Edward Cremata, DC, QME, FRCP(US)

Fremont Chiropractic Group

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American Association of Manipulation Under Anesthesia Providers

AMERICAN ASSOCIATION OF MANIPULATION UNDER ANESTHESIA PROVIDERS

GUIDELINES

(Revised March, 2012)

DISCLAIMER

The American Academy of Manipulation Under Anesthesia Physicians provides these guidelines for practitioners, facilities, and other interested parties, and notes that decisions to adopt particular courses of action must be made by trained practitioners on the basis of the available resources and the particular circumstances of the individual patient.

These guidelines are not to be applied to any specific patient, in any manner, and any decision requiring necessary testing, patient candidacy or follow-up procedures must be made by the individual doctor and determined by the needs of the patient. Safety and Efficacy should drive the doctor's decision when considering Manipulation Under Anesthesia protocols. These guidelines are not intended for utilization review purposes.

Accordingly, the American Academy of Manipulation Under Anesthesia Physicians denies responsibility for any injury or damage resulting from actions taken by practitioners after considering these guidelines.

PURPOSE STATEMENT

The purpose of the American Academy of Manipulation Under Anesthesia Physicians is to standardize and regularly update the procedure of manipulation under anesthesia, and to make available resources for the safest, most effective, and most ethical practice of manipulation under anesthesia.

Our common goal is to support quality assurance for all programs, doctors, and facilities to encourage adherence to the highest standards for ethical manipulation under anesthesia practice.

Our general objective is to recommend, promote and review protocols and programs for the use of manipulation under general anesthesia on a National level (United States). The Academy does not recognize those programs, procedures, facilities, or doctors that do not adhere to accepted standards of care as established by the academy and/or recognized through joint accrediting commissions or other state and federally regulated licensing organizations for doctors, hospitals and/or ambulatory surgical care facilities.

Members of the Academy must have completed an MUA certificate program from a CCE/CME accredited institution or be an Allied Health Care provider/facility who is actively involved in rendering opinion or service to the MUA program or procedures.

Members are credentialed into the Academy by a committee that examines state licensure, malpractice coverage and certification of appropriate training in MUA.

PROTOCOLS AND STANDARDS

PATIENT SELECTION

Clinical Candidacy for Manipulation Under Anesthesia

§ The patient has responded sub-optimally to conservative physical medicine treatment, usually including spinal adjustments by a chiropractor, and often with medical co-management, and continues to experience intractable pain, interference to activities of daily living, and/or biomechanical dysfunction.

§ Sufficient care has been rendered prior to recommending MUA. A sufficient time period is usually considered a minimum of four to eight weeks, but exceptions may apply depending on the patient's individual needs. Most patients selected for MUA procedures have had longer courses of care, but those with more severe symptoms and little or no response to conservative management are best considered sooner than later to avoid unnecessary additional costs and increased suffering.

§ Physical medicine procedures have been utilized in a clinical setting during the six to eight-week period prior to recommending MUA.

§ The patient's level of reproduced pain interferes with activities of daily living or causes disability.

§ Diagnosed conditions must fall within the recognized categories of conditions responsive to MUA. The following disorders are classified as acceptable conditions for utilization of manipulation under anesthesia:

1) Patients whereby manipulation of the spine or other articulations is the treatment of choice; however, the patient's pain threshold inhibits the effectiveness of conservative manipulation.

2) Patients whereby manipulation of the spine or other articulations is the treatment of choice; however, due to the extent of the injury mechanism, conservative manipulation has been minimally effective during a minimum of four to eight weeks of care and a greater degree of movement of the affected joint(s) is needed to obtain patient progress.

3) Patients whereby manipulation of the spine or other articulations is the treatment of choice by the doctor; however, due to the chronicity of the problem and/or the fibrous tissue adhesions present, in-office manipulation has been incomplete and the plateau in the patient's improvement is unsatisfactory.

4) When the patient is considered for spinal disc surgery, MUA is an alternative and/or an interim treatment and may be used as a therapeutic and/or diagnostic tool in the overall consideration of the patient's condition.

