More on Croft Guidelines for Whiplash Treatment in Baltimore, MD

More on Croft Guidelines for Whiplash Treatment in Baltimore, MD

In my last blog post I referenced the Croft Guidelines. These are industry accepted guidelines for the length of treatment usually required by people involved in auto accidents that are injured and require auto accident treatment (in Baltimore and across the country). Dr. Croft notes that no two people are the same, so it is acceptable to deviate from these guidelines if need be, but in general they should be adhered to. Once patients begin requiring treatment in excess of the Croft Guidelines it is generally a good idea to get a medical specialist on board to co-treat the patient.

Dr. Croft classifies injury severity into 5 different categories and then gives treatment guidelines depending upon which category a patient falls into:

1. Grade 1: Minimal Severity. No limitation in ROM, no ligamentous injury, no neuro findings

2. Grade 2: Slight Severity. Slight limitation in ROM, no ligamentous injury, no neuro findings

3. Grade 3: Moderate Severity. Moderate limitation in ROM, some ligamentous injury, possible neuro findings

4. Grade 4: Moderate-to-Severe. Limitation in ROM, some ligamentous injury, neurological findings present, probable hard tissue damage (fracture) and/or disc derangement

5. Grade 5: Severe. Requires surgical management/stabilization.

Of note, I would say that the vast majority of Baltimore auto accident injuries present with severity grades 1-3, with grade 2 being the most common.

Using these grading classifications Baltimore auto accident chiropractors such as myself can put together an effective treatment plan for recovery and can keep in mind how much time and treatment may be required.

If you look at table 12.3 here you will see that even patients with grade 1 injuries that have No ROM limitation, no ligamentous injury and no neurological findings still fall into the category of allowing for daily care for a week, 3x/week for 1-2 weeks, 2x/week for 2-3 weeks, 1x/week for less than 4 weeks for a total treatment duration of less than 11 weeks with 21 or fewer total treatments.

Although the research by Dr. Croft and his colleagues dictate that even grade 1 patients may require treatment of around 11 weeks duration, it is interesting to note that most third party payers (insurance companies) generally look to disallow care following 12 weeks, thinking that “everyone is healed by then.” I can tell you from my 5 years experience treating auto accident patients (of which I have seen more than 1000 different cases) in Baltimore and Las Vegas that it is not the case. Often the Croft Guidelines are a useful tool to reference to justify to insurance companies the need for continued care for my patients.

If you, or someone you know, has suffered from a Baltimore auto accident and has experienced whiplash and want help to recover, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Croft Guidelines for Whiplash Treatment in Baltimore, MD

As a Chiropractor that spends many hours a week treating patients involved in Baltimore car accidents resulting in whiplash, I often get asked how long any given patient should expect to take to recover from their injuries. Asked another way, patients often want to know how long they should expect to need treatment for their injuries. It is a fair question, since many patients end of missing time from work and leisure activities in order to present for treatment. Unfortunately there is no simple answer to that question. As we have seen in past blog posts, every patient undergoes unique loading mechanisms during Baltimore auto accidents and has different relative risks of injury. As such, it should stand to reason that some patients might not get hurt at all, while others can suffer with debilitating injuries that take weeks or months to heal, while others never fully heal.

Fortunately there is a professionally accepted standard for treatment of whiplash patients that helps to grade the severity of the patient’s presentation. These guidelines are then useful in predicting how long a patient should be under care in order to reach maximum therapeutic benefit (or referred to as maximum medical improvement, MMI).

Keep in mind a few things here:

1) A patient’s ability to return to work, depending on what they do for a living, can occur prior to their being “healed.” I often release patients to work at either light duty or even full duty even while they are having pain.

2) Patients that feel better and have no pain are still healing even after I dismiss them from care. The healing process takes months to years for new connective tissue to effectively replace old, torn, injured tissue. This is why we see patients involved in multiple auto accidents often having more severe symptoms if their second crash occurs in quick succession to the first.

3) Not every patient fits into this guideline. Some patients can be outliers to this guidelines and may require MORE or LESS care, depending on their specific health characteristics and comorbid conditions.

For a link to the croft guidelines, click here.

