SPINE CONDITIONS

Osteopathic Manipulative Medicine

and the Athlete
P. Gunnar Brolinson, Sarah M.G. McGinley, and Shawn Kerger
Virginia College of Osteopathic Medicine and Virginia Tech University, Blacksburg, VA

BROLINSON, P. GUNNAR, S.M.G. McGINLEY, and S. KERGER. Osteopathic manipulative medicine and the athlete.
Curr. Sports Med. Rep., Vol. 7, No. 1, pp. 49Y56, 2008. Osteopathic medicine is among the fastest-growing sectors of health care. By
the year 2020, it is projected that approximately 100,000 doctors of osteopathic medicine will be practicing in the United States. Despite
its growing popularity, osteopathic medicine is not as widely understood as traditional medicine, also known as allopathic medicine.
Manipulation, a component of osteopathic medicine, is often a subject of debate, especially in today’s age of evidence-based medicine.
Questions are raised: What is the purpose of osteopathic manipulation? Who would benefit from it? What harm can come from the
practice? This article answers these questions by discussing the philosophy of osteopathic medicine, delineating the differences between
osteopathic physicians and other practitioners who perform manual medicine, and reviewing some of the current literature available. The
article particularly focuses on the use of manipulation in the athletic setting. This is a subject that has not been investigated to any
significant degree in the scientific literature, despite its widespread use.

INTRODUCTION them of their ailment or prevent the onset of an ailment.

The first osteopathic medical school was founded in 1892
by Andrew Taylor Still. His early work and philosophy on
the body’s innate ability to heal itself is the cornerstone of
osteopathic medicine. Today, osteopathic medicine has
evolved into a complete system of medical care with a
philosophy that combines the needs of the patient with
current practices of medicine, surgery, and obstetrics.
Emphasis, in the care of the patient, is put on the inter-
relationship between structure and function and the body’s
ability to heal itself (1).
In the beginning, Still’s philosophy of medicine was
called osteopathy. An osteopath did not prescribe pharma-
ceuticals, as Still believed the pharmaceuticals available at
the time were not conducive to healing. He turned to the
human form itself (anatomy) and how it relates to the
body’s function to understand what causes ailments and how
to alleviate them. Still reasoned that the cause of most
diseases was mechanical, and therefore, treatment must
follow the laws of mechanics. Still and his colleagues
devised manual techniques, based on the study of the
human form, to be applied to patients to ultimately relieve
Address for correspondence: P. Gunnar Brolinson, D.O., Virginia College of
Osteopathic Medicine and Virginia Tech University, Sports Medicine Department,
2265 Kraft Drive, Blacksburg, VA 24060 (E-mail: techdo@vt.edu).
1537-890X/0701/49Y56
Current Sports Medicine Reports
Copyright * 2008 by the American College of Sports Medicine
Osteopaths used manipulative approaches designed to
release barriers to the functioning of the nervous and
circulatory systems to improve the body’s ability to heal
itself (1). When asked what osteopathy was, Still stated, ‘‘It
is a scientific knowledge of anatomy and physiology in the
hands of a person of intelligence and skill, who can apply
that knowledge to the use of man when sick or wounded by
strains, shocks, falls, or mechanical derangement or injury of
any kind to the body’’ (1).
With advances in technology, osteopathy has developed
into osteopathic medicine, now encompassing the appro-
priate use of pharmaceuticals, diagnostic studies, and tests,
as well as surgical procedures when indicated. Osteopathic
medical practitioners follow accepted methods of physical
diagnosis and surgical diagnosis and treatment, including
additional training in the evaluation and treatment of the
neuromusculoskeletal system, and they seek to achieve
normal body mechanics (2). Today, osteopathic medicine
still has its roots deeply seeded in four general principles:
1. The body is a unit; the person a unit of body, mind, and
spirit.
2. The body is capable of self regulation, self healing, and
health maintenance.
3. Structure and function are reciprocally interrelated.
4. Rational treatment is based on an understanding of the
above three principles (1).
The use of manual medicine, or joint manipulation, for
the treatment of athletic injuries dates back thousands of

