Manipulation under anesthesia

Manipulation under anesthesia (MUA) or fibrosis release procedures 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) 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 (scar tissue) 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. Manipulation under anesthesia (MUA) or fibrosis release procedures 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) 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 (scar tissue) 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. In the outpatient ambulatory or hospital-based setting, with a qualified medical physician in attendance, the anesthetic or medication component/s of the spinal MUA procedure may be provided in one of two ways. Historically, the medical literature identifies sodium pentothal as the earliest of the anesthetizing agents used with the MUA procedure. That was followed by a period during which propofol was used to induce a “twilight state” (aka, IV sedation or conscious sedation ). The latter became the doctor-preferred means of rendering the service, as it offered preservation of patient responsiveness during the delivery of treatment. With today’s MUA procedure, deep conscious sedation is accomplished with agents such as propofol, through monitored anesthesia care (MAC). As a less common mode of MUA treatment, select injectable medications can be administered directly to affected synovial joints, spinal facet joints or into the surrounding epidural space. 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). Medication Assisted Manipulation (MAM) has been used since the 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). In the MUA literature, spinal manipulation under anesthesia has been described as a controversial procedure. It has had a history susceptible to enthusiastic claims of success and indiscriminate use. With continued misperceptions about the findings and significance of primary research, similar issues remain today. An example of this is seen in endorsements for MUA that inaccurately cite study outcomes and/or focus on selective information which places the procedure, and the practice of multiple day applications, in a more favorable light. The table that follows provides detail concerning this phenomenon. Since the 1930s, spinal manipulation under anesthesia has been reported in the published medical literature. Within the existing base of studies are some reports of positive results. However, it appears that as part of the evolution of the procedure, the medical literature reveals many variations in the type of sedatives/medications used, manipulation technique, the number of MUA sessions employed, the span of time between procedure doses (if administered in series), and the types and breadth of application of post-MUA adjunctive and/or rehabilitative measures. 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. Also, because the preponderance of studies are of lower level evidence 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, and other spinal regions, relates to the two presiding theories that flexibility of the spine may be increased when adhesions are reduced, and 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. To date, after tens of thousands of spinal MUA procedures having been performed in the United States, and with more than eight decades worth of related studies, there is only one published paper in the MUA literature that clearly demonstrates the presence of spinal adhesions. That relates to two patients, whose pre-MUA advanced diagnostic imaging revealed fibrosis after prior lumbar surgery. A 2005 consensus statement from the American Academy of Osteopathy indicates that research and publication is limited for the use and effectiveness of MUA. 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. On account of that, a Delphi process was undertaken to develop evidence-informed and consensus-based guidelines for the chiropractic profession. The outcome of that process offers direction to MUA practitioners and facilities, although not intended for individual patients.