Abstract
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.
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 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.
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 load-bearing equipment, there have been enhancements in modern operational capabilities, though these enhancements have increased demands on individual soldiers' musculoskeletal systems.
15
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.
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 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 Force
18 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 report
18 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 report
18 acknowledges the generalized inefficiency of traditional multispecialty, referral-based 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.
The recommendations in the Pain Management Task Force's final report
18 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 follows
18:
The task force report
18 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 report
18 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 report
18 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 report
16 recommends, but is not limited to, the following pilot research-related projects:
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.
The Pain Management Task Force's final report
18 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.
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.