49

Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
years. Hippocrates was well known for his use of manipu-
lation with the ancient Greek athletes around 400 BCE. His
writings contain actual technique descriptions for various
musculoskeletal maladies (3). Later, at the turn of the 19th
century, when Still opened the American School of
Osteopathy, professional and collegiate sports were becom-
ing popular. Still’s reputation and that of osteopaths in
general grew to the level of highly skilled practitioners
providing relief from sprains, strains, and dislocations. Many
injured athletes seeking manipulative treatment made their
way to Still and other osteopathic practitioners. Accord-
ingly, Still became known as a pioneer in sports medicine.
One of the best known sports figures to attend the
American School of Osteopathy and use osteopathic
manipulative medicine in the treatment of his injured
athletes was Forrest ‘‘Phog’’ Allen (1885Y1974). Allen was
the legendary basketball coach of the Kansas Jayhawks. In
addition to his job as head coach, he also functioned as team
physician and trainer. Allen is known by many as the
‘‘father of basketball coaching,’’ with his teams winning 24
conference championships and 771 basketball games during
his long tenure at the University of Kansas (4). Allen
captured the attention of physicians, athletes, and coaches
and demonstrated first-hand the impact that manipulative
medicine could have in the athletic arena. Today, osteo-
pathic physicians and chiropractors provide manual medi-
cine services to athletes at all levels, including high school,
collegiate, Olympic, and professional teams. Despite its
pervasive use, it has not been subjected to rigorous
investigation in the literature [(4) (Brolinson, P.G., et al.,
Pre-competition manipulation and athletic performance:
emerging evidence on the benefits of OMT in athletes,
unpublished manuscript)].
GOALS OF OSTEOPATHIC MANIPULATION
The ultimate goal of manipulation of the musculoskeletal
system is to go beyond aiding the relief of immediate
symptoms. It is directed toward strengthening homeostatic
and protective mechanisms of the body so there can be
optimal healing and better resistance to breakdown in the
future (5). An osteopathic physician is trained to evaluate
the body structurally to determine whether somatic dys-
function exists. Somatic dysfunction is defined as tissue
texture changes, asymmetry, restricted range of motion, and
tenderness (TART). Somatic dysfunction can exist in a
wide array of illnesses and disorders. If somatic dysfunction
does exist, the physician integrates these findings with the
patient’s history and clinical exam. A diagnosis is estab-
lished and treatment is implemented. Treatment today
often consists of contemporary medicinal approaches and,
if not contraindicated, is complemented by osteopathic
manipulative medicine (OMM).
It is biomechanically and physiologically intuitive to use
manual medicine in treating athletes, as sport performance
is primarily a function of the neuromusculoskeletal system.
The body economy (cardiovascular and pulmonary systems)
is constantly tuned to the high and variable demands of the
neuromusculoskeletal system. The athlete is subject to the
50 Current Sports Medicine Reports
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
biomechanical strength and flexibility demands of his or her
particular sport, as well as gravitational challenges produc-
ing the ground reaction forces of the associated sports
performance (3). The goal, in this setting, is to restore
maximal, pain-free movement of the musculoskeletal system
in postural balance (Brolinson, P.G., unpublished data).
Most techniques are aimed at ‘‘warming up’’ the soft tissues,
addressing the periarticular structures, and optimizing joint
function (4). Sports medicine physicians must learn to
identify dysfunctional patterns and seek to guide our
athletic patients in neuromusculoskeletal behavioral pat-
terns that are less costly biomechanically and more
favorable to health and efficient functioning (3).
Our personal experience at the high school, collegiate,
and Olympic levels demonstrates two typical encounters. In
the first typical encounter, an athlete will present with a
painful structure that impedes performance; manipulation
may be indicated as part or all of the treatment for that
particular symptom. Other athletes that present to the
clinic request structural evaluation and manipulation
because they feel their performance is enhanced after
receiving these treatments.
FORMS OF OSTEOPATHIC MANIPULATION
Osteopathic and chiropractic techniques overlap, but
there are distinct differences. In contrast to the chiropractic
approach that focuses on the nervous system and advocates
adjustments to the spinal vertebrae, osteopathic medicine
uses manual therapy in combination with standard treat-
ment methods and focuses on the need to optimize blood
circulation to maintain and restore health (6). Osteopathic
practitioners will incorporate the soft tissues and joints, in
addition to spinal manipulation, during treatment sessions.
While both chiropractors and osteopathic practitioners
perform articular techniques with rapid, short movements
(high velocity, low amplitude), osteopathic manipulation
also incorporates the use of tissues surrounding and sup-
porting the spine or joint to achieve increased mobility. No
distinction is absolute, and many chiropractic and osteo-
pathic methods do not fit neatly into categories (7).
There are several osteopathic techniques in wide use
today. These techniques follow various conceptual models
regarding the underlying neurobiologic mechanisms of
manipulation, some of which include structural, postural,
neurologic, respiratory, bioenergetic, and psycho-behavioral.
Most types of osteopathic manipulation have a primarily
biomechanical orientation. Some of these techniques
include soft tissue and lymphatic procedures, muscle energy,
strain/counterstrain, facilitated positional release, myofascial
release, articulatory (high velocity, low amplitude and low
velocity, high amplitude), and osteopathy in the cranial
field (OCF) (Tables 1 and 2).
EVALUATING THE EVIDENCE
In today’s age of evidence-based medicine, studies
involving osteopathic manipulation are often criticized.
www.acsm-csmr.org
 TABLE 1. Osteopathic manipulative medicine techniques
Techniques Description Direct/Indirecta Active/Passiveb Developed By

