MUA Is A Non-Surgical Solution To Back Pain Where Standard Chiropractic Manipulations Had Minimal Results
A Conservative Treatment Alternative For Patients With Chronic Pain
Spinal manipulation under anesthesia is a procedure that primarily originated with the osteopathic profession and has been utilized for the treatment of spinal pain since the late 1930s. Documentation regarding the success and value of manipulation under anesthesia has been recorded in the osteopathic literature since 1948 when Clybourne reported in the Journal of American Osteopath Association a success rate of 80-90% which has been maintained to this day.
In the last two decades, the emphasis regarding manipulation in osteopathic education has greatly decreased. Therefore, the osteopaths that had been adequately trained in manipulation are coming to the close of their careers or have retired. Because of the need for continuance of this procedure, the focus for the performance of spinal manipulation under anesthesia has now shifted to chiropractors and their expertise in spinal manipulation skills.
Indication For Manipulation Under Anesthesia
Spinal manipulation under anesthesia is a procedure that is intended for patients that suffer from sometimes acute, but mostly chronic musculoskeletal disorders in conjunction with biomechanical aberrancies. These individuals have also been minimally responsive to previous conservative therapy. Etiology of their pain can be disc bulge/herniation, chronic sprain/strain, failed back surgery, myofacial pain syndromes in conjunction with those listed below. The procedure is extremely beneficial for the patient that has muscle spasm accompanied with pain and terminal joint range of motion loss. These types of patients typically respond well to manipulation/physical therapy/exercise, but their relief may only be temporary (days to weeks). To ensure good results with a procedure of this type, one of the most important considerations is patient selection.
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- Bulging, protruded, prolapsed or herniated discs without free fragment and are not surgical candidates
- Frozen or fixated articulations
- Failed low back surgery
- Compression syndromes with or without radiculopathies caused from adhesion formation, but not associated with osteophyic entrapment
- Restricted motion, which causes pain and apprehension from the patient
- Minimally responsive to manipulation and adjustment when they are the therapy of choice
- Minimally responsive pain, which interferes with the function of daily life and sleep patterns, but which falls within the parameters for manipulative treatment
- Minimally responsive muscle contraction, which is preventing normal daily activities and function
- Post-traumatic syndrome injuries from acceleration/deceleration or deceleration/acceleration types of injuries, which result in painful exacerbation of chronic fixations
- Chronic recurrent neuromusculoskeletal dysfunction syndromes, which result in a regular periodic treatment series, that are always exacerbation of the same condition
- Neuromusculoskeletal conditions that are not surgical candidates but have reached MMI especially with occupational injuries
- Any form of malignancy
- Metastatic bone disease
- TB of bone
- Acute bone fractures
- Direct manipulation of old compression fractures
- Acute inflammatory arthritis
- Acute inflammatory gout
- Uncontrolled diabetic neuropathy
- Syphilitic articular or periarticular lesion
- Gonorrheal spinal arthritis
- Advanced osteoporosis
- Evidence of cord or caudal compression by tumor or disc herniation beyond 5mm
- Widespread staph/strep infection
- Sign/symptom of aneurysm
- Unstable apondylolysis
MUA Procedure and Follow Up Care
Manipulation under anesthesia (MUA) is performed using Deep IV using Monitored Anesthesia Care (MAC) usually using Diprivan (Propofol), and Versed as the anesthesia. The patient is taken through passive cervical/thoracic and lumbar ranges of motion in flexion, lateral flexion and rotation. Specific spinal manipulation is performed when the elastic barrier of resistance and segmental end range of motion is achieved. Then stretching of the paraspinal and surrounding supportive musculature is performed to promote cervical, thoracic, lumbar and lumbopelvic flexibility in conjunction with attempting to restore proper kinetic motion.
The Patient is then awakened from the anesthesia, which usually occurs minutes after the diprivan is stopped. They are taken to recovery and monitored until full recovery has occurred. This varies but is usually accomplished within a very short period of time. The patient is then discharged to rest until post-MUA therapy is begun later the same day.
