Manipulation  Under Anesthesia

 

A Conservative Treatment Alternative For

The Chronic Pain Patient

 

Robert C. Gordon, D.C., ABCS, FRCCM, DAAPM

 

Knowledge Brings Better Tomorrows ……….

 

 

Manipulation under anesthesia is a procedure hat primarily originated the osteopathic profession and has been utilized for the treatment of pain since the late 1930s. Documentation regarding the success value of manipulation under anesthesia has been recorded in the osteopathic literature since 1948 when Clybourne reported in the Journal of American Osteopath Association. A success rate of 80-90%, which has been maintained to this day. In the last two decades, the emphasis regarding manipulation in osteopathic education has greatly decreased. Therefore, the paths that had been adequately trained in manipulation are coming to lose of their careers or have retired. Because of the need for continue of this procedure, the focus for the performance of spinal manipulation under anesthesia has now shifted to chiropractic and their expertise in spinal manipulative skills.

 

Medications for MUA

Spinal manipulation under anesthesia is a procedure hat is intended for patients that suffer from sometimes acute, but mostly chronic musculoskeletal disorders in conjunction with biomechanical aberrancies. These individuals have also been unresponsive to pre conservative therapy. Etiology of their pain can be disc bulge/herniation, chronic sprain, failed back surgery myofacial pain syndromes in conjunction with those listed below. The procedure is extremely beneficial for the patient that has muscle spasm accompanied with pain and terminal joint range of motion. These types of patients typically respond well to manipulation/physical exercise but their relief may only be temporary (days to weeks). To ensure good results with a procedure of this type, one of the most important considerations is patient selection. The indication/contraindications being adhered for this procedure are as follows:

 

INDICATIONS

  1. Bulging protruded, prolapsed or herniated discs without free frag and are not surgical candidates.
  2. Frozen or fixated articulations from adhesion formation.
  3. Failed low back surgery.
  4. Compression syndromes with or without radiculopathies caused from adhesion formation, but not associated with osteophytic entrapment.
  5. Restricted motion, which causes pain and apprehension from the patient, but manipulation is the therapy of choice.
  6. Unresponsive to manipulation and adjustment when they are the therapy of choice.
  7. Unresponsive pain, which interferes with the function of daily life and sleep patterns, but which fall within the parameters of manipulative treatment.
  8. Unresponsive muscle contracture which is preventing normal daily activities and function.
  9. Post-traumatic syndrome injuries from acceleration/ deceleration or deceleration/ acceleration types of injuries which result in painful exacerbation of chronic fixations.
  10. Chronic recurrent neuro musculoskeletal dysfunction syndromes, which result in a regular periodic treatment series, that are always exacerbation of the same condition.
  11. Neuromusculoskeletal conditions that are not surgical candidates but have reached MMI, especially with occupational injuries.

 

 

CONTRAINDICATIONS:

 

  1. Any form of malignancy.
  2. Metastatic bone disease.
  3. TB of bone.

4.   Acute bone fractures.

5.   Direct manipulation of old compression fractures.

6.   Acute inflammatory arthritis.

7.   Acute inflammatory gout.

8.   Uncontrolled diabetic neuropathy.

9.   Syphilitic articular or periarticular lesion.

10. Gonorrheal spinal arthritis.

  1. Advanced osteoporosis (as indicated diagnostically).
  2. Evidence of cord or caudal compression by tumor or disc himation beyond 5 mm.
  3. Osteomyelitis.
  4. Widespread staph/strep infection.
  5. Sign/symptom of aneurysm
  6. Unstable spondylolysis.

