Utilizing the Croft Guidelines with the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition

By Gregg B. Friedman, D.C., C.C.S.P., F.I.A.C.A.

How many times do we, as chiropractors who treat people who have been involved in automobile accidents, have to deal with the “over-utilization” mantra from the insurance companies or even attorneys? Let’s say you’ve done everything right – even by the book – the AMA Guides book. You’ve done a great job of examining your patient, you’ve documented all of the objective findings and you can prove that the patient was injured and to what extent. You end up treating the patient a total of 34 times. Once you’ve released the patient from care, the opposing insurance company sends your patient to an orthopedist, or even a chiropractor, for an IME. The IME report states that your patient is fine (which is often true, since you did release him from care – unless, of course, the patient has a permanent impairment). The IME doctor goes on to say that your patient should have been well within 12 visits and that the other 22 visits were “unnecessary”. What can you show the insurance company and/or the attorney that will make them believe that you did not over treat? The IME doctors often come up with arbitrary numbers of treatment and duration of treatment that seem to come out of nowhere. How do we fight back?

Well, thanks to one of our own, Dr. Arthur C. Croft, of the Spine Research Institute of San Diego, we have some ammunition. In 1993, Croft published a set of management guidelines in the ACA Journal. These guidelines have also been published in Whiplash Injuries: the Cervical Acceleration/Deceleration Syndrome, second edition, in 1995 and in a recent Canadian practitioner’s guide to whiplash injuries, sanctioned by the Canadian Chiropractic Association.

The Croft Guidelines have been a part of our literature now for eight years. No competing guidelines relative to CAD treatment have been published during that time, with the exception of the Quebec Task Force Guidelines on WAD, but these are only applicable for patients who remain on disability. Several American state chiropractic organizations and associations, as well as in at least one Canadian province, have now adopted the Croft Guidelines.

The following is a summary of the Croft Guidelines for the Treatment of CAD Injuries. For the complete article by Dr. Arthur Croft, you may e-mail him at http://www.srisd.com.

Grades of Severity of Injury

• Grade 1 – Minimal; No limitation of motion; No ligamentous injury; No neurological findings
• Grade 2 – Slight; Limitation of motion; No ligamentous injury; No neurological findings
• Grade 3 – Moderate; Limitation of motion; Ligamentous instability; Neurological findings may be present
• Grade 4 – Moderate to Severe; Limitation of Motion; Some ligamentous injury; Neurological findings present; Fracture or disc derangement
• Grade 5 – Severe; Requires surgical management/stabilization

Guidelines for Frequency and Duration of Care in Cervical Acceleration/Deceleration Trauma

	Daily	3x/wk	2x/wk	1x/wk	1x/mo	TD	TN
Grade I	1 wk	1-2 wk	2-3 wk	<4 wk	*	<11 wk	<21
Grade II	1 wk	<4 wk	<4 wk	<4 wk	<4 mo	<29 wk	<33
Grade III	1-2 wk	<10 wk	<10 wk	<10 wk	<6 mo	<56 wk	<76
Grade IV	2-3 wk	<16 wk	<12 wk	<20 wk	**	**	**
Grade V	Surgical stabilization necessary - chiropractic care is post-surgical
TD = treatment duration; TN = treatment number * = Possible follow-up at 1 month ** = May require permanent monthly or p.r.n. treatment

Common Factors Potentially Complicating CAD Trauma Management

• Advanced age
• Metabolic disorders
• Congenital anomalies of the spine
• Developmental anomalies of the spine
• Degenerative disc disease
• Disc protrusion (HNP)
• Spondylosis
• Facet arthrosis
• Rheumatoid arthritis or other arthridities affecting the spine
• Ankylosing spondylitis or other spondylarthropathy
• Scoliosis
• Prior cervical spinal surgery
• Prior lumbar spinal surgery
• Prior vertebral fracture
• Osteoporosis
• Paget’s disease or other disease of bone
• Spinal stenosis or foraminal stenosis
• Paraplegia or quadriplegia
• Prior spinal injury

So let’s put this all together. If we see a patient in our office that has been involved in an automobile accident, we first need to do a consultation. Next, we perform an examination on the patient, based on the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition. That means that we have the patient complete Activity of Daily Living Questionnaires, such as the Neck Pain Disability Index Questionnaire, the Roland Morris Acute Low Back Pain Index Questionnaire or the Oswestry Chronic Low Back Disability Index Questionnaire, and the Rand 36 Item Health Survey. We then measure the patient’s spinal range of motion, preferably using inclinometers, test for muscle strength and take x-rays, including flexion and extension views, to determine if there is loss of motion segment integrity or not (ligamentous instability). Once we have determined how severely the patient was injured, we take a look at the Croft Guidelines and see where the patient falls. When patients have more risk factors or complicating features, they are more likely to need treatment reaching to the end of the guidelines. If they have a lot of complicating factors, of course, they may exceed the guidelines and, in some cases, the guidelines simply can't be applied. The guidelines are not about permitted treatment periods. They should also not be considered a license to treat or a justification to treat. It all boils down to the individual patient. If the patient has symptoms and is responding to care, then treatment is appropriate. If not, treatment is not appropriate--even when it would fall within the temporal or frequency parameters of the guidelines.

When the IME doctor challenges our treatment frequency and duration, we simply cite the Croft Guidelines. Now they are on the defensive. All they have to do is show us from where they got their information stating that our patient only needed 12 visits – I’m afraid that will be quite a challenge for them.

This is just what the chiropractic profession has needed. Finally, we have the AMA helping us out, telling us basically how to examine patients who have been victims of a traumatic injury, like a car accident. Dr. Croft gives us some guidelines for how many treatments and for what duration a patient should be treated, based on various injury severity factors. The pieces of the puzzle are finally coming together. Information such as this is what will help propel chiropractic into the forefront of healthcare for generations to come.

Please feel free to contact me at: drgregg@Myo-Logic.com