Treatment of Whiplash associated disorders
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Treatment of Whiplash associated disorders
In our clinics we see many patients with chronic whiplash symptoms. They usually have taken a long medical journey bouncing from one clinician to another looking for answers to problems that seemingly evade all treatments. In this article we will present our clinical findings and observations on how the treatment of cervical ligament damage may be the answer that has eluded them.
When we see a patient in our Oak Park or Fort Myers’ offices with chronic whiplash symptoms, we typically hear a story like this:
I was in a car accident where I was rear ended. Following the accident I had severe pain in my neck. As the days passed the pain crept into my my upper back and shoulders. I had an x-ray and nothing “remarkable,” was seen. As the pain progressed I was put on pain management and physical therapy. The physical therapy I did twice to three times a week. As the PT was not helping my pain management was expanded from over the counter pain medications to a recommendation to an epidural steroid injection.
The first epidural helped a lot but the pain started to come back. I was sent for a second epidural. That did not help at all. I was sent to an MRI where again, “nothing remarkable” was found that would be significant enough to cause my pain issues.
As more time passed I was diagnosed with “whiplash associated disorder.” My symptoms now included dizziness, headaches, severe pain that starts in my neck and goes through my upper back, into my shoulder, down my arm, into my elbow and hand. I have numbness as well. I was told that eventually all these problems would go away. My problems are not going away, they are getting worse and making it difficult for me to go to work.
I started to do a lot of research to see if I could help myself. My MRI and x-ray did not show anything wrong. I did see research that said that I may have a problem of ligament sprains in the neck. I was relieved in a way that my problems were “not in my mind.” I have also had a lot of negative thoughts that I would never get well. I take a lot of pain medications and do a lot of PT still. I do not have great expectation that these treatments will help me.
Whiplash associated disorders treatments. Why do patients have a poor expectation of recovery?
In the August 2018 edition of The Clinical Journal of Pain, (1) researchers looked into the minds of automobile accident victims to help doctors determine which psychological factors are important in the development of chronic whiplash symptoms.
The patients studied were more likely to have:
- Poor expectations of recovery,
- Posttraumatic stress symptoms, (which may include severe anxiety, flashback to accident fears, anger, self-destructive behavior (drug or alcohol use) and isolation.
In this group is also the challenge of avoidance of treatment or what doctors term “passive coping.” The patient avoids trying to solve the problems they are facing, partly because they have a poor expectation of recovery.
From Ross Hauser, M.D. Early in my career, while my Prolotherapy practice was building, I did hundreds of expert medical reports, reviewing medical records of patients who were injured in car accidents. I did my best to be honest and render expert opinions about what I felt the injuries were due to and what was appropriate care for their injuries. Most patients, lawyers, and even doctors involved in both the healthcare aspect and legal aspect of whiplash injury often don’t understand some of the key concepts of whiplash that we will discuss below.
After reviewing all these cases, I personally believe the best treatment for whiplash injuries is Prolotherapy. Why? When a person has a whiplash injury, they suffer a very quick flexion and extension of the neck and that causes injuries to the cervical neck ligaments. It is these ligament injuries that cause the long-term pain. Whiplash injury causes ligament injury, which causes joint instability, which causes the vertebrae to go out of alignment.
Prolotherapy is an injection technique that stimulates the ligaments to repair themselves. Specifically, Prolotherapy involves the injection of a healing stimulating proliferant (dextrose) into the damaged ligaments. This causes the ligaments to tighten and strengthen, making for stability in the neck which stops muscle spasms and resolve pain.
Our results of treatment are published below.
Physical therapy and exercise, researchers do not know if this is any good in alleviating whiplash symptoms.
Some people do get varying degrees of benefit from exercise and physical therapy for their whiplash related symptoms. These are the people we usually do not see in our offices. We see the people who had less than hoped for success. In an August 2019 study led by the The University of Queensland appearing in the Journal of Clinical Medicine, (2) doctors wrote:
“The results of this review found that the strongest (chronic neck pain) treatment effects to date are those associated with exercise. Strengthening exercises of the neck and upper quadrant have a moderate effect on neck pain in the short-term. The evidence was of moderate quality at best, indicating that future research will likely change these conclusions. Lower quality evidence and smaller effects were found for other exercise approaches. Other treatments, including education/advice and psychological treatment, showed only very small to small effects, based on low to moderate quality evidence.”
