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THE PROVIDER’S GUIDE FORINTERPRETING THE CRMAᵀᴹ REPORTSPINAL KINETICS 2024

Copyright Notice© 2024, Spinal Kinetics. All rights reserved.No part of this publication may be reproduced, distributed, or transmitted inany form or by any means, including photocopying, recording, or otherelectronic or mechanical methods, without the prior written permission ofthe publisher, except in the case of brief quotations embodied in criticalreviews and certain other noncommercial uses permitted by copyright law.For permission requests, write to the publisher, addressed “Attention:Permissions Coordinator,” at the address below.Spinal Kinetics 246 Tierney Drive, Suite 1 New Richmond, WI 54017 Phone: 877-508-9729www.thespinalkinetics.comThe content within this booklet, including but not limited to text, graphics,images, and other material, is for informational purposes only and notintended to substitute professional advice, diagnosis, or treatment. Alwaysseek the advice of your professional advisors or other qualified providerswith any questions you may have regarding a specific condition.The publisher and author have made every effort to ensure the accuracy ofthe information within this book was correct at press time. The publisherand author do not assume and hereby disclaim any liability to any party forany loss, damage, or disruption caused by errors or omissions, whether sucherrors or omissions result from negligence, accident, or any other cause.This publication is designed to provide accurate and authoritativeinformation in regard to the subject matter covered. It is sold with theunderstanding that the publisher and author are not engaged in renderinglegal, intellectual property, or other professional services. If legal advice orother expert assistance is required, the services of a competent professionalshould be sought.

CONTENTSTABLE OFWhat is CRMA™ Report?Indications for a CRMA™ ReportGrading the Sprain04060812Croft Treatment Guidelines14Impairment RatingsInsurance Surgical Guidelines1618Activity RestrictionsFurther Uses for a CRMA™ Report20BONUS: Watch our videos on each of oursections from our FREE CRMA™ Masterclass!SIGN UPNOW!

It is a sophisticated, AI-assisted, measurement of theexcessive intersegmental motion in a patient’s spine. Bymeasuring the amount of excessive translation and angularmotion, you can determine the severity and location of yourpatient’s non-disco ligamentous spinal injuries. An excessive motion test is different from that of ageneral radiology report. While your local radiologist maymention whether there’s any intersegmental motionabnormality, there are no measurements, therefore it is notspecific or objective. If you sent those same X-rays to 20different radiologists, you’d likely get 20 different reportswith varying levels of findings. Computerized RadiographicMensuration Analysis (CRMA™) Reportis produced by Spinal Kinetics, andperformed by our board-certifiedmedical radiologists. It is notperformed by the provider themself orany other entity. What is CRMAᵀᴹ Report?G R A D I N G T H E S P R A I N04

Our analysis measures excessive motion from C1-C7 andL1-S1. We do this by using FDA-cleared AI-assistedmensuration technology to evaluate stress view radiology,also commonly referred to as functional radiology orflexion/extension radiology. Our board-certified medicalradiologists licensed in the state of the ordering providercan then conduct an extremely accurate analysis allowingdoctors to better document and diagnose the spinal injuriestheir patients have suffered. Providers digitally send us their DICOM images andreceive a robust report with a lightning-fast 24-hourturnaround time. This analysis is currently the most reliable way todetermine your patient’s non-disc spinal ligament injuries. It is widely regarded by chiropractors, medical doctors,physical therapists, attorneys, insurance carriers, and manyother professionals who work hard to ensure the bestoutcomes and physical recoveries of spinal injury patients. G R A D I N G T H E S P R A I N05IS FDA-CLEAREDWITHSTANDS LEGAL ANDINSURANCE CARRIER SCRUTINYIS FULLY ALIGNED WITH AMA ANDSURGICAL GUIDELINESREMOVES SUSPICION OF TREATMENT PROVIDER BIASWhy Choose Spinal Kinetics?