In future blog posts I will discuss more in depth the different classifications associated with the croft guidelines and which classifications usually present in a chiropractic office.

If you, or someone you know, has suffered whiplash injuries as a result of a Baltimore auto accident please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Determination of Causation of Intervertebral Disc Injuries Following Baltimore Auto Accidents

As a Baltimore Chiropractor that routinely treats patients involved in Baltimore auto accidents, I am often called upon to determine causation of injuries. That is, I need to determine do a reasonable degree of medical probability whether or not a patient’s symptoms are causally related to a Baltimore auto accident. In the state of Maryland, the threshold of certainty is 51%. In other words, based upon the patients history, physical examination and objective evaluations (x-ray, MRI, etc), I have to be 51-100% sure that the patient’s complaints (whiplash, headaches, neck pain, back pain, etc) are causally related to the Baltimore auto accident. Clinically I am not concerned about causation, as it is my duty to treat a patient’s symptoms. However, medico-legally the determination of causation is extremely important when assigning fault or financial culpability for an injury.

The issue of clinical causation comes up a lot in my clinical practice. Typically an injured patient claims that part or all of their complaints are causally related to their Baltimore auto accident while the adverse (at-fault) insurance company claims that my patient is either not injured or that their injuries predated the Baltimore auto accident.

Fortunately a well respected researcher, Michael Freeman PhD, combed the literature to determine the appropriate systematic guidelines to make such a determination. A link to his study can be found here.

Mr. Freeman determined that for a clinician to draw causality three criteria must be met:

1. Biological plausibility– There must be a possible link between an injury and a Baltimore auto accident. A Baltimore auto accident could plausibly cause an injury to the spine including the intervertebral discs, but it is not likely that it can cause cancer.

2. Temporal relationship– The outcome (injury) can not pre-date the auto accident (with the exception of pre-existing degenerated non-symptomatic disc injuries which are beyond the scope of this blog post) AND the outcome can not unreasonably post date the auto accident (It is not plausible to relate neck pain 6 months after an auto accident if it did not show up sooner).

3. A lack of a more likely or probable alternative explanation for the symptoms– A patient who is obese but has no signs of prior back pain can not have their obesity blamed for their back pain if the pain first presents following a Baltimore auto accident.

Mr. Freeman concludes that “when using these guidelines in a narrative report setting, the clinician can write that the essential causal elements of biologic plausibility, temporality, and lack of likely alternative explanation have been met for a give case…and that a particular symptomatic disk injury resulted from a particular motor vehicle crash, as a reasonable medical probability.”

Disk injuries are very common injuries following Baltimore auto accidents. It is imperative that any provider understand how to appropriately diagnose and causally relate these injuries, as it affects the ability to properly treat these injuries and bring about symptomatic relief for patients.

If you, or anyone you know was involved in a Baltimore auto accident and have suffered from intervertebral disc injuries, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

Dr. Gulitz

Seat Belt Induced Injuries in Baltimore Auto Accidents

Believe it or not, wearing a seat belt can actually cause injuries if you are involved in a Baltimore auto accident. Don’t get me wrong- this is not a license to unbuckle and drive without a seat belt harness. Seat belts were invented to prevent catastrophic injury and ejection from a vehicle and should be worn any time an occupant gets behind the wheel. Interestingly, the forces that restrain an occupant and prevent ejection can be the cause of other lesser seen injuries in the cases of Baltimore auto accidents.

One of the most important indicators to the possible presences of these seat belt injuries is what is referred to as “seat belt sign.” This is the presence of an abrasion (redness, scraping) located over the abdomen, pelvic region, neck, or breasts (or anywhere a seat belt is worn).

In children the presence of seat belt sign may indicate a SCIWORA injury. This stands for Spinal Cord Injury Without Radiographic Abnormality. Admittedly, I have never seen it in my 5 years of clinic practice to date. During the deceleration phase of the rear-end whiplash injury internal organs can sometimes get compressed between the seat belt and the spine causing organ damage and even dislocation of spinal segments. This can cause severe compression to the spinal cord that can be missed on standard radiographic (x-ray) examination. Presence of a seat belt sign in children should warrant further abdominal MRI in children and may prompt an MRI to rule out SCIWORA.

