COMMON CROSS EXAMINE QUESTIONS, AKRON SQUARE CHIROPRACTIC

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.

Most of these questions are the same old utilitarian nuts and bolts legalese lawyers have used to gainsay chiropractors for years. The questions continue to be effective precisely because they continue to trip up doctors in predictable ways. Thus, knowing what to expect offers a huge strategic advantage to the field practitioner: developing effective and concise answers before these questions are ever asked is infinitely more satisfying than realizing an hour after your testimony what would have been the best answer. Without further fanfare, here are a few of the more common questions, followed by some ideas on how to best construct your answers to them.

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.
References

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, these strategies can be roughly classified into two categories: 1) fair and reasonable; and 2) disingenuous and unreasonable. In the latter category, three documents have become veritable Swiss Army knives of the slash-and-deny technique. This article looks at the misuse of guidelines in the peer review process as it pertains to CAD injuries.

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.
Conclusions
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.
References

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.

 

Specifically, when a provider was tagged by one of the DCs on this peer-review board as providing what they viewed as excessive care, overutilization, or other excess, the case would be sent to a branch of the attorney general's office and an investigation initiated.

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

Conclusion
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.
References

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.

Arthur Croft,DC,MS,FACO,FACFE
Director, Spine Research Institute of San Diego
San Diego, California

low speed impacts, Akron Square Chiropractic

Low-Speed Rear Impact Collision

Conference of the Society of Automotive Engineers: A Synopsis

By Arthur Croft, DC, MS, MPH, FACO

On August 8-9, 1994 I attended the Low-Speed Rear Impact Collision technical workshop of the Society of Automotive Engineers in Irvine, California.

The following are some of my observations and thoughts.

