Manipulation under anesthesia (MUA) is a noninvasive stretching and manipulative technique. MUA may be performed to offer relief from chronic and recurrent back pain and other types of pain that have not responded to long-term conservative (ie, nonsurgical) care. MUA breaks up adhesions (internal scar tissue that can result from injury or surgery) and may help restore more normal range of motion and reduce pain. It is used to treat back, neck and joint pain, as well as muscle spasms and long-lasting pain syndromes.

• Adhesions can grow around spinal joints and nerve roots, and inside surrounding muscles, resulting in restricted movement, limited flexibility, and pain.

A patient undergoing manipulation under anesthesia is sedated. While sedated, the patient is in a relaxed “twilight” state, similar to the sedation for a colonoscopy. Twilight sedation allows the doctor to adjust bone/joint alignment and stretch muscles without the patient’s voluntary or reflexive resistance to the treatment. Sedation allows the doctor to apply less force, and makes the procedure painless.

Certified MUA Specialists
Manipulation under anesthesia is a subspecialty procedure. MUA is only performed by trained and certified physicians in the fields of chiropractic medicine, orthopaedics, physical medicine and rehabilitation, and osteopathy.

Are there advantages to MUA treatment?
Some patients with back pain respond well to chiropractic manipulation, physical therapy or exercise—but their relief may only last days or weeks. Sometimes, MUA is more successful in improving range of motion and relieving pain. Manipulation under anesthesia, which has been performed for more than 60 years, can be more cost-effective and safer than invasive treatments, such as spine surgery.

• MUA is recognized and covered by most insurance and workers’ compensation.

How does the doctor determine if MUA is appropriate care?
Similar to any other type of treatment recommended, the doctor thoughtfully considers the patient’s medical history, symptoms, and previous treatments and level of effectiveness. Manipulation under anesthesia is not for all people with back pain. Rather, the doctor only recommends MUA to patients who meet the procedure’s selection criteria.

In additional to talking with the patient about their complete medical history, the doctor performs a physical and neurological examination. Test results help the doctor confirm the patient’s diagnosis and determine if MUA can help relieve pain and other symptoms.

• X-ray
• MRI or CT scan
• Musculoskeletal sonogram (ultrasound imaging that uses sound waves to produce pictures of muscles, tendons, ligaments and joints in the body)
• EKG (electrocardiogram); a test that checks for problems with the heart’s electrical activity
• Nerve conduction velocity test or NCV; a test to see how fast electrical signals move through a nerve
• Pregnancy test for women of childbearing age

MUA may be considered in a patient with:

• Acute muscle spasms
• Chronic disc conditions
• Chronic sprain/strain
• Failed back surgery syndrome
• Fibromyalgia
• Fibrous adhesion(s)
• Painful, restricted range of motion
• Persistent neck or back pain
• Pinched or entrapped nerve

MUA is not an appropriate standard of care in a patient with:

• Acute (or healing) bone fracture
• Acute inflammatory arthritis
• Acute inflammatory gout
• Any type of cancer
• Metastatic bone disease (eg, bone cancer)
• Morbid obesity
• Osteomyelitis (vertebral bone infection)
• Severe osteoporosis or bone demineralization
• Spinal cord compression
• Tuberculosis (TB) of the bone
• Uncontrolled diabetic neuropathy

Bear in mind, the two lists above are not inclusive. That means there may be other disorders that can be treated using MUA. In addition, because of a co-existing medical problem, some patients may not be able to undergo any procedure that requires sedation. This is another reason why the patient’s complete medical history is vital.

How is manipulation under anesthesia performed?
MUA is often performed in an ambulatory surgery center or hospital. Anesthesia is administered by an anesthesiologist. MUA may be performed while the patient is under twilight anesthesia (sedated but not unconscious) or general anesthesia. The choice of sedation may be dependent on many factors, such as the patient’s diagnosis and severity of their condition (eg, pain). The anesthesiologist may recommend a specific type or mix of medications for patient comfort during and after the procedure.

Once sedated, the doctor employs specialized techniques (ie, manipulations) to stretch, adjust and mobilize the affected areas of the spine and/or body. The manipulations help to free up fibrous adhesions or scar tissue in one or more areas of the spine and tissues nearby.

The MUA procedure typically takes 15 to 30 minutes. The patient generally awakens quickly and is carefully monitored in a recovery area. Many patients report an immediate reduction in pain and a fuller range of motion after the first session. It is common to experience temporary muscle soreness, similar to what you might experience after a vigorous workout.

What type of MUA after care is recommended?
Before the patient is discharged, he/she is provided written instructions about therapeutic after care. Instructions for after care may include at home warm up movements, and help from a physical therapist. Physical therapy may include passive stretching, electrical stimulation, and/or cryotherapy (ie, cold therapy to help reduce inflammation and pain).

How many MUA sessions are necessary?
Depending on the patient’s diagnosis and response to the first session, manipulation under anesthesia may be performed on consecutive days; 2 to 4 days in a row. A little more movement each day incrementally may help achieve the desired increase in range of movement and reduce pain better.

Physical therapy, exercise, stretching
During the 3 to 6 weeks after MUA, the patient continues their physical therapy plan to help prevent back pain from returning and reformation of fibrous adhesions and scar tissue that was broken up during the MUA procedure. Exercise and stretching can help strengthen and stabilize the abdominal and spinal muscles, and prevent back pain from returning.