'Manipulation under anesthesia' stirs controversy

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By JOHN HILL and KEVIN YAMAMURA
Saturday, March 31, 2007

Anesthesia lulls the patient's protective reflexes to sleep. Then a chiropractor goes to work on the spine, making adjustments that, without anesthesia, might cause the patient to tense up or wince in pain.

The procedure, known as "manipulation under anesthesia," is at the heart of recent controversy at the state Board of Chiropractic Examiners, where appointees of Gov. Arnold Schwarzenegger, including two longtime friends from his bodybuilding days, have tangled with their own staff over the board's oversight of California's 15,000 or so chiropractors.

Critics call it a lucrative and largely unnecessary procedure. Supporters say it's been practiced safely and successfully for years on patients who don't respond to more conventional treatment, pointing out that it has been endorsed by the state board at least since 1990.

The debate over MUA, as it is known, also reflects a wider disagreement over how far chiropractors can go into territory that was uncharted in 1922, when California voters passed an initiative governing the profession.

Medical groups argue that "manipulation under anesthesia" blurs the lines between their territory and chiropractic. Chiropractors who favor it say that MUA relies on exactly the same methods they use on conscious patients, only with the help of an anesthesiologist.

At its March 1 meeting, the Board of Chiropractic Examiners approved a resolution stating that MUA falls under chiropractors' scope of practice.

But even as the board was passing its resolution, a prosecutor in San Joaquin County was pursuing criminal charges against chiropractors who performed MUA. By working on patients who had been administered medication, the chiropractors were practicing uncertified medicine, according to a criminal complaint that lists several other charges.

The discrepancy highlights the quirks of the chiropractic profession in California. Chiropractors are governed by a 1922 initiative that put them largely beyond the reach of the Legislature and the state bureaucracy.

But those origins have also left the profession, in some ways, frozen in time, creating legal uncertainty about techniques that chiropractors have embraced in the eight decades since the initiative was approved by voters.

Schwarzenegger's appointees on the board have wasted no time wading into the fray. The board includes Chairman Richard Tyler, one of Schwarzenegger's earliest friends in bodybuilding, and two-time Mr. Olympia Franco Columbu, who trained with the governor, stood as best man in his wedding and appeared in some of his movies.

Another Schwarzenegger appointee, Fred Lerner, is a chiropractor who three years ago appeared before the board to speak on behalf of MUA, calling it "a very effective procedure." Lerner told the board that he had performed MUA "fairly regularly."

In one of several moves signifying that they take an expansive view of chiropractors' scope of practice, the board, in its first meeting with Tyler at the helm, endorsed MUA.

An earlier attempt in December had failed, when two holdovers appointed by former Gov. Gray Davis _ Barbara Stanfield and David Yoshida _ voted against it.

Tyler nonetheless made an impassioned plea in favor of MUA, arguing that a constricted view of chiropractors' scope of practice would leave the profession stuck in the 1920s.

"I personally will not practice MUAs, but my concerns are that we are continuing to let others decide what we can and cannot do based on their personal, professional and legal bias," Tyler said.

The resolution failed in that December meeting after a deputy attorney general representing the board pointed out that it had been written by a lawyer for the California Chiropractic Association.

"It may be a little troubling to you and you might want to put this off," Deputy Attorney General Jana Tuton said. "To be given this professional association's opinion the day before the board meeting doesn't really allow you to thoughtfully spend some time considering it."

After The Bee and state legislators started examining the board's actions, the board backed away from the March 1 resolution, voting at a special meeting last Friday to revisit the issue.

Both sides of the MUA debate agree that the technique has been around for decades.

Chris Cotton of Pleasanton decided to have MUA after injuries to his lower back from a car accident did not respond to other treatments. He had two days of one- to two-hour treatments under general anesthesia. Cotton said he was sore at first, but that his mobility and range of motion soon improved dramatically,

"It was one of the best things ever," said Cotton, who designs fire protection systems. "It just made a world of difference."

Only in recent years did it become controversial - the result, some critics say, of increasing use of the procedure and growing costs for insurers, particularly in the realm of workers' compensation.

No one knows for certain how often the procedure is used. But workers' comp carriers face bills of as much as $20,000 to pay for three successive days of MUA treatments, said Steve Jimenez, an attorney who has often found himself opposing chiropractors in workers' compensation cases.

In many cases, the chiropractors own shares of the surgery centers where the procedures are done, Jimenez said, giving them a "huge economic incentive" to recommend that their patients undergo the treatment.

"It's being litigated left and right," he said.

Jimenez said that there has never been a large-scale scientific study proving that MUA works any better than spinal manipulations done on conscious patients.

Ed Cremata, a chiropractor who advocates for MUA, said there's at least as much evidence as there is for other options for patients with back, shoulder and neck problems, such as physical therapy and injections.

It's true that some chiropractors own shares of surgery centers where MUA is done, Cremata said. But physicians have owned surgery centers for two decades, he said, and could be accused of having a financial interest in recommending just about any medical treatment.

He said most MUA treatments cost $2,000 to $3,500 per day, considerably less than the figure cited by Jimenez.

Cremata and others argue that nothing in the 1922 initiative prohibits MUA, since chiropractors are not administering the drugs themselves.

Others disagree. The California Society of Anesthesiologists opposes MUA and advises its 4,000 members - roughly 80 percent of practitioners in the state - not to participate in the procedure.

CSA President Mark Singleton said his group believes there is little evidence attesting to the safety of MUA. He said the group also objects because it believes the 1922 Chiropractic Act prohibits chiropractors from engaging in any procedure that involves medicine even if they don't administer it themselves.

There are also practical reasons for the group's opposition, Singleton said. In normal chiropractic procedures, "the patient is awake and able to report objective feelings, and that is a critical element of maintaining the safety of manipulation," he said. "By masking that and having the patient unconscious, you remove a critical safety element."

The Osteopathic Physicians and Surgeons of California also oppose MUA and spoke against the chiropractic board's resolution in December.

Likewise, the California Medical Association opposed MUA in 2004, when the board unsuccessfully tried to pass a regulation to govern use of the technique. Because MUA wasn't taught in chiropractic schools in 1922, the association said, it could not be considered within chiropractors' scope of practice.

Cremata says that the technique is perfectly safe. Patients under anesthesia are only subjected to a normal range of motion to relieve the buildup of scar tissue, he said. While the manipulation might cause pain in a conscious patient, Cremata said, it would not do any damage.

Cremata and other supporters say that California case law has made it clear that the profession should not be stuck in 1922.

The court decisions, Cremata said, "always support the fact that it wasn't meant to be static."

(Contact John Hill at jhill@sacbee.com.)