MUA Procedure & Follow Up Care

Manipulation under anesthesia (MUA) is performed using conscious sedation usually using Diprivan (Propofol), and Versed as the anesthesia.  The patient is taken through passive cervical /thoracic and lumbar ranges of motion in flexion lateral flexion and motion. Specific spinal manipulation is performed when the elastic barrier of resistance and segmental end range of motion is achieved. Then stretching of the para spinal and surrounding supportive musculature is performed to promote cervical, thoracic, lumbar and lumbopelvic flexibility in conjunction with attempting to restore proper kinetic motion. The patient is then awakened from anesthesia which usually occurs minutes after the diprivan is stopped. They are taken to recovery and monitored until full recovery has occurred. This varies but is usually accomplished within a very short period of time. The patient is then discharged to rest until post MUA therapy is begun later the same day. Post MUA therapy is a vital part of the MUA procedure and is accomplished the same day as the procedure to help continue the alteration of adhesions in the joints, joint capsules and surrounding holding elements. Post MUA therapy consists of warming up the involved areas, passive stretching as was accomplished in the MUA procedure, followed by interferential stimulation and cryotherapy. The patient is then sent home to rest. This exact procedure is repeated serially in most cases by having the patient return to the facility the next day and the following day(s). The average number of days for the MUA procedure to accomplish the desired outcome has been shown to be between 2-4 days. Consecutive day procedures have been shown to alter adhesion formation and joint dysfunction in a manner that single procedures do not accomplish. The concept is that a little more movement each day is incremental movements accomplishes the desired increase in range of movement and decrease pain far better than trying to spend great amounts of time on one day to accomplish the same movement. This also has a dramatic effect on decreasing the post MUA therapy time. This protocol for post MUA therapy is repeated 7-10 days straight after the final MUA followed by pre-rehabilitation and then formal rehabilitation for 3-6 weeks. Additional assistance with the reduction of soreness and mild edema with an increase in range of motion, has been noted when small, portable, multi-modality inter ferential/NMES/HVPC devices are applied in the OR directly after the MUA procedures are accomplished and the patients are sent home with these units prior to receiving post MUA therapy. The rehabilitation program continues for 3-6 weeks following the MUA procedure to give the patient time to recover to pre- injury status. It gives the patient confidence that they have

achieved recovery and in most cases the patient’s return to work and daily lifestyle with a renewed feeling of confidence in their ability to accomplish everyday tasks that they have previously been unable to accomplish due to pain and reduced movement. Marked improvement (80-97%) has been the general rule when the properly selected cases have received this procedure. Strict adherence to standards and protocols should be rule of thumb when considering the MUA procedure and only certified MUA practitioners taught through accredited institutions should be allowed to practice this technique, and reimbursement should also reflect that proper educational standards have been achieved.

 

The graph on the following page depict the various stages of manual therapy and adjustive procedures and show the changes attained with the patient who has been placed under conscious sedation as represented in graph 4.

Patient Evaluation/ Screening

In addition to the parameters of patient selection, appropriate pre-MUA conservative procedures are required. This includes traditional chiropractic/ manual therapy for a minimum of 4-6 weeks (2-4 in acute cases), plain film radiographs and advanced imaging study such as MRI, CT when required by the condition. Neurologic and/or orthopedic evaluation in conjunction with EMG/NCV/SSEP studies in many cases are also performed. This provides cross-disciplinary evaluations that support the concept that this is a team effort. Also, any other appropriately recommended treatment options/testing would be considered at this time. Any other recommended treatment options would be made available to the patient prior to undergoing the MUA procedure. Just prior to the MUA procedure a medical history and physical examination is to be performed to assure that the patient is capable of undergoing the procedure with no additional medical complications. Included with this evaluation should be an ASA standard testing for conscious sedation such as chest x-ray, and EKG (if the patient is over 50, or if their physical condition warrants it) and pregnancy testing for females. An anesthesia interview is then provided. This is to assure that the anesthesia, Diprivan (Propofol) Versed and sometimes Fentanyl would be appropriate for the patient and if there are any projected complications from the anesthesia that should be addressed.

 

Considerations

These patients have been relatively unresponsive to other conservative methods of treatment and not much more is available through the traditional health care delivery system. As with any procedure, there are no guarantees of success. However, if the protocol is closely adhered to, the likelihood of a positive outcome is increased. It is also extremely imperative that the physician providing the manipulation is properly trained and proficient in providing manipulation while the patient is under anesthesia.

 

Professional Acceptance

Professional differences of opinion regarding MUA are common. Once an adequate explanation of the procedure and clinical rationale for performing the procedure is understood, MUA is generally well accepted within the chiropractic and medical communities. This is truly a multi-disciplinary approach for the treatment of spinal pain.

 

Parameters for selection of the Number of MUAs to Accompany the Algorithm

As with any treatment technique, determining the exact number of treatments is like trying to look into a crystal ball and being correct with what you see.

To determine the amount or number of treatments required to get the desired results is more accurately measured if we place numerical or response indices with patient reaction to the procedure. Parameters, such as chronicity and age, which have already been established in the protocols and standards in determining the number of MUAs required, are then factored in.

The spinal MUA procedure is a procedure that has seen transitional and historical evolution. Today, with the advancement in mobilization, manipulation, and adjustive techniques which are being used extensively and exclusively within the Chiropractic profession, the MUA technique has taken on significant importance in the care of many neuromusculoskeletal conditions. In the past these conditions were not responding to care and were not surgical candidates, so the patient was simply left to live with the discomfort.

