Fax #: 801-377-3697
Journal of Muscle IQ - Volume 1
March 2023
Does Whiplash Disability Score Improve after 3 months? - A Case Study of a Real Whiplash Patient
Author: Dr. Chris Knudsen, Physical Therapist at Muscle IQ in Orem, Ut.
Introduction
Recent studies show that recovery rates after a car accident are varied and complex. Some individuals recover quickly and fully, while others experience ongoing pain and disability. It is widely accepted that only 50% of whiplash patients will ever fully recover. One study shows that nearly 15.5 million Americans are still suffering from whiplash due to an old motor vehicle accident. Another study states that 86% of patients who are symptomatic after 3 months will remain so after 2 years. Several studies have concluded that the strongest predictor of successful full recovery is the initial disability score right after the accident. Those starting with a low disability score have a high recovery rate and those with a high disability score have a low recovery rate. Why do those with a high disability score at the beginning have such a had time reaching a full recovery?
It is logical that people who are less injured (i.e. 20% disability) will have an easier time reducing their disability rating back down to 10% or less, and those that are more injured (50% or 60% disability) will have a harder time reducing their disability rating down to 10% or less. That does not mean that it is impossible for these people to reach a full recovery. Another study says that almost all progress seems to occur within the first 3 months after the accident (See Graph #1 below), and almost no progress after 6 months. Why does progress start dropping off at 3 months? It is our strong belief that progress ends around the same time that care ends, or progress ends because everything that can be done for the outer muscles has been done and to see continued progress the focus must be on the deep neck flexor muscles of the neck like the longus colli muscle.
The high rate of non-recovery in whiplash and other auto accident injuries continues to drive research into whiplash and other disabling conditions, but most research is focussed on how to decrease costs, not how to increase the number of whiplash patients achieving a full recovery. There is a push from many government institutions, insurance companies, and corporate healthcare entities, who own said insurance companies, to decrease healthcare utilization. The same thing occurs with auto accident injuries. It is the job of Insurance Adjusters to decrease costs and push auto accident patients to a quick end of care. They have argued directly with our patients that more care for their auto injuries was unnecessary and one even tried quoting the Mayo clinic saying, "low level soft tissue injuries should recover in 6 to 8 weeks", and that more care after this is "unnecessary".
Measuring Muscle Strength is Key to Fixing Whiplash
We need to give more care to those who start with a higher disability rating if we want to achieve a lower disability rating for these patients. Physical therapists need to use objective data to prove the need for continuing care when it is needed. How do therapists measure weakness? Muscle strength testing is traditionally measured by manual muscle strength testing using a 0 to 5 scale. This way of strength testing is not helpful when trying to argue for continued care for a patient. The National Institutes of Health (NIH) states that with manual strength testing, "Scoring is subjective based on the examiner’s perception." You need objective strength testing data in order to show true weakness. The David Spine Concept machines measure muscle strength in newton-meters (Nm) of force. This way of testing gives us objective strength measurements that can be followed over time. Most physical therapy clinics do not have this equipment and are unable to provide objective strength data to show when an auto accident patient is still weak and needs more therapy. They feel unable to justify continued therapy and so therapy may end prematurely. That is why we feel progress usually ends at 3 months in these studies, because care ended at 3 months.
At Muscle IQ we have the machines that give us objective and complete strength data, helping us to prove the need for continued therapy in order to continue progressing the patient toward a full recovery.
The Whiplash and Low Back Pain Case Study
The following is a case study of a real patient who came in for physical therapy from Orem. This patient arrived at the clinic with whiplash, neck pain and low back pain after a car accident. She was experiencing severe pain, a lot of weakness, and stiffness in her joints. She was reporting severe disability in her neck and back with her daily activities. After a lot of hard work, and consistent visits to Muscle IQ, she experienced a remarkable recovery.
We believe our car accident injury patients achieve better than expected results because of our:
-
Superior evaluation techniques.
-
Skilled hands-on care every visit.
-
World-class computerized medical exercise machines.
-
Computer generated strength reports showing the progress of the patient every step of the way.
