Manipulation Under Anesthesia
Didactic and Clinical Proctoring Protocol
For MUA Certification Courses

Manipulation under Anesthesia is spinal and appendicular manipulation performed while the patient is under anesthesia. The procedure is intended for patients who suffer from certain neuromusculoskeletal disorders in conjunction with biomechanical dysfunction. MUA procedures are to be performed only in a licensed accredited facility by appropriately credentialed and MUA certified chiropractors.
MUA has been utilized in manual medicine for over 70 years and is well documented in the medical literature. Increased participation of chiropractors on hospital medical staffs has made both the facilities and training more available for performing and credentialing this procedure.
Currently, MUA certification courses offered through accredited chiropractic college post graduate departments are recognized by malpractice carriers for inclusive coverage. It has been important to regulatory agencies, academic institutions, professional associations and organizations and malpractice carriers to recognize appropriate training programs. Towards that end, specific criteria have been adopted to establish credible certification course offerings. Standards and protocol establishing credible certification training programs are recognized by the National MUA Academy of Physicians and the International Academy of MUA Physicians.
Manipulation Under Anesthesia (MUA) certification training courses are taught under the auspices of CCE accredited chiropractic college post graduate programs. Training consists of two distinct components, a didactic session and a clinical proctorship.

            The didactic sessions are designed to instruct licensed doctors in all areas of MUA practice including hospital protocol, operating room protocol, pathomechanical, pathophysiological and neuromusculoskeletal considerations of MUA procedures and sequela, MUA literature and research, indications and contraindications of the MUA procedures, obtaining hospital medical staff privileges, proper coding and billing practices and other administrative and management topics related to performing MUA procedures.
           
The clinical proctorship sessions are designed to document and verify that the doctors being proctored have met the clinical competencies necessary to demonstrate an adequately selected and appropriate candidate for the MUA procedure.

Towards that end, during the clinical proctorship, the doctor undergoing certification training must follow prescribed protocol for selecting five appropriate candidates from the doctor’s patient population, whether that patient population be candidates in his own private practice or patients referred to the training doctor from other physicians for MUA evaluation, examination and treatment. Clinical competencies must be met and submitted for review to the proctor for all five candidates selected.

            It is usual and customary in teaching hospitals for doctors undergoing proctorships to be supervised on five different cases prior to being granted privileges or certification to perform procedures in the operating room without supervision.
           
            Towards an effort to maintain and ensure quality assurance in certification training, it is recommended that during the clinical proctorship sessions, patients not be provided to training doctors for clinical proctoring purposes.

The practice of providing patients who have already been worked up diagnostically and clinically dilutes the training and in no way is a verification of the training doctors’ ability to appropriately select and adequately evaluate and diagnose candidates for MUA procedures. Providing patients who have already been determined to be appropriate candidates forgoes the opportunity for the training doctor to demonstrate adequately met clinical competencies for patient selection.

Furthermore, the practice of providing patients for MUA clinical proctorship denies the opportunity for the instructing doctor, the teaching facility, MUA course sponsoring academic institutions, liability carriers, regulatory agencies and others to validate, document, and verify that the training doctor has actually performed a complete clinical proctorship during MUA certification training course and has actually undergone the clinical supervision process of patient selection which is designed to ensure that the training doctor has met all the clinical competencies necessary to determine that the training doctor is able to competently select appropriate patients for MUA procedures.

Awarding certification to training doctors who only observe MUA procedures or who have only manipulated patients provided to them in the operating room, patients who have been clinically evaluated and selected by others, does in no way establish, verify or document that the training doctor has demonstrated the ability to adequately select an appropriate candidate for MUA procedures.

The practice of providing patients is a liability to all parties involved by misrepresenting that the training doctor has demonstrated the necessary clinical skills and competency to appropriately select MUA candidates when in fact, the patients were pre-selected with no competencies demonstrated or met by the training doctor during clinical proctorship.

The medical literature is emphatic that patient selection is the single most important aspect of successful outcome for MUA procedures. The practice of providing patients for MUA certification training obviates this essential training and skill assessment for the proctoring doctor during MUA certification training.

