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Cracking the Case:
Quick, Easy OMT in a Nutshell
JESSICA KELNER, DO
BRIAN BROWNING, DO
FAMILY MEDICINE
NEUROMUSCULAR MEDICINE
Today’s lecture
 3 musculoskeletal cases
 Differential Diagnosis
 Documentation and Billing for OMT
 Pertinent anatomy and special tests
 3 OMT treatments for each case
 Lab after each case
Case 1 - HPI
 35 year old female c/o intermittent progressively
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worsening headaches x 1 month.
3-4x a week, worse when she is stressed, better with
lying down and closing her eyes
Headaches start in the back of her head on the right
and radiate around toward the back of her right eye.
Pain is “achy” and “sharp” behind her eye, rates them
as a 7/10.
Associated discomfort on right side of her neck.
Tried taking ibuprofen and Excedrin which helps for
an hour or two.
Case 1
 She denies recent head trauma.
 No association with menstruation
 ROS: +headache, +right sided neck pain, denies
numbness or tingling, denies blurry vision,+ Light
sensitivity when she gets the headaches. denies
N/V/D/F, denies weakness, denies fatigue
 All other ROS are negative
Medical History
 Medical History: seasonal allergies, no past
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history of headaches or motion sickness as a child.
Surgical History: none
Medications: zyrtec 10mg during allergy season,
ibuprofen 600mg every 6 hours as needed for
headache
Family History: Mom – headaches, HTN
Social History: works as a secretary, drinks 2 cups of
coffee/day, processed food diet, no exercise, non
smoker, lives with husband
Physical Exam
Temp: 98.8 deg F BP: 128/75 Pulse: 70 Ht: 66inches Wt:
160lbs
GEN: Well-nourish, well-hydrated. NAD
HEAD: normocephalic, atraumatic
ORO-PARYNX: mucus membranes mildly
dehydrated, clear, no exudates
EYE: PERLA, EOMI
LUNGS: CTA B/L, no wheezing or rhonchi
CV: RRR, no M/R/G
Abd: Soft, NT/ND, no organomegaly
NEURO: sensation in b/l upper extremities in-tact to
light touch
PSYCH: A&O x 3, judgment, memory and insight intact
Physical Exam
MSK
 hypertonic paraspinal muscles in thoracic spine and
cervical spine B/L
 hypertonic trapezius B/L
 hypertonic levator scapula B/L
 decreased cervical lordosis
 hypertonic anterior and middle scalenes B/L
 TTP over right occipital condyle with reproduction of
symptoms
 ROM of head: decreased rotation to the right compared to
the left, otherwise full ROM of neck, neck is supple
 Negative Spurling’s test
Osteopathic Exam
Patient was found to have tenderness, asymmetry,
restriction of ROM, and tissue texture changes in the
following areas:
 HEAD: OA compression on the right, with TTP over
occipital condyle
 CERVICAL SPINE: C2 Flexed RRSR
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anterior and middle scalenes restriction Right, Right SCM
restriction
 THORACIC SPINE: T2 Flexed SLRL
 B/L trigger points in upper trapezius
Differential Diagnosis
 Tension headache
 Migraine headache
 Dehydration
 Cerebral aneurysm
 Meningitis
 Viral syndrome
 Trigeminal neuralgia
 Pseudotumor cerebri
 Giant Cell Arteritis
Diagnosis
 Allopathic Assessment and Plan
 Tension headache (G44.209)
 Muscle spasm of paraspinal muscles (M62.838)
Heating pad
 Stretching exercises for upper back and neck
 Increase oral fluid intake
 Diclofenac PRN
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 Osteopathic Assessment and Plan
 Somatic Dysfunction of Head Region (M99.00)
 Somatic Dysfunction of Cervical Region (M99.01)
 Somatic Dysfunction of Thoracic Region (M99.02)
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OMT to 3 Body Regions (98926)
Billing for this Visit
 99213 (E/M level 3 establish patient office visit)
 - 25 modifier on E/M code for other separate
procedure (OMT)
 98926 (3-4 Body Regions Treated)
Billing Tips
 Evaluation and Management Codes:
 99202, 99203, 99204 most often used for new patients
 99212, 99213, 99214 most often used for established patients
 Modifier
 25 for “separate and identifiable procedure done the same day”
 CPT codes
 98925 (OMT to 1-2 body regions)
 98926 (OMT to 3-4 body regions)
 98927 (OMT to 5-6 body regions)
 98928 (OMT to 7-8 body regions)
 98929 (OMT to 9-10 body regions)
Greater Occipital Nerve
 Originates from C2
spinal
 Between C1 and C2,
along with the lesser
occipital nerve
 Emerges inferior to
the suboccipital
triangle (obliquus
capitis
inferior) muscle
 Passes through
the trapezius muscle
and ascends to
innervate the skin
along the posterior
scalp to the vertex of
the head
Greater Occipital Nerve
OMT Techniques
 OA decompression
 Muscle Energy for Cervical Spine
 Muscle Energy for the shoulder girdle
 Upper Thoracic Soft Tissue
OA Decompression
 Used for abnormal tension,
hypertonicity or spasm of
the cranial base that can
interfere with cranial-sacral
functioning
 Releases tissues around the
jugular foramen thus
enhancing fluid drainage
from the cranial vault and
reducing intracranial fluid
congestion.
 Restores normal vagal
tone.
 Can also benefit the
glossopharyngeal nerve, and
the spinal accessory nerve.
OA Decompression
 Physician: seated at the head of patient
 Patient: supine
 Place fingers vertically (pointing toward ceiling) so that the
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patient’s sub-occipital area is balanced on the physicians fingertips.
The pads of the fingers should maintain contact with this area.
The weight of the patient’s head is the only therapeutic force
applied.
As tissues relax, maintain pressure, until you can palpate the
posterior arch of the atlas (C1).
Continue pressure to slowly disengage the atlas from the
occiput. Disengagement will be noted by a “floating sensation” of
the atlas
As the atlas floats, balance it, support it with the tips of your ring
finger while moving the occiput gently in a cephalad direction
with the tips of your middle fingers. This will further disengage the
occiput from the atlas and decompress the condylar region.
Cervical Spine Muscle Energy
Cervical Spine Muscle Energy
Dysfunction (C2 F RRSR)
 Physician: seated at the head of the table
 Patient: supine
 Cradle the patient’s head in your hands and palpate the articular
pillars at the level of C2
 Extend the patient’s head until motion is felt under your palpating fingers
 Rotate the patient’s head to the left until motion is felt under your palpating
fingers
 Sidebend your patient to the left at C2 by translating C2 to the right with
your left finger (creating left sidebending)
 Instruct the patient to attempt to bring their head toward their right
ear (right sidebending) while providing isometric resistance for 3-5
seconds
 Instruct the patient to relax while easing your counterforce
 Reposition to a new restrictive barrier by increasing flexion, left
rotation and left sidebending
 Repeat 3-5x or until no further progress is made
 Re-check
Shoulder Girdle Muscle Energy
Shoulder Girdle Muscle Energy
 Patient: seated or supine
 Physician position: standing (if patient is seated) or
seated (if patient is supine)
 Used to assist in relaxation of the superior head of
trapezius
 Contact AC joint and ipsilateral neck with hands and
have patient shrug shoulder against counterforce.
 Have the patient relax, take up the slack, and repeat
2 more times or until tissues soften
Seated Soft Tissue
Upper Thoracic Soft Tissue
 Can be done in any position (supine, prone, lateral
recumbant or seated)
 Primarily used to address the root of the neck
 Also to some degree addresses sympathetic
innervation (especially if used in conjunction with
rib raising)