Manipulation under Anesthesia

Manipulation under anesthesia, as practiced today, has had a rather tenacious resurgence since its early beginnings in the late 1930s. There have been a lot of good changes in the techniques used for the procedure over the years, and we certainly have discovered more scientific basis for the results that we are achieving, but the one thing that has remained constant since the early articles were written about MUA¹ has been the concept of education and training for the doctor performing the procedure. The early practitioners of this procedure had no reference for support for what they were trying to accomplish. They were manual practitioners who believed that if they placed patients in a more relaxed state and manipulated the areas of involvement, they should see a greater change in the desired outcome of the patients' problems. Since the anesthesia procedures were not as advanced as they are today, they used general anesthesia and general mobilization techniques, and were rewarded with rather remarkable results even with the more primitive techniques used. The literature has indicated that the MUA technique was responsible for correcting many problems that were not responding to other more conservative manual techniques and that, when taken into the O.R. and mobilized under general anesthesia, the results were very good.^2-4

When the early articles on MUA (part of the time-honored manual practice) were written, there were educational and training factors indicated by many authors, but the training that was indicated was handed down from one practitioner to another in more of an apprentice fashion. One manual practitioner would show another how to do certain techniques, and in turn that practitioner would show others. There was no formal training, as there is today. However, the concept of education and training by an already trained practitioner has always been the foundation for good practice with the MUA technique.

Today, with the resurgence of the MUA technique primarily by the chiropractic professional, we are changing the approach to the educational and training methods, and we are no longer relying on one practitioner showing another practitioner how the procedure is to be performed. With the advent of educational requirements necessary for professional health care colleges to maintain national certification to graduate highly trained health care professionals, the MUA procedure is being taught through accredited institutions. The most prominent educational entity in the chiropractic profession is the Council on Chiropractic Education (CCE), which sets the national standards of professional educational requirements for chiropractic colleges. Because postgraduate programs fall within the framework of CCE-accredited chiropractic colleges, the same high standards of education are required of postgraduate courses as those of undergraduate study standards. This is important when we discuss the core curriculum for the MUA postgraduate courses taught by the accredited chiropractic schools, because these courses have gone through the same high standards of auditing and investigation as other courses taught at the undergraduate level.

CCE does not accredit postgraduate courses, but chiropractic colleges, which adopt protocols for postgraduate courses that follow its same stringent guidelines. This is why courses have schedules; specific materials that have been reviewed and approved by the colleges; and why the instructors are contracted to teach through the postgraduate departments of each accredited chiropractic college. A course with no sponsorship has no quality assurance parameters. In other words, there is nobody watching what they teach; there are no standards of education; and there is usually a secondary personal financial interest in the program that is not allowed with regularly scheduled postgraduate programs.

Why is it so important for you, the practicing doctor, to take CCE-accredited chiropractic college postgraduate programs, especially when we talk about the MUA procedure? There are many reasons, but of primary concern is liability. The program, while not directly involved in your liability insurance, shows that you have taken proper educational standards to become certified to perform the procedure. Those standards are directly related to the outcome of any case that might arise out of purported negligence issues, in a case in which malpractice is accused. If doctors can show that they followed proper standards of care and proper protocols as taught through CCE-accredited chiropractic college postgraduate course curriculum for MUA, they have a much better chance of defending their position in a potential malpractice case.

This is also a factor to be considered by facilities where MUA is performed. For many years, as a consultant to hospitals and ambulatory surgical centers, it has always been a real concern to require the doctor who performs it to have graduated from a CCE-accredited chiropractic college MUA certification program. This puts the facility in a much better position with its liability carrier, and if the facility is accredited through agencies such as the Joint Commission on Accreditation of Hospital Organizations, it shows this agency that the facility only recognizes fully certified practitioners who have taken their certification through accredited institutions.