Articulatory treatment A low velocity/moderate to high Direct Passive No one in particular

(ART)
Balanced ligamentous
tension/ligamentous
articular strain
(BLT/LAS)
Chapman’s reflex points
Counterstrain or strain/
counterstrain (CS/SCS)
Facilitated positional
release (FPR)
Inhibitory pressure
treatment
Lymphatic techniques
amplitude technique is credited with
this technique
Joint is carried through its full
motion with therapeutic goal
of increased freedom range of
movement (ROM)
Set of myofascial-release techniques Indirect Passive; can use Howard and Rebecca
aimed at disengaging the restrictive respiration to assist Lippincott
barrier, then exaggerating the joint
motion (return to position of injury)
and balancing the tension to
re-establish physiologic
balanced tension
A system of reflex points that manifest Mostly used for diagnosis; Passive Frank Chapman
as a plaque-like change of stringiness treatment of the reflex
of the involved tissues that can then point may not result in
be palpated; the reflex points treatment of the
represent predictable anterior and visceral dysfunction,
posterior fascial tissue texture and treatment of the
abnormalities assumed to be reflex point involves
reflections of visceral direct inhibition
dysfunction or pathology
Technique designed to inhibit Indirect Passive Lawrence Jones
inappropriate strain reflexes by
applying a position of mild strain
in the direction exactly opposite to
that of the false strain reflex
A system of myofascial release where a Indirect Passive Stanley Schiowitz
component region of the body is
placed in a neutral position,
diminishing tissue and joint tension,
in all planes, and an activating force
(compression or traction) is added
The application of steady pressure to Direct Passive No one in particular
soft tissues to reduce reflex activity is credited with
and produce relaxation this technique
Several techniques designed to improve Direct and indirect Passive; can use Various clinicians
lymphatic flow; some examples respiration to assist
include Thoracic Inlet Release, Some techniques are active
Galbreath Drainage, Miller (e.g., Marion Clark Drainage)
Thoracic Pump, Doming the
Diaphragm, Marion Clark Drainage,
Pelvic Diaphragm Release, and
Dalrymple Pedal Pump

Data from (42,43).

a
Direct: technique involves engaging the restrictive barrier. Indirect: technique does not engage the restrictive barrier.
b
Active: technique involves action, as directed by the physician, from the patient ( e.g.,‘‘move your head to the right’’). Passive: technique does not involve
any action to be performed by patient, patient is relaxed.

Critics point out that there is insufficient evidence to truly
determine the benefit of manipulation over other forms of
treatment. However, some studies of osteopathic manipu-
lative medicine conclude that it is as efficacious for pain
control as the use of high-dose pain medications (6,8,9).
Clearly there is still a need for further investigation.
When evaluating evidence, one must take into consid-
eration the many factors involved with research. Osteopathic
manipulation is not a drug, but it is often studied using a
‘‘pharmaceutical’’ approach. To fit into the double-blind,
placebo-controlled research model, researchers must con-
struct ‘‘sham’’ treatments and compare these with ‘‘real’’
osteopathic manipulation treatments. The problem is that
osteopathic manipulation is the application of a set of
procedures, and therefore should be studied under protocols
that evaluate medical procedures: ‘‘For instance, ‘sham’

Volume 7 ●
Number 1 ●
January/February 2008 Osteopathic Manipulative Medicine and the Athlete 51

Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 TABLE 2. Osteopathic manipulative medicine techniques (continued)
Technique Description Direct/Indirecta Active/Passiveb Developed By

Muscle energy
Myofascial release
treatment (MFR)
Osteopathy in the
cranial field
Soft tissue treatment Palpatory procedure directed toward tissues
(ST)/myofascial treatment
Thrust treatment/impulse
mobilization (HVLA)
Visceral manipulation
Technique where the patient voluntarily Direct Active Fred Mitchell, Sr.
moves the body from a precisely
controlled position, against a defined
resistance by the physician
A continuous palpatory technique that Direct or indirect Passive A.T. Still
involves feedback from the tissues and
repositioning to ultimately achieve
a release
Diagnosis and treatment using the primary Adults = indirect or direct Passive William G. Sutherland
respiratory mechanism: 1) The inherent Children, under 6 yr = and Harold Magoun, Sr.
motility of the brain and spinal cord; direct or indirect
2) Fluctuations of CSF; 3) Mobility of the
intracranial and intraspinal membranes;
4) Articular mobility of the cranial bones;
5) Involuntary mobility of the sacrum
between the ilia
Direct or indirect Passive No one in particular is
other than skeletal or arthrodial elements; credited with this
techniques directed at the muscles technique
and fascia
Articulatory technique that uses Direct Passive No one in particular is
high velocity, low amplitude after proper credited with
positioning to achieve improved this technique
mobilization of a joint
Techniques directed towards the viscera to Direct or indirect Passive; can use No one in particular is
improve physiologic functioning; typically respiration to assist credited with the
viscera are moved towards their fascial development of
attachments to a point of fascial balance these techniques

