Targeted therapy for acute whiplash gets it in the neck (again)

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 “one size fits all” 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 “what I would do”. 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, they have just published an RCT 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 –traumatic stress reactions. All treatment was clinician-led and individually targeted,  no “one size fits all” 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 “best practice”. 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.  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?  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).  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. The recent MINT trial found that an early “active management” 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 no improvement in recovery rates from multi-disciplinary interventions and that more care may lead to worse outcome (see here and here).

This result is important because it reveals, even more starkly, an uncomfortable truth. What we think may be “the right thing” for the management of whiplash is not resulting in the right outcomes.  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

Neil O'ConnellAs well as writing for Body in Mind, Dr Neil O’Connell, (PhD, not MD) 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! @NeilOConnell
Neil’s main research interests 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 for the Cochrane Collaboration. He also makes a mean Yorkshire pudding despite being a child of Essex.
Link to Neil’s published research here. Downloadable PDFs here.

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: 23726933

Côté 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: 17530688

Côté 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: 16246992

Cassidy JD, Carroll LJ, Côté P, & Frank J (2007). Does multidisciplinary rehabilitation benefit whiplash recovery?: results of a population-based incidence cohort study. Spine, 32 (1), 126-31 PMID: 17202903

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: 23260167