Many of our patients start therapy with a disability rating above 40% and by the end of therapy have a disability rating below 15%, which we consider a full recovery. Success happens faster when the patient starts with us one or two weeks after their accident, but we have also seen good results with patients who start with us a year or more after their accident. The more time between the accident and start of care the longer the duration of treatment will need to be in order to reach a full recovery. The case study patient we will be discussing in this report came in to see us less than one month after her accident.
Frequency, Duration, and Treatments
This patient was seen 2 to 3 times a week for 36 visits from 9/23/21 to 1/10/2022 (about 15 weeks or 2.4 visits per week on average). Each visit consisted of about 60 minutes of personalized therapeutic exercises and about 30 minutes of hands-on manual therapy. The therapeutic exercises included the David Spine Concept neck and back exercises as well as other exercises. The David machines are computerized medical exercise machines that offer visual biofeedback on a computer screen in front of the patient as the patient is doing the exercise. These machines help the patient perform specific exercises at the right speed, force, and range of motion.
The Manual therapy treatments varied each visit based on assessment that day, and the types of manual therapy used were derived from the Fascial Distortion Model and the Afferent Input Model. The goal at every visit was to identify pain, weakness, and loss of motion and provide treatments for each.
Progress of the patient was measured by the Modified Oswestry and Neck Disability Index questionnaires, and with David Spine Concept muscle strength testing reports. Re-evaluations and re-testing were performed on the 12th, 24th, and 36th visits.
Photo 1: The David Spine Concept
Measuring Disability
The first measurement we will discuss in this case study is disability rating. Every auto accident patient answers questions about their current functional abilities during the first visit and at intervals every re-evaluation day after that. A final measurement is also taken on the last visit and the scores are compared for these measurements to see how much progress a patient has made with their disability rating.
Table 1: Case Study Disability Change
The graph above shows that this patient had a 50% disability rating for her low back and a 50% disability rating for her neck at the start of therapy on 9/23/21. At the end of her therapy she had 8% disability for her back and 14% disability for her neck on 1/10/22.
Predicted Whiplash Disability Outcomes
Graph 1: Predicted NDI Score
The graph above shows the predicted recovery rates from a whiplash injury after an accident. The worse the disability rating is on the first visit the less likely you are to reach a full recovery. According to this study, most whiplash patients see a change in disability of 10 to 15% within the first year after the accident. If you start with a disability of 20% you can expect a recovery to 5% disability. If you start with a disability rating of 40% you most likely will finish with a disability rating of 25% or so. Patients who start with a disability rating of 60% usually do not reach less than 45% disability within a year after their accident. We strongly believe these numbers represent the normal care received after an accident. It seems obvious to us that most patients only receive care for the first 3 months after an accident and their progress stops once they are discharged from therapy.
The patient from this case study started out with a 50% disability score and as per this graph would have an expected recovery to about 35% disability after 12 months. Instead, by coming to Muscle IQ, she saw a reduction to 14% disability, which is a 36% disability change instead of the usual 10 to 15% change.
Predicted Chronic Low Back Pain Disability Outcomes
Table 2: Expected Outcomes for Chronic Back Pain
(Predictive factors for successful clinical outcome 1 year after... Miranda van Hooff, et, al)
The Table above shows the expected outcomes of chronic back pain patients with a normal therapy program. The average % disability change was 13.8% (a starting score of 41.4% and an ending score of 27.6). Another study shows that a decrease of 8 points in the Oswestry score is a significant improvement. Our case study patient started with a 50% low back disability and ended with an 8% disability. This outcome is better than studies would predict for a normal outcome.
Graph 2: Range of Motion Measurements - Back and Neck
The graph above shows the improvements this patient made in range of motion from 9/24/21 to 1/10/22. She started with almost every neck and back motion being below normal and ended with every motion being normal or above normal.
Neck and Back Muscle Strength Testing Scores
The first graph below shows the test scores for our case study patient on the testing dates of 9/24/21, 10/18/21, and 11/24/21. She started off with severe muscle weakness. Neck extension strength was 64% below normal and Lumbar extension strength was 69% below normal. Within two months of starting therapy she had significant strength increases, but was not yet back to normal strength for several muscle tests in the neck and back. Unlike the average therapy, we continued because we saw significant progress and potential for more progress and the patient had not met full recovery yet in strength scores or Disability Questionaire scores. She may have been stuck with 34% disability in her back and 28% disability in her neck for the rest of her life. As seen in the studies mentioned above, most patients do not make much progress once therapy is stopped.
