Wednesday, November 2, 2011

Chiropractic Care For Whiplahs Patients, Akron Square Chiropractic

Chiropractic Care for Acute Whiplash Patients

We Must Take up the Challenge of Research

By Arthur Croft, DC, MS, MPH, FACO
I urge all readers to take a moment to read this message. This has to be one of the most important pieces I've written, because I must compel you all to act decisively - both for your own future, and for that of your profession. The Challenge
Automakers create cars primarily to capture your imagination. Along the way they must also satisfy emission, fuel economy, and certain safety standards. These standards are known as Federal Motor Vehicle Safety Standards (FMVSS). They require, among other things, frontal crash testing at 30 mph into fixed barriers. The National Highway and Traffic Safety Administration (NHTSA)-that's your government-defines those standards. It has tried to raise the crash test standards in recent years, but lobbyists have prevented that. So NHTSA proposed nonmandatory additional testing in the form of the New Car Assessment Program (NCAP). Here, the cars are crashed at 35 mph and receive a star rating based on the car's and the dummy's performance. A perfect rating of five stars means that the risk of death or serious injury in that crash are very low.
The Insurance Institute for Highway Safety (IIHS), a consortium of auto insurers, takes this a step further and crashes cars into deformable barriers at 40 mph in more challenging offset impacts. But here's the challenge: (1) there is no low-speed performance standard or neck injury criterion; and (2) to improve their performance in these higher speed crashes, manufacturers have been making their cars progressively stiffer. The end result is that the risk for whiplash has significantly increased in recent years.
Do manufacturers know how their cars perform in low-speed crashes? Yes. Are they required to divulge that data to the public? No, it is proprietary. Does the IIHS test cars in low-speed crashes? Yes, but only to determine the cost of repairing bumpers. Quantifying an occupant risk in low speed crashes would be rather counterproductive for a consortium of insurers. And what about NHTSA? Do they conduct low-speed crashes? No.
The only other groups who have done human subject crash testing (besides the Spine Research Institute of San Diego) generally work under grants from insurers and, not coincidentally, later become the key experts for these insurers in lawsuits. This is a hugely profitable business that is often based on just a handful of crash tests.
Goals of CRASH
We at CRASH are not connected with the government, nor are we not beholding to the insurance industry. We have no particular axe to grind in either defending or attacking any manufacturer or product. Our principal concern is with the public welfare. And believe it or not, there are no other research organizations in the U.S. doing this work! Our primary goals are to: crash test the current fleet of passenger cars; assign a low speed star rating; and make our data available to the public so that they can make informed decisions about purchasing cars on the basis of safety and crashworthiness in low-speed crashes from which, paradoxically, most chronic pain and monetary expenditures stem.
I fully expect to see our results announced on CNN and the major network news programs some day. Of course, there will also be legal implications, since both insurers and lawyers of plaintiffs will likely use this information to argue their cases. But these arguments will now be more academic and scientific, and less rhetorical and myth-based. Our results will likely also cause manufacturers to reconsider low-speed crashworthiness. We further expect to provide legislators with the impetus for adopting a low-speed crash test regulation and a neck injury criterion.
Other goals will be to make the public aware of the enormity of this public health problem called whiplash. The misinformation foisted upon the general public from ongoing industrially-inspired junk science and highly biased television programs over the years has left in its wake a populace that largely believes whiplash is either benign or nonexistent. We also plan, though rigorous scientific research, to define optimal treatment methods and protocols - an undertaking which should not be left for those outside the health professions. And make no mistake, that will happen if we fail to act. Again, chiropractic management will likely take the lead role in the definitive management - but we have yet to prove that.
We need research. Do you realize that there have been no studies testing the effectiveness of chiropractic care for acute whiplash patients? We simply must take up the challenge of research, and we must do it now. But to achieve these goals will take time, determination, and, most importantly, resources. That's where you come in.
What CRASH Will Do for You
Most important for you will be the fact that your profession has taken a leading role in a worthy, public health-minded action like never in its history. Eventually, we will have eclipsed all others in this field of research and will rightfully become the de facto experts in the field, not merely a group providing expendable luxury treatment. Think about what that means. Chiropractic will become to whiplash what dentists are to teeth. After 20 years in academia and science, I know how we can reach that goal.
We need funds to purchase equipment for crash testing. The BioRID crash test dummy alone will cost $57,000. And we need high-speed video cameras and lots of other electronic tools that will require nearly $200,000 to purchase. After that, we will need an operating budget. I'm encouraged to report that, after nine months, we have raised about $50,000 through charitable donations from generous and forward-looking chiropractors, two of whom (Drs. Bill Kuntz and Steve Whitelaw) have even pledged as much as $500/month on a permanent basis. But even with this level of extraordinary generosity, we can't sustain this project when only a small proportion of the profession supports us. That's why I'm urging everyone to give whatever monetary contribution they can afford. Please don't leave it for others to do. To make it even easier we can set up an automatic debit from your credit card account. You don't even have to think about it after that, but you'll know you're contributing to a very worthy fund every month. And we have full tax-exempt status from the IRS as a 501c3 corporation.
So please contribute to the future of your profession. All donations are welcome, whether a one-time donation or credit debit plans-even $10/month-can have a big impact when enough contribute. Give what you can afford, give from your heart and do it today-not tomorrow. Tell your colleagues to do the same. I am committed to keep our overhead minimal so that nearly every penny goes toward research. None of the officers of CRASH, including myself, will take any salary or compensation. As always, I am available at &#100;&#114;&#99;&#114;&#111;&#102;&#116;<img width="11" height="12" align="absmiddle" border="0" alt=" -at- " src="/include/mpacms/spam_vaccine/at_medium.gif">&#115;&#114;&#105;&#115;&#100;.&#99;&#111;&#109; to answer any questions you might have. To contribute, please call us at my institute (800) 423-9860 or (619) 660-8802.
Let's all, for once, stare into the future-invest in it-and imagine where it might take us.
Thanks for your help,
Arthur Croft,DC,MS,MPH
Director, Spine Research Institute of San Diego
President, Center for Research into Automotive Safety and Health (CRASH)

Whiplash and Brain Injuries: Cognitive Defect or Fertile Imagination - AKRON SQUARE CHIROPRACTIC

Whiplash and Brain Injuries: Cognitive Defect or Fertile Imagination?