Data from (42,43).

a
Direct: technique involves engaging the restrictive barrier. Indirect: technique does not engage the restrictive barrier.
b
Active: technique involves action, as directed by the physician, from the patient (e.g.,‘‘move your head to the right’’). Passive: technique does not involve
any action to be performed by patient, patient is relaxed.
CSF, cerebral spinal fluid.

OMM is as illegitimate as ‘sham’ appendectomy would be in a
study of lower abdominal pain’’ (8).
Another consideration is that osteopathic physicians use
manipulation to complement conventional treatment of
illnesses and disorders. It is often used congruently with
pharmaceuticals, lifestyle modifications, physical therapy,
and other modalities. As a result, a manipulative treatment
often needs to be individualized to the patient. For example,
one patient may need OMM in the form of muscle energy,
bracing, and home exercises for lateral epicondylitis,
whereas another patient may need a corticosteroid injec-
tion, bracing, and OMM in the form of strain/counterstrain
to get the same relief. Therefore, studies involving specific
OMM protocols that are then generalized to the study
population may not have the same outcome as a patient in a
clinical setting.
CURRENT EVIDENCE ON OMM FOR THE SPINE
Several studies on the efficacy of OMM for low back pain
and neck pain have been undertaken. In 1994, a compre-
hensive evaluation of spinal manipulation for low back pain
undertaken by the Agency for Health Care Policy and
Research in the United States concluded that spinal
manipulation can be helpful for patients with acute low
back problems without radiculopathy when used within the
first month of symptoms (10). Because a majority of the
studies evaluated by this agency involve spinal manipulation
performed by a chiropractor or physical therapist, it is
unclear whether these studies adequately reflect the efficacy
of OMM (11). In 1999, Andersson et al. compared
osteopathic spinal manipulation with standard care for
patients with low back pain in 178 patients. His study
found that both standard care and OMM plus standard care
have similar clinical results, although those subjects treated
with OMM used less medication than those with standard
care alone (6). In 2003, Licciardone et al. published a study
evaluating osteopathic manipulative treatment for chronic
low back pain. His study involved 91 subjects that received
usual care plus OMM, usual care plus sham manipulation,
or usual care only. The study concluded that OMM and
sham OMM provided an additional benefit when used with
usual care for the treatment of chronic nonspecific back
pain. It still remains unclear as to whether the benefits of
osteopathic treatment can be attributed to the techniques

