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NOW SERVING
TWO
REGIONS IN N.C.
THE
TRIANGLE
APEX MEDICAL PARK
1011 W. WILLIAMS ST.
SUITE 104
APEX, NC 27502
PH. 919-303-2213
EASTERN N.C.
1304 E. ASH ST.
GOLDSBORO, NC
27530
PH. 919-735-4300
|
Chiropractic Health Care for Your Active Lifestyle
Chiropractic First!
The
Croft Whiplash
Management Guidelines
Results of a Preliminary Practice Survey
Arthur C. Croft, D.C., M.Sc.,
M.P.H., F.A.C.O.
drcroft@srisd.com
Spine
Research Institute of San Diego
www.srisd.com |
| Introduction
Chiropractic physicians who care for cervical acceleration/deceleration
(CAD or whiplash) patients with any degree
of regularity are often confronted by representatives
of third party payers concerning the issue of alleged
excessive utilization. The ensuing dispute is typically
based on opinion, company policy, or misinformation,
rather than the common practice patterns of chiropractic
physicians within the community. There is a dearth
of information available in the chiropractic literature
to give assistance to anyone engaged in one of these
disputes. In 1993, however, Croft published a set
of management guidelines in the ACA Journal (1).
These guidelines have also been published in Whiplash
Injuries: the Cervical Acceleration/Deceleration Syndrome,
2nd edition (2) in 1995 and
in a recent Canadian practitioner’s guide to
whiplash injuries, sanctioned by the Canadian Chiropractic
Association (3). (Note:
these guidelines also appeared in the 3rd edition
of that textbook in 2001.) This paper will endeavor
to make a case for the general adoption of the Croft
Guidelines by practitioners as well as payers for
evaluating the reasonableness of CAD treatment.
Development
of Treatment Guidelines
Historically,
a number of different methods have been employed in
the development of guidelines. The RAND Corporation
used the so-called delphi technique in developing
cervical manipulation guidelines (2).
A panel of experts (including myself) from divergent
fields analyzed the evidence for support of treatment
by cervical spine manipulation and ranked a large
series of potentially treatable conditions accordingly.
Another
method of guideline development comprises practice
surveys. This method has also been used by RAND and
was utilized by the Spine Research Institute of San
Diego to develop the Croft Guidelines for the treatment
of CAD injuries. A review of 2,000 cases, graded as
to severity (i.e., Grades I-V - see Table I),
provided the basis for the Croft Guidelines (see
Table II). Subsequently, the Insurance Research
Council (IRC) reported that the average number
of treatments provided by DCs in cases of CAD trauma
was 32 (5). Considering that
most CAD injuries requiring treatment will be graded
either Grade I, II, or III, this serves to validate
the guidelines to some degree. In a practitioner survey
recently conducted in the state of Washington, the
average number of treatments rendered under the general
heading “trauma” was reported to be 34
(6). Similarly, we have recently
been informed by a representative of the Manitoba
auto insurance company that the average number of
treatments rendered by DCs for whiplash was 33 (7).
Most recently, the grading system originally developed
by Croft, and later adopted by the Quebec Task Force
on Whiplash Associated Disorders (WAD), was validated
in regard to its ability to predict outcome (8).
We used the authors’ breakdown of patients into
grades of severity (14% grade I; 83% grade II;
3% grade III) and applied the guidelines. Based
on maximal guideline allowance, the average number
of treatments would again fall in the mid 30s, consistent
with other data.
The
fact that the average number of treatments is about
32-34, however, doesn't in any way imply that this
is the optimal in terms of treatment results. It is
quite likely that less than optimal care was provided
in many cases, since many DCs-like their medical counterparts-are
not well trained in managing these cases. Optimizing
treatment methods would very likely result in both
reduced treatment duration and improved outcomes.
Nevertheless, these numbers do represent current practice
standards.
