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'''Manipulation under anesthesia''' ('''MUA''') or fibrosis belease procedures<ref>Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014 Feb 3;22(1):7. http://www.chiromt.com/content/22/1/7</ref> is a multidisciplinary, chronic pain-related manual therapy modality which is used for the purpose of improving articular and soft tissue movement. This is accomplished by way of a combination of controlled joint mobilization/manipulation and myofascial release techniques. Medication-assisted manipulation (MAM)<ref>Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther. 2005 May;28(4):245-52.</ref> may also be used to describe the procedure, although that term more broadly categorizes the varied forms of existing MUA techniques. In any form, MUA is used by osteopathic/orthopedic physicians and specially trained (MUA certified) chiropractors. It is intended as a means of breaking up adhesions of or about spinal joints (cervical, thoracic, lumbar, sacral, or pelvic regions), or extremity joint articulations (i.e., knee, shoulder, hip) to which painfully restricted range of motion significantly limits function. Failed attempts at other standard conservative treatment methods (i.e., manipulation, physical therapy, medication), over a sufficient time-frame, is one of the principal patient qualifiers <ref>Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014 Feb 3;22(1):7. http://www.chiromt.com/content/22/1/7</ref><ref> Francis R. Spinal manipulation under general anesthesia: a chiropractic approach in a hospital setting. J Am Chiro Assoc. 1989 26(12):39-41.</ref><ref>Williams HA. Part II. Manipulation Under Anesthesia: Key Aspects. J Am Chiro Assoc. 1998 35(1):44,46-9.</ref><ref>Cremata E, Collins S, Clauson W, Solinger AB, Roberts ES. Manipulation under anesthesia: a report of four cases. J Manipulative Physiol Ther. 2005 Sep;28(7):526-33.</ref><ref>American Academy of Osteopathy consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. Am Acad Osteo Jnl. 2005 15(2):26-27.</ref>.
'''Manipulation under anesthesia''' ('''MUA''') or fibrosis belease procedures<ref name=pmid24490957>{{cite journal |doi=10.1186/2045-709X-22-7 }}</ref> is a multidisciplinary, chronic pain-related manual therapy modality which is used for the purpose of improving articular and soft tissue movement. This is accomplished by way of a combination of controlled joint mobilization/manipulation and myofascial release techniques. Medication-assisted manipulation (MAM)<ref name=pmid15883577>{{cite journal |doi=10.1016/j.jmpt.2005.03.003 }}</ref> may also be used to describe the procedure, although that term more broadly categorizes the varied forms of existing MUA techniques. In any form, MUA is used by osteopathic/orthopedic physicians and specially trained (MUA certified) chiropractors. It is intended as a means of breaking up adhesions of or about spinal joints (cervical, thoracic, lumbar, sacral, or pelvic regions), or extremity joint articulations (i.e., knee, shoulder, hip) to which painfully restricted range of motion significantly limits function. Failed attempts at other standard conservative treatment methods (i.e., manipulation, physical therapy, medication), over a sufficient time-frame, is one of the principal patient qualifiers.<ref name=pmid24490957/><ref name=Francis1989>{{cite journal |last1=Francis |first1=R |title=Spinal manipulation under general anesthesia: a chiropractic approach in a hospital setting |journal=J Am Chiro Assoc |year=1989 |volume=26 |issue=12 |issue=39-41 }}</ref><ref name=Williams1998>{{cite journal |last1=Williams |first1=HA |title=Part II. Manipulation Under Anesthesia: Key Aspects |journal=J Am Chiro Assoc |year=1998 |volume=35 |issue=1 |pages=44,46-9 }}</ref><ref name=pmid16182028>{{cite journal |doi=10.1016/j.jmpt.2005.07.011 }}</ref><ref name=AAO2005>{{cite web |title=American Academy of Osteopathy consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation |date=March 16, 2005 |url=http://files.academyofosteopathy.org/MemberResourceGuide/AAOStatementAnesthesia.pdf }}</ref>


In the outpatient ambulatory or hospital-based setting, with a qualified medical physician in attendance, the anesthetic or medication component/s of the MUA procedure may be provided in one of two ways.
In the outpatient ambulatory or hospital-based setting, with a qualified medical physician in attendance, the anesthetic or medication component/s of the MUA procedure may be provided in one of two ways.


==== Intravenous (IV) infusion (administered by an anesthesiologist) ====
==== Intravenous (IV) infusion (administered by an anesthesiologist) ====
Historically, the medical literature identifies sodium pentothal as the earliest of the anesthetizing agents used with the MUA procedure <ref>Francis R. Spinal manipulation under general anesthesia: a chiropractic approach in a hospital setting. J Am Chiro Assoc. 1989 26(12):39-41.</ref><ref>Clybourne HE. Manipulation of the low-back region under anesthesia. J Am Osteopath Assoc. 1948 Sep;48(1):10.</ref><ref>Mensor MC. Non-operative treatment, including manipulation, for lumbar intervertebral disc syndrome. J Bone Joint Surg Am. 1955 Oct;37-A(5):925-36.</ref><ref>Siehl D. Manipulation of the spine under general anesthesia. J Am Osteopath Assoc. 1963 Jun;62:881-7</ref><ref>Chrisman OD, Mittnacht A, Snook GA. A Study of the Results Following Rotatory Manipulation in the Lumbar Intervertebral-Disc Syndrome. J Bone Joint Surg Am. 1964 Apr;46:517-24.</ref><ref>Rumney IC. Manipulation of the spine and appendages under anesthesia: An evaluation. J Am Osteopath Assoc. 1968 Nov;68(3):235-45.</ref>. That was followed by a period during which propofol was used to induce a “twilight state” <ref>Herzog J. Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome. J Manipulative Physiol Ther. 1999 Mar-Apr;22(3):166-70</ref> (aka, IV sedation or conscious sedation <ref>Manipulation Under Anesthesia. mdStrategies. June 2012 https://mdstrategies.com/nl_06_12.htm</ref>). The latter became the doctor-preferred means of rendering the service, as it offered preservation of patient responsiveness during the delivery of treatment. <ref>West DT, Mathews RS, Miller MR, Kent GM. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther. 1999 Jun;22(5):299-308.</ref> With today’s MUA procedure, deep conscious sedation is accomplished with agents such as propofol, <ref>Cremata E, Collins S, Clauson W, Solinger AB, Roberts ES. Manipulation under anesthesia: a report of four cases. J Manipulative Physiol Ther. 2005 Sep;28(7):526-33.</ref><ref>Dagenais S, Mayer J, Wooley JR, Haldeman S. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J. 2008 Jan-Feb;8(1):142-9.</ref><ref>Morningstar MW, Strauchman MN. Management of a 59-year-old female patient with adult degenerative scoliosis using manipulation under anesthesia. J Chiropr Med. 2010 Jun;9(2):77-83.</ref><ref>Morningstar MW, Strauchman MN. Manipulation under anesthesia for patients with failed back surgery: retrospective report of 3 cases with 1-year follow-up. J Chiropr Med. 2012 Mar;11(1):30-5.</ref> through monitored anesthesia care (MAC).
Historically, the medical literature identifies sodium pentothal as the earliest of the anesthetizing agents used with the MUA procedure.<ref name=Francis1989/><ref name=pmid18883818>{{cite journal |pmid=18883818 }}</ref><ref name=pmid13263339>{{cite journal |pmid=13263339 |url=http://journals.lww.com/jbjsjournal/Abstract/1955/37050/NON_OPERATIVE_TREATMENT,_INCLUDING_MANIPULATION,.3.aspx }}</ref><ref name=pmid13988981>{{cite journal |pmid=13988981 }}</ref><ref name=pmid14133339>{{cite journal |pmid=14133339 |url=http://journals.lww.com/jbjsjournal/Citation/1964/46030/A_Study_of_the_Results_Following_Rotatory.5.aspx }}</ref><ref name=pmid5189345>{{cite journal |pmid=5189345 }}</ref> That was followed by a period during which propofol was used to induce a “twilight state”<ref name=pmid10220716>{{cite journal |doi=10.1016/S0161-4754(99)70131-4 }}</ref> (aka, IV sedation or conscious sedation <ref>Manipulation Under Anesthesia. mdStrategies. June 2012 https://mdstrategies.com/nl_06_12.htm</ref>). The latter became the doctor-preferred means of rendering the service, as it offered preservation of patient responsiveness during the delivery of treatment.<ref name=pmid10395432>{{cite journal |doi=10.1016/S0161-4754(99)70062-X }}</ref> With today’s MUA procedure, deep conscious sedation is accomplished with agents such as propofol, <ref name=pmid16182028/><ref name=pmid18164469>{{cite journal |doi=10.1016/j.spinee.2007.10.023 }}</ref><ref name=pmid21629554>{{cite journal |doi=10.1016/j.jcm.2010.02.002 }}</ref><ref name=pmid22942839>{{cite journal |doi=10.1016/j.jcm.2011.08.006 }}</ref> through monitored anesthesia care (MAC).


