Manipulation Under Anesthesia
Most people are familiar with either Osteopathic manipulation or Chiropractic treatments, and frequently talk about having their back “cracked”. The purpose of this entry is not to discuss the efficacy of manipulation as a whole, but to rather focus on one specific type of treatment. Manipulation Under Anesthesia (MUA) has been used by physicians and chiropractors with the theory being that the anesthesia will result in a loss of conscious guarding from a patient, therefore leading to a better manipulation. This procedure is generally not covered by insurance and many practitioners are charging very high fees for the service, sometimes more than the cost of actual spine surgery.
The efficacy of this procedure, however, is very controversial. I personally performed a search of the medical literature using PubMed which comprises more than 26 million citations for biomedical literature from MEDLINE, life science journals, and online books. It is maintained by the US National Library of Medicine at the NIH and is also considered one of the most respected search engines for medical literature which is used daily by thousands of medical professionals. Essentially, this is the ‘go to’ place to find answers to questions in the medical literature. I queried ‘Manipulation Under Anesthesia’ in effort to assess the quality of the data behind this treatment.
Unfortunately, there is a paucity of published studies on this treatment within this database. In addition, the studies which have been published consist primarily of case reports and expert opinions, which are considered the lowest level of impact/reliability in the medical literature, ‘Level 4 or 5’. This is in contrast to the typical large, placebo controlled, double-blinded studies which are generally given the highest ‘Level 1’ rating. One of the best articles I came across was actually published in the chiropractic literature. Dennis DiGiorgi wrote an excellent commentary regarding the indications for and data regarding Manipulation Under Anesthesia (Spinal Manipulation Under Anesthesia: A Narrative Review of the Literature and Commentary. Chiropractic & Manual Therapies, 21:14, 2013). In this review, he highlights the points made above regarding the lack of literature and the low quality of evidence supporting the routine use of Manipulation Under Anesthesia. According to the article, MUA should only be used in patients with chronic symptoms who have failed conservative treatments as part of a comprehensive treatment plan, including post-procedure rehabilitation. It is not meant to be performed as a stand-alone therapy. There is also no evidence to support treating the entire body, rather the procedure should only be performed on just the symptomatic region if at all.
As an Osteopathic Physician, I was trained in various types of manipulation during medical school. I was taught that there are a few different types of ‘barriers’ to consider when performing manipulation. The most important of these is the ‘anatomic barrier’. The anatomic barrier is the physical barrier created by the integrity of the supporting ligaments, bones, etc. Moving a joint though the anatomic barrier will likely result in permanent compromise to the structural integrity of the joint or even a fracture. Most of the time, a conscious patient is able to protect themselves from reaching the anatomic barrier by ‘guarding’ themselves before it is reached. My concern is that since this guarding is eliminated during anesthesia, the manipulation may inadvertently cross the anatomic barrier and result in structural damage.
My recommendation is to approach this treatment with caution and skepticism until quality data is available which can either support or refute it. Ideally, this data would include a comparison to other less costly treatments, such as physical therapy.
- Feuerstein C, Weil L Jr, Weil LS Sr, Klein EE, Argerakis N, Fleischer AE. Joint Manipulation Under Anesthesia for Arthrofibrosis After Hallux Valgus Surgery. J Foot Ankle Surg. 2016 Jan-Feb;55(1):76-80. PubMed PMID: 26256296