Manipulation under anesthesia

Manipulation under Anesthesia or MUA is spinal manipulation performed while the patient is under anesthesia. This procedure is used in the hospital out patient setting for patients whose condition is unresponsive to other forms of in-office treatment.

Introduction
Manipulations consist of accurately determined and specifically directed manual forces to areas of restriction, whether the restriction is in ligaments, muscle or joints; the result of which may be improvement in posture and locomotion, improvement in function elsewhere in the body and the enhancement of the sense of well-being. MUA has been utilized in manual medicine for over 70 years. Increased participation of chiropractors on hospital medical staffs and with medical physicians has made both the facilities and training more available for performing and credentialing this procedure.

Chiropractors constitute the group who most actively practice MUA. While in Europe MDs and DCs actively practice spinal manipulative therapy, it nevertheless remains largely the clinical domain of the chiropractor.

Training
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 and are subscribed to by the accredited academic institutions offering post graduate certification in Manipulation Under Anesthesia.

History of procedure
Spinal manipulative therapy gained widespread recognition during the 1980’s by mainstream medicine with supporters such as James Cyriax, MD, John McM. Mennell, M.D., Scott Haldeman, D.C., Ph.D., M.D.and most notably Robert S. Francis, D.C.,Ph.D., Dean of Clinical Sciences at Texas Chiropractic College (TCC). Dr. Francis pioneered the chiropractic entrance into the orthodox health care delivery system with the development of post graduate certification courses in manipulation under anesthesia (MUA) procedures for recalcitrant spinal disorders. Dr. Francis organized and developed the first academic hospital rotation programs for chiropractic interns towards an effort to enhance the clinical training for chiropractors heretofore not included in the orthodox health care delivery system.

Dr. Rob Francis was singularly instrumental in securing hospital medical staff privileges for chiropractors in the mid 1980's in Houston area hospitals. Eventually, Manipulation Under Anesthesia certification and training programs became widespread under the tutelage of Dr. Francis and are now taught across the United States through a variety of university postgraduate programs sponsored through the National Institute of Manipulation Under Anesthesia and in Europe where Dr. Francis continues to teach MUA under the auspices of the International MUA Academy of MUA Pysicians.(www.muaphysicians.com)

Robert C. Gordon, D.C., FABCS, FRCCM, DAAPM has also contributed in the education of doctors of multidisciplines and has been teaching MUA since the early 90's with sponsorship from the National University of Health Sciences. In 2005 Dr. Gordon authored and edited the first textbook on MUA: "Manipulation Under Anesthesia, Concepts In Theory and Application". It was his great pleasure to welcome Dr. Robert Francis as one of the contributing authors in the textbook. So much has changed over the past 17 years since the introduction of MUA into the Chiropractic profession and each class in this procedure should be presenting up dates each time the procedure is taught. As with every procedure there are continuous needs to further the education of the doctors performing the MUA procedure by continued education. Currently there are a number of research projects that are either being completed or are proposed so that this wonderful procedure receives the declaration of clinical validity that it deserves. Thousands of patients have benefited from this procedure and only through continued documentation and exploration into the scientific or evidence based arena are we going to be able to truly show the significance of the MUA procedure. The National Academy of MUA Physicians formed in 1995, continues to regularly update their standards and protocols to give guidance to the credibility of MUA and regularly asks for the assistance of it's members to record and document their results so that more and more clinical outcomes become available. The Academy is currently in a rebuilding state and has been reformed since the MUA board certification in Las Vegas in April of this year (2007). We welcome members and hope all practicing MUA physicians will want to become part of the Academy and eventually want to receive MUA board certification from the Royal College of Chiropractic Medicine (and arm of the Royal College of Physicians and Surgeons (US)).

Integration into healthcare
The National Institutes of Health has provided educational research grants to medical schools across the US specifically designed to incorporate Complimentary and Alternative Medicine (CAM) into medical school curriculum. Dr Rob Francis, Clinical Assistant Professor of Family Medicine, Department of Family Medicine at UTMB in Galveston, Texas, was one of the first chiropractic members of the Core Curriculum Committee at UTMB Department of Family Medicine charged with the design and development of medical school curriculum that meets the objectives of NIH educational grants regarding CAM curriculum.

