Is Minimal Care Best for Whiplash?
By Stan Innes BAppSc(Chiro), BA(Hons), Mpsych.

Results from a recent study have been interpreted as suggesting that “Whiplash” patients may benefit from benign neglect (Côté P et al. “Early Aggressive Care and Delayed Recovery from Whiplash: Isolated Finding or Reproducible Result?” Arthritis Care & Research 2007). In a cohort of patients in the Canadian province of Saskatchewan, aggressive treatment of whiplash was associated with a slower time to recovery. The finding appears to replicate a previous observation by the same authors, but in an independent population and with a different medical insurance scheme in the June issue of Arthritis Care & Research 2007.

The best choice for patients was two or fewer visits to a generalist, while the worst was more than six visits to the doctor, combined with chiropractic care, the researchers found. The researcher looked at medical and insurance records of 1,693 Saskatchewan adults who had claims for whiplash between July 1, 1994 and Dec. 31, 1994. The cut-off date was chosen because the province’s insurance system changed at the end of 1994 from a tort-based to a no-fault system. The earlier study had looked at 2,486 patients who made claims for whiplash from Jan. 1 to Dec. 31, 1995 after the switch to the no-fault system.

The researcher identified eight patterns of care,

• Two or fewer visits to a family doctor.
• More than two visits to a family doctor.
• One through six visits to a chiropractor.
• More than six visits to a chiropractor.
• Any number of visits to a family doctor, combined with one through six visits to a chiropractor.
• Any number of visits to a family doctor, combined with more than six visits to a chiropractor.
• Any number of visits to a family doctor, combined with any number of visits to a specialist.
• A general medical group — any number of visits to a family doctor, but the submitted diagnosis wasn’t whiplash.

The primary endpoint of the analysis was time to recovery, defined as the number of days between the beginning and the end of the insurance claim. On the scale, patients in the general medical group did best, with a median time to recovery of 323 days, followed by those who had one or two visits to the doctor, at 362 days, and patients with more than six visits to a chiropractor, at 363 days.

The researchers also found:

• Patients with one through six visits to a chiropractor had a median time to recovery of 375 days.
• Patients who visited a generalist and a specialist had a time to recovery of 405 days.
• Patients who combined treatment by a family doctor with six or fewer trips to the chiropractor recovered in 516 days.
• Patients who made more than two visits to a family doctor recovered in 517 days.
• And patients who made any number of visits to a family doctor, combined with more than six visits to a chiropractor, had a median time to recovery of 689 days.

The results “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 researchers said. One possible explanation for the finding, they said, is that over-reliance on medical care is a form of “passive coping strategy” that reinforces the view that whiplash often leads to disability. In contrast, minimal care that promotes activation of the injured region is more likely to results in a quicker recovery, they said.

There have been several published responses to the conclusions of the study. R J Farabaugh The Council on Chiropractic Guidelines &Practice Parameters (CCGPP) Secretary J. Farabaugh, CCGPP Secretary stated that the conclusion of the study would lead one to believe that virtually any treatment would not only be ineffective, but actually delay recovery. He felt that significant literature exists pertaining to both the benefits of joint mobility, and the deleterious affects of joint immobility. He voiced a concern in regard to the potential for acute pain patients to be under-treated based upon the recommendations of this study, allowing their conditions to develop into a chronic pain state, resulting in unnecessary pain and higher future treatment costs. He concluded by expressing concerned about the potential inappropriate reaction of the third party payor industry to this isolated study, which could adversely affect patient care. He reminded all physicians, patients, and the insurance industry that authorization or denial of care should never be based upon the results of a singular piece of evidence, especially one that is so contradictory to the clinical experience of tens of thousands of practicing physicians. It should be noted that “evidence” includes not only research, but the unique factors relating to each patient, risk factors/stratification, response to care, documentation, the process of care, existing guidelines, etc. Similar to guidelines, specific research should serve as background information only to assist physicians in the decision-making process. This paper should not be used punitively, or as a prescription for care. Singular pieces of evidence should not be used as stand-alone measures for the authorization or denial of care or the formation of contract benefits.