5) When there are no better treatment options available for the patient in the opinions of the treating doctor and patient and in consideration of the cause of the patient's related pain, impairment, and/or disability.

DIAGNOSIS

Establishing Medical Necessity

Every condition treated must be diagnosed and justified by clinical documentation in order to establish medical necessity. Documentation of the patient's progress and the patient's response to treatment are combined to confirm the working diagnosis. Those diagnoses which are most responsive to MUA include, but are not limited to the following:

§ Sclerotogenous pain from the medical branch of the dorsal rami.

§ Cervical, thoracic, lumbar, sacroiliac, and sacrococcygeal sprain/strain subluxations (neuromechanical dysfunctions) with or without resultant myofascial pain syndromes.

§ Intervertebral disc syndromes without fragment, sequestration, or any contraindication to in-office manipulative procedures and with or without radiculopathy.

§ Cervical brachial pain syndrome associated with torticollis.

§ Chronic recurrent headaches.

§ Failed back surgeries with adhesion formation in a patient that has not adequately responded to clinical therapeutic trials of manipulation, traction, and fibrous release procedures.

§ Adhesive capsulitis and/or soft tissue contractures relative to articular motion of the appendicular skeleton, e.g. shoulder and knee.

§ Paravertebral muscle contraction related to functional biomechanical dysfunction syndromes (sprain/strain with fixation and vertebral subluxation complex). Functional radiography and particularly lateral bending, weightbearing radiographs are recommended to detect and characterize intersegmental motion restrictions in the spine, but not required in every case.

§ Extraspinal (extremities) dysfunction that has also been considered to relate to the spinal abnormality. Extraspinal dysfunction and the treatment thereof has always been a part of the standard of care in the chiropractic profession and in the manual therapist's regime of treatment. The same standards of examination, radiographic evaluation when necessary and pre-care prior to MUA that is recognized in the spinal treatment would be considered the standard of care with extremities as well.

FREQUENCY AND FOLLOW-UP PROCEDURES

Guidelines for Determining the Necessity and Frequency of MUA

The American Academy of MUA Physicians recommends the following considerations when determining the necessity and frequency of manipulation under anesthesia.

§ The patient's response and progress to previous conservative care.

§ Consideration of activities of daily living and disability.

§ The patient's psychological acceptance of the MUA procedure, and the psychosomatic response to overcoming chronic pain and discomfort.

§ Prevention of additional gross deterioration.

§ Prevention of possible surgical intervention.

§ Chronicity

§ Length of current treatment and patient progress.

§ Patient's age.

§ Number of previous injuries to the same area.

§ Level of pain considering standard 4-6 week minimum protocol parameters and deciding whether a variation from the guidelines may be appropriate for the individual patient's needs.

§ Patient's tolerance of previous treatment procedures and success or failures from those procedures.

§ Muscle contraction level (beyond splinting).

§ Response to previous MUA's based on objective clinical documentation and protocols for determining patient progress.

§ Fibrous adhesion from failed back surgery or prior injury.

§ Patient willingness and availability to participate in appropriate post-procedures follow-up to optimize results.

Protocols for Determining the Frequency of the MUA Procedure

A summary of the evidence below shows the best results when patients have undergone serial procedures with a typical treatment plan comprising of three consecutive days of treatment and showing that 70% of this patient group reported a good to excellent result. Studies showing benefit in approximately 50% of patients were typically one day procedures. Expert opinion suggests that serial procedures allow a gentler and effective treatment plan allowing more controlled force, safer procedures with less force required, and more focused and effective subsequent day procedures after monitoring the effects of the earlier day's procedures. This is consistent with expert opinion on this subject (17).

The Academy recommends that ranges of motion are always measured after an appropriate warm-up period for consistency and as recommended within the American Medical Association Impairment Guidelines, Fifth Edition.

§ Single spinal MUA is most often recommended when the patient is of a younger age, when the injury is first to an area, and when the verifiable global and intersegmental motion restrictions are relatively mild.

§ Single spinal MUA is most often recommended when conservative care has been rendered for a sufficient time (usually a 4-6 week minimum) and the patient's activities of daily living or work activities are interrupted in such a fashion as to warrant a more aggressive approach.

