Manipulation under anesthesia ( MUA ) or fibrosis release procedure is a multidisciplinary, chronic-associated manual therapy modality used for the purpose of enhancing articular and soft tissue movements. This is achieved by a combination of mobilization/manipulation and myofascial release techniques. Drug-assisted manipulation (MAM) can also be used to describe the procedure, although the broader term categorizes different forms of MUA techniques that exist. In any form, MUA is used by osteopathic/orthopedic doctors and specially trained bone experts (certified MUA). It is intended as a means to solve adhesions (scarring) from or about the spinal joint (cervical, thoracic, lumbar, sacral, or pelvic regions), or the joints of the extremities of the extremities (ie, knees, shoulders, hips) that are highly restricted range of motion significantly limiting the function. Unsuccessful attempts at other standard conservative treatment methods (ie manipulation, physical therapy, treatment), over an extended period of time, are one of the main patient qualifications.
Video Manipulation under anesthesia
Prosedur
In an outpatient or outpatient setting, with a qualified medical doctor present, an anesthesia or medication component of the MUA spine procedure may be administered in one of two ways.
Intravenous infusion (IV) (given by anesthetist)
Historically, medical literature identified sodium pentothal as the earliest of the anesthetic agents used with the MUA procedure. This is followed by the period in which propofol is used to induce "twilight state" (aka, sedation IV or conscious sedation). The latter becomes the preferred means of doctors in providing services, as it offers the preservation of the patient's response during treatment delivery. With the current MUA procedure, deep-conscious consciousness is achieved with agents such as propofol, through monitored anesthetic treatment (MAC).
Local injection (given by an anesthesiologist or pain management expert)
As a less common way of MUA treatment, the choice of injectable drug may be given directly to the affected synovial joint, spinal fusion joint or to the surrounding epidural space. Injections of local anesthesia allow previously incomplete, manual-based manual therapy methods to be better tolerated, but outside the scenario of general anesthesia. When given to the spine, these MUA procedures qualify with terms such as manipulation under joint anesthesia (MUJA) and manipulation under epidural anesthesia (MUEA).
Maps Manipulation under anesthesia
History
Drug Assisted Manipulation (MAM) has been used since the 1930s, and MUA was practiced by osteopathic physicians and orthopedic surgeons in the 1940s and 1950s. It was largely abandoned due to complications from general anesthesia and because of the type of nonspecific manipulation procedure used. It was modified and revived in the 1990s, mainly by chiropractors, and also by osteopathic doctors; this may be because safer anesthesia is used for conscious sedation, along with increased interest in spinal manipulation (SM).
In the MUA literature, spinal manipulation under anesthesia has been described as a controversial procedure. It has a history that is vulnerable to enthusiastic claims of success and indiscriminate use. With the ongoing misconceptions about the findings and the significance of major research, similar problems persist to this day. This example looks at support for MUAs that inaccurately cite learning outcomes and/or focus on selective information that places the procedures, and practices of multiple days' applications , in a more favorable light. The following table provides details about this phenomenon.
Some historical misconceptions about MUA spine research findings
Status of evidence
MUA Spinal
Since the 1930s, spinal manipulation under anesthesia has been reported in published medical literature. In the existing study base there are several reports of positive results. However, apparently as part of the evolution of the procedure, the medical literature reveals many variations in the [A] type of sedative/drug used, [B] manipulation techniques, [C] number of MUA sessions used, [D]] span of time between doses of procedure (if given in series), and [E] the type and extent of adoption of post-MUA and/or rehabilitation adjunctive steps.
It has existed and remains a strong theoretical foundation for the MUA spine. However, given the previously mentioned differences in published studies, field practitioners do not yet have a uniform purpose and method for establishing evidence-based treatment protocols. Also, since the number of studies is evidence of a lower level of long-term effectiveness problems of MUA in the management of specific spinal conditions has not been investigated. Other fields not supported by basic experimental studies to support the efficacy of MUA treatment of the lower back, and other spinal areas, are associated with two leading theories that spinal flexibility can increase as adhesion is reduced, and MUA is more effective in treating adhesion rather than an office-based manual therapy method. Perhaps from the greater significance, the circumstances in which or how often spinal adhesion (scar tissue) may form in the general population, with the presence or absence of prior surgery or vertebral fractures, have not been discussed in the medical literature. To date, after tens of thousands of spinal MUA procedures have been performed in the United States, and with more than eight decades of related studies, there is only one paper published in the MUA literature that clearly indicates the presence of spinal attachment. It was associated with two patients, whose pre-MUA advanced diagnostic imaging revealed fibrosis after previous lumbar surgery.