NECK PAINHEADACHESRADICULAR COMPLAINTSVISUAL DISTURBANCESTINNITUSDIZZINESSPOST-CONCUSSIVE SYNDROMENEUROPATHY (WEAKNESS, NUMBNESS, PARESTHESIA)DIFFICULTY SLEEPING DUE TO PAINDISTURBED CONCENTRATION AND MEMORYLOWER BACK PAINPAIN RADIATING DOWN THE LEGIRRITATION OF HERNIATED DISCS AND MOREIndications for a CRMAᵀᴹ ReportBest Practice Tip: Any patient whoyou suspect may be suffering from aspinal ligament injury should receive a CRMA™ report. The ligaments in the spine are responsible for keeping thespine in alignment. When these tough fibrous tissues arederanged, it can lead to spinal misalignments, also commonlyreferred to as spinal instability or intersegmental excessivemotion. When the vertebral motion units move excessively it causesnerve interference and discomfort leading to an array ofsymptoms which can include (1), but are not limited to:06Freeman MD, Stephenson RO. Cervical Sprain and Strain Clinical Presentation. Medscape. UpdatedOctober 17, 2023. 1. click to watch video!www.skbackoffice.com/login

G R A D I N G T H E S P R A I NCONTRA-INDICATIONS FOR A CRMAᵀᴹ REPORT There is currently no way for a provider to accurately andobjectively diagnose this injury without the use ofexcessive motion testing. (2) Since the majority of ourproviders operate in the personal injury space, the precisedocumentation and imaging of any injury is paramount tothat injury being recognized to the patient’s insurancecarrier. You would not order a CRMA™ report on a patient whoyou did not suspect was suffering from a spinal supportligament condition. Also, you would not order a CRMA™report for a patient who could not physically getthemselves into the appropriate position for the necessaryimaging. Once that patient regains their range of motion,you could then order a CRMA™ report.IMPORTANT NOTE07“Motion of individual spine segments cannot be determined by a physical examination but is evaluatedwith flexion extension radiographs.” AMA Guides to the Evaluation of Permanent Impairment 5th EditionPage 383.2. Watch Video!www.skbackoffice.com/login

GRADE IGRADE IIGRADE IIINORMALABNORMALSEVERETRANSLATION0 - 0.99mm1 - 3.49mm>3.5mmANGULATION< 7 degrees7 - 10.99 degrees>11 degreesC E R V I C A L S P I N E It’s important to identify and document the grade of thesprain. If a general sprain code is used it automaticallydefaults to a mild sprain since it is not indicated otherwise inyour documentation. Grading the Sprain A general sprain code can undermine the significance of thecondition and often reduce your patients' access to thebenefits that they may be entitled to.Best Practice Tip: In the interest of beingspecific and objective, use the resultsfrom your patient’s CRMA™ report todetermine and document the grade oftheir sprain. G R A D I N G T H E S P R A I N08 Measurements over 1mm Translation and/or over 7° Angular Variation are considered to be clinically significant and inexcess of normal flexibility of the cervical spine. (SPINE 2001, February; 26(3): (256-261), Lin, Tsai, Chu and Chang (the1mm was rounded up) In the lumbar spine the same 1mm or translation is being accepted as normal. Wang S, et al.,Spine. 2008 May 15;33(11):E355-613. Watch Video!www.skbackoffice.com/login

G R A D I N G T H E S P R A I NExample of Cervical Findings09

GRADE IGRADE IIGRADE IIINORMALABNORMALSEVEREL1-L2<11 degrees11-15 degrees15< degreesL2-L3<11 degrees11-15 degrees15< degreesL3-L4<11 degrees11-15 degrees15< degreesL4-L5<15 degrees15-20 degrees20< degreesL UMBARA NGULAT I O NGRADE IGRADE IIGRADE IIINORMALABNORMALSEVERE0 - 0.99mm1 - 4.49mm>4.50mmL U M B A RT R A N S L A T I O N The lumbar spine is graded differently than the cervicalspine. In the case of lumbar angulation, the parametersmeasuring the sprain are broken up by different segments.Grading theLumbar Sprain10

