SPINE Volume 31, Number 7, pp 723–731 ©2006, Lippincott Williams & Wilkins, Inc. Education by General Practitioners or Education and Exercises by Physiotherapists for Patients With Whiplash-Associated Disorders? A Randomized Clinical Trial Gwendolijne G. M. Scholten-Peeters, PhD,*†‡§ Catharina W. M. Neeleman-van der Steen, MSc,* Danie ¨lle A. W. M. van der Windt, PhD, Erik J. M. Hendriks, PhD,*¶ Arianne P. Verhagen, PhD,** and Rob A. B. Oostendorp, PhD*†‡ Study Design. Randomized clinical trial. Objective. To compare the effectiveness of education and advice given by general practitioners (GPs) with ed- ucation, advice, and active exercise therapy given by physiotherapists (PTs) for patients with whiplash-associ- ated disorders. Summary of Background Data. Available evidence from systematic reviews has indicated beneficial effects for active interventions in patients with whiplash-associated disor- ders. However, it remained unclear which kind of active treatment was most effective. Methods. Whiplash patients with symptoms or dis- abilities at 2 weeks after accident were recruited in pri- mary care. Eligible patients still having symptoms or dis- abilities at 4 weeks were randomly allocated to GP care or physiotherapy. GPs and PTs treated patients according to a dynamic multimodal treatment protocol primarily aimed to increase activities and influence unfavorable psychosocial factors for recovery. We trained all health care providers about the characteristics of the whiplash problem, available evidence regarding prognosis and treatment, and protocol of the interventions. The content of the information provided to patients during treatment depended on the treatment goals set by the GPs or PTs. Also, the type of exercises chosen by the PTs depended on the treatment goals, and it was not explicitly necessary that exercise therapy was provided in all patients. Primary outcome measures included neck pain intensity, head- ache intensity, and work activities. Furthermore, an inde- pendent blinded assessor measured functional recovery, cervical range of motion, disability, housekeeping and social activities, fear of movement, coping, and general health status. We assessed outcomes at 8, 12, 26, and 52 weeks after the accident. Results. A total of 80 patients were randomized to either GP care (n = 42) or physiotherapy (n = 38). At 12 and 52 weeks, no significant differences were found con- cerning the primary outcome measures. At 12 weeks, physiotherapy was significantly more effective than GP care for improving 1 of the measures of cervical range of motion (adjusted mean difference 12.3°; 95% confidence interval [CI] 2.7–21.9). Long-term differences between the groups favored GP care but were statistically significant only for some secondary outcome measures, including functional recovery (adjusted relative risk 2.3; 95% CI 1.0 – 5.0), coping (adjusted mean difference 1.7 points; 95% CI 0.2–3.3), and physical functioning (adjusted mean differ- ence 8.9 points; 95% CI 0.6 –17.2). Conclusions. We found no significant differences for the primary outcome measures. Treatment by GPs and PTs were of similar effectiveness. The long-term effects of GP care seem to be better compared to physiotherapy for func- tional recovery, coping, and physical functioning. Physio- therapy seems to be more effective than GP care on cervical range of motion at short-term follow-up. Key words: whiplash, randomized clinical trial, educa- tion, physiotherapy, general practitioner care, effectiveness. Spine 2006;31:723–731 Whiplash injuries and, in particular, the development of chronic symptoms and disability are a clinical and social problem. To date, whiplash is usually defined as an ac- celeration-deceleration mechanism of energy transfer to the neck that results from rear-end or side-impact motor vehicle collisions, diving accidents, or other mishaps. The impact results in bony or soft tissue injuries (whip- lash injury), which in turn may lead to a variety of clin- ical manifestations called whiplash-associated disorders (WAD). 1 The most commonly presented symptoms are neck pain and headache. 2 The majority of whiplash in- juries are indicated as WAD grade 1 or 2. These patients have neck symptoms (grade 1) or neck symptoms with musculoskeletal signs (grade 2), which are usually being attributed to soft tissue injuries. Reports on the course of WAD grades 1–2 show highly variable results. Most patients recover quickly and completely, but chronic symptoms or disability de- velop in a significant proportion (19% to 60%). 3,4 The From the *Dutch Institute of Allied Health Care, Amersfoort, The Netherlands; †Research Center for Allied Health Care, Department of Quality of Care, Radboud University Medical Center, Nijmegen, The Netherlands; ‡Faculty of Medicine and Pharmacology, Depart- ment of Manual Therapy, Vrije Universiteit Brussel, Brussels, Belgium; §Spine and Rehabilitation Center, Uden, The Netherlands; Depart- ment of General Practice, Institute for Research in Extramural Medi- cine, Vrije Universiteit Medical Center, Amsterdam, The Netherlands; ¶Department of Epidemiology, Center of Evidence Based Physiother- apy, Maastricht University, Maastricht, The Netherlands; and **De- partment of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands. Acknowledgment date: January 31, 2005. First revision date: April 21, 2005. Acceptance date: April 21, 2005. The manuscript submitted does not contain information about medical device(s)/drug(s). Professional Organization funds were received in support of this work. No benefits in any form have been or will be received from a commer- cial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Gwendolijne G.M. Schol- ten-Peeters, PhD, Spine and Rehabilitation Center Uden, Volkelseweg 18 c/d, 5405 NA Uden, The Netherlands; E-mail: wendy.scholten@planet.nl 723