52 Current Sports Medicine Reports www.acsm-csmr.org

Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
themselves or whether they are related to other aspects of
OMM, such as range of motion or time spent interacting
with patients, which may represent placebo effects (12).
Another study, also published in 2003, looked at osteo-
pathic manipulation for spinal pain in a primary care sett-
ing. The study was conducted in England on 201 subjects
with neck or back pain of 2Y12 wk duration. Subjects
received usual primary care for their neck or back pain or
the usual care plus three sessions of osteopathic spinal
manipulation. The study concluded that subjects receiving
osteopathic manipulation in addition to usual care improved
short-term physical outcomes and long-term psychological
outcomes, over usual care alone, at little extra cost (13).
In 2003, Cherkin et al. conducted a systematic review of
previous randomized controlled trial meta-analyses pub-
lished since 1995 that evaluated acupuncture, massage
therapy, or spinal manipulation for nonspecific back pain.
Any randomized controlled trials published since the
reviews were conducted also were included in Cherkin and
colleagues’ review. The study specifically evaluated three
meta-analyses or best evidence synthesis for the efficacy of
spinal manipulation for back pain (14Y16). The investiga-
tors concluded that initial studies found massage to be
effective for persistent back pain. Spinal manipulation
provides clinical benefits equivalent to that of other
commonly used therapies. The effectiveness of acupuncture
remains unclear. All of these treatments seem to be
relatively safe (17). It is important to thoroughly review
this article as well as the studies included in the meta-
analyses previously conducted before coming to definitive
conclusions. For instance, the comparison treatment groups
including general practitioner, physiotherapy, exercises,
traction, and bed rest were considered homogenous in the
Bronfort and Koes reviews. One must consider that each of
these treatment groups has the potential to provide
significant differences if studied in a large population of
patients with back pain.
In 2005, Licciardone, Brimhall, and King published a
systematic review and meta-analysis of randomized con-
trolled trials on OMM as a treatment for low back pain.
Two of the previously mentioned studies were included in
this review, along with the Cherkin, Koes, Bronfort, and
Assendelft reviews (6,12,14Y16), in addition to a more
recent review by Bronfort and colleagues (18). Licciardone
and colleagues also were trying to delineate the differences
between OMM and other forms of manipulative technique,
as all manipulative therapies and treatments provided by
various practitioners are often lumped together in meta-
analyses to generate larger study population numbers. This
systematic review concluded that OMM significantly
reduced low back pain. Stratified analyses demonstrated
significant pain reductions in trials of OMM versus active
treatment or placebo control and OMM versus no treatment
control. There were significant pain reductions with OMM
whether trials were performed in the United Kingdom or
the United States. Significant pain reductions also were
observed during short-, intermediate-, and long-term follow-
up (11).
In 2003, Korthals-de Bos and colleagues studied the cost
effectiveness of physiotherapy, manual therapy, and general
Volume 7 ●
Number 1 ●
January/February 2008
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
practitioner care for neck pain. The study involved 183
individuals with neck pain. The study showed that partic-
ipants who received OMM had faster recovery and experi-
enced fewer days off work than those who received standard
physical therapy or general medical care. The OMM arm
also appeared less expensive then the other two approaches,
but the researchers limited the allowed OMM sessions,
making direct cost comparisons questionable (19). In 2006,
Burns and Wells published a study evaluating gross range of
motion in the cervical spine of asymptomatic subjects,
specifically looking at the effects of muscle energy. The
study included 32 young and middle-aged adults. Active
cervical range of motion was evaluated, and then 18
subjects received muscle energy treatments. Active cervical
range of motion was reevaluated post treatment, and
differences were compared with 14 matched controls who
received sham manipulative treatment. The study con-
cluded that the application of muscle energy techniques
can produce acute increases in the active cervical range of
motion in asymptomatic subjects (20).
To further address the medical community’s need for
evidence on the efficacy of manual medicine, Seffinger
and Hruby published Evidence-Based Manual Medicine: A
Problem-Oriented Approach (21). The text reviews clinical
trials that document the effectiveness of manual techniques.
It is an evidence-driven resource for physicians who wish to
use or refer their patients for manual medicine treatments.
The text covers a wide variety of treatments for ailments
such as mechanical low back pain, mechanical upper back
and neck pain, carpal tunnel syndrome, upper respiratory
congestion, ankle sprains, and cervicogenic headache.
CURRENT EVIDENCE FOR OSTEOPATHIC
MANIPULATION IN ATHLETES
Unfortunately, there are little data on the efficacy of
OMM in an athletic population. Given the principles and
philosophy behind osteopathic manipulation, it makes
biomechanic and physiologic sense to apply manipulation
in an athletic setting. After all, normalized range of motion
and decreased pain would benefit athletic performance. One
might argue that OMM in the athletic setting is merely a
placebo effect. One certainly cannot discount the powerful
effect of touch when treating athletes, and any patient for
that matter (22Y24). On the other hand, preliminary find-
ings from small trials suggest an association that goes beyond
these non-specific treatment effects. Keller and Collocca
looked at trunk muscle strength via surface electromyog-
raphy following spinal manipulation and found a significant
increase in erector spinae isometric muscle output (25).
These findings suggest that altered muscle function may be a
potential short-term effect of spinal manipulation.
Successful athletes encompass the qualities of endurance,
strength, flexibility, proprioception, spatial awareness, and
mental and spiritual harmony. Competing at a high level
requires structurally and functionally healthy tissues, coordi-
nation of the neuromuscular network, and a clear and focused
mind (26). In the chiropractic literature, there have been
reports on the relationship between cervical manipulation
Osteopathic Manipulative Medicine and the Athlete 53