There are other MUA programs that you can take. There is always a way around standards and protocols. There is no way we can prevent you from taking another course not taught through am accredited college, or take any action to interfere with one running a financial venture. However, if these other programs want to teach MUA, why are they not affiliated with CCE- accredited chiropractic colleges, or CME-accredited medical/osteopathic colleges? It seems to me that if an institution had a quality program with quality educational standards at the core of its reason for providing a procedural program as important as the education required to perform MUA, that educational entity would want to have all the quality assurance parameters it could provide to the doctors taking the program.

Disingenuous people and programs are rampant in the chiropractic profession, and always have been since I became a chiropractic physician. People constantly try to take advantage of my chiropractic brethren because they can. We are all gullible when it comes to survival; we attack each other at every chance we get if we feel we are being threatened. I don't profess to have all the answers, but I've put enough time into this field and have the track record to prove that this procedure must be performed with the highest educational quality and standards, or someone will get hurt. As long as we maintain the highest standards of care, we keep those things from occurring. But things do happen, even to the best of us, and when they do, you had better think about where your training came from and who sponsored it. A program that has no quality assurance parameters may not be available if you need to find them. And even if you find them, they may not be able to justify the training you were given through any nationally recognized educational requirements.

As a matter of record, unless you have taken a CCE-accredited chiropractic college program of at least 32 hours, you are not eligible for membership in the National Academy of MUA Physicians (NAMUAP). This is a national organization that has established national standards and protocols for the procedure. Insurance provider NCMIC recognizes only those doctors for malpractice coverage for MUA that have taken CCE coursework for certification. Many insurance companies now are requesting this, and they are noticing if a course was taught with sponsorship by an accredited institution. Many state boards have adopted provisions that state: "MUA is within the scope of chiropractic practice because it is taught by CCE-accredited chiropractic colleges." As stated above, most reputable hospitals and ambulatory surgical centers are requiring that, to practice MUA in their facilities, you must have taken your course through a CCE or CME- accredited institution. This reverts to concerns over liability issues.

So you see, taking your course through proper accredited institutions is extremely important. When you decide to take this training, please check to see if the course you are taking is "sponsored by" a CCE-accredited chiropractic college. Don't accept any second-hand information. Check with those chiropractic colleges that have these programs in place. They are usually aware of the other colleges that have the programs. One of the reasons for that is that we are now involved in trying to standardize MUA educational requirements. The NAMUAP has educational standards we are trying to get all colleges to recognize. It will set educational standards for the procedure in all colleges.

Most CCE-accredited chiropractic colleges that sponsor MUA programs are using the same or similar information, and the techniques are the same, with the addition of the instructors' backgrounds in therapeutic adjustive procedures. This is the best possible scenario we could hope for. For once in this profession, we are teaching the same standard of education with similar technique. This is not a trend in technique, and there are no gurus of MUA; the technique, completed at its best, obtains wonderful results that have been duplicated over the years by many practitioners. If you are going to learn this very valuable procedure, add it to your practitioners' tool box, then learn it right, and make sure you challenge those that are doing it wrong. Completed by untrained unqualified practitioners, all we have is another "pseudotherapy learned for the express purpose of financial gain."⁵

References

1. Clybourne HE. Manipulation of low back region under anesthesia. J Am Osteopath Assoc 1948;Sept:10-11.
2. Siehl D, Bradford W. Manipulation of the low back under general anesthesia. J Am Osteopath Assoc from the article (Persol's International Med. Clinic Case Study 1938) 1952;Dec:239-242.
3. Rumney IC. Manipulation of the spine and appendages under anesthesia: an evolution. J Am Osteopath Assoc Nov. 1968;63:235-75;239-79.
4. Greenman PE. Manipulation with the patient under anesthesia. J Am Osteopath Assoc 1992;92:1159-70.
5. Wyke B. Articular neurology, a review. Physiotherapy Journal of the Chartered Society of Physiotherapy. 58:14. Bedford Row, London, WCIR; 1972;94-9.