110 MVAs and MMI: How Much Is Enough?
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Dynamic Chiropractic – July 31, 1992, Vol. 10, Issue 16

MVAs and MMI: How Much Is Enough?

By Arthur Croft, DC, MS, MPH, FACO
For many of us, the issue of maximum medical improvement (MMI) is a true conundrum. This is particularly so in motor vehicle accidents (MVAs) where our patients have often been injured by a negligent driver. In the interest of fairness it would seem most reasonable to allow for indefinite treatment of an injured victim if necessary. In the real world, however, practicality dictates that at some point we make a declaration of MMI. This allows any legal remedy to come to a conclusion and all debts to be (hopefully) paid. Any awards bestowed upon an injured party should take into account the need for future medical or chiropractic care. Patients can also be treated under general health insurance policies in many cases.

Some have suggested using the term "maximum chiropractic improvement" instead of "maximum medical improvement." The difference seems nebulous to me since it presumes that patients treated by chiropractors and medical doctors improve to different degrees, and that has yet to be established (although research is currently under way). In certain settings, a certain amount of ambiguity is allowed anyway. I am a state-appointed independent medical examiner, for example.

I believe the best approach to arriving at MMI is the following: First, grade the severity of the patient's trauma using the severity scale of the SRISD classification of cervical acceleration/deceleration (CAD) trauma,1 Table 1. Next, use the potentially complicating factors in Table 2 as a guide to modify the figures in Table 3 to arrive at a reasonable treatment frequency and duration. For example, in a patient categorized as Grade III with one or two moderate complicating factors, the treatment duration will average about 56 weeks (shorter with no complicating factors and longer with more complicating factors or more severe complications).

Finally, refer to Table 4 to determine MMI. Beyond the active treatment period as suggested by Table 2, after three consecutive monthly re-exams with no further significant objective improvement (range of motion, trigger points, muscle strength, gait, antalgia, orthopedic/neurologic/radiographic signs), you should consider the patient MMI. Gradual further subjective improvement is variable.

References

  1. Croft AC: Whiplash: the Master's Program. Module I, Whiplash, an Overview. Coronado, Spine Research Institute of San Diego, p 73, 1992.

     

  2. Croft AC: Whiplash: the Master's Program. Module III, Treatment and an Introduction to TMJ. Coronado, Spine Research.

Table I

Grades of severity of CAD injury:

Grade I minimal, no limitation of motion, no ligamentous injury, no neurological findings

Grade II slight, limitation of motion, no ligamentous injury, no neurological findings

Grade III moderate, limitation of motion, some ligamentous injury, neurological findings present

Grade IV moderate to severe, limitation of motion, ligamentous instability, neurological findings present, fracture or disc derangement

Grade V severe, requires surgical management/stabilization

Adapted from reference #1

Table 2

Common factors potentially complicating CAD trauma management:

  1. Advanced age
  2. Metabolic disorders
  3. Congenital anomalies of the spine
  4. Developmental anomalies of the spine
  5. Degenerative disc disease
  6. Disc protrusion (HNP)
  7. Spondylosis
  8. Facet arthrosis
  9. Rheumatoid arthritis or other arthritides affecting the spine
  10. Ankylosing spondylitis or other spondylarthropathy
  11. Scoliosis
  12. Prior cervical spinal surgery
  13. Prior lumbar spinal surgery
  14. Prior vertebral fracture
  15. Osteoporosis
  16. Paget's disease or other disease of bone
  17. Spinal stenosis or foraminal stenosis
  18. Paraplegia or quadriplegia
  19. Prior spinal injury

Especially laminectomy and discectomy without fusion. Adapted from reference 2.

Table 3
Frequency and duration of care in CAD trauma:
  Daily 3x/w 2x/w 1x/w 1x/mos. TD TN
 
Grade I 1w 1-2w 2-3w <4w = <9w <17
 
Grade II 1w <4w <4w <4w <4 mos. <25w <29w
 
Grade III 1-2w <10w <10w <10w <6 mos. <56w <76w
 
Grade IV 2-3w <16w <12w <20w * * *
 
Grade V Surgical stabilization necessary -- chiropractic care is postsurgical
 
TD = treatment duration. = Possible follow-up at one month
TN = treatment total number. * May require permanent monthly or p.r.n. treatment
 
Adapted from reference #2

image - Copyright – Stock Photo / Register Mark

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

Editor's Note:

You can get more of Dr. Croft's helpful and educational insights from the video (with Dr. Stephen M. Foreman) "Advances in Personal Injury Practice," #V-435 on the Preferred Reading and Viewing list.

Click here for previous articles by Arthur Croft, DC, MS, MPH, FACO.

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