The Whiplash Page, aka
Cervical Acceleration – Deceleration  (CAD) aka,
Whiplash – Associated Disorders  (WAD)

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:

If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary. If you want information about a specific disease, you can access the Merck Manual. You can also search Pub Med for more abstracts on this, or any other health topic.

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[Brain Stem Stretch]
Stretching of the Brainstem with a Flexion-type Injury
Used with permission from Dr. A.C. Croft

Primary Whiplash Resources

Chiropractic And Chronic Neck Pain
A Chiro.Org article collection
This page discusses the benefits of chiropractic for chronic neck pain.

Radiculopathy and Chiropractic Page
A Chiro.Org article collection
This page discusses the benefits of chiropractic for radiculopathy.

Chiro.Org's Cervical Spine Bookshelf
Please browse our Cervical Spine book shelf.
Any books you purchase will help to support our non-commercial website.

Cervical Spine Trauma
Chapter 22 from:   “The Rehabilitation Monograph Series”

By Richard C. Schafer, D.C., FICC and the ACAPress

The cervical spine provides structural stability and support for the cranium, and a flexible and protective column for movement and balance adaptation, along with housing of the spinal cord and vertebral arteries. It also allows for directional orientation of the eyes and ears. Nowhere in the spine is the relationship between the osseous structures and the surrounding neurologic and vascular beds as intimate or subject to disturbance as it is in the cervical region. Whether induced by trauma or not, cervical subluxation syndromes may be reflected in total body habitus. IVF insults, and the effects of articular fixations can manifest throughout the motor, sensory, and autonomic nervous systems. Many peripheral nerve symptoms in the shoulder, arm, and hand will find their origin in the cervical spine, as may numerous brainstem disorders.

Soft-Tissue Neck Trauma
Chapter 15 from:   “The Rehabilitation Monograph Series”

By Richard C. Schafer, D.C., FICC and the ACAPress

The mechanical relationship between the head and neck has been crudely compared to a brick attached to a flexible rod. As the structural mass of the head is so much greater than that of the neck, it is no wonder that injuries of the neck are so prevalent. Even the person with a short neck and well-developed neck muscles and ligaments is not free of potential injury.

Joint Trauma
Chapter 8 from:   “The Rehabilitation Monograph Series”

By Richard C. Schafer, D.C., FICC and the ACAPress

The general stability of synovial joints is established by action of surrounding muscles. Excessive joint stress results in strained muscles and tendons and sprained or ruptured ligaments and capsules. When stress is chronic, degenerative changes occur. The lining of synovial joints is slightly phagocytic, is regenerative if damaged, and secretes synovial fluid that is a nutritive lubricant having bacteriostatic and anticoagulant characteristics. This anticoagulant effect may result in poor callus formation in intra-articular fractures where the fracture line is exposed to synovial fluid. Synovial versus mechanical causes of joint pain are shown in Table 1.

Neck Injury Guidelines
New additions include 7 tables from Dr. Arthur C. Croft's Whiplash Injuries: The Cervical Acceleration/ Deceleration Syndrome which contain information on complicating factors for recovery, guidelines for frequency and duration of care, treatment adjuncts and contraindications to manipulation. It also includes guidelines from the California Industrial Medical Council.
You may also want to review the complete Guidelines Section.

Arthur C. Croft, D.C. "Dynamic Chiropractic" Articles
There are 107 articles here for your review.   You may also enjoy reviewing   Dr. Croft's website.

Whiplash: A Medical Doctor's Review of the Literature
Enjoy this facinating collection of citations on the effects of rear-end motor vehicle accidents.

What Causes Chronic Neck Pain?
North American Spine Society

It is usually not possible to know the exact cause of neck pain in the days or weeks after a car accident. We know the muscles and ligaments get strained and are probably inflamed, but they usually heal within six to ten weeks. Pain that lasts longer (than 6–10 weeks) is usually due to deeper problems such as injury to the disc or facet joint, or both.   Read more here.

Whiplash & Chiropractic
ACA News ~ Feb 2000 ~ FULL TEXT

Whiplash is an enigmatic injury.   We spend billions of dollars each year to treat it.   Yet many lawyers, legislators, and medical doctors deny its existence.   It affects millions of people around the world, yet research is severely under-funded.   It is a largely preventable injury, yet we do little to prevent it.   Fortunately, times are changing as whiplash enters a new phase of research and understanding.