The program was organized by a gentleman from Collision Research and Analysis, Inc. I was initially disappointed in the speakers who addressed the audience of engineers, designers, physicians, accident reconstructionists, attorneys, and scientists. Several of the speakers had no advanced degrees and, despite the titles they awarded themselves (research engineer, etc.), they appeared to be accident reconstructionists with a decidedly defense-biased attitude. (More than 80 percent of the clients of accident reconstructionists are defense lawyers). Side comments concerning the "green poultice syndrome" were met with predictable audience snickers. They shared their work on seatback stiffness testing and simple rear impact crash testing, but there is nothing particularly interesting to report. One of the researchers who served as volunteer in a very low speed crash test was not wearing his restraint system. When asked why by one of the audience, he replied, "It doesn't make any difference if they are used in low speed impacts." Hmmmm.
The program also included plaintiff and defense attorneys. Both naturally followed party lines. The plaintiff lawyer pointed out that it is important to be able to show actual damage to a vehicle and provided several examples that attested to significant collisions in cars that appeared, to the untrained eye, undamaged. Bolts on the frame that were bent or sprung seatbacks were a few examples. The defense attorney discussed the problems of reliability of the science used in the courtroom, citing as a recent example the case of Dauber vs. Merrill Dow. The proposed use of "qualified juries" (i.e., those with special education or knowledge) in complicated cases will not come into being, in his opinion.
Dennis Schneider, PhD, president of Biokinetics Engineering, Inc., discussed some of the recent research leading up to our current state of knowledge of whiplash. Most of what he reviewed can be found in chapter one of my textbook (Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome, First Edition).4 His talk was lucid and enlightening. Alan Nahum, MD, spoke very briefly. I thought his notions were out of date. He used dated photographs from Ian Macnab's work to describe the whiplash phenomenon despite more recent work that has necessitated a modification of some of Macnab's models. Nahum told us, for example, that the chin will strike the chest during the flexion phase. In fact, of course, it will not.
Nahum shared the stage with Mark Gomez, PhD. Dr. Gomez gave a from-the-ground-up discussion of whiplash beginning with anatomy which I am sure was appreciated by the non-physicians in the audience. I would disagree with some of his comments, however. He said the discs do not fail in whiplash -- only the end plate or the disc/bone interface. His group experimented with the serial cutting of spinal ligaments (sounded to me like something that White and Panjabi had done) to assess their contribution to spinal stability. Interestingly, they found that the radiographic appearance was not altered by cutting the posterior ligaments.
Several engineers from Biodynamic Engineering, Inc., were on hand to share their findings from crash testing with human volunteers (themselves actually). You will not have access to this material because their "clients" will not allow them to publish their results -- a practice that runs counter to the general aims and philosophy of science. Carley Ward, PhD, the president, remarked later that the research was to be used to refute injury claims in "fraud" cases. I might add that I have had personal experience with one of these engineers. He testified for the defense in a case where I was acting as an expert for the plaintiff and stated confidently that he could precisely calculate the g forces that had been delivered to the low back of the plaintiff (merely by looking at a photograph of her car). In fact, of course, you cannot. Among other things, as an example, you must determine if the bumper isolators were functional at the time of the accident.
The presentation of the research was interesting but generally misleading. The speakers compared the effects of the low speed rear impact with amusement park rides and I was sure that most of the attendees must have concluded that it would be nearly impossible for an injury to occur under such trivial conditions. However, mingling with them later I found it heartening that many didn't buy it.
Overall, I was not pleased with the first day. None of the presenters were physicians and therefore had had no real patient contact, nor did they have any understanding of human anatomical and physiological systems. I sensed that we had spent the entire day using relatively contrived and artificial crash simulations along with applied principles of physics and engineering to "prove" that people are unlikely to be injured in low speed rear impact collisions. Epidemiological data, outcome studies, and animal research were never discussed.
The next day Donald Huelke, PhD, well known for his work in the development of the AIS scale and other projects relating to injury mechanisms in crashes, shared a new finding coming from Europe. It has been discovered that during the whiplash injury a pulse of CSF is injected under high pressure into the nerve root sleeves and may be responsible for some radicular syndromes. This has not yet been published.
Richard Howard, MD, and Whit McConnell, MD, principals of the Biodynamic Research Corporation, discussed their earlier work on full scale human volunteer crash testing¹ and their most recent work (as yet unpublished). You may recall Howard as the lead author of a rather "interesting" paper that suggested that the TM joint is subjected to no more trauma in whiplash than "everyday chewing"² -- a paper that has been highly criticized in dental circles³ and widely applied in defense strategies. Using split bite blocks in the mouths of test subjects (again, the authors themselves) they concluded that whiplash at low speeds would be about as stressful as "vigorously flossing your teeth." Hmmmm. I might point out that the "clients" of BRC are automobile insurance carriers and manufacturers. The results of all of this research have actually been quite enlightening and I have discussed the implications of it at length in the newest edition of my textbook⁴ which will be released in December. You should be aware, however, that their work is frequently mischaracterized in medical-legal settings -- much to the disadvantage of plaintiffs and treating doctors. Usually this takes the form of extrapolating beyond the collected data. The research shows that significant forces are applied to the head and neck, and adds greatly to our knowledge of the kinematics of these collisions. It does not prove, however, as it is frequently claimed, that persons other than "robustly healthy" middle-aged males, who are perfectly seated and restrained and prepared for an impending controlled crash, with no brakes applied, and with no second collisions, are not likely to be injured.
Also, of course, it is possible to support an incorrect hypothesis. I don't mean to belittle their important contribution to science, but it reminds me of the famous Austrian physiologist who experimented with frogs. He amputated one limb and ordered the frog to jump. It did. He then amputated another and then another. Again, when ordering to, the frog jumped. When the fourth limb was amputated the frog would not jump, providing the scientist's hypothesis that frogs become deaf when all four limbs are missing.
References

1. McConnell WH, Howard RP, Guzman HM, et al. Analysis of human test subject kinematic responses to low velocity rear end impacts. SAE Technical Paper Series 9308889, Society of Automotive Engineers, 21-31, 1993.
2. Howard RP, Benedict JV, Raddin JH, Smith HL. Assessing neck extension-flexion as a basis for temporomandibular joint dysfunction. J Oral Maxillofac Surg 49:1210-1213, 1991.
3. Rogal OJ, Haden J, Keropian B, et al. (representing the College of Trauma, American Academy of Head, Neck, Facial Pain and TMJ Orthopedics): Whiplash-TMD theory refuted. News J AM Acad Head Neck Facial Pain TMJ Orthopedic 4(1):3-4, 1992.
4. Foreman SM, Croft AC. Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome. Second Edition. Baltimore, Williams & Wilkins Co., 1995.

