Effect of early intensive care on recovery from whiplash-associated disorders

The aim of this population-based cohort study was to determine whether the results from previous research suggesting that early intensive health care delays recovery from whiplash-associated disorders (WADs) were confounded by expectations of recovery and whether the association between early health care intensity and time to recovery varies across patterns of health care.

The study included 5204 adults (≥18y) injured in motor vehicle collisions who received treatment from a regulated health professional or reported their injuries to the single provincially administered motor vehicle insurer. Self-report visits to physicians, chiropractors, physiotherapists, massage therapists, and other professionals during the first 42 days postcollision were used to define health care intensity. The study’s main outcome measure was self-perceived recovery.

Individuals with high utilization health care had slower recovery independent of expectation of recovery and other confounders. Compared with individuals who reported low utilization of physician services, recovery was slower for those with high health care utilization, regardless of the type of profession. For instance, those with high physician (hazard rate ratio [HRR]=.56; 95% confidence interval [CI], .42-.75), physician and high physiotherapy utilization (HRR=.68; 95% CI, .61-.77), physician and high chiropractor utilization (HRR=.74; 95% CI, .64-.85), and physician and high massage therapy utilization (HRR=.78; 95% CI, .68-.90) had significantly slower recovery.

Our study adds to the existing evidence that early intensive care is associated with slower recovery from WAD, independent of expectation of recovery. The results have policy implications and suggest that the optimal management of WADs focuses on reassurance and education instead of intensive care.

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Comments

Rachel Katz, PT, SEP

How might have the study discriminated between those who sought care earlier who perhaps were more injured than those who sought care later? There is so much variation between what is going on with whiplash that I wonder how the study can adequately discern this. Perhaps those seeking less care earlier on were better able to tolerate a wait and see approach. Many people with whiplash respond better, heal quicker, and avoid longer more difficult recoveries with appropriate early intervention. Also, without an in depth history that gets at a person’s full history, issues that are usually considered psychological such as exposure to the spectrum of traumatic stress they’ve had, the data will misleading.

Evan Thomas

Great points Rachel. WAD is a very complex experience with many variables at play, and although I see what the authors were trying to get at (i.e. you shouldn’t have to over-treat/overspend to get a good outcome), they needed to be a bit more specific. It seems that they were purely going after things from a cost effective standpoint and looking at the overall outcome (“recovered” vs not “recovered”, which in and of itself is a tricky thing to determine or quantify).
With respect to how might they have discriminated between those who sought care earlier versus later, it appears as though they did not take that into consideration. They restricted their sample to those who 1) made a claim within 42 days of their injury, and 2) answered “yes” to the question “did the accident cause you neck or shoulder pain”?
The authors also did not state the type/kind of care that was provided – they only looked at what professions were providing the care (physio, chiro, massage, physician) and to what degree (minimal vs a lot of treatment). As such, a think your point about “appropriate early intervention” allowing for a quicker recovering is very key, and again is something these authors did not investigate. Had they divided these groups further into something along the lines of quantity of “conventional physio/chiro/etc” vs “conventional therapy + neuro/pain science education” in WAD recovery, my guess would be that the outcomes would have been different and would have hopefully shed a more positive light on the different health professions (well, fingers crossed anyways!).
They somewhat alluded to this fact in their article by stating “clinicians may inadvertently contribute to the development of iatrogenic disability in care of WAD by overdiagnosing and overtreating benign disorders, thereby promoting chronic illness behavior”, and “health professionals are highly influential on patients’ behaviors and beliefs” both of which have been quite the hot research topics over recent years, as well as a ‘hands on’ vs ‘hands off’ approach in both this population as well as cLBP groups. Our choice of words, attitudes, body language, empathy, etc all play a big role in patient recovery, as well as our ability to listen and obtain a proper history and sense of their psychosocial state.
They close by saying “some may suggest that minimal care may be the appropriate approach to manage patients with WAD” and that they agree with this, “however, we do not suggest that patients with WAD should not receive any care at all”. So I guess they tried to save their butts quickly at the end with these lines in fear of ending-up with bags of angry letters from the medical community their doorstep!
Their bottom line was “the optimal management of WAD focuses on reassurance and education instead of intensive care that involves stacking interventions and health professionals”, which I am in complete agreeance with, which it sounds like you are too if I’m not mistaken?

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