Manipulation under anesthesia

Manipulation Under Anesthesia (MUA) is multidisciplinary manual therapy treatment system which is used to improve articular and soft tissue movement using specifically controlled release, myofascial manipulation, and mobilization techniques while the patient is under moderate to deep IV sedation using monitorized anesthesia care (MAC).^[1]

This procedure is used by specially trained chiropractors and orthopedic surgeons as a means of breaking up scar tissue around a joint without complete range of motion. 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.^[2]

Training

Currently MUA certification courses offered through accredited chiropractic college post graduate departments are recognized by malpractice carriers for inclusive coverage. It has been important to regulatory agencies, academic institutions, professional associations and organizations and malpractice carriers to recognize appropriate training programs. Towards that end, specific criteria have been adopted to establish credible certification course offerings. Standards and protocol establishing credible certification training programs are recognized by the National MUA Academy of Physicians and the International Academy of MUA Physicians and are subscribed to by the accredited academic institutions offering post graduate certification in Manipulation Under Anesthesia.^[3]

Evidence basis

• “In a first study by Siehl ad Bradford published in 1952, 33 percent of the patients … demonstrated good (symptom-free) results.” Page 294
• “Siehl’s followup study … 96 percent reported successful (good or fair) outcomes.”
• “In Chrisman’s study 83 percent of the subjects reported good or excellent result after a 3-year follow-up.” Page 294
• “In Morey’s 1973 review … treating physician reported excellent or good results in 85 percent of the cases.” Page 294
• “In a study published in 1986 by Krumhansel and Nowacek … outcomes were reported as 25 percent ‘cured’, 50 percent ‘much improved’, and 20 percent ‘better, but’. Page 294
• “In a 1990 article by Mennell … 30 percent with symptoms cured, 35 percent with marked improvement, 29 percent with moderate improvement…” Page 294
• “In a recent case series by West et al … VAS scores improved 4.6 points for cervical pain and 4.31 points for lumbar pain. Decrease in time off work and less use of prescription pain medication were also reported.” Page 294
• “We have been unable to find any report of complications using more modern osteopathic and chiropractic techniques or as a result of the use of anesthesia.” Page 297 ^[4]

In addition, for over 30 years now, the collection of MUA procedures (including hip, pelvis, spine, and back among other body regions), has been listed as a Category I CPT ^[5] code in the AMA Codebook of Reimbursable Procedures.^[6] The introduction of that book notes that in order to qualify as a Category I code, "the clinical efficacy of the service/procedure is well established and documented in the United States per review literature." This was later reaffirmed by the AMA, where they noted that simply by having a Category I code, a procedure, by definition is not experimental and has a well established clinical efficacy.

History

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 SM.^[7]

References

External links

• Manipulation Under Anesthesia: A Report of Four Cases. Cremata, et al. J Manipulative Physiol Ther. 2005 Sep;28(7):526-33