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Guidelines for the MUA program

Presented by: Robert Malhoit,DC

Indications and Contraindications for MUA

The “chronic patient” as the term pertains to the MUA patient, is a patient who has developed patterns of pain or restriction of movement over a prolonged period of time and who returns regularly for similar problems that are located in similar areas of the body.

The definition of “acute,” as it pertains to the MUA patient is based on severity.  When a patient who has undergone a reasonable period of conservative chiropractic/manual therapy care remains pain expressive and symptomatically unchanged, or has an exacerbation of a recurrent problem, that may express an acute episode, but the condition has had a history of care.  (Acute trauma or immediate injury is contraindicated with the MUA procedure in most instances.)  A reasonable period of conservative care is 6-8 weeks

 Deviation from this protocol is left to the discretion of the treating practitioner based on objective documentation of necessity.  An example of this would be intractable pain and muscle splinting with little or no relief that interferes with activities of daily living, such as sleep, where no therapy, including pharmacologic intervention, is relieving the pain.

Indications of MUA with regard to objective and subjective clinical observations are as follows:

1. Neuromusculoskeletal conditions where manipulation and adjustment have had incomplete results but where manipulation is the treatment of choice.

2.      Neuromusculoskeletal conditions that fall within the parameters for manipulation, but are so painful that narcotics and other analgesics have had little if any benefits and that may have been causing unwanted side effects.

3.      The chronic patient who has reached maximum medical improvement (MMI) but who continues to have exacerbations that require therapeutic intervention to maintain the level of physical impairment.

4.      Patients who have been treated for 6-8 weeks but who continue to have a pain threshold that does not allow manipulation or adjustments when this is the therapy of choice.  (The decision early on in conservation care would be based on the pain interfering with sleep and normal daily function activities.)

5.      Patients who cannot control voluntary contracture or muscle splinting during manipulation or adjusting, and where treatment is being delayed or prolonged.  In these cases, MUA would greatly reduce the patient’s treatment period.

6.      Patients who are candidates for manipulative and adjustive therapy in the office, but the extent of the injury have caused ineffective results and prolonged care because greater movement to the involved joint is necessary to produce expected clinical results.

7.      Patients who are considered disc surgery patients but who fall within the parameters of MUA, which may be an alternative or interim step and may be useful as either a therapeutic or a diagnostic tool in determining the prognosis of this patient’s care.

8.      The patients who are candidates for manipulative or adjustive therapy but, due to restrictive adhesions causing articular fixation, are responding only minimally to conservative clinical care.

Simply because the patient did not respond to conservative care is not a reason to use the MUA procedure.  The patient needs to fall within the parameters of varying indications for MUA.  Those indications for MUA that have been shown to be most responsive include but are not necessarily limited to

·         Unresponsive pain, which interferes with the function of daily life and sleep patterns but which falls within the parameters for manipulation treatment

·         Unresponsive to manipulation and adjustment when these are the therapies of choice

·         Unresponsive muscle contracture, which is preventing normal daily activities and function

·         Bulging, protruded, prolapsed, or herniated discs without free fragment

·         Failing back surgery

·         Restricted motion, which causes pain and apprehension from the patients, but manipulation is the therapy of choice

·         Frozen or fixed articulations from adhesion formation

·         Compression syndromes with or without radiculopathies caused from adhesion formation but not associated osteophytic entrapment

·         Post-traumatic symptoms from acceleration/deceleration or deceleration/acceleration types of injuries that result in painful exacerbations of chronic fixations

·         Chronic recurrent neuromusculoskeletal dysfunction syndromes that result in regular periodic treatment series that always exacerbation of the same condition

·         Neuromusculoskeletal conditions that are not surgical candidates but that have reached MMI, especially with occupational injuries

Indications

            The following conditions have been found to respond well to manipulation under anesthesia.  NOTE: one particular condition might involve more than one set of etiological symptoms as listed here:

1.       Nerve entrapment

Radicular- toward or close to spinal nerve root (i.e., facet syndrome); peripheral-causing blockage; away from the spinal cord (i.e., piriformis muscle contracture around sciatic nerve)

2.      Chronic myofascitis

Peripheral; muscular, fibrotic adhesion formation (i.e., chronic muscle splinting or contracture)

3.      Chronic fibrositis

Can be muscular or articular; related to fibrotic adhesion buildup (i.e., facet joint encapsulation or encapsulitis with chronic restriction of joint motion)

