Manipulation Under Anesthesia (MUA)

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 chiropractic physicians.

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 free fragment
  • 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 dysfunction
  • Unresponsive musculoskeletal pain which interferes with daily life and sleep patterns that is appropriate for treatment by manipulation
  • Unresponsive muscle contraction
  • Chronic posttraumatic/whiplash syndrome
  • Chronic neuromusculoskeletal pain requiring ongoing periodic treatment.

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 the procedure.

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 considered.
  • Prevention of additional deterioration with performance of the MUA procedure versus continued conservative and/or surgical care.
  • 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 performed.

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 scoliosis.

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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