By Arthur Croft, DC, MS, MPH, FACO
A generally accepted fact is that the most common cause of closed head injury (CHI) is acceleration/deceleration of the brain. Since the brain is a soft structure confined in a non-yielding cranium, the mechanism of injury may be due either to a shearing of axons passing perpendicular to opposing stress planes or due to the impact of the brain against the bony skull. The fact that even minor head injuries can result in long-term residual complaints such as headache, dizziness, visual disturbance, fatigue, sleep disturbances, difficulty with concentration, and personality changes, etc., was known to even the earliest civilizations. The Edwin Smith Surgical Papyrus, a translation of an Egyptian document dating back some 5,000 years, describes just such a syndrome which today is usually referred to as the postconcussion syndrome (PCS).
The statistics are staggering. In the last 12 years alone, more Americans have died from head trauma than in all of the battles since the founding of this country. Conservative estimates of non- fatal CHI are 2 million per year, with a total cost to society of about $25 billion annually.1 Motor vehicle accidents (MVA) are the most common agent in both fatal and non-fatal CHI accounting for more than 40 percent of mild brain injuries. Because CHI runs the gamut from very mild to quite severe, a more precise estimate of the number of patients suffering from PCS is impossible. Many physicians (DCs and MDs alike) have been reluctant to make the diagnosis in disorders of PCS found at the "minor" end of the continuum.
This reluctance has been due largely to be the lack of objective findings, lack of information about this disorder and, in part, due to the suggestion by some that PCS is largely of a neurotic nature, with little or no organic basis. Henry Miller,2 a prominent British neurologist, suggested that the majority of these patients were suffering from "accident neurosis." His writings remain influential in medicolegal settings today in spite of the fact that they have been almost universally debunked for the past 30 years.3,4,5
In the last 2-1/2 decades, we have learned a great deal about these CHIs and the ensuing PCS. We know that the responsible lesion is the diffuse axonal injury (DAI) which consists of axonal swellings (retraction balls), micro-hemorrhages, and chromatolysis of cell bodies. And, while visible on MRI and CAT scans in more severe cases, these lesions are often not detectable by high resolution studies.
We also know that the electroencephalograph (EEG) is no longer a valid diagnostic test for PCS, although some neurologists continue to "rule out" the disorder in this way. Brain stem auditory evoked responses (BAER) and topographic brain mapping are currently the most sensitive electrodiagnostic procedures, although positron emission tomography (PET) scanning and magnetoencephalography (MEG) are promising technologies in this regard. However, these tests may also fail to uncover a significant number of brain injuries.
We know that angular or non-centroidal acceleration can produce this DAI in experimental animals -- a lesion indistinguishable from that seen in man.6 We know that the tolerance of the brain to concussion is on an order of magnitude of 1600-1800 rad/sec2, an expression of angular acceleration.7 We also know that a coronal plane acceleration, such as would occur in a broadside MVA, will produce greater injury than a sagittal plane acceleration.6 We know that in primates, non-centroidal accelerations of 4,000-12,000 rad/sec2 will produce DAI.
The two current gaps in our understanding of this phenomenon are those of thresholds; in particular -- what is the threshold of DAI in man, in terms of non-centroidal acceleration? The other gap concerns diagnostic thresholds. Even our most sophisticated imagining modalities and electrodiagnostic procedures lack the sensitivity to detect or guantify the more minor of these lesions. It is quite difficult to estimate the number of false-negative results. Psychometric tests such as the Paced Auditory Serial Addition Test (PASAT) have been employed by neuropsychologists as a way of measuring cognitive defects.8
Whiplash, with or without head contact, has been shown to be the second most common cause of PCS,9 and most recently Radanov, et al.,10 have described cognitive defects in whiplash victims which they referred to as the "cervicoencephalic syndrome." It is characterized by headache, fatigue, dizziness, poor concentration, disturbed accommodation, and impaired adaptation to light intensity. Cognitive defects included a reduced speed of information processing and difficulty with divided attention. This report supports many others and provides further and compelling evidence that these cognitive and other defects such as diminished IQ,11 increased sensitivity to sound, disorganized communication skills,12 slowed reaction time,13 and psychosocial problems,14 are not simply the work of fertile imaginations.
  1. Goldstein M: Traumatic brain injury: a silent epidemic. Ann Neurol., 27(3):326, 1990.
  2. Miller H: Accident neurosis. Br Med J., 919-925, 1961.
  3. Mendelson G: Not "cured by verdict." Effect of legal settlement on compensation claimants. Med J. Austr., 2:132-134, 1982.
  4. Merskey H: Psychiatry and the cervical sprain syndrome. Can Med Assoc J., 130:1119-1121, 1984.
  5. Mendelson G: Persistent work disability following settlement of compensation claims. Law Instit J., 55:342-345, 1981.
  6. Genarelli TA, Thibault LE, Tomei G, et al: Directional dependence of axonal brain injury due to centroidal and non-centroidal acceleration. SAE 872197, in Proceedings of the Thirty-first Stapp Car Crash Conference, Society of Automotive Engineers, 49-53, 1987.
  7. Ommaya AK, Hirsch AE: Tolerances for cerebral concussion from head impact and whiplash in primate. J Biomechanics, 4:13-21, 1971.
  8. Speed WG III: Closed head injury sequelae: Changing concepts. Headache, 643-647, 1989.
  9. Barnat MR: Posttraumatic headache patients I: dermographics, injuries, headache, and health status. Headache, 26:271-277, 1986.
  10. Radanov BP, Dvorak J, Valach L: Cognitive deficits in patients after soft tissue injury of the cervical spine. Spine, 17(2):127-131, 1992.
  11. Gensemer I, Walker JC, McMurry FG, et al: IQ levels following trauma. J Trauma, 29(12):1616-1618, 1989.
  12. Payne-Johnson JC: Evaluation of communication competence in patients with closed head injury and whiplash. J Commun Disorder, 19:237-249, 1986.
  13. MacFlynn G, Montgomery EA, Fenton GW, et al: Measurement of reaction time following minor head injury. J Neurol Neurosurg Psychiatr., 47:1326-1331, 1984.
  14. Ruys MBM, Keyser A, Gabreeds FIM: Long-term sequelae of brain damage from closed head injury in children and adolescents. Clin Neurol Neurosurg., 92(4):323-328, 1990.