==== Local injection (administered by an anesthesiologist or pain management physician) ====
==== Local injection (administered by an anesthesiologist or pain management physician) ====
As a less common mode of MUA treatment, select injectable medications can be administered directly to affected synovial joints, <ref>Luukkainen R, Sipola E, Varjo P. Successful Treatment of Frozen Hip with Manipulation and Pressure Dilatation. Open Rheumatol J. 2008; 2: 31–32.</ref> spinal facet joints <ref>Dreyfuss P, Michaelsen M, Horne M. MUJA: manipulation under joint anesthesia/analgesia: a treatment approach for recalcitrant low back pain of synovial joint origin. J Manipulative Physiol Ther. 1995 18(8):537-46.</ref> or into the surrounding epidural space.<ref>Ben-David B, Raboy M. Manipulation under anesthesia combined with epidural steroid injection. J Manipulative Physiol Ther. 1994 Nov-Dec;17(9):605-9.</ref><ref>Aspegren DD, Wright RE, Hemler DE. Manipulation under epidural anesthesia with corticosteroid injection: two case reports. J Manipulative Physiol Ther. 1997 Nov-Dec;20(9):618-21.</ref><ref>Nelson L, Aspegren D, Bova C. The use of epidural steroid injection and manipulation on patients with chronic low back pain. J Manipulative Physiol Ther. 1997 May;20(4):263-6.</ref><ref>Dougherty P, Bajwa S, Burke J, Dishman JD. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: a retrospective case series. J Manipulative Physiol Ther. 2004 Sep;27(7):449-56.</ref> Local anesthetic injection allows previously incomplete office-based manual therapy methods to be better delivered/tolerated, but outside of the general anesthesia scenario. When rendered to the spine, this variety of MUA procedure is qualified by terms such as manipulation under joint anesthesia (MUJA) and manipulation under epidural anesthesia (MUEA).
As a less common mode of MUA treatment, select injectable medications can be administered directly to affected synovial joints,<ref name=pmid19088868>{{cite journal |doi=10.2174/1874312900802010031 }}</ref> spinal facet joints<ref name=pmid8583177>{{cite journal |pmid=8583177 }}</ref> or into the surrounding epidural space.<ref name=pmid7884331>{{cite journal |pmid=7884331 }}</ref><ref name=pmid9436147>{{cite journal |pmid=9436147 }}</ref><ref name=pmid9168411>{{cite journal |pmid=9168411 }}</ref><ref name=pmid15389176>{{cite journal |doi=10.1016/j.jmpt.2004.06.003 }}</ref> Local anesthetic injection allows previously incomplete office-based manual therapy methods to be better delivered/tolerated, but outside of the general anesthesia scenario. When rendered to the spine, this variety of MUA procedure is qualified by terms such as manipulation under joint anesthesia (MUJA) and manipulation under epidural anesthesia (MUEA).


===== MUA following total knee replacement =====
===== MUA following total knee replacement =====
In cases of post operative total [[knee replacement]], for example, if a patient is having difficulty achieving their flexibility after a 6-8 week period, the surgeon may elect to bring the patient back to the [[Operating theatre|operating room]], place them under anesthesia and perform a manipulation under anesthesia. The procedure takes a relatively short period of time (15- 20 min) and the surgeon can gain improved range of motion for the patient. This can also be performed for other orthopedic musculoskeletal limitations, as indicated. Knee manipulation under anesthesia (MUA) is indicated for total knee arthroplasty (TKA) patients who have not obtained at least 90° of flexion by the 6th postoperative week.<ref>http://www3.aaos.org/education/anmeet/anmt2009/poster/poster.cfm?Pevent=P197</ref>
In cases of post operative total [[knee replacement]], for example, if a patient is having difficulty achieving their flexibility after a 6-8 week period, the surgeon may elect to bring the patient back to the [[Operating theatre|operating room]], place them under anesthesia and perform a manipulation under anesthesia. The procedure takes a relatively short period of time (15- 20 min) and the surgeon can gain improved range of motion for the patient. This can also be performed for other orthopedic musculoskeletal limitations, as indicated. Knee manipulation under anesthesia (MUA) is indicated for total knee arthroplasty (TKA) patients who have not obtained at least 90° of flexion by the 6th postoperative week.<ref>http://www3.aaos.org/education/anmeet/anmt2009/poster/poster.cfm?Pevent=P197{{full}}</ref>


