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Obstetrics/Gynecology and Pediatrics  |   December 2020
Characteristics and Management of Pregnant Patients From a Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine Clinic
Author Notes
  • From the Departments of Osteopathic Manipulative Medicine (Dr Frank) and Family Medicine, Preventative Medicine, and Community Health (Dr Snider) at Kirksville College of Osteopathic Medicine and the Department of Research Support (Ms Bhatia) at A.T. Still University in Kirksville, Missouri. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Leah D. Frank, DO, Praxis für Orthopädie und Osteopathie, Klever Str. 25, 40477 Düsseldorf, Germany (Deutschland). Email: leahfrankdo@gmail.com
     
Article Information
Obstetrics/Gynecology and Pediatrics   |   December 2020
Characteristics and Management of Pregnant Patients From a Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine Clinic
The Journal of the American Osteopathic Association, December 2020, Vol. 120, 913-920. doi:https://doi.org/10.7556/jaoa.2020.151
The Journal of the American Osteopathic Association, December 2020, Vol. 120, 913-920. doi:https://doi.org/10.7556/jaoa.2020.151
Abstract

Context: Osteopathic manipulative medicine (OMM) is considered beneficial in the treatment of pregnant women, but few studies have outlined the presenting complaints and diagnoses that warrant consideration and utilization of osteopathic manipulative treatment (OMT) in this population.

Objective: To describe the characteristics of pregnant patients receiving OMM at a neuromusculoskeletal medicine (NMM)/OMM specialty outpatient clinic, for the purpose of identifying patients who would benefit from referral to NMM specialty clinics or to be considered for treatment by DOs in non-NMM specialty clinics.

Methods: Electronic health records were reviewed from a single clinic for a 3-year period from October 2015 through September 2018 for patient encounters involving patients with an International Classification of Diseases 10th Revision code for pregnancy. Data regarding patient demographics, payment methods, presenting complaints, treatment modalities, regions treated, and assessment diagnoses were collected and analyzed.

Results: Records showed 465 clinical encounters with 194 pregnant patients (mean [SD] number of encounters per patient, 2.4 [2.0]). The most common presenting complaints involved the back (371; 55.4%), hip and pelvis (99; 14.8%), neck (62; 9.3%), and head (54; 8.1%). The most common clinical assessments were lumbar and thoracic spine neuromusculoskeletal diagnoses (420; 53.0%). There were 2604 somatic dysfunction assessments documented; lumbar (409; 15.7%) and sacral (396; 15.2%) somatic dysfunction were most commonly assessed. There were 2518 OMT techniques documented, and muscle energy was most frequently used (406; 16.1%).

Conclusions: This data, which documents the most frequent presenting complaints of pregnant patients in an NMM/OMM clinic, may be used by clinicians to better understand the role of OMM as an obstetric adjunctive treatment approach and to identify conditions to investigate in future outcome studies.

Osteopathic manipulative medicine (OMM) is used to diagnose and manage somatic dysfunction, normalize structure-function relationships, and promote the intrinsic self-healing mechanisms of the body.1 Along with other types of manual medicine, OMM is a common adjunctive treatment approach in the care of patients, including obstetric patients.2 OMM has been studied in obstetric and gynecologic patients in various age categories and for a variety of conditions. It is considered a safe and effective adjunctive treatment for numerous conditions, such as dysmenorrhea,3 endometriosis,4 and lower urinary tract infections,5 commonly seen in outpatient primary care and women's health specialty settings. Multiple studies have shown improvements in low back pain,6-8 functional status,6 and birth outcomes9-12 when women are provided with osteopathic manipulative treatment (OMT) during the prenatal period. 
Although OMM is recognized as an adjunctive treatment option for the treatment of pregnant patients, few studies have published detailed characteristics of these patients or the conditions for which they are frequently treated. Consequently, there may be inadequate physician knowledge of OMM in the general medical community, the role that OMM plays in a multimodal treatment strategy, and the indications for referral of pregnant patients to an OMM specialty clinic. 
Given the limited studies in this area, the purpose of the current study was to describe the characteristics of pregnant patients receiving OMM at a neuromusculoskeletal medicine (NMM)/OMM specialty outpatient clinic, in order to help identify patients who would benefit from referral to NMM specialty clinics or to be considered for treatment by DOs in non-NMM specialty clinics. We hypothesized that OMM would primarily be used for neuromusculoskeletal complaints but that presenting complaints, clinical assessments, and OMT techniques used would vary based on the age of the patient, with the needs of patients of advanced maternal age differing from those of women earlier in their reproductive period. Reporting such age-specific data may be beneficial to better describe the appropriate use of OMM as an adjunctive treatment and to determine target populations for future studies. 
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 10th 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. 
Statistical Analysis
Categorical data were summarized using frequency and percent, and continuous data were summarized using mean and standard deviation (SD). Primary payment method was collectively termed as private when the patient had Aetna, Blue Cross Blue Shield, Cigna, Healthlink, Tricare, UnitedHealthcare, or another commercial payer as their primary payment method. Analysis of variance (ANOVA) was used to compare mean number of regions treated per encounter with primary payment method. All data analyses were performed using SAS (version 9.4, SAS Inc.). P <.05 was considered statistically significant. 
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). 
Frequency of Osteopathic Manipulative Treatment of Pregnant Patients by Age Categorya
Age category
Variable 1 2 3 4 5
Unique patients, n(%) (N=194) 13 (6.7) 57 (29.4) 76 (39.2) 36 (18.6) 12 (6.2)
Encounters, n(%) (N=465) 39 (8.4) 135 (29.0) 169 (36.3) 83 (17.8) 39 (8.4)
Encounters per patient, mean (standard deviation) 3.0 (1.6) 2.1 (1.6) 2.4 (2.2) 2.4 (1.8) 3.3 (2.8)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

