November 13, 2012 Posted by Matthew Dolman in Blog

Is Manipulation Under Anesthesia a Legitimate Procedure?

Manipulation Under Anesthesia (MUA) is a therapy that is claimed by practicing practitioners to improve articular and soft tissue movement using a controlled release, myofascial (pressure point) manipulation, and mobilization while the patient is under moderate to deep sedation.

The procedure allegedly breaks up scar tissue around a joint that lacks a complete range of motion. For example, knee replacement patients who struggle to flex to 90 degrees six weeks after their operation are considered candidates for MUA. The procedure takes 15-20 minutes. The patient is placed under anesthesia and the manipulation is performed one time per day generally over a course of three days.

However, MUA’s have drawn harsh criticism by many physicians who believe many practitioners (a majority being Chiropractors) and surgery centers view the procedure as a cash cow and often bill insurance carriers in excess of $50,000.00 an hour. Further, critics state that the procedure is vastly overused due to profit motives as very few individuals are truly candidates for an MUA. In fact, MUA’s are clinically indicated for individuals with frozen shoulder and knee manipulation under anesthesia (MUA) is indicated for total knee arthroplasty (TKA) patients who have not obtained at least 90° of flexion by the 6th postoperative week. However, this procedure has been alleged to be overused for the treatment of neck and back injuries by overzealous Chiropractors who see this as an easy method to make money on patients who have not responded to conservative care. MUA’s have been criticized for being nothing more than an experimental and investigative procedure with little in the way of long term research and peer reviewed medical journals articles supporting such. In fact many Orthopedic Surgeons claim that MUA’s are alarmingly overused by Chiropractors for profit motives when the patient should have been sent to a specialist (i.e., surgeon) when conservative care failed to alleviate chronic pain.

In an article written by John Dillon in anesthesiologynews.com, the author exposes the dangers surrounding this procedure in interviews with some of the most prominent and respected physicians nationwide. “If [a patient is] anesthetized, there’s no way to respond to show that you’re compressing the spinal column too much,” added James F. Arens, MD, professor of anesthesiology at the M.D. Anderson Cancer Center in Houston, and chair of the ASA practice parameters committee. “There’s a real danger.”

According to John C. Rowlingson, MD, professor of anesthesiology at the University of Virginia School of Medicine in Charlottesville, “no large, randomized trials have proved its merit.”

Bob LaMendola of the Ft. Lauderdale Sun Sentinel in an article entitled ‘Medical Safety Spotlight Growing’ states “While no one tracks MUA deaths and complications, medical groups have linked the procedure to strokes and to damage in blood vessels, the spine and nerves in some patients. Critics also say MUA has been done on patients with obesity, high blood pressure and other conditions that raise their risk for heart attacks and bad reactions to anesthesia.”

"It's absolutely unconscionable. They are doing it on almost anyone. It has really just become a method of billing for income," said Charles A. Bender, former president of the New Jersey chiropractic board and a critic of MUA, who was quoted in the Sun Sentinel article.

MUA certification courses may be offered through accredited chiropractic colleges are recognized by malpractice carriers for coverage. Specific criteria for certification is required. These standards and protocols, established by the National MUA Academy of Physicians and the International Academy of MUA Physicians, are subscribed to by accredited institutions offering this certification.

The first study regarding MUA was published in 1952 and showed that 33 percent of patients demonstrated symptom-free results. Followup studies implied similar positive results. Yet, today there is still significant amounts of conflicting research, opinion and testimony regarding the effectiveness of MUA treatment.

For 30 years MUA procedures have been listed as Current Procedural Terminology by the American Medical Association’s (AMA) Codebook of Reimbursable Procedures. In order to qualify for being a Category I procedure in the codebook, the AMA requires that the clinical efficacy of the procedure is well established and documented in the United States per review literature.

In a 2009 Western Claim Conference presentation, Cathy Bailey of Cigna identified instances of MUA or Spinal MUA schemes that some practitioners use to over bill clients and insurance. Bailey identified that MUA’s are normally a single treatment session and that some providers leave a Spinal MUA off the claims, but show spinal treatment in the records. Instances where MUA treatments occur multiple times should automatically raise red flags as to the course of treatment.

In recent years, MUA and Spinal MUA has seen an increase in being diagnosed. Both chiropractors and M.D.’s are getting involved in the treatment. Unfortunately some of the facilities used are unlicensed or not owned by the person giving treatment. Patients are often unaware of these charlatans, until the bills come due and the insurance carrier refuses to pay. This serves to increase the fervor of critics who claim that this is a lucrative and largely unnecessary procedure.

This leaves one to question whether or not they can trust the information that’s out there. They wonder who they can trust and what information is accurate. There are a number or case studies and testimonials regarding the efficacy of the procedure. We can neither condone, nor condemn this procedure. However, the fact that the treatment is well over 50 years old and not fully recognized as a solution to these issues with movement should raise the eyebrows of patients. Of course, this could be to a variety of issues including over diagnosis of this treatment option when it is unnecessary or would not actually help the patient.

The best solution is to read as much as you can about the procedure and, if possible, consult a second, independent opinion and make your decision. Treatment is a personal decision that should be pursued as far as one can take it. However, pursuit of treatment does not mean pursuing unnecessary or unhelpful treatments.

It is the opinion of this author, if a patient must undergo anesthesia the patient should be treated by an Orthopedic Surgeon, not a Chiropractor. Further, one would be wise to seek a second opinion from an Orthopedic Surgeon, before complying with a Chiropractor’s recommendation for an MUA.

In my practice, I have not come across a victim of an auto accident or motorcycle accident that was referred out for an MUA by a Orthopedic Surgeon, Physiatrist or any other Medical Doctor, unless such physician was set to play a role in the actual MUA. This raises the question as to whether profit motives are driving this procedure and if the MUA is truly a legitimate procedure. I have seen outrageous bills associated with the MUA procedure by practitioners here in Clearwater and Tampa. It surely raises an eyebrow, when you learn that practitioners have billed in excess of $60,000.00 and in some cases well over $100,000.00 for an MUA, in light of the fact that many Spine Surgeons charge less for a fusion or a laminectomy.

If you have been injured as a result of an auto accident, call the injury law attorneys at the Dolman Law Group today at: (727) 451-6900

REFERENCES

Letter From American Medical Association Regarding Whether Or Not MUA is or is not Experimental