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Manipulation under Anesthesia
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MANUAL MEDICINE
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MANIPULATION UNDER ANESTHESIA Michael C. Geraci, Jr, MD, PT, Joseph T. Alleva, MD, a n d Heidi Prather, DO
Manipulation under anesthesia is well documented in the medical literature when general anesthetics are used. Manipulation procedures applied after a regional anesthetic block appear to be less well documented, however. There appears to be a small but increasing number of practitioners incorporating manual medicine procedures along with regional anesthetic block in the management of recalcitrant cases. This article reviews the current literature on the uses and manipulation under general anesthesia. The use and manipulation under regional anesthetic blocks are discussed in detail using several examples. A brief review of the literature as well as a description of the conditions amenable to these procedures and the procedures themselves is presented.
MANIPULATION UNDER GENERAL ANESTHESIA It is a common perception that manipulation under general anesthesia is a procedure performed by the orthopedic surgeon on those patients with restricted ranges of motion in peripheral joints. For example, Dillingham9 speaks of the manipulation of an arthrofibrosed knee at approximately 7 to 9 weeks after repair of the anterior cruciate ligament. Other examples include the manipulaand adhesive capsulitis of the tion of joints with heterotopic o~sification'~
From Buffalo Spine and Sports Medicine, Williamsville, New York (MCG); Department of Physical Medicine and Rehabilitation, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York (MCG); Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan (MCG); Department of Rehabilitation Medicine, Evanston Hospital, Evanston (JTA); Department of Physical Medicine and Rehabilitation, Northwestern University School of Medicine (JTA); and Rehabilitation Institute of Chicago (HP), Chicago, Illinois
PHYSICAL MEDICINE AND REHABILITATION CLINICS OF NORTH AMERICA VOLUME 7 . NUMBER 4. NOVEMBER 1996
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shoulder,"j, 26 and probably most familiar, it is used as a means to achieve full range of motion in patients with joint replacement. This section reviews topics such as these; however, it discusses osteopathic approaches to manipulation under anesthesia in greater detail. Indications and Objectives
The principal goal of manipulation is to mobilize restricted joints through their normal range of motion. It is performed in conjunction with general anesthesia when a joint cannot be mobilized under normal circumstances. Greenman13gives examples such as chronic vertebral somatic dysfunctions unresponsive to conservative management and dysfunctions that do not respond secondary to muscular spasm or irritability. Rumney31 states conditions such as chronic hbrositis and miositis, whiplash syndrome, and nerve entrapment as well as recalcitrant somatic dvsfunctions that are all varticularlv , resvonsive to this procedure. This procedure clearly is performed not only on peripheral joints but also on the spine, including the cervical spine.13,l7 L
Contraindications
Absolute contraindications are fairly well established among those who perform these techniques. They include joint hypermobility or instability, malignant or acute inflammatory disease involving that joint, and, obviously, fracture.13, 17. 24. 31. 34 ~ ~ and Greenman13 ~ ~ add organic ~ neuropathies 3 1 as an absolute contraindication. Relative contraindications are less well defined. Some clinicians believe that this technique should be avoided with acute herniated nucleus pulposus, particularly in the presence of a free fragment.13 Others believe it actually may prove beneficiaL31,34 Finally, the consensus is that these procedures should be avoided with severe osteoporosis.", 17, 24, 31, 34 Procedure Criteria
Given the use of general anesthesia, these types of procedures must be performed in a hospital or ambulatory surgery setting. The procedure should be performed by a skilled graduate of manual medicine who has a minimum of 10 supervised cases.13,31 Most authors13,17, 24, 31, 34 also agree that for optimal control and treatment of the musculoskeletal system an assistant(s), also trained in manual skills, should be present. Successful treatment depends on accurate diagnosis and treatment. Preprocedure Protocol
A comprehensive history and physical examination are critical to rule out potential contraindications, and they are geared toward identifying significant somatic dysfunctions. Clinicians should pay particular attention to joint restrictions, joint hypermobility, and changes in muscle tone as well as fascia1 restrictions.
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Radiographs of all the spinal regions and extremities to be manipulated are mandatory. Anterior, posterior, and lateral views are believed to be the minimum studies needed. Dynamic studies (i.e., flexion/extension views) may aid the diagnosis and treatment further.13,17, 24, 31, 34 Opinions on laboratory work before the procedures vary, but it generally is accepted that at least the standard preoperative laboratories be performed. Osteopathic Manipulation under Anesthesia
A detailed description of the osteopathic techniques used on the anesthetized patient is beyond the scope of this article; however, some general principles are presented. In-office manipulative therapy generally consists of operator forces (i.e., mobilization with impulse), patient forces (i.e., muscular energy), inherent forces (i.e., functional techniques), or a combination of these. Because the patient is anesthetized, one must depend solely on operator forces. The more commonly used operator forces include mobilization with impulse (high velocity, low amplitude), mobilization without impulse, and myofascial release. Mobilization with impulse commonly refers to engaging the restrictive barrier of the involved joint and thrusting through the barrier to achieve normal joint motion.14 Greenman13recommends mobilization without impulse of the articular-type when significant capsular and pericapsular adhesions are absent. This basically entails a repetitive oscillatory technique applied by the clinician against the restrictive barrier with the plane of restrictive movement of a joint. The intent is to restore range of motion and stretch the surrounding connective tissue. Finally, myofascial release refers to application of traction, tension, and twisting force to engage the tissues (mainly fascia and muscle) following directly or indirectly along fascial planes based on tightness and loo~eness.'~ Postprocedure Phase
Given the stretching, mobilization, and disruption of fibrotic tissues, flareup symptoms have been reported.13 Standard postoperative care to circumvent this includes ice and the use of steroids and appropriate analgesics.13 The temporary use of orthoses and traction also has been recommended by some authors.1731 These authors, as well as the literature, generally support postprocedure stretching, strengthening, and range of motion exercising to maintain gains achieved by this procedure. The manipuiation of the spine and extremities under general anesthesia is an effective means of treating recalcitrant somatic dysfunctions and their secondary sequelae. The success of the selective procedure depends on the operator's diagnosis and manipulative skills. MANIPULATION UNDER REGIONAL ANESTHESIA
Manipulation of a peripheral joint or the spine under anesthesia is a procedure that has been used as part of the manual medicine approach for the treatment of acute and chronic musculoskeletal dysfunctions. The procedure is reserved for those patients who have been unresponsive to more conservative treatment.13,24, 31 A body of literaturen-l419-21, 25, 29, 31,33 reports about the use of
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manipulation under general anesthesia. A review of the literature fails to reveal reports of the benefits or complications of manipulation under regional anesthesia, however. Investigations and reviews comparing regional anesthesia with general anesthesia used for peripheral joint procedures are well documented. A short review of these is included. It is well recognized that regional anesthesia, when compared with general anesthesia, allows a minor procedure to be performed with less postoperative management and complication issues. The advantages of regional anesthesia include less risk of aspiration, less risk of complications in patients with multiple comorbidities, less nursing care, and less recovery time required p~stanesthesia.~ This review compares operative procedure tolerance, side effects, complications, and timeliness of recovery of general versus regional anesthesia. Regional anesthesia provides selective block of the anatomy involved, fewer side effects and complications, less risk in some populations, less recovery management and time, and earlier discharge.', 3, 6, 7, 23, 2629, 31 Some patients require fewer analgesics intraoperatively and postoperati~ely.~~ Manual medicine techniques involving manipulation under anesthesia clearly would benefit from using regional anesthesia. Patients' early active involvement in a therapy program, which is vital to the long-term success of the procedure, is facilitated by the use of regional anesthesia. Indications and Objectives