As we have suggested many times, exercise and physical therapy are examples of resistance. If the soft tissue of the neck, that is the ligaments and tendons are damaged or weakened, they cannot provide the sufficient resistance needed to strengthen muscles. A November 2018 study (3) from the Scientific Institute for Quality of Healthcare at Radboud University in the Netherlands does suggest however, that physiotherapy care understanding in treating whiplash related disorders has been improving.
“Whiplash causes you more pain than imaging studies can verify – doctors can become skeptical of your pain.”
In the patient story related above, we found that an x-ray and MRI showed “nothing remarkable.” In other words, what the imaging studies revealed was “nothing here to see.” Most patients, lawyers and even doctors involved in both the healthcare aspect and legal aspect of whiplash injury often don’t understand some of the key concepts of whiplash. A lot of times MRI and x-rays show nothing. This however does not mean that there is nothing there. That is not solely our opinion.
In research published in the medical journal Spine (4) and reprinted in the Journal of Manipulative and Physiological Therapeutics, Linda J. Carroll, Ph.D, of the Department of Public Health Sciences, School of Public Health, University of Alberta lead a study from The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) came up with this conclusion in regard to patients suffering from whiplash-associated disorders (WAD).
In examining 226 articles related to treatment course and prognostic factors in neck pain and its associated disorders, the team discovered that the evidence suggests that:
- Approximately 50% of patients with WAD will report neck pain symptoms 1 year after their injuries.
- Greater initial pain, more symptoms, and greater initial disability predicted slower recovery.
- Few factors related to the collision itself (for example, the direction of the collision, headrest type) were prognostic; however, post-injury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery.
Dr. Michele Sterling of the Centre for National Research on Disability and Rehabilitation Medicine, at The University of Queensland, interpreted these findings in the The Journal of manual & manipulative therapy as:
“Whiplash-associated disorders are a common, disabling, and costly condition that occurs usually as a consequence of a motor vehicle crash. While the figures vary depending on the cohort studied, current data indicate that up to 50% of people who experience a whiplash injury will never fully recover and up to 30% will remain moderately to severely disabled by their condition.”(5)
Writing in the European Pain Journal, (6) Norwegian doctors found that whiplash caused more pain in other regions of the body than other pain causes. For example, whiplash associated disorders caused:
- greater intensity back pain than chronic back pain did,
- greater intensity shoulder pain than chronic shoulder pain did,
- even greater intensity neck pain than chronic neck pain not associated with whiplash.
- Women with WAD also reported pain in the hip, arm, hand, stomach, chest and genitalia more often than women with chronic pain originating in other joints.
With individuals with WAD also reporting pain in a wide range of bodily locations, a higher number of painful locations and higher pain intensity than individuals with chronic pain from other causes AND no differences were not accounted for by differences in pain tolerance than with control subjects, clearly there is something causing more pain for these people.
This theory was also supported by research from The University of Sydney in the medical journal Injury which looks at why some patients recover more quickly than others and why some patients remain with chronic problems.
Whiplash-associated disorders – the first step in treatment? Have doctors believe Whiplash-associated disorders are real. The second step: have them believe something more can be done.
In December 2017, doctors at the University of Queensland and Griffith University, in Australia published their findings on the Whiplash associated disorders patient experience with healthcare in the journal BMC musculoskeletal disorders. (7)
- Whiplash associated disorders are the most common non-hospitalised injury resulting from a motor vehicle crash.
- (As mentioned above) Approximately 50% of individuals with WAD experience on-going pain and disability.
- Results from intervention trials for individuals with chronic Whiplash associated disorders are equivocal and optimal treatment continues to be a challenge. (What the researchers are saying here is that treatment studies and outcomes are open to interpretation, and optimal treatment continues to be a challenge. They do not see a gold standard in conventional medicine).
These researchers were looking for hope. The main finding of this study was to see IF the patients were actually benefiting from any treatment but did not know how to say so in the study questionnaire format.
- Twenty-seven individuals with chronic Whiplash associated disorders participated in a one-on-one, semi-structured individual telephone interview.
- Two themes emerged that described the experience of living with chronic Whiplash associated disorders.
- First, all participants described navigating the healthcare system after their whiplash injury to help understand their injury and interpret therapeutic recommendations. Participants highlighted the need to ‘find the right healthcare practitioner (HCP)’ to help with this process. Many participants also described additional complexities in navigating and understanding healthcare incurred by interactions with compensation and funding systems (These would be insurance coverage complexities).
