An Osteopathic Approach to Low Back Pain. Ryan Seals DO Interim Chair of Family Medicine and OMM

Transcription

1 An Osteopathic Approach to Low Back Pain Ryan Seals DO Interim Chair of Family Medicine and OMM

2 Objectives Review Osteopathic Philosophy and Principles Discuss how somatic dysfunction influences low back pain Review research supporting OMT Discuss billing and coding for OMT

3 What is Osteopathic Medicine? How many MD s and DO s are here?

4 Tenets of Osteopathic Medicine The body is a unit of mind, body, and spirit 1 Treating the whole person, not just the diagnosis Considering lifestyle and emotional aspects The body is capable of self-regulation, self-healing, and health maintenance Structure and function are reciprocally inter-related Rational therapy is based on the above tenets Most back pain resolves on its own in 2-3 months Muscle weakness Posture Within man s body there is a capacity for health. If this capacity is recognized and normalized, disease can be both prevented and treated. --- A. T. Still.

5 Somatic Dysfunction impaired or altered function of related components of the somatic (bodywork) system including: the skeletal, arthrodial, and myofascial structures, and their related vascular, lymphatic, and neural elements

6 Osteopathic Manipulation What is the purpose of using OMM on patients? Removal of mechanical restrictions around joints, muscles, fascia, ligaments, and viscera allows for uninterrupted nerve function arterial delivery of blood venous return of blood lymphatic drainage A variety of techniques can be used to remove restrictions by using the least amount of force needed to accomplish this task

7 Case A 56 year-old male presents to the clinic with lower back pain. The pain started about four weeks ago. He denies any injury and states he sits at a desk most of the day. Pain is located more on the right side than the left, but pain seems to radiate partly down the back of his left leg. Seems to be worse when standing up after prolonged sitting. The pain has not really improved with rest or Ibuprofen. ROS: Denies fever, numbness, weakness, or incontinence. PMH: No cancer history, no IV drug use. Physical exam reveals 2/4 reflexes patellar and achilles regions bilaterally. Straight leg raise is painful at 75 degrees on the left. Thomas test is positive on the right. Fine touch and pain sensation are intact. Strength 5/5 in lower extremity throughout.

8 Low Back Pain Signficance Affects 5.6 % of U.S. adults daily. 18 % of U.S. adults report having LBP in past month. Lifetime prevalence 60-70%. Kindkade, Scott, MD, Evaluation and Treatment of Acute Low Back Pain, American Family Physician Vol 75 No 8 April 15, Acute vs. Chronic % resolve in one week % recover in six weeks. Approx. 95 % recover by week 12 Back pain greater than 12 weeks is considered Chronic. 2-8% of LBP is Chronic. Wheeler, Anthony, MD, Pathophysiology of Chronic Back Pain, emedicine July 9,

9 Low Back Pain Natural History An estimated 65% to 80% of the population will experience LBP during their lifetime. LBP is the most prevalent chronic pain syndrome and the leading cause of limitation of activity in patients younger than the age of 45. It is also the second most frequent reason for a visit to the physician's office and the third most common surgical indication. The incidence of LBP increases with age, and LBP more commonly affects women 90% better by 8 weeks Kelley's Textbook of Rheumatology, Ninth Edition Gary S. Firestein, et al. Chapter 47 Low Back pain

10 Low Back Pain What causes it? 97% of Low Back Pain is considered mechanical DJD-10% Herniated Disc-4% Compression Fracture-4% Spinal Stenosis-3% Spondylolisthesis-2% Remainder are nonspecific-74% Pain sensing structures are muscles, ligaments, fascia, joints, discs, nerves

11 Low Back Pain Mechanical causes Sclerotomal/myotomal pain This pain can arise from pathology within the disk, facet joint, or lumbar paraspinal muscles and ligaments. Like sciatica, sclerotomal pain is often referred into the lower extremities, but unlike sciatica, sclerotomal pain is nondermatomal in distribution, it is dull in quality, and the pain usually does not radiate below the knee or have associated paresthesias. Most radiant pain is sclerotomal Kelley's Textbook of Rheumatology, Ninth Edition Gary S. Firestein, et al. Chapter 47 Low Back pain