=== State of the evidence for spinal MUA ===
=== State of the evidence for spinal MUA ===
Since the 1930’s, spinal manipulation under anesthesia has been reported in the published medical literature. Within the existing base of studies are reports of mostly positive results. However, as part of the evolution of the procedure, the medical literature reveals many variations in [A] the type of sedatives/medications used, [B] manipulation technique, [C] the number of MUA sessions employed, [D] the span of time between procedure doses (if administered in series), and [E] the types and breadth of application of post-MUA adjunctive and/or rehabilitative measures. <ref>DiGiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013 May 14;21(1):14. http://www.chiromt.com/content/21/1/14</ref>
Since the 1930’s, spinal manipulation under anesthesia has been reported in the published medical literature. Within the existing base of studies are reports of mostly positive results. However, as part of the evolution of the procedure, the medical literature reveals many variations in [A] the type of sedatives/medications used, [B] manipulation technique, [C] the number of MUA sessions employed, [D] the span of time between procedure doses (if administered in series), and [E] the types and breadth of application of post-MUA adjunctive and/or rehabilitative measures.<ref name=pmid23672974>{{cite journal |doi=10.1186/2045-709X-21-14 }}</ref>
There has been and remains a strong theoretical basis for spinal MUA. However, considering the aforementioned differences in existing published studies, field practitioners have not had an objective and uniform means by which to establish evidence-based treatment protocols.<ref>DiGiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013 May 14;21(1):14. http://www.chiromt.com/content/21/1/14</ref> Also, because the preponderance of studies are of lower level evidence [1, 24]<ref>Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014 Feb 3;22(1):7. http://www.chiromt.com/content/22/1/7</ref><ref>DiGiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013 May 14;21(1):14. http://www.chiromt.com/content/21/1/14</ref>the issue of long-term effectiveness of MUA in the management of specific spinal conditions has yet to be investigated. Another area for which basic experimental research is lacking to support the efficacy of MUA treatment of the low back,<ref>Dagenais S, Mayer J, Wooley JR, Haldeman S. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J. 2008 Jan-Feb;8(1):142-9.</ref> and other spinal regions relates to the two presiding theories that [1] flexibility of the spine may be increased when adhesions are reduced, and [2] MUA is more effective at treating adhesions than office-based manual therapy methods. Perhaps of greater significance, the circumstances by which or how often spinal adhesions (scar tissue) may form in the general population, in the presence or absence of prior surgery or vertebral fracture, have not been addressed in the medical literature.
There has been and remains a strong theoretical basis for spinal MUA. However, considering the aforementioned differences in existing published studies, field practitioners have not had an objective and uniform means by which to establish evidence-based treatment protocols.<ref name=pmid23672974/> Also, because the preponderance of studies are of lower level evidence<ref name=pmid24490957/><ref name=pmid23672974/> the issue of long-term effectiveness of MUA in the management of specific spinal conditions has yet to be investigated. Another area for which basic experimental research is lacking to support the efficacy of MUA treatment of the low back,<ref name=pmid18164469/> and other spinal regions relates to the two presiding theories that [1] flexibility of the spine may be increased when adhesions are reduced, and [2] MUA is more effective at treating adhesions than office-based manual therapy methods. Perhaps of greater significance, the circumstances by which or how often spinal adhesions (scar tissue) may form in the general population, in the presence or absence of prior surgery or vertebral fracture, have not been addressed in the medical literature.
A 2005 consensus statement from the American Academy of Osteopathy indicates that research and publication is limited for the use and effectiveness of MUA. <ref>American Academy of Osteopathy consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. Am Acad Osteo Jnl. 2005 15(2):26-27.</ref>. More recently, it has been reported that there are gaps in the medical literature for spinal MUA in the areas of patient selection and treatment protocols.<ref>Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014 Feb 3;22(1):7. http://www.chiromt.com/content/22/1/7</ref> On account of that, a Delphi process was undertaken to develop evidence-informed and consensus-based guidelines for the chiropractic profession [1]. The outcome of that process offers direction to MUA practitioners and facilities, although not intended for individual patients.<ref>Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014 Feb 3;22(1):7. http://www.chiromt.com/content/22/1/7</ref>
A 2005 consensus statement from the American Academy of Osteopathy indicates that research and publication is limited for the use and effectiveness of MUA.<ref name=AAO2005/> More recently, it has been reported that there are gaps in the medical literature for spinal MUA in the areas of patient selection and treatment protocols.<ref name=pmid24490957/> On account of that, a Delphi process was undertaken to develop evidence-informed and consensus-based guidelines for the chiropractic profession [1]. The outcome of that process offers direction to MUA practitioners and facilities, although not intended for individual patients.<ref name=pmid24490957/>


Notably, the criteria recommended by members of the chiropractic profession<ref>Gordon R, Cremata E, Hawk C. Guidelines for the practice and performance of manipulation under anesthesia. Chiropr Man Therap. 2014 Feb 3;22(1):7. http://www.chiromt.com/content/22/1/7</ref> are distinctly different from the criteria established by the American Academy of Osteopathy.<ref>American Academy of Osteopathy consensus statement for osteopathic manipulation of somatic dysfunction under anesthesia and conscious sedation. Am Acad Osteo Jnl. 2005 15(2):26-27.</ref>. Moreover, the Delphi method is a consensus process which represents consenting opinion from an impaneled group of experts. But with expert opinion serving as the lowest level of evidence (level V) in the medical evidence hierarchy <ref>Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Joint Surg Am. 2003 Jan;85-A(1):1-3. http://jbjs.org/content/85/1/1</ref>, the MUA-related Delphi process publication of 2014 does not enhance the state of the evidence for spinal MUA. Therefore, the largely anecdotal basis for procedural effectiveness <ref>DiGiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013 May 14;21(1):14. http://www.chiromt.com/content/21/1/14</ref>, and continued reliance upon the spinal MUA protocols historically used, are what principally influence the practice of MUA today.
Notably, the criteria recommended by members of the chiropractic profession<ref name=pmid24490957/> are distinctly different from the criteria established by the American Academy of Osteopathy.<ref name=AAO2005/> Moreover, the Delphi method is a consensus process which represents consenting opinion from an impaneled group of experts. But with expert opinion serving as the lowest level of evidence (level V) in the medical evidence hierarchy,<ref name=pmid12533564>{{cite journal |pmid=12533564 |url=http://journals.lww.com/jbjsjournal/Fulltext/2003/01000/Introducing_Levels_of_Evidence_to_The_Journal.1.aspx }}</ref> the MUA-related Delphi process publication of 2014 does not enhance the state of the evidence for spinal MUA. Therefore, the largely anecdotal basis for procedural effectiveness,<ref name=pmid23672974/> and continued reliance upon the spinal MUA protocols historically used, are what principally influence the practice of MUA today.
In comparison to other available treatment options for chronic spine pain patients, it is the benchmark of the randomized controlled trial that could best define patient candidacy, optimal procedure dosing, and long-term effectiveness for MUA. Previous MUA investigators have mentioned the use of inconsistent protocols <ref>Kohlbeck FJ, Haldeman S. Medication-assisted spinal manipulation. Spine J. 2002 Jul-Aug;2(4):288-302.</ref> and have called for large-scale MUA studies (randomized trials) for chronic low back pain <ref>Kohlbeck FJ, Haldeman S, Hurwitz EL, Dagenais S. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther. 2005 May;28(4):245-52.</ref><ref>Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther. 2002 Oct;25(8):E8-E17.</ref> To date, no such studies have been undertaken.
In comparison to other available treatment options for chronic spine pain patients, it is the benchmark of the randomized controlled trial that could best define patient candidacy, optimal procedure dosing, and long-term effectiveness for MUA. Previous MUA investigators have mentioned the use of inconsistent protocols<ref name=pmid14589481>{{cite journal |doi=10.1016/S1529-9430(02)00196-1 }}</ref> and have called for large-scale MUA studies (randomized trials) for chronic low back pain.<ref name=pmid15883577/><ref name=pmid12381983>{{cite journal |doi=10.1067/mmt.2002.127072 }}</ref> To date, no such studies have been undertaken.{{fact}}
There is a lack of high-level research evidence for the long-term clinical efficacy of spinal MUA, from which evidence-based parameters for patient selection and dosing may be established. Accordingly, most insurance carriers in the United States maintain medical policy which deems the procedure unproven or experimental/investigational (see medical policy examples. [28-30]).<ref>UnitedHealth Medical Policy- Manipulation Under Anesthesia. Policy Number 2017T0515O, Effective date March 1, 2017.</ref><ref>Premera Blue Cross Medical Policy for Chiropractic Services, Effective date April 1, 2017.</ref><ref>Cigna Medical Coverage Policy- Manipulation Under Anesthesia. Coverage Policy Number 0276. Effective date 10/15/16.</ref> However, this issue can serve as a source of confusion for doctors and patients when viewed against [A] the backdrop of assuredness for spinal MUA communicated by MUA instructors/proponents, [B] the enthusiastic claims seen with internet-based advertising and patient testimonials, and [C] the fact that most spinal MUA procedures are being performed in the motor vehicle accident market, where pre-authorization is not required. For some, these elements may appear to indicate that the procedure is broadly accepted by the chiropractic and medical professions alike and that it is used in general as an effective means of treatment for chronic spine pain.
There is a lack of high-level research evidence for the long-term clinical efficacy of spinal MUA, from which evidence-based parameters for patient selection and dosing may be established. Accordingly, most insurance carriers in the United States maintain medical policy which deems the procedure unproven or experimental/investigational (see medical policy examples. [28-30]).<ref>UnitedHealth Medical Policy- Manipulation Under Anesthesia. Policy Number 2017T0515O, Effective date March 1, 2017.</ref><ref>Premera Blue Cross Medical Policy for Chiropractic Services, Effective date April 1, 2017.</ref><ref>Cigna Medical Coverage Policy- Manipulation Under Anesthesia. Coverage Policy Number 0276. Effective date 10/15/16.</ref> However, this issue can serve as a source of confusion for doctors and patients when viewed against [A] the backdrop of assuredness for spinal MUA communicated by MUA instructors/proponents, [B] the enthusiastic claims seen with internet-based advertising and patient testimonials, and [C] the fact that most spinal MUA procedures are being performed in the motor vehicle accident market, where pre-authorization is not required. For some, these elements may appear to indicate that the procedure is broadly accepted by the chiropractic and medical professions alike and that it is used in general as an effective means of treatment for chronic spine pain.