4.      Traumatically induced restriction motion could be peripheral or radicular; may encompass all of the above entities; a differential diagnosis would be to rule out disc involvement (i.e., torticollis; spontaneous disc herniation)

5.      Chronic muscle contracture

Peripheral in nature; away from the spinal cord; could be related to vertebral misalignment; a differential diagnosis would be to rule out muscle disease or muscle involved tumor (i.e., chronic muscle shortening from severe biomechanical postural change or congenital shortening of extremity , short leg syndrome, pelvic tilt, or rotation occipital shifting)

6.       Acute muscle spasm associated with subluxation/vertebral misalignment

Can be peripheral or involve radicular if subluxation/ vertebral misalignment closes off IVF; encompasses many of the previously listed entities (i.e., chronic rib head subluxation/ misalignment causing dorsal paravertebral muscle spasm and intercostal neuralgia; subluxation/ vertebral misalignment of C6-C7-T1, causing chronic upper trapezius spasm; combination of both)

7.       Chronic productive arthritis, such as spondylosis; spondylarthritis , spondylarthrosis.

It can be multiple joints or articulations (i.e., degenerative osteoarthritis causing multiple fibrotic adhesive sites)

8.      Lumbarization associated with chronic pain

Peripheral in nature; causing muscle splinting,; fibrotic adhesions; chronic spasm

9.       Sacralization associated with chronic pain

Peripheral; can cause chronic muscle splinting, contracture, spasm; fibrotic adhesion formation (i.e., relating to degenerative changes)

10.   Chronic disc changes associated with fibrotic adhesions from degenerative changes

11.   Disc bulge; can be peripheral or radicular pain, but usually associated with radicular (having to do with the nerve root).  May be chronic or acute (i.e., spontaneous disc herniation from traumatic entity).

The following is a list of spinal dysfunction conditions that have been shown to repond well to MUA procedure:

Cervical Spine

Cervicalbrachial syndrome                

Cluster headaches                

Migraine headaches

Torticollis                                           

Cervical facet syndrome        

TMJ

Cervicogenic headache                     

Cervical articular dyskinesia

Fibromyalgia

Cervical discogenic spondylosis

Cervical disc herniation ( contained within the annulus, with medical intervention)

Myofascitis of the trapezius and occipital muscular band

Acceleration/ deceleration and deceleration/acceleration injuries (chronic)

Segmental dysfunction of the cervical spinal area(s)

Thoracic Spine

Mainly myofascial problems related to segmental joint dysfunction and rib head articular dyskinesia

Medial scapular border myofascitis

Thoracic scoliosis and concomitant articular dyskinesia

Lumbar Spine

Discogenic spondylosis

Lumbar radiculopathy

Lumbopelvic articular dyskinesia

Lumbar facet syndrome

Disc herniation (contained with no fragmentation)

Myofascitis secondary to discogenic involvement

Lumbar segmental dysfunction

Chronic myofascial paravertebral muscle spasm

SI dysfunction with secondary myofascitis

Hip/pelvic rotation secondary to segmental dysfunction (or in conjunction with lumbar scoliosis)

Contraindications

Any form of malignancy

Metastatic bone disease

Tuberculosis of the bone

Acute fractures

Direct manipulation of old compression fractures

Acute inflammatory arthritis

Acute inflammatory gout

Uncontrolled diabetes or diabetic neuropathy

Syphilitic articular or periarticular lesions

Gonorrheal spinal arthritis

Osteoporosis; advanced as indicated diagnostically

Evidence of cord or caudal compression by tumor

Widespread staph or strep infection

Infectious bone disease

Blood clotting disorders or treatment present

Myocardial disorders

Sign of or symptom of aneurysm

Making a case for the MUA Patient

The typical chiropractic/ osteopathic patient who is a candidate for the MUA program has been receiving care anywhere from 6-8  weeks to 4 months (on average) or has been evaluated for “intractable” pain in a 2-week period.  The patient has undergone regular adjustive techniques that have had only minimal results.

When a patient has undergone a conservative manual therapy program or medicinal/ pain management program and has not improved as expected, several things need to be on the treating physician’s mind:

1.      Is this a patient who truly is a MUA program candidate? (refer to indications for MUA)

2.      Have I given this patient time to respond to conservative manual therapy care?

3.      Are there any other conservative modalities that I have not yet offered or that the patient has not received?

4.      Does this patient have any pathology that I have overlooked or that may be causing the slowdown in response to the current therapy program?

5.      Does this patient need to have further referral evaluation by a specific specialist to help support my conclusions or suspected diagnosis/pathology?