Insurance Institute for Highway Safety's Whiplash Page
This page accurately defines whiplash injury, and offers other interesting FAQs


Whiplash Articles

Are People With Whiplash Associated Neck Pain
Different to People With Non-Specific Neck Pain?

J Orthop Sports Phys Ther. 2016 (Sep 3) [Epub]

2,578 participants were included in the study. Of these 488 (19%) were classified as having WAD. At presentation patients with WAD were statistically different to patients without WAD for almost all characteristics investigated. While most differences were small (1.1 points on an 11-point pain rating scale and 11 percentage points on the Neck Disability Index) others including the presence of dizziness and memory difficulties were substantial. The between group differences in pain and disability increased significantly (P<.001) over 12 months. At 12–month follow-up the patients with WAD on average had approximately 2 points more pain and 16 percentage points more disability than those with non-specific neck pain.

Comparing 2 Whiplash Grading Systems
To Predict Clinical Outcomes

Journal of Chiropractic Medicine 2016 (Jun);   15 (2):   81–86 ~ FULL TEXT

Applying the criteria of the original 1993 Croft grading system, the subset comprised 1 grade 1 injury, 32 grade 2 injuries, 53 grade 3 injuries, and 32 grade 4 injuries. Applying the criteria of the modified (QTF-WAD) grading system, there were 1 grade 1 injury, 89 grade 2 injuries, and 28 grade 3 injuries. Both whiplash grading systems correlated negatively with recovery; that is, higher severity grades predicted a lower probability of recovery, and statistically significant correlations were observed in both, but the Croft grading system substantially outperformed the QTF-WAD system on this measure.

Variations in Patterns of Utilization and Charges for the
Care of Neck Pain in North Carolina, 2000 to 2009:
A Statewide Claims' Data Analysis

J Manipulative Physiol Ther. 2016 (May);   39 (4):   240–251 ~ FULL TEXT

Increases in utilization and charges were the highest among patterns involving MDs, PTs and referral providers.   These findings are consistent with previous studies showing that medical specialty, diagnostic imaging, and invasive procedures (eg, spine injections, surgery) [17, 19, 20, 21] are significant drivers of increasing spine care costs.

Patients' Experiences With Vehicle Collision to Inform the Development
of Clinical Practice Guidelines: A Narrative Inquiry

J Manipulative Physiol Ther 2016 (Feb 26) [Epub ahead of print] ~ FULL TEXT

Four recommended directions were identified from the narrative inquiry process and applied. First, terminology that caused stigma was a concern. This resulted in modified language ("injured persons") being adopted by the Expert Panel, and a new nomenclature categorizing layers of injury was identified. Second, participants valued being engaged as partners with health care practitioners. This resulted in inclusion of shared decision-making as a foundational recommendation connecting CPGs and care planning. Third, emotional distress was recognized as a factor in recovery.

Function in Patients With Cervical Radiculopathy or Chronic Whiplash-
Associated Disorders Compared With Healthy Volunteers

J Manipulative Physiol Ther 2014 (May);   37 (4):   211–218 ~ FULL TEXT

Patient groups exhibited significantly lower performance than the healthy group in all physical measures (P < .0005) except for neck muscle endurance in flexion for women (P > .09). There was a general trend toward worse results in the CR group than the WAD group, with significant differences in neck active range of motion, left hand strength for women, pain intensity, Neck Disability Index, EuroQol 5-dimensional self-classifier, and Self-Efficacy Scale (P < .0001). Patients had worse values than healthy individuals in almost all physical measures. There was a trend toward worse results for CR than WAD patients.

Does Structured Patient Education Improve the Recovery and Clinical Outcomes of Patients with Neck Pain? A Systematic Review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration
Spine J. 2014 (Apr 4) [Epub ahead of print]

Results suggest that structured patient education alone cannot be expected to yield large benefits in clinical effectiveness compared with other conservative interventions (including spinal manipulation, massage, supervised exercise, and physiotherapy) for patients with WAD or NAD.   Moreover, structured patient education may be of benefit during the recovery of patients with WAD when used as an adjunct therapy to physiotherapy or emergency room care. These benefits are small and short lived.