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

whiplash article, akron square chiropractic

"What Causes Those Symptoms, Doctor?"

By Arthur Croft, DC, MS, MPH, FACO

Introduction: The symptoms of whiplash or cervical acceleration/deceleration (CAD) injury are very often referred to as "bizarre," particularly by authors not thoroughly familiar with the condition.

 

To describe them in this way may suggest an honest bewilderment or perhaps a trace of skepticism. Other authors, however, have attempted to solve some of the puzzling clinical questions about the strange-seeming constellation of complaints which frequently surround CAD injuries.

Most of us have developed methods of coping with our patients' difficult, but otherwise benign, questions. "Gee doctor, when you pushed on my right knee, I felt it behind my left ear. Why is that?" We then mumble something about how we expected that and then proceed with our examination and treatment of the patient. Don't get me wrong here, I'm not suggesting that your patients' input or questions are not important but there are times ... Other times, however, our patients have legitimate concerns and do require thoughtful answers. When cases are litigated we may find ourselves responding to questions under cross-examination or in a deposition about why a patient is in pain or is dizzy. This article will review what we do know about the signs and symptoms of CAD trauma.
Symptoms and Signs
Table I list the 14 most frequently described complaints in CAD trauma. Note that some may be related to the postconcussion syndrome, the Barre-Lieou syndrome or TMJ dysfunction.
TABLE I
Common Symptoms Following Whiplash in Order of Prevalence
Neck Pain
Neck stiffness
Trapezius pain
Headache*@+
Interscapular pain
Back pain
Paresthesiae
Extremity pain/weakness
Dizziness/lightheadedness*@+
Facial pain and TMJ related symptoms
(clicking, closed lock, etc.)+
Auditory symptoms (phonophobia,
tinnitus, loss of hearing)*@+
Vertigo*@
Ocular dysfunction (blurred vision,
photophobia)*@
Dysphagia/hoarseness
* May be part of PCS
@ May be part of Barre-Lieou syndrome
+ May be part of TMJ dysfunction
Neck pain is easily explained by tearing of any soft tissue, disc injury/herniation or end plate fracture. Immediate pain indicates more severe injury. Stiffness is usually the result of muscle spasm. Shoulder pain may be the result of direct shoulder injury or referred pain from cervical disc injury (discogenic pain) or soft tissue injury (sclerotogenous pain). Headaches can result from injury to the upper cervical spine, reflex muscle spasm, TMJ dysfunction, the Barre-Lieou syndrome (rarely) or direct brain injury (i.e. postconcussion headaches). They may also have a vascular origin.
Interscapular pain may be due to direct injury to paraspinal muscles in this area but most often is due to muscle spasm or referred (sclerotogenous) pain from cervical soft tissues or from cervical discs. Later onset indicates myofascitis. Croft and Foreman¹ found low back pain (LBP) in 57 percent of their CAD cases (71 percent in broadside collisions) while Braaf and Rosner² noted LBP in 42 percent of their cases. Hohl³ described LBP in 35 percent of his cases. It is interesting though that in a long term follow up study of CAD victims, Watkins et al.⁴ found that while only 24 percent initially complained of LBP, after a mean of 10.8 years, 34 percent had LBP. Precise interpretation of this is difficult.
While parathesiae are usually blamed on direct nerve injury or irritation, thoracic outlet syndrome (which is probably an advanced manifestation of myofascitis) and sclertogenous pain can be associated with paresthesiae. Other causes include sympathetic disturbance and spinal cord injury. Extremity pain and weakness may be explained in the same way. Braaf and Rosner² found sciatica in 15 percent of their cases.
It has been shown that dizziness and lightheadedness can be produced by injection of saline solution into the SCM muscle⁴. Muscular injury or vascular compromise due to increased sympathetic tone may have the same effect. Inner ear damage, such as a perilymph fistula, or a minor brain injury, may give the same symptom. Tinnitus may be the result of inner ear injury, TMJ injury/derangement or (rarely) Barre-Lieou syndrome. Phonophobia typically accompanies minor head injury. Vertigo usually indicates a labyrinthine pathology or brain stem disorder, although it can be due to ischemia. Short duration vertigo (5-10 sec.) associated with quick movements of the head is referred to a benign paroxysmal positional nystagmus (BPPN). This may be due to free floating otoconia which have been detached from the otolithic membrane. With abrupt movements of the head, they are swept up in the current of semicircular canal, causing displacement of the cupola. The resulting barrage of impulses causes BPPN, a condition sometimes referred to as cupolithiasis^5,6.
Pupillary dilatation will often result in blurred vision and is generally the result of injury to the sympathetic system. Note that interruption of sympathetic fibers results in miosis e.g., Horner's syndrome. Irritation has the opposite effect. Nystagmus implicates the vestibular apparatus. Photophobia is common with mild head injury. Hildingsson et al.⁵ have proposed dysfunction of the proprioceptive system of the cervicocranial region as an explanation for visual tracking (smooth pursuit) abnormalities.
Dysphagia and/or hoarseness often is the result of swelling/spasm of the longus colli -- one of the chief culprits in straightening of the cervical lordotic curve. However, retrotracheal or retropharyngeal hematoma may give the same symptoms and should prompt immediate investigation. Hoarseness may also reflect direct laryngeal injury or injury to cranial nerves (brain stem lesions) or the recurrent laryngeal nerve.
Most often in CAD trauma, facial pain is due to a TMJ disorder (a.k.a. TMD). Associated clicking, popping, locking, limited opening, deviations, deflections, and palpable pain should prompt TMJ evaluation/referral.
Remember that delayed onset of symptoms is quite common following CAD trauma. Classic and contemporary writings have reflected this^6-13. Some authors have described delays of months or even years² although some of these conditions represent secondary adaptations to otherwise minimally symptomatic or asymptomatic conditions. Physicians who are cognizant of these numerous conditions and their protean manifestations will be best equipped to manage CAD trauma not only from the standpoint of diagnosis and treatment but also for medicolegal reasons.
References

