WHAT IS MANIPULATION UNDER ANESTHESIA?

Manipulation Under Anesthesia, otherwise known as MUA, is a non-invasive procedure offered for acute and chronic conditions, including: neck, back, and joint pain, muscle spasms, tight muscles, fibrous adhesions and long term pain syndromes.

Manipulation of the spine with the patient sedated is one of the most gentle and effective methods of helping patients control their pain. MUA provides manipulation and adjustments of the spine and surrounding tissue in an atmosphere where the patient is more responsive and less apprehensive, therefore eliminating resistance from contracted and spastic muscles.

For those patients with chronic pain and joint, muscle, ligament disorders who are not finding relief through more conventional treatments including physical therapy, narcotic pain medications, chiropractic manipulation without anesthesia, or other invasive procedures such as epidural injections and surgery, MUA combined with simple post-procedure treatment, exercise and therapy has been proven to eliminate or greatly reduce pain and restore or greatly improve range of motion.

WHAT IS THE HISTORY OF MUA?
Manipulation Under Anesthesia (MUA) is neither new nor experimental. It’s been practiced since the 1930s and used by osteopathic and orthopedic physicians as a proven form of treatment. Thanks to advances in anesthesiology and technique, MUA has become a multidisciplinary outpatient procedure that can take place in an ambulatory surgical setting using conscious sedation and specialized manipulation techniques supported by the expertise of licensed physicians with specialized training & certification for the procedure. The procedure usually takes place over the course of three (3) consecutive days.

Established and widely recognized in the manual medical arena since the 1930’s, MUA is a viable alternative for patients that do not respond to traditional care or invasive surgical procedures. The MUA procedure continues to gain widespread support and recognition in the medical community and is helping to bring much-needed relief to a greater patient base than ever before.

WHAT DO OTHER DR.’S AND CLINICAL RESEARCH REPORTS SAY ABOUT MUA
Multiple prospective and retrospective clinical studies have been performed evaluating MUA in chronic unresolved back pain, acute and chronic disc herniations, cervicogenic cephalgia, and many other neuromusculoskeletal conditions with attendant articular dyskinesia.

Robert Mensor, M.D. orthopedic surgeon compared the outcomes of MUA and laminectomy (a surgical procedure) in patients with lumbar Intervertebral disc lesions and found that 83% of MUA patients had good to excellent results while only 51% of the surgical patients reported the same outcome.

Donald Chrisman, M.D. orthopedic surgeon reported that 51% of patients with unequivocal disc lesions and unrelieved symptoms after conservative care had been rendered reported good to excellent results post MUA at three years follow up.

Bradford & Siehl reported on 723 MUA patients, the largest clinical trial conducted on MUA procedures, that 71% had good results, and that 25% had fair results and 4% ultimately required surgical intervention.

Krumhansl and Nowacek reported on 171 patients who experienced constant intractable pain, of durations from several months to 18 years, and who underwent MUA. All patients had failed at previous conservative interventions. Results reported that post MUA, 25% had no pain at all and were “cured”, 50% were “much improved” with pain markedly reduced and ADLs essentially unaffected, 20% were “better but” pain continued to interfere with activities and finally 5% had minimal or no relief.

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.

In 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.

In addition the extant literature, there are currently ongoing prospective clinical trials with appropriate outcome instruments assessing the clinical and fiscal efficacy of MUA in a selected patient population.

The medical literature is replete with case studies and literature reviews on MUA, in addition to clinical trials, all of which report positive clinical outcomes.

Further research is ongoing. 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.

WHO CAN BENEFIT FROM MUA?
MUA can be a valuable, effective procedure for those people who have conditions that have not responded to conventional treatment. These conditions include:

• Neck, mid-back and low back pain
• Chronic Muscle pain and inflammation
• Acute and chronic muscle spasm
• Decreased spinal and joint range of motion
• Fibromyalgia
• Frozen shoulder
• Disc pathology - Disc protrusions, bulging discs, or herniations less than 3 mm in the cervical spine & less than 5 mm in the lumbar spine, spontaneous or traumatic origin, documented by CT Scan, MRI or Myelography.
• Chronic occipital or tension headaches
• Sciatica where disc bulges are contained less than 5 mm
• Hip joint motion restrictions
• Failed back surgery
• Conditions where narcotic pain relievers are of little benefit
• Traumatic torticollis
• RSD
• Chronic fibrositis
• Myofascial Pain Syndrome
• Nerve entrapment
• Pseudo-sciatica

WHO SHOULD NOT HAVE MUA?
Since the main reason for MUA is the persistence of a stubbornly dysfunctional and disabling spine or joint, the absence of joint/spine dysfunction is an obvious reason not to undergo MUA. There are also specific conditions that would be contraindications for MUA such as:

