Use of short-term cervical collars is associated with emotional discomfort

We read with interest the manuscript on the topic of cervical collars for the management of spinal cord injuries.¹ Kolli et al. provide compelling evidence on the low levels of evidence for cervical collars to restrict movement and prevent worsening injury. On the contrary, evidence towards delayed recovery and worse pain profiles suggest adverse effects from collar use.¹

The association of long-term collar use with poorer quality of life was highlighted.¹ especially in older adults.^{2, 3} However, patient experiences of wearing cervical collars for shorter times in an emergency department (ED) setting have not been previously evaluated. The current standard of care in Victoria, Australia is the use of rigid foam cervical collars for spinal immobilisation in a patient with suspected cervical spine injury.⁴

We conducted a pilot prospective cohort study at an adult major trauma centre in Australia which records approximately 10 000 trauma presentations a year. The aim of this study was to evaluate patients’ experiences in a short-term cervical collar and the purpose of the study was to generate a hypothesis of harm. Short-term was defined as the period between application of the collar and until being cleared of any cervical spine injuries, which is less than 12 h.

A total of 20 participants enrolled by convenience sampling who were managed in cervical collars awaiting clearance with a Glasgow Coma Scale rating of 15, and who could converse in English formed the exposure group. A non-exposure group of 20 participants included adult patients not in cervical collars awaiting the results of investigations in the ED. All 40 participants were admitted to the short-stay unit in the ED with an aim to be discharged home in 24 h which suggests they all had low disease severity. The groups were matched for age (± 2 years) and gender. All 40 participants were assessed at a single time point using the Patient Evaluation of Emotional Comfort Experience (PEECE) questionnaire.⁵ This tool evaluates positive mental well-being elements like emotional comfort rather than negative health outcomes.

Each component of the PEECE score and the total were summarised using medians (inter-quartile range) and differences were compared using the Wilcoxon Rank Sum test. A p-value of <.05 was defined to be statistically significant. All analyses were conducted using Stata v18.0.

The total PEECE score among patients with a collar was 30.5 (interquartile range [IQR] 21–39.5), significantly lower than patients without a collar (total score 38.5; IQR 32–41.5, p = .016) (Figure 1). With a collar in place, patients reported significantly lower scores for positive emotions of being at ease, relaxed or wanting to smile. In addition, they also scored significantly lower perceptions of being valued, feeling safe or being thankful (Table 1). We acknowledge the limitation of a small sample size and the presence of unknown confounders. Therefore no power calculation was performed.

Patients with cervical collars are limited in their field of vision as most are instructed to lie flat on their backs and cannot move their necks. As a result, unless they are fully informed and educated about their treatment, they may not be able to comprehend all of the care being provided to them. A few hours in such a position appeared to be associated with significant discomfort.^{6, 7} In a cervical collar, patients reported lower scores of feeling in control and higher perceptions of feeling informed and cared for, indicating specific and unique needs for patients in a collar.

Enabling earlier clearance of the cervical spine through faster assessment presents a preventive strategy. When necessary, the hospital management of collars requires specific attention to comfort and frequent updates on progress. Emotional support could be provided through audio-visual stimuli that are accessible while patients are bed-bound and supine. Kolli et al.¹ posit that the use of cervical collars can be harmful to certain patient populations and that inappropriate use may also increase the likelihood of unfavourable patient outcomes. When this is considered alongside the results of our study, it is clear that the need for innovative strategies to improve the care of patients with suspected or actual cervical spine injury is imperative.

Initial idea conceived by AU, ES, and BM. Idea revised and data collected by AS and JC. Manuscript write up completed by AS, JC, BM and JH. Manuscript reviewed and edits provided by all authors.

The authors declare no conflict of interest.

Nil funding was availed for this study.

The ethical approval was provided by The Alfred Human Research and Ethics Committee (Project ID 487/18).