BACKGROUND: INCEPTION OF THE MINOR INJURY TREATMENT PROTOCOL PROJECT (MITPP)
The FSCO Superintendent’s 2009 Five Year Review recommended the development of a minor injury treatment protocol that reflected current scientific and medical literature. [1] This recommendation was accepted by the Ontario government and confirmed in the 2012 Budget. [2]
Dr. Pierre Côté was awarded the consulting contract to spearhead the development of a new Minor Injury Treatment Protocol. Dr. Côté is an Associate Professor in the Faculty of Health Sciences at the University of Ontario Institute of Technology.
The team that was assembled to develop the new protocol is known as the Ontario Protocol for Traffic Management (OPTIMa) Collaboration. This multidisciplinary team of practitioners, academics, scientists, insurers, a retired judge, a patient liaison, and a consumer advocate, produced a report entitled “Enabling Recovery From Common Traffic Injuries: A Focus on the Injured Person,” which contains a number of minor injury treatment protocols for various types of injuries.
The Final Report (CTI Report) was delivered to FSCO in December 2014 and released to the public in mid-2015. [3] It is lengthy, numbering 279 pages and referencing voluminous background material.
FSCO invited feedback on the CTI Report addressing its impact on individual stakeholders. [4]
THE CTI REPORT: ENABLING RECOVERY FROM COMMON TRAFFIC INJURIES
The CTI Report addresses and outlines science-based treatment for “common traffic injuries”. The OPTIMa Collaboration was tasked with developing “Care Pathways” to promote recovery from common traffic injuries. [5] These take the shape of clinical practice guidelines that form the bulk of the CTI Report. These Care Pathways or guidelines cover the following injury types:
- neck pain and associated disorders;
- headaches associated with neck pain;
- soft tissue disorders of the upper extremity;
- soft tissue disorders of the lower extremity;
- temporomandibular disorders;
- mild traumatic brain injury; and
- low back pain with and without radiculopathy.
The “common traffic injury” classification was adopted to replace the term “minor injury”, which the Collaboration viewed as inappropriate. It reached this conclusion after canvassing a small number of injured persons with minor injuries, inviting comments on the terminology.
In a further movement away from the “minor injury” terminology, the CTI Report proposes a new categorization of motor vehicle accident injuries into one of three categories: Type I; Type II; or Type III.
Type I injuries roughly encompass today’s concept of minor injuries, but notably explicitly include traumatic radiculopathies, mild traumatic brain injuries, and post-traumatic psychological symptoms such as anxiety and stress. [6] The Report acknowledges that a small number of patients with these injuries will experience residual problems over time and develop chronic and more widespread pain, regardless of intervention. [7]
Type I injuries are comprised of three subcategories: [8]
- Physical impairments: grades I to III NAD; headaches associated with neck pain; non-specific thoracic and lumbar spine pain, thoracic and lumbar radiculopathy [nerve root injury]; grades I and II girdle and limb sprains and strains; grades I and II sprains and strains of the temporomandibular joint; skin and muscle contusions, abrasions and skin lacerations (which do not extend beneath the dermis).
- Mental impairments : concussion/mild traumatic brain injury as defined by the American Congress of Rehabilitation Medicine (MTBI is defined by loss of consciousness of less than 30 minutes, with altered consciousness < 24 hours, and post-traumatic amnesia < 1 day, and a Glasgow Coma Scale of 13 to 15) and normal structural imaging.
- Psychological impairments : “early” psychological signs and symptoms that include poor expectations of recovery, post-collision depressive symptomatology, fear, anger and frustration.
By contrast, the current “minor injury” definition covers sprains, strains, whiplash associated disorder, contusions, abrasions, lacerations or subluxation and any clinically associated sequelae. Though the inclusion of “clinically associated sequelae” and the ambiguity of this term broadens the existing definition, it appears that the new “common traffic injuries” or Type I injuries concept covers more injuries than the current minor injury definition, most notably by the explicit inclusion of some mental and psychological impairments.
