Chiro question re: MUA

[fab4fan]

OK, I'm going to preface this by saying it's not my intent to start a flame war, and I am merely asking for info. to help me in my practice. If anyone feels the need to make ignorant comments, please...just keep moving.

That said, I work in PACU, and see quite a few pts. who've had MUA (manipulation under anesthesia). I suppose the reason for doing this is to be able to do manipulation the pt. might not be able to tolerate if awake. (I don't know for sure...no one's really been able to explain it to me). The other part I don't understand is why, after the pt. has had an MUA, he has to go to the office a few hours later for yet another manipulation (this time minus the conscious sedation). These MUAs are done three days in a row, which seems like a lot to me. (Three MUAs plus three office visits).

Is there a chiro here who would kindly explain this to me? It would make my life easier when it comes to pt. teaching, plus I'd really like to know the whys and wherefores of it as well.

Thanks!

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[PublicHealth]

I'm not a DC, but here's some info to get you started:

http://www.spine-health.com/topics/conserv/manipulation/manip01.html

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=16182028&query_hl=3

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=15965411&query_hl=3

http://www.skurkachiropracticcenters.com/services/mua.html

http://www.fcghealth.com/pages/mua_home.htm

 

[FoughtFyr]

I am also not a DC (I am an MD/MPH), but I would love an explanation of how MUA fits with the chiropractic philosophy of treatment "without drugs or surgery". If I understand the posts PublicHealth provided, some chiropractors think that general anesthetic agents, i.e., the some of the most powerful drugs on the market, and among the most risky, are o.k.? How does that work?

To the OP, I would have real problems being involved in a patient these treatments. According to the JCAHO informed consent MUST consist of a discussion of the risks, benefits and alternatives to any procedure. There are no clearly described benefits to such procedures (MUA) in the scientific literature. The risks are multiplied far above the baseline risks to chiropractic treatment to now include those of the anesthesia (again, with NO proven benefit). As there are proven alternatives available, how can these procedures be ethically performed? I would not want to have to defend in court a bad anesthesia outcome for MUA. I can't see how it could or would be defended...

- H

 

[chirodoc]

My buddy is MUA certified or just certifiable and I'll ask him. I am a D.C. and truthfully...yes, if they are so stiff and unable to relax that's when it's suggested to have an MUA. However, when D.C.'s were able to get paid well for it, it was done willy nilly at a $1K a pop. Don't hate the D.C.'s, the MD anesthesiologists were right in there, too. It helps to have them knocked out so they won't feel you lifting their wallet.

Now days, at least where I'm at, it's mostly D.O.'s doing the crackin. As far as twice a day, 3 day protocol...as with most protocols...."says who". It's probably something someone came up with as a maximum billing "protocol" and with zero efficacy.

Do I send patients to get MUA...well I refer them to a D.O. for pain management and he does ESI and MUA to the same patient. My reasons? Sometimes b/c I can't get rid of a phony patient who insists that everythings hurts (balogne) and I'm at the end of conservative care so I figure...alrighty then you can go to Dr. So and So and get his form of tx. I NEVER SEE THEM AGAIN. So in a way, at least for me it's a malingering test.

I suppose if someone has a lot of adhesions that prevent any manipulation then it would be useful to have them under while manipulating. Of course they won't be able to tell you that now they can't feel their arms/legs anymore and the whole room just went black. (Just joking)

 

[PublicHealth]

There are no clearly described benefits to such procedures (MUA) in the scientific literature. The risks are multiplied far above the baseline risks to chiropractic treatment to now include those of the anesthesia (again, with NO proven benefit).

Which literature are you reading? The reports I read show that MUA is generally safe and effective in treating acute and chronic spinal pain disorders. Sure, there's room for additional research in this area, but why shoot down MUA altogether because it's not part of mainstream medical care? Pain relief is not only about drugs and surgery.

Here are two "better" studies in the MUA literature:

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10395432&query_hl=7

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=12381983&query_hl=7

 

[fab4fan]

Thanks for the links, PublicHealth!

I have to say I'm a bit skeptical; part of me thinks maybe there's something to it, and the other part wonders how much of the benefit is really just "placebo effect." If the pt. ultimately has less pain and improved range of motion, I guess that's what's important.

As far as the drugs used, normally we use a combination of fentanyl and midazolam; sometimes some of the CRNAs/anesthesiologists will use low doses of propofol.

I do have to laugh...the pt is charged for "cryotherapy," which consists of the nurse applying an ice pack to the affected area.

Thanks to all who responded.

 

[FoughtFyr]

Which literature are you reading? The reports I read show that MUA is generally safe and effective in treating acute and chronic spinal pain disorders. Sure, there's room for additional research in this area, but why shoot down MUA altogether because it's not part of mainstream medical care? Pain relief is not only about drugs and surgery.

Here are two "better" studies in the MUA literature:

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=10395432&query_hl=7

http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=12381983&query_hl=7

Wow, PH I really expected better of you. Even if you are not an MD/DO you are an MPH right? Two non-randomized, non-blinded studies that do not even describe risk, do not contain a control group, and are solely based on subjective reporting are not "better" studies under anyone's realistic definitions. Nor do they "show that MUA is generally safe and effective in treating acute and chronic spinal pain disorder". Do you even leave room for the possibility that the gateway theory of pain would account for these findings (if they are real) in that a period of anesthesia alone could relieve pain? Trigger point anesthesia injections have been used this way for years and are well proven. As now are lower cervical intramuscular anesthetic injections (here: http://www.ncbi.nlm.nih.gov/entrez/...d&dopt=Abstract&list_uids=14629248&query_hl=6. There is an entire body of literature here, and even through all of these studies, each suggests more study is needed and none is considered mainstream: http://www.ncbi.nlm.nih.gov/entrez/...=Display&dopt=pubmed_pubmed&from_uid=14629248.). You are right that there is more to pain management than drugs and surgery, but let's stick with proven modalities, o.k.?

And how do you reconcile the chiropractic philosophy with the use of these pharmaceutical agents? I am not "(shooting) down MUA altogether because it's not part of mainstream medical care", I am questioning if it has been proven to do anything but lighten the wallets of people in pain.

And fab4fan, I'd be very careful about anything where the billing is that circular. Referencing your "the pt is charged for 'cryotherapy,' which consists of the nurse appling an ice pack to the affected area" quote. Remember that anyone with a professional license and knowledge of insurance or medicare/medicaid fraud could be themselves liable. Charging for a service other than for the service provided is illegal.

- H

 

[fab4fan]

Well, I certainly don't charge for it. It's on the superbill, and the doc circles the charges. Thanks for the reminder about billing, but I was already aware of those regs.; I used to be the clinical director for a home care program.

I'm surprised that insurance covers this. Maybe the MUA, but to cover the office visit a few hours later? It's hard to believe they go along with this.

Again, I appreciate info. from all sides. As I said, I tend to be skeptical about how beneficial this treatment is, so I'm interested in hearing a variety of viewpoints. I'm trying to keep an open mind.

 

[611]

I am a D.C. and a graduate of Vanderbilt University (undergrad.). In my opinion MUA is strictly a money making scheme. My approach would be to give PT until the pain and spasm has been reduced enough to perform manipulation...and yes Rx if necessary.