- Second, participants described a journey of realization, and the trial and error used to establish self-management strategies to both prevent and relieve pain. (The patients took an active role in their own health care, possibly because of less than hoped for results in their doctor driven treatments).
- Participants described trying to understand the impact of their initial injury in relation to the gradual realization that there may be an on-going residual deficit.
- Seeking information from multiple sources, including personal experience gained through trial and error, was important in the search for acceptable management strategies.
- Recovery from a whiplash injury is an adaptive process and more than the elimination of pain or disability, therefore, may be different from common clinical patient-reported outcomes.
- (In this statement the researchers are suggesting that people with whiplash-associated disorders, benefit when they come to terms that there is no likely curative treatment for them and that they would do better at managing their pain and disability. Obviously, this is not a statement we would agree with unless Comprehensive Prolotherapy failed).
- Early identification of patient understandings of pain, expectations of recovery, symptoms, and therapy may help merge patient and healthcare professional understandings. (The patient and doctor are not on the same page, and it would be helpful if the patient found a doctor who understood what they are going through). This was followed up by this statement: “acknowledgment and validation of the whiplash injury by health care professionals is seen by many as a necessary step in the recovery process.”
The problems of whiplash associated disorder that you have to deal with every day and their links to cervical instability. Is cervical instability treatment the answer?
Vision problems are a whiplash associated disorder
January 2019: Researchers at the The University of Queensland published in PM & R: The Journal of Injury, Function, and Rehabilitation,(8) an examination of people with whiplash-associated disorders who have difficulty with quick head movements and cervico-ocular dysfunctions. Their study suspected that changes in coordination between eye movement and neck muscle activity may be involved.
In other words, something is off between your eye movements and your neck muscle movements. There is a break in the connection between how your head turns and how your eyes focus. In many patients, we see the break is cervical instability which we explain below.
It is interesting to note that the research above also suggests that this problem with the neck muscles should be explored because not only is there a connection to vision problems, but, “Contrasting (new) changes are present in deep and superficial neck muscles with implications for neck function that may explain some common WAD symptoms.” If the muscle problem is effecting vision, it is effecting other symptoms as well. For more on this subject see our article Chronic Neck Pain and Vision Problems
Swaying, posture control, balance, jaw pain TMD, head tremors, ringing in the ears (tinnitus) are whiplash associated disorders and they are all connected
The complexity of and the riddle of treatment of Whiplash Associated Disorders is on full display in this next three studies. Here we can also ask if it is muscle problems or a broader cervical instability that involve the cervical ligaments as well.
In the January 2019 issue of Archives of oral biology, (9) a group of physiologists from learning universities in Sweden and Saudi Arabia, examined a phenomenon of instant reduction in postural sway during quiet standing by using a dental appliance. When human beings stand still (quite standing) we sway to keep from tipping over. However, if we sway too much we lose balance. People with Whiplash Associated Disorders may sway too much and this is causing balance issues.
Here is the conclusion of this research and then we will explain it:
“The prompt reduction in standing postural sway from intervention by intraoral dental appliance i.e. improved standing balance, suggests a potent effect on the postural control system by modulation of the jaw sensorimotor system, probably involving reflex transmission. The result opens for new insight into mechanisms behind postural control and the pathophysiology of balance disorders and adds to the knowledge on the plasticity of the nervous system. It may help develop new procedures for assessment and management of impaired balance in WAD and non-trauma neck pain patients.”
The researchers present an exciting conclusion because they have recognized the need for postural stability in helping with balance issues in Whiplash Associated Disorders and they found their answer in providing stabilization in the movement of the jaw. Now watch this:
A study from the University of Antwerp published in the journal Experimental brain research (10) looked at the Cervical dystonia patient’s inability to have posture control. Some patients with Cervical dystonia (head tilt, muscle spasms, and tremors), sway too much when they are standing and they sway too much when they are sitting. The excessive sway is caused by impaired cervical sensorimotor control (sense of position and place). The researchers found that as the sway worsens the patients lose their sense of position and place, and with it, their center of balance. Their entire body becomes unstable. A suggested fix the researchers recommend is for a look at the cervical area (cervical instability) and the potential that the problem of instability is coming from a weakened neck. They recommended: “Further research towards the potential value of postural control exercises is recommended.” When you exercise, you are attempting to stabilize cervical instability.
