Characteristics and Management of Pregnant Patients From a Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine Clinic

Methods

In October 2018, we retrospectively reviewed electronic health records (EHR) for clinical encounters of pregnant patients treated at an NMM/OMM specialty outpatient clinic in Kirksville, Missouri, between October 1, 2015 and September 30, 2018. Encounters were selected using International Classification of Diseases 10^th Revision (ICD-10) codes indicating current pregnancy: O00.01 (abdominal pregnancy with intrauterine pregnancy), O99 (other maternal diseases complicating pregnancy, childbirth, and the puerperium), Z33.1 (incidental pregnant state), and Z33.3 (pregnant state, gestational carrier). Encounters of all patients coded as pregnant at the time of the encounter who also received OMT were included in the study. Encounters with pregnant patients treated with OMM in other specialty clinics within the clinic group (including family medicine) were excluded, as our interest was in those patients evaluated and treated or supervised by board-certified NMM specialists. The current retrospective chart review study was reviewed by the institutional review board of A.T. Still University—Kirksville College of Osteopathic Medicine and was determined to be exempt.

Patient data from 8 attending and 14 resident physicians were included in the study; resident physicians saw patients under the supervision of an attending physician. All attending physicians were board-certified in NMM/OMM or had a Certification of Special Proficiency in OMM. Three attending physicians were also board certified in family practice/OMT. Seven of the resident physicians were training in an NMM/OMM residency program and 7 in an NMM-combined residency-training program (family medicine/NMM or internal medicine/NMM).

Data were obtained from queries to the clinic's EHR, NextGen Healthcare Ambulatory EHR version 5.8.3 with knowledge-based model templates version 8.3.8 from October 1, 2015, through April 1, 2018. After that date, the system was updated to EHR version 5.9 with knowledge-based model templates version 8.4, which was used for the remainder of the study period. Collected data included patient age, number of encounters, presenting complaints, clinical assessments, body regions of somatic dysfunction assessed, OMT techniques used by the physician during the encounter, and payment method. The data were then grouped according to patient age categories as follows: less than 20 years old, 20 to 24 years, 25 to 29 years, 30 to 34 years, and 35 years and older.

Presenting complaints were grouped according to the complaint or body region and sorted using the defined age categories. Clinical assessments were grouped by their ICD-10 code, body region, and clinical similarity (eg, all causes of headache were grouped together and given the designation “headache” for analysis). Payment methods were grouped by primary method of payment: private insurance, Medicaid, Medicare, or self-pay.

Results

The EHR search resulted in data for 194 pregnant patients who received OMM over 465 clinical encounters during the study period (Table 1). The 25-29 years age category had the largest number of unique patients (76; 39.2%) and the largest number of encounters (169; 36.3%). The mean (SD) number of encounters per patient was 2.4 (2.0).

For all encounters, there were 670 separate presenting complaints documented. The most common presenting complaints by age category are shown in Table 2. The 4 most common presenting complaints were for the back (371; 55.4%), hip and pelvis (99; 14.8%), neck (62; 9.3%), and head (54; 8.1%); the 2 most common presenting complaints (back; hip and pelvis) were consistent for all age categories.

Overall, there were 792 clinical assessments documented, excluding somatic dysfunction and pregnancy codes. The most common clinical assessment regions by age category are presented in Table 3. The 4 most common clinical assessment regions were thoracic or lumbar (420; 53.0%), hip or pelvic (124; 15.7%), cervical (85; 10.7%), and head (55; 6.9%).

There were 2604 documented somatic dysfunction assessments. The frequency of the 10 body regions of somatic dysfunction assessed by age category is presented in Table 4. The 4 most frequently assessed regions were the lumbar (409; 15.7%), sacral (396; 15.2%), thoracic (374; 14.4%), and pelvic (346; 13.3) regions. In patients less than 20 years old, the thoracic and sacral regions (both 37; 24.5%) were most frequently assessed. The lumbar region was most commonly assessed in those aged 20 to 24 years (118; 15.6%), 25 to 29 years (153; 16.5%), and 30 to 34 years (72; 16.0%). In those 35 years and older, the thoracic and lumbar regions (both 32; 15.1%) were most frequently assessed.

There were 2518 OMT techniques documented. The types of OMT techniques used by age category are presented in Table 5. Muscle energy was the most frequently used technique overall (406; 16.1%) and for each age category. The next most common technique used overall was myofascial release (338; 13.4%), followed by articular (269; 10.7%) and high-velocity, low-amplitude (250; 9.9%).

Primary payment method was documented for all 465 patient encounters. Of these, 117 patients accounting for 263 (56.6%) encounters had private insurance, 72 patients accounting for 191 (41.1%) encounters used Medicaid, 3 patients accounting for 4 (0.9%) encounters were self-pay, and 2 patients accounting for 7 (1.5%) encounters used Medicare. No difference was found between mean number of regions treated per encounter and primary payment method (P=.07). The mean (SD) number of regions treated per encounter by payment method was 5.8 (1.5) for Medicaid, 5.7 (1.3) for Medicare, 5.5 (1.5) for private, and 4.8 (1.7) for self-pay.