In a detailed analysis of the paper Freeman et al (Arch Int Med 2006;166(11):1238-9) also expressed several concerns. They made not that not once in the paper did the authors mention the common sense conclusion that patients with more severe injuries tend to both treat more frequently initially and take longer to recover from their injuries. The authors’ conclusion that treatment for a painful injury prolongs the duration of the injury is unsupported beyond the misinterpretation of their data and possibly misrepresentation of their results.

They further disputed the author’s claim on the following grounds. First, that Cote et al claimed to have “considered the confounding effect of 87 variables” in their data analysis, encouraging the reader to believe that the only real difference between treatment groups is the number of treatments received by the subjects in the study. This claim is not elucidated in their description of their methods, and is far-fetched given that the total number of subjects in two of the chiropractic treatment subgroups was less than 120 each, and less than 150 each in two others. There are only so many sub-subgroups that a subgroup can be stratified into in order to evaluate and control for all real and possible confounders before there are too few subjects from which to draw any meaningful conclusions. Although Cote et al. claim to have studied nearly 2500 subjects, because of their stated methods they would have had to divide groups of 100-150 subjects into at least 20-40 substrata to control for confounding variables (they do not tell us exactly what they did or how they did it), ultimately comparing non-overlapping groups of minimal or no subjects in some instances. Valid conclusions cannot be drawn from such a data analysis, but without any details of their subgroup analysis there is no way to know what these authors did.

Second, Cote a et al claim to have controlled for injury severity as a potential confounder; however, the only index of injury severity that was measured was pain intensity. Frequency, duration, and distribution (beyond a non-specific indication of pain in a body part) of symptoms were not measured. This difference alone between groups was enough to confound the results of the study by injury severity, rendering them meaningless.

Third, that the authors of the Canadian study claim to have controlled for an unbelievable number of variables in their analysis (at least 26 pertaining to symptoms alone) yet they do not explain significant group differences. For example, the baseline mean level of headache pain (0-100 scale) for the group of subjects treating with only a chiropractor for more than 6 visits (“high utilization”) was reported at 34.7. This was more than twice as high as that of the “low utilization” group (1-6 visits) at 15.8. The authors do not tell how their subgroup stratification of 112 and 115 subjects, respectively, controlled for such an enormous disparity between the two groups, or how it would have affected the power of their study. The difference reported in headache pain intensity between the low and high utilization chiropractic groups is not an isolated finding; in fact, in all 6 measurements of pain intensity for the 3 different comparison groups (GP 1-2 vs. >2 visits, DC 1-6 vs. >6 visits, and GP and DC 1-6 vs. >6 visits) the higher utilization group reported higher levels of initial pain in every one of 18 measurements.

Freeman et al highlight other important differences between the low and high utilization groups, such as their pre-crash health status. More than twice as many of the high utilization DC group subjects sought chiropractic care in the year prior to the crash in comparison with the low utilization group (14.7% vs. 6.8%); this is not surprising giving the fact that 53.6% of the high utilization group had pre-crash neck pain, versus 38.3% of the low utilization group. Additionally, half as many subjects in the high utilization DC group rated their pre-crash health as “excellent” versus the low DC utilization group (19.6% vs 39.1%). It is clear from Cote at al’s own data that the higher utilization groups hurt more and had more pre-existing problems than the lower utilization groups. They summarise this section by stating that “here is yet another common sense conclusion overlooked by Cote et al: patients with relatively poorer pre-crash health are more likely to be more significantly injured in a crash in comparison with their healthier counterparts, and they are also more likely to require more initial treatment as a result. This stands in direct contrast to Cote et al conclusion that it is the “clinicians who promote frequent visits”.

Freeman et al conclude there critique with “It is not surprising in the least that the more significantly injured and more fragile patients went on to suffer more persisting symptoms following an injury, regardless of their frequency of treatment. What is surprising is how Cote et al. twisted this common sense finding into a new paradigm of healthcare: the more treatment a patient receives, the sicker he or she gets. The authors cite no publications to support their new theory of the dangers of healthcare. It appears that, despite their frequent claims to the contrary, the authors’ method of stratifying their subjects by treatment frequency resulted in a hopeless confounding of their data by injury severity, because more severely injured patients always will be more likely to seek care more frequently. It is a shame that a paper with such plainly obvious and fatal flaws has appeared in the Archives of Internal Medicine. It is our opinion that this paper should not have been published.”