International MUA Academy of Physicians
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An Overview of
Manipulation Under Anesthesia (MUA)

Chapter Author:

Dr. Robert S. Francis
Clinical Assistant Professor of Family Medicine
Department of Family Medicine
University of Texas Medical Branch at Galveston

Associate Professor of Clinical Sciences
Course Director, Division of Post Graduate Studies
Texas Chiropractic College

Chief, Department of Chiropractic Medicine
Vista Medical Center Hospital

Taylor & Francis

Taylor & Francis Imprint
A CRC Press title

To Contact Dr. Rob Francis to schedule speaking engagements, training and certification courses in Manipulation Under Anesthesia, please call 281-998-9454 or email at


The first certification course in MUA for chiropractors was developed in the mid-1980’s, by Dr. Rob Francis while Dean of Clinical Sciences at Texas Chiropractic College and after being certified and proctored in MUA by board certified orthopedic surgeons. A variety of standards for MUA have been taught since by non-academic proprietary organizations over the last fifteen years. MUA has been utilized in manual medicine for over 70 years. Increased participation of chiropractors on hospital medical staffs and with medical physicians has made both the facilities and training more available for performing and credentialing this procedure.

Specific protocol for the procedure has been developed by academic institutions and national and international organizations towards an effort to recognize training programs and clinical outcomes that establish a safe and effective means of implementing this procedure across the country in appropriate hospital and ambulatory surgical settings. Most recently the International MUA Academy of Physicians was organized to provide an avenue for the dissemination of valid and authoritative database of current research and new scientific developments in the field of Manipulation Under Anesthesia for physicians dealing with chronic difficult cases through efforts to develop evidence-based principles for MUA clinical application and practice.

The National Academy of MUA Physicians has developed and published guidelines and protocol for MUA consistent with the CCE accredited MUA programs of Texas Chiropractic College. Standardization of MUA protocol is largely accomplished across the country and in Europe.

Continuing education and international conferences are designed to accomplish, implement, fulfill and discharge the purpose and intent of this mission. The objectives of these continuing education conferences are to present by an international and interdisciplinary faculty a state of the art review of the present knowledge in the field of non-operative care, interventional diagnostic and therapeutic procedures other relevant treatment modalities affecting the spine.

It has been well documented in the medical literature for well over forty years that chronic unresolved non-surgical musculoskeletal conditions respond well to manipulation under anesthesia. MUA is a procedure designed to restore the lost range of motion of the spine and extremities and to reduce scar tissue in soft tissues and peri and intra articular structures which results in articular dyskinesia.

The restoration of motion and the reduction of scar tissue results in more flexibility and visco-elasticity of the paraspinal musculature and associated articulations thereby increasing the functional capacity of the patient. MUA is a procedure utilized in a selected patient population which has been recalcitrant to an adequate trial of conservative care in the office setting.

MUA requires the use of non-paralyzing anesthesia (patients continue to breath on their own during the procedure) towards an effort to provide relaxed skeletal musculature enabling the manipulator to reduce fibroblastic proliferative tissue and restore articular motion without patient guarding and pain. Generally, pre-op medications include Versed and Fentanyl with Propofol used in the Operating Room without intubation to accomplish flaccid muscular relaxation.

This procedure is an out patient procedure and is performed in an appropriate setting providing access to monitoring and resuscitation equipment in a facility certified or licensed to provide a safe operative environment which can provide transfer capability to inpatient care.

It is recommended that an assistant who is certified in the procedure be present to assist in the performance of MUA. It is essential that the assistant be knowledgeable in the biomechanics and pathomechanics of the condition being treated towards an effort to assist proper positioning before and during the manipulative procedures performed by the primary physician. Many manipulative procedures under anesthesia are performed in tandem by the manipulator and assistant. Most facilities require a MUA certified assistant be present for spinal MUA cases.