Discussion

In a retrospective chart review, we summarized the characteristics of pregnant patients who received OMM as adjunctive treatment at an NMM/OMM specialty outpatient clinic. We found that OMM was used as adjunctive treatment across all payment method categories and identified consistency across defined age categories in most common presenting complaints, clinical assessments, and type of OMT technique used. Back and hip or pelvic complaints were the most frequently documented presenting complaints for all age categories, and our findings for clinical assessments reflected that. This level of consistency may indicate that future studies do not require defined age groups for data analysis.

Past research suggests that the most frequently reported musculoskeletal complaints during pregnancy are back pain, hip pain, and upper extremity issues, such as carpal tunnel and de Quervain's stenosing tenosynovitis.^13-15 These findings are consistent with our results, where back pain and hip or pelvic complaints were the 2 most common presenting complaints for all age categories. Neck pain was the third most common presenting complaint and seemed to have increasing incidence with increased age. However, neck pain is not reported in the literature as a frequent complaint during pregnancy. Therefore, it may represent an area for further study.

Back pain and hip or pelvic pain during pregnancy have been frequently investigated. In a study by Mogren and Pohjanen,¹⁶ the prevalence of low back and pelvic pain in pregnancy was 72%. Casagrande et al¹⁷ found lumbopelvic pain prevalence was 62% early in pregnancy and increased to 71% toward the end. This presenting complaint can become a longer-term issue for many women. Padua et al¹⁸ found more than 50% of women with back pain during pregnancy reported persistent pain at 1-year follow-up, and Noren et al¹⁹ found that 20% of women with back pain during pregnancy had persistent pain 3 years later. Multiple studies^6,8 have reported a positive impact of OMT on low back and pelvic pain in obstetric patients. Therefore, given the high frequency of back pain observed during and after pregnancy^18-20 and reported improvements in back pain after OMT as an intervention,⁶ future studies should further investigate the use of OMT to relieve back pain during pregnancy. Also, because of the potential long-term nature of persistent pregnancy-related back pain, studies should follow participants beyond delivery to better characterize the long-term impact.

In our study, the lumbar and sacral regions were the most common body regions of assessed somatic dysfunction. Muscle energy was the most common OMT technique overall and for all age categories; myofascial release and articular were the next most common techniques. Previous research has reported improved pain symptoms with OMT during pregnancy when muscle energy, myofascial release, or articular techniques were used as treatment modalities in the OMT protocol.^7-9,11,12 Chiropractic manipulation studies have also shown improvement in back pain in pregnant patients during and after pregnancy.^21,22 These chiropractic studies^21,22 primarily involved high-velocity, low-amplitude, which was the fourth most commonly used technique in our study. Given the positive effects of OMT techniques in the treatment of back pain in pregnancy, future studies should investigate the effects of specific OMT techniques on reduction in pain.

The current study had several limitations. Race was not included as a demographic variable because it was not collected on our clinic's new patient history form, which was completed during each patient's initial patient encounter. Gestational age and parity were not tracked either, since they were not recorded at each encounter in an electronically-searchable fashion. Another limitation may be that our EHR search was not inclusive of all encounters with pregnant patients because we only included encounters with our selected ICD-10 pregnancy codes. If a provider did not use one of those assessment codes for the evaluation and management service, then the encounter was not included. While this limitation affects the reliability of the total numbers for each category of data collected, the relative frequency is likely representative of the clinic patient population. Additionally, only presenting complaints that were recorded in the “complaint” fields of the EHR were included in our data analysis. However, providers may have typed additional complaints as narratives in free text comment boxes in the EHR. Presenting complaints that were recorded as narratives were not included in our study. Concerns considered secondary to neuromusculoskeletal complaints, such as lower extremity edema, constipation, and gastric reflux, may have been not included in the study even though they may have been recorded as narratives in the history and treatment plan without a unique clinical assessment code. Because of these limitations, future studies should include provider education as part of the planning process so all history and clinical assessments are documented in a searchable fashion. For example, evaluation and management documentation should always include a pregnancy-related ICD-10 clinical assessment code for encounters with pregnant patients.

Another limitation was that our data were obtained from a single NMM/OMM specialty outpatient clinic with NMM/OMM and NMM-combined residency programs. The treatment data were pooled from 8 attending physicians and 14 resident physicians. Therefore, our results may not be representative of individual physicians within the practice or physicians outside the practice, which limits the generalizability of the treatment data. Further, because our patients were treated in an NMM/OMM specialty clinic, our results may not reflect the presentation of patients or the approach taken by osteopathic physicians of other specialties.

Conclusion

The current study was a retrospective chart review of pregnant patients presenting to an NMM/OMM specialty outpatient clinic. We identified common presenting complaints, clinical assessments, body regions of somatic dysfunction assessed, and OMT techniques used for defined age categories. Consistent with the specialty, patients were predominately seen for neuromusculoskeletal conditions, and we found minimal variability between age group categories. By identifying common complaints and OMM treatments used by NMM specialists, we hope to better define the role of OMM as an adjunctive treatment in the treatment of pregnant patients and thereby encourage physicians to provide or refer for OMM as part of patient management for these conditions. Additionally, results of the current study may be used as a guide for future outcome studies by identifying common presenting complaints of pregnant patients receiving OMM.