Figure 1. Dr. Sarah McGinley manipulating an athlete’s spine with an
articular technique. Photo courtesy of Dr. Shawn Kerger.
and changes in brain function, as well as visual function
(27,28). This work implies that brain function may be
influenced and activated by cervical spinal manipulation
and that cervical spinal strain may cause visual perception
deficits that can be remedied with cervical spinal manipu-
lation (Fig. 1). Both implications, should this work be
confirmed, would be important in an athlete trying to
achieve better performance leading to successful outcomes.
Several investigators have assessed the effects of spinal
manipulation in various kinematic parameters of spine,
pelvis, and hip motion and have shown positive benefit,
once again rationalizing that manipulation, which improves
range of motion, will lead to better performance and
successful outcomes in an athletic competition (3,20,25,29).
PRE-COMPETITION MANIPULATION
At Virginia Tech, a pilot study was conducted to further
explore the relationship between manipulation and the
athlete’s perceived benefits using a self-report tool. Manipu-
lation is used by many highly trained athletes during their
careers. Some look to manipulation to manage pain associated
with competition and athletic injury, while others use it as an
avenue to improve performance during competition, or for a
combination of these reasons (Fig. 2). The study provided the
first data to examine the use of pre-competition manipulation
and associate it with player perception. This was an initial
attempt to understand the factors associated with the use of pre-
competition manipulation, self-reported pain, perceived bene-
fits to a player’s competitive abilities, and other factors that
may mediate this relationship. Specifically, this study char-
acterized players who seek and do not seek pre-competition
manipulation, identified the reasons for seeking manipu-
lation, and provided initial data upon which to develop
larger studies across this and other athletic endeavors.
A brief questionnaire was completed at baseline and the
end of the season. This survey encompassed reasons for
seeking manipulation, description of any pain experienced,
manipulation and injury history, and general beliefs about
54 Current Sports Medicine Reports
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
manipulation. This was an exploratory, pilot study with no
specific hypotheses. Data have been analyzed using descrip-
tive and associative statistics (correlation).
Surprisingly a large number of players reported that most
visits were related to performance enhancement. Overall,
68% of the players said the majority of their manipulation
visits occurred for this reason. Slightly fewer than 47% of
players reported that a majority of their manipulation visits
were sought to help manage the pain associated with
competition. Of the survey participants, 50% said they
sought treatment for both reasons. Perception of back
health also was taken into consideration. Those athletes
who perceived their back health as excellent, very good, or
good were less likely to report using manipulation visits for
pain management than those who perceived their back
health as fair or poor (median 35% of visits vs 55% of visits
respectively; P G 0.04). No differences were observed
between the two back health groups, however, in terms of
percentage of manipulation visits for performance enhance-
ment (median 75% vs 63% respectively, P = 0.35). A
median 80% of manipulation visits were for a combination
of controlling back pain and enhancing performance in
those who perceived their back health as fair to poor. A
median 45% of the visits in those who perceived their back
health as excellent to good were for controlling pain and
performance enhancement (P G 0.01 between the groups).
This pilot study indicates that a significant portion of
athletes access pre-game manipulative services for both pain
control and performance enhancement. Given these data,
larger studies need to be conducted to tease out the degree
to which the reported benefits in pain control and perform-
ance enhancement are related to the actual manipulation
and how much can be attributed to a placebo effect. In this
regard, data collection is ongoing at Virginia Tech.
SAFETY OF OSTEOPATHIC MANIPULATION
Several case reports and studies have been published to
determine the safety of spinal manipulation and incidence of
Figure 2. Dr. P. Gunnar Brolinson manipulates an athlete’s cervical
spine with muscle energy. Photo courtesy of Dr. Delmas Bolin.
www.acsm-csmr.org
iatrogenic injury associated with a manipulative treatment,
particularly with regards to cervical spinal manipulation
(30Y40). Many of the reported cases of adverse outcomes do
not distinguish the type of manipulative treatment provided
(e.g., thrust vs muscle energy) or the training of the
practitioner. One of the most commonly studied adverse