<!---
COMMENTING OUT UNTIL PROPERLY SOURCED.

MUA consists of accurately determined and specifically directed manual forces to areas of restriction, whether the restriction is in ligaments, muscles or joints; the result of which may be improvement in posture and locomotion, improvement in function elsewhere in the body and the enhancement of the sense of well-being. MUA has been utilized in manual medicine for over 70 years. Increased participation of chiropractors on hospital medical staffs and has made both the facilities and training more available for performing and credentialing this procedure.{{Needs citation}}

[[Chiropractor]]s constitute the group who most actively practice MUA.{{Needs citation}}
-->


== Training ==
== Training ==
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! Author(s) cited !! Commonly advertised outcomes claims !! Actual outcomes data and relevant study methods, as reported by publication
! Author(s) cited !! Commonly advertised outcomes claims !! Actual outcomes data and relevant study methods, as reported by publication
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| Bradford and Siehl || 71% of 723 MUA patients had good results (return to normal activity relatively symptom free) and 25.3% had fair results (return to normal activity with slight residuals) || Overall, for 723 cases (666 different patients), 60% had good results, 30% had fair results, and 10% had poor results. Most patients received a single procedure dose. As for the 185 patients with herniated disc, 26.4% had good results and 44.3% had fair results, with the author reporting, “improvement was quite temporary in a number of cases, since 51% required subsequent operation.” <ref>Siehl D. Manipulation of the spine under general anesthesia. J Am Osteopath Assoc. 1963 Jun;62:881-7.</ref>
| Bradford and Siehl || 71% of 723 MUA patients had good results (return to normal activity relatively symptom free) and 25.3% had fair results (return to normal activity with slight residuals) || Overall, for 723 cases (666 different patients), 60% had good results, 30% had fair results, and 10% had poor results. Most patients received a single procedure dose. As for the 185 patients with herniated disc, 26.4% had good results and 44.3% had fair results, with the author reporting, “improvement was quite temporary in a number of cases, since 51% required subsequent operation.”<ref name=pmid13988981/>
|-
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| Chrisman, et al.|| 51% of patients reported good to excellent results three years post MUA|| 51% of 39 patients had good or excellent results after rotatory manipulation of the spine under anesthesia. Of patients with positive myelograms, 37% (10 of 27) had good to excellent results three years or more after manipulation. All patients received a single procedure dose.<ref>Chrisman OD, Mittnacht A, Snook GA. A Study of the Results Following Rotatory Manipulation in the Lumbar Intervertebral-Disc Syndrome. J Bone Joint Surg Am. 1964 Apr;46:517-24.</ref>
| Chrisman, et al.|| 51% of patients reported good to excellent results three years post MUA|| 51% of 39 patients had good or excellent results after rotatory manipulation of the spine under anesthesia. Of patients with positive myelograms, 37% (10 of 27) had good to excellent results three years or more after manipulation. All patients received a single procedure dose.<ref name=pmid14133339/>
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| Krumhansl and Nowacek || Of 171 patients receiving MUA, 25% had no pain, 50% were much improved (with pain markedly decreased), and 20% were better and could tolerate their pain (but it interfered with work and recreation)|| Of 171 patients, most of whom received a single procedure dose, approximately 25% were “cured” (having no pain of the type experienced prior to MUA), 50% were “much improved” (with markedly diminished pain and function restored but with intermittent nuisance type pain with weather changes or strenuous activity) and 20% were “better, but” (having a tolerable pain level but remained dysfunctional for work and recreational activities).<ref>Krumhansl BR, Nowacek CJ. Manipulation Under Anesthesia. In: Grieve GP, editor. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone. 1986:777-86.</ref>
| Krumhansl and Nowacek || Of 171 patients receiving MUA, 25% had no pain, 50% were much improved (with pain markedly decreased), and 20% were better and could tolerate their pain (but it interfered with work and recreation)|| Of 171 patients, most of whom received a single procedure dose, approximately 25% were “cured” (having no pain of the type experienced prior to MUA), 50% were “much improved” (with markedly diminished pain and function restored but with intermittent nuisance type pain with weather changes or strenuous activity) and 20% were “better, but” (having a tolerable pain level but remained dysfunctional for work and recreational activities).<ref>Krumhansl BR, Nowacek CJ. Manipulation Under Anesthesia. In: Grieve GP, editor. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone. 1986:777-86.</ref>
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| Kuo and Loh|| 83% of 517 patients treated with MUA responded well|| Of 517 patients receiving manipulation, 76.8% had satisfactory results. However, the number of patients anesthetized during manipulation is not reported (if any). In general terms, the authors state, “Prior to manipulation, general anesthesia with intravenous thiopental sodium may be given to suppress pain and muscle spasm.” Seventy-three patients (14%) had a condition recurrence or relapse, ranging from 2 months to 12 years after the first series of manipulations. Unresponsive patients (9%, overall) underwent surgical exploration and received a second series of manipulations after revision of the treatment protocol such that 434 of 517 patients (83.9%) are reported as having responded well to manipulation.<ref>Kuo PP, Loh ZC. Treatment of lumbar intervertebral disc protrusions by manipulation. Clin Orthop Relat Res. 1987; (215):47-55.</ref>
| Kuo and Loh|| 83% of 517 patients treated with MUA responded well|| Of 517 patients receiving manipulation, 76.8% had satisfactory results. However, the number of patients anesthetized during manipulation is not reported (if any). In general terms, the authors state, “Prior to manipulation, general anesthesia with intravenous thiopental sodium may be given to suppress pain and muscle spasm.” Seventy-three patients (14%) had a condition recurrence or relapse, ranging from 2 months to 12 years after the first series of manipulations. Unresponsive patients (9%, overall) underwent surgical exploration and received a second series of manipulations after revision of the treatment protocol such that 434 of 517 patients (83.9%) are reported as having responded well to manipulation.<ref>Kuo PP, Loh ZC. Treatment of lumbar intervertebral disc protrusions by manipulation. Clin Orthop Relat Res. 1987; (215):47-55.</ref>
|-
|-
