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Word of the Day

Advice = comprehensive physiotherapy in chronic whiplash (PROMISE)

Clinical Question:
Does physiotherapy improve patient outcomes more than advice in patients with chronic whiplash?

Bottom Line:
In this trial of patients with chronic pain from whiplash, 30 minutes of brief advice was as effective as 20 individualized comprehensive sessions with a physiotherapist. (LOE = 1b)

Michaleff ZA, Maher CG, Lin CW, et al. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomised controlled trial. Lancet 2014;384(9938):133-141.  [PMID:24703832]

Study Design:
Randomized controlled trial (single-blinded)




This trial (PROMISE: an acronym so tortured the authors never spell it out) was designed as a pragmatic trial (intended to reflect the real world) that compared outcomes of 172 patients with whiplash treated with simple advice or a comprehensive physiotherapy program. The researchers recruited adults from communities through advertising campaigns, and excluded patients with serious spine disease, nerve root compromise, fracture or dislocation, and those treated surgically. The included patients had chronic (lasting between 3 months and 5 years) grade 1 or grade 2 whiplash. All study participants received a booklet that advised patients about the self-management of symptoms and provided a simple home-exercise program. Additionally, the researchers randomized patients to receive advice (30 minutes of advice from a physiotherapist about the contents in the educational booklet and a run-through of the exercises) or to a comprehensive physiotherapy program (20 sessions of individually tailored exercises and cognitive-behavioral therapy strategies supervised by a physiotherapist). One of the investigators, unaware of treatment assignment, assessed each patient at baseline, 14 weeks, 6 months, and 1 year. At the end of the study, the researchers excluded only 1 patient from each group. Using intention-to-treat analysis, the authors found no difference in pain scores at any point throughout the study. No prespecified subgroups of patients fared any differently, either


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