Osteopathic Manipulation In Operation Iraqi Freedom

Source: amops.org/html/austere.doc

Christopher Prior, DO
CPT(P), MC, USA

Christopher Milstead, FNP
MAJ, NC, USA

Back pain, a common problem in primary care, can lead to medical evacuation and termination of a mission.1 Even in the most austere conditions early identification and treatment increases the soldiers’ ability to return to his or her unit. Early treatment, education, and utilization of available resources can keep a soldier in the theater of operations—increasing morale and success of the mission.

The admitting diagnosis for 25 percent of the soldiers admitted to the 115th Field Hospital in Kuwait during Operation Enduring Freedom and Operation Iraqi Freedom was back pain. Common causes included motor/mechanized vehicle accidents, falls, and shrapnel injuries. Many soldiers required evacuation to rear echelons of care for more advanced radiological studies, including CT and MRI. Many soldiers were immobilized through out the multi tiered evacuation process sometimes lasting 48-72 hours. While conservative measures are expected in the most forward care settings, many soldiers could have been re-evaluated and treated sooner. In many circumstances the prolonged immobilization hindered prompt recovery. Early evaluation and treatment enables soldiers with back pain to return to duty sooner—seventy five percent of those soldiers that returned to duty were evaluated within 48 hours of their injury. Those soldiers who were immobilized for extended periods of time naturally took a longer time to recover. Soldiers with fractures and radicular signs were quickly identified and evacuated to the most rear facilities for extended treatment which sometimes lasted up to 2 weeks.

In the outpatient setting at the Arifjan Troop Medical Clinic, back pain only accounted for approximately 5 percent of sick call visits. Most of these soldiers returned to duty if not immediately, usually within 48 hours. These soldiers had multiple modalities of manual medicine available daily and could return to duty with slight modifications in workload. The predominate cause of back injuries at the Troop Medical Clinic was lifting injuries. Some injuries could have been prevented with proper lifting techniques and precautions. Unfortunately “Back School” was not readily available for all units beforehand.

Possible causes of increased rates of back pain include altered work rest cycles, poor sleep patterns, poor sleep conditions, and combat stress. One of the more common causes was the increased load of personal protective equipment worn during operational activities. This can be corrected by training with protective equipment or the redesign of the personal equipment carrier, perhaps similar to the British Armed Forces load bearing back-pack. In some situations the rest-work cycles and sleep cycles can not be altered for obvious reasons. Primary care providers, physical therapists, psychologists and psychiatrists were readily available to identify possible victims of combat stress. Behavioral health counselors were immediately incorporated into management plans to assist soldiers at risk for combat stress.

Treatment options include osteopathic manipulation, physical therapy techniques including traction and transcutaneous electrical nerve stimulator (TENS) unit, moist heat, ice, anti inflammatory medications, muscle relaxants, and steroid injections. Even in the most austere environments osteopathic manipulation, TENS, traction, stretching exercises, and pain medicines were readily available.

Some barriers to treatment included delayed triage, prolonged immobilization, combat stress, and poor advice early in the treatment plan. Most patients whose triage was delayed or who were immobilized for prolonged periods felt that their pain was not being addressed. This decreased their trust in the delivery and quality of health care they received and sometimes delayed their eventual recovery. Unfortunately, if a soldier was advised they would be medically evacuated out of the theater of operation it was extremely difficult to change this patients’ lack of motivation for a timely recovery and usually resulted in their medical evacuation.
In the traditional primary care setting, back pain is one of the most costly ailments because of days missed from work. In support of Operation Enduring Freedom and Operation Iraqi Freedom back pain not only decreases morale and efficiency of a unit, but it also puts individuals and units at greater risk of failure of a mission and potential loss of soldiers. Even in the most austere conditions, we found osteopathic manipulation and physical therapy increased efficiency and improved morale and the ability to accomplish the mission. Additionally we found that the back pain patients treated with osteopathic manipulation and physical therapy had the greatest understanding of their medical conditions and treatment plans as opposed to other medical or surgical admissions.

References:
1. Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a US national Survey. Spin 1995; 20:11-9.

The opinions and assertions contained herein are the private views of the author and are not to be construed as views as official or as reflecting the views of the US Army Medical Department of the US Army Service at large.