In a 2-step trial conducted in the United Kingdom, providing active management consultation for patients with acute whiplash injury in emergency departments (ED) did not show additional benefit compared with usual care consultations, say authors of an article published in February in The Lancet. Physical therapy resulted in a modest acceleration to early recovery of persisting symptoms but was not cost effective from the National Health Service's (NHS) perspective. Usual consultations in EDs and a single physical therapy advice session for persistent symptoms are recommended, the authors add. 

Step 1 was a pragmatic, cluster randomized trial of 12 NHS Trust hospitals including 15 EDs that treated patients with acute whiplash associated disorder of grades I-III. The hospitals were randomized by clusters to either active management or usual care consultations. In step 2, the researchers used a nested individually randomized trial. Patients were randomly assigned to receive either a package of up to 6 physical therapy sessions or a single physical therapy advice session. Randomization in Step 2 was stratified by the center. Investigator-masked outcomes were obtained at 4, 8, and 12 months. The primary outcome was the Neck Disability Index (NDI). Analysis was intention to treat, and included an economic evaluation.

In step 1, 12 NHS Trusts were randomized, and 3,851 of 6,952 eligible patients agreed to participate (1,598 patients were assigned to usual care and 2,253 patients were assigned to active management). Of the 3,851 eligible patients, 2,704 (70%) provided data at 12 months. NDI score did not differ between active management and usual care consultations (difference at 12 months 0.5).

In step 2, 599 patients were randomly assigned to receive either a single physical therapy advice session (299 patients) or 6 physical therapy sessions (300 patients); 479 (80%) patients provided data at 12 months. At 4 months, patients who received physical therapy showed a modest benefit compared with advice (NDI difference -3.7, -6.1 to -1.3), but not at 8 or 12 months. Active management consultations and physical therapy were more expensive than usual care and a single advice session. No treatment-related serious adverse events or deaths were noted.