1. Foreman SM, Croft AC: Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome. Baltimore, Williams & Wilkins, 1988.
2. Braaf MM, Rosner S: Symptomatology and treatment of injuries of the neck. NY State J Med 55: 237-242, 1955.
3. Hohl M: Soft tissue injuries of the neck in automobile accidents: Factors influencing prognosis. J Bone Joint Surg 56A(8): 1675-1682, 1974.
4. Macnab I: The "whiplash syndrome." Orth Clin N Amer 2(2): 389-403, 1971.
5. Hildingsson C, Wenngren B-I, Bring G, Toolanen G: Oculomotor problems after cervical spine injury. Acta Orthop Scand 60(5): 513-516, 1989.
6. Gotten N: Survey of one hundred cases of whiplash injury after settlement of litigation. JAMA 162(9): 865-867, 1956.
7. Goldberg AC, Rothfus WE, Deeb ZL, Frankel DG, Wilberger JE Jr, Daffner RH: Hyperextension injuries of the cervical spine. Skeletal Radiol 18: 283-288, 1989.
8. Green JD, Harle TS, Harris JH Jr: Anterior subluxation of the cervical spine: hyperflexion sprain. AJNR 2: 243-250, 1981.
9. Evans DK: Anterior cervical subluxation. J Bone Joint Surg 58B (3): 318-321, 1976.
10. Hildingson C, Toolanen G: Outcome after soft-tissue injury of the cervical spine. Acta Orthop Scand 61(4): 357-359, 1990.
11. Schneider K, Zernicke RF, Clark G: Modeling of jaw-head-neck dynamics during whiplash. J Dent Res 68(9): 1360-1365, 1989.
12. Croft AC: Whiplash. In Steigerwald DP, Croft AC (eds): Whiplash and Temporomandibular Joint Dysfunction: a Interdisciplinary Approach to Case Management. Encinitas, Keiser Publishing, 1992 (in press).
13. Deans GT, Magalliard JN, Kerr M, Rutherford WH: Neck sprain -- a major cause of disability following care accidents. Injury 18: 10-12, 1987.

