OAT AND MCD TREATMENT PROCEDURE

Maxim Bakhtadze, MD, PhD and Allan Austin Oolo, DO, DC, CCRD, CCSP
Russian Journal of Manual Therapy, Dec, 2012.

The purpose of this article is to present and evaluate a neuromanual treatment for frozen shoulder (FS) using local anesthetic while the patient is fully conscious. The unique term neuromanual is used here to denote interactive, patient initiated, facilitative overload of shoulder muscle mechanoreceptors during the manual procedure. Although external incisions are not made, the term dissection is used in this article to denote the actual internal non-surgical separation of adhesed tissues during the procedure. (Using a therapeutic physical transduction, multimodal stimulation approach describes the neurosummative afferent overload methodology used in Dr. Oolo-Austin’s neuro-muscular treatment system which is also referred to in association with the phrases Functional Muscle Neurology and Myoneural Medicine. Historically neuro-muscular treatment system is the first physical medicine treatment method to simultaneously combine resisted exercise with manipulative soft tissue treatment.) Over 100 MCD Procedures have been performed since its inception in 2004. Dr. Oolo-Austin is also known as Dr. Austin Oolo.

For this study, shoulder abduction was measured before and after the treatment. The results showed near or complete recovery of shoulder abduction as well as increased muscle strength and decreased pain immediately following the procedure. Readers of this study familiar with the generally accepted difficulty in achieving even minor results with conservative treatment of FS will acknowledge that results such as these without surgery or manipulation under general anesthetic are unprecedented. The results of this study are statistically significant with a p value of 0.00057. There were 6 women and 4 men. The right shoulder was more frequently affected than the left one.

Method: 10 patients who were suffering with frozen shoulder were randomly assigned to the study. Arm abduction using a digital inclinometer called the Microfet 3 was used to measure arm abduction before and immediately after the procedure. A case study was also performed on one of the participants to determine patient’s feedback on the treatment. Results showed that there was a remarkable recovery in shoulder abduction in the first treatment. The study concluded that the MCD Procedure represents an excellent alternative for frozen shoulder patients not wishing to undergo painful prolonged lengthy treatment programs or higher risk procedures such as surgery or manipulation under general anesthesia.

Frozen Shoulder (FS) is a term used to describe what is otherwise referred to as adhesive capsulitis. The condition is commonly called frozen shoulder because of its trademark loss of movement ability (Yang et al 2007) being analogous to anything which is completely frozen. It is a terribly painful, debilitating condition displaying very significant restriction (both passive and active) of shoulder motion in an individual whose radiographs are typically normal. Persons having this affliction are usually not able to abduct or flex their affected arm up more than 20-90 degrees (Fayad et al 2007) and are often unable to place their hand behind their back due to accompanying restriction of humeral rotation. Basically there are no movements of the shoulder which are totally free and without pain. Movements such as putting on a jacket or bra are often impossible. Frozen shoulder may also be referred to as pericapsulitis and, although not well known by the public, occurs in up to 5% of the general population. (Wies 2004) It is more common in women (60%) (Wong, Tan 2010) and 5 times more common in the diabetic population. (Dias, Cutts, Massoud 2005) The exact cause for this condition is unknown but is sometimes associated with previous injury to the shoulder. Some medical researchers contend the condition results from synovial inflammation with subsequent reactive capsular fibrosis. This condition often lasts for up to 3 years or more (Wang et al. 2006) and, in some cases, even for the life of the patient. (Shaffer et al., 1992) Major factors associated with this condition are age (40-60 age group), diabetes (20 % are affected) (Pal et al 1986), prior shoulder surgery, Parkinson’s disease, multiple sclerosis and mental stress disorders.

Normally, the shoulder ball and socket joint allows more motion with more directions than any other joint in the body. In a frozen shoulder the capsule surrounding the joint contracts while the patient forms bands of adhesive scar tissue which drastically inhibits motion. In addition, one or more bursas may also stick together causing loss of ability to move the shoulder. (This seems to frequently occur with the subscapular bursa.) Contraction of the capsule with formation of the adhesions causes the shoulder to become remarkably stiff and cause movement beyond a certain degrees to become excruciatingly painful. The appearance is analogous to that of a hinge if one were to “freeze” it. The typical symptoms of FS is dull aching shoulder pain, severely limited shoulder movement, feeling incredible pain if it is moved beyond a certain point, difficulty with normal arm activities and feeling pain when sleeping on that shoulder. (Lorbach et al 2010) Although patients with frozen shoulder describe chronic pain symptoms, the primarily complaint is actually that of the severe debilitating stiffness The loss of range of motion causes various degrees of significantly impaired function, including limited reaching (overhead, across the chest, etc) and limited rotation (unable to scratch the back, put on a coat, etc). The three stages of frozen shoulder are the freezing stage (most pain, restrictive movement), the frozen stage, and the thawing stage (partial movement).

