Manipulation under anesthesia and a technique for helping patients
originally pioneered by osteopathic physicians in the late 1930s.
This treatment format has been documented in osteopathic literature
since 1948 as reported by Clybourne with a success rate of 80-90%
with this procedure. As chiropractic physicians performed the
overwhelming majority of manipulation treatments, interested in this
procedure developed and has been practice for the last 25 years by
INDICATIONS FOR THE PROCEDURE
Manipulation of spine and extremity joints under anesthesia is
recommended for patients suffering from acute but mostly chronic
musculoskeletal problems. The patient's have been unresponsive to
previous conservative therapy. Patients with spinal disc disease,
chronic sprain and strain problems, myofascial pain syndromes and
muscular spasm resulting in restricted range of motion often benefit
from this procedure. These types of patients generally received
improvement with conservative manual therapy but the relief is often
only temporary. This more advanced manipulation therapy frequently
results in significant long-term improvement.
The following conditions are often treated with MUA:
Bulging, protruded, extruded, or herniated discs without
Frozen or fixated spinal or extremity joints
Failed low back surgery patient's
Nerve compression syndromes related to adhesion formation
Restricted range of motion with associated pain and
Unresponsive musculoskeletal pain which interferes with
daily life and sleep patterns that is appropriate for treatment
CONTRAINDICATIONS Certain medical conditions are contraindications to MUA. These
include the following:
Any form of malignancy; metastatic bone disease; tuberculosis of the
bone; acute bone fracture; direct manipulation of old compression
fractures; acute inflammatory arthritis; acute inflammatory gallop;
uncontrolled diabetic neuropathy; syphilitic articular or
periarticular lesion; gonorrheal spinal arthritis; advanced
osteoporosis; evidence of cord or carpal compression by tumor or
disc herniation beyond 5 mm; osteomyelitis; widespread staph/strep
infection; sign flash symptom of aneurysm; unstable spondylolysis.
Manipulation under anesthesia is a treatment performed using
conscious sedation. This is typically provided by the use of
Diprivan (Propofol) as well as Versed as a medical anesthetic
product. This is administered through an IV line. Under the
supervision of an anesthesiologist the patient is lightly sedated.
The patient has been treated with passive range of motion throughout
the normal planes of motion of the joints to include the spine as
well as the extremity. After the passive range of motion is
performed, stretching of the surrounding supportive musculature is
carried out. Manual manipulation of the articulation is then
performed. The entire procedure can last anywhere from 5-20 minutes
depending on the number of body regions being treated.
Under the control of the anesthesiologist, the patient has been
awakened. This usually takes 1 to 2 minutes by stopping the IV drip
of medication. The patient is then taken to the recovery room area
and monitored until full recovery has occurred. This usually takes
15-45 minutes. The patient is then discharged and instructed to
return for the the second and third day of treatment. Most widely
accepted protocol at this time is to perform this procedure 3 days
in a row for optimum results.
After the manipulation under anesthesia procedures have been
performed, the patient is scheduled for continued therapy usually
for 6 week period. The first week to 2 weeks is daily treatment
followed by reduction of 3 times per week for the remaining weeks.
This is a general rule of thumb and every patient is different and
responds differently. Individual alterations of the schedule is
dependent on the patient's response to treatment and progress.
Treatment includes a gentle warming of the areas of treatment
followed by passive modalities of ultrasound or electric muscle
stimulation and subsequent cryotherapy treatment. A physical therapy
exercise program is also instituted within a week or 10 days after
In some cases, the patient is prescribed and dispensed a home
portable electric muscle stimulation device.
The patient selected for manipulation under anesthesia should have a
well-defined diagnosis impression developed that correlates with the
patient's history and imaging studies. Conservative treatment is
required prior to proceeding with MUA. Typically traditional
chiropractic/manual therapy for a minimum of 4-6 weeks, plain film
radiographs and other imaging studies such as MRI or CT are acquired
and reviewed. Evaluation by neurologist and orthopedist is
recommended. Nerve conduction studies are performed encases
involving neurological complaints. His team approach and is in any
discipline improves outcome results. Review of the patient's past
medical history and physical examination should be performed just
prior to the MUA procedure. This assures the patient is capable of
undergoing the procedure with no additional medical complications.
Procedure such as a chest x-ray, EKG and pregnancy testing for
females is recommended. An interview with an anesthesiologist is
provided prior to the procedure. Review of any contraindications or
complications from undergoing anesthesia must be addressed.
As any procedure, no guarantees of success are made to the patient.
However, past history and outcomes with this procedure is generally
in the 80% plus range when proper patient selection, proper protocol
and proper post MUA therapies are performed.
The National Academy of MUA Physicians recommends the following
considerations when considering conservative care versus a single
MUA versus serial MUA treatments.
