So, you want to treat patients that have suffered a cervical acceleration/deceleration (CAD) trauma. Then you must learn to examine and treat a CAD injured person properly and with the proper tools. First of all, if you have never treated these types of injuries before, then you should arm yourself with the knowledge of the etiology of CAD trauma. Courses like those given by Dr. Arthur Croft (CRASH) and Dr. Dan Murphy (CCST) can help you understand the mechanics behind the injury. But this, alone, won’t help you. Imagine that you have a real-life patient that is hurting in front of you and you need to evaluate that patient in such a way that you take that patient’s subjective symptoms and turn them into objective evidence—FACTS, the type of facts that a jury can understand and use in order to make an informed verdict.
Let’s take a look at a typical CAD injury evaluation. It looks like this in its simplest form:
HISTORY EVALUATION DIAGNOSTIC TESTING
According to the above examination flow chart, the doctor takes the history of the injury and records the appropriate responses that lead to the mechanism of injury. The history should focus on the patient’s past and current history so that the doctor can apply the latest evidence in the form of research studies to formulate the answer to questions on whether or not this injury could have happened—questions that relate to prior accidents, size of vehicles, seatbelts on/off, loss of consciousness, etc.
The doctor then performs the standard cervical evaluation by performing the needed orthopedic examination, neurological examination, ROM and muscle tests. This paints a picture as to how the patient was doing physically when the patient was initially examined. However, the examination process is very subjective and should not stop there. The doctor should take the subjective examination results and examine them in an objective manner by utilizing diagnostic tests.
All of the subjective complaints and tests that were found during the evaluation process need to be evaluated by utilizing diagnostic tests. The diagnostic tests that are chosen should be reliable and reproducible for what they are examining. For instance, the Guides to the Evaluation of Permanent Impairment, 5th edition, (AMA Guides), states that ROM testing should be evaluated utilizing dual inclinometry. Dual inclinometry is the most accurate and reliable means to perform ROM tests. The research literature also states that computerized duel inclinometry is the gold standard along with computerized muscle testing.1,2,3 Diagnostic tests then serve two purposes. Firstly, diagnostic tests are able to document the injury of the patient and, secondly, they are able to provide information that can be readily retested so that the doctor can prove whether or not the patient is improving, staying the same or getting worse. The subjective complaints and the diagnostic tests that should accompany them are listed in Table 1.
| Subjective Complaint
||Diagnostic Tests That Should Accompany Them|
|Pain||OA Questionaires (Oswetry, Neck Pain, Roland Morris, VAS, Headaches Disability Index), Pain Presure Treshold Testing (Algometry)|
| NCV testing, EMG testing, DSEP Testing
| Disc Lesions
| Loss of Range of Motion
| Loss of strength
|| cMT Testing
Questionnaires provide a reliable means of documenting the patient’s level of pain and its impact on their activities of daily living (ADL’s).4,5 Questionnaires such as the Neck Pain Disability Index and the Rand-36 should be utilized. Even though they are considered to be subjective, they are a high form of subjective data. So high, in fact, that insurance companies such as United Healthcare with ACN require that the patient complete a health-oriented questionnaire to pre-authorize care and every time there is a request for more visits.
Nerve conduction velocity (NCV), electromyography (EMG), and dermatomal somatosensory evoked potential (DSEP) testing provide a valid and reliable means of documenting the patients neurological pain.6 The AMA Guides place objective neurological findings in a DRE Category III 15-18 percent Impairment of the Whole Person (AMA Guides Table 15-5). Foreman and Croft place the patient in a Grade III Major Injury Category (MIC) when there are neurological findings present. This is significant, because the treatment recommendations for a patient in a Grade III MIC are seventy-six visits or more. Therefore, the significance of performing neurological tests and other diagnostic tests on your patients goes beyond your simply evaluating the patient. You are able to create an objective treatment plan, a treatment plan that is not based on your opinion but based on the objective data and placed in a set of guidelines (Whiplash Injuries, 3rd edition, by Foreman and Croft).
MRI studies are very useful in evaluating the patient for disc lesions. Computed tomography (CT) is very useful in evaluating the skeletal structures for fractures, especially those that are missed by radiographic analysis. MRI studies that demonstrate a herniated disc at the level and on the side that would be expected for a subjective radiculopathy equates to a DRE Category II 5-8 percent Impairment of the Whole Person, according to Table 15-5 of the AMA Guides.
Computerized range of motion testing (cROM) is very useful in determining the degree of the loss of cervical function. ROM testing is able to reliably indicate a physical impairment in people suffering from chronic whiplash.2
Computerized muscle testing (cMT) is an excellent way of determining a loss of muscle function, because it is not based on a subjective standard. In order to reliably determine that a patient has a decrease in muscle strength, the patient must have at least a 35 percent loss in strength. This means that a doctor would not be able to reliably determine a loss in strength if it is only a 25 percent loss. Muscle strength should be compared from left and right measurements and they should not exceed more than 10 percent.
Radiographs should be taken and then digitized to examine for motion segment integrity loss (MISL) as defined by the AMA Guides. The AMA Guides state that the only way to evaluate a patient for MSIL is by utilizing the flexion/extension films and measuring for an increase in translational or rotational movement. Translation and rotation are biomechanical terms. Translation is movement of a body in straight line and should not exceed 3.5mm in the cervical spine. Rotation is defined as movement of body about a fixed point and should not exceed 11 degrees in the cervical spine (AMA Guides Table 15-5). These are significant findings according to the AMA Guides because, if the patient has MSIL, as defined by the flexion/extension radiographs, then the patient is placed in a Category IV 25-28 percent Impairment of the Whole Person. This equates to the same thing as a greater than 50 percent compression fracture of a vertebral body. What does this mean clinically? It means that you would not adjust someone at C5 if they had a 50 percent fracture of the C5 vertebrae and, therefore, you should not adjust someone that has an increased motion segment at C5 either. The only objective way to determine the MSIL is by having the radiographs digitized. This allows an outside source to determine the injury and how bad that injury is. If the defense attorney tries to refute the findings, he looks very incompetent in front of the jury because he is arguing against the facts.
As you can imagine, the jury likes to have concrete facts of the case to make an informed decision. This is why shows like CSI are very popular right now. For those of you that get frustrated at the thought of treating personal injury cases, it’s probably due to the fact that you are not collecting all of the objective evidence and providing only subjective data to the attorneys. Give the plaintiff’s attorney facts to argue with, not opinion. Believe me, there will be enough opinions flying out of the defense attorney. Get the equipment that will objectively gather the data, like computerized ROM testing and computerized muscle testing and algometry. The proper treatment protocols for treating CAD injuries can be found in Foreman and Croft’s, Whiplash Injuries, 3rd Edition, and the AMA Guides, 5th Edition. If you are not following the protocols set forth in these two texts, you are going to become increasingly frustrated. A very good friend of mine once stated, “Learn the rules, play by the rules, and win by the rules.”
Dr. Dwight C. Whynot is in fulltime practice in Johnson City, Tennessee. Dr. Whynot gives license-renewal lectures on Evidence-Based Chiropractic Practices which are promoted by the International Chiropractors Association and sponsored by Myologic and Spinal-logic Diagnostics. For questions regarding evidence-based practice procedures, email questions to [email protected]
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