Manipulation under Anesthesia, Who Needs it?

For hundreds of doctors of chiropractic and many more of their
patients, Manipulation Under Anesthesia (MUA) is proving to be the
"missing link" in spinal care. MUA is nothing new (CPT code
22505), we just haven't had access to it until recently. The
procedure has appeared abundantly in orthopedic and osteopathic
literature since the 1940s and continuously up to the present.^1,6 It is new to the chiropractic profession because this procedure must be done in a hospital or surgery center; chiropractors just haven't had access to these facilities until recently (thank you
Dr. Wilk, et al.). Who should be manipulating these spines? We
who do 95 percent of the manipulation in this country or the others
with their 5 percent?

Any DC who includes in their practice the treatment of traumatic
spinal conditions has encountered the chronically fibrosed and
hypomobile spine. In the minority of these cases, these spines
remain fixated even following weeks to months of our best effort
to restore them to a functional state. What happens to these
patients? Many of us habitually place them on lifetime "maintenance
care," but eventually they drift away, disappointed in chiropractic,
and are lured to settle for the pharmaceutical approach and/or submit
to surgery of dubious benefit.

It's not just chiropractic philosophy, it's a scientific fact:
Synovial joints that are not allowed to move within the
physiological range of motion will degenerate.⁷ It is necessary to restore mobility as soon as possible. Fibrotic changes in the intra, peri, and pariarticular soft tissues restrict motion and
sometimes it's necessary to anesthetize a patient to achieve total
muscle relaxation to effectively manipulate the spine, thus lysing
adhesions and stretching the restricting fibrotic tissue to a
length compatible with motion.

The purpose of this article is to help the chiropractic clinician
understand from a real "nuts and bolts" approach the patient
selection process in determining the chiropractic necessity of MUA.
Even though the following exercise in patient selection may appear
oversimplistic, it will graphically demonstrate to the practitioner
reading this article just how many patients pass through our
practices who are actual candidates according to the literature of
MUA.

1. Have someone in your office make a list of all patients you
have treated in your office for over six weeks that still have
symptomatic spinal motion restriction.⁸

2. Remove from that list any patients who have had any of the
classic contraindications to spinal manipulation (if needed, please
refer to any standard chiropractic text with a laundry list of
contraindications to spinal manipulation).

3. Now remove from that list patients of advanced age. The reason
for screening out elderly patients, besides anesthesia concerns and
osteoprosis, is because MUA is directly focused towards changing
the pliability and elasticity of soft tissues relating to the
vertebral motor unit. Patients of advanced age usually have a much
compromised ability to replace damaged soft tissue with any
reparative tissue other than the most dysfunctional grade of
fibrotic tissue. The result of the manipulation that we provide in
MUA will actually lyse fibrotic tissue, break adhesions, and
lengthen chronically shortened and dysfunctional fibrotic tissue.

4. Now remove from your list as potential MUA candidates those
cases where there is full intersegmental motion throughout the
spine. If there is no motion restriction, then manipulation isn't
indicated whether it's done under anesthesia or not. Note: Many
patients exhibit a gross range of motion which could be considered
within normal limits, but we must remember as chiropractors we are
interested in the intersegmental motion, not just the gross number
of degrees that the patient's entire spine can move in any one
direction. Many times in our offices we have patients who can bend
forward and nearly touch the floor with their fingertips, but yet
upon examining their lumbar spine in this position, they have a
statically fixated lumbar lordosis without any flattening on
flexion; therefore we know that most of their motion is coming from
their hips.

