.

Cervical Spine Muscle Energy

Cervical Spine Muscle Energy

Dysfunction (C2 F RRSR) Physician: seated at the head of the table Patient: supine Cradle the patient’s head in your hands and palpate the articular pillars

at the level of C2 Extend the patient’s head until motion is felt under your palpating fingers Rotate the patient’s head to the left until motion is felt under your

palpating fingers Sidebend your patient to the left at C2 by translating C2 to the right with

your left finger (creating left sidebending) Instruct the patient to attempt to bring their head toward their right

ear (right sidebending) while providing isometric resistance for 3-5 seconds

Instruct the patient to relax while easing your counterforce Reposition to a new restrictive barrier by increasing flexion, left rotation

and left sidebending Repeat 3-5x or until no further progress is made Re-check

Shoulder Girdle Muscle Energy

Shoulder Girdle Muscle Energy

Patient: seated or supinePhysician position: standing (if patient is

seated) or seated (if patient is supine)Used to assist in relaxation of the superior

head of trapeziusContact AC joint and ipsilateral neck with

hands and have patient shrug shoulder against counterforce.

Have the patient relax, take up the slack, and repeat 2 more times or until tissues soften

Seated Soft Tissue

Upper Thoracic Soft Tissue

Can be done in any position (supine, prone, lateral recumbant or seated)

Primarily used to address the root of the neckAlso to some degree addresses sympathetic

innervation (especially if used in conjunction with rib raising)