Presurgery Interscalene Block for Shoulder Surgery. The use of an interscalene block for shoulder surgery has shown promising result^.^, 6- 7, 23, 28, 32, 35 Winnie and Collins38were the first to describe a subclavian perivascular technique for a brachial plexus block. A review of 300 shoulder surgeries using this technique revealed that 4.67% required additional anesthesia, 0.67% developed spinal block, and 2.67% developed pneumothorax. Although nearly a 100% success rate was reported, no patient satisfaction or functional outcome data were ~ollected.~ Tetzlaft et a135surveyed patients who previously had received general anesthesia for shoulder surgery and who were willing to undergo interscalene block for their next procedure. Results indicated that patients preferred the regional block because fewer side effects were experienced as compared with anesthesia. Others have compared retrospectively outcomes of patients receiving general or regional anesthesia for glenohumeral surgery. Patients receiving regional anesthesia rated intraoperative analgesia as "excellent," surgeons were satisfied with muscular relaxation, hospital stays were shorter, and less blood loss was r e ~ o r d e d .Interscalene ~,~~ and cervical plexus block failures are caused by incomplete anesthesia and intraoperative complications. Conn et a17 reported an 82% success rate in 100 patients undergoing regional anesthesia for shoulder surgery. High anesthetic blood levels caused loss of consciousness and respiratory depression in 3% and seizure in 1%. Spinal and Peripheral Nerve Blocks for Lower Extremity Procedures. Manual medicine application of manipulation of lower extremity joint dysfunc* , ~ use l of general anesthesia tion under anesthesia is reported in case f ~ r m . ~ The has been documented without comment about regional anesthesia. With the widespread use of spinal and epidural anesthesia and increasing use of nerve
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blockade, consideration should be given in using these techniques for manipulation. Conduction anesthesia requires only one injection, and predictable dose relationships allow easy control of the levels of anesthesia. For prolonged procedures or the management of postprocedure pain, a catheter can be used to continue anesthetic admini~tration.3;~~ Recent literature discusses the use of regional nerve block anesthesia for lower extremity surgery. Winnie et aP9 describe an inguinal paravascular technique for lumbar plexus anesthesia called a three-in-one block. The name describes the procedure where from one injection the femoral, obturator, and lateral cutaneous nerves are blocked; this provides anesthesia for anterior, medial, and lateral thigh, femur periosteum, and knee. This procedure combined with a sciatic nerve block has been used to evaluate knee injuries8,30 and for arthroscopic knee surgery.' In a randomized, prospective study, Pate1 et alZ7 compared general anesthesia, three-in-one block anesthesia, and three-in-one block with a separate lateral femoral cutaneous nerve block for patients undergoing knee arthroscopy. Patients who received the single or combined block anesthesias had adequate anesthesia and muscular relaxation, had reduced recovery time, and required less sedation and fewer analgesics intraoperatively and postoperatively compared with those receiving general anesthesia. Patients receiving the additional lateral femoral cutaneous block had less incisional pain than those receiving the three-in-one block alone. Regional nerve block allows for selective lower extremity anesthetization, which allows for greater functional crutch ambulation postoperatively and rapid discharge from the day surgical unit.' Intra-articular Anesthesia for Dislocation Reduction
Another application form of anesthesia, intra-articular anesthetic, has been used for reduction of acute shoulder dislocations. Authors compared the intraarticular administration of 20 cm3 of 1%lidocaine with an intravenous sedation group. Both applications provided adequate muscular relaxation, and no significant difference in pain ratings during the procedure was noted. The intraarticular injection groups had no complications and shorter lengths of stay.'RZ1 Loyd and LoydZ0used 3 to 5 cm3 of 1%lidocaine in the glenohumeral joint to passively range the shoulder before arthrography-guided steroid injection. Postprocedure, all patients received home exercises or outpatient physical therapy. Excellent (94%) relief of symptoms and improved function were reported. The high success rate was attributed to the arthrography that confirmed the diagnosis and ensured intra-articular injection of steroids.20No comments were made about the methods used in ranging the shoulder or the benefits of an immediate postprocedure range of motion, stretching, and strengthening therapeutic program. In contrast to recommendations described in this article, several reports emphasize the importance of hospitalization of the patient after manipulation under anesthesia. Reasons for hospitalization include the patient's noncompliance with positioning the arm in abduction during the first 5 postoperative days and inability to participate in therapy secondary to pain. Inpatient pain management required parenteral narcotics or maintenance of an interscalene brachial plexus catheter for administration of anesthetic. All agreed on the importance of intensive physical therapy postpr~cedure.'~~"~ 29, 37 Others support the application of manipulation under intra-articular local anesthesia in the outpatient setting in association with a home exercise program or outpatient physical therapy.20Regional anesthesia for manipulation of the upper extremity
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seemingly would have its place in outpatient management if aggressive pain management and physical therapy are in place postprocedure. Premanipulation
1. Spine: regional, cervical, or lumbar epidural injections for severe joint restrictions.1° 2. Sacroiliac joint injection: intra-articular block2for manipulation to restore motion or before reduction of an innominate shear dysfunction. 3. Peripheral joints: regional blocks before manipulation to restore joint play and full range of motion. 4. Shoulder: interscalene block5 or intra-articular block for adhesive capsulitis. 5. Wrist: axillary brachial plexus5block for arthrofibrosis. 6. Hip: intra-articular block followed by joint capsular mobilizations. 7. Neuromobilization: selective epidural^.^" To facilitate mobilization of scar tissue postsurgically. To facilitate connective tissue mobilizations of femoral and sciatic nerves for radiculopathy. Contraindications and Cautions
1. Spine: avoidance in acute herniated nucleus pulposus, especially if sequestration or extrusion of disc material is documented. This is a relative contraindication, especially concerning thrusting procedures. 2. Sacroiliac and peripheral joints: severe osteoporosis, malignant or acute inflammatory disease when known, infection or hemarthrosis of the joint. 3. Neuromobilizations: caution should be taken not to give a dense block to the nerve root during selective epidurals. This must be remembered because the general rule is that muscle always will protect nerve. This protective mechanism is lost if the regional anesthesia is in too high a concentration (i.e., 2% lidocaine or 0.5% Marcaine). 4. Anticoagulation: any patient on anticoagulation should discontinue his or her use 3 days before the procedure if not contraindicated. Nonsteroidal anti-inflammatory drugs should be discontinued 3 days before the procedure, and aspirin 5 to 7 days before the procedure. Preprocedural Phase
1. Imaging: adequate imaging must be done and reviewed by the physician performing the procedure. 2. Serology: appropriate laboratory data are collected such as erythrocyte sedimentation rate, complete blood count, and tests for clotting factors and bleeding times. 3. Previous treatment record: clinicians must review all previous care that has been rendered before offering the patient an invasive procedure such as the following. Procedures
The following description of regional anesthetic blocks and the manual medicine techniques that are used afterward are not new procedures or tech-
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niques. The authors have found a paucity in the literature describing these regional anesthetic blocks used in combination with manual medicine procedures, however. The authors therefore describe these two procedures using five examples of the most common uses of manipulation under regional anesthesia employed: 1. Severely restricted cervical spine range of motion following acceleration/ deceleration injury or axial loading. 2. Shoulder adhesive capsulitis from post-traumatic and numerous other causes. 3. Wrist arthrofibrosis following trauma or overuse. 4. Hip osteoarthritis/synovitis with capsular patterns of tightness. 5. Radiculopathies with fibrosis or adverse neurodynamic tension of connective tissue. Along with these examples are two case studies presented to describe further what types of patients have benefited from their use. Cervical spine: severely restricted cervical spine range of motion can occur after motor vehicle accident acceleration/deceleration injury or axial loading. The latter can result in individuals who rise from a crouched position, hitting their head on a low ceiling or beam unexpectedly. Block: use cervical epidural (Fig. 1).