Table 1.
Frequency of Osteopathic Manipulative Treatment of Pregnant Patients by Age Categorya
Age category
Variable 1 2 3 4 5
Unique patients, n(%) (N=194) 13 (6.7) 57 (29.4) 76 (39.2) 36 (18.6) 12 (6.2)
Encounters, n(%) (N=465) 39 (8.4) 135 (29.0) 169 (36.3) 83 (17.8) 39 (8.4)
Encounters per patient, mean (standard deviation) 3.0 (1.6) 2.1 (1.6) 2.4 (2.2) 2.4 (1.8) 3.3 (2.8)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

×
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. 
Most Common Presenting Complaints of Pregnant Patients by Age Category (N=670)a
Complaint Age categories, no. (%)
1 (n=60) 2 (n=202) 3 (n=232) 4 (n=118) 5 (n=58)
Back (n=371) 35 (58.3) 120 (59.4) 137 (59.1) 57 (48.3) 22 (37.9)
Hip/pelvis (n=99) 8 (13.3) 25 (12.4) 33 (14.2) 23 (19.5) 10 (17.2)
Head (n=54) 7 (11.7) 18 (8.9) 20 (8.6) 4 (3.4) 5 (8.6)
Neck (n=62) 6 (10.0) 14 (6.9) 21 (9.1) 12 (10.2) 9 (15.5)
Ribcage (n=23) 1 (1.7) 4 (2.0) 6 (2.6) 10 (8.5) 2 (3.5)
Lower extremity (n=21) 1 (1.7) 8 (4.0) 2 (0.9) 2 (1.7) 8 (13.8)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

Table 2.
Most Common Presenting Complaints of Pregnant Patients by Age Category (N=670)a
Complaint Age categories, no. (%)
1 (n=60) 2 (n=202) 3 (n=232) 4 (n=118) 5 (n=58)
Back (n=371) 35 (58.3) 120 (59.4) 137 (59.1) 57 (48.3) 22 (37.9)
Hip/pelvis (n=99) 8 (13.3) 25 (12.4) 33 (14.2) 23 (19.5) 10 (17.2)
Head (n=54) 7 (11.7) 18 (8.9) 20 (8.6) 4 (3.4) 5 (8.6)
Neck (n=62) 6 (10.0) 14 (6.9) 21 (9.1) 12 (10.2) 9 (15.5)
Ribcage (n=23) 1 (1.7) 4 (2.0) 6 (2.6) 10 (8.5) 2 (3.5)
Lower extremity (n=21) 1 (1.7) 8 (4.0) 2 (0.9) 2 (1.7) 8 (13.8)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

×
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%). 
Table 3.
Regions of Clinical Assessments in Pregnant Patients by Age Category (N=792)a
Diagnosis regionsb Age categories, no. (%)
1 (n=76) 2 (n=239) 3 (n=272) 4 (n=124) 5 (n=81)
Thoracic or lumbarc (n=420) 44 (57.9) 129 (54.0) 153 (56.3) 64 (51.6) 30 (37.0)
Cervicald (n=85) 9 (11.8) 27 (11.3) 32 (11.8) 9 (7.3) 8 (9.9)
Hip or pelvice (n=124) 8 (10.5) 25 (10.5) 50 (18.4) 28 (22.6) 13 (16.0)
Headf (n=55) 7 (9.2) 18 (7.5) 17 (6.3) 6 (4.8) 7 (8.6)
Upper extremityg (n=26) 2 (2.6) 10 (4.2) 4 (3.2) 8 (6.5) 2 (2.5)
Lower extremityh (n=36) 2 (2.6) 13 (5.4) 4 (3.2) 2 (1.6) 15 (18.5)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b Grouped by International Classification of Diseases, 10th Revision Codes, body region, and clinical similarity.

c Diagnoses included M46.06, M54.40, M54.41, M54.5, M54.6, M54.89, M54.9, and M62.830.

d Diagnoses included M54.2.

e Diagnoses included M25.551, M25.552, M25.559, M46.07, M46.1, M53.3, M53.88, M70.62, and R10.2.

f Diagnoses included G43.001, G43.009, G43.111, G43.119, G43.909, G44.201, G44.209, G44.219, G44.229, G44.52, G44.89, M54.81, R51, and R68.84.

g Diagnoses included G54.0, G56.03, G56.10, M25.511, M25.512, M25.519, M25.531, M65.4, and S43.085S.

h Diagnoses included G25.81, G57.02, G57.10, G57.11, G57.12, M21.70, M25.561, M25.562, M25.569, M25.571, M25.572, M72.2, M79.661, M79.662, M79.672, and Q72.811.

Table 3.
Regions of Clinical Assessments in Pregnant Patients by Age Category (N=792)a
Diagnosis regionsb Age categories, no. (%)
1 (n=76) 2 (n=239) 3 (n=272) 4 (n=124) 5 (n=81)
Thoracic or lumbarc (n=420) 44 (57.9) 129 (54.0) 153 (56.3) 64 (51.6) 30 (37.0)
Cervicald (n=85) 9 (11.8) 27 (11.3) 32 (11.8) 9 (7.3) 8 (9.9)
Hip or pelvice (n=124) 8 (10.5) 25 (10.5) 50 (18.4) 28 (22.6) 13 (16.0)
Headf (n=55) 7 (9.2) 18 (7.5) 17 (6.3) 6 (4.8) 7 (8.6)
Upper extremityg (n=26) 2 (2.6) 10 (4.2) 4 (3.2) 8 (6.5) 2 (2.5)
Lower extremityh (n=36) 2 (2.6) 13 (5.4) 4 (3.2) 2 (1.6) 15 (18.5)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b Grouped by International Classification of Diseases, 10th Revision Codes, body region, and clinical similarity.

