Manual Manipulation for
the Adaptive Sports
Athlete
Shounuck I. Patel, DO
Samuel A. Yoakum, DO
Gina M. Benaquista DeSipio, DO
Julie Lanphere, DO
Arthur J. De Luigi, DO
Disclosures
none
Outline
Background
Definitions
Diagnosis
Techniques
Billing
Manual Therapy in Adaptive Sports
Valuable complementary treatment for injury
in the adaptive sports athlete
Adaptive sports athletes can have
musculoskeletal pain directly related to their
condition, or secondary to injuries to which
they are more susceptible
Adaptive sports
● Primary conditions
o
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Spasticity
Lumbosacral/sacroiliac dysfunction due to limb
length inequality, hemiparesis, etc.
● Secondary injuries
o
o
Neck & Shoulder pain
 Myofascial thoracic outlet syndrome
 Scapular dyskinesia
Overuse syndromes
 Tendinopathies/enthesopathies
 Carpal tunnel syndrome
Definitions
Manual manipulation/therapy
Hands-on mobilization, manipulation, and
balancingn techniques involving
articulations and/or soft tissues in order to
improve range of motion, biomechanics,
and function.
Manual therapy
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Acupressure
Bodywork
Bowen technique
Chiropractic
Cranial Osteopathy
Craniosacral therapy
Indian head massage
Lomilomi
Manual lymphatic drainage
Massage therapy
Naprapathy
Osteopathic medicine
Physical therapy
Rolfing structural integration
Shiatsu
Thai massage
Tui na
Watsu
Osteopathic Medicine
Definitions:
•Osteopathy = Osteopathic medicine
•Osteopathic manipulative medicine = OMM
•Osteopathic manipulative treatment/techniques = OMT
•Doctor of Osteopathy = DO
According to the World Osteopathic Health Organization, Osteopathy is a
“…system of healthcare which relies on manual contact for diagnosis and
treatment. It respects the relationship of body, mind and spirit in health and
disease; it lays emphasis on the structural and functional integrity of the body
and the body's intrinsic tendency for self-healing.”
Tenets of Osteopathy
● The body is a unit
o Understanding this concept allows the treatment of patients as
a functional whole.
● Structure and Function are interrelated
o According to AT Still, the founder of Osteopathy, “Disease is
the result of anatomical abnormalities followed by physiologic
discord”
● The body possesses self-regulatory and self-healing
mechanisms
● Rational treatment is based on applying these principles
Case Example
40 yo F with T4 complete paraplegia
CC: sharp pain at posterior mid thoracic region
HPI: Pain began the day after hand cycling dozens of
miles in a benefit race, and is band-like in upper-mid
thoracic region Rt>Lt, stabbing in nature. No motor,
sensory, bowel or bladder changes.
Diagnosis
Somatic Dysfunction
● Tissue Texture Changes
o Boggy/edematous, taught/hypertonic “knots”, ropy/fibrosed,
atrophied, rigid, moist, dry
● Asymmetry
o ‘Inspection’
● Restriction of motion = a deeper look at A/PROM
o Named for FREEDOM Of MOTION
o Restricted motion is the BARRIER
● Tenderness
o Tenderpoints vs. Triggerpoints
Diagnosis
Physiatric Exam <-> Osteopathic Exam
Inspection <-> Asymmetry
Palpation <-> Tissue texture and tenderness
ROM <-> Restriction of motion
Motor, Sensory, Reflexes
Special tests
Tissue Texture Changes
● Acute
o Edematous
o Erythematous
● Acute
○ Acute MSK injuries
○ OA exacerbation
o Boggy
o Increased moisture
● Chronic
o No edema/erythema
o Cool dry skin
o Decreased muscle tone
o Flaccid, ropy, fibrotic
● Chronic
○ Atrophy in SCI/TBI/CVA
○ Old OA
Asymmetry
● Posture
● Scoliosis (kyphosis/lordosis, levo-/dextro-)
● Side-to-side
● Mastoid
● Acromion
● Lower ribs
● Iliac crests
● Greater trochanters
● Lateral femoral condyles
● Lateral malleoli
Restriction of motion
● Orthopedic
o
Very Loose
● Rheumatologic
o
Very Restricted
● Somatic Dysfunction
o
Free in one direction + restricted in the other
Restriction of motion
● BARRIER stops motion
● FREEDOM Of MOTION is opposite the barrier
● Barriers