Exploring the Clinical Course of Neck Pain
in Physical Therapy: A Longitudinal Study

Arch Phys Med Rehabil. 2014 (Feb);   95 (2):   303–308

The purpose of this exploratory study was to longitudinally describe the clinical course of mechanical neck pain during 1 month of usual-care outpatient physical therapy treatment. This was intended as a hypothesis-generating rather than confirmatory exercise and to provide guidance for future clinical trials of nonmedical neck pain management. We have shown that the trajectory, on average, in our sample of 50 subjects with mechanical neck pain of varying cause and duration, suggests an improvement of roughly 1.5 NDI points and 0.5 NRS points per week that adequately approximates a linear curve. In showing a mean linear trend over the course of 1 month, clinical trialists can be confident that a 1-month follow-up period is neither too short to identify measurable change, nor too long to risk missing early, rapid change.

Comparison of Outcomes in Neck Pain Patients With and Without Dizziness
Undergoing Chiropractic Treatment: A Prospective Cohort Study
With 6 month Follow-up

Chiropractic & Manual Therapies 2013 (Jan 7);   21:   3 ~ FULL TEXT

Neck pain patients with dizziness reported significantly higher pain and disability scores at baseline compared to patients without dizziness. A high proportion of patients in both groups reported clinically relevant improvement on the PGIC scale. At 6 months after start of chiropractic treatment there were no differences in any outcome measures between the two groups.

Sleep Characteristics in Patients with Whiplash-Associated Disorders:
A Descriptive Study

Topics in Integrative Health Care 2012 (Dec 31);   3 (4) ~ FULL TEXT

Neck pain related to whiplash-associated disorders (WAD) constitutes a significant health issue that leads patients to seek medical care in chiropractic and other physical therapy, rehabilitative clinics. Studies have indicated that individuals experience multiple clinical manifestations of WADs that lead to chronicity including postural changes, disability, headache, fatigue, and sleep disturbances. [1–4] Although studies have shown that sleep disturbances occur as a result of chronic pain, few studies have explored the relationship between patients with WAD and sleep quality. [4–6]

Responsiveness of the Cervical Northern American Spine Society
Questionnaire (NASS) and the Short Form 36 (SF–36) in Chronic Whiplash

Clin Rehabil. 2012 (Feb);   26 (2):   142–151

The generic SF–36 was more responsive in function and equally responsive in pain when compared to the condition-specific NASS. The SF–36 can be recommended as a responsive instrument for measurement of pain and function in chronic whiplash syndrome.

The Risk Assessment Score in Acute Whiplash Injury Predicts
Outcome and Reflects Biopsychosocial Factors

Spine (Phila Pa 1976). 2011 (Dec 1);   36 (25 Suppl):   S263–267

A receiver operating characteristics curve for the Risk Assessment Score and 1–year work disability showed an area of 0.90. Risk strata and number of sick days showed a log-linear relationship. In stratum 1 full recovery was encountered, but for high-risk patients in stratum 6 only 50% and 7 only 20% had returned to work after 1 year (P < 5.4 × 10). Strength measures, psychophysical pain measurements, and psychological and social data (reported elsewhere) showed significant relation to risk strata. The Risk Assessment score is suggested as a valuable tool for grading WLP early after injury. It has reasonable screening power for encountering work disability and reflects the biopsychosocial nature of whiplash injuries.

Pain-related Emotions in Early Stages of Recovery in Whiplash-associated
Disorders: Their Presence, Intensity, and Association With Pain Recovery

Psychosom Med. 2011 (Oct);   73 (8):   708–715

Psychological factors such as depression affect recovery after whiplash-associated disorders. This study examined the prevalence of pain-related emotions, such as frustration, anger, and anxiety, and their predictive value for postcrash pain recovery during a 1-year follow-up.

A Systematic Review of Chiropractic Management of Adults with Whiplash Associated Disorders: Recommendations for Advancing Evidence-based Practice and Research
Journal of the Academy of Chiropractic Orthopedists 2011 (Mar);   8 (1) ~ FULL TEXT

There is a baseline of evidence that suggests chiropractic care improves the cervical range of motion (cROM) and pain in the management of WAD. However, the level of this evidence relevant to clinical practice remains low or draws on clinical consensus at this time. The WAD-Plus Model has implications for use by chiropractors and interdisciplinary professionals in the assessment and management of acute, sub-acute and chronic pain due to WAD. Furthermore, the WAD-Plus Model can be used in the future study of interventions and outcomes to advanced evidenced-based care in the management of WAD.