Post-MUA therapy is a vital part of the MUA procedure and is accomplished the same day as the procedure to help continue the alteration of adhesions in the joints, joint capsules, and surrounding holding elements. Post MUA therapy consists of warming up the involved areas with passive stretching as was accomplished in the MUA procedure, followed by interferential stimulation and cryotherapy. The patient is then sent home to rest.
This exact procedure is repeated serially in most cases by having the patient return to the facility the next day and the following day(s). The average number of days for the MUA procedure to accomplish the desired outcome has been shown to be between 2-4 days. Consecutive day procedures have been shown to alter adhesion formation and joint dysfunction in a manner that single procedures do not accomplish. The concept is that a little more movement each day in incremental movements accomplishes the desired increase in range of movement and decrease pain far better than trying to spend great amounts of time on one day to accomplish the same movement.
This also has a dramatic effect on decreasing the post-MUA therapy time. This protocol for post-MUA therapy is repeated 7-10 days straight after the final MUA followed by pre-rehabilitation and then formal rehabilitation for 3-6 weeks. Additional assistance with the reduction of soreness and mild edema with an increase in range of motion, has been noted when small, portable, multi-modality interferential/NMES/HVPC devices are applied in the OR directly after the MUA procedures are accomplished and the patients are sent home with these units prior to receiving post-MUA therapy.
The rehabilitation program continues for 3-6 weeks following the MUA procedure to give the patient time to recover to pre-injury status. It gives the patient confidence that they have achieved recovery, and in most cases, the patient’s return to work and daily lifestyle with a renewed feeling of confidence in their ability to accomplish everyday tasks that they have previously been unable to accomplish due to pain and reduced movement. Marked improvement (80-97%) has been the general rule when the properly selected cases have received this procedure. Strict adherence to standards and protocols should be the rule of thumb when considering the MUA procedure and only certified MUA practitioners taught through accredited institutions should be allowed to practice this technique – reimbursement should also reflect that proper educational standards have been achieved.
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In addition to the parameters of patient selection, appropriate pre-MUA conservative procedures are required. This includes traditional chiropractic/manual therapy for a minimum of 4-6 weeks (2-4 in acute cases), plain film radiographs and advanced imaging study such as MRI, CT when required by the condition. Neurological and/or orthopedic evaluation, in conjunction with EMG/NCV/SSEP studies, in many cases are also performed. This provides cross-disciplinary evaluations that support the concept that this is a team effort. Also, any other appropriately recommended treatment options/testing would be considered at this time. Any other recommended treatment options/testing would be made available to the patient prior to undergoing the MUA procedure.
Just prior to the MUA procedure, a medical history and physical examination is to be performed to assure that the patient is capable of undergoing the procedure with no additional medical complications. Included with this evaluation should be an ASA standard testing for conscious sedation such as chest x-ray, EKG (if the patient is over 50, or if their physical condition warrants it), and pregnancy testing for females. An anesthesia interview is then provided. This is to assure that the anesthesia, Diprivan (Propofol), Versed and sometimes Fentanyl would be appropriate for the patient and if there are any projected complications from the anesthesia that should be addressed. Back to top
These patients have been relatively minimally responsive to other conservative methods of treatment and not much more is available through the traditional health care delivery system. As with any procedure, there are no guarantees of success. However, if the protocol is closely adhered to, the likelihood of a positive outcome is increased. It is also extremely imperative that the physician providing the manipulation is properly trained. Back to top
Professional differences of opinion regarding MUA are common. Once an adequate explanation of the procedure and clinical rationale for performing the procedure is understood, MUA is generally well accepted within the chiropractic and medical communities. This is truly a multi-disciplinary approach for the treatment of spinal pain.
Parameters for Selection of the Number of MUAs to Accompany the Algorithm
As with any treatment technique, determining the exact number of treatments is like trying to look into a crystal ball and being correct with what you see.
To determine the amount or number of treatments required to get the desired results is more accurately measured if we place numerical or response indices with patient reaction to the procedure. Parameters, such as chronicity and age, which have already been established in the protocols and standards in determining the number of MUAs required, are then factored in.