| Mensor|| 83% of 600 patients with EMG-verified radiculopathies reported significant improvement following MUA|| For over 600 patients treated, a cursory evaluation led the author to “believe that the percentage of success or failure has not changed materially” from the original report.<ref>Mensor MC. Non-operative treatment, including manipulation, for lumbar intervertebral-disc syndrome. J Bone Joint Surg Am. 1965;47-A:1073-4.</ref> The original report cited excellent to good results in 64% of private patients and 45% of industrial accident patients with disabilities.<ref>Mensor MC. Non-operative treatment, including manipulation, for lumbar intervertebral disc syndrome. J Bone Joint Surg Am. 1955 Oct;37-A(5):925-36.</ref> Overall, 83% of patients received a single procedure dose, with the author reporting, “repeated manipulation is not justified” for satisfactory results. Within neither paper is EMG testing mentioned as part of the patient’s objective findings or as a qualifier for treatment.
| Mensor|| 83% of 600 patients with EMG-verified radiculopathies reported significant improvement following MUA|| For over 600 patients treated, a cursory evaluation led the author to “believe that the percentage of success or failure has not changed materially” from the original report.<ref>Mensor MC. Non-operative treatment, including manipulation, for lumbar intervertebral-disc syndrome. J Bone Joint Surg Am. 1965;47-A:1073-4.</ref> The original report cited excellent to good results in 64% of private patients and 45% of industrial accident patients with disabilities.<ref name=pmid13263339/> Overall, 83% of patients received a single procedure dose, with the author reporting, “repeated manipulation is not justified” for satisfactory results. Within neither paper is EMG testing mentioned as part of the patient’s objective findings or as a qualifier for treatment.
|-
|-
| Ongley, et. al.|| Patients who had back pain for a minimum of 10 years reported an 87% recovery rate after MUA|| 81 patients had an average pain duration of 10 years. Patients in the experimental group were placed in a diazepam-induced amnesic state, and received manipulation after administration of local anesthetic to six different ligaments of the lumbar, lumbopelvic, and sacroiliac regions. At six months, of the 40 patients in the experimental group who received a single procedure dose, 87.5% had greater than 50% improvement in disability scores and 37.5% had recovered completely (“free from disability”).<ref>Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ. A new approach to the treatment of chronic low back pain. Lancet. 1987;18;2(8551):143-6.</ref>
| Ongley, et. al.|| Patients who had back pain for a minimum of 10 years reported an 87% recovery rate after MUA|| 81 patients had an average pain duration of 10 years. Patients in the experimental group were placed in a diazepam-induced amnesic state, and received manipulation after administration of local anesthetic to six different ligaments of the lumbar, lumbopelvic, and sacroiliac regions. At six months, of the 40 patients in the experimental group who received a single procedure dose, 87.5% had greater than 50% improvement in disability scores and 37.5% had recovered completely (“free from disability”).<ref>Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ. A new approach to the treatment of chronic low back pain. Lancet. 1987;18;2(8551):143-6.</ref>
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Outside of the above clinical scenario and related research, the supportive evidence for MUA to other extremity joints is weak, inconclusive or non-existent. The shoulder, when failing to achieve flexibility following standard treatment, is one of the extremity regions for which the frozen shoulder condition has traditionally been cited as an indication for MUA. There are some supportive studies in this area, including one showing that patients fare better with intervention at 6 and 9 months after condition onset (having significantly better abduction and external rotation, with less pain at rest and at night).<ref>Vastamäki H, Varjonen L, Vastamäki M. Optimal time for manipulation of frozen shoulder may be between 6 and 9 months. Scand J Surg. 2015 Jan 26.</ref> However, for those studies which represent the highest level of research evidence, the results of two recent systematic reviews for frozen shoulder raise question as to treatment superiority when compared to other forms of treatment. Namely, in the 2012 systematic review, Maund, et. al. found a single adequate study, but no evidence there of better outcome with MUA versus home exercise.<ref>Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G, Robertson J, McDaid C. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2012;16(11):1-264</ref> In the 2015 systematic review, Uppal, et. al. determined MUA to be equivocal at best, when compared to hydrodilation and steroid injection.<ref>Uppal HS, Evans JP, Smith C. Frozen shoulder: A systematic review of therapeutic options. World J Orthop 2015; 6(2): 263-268. http://www.wjgnet.com/2218-5836/full/v6/ i2/263.htm</ref>
Outside of the above clinical scenario and related research, the supportive evidence for MUA to other extremity joints is weak, inconclusive or non-existent. The shoulder, when failing to achieve flexibility following standard treatment, is one of the extremity regions for which the frozen shoulder condition has traditionally been cited as an indication for MUA. There are some supportive studies in this area, including one showing that patients fare better with intervention at 6 and 9 months after condition onset (having significantly better abduction and external rotation, with less pain at rest and at night).<ref>Vastamäki H, Varjonen L, Vastamäki M. Optimal time for manipulation of frozen shoulder may be between 6 and 9 months. Scand J Surg. 2015 Jan 26.</ref> However, for those studies which represent the highest level of research evidence, the results of two recent systematic reviews for frozen shoulder raise question as to treatment superiority when compared to other forms of treatment. Namely, in the 2012 systematic review, Maund, et. al. found a single adequate study, but no evidence there of better outcome with MUA versus home exercise.<ref>Maund E, Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G, Robertson J, McDaid C. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Health Technol Assess. 2012;16(11):1-264</ref> In the 2015 systematic review, Uppal, et. al. determined MUA to be equivocal at best, when compared to hydrodilation and steroid injection.<ref>Uppal HS, Evans JP, Smith C. Frozen shoulder: A systematic review of therapeutic options. World J Orthop 2015; 6(2): 263-268. http://www.wjgnet.com/2218-5836/full/v6/ i2/263.htm</ref>
The provision of MUA to an extremity joint is reserved for primary conditions thereof, such as a frozen articulation. The practice of applying MUA to an extremity joint that conjoins the spine (i.e., shoulder and/or hip), as a routine component or an extension of a spinal MUA procedure, is not supported by clinical investigation.<ref>DiGiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap. 2013 May 14;21(1):14. http://www.chiromt.com/content/21/1/14</ref> High-quality primary research is needed in this area.
The provision of MUA to an extremity joint is reserved for primary conditions thereof, such as a frozen articulation. The practice of applying MUA to an extremity joint that conjoins the spine (i.e., shoulder and/or hip), as a routine component or an extension of a spinal MUA procedure, is not supported by clinical investigation.<ref name=pmid23672974/> High-quality primary research is needed in this area.


