Active Interventions, Act-As-Usual Have Similar Outcomes After Whiplash Injury

April 2, 2007 — Immobilization, act-as-usual, and mobilization had similar effects regarding prevention of pain, disability, and work capability 1 year after whiplash injury, according to the results of a randomized, parallel-group, controlled trial reported in the March 15 issue of Spine.

"Long-lasting pain and disability, known as chronic whiplash-associated disorder (WAD), may develop after a forced flexion-extension trauma to the cervical spine," write Alice Kongsted, DC, PhD, from the University of Southern Denmark in Ringe, and colleagues. "It is unclear whether this, in some cases disabling, condition can be prevented by early intervention. Active interventions have been recommended but have not been compared with information only."

In this study, 458 participants were recruited from emergency units and general practitioners within 10 days after a whiplash injury. They were randomized to receive 1 of the following: immobilization of the cervical spine in a rigid collar followed by active mobilization, advice to act as usual, or an active mobilization program (Mechanical Diagnosis and Therapy). At 3-, 6-, and 12-month follow-ups, treatment effect was measured in terms of headache and neck pain intensity (scale, 0 - 10), disability, and work capability.

At the 1-year follow-up, 48% of participants reported considerable neck pain, 53% reported disability, and 14% were still listed as sick. There were no significant differences noted between the 3 intervention groups. Per-protocol analyses showed results very close to the primary analyses (intent-to-treat), but the neck collar group tended to have a poorer outcome.

"Immobilization, act-as-usual, and mobilization had similar effects regarding prevention of pain, disability, and work capability 1 year after a whiplash injury," the authors write. "We find our results adequately sound to conclude that earlier recommendations of active treatment regimens cannot be supported. Moreover, taking the per protocol analyses into account, use of a stiff neck collar should be discouraged as a standard approach."

Study limitations include poor compliance with treatment, frequent use of treatment other than prescribed, and more participants lost to follow-up in the act-as-usual group.

"The present trial shows clearly that active intervention in the first weeks after an injury does not result in a better outcome than an 'act as usual' program when prescribed to a high-risk patient group," the authors conclude. "There might be subgroups that respond to treatment, but in a large group of patients the prognosis was not improved by active treatment. Until such subgroups have been identified, our general recommendation is that advice to act as usual, the less expensive intervention, should be the preferred treatment."

The Danish Insurance Association, PTU, the Karen Elise Jensens Foundation, and the IMK Foundation supported this study.

Spine. 2007;32:618-626.

Source: http://www.medscape.com/viewarticle/554471?src=mp