Robert S. Francis, D.C.
Email: rfrancis11@comcast.net

REFERENENCES:

1) Manipulation Under Anesthesia: A Report Of Four Cases, JMPT, 9.2005 (Full Article)
Four patients that had not improved adequately to numerous months of in-office chiropractic management improved substantially after MUA/FRP procedures. This study also reports a 70% success rate found during a Quality Assurance review of the surgery center where MUA cases are performed. 70% of patients interviewed after MUA procedures reported that they were “very satisfied” with the improvement that they obtained from the procedure. This recent MUA study confirms the findings of other researchers that reported similar results.

2) Frank Kohlbeck , DC and Scott Haldeman, DC, MD, PhD, published a literature review of MUA ( 49 published articles) in THE SPINE JOURNAL in (2002) Medication Assisted Spinal Manipulation and concluded the following: (Full Article)
“Medicine-assisted spinal manipulation therapies have a relatively long history of clinical use and have been reported in the literature for over 70 years.” Page 288
“Recent advances in highly titratable and reversible intravenous anesthesia have significantly reduced risks associated with manipulation under anesthesia (MUA), analgesia and sedation, which can now be performed in outpatient surgical centers.” Page 289
“There are case reports and case series describing the successful use of MUA and other medically assisted manual therapies in patients …” Page 289
“The rationale for the use of MUA is that anesthesia and analgesia help to eliminate or reduce pain and muscle spasm that hinder the effective use of traditional manipulation … to break up joint adhesions and reduce segmental dysfunction to a greater extent than if anesthesia had not been employed.” Page 289
“The earliest MUA study … was published in 1930 by The Lancet … overall 75 percent of patients improved.” Page 290
“In a first study by Siehl ad Bradford published in 1952, 33 percent of the patients … demonstrated good (symptom-free) results.” Page 294
“Siehl’s followup study … 96 percent reported successful (good or fair) outcomes.”
Mensor’s study included 205 patients … 51 percent of the patients reported satisfactory results.” Page 294
“In Chrisman’s study 83 percent of the subjects reported good or excellent result after a 3-year follow-up.” Page 294
“In Morey’s 1973 review … treating physician reported excellent or good results in 85 percent of the cases.” Page 294
“In a study published in 1986 by Krumhansel and Nowacek … outcomes were reported as 25 percent ‘cured’, 50 percent ‘much improved’, and 20 percent ‘better, but’. Page 294
“In a 1990 article by Mennell … 30 percent with symptoms cured, 35 percent with marked improvement, 29 percent with moderate improvement…” Page 294
“In a recent case series by West et al … VAS scores improved 4.6 points for cervical pain and 4.31 points for lumbar pain. Decrease in time off work and less use of prescription pain medication were also reported.” Page 294 (This is the ONLY article reviewed by ACOEM and somehow led to their conclusion of “not recommended”)
“Current procedures more commonly use specific, short-lever, high velocity low amplitude thrusts characteristic of chiropractic and modern osteopathic adjustive techniques in addition to mobilization.” Page 294
“A typical MUA procedure involves placing the patient in a twilight anesthesia by a board-certified anesthesiologist while the clinician with the aid of a skilled assistant provides specific mobilization and manipulation techniques to the affected joints and spinal regions.” Page 294
“Current guidelines recommend the presence of a primary physician and assisting physician who have both undergone adequate training in MUA procedures. An assistant is necessary to position the patient and stabilize the sedated patient.” Page 295
“We have been unable to find any report of complications using more modern osteopathic and chiropractic techniques or as a result of the use of anesthesia.” Page 297
“If a clinician recommends MUA it would be difficult to deny the use of medication-assisted manipulation or fail to reimburse for it.”
“The literature (a PubMed search from 1966) consists primarily of case reports and case series with two randomized controlled trials and one cohort study.”