== Risk versus benefit ==
== Risk versus benefit ==
As with any procedure, there are inherent risks with MUA. The chiropractic literature seems to best address concern for potential complications with spinal MUA.<ref>Kohlbeck FJ, Haldeman S. Medication-assisted spinal manipulation. Spine J. 2002 Jul-Aug;2(4):288-302.</ref> <ref>Gordon RC. An evaluation of the experimental and investigational status and clinical validity of manipulation of patients under anesthesia: a contemporary opinion. J Manipulative Physiol Ther. 2001 Nov-Dec;24(9):603-11.</ref> Tens of thousands of uneventful spinal and extremity MUA procedures have been performed in the United States over the past several decades. As such, in all likelihood, the risks with the procedure are relatively low or minimized with current techniques and when patients are properly selected and evaluated by the anesthesiologist, the medical physician who is providing medical clearance, and the MUA manual therapy practitioner (DC, DO, MD). However, complications or injuries have been reported in the literature. In part, these include severe sacroiliac pain with transient “pain paralysis” (of one or both legs)<ref>Krumhansl BR, Nowacek CJ. Manipulation Under Anesthesia. In: Grieve GP, editor. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone. 1986:777-86.</ref>, transient respiratory distress<ref>Krumhansl BR, Nowacek CJ. Manipulation Under Anesthesia. In: Grieve GP, editor. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone. 1986:777-86.</ref>, a significant adverse cardiovascular event<ref>LaMendola B. Medical safety spotlight growing- Man unresponsive after ‘manipulation under anesthesia’. March 22, 2009. Sun Sentinel. http://articles.sun-sentinel.com/2009-03-22/news/0903210114_1_mua-chiropractor-procedure</ref>, spinal fracture with hemothorax<ref>Gardner SC, Majercik SD, VanBoerum D, Macfarlane JR. Man, 57, with dyspnea after chiropractic manipulation. Clinician Reviews. 2013;23(4)23-24, 27-28. http://www.clinicianreviews.com/the-publication/past-issues-single-view/man-57-with-dyspnea-after-chiropractic-manipulation/c08c9df36447055f498e98529591e1f3.html</ref>, lower extremity fracture<ref>Smith EL, Banerjee SB, Bono JV. Supracondylar femur fracture after knee manipulation: a report of 3 cases. Orthopedics. 2009 Jan;32(1):18.</ref> <ref>Rodriguez-Merchan EC, Gomez-Cardero P, Jimenez-Yuste V. Iatrogenic fracture of the proximal tibia as a complication of knee manipulation under anaesthesia in a haemophilia patient with an ipsilateral stiff knee secondary to a supracondylar non-union of the femur. Haemophilia. 2012 Jul;18(4):e354-6</ref>, glenoid fracture <ref>Magnussen RA, Taylor DC. Glenoid fracture during manipulation under anesthesia for adhesive capsulitis: a case report. J Shoulder Elbow Surg. 2011 Apr;20(3):e23-6.</ref> [50], shoulder dislocation<ref>Roubal PJ, Placzek JD. Long-Lever-Arm Manipulation Under Anesthesia With Resultant Traumatic Anterior Shoulder Dislocation. J Orthop Sports Phys Ther. 2016 Aug;46(8):707.</ref>, and pseudoaneurysm <ref>Sambaziotis C, Plymale M, Lovy A, O'Halloran K, McCulloch K, Geller DS. Pseudoaneurysm of the distal thigh after manipulation of a total knee arthroplasty. J Arthroplasty. 2012 Aug;27(7):1414.e5-7.</ref> <ref>Brigido SA, Bleazey ST, Oskin TC, Protzman NM. Pseudoaneurysm of the posterior tibial artery after manipulation under anesthesia of a total ankle replacement. J Foot Ankle Surg. 2013 Sep-Oct;52(5):655-8.</ref>. As the evidence for the effectiveness of MUA of most body regions remains largely anecdotal, the potential long term benefits of such treatment for chronic musculoskeletal pain must be weighed against these risks and others.
As with any procedure, there are inherent risks with MUA. The chiropractic literature seems to best address concern for potential complications with spinal MUA.<ref name=pmid14589481/><ref>Gordon RC. An evaluation of the experimental and investigational status and clinical validity of manipulation of patients under anesthesia: a contemporary opinion. J Manipulative Physiol Ther. 2001 Nov-Dec;24(9):603-11.</ref> Tens of thousands of uneventful spinal and extremity MUA procedures have been performed in the United States over the past several decades. As such, in all likelihood, the risks with the procedure are relatively low or minimized with current techniques and when patients are properly selected and evaluated by the anesthesiologist, the medical physician who is providing medical clearance, and the MUA manual therapy practitioner (DC, DO, MD). However, complications or injuries have been reported in the literature. In part, these include severe sacroiliac pain with transient “pain paralysis” (of one or both legs)<ref>Krumhansl BR, Nowacek CJ. Manipulation Under Anesthesia. In: Grieve GP, editor. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone. 1986:777-86.</ref>, transient respiratory distress<ref>Krumhansl BR, Nowacek CJ. Manipulation Under Anesthesia. In: Grieve GP, editor. Modern manual therapy of the vertebral column. Edinburgh: Churchill Livingstone. 1986:777-86.</ref>, a significant adverse cardiovascular event<ref>LaMendola B. Medical safety spotlight growing- Man unresponsive after ‘manipulation under anesthesia’. March 22, 2009. Sun Sentinel. http://articles.sun-sentinel.com/2009-03-22/news/0903210114_1_mua-chiropractor-procedure</ref>, spinal fracture with hemothorax<ref>Gardner SC, Majercik SD, VanBoerum D, Macfarlane JR. Man, 57, with dyspnea after chiropractic manipulation. Clinician Reviews. 2013;23(4)23-24, 27-28. http://www.clinicianreviews.com/the-publication/past-issues-single-view/man-57-with-dyspnea-after-chiropractic-manipulation/c08c9df36447055f498e98529591e1f3.html</ref>, lower extremity fracture<ref>Smith EL, Banerjee SB, Bono JV. Supracondylar femur fracture after knee manipulation: a report of 3 cases. Orthopedics. 2009 Jan;32(1):18.</ref> <ref>Rodriguez-Merchan EC, Gomez-Cardero P, Jimenez-Yuste V. Iatrogenic fracture of the proximal tibia as a complication of knee manipulation under anaesthesia in a haemophilia patient with an ipsilateral stiff knee secondary to a supracondylar non-union of the femur. Haemophilia. 2012 Jul;18(4):e354-6</ref>, glenoid fracture <ref>Magnussen RA, Taylor DC. Glenoid fracture during manipulation under anesthesia for adhesive capsulitis: a case report. J Shoulder Elbow Surg. 2011 Apr;20(3):e23-6.</ref> [50], shoulder dislocation<ref>Roubal PJ, Placzek JD. Long-Lever-Arm Manipulation Under Anesthesia With Resultant Traumatic Anterior Shoulder Dislocation. J Orthop Sports Phys Ther. 2016 Aug;46(8):707.</ref>, and pseudoaneurysm <ref>Sambaziotis C, Plymale M, Lovy A, O'Halloran K, McCulloch K, Geller DS. Pseudoaneurysm of the distal thigh after manipulation of a total knee arthroplasty. J Arthroplasty. 2012 Aug;27(7):1414.e5-7.</ref> <ref>Brigido SA, Bleazey ST, Oskin TC, Protzman NM. Pseudoaneurysm of the posterior tibial artery after manipulation under anesthesia of a total ankle replacement. J Foot Ankle Surg. 2013 Sep-Oct;52(5):655-8.</ref>. As the evidence for the effectiveness of MUA of most body regions remains largely anecdotal, the potential long term benefits of such treatment for chronic musculoskeletal pain must be weighed against these risks and others.


== References ==
== References ==

Revision as of 17:23, 13 September 2017

Manipulation under anesthesia (MUA) or fibrosis belease procedures[1] is a multidisciplinary, chronic pain-related manual therapy modality which is used for the purpose of improving articular and soft tissue movement. This is accomplished by way of a combination of controlled joint mobilization/manipulation and myofascial release techniques. Medication-assisted manipulation (MAM)[2] may also be used to describe the procedure, although that term more broadly categorizes the varied forms of existing MUA techniques. In any form, MUA is used by osteopathic/orthopedic physicians and specially trained (MUA certified) chiropractors. It is intended as a means of breaking up adhesions of or about spinal joints (cervical, thoracic, lumbar, sacral, or pelvic regions), or extremity joint articulations (i.e., knee, shoulder, hip) to which painfully restricted range of motion significantly limits function. Failed attempts at other standard conservative treatment methods (i.e., manipulation, physical therapy, medication), over a sufficient time-frame, is one of the principal patient qualifiers.[1][3][4][5][6]

In the outpatient ambulatory or hospital-based setting, with a qualified medical physician in attendance, the anesthetic or medication component/s of the MUA procedure may be provided in one of two ways.

