A Conservative Treatment Alternative For Patients With Chronic Pain
Spinal manipulation under anesthesia is a procedure that primarily originated with the osteopathic profession and has been utilized for the treatment of spinal pain since the late 1930s. Documentation regarding the success and 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 osteopaths that had been adequately trained in manipulation are coming to the close of their careers or have retired. Because of the need for continuance of this procedure, the focus for the performance of spinal manipulation under anesthesia has now shifted to chiropractors and their expertise in spinal manipulation skills.
Indication For Manipulation Under Anesthesia
Spinal manipulation under anesthesia is a procedure that 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 previous conservative therapy. Etiology of their pain can be disc bulge/herniation, chronic sprain/strain, 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 loss. These types of patients typically respond well to manipulation/physical therapy/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.
1 Bulging, protruded, prolapsed or herniated discs without free fragment and are not surgical candidates
2 Frozen or fixated articulations
3 Failed low back surgery
4 Compression syndromes with or without radiculopathies caused from adhesion formation, but not associated with osteophyic entrapment
5 Restricted motion, which causes pain and apprehension from the patient
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 falls within the parameters for manipulative treatment
8 Unresponsive muscle contraction, 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 neuromusculoskeletal 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
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
11 Advanced osteoporosis
12 Evidence of cord or caudal compression by tumor or disc herniation beyond 5mm
14 Widespread staph/strep infection
15 Sign/symptom of aneurysm
16 Unstable apondylolysis
MUA Procedure and 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 rotation. Specific spinal manipulation is performed when the elastic barrier of resistance and segmental end range of motion is achieved. Then stretching of the paraspinal and surrounding supportive musculature is performed to promote cervical, thoracic, lumbar and lumbopelvic flexibility in conjunction with attempting to restore proper kinetic motion.
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The Patient is then awakened from the 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 with 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 in 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 interferential/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 the rule of thumb when considering the MUA procedure and only certified MUA practitioners taught through accredited institutions should be allowed to practice this technique - reimbursement should also reflect that proper educational standards have been achieved.
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. Neurological 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/testing 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, 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.
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
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 Care Plan
As with any treatment technique, determining the exact number of treatments is like trying to look into a crystal ball and being correct about 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 in Newport News, VA. Clinical trials of some 6,000 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 to rendered conservative care. Patient's response 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 workload 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.
In comparing clinical reaction to MUA that has been observed by the majority of the 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 first injury to the involved area). Single Spinal MUA is 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 the academy standards.) NOTE: The National Academy of MUA Physicians feels 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 continuing with the Serial MUA treatment plan or discontinuing the procedure for further evaluation:
If the patient regains 80% or better of the 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 the 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 MUAs 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 a 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 the patient's condition.
Considerations for Manipulation Under Joint Anesthesia (MUJA)
MUJA, has advanced into the field in the past 4 or 5 years as an alternative to conscious sedation by using joint injection to decrease the inflammation in the joint, anesthetize the joint, and manipulate the joint to provide mobilization and flexibility while decreasing joint irritation.
MUJA is used for acute care MUA and is being put forward by the concept that relief from intractable pain (pain, neuromusculoskeletal in origin, with no relief) could be provided by injection into the affected joint, with mobilization and manipulation used secondarily to diffuse the injected medicine and help eliminate the inflammatory reaction in the affected joints (Dreyfuss, Michaelsen, & Home, 1995).
Early mobilization of the involved joints, despite otherwise intractable pain and/or muscle spasm, reduces compressive forces on the discs, facet capsules, and nerve roots (Which would cause additional scar tissue if left untreated), thereby allowing nutrients and fluids into the area of the lesion and helping the body heal itself more naturally and rapidly.
In Acute Care MUA, MUJA reduces:
- Excessive scar tissue build-up ·
- The chance for muscle contracture · Duration and frequency of regular outpatient spinal manipulative therapy ·
- The percentage of resultant permanent impairment
MUJA has been used to affect joint involvement in chronic neuromusculoskeletal conditions. Injection into the involved joint to determine the pain location has been utilized for many years as both an objective diagnostic tool and a therapeutic tool. It is employed in conjunction with the injection to improve joint mobility. The same standards of care and protocols are followed when patients are chosen for the MUJA procedure as for the MUA procedure. The conditions treated with MUJA are somewhat the same as MUA, with the exception being more joint involvement as compared to myofascial and/or muscular involvement.
The majority of MUA candidates historically have been those patients who suffer from chronic joint restriction due to fixation from disuse following trauma. This syndrome sets up a vicious cycle that Michael Alter (1988) calls the "self perpetuating cycle of muscle spasm." In this cycle, the patient undergoes a form of trauma, which can be caused by direct contact or through repetitive incremental injuries. These injuries then set up pain stimuli, inflammation, emotional tension, sometimes infection, temperature variations, and eventual immobilization from disuse. As the cycle proceeds, it sets up reflex muscle contraction which, if gone untreated, progresses to muscle contracture. This, in turn, progresses to restricted movement and fixation in the joints, which has a direct effect on what Wyke (1972) calls "dysfunctional postural kinesthetics." Wyke refers to a disturbance in postural kinesthetics resulting in altered mechanoreceptor response. Typically, Types I, II, and IV mechanoreceptors are concurrently involved, setting up a cycle of trauma induced altered posture affecting movement, which then stimulates nociceptive response.
Using the MUA technique, we complete stretching maneuvers and mobilization techniques coupled with specific adjustive techniques to help alter adhesion accumulation that has been laid down by the body as connective tissue protective mechanisms to prevent further damage to the areas involved. Because new medications allow us to perform this technique while the patient is in conscious sedation, we can provide progressive linear forces to these areas and alter these adhesions without tearing tissue in the process. Because these medications allow the patient to relax and not respond with immediate muscle contraction when pain is perceived, we are able to perform these maneuvers so that end range is not lost. The natural protective mechanisms are present but are slowed down temporarily, and pain is perceived, but not remembered (Gordon, 1993).
By completing the MUA procedure as a team, with the anesthesiologist as a very valuable member who provides just the right medications to allow this physiological change from the normal office manipulative therapy program, the certified MUA doctor is able to accomplish considerably more with MUA than if the same patient were to undergo these procedures in the office setting without the conscious sedation. The most important concept here is that if the patient were able to recover in the office setting without the use of conscious sedation, the patient would not have been a candidate for the MUA procedure in the first place.