3) Supplemental Care With Medication-Assisted Manipulation Versus Spinal Manipulation Therapy Alone For Patients With Chronic Low Back Pain, 2005 JMPT (Full Article)
“Medication-assisted manipulation appears to offer patients increased improvement in low back pain and disability when compared to usual chiropractic care.” Page 258
“The relative odds of experiencing a 10-point improvement in pain and disability favored the medication-assisted manipulation group at 3 months and one year.” Page 258

4) Daniel West et al reported in a JMPT 1999;22(5) study titled “Effective Management of Spinal Pain in 177 Patients Evaluated for MUA” (Full Article)
“VAS ratings improved by 62.2 percent in those patients with cervical pain problems and 60.1 percent in those patients with lumbar pain problems. There was a near-complete reversal (68 percent) in patients out of work before MUA, and those returning to unrestricted activities at 6 months after MUA totaled 64.1 percent. There was a 58.4 percent reduction in the percentage of patients requiring prescription pain medication from the pre-MUA period to 6 months after MUA. Additionally, 24 percent of the treatment group required no medication at 6 months after MUA.” Page 299
“The addition of anesthetic allows for the benefits of manipulation to be shared with those patients who cannot tolerate manual techniques because of pain response, spasm, muscle contractures, and guarding.” Page 300
“MUA has been used successfully in treating those patients unresponsive to acute and chronic musculoskeletal conditions for years.” Page 300
“Only highly skilled, graduate practitioners who have been trained in structural diagnosis and manipulative treatments should be performing these procedures.” Page 300
“All patients with diagnosed spinal conditions received treatment in the area of primary diagnosis, as well as the areas superior and inferior. This is due to the anatomy of the ligamentous, tendinous, and muscular origins and insertions (i.e. if the lumbar spine is the primary site of injury, the treatment areas were thoracic, lumbar, and pelvic).” Page 303
“Performance of the MUA procedure requires a certified MUA first assistant for stabilization and patient positioning, as well as direct ancillary treatment.” Page 304
“We believe we have shown that this treatment program is safe and efficacious in comparison with other treatment options.” Page 307

5) Palmieri et al , October 2002. Chronic LBP: A study of the effects of MUA. JMPT Oct 2002;25(8):E8] (Full Article)
Demonstrated clinical efficacy of MUA performed in a series of three consecutive procedures. The average Numeric Pain Scale scores in the MUA group decreased by 50 percent, and the Roland-Morris Questionnaire scores decreased by 51 percent compared to a controlled group.
“Existing methods for managing nonpathologic chronic back pain include patient education, back schools, spinal injections, medications, physical therapy, exercise and rehabilitation, acupuncture, spinal mobilization and manipulation, behavioral modification, and work and lifestyle activity modification. The MUA procedure is typically performed on patients who have received some or all of these treatments without favorable results.” Page 2

6) Siehl D. Manipulation of the Spine under General Anesthesia. J Am Osteopath Assoc. June 1963;62:35-41. (Full Article)
“… the reposition under anesthesia is harmless and presents absolutely an acknowledged and trustworthy procedure in treatment.” Page 36
“However, I believe that manipulation under anesthesia might well be the ideal treatment in many cases of acute low back and neck problems.” Page 37
“Of the patients having merely myofibrositis or a similar pathologic state, 96.3 percent were improved (good to fair results), making manipulation (under anesthesia) worth while.” Page 38
“It becomes evident from the review of these cases that manipulation of the spine under general anesthesia is a valuable procedure, but the cases must be specifically selected.” Page 39
“The steady spasm and the consequent postural defects combine with local pain, tetalgia, disturbances of the sympathetic nervous system, insomnia, and fatigue to form a vicious circle which magnifies the disability. Therefore, in an attempt to break up this vicious circle, manipulation of various types is carried out through the spinal areas. This can be applied more effectively in many cases with the patient under general anesthesia.” Page 39
“A high percentage of good results can be obtained with careful evaluation and selection of cases.” Page 39