o Anatomical
o Physiological
o Restrictive
Anatomical & Physiological Barriers
Restrictive Barrier
Case - Osteopathic exam
● Tissue texture change:
o Fullness and tenderness at suboccipital region
o No skin changes
● Asymmetry
o R downward scapular rotation
● Restriction of motion:
o Cervical ROM decreased in left sidebending and
rotation
● Tenderness:
o Point ttp Rt T4-T7 paraspinal region, Rt levator and
Rt supraclavicular space resulting in band-like
radiation of pain, concordant with chief complaint
Osteopathic Manipulative Techniques
● Direct Techniques
o Engage (go into) the dysfunctional barrier
o Goal is moving through the barrier to restore normal motion
● Indirect Techniques
o Disengage (go away from) the barrier
o Using the path of least resistance
● Combined Techniques
o Begin indirect, then go direct
OMT
● Soft tissue mobilization / Articulatory Techniques
o Direct
● Myofascial Release (MFR)
o Direct or Indirect
● Muscle Energy (contract-relax)
o Direct
● Jones Counterstrain & FPR
o Indirect
● High Velocity Low Amplitude (HVLA)
o Direct
● Low Velocity High Amplitude (LVHA)
o Direct
● Craniosacral
o Direct or Indirect
Massage techniques
● Similarities with soft tissue mobilization/articulatory
techniques and myofascial release
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Effleurage = stroking and gliding (effortlessly)
Petrissage = kneading (pinching)
Tapotement = percussion (tapping)
Deep friction = deep linear/circular rubbing to prevent
adhesions in subacute/chronic injuries
● Acupressure = sustained deep pressure over
acupuncture points OR Travell trigger points
Physical Therapy
● Contract-Relax
o Muscle Energy
● Joint Mobilizations = “Mobs” = direct technique with a
range of force and velocity (Grade I-V)
o Deep articulation
Chiropractic
● “Adjustment” of subluxations
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Direct “thrust” maneuvers
Similarities with HVLA
Soft Tissue Mobilization
● Soft tissue tensions affect function of the soft tissues
and the joints to which they attach.
● Allows treatment to other parts of the body to be more
effective.
● Gently and directly applying pressure as to separate the
origin and insertion of muscle fibers from each other.
● Deep articulation, in contrast, is the repeated
engagement of the barrier or endpoint of joint motion in
order to increase mobility and ROM.
Myofascial Release (MFR)
● MFR is an umbrella term
encompassing several types of
osteopathic manipulative techniques
(OMT) that stretch and release
muscle and fascia restrictions.
● MFR first involves palpating a
restriction in the fascia/soft tissue.
● Direct MFR = practitioner engages
the restrictive barrier and holds until
a release is felt in the tissue.
● Indirect MFR = practitioner moves
the myofascial structures away from
the restrictive barrier.
Counterstrain
Used to treat Tenderpoints
● Tenderpoints are small tense edematous areas of
tenderness typically located near tendon attachments,
ligaments, or in the belly of some muscles.
● Tenderpoints, unlike trigger points, do not radiate pain
when compressed.
Counterstrain
● Jones Counterstrain = passive indirect
technique
o Muscle being treated is positioned at a point of balance or
ease, away from the restrictive barrier.
o “Fold and hold” for 90 sec
● This is a neurosensory approach to the
treatment of tenderpoints.
o Mimicking the original strain position -> reducing
aberrant afferent flow from the muscle spindle ->
relaxes the muscle “spasm” associated with a
tenderpoint
Facilitated Positional Release (FPR)
● Indirect technique
● Place tissue in neutral position to diminish tissue/joint
tension in all planes
● Add activating force (compression or distraction)
● Takes 3-4 seconds to induce a release
● Good for superficial muscles or deep intervertebral
muscles
Muscle Energy
● Muscle energy, also known as “contract-relax,”
is a direct technique used to improve range of
motion.