Type II and III injuries are not dealt with in the CTI Report, but roughly correspond with what today would be referred to as non-minor and catastrophic injuries, respectively. In more technical terms, the CTI Report defines Type II injuries as typically involving a “substantial loss of anatomical alignment, structural integrity, psychological, cognitive, and/or psychological functioning.” By way of example, the Report states that depression and PTSD, among many other injuries, fall into this category.
SUBMISSIONS OF VARIOUS STAKEHOLDERS
It appears that consultations between FSCO and various stakeholder groups have occurred. A number of stakeholders have also taken the opportunity to provide submissions on the CTI Report and a draft CTI Guideline.
Concerns regarding the CTI definition
First, there are concerns about the terminology used in the new CTI definition and the definition itself.
The inclusion of “early” psychological signs addresses the MIG’s silence on psychological issues, but falls under scrutiny. Some stakeholders argue that this terminology is confusing, particularly when diagnosis of such symptoms and their severity relies heavily on subjective judgments and self-reporting. Others suggest avoiding reference to potentially confusing terms that might imply a diagnosed disorder, such as “depression”, “anxiety”, and “post-traumatic stress”. [9]
Second, and predictably so, there is disagreement from stakeholders as to what injuries should and should not be included in the Type I category. As noted above, the CTI definition appears to be a broadening of its minor injury predecessor.
Some psychological practitioners suggest that psychological, mental and behavioral disorders should be considered Type II injuries. [10] Notably, the inclusion of depression and PTSD in Type II, two frequently disputed issues between claimants and insurers, is furthermore likely to continue to generate disputes.
Other practitioners point out that traumatic radiculopathies can have different courses of care and if neurological signs outweigh musculoskeletal symptoms, such an injury should not be considered Type I. [11] These same practitioners do not support the inclusion of minor traumatic brain injuries in Type I. [12]
The definition of Type II injuries appears to suggest that Type I injuries could become Type II if they persist beyond six months, thus escaping the CTI financial limits. [13] Notably, the CTI financial limits have yet to be discussed and agreed upon, and are likely to generate further criticism from stakeholders.
Concerns regarding the OPTIMa Collaboration’s methodology and the nature of the Care Pathways
Some stakeholders have argued that the research of the OPTIMa Collaboration did not account for cumulative effects of multiple injuries, particularly with respect to recovery time, response to treatment, and risk factors, and how these may impact the recommended Care Pathway or treatment protocol. [14]
There have also been concerns expressed about the allegedly disproportionate composition of the professionals on the MITPP teams and the minor injury clients they consulted. Some stakeholders note that these teams featured a large number of chiropractors and clinicians specializing in insurer examinations, with no representation from, for example, speech language pathologists, social workers, psychologists or clinicians that carry out treatment. [15] Others add that there was a notable lack of consultation with broader clinical and academic communities before finalizing the CTI Report and the treatment protocols contained therein. [16]
Some practitioners criticize the Care Pathways as being overly directive, noting that the options within certain Pathways are very limited. [17] Others consider it troubling that occupational therapists are left off the list of permitted initiating and coordinating health professionals. [18]
Though the intention of the MITPP was to base treatment protocols on proven scientific research, some stakeholders are also critical of the Collaboration’s position that only practices proven to be effective by quality research are worth implementing. [19]
Stakeholders have drawn attention to the specific language used in the CTI Report and draft Guideline, noting places where terms could be clarified or modified because, as written, they are likely to cause confusion. [20]
Concerns regarding reliance on Self Reporting and Shared Decision-Making
From a defence perspective, there are a couple a features of the CTI Report that may cause concern, namely the reliance on a claimant’s self-reporting of his or her injuries and the notion of “shared decision-making” that appears throughout the Report. Though “a focus on the injured person” is not doubt invaluable in a healthcare context, the SABS environment is compensation driven, where a claimant will generally receive greater benefits for a more serious impairment. This is a financial incentive that is likely to affect how the CTI structure may play out if implemented.
COMMENTARY
The Minor Injury Treatment Protocol Project and the CTI Report produced by the OPTIMa Collaboration are, at least in one way, beneficial to nearly all stakeholders in that they provide some clarity around the definition of common traffic injuries and the appropriate treatment protocols for certain commonly encountered subsets of injuries within this category. The process that led to the Report appears robust, reflecting a thorough analysis of existing scientific research.