Example of Lumbar Findings11G R A D I N G T H E S P R A I N

GRADE IMinimal; No limitation of motion; Noligamentous injury; No neurological findings.< 7 degrees0 - 0.99mmGRADE IISlight; Limitation of motion; No ligamentousinjury; No neurological findings.< 7 degrees0 - 0.99mmGRADE IIIModerate; Limitation of motion; Someligamentous injury; Neurological symptoms.7 - 10.99degrees1 - 3.49mmGRADE IVModerate to severe; Limitation of motion;Ligamentous instability; neurologicalsymptoms; Fracture or disc derangement. >11 degrees>3.5mmGRADE VSevere; Requires surgicalmanagement/stabilization>11 degrees>3.5mm It’s important to have a standard by which you, as thedoctor, or the insurer, can determine if the frequency andduration of your care was medically necessary. The severity of your patient’s injuries should be consideredwhen making that determination.C R O F T T R E A T M E N T G U I D E L I N E SUSE THE FOLLOWING CHARTS TO HELP YOU PLACE YOURPATIENT’S INJURIES INTO THE APPROPRIATE CATEGORY.CERVICALANGULATIONCERVICALTRANSLATIONCroft TreatmentGuidelines12

Daily3x/wk2x/wk1x/wk1x/moTTGRADE I1 wk1-2wks2-3wks<4wks----<10wks<21GRADE II1 wk<4wks<4wks<4wks<4 mo<29wks<33GRADE III1-2wks<10wks<10wks<10wks<6 mo<56wks<76GRADE IV2-3wks<16wks<12wks<20wks------------GRADE VSurgical Stabilization Necessary - Chiropractic care is post-surgical.C R O F T T R E A T M E N T G U I D E L I N E STreatment Frequency1222D NUsing the results of your patient’s CRMA™report, combined with the nationally acceptedCroft Treatment Guidelines helps providers allover the country to stay compliant in theutilization of their care. Croft TreatmentGuidelinesWatch Video!13www.skbackoffice.com/loginT = treatment duration; T = treatment number. ¹ Possible follow-up at 1 month.² May require permanent monthly or p.r.n. treatment.D N

The AMA Guides to the Evaluation of PermanentImpairment are a commonly used and nationally recognizedset of guidelines for determining the permanency of yourpatient’s injuries. By using the results from your patient’s CRMAᵀᴹ reportand the rating system outlined by the AMA, you candocument the whole-person-impairment of their injury. This provides grounds for making future carerecommendations as your patient reaches maximummedical improvement. Impairment RatingsSee the next page for anexample of correlatingCRMAᵀᴹ reportmeasurements to theseimpairment ratings.14Watch Video!www.skbackoffice.com/login

ANGULATIONTRANSLATIONIMIPAIRMENT RATING0-6.99 degrees0 - 0.99mm0%7 - 10.99 degrees1 - 3.49mm5-8%*> 11 degrees> 3.5mm25%5TH EDITIONCERVICAL SPINE EXAMPLE*patient must also have asymmetrical range of motionI M P A I R M E N T R A T I N G S15

Athletes or contact-sports participants can be highlysusceptible to spinal injuries depending on the sportthat they play. It’s vitally important to monitor thatathlete’s safe return to play. Criteria for returning to collision activities, such asfootball, after cervical spine injuries are well-documented. (4) Using the results of your CRMAᵀᴹreport allows you to make athletic play suggestionsthat are supported by clinical evidence and rationale. Activity RestrictionsIs it safe for them to return to contact sports?16Watch Video!www.skbackoffice.com/login

A T H L E T E P A T I E N T17Torg JS. Cervical spine injuries and the return to football. Sports Health. 2009;1(5):367-373.doi:10.1177/1941738109343161.4.