Management of Neck Pain in Royal Australian Air Force Fast Jet Aircrew
Military Medicine 2011 (Jan);   176 (1):   106–109

Eighty-two RAAF FJ aircrew responded to the survey. Ninety-five percent of the respondents experienced flight-related neck pain. The most commonly sought treatment modalities were on-base medical and physiotherapy services. Many respondents reported that currently provided on-base treatment and ancillary services such as chiropractic therapy are the most effective in alleviating symptoms.

25 Years of Whiplash Research:   An interview with Arthur Croft, D.C.
The American Chiropractor ~ September 2010 ~ FULL TEXT

(Our Profession) lack(s) cohesion and a failure to understand that the old "separate but equal" philosophy is no longer viable. Most chiropractors don’t seem to recognize that we won’t be able to legislatively insulate ourselves from extinction. Many have been falsely buoyed by the Wilk’s case. This merely changed the game plan of chiropractic’s enemies. The erosion of our influence and scope is evident in many states, including California. With a stroke of his pen, long-time chiropractic friend and now Governor Arnold Schwarzenegger sharply limited our place in the workers’ compensation system.

A Systematic Review of Chiropractic Management of Adults with Whiplash-Associated Disorders: Recommendations for Advancing Evidence-based Practice and Research
Work (A Journal of Prevention, Assessment and Rehabilitation) 2010;   35 (3):   369–394

There is a baseline of evidence that suggests chiropractic care improves cervical range of motion (cROM) and pain in the management of WAD. However, the level of this evidence relevant to clinical practice remains low or draws on clinical consensus at this time. The WAD-Plus Model has implications for use by chiropractors and interdisciplinary professionals in the assessment and management of acute, subacute and chronic pain due to WAD. Furthermore, the WAD-Plus Model can be used in the future study of interventions and outcomes to advance evidence-based care in the management of WAD.

The Cervical Flexion-Relaxation Ratio: Reproducibility and
Comparison Between Chronic Neck Pain Patients and Controls

SPINE (Phila Pa 1976) 2010 (Nov 15);   35 (24):   2103–2108

The cervical extensor muscles exhibit a consistent flexion-relaxation (FFR) phenomenon in healthy control subjects and the measurement is highly reproducible when measured 4 weeks apart in both controls and chronic neck pain patients. The FRR in neck pain patients is significantly higher than in control subjects suggesting that this measure may be a useful marker of altered neuromuscular function.

The Association Between a Lifetime History of a Neck Injury in a Motor Vehicle Collision and Future Neck Pain: A Population-based Cohort Study
European Spine Journal 2010 (Jun);   19 (6):   972–981 ~ FULL TEXT

The objective of this population-based cohort study was to investigate the association between a lifetime history of neck injury from a motor vehicle collision and the development of troublesome neck pain. The current evidence suggests that individuals with a history of neck injury in a traffic collision are more likely to experience future neck pain. We formed a cohort of 919 randomly sampled Saskatchewan adults with no or mild neck pain in September 1995. At baseline, participants were asked if they ever injured their neck in a motor vehicle collision. Six and twelve months later, we asked about the presence of troublesome neck pain (grade II–IV) on the chronic pain grade questionnaire.   We found a positive association between a history of neck injury in a motor vehicle collision and the onset of troublesome neck pain after controlling for bodily pain and body mass index (adjusted HRR = 2.14; 95% CI 1.12–4.10). Our analysis suggests that a history of neck injury in a motor vehicle collision is a risk factor for developing future troublesome neck pain.

   The Bone and Joint Decade 2000–2010 Task Force   

The Bone and Joint Decade 2000–2010 Task Force on Neck Pain
And Its Associated Disorders:   Executive Summary

J Manipulative Physiol Ther. 2009 (Feb);   32 (2 Suppl):   S7–S9 ~ FULL TEXT

The prognosis for neck pain also appears to be multifactorial. Younger age was associated with a better prognosis, whereas poor health and prior neck pain episodes were associated with a poorer prognosis. Poorer prognosis was also associated with poor psychological health, worrying, and becoming angry or frustrated in response to neck pain. Greater optimism, a coping style that involved self-assurance, and having less need to socialize, were all associated with better prognosis. A number of nonsurgical treatments appeared to be more beneficial than usual care, sham, or alternative interventions but none of the active treatments were clearly superior to any other in the short or long term. Educational videos, mobilization, manual therapy, exercises, low-level laser therapy, and perhaps acupuncture appeared to have some benefit. For both WAD and other neck pain without radicular symptoms, interventions that focused on regaining function and returning to work as soon as possible were relatively more effective than interventions that did not have such a focus.