c Diagnoses included M46.06, M54.40, M54.41, M54.5, M54.6, M54.89, M54.9, and M62.830.

d Diagnoses included M54.2.

e Diagnoses included M25.551, M25.552, M25.559, M46.07, M46.1, M53.3, M53.88, M70.62, and R10.2.

f Diagnoses included G43.001, G43.009, G43.111, G43.119, G43.909, G44.201, G44.209, G44.219, G44.229, G44.52, G44.89, M54.81, R51, and R68.84.

g Diagnoses included G54.0, G56.03, G56.10, M25.511, M25.512, M25.519, M25.531, M65.4, and S43.085S.

h Diagnoses included G25.81, G57.02, G57.10, G57.11, G57.12, M21.70, M25.561, M25.562, M25.569, M25.571, M25.572, M72.2, M79.661, M79.662, M79.672, and Q72.811.

×
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. 
Table 4.
Somatic Dysfunction Assessments for Pregnant Patients by Age Category (N=2604)a
Body regionb,c Age categories,d no. (%)
1 (n=255) 2 (n=758) 3 (n=928) 4 (n=451) 5 (n=212)
Head (M99.00) (n=280) 34 (13.3) 85 (11.2) 100 (10.8) 38 (8.4) 23 (10.8)
Cervical (M99.01) (n=306) 35 (13.7) 88 (11.6) 109 (11.7) 43 (9.5) 31 (14.6)
Thoracic (M99.02) (n=374) 37 (14.5) 109 (14.4) 132 (14.2) 64 (14.2) 32 (15.1)
Lumbar (M99.03) (n=409) 34 (13.3) 118 (15.6) 153 (16.5) 72 (16.0) 32 (15.1)
Sacral (M99.04) (n=396) 37 (14.5) 115 (15.2) 147 (15.8) 68 (15.1) 29 (13.7)
Pelvis (M99.05) (n=346) 28 (11.0) 100 (13.2) 129 (13.9) 64 (14.2) 25 (11.8)
Lower extremities (M99.06) (n=126) 11 (4.3) 38 (5.0) 41 (4.4) 26 (5.8) 10 (4.7)
Upper extremities (M99.07) (n=53) 9 (3.5) 17 (2.2) 11 (1.2) 10 (2.2) 6 (2.8)
Rib (M99.08) (n=273) 25 (9.8) 78 (10.3) 93 (10.0) 54 (12.0) 23 (10.8)
Abdomen (M99.09) (n=41) 5 (2.0) 10 (1.3) 13 (1.4) 12 (2.7) 1 (0.5)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b By International Classification of Diseases, 10th Revision Codes.

c The n for body region indicates the number of total encounters during which the indicated body region was treated.

d The n for age category indicates the number of total body regions treated across all encounters in the individual age group.

Table 4.
Somatic Dysfunction Assessments for Pregnant Patients by Age Category (N=2604)a
Body regionb,c Age categories,d no. (%)
1 (n=255) 2 (n=758) 3 (n=928) 4 (n=451) 5 (n=212)
Head (M99.00) (n=280) 34 (13.3) 85 (11.2) 100 (10.8) 38 (8.4) 23 (10.8)
Cervical (M99.01) (n=306) 35 (13.7) 88 (11.6) 109 (11.7) 43 (9.5) 31 (14.6)
Thoracic (M99.02) (n=374) 37 (14.5) 109 (14.4) 132 (14.2) 64 (14.2) 32 (15.1)
Lumbar (M99.03) (n=409) 34 (13.3) 118 (15.6) 153 (16.5) 72 (16.0) 32 (15.1)
Sacral (M99.04) (n=396) 37 (14.5) 115 (15.2) 147 (15.8) 68 (15.1) 29 (13.7)
Pelvis (M99.05) (n=346) 28 (11.0) 100 (13.2) 129 (13.9) 64 (14.2) 25 (11.8)
Lower extremities (M99.06) (n=126) 11 (4.3) 38 (5.0) 41 (4.4) 26 (5.8) 10 (4.7)
Upper extremities (M99.07) (n=53) 9 (3.5) 17 (2.2) 11 (1.2) 10 (2.2) 6 (2.8)
Rib (M99.08) (n=273) 25 (9.8) 78 (10.3) 93 (10.0) 54 (12.0) 23 (10.8)
Abdomen (M99.09) (n=41) 5 (2.0) 10 (1.3) 13 (1.4) 12 (2.7) 1 (0.5)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b By International Classification of Diseases, 10th Revision Codes.

c The n for body region indicates the number of total encounters during which the indicated body region was treated.

d The n for age category indicates the number of total body regions treated across all encounters in the individual age group.

