What is MUA?
Manipulation under anesthesia (MUA) is a non-invasive medically approved procedure for acute and chronic neck, back and joint pain. It is safely and effectively utilized to treat pain arising from the cervical, thoracic and lumbar spine as well as the sacroiliac and pelvic regions.
MUA uses a combination of specific short level arm manipulations, passive stretches and specific articular and postural kinesthetic integrations to break up fibrous adhesions around the spine and surrounding tissue. The combination of manipulation and anesthesia is not new as this treatment has been part of the manual medical arena for more than 60 years.
MUA is performed by a licensed physician with specialized training and certification specifically for the procedure. A team approach is required to have a safe and successful outcome. The team includes the anesthesiologist, the prime physician/surgeon and the first assistant, also a physician duly licensed in MUA. The procedure must be performed in a hospital or surgical center.
Manipulation Under Anesthesia is an established medical procedure with a CPT Code designate of 22505. This is noted in the American Medical Associations Current Procedural Terminology Publication. The procedure is neither experimental nor investigational.
Who should be considered?
Certain neck, mid back, low back or other spinal conditions respond poorly to conventional care. The problem is that due to past or present injury, adhesions and scar tissue have built up around spinal joints and within the surrounding muscles causing chronic pain. Patients often undergo various treatments from physical therapy, chiropractic care, epidural injections, back surgery or other treatments that do not address the fibrous adhesions. Some patients feel better temporarily, but their pain returns as the fibrous adhesions have not been removed.
In general, patients selected for MUA are those who have received conservative care for 6 to 8 weeks. If limited or no improvements in symptoms or objective findings has occurred in the character or the quality of these findings then MUA is an appropriate alternative.
Protocols of diagnostic testing document injuries support the need for treatment and eliminate questions of malingering. In addition to X-ray, MRI or CT scan, a musculoskeletal sonogram or Nerve conduction velocity test may be ordered. Both tests are read by a board certified Medical Neurologist.
Effects of Therapy
- Breaking up scar tissue (adhesions) both in and around the spinal joints commonly caused by multiple injuries and failed back surgery.
- Decreasing chronic muscle spasm.
- Overcoming super sensitivity of injured areas making the patient unable to cooperate for effective treatment.
- Stretching persistent shortened muscles, ligaments and tendons.
- Relieving pain and radiating symptoms from damaged intervertebral discs.
Anesthesia & Manipulation
Of course, when movement of the spine is extremely and intolerably painful to the patient, the benefit of being unconscious is obvious, but the anesthesia performs other equally important functions, such as:
- Shuts off the muscle spasm cycle to allow spinal movement.
- Sedates the pain perceiving nerves that have been irritated due to the dysfunctional spine.
- Allows complete muscle relaxation to allow the doctor to stretch shortened muscle groups and to break up adhesions caused by scar tissue.
Indication
- Neck, mid back and low back pain
- Chronic muscle pain and inflammation
- Acute and chronic muscle spasm
- Decreased spinal range of motion
- Chronic fibrositis
- Nerve entrapment
- Pseudo-sciatica
- Sciatica where disc bulges are contained less than 5 mm
- Failed back surgery
- Chronic occipital or tension headaches
- Conditions where narcotic pain relievers are of little benefit
- Traumatic torticollis
- RSD
Contraindications
Contraindication to anesthesia as determined by current medical literature and is the responsibility of the licensed medical co-manager (anesthesiologist).
Contraindications to manual manipulation of high velocity, low velocity or soft tissue techniques as established by current literature relative to technique specific for articular derangements, bone weakening and destruction disorders, circulatory and cardiovascular disorders, or neurological disorders.
Specific contraindications to manipulation of the spine under anesthesia are malignancy with metastasis to bone, tuberculosis of the bone, fractures, acute arthritis, acute gout, uncontrolled diabetic neuropathy, syphilitic articular or periarticular lesions, gonorrheal spinal arthritis, excessive spinal osteoporosis, evidence of cord or caudal compression by tumor, ankylosis and malacia bone disease.
Evaluation of Patient
Candidates are selected for manipulation under anesthesia after obtaining an adequate history, thorough physical examination, and the appropriate diagnostic imaging and laboratory procedures necessary for an accurate diagnosis of the underlying condition.
History and Physical
The burden of proof for medical necessity rests with the treating doctor. It should be substantially documented in the history and physical with specific emphasis on the failure to respond to conservative means in the history; indication of fibrosis and/or myofibrosis in the physical examination; and any supportive diagnostic testing as indicated and warranted by medical necessity of the patients condition.