Here we have two studies. The first says that if you stabilize the jaw, you stabilize the head and neck. The sway goes away. The second study says, if you strengthen instability issues in the neck, you can reduce balance issues.
We have a comprehensive article Cervical disc disease and difficulty swallowing – cervicogenic dysphagia on this subject. To touch on this problem here within the context of whiplash associated disorder we will highlight a portion of that article:
- Cervical instability in the neck has been linked to swallowing difficulties, diagnosed as cervicogenic dysphagia.
- Cervical instability has been linked to cervical spine nerve compression which can be an “unseen” cause of swallowing difficulties.
- Cervicogenic dysphagia is not a problem treated in isolation, it is one of a myriad of symptoms related to neck pain and neck hypermobility and can be found in Whiplash Associated Disorders
When a patient comes into our clinic with problems of swallowing difficulties, the swallowing difficulties are usually not a problem in isolation. While patients may tell us of their swallowing difficulties, most come in with primary complaints of neck pain or neck instability, whiplash associated disorders, or post-concussion syndrome. Swallowing difficulties may be accompanied by headaches, dizziness, hearing problems, severe muscle spasms in the neck, to name but just a few symptoms.
Swallowing difficulty involves the sensation that food is stuck in the throat or upper chest. This sensation may be perceived either high in the neck or lower down, behind the sternum, or breastbone. Swallowing difficulty can become a serious problem among the elderly. The symptoms the patients describe are usually extremely debilitating and the patient often tells us that they are at the “end of their rope.” A feeling of abandonment by the medical community is also a common complaint.
In research from August 2019, research lead by the The University of Sydney noted in the journal Dysphagia.(11)
- Non-specific self-reports of dysphagia have been described in people with whiplash-associated disorders (WAD) following motor vehicle collision; however, incidence and mechanistic drivers remain poorly understood.
- Alterations in oropharyngeal dimensions (the narrowing of space of the pathways in the middle part of throat) on magnetic resonance imaging (possibly caused by cervical neck instability), along with heightened levels of stress, pain, and changes in stress-dependent microRNA expression (the immune system’s inability to heal damage) have been also associated with WAD, suggesting multi-factorial issues may underpin any potential swallowing changes.
The researchers suggested treatment parameters to included:
- expanding oropharyngeal space
- peritraumatic miR-320a expression (addressing possible immune system involvement), and
- psychological distress.
In a September 2019 study in the medical journal Pain (12), doctors at the The University of Queensland and the Australian Catholic University investigated the direction of the relationship between pain and traumatic stress and the role that pain-related fear plays, for patients with acute whiplash-associated disorder. Here is how the study went:
- 99 Patients used an electronic diary to record hourly ratings of:
- traumatic stress,
- and fear of pain symptoms over a day.
- Of note:
- Traumatic stress was associated with previous pain, even after controlling for previous traumatic stress and current pain;
- current pain was not associated with previous traumatic stress.
- The relationship between traumatic stress and previous pain became negligible after controlling for the problem of Fear of Pain, except for traumatic stress symptoms of hyperarousal (over sensation of pain) that were driven directly by pain.
- Overall, these results support a pain primacy model, and suggest that pain-related fear is important in the maintenance and development of comorbid pain and traumatic stress symptoms.
- The results also confirm that traumatic stress symptoms of hyperarousal are central in this relationship.
- Traumatic stress may affect pain over longer time intervals than measured in this study. Future research could explore how relationships between traumatic stress symptoms, pain, and Fear of Pain change over time, and whether previous experiences of traumatic stress influence these relationships.
The key it appears suggested by this research is control for the problem of Fear of Pain. One way to control that fear of pain is to heal the injuries and reduce pain.
A treatment of interest: Prolotherapy for cervical ligaments damage and cervical neck instability
The above research shows us where medicine is in regard to the difficult to treat patients with whiplash-associated disorders. Treat the depression, treat the fear, treat the anxiety, keep looking for answers. Prolotherapy doctors have known for a long time that the best way to treat these problems is to treat and stabilize the cervical neck ligaments.
In our opinion, prolonged symptoms of whiplash – neck pain, headaches, dizziness, burning or prickling sensations (paresthesias), back or shoulder pain, and difficulties with concentration and memory are usually not problems solely correlated with the cervical discs damaged in whiplash but a problem of damage to the cervical ligaments.