The spinal MUA procedure is a procedure that has seen transitional and historical evolution. Today, with the advancement in mobilization, manipulation, and adjustive techniques which are being used extensively and exclusively within the Chiropractic profession, the MUA technique has taken on significant importance in the care of many neuromusculoskeletal conditions. In the past these conditions were not responding to care and were not surgical candidates, so the patient was simply left to “live with the discomfort”.
These new parameters for determining the number of MUAs come from the outcome assessments of a 60 case study in Newport News, VA, (R. Gordon; B. Rubin, 1994). Clinical trials of some 10,000 cases reviewed and completed by the National Academy of MUA Physicians membership over the past 15 years, and current studies being completed in Lancaster, PA, Pittsburgh, PA, New York, and California have also aided in determining these parameters.
The American Association of Manipulation Under Anesthesia Providers (AAMUAP) in conjunction with the old National Academy of MUA Physicians standards and protocols, recommends the following considerations when determining the need for MUA and the addition of serial MUA to the treatment protocol:
- Patient response and progress to rendered conservative care.
- Patient’s responses to the ability to function with everyday activities given the current care being rendered.
- The patient’s psychological acceptance of the MUA technique, and the psychosomatic response to overcoming chronic pain and discomfort given the length of time the patient has been away from the work load environment.
- Prevention of further gross neuromusculoskeletal deterioration if the MUA procedure were not performed given the amount of time the patient has been under conservative and/or surgical care.
- Prevention of or the diagnosing of specific parameters for surgical intervention.
- Correction of failed surgical intervention.
In comparing clinical reaction to MUA that has been observed by the majority of the National Academy of MUA Physicians membership with the studies that are currently being completed, the following parameters for continuing with the plan for single or serial MUA has been recommended:
Single Spinal MUA is most often performed when the patient is of a younger age, and when the injury to the area is of the first order (determined to be the first injury to the involved area).
Single Spinal MUA is most often performed when the injury is of the first order and the care being rendered has had sufficient time (protocols determined minimum 4-6 weeks) of conservative care and where the patient’s lifestyle and daily activities are being interrupted in such a fashion as to warrant immediate relief. (Medical intervention and evaluation is recommended by the academy standards.) NOTE: The National Academy of MUA Physicians feels that in this instance, if the patient is treated for the *intractable type of pain with a single MUA procedure and responds well, the necessity for future MUAs is greatly reduced.
* intractable pain – pain that is interfering with activities of daily living in such a manner as to prevent normal daily routines; are minimally responsive to pharmocological interventions orally or by injectibles, have become only minimally responsive to physical manual therapy, and are determined not to have the pre-requisites for surgical interventions at the time of evaluation for MUA.
Serial MUA (more than one MUA) is recommended when conservative care, as described in the National Academy of MUA Physicians standards and protocols, has been completed and when the condition is chronically present. When the injury is recurrent in nature, and when it is determined that fibroblastic proliferative changes in the collagen tissues and articular fixation (arthrokinetic dysfunction) prevents a single MUA from being effective then serial MUA is recommended.
Determining the Number of MUAs
The older versions of the National Academy of MUA Physicians standards and protocols refer to a numeric scale for determining whether serial MUAs and the number of serial MUAs is the correct choice. This early scale was used as a “guideline” only for trying to determine the correct clinical validity in moving forward with additional MUAs, or whether one MUA was sufficient to warrant the ability of the patient to respond again to conservative office care or whether additional MUAs were necessary for that return to conservative care.
It became very evident that the use of percentages of improvement were subjective evaluations and therefore open to interpretation by either the physician, or anyone who would look at these “guidelines” as the only determining factor in whether additional MUAs were warranted. Since I am responsible for defining these percentages which came from an original 60 case study completed in Newport News, VA in 1994, it becomes my responsibility to suggest that these percentages were used to help determine improvement in a patient which along with pain scales, range of motion, electro-diagnostic studies, x-rays and the patients over all feelings of improvement were addressed as we proceeded with additional MUAs when these factors showed that the patient was not improved as we would like to see. That’s why these percentages were created and originally used, and that’s how they came to be part of the National Academy of MUA Physicians.
