(OMT) for Patients with Low Back Pain - American Academy of ...

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osteopathic physicians. It is utilized as an adjunct or complementary to conventional or alternativemethods of treatment.17. Algorithm: Provide (when appropriate) a graphical description of the stages and decisions inclinical care described by the guideline.Once a patient with low back pain is diagnosed with somatic dysfunction as the cause, orcontributing factor, of the low back pain, OMT should be utilized by the osteopathic physician. Thediagnosis of somatic dysfunction entails a focal or complete history and physical exam, including anosteopathic structural exam that provides evidence of asymmetrical anatomical landmarks,restriction or altered range of joint motion, and palpatory abnormalities of soft tissues. OMT totreat somatic dysfunction is utilized after other potential causes of low back pain are ruled out orconsidered improbable by the treating physician; i.e., vertebral fracture; vertebral joint dislocation;muscle tears or lacerations; spinal or vertebral joint ligament rupture; inflammation of intervertebraldiscs, spinal zygapophyseal facets joints, muscles or fascia; skin lacerations; sacroiliitis; ankylosingspondylitis; masses in or from the low back structures; or organic (visceral) disease referring pain tothe back or causing low back muscle spasms.Algorithm for OMT LBP decision making.Adapted from: Chapter 4. “The manipulative prescription,” In: Somatic Dysfunction in OsteopathicFamily Medicine. Nelson, Glonek, eds., Baltimore, MD: Lippincott, Williams & Wilkins; 2007;27-32.Is Somatic dysfunction the cause,or a contributing factor, in thepresentation of LBP (Look for “RedFlags.”)YesCause:A) Define type of dysfunctionalmechanics and as appropriate, definethe dysfunctional barrier.NoIdentify cause of LBP andtreat accordingly.Contributing factor: Identifyprimary cause of LBP andtreat accordingly. Treatcontributing somaticdysfunction using the samedecision making as followed ifthe LBP is solely the result ofsomatic dysfunction.B) Determine why the dysfunction is present (e.g., articular, muscular, myofascial,neuroreflex, membranous).C) Determine the patient’s level of tolerance for OMT.D) Decide upon the type of OMT to most effectively address thecause of the dysfunction with consideration for patient tolerance.10
E) Apply OMT to accomplish the desired response.F) Reassess the dysfunction and determine if and when follow‐upevaluation is necessary.Follow‐up, if appropriate, and repeat steps A‐F.18. Implementation considerations: Describe anticipated barriers to application of therecommendations. Provide reference to any auxiliary documents for providers or patients that areintended to facilitate implementation. Suggest review criteria for measuring changes in care when theguideline is implemented.One of the barriers to application of the recommendations cited by osteopathic physicians has beenpoor reimbursement for OMT. 61 However, Medicare has reimbursed osteopathic physicians for thisprocedure (ICD-9 code: 98926-9), for over 30 years. Many osteopathic physicians apparently donot utilize OMT in clinical practice due to a number of barriers, including time constraints, lack ofconfidence, loss of skill over time from disuse, and inadequate office space. 61 Some specialists, i.e.,pathologists and radiologists, do not use OMT as it is not applicable to their duties within theirspecialty. The AOA believes patients with low back pain should be treated with OMT given the highlevel of evidence that supports its efficacy. Changes in care when this guideline is implemented willbe determined by physician and patient surveys, billing and coding practice patterns amongstosteopathic physicians, data gathered from osteopathic physicians via the AOA’s ClinicalAssessment Program, and other registry data gathering tools currently being developed byresearchers.REFERENCES1. Cypress BK: Characteristics of physician visits for back symptoms: a national perspective.American Journal of Public Health 1983, 73:389-395.2. Licciardone JC, Herron KM: Characteristics, satisfaction, and perceptions of patients receivingambulatory healthcare from osteopathic physicians: a comparative national survey. Journal of theAmerican Osteopathic Association 2001, 101:374-385.3. Licciardone JC: Awareness and use of osteopathic physicians in the United States: results of theSecond Osteopathic Survey of Health Care in America (OSTEOSURV-II). Journal of the AmericanOsteopathic Association 2003, 103:281-289.4. Bigos S, Bowyer O, Braen G, et al: Acute Low Back Problems in Adults. Clinical Practice Guideline No.14. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, USDepartment of Health and Human Services; 1994.5. Kuchera ML, DiGiovanna EL, Greenspan PE: Efficacy and complications. In Foundations forOsteopathic Medicine. 2nd edition. Edited by Ward RC. Philadelphia, PA: Lippincott Williams &Wilkins; 2003:1143-1152.11
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