Pain Management and Osteopathic Manipulative Medicine in the Army ...

SPECIAL COMMUNICATION

Pain Management and Osteopathic Manipulative Medicine in the Army: New Opportunities for the Osteopathic Medical Profession MAJ Brandon J. Goff, DO, MC, USA; MAJ Aaron D. Nelson, DO, MC, USA; MAJ Mary G. Deighton, DO, MC, USA; and COL Todd R. Fredricks, DO, MC, USA

Osteopathic manipulative medicine (OMM) is the most visible distinction between osteopathic physicians and allopathic physicians, and the osteopathic medical profession recognizes the proven clinical efficacy and value of OMM. The recently published report by the US Army Surgeon General’s Pain Management Task Force provides a strong endorsement for the Army to increase the practice of OMM, to create OMM continuing medical education opportunities, and to improve research in OMM’s role in pain management. This comprehensive restructuring of the Army’s approach to pain management provides a unique opportunity for the civilian osteopathic medical profession—the true OMM experts—to collaborate with Army osteopathic physicians in OMM training, teaching, and research. J Am Osteopath Assoc. 2011;111(5):331-334

Osteopathic medicine in the United States Army has matured rapidly over a relatively short period. During World War I, World War II, and the Korean War, osteopathic physicians (ie, DOs) were drafted as enlisted soldiers and served in the role of medics or, more often, in nonmedical roles.1 Their training as physicians was not recognized by the Army at that time. In 1966, the casualty demands of the Vietnam War forced the Army to enlarge the physician draft, and DOs were then

From the Medical Corps, US Army (Drs Goff, Nelson, Deighton, and Fredricks); Brooke Army Medical Center in Fort Sam Houston, Texas (Drs Goff and Nelson); Uniformed Services University of Health Sciences in Bethesda, Maryland (Dr Goff); and the VA Medical Center in Chillicothe, Ohio, and Ohio University College of Osteopathic Medicine in Athens (Dr Fredricks). This article was prepared as part of the official duties of the authors as government employees. The opinions or assertions expressed herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Army or the US Department of Defense. Financial Disclosures: None reported. Address correspondence to MAJ Brandon J. Goff, DO, MC, USA, Squadron Surgeon, 4-10 Cavalry Squadron Aid Station, Nasariyah, Iraq. E-mail: [email protected]. Submitted September 9, 2010; accepted November 4, 2010.

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afforded the same status as allopathic physicians (MDs) in the Army Medical Corps.1 Also during the Vietnam War, DOs were first accepted into Army graduate medical education (GME) training programs.1 In 1996, the Army appointed Lieutenant General Ronald R. Blanck, DO, as the Surgeon General of the Army.2 Dr Blanck served in that position until 2000. The Army now views board certification through the Bureau of Osteopathic Specialists of the American Osteopathic Association (AOA) as being equivalent to certification through the allopathic American Board of Medical Specialties—except for the specialty of neuromusculoskeletal medicine, which does not have an equivalent allopathic specialty.3-5 Osteopathic physicians represent every specialty and subspecialty in the Army Medical Corps. In the present article, we review the practice of osteopathic medicine in the Army, and we examine how recent developments in the Army’s approach to pain management provide a unique opportunity for civilian DOs to collaborate with Army DOs in training, teaching, and research related to osteopathic manipulative medicine.

Applicability of Osteopathic Manipulative Medicine in the Army During the past decade, as a result of the ongoing wars in Afghanistan and Iraq, the Army has dramatically refined and improved its approach to management of acute and chronic pain in the care of individuals with complex combat injuries and painful sequelae.6-9 Warfare produces some of the most catastrophic injuries imaginable, and modern medical and surgical care in combat routinely saves the lives of soldiers who would not have survived the same injuries in previous wars. The majority of evacuations from the combat theater involve neuromusculoskeletal injuries and pain complaints amenable to osteopathic manipulative medicine (OMM), and the literature demonstrates that the majority of wartime medical problems involve low back pain, other spinal pain, and musculoskeletal injuries.10-14 In terms of soldiers’ personal protective equipment (eg, body armor, helmets) and loadbearing equipment, there have been enhancements in modern operational capabilities, though these enhancements have increased demands on individual soldiers’ musculoskeletal systems.15 JAOA • Vol 111 • No 5 • May 2011 • 331

SPECIAL COMMUNICATION When considering these matters, it is important to note that soldiers who are not deployed, their families, and the retired military community have similar demographic characteristics and health problems as members of the wider civilian population, which has been well served over the years by the judicious application of OMM.

