Is a government-regulated rehabilitation guideline more effective than general practitioner education or preferred-provider rehabilitation in promoting recovery from acute whiplash-associated disorders? A pragmatic randomised controlled trial.
OBJECTIVE
To evaluate the effectiveness of a government-regulated rehabilitation guideline compared with education and activation by general practitioners, and to a preferred-provider insurance-based rehabilitation programme on self-reported global recovery from acute whiplash-associated disorders (WAD) grade I-II.


DESIGN
Pragmatic randomised clinical trial with blinded outcome assessment.


SETTING
Multidisciplinary rehabilitation clinics and general practitioners in Ontario, Canada.


PARTICIPANTS
340 participants with acute WAD grade I and II. Potential participants were sampled from a large automobile insurer when reporting a traffic injury.


INTERVENTIONS
Participants were randomised to receive one of three protocols: government-regulated rehabilitation guideline, education and activation by general practitioners or a preferred-provider insurance-based rehabilitation.


PRIMARY AND SECONDARY OUTCOME MEASURES
Our primary outcome was time to self-reported global recovery. Secondary outcomes included time on insurance benefits, neck pain intensity, whiplash-related disability, health-related quality of life and depressive symptomatology at 6 weeks and 3, 6, 9 and 12 months postinjury.


RESULTS
The median time to self-reported global recovery was 59 days (95% CI 55 to 68) for the government-regulated guideline group, 105 days (95% CI 61 to 126) for the preferred-provider group and 108 days (95% CI 93 to 206) for the general practitioner group; the difference was not statistically significant (Χ2=3.96; 2 df: p=0.138). We found no clinically important differences between groups in secondary outcomes. Post hoc analysis suggests that the general practitioner (hazard rate ratio (HRR)=0.51, 95% CI 0.34 to 0.77) and preferred-provider groups (HRR=0.67, 95% CI 0.46 to 0.96) had slower recovery than the government-regulated guideline group during the first 80 days postinjury. No major adverse events were reported.


CONCLUSIONS
Time-to-recovery did not significantly differ across intervention groups. We found no differences between groups with regard to neck-specific outcomes, depression and health-related quality of life.


TRIAL REGISTRATION NUMBER
NCT00546806.
['Côté|Pierre|P|', 'Boyle|Eleanor|E|', 'Shearer|Heather M|HM|', 'Stupar|Maja|M|', 'Jacobs|Craig|C|', 'Cassidy|John David|JD|', 'Carette|Simon|S|', 'van der Velde|Gabrielle|G|', 'Wong|Jessica J|JJ|', 'Hogg-Johnson|Sheilah|S|', 'Ammendolia|Carlo|C|', 'Hayden|Jill Alison|JA|', 'van Tulder|Maurits|M|', 'Frank|John W|JW|']
D000208:Acute Disease D000328:Adult D015897:Comorbidity D005260:Female D058005:General Practitioners D033161:Government Regulation D006801:Humans D053208:Kaplan-Meier Estimate D008297:Male D008875:Middle Aged D009864:Ontario D010353:Patient Education as Topic D017410:Practice Guidelines as Topic D016016:Proportional Hazards Models D011788:Quality of Life D057566:Self Report D016896:Treatment Outcome D014911:Whiplash Injuries
whiplash-associated disorders activation physician education physiotherapy randomized controlled trial treatment