The
Croft Guidelines have been a part of our literature
now for more than a decade. The Croft Guidelines are
applicable independent of disability status, and have
now been adopted by several American state chiropractic
organizations and associations (AK, UT, OH, CO,
NC, SD, KY, WA) and one state board of examiners
(OK), as well as in at least one Canadian
province. They are the only widely published CAD guidelines
and they are based on actual practice patterns of
chiropractic physicians, patterns which appear to
be consistent throughout North America. |
| Table
I - Grades of Severity of Injury |
| Grade |
|
|
I |
Minimal;
No limitation of motion; No ligamentous injury; No neurological
findings |
|
II |
Slight;
Limitation of motion; No ligamentous injury; No neurological
findings |
|
III |
Moderate;
Limitation of motion; Some ligamentous injury; Neurological
symptoms |
|
IV |
Moderate
to Severe; Limitation of motion; Ligamentous instability;
Neurological symptoms; Fracture or disc derangement |
| V |
Severe;
Requires surgical management/stabilization |
| |
|
| Table
II - Guidelines for Frequency and Duration of Care
in
Cervical Acceleration/Deceleration Trauma
(2) |
| Grade |
Daily |
3x/wk |
2x/wk |
1x/wk |
1x/mo |
TD
|
TN |
| I |
1
wk |
1-2
wk |
2-3
wk |
<4
wk |
_1 |
<11
wk |
<21 |
|
II |
1
wk |
<4
wk |
<4
wk |
<4
wk |
<4
mo |
<29
wk |
<33 |
|
III |
1-2
wk |
<10
wk |
<10
wk |
<10
wk |
<6
mo |
<56
wk |
<76 |
|
IV |
2-3
wk |
<16
wk |
<12
wk |
<20
wk |
_2 |
_2 |
_2 |
|
V |
Surgical
stabilization necessary; chiropractic care is post-surgical. |
| TD
= treatment duration; TN = treatment
number. 1 Possible follow-up at
1 month. 2 May require permanent
monthly or p.r.n. treatment. |
| |
| Most recently, we have been conducting an informal
practitioner survey as a prelude to a more formally
applied study. This study is ongoing and readers are
encouraged to participate. At the website www.srisd.com,
a site with an average current visitation frequency
of over 6,000/week-about 61% of whom are chiropractic
physicians-we ask practitioners with DC degrees to estimate
the number of treatment visits required for their average
CAD patient. The results of this preliminary survey
are illustrated in Figure 1. While our results, of course,
don’t allow us to draw firm conclusions about
the breakdown of injury grades, nor the appropriateness
of care, they would be roughly concordant with a mix
of Grade I-III patients, with a smaller number of Grade
IV. I believe a significant portion of persons with
Grade I injuries self-treat only and that the majority
of those seeking care would be Grade II. This is what
most recent studies are showing. |
| 
Figure
1. Results of a recent preliminary survey conducted
at www.srisd.com for practitioners with DC degrees.
The results would be consistent with a mix of Grades
I through III CAD injuries, with the majority graded
as II.
|
|
Application
of Guidelines
Reasonable and equitable peer review requires a serious
consideration of an individual patient, his/her complaints,
and the physical and laboratory findings, along with
a consideration of known risk factors and complicating
features. It is scientifically, clinically, and ethically
unsound to apply any practice guideline without such
consideration. The consanguineous marriage of statistics
and guidelines-in the vacuum of clinical information-provides
nothing more than an example of a wrong question inviting
an irrelevant answer. In the meantime, we do have
guidelines which, like science, are thankfully self-correcting
over time.
As with most guidelines, the Croft Guidelines assume
that the patient's response to care is the best measure
of the need for care, and that complicating factors
may increase the need for care. Table III is a partial
list of factors that may complicate and prolong the
need for care in the management of CAD cases. However,
it is important to note that these guidelines are
not intended as recommended treatment plans or prescriptions
for care; many patients, particularly those without
complicating features, will not require the maximum
treatment numbers and duration allowed by these guidelines.
Conversely, other patients, due to complicating factors
such as advanced age, prior disease, etc., might require
treatment approaches exceeding the guidelines. As
always, a clinician’s most important management
compass is the patient.