×
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%). 
Table 5.
Osteopathic Manipulative Treatment Techniques Used for Pregnant Patients by Age Category (N=2518)a
Age categories,c no. (%)
Techniqueb 1 (n=238) 2 (n=729) 3 (n=912) 4 (n=443) 5 (n=196)
Articular (n=269) 18 (7.6) 73 (10.0) 99 (10.9) 57 (12.9) 22 (11.2)
Counterstrain (n=195) 19 (8.0) 61 (8.4) 66 (7.2) 35 (7.9) 14 (7.1)
Osteopathic cranial manipulative medicine (n=94) 10 (4.2) 28 (3.8) 40 (4.4) 12 (2.7) 4 (2.0)
Facilitated positional release (n=38) 1 (0.4) 10 (1.4) 18 (2.0) 6 (1.4) 3 (1.5)
High-velocity, low-amplitude (n=250) 27 (11.3) 67 (9.2) 89 (9.7) 47 (10.6) 20 (10.2)
Indirect balanced ligamentous tension (n=147) 13 (5.5) 54 (7.4) 44 (4.8) 26 (5.9) 10 (5.1)
Integrated neuromuscular release (n=8) 1 (0.4) 3 (0.4) 2 (0.2) 2 (0.5) 0 (0)
Ligamentous articular strain (n=70) 6 (2.5) 22 (3.0) 26 (2.9) 12 (2.7) 4 (2.0)
Lymphatic (n=11) 1 (0.4) 2 (0.3) 1 (0.1) 6 (1.4) 1 (0.5)
Muscle energy (n=406) 35 (14.7) 111 (15.2) 156 (17.1) 68 (15.3) 36 (18.4)
Myofascial release (n=338) 34 (14.3) 98 (13.4) 121 (13.3) 58 (13.1) 27 (13.8)
Neurofascial release (n=2) 1 (0.4) 0 (0) 0 (0) 1 (0.2) 0 (0)
Percussion hammer (n=65) 11 (4.6) 0 (0) 20 (2.2) 6 (1.4) 5 (2.6)
Progressive inhibition (n=20) 2 (0.8) 8 (1.1) 6 (0.7) 4 (0.9) 0 (0)
Soft tissue (n=248) 25 (10.5) 67 (9.2) 99 (10.9) 39 (8.8) 18 (9.2)
Still technique (n=241) 19 (8.0) 75 (10.3) 86 (9.4) 39 (8.8) 22 (11.2)
Visceral manipulation (n=21) 5 (2.1) 3 (0.4) 5 (0.5) 6 (1.4) 2 (1.0)
Functional technique (n=72) 8 (3.4) 28 (3.8) 27 (3.0) 13 (2.9) 4 (2.0)
Other (n=23) 2 (0.8) 17 (2.3) 7 (0.8) 6 (1.4) 4 (2.0)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b The n for technique indicates the number of encounters where the indicated technique was used.

c The n for age category indicates the number of documented techniques used across all encounters in the individual age group.

Table 5.
Osteopathic Manipulative Treatment Techniques Used for Pregnant Patients by Age Category (N=2518)a
Age categories,c no. (%)
Techniqueb 1 (n=238) 2 (n=729) 3 (n=912) 4 (n=443) 5 (n=196)
Articular (n=269) 18 (7.6) 73 (10.0) 99 (10.9) 57 (12.9) 22 (11.2)
Counterstrain (n=195) 19 (8.0) 61 (8.4) 66 (7.2) 35 (7.9) 14 (7.1)
Osteopathic cranial manipulative medicine (n=94) 10 (4.2) 28 (3.8) 40 (4.4) 12 (2.7) 4 (2.0)
Facilitated positional release (n=38) 1 (0.4) 10 (1.4) 18 (2.0) 6 (1.4) 3 (1.5)
High-velocity, low-amplitude (n=250) 27 (11.3) 67 (9.2) 89 (9.7) 47 (10.6) 20 (10.2)
Indirect balanced ligamentous tension (n=147) 13 (5.5) 54 (7.4) 44 (4.8) 26 (5.9) 10 (5.1)
Integrated neuromuscular release (n=8) 1 (0.4) 3 (0.4) 2 (0.2) 2 (0.5) 0 (0)
Ligamentous articular strain (n=70) 6 (2.5) 22 (3.0) 26 (2.9) 12 (2.7) 4 (2.0)
Lymphatic (n=11) 1 (0.4) 2 (0.3) 1 (0.1) 6 (1.4) 1 (0.5)
Muscle energy (n=406) 35 (14.7) 111 (15.2) 156 (17.1) 68 (15.3) 36 (18.4)
Myofascial release (n=338) 34 (14.3) 98 (13.4) 121 (13.3) 58 (13.1) 27 (13.8)
Neurofascial release (n=2) 1 (0.4) 0 (0) 0 (0) 1 (0.2) 0 (0)
Percussion hammer (n=65) 11 (4.6) 0 (0) 20 (2.2) 6 (1.4) 5 (2.6)
Progressive inhibition (n=20) 2 (0.8) 8 (1.1) 6 (0.7) 4 (0.9) 0 (0)
Soft tissue (n=248) 25 (10.5) 67 (9.2) 99 (10.9) 39 (8.8) 18 (9.2)
Still technique (n=241) 19 (8.0) 75 (10.3) 86 (9.4) 39 (8.8) 22 (11.2)
Visceral manipulation (n=21) 5 (2.1) 3 (0.4) 5 (0.5) 6 (1.4) 2 (1.0)
Functional technique (n=72) 8 (3.4) 28 (3.8) 27 (3.0) 13 (2.9) 4 (2.0)
Other (n=23) 2 (0.8) 17 (2.3) 7 (0.8) 6 (1.4) 4 (2.0)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b The n for technique indicates the number of encounters where the indicated technique was used.

c The n for age category indicates the number of documented techniques used across all encounters in the individual age group.