How the patient responds and progresses to the treatment and
how the patient is able to perform with activities of daily
living with current care being rendered.
The patient psychological acceptance of the MUA technique.
Chronic pain syndrome and time away from work are also
Prevention of additional deterioration with performance of
the MUA procedure versus continued conservative and/or surgical
For prevention of surgical intervention.
Correction of failed surgical intervention.
Single MUA is often recommended for patients of her younger age
and of injuries that are less chronic and usually more regional and
global and area. If serial MUA's are recommended, the following
parameters should be considered. The patient should regain 80% or
better of the normal biomechanical function during the procedure and
continues to demonstrate 80% or better by mechanical improvement
after the post MUA follow up, the procedure is considered successful
and additional MUA's are not necessary as long as proper follow up
post MUA therapy and rehabilitation is performed.
If the patient has less than 50-70% improvement in the desired
function during the MUA procedure and continues to show only a
50-70% improvement during post MUA evaluation, the second MUA is
recommended and benefit is expected. If the patient does improve
after the second MUA but does not improve at least 80% improvement
in the third MUA is recommended and has been found to be beneficial.
Rarely is a fourth or fifth MUA recommended but this is sometimes
If the patient responds with only a 10-15% improvement during the
first MUA and continues to only reported 10-15% functional
improvement in the post MUA evaluation, additional evaluation is
recommended for the patient to determine whether or not the
procedure is the best option for the patient.
In review, after careful patient selection which includes detailed
history, physical examination, diagnostic imaging and testing,
co-management with other medical specialties and documented failure
to respond adequately to conservative therapy, manipulation under
anesthesia should be strongly considered by any patient, barring
medical contraindications listed above, as a treatment option to
reduce pain and improve function.
Dr. Hopkins received his certification in manipulation under
anesthesia under the training and supervision of Dr. Robert Gordon.
The following information is from his website
Robert C. Gordon, DC, FABCS, FRCCM, DAAPM, is a presenter in the
field of MUA with CE hours sponsored by New York Chiropractic
College. He holds active licenses to practice chiropractic in
Florida and New Jersey. Dr. Gordon earned his undergraduate degrees
from Florida State University in physical education, recreational
science, and sports medicine and was involved in the masters program
in exercise physiology.
Since graduating from the National College of Chiropractic in 1975,
Dr. Gordon has specialized in the fields of sports medicine and
industrial chiropractic, and it is within these fields that he
pursued his early interest and training at the Texas College of
Chiropractic in the science of manipulation under anesthesia (MUA).
Most of the early research for his work in MUA was completed at the
Southeastern University of Health Sciences (which is now Nova
Southeastern University), an osteopathic college in South Florida.
Dr. Gordon has been actively teaching and researching MUA since 1992
and has been involved in compiling information on the subject since
1985. His interest in the industrial field led him to receive his
training as an authorized trainer for the Occupational Safety and
Health Administration (OSHA) in 2001, and it is in the sports
medicine and industrial fields that Dr. Gordon has used the MUA
procedure to bring recovery to many injured employees and athletes
over the years. Dr. Gordon holds many awards from his years in the
chiropractic field, including Chiropractor of the Year from the
Broward Chiropractic Society and the KUDO award from the Florida
Chiropractic Association for his work as the state chairman for
Dr. Gordon is the executive director of the National Academy of MUA
Physicians and is an active member of the American Academy of Pain
Management. He was an active member of the American Chiropractic
Association for many years, as well as an active member of the
Florida Chiropractic Association, and he held many offices in the
Broward County Chiropractic Society, including president. He is
currently active with the North Carolina Chiropractic Association as
an associate member and lectures on manipulation under anesthesia
regularly for many organizations and universities, including the
American Academy of Pain Management. He is a consultant for the MUA
procedure for many hospitals and ambulatory surgical centers
throughout the U.S. and has taught more than 1600 doctors of
chiropractic and osteopathy. He is the author/editor of the recently
published "Manipulation Under Anesthesia: Concepts In Theory and
Application," the first comprehensive text on MUA (available in our
Marketing Media section.)
Dr. Gordon was recently inducted into the Royal College of
Physicians and Surgeons (U.S.) and is vice chairman of the newly
formed Royal College of Chiropractic Medicine (FRCCM) of the United
States. Dr. Gordon will also assume the position of Professor of
Chiropractic Medicine at the American International University.
Through the Royal College of Chiropractic Medicine, the American
Board of Chiropractic Specialists (ABCS) has been formed, which
recognizes board certification in MUA, neurobiomechanics, and
hospital emergency room procedures.
Dr. Hopkins received his training and certification in this
procedure in November of 2009.
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Hopkins Clinic at 727-544-3330 today.
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