Manual Treatments Currently Practiced in the Army Our observations suggest that many DOs in the Army follow a practice pattern similar to that followed by civilian DOs— minimizing or entirely jettisoning the practice of OMM as a treatment option. In the Army, OMM has been primarily performed by small numbers of DOs who specialize in family medicine, internal medicine, physical medicine and rehabilitation, or pain medicine. Paradoxically, the number of non-DO practitioners who perform various forms of manual therapies has slowly increased in recent years, especially in those clinical settings in which neuromusculoskeletal problems are frequently encountered and in austere environments, such as combat theaters. For example, our observations have shown that there are a number of Army MDs who practice manual therapy after learning the skills from DO colleagues, from professional courses, or from previous training as doctors of chiropractic. There are also many civilian chiropractors employed by the Army originally through Chiropractic Health Care Demonstration Program of the Department of Defense (DoD) to perform chiropractic manipulation, though their services are usually limited to active-duty soldiers.16 In addition, fellowship-trained physical therapists practice manual therapy extensively throughout the Army, including as part of brigade combat teams in the Afghanistan and Iraq theaters of combat.17

Recent Developments in Army Pain Management Related to the Osteopathic Medical Profession In 2009, the Army Surgeon General, Lieutenant General Eric B. Schoomaker, MD, PhD, chartered the Pain Management Task Force.18 This task force was composed of representative experts from the Army, Navy, Air Force, and Veterans Administration (VA), including all medical specialties with a stake in pain management. The task force’s mandate was to make recommendations for a comprehensive pain management strategy that is holistic, multidisciplinary, and multimodal in its approach; that uses state-of-the-art modalities and technologies; and that provides optimal quality-of-life care for soldiers and other patients with acute and chronic pain. The final report of the task force, which is 169 pages in length, is available for review online (http://www.armymedicine.army.mil/reports/Pain_Management_Task_Force.pdf).18 Complementary to the Pain Management Task Force report,18 the National Defense Authorization Act for Fiscal Year 2010 tasked the secretary of defense with developing 332 • JAOA • Vol 111 • No 5 • May 2011

and implementing a comprehensive pain management policy for the military healthcare system by 2011.19 The Army medical leadership is currently working with the regional medical commands to implement the changes in pain management contained in the new recommendations and policy throughout the Army healthcare system. Although instituting the new recommendations and policy will bring sweeping and positive changes to Army pain management as a whole, these actions also carry important implications for the osteopathic medical profession and the future role of OMM in the Army and, potentially, throughout the military healthcare system (including, by extension, the VA medical system). The Army Medical Corps is the largest health system among the US uniformed military services and one of the largest medical healthcare systems in the world. Because the recommendations of the Army’s Pain Management Task Force18 were collaborative in nature among all the military services and the VA, the long-term results of implementation of the recommendations are likely to spread throughout the DoD and VA. One section of the Pain Management Task Force’s final report18 is devoted to OMM, with the stated objective being to leverage embedded Army osteopathic medical resources in the provision of OMM for patients with musculoskeletal pain. Furthermore, the task force’s final report18 acknowledges the generalized inefficiency of traditional multispecialty, referralbased treatment (eg, physician evaluation followed by referral to a physical therapist or chiropractor and later follow-up with the physician), and the report recognizes the potential for OMM to allow DOs to treat patients with greater efficiency.

Pain Management Task Force Recommendations The recommendations in the Pain Management Task Force’s final report18 are encouraging for the osteopathic medical profession, bringing substantial potential for collaboration between the wider osteopathic medical profession and the Army healthcare system. The main recommendations related to the osteopathic medical profession are as follows18: ◾ Support the use of OMM in Army clinics. ◾ Survey active-duty DOs to understand their uses and practices of OMM and the barriers to OMM use. ◾ Implement and support OMM GME during primary care and physiatry residency programs in order to use and continue developing current Army OMM resources. ◾ Implement and encourage the use of OMM in theaters of combat and other deployed areas. ◾ Incorporate OMM referrals into case management in Warrior Transition Units (ie, Army specialty units dedicated to the care of injured soldiers in the United States proper). ◾ Improve metrics, such as relative value units, that, although currently used to measure the success of providers in treating patients, do not actually measure patient improvement. Goff et al • Special Communication