×
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 studies6,8 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 pregnancy18-20 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 studies21,22 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. 
Acknowledgments
The authors thank Toni Matticks, Clinical Business Analyst at A.T. Still University, for her assistance in extracting electronic health record data. They also thank Deborah Goggin, MA, ELS, Scientific Writer at A.T. Still University, for her editorial assistance. 
References
Nelson KE, Stager WH. In: Nelson KE, Glonek T, eds. Somatic Dysfunction in Osteopathic Family Medicine. 2nd ed. Baltimore, MD: Wolters Kluwer Health; 2015:11-15.
Tettambel M, Nelson KE. The female patient. In: Nelson KE, Glonek T, eds. Somatic Dysfunction in Osteopathic Family Medicine. 2nd ed. Baltimore, MD: Wolters Kluwer Health; 2015:127-142.
Boesler D, Warner M, Alpers A, Finnerty EP, Kilmore MA. Efficacy of high-velocity low-amplitude manipulative technique in subjects with low-back pain during menstrual cramping. J Am Osteopath Assoc. 1993;93(2):203-208, 213-204. doi: 10.7556/jaoa.1993.93.2.203 [CrossRef] [PubMed]
Darai C, Deboute O, Zacharopoulou C, et al. Impact of osteopathic manipulative therapy on quality of life of patients with deep infiltrating endometriosis with colorectal involvement: results of a pilot study. Eur J Obstet Gynecol Reprod Biol. . 2015;188:70-73. doi: 10.1016/j.ejogrb.2015.03.001 [CrossRef] [PubMed]
Franke H, Hoesele K. Osteopathic manipulative treatment (OMT) for lower urinary tract symptoms (LUTS) in women. J Bodyw Mov Ther. . 2013;17(1):11-18. doi: 10.1016/j.jbmt.2012.05.001 [CrossRef] [PubMed]
Franke H, Franke JD, Belz S, Fryer G. Osteopathic manipulative treatment for low back and pelvic girdle pain during and after pregnancy: a systematic review and meta-analysis. J Bodyw Mov Ther. . 2017;21(4):752-762. doi: 10.1016/j.jbmt.2017.05.014 [CrossRef] [PubMed]
Licciardone JC, Aryal S. Prevention of progressive back-specific dysfunction during pregnancy: an assessment of osteopathic manual treatment based on Cochrane Back Review Group criteria. J Am Osteopath Assoc. . 2013;113(10):728-736. doi: 10.7556/jaoa.2013.043 [CrossRef] [PubMed]
Licciardone JC, Buchanan S, Hensel KL, King HH, Fulda KG, Stoll ST. Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial. Am J Obstet Gynecol. . 2010;202(1):43 e41-48. doi: 10.1016/j.ajog.2009.07.057 [CrossRef] [PubMed]
Hensel KL, Buchanan S, Brown SK, Rodriguez M, Cruser d A. Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects: the PROMOTE study. Am J Obstet Gynecol. . 2015;212(1):108 e101-109. doi: 10.1016/j.ajog.2014.07.043 [CrossRef] [PubMed]
Hensel KL, Roane BM, Chaphekar AV, Smith-Barbaro P. PROMOTE study: safety of osteopathic manipulative treatment during the third trimester by labor and delivery outcomes. J Am Osteopath Assoc. 2016;116(11):698-703. doi: 10.7556/jaoa.2016.140 [CrossRef] [PubMed]
King HH, Tettambel MA, Lockwood MD, Johnson KH, Arsenault DA, Quist R. Osteopathic manipulative treatment in prenatal care: a retrospective case control design study. J Am Osteopath Assoc. 2003;103(12):577-582. [PubMed]
Smallwood CR, Borgerding CJ, Cox MS, Berkowitz MR. Osteopathic manipulative treatment (OMT) during labor facilitates a natural, drug-free childbirth for a primigravida patient: a case report. Int J Osteopath Med. 2013;16(3):170-177. doi: 10.1016/j.ijosm.2012.10.005 [CrossRef]
Kesikburun S, Guzelkucuk U, Fidan U, Demir Y, Ergun A, Tan AK. Musculoskeletal pain and symptoms in pregnancy: a descriptive study. Ther Adv Musculoskelet Dis. 2018;10(12):229-234. doi: 10.1177/1759720X18812449 [CrossRef] [PubMed]
Smith MW, Marcus PS, Wurtz LD. Orthopedic issues in pregnancy. Obstet Gynecol Surv. 2008;63(2):103-111. doi: 10.1097/OGX.0b013e318160161c [CrossRef] [PubMed]
Thabah M, Ravindran V. Musculoskeletal problems in pregnancy. Rheumatol Int. 2015;35(4):581-587. doi: 10.1007/s00296-014-3135-7 [CrossRef] [PubMed]
Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine (Phila Pa 1976). 2005;30(8):983-991. doi: 10.1097/01.brs.0000158957.42198.8e
Casagrande D, Gugala Z, Clark SM, Lindsey RW. Low back pain and pelvic girdle pain in pregnancy. J Am Acad Orthop Surg. 2015;23(9):539-549. doi: 10.5435/JAAOS-D-14-00248 [CrossRef] [PubMed]
Padua L, Caliandro P, Aprile I, et al. Back pain in pregnancy: 1-year follow-up of untreated cases. Eur Spine J. 2005;14(2):151-154. doi: 10.1007/s00586-004-0712-6 [CrossRef] [PubMed]
Noren L, Ostgaard S, Johansson G, Ostgaard HC. Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up. Eur Spine J. 2002;11(3):267-271. doi: 10.1007/s00586-001-0357-7 [CrossRef] [PubMed]
Wu WH, Meijer OG, Uegaki K, et al. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J. 2004;13(7):575-589. doi: 10.1007/s00586-003-0615-y [CrossRef] [PubMed]
Lisi AJ. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. J Midwifery Womens Health. 2006;51(1):e7-10. doi: 10.1016/j.jmwh.2005.09.001 [CrossRef] [PubMed]
Peterson CK, Muhlemann D, Humphreys BK. Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: a prospective cohort study with short term, medium term and 1 year follow-up. Chiropr Man Therap. 2014;22(1):15. doi: 10.1186/2045-709X-22-15 [CrossRef] [PubMed]
Age category
Variable 1 2 3 4 5
Unique patients, n(%) (N=194) 13 (6.7) 57 (29.4) 76 (39.2) 36 (18.6) 12 (6.2)
Encounters, n(%) (N=465) 39 (8.4) 135 (29.0) 169 (36.3) 83 (17.8) 39 (8.4)
Encounters per patient, mean (standard deviation) 3.0 (1.6) 2.1 (1.6) 2.4 (2.2) 2.4 (1.8) 3.3 (2.8)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

