CTI – WTF?

WHY CTI -In 2003 the first PAF was introduced. It was revised in 2005 and re- introduced in Prior to 2010 all non-cat claimants were eligible to receive up to $100k in med-rehab benefit to the extent that the PAF was not successful in addressing the symptoms. -In 2010 MIG was instituted limiting med-rehab funding to $3500 over a 12- week period if definition was met. -MIG was introduced as an interim measure to be replaced with a permanent evidence-based protocol in the future. -In July 2012 Dr. Cote was hired to initiate the process of redefining MIG.

The Process -Dr. Cote hired to head the project team to come up with the following: -Review evidence-based research of regular MVA treatment protocols. -Development of a clinical prediction tool to be used by claimants and insurers to screen for clients who may be at higher risk to develop chronic pain and disability. -Develop a traffic injury protocol for incorporation by FSCO for the treatment of traffic injuries based on best evidence as identified through research.

The Process -The Core Scientific Team to oversee work of the Technical Team -Consists of 9 individuals including: 5 epidemiologists, 1 researcher, 1 physiatrist (Emeis), 1 chiropractor and 1 rehabilitation scientist. -Technical Team -Consists of 13 individuals who conducted the actual research and administrative activities. -This team is assisted by 14 graduate students who were recruited to help. -Claimant pool – 11 current participants in MIG treatment were interviewed.

Injury Classification -MVA injuries were classified into three groups: -Type I injury characterization: -Injuries have favorable natural history of recovery ranging from days to months. Including: NAD I-III, Grade I-II sprains, strains of spine and limbs, traumatic radiculopathies, mTBI, post traumatic psychological symptoms such as anxiety and stress. -According to the study the impact of the most effective treatments is “modest” and “many commonly used interventions provide no more benefit than sham or placebo”

Injury Classification -MVA injuries were classified into three groups: -Type II injury characterization: -Involve a substantial loss of anatomical alignment, structural integrity, psychological, cognitive and/or physiological functioning. -Majority of patients with such injuries will require a significant amount of medical, surgical, rehabilitation, and/or psychiatric/psychological intervention. -This would include fractures, dislocations (complete and incomplete), depression and PTSD. -Type III injury characterization: -Basically Catastrophic injuries. -Care for Type II and III type injuries is not covered within this report.

The high-level conclusion: “A Type I injury is likely to recover within days to a few months of the collision; but during the period of recovery the patient may benefit from education, advice, reassurance and time-limited evidence-based clinical care.“ “In the general population of those with traffic-related NAD, recovery appears to take between 3 and 6* months, depending on the criterion used to indicate recovery. There is strong evidence that a history of traffic-related NAD increases the risk of future neck pain, and that high level of health care utilization in the first weeks after the collision is associated with poorer recovery. There is also strong evidence that post-collision psychological factors are associated with poorer recovery. These factors include injured persons having poor expectations about recovery; having a poor pain coping style; having high levels of post-collision fear, anxiety, anger and/or frustration related to their pain; and having post-collision depression/depressive symptoms.” * Note that in another place the following note was: “In the general population of persons with traffic-related NAD, half recovered between 3 months and 6 months”.

The high-level conclusion: “A Type I injury is likely to recover within days to a few months of the collision; but during the period of recovery the patient may benefit from education, advice, reassurance and time-limited evidence-based clinical care.“ Recommendations in research included: Advice, education and reassurance be offered to patients to manage whiplash-associated disorders, anxiety and mild traumatic brain injuries; Exercise, return-to-activity, mobilization/manipulation, and analgesics be used to manage whiplash-associated disorders; Collars should not be used to treat whiplash-associated disorders; Support (e.g. provide comfort, information, and give opportunity to discuss the experience), pharmacotherapy and cognitive behavioural therapy be used as first-line interventions for anxiety; Patients with mild traumatic brain injuries be monitored for complications and provided advice (about common symptoms and strategies to manage symptoms and resume activities) upon discharge from the emergency room; Patients with mild traumatic brain injuries be followed every 2-4 weeks until symptom resolution/ reassessment; Patients with mild traumatic brain injuries should be referred to a specialist if symptoms persist for more than three months.

Resulting pathways: -Clinical Management of Neck and Associated Disorders (NAD) -Clinical Management of Persistent Headaches Associated with Neck Pain -Clinical Management of Soft Tissue Disorders of the Upper Extremity -Clinical Management of Soft Tissue Disorders of the Lower Extremity -Clinical Management of Temporomandibular Disorders -Clinical Management of Mild Traumatic Brain Injury -Clinical Management of Low Back Pain with and without Radiculopathy

The FSCO Guideline: -Has been published in draft form only in July. -Consultation with stakeholders was held in August. -Feedback with respect to the FSCO Guideline and CTI report will be considered in a future release of the final guideline.

CTI Definition: Physical impairments: grades I, II and III (cervical radiculopathy) neck pain and its associated disorders (NAD); headaches associated with neck pain; thoracic and lumbar spine pain; thoracic radiculopathy and lumbar radiculopathy (nerve root injury); grades I and II girdle and limb sprains and strains and related soft tissue injuries; grades I and II sprains and strains of the temporomandibular joint and related soft tissue injuries; skin and muscle contusions; abrasions and skin lacerations which do not extend beneath the dermis; and pain associated with any of the above listed impairments.

CTI Definition: Mental impairments: mild traumatic brain injury (MTBI) (manifested as a loss of consciousness lasting less than 30 minutes after the accident, altered consciousness ≤ 24 hours after the accident, post-traumatic amnesia ≤ 24 hours after the accident, and an initial Glasgow Coma Scale of 13 to 15), with normal structural imaging, and with signs and symptoms resulting from the MTBI lasting no more than 3 months. Psychological impairments: early psychological signs and symptoms, including: depressed mood, anxiety, fear, anger, frustration and poor expectation of recovery.

Impairments That Do Not Come within CTI: An insured person’s impairment does not come within this Guideline if a health practitioner (as identified depending on the circumstances described below), acting impartially and within the scope of his or her expertise, confirms in writing and provides compelling evidence that: (a) the CTI is not the most serious impairment sustained by the insured person as a result of the motor vehicle accident OR (b) the CTI is the most serious impairment sustained by the insured person as a result of the motor vehicle accident, but the insured person: i. has any of the following conditions (which may pre-date the accident or develop during the course of treatment under this Guideline): Neurological disorder (for example, cervical spondylotic myelopathy) Autoimmune disorder with or without joint involvement (for example, Type 1 Diabetes in an uncontrolled state) Psychiatric condition (for example, active psychoses, severe PTSD) Other serious pathology (for example, active cancer) AND ii. the condition is likely to prevent the insured person from recovering if treated only under the care pathways.

Impairments That Do Not Come within CTI: Where an insured person has not received any treatment under this Guideline, the confirmation and compelling evidence referred to above must be provided by a health practitioner, as defined in the SABS, in a completed and signed OCF-18 Treatment and Assessment Plan (unless the requirement for the OCF-18 has been waived by the insurer). Where an insured person has already received any treatment under this Guideline, the confirmation and compelling evidence referred to above must be provided only by a physician or nurse practitioner in a completed and signed OCF-24 (unless the requirement for the OCF-24 has been waived by the insurer).

Healthcare professionals who can initiate: Chiropractors Dentists nurse practitioners physicians physiotherapists

Timeframe and Fees: -Up to 6 months -2 phases of 1-3 months and 4-6 months. -Treatment should correspond to time frame in the pathway. For example if a person begins treatment at 2 months post collision they can access all treatment in the first phase. However, if a person begins treatment in month 4 they can only access the second phase. -Fees are not yet published. -All EHB available to a claimant are to be deducted from the amounts payable by the insurer.