The Proliferation of MUA Programs

Over the last few months, there hasn't been as much talk or publicity regarding chiropractors performing Manipulation Under Anesthesia (MUA), as there had been towards the end of 1991 and the beginning of 1992. The reason for the lack of attention in the public media and in the chiropractic periodicals is basically because the novelty has worn off. The idea of a chiropractor performing a hospital procedure isn't shocking and controversial enough to be interesting.

Since the "ABC Network News" broadcast last March that focused attention on MUA in Southern California, the number of facilities with chiropractic programs in the Los Angeles area has grown from just two hospitals to six hospitals, four outpatient surgery centers regularly performing MUA procedures, and another five facilities in the development stage. There are now three CCE accredited chiropractic colleges offering MUA training.

Interest in the procedure has not only grown within our own profession, but numerous inquiries have been received from various medical specialists who have been very impressed with the results that the chiropractors have been achieving, with what many considered to be "no hope" and "pain in the @!#" cases.

I have heard the unsubstantiated comment that MUA was a procedure that the osteopaths did in the past and have since discarded. The truth of the matter is most osteopaths who perform MUA are orthopedic surgeons; within the osteopathic orthopedic community, MUA is alive and well. As a mater of fact, the September issue of the Journal of American Osteopathic Association contains an article extolling the virtues of "Cervical Manipulation Under Anesthesia," written by the well-respected osteopathic author and researcher, Philip E. Greenman, D.O.¹ To the dismay of many of the traditional osteopaths, osteopathic education over the last few decades has de-emphasized the importance of spinal manipulation and at many colleges, osteopathic manipulation is an elective course.

The fact that few osteopaths perform MUA is not surprising, since most osteopaths these days don't manipulate at all and aren't particularly interested in the treatment of musculoskeletal conditions. They have shifted to fill the void which exists in this country for the "Marcus Welby-type" general practitioner.

I have received several inquiries from doctors in areas where there currently isn't an MUA training program or a facility in which they can perform the procedure. They have requested information on how to get this important training in a facility in this area. The following is a step-by-step guide which, with effort, should eventually result in hospital or surgery center privileges for the trained doctors of chiropractic to perform MUA:

1. Request your state examining board to render an opinion if MUA is within your state's scope of practice. As an example, the California Board of Chiropractic Examiners has stated the following regarding MUA: "Proper adjustment or manipulation is not made unlawful because it is conducted under anesthesia."² Also: "A proper chiropractic adjustment, if within the scope of practice of section 302, is not made illegal simply because the patient is under anesthesia."³ You may also want to obtain a statement from your state's major chiropractic association.

The California Chiropractic Association Board of Directors made the following statement: "The performance of a chiropractic manipulation and/or adjustment on a patient who is under local or general anesthesia is within the legal scope of practice for a licensed chiropractic doctor as long as the anesthesia is administered and monitored by a health care professional duly licensed to do so. Chiropractic manipulation and/or adjustment under anesthesia should only be performed at a duly licensed acute care facility by a chiropractic doctor who is both appropriately trained and who is acting pursuant to such acute care facilities" written protocol."⁴

2. Assemble a group of enthusiastic chiropractors to target a facility that would be located in an area of greatest concentration of chiropractic practices. This facility could either be a hospital or a certified outpatient surgery center. You would most likely have more success with a small or medium-sized independent hospital, especially during these days of economic hardship when many facilities are looking for ways to increase services. To further convince them that they need a chiropractic program, you may wish to obtain the ACA's Chiropractic and Hospital Privileges Information Program.⁵

3. Once you have established your relationship with the facility, it would then be necessary for the hospital or surgery center to form a committee to amend or change the bylaws of that facility to allow chiropractic privileges. Originally, what most of the hospitals did was simply use the bylaws pertaining to podiatry and dentistry privileges and merely substitute those terms with "chiropractic," with a few variations of language and emphasis to accommodate chiropractic scope of practice. It may also be helpful to order the ICA publication, Chiropractic and Hospital Privileges Protocol, by Karl C. Kranz, D.C.⁶

4. Contact your malpractice liability insurance carrier and ask if your coverage includes the practice of MUA in a hospital and surgery center.

5. Of the three CCE accredited chiropractic colleges that have a postgraduate training course in MUA, only one currently has a nationwide program where an instructor will come to your state and, over a five-day period, will instruct and train the hospital personnel and the chiropractic staff in the necessary protocol to provide MUA services.

After having established your chiropractic privileges and MUA program, there are certain principles that must be understood for your program to survive and be fruitful. Primarily, the following concept must be understood by every chiropractor and hospital administrator involved: Being the only MUA program in town makes you a vulnerable target for attack by our adversaries.

You must be aware of the concerns of the hospital and surgery facilities because they look upon the chiropractic privileges program as a marketing niche and a way of capturing a corner of the market. But the reality of it is, a program that is isolated will not survive and the more facilities providing these services, the better for everyone concerned. Every hospital should have chiropractic privileges and be able to provide MUA services. The programs that treat the chiropractors and their patients right, charge reasonable fees, and basically behave themselves will be the ones that prosper. Doctors will go to the facilities that are the most convenient and those that both they and their patients are most comfortable in dealing with.

Another phenomenon which happens when a chiropractic department is formed is "politics." The problem is that the most talented and capable chiropractors usually do not have time for additional positions of responsibility such as department chairman and committee work, and what happens many times is some of our least talented and egotistical members seize power and then run the program into the ground. The next caveat would be to avoid "conflicts of interest" and be aware that once entering the integrated profession's atmosphere, enticements for quid pro quo and kickback schemes will be offered; so in the words of Nancy Reagan, "Just say no."

When beginning a program like this, a few objections from various parties may be brought up. There are literally dozens of articles and clinical trials of MUA in the literature, all showing a preponderance of good to excellent results with MUA. As a matter of fact, one of the most popularly quoted pro-manipulation medical references used when discussing manipulation, generally in the presence of intervertebral disc disorders, was a study published in 1955 by Mensor which appears in the Journal of Bone and Joint Surgery.⁷ What is usually not mentioned in reference to this study is the fact that this was actually an MUA study that was supported by the State Compensation Insurance Fund, the largest workers' compensation carrier in the state of California. At the present, there are clinical trials of chiropractic MUA being performed and reference extraction continues, and I will continue to present some of this interesting literature in future articles on MUA.

If you would like any further information, you are welcome to contact me at the following address: Tim Mills, D.C., c/o MUA Associates of Southern California, P.O. Box 16305, Beverly Hills, California 90209-2305, (310) 864-3627.

References

1. Greenman PE: Manipulation with the patient under anesthesia. J. Amer. Osteopathic Assoc., 92(9):1159-1167, September 1992.

    

2. California Board of Chiropractic Examiners, Informal Hearing, San Diego, California, July 23, 1992.

    

3. Statement received by California Chiropractic Association from the California Board of Chiropractic Examiners, September 17, 1990.

    

4. Statement adopted by the CCA Board of Directors, October 13, 1990.

    

5. ACA's Chiropractic and Hospital Privileges can be ordered by calling (800) 359-2289, MPI order desk, #J-315-C.

    

6. Kranz KC: Chiropractic and Hospital Privileges Protocol, published by the International Chiropractors Association, order desk (800) 423-4690.

    

7. Mensor MC: Non-operative treatment, including manipulation, for lumbar intervertebral disc syndrome, J. Bone & Joint Surg, 37A:925-936, 984, October 1955.