Table 1.
Frequency of Osteopathic Manipulative Treatment of Pregnant Patients by Age Categorya
Age category
Variable 1 2 3 4 5
Unique patients, n(%) (N=194) 13 (6.7) 57 (29.4) 76 (39.2) 36 (18.6) 12 (6.2)
Encounters, n(%) (N=465) 39 (8.4) 135 (29.0) 169 (36.3) 83 (17.8) 39 (8.4)
Encounters per patient, mean (standard deviation) 3.0 (1.6) 2.1 (1.6) 2.4 (2.2) 2.4 (1.8) 3.3 (2.8)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

×
Complaint Age categories, no. (%)
1 (n=60) 2 (n=202) 3 (n=232) 4 (n=118) 5 (n=58)
Back (n=371) 35 (58.3) 120 (59.4) 137 (59.1) 57 (48.3) 22 (37.9)
Hip/pelvis (n=99) 8 (13.3) 25 (12.4) 33 (14.2) 23 (19.5) 10 (17.2)
Head (n=54) 7 (11.7) 18 (8.9) 20 (8.6) 4 (3.4) 5 (8.6)
Neck (n=62) 6 (10.0) 14 (6.9) 21 (9.1) 12 (10.2) 9 (15.5)
Ribcage (n=23) 1 (1.7) 4 (2.0) 6 (2.6) 10 (8.5) 2 (3.5)
Lower extremity (n=21) 1 (1.7) 8 (4.0) 2 (0.9) 2 (1.7) 8 (13.8)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

Table 2.
Most Common Presenting Complaints of Pregnant Patients by Age Category (N=670)a
Complaint Age categories, no. (%)
1 (n=60) 2 (n=202) 3 (n=232) 4 (n=118) 5 (n=58)
Back (n=371) 35 (58.3) 120 (59.4) 137 (59.1) 57 (48.3) 22 (37.9)
Hip/pelvis (n=99) 8 (13.3) 25 (12.4) 33 (14.2) 23 (19.5) 10 (17.2)
Head (n=54) 7 (11.7) 18 (8.9) 20 (8.6) 4 (3.4) 5 (8.6)
Neck (n=62) 6 (10.0) 14 (6.9) 21 (9.1) 12 (10.2) 9 (15.5)
Ribcage (n=23) 1 (1.7) 4 (2.0) 6 (2.6) 10 (8.5) 2 (3.5)
Lower extremity (n=21) 1 (1.7) 8 (4.0) 2 (0.9) 2 (1.7) 8 (13.8)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

×
Table 3.
Regions of Clinical Assessments in Pregnant Patients by Age Category (N=792)a
Diagnosis regionsb Age categories, no. (%)
1 (n=76) 2 (n=239) 3 (n=272) 4 (n=124) 5 (n=81)
Thoracic or lumbarc (n=420) 44 (57.9) 129 (54.0) 153 (56.3) 64 (51.6) 30 (37.0)
Cervicald (n=85) 9 (11.8) 27 (11.3) 32 (11.8) 9 (7.3) 8 (9.9)
Hip or pelvice (n=124) 8 (10.5) 25 (10.5) 50 (18.4) 28 (22.6) 13 (16.0)
Headf (n=55) 7 (9.2) 18 (7.5) 17 (6.3) 6 (4.8) 7 (8.6)
Upper extremityg (n=26) 2 (2.6) 10 (4.2) 4 (3.2) 8 (6.5) 2 (2.5)
Lower extremityh (n=36) 2 (2.6) 13 (5.4) 4 (3.2) 2 (1.6) 15 (18.5)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b Grouped by International Classification of Diseases, 10th Revision Codes, body region, and clinical similarity.

c Diagnoses included M46.06, M54.40, M54.41, M54.5, M54.6, M54.89, M54.9, and M62.830.

d Diagnoses included M54.2.

e Diagnoses included M25.551, M25.552, M25.559, M46.07, M46.1, M53.3, M53.88, M70.62, and R10.2.

f Diagnoses included G43.001, G43.009, G43.111, G43.119, G43.909, G44.201, G44.209, G44.219, G44.229, G44.52, G44.89, M54.81, R51, and R68.84.

g Diagnoses included G54.0, G56.03, G56.10, M25.511, M25.512, M25.519, M25.531, M65.4, and S43.085S.

h Diagnoses included G25.81, G57.02, G57.10, G57.11, G57.12, M21.70, M25.561, M25.562, M25.569, M25.571, M25.572, M72.2, M79.661, M79.662, M79.672, and Q72.811.

Table 3.
Regions of Clinical Assessments in Pregnant Patients by Age Category (N=792)a
Diagnosis regionsb Age categories, no. (%)
1 (n=76) 2 (n=239) 3 (n=272) 4 (n=124) 5 (n=81)
Thoracic or lumbarc (n=420) 44 (57.9) 129 (54.0) 153 (56.3) 64 (51.6) 30 (37.0)
Cervicald (n=85) 9 (11.8) 27 (11.3) 32 (11.8) 9 (7.3) 8 (9.9)
Hip or pelvice (n=124) 8 (10.5) 25 (10.5) 50 (18.4) 28 (22.6) 13 (16.0)
Headf (n=55) 7 (9.2) 18 (7.5) 17 (6.3) 6 (4.8) 7 (8.6)
Upper extremityg (n=26) 2 (2.6) 10 (4.2) 4 (3.2) 8 (6.5) 2 (2.5)
Lower extremityh (n=36) 2 (2.6) 13 (5.4) 4 (3.2) 2 (1.6) 15 (18.5)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b Grouped by International Classification of Diseases, 10th Revision Codes, body region, and clinical similarity.

c Diagnoses included M46.06, M54.40, M54.41, M54.5, M54.6, M54.89, M54.9, and M62.830.

d Diagnoses included M54.2.

e Diagnoses included M25.551, M25.552, M25.559, M46.07, M46.1, M53.3, M53.88, M70.62, and R10.2.

f Diagnoses included G43.001, G43.009, G43.111, G43.119, G43.909, G44.201, G44.209, G44.219, G44.229, G44.52, G44.89, M54.81, R51, and R68.84.

g Diagnoses included G54.0, G56.03, G56.10, M25.511, M25.512, M25.519, M25.531, M65.4, and S43.085S.

h Diagnoses included G25.81, G57.02, G57.10, G57.11, G57.12, M21.70, M25.561, M25.562, M25.569, M25.571, M25.572, M72.2, M79.661, M79.662, M79.672, and Q72.811.

×
Table 4.
Somatic Dysfunction Assessments for Pregnant Patients by Age Category (N=2604)a
Body regionb,c Age categories,d no. (%)
1 (n=255) 2 (n=758) 3 (n=928) 4 (n=451) 5 (n=212)
Head (M99.00) (n=280) 34 (13.3) 85 (11.2) 100 (10.8) 38 (8.4) 23 (10.8)
Cervical (M99.01) (n=306) 35 (13.7) 88 (11.6) 109 (11.7) 43 (9.5) 31 (14.6)
Thoracic (M99.02) (n=374) 37 (14.5) 109 (14.4) 132 (14.2) 64 (14.2) 32 (15.1)
Lumbar (M99.03) (n=409) 34 (13.3) 118 (15.6) 153 (16.5) 72 (16.0) 32 (15.1)
Sacral (M99.04) (n=396) 37 (14.5) 115 (15.2) 147 (15.8) 68 (15.1) 29 (13.7)
Pelvis (M99.05) (n=346) 28 (11.0) 100 (13.2) 129 (13.9) 64 (14.2) 25 (11.8)
Lower extremities (M99.06) (n=126) 11 (4.3) 38 (5.0) 41 (4.4) 26 (5.8) 10 (4.7)
Upper extremities (M99.07) (n=53) 9 (3.5) 17 (2.2) 11 (1.2) 10 (2.2) 6 (2.8)
Rib (M99.08) (n=273) 25 (9.8) 78 (10.3) 93 (10.0) 54 (12.0) 23 (10.8)
Abdomen (M99.09) (n=41) 5 (2.0) 10 (1.3) 13 (1.4) 12 (2.7) 1 (0.5)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b By International Classification of Diseases, 10th Revision Codes.

c The n for body region indicates the number of total encounters during which the indicated body region was treated.

d The n for age category indicates the number of total body regions treated across all encounters in the individual age group.

Table 4.
Somatic Dysfunction Assessments for Pregnant Patients by Age Category (N=2604)a
Body regionb,c Age categories,d no. (%)
1 (n=255) 2 (n=758) 3 (n=928) 4 (n=451) 5 (n=212)
Head (M99.00) (n=280) 34 (13.3) 85 (11.2) 100 (10.8) 38 (8.4) 23 (10.8)
Cervical (M99.01) (n=306) 35 (13.7) 88 (11.6) 109 (11.7) 43 (9.5) 31 (14.6)
Thoracic (M99.02) (n=374) 37 (14.5) 109 (14.4) 132 (14.2) 64 (14.2) 32 (15.1)
Lumbar (M99.03) (n=409) 34 (13.3) 118 (15.6) 153 (16.5) 72 (16.0) 32 (15.1)
Sacral (M99.04) (n=396) 37 (14.5) 115 (15.2) 147 (15.8) 68 (15.1) 29 (13.7)
Pelvis (M99.05) (n=346) 28 (11.0) 100 (13.2) 129 (13.9) 64 (14.2) 25 (11.8)
Lower extremities (M99.06) (n=126) 11 (4.3) 38 (5.0) 41 (4.4) 26 (5.8) 10 (4.7)
Upper extremities (M99.07) (n=53) 9 (3.5) 17 (2.2) 11 (1.2) 10 (2.2) 6 (2.8)
Rib (M99.08) (n=273) 25 (9.8) 78 (10.3) 93 (10.0) 54 (12.0) 23 (10.8)
Abdomen (M99.09) (n=41) 5 (2.0) 10 (1.3) 13 (1.4) 12 (2.7) 1 (0.5)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b By International Classification of Diseases, 10th Revision Codes.

c The n for body region indicates the number of total encounters during which the indicated body region was treated.

d The n for age category indicates the number of total body regions treated across all encounters in the individual age group.