Figure 1. Radiographic spot film of a cervical epidural injection under fluoroscopic guidance with contrast enhancement. (Courtesy of Radiology Department, Kenmore Mercy Hospital, Kenrnore, NY.)
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Figure 2. Radiogra ~ l d e rarthrogram undc?r fluoroscc)py with contrast .:-..+;-.. -4 enhancement to ~OGUIII~IIL placeltlellL wefore intra-articular irllc;~llvll vl local anesthetic. NY .) (Courtesy of Radiology Department, Kenmore Merc!y Hospital,
Procedure: start with soft-tissue manual mealclne procedures such as mobilization without impulse and myofascial release. Progression to post-isometric relaxation (contract-relax) techniques. The specific segmental dysfunctions remaining then can be dealt with using muscle energy techniques and finally articulatory techniques and high velocity tiGusit. re capsulitis when 1ihe patient is in Shoulder: rnost comrnon use fi the fibrosis/adhesivt 2 phase. -- 2-L -1---5 -- : ,.I-" /c:- ? \ Block: use ul~e~b~alelteVI 111uc~al LICulal (I 16. L,. Procedure: start with joint mobilizations of the anterior and poziterior glenohumeral joint capsule. Mobilizations provide an excellent entry point. Soft-tissue mobilizations of the scapulothoracic region ancipro-I.... gression to the thoracic inlet and outlet regions. Myofascial release techniques are suited ideally for this. Joint play of the sternoclavicular, acromioclavicular, and glenohumeral joints is carried out next. Muscle energy techniques, high velocity thrust at end range for internal and external rotation, and finally neuromobilizations are performed. Case Study 1
K.E. is a 32-year-old right-handed woman who was seen for an initial evaluation on November 22, 1993, with complaints of neck and thoracic pain
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and bilateral upper extremity paresthesias since a motor vehicle accident on October 2, 1992. She stated a history of decreased range of motion in her left shoulder and also marked reduction in the range of motion of her cervical spine that is especially worse on extension. She started physical therapy 1 month after her injury, three times a week, and was seen by an orthopedic surgeon who had placed her in a cervical collar for the initial period after the injury. She has a negative past medical and surgical history. Before her accident, she enjoyed running, aerobics, racquetball, karate, and cooking, which she has not been able to do except for some limited cooking. She is married and has two children and describes herself as a mother and housewife. On physical examination, her posture was significant for a forward placed head in relationship to her thorax, with a decrease in the interscapular kyphosis and lumbar lordosis. There was full range of motion of the lumbar spine. Cervical range of motion showed 100% loss of extension, 75% loss on bilateral side bending, 50% loss on rotational movements, and 25% loss on forward flexion. The strength, deep tendon reflexes, and sensory examination were normal. The only abnormality on strength was inhibition of her mid and lower scapular stabilizers. There was tightness of the upper trapezius, levator scapula, sternocleidomastoid, and scaleni muscles to a marked degree. The range of motion in the left shoulder showed 120" of flexion and abduction and 45" of internal and external rotation. Before this visit, the patient had seen a neurosurgeon and had normal plain radiographic examinations of the cervical and thoracic spine, with flexion and extension views of the cervical spine showing a slightly flexed posture in neutral, and on extension she could not fully reverse this flexed position. The CT scan and MR imaging of the cervical spine revealed only bulging of the C3-4, C P 5 and C5-6 discs and normal size of the spinal canal. An electrodiagnostic study was performed previously and was also normal, testing the cervical spine and left upper extremity musculature from C5 through T1 levels. On the initial visit, the patient was treated with myofascial release techniques and muscular energy techniques to the cervical and thoracic spine, with no significant change in range of motion. She subsequently received physical therapy for 2 months, with continued manual treatments including muscle energy techniques, myofascial release, post-isometric relaxation stretching, and scapulothoracic and cervical stabilization exercises. On follow-up evaluation 2 months later, the patient showed no change in cervical range of motion. The left shoulder showed 150" of flexion and approximately 130" of abduction, with no change in internal and external rotation (which were still approximately 45"). The patient was advised of procedures that could be done under regional anesthesia to help increase the range of motion and was contemplating this but wanted to continue physical therapy for several more months. Two months later, the patient returned with flexion of the left shoulder at 120". Abduction was now 90°, and internal and external rotation still were limited, with only 25" of external rotation and 45" of internal rotation. Cervical range of motion was unchanged, with marked limitation still present. The patient agreed to have the left shoulder manipulation done under regional anesthesia using an interscalene block of the brachial plexus. Manual medicine procedures also were done using the techniques as described previously in the shoulder section. The patient gained full range of motion of the shoulder and 18 months later still has full range of motion of the shoulder and excellent functional use. Several weeks later the patient agreed to have cervical epidural injection
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Figure 3. Radiographic spot film of an axillary brachial plexus block with contrast enhancing the sheath of the plexus at the level of the axilla. This provides documentation of placement before injection of local anesthetic. (Courtesy of Radiology Department, Kenmore Mercy Hospital, Kenmore, NY.)
done, followed by manipulation under this regional anesthetic block. The techniques as described in the previous section under cervical spine were used. The patient developed full range of motion in all directions except for a persistent 25% loss on cervical extension but certainly is pleased with the results 18 months later because she has functional use. Wrist: arthrofibrosis, in the authors' experience, is the condition that requires this procedure most often. Block: use axillary brachial plexus block5 (Fig. 3). Procedure: perform myofascial release, joint play of the elbow, proximal and distal radioulnar joints, ulnomeniscotriquetral joints, and wrist (including radial and ulnar deviations). Anteroposterior and posteroanterior glides of the wrist joints (including the capitolunate joint), carpal ligament stretching, and mid-carpal joint mobilizations then are carried out. Finally, neuromobilizations are performed. Case Study 2
J.C. is a 23-year-old right-handed man who developed wrist pain on February 15, 1995, after playing rugby, with no specific injury reported. He also states he was lifting boxes weighing approximately 50 lbs on a repetitive basis while
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helping out fellow workers for several hours. He felt pain in the wrist, which he stags was a shooting sensation into the middle and ring fingers. He noted swelling for approximately 1 week after the incident and then was taking nonsteroidal anti-inflammatorv medications with a decrease in swelline. " He could not play rugby, but continued his regular work as a manager of a clothing retail store. Past medical and surgical history as well as family history was negative. He hoped to return to rugby and to continue his running and roller-blading activities. The physical examination revealed full range of motion of the spine. He had normal strength and deep tendon reflexes. The right wrist showed decreased flexion at 60" and decreased extension at 45". There was decreased joint play, especially of the mid-carpal joints, and an apparent right capitate posterior subluxation was noted clinically. Radiographic examinations from February 16, 1995, confirmed a capitolunate subluxation with an angle measured at 30' (normal less than 15"). The possibility of a carpal stress fracture could not be ruled out, and therefore a bone scan was requested at that time. These findings were observed on his evaluation of March 27, 1995. A subsequent bone scan on April 7,1995, revealed intense increased radioactivity involving almost the entire right wrist (Fig. 4). The patient had three subsequent visits 2 weeks apart, and there was progressive decrease in range of motion noted in the right wrist on flexion and extension despite physical therapy. A rheumatologic work-up was negative, including an erythrocyte sedimentation rate of two. i
Figure 4. Bone scan of wrists and hands. Note the intense increased radioactivity involving almost the entire right wrist. (Courtesy of Nuclear Medicine Department, Kenmore Mercy Hospital, Kenrnore, NY.)
