Less is more for emergency department treatment of whiplash
medwireNews: Researchers recommend that patients presenting to emergency departments with acute whiplash should receive usual consultations and a single physiotherapy advice session for persistent symptoms.
They found no additional benefit to patients receiving active management consultations. Also, although a physiotherapy package including exercise and manual therapy was effective in accelerating recovery of function and reducing work absence, they report in The Lancet that it had modest long-term benefits compared with a single session and was not cost-effective from a UK NHS perspective.
Robert Ferrari, from the University of Alberta in Edmonton, Canada, suggests in a related commentary that "part of the issue might be that people with whiplash should not be attending an emergency department."
He explains: "There is no physical or psychological measure that emergency departments can undertake in the acute setting that will allow them to separate patients with whiplash into those who will recover quickly and those who will not.
"Even if a measure existed whether the offer of more therapy would make a difference, or what that therapy should be, is not clear."
For the current study, which was conducted in two parts, Sarah Lamb, from the University of Warwick in Coventry, UK, and colleagues randomly assigned 3851 patients with acute whiplash, mainly due to traffic accidents, to attend emergency departments that provided either active management consultations or usual consultations.
Training of staff from both groups included an overview of whiplash injury and study procedures.
Staff providing active management consultations were additionally trained to reassure the 2253 assigned patients that prognosis after whiplash is good, to encourage patients to return to normal activities as soon as possible and to practise neck exercises, and to ensure that all patients received a copy of The Whiplash Book.
The results showed that there was no significant advantage of active management consultations over usual care at 12 months, with both groups scoring an average 14.4 on the neck disability index (NDI).
For the second part of the study, involving 599 patients randomly assigned to receive either advice (n=299) or a physiotherapy package, patients receiving the physiotherapy package showed a modest benefit at 4 months, with a -3.7 difference on the NDI. However, there was no significant difference at 8 or 12 months.
Ferrari believes the challenge now is to "change societal expectations about whiplash injury."
He says: "Not prescribing unnecessary treatment might also help to change beliefs about the nature of the injury.
"At the very least, to reduce health-care costs, Lamb and colleagues have shown that emergency departments are providing evidence-based and cost-effective treatment when they do less, not more."
By Lucy Piper, Senior medwireNews Reporter