What to do about whiplash? Trials have historically produced disappointing results across the board for our management strategies. As is so often the case the interpretation of those results can be broadly divided into 2 camps. One camp (often rather small) who accept that current treatments are not really doing the job, the other who find fault with the trials and feel that they have not provided the fair test to which they claim.
The arguments are familiar, not wildly unreasonable, and by no means unique to whiplash. Trials did not find an effect because they applied 鈥渙ne size fits all鈥� treatments to a wildly varied patient group, because they failed to consider subgroups in the population, because the treatment did not reflect best practice or 鈥渨hat I would do鈥�. Luckily most of these are hypotheses that can be tested.
Prof Gwen Jull and colleagues have done just that. Hypothesizing that many of these arguments against existing trial results may be valid, of individualised targeted care versus usual care for acute whiplash. The targeted care group received a 10 week course of medical & pharmacological management, physiotherapy (including individualised exercise, manual therapy, and other modalities), and psychological care, with a specific emphasis on targeting post 鈥搕raumatic stress reactions. All treatment was clinician-led and individually targeted,聽 no 鈥渙ne size fits all鈥� here. The usual care group sought care as usual via their GPs, including visits to physiotherapy, chiropractic etc.
The findings are something of a bombshell for this model of 鈥渂est practice鈥�. There was simply no difference between the two groups at 6 month or 12 month follow-up. No difference in recovery rates, no difference in disability levels, no difference in pain levels.聽 This study quite reasonably hypothesized that multi-modal care, delivered in a way unique to each patients needs would result in better outcomes than the norm. The results do not support this.
Is there an escape route in the design or process of the trial itself?聽 Not really, since the trial was robustly designed, the treatment package was well reasoned and comprehensive and while the trial is a little small (n=101), there was no trend to be seen towards an improvement in the intervention group (in fact the trend appears to move in the opposite direction).聽 It is also worth remembering that these pragmatic trial designs tend to introduce an unavoidable bias which favours the intervention.
These results are not entirely unique. found that an early 鈥渁ctive management鈥� intervention delivered in accident and emergency had no beneficial impact and that a course of physiotherapy for those who remained symptomatic 3 weeks later had only a modest and short term benefit that disappeared quickly. These are two well designed and well conducted trials, with a familiar message. Then there is the context offered by some larger population based studies which have variously shown and that more care may lead to worse outcome (see and ).
This result is important because it reveals, even more starkly, an uncomfortable truth. What we think may be 鈥渢he right thing鈥� for the management of whiplash is not resulting in the right outcomes. 聽While we have some predictors of poor outcome, our efforts to modify them are not particularly successful. Current therapy for whiplash does not appear to be impressively therapeutic. More does not always mean better.
About Neil O’Connell
As well as writing for , Dr Neil O鈥機onnell, (PhD,聽not MD)聽is a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He divides his time between research and training new physiotherapists and previously worked extensively as a musculoskeletal physiotherapist.
He also tweets!
Neil’s main research interests聽are chronic low back pain and chronic pain more broadly with a focus on evidence based practice. He has conducted numerous systematic reviews including some聽for the Cochrane Collaboration. He also makes a mean Yorkshire pudding despite being聽a child of聽Essex.
Link to .听顿辞飞苍濒辞补诲补产濒别听.
References
Jull G, Kenardy J, Hendrikz J, Cohen M, & Sterling M (2013). Management of acute whiplash: A randomized controlled trial of multidisciplinary stratified treatments. Pain PMID:
C么t茅 P, Hogg-Johnson S, Cassidy JD, Carroll L, Frank JW, & Bombardier C (2007). Early aggressive care and delayed recovery from whiplash: isolated finding or reproducible result? Arthritis and rheumatism, 57 (5), 861-8 PMID:
C么t茅 P, Hogg-Johnson S, Cassidy JD, Carroll L, Frank JW, & Bombardier C (2005). Initial patterns of clinical care and recovery from whiplash injuries: a population-based cohort study. Archives of internal medicine, 165 (19), 2257-63 PMID:
Cassidy JD, Carroll LJ, C么t茅 P, & Frank J (2007). Does multidisciplinary rehabilitation benefit whiplash recovery?: results of a population-based incidence cohort study. Spine, 32 (1), 126-31 PMID:
Lamb SE, Gates S, Williams MA, Williamson EM, Mt-Isa S, Withers EJ, Castelnuovo E, Smith J, Ashby D, Cooke MW, Petrou S, Underwood MR, & Managing Injuries of the Neck Trial (MINT) Study Team (2013). Emergency department treatments and physiotherapy for acute whiplash: a pragmatic, two-step, randomised controlled trial. Lancet, 381 (9866), 546-56 PMID: