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Griffin A1,2, Jagnoor J2,3, Arora M2, Cameron I2, Annette K2, Sterling M4,5, Kenardy J5, Rebbeck T1,2
1The University of Sydney, Faculty of Health Sciences, Sydney, Australia, 2John Walsh Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, Australia, 3The George Institute for Global Health, Newtown, Australia, 4University of Queensland, NHMRC Centre of Research Excellence in Road Traffic Injury, St Lucia, Australia, 5University of Queensland, Recovery Injury Research Centre, Herston, Australia
Background: Studies aimed at improving the provision of evidence-based care (EBC) for the management of acute whiplash injuries have been largely successful. However, whether EBC is broadly provided and whether delivery of EBC varies based on risk of non-recovery, is uncertain. Receiving EBC should improve recovery, though this relationship has yet to be established. Further, mediating the effect of EBC is the relationship, or 'alliance' with the practitioner.
Purpose: This study aimed to determine the proportion of individuals with whiplash, at differing baseline risk levels, receiving EBC. This study also aimed to determine whether baseline risk level, receiving EBC and the therapeutic alliance, were associated with recovery at 3 months post injury.
Methods: Participants with acute whiplash were assessed for risk of non-recovery using a validated clinical prediction rule (CPR) and completed questionnaires at baseline and 3-months post injury. Primary health care providers (HCPs) treating these participants also completed questionnaires at 3-months. Recovery was defined as Neck Disability Index ≤ 4/50 and global perceived effect of ≥ 4/5. Therapeutic alliance was assessed using a modified Working Alliance Theory Of Change Inventory (WATOCI) scale with a score range of 9 - 45.
Results: Two hundred and twenty-eight participants with whiplash and 53 HCPs participated. The majority of the cohort reported receiving EBC at 3-months, with correct application of the Canadian C-spine rule (n=116/160; 73%), and provision of active treatments (e.g. n = 142/160; 89% receiving advice) being reported as high. Non-recommended (passive) treatments were also received by a large proportion of the cohort (e.g. n = 80/160; 50% receiving massage). The ability of primary HCPs to identify individuals at high risk of non-recovery and tailor management accordingly was poor (e.g. 13% correctly identified, and a mean(SD) of 8(6) treatment sessions for low-risk vs mean(SD) of 10(7) treatment sessions for high-risk). Thirty-five percent of the cohort had recovered at 3 months, with lower baseline risk and positive therapeutic alliance predictive of recovery.
Conclusion(s): Guideline-based knowledge and practice, such as providing active treatments, has been retained from previous implementation strategies. However, recommendations for routine risk identification and tailored management, and reduction in the provision of passive treatment have not. Positive therapeutic alliance was identified as one of several important predictors of recovery, suggesting that clinicians must develop rapport and understanding with their patients to improve the likelihood of recovery.
Implications: Guideline implementation strategies must now focus on improving the process for management of people with whiplash injuries, including practices relating to risk-identification and the referral of at-risk individuals. The therapeutic alliance should form an important focus in the management of this population.
Keywords: Whiplash injuries, evidence-based care, clinical practice guidelines
Funding acknowledgements: The State Insurance Regulatory Authority (SIRA) of New South Wales, Australia funded this research.
Purpose: This study aimed to determine the proportion of individuals with whiplash, at differing baseline risk levels, receiving EBC. This study also aimed to determine whether baseline risk level, receiving EBC and the therapeutic alliance, were associated with recovery at 3 months post injury.
Methods: Participants with acute whiplash were assessed for risk of non-recovery using a validated clinical prediction rule (CPR) and completed questionnaires at baseline and 3-months post injury. Primary health care providers (HCPs) treating these participants also completed questionnaires at 3-months. Recovery was defined as Neck Disability Index ≤ 4/50 and global perceived effect of ≥ 4/5. Therapeutic alliance was assessed using a modified Working Alliance Theory Of Change Inventory (WATOCI) scale with a score range of 9 - 45.
Results: Two hundred and twenty-eight participants with whiplash and 53 HCPs participated. The majority of the cohort reported receiving EBC at 3-months, with correct application of the Canadian C-spine rule (n=116/160; 73%), and provision of active treatments (e.g. n = 142/160; 89% receiving advice) being reported as high. Non-recommended (passive) treatments were also received by a large proportion of the cohort (e.g. n = 80/160; 50% receiving massage). The ability of primary HCPs to identify individuals at high risk of non-recovery and tailor management accordingly was poor (e.g. 13% correctly identified, and a mean(SD) of 8(6) treatment sessions for low-risk vs mean(SD) of 10(7) treatment sessions for high-risk). Thirty-five percent of the cohort had recovered at 3 months, with lower baseline risk and positive therapeutic alliance predictive of recovery.
Conclusion(s): Guideline-based knowledge and practice, such as providing active treatments, has been retained from previous implementation strategies. However, recommendations for routine risk identification and tailored management, and reduction in the provision of passive treatment have not. Positive therapeutic alliance was identified as one of several important predictors of recovery, suggesting that clinicians must develop rapport and understanding with their patients to improve the likelihood of recovery.
Implications: Guideline implementation strategies must now focus on improving the process for management of people with whiplash injuries, including practices relating to risk-identification and the referral of at-risk individuals. The therapeutic alliance should form an important focus in the management of this population.
Keywords: Whiplash injuries, evidence-based care, clinical practice guidelines
Funding acknowledgements: The State Insurance Regulatory Authority (SIRA) of New South Wales, Australia funded this research.
Topic: Musculoskeletal: spine; Globalisation: health systems, policies & strategies; Musculoskeletal
Ethics approval required: Yes
Institution: New South Wales Health
Ethics committee: Sydney Local Health District Ethics Committee
Ethics number: HREC/13/CRGH/67
All authors, affiliations and abstracts have been published as submitted.
