Usual care worked as well as an intensive management program for patients with acute whiplash injury, according to results of a large randomized trial.
Active clinical management that included physical therapy showed a small advantage over usual care after 4 months, as assessed by the Neck Disability Index (NDI). The advantage had disappeared by 8 months, and outcomes in the treatment groups remained similar at 12 months.
An economic analysis showed that active management cost more and provided less quantitative benefit compared with usual care, as reported online in The Lancet.
“Our findings show that no additional benefit exists to providing active management consultations in the emergency department,” said Sarah E. Lamb, DPhil, of the University of Warwick in Coventry, England. A package of physiotherapy has a modest effect on early recovery of persisting symptoms but is not cost effective from a U.K. National Health Services perspective.”
Extensive reviews of interventions for whiplash injury have found little or no data to support many of the treatments employed.
Following its review of the evidence, the Quebec Task Force on Whiplash Injury suggested a stepped-care approach, beginning with advice and positive reinforcement and moving on to other interventions, including physical therapy, if symptoms persist (Spine 1995; 20(8 suppl): 1S-73S). A similar approach has been used successfully in the management of back pain, the authors noted.
Some clinical guidelines recommend physical therapy, which lacks supporting evidence, they added.
Borrowing elements from several different clinical strategies, Lamb and colleagues conducted a two-phase randomized study involving emergency departments at 12 hospitals that treated patients with grade I-III acute whiplash-associated disorder.
In the first phase, investigators randomized the hospitals to usual care or active management, which included distribution of a patient education booklet to augment active-management consultations that focused on changing beliefs and negative health behaviors.
Investigators trained emergency-department personnel in active management, which was applied during clinical visits with patients who came to the hospitals randomized to active management. Staff members were instructed to limit treatments to those that would be appropriate for soft-tissue injury. The first phase lasted 12 months.
During the second phase of the study, investigators randomized patients from the first phase to six sessions of physical therapy or a single advice session. The sessions included reinforcement of advice provided during the emergency-department visit.
The primary outcome was the change in Neck Disability Index (NDI) at the end of each phase of the study. The NDI assesses pain-related activity restriction across 10 domains. A secondary outcome was the change in score on the Short Form-12 and in other instruments that addressed neck-specific symptoms, work restriction and lost compensation, and healthcare resource use.
The investigators randomized 3,851 patients, of whom 2,704 provided follow-up data to 12 months. The results showed a 0.5-point difference between groups on the mean NDI score, which did not reach statistical significance.
During the second phase of the study, investigators randomized 599 volunteers from the first phase to usual-care consultations and a single physical therapy advice session or to six sessions of physical therapy that included reinforcement of clinical advice as well as hands-on therapy targeted to soft tissue injury. The NDI was completed after 4, 8, and 12 months.
Blinding of patients and clinicians to treatment group assignments at all phases of the study was not possible.
After 4 months, the patients assigned to the more intensive treatment arm showed a net treatment effect of 3.7 points on the NDI compared with the usual-care group (P=0.0029). By 8 months, the difference had dwindled to 1 point and then increased to 2 points at 12 months, neither of which was statistically significant.
A 4-day (adjusted) difference in lost work days favored active intervention at all time points. Patients’ self-rated benefit was significantly higher at 4 months with active intervention (P<0.0001) but not at the other assessments. Other secondary endpoints did not differ significantly between groups at any assessment.
The economic analysis produced a higher cost for active intervention during both phases of the study. The estimated cost of active intervention averaged about $500 per patient during the first phase and $675 during the second phase. Corresponding costs for usual care were $450 and $580.
Comparison of quality-adjusted life years showed a lower average gain for active treatment during phase I (0.755 versus 0.758) and during the second phase (0.691 versus 0.702).
The author of an accompanying commentary suggested that meaningful improvement in whiplash management will occur only when expectations and behaviors change.
“Part of the issue might be that people with whiplash should not be attending an emergency department,” Robert Ferrari, MD, of the University of Alberta in Edmonton, wrote. “It is unlikely that most whiplash victims have any need for radiological studies, and what the emergency physician otherwise has to offer these patients is not clear.”
Expectations and beliefs could be the key to better outcomes after whiplash, he continued. A Canadian study showed that whiplash patients who expected to “get better soon” recovered three times as quickly compared with patients who thought they would never get better.
“Those who hold expectations of a poor outcome might be having those expectations reinforced by the experience of a presentation to an accident and emergency department,” Ferrari wrote.
Legislative action could effect changes in expectations surrounding whiplash by reducing “the extent to which expectations can be met – i.e., less contact with lawyers, insurers, and the treatment industry could reduce the encouragement of these expectations and the behavior that follows.”
Primary source: The Lancet
Source reference: Lamb SE, et al “Emergency department treatments and physiotherapy for acute whiplash: A pragmatic, two-step, randomized controlled trial” Lancet 2012; DOI:10.1016/S0140-06736(12)61304-X.