Manipulation under anesthesia or MUA is a procedure to be considered when a patients fail to reach
adequate outcomes from regular conservative care such as chiropractic or physical therapy. A patient
with a chronic condition of pain and spasm relating to the compromise of joint function caused by
fibrotic adhesions leading to a limitation of range of motion/intractable joint restriction are the most
suitable candidates. As pain and spasm often limit the extent of conservative treatment methods that
can be used when treating these cases. These patients must have already undergone a regular course of
care conservative care, at least 4 to 8 weeks, and still be suffering from reproducible and residual
symptoms of pain and dysfunction that are interfering with their activities of daily living. Imaging should
be used to identify the specific areas of fixation and in spinal cases to identify levels of disc bulges and
herniation. This procedure is best suited to reduce joint restrictions caused by fibrotic tissue that causes
the above mentioned symptoms.
When a patient has been identified that would potentially benefit from the MUA procedure
contraindications must be considered to see if the patient is eligible to have the procedure. The
contraindications for MUA include those from both the manipulative therapy and the anesthesia that
are involved in the procedure. These contraindications include tuberculosis or any other infectious bone
disease, any metastatic malignancy to the bone, recent fractures, acute arthritic episodes, acute gout,
unmanageable diabetic neuropathies, syphilitic and/or periarticular lesions, gonorrheal spinal arthritis,
advanced levels of osteoporosis, fragmented discs, nerve impingement that would negate manipulative
treatment and cord or caudal compression via stenosis or SOL. A complete patient exam and history
needs to be completed and reviewed for any possible anesthetic complication relating blood
pressure/hypertension, heart disease, stroke risk, other metabolic disorders, allergies and current
Following an MUA, prompt and complete follow up care is required for the best possible outcomes.
Rehabilitation following the MUA minimizes the reformation of scar tissue and adhesions, reduces
inflammation and pain thus helping retaining the increased range of motion. It is recommended post
MUA therapy begin the same day as the initial procedure including PROM’s through all normal ranges,
interferential or TENS therapy, neuromuscular reeducation and cryotherapy. This protocol should be
followed after every MUA procedure with manipulation not recommencing till after the last MUA
treatment. Home rehabilitative exercises can be added to the treatment protocol in weeks 2 and 3.
Starting in weeks 4 or 5 treatment frequency can be reduced to 1 or 2 times a week and strengthening
and stabilization exercises can be added to in office and home care protocols. Proprioception/co-
ordination, flexibility and endurance exercises all should be added during the last weeks to enable the
patient to reach maximum levels of improvement from MUA. These protocols should all be adapted to
the specific patient’s progress levels.
Manipulation under Anesthesia is a multi-disciplinary procedure and requires several different health
care professionals to be performed. Anesthesia is performed by a state certified and licensed
anesthesiologist, they supervise the administration of the medications following the guidelines of their
profession. The anesthesiologist is the party responsible for the medical practices during performance
of an MUA. As such the anesthesiologist also can make their own determination if the patient can
tolerate or be a candidate for anesthesia.
A nurse will also assist with the procedure from beginning to end, they will aid the patient filling out the
required paper work and directing them through the pre-operation process, they will aid with MUA, and
transport and tend to the patient after the procedure. The nurse is responsible for procedure that fall
under the practice of medicine as these are in their scope of practice and not the chiropractor’s.
Co-managing patients can often be required when treating with MUA orthopedists or other MD’s are
often included for pre or post procedure injections. Physical therapists are another health care provider
that should be considered as post-surgical rehabilitation can be time consuming and require certain
modalities that are not readily available to the chiropractor. These factors sometimes make a physical therapists better suited to post-surgical management.