Guidelines for the practice and performance of manipulation under anesthesia

Abstract

BackgroundThere are currently no widely accepted guidelines on standards for the practice of chiropractic or manual therapy manipulation under anesthesia, and the evidence base for this practice is composed primarily of lower-level evidence. The purpose of this project was to develop evidence-informed and consensus-based guidelines on spinal manipulation under anesthesia to address the gaps in the literature with respect to patient selection and treatment protocols.MethodsAn expert consensus process was conducted from August-October 2013 using the Delphi method. Panelists were first provided with background literature, consisting of three review articles on manipulation under anesthesia. The Delphi rounds were conducted using the widely-used and well-established RAND-UCLA consensus process methodology to rate seed statements for their appropriateness. Consensus was determined to be reached if 80% of the 15 panelists rated a statement as appropriate. Consensus was reached on all 43 statements in two Delphi rounds.ResultsThe Delphi process was conducted from August-October 2013. Consensus was reached on recommendations related to all aspects of manipulation under anesthesia, including patient selection; diagnosis and establishing medical necessity; treatment and follow-up procedures; evaluation of response to treatment; safety practices; appropriate compensation considerations; and facilities, anesthesia and nursing standards.ConclusionsA high level of agreement was achieved in developing evidence-informed recommendations about the practice of chiropractic/manual therapy manipulation under anesthesia.

Outcomes indicators and a risk classification system for spinal manipulation under anesthesia: a narrative review and proposal

“…As the fundamental basis for SMUA, the adhesion-disruption theory remains clinically appealing. The term Fibrosis Release Procedures (FRP) is a broader designation for spinal manipulation under anesthesia which has been more recently introduced in the chiropractic literature and within the published AAMUAP guidelines [ 3 ]. This terminology establishes that mobilization (stretching) is the primary manual therapy component of the procedure.…”

“…With various spinal tissues known to account for pain and impaired function, it defies clinical logic that adhesions might serve as a pathological feature common to patients with chronic pain. Thus, what may account for a favorable response to SMUA treatment, and purportedly for numerous diagnoses [ 3 ], has yet to be elucidated. The genetic profiles that contribute to fibrosis and ligament hypertrophy in specific spinal conditions [ 24 , 25 ], and how identifying the like may assist in patient selection/rejection for SMUA, are areas worthy of investigation.…”

“…Published MUA guidelines specify that electromyography (EMG) and/or nerve conduction studies may be used to determine patient progress with SMUA [ 3 ]. Implied, in part, is that a positive EMG study may serve as a diagnostic indicator for treatment.…”

“…A revised version of the original NAMUAP standards and protocols was put forth in 2012, as adopted by the newly established American Association of Manipulation Under Anesthesia Providers (AAMUAP). That document subsequently underwent a consensus-based review, in developing recommendations for the contemporary practice of MUA [ 3 ].…”

The risk associated with spinal manipulation: an overview of reviews

“…Today, SMT is included in many guidelines for primary care, such as the management of non-specific low back pain [5], and several evidence-based guidelines exist on the practice of SMT [6–10]. SMT is widely used; it has been estimated that 12% of adults in the USA and Canada are attending chiropractors each year, with 80% of the visits involving SMT [11, 12], and use of SMT has been increasing in the past several decades [13].…”