Guidelines
further allow clinicians to gauge their own clinical
efficacy and, in some cases, to suspect that occult
lesions may be present. Some patients may require
upgrading or downgrading as more clinical or laboratory
information becomes available.
|
| Table
III - Common 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, Ankylosing
spondylitis or other spondylarthropathy, Scoliosis,
Prior cervical spinal surgery, Prior lumbar spinal
surgery, Prior vertebral fracture, Osteoporosis, Paget's
disease or other disease of bone, Spinal stenosis
or foraminal stenosis, Paraplegia or quadriplegia,
Prior spinal injury.
|
|
Using
These Guidelines Properly
Guideline misuse can hinder their widespread adoption,
so it is critical to use them appropriately. It is
important to remember that a guideline is simply a
set of general rules to follow, which allow clinicians
to make rational decisions regarding specific cases.
These guidelines should not be viewed as prescriptions,
allowances, or recommendations for treatment. Thus,
they do not supercede the basic tenets of ethical
practice parameters. For example, when a patient has
returned to his or her preinjury status, or if it
is apparent that no further treatment will provide
a significant benefit, no further treatment is indicated
even if the maximal number of visits in that particular
grade of CAD severity may be greater. Conversely,
there will be circumstances in which the guidelines
will not apply to a patient and the guideline periods
may need to be exceeded. No guidelines can be applied
to every patient. Practitioners who can document that
continued care is justifiable on the basis of its
mitigation of significant pain or disability, will
continue to treat beyond the guidelines. The guidelines
anticipate that patients with few complicating factors
which might impede healing should not require the
maximum treatment durations as provided in the guideline
table.
Why
and How Adopting Guidelines
Can Benefit Patients and Providers
Until the state of Oklahoma Board of Chiropractic
Examiners adopted these guidelines, file reviewers
and IME doctors working for various insurance companies,
HMOs, PPOs, etc., were left to their own devices for
determining reasonable and customary treatment schedules.
This often led to unreasonable denials of care based
on individual biases and reliance on unscientific
literature. For example, the theory that most CAD
injuries resolve in 6-12 weeks simply hasn’t
been able to stand up to scientific scrutiny and is
overly sanguine, yet is extremely prevalent in defense
circles. Similarly, many operate under the misconception
that injuries are unlikely in the absence of significant
property damage to the involved vehicles. Again, the
evidence to support this view is lacking, while the
countervailing evidence is overpowering.
Now, peer (file) reviewers and IMEs alike
are required to follow the guidelines above, which
allows for a more reasonable treatment schedule. Now,
disputes are more focused and academic; for example
questioning the determination of one grade vs. another
rather than following flawed theories of outcome.
I recently spoke to a chiropractic group in Florida.
The organizer related an interesting story. It seems
that several years ago the state had adopted a peer
review system which had identified his young associate
as having overtreated one female patient. This alleged
overtreatment was based on the opinion of one of the
reviewers. Subsequently, the Attorney General’s
office seized the chiropractor’s records and
launched a long and drawn out investigation of possible
insurance fraud. The potential ramifications of this
investigation included-in addition to large attorney
fees-loss of licensure and even prison time. This
case dragged on for two or three years. Finally the
file reviewer was deposed by the associate’s
attorney. The attorney noticed that the reviewer’s
CV included a reference to having been through Croft’s
training program in whiplash. He was asked if the
program was scientific and whether he subscribed to
most of the theories taught, answering in the affirmative.
He was then shown the textbook (2)
and the patient’s medical records and asked
to determine the patient’s grade of injury.
He was then asked to look at the guidelines and state
again whether her treatment had been either reasonable
or excessive. Since she had undeniable neurological
involvement, she fit into the Grade III category.
This reviewer then looked at the attorney and said,
“I guess the treatment was reasonable.”
The AG’s case was dropped. This prolonged and
pointless investigation could have been obviated had
the state adopted these guidelines.
What
Other Guidelines Have Been Developed
for Whiplash Trauma?