The identification and description of treatment protocols is an important step in the evaluation of the “minor injury” concept, particularly because – at the very least – it distinguishes between treatment approaches that are valuable and those that are not supported by existing scientific literature.
Predictably there are concerns from various stakeholders regarding the terminology, the definition, the methodologies in determining the Care Pathways and the protocols as well as the heavy reliance on subjective reporting.
The challenge with the CTI Report will come now as the government seeks to integrate elements of the Report into the existing and evolving statutory accident benefits framework.
[1] FSCO, “Minor Injury Treatment Protocol”: < https://www.fsco.gov.on.ca/en/auto/Pages/minor-injury-treatment-protocol.aspx>.
[2] FSCO, “Minor Injury Treatment Protocol”: < https://www.fsco.gov.on.ca/en/auto/Pages/minor-injury-treatment-protocol.aspx>.
[3] FSCO, “Minor Injury Treatment Protocol”: < https://www.fsco.gov.on.ca/en/auto/Pages/minor-injury-treatment-protocol.aspx>.
[4] FSCO, “Minor Injury Treatment Protocol”: < https://www.fsco.gov.on.ca/en/auto/Pages/minor-injury-treatment-protocol.aspx >.
[5] Ontario Protocol For Traffic Injury Management Collaboration, “Enabling Recovery From Common Traffic Injuries: A Focus On The Injured Person”, p. 5.
[6] Ontario Protocol For Traffic Injury Management Collaboration, “Enabling Recovery From Common Traffic Injuries: A Focus On The Injured Person”, p. 7.
[7] Ontario Protocol For Traffic Injury Management Collaboration, “Enabling Recovery From Common Traffic Injuries: A Focus On The Injured Person”, p. 7.
[8] Ontario Protocol For Traffic Injury Management Collaboration, “Enabling Recovery From Common Traffic Injuries: A Focus On The Injured Person”, p. 34.
[9] Ontario Psychological Association, “OPA Response to: Enabling Recovery From Common Traffic Injuries: A Focus On The Injured Person”, p. 5.
[10] Ontario Psychological Association, “OPA Response to: Enabling Recovery From Common Traffic Injuries: A Focus On The Injured Person”, p. 5.
[11] Coalition of Health Professional Associations in Ontario Automobile Insurance Services, Letter to FSCO re: The Optima Report “Enabling Recovery from Common Traffic Injuries: A Focus on the Injured Person”, p. 2.
[12] Coalition of Health Professional Associations in Ontario Automobile Insurance Services, Letter to FSCO re: The Optima Report “Enabling Recovery from Common Traffic Injuries: A Focus on the Injured Person”, p. 4.
[13] Coalition of Health Professional Associations in Ontario Automobile Insurance Services, Letter to FSCO re: The Optima Report “Enabling Recovery from Common Traffic Injuries: A Focus on the Injured Person”, p. 3.
[14] Coalition of Health Professional Associations in Ontario Automobile Insurance Services, Letter to FSCO re: The Optima Report “Enabling Recovery from Common Traffic Injuries: A Focus on the Injured Person”, p. 2.
[15] Ontario Rehab Alliance, “Response to the Draft Superintendent’s CTI Guideline”, September 3, 2015, p. 1.
[16] Coalition of Health Professional Associations in Ontario Automobile Insurance Services, Letter to FSCO re: The Optima Report “Enabling Recovery from Common Traffic Injuries: A Focus on the Injured Person”, p. 1.
[17] Coalition of Health Professional Associations in Ontario Automobile Insurance Services, Letter to FSCO re: The Optima Report “Enabling Recovery from Common Traffic Injuries: A Focus on the Injured Person”, p. 3.
[18] Ontario Rehab Alliance, “Response to the Draft Superintendent’s CTI Guideline”, September 3, 2015, p. 4.
[19] Ontario Rehab Alliance, “Response to the Draft Superintendent’s CTI Guideline”, September 3, 2015, p. 2.
[20] Ontario Psychological Association, “OPA Submission Regarding the CTI Guideline”, p.6.