During the 1980's,while Dean at the Texas Chiropractic College, Dr. Rob Francis developed the first program designed to integrate chiropractic students into the medical community through hospital and private medical service rotations in the disciplines of orthopedic surgery, neurosurgery, internal medicine, family medicine, pain management, anesthesiology, and radiology. This interaction of chiropractic interns, chiropractors and medical physicians effectively bridged the historical chasm of communication that has existed for over a century between the different health care communities.

As a result of this increased communication between the medical and chiropractic communities, chiropractors were offered and credentialed medical staff hospital privileges and began to co-manage patients with medical physicians.

Subsequent to the first academic program developed by Dr. Rob Francis at Texas Chiropractic College, other colleges followed suit making MUA training programs available to chiropractors across the country. The ensuing years saw a variety of educational programs and standards for MUA taught by proprietary organizations not affiliated with CCE (Council on Chiropractic Education) accredited institutions. The first national organization, the National Academy of MUA Physicians, was developed in 1995 towards an effort to solidify national standards and protocol for MUA procedures.

Dr. Rob Francis serves as the first President of the International MUA Academy of Physicians, a multidisciplinary organization whose purpose is to provide an avenue for the dissemination of valid and authoritative database of current research and new scientific developments in the field of MUA for physicians dealing with chronic difficult cases. It is through efforts to develop evidence-based principles for MUA clinical application and practice that these organizations have promulgated effective and consistent standards and protocols for MUA.

These organizations make available to the practicing MUA community of physicians continuing education, national and international conferences designed to accomplish, implement, fulfill and discharge the purpose and intent of this mission. The objectives of these continuing education conferences are to present by an authoritative and interdisciplinary faculty state of the art review of the present knowledge in the field of non-operative care, interventional diagnostic and therapeutic procedures and other relevant treatment modalities affecting the spine.

Scientific evaluation of MUA
Multiple prospective and retrospective clinical studies have been performed evaluating MUA in chronic unresolved back pain, acute and chronic disc herniations, cervicogenic cephalgia, and many other neuromusculoskeletal conditions with attendant articular dyskinesia.

Robert Mensor, M.D. orthopedic surgeon, compared the outcomes MUA and laminectomy in patients with lumbar intervertbral disc lesions and found that 83% of MUA patients had good to excellent results while only 51% of the surgical patients reported the same outcome.

Donald Chrisman, M.D. orthopedic surgeon, reported that 51% of patients with unequivocal disc lesions and unrelieved symptoms after conservative care had been rendered reported good to excellent results post MUA at three years follow up.

Bradford & Siehl reported on 723 MUA patients, the largest clinical trial conducted on MUA procedures, that 71% had good results, and that 25% had fair results and 4% ultimately required surgical intervention.

Krumhansl and Nowacek reported on 171 patients who experienced constant intractable pain, of durations from several months to 18 years, and who underwent MUA. All patients had failed at previous conservative interventions. Results reported that post MUA, 25% had no pain at all and were “cured”, 50% were “much improved” with pain markedly reduced and ADLs essentially unaffected, 20% were “better but” pain continued to interfere with activities and finally 5% had minimal or no relief.

West et al reported in a 1998 study of 177 patients that 68.6% of patients out of work returned to unrestricted work activities after a series of three consecutive MUA procedures at 6 months post MUA, that 58.4% of the MUA patients receiving medications prior to the procedure required no prescription medication post procedure and finally that 60.1% of patients with lumbar pain resolved post MUA series of procedures.

In 2002 Palmieri et al 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%, and the average Roland-Morris Questionnaire scores decreased by 51% compared to controlled group.

In addition the extant literature, there are currently ongoing prospective clinical trials with appropriate outcome instruments assessing the clinical and fiscal efficacy of MUA in a selected patient population.

The medical literature is replete with case studies and literature reviews on MUA, in addition to clinical trials, all of which report positive clinical outcomes. Further research is ongoing.

It is important to note that to date there has been no clinical trial that demonstrates MUA to be ineffective in an appropriately selected patient population.

Since the introduction of Manipulation Under Anesthesia training and certification courses in Switzerland by Dr. Rob Francis in 2002, the European chiropractic community has enthusiastically embraced the practice of Manipulation Under Anesthesia. Dr. Francis continues to train chiropractors and medical doctors in Europe through his university sponsored MUA certification courses.