When ligaments are subjected to quick forces, as occurs in whiplash traumas, it does not take much to tear or overstretch them. All whiplash traumas have the potential to significantly injure cervical ligaments and cause neck instability.
If it is not a problem of discs, but ligaments, cervical fusion is the wrong treatment for whiplash
Research has shown that a small percentage of patients with whiplash-associated disorders, cervical fusion can be successful. Dr. Bo Nystrom, a surgeon whose work we often cite, published a study in 2016 that suggested fusion may be of benefit in a group of carefully qualified patients whose problems came from segmental mobility issues, that is, functional problems in the disc.(13) Even so, this is a small group of patients and success was 2 out of 3 achieving pain relief. One out of three did not and had an unsuccessful surgery.
We like to see patients before the cervical neck fusion surgery when the problems of a failed surgery compound a pre-existing problem. Unfortunately, we do not always see the patient first and see them after a cage, screws, and other fusion materials are already in place and the pain remains.
RESEARCH: Fusion creates the same problem it is trying to fix in whiplash patients
Another problem that can manifest in fusion patients looking for relief from their prolonged whiplash syndrome is that the fusion may mimic the problems the fusion was trying to fix. It is interesting that doctors from the University of Pittsburgh writing in the medical publication The Spine Journal discussed similar characteristics between whiplash and patients who underwent cervical fusion. What they found was that when the head moves, up, down, side to side, or during rotation, the forces of motion come into play throughout the cervical spine.
Patients who have limited range of motion from whiplash injury and patients who underwent cervical spinal fusion, exhibited the same problems, not only reduced range of motion but increased segmental instability (meaning that the vertebrae above and below the fusion and near the points of injury in whiplash were under stress to help provide movement and neck stability).
The medical advice: “the clinician may advise the patient to avoid end range of motion positions to lessen the demand on the discs.”(14) Please refer to my article Cervical pain, adjacent segment disease following neck surgery for a more detailed understanding of this problem.
So surgery to help patients with whiplash injury, the cervical fusion, in this case, and for many patients, does not alleviate the problems of pain-free neck movement. In fact, it contributes to it.
Researchers want answers for perplexing and challenging whiplash patients
Most head traumas and whiplash injuries result in flexion and rotatory stress onto the upper cervical vertebrae, which disrupts the capsular ligaments (cervical facet joints).
There are four basic mechanisms of neck injuries:
- flexion (head snaps forward),
- extension (head snaps backward),
- rotation (head snaps top left or right or both) and
- compression (impact).
Most often head and neck trauma contain all four mechanisms. Any trauma that involves a rotatory component of the neck will then by definition injure the capsular ligaments.
Doctors in Belgium writing in the Journal of Manipulative and Physiological Therapeutics acknowledge that difficulty in diagnosing cervical neck injury lies in the fact that major injury to the cervical spine may only produce minor symptoms in some patients, whereas minor injury may produce more severe symptoms in others. Here is what they wrote in regard to MRI, CT Scans, and X-rays.
“There seems to be no correlation between the amount of hypermobility or subluxation and the presence of clinical signs or neurological signs. The clinical signs can vary from relatively diffuse complaints, no symptoms and signs to serious ones.
Radiology does not seem to be a reliable diagnostic mechanism in relation to upper-cervical instability. Conventional X-rays fail to give adequate information about atlanto-axial stability. CT-scan and MRI can visualize much more because of the direct sagittal projection (basically a cross-section view) but neither is an absolute standard. Furthermore, in relation to upper-cervical hypermobility, the validity of radiology is under debate.”(15)
Dr. Bengt H Johansson in the medical journal Pain Research and Management wrote: Damage to cervical ligaments from whiplash trauma has been well studied, yet these injuries are still often difficult to diagnose and treat. Standard x-rays often do not reveal the present injury to the cervical spine and as a consequence, these injuries go unreported and patients are left without proper treatment for their condition.
“Diagnosis is particularly difficult in injuries to the upper segments of the cervical spine (craniocervical joint [CCJ] complex). Studies indicate that injuries in that region may be responsible for the cervicoencephalic syndrome, as evidenced by headaches, balance problems, vertigo, dizziness, eye problems, tinnitus, poor concentration, sensitivity to light and pronounced fatigue.”(16)
Cervical ligaments and chronic whiplash associated disorders – the answer is in the examination
Here is a study from the journal Traffic Injury Prevention: What the doctors were looking for was how the placement of the head at the time of impact affected long-term symptoms. In other words – how stretched were the neck ligaments at the time of impact – and how much more did they get stretched during the impact. They key here is the injury to the ligaments and future impact on neck instability.
