Treatment guidelines

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Docs,

Here is Croft's treatment schedule for auto trauma: Also, you can go to www.chiroweb.com and type in "Croft". You will find a ton of articles he has written.

Matt Terreri, DC

MVAs and MMI: How Much Is Enough?

For many of us, the issue of maximum medical improvement (MMI) is a true conundrum. This is particularly so in motor vehicle accidents (MVAs) where our patients have often been injured by a negligent driver. In the interest of fairness it would seem most reasonable to allow for indefinite treatment of an injured victim if necessary. In the real world, however, practicality dictates that at some point we make a declaration of MMI. This allows any legal remedy to come to a conclusion and all debts to be (hopefully) paid. Any awards bestowed upon an injured party should take into account the need for future medical or chiropractic care. Patients can also be treated under general health insurance policies in many cases. Some have suggested using the term "maximum chiropractic improvement" instead of "maximum medical improvement." The difference seems nebulous to me since it presumes that patients treated by chiropractors and medical doctors improve to different degrees, and that has yet to be established (although research is currently under way). In certain settings, a certain amount of ambiguity is allowed anyway. I am a state-appointed independent medical examiner, for example. I believe the best approach to arriving at MMI is the following: First, grade the severity of the patient's trauma using the severity scale of the SRISD classification of cervical acceleration/deceleration (CAD) trauma,1 Table 1. Next, use the potentially complicating factors in Table 2 as a guide to modify the figures in Table 3 to arrive at a reasonable treatment frequency and duration. For example, in a patient categorized as Grade III with one or two moderate complicating factors, the treatment duration will average about 56 weeks (shorter with no complicating factors and longer with more complicating factors or more severe complications). Finally, refer to Table 4 to determine MMI. Beyond the active treatment period as suggested by Table 2, after three consecutive monthly re-exams with no further significant objective improvement (range of motion, trigger points, muscle strength, gait, antalgia, orthopedic/neurologic/radiographic signs), you should consider the patient MMI. Gradual further subjective improvement is variable.

References

Croft AC: Whiplash: the Master's Program. Module I, Whiplash, an Overview. Coronado, Spine Research Institute of San Diego, p 73, 1992.

Croft AC: Whiplash: the Master's Program. Module III, Treatment and an Introduction to TMJ. Coronado, Spine Research.

Table IGrades of severity of CAD injury: Grade I minimal, no limitation of motion, no ligamentous injury, no neurological findings Grade II slight, limitation of motion, no ligamentous injury, no neurological findings Grade III moderate, limitation of motion, some ligamentous injury, neurological findings present Grade IV moderate to severe, limitation of motion, ligamentous instability, neurological findings present, fracture or disc derangement Grade V severe, requires surgical management/stabilization Adapted from reference #1

Table 2Common factors potentially complicating CAD trauma management:

Advanced age Metabolic disorders Congenital anomalies of the spine Developmental anomalies of the spine Degenerative disc disease Disc protrusion (HNP) Spondylosis Facet arthrosis Rheumatoid arthritis or other arthritides affecting the spine 10. Ankylosing spondylitis or other spondylarthropathy 11. Scoliosis 12. Prior cervical spinal surgery 13. Prior lumbar spinal surgery 14. Prior vertebral fracture 15. Osteoporosis 16. Paget's disease or other disease of bone 17. Spinal stenosis or foraminal stenosis 18. Paraplegia or quadriplegia 19. Prior spinal injury Especially laminectomy and discectomy without fusion. Adapted from reference 2.

Table 3Frequency and duration of care in CAD trauma: Daily 3x/w 2x/w 1x/w 1x/mos. TD TN

Grade I 1w 1-2w 2-3w 4w - 9w 17

Grade II 1w 4w 4w 4w 4 mos. 25w 29w

Grade III 1-2w 10w 10w 10w 6 mos. 56w 76w

Grade IV 2-3w 16w 12w 20w

Grade V Surgical stabilization necessary -- chiropractic care

is postsurgical

TD = treatment duration. Possible follow-up at one month

TN = treatment total number. May require permanent monthly or

p.r.n. treatment

Adapted from reference #2

Arthur C. Croft, D.C., M.S., DABCOCoronado, California Editor's Note: You can get more of Dr. Croft's helpful and educational insights from the video (with Dr. M. Foreman) "Advances in Personal Injury Practice," #V-435 on the Preferred Reading and Viewing list.

Dynamic ChiropracticJuly 31, 1992, Volume 10, Issue 16

Printer Friendly VersionEmail to a Friend I would like to thank Arthur C. Croft, DC, MS, MPH, FACO, FACFE, FAAIM for the generous contribution of these 6 tables from the 12th chapter of his text Whiplash Injuries: The Cervical Acceleration/ Deceleration Syndrome. To the best of my knowledge, this is the only on-line source of well documented treatment guidelines for the whiplash patient, which actually suggests the number of treatments which may be necessary. Please refer to Dr. Croft's text (3rd edition, 2001) for further explanation. You might also enjoy some of Dr. Croft's articles and his November 15, 2000 article, referring to these guidelines, titled Guidelines for the Management of CAD Trauma.