Arthur C. Croft, D.C., M.S., DABCO
Coronado, California


Effectiveness of Chiropractic Management in Chronic CAD Cases

By Arthur Croft, DC, MS, MPH, FACO
My colleagues in Bristol (UK), Martin Gargan, MD, and Gordon Bannister, MD, in concert with another orthopaedic surgeon and a chiropractic physician named Jonathan Cook, have recently reported their success in the management of chronic whiplash (i.e., cervical acceleration/deceleration or CAD) injuries. You might recall my previous discussion of an important paper published by this group three years ago (Woodward MM, Cook JCH, Gargan MF, Bannister GC. Chiropractic treatment of chronic whiplash injuries. Injury 1996;27:643-645). In that study, a series of patients who had been through a variety of traditional treatment regimes (medication, physical therapy, rest, four with chiropractic care) without success underwent a trial of chiropractic care by Dr. Cook. Dr. Woodward, an orthopaedic surgeon, conducted the before and after examinations.
Although it was a relatively small study, the results were very encouraging: 93% success, with 26 of 28 patients getting a benefit from treatment. While the results of this study cannot be extrapolated directly to the acute CAD case, it would seem that these chronic cases would typically be more challenging than acute cases. Both of these papers should be in the library of every DC who treats CAD patients and struggles with the daily clinical vicissitudes arising from file reviewers, IME doctors and insurance adjustors.
The most recent paper seeks to identify which chronic CAD patients will benefit most from chiropractic management. Using a structured telephone interview of 93 consecutive patients (68 female) referred for chiropractic care, the authors recognized three groups of patients. The mean time from injury to referral was 12.7 months. Group One consisted of patients with isolated neck pain and limited range of motion. Group Two had neurological signs or symptoms and associated range of motion restrictions. Group Three patients had "severe" neck pain and a normal range of motion, and frequently complained of "an unusual group of symptoms, with a bizarre, non-dermatomal pain distribution."
The main outcome measure was the Gargan and Bannister grading system in which grade A was an absence of symptoms; grade B symptoms were described as a "nuisance"; grade C symptoms were "intrusive"; and grade D symptoms were classified as "disabling." To some degree, those of us in the research community groan at the prospect of new grading systems and the vagarities and capriciousness of the English language. However, Gargan and Bannister have been at this CAD work for a long time and have in fact provided much of the foundational work upon which the grading system later developed by me (Croft AC: Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). ACA J Chiro 1993;30(1):41-45; Croft AC: Proposed classification of cervical acceleration/deceleration (CAD) injuries with a review of the prognostic research. Palmer J Research 1994;1(1):10-21) was based.
Some time later (1995), the Quebec Task Force published the same grading system, claiming it as one of their most important accomplishments. My work was not cited in that publication. Needless to say, the so-called WAD (whiplash-associated disorders) grading system (a.k.a. Quebec Grading System) is now de rigueur in the scientific community. A personal groan. For those familiar with these grading systems, the groupings used by the present authors may be a bit confusing, since their group one patients would be classified as grade two; their group two patients would best fit into a grade three; and their group three patients do not fit any of the CAD grades well, at least to the extent that they were described in the paper.
One might also ask what is meant by the terms "nuisance," "intrusive" and "disabling"? They probably correspond to the more common terms used here in the U.S.: "slight," "moderate," and "severe." Perhaps "minimal" is thrown in with group A. At least that was the impression I got when they first published this grading system several years back. Now, however, group A patients appear to be asymptomatic. Thus, these categories remain marginally defined.
Still, since the patients were always classified using the authors' operative definitions, changes from one group rating to another could be used to measure the effectiveness of chiropractic care. Also, it would only be fair to point out that within the CAD literature, it is a nearly universal practice to leave the term "disabled" entirely undefined. This has always made meaningful comparison of one study to the next highly problematic. Clearly, the term "disability" covers a very broad range of physical complaints and degrees of impairment. A quantifiable impairment level would be preferable, if such a thing existed. The AMA guidelines attempt this rather unconvincingly.
All patients were treated with standard high velocity, low amplitude thrust techniques and had a mean of 19.3 treatments over a mean period of 4.1 months. In Group One (n=50), 36 patients (72%) gained some benefit from spinal manipulation. Twelve (24%) became asymptomatic and 12 (24%) improved by two group ratings (e.g., going from a group D to a group B rating).
In Group Two (n=32), 30 patients (94%) responded well to treatment, with 12 (38%) becoming asymptomatic and 13 (43%) improving by two group ratings. Only three of the 11 patients in Group Three (27%) improved following treatment, one patient considering that his symptoms became worse. Overall, 74% of the 93 patients in this study showed improvement.
The authors concluded, "Whiplash injuries are common. Chiropractic is the only proven effective treatment in chronic cases." Those patients in Group Three were identified as a special group of non-responders. They had "severe" neck pain (again, it should be pointed out that in contrast to the American descriptions/classifications of pain, where "severe" pain is synonymous with totally disabling pain and is the highest rating of pain, the British often describe higher levels: above the rating of "severe" disability in the Revised Oswestry, for example, we have "crippled"). These patients also had non-dermatomal pain distributions, blackouts, visual disturbances, nausea, vomiting and chest pain.
The defining characteristics of this group were full range of motion in the neck, bizarre symptoms, female gender and ongoing litigation. It should be pointed out, however, that there were no statistically significant differences between groups as to litigation. As the authors acknowledged, more severely injured patients are more likely to be involved in litigation than those injured less severely.
It is also worth noting that non-dermatomal patterns are fairly common in persons suffering from CAD trauma. This scleratogenous (a.k.a. referred) type of pain has been know for years, most recently nicely explored by Bogduk in the 1990s. Injured spines are not universally hypomobile. In cases of ligamentous injury, the opposite may be the case. Thus, full range of motion does not necessarily constitute an improbable finding in the presence of neck pain.
Moreover, visual disturbances and balance disorders (which might be associated with nausea and vomiting) are also fairly common following CAD trauma (although not usually presenting with nausea and vomiting). Thus, one wonders whether this group's collective symptoms were really so "bizarre" after all, or whether there were some who were malingering or suffering from psychological problems. In any event, they did get 27% improvement which, depending on the weighing of the cost of care and the risk of treatment (one patient's condition was worsened by this treatment) against the potential benefit to the patient, his/her family and employer, might very well justify chiropractic care even in this group of non-responders. It would be particularly cost effective if it obviated the need for surgical intervention.


Radionuclide Bone Scan: How Useful in Cervical Spine Trauma?

By Arthur Croft, DC, MS, MPH, FACO
A sensitive method of measuring bone activity is the radionuclide bone scan. A diphosphonate ester compound, labeled with technetium 99m, is injected intravenously. The half-life distribution of these tracers from the vascular to the extravascular spaces is two to four minutes. By three hours time, about 35 percent of the tracer has been excreted by the kidney, 30-40 percent has been absorbed by bone, 10-15 percent is in other tissues, and about 5 percent remains in the blood. Photons of energy are given off by the tracer and are recorded by a gamma camera. Newer systems allow a larger field of view so that whole body scans are able to provide excellent images and may be preferable to limited regional studies for practical reasons.
Scintigraphy, a more formal name for bone scanning, using technetium 99m methylene diphosphonate (MDP) will reveal a variety of non-osseous disorders, including neoplastic, hormonal, inflammatory, ischemic, traumatic, and excretory. Soft tissue Tc99m MDP uptake can be observed in benign conditions, such as tumoral calcinosis or myositis ossificans, and in malignant conditions, such as sarcomas, adenocarcinomas, and metastases. Moreover, tissue damage (which may be due to inflammation, physical injury, or infection), generally results in localized hyperemia, edema, or calcium (and hemosiderin) deposition. These can also be visualized with scintigraphy.1
For deeper structures, single photon emission computed tomography (SPECT) can produce increased image contrast and improve spacial resolution.2 Limitations to imaging the cervical spine with SPECT include decreased resolution, as a result of the relatively low bone mass of the cervical spine, and the relatively large radius of rotation necessitated by the mass of the shoulders. Despite such limitations, a recent report reveals the usefulness of cervical SPECT in trauma cases; the authors were able to make the diagnosis of occult fractures not seen with conventional plain film, demonstrate periosteal injury, differentiate radiographic abnormalities from healed fractures, and identify active posttraumatic osteoarthritis superimposed on chronic degenerative disease.3 Their proposed algorithm for the diagnosis of cervical spine injury after trauma is presented in Figure 1.
Figure 1
Neck Trauma
Cervical spine series
Negative fracture
Positive acute fracture
Positive DDD(?) fracture
Persistent pain
Flexion/extension films
Persistent pain
Positive Negative
Consider Bone
Consider CT, immobilization Conservative treatment

SPECT appears to be a promising method for the evaluation of mild traumatic brain injuries (MTBI). Measuring regional cerebral blood flow (rCBF), Nedd et al.4 compared the results of the SPECT study with CT findings and found intraparenchymal abnormalities with SPECT in 87.5 percent vs. only 37.5 percent with CT. Areas of involvement were larger in the SPECT studies and contrecoup lesions were detected more often with SPECT. All patients with skull fractures had normal CT (brain) scans in this series, whereas 43.7 percent had rCBF abnormalities on SPECT. In a similar comparative study,5 this time for low back pain, SPECT was shown to be superior to both plain film radiology and CT in the identification of lesions. Eighty percent of the SPECT visualized lesions were seen on CT, but only 37 percent were seen on plain film studies. Another report suggests that SPECT may be more likely than CT to correlate with clinical findings in cases of spondylosis.6
About 90 percent of fractures will appear normal on bone scan within two years. They can be detected within hours of injury in the majority of cases. The occasional exception to this rule is in hip fractures in the elderly.
In many cases, bone scan can detect bone injuries which are too subtle for plain film radiography or CT -- modalities that detect fracture on the basis of absolute loss of bone crystal. Below is the list of the conditions detectable with scintigraphy.
Conditions Detectable with Radionuclide Imaging:
  1. Avulsion fractures
  2. Stress fractures
  3. Shin splints
  4. Insufficiency fractures
  5. Bone bruises (focal periosteal, cartilaginous, subchondral, or interosseous trauma)
  6. Pars defects
  7. Osteonecrosis
  8. Plantar fascitis
  9. Muscle Injuries
  10. Tendinitis
  11. Bursitis
  12. Frostbite
  13. Electrical burns
  14. Child abuse
  15. Chronic radiation injury
  16. Osteomyelitis
  17. Reflex sympathetic dystrophy
  18. Osteoarthritis and other arthritides (including those affecting the TM joint)
  19. Osteochondroses
  20. Osteochondroses
  21. CA
  22. Discitis

  1. Peller PJ, Ho VB, Kransdorf MJ. Extraosseous Tc-99m MDP uptake -- a pathophysiologic approach. Radiographics 13(4):715-734, 1993.
  2. Front D, Israel O, Jerushalmi J, et al. Quantitative bone scintigraphy using SPECT. J Nucl Med 30:240-245, 1989.
  3. Seitz JP, Unguez CE, Corbus HF, Wooten WW. SPECT of the cervical spine in the evaluation of neck pain after trauma. Clin Nuc Med 20(8):667-673, 1995.
  4. Nedd K, Sfakianakis G, Ganz W, et al. 99mTc-HMPAO SPECT of the brain in mild to moderate traumatic brain injury patients -- compared with CT -- a prospective study. Brain Injury 7(6):469-479, 1993.
  5. Ryan PJ, Evans PA, Gibson T, et al. Chronic low back pain -- comparison of bone SPECT with radiography and CT. Radiology 182(3):849-854, 1992.
  6. Raby N, Mathews S. Symptomatic spondylosis -- correlation of CT and SPECT with clinical outcome. Clin Radiology 48(2):97-99, 1993.

Arthur Croft, DC, MS, FACO
San Diego, California


A Few Common Cross-Examination Questions

By Arthur Croft, DC, MS, MPH, FACO
'Tis the season (or at least approaching the season) for closing out the year's medicolegal cases. Many of your PI cases will be settling, arbitrating, or going to trial, so I thought I'd take the opportunity to mention just a few of the common medicolegal cross-examination questions likely to be coming your way soon. Q: "Do you have any degrees in engineering or biomechanics, or are you an accident reconstructionist?" (Sometimes you are asked to reaffirm a negative statement: "Doctor, you're not an engineer or an accident reconstructionist, are you?")
This question is designed to preempt your later comments regarding causation between motor vehicle crashes (MVC) and alleged injuries. If the court allows such testimony from you, it will at least carry less weight coming from someone without engineering or related credentials.
The solution to this common problem would actually have started with a solid direct examination. Your patient's lawyer would have asked you if you had any training in biomechanics. You would have answered in the affirmative since you studied biomechanics, essentially, throughout chiropractic school, including some courses bearing that title. Moreover, you could recite the relevant postgraduate courses you had attended, as well as the scientific literature and other learned treatises you had studied.
Q: "Doctor, isn't it true that D.D. Palmer was a fish peddler before he became a chiropractor?"
This is one of my favorites. When you are asked questions like this one, it usually means that the lawyer asking them doesn't have anything of great substance, otherwise he wouldn't waste time with this genre of muckraking. Most jurors, after all, will see it as just that, and there's little to be gained by risking the jury's disapproval.
A student of mine told me that he had been asked this question once. When I was asked the question years later, I was floored, but amused. After a moment's reflection, I answered that I didn't know D.D. Palmer's personal history well enough to answer the question, but if it were true, it would be a thing he shared with Hippocrates -- the father of modern medicine. I think that evened the score, since neither the lawyer nor I really knew whether either Palmer or Hippocrates ever really sold a fish, but it was certainly too late to look up.
Q: "What books did you consult in diagnosing this patient's condition (or in arriving at the opinions you are expressing in this case)?"
I think that the truthful answer most of the time is going to be, "None, actually." Usually, we don't need to consult with a textbook in making our diagnoses. A rare form of pheochromocytoma, yes. Lumbar disk herniation, no.
Incidentally, when you are asked how you formed your opinions, or what your opinions are based upon, the best (and clearly most accurate) answer is, "My opinion is based on my training as a chiropractic physician (or doctor of chiropractic, if you prefer), my experience with similar cases (or patients, if you refer) and the books and scientific/clinical papers I've read (and, of course, any other training or experience you might have had)."
Q: "You're not a medical doctor, are you?"
Depending on the degree of invective thrown your way, this might even be "You're not a real doctor" or "You're not a doctor, are you?" It usually comes attached to a string of similar questions designed to impugn you second-class standing in the medical community, such as, "You don't have any formal medical training, do you?" or "You never went to medical school, did you?" or "You're not a member of any recognized medical association, are you?" This continues on with hospital privileges, membership in the AMA, the privileges of prescribing medication and so on.
The implication seems to be that medical doctors must have a monopoly on knowledge and wisdom. Therefore, whatever your opinion might happen to be, their expert medical opinion will always eclipse yours, a handy thing indeed if their experts know nothing about the subject at hand.
This problem is again best handled during the direct examination, which precedes the cross-examination. Here the patient's lawyer asks you about your training: how many years of college you had before chiropractic school; how many years in chiropractic school; what subjects did you study; what is the philosophy of chiropractic (i.e., drugless, non-surgical); what does a chiropractor actually do for patients such as yours; why does it work; how do we know it works; etc.
By the time this is finished, most jurors will realize that you were the right choice of provider and had the most to offer. And needless to say, those cross-examination questions will no longer be effective, because the jury will already know that you don't, for example, prescribe drugs. In fact, they'll now know why you don't! And in case you haven't noticed, drugs and surgery have become progressively declasse. Alternative medicine is in.
(It's been interesting for me to be a part of this profession at this watershed of general acceptability. When I was a new DC, we really didn't have much in the way of high-quality scientific validation. So when our detractors argued that we were unscientific and unproven, we really didn't have any stinging riposte to send their way. Gradually, though, the shoes have changed feet. While almost all medical remedies for back pain have failed to pass scientific muster, chiropractic continues to come up smelling like roses. Now when I go to medical conferences, I sense a big change in attitude -- a positive change.)
Q: "Chiropractors read/interpret x-rays differently than medical doctors, don't they?"
The words "see things that really aren't there" hang gravidly, yet unspoken, in this question. My answer is that with regard to pathology, there shouldn't be any difference at all in the interpretation between DCs and MDs. After all, we study mostly from medical textbooks of radiology. However, when it comes to spinal biomechanics, chiropractors do usually take more of an interest in subtle lesions. Still, when it comes to spinal biomechanics, not all of our medical brethren are voiceless. White and Panjabi1 have spent considerable time in this area. Griffiths, et al.2 have more recently validated a radiographic procedure for analyzing whiplash trauma.
Final Thoughts
As is illustrated in two of these questions, a careful direct examination must precede your cross-examination. Without it, you are essentially a sitting duck. Do you suppose they teach lawyers how to conduct a direct examination of a chiropractor in law school? Needless to say, a chiropractic case is nearly antipodal to a medical case, and this means you must sit down with the lawyer long before a trial or arbitration and discuss the best ways of bringing forth your testimony.
  1. White AA, Panjabi MM (eds.) Clinical Biomechanics of the Spine, second edition. Philadelphia, J.B. Lippincott, 1990.
  2. Griffiths HJ, Olson PN, Everson LI, Winemiller M. Hyperextension strain or "whiplash" injuries to the cervical spine. Skel Radiol 1995;24(4):263-266.