The doctors then came up with a model that would predict ligament damage. Here is what they concluded:
- Higher potential for injury when the head was turned (ligaments will be stretched in head turned position). This time of impact position could lead to a higher potential for whiplash injury by as much as 50%.(17)
This is agreed to and embellished in a paper from Fort Lewis College and Colorado State University researchers who suggested doctors can be misled in their diagnosis and treatment by not fully understanding the complexities of the range of motion in the neck. To find the cause of cervical instability – doctors need to increase the physical examination of the neck ligaments.(18)
Evidence closing in on untreated ligament injury as the cause of whiplash associated pain
In research from December 2016, (19) doctors in Sweden used nerve blocks in Chronic Whiplash-Associated Disorders looking for evidence that the problems related to whiplash were coming from cervical vertebrae facet joints – a sign of ligament instability. They tested the C2-C7 joints and begin with a bupivacaine-based nerve block and for control also tested with saline.
The results showed that:
- 29% of patients had pain relief with the nerve block
- 60% did not respond,
- and 11% placebo responders. (Saline injections do work)
The doctors concluded: A substantial amount of patients with Chronic Whiplash Associated Disorders have their persistent pain emanating from cervical zygapophyseal joints.
It can be suggested then that 3 out of 10 patients who would normally be sent to fusion surgery, would be sent to unnecessary surgery.
Caring Medical Published Research
This is also confirmed in our own published research spearheaded by Danielle R. Steilen-Matias, PA-C. In this research that appeared in The Open Orthopaedics Journal, we showed that conventional treatments for chronic neck pain remain debatable, primarily because most treatments have had limited success because they did not address the cervical ligaments.
Multiple studies have implicated the cervical facet joint and its capsule as a primary anatomical site of injury during whiplash exposure to the neck. Others have shown that injury to the cervical facet joints and capsular ligaments are the most common cause of pain in post-whiplash patients.
In our study, we were able to conclude and document Prolotherapy injections to be an effective treatment for chronic neck pain and cervical instability due to whiplash, especially when due to ligament laxity in the cervical joints.(20)
In 1984, doctors at the University of Iowa produced a study that is often cited in medical research even today. Here the researchers examined the relative motion between various vertebrae of multi-level cervical ligamentous spinal segments. They found an that when there is an injury to a particular capsular ligament, say at C5-C6, it produces a significant increase in relative motion at the next superior vertebrae, in this case, C4-C5, as well as at the level of injury.(21)
In over two decades of experience specializing in cervical spine cases and reviewing the medical research on whiplash and cervical spine instability, we developed Caring Cervical Realignment Therapy (CCRT). For patients who are struggling with post-traumatic injuries to the neck and have been trying everything from rest to physical therapy to medications and even surgery, CCRT makes the most sense for long-term relief of pain and symptoms, as well as restoring the normal curve to the spine!
In other words, injury or ligament damage instability, at one level of the cervical neck impacts the whole neck and the whole body.
If you have questions and would like to discuss your whiplash pain issues with our staff you can get help and information from us.