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On the preprocedure visit of May 25, 1995, he had complete loss of range of motion in the right wrist. CT scan examination and subsequent MR imaging were done to determine the cause of the arthrofibrosis that had developed in the right wrist. The CT scan of the right wrist (Fig. 5) revealed fluid surrounding the carpal bones, most significantly accumulating on the dorsal surface to almost 8 mm in thickness. This was clearly different than the left wrist, which was used for comparison. There was no evidence of fracture or dislocation. The MR imaging showed evidence of diffuse soft-tissue thickening with contrast enhancement in the synovium or capsule of the right wrist joint (Fig. 6). On June 28, 1995, the patient underwent manipulation of the right wrist after a right axillary brachial plexus block was performed (see Fig. 3). The manual techniques after the regional anesthetic block were as described previously. The patient gained near full range of motion in wrist extension and flexion but still exhibited significant shortening of the soft tissues and wrist and finger " flexors. The patient continued physical therapy two times a week for 3 months and was seen by the authors at monthly intervals for the first 3 months postprocedure. By 3 months, the patient gained full range of motion, and normal strength and flexion also returned. At 6-month follow-up, the patient maintained full range of motion of the right wrist, had normal strength, and was participating in all his usual work and athletic activities, including rugby. Hip: patients with osteoarthritis or synovitis are suited best for these procedures. Block: use intracapsular (Fig. 7).
Figure 5. CT scan of the wrists. The scan on the left represents the right wrist and shows fibrous thickening between the carpal bones and dorsal surface. Compare with the uninvolved left wrist on the right. (Courtesy of Amherst CT Associates, Williamsville, NY.)
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Figure 6. MR image of the right wrist showing thickenilly soft tissues between the carpal bones and the dorsal surface of the wrist. (Courtesy of Amherst Magnetic Imaging, Williamsville, NY.)
Figure 7. Radiographic spot film under fluoroscopy of intracapsular injection of the hip with contrast enhancement to document placement before delivery of local anesthetic. (Courtesy of Radiology Department, Kenmore Mercy Hospital, Kenmore, NY.)
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Procedure: start with anterior capsular mobilizations followed by iliopsoas stretching and neuromobilization of the femoral nerve, and finally rectus femoris stretching. Posterior hip joint capsular mobilizations and piriformis stretching then would follow. Neuromobilizations. Block: use L2, L3, or L4 selective epidural. Procedure: use femoral neuromobilizations. Block: use L4, L5, or S1 selective epidural (Fig. 8). Procedure: start with sciatic neuromobilizations using slump position, or the patient is placed supine. Postprocedural Phase
It is recommended that the area be iced for 20 minutes every hour for the first 4 hours after the procedure; icing then should be used four times a day for the next 2 to 3 days after the procedure. Physical therapy is started the next day to continue joint mobilizations, stretching, and neuromobilizations. The first follow-up visit should be in approximately 1 week. Complications
In addition to the complications discussed previously under the section on general anesthesia, the potential for nerve injury may be the most common
Figure 8. Radiographic spot rllm or lert L5 and Sf selective epidurals using contrast enhancement to document placement before injection of local anesthetic and steroid. (Courtesy of Radiology Department, Kenmore Mercy Hospital, Kenmore, NY.)
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complication. Muscle always will protect nerve; however, with a regional anesthetic block, overstretching of the nerve may occur and lead to injury. Arthroscopic observations support the use of manual manipulation in the treatment of frozen shoulder. Uitvouet and ~ o l l eua e u e sstudied ~~ 21 shoulders u premanipulation and postmanipulation via glenohumeral joint arthroscopy. The second look postmanipulation arthroscopy was performed in 10 patients. After manipulation, the joint was able to accept large amounts of fluid because of increased joint space, and capsular tears allowed for extravasation of fluid. After manipulation, the humeral head was distracted away from the glenoid. A greater distance between the head of biceps tendon also was noted. Bloody fluid presented and was thought to be related to tearing of the synovium or capsular ligaments. In some patients, tissue tearing occurred around the anterior inferior walls of the glenoid as well as the subscapularis bursa. One of 10 shoulders was found to have a middle glenohumeral ligament tear; 6 of 10 were found to have an inferior glenohumeral ligament tear. No rotator cuff or biceps tendon tears were noted. No humeral fractures were created with the manipulation. These data appear to support the use of manipulation and treatment of frozen joints as well as the idea that the capsular structures are contractive.
CONCLUSION
Manipulation under regional anesthesia appears to be relatively safe and effective in restoring joint motion when other treatment modalities have failed. As with the procedures done under general anesthesia, especially manipulation of the shoulder, the risk of nerve injury is possible, however. This is especially true with shoulder manipulation when hyperabduction occurs and the brachial plexus is overstretched. This should be less likely to occur under regional anesthesia because the patient is awake, some sensation remains, and feedback also is reported by the patient. The procedures under regional anesthesia that employ manual medicine techniques by an experienced practitioner should prove more effective and have fewer complications than those under general anesthesia when nonspecific manipulations are used.
References 1. Anapolle DM, Bodach M, Mclnemey VK, et al: Knee arthroscopy using regional nerve blockade. Orthopedic Review 449-452, 1994 2. April1 CN: The role of anatomically specific injections into the sacroiliac joint. Presented at the First Interdisciplinary World Congress on Low Back Pain and Its Relationship to the Sacroiliac roint. San Diego, November 5 4 , 1992 3. ~ a f a sGI: Regional anesthesia for surgery on the shoulder. Anesth Analg 50:103& 1041. 1971 h Regional anesthesia for outpatient surgery. Reg Anesth 85-7, 1979 4. ~ r i d e n b a u ~LD: 5. Bridenbaugh LD: The upper extremity: Somatic blockade. In Cousins MJ, Bridenbaugh PO (eds): Neural Blockade, ed 2. Philadelphia, JB Lippincott, 1988, pp 397403
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6. Brown AR, Weiss R, Greenberg C: Interscalene block for shoulder arthroscopy: Comparison with general anesthesia. Arthroscopy 9295-300, 1993 7. Corn RA, Cofield RH, Byer DE, et al: Interscalene block anesthesia for shoulder surgery. Clin Orthop 21694-98, 1987 8. DeHaven K: Diagnosis of acute knee injuries with hemarthrosis. Am J Sports Med 8:9, 1980 9. Dillingham M: Rehabilitation of the knee following anterior cruciate ligament and medial collateral ligament injuries. Physical Medicine and Rehabilitation Clinics of North America 5:175-195, 1994 10. Dreyfuss P, Michaelsen M, Home M: Manipulation under joint anesthesia/analgesia: A treatment approach for recalcitrant low back pain of synovial joint origin. J Manipulative Physiol Ther 18:537-546, 1995 11. Ekelund AL, Rydell N: Combination treatment for adhesive capsulitis of the shoulder. Clin Orthop 282105-109, 1992 12. Garland DE, Razza BE, Waters RL: Forceful joint manipulation in head-injured adults with heterotopic ossification. Clin Orthop 169:133-139, 1982 13. Greenman PE: Manipulation with the patient under anesthesia. J Am Osteopath Assoc 9:1159-1160,1167-1170, 1992 14. Greenrnan PE: Principles of Manual Medicine. Baltimore, Williams and Wilkins, 1989 15. Helbig