6.      Does this patient fit the standard selection criteria?( see indications)

7.      Has this patient undergone the standard 6-8 weeks of conservative care, and if not, what are my reasons for moving the patient into the MUA program?

8.      Have I followed standard office procedures format (see below)that will support moving the patient from conservative care into advanced manual therapy intervention (MUA procedure)?

To be a candidate for the MUA program, specific procedures should be followed in a sequential format.  Before you contact the surgery center to enroll your patient into the MUA program, it will be necessary for you to verify all records are in a standardized procedure format. Once complete your patient will be pre-certified for the MUA.  The surgery center will, after insurance coverage is certified, instruct the patient as to all necessary pre-op preparation and testing.  Physicians that submit records that do not follow the necessary format are less likely to get their patients certified for the MUA procedure.

 The necessary format is:

(See Case Study- must be in written format)

Patient Information

Chief Complaint

History of Present condition

Past Medical History (any previous medical records; includes diagnostic reports)

Past Treatment history

Family, Social, Occupational History

Physical examination (includes deep tendon reflex testing, sensory perception, orthopedic evaluation, palpation, muscle testing, ROM study C-spine/T-spine/L-spine/extremity; when indicated, and radiographic study)

Clinical impressions/Recommendations

Rationale for MUA

Treatment notes (min. 6-8 weeks of conservative care-TELL YOUR STORY)(See forms for tx notes)

The MUA program coordinators will assist patients with insurance certification, scheduling pre-operative blood work, scheduling chest films, any other diagnostics, pre-operative physicals, and pre-operative report.  

Once the patients have completed the MUA procedures they will be given instructions for post-operative care.  These patients will then return to your office for post-MUA therapy and rehabilitation.  The program does not end here.  The success of the MUA procedure is very much dependant on this phase of care.  Documentation must continue at the same level of excellence in order for the program to be a success. Physicians that do not meet these requirements will be adversely affecting their patients care.  (There may be a need for additional MUA procedures and it would be more difficult to qualify these procedures.)

Post MUA Physical Therapy and Rehabilitation Guidelines

As noted in the MUA protocols (NAMUAP), physical therapy is to be carried out daily, beginning after the first MUA and continuing 7-10 days thereafter, with the rehabilitation portion continuing on through day 35.

The rehabilitation process begins in the acute and subsequent subacute stage of healing days 1-5.  The goals of these stages are to:

1.      Control inflammation

2.      Create analgesic environment (for manipulated area)

3.      Limit edema formation

4.      Decrease joint effusion

5.      Establish environment for new collagen formation

6.      Reassure patient and stabilize doubts and fears about MUA

In order to reach these goals, the following represents acceptable post MUA physical therapy and rehabilitation treatment:

The patient is to fill out a pain scale prior to undergoing the MUA procedure, after the third MUA procedure, and prior to initiating therapy on day 7 as well as after the final re-exam.  This scale will be used as a prognostic indicator to monitor when the switch over to thermotherapy will be indicated.

For the patient’s first 3 days of MUA, the patient should receive cryotherapy on the manipulated area of the spine as soon as possible post-manipulation.  This will be provided or the patient will be instructed to use their own ice packs.

On days 4-6, if the pain on the visual analog scale is decreased by 50%, thermotherapy is initiated by either using HMP (hot moist pack) placed on top of the IFC (interferential)setups or by preheating the affected areas with US (ultrasound) and then utilization the IFC therapy.  In either case, the intensity should be a “light motor” muscle contraction, with a small sweep of 100-130 HZ or a “constant” setting of 130HZ.

If thermotherapy is initiated (Days 4-6), PROM (passive range of motion) exercise is also added.  It is recommended that stretching techniques be implemented prior to instituting the PROM exercises.  Utilize passive movement throughout only the “pain-free” range of the appropriate spinal area involved.  Examples of standard PROM and AROM (active range of motion) exercises can be found in most physical therapy texts.

After 3 days of post MUA, if the pain is not decreased by 50% the practitioner/therapist should maintain the use of cryotherapy applied over to the IFC setup.  The intensity should be retained at “sensory” level and the frequency at 130HZ constant.  PROM and chiropractic/osteopathic manipulative therapy (CMT, OMT) should still be continued even if pain is not decreased by the required 50%.  Prior to initiating therapy on day 7, the patient should be given another visual analogue pain scale.  By this time, the patient pain intensity should be decreased by 50%.  If so, then proceed to the settings for days 7-10.  If not, then maintain the use of ice and IFC, using the frequency noted above for days 7-10, while again also instituting PROM and manipulation.