In addition to the lap belt causing injury, the shoulder harness can injure an occupant as well, depending on where it contacts the neck of an occupant. This is also especially true when the webbing lays across a child/young adult’s neck rather than their chest. This is seen when the webbing is not adjusted to an occupants height appropriately. It can cause seat belt sign on the neck which can indicate damage to the vascular structures of the neck. Most notably, it can cause compression and tearing of the carotid and/or vertebral arteries. Careful evaluation may include doppler ultrasound to the affected structures or MRA evaluation. The discussion of MRA evaluation is beyond the scope of this blog post. Please contact me if you want more information.

Finally, women are especially susceptible to seat belt sign following a Baltimore auto accident as well. Due to the anatomy of their breasts, they can develop seat belt sign across their breasts. In some cases this can cause break down of fatty tissue in the breast region, known as traumatic fat necrosis. This can lead to a change in the shape and look of their breast tissue. There has been some research indicating that this can lead to breast cancer, although research in that category is not conclusive at this time. Additionally, women who have artificially augmented their bosoms can suffer from a traumatic capsulotomy where their augmented breasts begin to display asymmetry following a whiplash injury or where their breast implants actually get punctured as a result of a motor vehicle collision in Baltimore.

Once again, these seat belt signs are certainly not very common and even when present, do not necessarily indicate internal damage as described above. I always tell patients that they know their body better than I do and that if they suspect there may be internal damage that they should talk to their providers about having more thorough examinations be performed.

If you, or anyone you know, has suffered from an auto accident in Baltimore and have seat belt sign or other forms of whiplash, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help!

The preceding information was found in the book “Whiplash and Mild Traumatic Brain Injuries” by Dr. Arthur C. Croft (pages 202-203.)

Dr. Gulitz

Neck Exercises Following a Baltimore Auto Accident

As a chiropractor that routinely treats patients with neck pain following Baltimore auto accidents, it is not uncommon for me to treat patients with a combination of both joint and muscle pain and dysfunction. Traditionally Chiropractors have been thought of as providers that only engage in only passive therapies- that is treatment where a patient has the therapies done TO them, instead of by them. To some degree this is true. I offer patients electrical muscle stimulation, ultrasound, intersegmental traction, and even spinal manipulation which are all passive modalities. Research has shown that in addition to passive treatments, more active treatments such as muscle stretching and resistance exercises help patients to decrease pain, increase ranges of motion, and decrease healing time. More interestingly, the faster a patient resumes active therapies following their injury, the faster they heal.

At Mid-Atlantic Spinal Rehab & Chiropractic we offer both passive and active modalities to help our injured patients heal from whiplash following Baltimore Auto Accidents.

Assuming that a patient has an injury to the joints and muscles of their neck, lets take a look at a few exercises we would likely have them perform in the office. Keep in mind- no two patients are the same and some patients may require additional or different exercises depending on their specific condition and injury. These exercises are to be considered a guideline for neck stretching. Please contact me or another healthcare professional if you have questions before performing any of these stretches on your own.

1. Side Bending Stretch (Lateral Flexion). A link can be seen here. You lean your ear to your shoulder as far as you can. Make sure to repeat both sides and not push past perception of pain.

2. Turning Stretch (Rotational Stretch). A link can be seen here. You turn your chin towards your shoulders as far as you can. Make sure to repeat both sides and not push past perception of pain.

3. Chin out/Chin Back (Protraction/Retraction Stretch). A link can be seen here. You “jut” your chin forward and bring it back (think about making a “double chin”), paying particular attention to not extend your neck. Typically extension will bother your condition following whiplash, although this is not always the case.

4. Isometric Resistance Stretching. A link can be seen here. This is the addition of light resistance, either by utilizing a hand, a towel, or a small ball to engage muscles actively while restricting joint motion. These are considered a progression over the first three stretches we discussed and should be worked up to over time.

If you, or someone you know, has suffered whiplash and has neck pain as a result of a Baltimore Auto Accident, please contact Mid-Atlantic Spinal Rehab & Chiropractic at (443) 842-5500. We would be glad to help.

Dr. Gulitz