C E R V I C A L S P I N E The results from your CRMAᵀᴹ report can indicate whetheror not your patient’s injuries reach a threshold that pre-qualifies them for spinal fusion surgery. While many of these patients can and will resolve theirsymptoms in conservative care, it can be beneficial toreference the surgical guidelines to demonstrate the severityof your patient’s spinal injuries. On the following page is an excerpt from EviCore’sguidelines. These same values are used in Blue Cross BlueShield and similar values can be found in Aetna’s and UnitedHealthcare’s insurance policies.Insurance SurgicalGuidelines18Watch Video!www.skbackoffice.com/login

S U R G I C A L G U I D E L I N E S19

Further Uses for a CRMA™ Report20The more translational motion there is in ajoint, the more of a facet injury is there.IDENTIFYING FACET INJURIESChronic neck pain may be linked to capsular ligament laxity and cervicalinstability (1). CRMA™ reports highlight the extent of facet joint damage,providing valuable insights for chiropractors, physical therapists, andpain management specialists.Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: Making the connection between capsular ligamentlaxity and cervical instability. Open Orthop J. 2014;8:326-345. doi:10.2174/1874325001408010326. PMCID:PMC4200875.5.Watch Video!

DISC INJURY CORRELATIONThe CRMA™ measurements aid doctors in making better MRI referralsand demonstrates that any disc injury was caused by trauma, not a pre-existing condition. Research shows a direct correlation between higher amounts ofexcessive motion and the likelihood of disc damage (2). This helps toestablish, on a more probable-than-not basis, that the patient's discinjury was caused by the accident and not a pre-existing condition.Kim CH, Hwang JM, Park JS, Han S, Park D. Predictability of severity of disc degeneration and disc protrusion usinghorizontal displacement of cervical dynamic radiographs: A retrospective comparison study with MRI. Medicine(Baltimore). 2018;97(25) doi:10.1097/MD.0000000000011098. PMID: 29924003. PMCID: PMC6024478.6.21G R A D I N G T H E S P R A I NExcessive MotionDisc Injury1.0 mm 1.5 mm 2.0 mm 2.5 mm 3.0 mm 3.5 mmBULGINGHERNIATEDRUPTUREDSEQUESTEREDResearch shows a direct correlationbetween higher amounts of excessivemotion and the likelihood of discdamage**Ilustration is not to scale and is forexample purposes only. Watch Video!www.skbackoffice.com/login

C E R V I C A L S P I N E CRMAᵀᴹ reports assist doctors in identifying anddocumenting one of the most severe injuries associated withmild traumatic brain injury (mTBI) cases: the upper cervicalinjury. This is also known as the Cervical Profile Injury in TBICertification Training. This type of injury can cause any of thesymptoms related to mTBI and should always be diagnosedand documented. If your patient has excessive motion in any of the first threecervical vertebrae, this could be an indication of a cervicalprofile injury. 22THE MTBI CONNECTIONWatch Video!www.skbackoffice.com/login

EXAMPLE OF AN INDICATION OFTHE CERVICAL PROFILE INJURY23This is a severe cervical profile injury,indicated by excessive motion in the firstthree vertebrae.D I A G N O S I N G T H E C E R V I C A L P R O F I L E I N J U R Y

Does it have to be third-party?Can you bill for this procedure?Should you be billing for it?Do you need FDA Clearance?When to order a CRMA report?Should it be done BY a Medical Radiologist?Overcoming the Pitfalls of Using this Procedure:CLICK NOW TO ACCESSADVANCE YOUR KNOWLEDGE!with the Spinal Kinetics Masterclass on CRMAᵀᴹ Reports.On this free 45-minute masterclass, our expert will walkyou through everything listed in this booklet as well as: CLICK BELOW TO SIGN UP TODAY!