Because of the extensive clinical data on the efficacy of MUA, manipulation under anesthesia has been endorsed and included in the American Medical Association’s CPT Code publication since 1971. The CPT code for spinal MUA is 22505. There are other CPT codes for appendicular manipulation under anesthesia.

Medicare Medical Policy Bulletin  (

Revision Date: 02/01/2002  (S-111A) Compliance with Transmittal # AB-00-126 (CR 1415)

 “Manipulation under anesthesia (MUA) is designed to stretch or tear the particular adhesions that form around the articular facets of the spine or around herniated or bulging discs. These particular adhesions tend to lock the spine in a state of fixation, preventing normal movement and causing pain. The paraspinal muscles cause a splinting or guarding at the adhesion site, which makes traditional manipulation less effective. By placing the patient in a "twilight" anesthesia, complete relaxation is achieved, allowing the provider to directly influence particular adhesions by diminishing the postural musculature. Since the adhesions are neurovascular, there is no bleeding or pain following the manipulation.

Indications and Limitations of Coverage and/or Medical Necessity:
Because of refinements in manipulative medicine techniques and improvements in physical therapy modalities, this procedure should only be performed on select patients who have failed to respond to conservative therapy.”

Below listed are selected references and partial abstracts outlining the efficacy of MUA.

Scott Haldeman, M.D. in AAOS 2003, in the most recent prospective RCT, “Medication –Assisted Manipulation for Low Back Pain” Department of Neurology, University of California, Irvine reported that:

 “Medication-assisted manipulation offers patients increased improvement in low back pain and disability when compared to usual chiropractic care.”

Published in THE SPINE JOURNAL in 2002, the authors, Frank Kohlbeck, DC and Scott Haldeman, DC, MD, PhD, performed a literature review of MUA (49 published articles) and concluded the following:

“Medicine-assisted spinal manipulation therapies have a relatively long history of clinical use and have been reported in the literature for over 70 years.  If a clinician recommends MUA it would be difficult to deny the use of medication-assisted manipulation or fail to reimburse for it.”

In October, 2002, Palmieri et al demonstrated clinical efficacy of MUA performed in a series of three consecutive procedures. The average Numeric Pain Scale scores in the MUA group decreased by 50%, and the average Roland-Morris Questionnaire scores decreased by 51% compared to controlled group.

Daniel West et al reported in a 1998 study of 177 patients that 68.6% of patients out of work returned to unrestricted work activities after a series of three consecutive MUA procedures at 6 months post MUA, that 58.4% of the MUA patients receiving medications prior to the procedure required no prescription medication post procedure and finally that 60.1% of patients with lumbar pain resolved post MUA series of procedures.

Samuel Turek, M.D., orthopedic surgeon, reports in his textbook, Principles and Applications of Orthopedics, that “good to excellent results” can be expected in 50% of patients with acute herniated nucleus pulposus with manipulation under anesthesia.

Thomas Dorman, M.D., orthopedist, recommends in his textbook, Diagnostic Techniques in Orthopedic Medicine, manipulation under anesthesia when the patient has failed at conservative in office care.

Robert Mensor, M.D., orthopedic surgeon, conducted a large clinical trial of over 600 patients with EMG verified radiculopathy and found that 83% responded well to manipulation under anesthesia.

These findings were verified by Donald Chrisman, M.D., orthopedic surgeon, reporting that 51% of patients with unrelieved symptoms after conservative care had good to excellent results even three years after MUA.

Bradford and Siehl reported on 723 MUA patients, the largest trial conducted on MUA procedures, and found that 71% had good results (normal activity, relatively symptom free) and that 25.3% had fair results (improvement, return to relatively normal activity with some residual symptoms) and that flexibility, elasticity and range of motion can be restored to patients with chronic back pain.

Paul Kuo, M.D., Professor of Orthopedic Surgery, reported his clinical investigation in 1986 of 517 patients treated with MUA with 83.9% of the cases responding well.