Graph 3: DAVID Muscle Testing Scores
Graph 4: Patient's Strength as Compared to Average
Graph 5: Patient's Strength Improvement in Nm
At the last testing day of 1/10/22, the case study patient had reached normal test scores for all neck and back muscle strength tests. Neck extension strength had increased 249% from 11.4 Nm to 39.8 Nm of force. Back extension muscle strength increased by 202% from 78 Nm of force to 236 Nm of force. Many other strength scores increased by 400, 500, or 600%.
Conclusion
Although many studies say that whiplash patients do not progress after three months, we have shown that individuals can progress further with the right treatments and that care should continue until disability ratings are better and strength scores have returned to normal. This case study followed the progress of a patient with whiplash and low back pain after a car accident. The patient started with 50% neck disability, 50% low back disability, and significant weakness in the neck and back muscles. At three months after her accident, this patient had close to 34% disability in her low back and 28% disability in her neck. At another clinic she may have been discharged at this time. However, care continued for another month and a half which resulted in a reduction of disability in the low back to 8% and in the neck to 14%. Her improvement was much better than the expected when compared to research study outcomes, which show minimal to no progress after 3 months.
We were able to show objective strength testing reports for the neck and back muscles because of the use of the David Spine Concept machines. This patient showed amazing strength gains and a return to normal strength for all neck and back muscle strength tests. This was a truly successful outcome for a patient with a bad prognosis, based on the average outcomes found in published research studies. She may not have reached such a good outcome without the unique treatments and exercises found only at Muscle IQ. Our objective data gave us the necessary information to justify continued therapy so that the patient could reach a successful outcome. This study shows the benefits for patients to receive more than the standard 6 to 8 weeks of care after an accident, as long as the patient is making progress and the therapist has objective data proving a continued lack of normal strength scores. Further case studies should be done showing the outcomes of patients with greater than 40% disability who present 6 months or more after their accident to document actual results for these types of patients.
Watch This Video Describing a David Test Report
Watch This Video Describing Muscle Inhibition and Afferent Input
Watch This Video Describing the David Spine Machines
Other Whiplash and Chronic Low Back Pain Research Articles (Abstracts)
Course and Prognostic Factors for Neck Pain in Whiplash-Associated Disorders (WAD): Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders
The evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1 year after their injuries. Greater initial pain, more symptoms, and greater initial disability predicted slower recovery.
The rate of recovery following whiplash injury
Fifty consecutive patients with soft-tissue neck injuries following rear end collisions were studied prospectively to assess their rate of recovery. Patients were seen within 5 days of the accident, after 3 months, 1 year and 2 years, and their symptoms were classified into one of four groups (A, asymptomatic; B, nuisance; C, intrusive; D, disabling). Fourteen of 15 patients (93%) who were asymptomatic after 3 months remained symptom-free after 2 years. Of 35 patients with symptoms after 3 months, 30 (86%) remained symptomatic after 2 years. After 1 year, 26 (52%) stated that they had recovered completely, but after 2 years this had fallen to 19 (38%). Nine of the 15 patients who had improved between 3 months and 1 year deteriorated to their previous status, or worse, between 1 and 2 years. In asymptomatic cases, a prognosis that is 93% accurate after 2 years can be given after 3 months, and 86% of patients who are symptomatic after 3 months will remain so after 2 years. However, the severity of their symptoms will change during this period and will be at the same degree of severity in less than 50%.
The Incidence of Whiplash Trauma and the Effects of Different Factors on Recovery
We performed a prospective study of patients with a whiplash trauma to the cervical spine to describe the incidence of these injuries and to evaluate prognostic factors for disability and recovery.
All the patients received a comprehensive questionnaire after the injury, and 296 cases responded to the follow-up protocol more than 1 year after the accident. Disability related to the whiplash trauma was used as the outcome variable for the assessment of prognostic factors.
