Letters to the Editor  |   August 2008
ED Physicians Beware When Using OMT for Patients With Motor Vehicle Injuries
Article Information
Emergency Medicine / Osteopathic Manipulative Treatment
Letters to the Editor   |   August 2008
ED Physicians Beware When Using OMT for Patients With Motor Vehicle Injuries
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 470-471. doi:
The Journal of the American Osteopathic Association, August 2008, Vol. 108, 470-471. doi:
To the Editor:  
I read the original contribution by Tamara M. McReynolds, DO, and Barry J. Sheridan, DO, titled “Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial” in the February 2005 issue of JAOA—The Journal of the American Osteopathic Association (2005;105:57-68) with a bit of apprehension. After rereading this study, I believe a few comments are in order. 
First, I congratulate the authors for undertaking the challenge of finding a better treatment for patients who have a problem that is “a real nuisance” to the emergency department (ED) physician—spinal pain, manifested in this particular setting as neck pain. 
My main concern with the study by Drs McReynolds and Sheridan, however, relates to the statement, “The majority of patients (58%) had cervical strain resulting from a motor vehicle collision.” In the study group receiving osteopathic manipulative treatment (OMT), there were 18 (62%) subjects with injuries caused by motor vehicle accidents. In the study group receiving ketorolac tromethamine, there were 16 (55%) subjects with this type of injury. 
Depending on the exact mechanism of injury, a small subset of patients in motor vehicle accidents may harbor injuries to the neck that are not readily apparent in plain film radiographs. Even if the findings of a patient's physical examination are normal and there is no neurologic complaint (eg, radiculopathy), there may still be structural problems that could be a contraindication to OMT. Facet joint fractures of the cervical spine may be so subtle that they are diagnosable only after imaging using computed tomography. In such cases, there could also be an associated laminar fracture. Furthermore, some ligamentous injuries may not be apparent in lateral cervical films. Such injuries may be noticed only with the assistance of magnetic resonance imaging. Days or weeks after the initial trauma, patients with these injuries may describe only “neck pain.” 
The diagnostic complexities associated with patients who were in motor vehicle accidents raise a number of questions. For example, should patients involved in motor vehicle accidents be excluded from clinical studies of OMT because of possible legal ramifications to the investigating physicians? Also, why add the ED physician to the list of candidates for possible future litigation in these situations, which are already primed for legal action? 
Some readers of the article by Drs McReynolds and Sheridan may have been left with the impression that OMT is broadly applicable in the ED setting. Such an impression has the potential to throw the door wide open for serious legal and financial consequences to osteopathic physicians in this setting. For those osteopathic physicians practicing in a clinical setting similar to that of Drs McReynolds and Sheridan (ie, an ED teaching hospital), the level of physician awareness of legal consequences is always high. Thus, OMT is likely to be used for only select patients, and the odds of an adverse outcome from OMT would be small, as the authors point out. This might not be the case, however, in other kinds of ED settings. 
The concept of using OMT in the ED setting is worthy of further study. However, obtaining a computed tomographic scan or magnetic resonance imaging of the patient's spine prior to the use of OMT would be a wise diagnostic adjunct and safeguard.