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Table 2 Manual therapy risk/outcome stratification with SMUA

From: Outcomes indicators and a risk classification system for spinal manipulation under anesthesia: a narrative review and proposal

SMUA Classification Patient profile or status Examplesb
SMUA I A normal, healthy patient with no frank clinical predictor for unfavorable outcome or harm A 40 year old male with a prior history of repetitive sports-related trauma to the low back, and:
- a normal neurological examination
- MRI findings of mild multilevel lumbar disc degeneration
- a more recent history of chronic recurrent back pain with significant debilitation, active/passive range of motion deficits, and muscle guarding
- limited response to adequate trials of office-based thrust manipulation and other modes of conservative care
SMUA II An otherwise normal, healthy patient with a clinical predictor or profile for unfavorable outcome but not harm Obesity, high anxiety/stress levela, litigation, work-related injury, somatizer, significantly inadequate response to an office-based trial of treatment including thrust manipulation
SMUA III c A patient with identifiable signs, symptoms or a history of comorbidity that may predict harm despite potential for diminution/remediation of complaint HTN Stage 1e, DVT, acute or chronic respiratory condition, history suggestive of osteoporosis, current history of drug or alcohol abuse, cancer history, night pain, unintentional weight loss, unexplained dizziness, structural deformity, ligamentum flavum hypertrophy, lumbar disc herniation/protrusion, positive lumbar EMG, corticosteroid use, prior non-fusion surgery to site of treatment, spinal fusion with adjacent segment disease, worsening of symptoms with office-based thrust manipulation
SMUA IVd A patient with significant comorbidity or a history that likely predicts unfavorable outcome and/or potential for harm HTN Stage 2f, angina pectoris, unstable bleeding disorders, uncontrolled diabetes, pain prone patient, hysteria, inflamed spinal tissues [47], joint hypermobility/instability, unstable spondylolisthesis, severe joint sprain, joint dislocation, advanced spondylosis with osteophytosis of or about the spinal canal or IVF, implant instrumentation (precludes manipulation to the site), advanced osteoporosis, multiple myeloma, joint/bone infection, acute inflammatory arthritis/gout, positive myelogram, marked motor signs, diastematomyelia, positive plantar reflex/clonus, ataxia
SMUA Vd A patient with a highly significant clinical condition or comorbidity that readily predicts unfavorable outcome, harm or death Hypertensive Crisisg, advanced carotid/vertebral artery disease, unstable aneurysm, acute abdominal pain with guarding, intracranial/intracanalicular hematoma, recent fracture, ankylosing spondylitis, malignant bone tumor or metastatic disease to bone, aggressive benign bone tumor, Paget’s disease, Tuberculosis of bone, disc sequestration, Arnold Chiari malformation, spinal cord/meningeal tumor, Cauda Equina Syndrome, bladder dysfunction, saddle anesthesia, myelopathy, septicemia, known anesthesia allergy
  1. aWhen assessed by Bournemouth Questionnaire, as per the findings of a recent prospective cohort study (Level II evidence) [29]
  2. bExamples include identifiable factors of unfavorable outcome, as reported by prior investigators, as well as relative and absolute contraindications to manipulation of unconscious patients. Contraindications and/or potential exclusion criteria are not limited to those shown
  3. cModification of technique may be required with this risk category, assuming that medical clearance has been obtained via sufficient multidisciplinary input for the specific precaution/s for harm. Examples of proper specialty input include a cardiologist for HTN Stage 1, and a vascular surgeon for DVT
  4. dThis category represents a red flag classification for the SMUA service
  5. eSystolic mm Hg of 130–139 or diastolic mm Hg of 80–89 [86]
  6. fSystolic mm Hg of 140 or higher or diastolic mm Hg of 90 or higher [86]
  7. gSystolic mm Hg higher than 180 or diastolic mm Hg higher than 120 [86]