Intravenous (IV) infusion (administered by an anesthesiologist)

Historically, the medical literature identifies sodium pentothal as the earliest of the anesthetizing agents used with the MUA procedure.[3][7][8][9][10][11] That was followed by a period during which propofol was used to induce a “twilight state”[12] (aka, IV sedation or conscious sedation [13]). The latter became the doctor-preferred means of rendering the service, as it offered preservation of patient responsiveness during the delivery of treatment.[14] With today’s MUA procedure, deep conscious sedation is accomplished with agents such as propofol, [5][15][16][17] through monitored anesthesia care (MAC).

Local injection (administered by an anesthesiologist or pain management physician)

As a less common mode of MUA treatment, select injectable medications can be administered directly to affected synovial joints,[18] spinal facet joints[19] or into the surrounding epidural space.[20][21][22][23] Local anesthetic injection allows previously incomplete office-based manual therapy methods to be better delivered/tolerated, but outside of the general anesthesia scenario. When rendered to the spine, this variety of MUA procedure is qualified by terms such as manipulation under joint anesthesia (MUJA) and manipulation under epidural anesthesia (MUEA).

MUA following total knee replacement

In cases of post operative total knee replacement, for example, if a patient is having difficulty achieving their flexibility after a 6-8 week period, the surgeon may elect to bring the patient back to the operating room, place them under anesthesia and perform a manipulation under anesthesia. The procedure takes a relatively short period of time (15- 20 min) and the surgeon can gain improved range of motion for the patient. This can also be performed for other orthopedic musculoskeletal limitations, as indicated. Knee manipulation under anesthesia (MUA) is indicated for total knee arthroplasty (TKA) patients who have not obtained at least 90° of flexion by the 6th postoperative week.[24]

State of the evidence for spinal MUA

Since the 1930’s, spinal manipulation under anesthesia has been reported in the published medical literature. Within the existing base of studies are reports of mostly positive results. However, as part of the evolution of the procedure, the medical literature reveals many variations in [A] the type of sedatives/medications used, [B] manipulation technique, [C] the number of MUA sessions employed, [D] the span of time between procedure doses (if administered in series), and [E] the types and breadth of application of post-MUA adjunctive and/or rehabilitative measures.[25]

There has been and remains a strong theoretical basis for spinal MUA. However, considering the aforementioned differences in existing published studies, field practitioners have not had an objective and uniform means by which to establish evidence-based treatment protocols.[25] Also, because the preponderance of studies are of lower level evidence[1][25] the issue of long-term effectiveness of MUA in the management of specific spinal conditions has yet to be investigated. Another area for which basic experimental research is lacking to support the efficacy of MUA treatment of the low back,[15] and other spinal regions relates to the two presiding theories that [1] flexibility of the spine may be increased when adhesions are reduced, and [2] MUA is more effective at treating adhesions than office-based manual therapy methods. Perhaps of greater significance, the circumstances by which or how often spinal adhesions (scar tissue) may form in the general population, in the presence or absence of prior surgery or vertebral fracture, have not been addressed in the medical literature.

A 2005 consensus statement from the American Academy of Osteopathy indicates that research and publication is limited for the use and effectiveness of MUA.[6] More recently, it has been reported that there are gaps in the medical literature for spinal MUA in the areas of patient selection and treatment protocols.[1] On account of that, a Delphi process was undertaken to develop evidence-informed and consensus-based guidelines for the chiropractic profession [1]. The outcome of that process offers direction to MUA practitioners and facilities, although not intended for individual patients.[1]

Notably, the criteria recommended by members of the chiropractic profession[1] are distinctly different from the criteria established by the American Academy of Osteopathy.[6] Moreover, the Delphi method is a consensus process which represents consenting opinion from an impaneled group of experts. But with expert opinion serving as the lowest level of evidence (level V) in the medical evidence hierarchy,[26] the MUA-related Delphi process publication of 2014 does not enhance the state of the evidence for spinal MUA. Therefore, the largely anecdotal basis for procedural effectiveness,[25] and continued reliance upon the spinal MUA protocols historically used, are what principally influence the practice of MUA today.

In comparison to other available treatment options for chronic spine pain patients, it is the benchmark of the randomized controlled trial that could best define patient candidacy, optimal procedure dosing, and long-term effectiveness for MUA. Previous MUA investigators have mentioned the use of inconsistent protocols[27] and have called for large-scale MUA studies (randomized trials) for chronic low back pain.[2][28] To date, no such studies have been undertaken.[citation needed]

There is a lack of high-level research evidence for the long-term clinical efficacy of spinal MUA, from which evidence-based parameters for patient selection and dosing may be established. Accordingly, most insurance carriers in the United States maintain medical policy which deems the procedure unproven or experimental/investigational (see medical policy examples. [28-30]).[29][30][31] However, this issue can serve as a source of confusion for doctors and patients when viewed against [A] the backdrop of assuredness for spinal MUA communicated by MUA instructors/proponents, [B] the enthusiastic claims seen with internet-based advertising and patient testimonials, and [C] the fact that most spinal MUA procedures are being performed in the motor vehicle accident market, where pre-authorization is not required. For some, these elements may appear to indicate that the procedure is broadly accepted by the chiropractic and medical professions alike and that it is used in general as an effective means of treatment for chronic spine pain.

Training

MUA certification courses are offered through accredited chiropractic college post-graduate departments. It has been important to regulatory agencies, academic institutions, professional associations and organizations and malpractice carriers to recognize appropriate training programs. The National MUA Academy of Physicians and the International Academy of MUA Physicians have proposed specific educational standards and protocols for establishing credible certification training programs to be used by accredited academic institutions offering post graduate certification in Manipulation Under Anesthesia.

The American Chiropractic Association public policy statement declares, "The American Chiropractic Association recognizes that CCE accredited chiropractic academic institutions and their related post graduate departments offer to the profession post-doctoral courses in manipulation under anesthesia (MUA); and

The American Chiropractic Association recognizes that manipulation under anesthesia has a long established history, supported by many years of clinical research, as an accepted established procedure within and outside the profession; and The American Chiropractic Association recognizes that each state has a legislatively established and statutorily authorized regulatory agency for the specific purposes of regulating the practice of chiropractic pursuant to each state's enabling legislation for such regulatory agencies; and WHEREAS, The American Chiropractic Association supports each state's right and privilege to establish separate and autonomous scopes of practice, practice parameters and regulatory agencies for the practice of chiropractic. Therefore be it RESOLVED, that the American Chiropractic Association recognize and support that Manipulation Under Anesthesia has a well established clinical history within the chiropractic profession, accredited chiropractic academic institutions, chiropractic clinical research, and chiropractic private practice sector in both hospital and ambulatory surgical center settings, and moreover that MUA procedures are appropriate in a selected patient population pursuant to established clinical guidelines promulgated by established chiropractic authoritative sources including accredited academic institutions' MUA training programs, state regulatory agencies rules and regulations, and qualified instructors of MUA procedures who teach the MUA courses under the auspices of accredited academic institutions."[32]

History

Medication Assisted Manipulation (MAM) has been used since then 1930s, and MUA was practiced by osteopathic physicians and orthopedic surgeons in the 1940s and 1950s. It was largely abandoned due to complications from general anesthesia and due to the type of nonspecific manipulation procedures used. It was modified and revived in the 1990s, primarily by chiropractors, and also by osteopathic physicians; this was likely due to safer anesthesia used for conscious sedation, along with increased interest in spinal manipulation (SM).[33]

The state of practitioner advertising for spinal MUA

The spinal MUA procedure has had a history susceptible to enthusiastic claims of success and indiscriminate use [26]. Today, similar deficiencies remain, with misperceptions about the findings of primary research. In this regard, some practitioner advertisements inaccurately cite study outcomes and/or provide selective information that places the procedure, and serial dosing, in a more favorable light. MUA practitioners may be surprised that widespread misinterpretation of the published evidence has led to unrealistic outcome expectations and overutilization of the procedure. Table 1 provides detail concerning this advertising phenomenon, which can presumptuously move patients toward treatment.


