O.M.T.
Demystified…
Rocco Caveng, D.O., M.B.A.
Resident Lecture
Aug 24, 2004
OMT
Goals:
1. What is O.M.T?
2. Who should be referred?
3. What happens during O.M.T.?
4. Benefits of OMT (to office/to patient)
OMT Definitions
What is O.M.T.?
• Osteopathic Manipulative Treatment
– aka: OMM, OPP or “a manipulation”
• What is that?
– It’s a lot of what you already know, and MORE…
• In order to use O.M.T., you need to find
something to “treat,” we call that Somatic
Dysfunction.
OMT Definitions
• Somatic Dysfunction:
– 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
– “Spinal Somatic Dysfunction” occurs when the spine
becomes restricted within the normal range of motion
of one or more of its planes of motion and fails to
return to its normal or neutral position when its
activity is over
Somatic Dysfunction
How to Diagnose Somatic Dysfunction
Tenderness: produced during palpation
Asymmetry: bones, muscles, or joints
Restriction of motion: motion barrier
(ie. Rotates neck to left 80 degrees and to the
right 45 degrees) Barrier to right rotation
Tissue Texture Changes: edematous, tender,
fibrosed, atrophied, rigid, hypertonic
OMT Clinic?
• Ok great, I can send’m to OMT clinic
• Well, who are you sending to OMT clinic?
And for what reason or complaint?
• Bread & Butter:
– Back pain
– Neck pain
– Sciatica
– Joint pain
OMT
Others diagnoses or complaints:
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Headaches (migraine, tension)
Carpal Tunnel Syndrome
Sinusitis (chronic/acute)
Otitis media (chronic/acute)
Allergies (chronic nasal congestion)
Pregnancy (back/hip complaints)
Chronic Edema (leg, arm)
Asthma/COPD
Bowel changes (chronic constipation)
Non-cardiac Chest Pain (costochondritis)
Joint pain (acute/chronic, shoulder, elbow, wrist, hip, knee, ankle)
Foot/Hand Pain, Plantar fasciitis
Shin splints
Fibromyalgia, Generalized chronic pain
TMJ
And more…
OMT
• So what happens, what
do you do, specifically to
patients?
OMT Techniques
• Not all “snap, crackle & pop”
– Although that is what we are mostly known for as
part of the “difference”
• Each treatment is tailored to patient build, risk
•
factors, request, response to previous treatment,
etc.
High velocity, low amplitude (HVLA)
– Yeah, that’s the crack the back one
• Muscle Energy – patient assisted
• Counterstrain – “position of comfort”
Live Demo
• How’s your back feelin’?
• Treatment of sinusitis
• Treatment of Sciatica (piriformis spasm)
• Treatment of spine (cervical, thoracic,
lumbar)
• Treatment of anything else mentioned?
OMT
• Goals of the Treatment
– Improve/Fix the Somatic dysfunction
– Decrease pain
– Improve function (ROM, use of painful part)
• Bonus features
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Improve doctor/patient relationship
Often immediate improvement that visit
Possibly decrease use of unnecessary tests
Possibly delay need for invasive procedures
Repeat business, referrals from happy patients 
For the D.O.’s
Some obstacles to using OMT:
• Not enough time?
– True sometimes, but use it often enough, you will become very efficient. Not too
different from your level 4 visit that hasn’t seen a doctor in 1-2 years and you
are given 15-30 minutes for, you make it work.
• Lost my touch during my 3rd + 4th year med school, now I’m not too
confident in my skills
– Yup, welcome to the club, but if you stop using it you will definitely lose it.
• Literally “practice” on your patients, no different than practicing other office
procedures, except these procedures you have quite a bit of experience at
already! Your patients will appreciate it regardless.
OMT
So, do we get paid for this?
• Yes!
• Even if not, you still get the warm & fuzzy
treatment goals and bonus features
• Summary of actual reimbursement at FMC
July 1, 2003 to July 1, 2004
$0
Insurance Provider
PPO - Par
Principle PPO
Medicare
Aetna/USHC EC
Aetna/USHC HMO
B/S THP - POS
coventry
Keystone
Ameri/Healthcare
Mid Atlantic POS
guarantor
cheap tricare
First State
Aetna USC, PPO
B/S - Out state - PA
Blue Cross /OS/other
BS ?