Thirty-two percent reported persisting disability at follow-up. The following factors were significantly associated with a poor prognosis: pretraumatic neck pain, low educational level, female gender, and whiplash-associated disorder grades 2–3.
Which patient-reported factors predict referral to spinal surgery? A cohort study among 4987 chronic low back pain patients
Female gender, previous back surgery, high intensity leg pain, somatization, and positive treatment expectations increased the odds of being referred to spinal surgery, while being obese, having comorbidities, pain in the thoracic spine, increased walking distance, and consultation location decreased the odds.
Currently, however, reliable tools for triaging CLBP patients to spinal surgery are lacking. As a better patient selection will likely result in reduced waiting time and healthcare costs and improved surgery outcomes [9], future research should focus on identifying subgroups for which spinal surgery is most likely to be effective, including imaging parameters. In the meantime, this study was the first to indicate that some patient-reported predictive factors of spinal surgery referral can be identified, indicating that surgeons are aware and to some extent adhere to the current scientific evidence. Nonetheless, although the identified predictive factors are known as common predictive factors of surgery outcome, they could only partly predict spinal surgery referral.
Risk factors for chronic disability in a cohort of patients with acute whiplash associated disorders seeking physiotherapy treatment for persisting symptoms
Results: 136 (30%) participants developed chronic disability. High baseline disability (OR 3.3, 95% CI 1.97 to 5.55), longer predicted recovery time (OR 2.4, 95% CI 1.45 to 3.87), psychological distress (OR 1.9, 95%CI 1.05 to 3.51), passive coping (OR 1.8, 95% CI 1.07 to 2.97) and greater number of symptoms (OR 1.7, 95% CI 1.07 to 2.78) were associated with chronic disability. One risk factor resulted in 3.5 times the risk (95% CI 1.04 to 11.45) of chronic disability but this risk increased to 16 times (95%CI 5.36 to 49.27) in those with four or five risk factors.
Conclusion: Baseline disability had the strongest association with chronic disability but psychological and behavioural factors were also important. Treatment strategies should reflect this which may require a change to current physiotherapy approaches for acute WAD. The number of risk factors present should be considered when evaluating potential for poor outcome.
The Long-term Impact of Whiplash Injuries on Patient Symptoms and the Associated Degenerative Changes Detected Using MRI
A Prospective 20-year Follow-up Study Comparing Patients with Whiplash-associated Disorders with Asymptomatic Subjects
After 20 years, whiplash injuries significantly impacted the residual symptoms of shoulder stiffness, headache, and arm pain when compared with initially asymptomatic volunteers.
In this follow-up, the prevalence of shoulder stiffness (72.0% vs. 45.9%), headache (24.0% vs. 12.2%), and arm pain (13.3% vs. 3.9%) were significantly greater in WAD patients than in control subjects.
Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychological programme for chronic low back pain
The ODI as the primary outcome measure was used to define successful treatment. ‘Normal’ healthy populations have an ODI mean score of 10 (SD 2–12) [25]. Therefore, being successful was defined as having reached a maximum of 22 points on the ODI at the 1-year follow-up, including the maximum reported standard deviation of 12 points (mean plus 2 SD). The scores of the patients were then dichotomised into ‘success’ (value = 1) and ‘failure’ (value = 0) for the programme, and both groups were compared to pre-treatment characteristics.
The most important finding of this longitudinal study is that being employed and the level of disability before treatment are predictive factors for relevant improvement in CLBP patients’ functional status at 1-year follow-up.
Chronic neck pain and whiplash: A case-control study of the relationship between acute whiplash injuries and chronic neck pain
The authors undertook a case-control study of chronic neck pain and whiplash injuries in nine states in the United States to determine whether whiplash injuries contributed significantly to the population of individuals with chronic neck and other spine pain.
The study findings suggest that injuries resulting from MVAs contribute significantly to the population of individuals with chronic spine pain in the United States. In addition, individuals with chronic pain in the neck, and neck and back, are more likely to have acquired their pain as a result of an MVA, in comparison with individuals with chronic back pain alone. The present study suggests that chronic symptoms following whiplash, or ‘late whiplash’, is considerably more prevalent than previously reported, affecting about 15.5 million Americans.