events following cervical manipulation is vertebrobasilar
accident (VBA) (30,37). In regards to the cervical spine,
most of the reported cases of adverse outcomes have involved
‘‘thrust’’ or ‘‘high velocity, low amplitude’’ types of manipu-
lative treatment (31). However, the risk of a VBA occurring
spontaneously is nearly twice the risk of a VBA resulting from
cervical spine manipulation (38).
Osteopathic manipulation is considered quite safe based
upon the evidence and incidence of harmful outcomes.
However, the importance of taking a good history and per-
forming a thorough physical exam prior to manipulation
are still emphasized, as this will help reduce the use of
manipulation when it is contraindicated (31,33,38,41).
CONCLUSION
From its beginning, osteopathic medicine has taken an
active role in promoting participation in athletics at all levels
as a means to a healthy lifestyle. Its role in the athletic
population may be of particular importance for improved
performance, recovery from injury, prevention of injury, and
ultimately successful outcomes in competition. Each patient,
including the patient-athlete, should be evaluated and treated
on an individual basis, including comprehensive evaluation of
both structure and function when appropriate. Implementa-
tion of osteopathic principles and practices, which may
include manual medicine, should then be applied to aid in
the recovery or prevention of illness or injury.
References
1. Sefinger, M.A., H.H. King, R.C. Ward, et al. Osteopathic philosophy.
In: Foundations for Osteopathic Medicine, 2nd ed, R.C. Ward, J.A.
Jerome, and J.M. Jones III (Eds.). Baltimore: Lippincott Williams &
Wilkins, 2002, pp. 5,7,10.
2. DiGiovanna, E.L. Introduction to osteopathic medicine. In: An
Osteopathic Approach to Diagnosis and Treatment, 2nd ed, E.L. Giovanna
and S. Schiowitz (Eds.). Philadelphia: Lippincott-Raven, 1997, p. 1.
3. Brolinson, P.G., K. Heinking, and A.J. Kozar. An osteopathic approach
to sports medicine. In: Foundations for Osteopathic Medicine, 2nd ed,
R.C. Ward, J.A. Jerome, and J.M. Jones III (Eds.). Baltimore:
Lippincott Williams & Wilkins, 2002, pp. 534Y550.
4. Brolinson, P.G. Precompetition manipulation: placebo or performance
enhnacer? Clin. J. Sports Med. 13:69Y70, 2003.
5. Kuchera, W.A., and M.L. Kuchera. Osteopathic Principles in Practice,
2nd ed. Columbus, OH: Greyden Press, 1993, p. 275.
6. Andersson, G.B., T. Lucente, A.M. Davis, et al. A comparison of
osteopathic spinal manipulation with standard care for patients with
low back pain. N. Eng. J. Med. 341:1426Y1431, 1999.
7. Aurora Health Care: Osteopathic Manipulation. Available at: http://
www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp.
Accessed August 2007.
8. McCombs, T.M. OMT: evidence, research, and practice (letter). J. Am.
Osteopath. Assoc. 106:379Y380, 2006.
9. Goldstein, F.J., S. Jeck, A.S. Nicolas, et al. Preoperative intravenous
morphine sulfate with post-operative osteopathic manipulative treat-
ment reduces patient analgesic use after total abdominal hysterectomy.
J. Am. Osteopath. Assoc. 105:273Y279, 2005.
Volume 7 ●
Number 1 ●
January/February 2008
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
10. Agency for Health Care Policy and Research [AHCPR]: Acute low
back problems in adults. In: Clinical Practice Guideline 14. Rockville,
MD: US Dept of Health and Human Services, 1994.
11. Licciardone, J.C., A.K. Brimhall, and L.N. King. Osteopathic manipu-
lative treatment for low back pain: a systematic review and meta-analysis
of randomized controlled trials. BMC Musculoskelet Disord. 6:43, 2005.
12. Licciardone, J.C., S.T. Stoll, K.G. Fulda, et al. Osteopathic manipu-
lative treatment for chronic low back pain: a randomized controlled
trial. Spine. 28:1355Y1362, 2003.
13. Williams, N.H., C. Wilkinson, I. Russell, et al. Randomized osteopathic
manipulation study (ROMANS): pragmatic trial for spinal pain in
primary care. Fam. Pract. 20:662Y669, 2003.
14. Koes, B.W., W.J. Assendelft, G.J. van der Heijden, and L.M. Bouter.
Spinal manipulation for low back pain: an updated systematic review of
randomized clinical trials. Spine. 21:2860Y2873, 1996.
15. Bronfort, G. Spinal manipulation: current state of research and its
indications. Neurol. Clin. 17:91Y111, 1999.
16. Assendelft, W.J., S.C. Morton, E.I. Yu, et al. Spinal manipulation
therapy for low back pain: a meta-analysis of effectiveness relative to
other therapies. Ann. Intern. Med. 138:871Y881, 2003.
17. Cherkin, D.C., K.J. Sherman, R.A. Deyo, and P.G. Shekelle. A review
of the evidence for the effectiveness, safety, and cost of acupuncture,
massage therapy, and spinal manipulation for back pain. Ann. Intern.
Med. 138:898Y906, 2003.
18. Bronfort, G., M. Haas, R.L. Evan, and L.M. Bouter. Efficacy of spinal
manipulation and mobilization for low back pain and neck pain: a
systematic review and best evidence synthesis. Spine J. 4:335Y356, 2004.