• Osteoporosis or other bone weakening disorder
• Serious heart disease
• Uncontrolled hypertension
• Advanced age
• Particular circulatory diseases
• Uncontrolled diabetes and/or related complications
• Acute arthritis
• Acute gout
• Acute fractures
• Previous stroke
• Syphilitic articular or periarticular lesions
• Gonorrheal spinal arthritis
• Tuberculosis of the bone
• Evidence of cord or caudal compression by tumor, ankylosis and malacia bone disease
• History of allergy to the anesthesia

HOW ARE CANDIDATES FOR MUA CHOSEN?
Patients for MUA are chosen by their physicians by standards established by the National Academy of MUA Physicians. The treatment plan begins with a medical screening process starting with a complete history and physical, documentation of all medications (including over-the-counter), any known allergies to anything, diagnostic testing (depending on the patient’s history) that can include CBC blood studies, blood chemistry, chest X-ray and electrocardiogram, pregnancy test for females of child bearing age (unless documentation indicates otherwise). Additional diagnostic testing that supports the need for the procedure includes a Magnet Resonance Imaging (MRI), CAT scan, and musculoskeletal X-rays. A thorough pain assessment is also done to eliminate questions of psychosocial factors that can influence pain responses. After medical clearance, the patient is scheduled at the facility where the MUA will be performed.

Manipulation Under Anesthesia is a viable alternative for those patients that have chronic pain and are not a surgical candidate

WHO PERFORMS THE MUA PROCEDURE?
Those involved during the MUA procedure include a Board Certified Anesthesiologist, an MUA certified M.D. / D.O. and Dr. Hope who will be performing the manipulation along with a skilled nursing staff to assist in the procedure as well as high-tech RNs who provide the pre and post procedure care. Only a physician that has been certified in MUA can perform the MUA procedure. At Hope Health & Wellness we take pride in our doctors who are not only certified by accredited institutions in MUA, but highly experienced, having helped relieve the pain of hundreds of patients.

WHAT IS THE MUA PROCEDURE LIKE?
The MUA procedure involves three consecutive days of treatment. During these three days, the patient is treated with spinal manipulative therapy and MUA stretches. The procedure is performed on Thursday, Friday and Saturday morning. It is recommended that you take off work during this procedure however, if you must go to work, make sure not to do anything very strenuous. Patients are given a low dose of anesthesia for the treatment which lasts between 15 to 25 minutes. Recovery after the procedure only takes about 10 – 15 minutes. This is not the same type of anesthesia used during surgery which has numerous side effects and takes much longer to recover from. The purpose of using a low dose of anesthesia is so that the muscles are completely relaxed and there is no muscle guarding. This type of sedation is called “twilight sedation” or “conscious sedation”. While you are under “conscious sedation”, Dr. Hope along with an M.D. / D.O. performs the manipulations to your spine and surrounding muscles and joints. The treatment is much like receiving a Physical Therapy stretching session, Deep Tissue Massage and a Chiropractic Manipulation but with less pain, less force and much more effective results as there is no muscle guarding or resistance. After the MUA procedure, treatment continues as strengthening and stabilization programs are initiated over the next few weeks. Post-Procedure care is a vital part of the MUA procedure. Follow-up visits with your Chiropractor are important during this time as you will be shown stretches and exercises to do while in the office and at home. These follow up visits are very important as the stretches shown after the procedure will help you regain strength and prevent future pain and discomfort.

WHY CONSCIOUS SEDATION?
When problems exist such as chronic muscle spasms; build up of adhesions around muscles & ligament; super-sensitivity of injured areas; persistent shortening of tendons, ligaments, muscles; or the radiating pain associated with damaged Intervertebral Discs; being able to put the spine or joints through normal range of motion is not feasible. Intravenous conscious sedation shuts off the muscle spasm cycle, sedates the pain perceiving nerves, and allows complete muscle relaxation. Although the patient is asleep, his/her protective reflexes remain intact. The physician is then able to gently manipulate the joints through their normal range of motion, reduce restrictive adhesions and reduce the misalignment of the spine. The procedure usually lasts 20 to 25 minutes and the patient wakes up quickly thereafter and is monitored by qualified personnel until you’re ready to be discharged. Recovery after the procedure usually takes only 10 – 15 minutes.

WHAT SHOULD I WEAR FOR THE MUA PROCEDURE?
On the three days of your procedure, we ask that you wear something that is very comfortable and non revealing. For women we suggest sweat pants or shorts, sports bra and a T-Shirt and socks. For men we suggest sweat pants or shorts and a T-Shirt and socks. You may get very cold after the procedure so bring a sweater or jacket or even a blanket if you prefer. We also suggest that you bring an extra set of clothing should you need them.

