May 27, 2007 Whiplash, the most common traffic injury, leads to neck pain, headache and other symptoms, resulting in a significant burden of disability and health care utilization. Although there are few effective treatments for whiplash, a growing body of evidence suggests that the type and intensity of treatment received shortly after the injury have a long-lasting influence on the prognosis. A new study published in the June 2007 issue of Arthritis Care & Research examined whether the association between early types of care and recovery time shown in an earlier study was reproducible with whiplash compensated under tort insurance.
A previous study led by Pierre Côté, of the University of Toronto in Toronto, Canada, found that patients compensated under no-fault insurance had a longer recovery if they visited general practitioners numerous times and/or consulted chiropractors or specialists than if they just visited general practitioners once or twice. In the current study, the authors examined patterns of care for 1,693 patients with whiplash injuries who were compensated under tort insurance.
The results showed that increasing the intensity of care to more than 2 visits to a general practitioner, 6 visits to a chiropractor, or adding chiropractic care to general practitioner care was associated with slower recovery. "The results agree with our previous analysis in a cohort of patients compensated under a no-fault insurance scheme and support the hypothesis that the prognosis of whiplash injuries is influenced by the type and intensity of care received within the first month after injury," the authors state.
They note that effective care, if medically needed, improves the prognosis of patients and that practice guidelines recommend treatment shortly after the injury. However, it may be that doctors responding to pressure from patients use treatments, schedule follow-up visits and refer patients to specialists when not medically needed. "This in turn may lead to adverse outcomes and even prolong recovery by legitimizing patients' fears and creating unnecessary anxiety," according to the authors.
It is also possible that early aggressive treatment delays recovery by encouraging the use of passive coping strategies. "Reliance on frequent clinical care, a form of passive coping strategy, may have a negative effect on recovery by reinforcing the patients' belief that whiplash injuries often lead to disability," the authors state. They cite another study that showed that whiplash patients who used coping strategies such as wishing for pain medication or believing that they couldn't do anything to lessen the pain had a slower recover than those who did not use such strategies.
Unlike the previous study, the current one did not show a slower recovery for patients who consulted a general practitioner and a specialist. This suggests that the insurance system (tort versus no-fault) can affect the association between certain patterns of care and recovery because it may influence how patients perceive their medical needs, the pressure they put on clinicians to be referred, and how insurers require them to legitimize their injury. The authors conclude that further trials "are essential to understand the influence of health care provision in preventing or facilitating disability."
Article: "Early Aggressive Care and Delayed Recovery From Whiplash: Isolated Finding or Reproducible Result"" Pierre Côté, Sheilah Hogg-Johnson, J. David Cassidy, Linda Carroll, John W. Frank, Claire Bombardier, Arthritis Care & Research, June 2007; (DOI: 10.1002/art.22775).
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