Arthur C. Croft, D.C., M.S., FACO
San Diego, California

akron square chiropractic

Notable Observations from Three Years of Human-Subject Crash Testing

By Arthur Croft, DC, MS, MPH, FACO and Michael Haneline, DC, FICR

The Spine Research Institute has sponsored three annual human-subject crash tests, beginning with CRASH 1999 (named after the Center for Research into Automotive Safety and Health). These tests have totaled almost 50 individual crashes, with vehicle closing speeds ranging from 2-50 mph.

 

The outcome of this research has given rise to a number of papers that have appeared in such publications as Accident Analysis and Prevention, and presentations at the International Congress on Whiplash-Associated Disorders; the International Research Council on the Biomechanics of Impact (IRCOBI); and the Association for the Advancement of Automotive Medicine annual conference. Since many of our chiropractic colleagues are not familiar with these findings, we thought it would be beneficial to provide an overview of some of our more notable observations. While we could have mentioned many more, the following is a list of six observations we believe every chiropractic physician who treats whiplash patients should understand:

Crash number and year of crash	Gender and direction of impact (front, rear)	Vc (mph at time of crash)	V (change in mph, or delta V)	Head linear resultant acceleration (g)
2 (99) 3 (99) 4 (99) 5 (99) 6 (99) 7 (99) 8 (99) 9 (99) 15 (99) 1 (00) 2 (00) 3 (00) 6 (00) 7 (00) 8 (00) 9 (00) 10 (00) 11 (00) 12 (00) 13 (00) 5 (01) 6 (01)	M (R) M (R) F (R) F (R) F (R) F (R) F (R) F (R) M (F) M (R) M (R) M (R) M (F) F (F) F (F) F (F) F (R) F (R) F (R) M (R) M (R) M (R)	9.3 9.9 3.7 7.2 6.6 4.1 7.2 7.0 36.9 4.8 7.8 8.3 7.7 4.2 7.9 9.9 3.0 7.5 8.6 3.6 8.1 8.0	5.2 6.0 3.2 5.8 5.6 3.3 5.7 5.2 17.1 3.8 5.8 5.9 5.5 3.2 5.6 7.1 2.8 6.0 6.7 2.9 5.0 4.8	12.5 13.0 5.6 11.1 13.5 6.8 12.8 8.9 10.3 5.0 12.7 8.2 2.9 1.7 3.1 4.6 2.9 12.8 15.0 4.0 7.8 5.0
Table 1. Selected crash sequences from CRASH 1999 and 2000.

1. Occupants may experience significant head accelerations without noticeable vehicle bumper damage.
2. Occupants of (target) vehicles struck from the rear undergo approximately three times the amount of force acting on the cervical spine, compared with occupants of striking (bullet) vehicles.
3. Vehicle speed changes are not linearly associated with occupant head accelerations.
4. In rear-impact collisions, females (or smaller persons) generally experience greater resultant head acceleration than do males (or larger persons).
5. Most vehicles tested have been able to withstand impacts resulting in delta Vs in excess of five miles per hour without noticeable vehicle bumper damage.
6. Occupants who are aware and braced in rear-impact collisions experience significantly less head acceleration and less violent neck kinematics than do unaware and unbraced occupants.

