Education by general practitioners or education and exercises by physiotherapists for patients with whiplash-associated disorders? A randomized clinical trial

STUDY DESIGN: Randomized clinical trial. OBJECTIVE: To compare the effectiveness of education and advice given by general practitioners (GPs) with education, advice, and active exercise therapy given by physiotherapists (PTs) for patients with whiplash-associated disorders. SUMMARY OF BACKGROUND DATA: Available evidence from systematic reviews has indicated beneficial effects for active interventions in patients with whiplash-associated disorders. However, it remained unclear which kind of active treatment was most effective. METHODS: Whiplash patients with symptoms or disabilities at 2 weeks after accident were recruited in primary care. Eligible patients still having symptoms or disabilities at 4 weeks were randomly allocated to GP care or physiotherapy. GPs and PTs treated patients according to a dynamic multimodal treatment protocol primarily aimed to increase activities and influence unfavorable psychosocial factors for recovery. We trained all health care providers about the characteristics of the whiplash problem, available evidence regarding prognosis and treatment, and protocol of the interventions. The content of the information provided to patients during treatment depended on the treatment goals set by the GPs or PTs. Also, the type of exercises chosen by the PTs depended on the treatment goals, and it was not explicitly necessary that exercise therapy was provided in all patients. Primary outcome measures included neck pain intensity, headache intensity, and work activities. Furthermore, an independent blinded assessor measured functional recovery, cervical range of motion, disability, housekeeping and social activities, fear of movement, coping, and general health status. We assessed outcomes at 8, 12, 26, and 52 weeks after the accident. RESULTS: A total of 80 patients were randomized to either GP care (n = 42) or physiotherapy (n = 38). At 12 and 52 weeks, no significant differences were found concerning the primary outcome measures. At 12 weeks, physiotherapy was significantly more effective than GP care for improving 1 of the measures of cervical range of motion (adjusted mean difference 12.3 degrees ; 95% confidence interval [CI] 2.7-21.9). Long-term differences between the groups favored GP care but were statistically significant only for some secondary outcome measures, including functional recovery (adjusted relative risk 2.3; 95% CI 1.0-5.0), coping (adjusted mean difference 1.7 points; 95% CI 0.2-3.3), and physical functioning (adjusted mean difference 8.9 points; 95% CI 0.6-17.2). CONCLUSIONS: We found no significant differences for the primary outcome measures. Treatment by GPs and PTs were of similar effectiveness. The long-term effects of GP care seem to be better compared to physiotherapy for functional recovery, coping, and physical functioning. Physiotherapy seems to be more effective than GP care on cervical range of motion at short-term follow-up