treatment guidelines, AKRON SQUARE CHIROPRACTIC

Of Guidelines and Gridlines

By Arthur Croft, DC, MS, MPH, FACO
Certainly we can all agree that peer review is an important form of checks and balances. In the course of their peer reviews and patient assessments, file reviewers and IME doctors have developed a number of strategies for reigning in or limiting treatment of cervical acceleration/deceleration (CAD or whiplash) patients. In my experience, three guidelines are the most commonly misquoted and/or misinterpreted: 1) the Mercy guidelines; 2) the AHCPR guidelines; and 3) the Quebec Task Force on WAD guidelines.
The Mercy Guidelines
On page IV of this document under the "General Disclaimer" heading is the following statement:
"These guidelines, which may need to be modified, are intended to be flexible. They are not standards of care. Adherence to them is voluntary. The Commission understands that alternative practices are possible and may be preferable under certain clinical conditions. The ultimate judgment regarding the propriety of any specific procedure must be made by the practitioner in light of the individual circumstances presented by each patient."
Just below that, it reads:
"This document may provide some assistance to third-party payers in the evaluation of care, but it is not itself a proper basis for evaluation. Many factors must be considered in determining clinical or medical necessity. Further, guidelines require constant re-evaluation as additional scientific and clinical information becomes available."
In chapter 8 ("Frequency and Duration of Care"), the area of these guidelines providing the basis for most of the more egregious misinterpretations I have seen, it reads (page 117):
"Guidelines concerning the treatment plan should be tempered with a balance of scientific information and systematic observation derived from clinical experience. Further, in order to be practical, they must be periodically upgraded to reflect advances in the ever-changing knowledge database. Their purpose is to assist the clinician in decision-making based on the expectation of outcome for the uncomplicated case. They are NOT [their emphasis] designed as a prescriptive or cookbook procedure for determining the absolute frequency and duration of treatment/care for any specific case."
They go on to note that:
"No attempt has been made to select for individual conditions by region of complaint or by diagnosis ... The majority of quantitative information available addresses the management of low-back [sic] and leg-pain complaints ... The references to low-back disorders in this section are used only as examples. There is no intent to imply that these conditions constitute the totality of chiropractic expertise or practice. Rather, since these recommendations were born from experience and from data on multivariate clinical circumstances, they may be extrapolated with appropriate case-specific modifications to most of the common complaints for which chiropractic care is sought."
On the same page, the authors go on to state:
"The approach to the development of guidelines for chiropractic quality assurance and standards of practice pertaining to the frequency and duration of treatment focuses on the uncomplicated case and logically includes the following considerations: 1) The natural history of common spinal disorders; 2) The characteristics and stages of tissue repair processes; and 3) Reasonable treatment/care outcome classified into short- and long-range goals."
On this page, and under the heading "Principles of Case Management," the authors note:
"The primary missions of health care delivery are to provide sufficient care to restore health, maintain it, and prevent the recurrence of injury or illness ... guidelines framing expectations of treatment outcome can be drawn from the literature and adapted by practical experience on a case-by-case basis."
Summary of the Mercy Document
As mentioned earlier, the literature review used by the authors was limited primarily to low-back research. For example, figure 8-1, which appears on page 128 of the guidelines, depicts the recovery of acute back-pain episodes as reported by John Triano, DC, MA. At the six-week mark, 100% recovery has occurred. Not surprisingly, this detail has spawned numerous misguided assumptions that CAD-injured patients will also achieve 100% recovery within six weeks.
In truth, the Mercy guidelines do not specifically consider CAD injuries in any section. Is it reasonable to extrapolate from acute, mostly industrial low-back strains all the way to a biomechanically and anatomically distinct structure such as the neck? And to simultaneously extrapolate from lifting and bending injuries to the very unique pathomechanics of CAD injury? No. Nor was this the intention of the authors. If this was possible, a logical assumption then would be that the recovery statistics of the two injuries are similar. In fact, they are not. Of the more than 35 outcome studies of CAD injury published in the past 32 years, the mean proportion of chronicity in these studies is 39% for mixed vector crashes and 56% for rear-impact vectors. Clearly, 100% recovery has never been reported in any published outcome study, although most such studies have not looked at patient populations treated solely by chiropractic paradigms.
Moreover, many risk factors for poor outcome in CAD have been verified in clinical and epidemiological studies. These include the following: 1) female gender; 2) non-awareness of impending collision; 3) head turned at impact; 4) pre-existing headaches, neck pain, or previous neck injury; 5) use of shoulder harness and seat belt; 6) being struck by a larger vehicle; 7) advanced age; 8) pre-existing spinal disease; and 9) poor head-restrain geometry. Any of these might lead us away from the uncomplicated category mentioned earlier and thus require longer duration care, as is allowed by the Mercy document. Multiple risk factors in particular will complicate the healing process.
If, as suggested by the Mercy authors, we consider the scientific literature on expected outcomes in the case of CAD, we find that the outcome is not particularly rosy. And if, as further suggested, we consider the healing time of tissues, we find that authors of animal studies of ligament and tendon injuries have reported a remodeling process that can exceed one year. Some would argue that chiropractic management on some regular basis would be prudent throughout this period when spinal ligaments are remodeling.