The Burden and Determinants of Neck Pain in the General Population:
Results of the Bone and Joint Decade 2000–2010 Task Force
on Neck Pain and Its Associated Disorders

J Manipulative Physiol Ther. 2009 (Feb);   32 (2 Suppl):   S46–S60 ~ FULL TEXT

The annual cumulative incidence of WAD differed substantially between countries. They found that occupant seat position and collision impact direction were associated with WAD in one study. Eliminating insurance payments for pain and suffering were associated with a lower incidence of WAD injury claims in one study. Younger ages and being a female were both associated with filing claims or seeking care for WAD, although the evidence is not consistent. Preliminary evidence suggested that headrests/car seats, aimed to limiting head extension during rear-end collisions had a preventive effect on reporting WAD, especially in females.

Course and Prognostic Factors for Neck Pain in the General Population:
Results of the Bone and Joint Decade 2000–2010 Task Force
on Neck Pain and Its Associated Disorders

J Manipulative Physiol Ther. 2009 (Feb);   32 (2 Suppl):   S87–S96 ~ FULL TEXT

The evidence suggests that approximately 50% of those 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, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.

Assessment of Neck Pain and Its Associated Disorders: Results of the
Bone and Joint Decade 2000–2010 Task Force on Neck Pain
and Its Associated Disorders

J Manipulative Physiol Ther. 2009 (Feb);   32 (2 Suppl):   S117–S140 ~ FULL TEXT

We found 359 articles on assessment of neck pain. After critical review, 95 (35%) were judged scientifically admissible. Screening protocols have high predictive values to detect cervical spine fracture in alert, low-risk patients seeking emergency care after blunt neck trauma. Computerized tomography (CT) scans had better validity (in adults and elderly) than radiographs in assessing high-risk and/or multi-injured blunt trauma neck patients. In the absence of serious pathology, clinical physical examinations are more predictive at excluding than confirming structural lesions causing neurologic compression. One exception is the manual provocation test for cervical radiculopathy, which has high positive predictive value. There was no evidence that specific MRI findings are associated with neck pain, cervicogenic headache, or whiplash exposure. No evidence supports using cervical provocative discography, anesthetic facet, or medial branch blocks in evaluating neck pain. Reliable and valid self-report questionnaires are useful in assessing pain, function, disability, and psychosocial status in individuals with neck pain.

Treatment of Neck Pain: Noninvasive Interventions: Results of the
Bone and Joint Decade 2000–2010 Task Force on Neck Pain and
Its Associated Disorders

J Manipulative Physiol Ther. 2009 (Feb);   32 (2 Suppl):   S141–S175 ~ FULL TEXT

For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus.

A Review of the Otological Aspects of Whiplash Injury
Journal of Forensic and Legal Medicine 2009 (Feb);   16 (2):   53–55

Approximately 10% of patients who have suffered with whiplash injury will develop otological symptoms such as tinnitus, deafness and vertigo. Some of these are purely subjective symptoms; nevertheless, for the majority there are specific tests that can be undertaken. These tests can quantify the extent and severity of the symptoms as well as provide guidance as to the correct rehabilitation pathway. This article reviews the body of literature relating to the otological aspects of whiplash injury and gives an overview for medical and legal professionals.

Predictors For Immediate and Global Responses to Chiropractic
Manipulation of the Cervical Spine

J Manipulative Physiol Ther 2008 (Mar);   31 (3):   172–183 ~ FULL TEXT

This study is the first attempt to identify variables that can predict immediate outcomes in terms of improvement and worsening of presenting symptoms, and global improvement, after cervical spine manipulation. From the findings, it was possible to identify some predictors of immediate improvement in presenting symptoms after cervical spine manipulation. Patients presenting with symptoms of “reduced neck, shoulder, arm movement, stiffness,” “neck pain,” “upper, mid back pain,” “headache,” “shoulder, arm pain,” and/or “none or one presenting symptom only” are likely to report immediate improvement in these symptoms after treatment. Patients presenting with any 4 of these symptoms were shown to have the highest probability of immediate improvement. This finding may enhance clinical decision making for selecting cervical manipulation in the treatment of patients with one or more of these complaints. Although it was possible to identify a number of predictor variables for immediate worsening in presenting symptoms and global improvement after cervical spine manipulation, these failed to provide a robust predictive model for clinical application.

