BlueCross BlueShield of Tennessee Medical Policy Manual

Manipulation of Musculoskeletal System Under Anesthesia (General, Mild Sedation and Local)


Manipulation under anesthesia (MUA) consists of passive movements and stretching of joints performed while the individual receives anesthesia (usually short acting anesthetics or moderate sedation).

Manipulation refers to a variety of manual adjustment techniques and is believed to ease pressure on nerves, break up fibrous scar tissue or restore normal musculoskeletal alignment to relieve pain and improve range of motion. Anesthesia or sedation is used to lessen pain, spasm and the conscious reflex muscle guarding; thereby reducing resistance and apprehension for the individual and enhance the therapeutic effects of the joint manipulation through a full range of motion. Manipulation procedures can be offered under general anesthesia, during mild sedation, or following the injection of anesthetic solutions (i.e. local anesthetic agent) into specific areas of the spine or joints. Typically, MUA is an alternative to conservative treatments that have lasted at least six to eight weeks without relieving pain or promoting a return to normal function.

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. In MUA, a low velocity/high amplitude technique may be used in contrast to the high velocity/low amplitude technique that is used in the typical chiropractic/osteopathic adjustment.

MUA has also been used as a treatment for fibroarthrosis following total knee replacement, in refractory cases of adhesive capsulitis (frozen shoulder), in the setting of displaced fractures and complete joint dislocations, and for temporomandibular joint syndrome.


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As with any treatment of pain, controlled clinical trials are considered particularly important to isolate the contribution of the intervention and to assess the extent of the expected placebo effect. A search of the published medical literature did not identify any controlled clinical trials. Several case series were identified, which included individuals with cervical, thoracic and lumbar back pain, treated according to varying protocols .


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American College of Occupational and Environmental Medicine (ACOEM). (2008). Occupational medicine practice guidelines. Chronic pain. Retrieved January 30, 2013 from

American College of Occupational and Environmental Medicine (ACOEM). (2011). Occupational medicine practice guidelines. Shoulder. Retrieved January 30, 2013 from

BlueCross BlueShield Association. Medical Policy Reference Manual. (12:2014). Manipulation under anesthesia. (8.01.40). Retrieved October 27, 2015 from BlueWeb. (12 articles and/or guidelines reviewed)

Gordon, R., Cremata, E., Hawk, C. (2014). Guidelines for the practice and performance of manipulation under anesthesia. Chiropractic and Manual Therapies, 22 (7). 1-10.

Hegmann, K. T., (Ed.). (2011). Hand, wrist and forearm disorders not including carpal tunnel syndrome. In: Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. 3rd ed. American College of Occupational and Environmental Medicine. Retrieved January 30, 2013 from 

International Chiropractors Association of California. (2009). Management of whiplash associated disorders. Retrieved January 30, 2013 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 - Independent)

Manske, R., Prohaska, D. (2008). Diagnosis and management of adhesive capsulitis. Current Reviews of Musculoskeletal Medicine, 1 (3-4), 180-189. (Level 5 evidence - Independent)

Meyer, C., Stein, G., Kellinghaus, J., & Schneider, T. (2015). Management of idiopathic frozen shoulder – prospective evaluation of mobilisation under anaesthesia and an additional subacromial cortisone injection. Journal of Orthopaedics and Traumatology. Abstract retrieved October 27, 2015 from PubMed database.

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 - Independent)

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 - Independent).

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

Winifred S. Hayes, Inc. Medical Technology Directory. (2011, February, last update search February 2015). Osteopathic manipulative treatment (OMT) for back pain. Retrieved October 27, 2015 from  (84 articles and/or guidelines reviewed)

Work Loss Data Institute. (2008). Hip & pelvis (acute & chronic). Retrieved January 30, 2012 from

Work Loss Data Institute. (2011). Forearm, wrist, & hand (acute & chronic), not including carpal tunnel syndrome. Retrieved January 30, 2013 from




Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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