And of course, it is the individual patient that always determines the need for care and its frequency and duration. The authors of the Mercy document are to be congratulated for their monumental and thankless hours devoted to the betterment of this profession, despite the undeserved upbraiding they have occasionally received at the hands of those lacking vision and insight. Nevertheless, when it comes to CAD, the Mercy document cannot be applied in anything more than very general terms. It does not provide treatment recommendations for frequency and duration of care. It does, however, allow for treatment as long as it can be shown to "provide sufficient care to restore health, maintain it, and prevent the recurrence of injury or illness." Needles to say, medical records must reflect this need.
AHCPR Guidelines on Low-Back Pain
On several occasions, I've read depositions in which chiropractors, acting as IMEs or expert witnesses, referred to "federal guidelines" which allegedly applied to CAD injuries, noting that the guidelines had been exceeded by the treating doctor. The "federal guidelines" they were referring to were the AHCPR (Agency for Health Care Policy and Research) Guidelines on Low Back Pain. This misrepresentation is even more disingenuous than those suggesting that one can determine a treatment protocol from the Mercy document. The AHCPR guidelines, after all, are titled, Acute Low Back Problems in Adults. The authors point out that they are not intended for use in children or in adults with chronic low-back pain. Needless to say, they are also not intended to be used as guidelines for the treatment of CAD injuries.
Summary of the AHCPR Guidelines
The AHCPR guidelines do not attempt to define treatment parameters or guidelines for CAD injuries. Extrapolation is not possible in any meaningful or scientific way.
The Quebec Task Force on Whiplash-Associated Disorders (WAD)
Published in April of 1995 in the journal Spine, these guidelines have gained wide currency (and some criticism) on the international scene. Readers who have followed my work know that my colleagues and I have been critical of these guidelines for several reasons. Our work on this subject is scheduled to be published in Spine in May 1998, and I will not prorogue the debate other than to deal specifically with two issues: 1) the QTF cohort; and 2) the actual guidelines for treatment as recommended by the QTF-WAD.
The cohort, which suffered from selection bias, was followed only to collect data on a return to usual activities. The QTF referred to this return as "recovered." No information was collected about whether patients continued to be symptomatic or whether they continued to need care. Thus, this study, which reported a 97% recovery after one year, actually only reported the proportion who had returned to work and cannot be used as a true outcome study.
The guidelines for treatment are not specific, but allow "short-term" chiropractic care in CAD grades II and above. No operational definition of "short-term" was provided. Moreover, these guidelines only apply to patients who have not yet "recovered," i.e., returned to work or school.
Summary of the QTF-WAD Guidelines
If the patient is back at work or school, one must rely on another guideline to determine whether his or her treatment is reasonable. The QTF-WAD guidelines offer no help to experts or peer reviewers struggling with the problems of frequency and duration of care. However, there is such a guideline.1 These guidelines are based on a grading system published earlier.2 Fortunately, the QTF's grading system describes the same pathology and is thus interchangeable. Maxima of treatment durations are as follows: Grade I -- <10 weeks; Grade II-- <29 weeks; Grade III -- <56 weeks; Grade IV -- may require permanent care on a prn basis. The maxima for total number of treatments are <21, <33, <76, and possible permanent prn care, respectively. While these guidelines have been adopted by some organizations and associations and criticized by others, they are, nevertheless, the only widely published CAD guidelines and are based on actual patient data and experience. Moreover, they more accurately reflect the scientific literature currently available and the stated spirit of both the Mercy and AHCPR guidelines.
As with any guidelines, these 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. These guidelines are also not intended as recommended treatment plans or prescriptions for care; many patients will recover earlier than allowed by the guidelines. They also allow clinicians to determine their own clinical efficiency 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.
Inveterate defense experts (IMEs and file reviewers) have become adroit in the manipulation of more than just spines. Their practice of disinformation and misuse of existing guidelines has resulted in a devolution in the credibility of and reliance upon these well-intentioned guidelines: a high price to pay for providing the mere pretext for some rather unsavory and doctrinaire methods of care cutting. As an example, it is a common practice to arbitrarily allow 12 weeks of active treatment for all CAD injuries, regardless of the clinical circumstances. After the precise calendar date has been reached, no more care is authorized by the file reviewer. This technique, as ethically dubious and unscientific as it is, allows these experts to burnish their reputation with their employers. It will, I suspect, become the epiphany for these reviewers when these employers finally realize that any high school graduate can count off 12 weeks on a calendar, or when another expert points out this mischief in a more public forum, such as a court case.
From my experiences in teaching postgraduate courses, I would estimate that only about two percent of the profession has actually carefully read these guidelines. Thus, they fall easy prey to these unscrupulous "experts" who seem to carry on with virtual impunity.
Reasonable and fair peer review requires a serious look at an individual patient, his/her complaints, and the physical and laboratory findings, along with a consideration of risk factors and complicating features. 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 truth, we are not likely to know the right question until we are closer to knowing the answer. In the meantime, we do have guidelines which, like science, are thankfully self-correcting over time.
  1. Croft AC: Management of soft tissue injuries. In: Foreman SM, Croft AC (eds). Whiplash Injuries: the Cervical Acceleration/Deceleration Syndrome. Baltimore, Williams & Wilkins Co., 1995, 459.
  2. Croft AC. Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). Am Chiro Assoc J Chiro 30(1):41-45, 1993.