ACOEM Guidelines with regard to
whiplash, the American College of Occupational and
Environmental Medicine (ACOEM) guidelines mention
the condition only to convey the advice made by the
Quebec Task Force in 1995, which was for patients
to remain active as opposed to having prolonged rest
or immobilization. These guidelines, which have recently
been adopted by the state of California, are aimed
primarily at workers compensation claims, but do provide
general algorithms of management which chiefly follow
a medical paradigm. And, although the authors do provide
statistical data on disability periods, they do not
make specific recommendations regarding treatment
or treatment durations. Some diagnostic and treatment
approaches are not recommended on the basis of evidence-based
medicine. Spinal manipulation is among the treatment
methods acknowledged as effective for both neck, upper
back, and lower back pain.
Acute Low Back Problems in Adults,
Clinical Practice Guideline Number 14, U.S. Department
of Heath and Human Services Public Health Service.
These guidelines, which are occasionally and somewhat
erroneously referred to as the “federal guidelines,”
were promulgated by the Agency for Health Care Policy
and Research (AHCPR) in 1994. The authors
point out that they do not consider children or adults
with chronic low back pain. Needless to say, they
are also not intended to be used as guidelines for
the treatment of whiplash injuries.
Guidelines for Chiropractic Quality Assurance
and Practice Parameters (Proceedings
of the Mercy Center Consensus Conference) The
Mercy guidelines, as they are most often referred
to, provide general guidelines to chiropractic practitioners
across a broad range of clinical subjects. However,
there is no specific provision for the treatment of
whiplash injuries in this document.
Procedural/Utilization Facts: Chiropractic/Physical
Therapy Treatment Standards-A Reference Guide,
5th edition. Also known commonly as the Olsen Guidelines,
this 159-page document, authored by Richard E. Olson,
DC, published by Data Management Ventures, Inc. Dr.
Olson is also the author of Fee Facts, Prevailing
Fees For Rehabilitative Medicine, A Reference Guide,
and author of the Chiropractic Services Program, Managed
Care Treatment Plans, A Reference Guide. The Olson
Guidelines mention “whiplash” three times:
twice in reference to PT modalities, and once in a
somewhat vague reference to manipulation. In no case
does he discuss treatment frequency or duration in
reference to whiplash injuries.
QTF Guidelines In 1995 the Quebec Task Force
on Whiplash-Associated Disorders published
the results of their best-evidence synthesis (Spitzer
WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J,
Suissa S, Zeiss E: Scientific monograph of the Quebec
task force on whiplash-associated disorders: redefining
“whiplash” and its management. Spine (Supplement)
20(8S):1S-73S, 1995). The
study has been widely acknowledged in the international
scientific community, but it has also received widespread
criticism for violating the very promise of best-evidence
synthesis because the authors ultimately resorted
to consensus-based-rather than evidence-based-methods
(Freeman MD, Croft AC, Rossignol AM: “Whiplash
Associated disorders: redefining whiplash and its
management” by the Quebec Task Force: a critical
evaluation. Spine 23(9):1043-1049,
1998).
The authors developed a guideline for whiplash management
based largely on the combination of a small number
of papers and a consensus of their own opinions. Spinal
manipulation was considered one appropriate means
of treatment. If a patient remains out of work for
more than three weeks, specialist advice should be
sought, they said. If out of work for six weeks, a
multidisciplinary team evaluation is recommended.
For persons not out of work, however, these guidelines
do not apply.
Reed Group, Ltd. The Medical Disability Adviser:
Workplace Guidelines for Disability Duration,
4th edition (2001) is edited by Presely Reed,
MD. In total, there are 2685 pages of text covering
everything from abdominal aneurism to herpes zoster.
In the preface he writes, “The Medical Disability
Advisor is intended to be used as a tool against which
the user should weigh the totality of his or her available
knowledge and the specific information [of the
individual case]. [And] Please use this
tool judiciously, tempering your decisions with thoughtfulness
and compassion.” There are no recommendations
for either medical or chiropractic care in the treatment
of whiplash patients.
