BlueCross BlueShield of Tennessee Medical Policy Manual

Manipulation Under Anesthesia (MUA) of the Musculoskeletal System


Manipulation under anesthesia (MUA) is a series of mobilization, stretching, and traction procedures performed while the patient is sedated (usually with 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 an accepted treatment for certain isolated joint conditions, such as arthrofibrosis of the knee. It is also used to reduce fractures (e.g., vertebral, long bones) and dislocations, and for temporomandibular joint syndrome.

Spinal manipulation under anesthesia has been explored in the treatment of acute and chronic back and neck pain where there has been limited success of prior attempts to manipulate the spine. Scientific evidence on spinal MUA, spinal manipulation with joint anesthesia, and spinal manipulation after epidural anesthesia and corticosteroid injection is very limited and insufficient to determine the effects on health outcomes.

Note: This policy does not apply to manipulation under anesthesia for adhesive capsulitis (i.e. shoulder). Please refer to the MCG: Release of Adhesive Capsulitis, Shoulder, Closed or Arthroscopic ACG: A-0526 (AC).


See also: 




American Association of Manipulation Under Anesthesia Providers (2014, February) Guidelines for the practice and performance of manipulation under anesthesia. Retrieved September 6, 2016 from the National Guideline Clearinghouse (NGC#010365).

BlueCross BlueShield Association. Medical Policy Reference Manual. (8:2016). Manipulation under anesthesia. (8.01.40). Retrieved September 6, 2016 from BlueWeb. (11 articles and/or guidelines reviewed)

First Coast Services Options, Inc. Local Coverage Determination: (LCD) Manipulation under anesthesia (MUA) (L33594). Retrieved September 6, 2016 from:

Kawchuk, G., Haugen, R., Fritz, J. (2009). A true blind for subjects who receive spinal manipulation therapy. Archives of Physical Medicine and Rehabilitation, 90 (2), 366-368. (Level 4 evidence)

Mohammed, R., Syed, S., & Ahmed, N. (2009). Manipulation under anesthesia for stiffness following knee arthroplasty. Annals of the Royal College of Surgeons of England, 91 (3), 220-223. (Level 4 evidence)

Morningstar, M., & Strauchman, M. (2012). Manipulation under anesthesia for patients with failed back surgery: retrospective report of 3 cases with 1 year follow-up. Journal of Chiropractic Medicine, 12 (11), 30-35. (Level 4 evidence)

National Institute for Health and Clinical Excellence. (2010). Sedation in children and young people. Retrieved January 30, 2013 from




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