Medicine Section - Manipulation Under Anesthesia for the Treatment of Chronic Pain

IMPORTANT REMINDER

Regence Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with contract terms. Benefit determinations are based in all cases on the applicable contract language. To the extent there may be any conflict between the Medical Policy and contract language, the contract language takes precedence.

PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that are considered investigational or cosmetic. Providers may bill members for services or procedures that are considered investigational or cosmetic. Providers are encouraged to inform members before rendering such services that the members are likely to be financially responsible for the cost of these services.

DESCRIPTION

Manipulation under anesthesia (MUA) consists of passive movements and stretching of joints performed while the patient receives anesthesia, usually general anesthesia or moderate sedation.  Manipulation is intended to break up fibrous and scar tissue to relieve pain and improve range of motion. Anesthesia or sedation is used to reduce pain, spasm and reflex muscle guarding that may interfere with the delivery of therapies and to allow the therapist to break up joint and soft-tissue adhesions with less force than would be required to overcome patient resistance or apprehension. MUA is generally performed with an anesthesiologist in attendance. (1)

Manipulation has also been performed after injection of local anesthetic into lumbar zygapophyseal and/or sacroiliac joints under fluoroscopic guidance (MUJA) and after epidural injection of corticosteroid and local anesthetic (MUESI).

POLICY/CRITERIA

Note: This policy does not address manipulation under anesthesia for fractures, completely dislocated joints, adhesive capsulitis (e.g., frozen shoulder), and/or fibrosis of a joint that may occur following total joint replacement.

Except as noted above, manipulation under any form of anesthesia is considered investigational for the treatment of chronic pain in any joint or combination of joints, including but not limited to the following:

1. Temporomandibular joint
2. Spine: cervical, thoracic, lumbar, sacral
3. Shoulder (see Note)
4. Wrist
5. Elbow
6. Fingers
7. Pelvis
8. Hip (See Note)
9. Knee (see Note)
10. Ankle
11. Toes

POSITION STATEMENT

The evidence is not sufficient to establish that spinal manipulation under anesthesia  (MUA), with or without manipulation of other joints, is effective as a treatment of chronic pain.

• There are no well-designed, prospective, randomized trials comparing standard spinal manipulative therapy (SMT) with MUA; therefore it is not possible to reach conclusions about whether MUA results in the same or better health outcomes.
• The risks and benefits of MUA compared to SMT are unknown.

Effectiveness

Literature

Randomized, placebo-controlled trials are considered particularly important when assessing any treatment of pain, not only to control for the expected placebo effect, but also for the variable natural history of pain, which may resolve with conservative treatment alone.  Randomized trials are also necessary to control for other forms of bias which might influence outcomes, such as patient selection bias and co-treatment effects.

• In a 2008 comprehensive review of the history of MUA and the published experimental literature, Dagenais and colleagues noted that there is no research to confirm theories about a mechanism of action for MUA and that the only randomized, controlled trial identified was published in 1971 when the techniques for spinal manipulation were different from those used at the present time. (2)
• Scientific evidence regarding spinal manipulation under anesthesia, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is limited to observational case series, nonrandomized comparative studies, and one small (n=6) randomized feasibility study investigating whether short-duration, low-risk general anesthesia can blind patients to the provision or withholding of spinal manipulative therapy. (3-7)  Data from these studies are unreliable because the study designs of these trials fail to control for biases that can influence study outcomes. 
• Large scale prospective, randomized, controlled trials are needed to determine the health outcome effects associated with MUA.

Clinical Practice Guidelines

• 2007 guidelines published by the American College of Occupational and Environmental Medicine concluded manipulation under anesthesia and medication-assisted spinal manipulation is not recommended for acute, subacute, or chronic LBP. (10) The level of evidence assigned to this determination was “I, ” defined as “insufficient for an evidence-based recommendation. The intervention is not recommended for appropriate patients because of high costs/high potential for harm to the patient.”
• Chiropractic guidelines rate manipulation under anesthesia as "equivocal" because the value of the treatment “can neither be confirmed nor denied." (11) 

Safety

The benefit of manipulation under anesthesia has not been proven to outweigh the potential risk. The following complications resulting from MUA have been reported in the published literature:

• Respiratory complications of anesthesia
• Fracture
• Vascular accident
• Disc herniation
• Cauda equina syndrome
• Increased pain
• Nerve palsy
• Tendon tears

REFERENCES

1. BlueCross BlueShield Association Medical Policy Reference Manual, Policy No. 8.01.40
2. Degenais S, Mayer J, Wooley JR et al. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Spine J 2008;8(1):142-9
3. West DT, Mathews RS, Miller MR et al. Effective management of spinal pain in one hundred seventy-seven patients evaluated for manipulation under anesthesia. J Manipulative Physiol Ther 1999; 22(5):299-308
4. Kohlbeck FJ, Haldeman S, Hurwitz EL et al. Supplemental care with medication-assisted manipulation versus spinal manipulation therapy alone for patients with chronic low back pain. J Manipulative Physiol Ther 2005;28(4):245-52
5. Palmieri NF, Smoyak S. Chronic low back pain: a study of the effects of manipulation under anesthesia. J Manipulative Physiol Ther 2002; 25(8):E8-E17
6. Dougherty P, Bajwa S, Burkke J et al. Spinal manipulation postepidural injection for lumbar and cervical radiculopathy: a retrospective case series. J Manipulative Physiol Ther 2004; 27(7):449-56
7. Kawchik GN, Haugen R, Fritz J.  A true blind for subjects who receive spinal manipulation therapy.  Arch Phys Med Rehabil  2009;90:366-8
8. 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;18(8):537-46
9. Michaelson 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;23(2):127-9
10. Hegmann KT, ed. Low back disorders. In: Glass LS, editor(s). Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2nd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2007. p. 366.  Also available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=12540& string=MUA
11. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference, Burlingame, CA, January 25-30, 1992. Haldeman S, Chapman-Smith D, Petersen DM (eds), Gaithersberg, MD: Aspen Publishers, 1993.  Also available at: http://www.chiro.org/documentation/FULL/Mercy_Recommendations.shtml (Verified 4/20/09)

CROSS REFERENCES

None

Medicine Section Table of Contents