As we have progressed in our knowledge of patient response to MUA over the past 20 years, it has become quite evident that these percentages were too limiting and did not take into consideration that each patient is different and that we are working with the human body, and percentages (being more mathematical entities) did not allow for the physician to make “patient oriented” decisions about patient progress. Yes, it is important to examine the patient following the MUA procedure each day, and yes it is important for the physician to see improvement (or for that matter, no improvement). But it cannot be limited to a mathematical number with no room for individual assessment and patient response. With that in mind we are changing the approach to determining whether single or serial MUA is necessary, and if serial MUA is necessary, we are going to determine that based on patient improvement using various mechanisms to show that improvement or lack of improvement as the case may be. This evaluation of the need for single or serial MUA will then be determined pre-MUA, and based on examination with the above referenced concerns as to patient physical demographics when the examination is performed specifically to indicate that the patient is an MUA candidate, and should not be based on re-evaluation between each MUA as it should already be determined that a single or a serial MUA is required for the completed treatment.
Since we are addressing the scientific evidence that change is occurring by evaluating the science of change that we are working toward, it becomes necessary to address these sources of change and then see how best to determine change that has occurred and therefore improvement (or no improvement). First we must consider the science of MUA and the changes that we are looking to see. Decrease in pain; increase in range of motion (ROM); decreased muscle spasm and contracture; improved patient arthro-kinetic movement; and over all psychological patient improvement are what we are looking at in determining if the MUA that we have completed has made change. So let’s address these mechanisms to determine if consideration of the evidence based opinion of improvement suggests patient improvement, how much improvement, and whether additional MUAs would be necessary to reach that level of improvement that we are seeking.
First, has the patient had a change in the painful stimuli that has affected their activities of daily living. Through the use of myofascial release techniques, stretching, and articular movement, the reticular formation which affects the alpha motor neurons in the dorsal horn have been affected thus decreasing the patients response to painful stimuli. The use of propofol, versed, and other medications provided by the anesthesiologist has also played a large role in the patients’ ability to respond to these gentle stretches and articular movements that have altered this mechanism of painful stimuli. Has the patient responded to these factors in such a manner as to have completely recovered from these symptoms, or is there residuals, that would make the second and/or third MUA necessary. The VAS is used and interpreted by the doctor and the patient to determine if there is change.
Second, has there been a reduction in or altering in fibroblastic collagen fiber proliferation in and about the joints, joint capsules, and muscles fibers to indicate that the patient has returned to pre-MUA status to sufficiently return to the conservative office therapy program? This is determined by increased range of motion; decrease in muscle spasm and muscle contracture, and increased artho-kinetic movement. Is there still muscle congestion, decreased ROM, and muscle guarding to indicate that the second and/or the third MUA is necessary?
Third, a base line psychological evaluation (i.e. Mensana; Roland Morris; Oswestry) should be part of the pre-MUA examination to understand the
psychosomatic mechanism that could be present with chronic segmental dysfunction. Post MUA evaluations should include change in these indices indicating that improvement has been achieved, and how much. This then would indicate that the second and/or third MUA would be necessary.
Fourth, physician evaluation of the patient. Evaluation of the patient is based on all of the above and can include computerized muscle testing; computerized range of motion testing; use of a visual analyzing scale that the patient becomes familiar with and understands; orthopedic and neurological testing; motion palpation and articular (arthro-kinectic) restriction evaluation; and patient/physician questioning.
As you can see, this is both subjective and objective. But results with MUA are also both subjective and objective. As we look into research within the MUA field we are concentrating on evaluating the possibility of disc decompression; the biomechanical lysing of intradural adhesions; the reduction of entrapment syndromes from painful soft tissue entrapment when there is abnormal biomechanical articular dyskinesia (the subluxation complex); and analyzing the effects that anesthesia has on the whole complex of relaxation-passive stretch-and articular movement. This is a more broad overview of evaluating the patient for serial MUA, but it is more practical also. If change occurs in patients that way that it does, patients with chronic muscle contracture and intense pain with concomitant joint restriction take longer to work with and require more treatments than patients who only have minimal restriction from injuries that have no chronic component. The concept here is to make the decision to incorporate serial MUA in cases that need the additional procedures, and not to just do a procedure because someone said three or four or even five procedures were the best. Evidence based decisions take evidence to prove that the right decision to perform single or serial MUA is the correct choice for the patient recovery. Happily in recent years the practitioners of the MUA procedure have taken it upon themselves to evaluate the patients as they undergo MUA each day, and as more and more procedures are taking place, the outcomes will replace opinion whether from the physicians, reviewers or carrier policy, and will be based on factual change in patient improvement levels.