If the therapy for days 4-6 progresses favorably, (I.e., pain at approximately”3” on the visual analogue pain scale), then for days 7-10, the only difference from days 4-6 is the changing of the IFC frequency from 100-130 Hz sweep to 80-110 Hz sweep.  This will begin to elicit a muscle contraction for a portion of the sweep (at 80 HZ) while still sedating the sensory nerves at 110 Hz.

This now concludes daily care for days 11-24; at this point, the office visits are reduced to three times a week.  If the PROM exercise is pain free, the patient may begin to experience muscle contractions in the physical therapy sessions and begin AROM exercises two times a day at home.  Thermotherapy and IFC are continued, but now the frequency and intensity are changed to promote more muscle involvement.  The frequency sweep is broad, with the baseline at 50 Hz (for muscle strengthening) contraction to 100 to Hz, which will still provide some sedation of the sensory nerves.  Keep in mind, the broader the frequency sweep, the less amount of time the current spends on a given frequency within that sweep.  Therefore, a more “narrow” or even “constant” setting should be preferred when an analgesic environment is desired, versus a “broad” sweep for working the muscles.  The intensity for this 2-week period should be “motor” (i.e., a visible muscle contraction) with manipulation to follow the physical therapy.

            This is now the pre-rehabilitation phase of post-MUA therapy.  During these two weeks, the patient is to given AROM exercise to be done at least two times a day at home.  These exercises are to be absent of any resistance and should be taught to the patient while in the office setting initially, to ensure that the patient understands and can perform the exercise correctly.

            After the second week of AROM exercise, the patient is to receive a re-examination.  Active range of motion should be measured and recorded, and the appropriate orthopedic/neurological test (if any) should be performed.  Another analogue pain scale should also be filled out for the progress assessment and records.

            For days 25-35 (post-re-exam) the patient office visit frequency is again reduced, now to two times a week.  The patient is now instructed on how to add resistance to the AROM exercise still to be preformed two times a day, while the physical therapy is optional from this period onward.  If instituted, the intensity should still be “motor” with the frequency sweep at the 30-80 Hz range.  This will provide muscle stimulation throughout the frequency sweep range. 

            Following the fifth week of therapy, the patient should be given a final examination to determine whether a return to activities of daily living is permissible.  Range of motion measurement should again be recorded and a muscle strength assessment/grade be evaluated for the appropriate area muscles.  The orthopedic and neurological evaluation should be unremarkable at the point, and maximum medical improvement (MMI) should be approaching.

            The following constitutes formal rehabilitation.  For days 35 and on, office visits are reduced to one time per week (note: there may be clinical exceptions) until the resisted ROM and/or the muscle testing of the involved area muscles are 5 out of 5.  Physical therapy is again optional, with the intensity at “motor” and the frequency at 50 Hz constant for an optimal muscle strengthening contraction.

            Once the patient has reached MMI, the patient should be counseled with respect to the fears and expectations of returning to a lifestyle that is free of pain with no restriction of range of motion.  It is also important to discuss a program designed to maintain and monitor the strength and flexibility of the affected areas because as was noted previously, collagen repair and maturation may take up to one year to complete.

            This is a point where individual practitioner variance will be subject to further study and debate as to the frequency and efficacy of future patient visits.

            In conclusion, the post-MUA physical therapy and rehabilitation program is of utmost importance in facilitating the proper environment needed for functions realignment of the collagen network.  If these guidelines are not adhered to, it is this author’s belief that certain functional disabilities are sure to return to the patient.  Rehabilitation is a specific and time-consuming venture.  If the clinic/office is not adequately oriented to achieve maximum results, the patient should be referred out to an appropriate facility.

References

1.       Capps, S., Texas College of Chiropractic, syllabus: Manipulation under anesthesia;  postgraduate course of study, 1992.

2.      Gordon, R., with contribution from Furno, P., Cornerstone Professional Education, MUA syllabus currently sponsored by the National University of Health Sciences, 5^th ed., August 1998.

3.      The National Academy of MUA Physicians Standards and Protocols, 1995, St. Louis Chapter.

4.      Francis, R., Associate Professor, Texas Chiropractic College: Manipulation under anesthesia; postgraduate course Director, 2002.

5.      Gordon, R., “Manipulation Under Anesthesia, Concepts in Theory and Application”, Taylor & Francis Group; 2005.  

Florida MUA also provides certification to physicians looking to provide Manipulation Under Anesthesia services to their patients.