§ If the patient is treated for intractable pain with a single MUA procedure and responds with 80% symptomatic and functional resolution, the necessity for future MUA's should be considered and depends in part on the objective parameters determined during and after the MUA procedures.

§ Serial MUA is recommended when the patient's condition is chronic and when conservative care as described in the Academy standards and protocols has been rendered.

§ Serial MUA is recommended when the injury is recurrent in nature and fibrotic tissue and articular fixation prevents a single MUA from being optimally effective.

Parameters for Determining MUA Progress may include, but are not limited to:

§ Subjective Changes

· Patient's pain index, visual analogue scale, faces of pain

· Patient's ability to engage in active range of motion

· Patient's change in activities of daily living

· Patient's change in job performance

§ Objective Changes

· Change in measurable muscle mass, function, and strength

· Change in muscle contractibility.

· Change in EMG and/or nerve conduction studies

· Change in controlled measurable passive range of motion

· Change in diagnostic studies (X-rays, CT, MRI), including functional radiography

General Post MUA Therapy

§ Therapy Following First MUA

· Repeat MUA stretching.

· Physiotherapeutic modalities as indicated by patient presentation.

· Patient to rest at home with walking and range of motion exercises encouraged to patient tolerance.

§ Therapy Following Subsequent MUAs

· Same as 1st day

· No further manipulation should be required.

· May add proprioceptive neurofacilitation protocols. These can be incorporated during stretching if tolerated.

§ Therapy Following Last MUA

· Same protocol as above with proprioceptive neurofacilitation.

· Additional home instructions to include range of motion and strengthening exercises as condition permits and to patient tolerance can be provided to the patient at this time.

§ Week Following Last MUA

· Treatment frequency during the first week should be 3-4 days dependent on the individual patient's needs. These followup procedures should include all fibrosis release and manipulative procedures performed during the MUA procedure to help prevent re-adhesion.

§ Next Two Weeks

§ Continue full protocols to include fibrosis release procedures, proprioceptive neurofacilitation, and manipulative procedures as needed to maintain global and intersegmental motion improvements obtained during the MUA procedure.

§ Begin home rehabilitation exercises 2-3 times per week

§ Next Four to Five Weeks

· Continue full protocol (fibrosis release procedures, proprioceptive neurofacilitation and manipulative procedures).

· Patient treated 1-2 times per week for 4-5 weeks depending on patient needs.

· Active progressive resistive strength/stabilization exercises, supervised/unsupervised 2-3 times per week; optimal rehabilitative procedures should include attention to aerobic, flexibility, strength, and coordination considerations.

SAFETY

The Academy requires the need for certified MUA physicians and certified co-attending doctors considered appropriate. The Academy recognizes two important factors regarding the certified MUA practitioner and the certified co-attending doctor.

Patient Safety and Efficacy

Manipulation under anesthesia is performed using the anesthesia techniques determined by the anesthesiologist to be appropriate for the patient. MUA is performed with the patient in a sedated state as determined safe and effective by the attending anesthesiologist. The chiropractic providers do not make any decisions regarding the medical management nor do they direct or use any of the medications required by the anesthesiologist during his or her medical management.

The primary doctor and the co-attending doctor move the patient into specific ranges of motion to accomplish the procedure. In this capacity, the patient depends on the primary doctor and co-attending doctor to protect them from bodily injury. Since the patient is only minimally responsive to painful stimuli and does not have the ability to respond to immediate proprioceptive input, both the primary doctor and the co-attending doctor are key to a safe and successful procedure.

The co-attending doctor is responsible for patient stability, patient movement, patient observation, and completing portions of the procedure should the primary doctor need assistance or become unable to perform the procedure. Since there are several instances during the procedure when the primary doctor has to move the patient, stabilizing and working with the patient would be unsafe without assistance from another doctor competent and knowledgeable in MUA. (19)

Doctor Safety

Manipulation under anesthesia is a very physically demanding therapeutic procedure. Since the patient is in a sedated state, the doctor has the added responsibility of insuring that the patient's extremities and torso do not fall from the treating surface. The doctor must also be able to move the patient without the assistance of the patient.