Further research is ongoing. Well designed prospective controlled clinical trials are being conducted to evaluate the clinical and cost effectiveness of MUA procedures in selected patient populations.

It is important to note that to date there has been no clinical trial that demonstrates MUA to be ineffective in an appropriately selected patient population. Clinical outcome assessments from these and previous studies will further delineate the parameters and the patient population within which MUA can be anticipated to be most effective.

Selected References :

1. Francis R. Guidelines for chiropractic quality assurance and practice parameters: proceedings of the Mercy Center Consensus Conference. Gaithersburg (MD): Aspen Publishers; 1993.
2. Francis R. Spinal manipulation under general anesthesia: a chiropractic approach in a hospital setting. ACA J Chiropr 1989 Dec;12:39-41.
3. Francis R, Beckett RH. Spinal manipulation under anesthesia. Adv Chiropr Mosby Publishers. 1994;1:325-40.
4. Francis R. Spinal manipulation under anesthesia: a review of chiropractic training programs and protocols. Am Chiropr 1995 Sep-Oct;27, 37.
5. Francis R. Manipulation under anesthesia. Am Chiropr 1991 Dec;24, 26-7.
6. Francis R. Postgraduate & continuing education courses: September. [internet]. Pasadena (TX): Texas Chiropractic College; 2002 [cited 2002 Oct 01]. [5 p]. Available:
7. Williams HA. Manipulation under anesthesia: review of the literature and discussion of the state of the art. ACA J Chiropr 1997 Dec;32-4, 36-8, 40-1.
8. Williams HA. Part III: Manipulation under anesthesia: discussion and critique. J Am Chiropractic Association 1998;53-5.
9. West S, King V, Carey TS, Lohr KN, McKoy N, Sutton SF, Lux L. Systems to rate the strength of scientific evidence. Evidence report/technology assessment No. 47 (Prepared by the Research Triangle Institute - University of North Carolina Evidence-based practice center under contract No. 290-97-0011). Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2002 Apr. 199 p. (AHRQ Publication; no. 02-E016).
10. Aspegren DD, Wright RE, Hemler DE. Manipulation under epidural anesthesia with corticosteroid injection: two case reports. J Manipulative Physiol Ther 1997 Nov-Dec;20(9):618-21.
11. Dreyfuss P, Michaelsen M, Horne M. MUJA: manipulation under joint anesthesia/analgesia: a treatment approach for recalcitrant low back pain of synovial joint origin. J Manipulative Physiol Ther 1995 Oct;18(8):537-46.
12. Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am 1991 Apr;22(2):263-71.
13. Kelsey JL, White AA 3rd. Epidemiology and impact of low-back pain. Spine 1980 Mar-Apr;5(2):133-42.
14. Faucett J. Chronic low back pain: early interventions. Annu Rev Nurs Res 1999;17:155-82.
15. Borenstein D. Epidemiology, etiology, diagnostic evaluation, and treatment of low back pain. Curr Opin Rheumatol 1996 Mar;8(2):124-9.
16. Williams HA. Manipulation under anesthesia: review of the literature and discussion of the state of the art. ACA J Chiropr 1997 Dec;32-4, 36-8, 40-1.
17. Manipulation under sedation treatment. Calif Chiropr J 1992 Jan 1;17(1):24.
18. Bronfort G. Spinal manipulation: current state of research and its indications. Neurol Clin 1999 Feb;17(1):91-111.
19. Williams HA. Part II. Manipulation under anesthesia: key aspects. J Am Chiropractic Association 1998;35(1):44, 46-9.
20. Greenman PE. Manipulation with the patient under anesthesia. J Am Osteopath Assoc 1992 Sep;92(9):1159-60, 1167-70.