12 Referred Pain Differentiation DERMATOMAL FACET SACROILIAC ILIOPSOAS PIRIFORMIS Differential diagnosis for referred pain to the posterior buttock, thigh, calf, and ankle. A) dermatome referred pain from irritation of the S1 nerve root B) sclerotomal referred pain from irritation of the L4-5 facet joint and/or capsule C) sclerotomal referred pain from the sacroiliac joint and/or sacroiliac ligaments; D) myotomal referred pain from the iliopsoas muscle E) myotomal referred pain from the piriformis muscle in full-blown piriformis syndrome. (A, B, and C taken from Mooney V, Saal J, Saal J. Evaluation and treatment of low back pain. Clinical Symposia 1996: 48(4); pages 4 and 11. D and E taken from Travell J, Simons D. Trigger Point Flip Charts, Lippincott Williams & Wilkins 1996.)

13 Low Back Pain Psoas syndrome History Common cause of low back pain due to psoas muscle spasm Often present with slightly flexed posture leaning toward side of tight psoas Exam Positive Thomas Test Type II upper lumbar dysfunction Need to treat lumbar to fully resolve dysfunction Positive pelvic shift test to contralateral side Contralateral Piriformis dysfunction Sacral dysfunction on oblique axis

14 Psoas Syndrome

15 Low Back Pain Treatment and Management Look for red flags Infection, Mass, Cord compression, neurologic compromise Imaging Not in the absence of red flags or trauma Prolonged pain NSAIDs, Muscle Relaxer, Opiods All weak recommendations Encourage patient to stay active Avoid bed rest Osteopathic Manipulation Evidence is similar to NSAIDs and other conservative modalities Home exercises or stretches

16 Volume 341: November 4, 1999 Number 19 Results: The osteopathic-treatment group required significantly less medication (analgesics, anti-inflammatory agents, and muscle relaxants) (P< 0.001) and used less physical therapy (0.2 percent vs. 2.6 percent, P<0.05

17 Annals of Internal Medicine 2003 American College of Physicians Volume 138(11) 3 June 2003 pp Spinal Manipulative Therapy for Low Back Pain: A Meta-Analysis of Effectiveness Relative to Other Therapies Assendelft, Willem J.J. MD, PhD; Morton, Sally C. PhD; Yu, Emily I. MPH; Suttorp, Marika J. MS; Shekelle, Paul G. MD, PhD

18 Annals of Internal Medicine 2003 American College of Physicians Volume 138(11) 3 June 2003 pp Spinal Manipulative Therapy for Low Back Pain: A Meta- Analysis of Effectiveness Relative to Other Therapies Assendelft, Willem J.J. MD, PhD; Morton, Sally C. PhD; Yu, Emily I. MPH; Suttorp, Marika J. MS; Shekelle, Paul G. MD, PhD Favors manipulation for long-term pain

19 Low Back Pain Evidence for OMT Licciardone, JC, et. al. Annals of Family Medicine. 11:2. March/April According to the study, OMT was not only more effective than ultrasound for treating low back pain, but its use also allowed participants to cut down on the amount of medication they took to treat their lower back pain throughout the 12-week study. Nearly two-thirds of the individuals who received OMT had a 30 percent reduction in their pain level, and half of those patients had a 50 percent reduction in their pain level, the study showed.

20 Low Back Pain How I approach a patient History and Physical Exam Including orthopedic and neurologic exams Including osteopathic structural exam Perform OMT to somatic dysfunctions based on exam findings Always err on the side of using less force especially if any clinical suspicion of nerve or cord compression Perform joint or trigger point injections as indicated Order imaging when needed Referrals for PT, Pain management, Neurosurgery as appropriate

21 OMM codes Somatic Dysfunction Cranial- M99.00 Cervical- M99.01 Thoracic- M99.02 Lumbar- M99.03 Sacrum- M99.04 Hip/Pelvis- M99.05 Lower Extremity- M99.06 Upper extremity- M99.07 Rib- M99.08 Abdomen- M99.09 Osteopathic Manipulation 98925: 1-2 body regions 98926: 3-4 body regions 98927: 5-6 body regions 98928: 7-8 body regions 98929: 9-10 body regions 25 modifier on E&M code for separately identifiable service

22 OMM clinic in PCC 6th floor

23 ANY QUESTIONS? RYAN SEALS, D.O.