The co-attending doctor is an integral part of this procedure and is responsible for helping the primary doctor move the patient through the prescribed ranges of motion. The co-attending doctor is present to insure that all movements are accomplished without injury to the patient or to the primary doctor performing the procedure. As a result of the added potential risk to the patient in a sedated state, there is a high risk of injury to the doctor and the patient if only one doctor were to attempt the complex techniques necessary for the MUA procedure. The co-attending doctor, who is a certified MUA practitioner, is the safest way to perform this procedure. It may be unsafe to perform an MUA without a competent and knowledgeable MUA doctor as the co-attending doctor and anything other than allowing another MUA certified doctor to act as a co-attending doctor imposes potential risks. By using a certified MUA practitioner as a co-attending doctor, optimal efficacy and safety standards are maintained. This is proper standard of care policy for the MUA procedure and needs to be recognized as such by anyone recommending MUA, or reimbursing for MUA. (20)

In the cervical spine, the co-attending doctor must secure the patient's shoulders and provide counterforce procedures to obtain the necessary traction for this part of the procedure. In the thoracic spine, the co-attending doctor turns the patient, stabilizes the patient and applies proper counter traction for the MUA maneuvers. In the lumbosacral area, the co-attending doctor coordinates movements with the primary doctor, assists with the actual procedures, and can complete the MUA procedures as necessary. Procedure efficacy is enhanced when both doctors are trained and knowledgeable regarding the appropriate forces and counterforces required to perform safe and effective MUA procedures.

A certified MUA physician carries the appropriate malpractice insurance to perform MUA and so does his or her co-attending doctor. Since non-certified assistants may not carry malpractice insurance for MUA, utilization of ancillary staff to assist with the MUA procedure may potentially place the entire team and the facility at risk and the Academy does not recommend anyone other than a certified MUA practitioner be available to co-attend with the MUA procedure.

FACILITIES

All MUA procedures should be performed in the highest quality facility available and within the parameters of state regulations. The Academy recommends performing MUA in hospitals, ambulatory surgery centers or other specialty centers that meet the American Society of Anesthesiology standards, and adhere to Academy standards of care.

COMPENSATION

Fees must be reasonable and in relation to standards and relative values within each state. The CPT codes used for MUA include but are not limited to 22505, 20999, 23700, 27275 and several extra spinal CPT codes such as the knee, ankle, foot, elbow, wrist and the TMJ. It is recommended that chiropractic/medical necessity and authorization be obtained prior to scheduling the patient. The Academy does not dictate fees in any manner, but does recommend restraint and reasonableness in our recommendation for standard fee structures.

ANESTHESIA STANDARDS

Guidelines for Outpatient Manipulation Under Anesthesia

§ Anesthesia is provided under the direct supervision of a board-certified anesthesiologist or other osteopathic or medical physician based on applicable state law. The MUA certified chiropractors limit their involvement to procedures within their scope of practice which may vary from state to state.

§ The anesthesia provided must adhere to guidelines and recommendations accepted in his/her community for delivering anesthesia to patients.

§ Pre-MUA

· Patients are appropriately evaluated by their chiropractic or MUA doctors to assess candidacy prior to the procedure. Anesthesiologists will typically perform a history and physical prior to the procedure and may elect to not go forward with and may cancel the procedure if they feel that the patient might be at risk from a medical standpoint.

· All appropriate clearance forms, laboratory results, imaging reports and other supported data are available for review in the patient's chart. Special testing should be provided only as deemed necessary and based on individual needs. Since the fibrosis release from manipulative procedures performed during MUA carries similar risks as chiropractic in-office procedures, the need for diagnostic tests is commonly determined using similar criteria as might be performed during in-office care with physical methods. Individual laboratory testing or special testing requirements may differ from state to state or from facility to facility.

§ Intra-MUA

· The anesthesiologist selects the anesthesia based on the patient's medical condition and is responsible for all medical decisions.

· The chiropractic doctor does not order or administer any medications.