Considerations for Manipulation Under Joint Anesthesia (MUJA)
MUJA, has advanced into the field in the past 4 or 5 years as an alternative to conscious sedation by using joint injection to decrease the inflammation in the joint, anesthetize the joint, and manipulate the joint to provide mobilization and flexibility while decreasing joint irritation.
MUJA is used for acute care MUA and is being put forward by the concept that relief from intractable pain (pain, neuromusculoskeletal in origin, with no relief) could be provided by injection into the affected joint, with mobilization and manipulation used secondarily to diffuse the injected medicine and help eliminate the inflammatory reaction in the affected joints (Dreyfuss, Michaelsen, & Home, 1995).
Early mobilization of the involved joints, despite otherwise intractable pain and/or muscle spasm, reduces compressive forces on the discs, facet capsules, and nerve roots (Which would cause additional scar tissue if left untreated), thereby allowing nutrients and fluids into the area of the lesion and helping the body heal itself more naturally and rapidly.
In Acute Care MUA, MUJA reduces:
- Excessive scar tissue build-up
- The chance for muscle contracture
- Duration and frequency of regular outpatient spinal manipulative therapy
- The percentage of resultant permanent impairment
MUJA has been used to affect joint involvement in chronic neuromusculoskeletal conditions. Injection into the involved joint to determine the pain location has been utilized for many years as both an objective diagnostic tool and a therapeutic tool. It is employed in conjunction with the injection to improve joint mobility. The same standards of care and protocols are followed when patients are chosen for the MUJA procedure as for the MUA procedure. The conditions treated with MUJA are somewhat the same as MUA, with the exception being more joint involvement as compared to myofascial and/or muscular involvement.
The majority of MUA candidates historically have been those patients who suffer from chronic joint restriction due to fixation from disuse following trauma. This syndrome sets up a vicious cycle that Michael Alter (1988) calls the “self perpetuating cycle of muscle spasm.” In this cycle, the patient undergoes a form of trauma, which can be caused by direct contact or through repetitive incremental injuries. These injuries then set up pain stimuli, inflammation, emotional tension, sometimes infection, temperature variations, and eventual immobilization from disuse. As the cycle proceeds, it sets up reflex muscle contraction which, if gone untreated, progresses to muscle contracture. This, in turn, progresses to restricted movement and fixation in the joints, which has a direct effect on what Wyke (1972) calls “dysfunctional postural kinesthetics.” Wyke refers to a disturbance in postural kinesthetics resulting in altered mechanoreceptor response. Typically, Types I, II, and IV mechanoreceptors are concurrently involved, setting up a cycle of trauma induced altered posture affecting movement, which then stimulates nociceptive response.
Using the MUA technique, we complete stretching maneuvers and mobilization techniques coupled with specific adjustive techniques to help alter adhesion accumulation that has been laid down by the body as connective tissue protective mechanisms to prevent further damage to the areas involved. Because new medications allow us to perform this technique while the patient is in conscious sedation, we can provide progressive linear forces to these areas and alter these adhesions without tearing tissue in the process. Because these medications allow the patient to relax and not respond with immediate muscle contraction when pain is perceived, we are able to perform these maneuvers so that end range is not lost. The natural protective mechanisms are present but are slowed down temporarily, and pain is perceived, but not remembered (Gordon, 1993).
By completing the MUA procedure as a team, with the anesthesiologist as a very valuable member who provides just the right medications to allow this physiological change from the normal office manipulative therapy program, the certified MUA doctor is able to accomplish considerably more with MUA than if the same patient were to undergo these procedures in the office setting without the conscious sedation. The most important concept here is that if the patient were able to recover in the office setting without the use of conscious sedation, the patient would not have been a candidate for the MUA procedure in the first place.