The Somatic Connection  |   October 2011
Osteopathic Manipulative Treatment is Effective for Acute Low Back Pain in the Military
Article Information
The Somatic Connection   |   October 2011
Osteopathic Manipulative Treatment is Effective for Acute Low Back Pain in the Military
The Journal of the American Osteopathic Association, October 2011, Vol. 111, 574-575. doi:
The Journal of the American Osteopathic Association, October 2011, Vol. 111, 574-575. doi:
Cruser dA, Maurer D, Hensel K, Brown SK, White K, Stoll ST. A randomized, controlled trial of osteopathic manipulative treatment for acute low back pain in active duty military personnel [published online ahead of print August 1, 2011]. J Man Manipulative Ther. >doi:10.1179/2042618611Y.0000000016. 
Low back injury during physical training occurs, on average, in 6% to 7% of US Army soldiers.1 Nonspecific (ie, mechanical) low back pain (LBP) has a 17% 5-year cumulative risk of disability and is among the most disabling musculoskeletal conditions sustained by Army personnel.2 Army physical training is the most common cause of lumbosacral sprain for both servicemen and servicewomen.3 
In 1999, the US Department of Veterans Affairs and Department of Defense (VA/DoD) developed evaluation and treatment guidelines for military personnel with acute LBP.4 The guidelines created an expeditious and standardized system for ruling out “red flags” and initiating appropriate treatment for soldiers with mechanical LBP using medication, spinal manipulation, and physical therapy. These military guidelines were developed based on data gathered from populations of civilians who were older (ie, aged 40-60 years) and less physically fit than populations in the Armed Forces.5 Although the VA/DoD guidelines endorsed spinal manipulation for military personnel with LBP, the recommendations were general and limited, as follows4: 

Manipulation consists of techniques to increase joint and soft tissue range of motion and decrease pain. Osteopathic physicians, specifically trained and certified allopathic physicians, and physical therapists practice it. Manipulation also may be practiced by licensed chiropractors where available.



    When used within the first month of symptoms, manipulation can be helpful for patients with acute LBP without radiculopathy.
    When findings suggest progressive or severe neurological deficits, an appropriate diagnostic assessment to rule out serious neurological conditions is indicated before beginning manipulation therapy. Selected patients with a non-progressive radiculopathy may benefit from a trial of manipulation.
    Evidence is insufficient to recommend manipulation for all patients with radiculopathy.
    A trial of manipulation in patients with symptoms longer than a month probably is safe, but its efficacy is still being researched.

Goff et al6 reported in the May issue of JAOA—The Journal of the American Osteopathic Association that the US Army Surgeon General's Pain Management Task Force strongly endorsed increased use of osteopathic manipulative medicine (OMM) in the military. There are many reasons why OMM is so highly endorsed. One reason is that it works. The study by Cruser et al reports on the first randomized, controlled clinical trial on the efficacy of OMM for active-duty military personnel with acute LBP. 
In 2002, the US Congress mandated that the DoD investigate complementary and alternative medicine approaches to the care of soldiers.7 The mandate led to the creation of the Complementary and Alternative Medicine Research for Military Operations and Healthcare (MIL-CAM) project, a cooperative endeavor between the Samueli Institute for Information Biology and the Uniformed Services University of the Health Sciences under contract to the DoD. The MIL-CAM project systematically identified and investigated selected areas of complementary and alternative medicine with the goals of enhancing and maintaining military personnel readiness, effectiveness, and well-being and mitigating injuries from battlefield and terrorist attacks. The MIL-CAM project awarded competitive funding to the Osteopathic Research Center at the University of North Texas Health Science Center in Fort Worth to examine the efficacy of specific OMM treatments in relieving and managing acute incidences of LBP in active-duty military personnel.7 
The randomized, controlled trial by Cruser et al was carried out with military personnel at Fort Lewis, Washington. Sixty-three soldiers—men and women aged from 18 to 35 years—with acute LBP (ie, new-onset back pain with a hiatus of at least 30 days since the previous episode) were randomly assigned to a group receiving osteopathic manipulative treatment (OMT) plus usual care or a group receiving usual care only (UCO). The UCO group received education, nonsteroidal analgesics (eg, acetaminophen, codeine), muscle relaxants, and physical therapy. The OMT group received OMT once weekly for 4 weeks. Treating physicians were allowed to use any OMT technique or series of OMT techniques listed in the Glossary of Osteopathic Terminology.8 
Evaluation and treatment in the OMT group were performed according to a protocol based on standard osteopathic structural examination procedures and techniques. In addition to tenderpoint assessment, researchers assessed and provided treatment for the 6 entities commonly found in patients with chronic LBP9 that were originally described by Greenman in 199610: nonneutral lumbar somatic dysfunction; dysfunction of the symphysis pubis (ie, pubic shear); restriction of the anterior movement of the sacral base; innominate shear dysfunction; short leg and pelvic tilt syndrome; and muscular imbalance of the trunk and lower extremity (including psoas syndrome). 
Three participants in the OMT group withdrew after the first visit and were not included in the final analysis. The remaining 30 participants in each group received the allocated interventions. There were 3 protocol violations in the OMT group and 4 violations in the UCO group. An intention-to-treat analysis was performed on the 30 participants in each group. The OMT was provided by 3 osteopathic physicians; 1 allopathic physician trained in manual medicine also provided manipulative treatment to the OMT group. All 4 physicians were commissioned medical officers in the Army Medical Corps. 
Participant demographics and symptoms at baseline were similar between groups, validating the randomization process. Use of medications was also similar at endpoint assessment. The primary outcome measures were pain intensity ratings on the Quadruple Visual Analog Scale (QVAS) and functioning ratings on the Roland-Morris Disability Questionnaire. Outcomes were measured immediately before each of the 4 treatment sessions and at 4 weeks after the trial. 
The intention-to-treat analysis found statistically significant greater posttrial improvement in the QVAS pain intensity rating of “Pain Now” for the OMT group, compared to the UCO group (P=.026). Furthermore, the OMT group reported lower ratings in the QVAS categories of “Pain Now” and “Pain Typical” at all visits (P=.025 and P=.020, respectively). The OMT group also achieved a more clinically meaningful improvement from baseline in the QVAS category of “Pain at Best” than the UCO group (P=.008), and the OMT group achieved improvement in that category sooner than the UCO group (P=.004). The OMT group reported statistically significant greater satisfaction with treatment than the UCO group (P=.01). 
This study supports the effectiveness of adding OMT to usual care practices for reducing symptoms of acute LBP in active-duty military personnel. The study suggests that the addition of OMT results in a reduction of symptoms sooner and more effectively than usual care alone.—M.A.S. 
   “The Somatic Connection” highlights and summarizes important contributions to the growing body of literature on the musculoskeletal system's role in health and disease. This section of JAOA—The Journal of the American Osteopathic Association strives to chronicle the significant increase in published research on manipulative methods and treatments in the United States and the renewed interest in manual medicine internationally, especially in Europe.    To submit scientific reports for possible inclusion in “The Somatic Connection,” readers are encouraged to contact JAOA Associate Editor Michael A. Seffinger, DO (, or Editorial Board Member Hollis H. King, DO, PhD (
   Editor's Note: Dr Seffinger served as Chair of the Data and Safety Monitoring Board for this study. In that capacity, he was charged with monitoring the safety of the participants, assessing when and if the primary research question was answerable before reaching the recruitment goal, and assuring the integrity of the data collection per protocol. He had no role in actual data collection, analysis, interpretation, or reporting.
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