7) Davis CG, DC. Fernando CA, MD. Do Motta MA, DC. Manipulation of the Low Back Under General Anesthesia: Case Studies and Discussion. J of Neuromusculoskeletal System. Fall 1993;1(3):126-134. (Full Article)
“Following this course of treatments, there was marked improvement in pain, with improvement in the orthopedic and neurologic exam. Medication use was decreased and functional capacity increased.” Page 126
“Failed back surgery syndrome is a common indication for MUA.” Page 126
“MUA was presented to the patient as an option for attempting to improve pain control and functioning. The procedure resulted in marked symptomatic improvement immediately after the MUA. Additionally, functional ability improved in these patients for whom physicians had expressed little hope of recovery of normal function.” Page 129
“The cross-links bind collagen fibers so that movement is restricted. When subjected to a high-velocity thrust, these cross-links may be disrupted without a resultant inflammatory reaction that would occur if the collagen fibers were torn.” Page 132
“The two patients in this case report had prolonged symptoms, and each had a number of back surgeries with radiographically identified postoperative scarring.” Page 132
“The MUA procedure in these cases have had longer lasting results than previous surgeries, nerve blocks, or medications.” Page 132
“Reports of manipulation under anesthesia have gone back as far as 1930 when
Riches reported successful treatment of 87 percent of his patients with chronic sciatica, and 92 percent with chronic sacroiliac strain with manipulation under anesthesia.” Page 132.
Many of the techniques require at least two operators, since control of the weight of the patient’s body and of the extremities rest entirely with the operators when the patient is under general anesthesia. This is particularly important with treatment directed at the lumbar spine and pelvis.” Page 133
“The assistant operator is needed for the positioning and stabilization of the patient and to assist in manipulations.” Page 133
“Care must be taken not to manipulate too vigorously under anesthesia. Instead of trying to achieve full range of motion in one manipulation, it is often better to manipulate more gently on two or more occasions.” Page 133
“Mennell has stated than it is no more irrational to use anesthesia to provide relaxation and to avoid pain in joint manipulation than it is to use anesthesia for the reduction of fractures and dislocation or extracting a tooth.” Page 133
“Both patients also regarded their functional capacity as being much improved.” Page 133
“With patients who have undergone surgery only to have the pain return due to scar tissue and fibrosis, MUA may be beneficial.” Page 134

8) Mennell J MCM , MD. The Validation of the Diagnosis “Joint Dysfunction” in the Synovial Joints of the Cervical Spine. JMPT Jan 1990;13(1):7-12. (Full Article)
“I use it (MUA) to obtain pure relaxation, for pain relief and sometimes for expedience – never so that I may use more force or any different technique.” Page 11
“My manipulative techniques are exactly the same with the patient awake or asleep. It is interesting that when asleep the patient’s restricted joint movement (amount of loss of function) is exactly the same as when they are awake.” Page 11
“When a patient is anesthetized, the therapeutic techniques used are exactly the same, though they are performed even more gently.” Page 11

9) Greenman PE, DO. Manipulation with the patient under anesthesia. JAOA Sept 1992;92(9):1159-1170. (Full Article)
“Safety and effectiveness are favored by appropriate selection of patients, knowledge of indications and contraindications, suitable anesthetic, and services of a qualified physician trained in structural diagnosis and manipulative technique.” Page 1159
“The patient was symptom-free for the succeeding 18 months, …” Page 1160
“The patient’s condition was greatly improved 24 hours after undergoing manipulation under anesthesia, and she was symptom-free within 10 days. No subsequent sequelae occurred for 18 months. Minor recurrence then responded quickly to more usual forms of manual medicine.” Page 1160
“The purpose of the anesthesia is to obliterate the pain and muscle spasm that has prevented other forms of conservative manual medicine care from being effective.” Page 1167
“Additionally, an experienced team can accomplish the procedure more quickly and save anesthesia time. Many of the techniques recommended … require a minimum of two operators.” Page 1167