Impact of Motor Vehicle Accidents on Neck Pain
and Disability in General Practice

British Journal of General Practice 2008 (Sep);   58 (554):   624–629 ~ FULL TEXT

This study showed that the percentage of patients who had been involved in an MVA and reported continuous neck pain was significantly higher than for those patients with other self-reported causes of neck pain. Reported prevalences of continuous neck pain in patients who had experienced MVAs vary widely in the literature and seem to consist of two different groups of figures – lower prevalence figures of chronic neck pain range between 8% and 24%, [21] while higher reported figures range from 43% up to 66%. [22, 23] Marshall reported that even 80% of patients experienced neck discomfort after an MVA. [12]

A Distinct Pattern of Myofascial Findings in Patients After Whiplash Injury
Archives of Physical Medicine and Rehabilitation 2008 (Jul);   89 (7):   1290–1293

Forty (85.1%) of the patients with whiplash had positive trigger points in the semispinalis capitis muscle. The patients with whiplash had a significantly higher prevalence of positive trigger points in the semispinalis capitis muscle than any of the control groups (P<.05). For the other examined muscles, the prevalence of trigger points in the patients with whiplash did not differ significantly from the patients with fibromyalgia or nontraumatic chronic cervical syndrome. It did differ from the patients with endogenous depression and the healthy controls.

Physical and Psychological Aspects of Whiplash:
Important Considerations for Primary Care Assessment

Manual Therapy 2008 (May);   13 (2):   93–102

Whiplash is a heterogenous and in many, a complex condition involving both physical and psychological factors. Primary care practitioners are often the first healthcare contact for individuals with a whiplash injury and as such play an important role in gauging prognosis as well as providing appropriate management for whiplash injured patients. It is imperative that factors associated with poor outcome are recognized and managed in the primary care environment at the crucial early acute stage post injury.

Fatty Infiltration in the Cervical Extensor Muscles in Persistent
Whiplash-Associated Disorders: A Magnetic Resonance Imaging Analysis

SPINE (Phila Pa 1976) 2006 (Oct 15);   31 (22):   E847–755

The WAD subjects had significantly larger amounts of fatty infiltrate for all of the cervical extensor muscles compared with healthy control subjects. In addition, the amount of fatty infiltrate varied by both cervical level and muscle, with the rectus capitis minor/major and multifidi at C3 having the largest amount of fatty infiltrate. Intramuscular fat was independent of age, self-reported pain/disability, compensation status, body mass index, and duration of symptoms.

Chronic Neck Pain And Whiplash: A Case-control Study of the Relationship
Between Acute Whiplash Injuries and Chronic Neck Pain

Pain Res Manag. 2006 (Summer);   11 (2):   79–83

Patients were defined as individuals with chronic neck pain, and controls as those with chronic back pain. The two groups were surveyed for cause of chronic pain as well as demographic information. The two groups were compared using an exposure-odds ratio. Forty-five per cent of the patients attributed their pain to a motor vehicle accident. An OR of 4.0 and 2.1 was calculated for men and women, respectively. Based on the results of the present study, it reasonable to infer that a significant proportion of individuals with chronic neck pain in the general population were originally injured in a motor vehicle accident.

Multiplanar Cervical Spine Injury Due to Head-Turned Rear Impact
SPINE (Phila Pa 1976) 2006 (Feb 15);   31 (4):   420–429

Epidemiologically and clinically, head-turned rear impact is associated with increased injury severity and symptom duration, as compared to forward facing. To our knowledge, no biomechanical data exist to explain this finding. Six human cervical spine specimens (C0–T1) with head-turned and muscle force replication were rear impacted at 3.5, 5, 6.5, and 8 g, and flexibility tests were performed before and after each impact. Head-turned rear impact caused significantly greater injury at C0–C1 and C5–C6, as compared to head-forward rear and frontal impacts, and resulted in multiplanar injuries at C5–C6 and C7–T1.

Onset of Neck Pain After a Motor Vehicle Accident:
A Case-control Study

J Rheumatol 2005 (Aug);   32 (8):   1576–1583

In total, 26% of drivers reported post-accident neck pain. Women, younger individuals, and those with a history of neck pain were more likely to report neck pain following their accident. In addition, a number of accident related and psychosocial factors were independently associated with reporting post-accident neck pain: collision from behind; vehicle stationary at impact; collision severity; not being at fault; and monotonous work. Based on these 8 factors, the likelihood of having neck pain increased from 7% with < or = 2 risk factors to 62% with > or = 5.