whiplash guidelines, akron square chiropractic

Guidelines for the Management of CAD Trauma - Use Them

By Arthur Croft, DC, MS, MPH, FACO
Case I Recently, I was in another state speaking for a private group of attorneys and a multidisciplinary health care audience. One of the DCs related a story to me. Without mentioning any names, it seems the DC's associate had been having difficulties with a now-defunct peer-review system.
I don't know whether the word "fraud" was used, but surely it was implied in this kind of thing. Apparently, records were seized, and for the next three years this hapless DC was squeezed through the emotional ringer as the lengthy investigation proceeded. Eventually, a plea bargain was proposed. The DC could cop to a lesser plea but his employer, the DC now telling me this story, wouldn't allow it. Essentially, we're talking about prosecuting the "crime" of treating a CAD patient about 70-some-odd times over a year or so - a treatment duration considered excessive by the peer review DC. This isn't an unusual case. I've heard many like it.
The owner DC hired a lawyer to handle the associate's case. Eventually they had the opportunity to depose this peer review DC. Noticing on his CV that he was a graduate of my whiplash certification program, the lawyer asked the DC about me. He conceded that he considered me an expert in CAD trauma. The hook was taken. He then asked the DC if he was aware that, in addition to pain and the physical findings of limitations of cervical spine motion, this patient also had neurological complaints. (Her neurological complaints were a major component of her condition and the complicating factor that necessitated her lengthy care.) The DC admitted that he was aware of the neurological complaints.
The attorney asked whether the DC would thus consider her injury a Grade III, alluding to the grading system that is now used universally to characterize whiplash/CAD trauma. He admitted that he would. The hook was set; the trap door sprung. Referring the DC to the guidelines published in my textbook1 and elsewhere (see Table I below), including the training manuals used at the program the DC had listed on his CV, the attorney asked if the treating DC had indeed been within the guidelines. The peer review DC paused and then admitted that the treatment was probably not excessive. After three long miserable years, the case was dropped.
Case II
Last year, under the strong leadership of Ron Tripp, DC, the Oklahoma State Board of Chiropractic Examiners adopted these guidelines for use in peer review disputes. (They have also been adopted by other states and associations.) Ron told me recently that when he is cross-examined in medicolegal situations about the length or frequency of care, he simply defers to the guidelines and finds this strategy to be essentially bombproof.
I imagine that the exuberant self-confidence characteristic of a former world heavyweight judo champion (which Ron is) doesn't hurt either, but the point I attempt to make here is simply this: We are all caught in a highly polarized health care system. Around every corner it seems we are being coerced into compromising our care and reducing our fees. The big business collective of insurers have their team of assimilated doctors whose job is to steer errant health care providers back onto what they perceive as the straight and narrow path of reasonable health care. But who decides what is reasonable? Is there really any question? These peer review physicians are all too often no more than loyal company lackeys programmed to churn out "boilerplate" reviews used as pretexts for denials of benefits - or worse, as in the above example. And, as in the example I gave above, published guidelines can be the treating physician's deliverance. Use them.
Case III
I testified in a trial in San Diego a few weeks ago involving a fairly high-speed crash. Liability was admitted. One of the critical issues in the case was the number of treatments provided by the patient's now-deceased DC. An orthopaedic surgeon performed an IME and concluded that 12 weeks of care should have been sufficient, and that anything beyond that was excessive.
During my direct examination, I explained to the jury that the patient had a Grade IV injury. I showed the jury a poster of these guidelines and how, with a Grade IV injury and so many other risk factors, the guidelines simply could not be applied to this patient. However, to the DC's credit, he had managed to treat a Grade IV injury within the Grade III guideline allowance. They apparently understood. The plaintiff prevailed in court.
Guideline Development
Where do these guidelines come from? A number of methods have been employed in the development of guidelines. At RAND we used the so-called delphi technique. A panel of experts from divergent fields analyzed the evidence for support of a treatment and ranked a large series of issues (for example, the appropriateness of cervical spine manipulation) accordingly.2 A somewhat less formal method is to invite a panel of experts to attend a meeting and come to a consensus on pre-selected topics. The results depend on the qualifications of the panelists. A good example of how such things can go wrong is the New Jersey case of a couple of years back.
The Banking and Insurance Commission (now there's an obvious concatenation) in New Jersey hired the accounting firm Pricewaterhouse Coopers to develop a set of "care paths," designed to act as guidelines for clinical practice. These algorithms were developed by a staff of non-experts, including RNs - even an MBA. They cited less than 20 scientific or clinical papers to support their findings. The depth of their befuddlement is illustrated by the fact that, while attempting to enlist the aid of the "Quebec Task Force on Whiplash-Associated Disorders" paper published in Spine in 19953 - one which promulgated guidelines based on faulty research methodology - they inadvertently cited the paper by Michael Freeman, myself, and Anne Rossignol criticizing the paper for those errors! Our paper was published in Spine in 1998,4 but the title contained the words "Quebec Task Force on Whiplash-Associated Disorders." It probably threw them off and, like most of the other cited literature, they probably didn't bother to read it.
The resulting "care paths" severely limited the amount of care available to whiplash patients from chiropractic physicians to just a handful of treatments. Make no mistake about it, these guidelines bear no relationship to actual practice norms, nor are they based on any scientific or academic work. Many other treatable conditions were dealt with, with similar careless and reckless disregard for science and public health. It was clearly a fait accompli for the BIC. And despite letters from myself, Michael Freeman, and even an appearance before the board by Scott Haldeman, the care paths were railroaded through the system at the expense of care providers and their patients, and served as a great pretext for denial of future claims.
According to a piece in the September 2000 issue of Smart Business Magazine, the Securities and Exchange Commission (Sec) reported that partners at the world's largest accounting firm routinely violated rules forbidding them from owning equity in companies they were auditing. "Thirty-one of Pricewaterhouse Coopers' 43 partners committed at least one violation, as did six of the 11 partners responsible for enforcing the investment and securities rules. The SEC probe uncovered 8,064 violations; five partners were dismissed in the aftermath." Hard to believe.
Another method of guideline development is to survey practices. That's how my guidelines were developed. A review of about 2,000 cases, graded as to severity (i.e., Grades I-V), provided the basis for these guidelines (see Table I). These were originally published in 1993.5 A few years later, the Insurance Research Council (IRC) reported that the average number of treatments provided by DCs in cases of CAD trauma was 32.6 Considering that most CAD injuries requiring treatment will be graded either Grade II or III, this serves to validate the guidelines to some degree. That the average number of treatments is 32 doesn't in any way imply that this is the best for which we can hope. 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 treating these patients. Optimal treatment methods are something we should strive to discover through future research.
Table I
As certain as death and taxes are, we can also expect to be subjected to somebody's guidelines. While they are useful for health care providers to monitor and gradually improve treatment strategies, they also have utility for reimbursement policy.
In the vacuum of existing guidelines, we can be expected to submit to the whims and fancies of peer reviewers whose opinions are largely reflective of their employers' company policies and generally ungrounded in science. We can simply stand around with our hands in our pockets, hoping for the best, and taking our chances with the likes of Pricewaterhouse Coopers, or we can take a stand and support a policy that we consider to be in the best interests of our patients and our own welfare; one that is based upon sound clinical experience, practice norms, and the best scientific evidence available. Clearly, the latter choice is the only reasonable one.
The guidelines presented in this paper have been in our literature now for seven years and no competing guidelines have been published during that time, with the exception of the Quebec Task Force Guidelines,3 but these are applicable only for patients who are on disability (i.e., not at work or their usual activities). Use the guidelines presented here to support the need for care, but remember - they are only guidelines, not prescriptions for treatment. Guidelines assist physicians to better treat their patients and to compare their practices with their peers. The patient is the ultimate guide to care, with some recovering well before the allotted guideline period suggests. And others, due to other complicating factors such as advanced age, prior disease, etc., cannot be practically placed within such a guideline.
  1. 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.
  2. 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.
  3. 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.
  4. Freeman MD, Croft AC, Rossignol AM: Whiplash associated disorders: redefining whiplash and its management. Quebec Task Force: a critical evaluation. Spine 23(9):1043-1049, 1998.
  5. Croft AC: Treatment paradigm for cervical acceleration/deceleration injuries (whiplash). ACA J Chiro 30(1):41-45, 1993.
  6. Paying for Auto Injuries: A Consumer Panel Survey of Auto Accident Victims. Insurance Research Council, May, 1994, p 9.

Director, Spine Research Institute of San Diego
San Diego, California