On physical examination, patients with a frozen shoulder will have at least a 50 percent reduction in both active and passive range of motion compared with the unaffected shoulder (Anderson, 2008). A digital inclinometer is recommended for accurate measurement of motion ranges. Range of motion is estimated as follows: 1) the Apley scratch test is used to assess rotation of the shoulder joint; patients with normal glenohumeral motion should be able to scratch the midback at the T8 to T10 level; patients with frozen shoulder are often not even able to scratch even their lower back; 2) the NFL touchdown sign is an active maneuver used to assess range of motion of the shoulder joint and the strength of abduction; patients with a frozen shoulder are unable to fully lift their arm straight overhead with most unable to abduct beyond 90 degrees; 3) passive movement of the arm in abduction and external rotation also is significantly reduced; the normal glenohumeral joint rotates externally to 90 degrees and abducts to 90 degrees.

The actual etiology of frozen shoulder is still unknown. Of note, however, is the first authors hypothesis that most frozen shoulders (and many cases of tendonitis) have a predisposing related cervical disc lesion etiology. In over 30 years of practice with clinical observations of thousands of shoulder syndromes, the MCD Procedure developer has observed that the vast majority of frozen shoulder cases have associated spinal lesions on the same side of the shoulder condition mostly at the level of C5-6. In this observation, it is considered more likely that the etiology of many shoulder condition are more likely to be cervicogenic rather than vice versa. It would stand to reason that, under the circumstance of being neurologically inhibited or impaired, the muscles of the shoulder would become damaged if put under a load which they would otherwise normally be able to accommodate. Overloading muscles is likely to happen when excessive force is put on normal tissues but also in cases when either normal or abnormal load is put on neurologically inhibited or otherwise damaged tissues.

The MCD (Manual Capsular Dissection) Procedure was performed on the study group by using non-incisive dissection of scar tissue in shoulder joints and bursas. The MCD Procedure involves a multimodal methodology with the patient awake and interactively participating during the procedure to facilitate outcome. With manipulation under anesthesia (MUA), the patient is completely flaccid and helpless. With the MCD Procedure, the patient is actually contracting specific muscles heavily during the manipulative dissection procedure. Follow up rehabilitative therapy and Dr. Oolo-Austin’s neuro-muscular retraining treatments are provided in stages over the period of 1 week to 6 weeks depending on the severity of the FS and the distance traveled by the patient for treatment. No surgical dissection instruments are used and no actual cutting or incisions of tissue is performed requiring sutures. The protocols of the MCD Procedure, in its entirety, last no more than 30 minutes with each actual dissection usually taking place in a matter seconds. The MCD Procedure is normally only required to be performed once during the course of the frozen shoulder treatment.

Prior to the procedure, patients are given local anesthetic injections in the common anterior and posterior shoulder joint injection sites. Unless contra-indicated, a corticosteroid is also injected simultaneously to prevent post-procedural inflammation. Medicine is also provided at the patient’s request or prescribed by the injecting physician if they are deemed to have pre-procedure anxiety. In the initial stages of its development, the procedure was actually performed without the aid of injectable medication with usually quite good results. In providing medication assistance, however, pain perception during the procedure was obviously found to be significantly reduced for the patient. Using local anesthetic then also usually makes the procedure easier to administer for the performing practitioner with more patient compliance and less resistance. (Although the shoulder is now frequently anesthetized during the procedure, patients do still experience some pain briefly during the actual procedure.)

The procedure requires 2 practitioners or therapists to perform with one attending to the scapulae and the other to the shoulder joint itself. A third person acting as an additional assistant is also recommended. The MCD Procedure is considered to be a better choice than performing manipulation under general anesthesia as it is performed with the patient fully conscious and interactively participating in the procedure to ensure than no iatrogenic damage occurs to the joint the bones or the surrounding tissues. In addition, the patient is able to immediately begin active range of movement exercises designed to create immediate sensorimotor retraining. Immediately following the procedure, patients are taken off of the treatment table and put through a series of MCD Procedure recovery exercises which involve movement in the full ranges of arm abduction and rotation to which they are newly capable. They are then sent home with a series of specific PNF exercises they are required to do hourly for 3 days prior to follow-up attendance for rehabilitative physiotherapy.

