Before you “POP IT”:A review of shotgun techniques for the vertebral column including soft tissue, articular and muscle

energy treatment modalities

Richard J Margaitis D.O.

Advent Health East Orlando

Center for Family Care

August 2, 2019

Objectives

• Describe Anatomy of areas targeted for treatment

• Identify common areas of neck and back pain

• Discuss documentation and billing for OMT in the office

• Describe in detail “shotgun” techniques that can quickly and effectively treat problem areas OR prepare tissue prior to performing more direct techniques such as HVLA (not specifically covered today) to the axial spine

• Instruct, even the DO with virtually no palpatory skills, on how to perform some beneficial maneuvers to help most patients {even those with FIBROMYALGIA} starting in clinic next Monday morning

ICD-10 Osteopathic codes (body regions)• Body regions

M99.00 Somatic Dysfunction of the HeadM99.01 Somatic Dysfunction of the Cervical SpineM99.02 Somatic Dysfunction of the Thoracic SpineM99.03 Somatic Dysfunction of the Lumbar SpineM99.04 Somatic Dysfunction of the Sacral RegionM99.05 Somatic Dysfunction of the Pelvis RegionM99.06 Somatic Dysfunction of the Lower ExtremityM99.07 Somatic Dysfunction of the Upper ExtremityM99.08 Somatic Dysfunction of the Rib CageM99.09 Somatic Dysfunction of the Visceral/Lymphatics

CPT codes for OMT

•98925 -> 1-2 Body regions; 0.46 wRVU•98926 -> 3-4 Body regions; 0.71 wRVU•98927 -> 5-6 Body regions; 0.96 wRVU•98928 -> 7-8 Body regions; 1.21 wRVU•98929 -> 9-10 Body regions; 1.46 wRVU

* Use a 25 modifier on the E/M code if addressing other problems in OV (non-osteopathic) problems

{LBP, Cervicalgia, GERD, HTN etc.}

Neck Anatomy Review

Greater Occipital Nerve commonly involved with Occipital headaches

Subacromial Decompression

Direct Inhibition, +/- Muscle Energy component

Soft Tissue Cervical spineTx of cervical paraspinalmuscles

Trapezius stretch/MET

Physician forcePhysician Counterforce stabilizing handPatient force

Counter-levarage Soft tissue technique Cervical Paraspinals:Cephalad hand stabilizer/counterforceCaudad hand contralateral soft tissue manipulator

UnilateralTrapezius/Levator Scapulae – Passive {ST} / Active {MET}1) Side-bend Head/Neck away from side to be treated2) Stabilize arm on the contralateral shoulder while stabilizing other hand in suboccipital sulcus

A) patient pushes head and neck into physician’s forearm {step 1} 3-5 setsB) patient shrugs shoulder up against physician’s hand stabilizing shoulder {step 2}, 3-5x

Bilateral/Unilateral Soft Tissue w/ Neck/Head Flexion

Passive (ST/ART) vs. Active (MET)

Superficial and Deeper muscles of the T/L spine

Thoracic/Lumbar: Lateral Recumbent Soft Tissue (bow-stringing technique)

• Hand placement in the ipsilateral paravertebral gutter, finger tips grip into tissues and forearms of the physician are placed on the anterior axillary fold and greater trochanter region to apply counterforce to hands as they pull traction superiorly

1 2 3

45

Modified SPENCERS TECH w/ or w/o MET for upper back pain

6) Descriptive ONLY: See next slideScapulothoracic Soft Tissue/MFR

Modified Spencer Technique Bonus:

• I Will commonly use a Scapulothoracic Release as my Final stage of the Spencer Technique

• This is accomplished by having the patient rest their arm upon the physician’s shoulder, while the physician is standing in front of the patient in the same, lateral recumbant position

• The physician grasps the medial border of the scapula with his finger tips and then applies anterior traction while moving from a cephalad to a caudad direction or vice versa

• Great for Scapulothoracic muscular tightness or Upper Thoracic tightness

Counter-leverage Prone lumbar soft tissue technique

1

2

3

4

1) Cephalad hand provides counterforce, while caudad hand pulls up on Contralateral hip, the contralateral tissue is locked as the hip moves posteriorly2) Cephalad hand provides a perpendicular stretch to the contralateral muscles, while the caudad hand allows the hip to follow the roll of the torso3) The cephalad hand continues the perpendicular stretch while the caudad hand rolls forward with the contralateral hip4) The cephalad and caudad hand complete rotation as hip and torso returnTo the table

Supine Lumbar Soft tissue/Articular Technique* Soft tissue becomes articular when joints are moved at end range of motion

Cephalad hand wraps to contralateral paraspinal muscles in the T/L region, caudad hand is on knees

Cephalad pulls torso anteriorly as the caudad hand pushes knees away

12

Lateral recumbent Lumbar spine (ART/MET)

Patient pushes feet towards ceiling/Physician Resists

*Physician hand monitoring lumbar paraspinal muscles Patient pushes feet towards floor/Physician Resists

*Physician hand monitoring lumbar paraspinal muscles

Lumbosacral distraction -> MET, patient pushes knees into physicians thigh(arrow -> patient’s force), {compressive force from physician}