B, Wagner P, Dohler R: Mobilization of frozen shoulder under general anesthesia. Int Orthop 17:275-278, 1993 16. Hill JJ: Manipulation in the treatment of frozen shoulder. Orthopedics 9:1255-1260, 1988 17. Hughes BL: Management of cervical disc syndrome utilizing man as a model. J Manipulative Physiol Ther 3:174-181, 1993 18. Lippitt SB, Kennedy JP, et al: Intraarticular lidocaine versus intravenous analgesia in reduction of dislocated shoulders. Orthopedic Review 15:804, 1991 19. Lloyd-Roberts GC, French PR: Periarthritis of the shoulder. BMJ 1569-1571, 1959 20. Loyd JA, Loyd HM: Adhesive capsulitis of the shoulder: Arthrographic diagnosis and treatment. South Med J 76:879-883,1983 21. Matthews DE, Roberts T: Intraarticular lidocaine versus intravenous analgesic for reduction of acute anterior shoulder dislocations. Am J Sports Med 23:55-58, 1995 22. Mennel J: Joint Pain. Boston, Little Brown and Company, 1964 23. Mitchell EI, Murphy FL, Wyche MQ, et al: Interscalene brachial plexus block anesthesia for the modified Bristow procedure. Am J Sports Med 10:79-81, 1982 24. Morey LW Jr: Osteopathic manipulation under general anesthesia. J Am Osteopath Assoc 73:11&127, 1973 25. Neviaser RJ, Neviaser TJ: The frozen shoulder diagnosis and management. Clin Orthop 223:59-64, 1987 26. Parker D: Frozen shoulder, Part I: Chronology, pathogenesis, clinical picture and treatment. Orthopedics 12869-873, 1989 27. Pate1 NJ, Flashburg MH, Paskin S, et al: A regional anesthetic technique compared to general anesthesia for outpatient knee arthroscopy. Anesth Analg 65185-187, 1986 28. Peterson DO: Shoulder block anesthesia for shoulder reconstruction surgery. Anesth Analg 64373-375, 1985 29. Pollock RG, Duralde XA, Flatow EI, et al: The use of arthroscopy in the treatment of resistant frozen shoulder. Clin Orthop 304:30-36, 1994 30. Rooks M, Fleming LL: Evaluation of acute knee injuries with sciatic/femoral nerve blocks. Clin Orthop 179185188, 1983 31. Rumney IC: Manipulation of the spine and appendages under anesthesia: An evaluation. J Am Osteopath Assoc 68:235-245, 1968 32. Sandin R, Stam T, Stemlo JE: Interscalene plexus block for arthroscopic of humeroscapular joint. Acta Anaesthesiol Scand 36:493-494, 1992 33. Shaffer B, Tibone JE, Kerlan RK: Frozen shoulder. J Bone Joint Surg Am 74:73%746, 1992 34. Siehl D: Manipulation of the spine under general anesthesia. J Am Osteopath Assoc 62:881-887, 1963
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35. Tetzlaft JE, Yoon HJ, Brems J: Patient acceptance of interscalene block for shoulder surgery. Reg Anesth 18:30-33, 1993 36. Traumatic disorders of joints. In Crenshaw AH (ed): Campbells' Operative Orthopaedics. St. Louis, Mosby-Yearbook, 1992, pp 1753-1755 37. Uitvougt G, Detrisac DA, Johnson LL, et al: Arthroscopic observations before and after manipulation of frozen shoulder. Arthroscopy 9:181-185, 1993 38. Winnie AP, Collins VJ: The subclavian perivascular technique of brachial plexus and anesthesia. Anesthesiology 25:35>363, 1964 39. Wimie AP, Ramamurthy DZ, Durrani Z: The inguinal paravascular technique of lumbar plexus anesthesia: The "3-in-1 Block." Anesth Analg 52989-996, 1973 40. Woodward JL, Weinstein SM: Epidural injections for the diagnosis and management of axial and radicular pain syndromes. Physical Medicine and Rehabilitation Clinics of North America 6:691-714, 1995 Address reprint requests to Michael C. Geraci, Jr, MD, PT Buffalo Spine and Sports Medicine, PC 9 Limestone Drive Williamsville, NY 14221
MANUAL MEDICINE
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MANIPULATION UNDER ANESTHESIA Michael C. Geraci, Jr, MD, PT, Joseph T. Alleva, MD, a n d Heidi Prather, DO
Manipulation under anesthesia is well documented in the medical literature when general anesthetics are used. Manipulation procedures applied after a regional anesthetic block appear to be less well documented, however. There appears to be a small but increasing number of practitioners incorporating manual medicine procedures along with regional anesthetic block in the management of recalcitrant cases. This article reviews the current literature on the uses and manipulation under general anesthesia. The use and manipulation under regional anesthetic blocks are discussed in detail using several examples. A brief review of the literature as well as a description of the conditions amenable to these procedures and the procedures themselves is presented.
MANIPULATION UNDER GENERAL ANESTHESIA It is a common perception that manipulation under general anesthesia is a procedure performed by the orthopedic surgeon on those patients with restricted ranges of motion in peripheral joints. For example, Dillingham9 speaks of the manipulation of an arthrofibrosed knee at approximately 7 to 9 weeks after repair of the anterior cruciate ligament. Other examples include the manipulaand adhesive capsulitis of the tion of joints with heterotopic o~sification'~
From Buffalo Spine and Sports Medicine, Williamsville, New York (MCG); Department of Physical Medicine and Rehabilitation, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York (MCG); Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine, East Lansing, Michigan (MCG); Department of Rehabilitation Medicine, Evanston Hospital, Evanston (JTA); Department of Physical Medicine and Rehabilitation, Northwestern University School of Medicine (JTA); and Rehabilitation Institute of Chicago (HP), Chicago, Illinois
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shoulder,"j, 26 and probably most familiar, it is used as a means to achieve full range of motion in patients with joint replacement. This section reviews topics such as these; however, it discusses osteopathic approaches to manipulation under anesthesia in greater detail. Indications and Objectives
The principal goal of manipulation is to mobilize restricted joints through their normal range of motion. It is performed in conjunction with general anesthesia when a joint cannot be mobilized under normal circumstances. Greenman13gives examples such as chronic vertebral somatic dysfunctions unresponsive to conservative management and dysfunctions that do not respond secondary to muscular spasm or irritability. Rumney31 states conditions such as chronic hbrositis and miositis, whiplash syndrome, and nerve entrapment as well as recalcitrant somatic dvsfunctions that are all varticularlv , resvonsive to this procedure. This procedure clearly is performed not only on peripheral joints but also on the spine, including the cervical spine.13,l7 L
Contraindications
Absolute contraindications are fairly well established among those who perform these techniques. They include joint hypermobility or instability, malignant or acute inflammatory disease involving that joint, and, obviously, fracture.13, 17. 24. 31. 34 ~ ~ and Greenman13 ~ ~ add organic ~ neuropathies 3 1 as an absolute contraindication. Relative contraindications are less well defined. Some clinicians believe that this technique should be avoided with acute herniated nucleus pulposus, particularly in the presence of a free fragment.13 Others believe it actually may prove beneficiaL31,34 Finally, the consensus is that these procedures should be avoided with severe osteoporosis.", 17, 24, 31, 34 Procedure Criteria
Given the use of general anesthesia, these types of procedures must be performed in a hospital or ambulatory surgery setting. The procedure should be performed by a skilled graduate of manual medicine who has a minimum of 10 supervised cases.13,31 Most authors13,17, 24, 31, 34 also agree that for optimal control and treatment of the musculoskeletal system an assistant(s), also trained in manual skills, should be present. Successful treatment depends on accurate diagnosis and treatment. Preprocedure Protocol
A comprehensive history and physical examination are critical to rule out potential contraindications, and they are geared toward identifying significant somatic dysfunctions. Clinicians should pay particular attention to joint restrictions, joint hypermobility, and changes in muscle tone as well as fascia1 restrictions.