A complete physical examination is performed paying special attention to motion palpation of the spine and a visual inspection and palpation of the skin (manifestation of sympathetic nervous system changes including edema, tissue texture, increase or decrease of moisture, temperature changes, etc). Additionally, digital palpation identifies increased or decreased changes in muscle and fascia tone which lead to altered biomechanics.
Laboratory Exam
Laboratory examinations should include a complete blood count, sedimentation rate, thyroid function tests, urinalysis, and blood uric acid, Creatinine, blood sugar, RA latex, C-reactive protein antiserum agglutination, and Electrophoretic serum protein determinations. Females of child bearing years should be evaluated for pregnancy. A male past 40 years of age should also have the following test done: serum alkaline and acid phosphatase. After completion of the preliminary work other laboratory procedures may be indicated.
Radiographic Examination
Anterior-posterior and lateral radiographs of the joints involved should be taken. Additionally, extension and lateral bending views may be of benefit in visualizing loss of function. Many times one may want detailed view of the joints which are to be manipulated under anesthesia. Motion studies on fluoroscopy may be helpful. One should repeat studies after serial manipulation under anesthesia to see what changes have been affected by the procedure. When warranted, CT Scan and/or MRI of the spine should be employed to rule out or confirm suspected pathology.
Electrodiagnostic Studies
Electrodiagnostic studies of the appropriate spinal outflows should be performed to rule out specific neurological dysfunction, and to confirm or differentiate whether it is a radicular or peripheral neurological condition.
Manipulative Techniques
Techniques may vary from patient to patient under anesthesia as medical necessity indicates by the involved tissues and existing relative contraindications and/or possible complications that may exist.
Some of the techniques include:
- Soft tissue procedures - lateral stretching, linear stretching, deep pressure, traction and/or separation of muscle origin and insertion.
Tissue: periarticular
Goals: decrease muscle spasm and increase tissue mobility
- Articulatory procedures - mobilization without impulse, low velocity techniques, placing articulation through full anatomic range of motion. A passive serial repetitive oscillatory rhythmic springing force in the direction of restriction.
Tissue: periarticular and articular
Goals: increase quantity of motion - gradual movement of restrictive barrier to restore range of motion increase quality of motion - smooth range of movement with normal elastic and feel
- Specific joint mobilization procedure - mobilization with impulse, high velocity technique. Extrinsic operator applied thrust overcoming restrictive articular movement. Engagement of the restrictive barrier and thrust through the barrier to achieve normal joint movement.
Tissue: articular and intra articular
Goals: increase joint range of motion reduce joint restrictions reduction of hyper tonicity stretch shortened fibrosed connective tissues of the articulation
Post Operative Care
Of course, when movement of the spine is extremely and intolerably painful to the patient, the benefit of being unconscious is obvious, but the anesthesia performs other equally important functions, such as:
- Shuts off the muscle spasm cycle to allow spinal movement.
- Sedates the pain perceiving nerves that have been irritated due to the dysfunctional spine.
- Allows complete muscle relaxation to allow the doctor to stretch shortened muscle groups and to break up adhesions caused by scar tissue.
Studies
MUA for the Shoulder
In the process of a manipulation under anesthesia the patient is brought into the operating room and given a general anesthetic by an anesthesiologist. With the patient asleep and with their muscles paralyzed, the shoulder is then taken through a "range of motion". In the course of manipulating the shoulder to reach a nearly full range of motion, popping sounds can often be heard inside the joint, signifying a tearing of the adhesions. At the same time, it is possible to gradually stretch the muscles that are external to the shoulder joint.
When a patient wakes up from this procedure, their shoulder is often a bit more painful than it was before the procedure. A special effort is made to control shoulder pain after a manipulation under anesthesia with narcotic pain medications so that the patient is able to move their shoulder without fear of disabling pain. The most important part of this process actually comes after the manipulation, because physical therapy is used to insure that the improvements in motion are not lost by inactivity. Therefore, it is very important that patients who have had a manipulation under anesthesia have easy access to physical therapy and are motivated to complete their home exercise.
What happens if this doesn't work?
Usually, a manipulation under anesthesia followed by physical therapy is successful in the majority of patients. However, if it is unsuccessful, a surgical procedure can be performed certain situations in which an arthroscope is placed in the shoulder and the adhesions and scar tissue are removed.