5. We now remove from our list any patients that are more than 50
pounds overweight, especially those who would not cooperate
regarding a weight reduction program. Excess adipose tissue
dissipates the applied forces needed and restricts the application
of proper MUA technique. For the obese patient, the long-term
prognosis would not warrant conducting the procedure anyway.⁶

6. Next remove from that list any patients who are non-cooperative
when it comes to following doctors' orders and particularly
regarding exercise programs. MUA is a team approach, and the
patient is the most important member of that team. If the MUA
patients does not maintain their newfound spinal mobility through
exercise, they will simply return to the chronically fibrotic state
that they were in previous to the procedure.⁶

7. The last screening criterion that we will use in this exercise
in the MUA patient selection process is that we must determine the
patient's desire to be rehabilitated. Many of the cases which fit
the criterion for MUA are cases in which there are med-legal
considerations (industrial and personal injury). If the patient
has no desire and is not motivated to return to normal spinal
function, then MUA would not be indicated because it is the
aggressive follow-up care after the MUA that determines the success
of its application.

In a nutshell, a good patient candidate for MUA is generally in
good "health," not much past middle age, preferably younger, who
has loss of spinal joint mobility not attributable to congenital
variation or progressive ankylosis; the patient who has undergone
at least six to eight weeks of traditionally indicated chiropractic
manipulation in-office without satisfactory results and has a
sincere desire to be rehabilitated.

Now take a look at your list. If there is no one left on that
list, you most likely do not have the type of practice where it
would warrant your receiving the training. If you did have a
patient that presents in your office fitting the criteria, it would
probably be in both your best interest to refer that patient to a
MUA practicing chiropractor who would then provide the service and
return that patient to you for the postoperative follow-up care.
If you have even one patient remaining on your list, it would
probably be in your best interest to receive the training and
obtain hospital or surgery center privileges that you might provide
this service to your patients. Most of the doctors who are MUA
certified have stated that considerably less than five percent of
their patients need MUA. Not every doctor of chiropractic sees the
same types of cases. Some practices are majority "chronic spinal
dysfunction" while others are "wellness and health maintenance"
predominant.

Many DCs have a majority practice of disc cases. Are disc cases a
contraindication to MUA? To the contrary, many of the orthopedic
and osteopathic researchers of MUA consider a moderate disc bulge
or even herniation to be an indication for MUA in an effort to
avoid surgery and have reported good to excellent results in
approximately half of the fully diagnosed disc lesions of moderate
severity.⁹

It is my intention in this first of several articles regarding MUA
and chiropractic privileges and protocol in hospitals and surgery
centers to motivate the inquisitive doctor of chiropractic to seek
this training.

My next column will be a step-by-step guide to establishing
chiropractic privileges in a hospital or surgery center in your
area and in obtaining competent instruction in MUA. There are
three CCE accredited chiropractic colleges offering MUA
postgraduate courses. Correspondence can be addressed to:

Tim Mills, D.C.,
c/o MUA Associates of Southern California,
P.O. Box 16305, Beverly Hills, CA 90209-2305.

References:

1., Fisher AGT: Treatment by Manipulation in General and
Consulting Practice. Hoeber, ed 4, 1944.

2. Clybourne HE: Manipulation of the low back region under
anesthesia. J. Amer. Osteopathic Assoc., 48:10-11, Sept. 1948.

3. Maitland GD: Manipulation Under Anesthesia (MUA), Vertebral
Manipulation. Butterworths, ed 4, 1977.

4. Adams JC: Manipulation, Clinical Methods, Outline of
Orthopedics, ed 9. Churchill Livingstone, 1981.

5. Turek SL: The Back, Orthopedics -- Principles and Their Application, Vol 2, J.B. Lippincott, 1984.

6. Krumhansl & Nowacek: Manipulation Under Anesthesia, Modern Manual Medicine. C.P. Grieve, 1986.

7. Radin EL: Osteoarthrosis: What is known about prevention? Clin. Orth. & Real Res., 222:60, Sept. 1987.

8. Rumney IC: Manipulation of the spine and appendages under general anesthesia: An evaluation. J. Amer. Osteopathic Assoc., 68:235. Nov. 1968.

9. Siehl D: Conservative treatment of the disk syndrome. J. Amer. Osteopathic Assoc., Vol. 71, March 1972.

Timothy L. Mills, D.C.
Cypress, California