1 Campbell L, Smith A, McGregor L, Sterling M. Psychological Factors and the Development of Chronic Whiplash–associated Disorder (s). The Clinical journal of pain. 2018 Aug 1;34(8):755-68. [Google Scholar]
2 Sterling M, de Zoete RM, Coppieters I, Farrell SF. Best Evidence Rehabilitation for Chronic Pain Part 4: Neck Pain. Journal of clinical medicine. 2019 Aug;8(8):1219. [Google Scholar]
3 Oostendorp RA, Elvers H, van Trijffel E, Rutten GM, Scholten-Peeters GG, Heijmans M, Hendriks E, Mikolajewska E, De Kooning M, Laekeman M, Nijs J. Has the quality of physiotherapy care in patients with Whiplash-associated disorders (WAD) improved over time? A retrospective study using routinely collected data and quality indicators. Patient preference and adherence. 2018;12:2291. [Google Scholar]
4 Carroll LJ, Holm LW, Hogg-Johnson S, Côtè P, Cassidy JD, Haldeman S, Nordin M, Hurwitz EL, Carragee EJ, van der Velde G, Peloso PM. Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Journal of manipulative and physiological therapeutics. 2009 Feb 28;32(2):S97-107. [Google Scholar]
5 Sterling M. Whiplash-associated disorder: musculoskeletal pain and related clinical findings. Journal of Manual & Manipulative Therapy. 2011 Nov 1;19(4):194-200. [Google Scholar]
6 Myrtveit SM, Skogen JC, Sivertsen B, Steingrímsdóttir ÓA, Stubhaug A, Nielsen CS. Pain and pain tolerance in whiplash‐associated disorders: A population‐based study. European Journal of Pain. 2016 Jul 1;20(6):949-58. [Google Scholar]
7 Ritchie C, Ehrlich C, Sterling M. Living with ongoing whiplash associated disorders: a qualitative study of individual perceptions and experiences. BMC musculoskeletal disorders. 2017 Dec;18(1):531. [Google Scholar]
8 Bexander CS, Hodges PW. Cervical rotator muscle activity with eye movement at different speeds is distorted in whiplash. PM&R. 2019 Jan. [Google Scholar]
9 Eriksson PO, Zafar H, Backén M. Instant reduction in postural sway during quiet standing by intraoral dental appliance in patients with Whiplash associated Disorders and non-trauma neck pain. Archives of oral biology. 2019 Jan 1;97:109-15. [Google Scholar]
10 De Pauw J, Mercelis R, Hallemans A, Van Gils G, Truijen S, Cras P, De Hertogh W. Postural control and the relation with cervical sensorimotor control in patients with idiopathic adult-onset cervical dystonia. Experimental brain research. 2018 Mar 1;236(3):803-11.
11 Stone D, Bogaardt H, Linnstaedt SD, Martin-Harris B, Smith AC, Walton DM, Ward E, Elliott JM. Whiplash-associated dysphagia: considerations of potential incidence and mechanisms. Dysphagia. 2019 Aug 3:1-1. [Google Scholar]
12 Eather A, Kenardy J, Healy KL, Haynes M, Sterling M. How are pain and traumatic stress symptoms related in acute whiplash–associated disorders? An investigation of the role of pain-related fear in a daily diary study. Pain. 2019 Sep 1;160(9):1954-66. [Google Scholar]
13 Nyström B, Svensson E, Larsson S, Schillberg B, Mörk A, Taube A. A small group Whiplash-Associated-Disorders (WAD) patients with central neck pain and movement induced stabbing pain, the painful segment determined by mechanical provocation: Fusion surgery was superior to multimodal rehabilitation in a randomized trial. Scandinavian Journal of Pain. 2016 Jul 31;12:33-42. [Google Scholar]
14 Anderst WJ, Donaldson WF, Lee JY, Kang JD. Cervical motion segment contributions to head motion during flexion\extension, lateral bending, and axial rotation. The Spine Journal. 2015 Dec 1;15(12):2538-43. [Google Scholar]
15. Swinkels RA, Oostendorp RA. Upper cervical instability fact or fiction. J Manip Physiol Ther. 1996;19(3): 185–94. [Google Scholar]
16 Johansson BH. Whiplash injuries can be visible by functional magnetic resonance imaging. Pain Research and Management. 2006;11(3):197-9. [Google Scholar]
17 Shateri H, Cronin DS. Out-of-Position Rear Impact Tissue-Level Investigation Using Detailed Finite Element Neck Model. Traffic Inj Prev. 2015;16(7):698-708. doi: 10.1080/15389588.2014.1003551. Epub 2015 Feb 9. [Google Scholar]
18 Leahy PD, Puttlitz CM. Addition of lateral bending range of motion measurement to standard sagittal measurement to improve diagnosis sensitivity of ligamentous injury in the human lower cervical spine. Eur Spine J. 2016 Jan;25(1):122-6. [Google Scholar]
19 Persson M, Sörensen J, Gerdle B. Chronic Whiplash Associated Disorders (WAD): Responses to Nerve Blocks of Cervical Zygapophyseal Joints. Pain Med. 2016 Dec;17(12):2162-2175. [Google Scholar]
20 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability. The Open Orthopaedics Journal. 2014;8:326-345. [Google Scholar]
21 Goel VK, Clark CR, McGowan D, Goyal S. An in-vitro study of the kinematics of the normal, injured and stabilized cervical spine. Journal of biomechanics. 1984 Jan 1;17(5):363-76. [Google Scholar]