Whiplash is the most common traffic injury, affecting 83% of people involved in motor vehicle collisions. The injury leads to "Whiplash-associated Disorders" (WAD), a clinical syndrome that includes neck pain and clusters of physical and psychological symptoms.[2, 3] WAD result in a significant burden of pain, disability and health care utilization.[1, 2, 4–7] Moreover, WAD may increase the risk of future health problems. Studies from Sweden and Saskatchewan suggest that individuals with a history of whiplash injuries may be more likely than those without a history of whiplash injuries to suffer from future episodes of neck pain, headaches, low back pain, shoulder pain, and sleep disturbances.[1, 8–10]
Exorbitant health care costs, increasing disability rates and uncertainty about the most effective management of WAD have led governments, insurers and clinicians throughout the Western world to develop treatment guidelines and programs of care for the treatment of whiplash injuries.[1, 2, 11–15] Traditionally, these guidelines have emphasized the delivery of clinical interventions and focused less on the environment surrounding the claim process. However, it is well known that the recovery from WAD also depends on contextual factors.[1, 4, 16, 17]
A growing body of evidence suggests that the type, intensity and timing of health care delivery are strongly and independently associated with time to recovery. Specifically, Côté et al. found that patients who made more than two visits to general practitioners, more than six visits to chiropractors, received care from general practitioner and chiropractors and those who consulted general practitioners and specialists within the first month of their injury took longer to recover than patients who visited general practitioners once or twice.[4, 5] In another cohort, Cassidy et al. investigated the effectiveness of a province-wide rehabilitation program in Saskatchewan and found that patients who attended fitness training or a multidisciplinary outpatient rehabilitation program within 120 days of their injury had slower recovery than those who received usual community care. Finally, a recent randomized trial compared "education and advice" by general practitioners to "education and exercises" by physiotherapists in patients with WAD lasting more than four weeks. One year after the injury, patients in the general practitioner group reported levels of neck pain and headache intensity that were lower than those treated by physiotherapists. Overall, this evidence suggests that the type and intensity of clinical care strongly influences the prognosis of whiplash injuries.
Despite the efforts of governments and insurers, we still do not know whether guidelines or programs of care are effective in improving health outcomes and reducing costs of patients with WAD. To date, no randomized trials have investigated the effectiveness of a coordinated and staged multidisciplinary rehabilitation program aimed at improving the health outcomes of patients with WAD. Moreover, it is not known whether rehabilitation programs are superior to physician-based education and activation in promoting better health outcomes. Therefore, there is a need for a pragmatic randomized controlled trial to investigate which program of care yields the best outcomes for patients.
Our primary objective is to determine whether education and activation by a physician is more effective than two rehabilitation programs of care ("Soft Tissue Injury Care Model" developed by AVIVA Canada and the "Pre-approved Framework Guideline for Grade I and II Whiplash Associated Disorders" developed by the Financial Services Commission of Ontario, an arm's length agency of the Ontario Ministry of Finance) in improving recovery from WAD.
Our secondary objectives will compare the effectiveness of the three interventions on reducing neck pain intensity, reducing whiplash-related disability, improving the health-related quality of life, reducing depressive symptoms, improving satisfaction with care, shorten insurance claim durations, and reducing the recurrence rate in patients with WAD.