Effects of Abnormal Posture on Capsular Ligament Elongations
in a Computational Model Subjected to Whiplash Loading

J Biomech 2005 (Jun);   38 (6):   1313–1323

Although considerable biomechanical investigations have been conducted to understand the response of the cervical spine under whiplash (rear impact-induced postero-anterior loading to the thorax), studies delineating the effects of initial spinal curvature are limited. Results from the present study, while providing quantified level- and region-specific kinematic data, concur with clinical findings that abnormal spinal curvatures enhance the likelihood of whiplash injury and may have long-term clinical and biomechanical implications.

A Proposed New Classification System for Whiplash Associated Disorders
- Implications for Assessment and Management

Manual Therapy 2004 (May);   9 (2):   60–70

Recent evidence is emerging that demonstrates differences in physical and psychological impairments between individuals who recover from the injury and those who develop persistent pain and disability. Motor dysfunction, local cervical mechanical hyperalgesia and psychological distress are present soon after injury in all whiplash injured persons irrespective of recovery.

Impairment in the Cervical Flexors: A Comparison of Whiplash
and Insidious Onset Neck Pain Patients

Manual Therapy 2004 (May);   9 (2):   89–94

The results indicated that both the insidious onset neck pain and whiplash groups had higher measures of EMG signal amplitude (normalized root mean square) in the sternocleidomastoid during each stage of the test compared to the control subjects (all P<0.05) and had significantly greater shortfalls from the pressure targets in the test stages (P<0.05). No significant differences were evident between the neck pain groups in either parameter indicating that this physical impairment in the neck flexor synergy is common to neck pain of both whiplash and insidious origin.

Chiropractic Management of Intractable Chronic Whiplash Syndrome
Clinical Chiropractic 2004 (Mar):   7 (1):   16–23

The management protocol in this case consisted of chiropractic spinal manipulative therapy, soft tissue work and post-isometric relaxation (PIR) techniques to address biomechanical somatic dysfunction. In addition, active rehabilitation exercises, self-stretches and proprioceptive exercises were utilised to address postural and muscle imbalance. On the seventh treatment, the patient reported no neck pain, no headaches and unrestricted cervical spine range of motion. At 4 months follow–up, the patient continued to be free of headaches and neck stiffness and reported only mild, intermittent neck pain.

The Possibility to Use Simple Validated Questionnaires to Predict
Long–term Health Problems After Whiplash Injury

SPINE (Phila Pa 1976) 2004 (Feb 1);   29 (3):   E47–51

The subjective experience of a notably decreased level of activity because of the neck pain when supplemented by the enhanced score of Neck Disability Index questionnaire predicts well poor outcome in long–term follow–up and can be used as a tool to identify persons who are at risk to suffer long–term health problems after whiplash injury.

Characterization of Acute Whiplash–associated Disorders
Spine (Phila Pa 1976). 2004 (Jan 15);   29 (2):   182–188

Acute whiplash subjects with higher levels of pain and disability were distinguished by sensory hypersensitivity to a variety of stimuli, suggestive of central nervous system sensitization occurring soon after injury. These responses occurred independently of psychological distress. These findings may be important for the differential diagnosis of acute whiplash injury and could be one reason why those with higher initial pain and disability demonstrate a poorer outcome.

Cervical Spine Curvature During Simulated Whiplash
Clin Biomech (Bristol, Avon) 2004 (Jan);   19 (1):   1–9

Average peak lower cervical spine extension first exceeded the physiological limits (P<0.05) at a horizontal T1 acceleration of 5 g. Average peak upper cervical spine extension exceeded the physiological limit at 8 g, while peak upper cervical spine flexion never exceeded the physiological limit. In the S–shape phase, lower cervical spine extension reached 84% of peak extension during whiplash. Both the upper and lower cervical spine are at risk for extension injury during rear–impact. Flexion injury is unlikely.

Sensory Hypersensitivity Occurs Soon After Whiplash Injury
And Is Associated With Poor Recovery

Pain. 2003 (Aug);   104 (3):   509–517 ~ FULL TEXT

All whiplash groups demonstrated local mechanical hyperalgesia in the cervical spine at 1 month post–injury. This hyperalgesia persisted in those with moderate/severe symptoms at 6 months but resolved by 2 months in those who had recovered or reported persistent mild symptoms. Only those with persistent moderate/severe symptoms at 6 months demonstrated generalised hypersensitivity to all sensory tests. These changes occurred within 1 month of injury and remained unchanged throughout the study period.