Other treatments for frozen shoulder include conventional physiotherapy, manual medicine, cortisone injections and surgery. Normally treatment requires a multitude of approaches and takes 9-18 months of often painful therapy to observe any difference if the patient is responsive unless spontaneous recovery occurs. (Dodenhoff et al 2000) In some cases, over exuberant practitioners have actually caused a worsening of the patients symptoms.

Early stages of Frozen Shoulder are often treated with physical therapy, exercises and home therapy. Various other forms of treatment have been employed, over the years, consisting of oral or injectable analgesics (pain killers), NSAID anti-inflammatory, steroid injections, physiotherapy and various forms of manual medicine including chiropractic and osteopathy. For refractory intractable cases, more aggressive treatment involves manipulation of the shoulder joint under anesthesia (Dias, et al., 2005) or an arthroscopic surgical capsular release (Griffen, 2003) or arthroscopic hydrodilation (Quraishi et al 2007). Doctors have tried using multiple shoulder manipulation techniques including manipulation with steroid injection, use of systemic steroids, manipulation following saline injection, manipulation under regional anesthesia and manipulation under general anesthesia (MUA). Although MUA is effective in terms of joint mobilization, it has been shown that iatrogenic intra-articular damage can result. (Loew, Heichel, Lehner 2005). When MUA is performed, it is with the intention of breaking up and mechanically dissecting or literally ripping open the adhesions surrounding the joint capsule to increase shoulder movement. While anesthetized, the patient is unconscious or under conscious sedation and in state of total muscular flaccidity. They are, therefore unable to provide any feedback or resist any forceful movements imposed upon their adhesed frozen shoulder joint. The practitioner also has little concept of where the physiological end range of shoulder joint movement exists with that patient.

According to Gill and Hawkins (2006) possible complications of surgical techniques include axillary neuropraxia, diffuse brachial plexopathy, operative instability, mild anterior instability with apprehension on full abduction and external rotation and diffuse swelling. Neurovascular damage is also reported by Zanotti, Kuhn (1997) as well as intra-articular lesions within the glenohumeral joint (Speed, 2006).

In addition to the above possible complications which can occur, there are also other basic complications of using general anesthetic for any surgery or manipulative procedure: Although uncommon, possible complications of GA are as follows:

Death (1/151,000 – 1/244,000), Hypothermia, Damage to mouth or pharynx including damage to teeth and artificial crowns during intubation, Hypoxemia, Hypercapnia and hypocapnia, Hypoventilation, Aspiration pneumonia, Perioperative neuropathy, Minor idiosyncratic/allergic reaction to agents, producing nausea and vomiting, Major idiosyncratic/all gic reaction to agents incites cardiovascular collapse, respiratory depression or obstruction and jaundice, Lung infections, Stoke, Heart Attack, Slow recovery from anesthetic due to poor cardiac, hepatic or renal function, drug interactions, incorrect drug or dosage, Hypotension, Hypertension, Arrhythmias, Malignant hyperpyrexia caused by anesthetic gas or suxamethonium, Prolonged apnea (non-breathing state) after succinylcholine caused by pseudocholinesterase deficiency (rare), Memory dysfunction. With some patients following general anesthesia, information is retained in the memory, but not accompanied by conscious recall of events, Awareness during surgery can occur when the patient is paralyzed but without effective anesthetic. (This means that the patient is literally tortured as the patient actually feels the pain of the cutting in the operation but is completely unable to respond.), Postoperative psychic trauma e.g. insomnia, depression, sleep disturbances, dreams, anxiety and fear of death which may persist for months or years, Malignant Hyperthermia (possibly fatal).

* It should be noted that cases of malignant hyperthermia (MH) which are very serious and known to be fatal, are normally brought on specifically by agents used in general anesthetics. General anesthetic drugs that have triggered MH include isoflurane, desflurane, enflurane, sevoflurane, methoxyflurane, cycl-propane halothane, and succinylcholine. MH, however, is not associated with drugs used for local or regional anesthesia.

The authors acknowledge that risks such as fractures or dislocations could exist with this procedure in certain circumstances. The MCD Procedure is designed specifically to prevent such occurrences but if performed improperly or without proper work-up and risks assessment for contra-indications or possibly with sudden uncontrolled movements by the patient during the procedure, injuries could conceivably result. The actual procedure itself is, therefore, not delineated in this article to mitigate liability from readers attempting to perform the MCD Procedure without proper qualifications or training. A randomized controlled study also still needs to be done with a much larger number of subjects to accurately ascertain success and risk factors.