Education of Patients After Whiplash Injury: Is Oral Advice Any Better Than a Pamphlet?
From: Spine. 2008 Sep 29; [Epub ahead of print]
Whiplash associated disorders are a condition with neck pain and a variety of other symptoms that may follow an acceleration deceleration trauma to the neck. Most frequently whiplash associated disorders is a result of a car collision. Large resources are allocated to the treatment of whiplash associated disorders and to financial compensation because of lost working ability due to whiplash.
A number of recent trials have pointed toward the lack of positive results of active treatments after whiplash injuries when compared to just informing patients about the injury and giving them advice to stay active. Neither immobilization in a semirigid collar nor active mobilization following the principles of Mechanical Diagnosis and Therapy were more effective than information given during an approximately 1 hour session with a nurse, in which focus was on reassurance of the patient and recommendation of activity despite the pain. Additionally, information given by the general practitioner has been shown to be as effective as education, advice, and active exercise therapy at physiotherapists.
The evidence to support that patient education actually affects the prognosis is somewhat conflicting. An educational pamphlet focusing on reassurance and continuation of normal activities did not reduce the risk of long-lasting symptoms compared to usual emergency department care, and a 20-minute video sent to patients only showed a tendency to improve the outcome. Oppositely, in one trial a 12-minute educational video shown at the bedside improved the prognosis dramatically compared with the standard care at the emergency unit.
The information in the 3 studies all focused on reassurance, and the patients were advised to get back to their ordinary activities. The seemingly effective video spent quite some effort to explain the mechanisms behind continuous muscle pain, including biofeedback, and physical as well as emotional triggers of muscle spasm. Also techniques to reduce muscle tension and breathing relaxation techniques were included, together with cervical exercises which were demonstrated in both videos. It is, however, unknown whether these components are related to the beneficial effects of the video, and it should be noted that the control group included more women and patients with a slightly higher severity index, although baseline differences were nonsignificant.
Education and advice potentially reduce the risk of sustained symptoms after whiplash injuries, and pure educational interventions after whiplash injuries seem generally as effective as more costly interventions. Still, it is unknown to which degree the way advice is communicated affects the results. On the one hand personally delivered information by a health care professional is time consuming, but it allows for individually modified advice and for direct dialogue with the patients. Pamphlets and videos, on the other hand, do not tie up substantial health care resources, and they have the advantage that information can be repeated as the patient wishes, but individual uncertainty or fear cannot be met. The objective of this trial was, thus, to evaluate whether
patient education communicated orally by a specially trained nurse is superior to giving patients a pamphlet to prevent chronic whiplash associated disorders.
Participants randomized to this group received information and advice from the project nurse at a home visit. The session lasted about 1 hour. To make sure that the substance of the patient education was standardized, it was based on a check-list and individual questions were answered in accordance with this list.
The whiplash mechanism was described; it was underlined that whiplash denotes a trauma mechanism rather than a diagnosis. A generally good prognosis and the importance of staying active were emphasized too, and it was explained how fear of pain and focus on pain can lead to a vicious circle that may be self-perpetuating. The participants were told that acute pain because of soft tissue injury is expectable and that the severity of additional muscle spasms might be reduced by attempting to move as naturally as possible. Generally it was the aim to reduce fear and uncertainty and to motivate the participants to resume normal activities.
At the end of the session the participants were given a list holding the following statements:
● Whiplash denotes a trauma mechanism that may lead to symptoms, but not necessarily do so.
● Most patients recover completely in relatively short time.
● By resuming normal activities and avoiding too much focus on the injury you reduce some of the muscle spasm that otherwise prolongs the pain.
● You should return to work and otherwise act as usual as far as the pain allows you to.
● If you need so, you can use mild painkillers and icepacks.
The pamphlet group received the same information as described above in an 8-pages A5 booklet (total word count equals 1503). The bullet-points listed above were highlighted in the pamphlet text and summed up in the last page too.
This study was the first to compare different ways of delivering patient education after whiplash injury; namely, a 1-hour educational session with a special trained nurse or a pamphlet. The population consisted of subjects seeking care because of relatively mild acute whiplash-related symptoms. We find this population represents patients who will typically be offered no other
care than the advice given in the emergency room well.
The prognosis did not differ significantly between the 2 tested patient education methods. It was, however, possible to detect a consistent tendency toward better outcome in the oral advice group.
When interpreting these results, it is worth noting that the pamphlet intervention in this trial was not perfectly similar to a real life setting since the pamphlet group were visited by the project nurse too, who spent time with them as they filled in the baseline questionnaire and the randomization procedure was performed. Hence, this group was also met with more attention and “loving
care” than a standard emergency department can provide. Therefore, the benefits from personal communicated education might be somewhat larger than demonstrated in this study. To investigate the real effect of the personal contact with a healthcare professional, randomization should be carried out at the emergency department making sure that the pamphlet group does not
receive more than standard care. This was not possible in the present study with recruitment from a number of hospitals, since such a design requires the project staff to be located at the emergency unit.
In addition to evaluating the effects of different kinds of education, the study illustrates the course of selfreported symptoms in a population with relatively mild complaints who visits an emergency unit after car collisions. One year after the accident almost all participants had returned to work. However, one third of the participants had not completely recovered, and about 15% did still report considerable symptoms. This should be viewed in the light of neck complaints being common, also without a preceding trauma. For example, in a random Danish population 18% of males and 29% of females reported neck or shoulder complaints during the past week.
The poor follow-up rate with only 50% and 71% responding to questionnaires was certainly a limitation of the 3- and 6-month follow-ups. However, those not participating did not differ from those responding to questionnaires on baseline parameters and the results of these follow-ups were in line with the 1-year follow-up which had a 87%-rate of participation. Another limitation
is the arbitrary choice of replacing missing items in the disability scales with worst case scores. This was done in order not to loose data from almost complete questionnaires, but met the problem at the 12-month follow-up that more items were missing in the pamphlet group than the personal communication group. Hence, reported disability scores at the last follow-up, particularly
in the pamphlet group, may give a slightly more negative picture than what was really present.
In summary, we recognize limitations of the present study but do not find that these alter the conclusions. No statistically significant differences were shown between the 2 groups, but a systematic tendency toward better outcome with personal communicated information was nevertheless observed. The question how patients should be educated to reduce the risk of chronicity after whiplash is worth further investigation, especially because no effective treatment can prevent long-lasting symptoms, and all forms of advice or educational therapy are so cheap that even a modest effect justifies its use.