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Radiographs of all the spinal regions and extremities to be manipulated are mandatory. Anterior, posterior, and lateral views are believed to be the minimum studies needed. Dynamic studies (i.e., flexion/extension views) may aid the diagnosis and treatment further.13,17, 24, 31, 34 Opinions on laboratory work before the procedures vary, but it generally is accepted that at least the standard preoperative laboratories be performed. Osteopathic Manipulation under Anesthesia
A detailed description of the osteopathic techniques used on the anesthetized patient is beyond the scope of this article; however, some general principles are presented. In-office manipulative therapy generally consists of operator forces (i.e., mobilization with impulse), patient forces (i.e., muscular energy), inherent forces (i.e., functional techniques), or a combination of these. Because the patient is anesthetized, one must depend solely on operator forces. The more commonly used operator forces include mobilization with impulse (high velocity, low amplitude), mobilization without impulse, and myofascial release. Mobilization with impulse commonly refers to engaging the restrictive barrier of the involved joint and thrusting through the barrier to achieve normal joint motion.14 Greenman13recommends mobilization without impulse of the articular-type when significant capsular and pericapsular adhesions are absent. This basically entails a repetitive oscillatory technique applied by the clinician against the restrictive barrier with the plane of restrictive movement of a joint. The intent is to restore range of motion and stretch the surrounding connective tissue. Finally, myofascial release refers to application of traction, tension, and twisting force to engage the tissues (mainly fascia and muscle) following directly or indirectly along fascial planes based on tightness and loo~eness.'~ Postprocedure Phase
Given the stretching, mobilization, and disruption of fibrotic tissues, flareup symptoms have been reported.13 Standard postoperative care to circumvent this includes ice and the use of steroids and appropriate analgesics.13 The temporary use of orthoses and traction also has been recommended by some authors.1731 These authors, as well as the literature, generally support postprocedure stretching, strengthening, and range of motion exercising to maintain gains achieved by this procedure. The manipuiation of the spine and extremities under general anesthesia is an effective means of treating recalcitrant somatic dysfunctions and their secondary sequelae. The success of the selective procedure depends on the operator's diagnosis and manipulative skills. MANIPULATION UNDER REGIONAL ANESTHESIA
Manipulation of a peripheral joint or the spine under anesthesia is a procedure that has been used as part of the manual medicine approach for the treatment of acute and chronic musculoskeletal dysfunctions. The procedure is reserved for those patients who have been unresponsive to more conservative treatment.13,24, 31 A body of literaturen-l419-21, 25, 29, 31,33 reports about the use of
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manipulation under general anesthesia. A review of the literature fails to reveal reports of the benefits or complications of manipulation under regional anesthesia, however. Investigations and reviews comparing regional anesthesia with general anesthesia used for peripheral joint procedures are well documented. A short review of these is included. It is well recognized that regional anesthesia, when compared with general anesthesia, allows a minor procedure to be performed with less postoperative management and complication issues. The advantages of regional anesthesia include less risk of aspiration, less risk of complications in patients with multiple comorbidities, less nursing care, and less recovery time required p~stanesthesia.~ This review compares operative procedure tolerance, side effects, complications, and timeliness of recovery of general versus regional anesthesia. Regional anesthesia provides selective block of the anatomy involved, fewer side effects and complications, less risk in some populations, less recovery management and time, and earlier discharge.', 3, 6, 7, 23, 2629, 31 Some patients require fewer analgesics intraoperatively and postoperati~ely.~~ Manual medicine techniques involving manipulation under anesthesia clearly would benefit from using regional anesthesia. Patients' early active involvement in a therapy program, which is vital to the long-term success of the procedure, is facilitated by the use of regional anesthesia. Indications and Objectives
Presurgery Interscalene Block for Shoulder Surgery. The use of an interscalene block for shoulder surgery has shown promising result^.^, 6- 7, 23, 28, 32, 35 Winnie and Collins38were the first to describe a subclavian perivascular technique for a brachial plexus block. A review of 300 shoulder surgeries using this technique revealed that 4.67% required additional anesthesia, 0.67% developed spinal block, and 2.67% developed pneumothorax. Although nearly a 100% success rate was reported, no patient satisfaction or functional outcome data were ~ollected.~ Tetzlaft et a135surveyed patients who previously had received general anesthesia for shoulder surgery and who were willing to undergo interscalene block for their next procedure. Results indicated that patients preferred the regional block because fewer side effects were experienced as compared with anesthesia. Others have compared retrospectively outcomes of patients receiving general or regional anesthesia for glenohumeral surgery. Patients receiving regional anesthesia rated intraoperative analgesia as "excellent," surgeons were satisfied with muscular relaxation, hospital stays were shorter, and less blood loss was r e ~ o r d e d .Interscalene ~,~~ and cervical plexus block failures are caused by incomplete anesthesia and intraoperative complications. Conn et a17 reported an 82% success rate in 100 patients undergoing regional anesthesia for shoulder surgery. High anesthetic blood levels caused loss of consciousness and respiratory depression in 3% and seizure in 1%. Spinal and Peripheral Nerve Blocks for Lower Extremity Procedures. Manual medicine application of manipulation of lower extremity joint dysfunc* , ~ use l of general anesthesia tion under anesthesia is reported in case f ~ r m . ~ The has been documented without comment about regional anesthesia. With the widespread use of spinal and epidural anesthesia and increasing use of nerve
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blockade, consideration should be given in using these techniques for manipulation. Conduction anesthesia requires only one injection, and predictable dose relationships allow easy control of the levels of anesthesia. For prolonged procedures or the management of postprocedure pain, a catheter can be used to continue anesthetic admini~tration.3;~~ Recent literature discusses the use of regional nerve block anesthesia for lower extremity surgery. Winnie et aP9 describe an inguinal paravascular technique for lumbar plexus anesthesia called a three-in-one block. The name describes the procedure where from one injection the femoral, obturator, and lateral cutaneous nerves are blocked; this provides anesthesia for anterior, medial, and lateral thigh, femur periosteum, and knee. This procedure combined with a sciatic nerve block has been used to evaluate knee injuries8,30 and for arthroscopic knee surgery.' In a randomized, prospective study, Pate1 et alZ7 compared general anesthesia, three-in-one block anesthesia, and three-in-one block with a separate lateral femoral cutaneous nerve block for patients undergoing knee arthroscopy. Patients who received the single or combined block anesthesias had adequate anesthesia and muscular relaxation, had reduced recovery time, and required less sedation and fewer analgesics intraoperatively and postoperatively compared with those receiving general anesthesia. Patients receiving the additional lateral femoral cutaneous block had less incisional pain than those receiving the three-in-one block alone. Regional nerve block allows for selective lower extremity anesthetization, which allows for greater functional crutch ambulation postoperatively and rapid discharge from the day surgical unit.' Intra-articular Anesthesia for Dislocation Reduction
Another application form of anesthesia, intra-articular anesthetic, has been used for reduction of acute shoulder dislocations. Authors compared the intraarticular administration of 20 cm3 of 1%lidocaine with an intravenous sedation group. Both applications provided adequate muscular relaxation, and no significant difference in pain ratings during the procedure was noted. The intraarticular injection groups had no complications and shorter lengths of stay.'RZ1 Loyd and LoydZ0used 3 to 5 cm3 of 1%lidocaine in the glenohumeral joint to passively range the shoulder before arthrography-guided steroid injection. Postprocedure, all patients received home exercises or outpatient physical therapy. Excellent (94%) relief of symptoms and improved function were reported. The high success rate was attributed to the arthrography that confirmed the diagnosis and ensured intra-articular injection of steroids.20No comments were made about the methods used in ranging the shoulder or the benefits of an immediate postprocedure range of motion, stretching, and strengthening therapeutic program. In contrast to recommendations described in this article, several reports emphasize the importance of hospitalization of the patient after manipulation under anesthesia. Reasons for hospitalization include the patient's noncompliance with positioning the arm in abduction during the first 5 postoperative days and inability to participate in therapy secondary to pain. Inpatient pain management required parenteral narcotics or maintenance of an interscalene brachial plexus catheter for administration of anesthetic. All agreed on the importance of intensive physical therapy postpr~cedure.'~~"~ 29, 37 Others support the application of manipulation under intra-articular local anesthesia in the outpatient setting in association with a home exercise program or outpatient physical therapy.20Regional anesthesia for manipulation of the upper extremity