Table 12.1

Effects of Experimental Spinal Fixation 1

Fibrous ingrowth Vascular invasion of tidemark Osteophytosis Subchondral remodeling Chondrolysis and cloning Absence of proteoglycans Fibrillated cartilage Loss of motion

1 Adapted from: Kahanovitz N, Arnoczky SP, Levine DB, Otis JP: "The effects of internal fixation on the articular cartilage of unfused canine facet joint cartilage."Spine 9(3): 268-272, 1984

Table 12.2

Common Factors Potentially ComplicatingCAD Trauma Management 1

Advanced age Metabolic disorders Congenital anomalies of the spine Developmental anomalies of the spine Degenerative disc disease Disc protrusion (HNP) Spondylosis Facet arthrosis Rheumatoid arthritis or other arthritides affecting the spine Ankylosing spondylitis or other spondylarthropathy Scoliosis Prior cervical spinal surgery 2

Prior lumbar spinal surgery 2

Prior vertebral fracture Osteoporosis Paget's disease or other disease of bone Spinal stenosis or foraminal stenosis Paraplegia or quadriplegia Prior spinal injury

1 From Croft AC: Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). Am Chiro Assoc J Chiro 30(1): 41-45, 1993.

2 Especially laminectomy and discectomy.

Table 12.3

Guidelines for Frequency and Duration of Care inCervical Acceleration/Deceleration Trauma 1

Daily

3x/wk

2x/wk

1x/wk

1x/mo

TD 2

TN 2

Grade I

1 wk

1-2 wk

2-3 wk

<4 wk

.....3

<11 wk

<21

Grade II

1 wk

<4 wk

<4 wk

<4 wk

<4 mo

<29 wk

<33

Grade III

1-2 wk

<10 wk

<10 wk

<10 wk

<6 mo

<56 wk

<76

Grade IV

2-3 wk

<16 wk

<12 wk

<20 wk

.....4

.....4

.....4

Grade V

Surgical stabilization necessary--chiropractic care is post-surgical

1 Adapted from Croft AC: Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). Am Chiro Assoc J Chiro 30(1): 41-45, 1993.

2 TD indicates treatment duration; TN treatment total number;

3 Possible follow-up at 1 month.

4 May require permanent monthly or p.r.n. treatment.

Table 8.12 is from Chapter 8 and explains the Grade I-V classification system used in the Table 12.3 above.

Table 8.12

Classification of Cervical Acceleration/DecelerationInjuries from Motor Vehicle Accidents (SRISD)1

A. Types of Collisions 2

Type I

Primary rear impact (struck car moving or stationary)

Type II

Primary side impact

Type III

Primary frontal impact

B. Grades of Severity of Injury

Grade I

Minimal; No limitation of motion; No ligamentous injury; No neurological findings

Grade II

Slight; Limitation of motion; No ligamentous injury; No neurological findings

Grade III

Moderate; Limitation of motion; Some ligamenetous injury; Neurological findings may be present

Grade IV

Moderate to Severe; Limitation of motion; Ligamentous instability; Neurological findings present; Fracture or disc derangement

Grade V

Severe; Requires surgical management/stabilization

C. Stages of Injury

Stage I

Acute; Inflammatory phase; Up to 72 hours

Stage II

Subacute; Repair phase; 72 hours to 14 weeks

Stage III

Remodeling phase; 14 weeks to 12 months or more

Stage IV

Chronic; Permanent1 Adapted from Croft, AC: "A Proposed Classification of Cervical Acceleration/Deceleration Injuries with a Review of Prognostic Research"Palmer J Research 1994; 1(1): 10-21

2 Occupant may be driver or passenger

SRISD = Spine Research Institute of San Diego. These criteria do not consider loss of consciousness, the use of seatbelts/shoulder harnesses, or other factors that will be accounted for in a forthcoming revised prognostic index.

Table 12.4

Treatment Adjuncts in Cervical Acceleration/Deceleration Trauma

Modality

Stage I

Stage II

Stage III

Stage IV

Cervical pillow

All grades

All grades

All grades

All grades

Cervical collars

- Rigid

Grades III-V 1,2

Grades III-V 1,2

--------

--------

- Soft

Grades II and III 1,2

--------

--------

--------

Home traction

--------

Grades II-IV 2

Grades II-IV

Grades II-IV

Home exercise

--------

Grades II-IV 2

Grades II-IV 2,3

--------

Ice

All grades

All grades

As needed

--------

Vit/min. suppl.

All grades

All grades

All grades

Recommended

DTM 4

Grades II-IV

Grades II-IV

As needed

--------

1 See text for indications.

2 Unless contraindicated.

3 Grade V after surgery.

4 Deep tissue massage.

Table 12.5

Contraindications to Manipulative Therapy

Relative ContraindicationsPatients with (+) 's testPatient with prior strokeFemales on oral contraceptivesAbdominal aortic aneurismVertebiobasilar syndromeMetastatic diseaseDisc herniationSpondylarthropathySevere spondylosisModerate to severe osteoporosisMetabolic bone diseaseOsteomyelitisDiscitisStable spinal fractureSevere atherosclerosisOsteogenesis imperfectaClotting disordersIntersegmental instability

Absolute ContraindicationsUnstable spinal fractureAcute spinal cord injuryLack of formal training in spinal manipulation

Table 12.6

Heating Modalities: Modes of Transfer 1

Mode of Heat Transfer

Modality

Depth

Conduction

Convection

Conversion

Hot packsParaffin bath

FluidotherapyHydrotherapyMoist airRadiant heatLaserMicrowaveShort waveUltrasound

Superficial heat

Deep heat

1 Adapted from Lehman JF, de Lateur BJ: "Therapeutic heat." In: Lehman JF, ed. Therapeutic Heat and Cold. 3rd ed. Baltimore: & Wilkins, 1982: 404-562.