Whiplash: A Practitioner’s Guide to
Understanding Whiplash Associated Disorders (WAD)
This was the result of a collaborative effort
of numerous authorities at the behest of the Canadian
Chiropractic Association. The 210-page guide was published
in 2000 and distributed to all Canadian chiropractors
by the CCA. The guide explores the topics of WAD physiology,
symptomatology, grading issues, management, legal
and road safety issues, third party payers, and the
practitioner’s role in reporting and note-taking.
In chapter 4.2, “Standardized WAD Grading Systems,”
the Croft treatment guidelines are introduced.
How
will insurers react to guideline adoption?
The insurance industry has developed a number of
strategies over the years to attempt to control or
contain what they view as runaway costs. Most recently,
Farmers Insurance has been misquoting the above-mentioned
Reed Group as a justification for claim denial beyond
an arbitrary point. Letters are being generated from
the Farmers National Document Center in Oklahoma City
which state that the Reed guidelines report that,
“the standard practice for length of treatment
for the type of injury your patient sustained is from
2 to 12 weeks.” In truth, the Reed guidelines
look only at the duration of disability in the workers
compensation world, and there is no reference to 2
to 12 weeks. They also do not discuss treatment.
The most egregious billing practices associated with
the chiropractic profession can be traced to a relatively
small minority of its practitioners. Sadly, the profession
at large suffers the resulting opprobrium and is forced
to suffer these desperate insurance industry-based
countermeasures. Insurers welcome adoption of reasonable
guidelines as a way of managing this problem without
having to resort to unfounded and non-defendable methods
which potentially expose them to large court settlements
and even bad faith lawsuits. Adoption and utilization
of guidelines can potentially cut their costs by controlling
overutilization. It would potentially require fewer
IMEs and reduce the number of lawsuits.
Discussion
In the absence of fundamentally solid guidelines
that are universally accepted and utilized by the
profession, we can expected to continue to be subjected
to the vicissitudes of an inconsistent and generally
biased peer reviewer/IME system and insurance claims
representatives whose opinions are more often grounded
in dogma and driven by financial bottom lines, rather
than being grounded in science and driven by the public
welfare. It is necessary to take a stand and support
a policy that we consider to be in the best interests
of our patients; one that is based upon sound clinical
experience, practice norms, and the best scientific
evidence available.
The Croft Guidelines for the treatment of CAD injuries
were developed scientifically and appear to have good
face validity, as provided from disparate sources.
It is in the best interest of this profession and
the patients we treat to adopt the Croft guidelines
for management of CAD trauma. Doing so will provide
for improved management, will help to identify excessive
or unnecessary care, will allow for comparisons of
different treatment methods, will allow for fair and
equitable peer review, and will forestall the inevitable
fate that awaits a profession without a formal and
universally ratified guideline in this changing world
of managed care. Unless we act in a unified manner,
the New Jersey experience is likely to be repeated
on a state by state basis.
References:
1) Croft AC: Treatment paradigm for cervical acceleration/deceleration
injuries (whiplash). ACA J Chiro 30(1):41-45, 1993.
2) Croft AC: Management of soft tissue injuries.
In Foreman SM, Croft AC (eds), Whiplash Injuries:
the Cervical Acceleration/Deceleration Syndrome, second
edition, Baltimore, Williams & Wilkins, 1995,
p 465.
3) Croft AC: Standardized WAD Grading Systems, in
Bryans R (editor): Whiplash: a Practitioner’s
Guide to Understanding Whiplash Associated Disorders
(WAD). Canadian Chiropractic Association, 2000.
4) Coulter ID, Hurwitz EL, Adams AH, Meeker WC, Hansen
DT, Mootz RD, Aker PD, Genovese BJ, Shekelle PG. The
Appropriateness of Manipulation of the Cervical Spine.
Santa Monica, RAND Corporation, 1996.
5) Paying for Auto Injuries: A Consumer Panel Survey
of Auto Accident Victims. Insurance Research Council,
May, 1994, p 9.
6) Personal communication.
7) Personal communication.
8) Soderlund A, Olerud C, Lindberg P. Acute whiplash-associated
disorders (WAD): the effects of early mobilization
and prognostic factors in long-term symptomatology.
Clinical Rehabilitation. 2000;14:457-467.
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