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seemingly would have its place in outpatient management if aggressive pain management and physical therapy are in place postprocedure. Premanipulation
1. Spine: regional, cervical, or lumbar epidural injections for severe joint restrictions.1° 2. Sacroiliac joint injection: intra-articular block2for manipulation to restore motion or before reduction of an innominate shear dysfunction. 3. Peripheral joints: regional blocks before manipulation to restore joint play and full range of motion. 4. Shoulder: interscalene block5 or intra-articular block for adhesive capsulitis. 5. Wrist: axillary brachial plexus5block for arthrofibrosis. 6. Hip: intra-articular block followed by joint capsular mobilizations. 7. Neuromobilization: selective epidural^.^" To facilitate mobilization of scar tissue postsurgically. To facilitate connective tissue mobilizations of femoral and sciatic nerves for radiculopathy. Contraindications and Cautions
1. Spine: avoidance in acute herniated nucleus pulposus, especially if sequestration or extrusion of disc material is documented. This is a relative contraindication, especially concerning thrusting procedures. 2. Sacroiliac and peripheral joints: severe osteoporosis, malignant or acute inflammatory disease when known, infection or hemarthrosis of the joint. 3. Neuromobilizations: caution should be taken not to give a dense block to the nerve root during selective epidurals. This must be remembered because the general rule is that muscle always will protect nerve. This protective mechanism is lost if the regional anesthesia is in too high a concentration (i.e., 2% lidocaine or 0.5% Marcaine). 4. Anticoagulation: any patient on anticoagulation should discontinue his or her use 3 days before the procedure if not contraindicated. Nonsteroidal anti-inflammatory drugs should be discontinued 3 days before the procedure, and aspirin 5 to 7 days before the procedure. Preprocedural Phase
1. Imaging: adequate imaging must be done and reviewed by the physician performing the procedure. 2. Serology: appropriate laboratory data are collected such as erythrocyte sedimentation rate, complete blood count, and tests for clotting factors and bleeding times. 3. Previous treatment record: clinicians must review all previous care that has been rendered before offering the patient an invasive procedure such as the following. Procedures
The following description of regional anesthetic blocks and the manual medicine techniques that are used afterward are not new procedures or tech-
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niques. The authors have found a paucity in the literature describing these regional anesthetic blocks used in combination with manual medicine procedures, however. The authors therefore describe these two procedures using five examples of the most common uses of manipulation under regional anesthesia employed: 1. Severely restricted cervical spine range of motion following acceleration/ deceleration injury or axial loading. 2. Shoulder adhesive capsulitis from post-traumatic and numerous other causes. 3. Wrist arthrofibrosis following trauma or overuse. 4. Hip osteoarthritis/synovitis with capsular patterns of tightness. 5. Radiculopathies with fibrosis or adverse neurodynamic tension of connective tissue. Along with these examples are two case studies presented to describe further what types of patients have benefited from their use. Cervical spine: severely restricted cervical spine range of motion can occur after motor vehicle accident acceleration/deceleration injury or axial loading. The latter can result in individuals who rise from a crouched position, hitting their head on a low ceiling or beam unexpectedly. Block: use cervical epidural (Fig. 1).
Figure 1. Radiographic spot film of a cervical epidural injection under fluoroscopic guidance with contrast enhancement. (Courtesy of Radiology Department, Kenmore Mercy Hospital, Kenrnore, NY.)
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Figure 2. Radiogra ~ l d e rarthrogram undc?r fluoroscc)py with contrast .:-..+;-.. -4 enhancement to ~OGUIII~IIL placeltlellL wefore intra-articular irllc;~llvll vl local anesthetic. NY .) (Courtesy of Radiology Department, Kenmore Merc!y Hospital,
Procedure: start with soft-tissue manual mealclne procedures such as mobilization without impulse and myofascial release. Progression to post-isometric relaxation (contract-relax) techniques. The specific segmental dysfunctions remaining then can be dealt with using muscle energy techniques and finally articulatory techniques and high velocity tiGusit. re capsulitis when 1ihe patient is in Shoulder: rnost comrnon use fi the fibrosis/adhesivt 2 phase. -- 2-L -1---5 -- : ,.I-" /c:- ? \ Block: use ul~e~b~alelteVI 111uc~al LICulal (I 16. L,. Procedure: start with joint mobilizations of the anterior and poziterior glenohumeral joint capsule. Mobilizations provide an excellent entry point. Soft-tissue mobilizations of the scapulothoracic region ancipro-I.... gression to the thoracic inlet and outlet regions. Myofascial release techniques are suited ideally for this. Joint play of the sternoclavicular, acromioclavicular, and glenohumeral joints is carried out next. Muscle energy techniques, high velocity thrust at end range for internal and external rotation, and finally neuromobilizations are performed. Case Study 1
K.E. is a 32-year-old right-handed woman who was seen for an initial evaluation on November 22, 1993, with complaints of neck and thoracic pain
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and bilateral upper extremity paresthesias since a motor vehicle accident on October 2, 1992. She stated a history of decreased range of motion in her left shoulder and also marked reduction in the range of motion of her cervical spine that is especially worse on extension. She started physical therapy 1 month after her injury, three times a week, and was seen by an orthopedic surgeon who had placed her in a cervical collar for the initial period after the injury. She has a negative past medical and surgical history. Before her accident, she enjoyed running, aerobics, racquetball, karate, and cooking, which she has not been able to do except for some limited cooking. She is married and has two children and describes herself as a mother and housewife. On physical examination, her posture was significant for a forward placed head in relationship to her thorax, with a decrease in the interscapular kyphosis and lumbar lordosis. There was full range of motion of the lumbar spine. Cervical range of motion showed 100% loss of extension, 75% loss on bilateral side bending, 50% loss on rotational movements, and 25% loss on forward flexion. The strength, deep tendon reflexes, and sensory examination were normal. The only abnormality on strength was inhibition of her mid and lower scapular stabilizers. There was tightness of the upper trapezius, levator scapula, sternocleidomastoid, and scaleni muscles to a marked degree. The range of motion in the left shoulder showed 120" of flexion and abduction and 45" of internal and external rotation. Before this visit, the patient had seen a neurosurgeon and had normal plain radiographic examinations of the cervical and thoracic spine, with flexion and extension views of the cervical spine showing a slightly flexed posture in neutral, and on extension she could not fully reverse this flexed position. The CT scan and MR imaging of the cervical spine revealed only bulging of the C3-4, C P 5 and C5-6 discs and normal size of the spinal canal. An electrodiagnostic study was performed previously and was also normal, testing the cervical spine and left upper extremity musculature from C5 through T1 levels. On the initial visit, the patient was treated with myofascial release techniques and muscular energy techniques to the cervical and thoracic spine, with no significant change in range of motion. She subsequently received physical therapy for 2 months, with continued manual treatments including muscle energy techniques, myofascial release, post-isometric relaxation stretching, and scapulothoracic and cervical stabilization exercises. On follow-up evaluation 2 months later, the patient showed no change in cervical range of motion. The left shoulder showed 150" of flexion and approximately 130" of abduction, with no change in internal and external rotation (which were still approximately 45"). The patient was advised of procedures that could be done under regional anesthesia to help increase the range of motion and was contemplating this but wanted to continue physical therapy for several more months. Two months later, the patient returned with flexion of the left shoulder at 120". Abduction was now 90°, and internal and external rotation still were limited, with only 25" of external rotation and 45" of internal rotation. Cervical range of motion was unchanged, with marked limitation still present. The patient agreed to have the left shoulder manipulation done under regional anesthesia using an interscalene block of the brachial plexus. Manual medicine procedures also were done using the techniques as described previously in the shoulder section. The patient gained full range of motion of the shoulder and 18 months later still has full range of motion of the shoulder and excellent functional use. Several weeks later the patient agreed to have cervical epidural injection
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Figure 3. Radiographic spot film of an axillary brachial plexus block with contrast enhancing the sheath of the plexus at the level of the axilla. This provides documentation of placement before injection of local anesthetic. (Courtesy of Radiology Department, Kenmore Mercy Hospital, Kenmore, NY.)