● This is a form of OMT in which the patient
actively uses his/her muscles against the
practitioner’s resistance.
o Physician engages a barrier and holds
o Patient is instructed to contract the muscle against
your holding force (Activating force)
o Relax
o Engage a new barrier
o Repeat
Case
Dx:
- Somatic dysfunction
- Levator Scapulae spasm / strain versus zone
of injury neuropathic pain
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“Band-like” radiating pain is not typical of levator
scapula referral patterns but this can present
differently in the setting of neurological injury
Case - Diagnosis
● Myofascial pain syndrome
● Levator spasm / strain
● Somatic dysfunction of Rib: elevated 1st rib
(inhaled)
● Somatic dysfunction of Cervical spine: C2
rotated right
● Somatic dysfunction of Thoracic spine: right
paraspinal muscles ropey and hypertonic
DDx includes neuropathic pain, fracture
Case - Treatment
C2: muscle energy
1st rib: facilitated positional release
Thoracic paraspinal muscles: myofascial
release
Levator muscle spasm: myofascial release or
counterstrain
*in thoracic region, passive techniques because pt may
not be able to provide enough force for active technique
due to neurological level of injury
Billing
● OMT is a procedure
● AMA CPT coding manual clearly states
manipulation codes are NOT specialty- or
profession-limiting
● OMT not the same as Chiropractic Tx (CMT)
o Separate and distinct codes
● MDs & DOs can bill for OMT or CMT
● CMT codes will not be covered here
Billing
1. Perform & document thorough H&P
2. Perform & document diagnostic &
therapeutic intervention
3. List ‘Somatic Dysfunction’ & the OMT codes
4. List secondary diagnoses
5. Use the -25 modifier on the E&M code
● This may only be possible if E&M is for a distinctly
separate issue than what is being treated by
manipulation
CPT: Osteopathic procedure codes
Used for both inpatient and outpatient
98925
98926
98927
98928
98929
= 1-2 body regions
= 3-4 body regions
= 5-6 body regions
= 7-8 body regions
= 9-10 body regions
ICD-9
739 = Nonallopathic lesions, not elsewhere classified
Includes Segmental Dysfunction & Somatic Dysfunction
739.0 = Head & Occipitocervical regions
739.1 = Cervical & Cervicothoracic regions
739.2 = Thoracic & Thoracolumbar regions
739.3 = Lumbosacral region
739.4 = Sacral and sacrococcygeal regions
739.5 = Pelvic region
739.6 = Lower extremities
739.7 = Upper extremities, AC and SC regions
739.8 = Rib cage, costochondral and costovertebral regions
739.9 = Abdomen and other
Case Example - Billing
ICD-9:
344.1 = paraplegia
728.85 = Spasm of muscle
739.1 = Somatic dysfunction Cervical regions
739.2 = Somatic dysfunction Thoracic regions
39.8 = Somatic dysfunction Rib cage
CPT:
99213 = level 3 outpt follow up
-25 = another separate service offered
98926 = OMT 3 body regions
ICD-10-CM (2015)
M99.0 = Segmental & Somatic Dysfunction
M99.00 = Head region
M99.01 = Cervical region
M99.02 = Thoracic region
M99.03 = Lumbar region
M99.04 = Sacral region
M99.05 = Pelvic region
M99.06 = Upper extremities
M99.07 = Lower extremities
M99.08 = Rib cage
M99.09 = Abdomen and other regions
ICD-10-PCS: Future procedure codes
7W0 = Osteopathic, Anatomical Regions, Treatment
7W00 = Head & Occipitocervical regions
7W01 = Cervical & Cervicothoracic regions
7W02 = Thoracic & Thoracolumbar regions
7W03 = Lumbosacral region
7W04 = Sacral and sacrococcygeal regions
7W05 = Pelvic region
7W06 = Lower extremities
7W07 = Upper extremities, AC and SC regions
7W08 = Rib cage, costochondral and costovertebral regions
7W09 = Abdomen and other
ICD-10-PCS: continued...
Each anatomical region is further subdivided by technique:
7W0_X_Z = Osteopathic treatment of ____ Region using ____
7W01X0Z = Cervical region using Articulatory-Raising forces
7W01X1Z = using Fascial Release
7W01X2Z = using General Mobilization
7W01X3Z = using High Velocity-Low Amplitude Forces
7W01X4Z = using Indirect Forces
7W01X5Z = using Low Velocity-High Amplitude Forces
7W01X6Z = using Lymphatic Pump
7W01X7Z = using Muscle Energy-Isometric Forces
7W01X8Z = using Muscle Energy-Isotonic Forces
7W01X9Z = using Other Method