· Blood pressure, oxygen saturation and EKG are recorded by the anesthesiologist, or at his direction, throughout the procedure.

· Supplemental oxygen is available in case it is needed.

· Resuscitate equipment and medications must be readily available at all times.

· An emergency facility must be available locally pursuant to state and accreditation agency requirements.

§ Post-MUA

· The anesthesia provider is responsible for the medical discharge of the patient.

· Once the patient is stable, the anesthesia provider may depart as long as there is a trained ACLS provider present in the facility and pursuant to local regulations and patient needs.

NURSING STANDARDS

Patient Care Responsibilities

· Pre-MUA

· Witness signature of procedure consent

· Verify and document NPO compliance

· Verify responsible adult driver or escort is available for the patient

· Verify and document present medications and allergies

· Direct and assist the patient with appropriate attire for procedure

· Escort the patient and medical chart to procedure room.

§ Intra-MUA

· Direct and assist patient in transferring to the procedure table

· Maintain patient safety, privacy and dignity

· Complete appropriate medical record forms

· Be available to assist anesthesia provider as needed

· Be available to assist MUA providers as needed.

· Assist in transferring the patient to a recovery bed

· Raise the bed's side rails for patient safety as required.

§ Post-MUA

· Transport patient to recovery room with anesthesia provider

· Receive report from anesthesia provider including medications given, vital signs, IV history and any other pertinent information

· Secure appropriate monitoring equipment

· Record vital signs on admission to recovery area and every 15 minutes until stable and then every 30 minutes until discharge

· When the patient is conscious and alert, oral fluids may be offered

· When the patient is tolerating fluids, a light snack may be offered

· When the patient is tolerating foods and fluids well and vital signs have remained stable for 15 minutes, the IV/heparin lock may be discontinued.

· The patient may then be discharged to their responsible adult escort/driver with written instructions for activity and follow-up care.

LITERATURE REVIEW AND OTHER REFERENCES CITED

The amount and level of scientific evidence for MUA is similar to other procedures available for a chronic pain patient including injections, surgery, physical therapy, etc. (2) A review of available published evidence is listed below for the reader's convenience.

Below is a list of selected references and partial abstracts, as well as textbook excerpts, outlining the efficacy of MUA. There have been over 50 published articles, all demonstrating its effectiveness for a select patient population. The Mercy Guidelines show MUA as an "equivocal" procedure, suggesting that the medical necessity needs to be established depending on the individual needs of a patient. The ICA Whiplash Guidelines considers spinal MUA as an appropriate consideration for those patients that sustained a whiplash injury.

1. Supplemental Care With Medication-Assisted Manipulation Versus Spinal Manipulation Therapy Alone For Patients With Chronic Low Back Pain, 2005 JMPT

"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

2. Frank Kohlbeck, DC and Scott Haldeman, DC, MD, PhD, published a literature review of MUA (49 published articles) in THE SPINE JOURNAL in 2(2002);288-302. Medication-Assisted Spinal Manipulation and concluded the following:

"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."

Mesner'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. Daniel West et al reported in a JMPT 1999;22(5) study titled "Effective Management of Spinal Pain in 177 Patients Evaluated for MUA"

"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

4.Palmieri et al, October 2002. Chronic LBP: A study of the effects of MUA. JMPT Oct 2002;25(8):E8]

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

5. Siehl D. Manipulation of the Spine under General Anesthesia. J Am Osteopath Assoc. June 1963;62:35-41.

"... 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) worthwhile." 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, testalgia, 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

6. 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.

"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

7. 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.

"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

8. Greenman PE, DO. Manipulation with the patient under anesthesia. JAOA Sept 1992;92(9):1159-1170.

"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

9. 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.

"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

10. Rumney IC, DO. Manipulation of the Spine and Appendages under Anesthesia: An evaluation. JOAO. Nov. 1968;68:75-85.

"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.

11. 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.

12. Thomas Dorman, MD, Orthopedist, Diagnosis Techniques in Orthopedic Medicine.

"MUA is recommended when the patient has failed at conservative in-office care."