done, followed by manipulation under this regional anesthetic block. The techniques as described in the previous section under cervical spine were used. The patient developed full range of motion in all directions except for a persistent 25% loss on cervical extension but certainly is pleased with the results 18 months later because she has functional use. Wrist: arthrofibrosis, in the authors' experience, is the condition that requires this procedure most often. Block: use axillary brachial plexus block5 (Fig. 3). Procedure: perform myofascial release, joint play of the elbow, proximal and distal radioulnar joints, ulnomeniscotriquetral joints, and wrist (including radial and ulnar deviations). Anteroposterior and posteroanterior glides of the wrist joints (including the capitolunate joint), carpal ligament stretching, and mid-carpal joint mobilizations then are carried out. Finally, neuromobilizations are performed. Case Study 2
J.C. is a 23-year-old right-handed man who developed wrist pain on February 15, 1995, after playing rugby, with no specific injury reported. He also states he was lifting boxes weighing approximately 50 lbs on a repetitive basis while
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helping out fellow workers for several hours. He felt pain in the wrist, which he stags was a shooting sensation into the middle and ring fingers. He noted swelling for approximately 1 week after the incident and then was taking nonsteroidal anti-inflammatorv medications with a decrease in swelline. " He could not play rugby, but continued his regular work as a manager of a clothing retail store. Past medical and surgical history as well as family history was negative. He hoped to return to rugby and to continue his running and roller-blading activities. The physical examination revealed full range of motion of the spine. He had normal strength and deep tendon reflexes. The right wrist showed decreased flexion at 60" and decreased extension at 45". There was decreased joint play, especially of the mid-carpal joints, and an apparent right capitate posterior subluxation was noted clinically. Radiographic examinations from February 16, 1995, confirmed a capitolunate subluxation with an angle measured at 30' (normal less than 15"). The possibility of a carpal stress fracture could not be ruled out, and therefore a bone scan was requested at that time. These findings were observed on his evaluation of March 27, 1995. A subsequent bone scan on April 7,1995, revealed intense increased radioactivity involving almost the entire right wrist (Fig. 4). The patient had three subsequent visits 2 weeks apart, and there was progressive decrease in range of motion noted in the right wrist on flexion and extension despite physical therapy. A rheumatologic work-up was negative, including an erythrocyte sedimentation rate of two. i
Figure 4. Bone scan of wrists and hands. Note the intense increased radioactivity involving almost the entire right wrist. (Courtesy of Nuclear Medicine Department, Kenmore Mercy Hospital, Kenrnore, NY.)
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On the preprocedure visit of May 25, 1995, he had complete loss of range of motion in the right wrist. CT scan examination and subsequent MR imaging were done to determine the cause of the arthrofibrosis that had developed in the right wrist. The CT scan of the right wrist (Fig. 5) revealed fluid surrounding the carpal bones, most significantly accumulating on the dorsal surface to almost 8 mm in thickness. This was clearly different than the left wrist, which was used for comparison. There was no evidence of fracture or dislocation. The MR imaging showed evidence of diffuse soft-tissue thickening with contrast enhancement in the synovium or capsule of the right wrist joint (Fig. 6). On June 28, 1995, the patient underwent manipulation of the right wrist after a right axillary brachial plexus block was performed (see Fig. 3). The manual techniques after the regional anesthetic block were as described previously. The patient gained near full range of motion in wrist extension and flexion but still exhibited significant shortening of the soft tissues and wrist and finger " flexors. The patient continued physical therapy two times a week for 3 months and was seen by the authors at monthly intervals for the first 3 months postprocedure. By 3 months, the patient gained full range of motion, and normal strength and flexion also returned. At 6-month follow-up, the patient maintained full range of motion of the right wrist, had normal strength, and was participating in all his usual work and athletic activities, including rugby. Hip: patients with osteoarthritis or synovitis are suited best for these procedures. Block: use intracapsular (Fig. 7).
Figure 5. CT scan of the wrists. The scan on the left represents the right wrist and shows fibrous thickening between the carpal bones and dorsal surface. Compare with the uninvolved left wrist on the right. (Courtesy of Amherst CT Associates, Williamsville, NY.)
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Figure 6. MR image of the right wrist showing thickenilly soft tissues between the carpal bones and the dorsal surface of the wrist. (Courtesy of Amherst Magnetic Imaging, Williamsville, NY.)
Figure 7. Radiographic spot film under fluoroscopy of intracapsular injection of the hip with contrast enhancement to document placement before delivery of local anesthetic. (Courtesy of Radiology Department, Kenmore Mercy Hospital, Kenmore, NY.)
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Procedure: start with anterior capsular mobilizations followed by iliopsoas stretching and neuromobilization of the femoral nerve, and finally rectus femoris stretching. Posterior hip joint capsular mobilizations and piriformis stretching then would follow. Neuromobilizations. Block: use L2, L3, or L4 selective epidural. Procedure: use femoral neuromobilizations. Block: use L4, L5, or S1 selective epidural (Fig. 8). Procedure: start with sciatic neuromobilizations using slump position, or the patient is placed supine. Postprocedural Phase
It is recommended that the area be iced for 20 minutes every hour for the first 4 hours after the procedure; icing then should be used four times a day for the next 2 to 3 days after the procedure. Physical therapy is started the next day to continue joint mobilizations, stretching, and neuromobilizations. The first follow-up visit should be in approximately 1 week. Complications
In addition to the complications discussed previously under the section on general anesthesia, the potential for nerve injury may be the most common
Figure 8. Radiographic spot rllm or lert L5 and Sf selective epidurals using contrast enhancement to document placement before injection of local anesthetic and steroid. (Courtesy of Radiology Department, Kenmore Mercy Hospital, Kenmore, NY.)
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complication. Muscle always will protect nerve; however, with a regional anesthetic block, overstretching of the nerve may occur and lead to injury. Arthroscopic observations support the use of manual manipulation in the treatment of frozen shoulder. Uitvouet and ~ o l l eua e u e sstudied ~~ 21 shoulders u premanipulation and postmanipulation via glenohumeral joint arthroscopy. The second look postmanipulation arthroscopy was performed in 10 patients. After manipulation, the joint was able to accept large amounts of fluid because of increased joint space, and capsular tears allowed for extravasation of fluid. After manipulation, the humeral head was distracted away from the glenoid. A greater distance between the head of biceps tendon also was noted. Bloody fluid presented and was thought to be related to tearing of the synovium or capsular ligaments. In some patients, tissue tearing occurred around the anterior inferior walls of the glenoid as well as the subscapularis bursa. One of 10 shoulders was found to have a middle glenohumeral ligament tear; 6 of 10 were found to have an inferior glenohumeral ligament tear. No rotator cuff or biceps tendon tears were noted. No humeral fractures were created with the manipulation. These data appear to support the use of manipulation and treatment of frozen joints as well as the idea that the capsular structures are contractive.
CONCLUSION
Manipulation under regional anesthesia appears to be relatively safe and effective in restoring joint motion when other treatment modalities have failed. As with the procedures done under general anesthesia, especially manipulation of the shoulder, the risk of nerve injury is possible, however. This is especially true with shoulder manipulation when hyperabduction occurs and the brachial plexus is overstretched. This should be less likely to occur under regional anesthesia because the patient is awake, some sensation remains, and feedback also is reported by the patient. The procedures under regional anesthesia that employ manual medicine techniques by an experienced practitioner should prove more effective and have fewer complications than those under general anesthesia when nonspecific manipulations are used.
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