×
Table 5.
Osteopathic Manipulative Treatment Techniques Used for Pregnant Patients by Age Category (N=2518)a
Age categories,c no. (%)
Techniqueb 1 (n=238) 2 (n=729) 3 (n=912) 4 (n=443) 5 (n=196)
Articular (n=269) 18 (7.6) 73 (10.0) 99 (10.9) 57 (12.9) 22 (11.2)
Counterstrain (n=195) 19 (8.0) 61 (8.4) 66 (7.2) 35 (7.9) 14 (7.1)
Osteopathic cranial manipulative medicine (n=94) 10 (4.2) 28 (3.8) 40 (4.4) 12 (2.7) 4 (2.0)
Facilitated positional release (n=38) 1 (0.4) 10 (1.4) 18 (2.0) 6 (1.4) 3 (1.5)
High-velocity, low-amplitude (n=250) 27 (11.3) 67 (9.2) 89 (9.7) 47 (10.6) 20 (10.2)
Indirect balanced ligamentous tension (n=147) 13 (5.5) 54 (7.4) 44 (4.8) 26 (5.9) 10 (5.1)
Integrated neuromuscular release (n=8) 1 (0.4) 3 (0.4) 2 (0.2) 2 (0.5) 0 (0)
Ligamentous articular strain (n=70) 6 (2.5) 22 (3.0) 26 (2.9) 12 (2.7) 4 (2.0)
Lymphatic (n=11) 1 (0.4) 2 (0.3) 1 (0.1) 6 (1.4) 1 (0.5)
Muscle energy (n=406) 35 (14.7) 111 (15.2) 156 (17.1) 68 (15.3) 36 (18.4)
Myofascial release (n=338) 34 (14.3) 98 (13.4) 121 (13.3) 58 (13.1) 27 (13.8)
Neurofascial release (n=2) 1 (0.4) 0 (0) 0 (0) 1 (0.2) 0 (0)
Percussion hammer (n=65) 11 (4.6) 0 (0) 20 (2.2) 6 (1.4) 5 (2.6)
Progressive inhibition (n=20) 2 (0.8) 8 (1.1) 6 (0.7) 4 (0.9) 0 (0)
Soft tissue (n=248) 25 (10.5) 67 (9.2) 99 (10.9) 39 (8.8) 18 (9.2)
Still technique (n=241) 19 (8.0) 75 (10.3) 86 (9.4) 39 (8.8) 22 (11.2)
Visceral manipulation (n=21) 5 (2.1) 3 (0.4) 5 (0.5) 6 (1.4) 2 (1.0)
Functional technique (n=72) 8 (3.4) 28 (3.8) 27 (3.0) 13 (2.9) 4 (2.0)
Other (n=23) 2 (0.8) 17 (2.3) 7 (0.8) 6 (1.4) 4 (2.0)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b The n for technique indicates the number of encounters where the indicated technique was used.

c The n for age category indicates the number of documented techniques used across all encounters in the individual age group.

Table 5.
Osteopathic Manipulative Treatment Techniques Used for Pregnant Patients by Age Category (N=2518)a
Age categories,c no. (%)
Techniqueb 1 (n=238) 2 (n=729) 3 (n=912) 4 (n=443) 5 (n=196)
Articular (n=269) 18 (7.6) 73 (10.0) 99 (10.9) 57 (12.9) 22 (11.2)
Counterstrain (n=195) 19 (8.0) 61 (8.4) 66 (7.2) 35 (7.9) 14 (7.1)
Osteopathic cranial manipulative medicine (n=94) 10 (4.2) 28 (3.8) 40 (4.4) 12 (2.7) 4 (2.0)
Facilitated positional release (n=38) 1 (0.4) 10 (1.4) 18 (2.0) 6 (1.4) 3 (1.5)
High-velocity, low-amplitude (n=250) 27 (11.3) 67 (9.2) 89 (9.7) 47 (10.6) 20 (10.2)
Indirect balanced ligamentous tension (n=147) 13 (5.5) 54 (7.4) 44 (4.8) 26 (5.9) 10 (5.1)
Integrated neuromuscular release (n=8) 1 (0.4) 3 (0.4) 2 (0.2) 2 (0.5) 0 (0)
Ligamentous articular strain (n=70) 6 (2.5) 22 (3.0) 26 (2.9) 12 (2.7) 4 (2.0)
Lymphatic (n=11) 1 (0.4) 2 (0.3) 1 (0.1) 6 (1.4) 1 (0.5)
Muscle energy (n=406) 35 (14.7) 111 (15.2) 156 (17.1) 68 (15.3) 36 (18.4)
Myofascial release (n=338) 34 (14.3) 98 (13.4) 121 (13.3) 58 (13.1) 27 (13.8)
Neurofascial release (n=2) 1 (0.4) 0 (0) 0 (0) 1 (0.2) 0 (0)
Percussion hammer (n=65) 11 (4.6) 0 (0) 20 (2.2) 6 (1.4) 5 (2.6)
Progressive inhibition (n=20) 2 (0.8) 8 (1.1) 6 (0.7) 4 (0.9) 0 (0)
Soft tissue (n=248) 25 (10.5) 67 (9.2) 99 (10.9) 39 (8.8) 18 (9.2)
Still technique (n=241) 19 (8.0) 75 (10.3) 86 (9.4) 39 (8.8) 22 (11.2)
Visceral manipulation (n=21) 5 (2.1) 3 (0.4) 5 (0.5) 6 (1.4) 2 (1.0)
Functional technique (n=72) 8 (3.4) 28 (3.8) 27 (3.0) 13 (2.9) 4 (2.0)
Other (n=23) 2 (0.8) 17 (2.3) 7 (0.8) 6 (1.4) 4 (2.0)

a Age categories: 1, <20 years; 2, 20-24 years; 3, 25-29 years; 4, 30-34 years; 5, 35+ years.

b The n for technique indicates the number of encounters where the indicated technique was used.

c The n for age category indicates the number of documented techniques used across all encounters in the individual age group.

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