21. Capps S. Manipulation under anesthesia or conscious sedation. Dyn Chiropr 1990 Jan 31;9, 18, 21 passim.        
22. Morey LW Jr. Osteopathic manipulation under general anesthesia. J Am Osteopath Assoc 1973 Oct;73(2):116-27.
23. West DT, Mathews RS, Miller MR, Kent GM. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther 1999 Jun;22(5):299-308.
24. Palmieri NF, Smoyak S. Chronic low back pain: A study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther 2002 Oct;25(8):E8-E17.
25. Maitland GD. Manipulation under anesthesia (MUA). In: Vertebral manipulation. 4th ed. London: Butterworth; 1977. p. 206‑7.
26. Michaelsen MR. Manipulation under joint anesthesia/analgesia: a proposed interdisciplinary treatment approach for recalcitrant spinal axis pain of synovial joint origin. J Manipulative Physiol Ther 2000 Feb;23(2):127-9.
27. Haldeman S, Chapman-Smith D, Petersen DM Jr, editors. Guidelines for chiropractic quality assurance and practice parameters: proceedings of the Mercy Center Consensus Conference. Gaithersburg (MD): Aspen Publishers; 1993. 222 p.
28. Advisory 92-09B.  Reimbursement for manipulation under anesthesia (MUA) chiropractic first assistant. [internet]. Austin (TX): Texas Workers' Compensation Commission; 1993 Jan 7 [cited 2002 Oct 01]. [1 p]. Available:
29. Manipulation of the spine under anesthesia. Policy no. S-111A. [internet]. Camp Hill (PA): HGSAdministrators; 1997 Apr 28 [cited 2002 Sep 27]. [3 p]. Available:
30. Manipulation under anesthesia (MUA). Policy no. 01-03-00. [internet]. Puerto Rico: Cooperative de Seguros de Vida de Puerto Rico; 2001 Aug 31 [cited 2002 Sep 27]. [3 p]. Available:
31. Spinal manipulation under anesthesia. [internet]. Chattanooga (TN): BlueCross BlueShield of Tennessee; 2002 Aug 1 [cited 2002 Sep 27]. [2 p]. Available:
32. Davis C, Fernando C, DaMotta M. Manipulation of the low back under general anesthesia: case studies and discussion. J Neuromusculoskeletal Syst 1993 Apr 1;1(3):126-34.
33. Gordon R. Justifying MUA within the standard chiropractic scope of practice. Fl Chiropr J 1995 Nov-Dec;16-9.
34. Siehl D, Olson DR, Ross HE, Rockwood EE. Manipulation of the lumbar spine with the patient under general anesthesia: evaluation by electromyography and clinical-neurologic examination of its use for lumbar nerve root compression syndrome. J Am Osteopath Assoc 1971 Jan;70(5):433-40.
35. Burn JM. Treatment of chronic lumbosciatic pain. Proc R Soc Med 1973 Jun;66(6):544.
36. Burn JM, Langdon L. Lumbar epidural injection for the treatment of chronic sciatica. Rheumatol Phys Med 1970;10(7):368-74.
37. Warr AC, Wilkinson JA, Burn JM, Langdon L. Chronic lumbosciatic syndrome treated by epidural injection and manipulation. Practitioner 1972 Jul;209(249):53-9.
38. Knutsson B. Comparative value of electromyographic, myelographic and clinical-neurologica; examinations in diagnosis of lumbar root compression syndrome. Acta Orthop Scand Suppl 1961;49:92-99.
39. Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine 1983 Mar;8(2):141-4.
40.    Rumney IC. Manipulation of the spine and appendages under anesthesia: an evaluation. J Am Osteopath Assoc 1968 Nov;68(3):235-45.
41. Gordon RC. An evaluation of the experimental and investigational status and clinical validity of manipulation of patients under anesthesia: a contemporary opinion. J Manipulative Physiol Ther 2001 Nov-Dec;24(9):603-11.
42. Morey L. Manipulation under general anesthesia. Osteopath Ann 1976 Mar 1;127-35.

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