Researchers in the UK have concluded that active management consultations of whiplash in the emergency department are not cost effective and do not improve patients’ prognosis in acute whiplash, which can cause a number of symptoms, including neck pain. The types of things included in active management for acute whiplash were intensive physiotherapy, promotion of positivity for recovery, exercise, early re-engagement in daily routines, an educational booklet on whiplash, and pain management assistance. Patients receiving this type of care, compared to standard care, saw little additional benefit and no long-term benefits leading the authors to conclude that ‘less is more’ when it comes to acute whiplash care.
Usual Care vs. Active Whiplash Management
The study was published in the Lancet’s February 16th edition and was carried out by Sarah E. Lamb, DPhil, and colleagues from the Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom. A two-step process was rolled out for patients visiting one of 12 hospitals or 15 emergency departments (EDs) taking part in the study. Six of the hospitals and seven of the EDs recruited patients for the active management protocol and the remainder proceeded with usual consultation practices. The data was adjusted for initial whiplash grade and other potential confounding factors.
Symptoms of Whiplash Associated Disorder
Whiplash can cause a number of ongoing problems years after the initial injury and many of these are difficult to connect to the neck trauma, leading to problems in applying proper treatment. There is some evidence that cervical spine instability is more common in those suffering whiplash, with conditions such as facet joint arthritis and tinnitus an increased risk for such patients. Whiplash associated disorder may also involve cognitive deficits that can take weeks, months or even years to resolve, if at all. Headaches and neck pain are commonly associated with whiplash associated disorder and patients are often advised to do their best to avoid unnecessary stress and strain on the neck.
Little Difference with Added Care
Some 3851 patients took part in the first stage of the study, 2253 of whom were seen in hospitals in the active management group and 1598 in the hospitals providing usual care. Just over half of the acute whiplash patients were women (55%) and the mean average age was 37 years. Follow-up data was available for 70% of patients at the 12 month mark and the results showed little difference between the groups. The median Neck Disability Index scores varied by 0.5; a difference of 3 points is considered clinically meaningful.
Is Additional Physiotherapy Helpful in Whiplash?
In step two of the study, half of the patients were given a single physiotherapy session, to consolidate the advice given in their earlier ED visit, and the other half had a series of six physiotherapy sessions. Two thirds (67%) of the patients in the active group completed the prescribed course of physio after whiplash and 80% of the usual care group finished the course; those who provided follow-up data at four months (80%) showed modest benefit for neck disability but there was no long-lasting benefit at eight or twelve months. The additional cost of these sessions and the lack of clear benefit led the researchers to conclude that a single session and usual care in the hospital or emergency department is the recommended treatment for acute whiplash.
Lamb, S.E., et al, Lancet. 2013;381:514-515, 546-556.
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