WHAT CAN PATIENT’S EXPECT FROM HAVING MUA?
The patient should experience an immediate increase in range of motion, even though there is some temporarily added muscle soreness similar to feeling of having completed an aggressive exercise session. In cases involving symptoms caused by adhesions and shortened tissues, there should be a significant change, either immediate or within a short period following the procedures. The most important post MUA care is an active rehabilitation program and makes it truly effective. The rehab will be planned and conducted by the referring physician. This regimented post-procedure therapy will help the patient to learn the necessary elements of maintaining function and range of motion regain strength and prevent future pain and disability. Most importantly however, Manipulation Under Anesthesia affords patients immediate relief and noticeable difference in their daily lives post-procedure. These positive results only continue to improve with time and post-MUA therapy.

MEDICAL CLEARANCE AND WORKUP
Patients who have been selected for Manipulation Under Anesthesia Procedure by their doctor typically undergo a medical screening process to determine true MUA candidacy. This screening process includes a medical history and physical examination and where indicated, CBC blood studies, chest X-Rays, EKG’s and other diagnostic tests such as MRI or CT’s. Once a patient is cleared and medical necessity for MUA is determined, a Hope Health & Wellness representative will pre-certify and schedule the procedure dates and times. Hope Health & Wellness will also handle the explanation of all pre and post-operative instructions, answer any questions the patient may have about the procedure and arrange transportation for the patient if necessary. At Hope Health & Wellness, we pride ourselves on working with our patients to make their MUA experience as hassle free, comfortable and successful as possible!

IMPORTANT INSTRUCTIONS
PLEASE READ THE FOLLOWING INSTRUCTIONS THOROUGHLY:
It is IMPORTANT that ALL patients to adhere to the following instructions:

It is IMPORTANT that ALL patients to adhere to the following instructions:

• Anesthesia must be given on an empty stomach.
• If you have a light meal, TOAST AND WATER ONLY, then nothing to eat or drink for six (6) hours prior to receiving anesthesia.
• If you have a heavy meal, ANYTHING OTHER THAN TOAST AND WATER, then nothing to eat or drink for eight (8) hours prior to receiving anesthesia.
• In order to prevent dehydration, it is important that you take in plenty of fluids for several days prior to the procedure, ESPECIALLY during the day and night before the procedure is scheduled.
• It is important that the patient take any regular prescribed medications, IF INSTRUCTED TO DO SO, or any medication provided by the center using only a sip of water. All medications are reviewed by the MUA team. It is the patient who must provide a complete list of current medications (prescribed & over-the-counter) including drug name, dose and frequency. It is advised that the patient avoid alcohol at least 24 hours prior to the procedures, abstain from alcohol throughout the three (3) procedure schedule, and for at least 24 hours beyond that.
• Patient must be accompanied by a responsible adult to drive him/her home & stay with the patient until fully recovered from the effects of anesthesia which (though rarely) can last up to twenty-four (24) hours.
• Patient is to wear comfortable, non-restrictive clothing that is non-static (T-shirt & gym shorts or pants), leave all jewelry at home or give to the accompanying adult prior to the procedure.
• A pre-procedure assessment will be completed by a qualified RN at which time consents for the MUA procedure and anesthesia will be signed by the patient. A urine pregnancy test will be performed on women patients, including those who are on birth control, who are of child-bearing age unless there is documentation specifying why they would be considered exempt.
• An intravenous catheter will be inserted into the patient’s hand or arm which will be used, by the anesthesiologist, to administer a small amount of conscious sedation. NOTE: once the pre-op assessment has been completed and peripheral IV site initiated, the patient must remain in the designated waiting area. Leaving the building is not permitted.
• After the MUA is completed (usually within 15-25 minutes), the patient is taken to the Recovery Unit and closely monitored by qualified RN’s until the patient is fully awake and ambulatory (usually within 10-15 minutes). The IV catheter will be removed by the RN prior to D/C unless ordered by the primary physician to be left in. If this is the case, the IV site will be flushed to maintain patency, secured to prevent dislodgement, and covered with an appropriate dressing to prevent infection.
• Since the MUA is repeated over a period of three (3) days, the above instructions apply to each day of the procedure.

ARE THERE RISKS ASSOCIATED WITH MUA?
All forms of health care carry some degree of risk. Much of the morbidity related to MUA is the result of heavy, general anesthesia, not conscious sedation, and to forceful manipulation, not gentle manipulation. The risks can be as follows: bruising, fractures, joint dislocation, numbness to the genitalia or thigh, dull pain to the buttocks, stroke, transient ischemic attack, death. Prevention of complications is facilitated through pre-procedure diagnostics, complete medical history and physical, medication profile (prescribed, OTC), allergy assessment (to anything), good professional judgment, and quality care.

IN SUMMARY: MUA is not an invasive procedure. It is simply manipulation and mobilization performed in an operating room environment. It is something similar to what is done in the chiropractor’s office, but with the added aide of twilight anesthesia. The actual adjustments are very gentle. Return to work is much faster as is the return to the pleasure of living.