10) Herzog J, DC. Use of Cervical Spine Manipulation Under Anesthesia for Management of Cervical Disk Herniation, Cervical Radiculopathy, and Associated Cervicogenic Headache Syndrome. JMPT Mar/Apr 1999;22(3):166-70. (Full Article)
“The patient had immediate relief after the first procedure. Her neck and arm pain were reported to be 50 percent better after the first trial, and her headaches were better by 80 percent after the third trial. Four months after the last procedure the patient reported a 95 percent improvement in her overall condition.” Page 166
“The generally accepted rationale for how MUA works is based on solid scientific data relating to muscle and joint physiology.” Page 166
“Siehl and Claybourne have documented the validity of MUA as a procedure useful in treating musculoskeletal disorders when restriction of the joint, joint capsule, and surrounding musculature has taken place as a result of the formation of fibrous adhesions.” Page 166
“She returned to work and maintained the improvement three months later.” Page 168
“The post-MUA therapy continues for a total of 6 to 8 weeks. At that time the patient will have achieved a maximum therapeutic benefit and be discharged. Rehabilitation and strengthening of the supporting tissues will help maintain the effects of the alteration of the fibrous adhesions that have occurred with the MUA.” Page 169
“Regardless, it seems to appear that MUA has a positive effect on certain types of conditions that have been unresponsive to traditional therapeutic approaches.” Page 169
“Significant increase in overall muscle flexibility and spinal range of motion was realized after each treatment. The rationale for MUA use is to control and alter the fibrous adhesions that are a result of the inflammatory cycle.” Page 170
“MUA has been shown to be of benefit in a case of cervical disk herniation with cervical radiculopathy and cervicogenic headache syndrome.” Page 170

11) Rumney IC, DO. Manipulation of the Spine and Appendages under Anesthesia: An evaluation. JOAO. Nov. 1968;68:75-85. (Full Article)
“Tospon reports that, in treating over 200 cases of ligamentous strain of the neck due to auto accident, early manipulation under anesthesia (second or third week after the accident) lessened the morbidity and hastened the recovery.” Page 76
“In 1955 Mensor reported good results in 64 percent of private practice patients and 45 percent of patients whose disability was caused by industrial accidents. After 20 years’ experience and treatment of more than 600 patients with manipulation of the back under anesthesia he has had sufficiently satisfactory results to continue with this procedure.” Page 76
“When the condition advances to fibrosis one is faced with a prolonged program, and it is at this point that manipulative therapy under anesthesia is most frequently indicated.” Page 77
“Even after the manipulative procedures break up the fibrosis, one must institute an adequate program of physical therapy and exercise. If one does not prevent, or lessen, the formation of fibrous tissue, the patient’s original problem will recur.” Page 77
“I believe there is a definite place for MUA. The procedure would definitely obviate the need for back surgery in many cases.” Page 85
“Only physicians who are well trained in the art of manipulative therapy should employ anesthesia for such procedures.” Page 85.

12) Samuel Turek , MD , orthopedic surgeon, reports in his textbook, Principles and Applications of Orthopedics.
“ good to excellent results” can be expected in 50 percent of patients with acute herniated nucleus pulposis with MUA.

13) Thomas Dorman , MD , Orthopedist, Diagnosis Techniques in Orthopedic Medicine.
“MUA is recommended when the patient has failed at conservative in-office care.”

14) Robert Mensor , MD , orthopedic surgeon. Lumbar Vertebral Disc Syndrome. (Full Article)
Conducted a large clinical trial of over 600 patients with EMG verified radiculopathy and found that 83 percent responded well to MUA.

15) Christman OD , MD. et al. A Study of the Results Following Rotatory Manipulation in the Lumbar IVD Syndrome. J Bone and Joint Surgery. 1964 Apr;46-A(3) (Full Article)
Reported that 51 percent of patients with unrelieved symptoms after conservative care had good to excellent results even three years after MUA.
16) MUA TEXTBOOK recommended for MUA certification courses:

Manipulation Under Anesthesia Concepts in Theory,
CRC Press, 2005
(Taylor & Francis Group, LLC,
PO Box 409267,
Atlanta, GA 30384
Telephone: 1-800-634-7064)