The task force report18 suggests that the hubs of Army OMM GME, skill sustainment, and continuing medical education (CME) should be the family medicine residency training program at DeWitt Army Community Hospital in Fort Belvoir, Virginia, and the physical medicine and rehabilitation service at Walter Reed National Military Medical Center in Bethesda, Maryland. Implementing the GME recommendations will create an ideal opportunity for immediate collaboration between the Army and a number of osteopathic professional organizations, including the AOA, the AOA Bureau of Osteopathic Specialists, the American College of Osteopathic Family Physicians, the American Osteopathic College of Physical Medicine and Rehabilitation, and the American Academy of Osteopathy. The opportunities for collaboration with the Army in the areas of osteopathic medical education and research multiply exponentially when broadening the horizon beyond the proposed hubs at DeWitt Army Community Hospital and Walter Reed National Military Medical Center—especially considering that the Army likely has the largest GME system in the nation. The task force report18 strongly emphasizes GME training in OMM and the creation of new program implementation policies to support this training. The report envisions OMM clinics in residency training programs with staff oversight, an education series on OMM, and hands-on reviews of osteopathic manipulative treatment (OMT). The goals of these recommendations are increased satisfaction of patients, decreased dispensing of medications, decreased writing of profiles (ie, individualized Army work restrictions for soldiers), improved return-to-duty rates after injuries, fewer referrals for musculoskeletal complaints, and fewer office visits for the same complaints. Because the osteopathic medical profession has assisted civilian GME programs with dual accreditation, the profession’s experience and resources might prove helpful as the Army seeks to create formalized OMM training and curricula throughout its GME programs. In addition to these GME recommendations, the task force report18 recommends that OMM CME be made available at local Army healthcare facilities. Because the osteopathic medical profession is the primary and best source of OMM CME, the profession should consider methods to collaborate with the Army in the provision of this large mandate. Apart from these GME and CME opportunities, the osteopathic medical profession could immediately collaborate with the Army in OMM research. The Army has a robust medical research infrastructure, and collaboration with civilian colleagues in osteopathic medical education research would be mutually beneficial.20 The task force report16 recommends, but is not limited to, the following pilot research-related projects:

◾ Conduct a survey of active-duty DOs to determine which DOs use OMM in clinic, hospital, or deployed settings; what barriers exist to the use of OMM; what amount of OMM CME is available at practice sites; what level of interest exists among DOs for participating with other providers in clinics specific for OMM; and why some DOs choose not to use their unique skill sets in OMM. ◾ Conduct qualitative and quantitative examinations of the impact of OMM on patients with acute and chronic pain syndromes. ◾ Use of OMT during deployment to prevent chronic complications from acute problems.

◾ Establish an OMM clinic in a GME setting that tracks residents to determine which residents continue to use OMM in their comprehensive practices after becoming staff DOs.

References


Research Funding Because of a Congressional mandate to improve pain management throughout the military,19 substantial increases in research funding for this purpose would be expected. Research involving OMM can be incorporated into any number of DoD funding requests, such as through the annual Peer Reviewed Orthopaedic Research Program, which is part of the Congressionally Directed Medical Research Programs.21 The military has been supportive of military-civilian research collaboration and consortia in the past, and future increases in research funding for pain management are ideal for this type of collaboration.

Value of DOs in the Army The Pain Management Task Force’s final report18 speaks to the overall value of DOs in uniform. Rather than hiring additional civilian chiropractors, who have a limited scope of practice and are not deployable, the task force recommends that the Army take the initiative to better use DOs and DOs-in-training for providing OMT, as well as education through CME. There is clearly great benefit to using a single DO who can deliver full-spectrum neuromusculoskeletal care and perform all other medical duties of his or her specialty for a particular military unit, especially in the austere environment of combat with limited resources. In addition to treating soldiers, the DO can provide comprehensive care and OMM to dependent families and military retirees.

Conclusion The support of the US Army Surgeon General’s Pain Management Task Force for OMT and for osteopathic medical education and research, as well as the task force’s support for DOs in uniform, represents an unprecedented opportunity for the osteopathic medical profession to collaborate with the Army. The task force’s recommendations are currently being implemented throughout the Army.

1. Gevitz N. The sword and the scalpel—the osteopathic “war” to enter the Military Medical Corps: 1916-1966. J Am Osteopath Assoc. 1998;98(5):279-286.