These new parameters for determining the number of MUAs come from the outcome assessments of a 60 case study a Newport News, VA. Clinical trials of  some 6000 cases completed by the National Academy of MUA Physicians membership over the past 2-4 years, and current studies being completed in Lancaster, PA, Pittsburgh, PA, New York, and California have also aided in determining these parameters.

The National Academy of MUA Physicians recommends the following considerations when determining the need for MUA and the addition of serial MUA to the treatment protocol.

·        Patient response and progress lo rendered conservative care.

·        Patient’s responses to the ability to function with everyday activities given the current care being rendered.

·        The patient’s psychological acceptance of the MUA technique, and the psychosomatic response to overcoming chronic pain and discomfort given the length of time the patient has been away from the work load environment.

·        Prevention of further gross deterioration if the MUA procedure were performed given the amount of time the patient has been under conservative and/or surgical care.

·        Prevention of or the diagnosing of specific parameters for surgical intervention.

·        Correction of failed surgical intervention.

 

On comparing clinical reaction to MUA that has been observed by the majority of (National Academy of MUA Physicians membership with the studies that are currently being completed, the following parameters for continuing with the plan for single or serial MUA has been recommended:

Single Spinal MUA is most often performed when the patient is of a younger age, and when the injury to the area is of the first order (determined to be the fast in to the involved area).

Single Spinal MUA most often performed when the injury is of the first order and the care being rendered has had sufficient time (protocols determined 2-4 weeks) of conservative care and where the patient’s lifestyle and daily activities are being interrupted in such a fashion as to warrant immediate relief. (Medical intervention and evaluation is recommended by he academy standards.) NOTE: The National Academy of MUA

Physicians feel that in this instance, if the patient is treated for the intractable type of pain with a single MUA procedure and responds well, the necessity for future MUAs is greatly reduced.

Serial MUA (more than one MUA) is recommended when conservative care, as described in the National Academy of MUA Physicians standards and protocols, has been completed and when the condition is chronically present. When the injury is recurrent in nature, and when it is determined that fibrotic tissue and articular fixation prevents a single MUA from ever being effective then serial MUA is recommended. The following parameters should be a guide to con with then serial MUA treatment plan, or discontinuing the procedure for further evaluation:

 

·        If the patient regains 80% or better of he normal biomechanical function during the procedure and continues to show at least an 80% functional improvement during post MUA evaluation on the same day as the MUA, then the series has been found to be unnecessary as long as the proper follow-up post MUA therapy and rehabilitation is performed.

·        If he patient has less than 50-70% improvement in desired function during the MUA procedure and continues to show only a 50-70% improvement during post MUA evaluation, the second MUA is recommended and found to be of great benefit.

·        If the patient continues to improve with the second MUA, but does not achieve at least an 80% improvement in function during the MUA and in the post MUA evaluation then the third MUA has been found to be of significant benefit. NOTE: At this time most patients have responded very well to the three-day procedure. However, if the patient has still not achieved an 80% increase in function then a fourth or fifth MUA has been clinically documented (This number of consecutive MUA is rare. In some cases MUAs have been repeated at a later date, and the rate of improvement is faster than when the MUA was originally performed.)

·        If the patient only shows a 10-15% improvement during the first MUA and continues to only show a 10-15% functional improvement during post MUA evaluations, then it is recommended that further evaluation be completed on the patient to determine if the MUA procedure is the treatment of choice. Since most patients gain between 50% and 75% improvement during the first day of serial MUA treatment plan, a small improvement in function may indicate more extensive involvement than what was determined in the initial treatment plan. This is important because MUA has been found to be both therapeutic and diagnostic. It has been used by both neurosurgeons and orthopedic surgeons in deciding objectively that surgical intervention is the right choice since the conservative therapeutic regime of office therapy and MUA were performed with little significant change in he patient’s condition.

Patient Testimonials

“ I surely am thankful for the MUA being there for me.”

“Thank you! It has been a long time since I felt this good.”

“By the third treatment — Hallelujah! I had full range motion with some tenderness but have been able to resume my secretarial duties without pain. I recommend this procedure for anyone with chronic problems.”

“Since the MUA, I no longer have the burning pain in my shoulders or the tightness in my lower back. I can even walk normal now.”

“Since having MUA done I have gained back considerable movement in my neck and upper back. I am in rehab to strengthen the muscles and feel that I would not be able to do this type of therapy if I hadn’t had the three MUAs.”