B/S PPO/HMO
Aetna
Total Dollar Amount
$400
98925
$350
$300
$250
$200
billed
paid
$150
$100
$50
$0
Insurance Provider
Medicare
Aetna/USHC EC
Aetna/USHC HMO
B/S THP - POS
coventry
Keystone
Ameri/Healthcare
Mid Atlantic POS
guarantor
cheap tricare
First State
Aetna USC, PPO
B/S - Out state - PA
Blue Cross /OS/other
BS ?
B/S PPO/HMO
Aetna
Total Dollar Amount
$1,600
98926
$1,400
$1,200
$1,000
$800
billed
paid
$600
$400
$200
Reimbursement Summary
• Some insurances pay better than others.
• On average, we get paid 50% of what we bill for
OMT. (apparently still learning the “appropriate”
way to bill for this)
– This can be above & beyond what we get paid for the
E&M visit.
• So bill $75 for office visit (back pain), get paid $40, add on
OMT, get an additional $20-$75 for that same visit.
• Plus you can have patient return for repeat sessions as
indicated. This is billed just as a procedure visit.
Example Case #1
New Patient
Subjective
A 30 year old male complains of low back pain. It started 2 days ago when
lifting some heavy furniture. The patient reports having a sharp pain in his
left lower back at the time of lifting. The next morning he was unable to
stand straight due to significant pain in low back. Denies
numbness/tingling or weakness of lower extremities. He took ibuprofen
with mild relief of pain. He has no prior history of back pain/injury. Denies
and medical or surgical history. No Allergies to medications.
Objective
Vitals BP-130/80, P-72, R-18, Temp 98.8
Ext: no edema. Dec ROM Lower Ext due to pain in lower back.
Neuro: DTR's +2/4 = b/L, Strength +5/5 = b/L, sensation intact. CN II-XII
grossly intact
Osteopathic Exam - focussed
L5 Flexed, Rotated Left, Sidebent Left
Lumbar paraspinal muscle spasm, tenderness to palpation L>R
Lumbar ROM: FB 75, BB 10, SBL 30, SBR 20
Example Case #1
Assessment
1. Lumbosacral sprain 846.0
2. Lumbar Somatic Dysfunction 739.3
Plan
1. OMT, Myofascial, HVLA to Lumbar spine with improvement of pain
and range of motion.
2. Continue ibuprofen as needed for pain
3. Exercise and stretching instruction given
4. Follow up in 1 week
E/M: 99204-25
OMT x1 region 98925
Example Case #2
Established Patient
Subjective
35 year old male presents to your office for an OMT treatment of his neck pain of 5 years.
Reports sometimes starts to get a headache from the tension in the back of his neck.
(his history is a car accident 5 years ago with negative imaging results). Mild
improvement with alleve. Occasional stretches and heating pad help. Denies
numbness/tingling/weakness of upper extremities. No recent trauma.
Objective
Vitals BP-120/75, P-68, R-18, Temp 97.8
Physical Exam - focussed
HEENT/neck: NC/AT, pharynx - benign, Neck supple, No nodes
CV: RRR s1 + s2, no murmurs
Neuro: DTR's +2/4 = b/L, Strength +5/5 = b/L, CN II-XII grossly intact
Osteopathic Exam:
Cervical Exam:
C3-5 Extended, Rotated Left, Sidebent Left
Tenderness over articular pillars L>R
Cervical ROM: FB 70, BB 50, SBL 45, SBR 30, Rot L 80, Rot R 65
Example Case #2
Assessment
1. Cervical Strain
2. Cervical Somatic Dysfunction 739.1
Plan
1. OMT, myofascial, HVLA to cervical spine with improvement of pain
and ROM
2. Continue Naprosyn 500mg PRN for pain
3. Stretching exercises given
4. Return to office PRN
E/M: 99211-25
OMT x1 region 98925
Questions?
• That’s all folks…
• Questions/comments
• Examples?
Resources
Savarese, D.O., Robert. OMT Review, 2nd ed. 1999.
Kimberly, D.O., Paul. The Kimberly Manual.
Revised edition 1999, KCOM class edition.
Ward, Robert. Foundations of Osteopathic
Medicine. 1st ed. 1997 Williams & Wilkins.
Online Resources:
www.aoa-net.org – AOA Website
www.do-online.com – AOA Website
Omt4fp.tripod.com - OMT for Family Practice (my personal design)
www.acofp.com - Amer Academy Osteopathic Family Physicians