13. Robert Mensor, MD, orthopedic surgeon

Conducted a large clinical trial of over 600 patients with EMG verified radiculopathy and found that 83 percent responded well to MUA.

14. Christman OD, MD. et al. A Study of the Results Following Rotatory Manipulation in the Lumbar IVD Syndrome. J Bone and Joint Surgery. 1984 Apr;46-A(3)

Reported that 51 percent of patients with unrelieved symptoms after conservative care had good to excellent results even three years after MUA.

15. Edward Cremata, DC, Stephen Collins, DC, William Clauson, MD,

Alan B. Solinger, PhD, and Edward S. Roberts, DC Manipulation Under Anesthesia: A Report of Four Cases. J Manipulative Physiol Ther 2005;28:526-533

Results: Increases in passive ranges of motion, decreases in the visual analog scale rating, and diminishment of subsequent visit frequency were seen in each of the patients.

Conclusion: Manipulation under anesthesia was an effective approach to restoring articular and myofascial movements for these 4 patients who did not adequately respond to either medical and/or in-office conservative chiropractic adjustments and adjunctive techniques.

16. Simon Dagenais, DC, PhD, John Mayer, DC, PhD, James R. Wooley, DC,

Scott Haldeman, DC, MD, PhD. The Spine Journal 8 (Jan., Feb. 2008) 142–149

From the Summary:

"As noted in previous studies, generalizing prior MUA literature is very challenging, perhaps even inappropriate, because of participant heterogeneity and differences in treatment procedures used several decades ago and those used today. Overall, the methodological quality of the studies uncovered related to MUA, MUESI, and MUJA is weak and evidence consists mainly of observational studies. None of the MAM procedures have been subjected to a RCT and the absence of a rigorous, comparable control group makes interpreting results difficult. However, almost all studies to date on these procedures have reported positive results, indicating that patients who undergo their procedures have a reasonable prognosis."

17. California Industrial Medical Council Work Group for Manipulation Under Anesthesia, member, Lawrence Tain, DC, IMC member. Consulting committee to Dr. Tain concluded as follows in a November, 2003 document to the IMC:

"SINGLE vs. SERIAL APPLICATIONS

Scientific publications and experts in the field recommend between one and five consecutive days of FRP-MUA procedures, with most patients needing three days (2,3,4). The physician can often obtain all treatment objectives within two days with younger, less complicated patients, whereas, the most difficult patients, in very rare instances, may require four or even five consecutive days. Acute patients that are unable to tolerate appropriate in-office procedures will generally only require one day of FRP-MUA procedures. The medical necessity for these procedures in the acute patient population is considered to be relatively uncommon."

18. PI Omega Delta Insurance Services. 900 Bonita Ave., La Verne, CA, 91750. March 27, 2007

Re: Manipulation Under Anesthesia (MUA)

Chiropractic Malpractice Program

TO WHOM IT MAY CONCERN:

We are the managing general agent for a doctor of chiropractic Malpractice program that has been active in the California marketplace for twenty years. In that endeavor, we have continuously insured in excess of 1500 chiropractors. Of these doctors, from the early 1990's on, we know of 30 or 40 who have regularly participated in MUA activities. It is the position of this program:

1. That the non-invasive procedure (MUA) is within the

statute of chiropractic in California.

2. That it has coverage under our policy of insurance.

3. That we do not charge an additional premium for

this specific risk.

Finally, in our 17+ years of this known activity in chiropractic,

we have not had a single claim or paid loss as a result of the MUA.

Should you need any additional information, please let me know.

Virgil Carter

Principal Agent

Contact Information

Phone: (510) 796-2225
email: Cremata@gmail.com

Address: 39355 California St. Suite 106 Fremont, CA 94538

Dr. Edward Cremata, DC, QME
Professor, Palmer College of Chiropractic West

Map & Directions

Monday: 10:00am - 12:00pm & 
2:00pm - 6:30pm
Tuesday: By Appointment for Treatment, Legal Exams and Special Procedures
Wednesday: 2:30pm - 6:30pm
Thursday: 1:30pm - 7:00pm
Friday: 9:00am - 1:00pm
Weekends: Urgent Appointments Only