Author(s) cited Commonly advertised outcomes claims Actual outcomes data and relevant study methods, as reported by publication
Bradford and Siehl 71% of 723 MUA patients had good results (return to normal activity relatively symptom free) and 25.3% had fair results (return to normal activity with slight residuals) Overall, for 723 cases (666 different patients), 60% had good results, 30% had fair results, and 10% had poor results. Most patients received a single procedure dose. As for the 185 patients with herniated disc, 26.4% had good results and 44.3% had fair results, with the author reporting, “improvement was quite temporary in a number of cases, since 51% required subsequent operation.”[9]
Chrisman, et al. 51% of patients reported good to excellent results three years post MUA 51% of 39 patients had good or excellent results after rotatory manipulation of the spine under anesthesia. Of patients with positive myelograms, 37% (10 of 27) had good to excellent results three years or more after manipulation. All patients received a single procedure dose.[10]
Krumhansl and Nowacek Of 171 patients receiving MUA, 25% had no pain, 50% were much improved (with pain markedly decreased), and 20% were better and could tolerate their pain (but it interfered with work and recreation) Of 171 patients, most of whom received a single procedure dose, approximately 25% were “cured” (having no pain of the type experienced prior to MUA), 50% were “much improved” (with markedly diminished pain and function restored but with intermittent nuisance type pain with weather changes or strenuous activity) and 20% were “better, but” (having a tolerable pain level but remained dysfunctional for work and recreational activities).[34]
Kuo and Loh 83% of 517 patients treated with MUA responded well Of 517 patients receiving manipulation, 76.8% had satisfactory results. However, the number of patients anesthetized during manipulation is not reported (if any). In general terms, the authors state, “Prior to manipulation, general anesthesia with intravenous thiopental sodium may be given to suppress pain and muscle spasm.” Seventy-three patients (14%) had a condition recurrence or relapse, ranging from 2 months to 12 years after the first series of manipulations. Unresponsive patients (9%, overall) underwent surgical exploration and received a second series of manipulations after revision of the treatment protocol such that 434 of 517 patients (83.9%) are reported as having responded well to manipulation.[35]
Mensor 83% of 600 patients with EMG-verified radiculopathies reported significant improvement following MUA For over 600 patients treated, a cursory evaluation led the author to “believe that the percentage of success or failure has not changed materially” from the original report.[36] The original report cited excellent to good results in 64% of private patients and 45% of industrial accident patients with disabilities.[8] Overall, 83% of patients received a single procedure dose, with the author reporting, “repeated manipulation is not justified” for satisfactory results. Within neither paper is EMG testing mentioned as part of the patient’s objective findings or as a qualifier for treatment.
Ongley, et. al. Patients who had back pain for a minimum of 10 years reported an 87% recovery rate after MUA 81 patients had an average pain duration of 10 years. Patients in the experimental group were placed in a diazepam-induced amnesic state, and received manipulation after administration of local anesthetic to six different ligaments of the lumbar, lumbopelvic, and sacroiliac regions. At six months, of the 40 patients in the experimental group who received a single procedure dose, 87.5% had greater than 50% improvement in disability scores and 37.5% had recovered completely (“free from disability”).[37]

Significant gaps in the medical evidence have seemingly been overlooked by MUA advocates in the United States, with some internet-based advertisements failing for accuracy. Patients may find themselves feeling optimistic about the procedure based on these inaccuracies and/or from the commonly advertised MUA marketing mantra, “...gives you your life back”. But when an MUA practitioner is unaware of the state of the evidence being relied upon in advocating for treatment, related professional advertisements may be seen as lacking regard for meeting the standard of informed consent. This amounts to a public health concern, as chronic pain patients may be persuaded of some absolute value to the spinal MUA procedure on the basis of these advertisements.

State of the evidence for extremity joint MUA

Patients that may qualify for MUA to an extremity joint include those with stiff post-operative knee joints that have undergone total knee replacement (total knee arthroplasty- TKA).[38] [39] [40] [41] Range of motion data taken at discharge following TKA have been suggested as an indicator for MUA, when falling short of the “optimal zone” of ≥70˚ flexion combined with an extension deficit of ≤10˚.[42] It appears that the ideal period for applying manipulation to knee stiffness after TKA is at less than 20 weeks from primary surgery, with no added benefit reported from re-manipulations.[43] Similarly, another recent study also found that MUA is useful for decreased range of motion but the success rate of repeated MUA was less than that of the primary dose.[44]

Outside of the above clinical scenario and related research, the supportive evidence for MUA to other extremity joints is weak, inconclusive or non-existent. The shoulder, when failing to achieve flexibility following standard treatment, is one of the extremity regions for which the frozen shoulder condition has traditionally been cited as an indication for MUA. There are some supportive studies in this area, including one showing that patients fare better with intervention at 6 and 9 months after condition onset (having significantly better abduction and external rotation, with less pain at rest and at night).[45] However, for those studies which represent the highest level of research evidence, the results of two recent systematic reviews for frozen shoulder raise question as to treatment superiority when compared to other forms of treatment. Namely, in the 2012 systematic review, Maund, et. al. found a single adequate study, but no evidence there of better outcome with MUA versus home exercise.[46] In the 2015 systematic review, Uppal, et. al. determined MUA to be equivocal at best, when compared to hydrodilation and steroid injection.[47] The provision of MUA to an extremity joint is reserved for primary conditions thereof, such as a frozen articulation. The practice of applying MUA to an extremity joint that conjoins the spine (i.e., shoulder and/or hip), as a routine component or an extension of a spinal MUA procedure, is not supported by clinical investigation.[25] High-quality primary research is needed in this area.

Risk versus benefit

As with any procedure, there are inherent risks with MUA. The chiropractic literature seems to best address concern for potential complications with spinal MUA.[27][48] Tens of thousands of uneventful spinal and extremity MUA procedures have been performed in the United States over the past several decades. As such, in all likelihood, the risks with the procedure are relatively low or minimized with current techniques and when patients are properly selected and evaluated by the anesthesiologist, the medical physician who is providing medical clearance, and the MUA manual therapy practitioner (DC, DO, MD). However, complications or injuries have been reported in the literature. In part, these include severe sacroiliac pain with transient “pain paralysis” (of one or both legs)[49], transient respiratory distress[50], a significant adverse cardiovascular event[51], spinal fracture with hemothorax[52], lower extremity fracture[53] [54], glenoid fracture [55] [50], shoulder dislocation[56], and pseudoaneurysm [57] [58]. As the evidence for the effectiveness of MUA of most body regions remains largely anecdotal, the potential long term benefits of such treatment for chronic musculoskeletal pain must be weighed against these risks and others.

References

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