TORONTO, Ontario, Canada—Patients with similar whiplash injuries are likely to have much slower recovery if they have very intensive medical management in the first month after injury and especially if they combine six or more visits to a chiropractor with care from a general practitioner, Canadian researchers report in Arthritis Care & Research.¹

"We analyzed a large cohort of patients compensated under a tort insurance provision and found that increasing the intensity of care to > 2 visits to a general practitioner, 6 visits to a chiropractor, or adding chiropractic care to general practitioner care was associated with slower recovery," writes lead researcher Pierre Côté, DC, PhD, with the Institute for Work & Health at the University of Toronto, in Toronto, Ontario.

Too much, too soon, too long?

Dr. Côté and colleagues analyzed claims data from a cohort study of 1693 adults who reported whiplash injuries within 30 days of the collision between July 1, 1994, and December 31, 1994, to the Saskatchewan Government Insurance program, and who responded yes to the questions: "Did the accident cause neck/shoulder pain?" and "Have you felt neck/shoulder pain, or reduced or painful neck movement since the accident?" Patients  with neck fractures or dislocations, skull fractures, or spinal cord injury were excluded from the study.

The primary outcome measure was time to recovery, defined as the number of days between the date of the injury and the date corresponding to the closure of the insurance claim, indicating the end of treatment. The investigators identified and adjusted for potential confounders related to injury severity, comorbidities, precollision health status, and previous healthcare utilization. Confounders related to injury severity included current and usual pain intensity in the neck, head, and other body locations; work absenteeism; and postcollision symptoms including headache, dizziness, nausea, vomiting, vision, memory or concentration problems, ringing in the ears, difficulty swallowing, reduced and/or painful jaw movement, low back pain, numbness or pain in the arms or legs, and loss of consciousness.

The claims data analysis showed that

•  Patients in the general medical group had the fastest recovery (median time to recovery of 323 days)
  
•  Patients who combined general practitioner (GP) care with more than six chiropractic visits had the slowest recovery (median time to recovery of 689 days)
  
•  Recovery time was 516 days for patients who combined GP care with one-to-six  chiropractic visits and 517 days for those who saw a GP more than twice

"[O]ur study augments the evidence that too much health care too early after a soft tissue injury negatively influences the prognosis of whiplash patients. Specifically, combining chiropractic and general practitioner care appears to confer no benefit to patients. Our research complements the findings of randomized clinical trials suggesting that early minimal care that promotes activation improves prognosis," the investigators conclude.

Dr. Côté suggests that early aggressive clinical care may be partly the result of patient pressure on physicians who "may use treatments, schedule followup visits, and refer patients when not medically needed" leading to "adverse outcomes and even prolong recovery by legitimizing patients' fears and creating unnecessary anxiety." Another possibility is that early aggressive clinical care might promote passive coping strategies that in turn delay recovery.

"Reliance on frequent clinical care, a form of passive coping strategy, may have a negative effect on recovery by reinforcing patients' beliefs that whiplash injuries often lead to disability," Dr. Côté notes.

E-mail any comments to .

Reference

1. Côté P, Hogg-Johnson S, Cassidy JD, et al. Early aggressive care and delayed recovery from whiplash: isolated finding or reproducible result? Arthritis Care & Research. 2007;57:861-868.