The 2005 consensus statement from the American Academy of Osteopathy shows that research and publication are limited to the use and effectiveness of MUA. Recently, it has been reported that there is a gap in the medical literature for MUA spine in the field of patient selection and treatment protocols. Therefore, the Delphi process is conducted to develop evidence-based and consensus-based guidelines for the chiropractic profession. The results of the process offer guidance to MUA practitioners and facilities, although not intended for individual patients.
In particular, the criteria recommended by members of the chiropractic profession are clearly different from the criteria set by the American Academy of Osteopathy. In addition, the Delphi method is a consensus process that represents an approved opinion of an unbroken group of experts. But with expert opinion that serves as the lowest level of evidence (Level V) in the hierarchy of medical evidence, the publication of the MUA-linked Delphi process of 2014 does not improve the circumstances of evidence for the MUA spine. Therefore, the most largely anecdotal basis for procedural effectiveness, and the continued dependence on the historically used spine MUA protocol, is what in principle influences MUA practice today.
Compared to other treatment options available to chronic spinal pain patients, it is the benchmark of randomized controlled trials that best determine patient candidacy, optimal dose procedures, and long-term effectiveness for MUA. MUA researchers have previously mentioned the use of inconsistent protocols and have called for large-scale MUA studies (randomized trials) for chronic low back pain. Until now, no research has been done.
Due to the lack of high-level research evidence for the long-term clinical efficacy of MUA spine, some traditional criteria for patient selection without support or remain unproven. Recent analysis of published medical evidence for MUA shows that herniation/protrusi qualify at least as a relative contraindication, with the risk of injury and no proven long-term benefits. Also, in the presence of a positive lumbar EMG (nerve root compression) study with lumbar herniation, Level II indicates that patients will eventually require surgical correction. For patients with chronic neck pain and lower back pain who also have significant anxiety/stress, Level II indicates that MUA will not be therapeutic. Thus, most insurance carriers in the United States maintain a medical policy that considers spinal MUA unproven or experimental/investigative.
MUA Shared Extremities
Patients who may qualify for MUA to limb joints include those with stiff post-surgical knee joints that have undergone total knee replacement (total arthroplasty of the knee-TKA). The range of motion data taken on the debit after the TKA has been suggested as an indicator for MUA, when it falls short of "optimal zone"> = 70? flexion combined with an elongation deficit of <= 10? It appears that the ideal period for applying manipulation for knee stiffness after TKA is less than 20 weeks of major surgery, with no additional benefits reported from re-manipulation. Similarly, another recent study also found that MUA is useful for decreasing range of motion but the success rate of MUA recurs is less than the primary dose.
Beyond the above clinical scenario and related research, the supporting evidence for MUA in other limb joints is weak, inconclusive or absent. The shoulder, when it fails to achieve flexibility after standard treatment, is one of the extremity areas where the frozen shoulder condition has traditionally been cited as an indication for the MUA. There are several supporting studies in this area, including one that shows that patients get better results with interventions at 6 and 9 months after the onset of conditions (having abduction and external rotation significantly better, with less pain at rest and night day). However, for research that represents the highest level of research evidence, the results of the two most recent systematic reviews for raising frozen shoulders raise questions about the superiority of care when compared to other forms of treatment. Namely, in a systematic review of 2012, Maund, et al. found an adequate study, but there was no evidence that there was better outcome with the MUA than at home exercise. In a systematic review of 2015, Uppal, et al. determined MUA to be vague at best, when compared with hydrodilation and steroid injections.
The provision of MUA to the extremity joints is provided for its primary conditions, such as frozen articulation. The practice of applying the MUA to the spinal cord joint (ie the shoulder and/or hip), as a routine component or an extension of the spine MUA procedure, is not supported by clinical investigations.
Risk
Tens of thousands of spine MUA procedures and irregular extremities have been performed in the United States over the last few decades. Thus, in all likelihood, the risk with this procedure is relatively low or minimized by current techniques and when the patient is chosen and evaluated appropriately by an anesthesiologist, medical doctor who provides medical permission, and MUA manual therapy therapist (DC, DO, MD). However, as with any procedure, there is an innate risk with MUA. The chiropractic literature seems best to deal with complications, adverse outcomes, or side effects with MUA spine.; However, better reporting of events is required in developing more definitive risk criteria. In part, these include severe sacroiliac pain with temporary "temporal paralysis" (from one or both legs), temporary respiratory distress, adverse cardiovascular events, spine fractures with hemothorax, lower extremity fractures, glenoid fractures, shoulder dislocations, and pseudoaneurism.
References
Source of the article : Wikipedia
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