19. Korthals-de Bos, I.B., J.L. Hoving, M.W. van Tulder, et al. Cost
effectiveness of physiotherapy, manual therapy, and general practi-
tioner care for neck pain: economic evaluation alongside a randomized
controlled trial. BMJ. 326:911, 2003.
20. Burns, D.K., and M.R. Wells. Gross range of motion in the cervical
spine: the effects of osteopathic muscle energy technique in asympto-
matic subjects. J. Am. Osteopath. Assoc. 106:137Y142, 2006.
21. Seffinger, M.A., and R.J. Hruby. Evidence-Based Manual Medicine: A
Problem-Oriented Approach. Philadelphia: Elsevier Science Health
Science Division, 2007.
22. Hawk, C., C. Phongphua, J. Bleeker, et al. Preliminary study of the
reliability of assessment procedures for indications for chiropractic
adjustments of the lumbar spine. J. Manipulative Physiol. Ther. 22:
382Y389, 1999.
23. Burton, K.A., T.D. McClune, R.D. Clarke, and C.J. Main. Long-term
follow-up of patients with low back pain attending for manipulative
care: outcomes and predictors. Man. Ther. 9:30Y35, 2004.
24. Licciardone, J.C., and D.P. Russo. Blinding protocols, treatment credibility,
and expectancy: methodologic issues in clinical trials of osteopathic
manipulative treatment. J. Am. Osteopath. Assoc. 106:457Y463, 2006.
25. Keller, T., and C. Collocoa. Mechanical force spinal manipulation
increases trunk strength assessed by electromyography: a comparative
clinical trial. J. Manipulative Physiol. Ther. 23:585Y595, 2000.
26. Mori, S., Y. Ohtani, and K. Imanka. Reaction times and anticipatory
skills of karate athletes. Hum. Mov. Sci. 21:213Y230, 2002.
27. Carrick, F.R. Changes in brain function after manipulation of the
cervical spine. J. Manipulative Physiol. Ther. 20:529Y545, 1997.
28. Gorman, R.F., and R.L. Anderson. Case report: spinal strain and visual
perception deficit. Chiropr. J. Aust. 24:131Y143, 1994.
29. Pollard, H., and G. Ward. The effect of upper cervical or sacroiliac
manipulation on hip flexion range of motion. J. Manipulative Physiol.
Ther. 21:9, 1998.
30. Haldeman, S., F.J. Kohlbeck, and M. McGregor. Unpredictability of
cerebrovascular ischemia associated with cervical spine manipulation: a
review of 64 cases after cervical spine manipulation therapy. Spine.
27:49Y55, 2002.
31. Assendelft, W.J.J., L.M. Bouter, and P.G. Knipschild. Complications of
spinal manipulation: a comprehensive review of the literature. J. Fam.
Pract. 42:475Y480, 1996.
32. Malone, D.G., N.G. Baldwin, F.J. Tomecek, et al. Complications of
cervical spine manipulation therapy: 5-year retrospective study in a
single-group practice. Neurosurg. Focus. 13:ecp1, 2002.
33. Vick, D.A., C. McKay, and C.R. Zengerle. The safety of manipulative
treatment: review of the literature from 1925 to 1993. J. Am. Osteopath.
Assoc. 96:113Y115, 1996.
Osteopathic Manipulative Medicine and the Athlete 55
34. Jentzen, J.M., J. Amatuzio, and G.F. Peterson. Complications of
cervical manipulation: a case report of fatal brainstem infarct with
review of the mechanisms and predisposing factors. J. Forensic Sci.
32:1089Y1094, 1987.
35. Koss, R.W. Quality assurance monitoring of osteopathic manipulative
treatment. J. Am. Osteopath. Assoc. 90:427Y433, 1990.
36. Dvorak, J., and F. Orelli. How dangerous is manipulation to the cervical
spine? Case report and results of a survey. Man. Med. 2:1Y4, 1985.
37. Haldeman, S., F.J. Kohlbeck, and M. McGregor. Stroke, cerebral artery
dissection, and cervical spine manipulative therapy. J. Neurol.
249:1098Y1104, 2002.
38. Hurwitz, E.L., P.D. Aker, A.H. Adams, et al. Manipulation and
mobilization of the cervical spine: a systematic review of the literature.
21:1746Y1756, 1996.
39. Hayes, N.M., and T.A. Bezilla. Incidence of iatrogenesis associated
with osteopathic manipulative treatment of pediatric patients. J. Am.
Osteopath. Assoc. 106:605Y608, 2006.
56 Current Sports Medicine Reports
Copyright @ 2007 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
40. Stevinson, C., and E. Ernst. Risks associated with spinal manipulation.
Am. J. Med. 112:566Y571, 2002.
41. American Osteopathic Association: Position Paper on Osteopathic
Manipulative Treatment of the Cervical Spine 2005. Available at:
http://www.osteopathic.org/pdf/aoa_postiono-y.pdf or http://www.
do-online.org/index.cfm?PageID=aoa_position. Accessed September
2007.
42. Glossary Review Committee, for Educational Council on Osteopathic
Principles and the American Association of Colleges of Osteopathic
Medicine. Glossary of Osteopathic Terminology Usage Guide. 2006.
Available at: https://www.do-online.org/pdf/sir_collegegloss.pdf?C-
FID=1319696&CFTOKEN=aa76bdb98f64bae6-F99DFFBA-C4A3-
36A5AEA8C4AE8E8BB03E&jsessionid=30309fe58952 5e2b1f2b.
Accessed September 2007.
43. Crow, W.T. The Comlex-USA Exam: The Osteopathic Principles and
Practice Review Book for Parts One, Two and Three, 1st ed. Indianapolis,
IN: American Academy of Osteopathy, 2000, pp. 14Y27.
www.acsm-csmr.org