Aggressive Care Might Delay Recovery From Whiplash

Increased intensity of care by a general practitioner or chiropractor is associated with slower recovery for patients with soft tissue injuries such as whiplash, according to the results of a study published in the May 25 Early View issue and June print issue of Arthritis & Rheumatism.
"Although there are few effective treatments for whiplash, a growing body of evidence suggests that the delivery of intensive health care shortly after the injury may lead to iatrogenic disability," write Pierre Côté, DC, PhD, from the University of Toronto and the Toronto Western Research Institute and Rehabilitations Solutions in Ontario, Canada, and colleagues. "The objective of our analysis was to test whether the association between early patterns of care and time to recovery reported by Côté et al in a cohort of patients compensated under no-fault insurance is reproducible in an independent cohort of patients with whiplash compensated under tort insurance."
The study cohort consisted of 1693 adults in Saskatchewan who sustained whiplash injuries between July 1, 1994, and December 31, 1994. The investigators studied 8 initial patterns of care that integrated type of provider (general practitioners, chiropractors, and specialists) and number of visits (low vs high utilization), using Cox models to estimate the association between patterns of care and time to recovery while controlling for injury severity and other confounders.
Even after controlling for important prognostic factors, patients in the low-utilization general practitioner group and those in the general medical group had the fastest recovery. Compared with the low-utilization general practitioner group, the high-utilization chiropractic group had a 1-year rate of recovery that was 25% slower (adjusted hazard rate ratio [HRR], 0.75; 95% confidence interval [CI], 0.54 - 1.04), the low-utilization general practitioner plus chiropractic group had a rate that was 26% slower (HRR, 0.74; 95% CI, 0.60 - 0.93), and the high-utilization general practitioner plus chiropractic combined group had a rate that was 36% slower (HRR, 0.64; 95% CI, 0.50 - 0.83).
"The observation that intensive health care utilization early after a whiplash injury is associated with slower recovery was reproduced in an independent cohort of patients," the authors write. "The results add to the body of evidence suggesting that early aggressive treatment of whiplash injuries does not promote faster recovery. In particular, the combination of chiropractic and general practitioner care significantly reduces the rate of recovery."
Study limitations include possible residual confounding by indication.
"Our research complements the findings of randomized clinical trials suggesting that early minimal care that promotes activation improves prognosis," the authors conclude. "Future research should include the design of pragmatic randomized trials to test the effectiveness of various patterns of care in the community. These trials are essential to understand the influence of health care provision in preventing or facilitating disability."
Health Canada, through the National Health Research and Development Program, and the Canadian Institutes for Health Research supported this study. Dr. Côté's work was supported by a Doctoral Fellowship Training award from the National Health Research and Development Program, a New Investigator award from the Canadian Institutes of Health Research, and the Workplace Safety and Insurance Board of Ontario through the Institute for Work & Health. Another author's work was supported by a Health Scholar award from the Alberta Heritage Foundation for Medical Research. Some of the authors have disclosed various financial relationships with the Insurance Bureau of Canada.
Arthritis Rheum. 2007;57:861-868.