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2. The surgeons general of the US Army and their predecessors. US Army Medical Department, Office of Medical History Web site. http://history.amedd .army.mil/surgeons.html. Accessed March 24, 2011. 3. AOA board certification. American Osteopathic Association Web site. http://www.osteopathic.org/inside-aoa/development/aoa-board-certification/Pages/default.aspx. Accessed March 24, 2011. 4. Specialties & subspecialties. Recognized physician specialty and subspecialty certificates. American Board of Medical Specialties Web site. http://www.abms.org/who_we_help/physicians/specialties.aspx. Accessed March 3, 2011. 5. About AOBNMM. American Osteopathic Board of Neuromusculoskeletal Medicine Web site. http://aobnmm.org/. Accessed March 3, 2011. 6. Peake JB. Beyond the purple heart—continuity of care for the wounded in Iraq. N Engl J Med. 2005;352(3):219-222. 7. Buckenmaier CC, Griffith S. Military pain management in 21st century war. Milit Med. July 2010;175(suppl 1):7-12. 8. Black IH, McManus J. Pain management in current combat operations. Prehosp Emerg Care. 2009;13(2):223-227. 9. Goff BJ, Castillo R, Raja SN. Painful sequelae following limb salvage: etiology and management. J Am Acad Orthop Surg. 2011;19(suppl 1):S23-S27. 10. Cohen SP, Griffith S, Larkin TM, Villena F, Larkin R. Presentation, diagnoses, mechanisms of injury, and treatment of soldiers injured in Operation Iraqi Freedom: an epidemiological study conducted at two military pain management centers. Anesth Analg. 2005;101(4):1098-1103. 11. White RL, Cohen SP. Return-to-duty rates among coalition forces treated in a forward-deployed pain treatment center: a prospective observational study. Anesthesiology. 2007;107(6):1003-1008. 12. Cohen SP, Kapoor SG, Nguyen C, et al. Neck pain during combat operations: an epidemiological study analyzing clinical and prognostic factors. Spine. 2010;35(7):758-763.

13. Cohen SP, Nguyen C, Kapoor SG, et al. Back pain during war: an analysis of factors affecting outcome. Arch Intern Med. 2009;169(20):1916-1923. 14. Cohen SP, Brown C, Kurihara C, Plunkett A, Nguyen C, Strassels SA. Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective cohort study. Lancet. 2010;375(9711):301309. 15. Goff BJ, Walker GA, Gloystein DM. Combat soldier loads: implications for cumulative overuse injuries and chronic pain. PM R. 2011;3(2):183-185. 16. Chiropractic care. TRICARE Management Activity, Military Health System Web site. http://www.tricare.mil/mybenefit/home/overview/SpecialPrograms /ChiropracticCare. Accessed March 3, 2011. 17. Physical therapy—Brooke Army Medical Center. US Army-Baylor University Postprofessional Doctoral Program in Orthopaedic and Manual Physical Therapy and the US Army Orthopaedic and Manual Physical Therapy Fellowship. Baylor University Web site. http://www.baylor.edu/ompt/. Accessed March 3, 2011. 18. Office of The Army Surgeon General. Pain Management Task Force: Final Report. Providing a Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and their Families. Washington, DC: US Army; May 2010. http://www.armymedicine.army.mil /reports/Pain_Management_Task_Force.pdf. Accessed May 16, 2011. 19. US House of Representatives. National Defense Authorization Act For Fiscal Year 2010. Conference Report to Accompany HR 2647. Washington, DC: US Government Printing Office; 2009:770-771. Report 111-288. http://www.dtic .mil/congressional_budget/pdfs/FY2010_pdfs/AUTH_CONF_111-288.pdf. Accessed May 16, 2011. 20. US Army Medical Department Medical Research and Materiel Command Web site. https://mrmc.detrick.army.mil/. Accessed March 3, 2011. 21. FY10 Peer Reviewed Orthopaedic Research Program (PRORP). US Department of Defense Congressionally Directed Medical Research Programs Web site. http://cdmrp.army.mil/funding/prorp.shtml. Accessed March 3, 2011.

Peer Reviewers Wanted JAOA—The Journal of the American Osteopathic Association is looking for physicians, basic scientists, and others in the biomedical professions who are interested in serving as peer reviewers. Each prospective peer reviewer should send a letter and curriculum vitae to AOA Editor in Chief Gilbert E. D’Alonzo, Jr, DO, at [email protected]. Applicants should describe in their letters why they are interested in becoming peer reviewers for the JAOA and indicate their areas of expertise or interest. For more information, visit http://www.jaoa.org/misc/peer.html.

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