The crash tests are carried out in a precise manner, utilizing established engineering practice. Institutional review board approval for human subject research is granted prior to testing in accordance with the Helsinki Doctrine. The informed and consenting human subjects (male and female) are instrumented with accelerometers, and then individually placed in instrumented crash test vehicles. Occupant accelerations are recorded for the head, thorax, and lumbar spines. Forces and moments can be calculated based on head accelerations and the principles of dynamics. Vehicle accelerations, closing velocities, and speed changes are recorded. Volunteers are subjected to rear, frontal and side-impact crashes, most of which are conducted in the "unaware" mode (subjects had no visual clues as to the time of impact and are distracted with loud music played through earphones). A few are in the "aware" mode, in which the subjects are allowed to brace for the impact. The data from a portion of the total number of crashes conducted in 1999 and 2000 is shown in Table 1.
One of our major purposes for this crash series was to compare the occupant kinematics and forces between the bullet and target vehicles. The same instrumented subjects underwent crash sequences with the same speed changes in the same vehicles under bullet and target conditions. Based on the recorded data, as well as observation of high-speed video, it is clear that the occupant kinematics and forces are dramatically different between the two crash conditions: being rear-ended is much more traumatic than rear-ending another vehicle when the subject, vehicle, and speed change are held constant.
This also addresses the common question: "How come it's always the guy in the front car who gets hurt?" A good example of this event is evident when comparing crash 9 (00) of Table 1, a frontal impact involving a female subject with a delta V of 7.1 mph and 4.6 g head acceleration; with crash 12 (00), a rear impact involving the same female subject with a 6.7-mph delta V and a remarkable 15g head acceleration.
We previously indicated that speed changes are not linearly associated with occupant head accelerations. Again, refer to Table 1, and compare crash 15 (99), a 17.1-mph delta V and 10.3g head acceleration, with crash 2 (99), where the subject experienced more significant head acceleration at only 5.2 mph delta V. The higher-speed crash test resulted in very significant crush damage to both crash test vehicles. This increased the duration of the high-speed crash test, and the resulting head acceleration to the driver of the bullet vehicle was relatively lower. Our findings in this area would be vital to present to attorneys, claims adjusters, and juries in certain real-world cases.

Another interesting finding is that multiple crash sequences can be performed within the crash metrics corridor, of which the upper boundary is generally held to be above the level that could produce injuries to human subjects (i.e., 5-mph delta V) without causing significant damage to the test vehicles. This is consistent with most of the other reported crash testing in the literature. Several of these nondamaging crash sequences are at closing speeds of nearly 10 mph. These observations are significant in light of the common myth that one can predict occupant injury from examining the vehicle damage, or that the absence of property damage is a reliable indication that the crash speeds must have been below the published bumper ratings. As a matter of fact, we exceeded these bumper ratings in nearly every test.

We also noticed that volunteers frequently reported that their heads did not make contact with the head restraints, usually after the first run, and sometimes even after the second, even though the head does make contact, which is quite obvious to the onlookers. It's not clear at this point why this rather abrupt contact is not registered by the volunteers. This phenomenon is also frequent among whiplash patients, and defense experts often use the argument that since the occupant doesn't report (or recall) striking the head restraint, it implies that no contact occurred. If that were the case, the collision would have been at a very low speed. Following this line of reasoning, the neck would not have been exposed to injurious forces.
Rear-impact crashes involving females demonstrated that they react more violently with the seat back than males. Crash 12 (00), which was a female volunteer, demonstrated the highest head acceleration of any on the entire table. Research done by Siegmund, et al.,¹ found similar kinematic differences between female and male volunteers.
Finally, compare the head accelerations of crash 5 (01), an unaware and unbraced volunteer, with crash 6 (01), the same volunteer who was aware and braced for the impact. Awareness and bracing obviously have a significant effect on head and neck kinematics in rear-end collisions. A number of other researchers have found that injury is less likely when occupants in a rear-impact collision are braced. Ryan, et al.,² found that unaware patients were 15 times more likely to have long-term pain. Consequently, this would be an important question to ask whiplash patients during the history portion of their examination.

CRASH has become an annual event, with our fourth program fast approaching in August. This year, in addition to human subjects, we will have a new RID II alpha crash-test dummy provided by First Technology in Plymouth, Michigan. We will then be able to place human volunteers in the seat next to the RID II alpha and compare the resulting accelerometry and kinematic data to help validate the dummy's biofidelity. As in previous years, qualified participants will be able to take advantage of the low-speed rear-impact crash (LOSRIC) reconstruction certification program offered in conjunction with CRASH 2002.

References

1. Siegmund GP, King DJ, Lawrence JM, Wheeler JB, Brault JR, Smith TA. Head/neck kinematic response of human subjects in low-speed, rear-end collisions. SAE Technical Paper 973341, 1997;357-385.
2. Ryan GA, Taylor GW, Moore VM, Dolinis J. Neck strain in car occupants: injury status after six months, and crash-related factors. Injury 1994;25(8):533-537.

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