Cervical Spine Geometry Correlated to Cervical Degenerative
Disease in a Symptomatic Group

J Manipulative Physiol Ther 2003 (Jul);   26 (6):   341–346 ~ FULL TEXT

We identified 5 geometric variables from the lateral cervical spine that were predictive 79% of the time for cervical degenerative joint disease. There were discrete age, sex, and symptom groups, which demonstrated an increased incidence of degenerative joint disease.

Development of Motor System Dysfunction Following Whiplash Injury
Pain. 2003 (May);   103 (1–2):   65–73

Dysfunction in the motor system is a feature of persistent whiplash associated disorders. Little is known about motor dysfunction in the early stages following injury and of its progress in those persons who recover and those who develop persistent symptoms. This study measured prospectively, motor system function (cervical range of movement (ROM), joint position error (JPE) and activity of the superficial neck flexors (EMG) during a test of cranio–cervical flexion) as well as a measure of fear of re–injury (TAMPA) in 66 whiplash subjects within 1 month of injury and then 2 and 3 months post injury. Subjects were classified at 3 months post injury using scores on the neck disability index: recovered (<8), mild pain and disability (10–28) or moderate/severe pain and disability (>30).

Dizziness and Unsteadiness Following Whiplash Injury: Characteristic
Features and Relationship With Cervical Joint Position Error

J Rehabil Med 2003 (Jan);   35 (1):   36–43

Dizziness and/or unsteadiness are common symptoms of chronic whiplash-associated disorders. This study aimed to report the characteristics of these symptoms and determine whether there was any relationship to cervical joint position error. Joint position error, the accuracy to return to the natural head posture following extension and rotation, was measured in 102 subjects with persistent whiplash-associated disorder and 44 control subjects.

The Use of Flexion and Extension MR in the Evaluation of Cervical
Spine Trauma: Initial Experience in 100 Trauma Patients
Compared with 100 Normal Subjects

Emerg Radiol 2002 (Nov);   9 (5):   249–253

The cervical spines of 100 consecutive uninjured normal asymptomatic adults and 100 adult accident victims following rear low-impact motor vehicle accidents were evaluated using rapid T2-weighted MRI. Injured subjects were evaluated during the subacute period, at 12 to 14 weeks after injury. The "normal subjects" showed: Loss of normal cervical lordosis (hypolordosis) in 4% (4 of 100) patients: Range of motion of 50° flexion, and 60° extension; and asymptomatic disk herniations were observed in 2% (2 of 100) patients. In the subacute post-traumatic subjects, there was a loss of the normal segmental motion pattern, with hypolordosis in 98% (98 of 100) patients. Range of motion was restricted, quantified as 25° flexion and 35°; and disk herniations were observed in 28% of the patients. The authors conclude that flexion and extension MR can be a valuable adjunct examination in the evaluation of patients in the clinical setting of subacute cervical spine trauma.

Is the Sagittal Configuration of the Cervical Spine Changed in Women
with Chronic Whiplash Syndrome? A Comparative Computer-assisted
Radiographic Assessment

J Manipulative Physiol Ther 2002 (Nov);   25 (9):   550–555 ~ FULL TEXT

The whiplash group showed a decreased ratio between the lower versus upper cervical spine but comparisons between groups were not statistically significant. The whiplash group was in a significantly more flexed position at the C4–C5 level compared with the asymptomatic group (P =.007). The reliability measures have to be strengthened to render these results definitely conclusive.

Cervical Spine Lesions After Road Traffic Accidents:
A Systematic Review

SPINE (Phila Pa 1976) 2002 (Sep 1);   27 (17):   1934–1941

Previous investigations have examined pathoanatomical conditions of the cervical spine of road traffic fatalities. However, different methods of investigation have been used, and results of studies are conflicting. Hence, potential pathoanatomical conditions in fatalities and survivors remain a controversial issue. Twenty-seven articles of which three fulfilled the quality criteria were reviewed. In these studies, subtle pathoanatomical lesions were found in the cervical intervertebral discs, cartilaginous endplates, and the articular surfaces and capsules of the zygapophysial joints. The lesions were found exclusively in the traumatized patients and in none of the patients in the control group. Occult pathoanatomical lesions in the cervical intervertebral disc and zygapophysial joints after fatal road traffic trauma may exist. Present imaging methods, especially conventional radiography, do not visualize these subtle lesions; hence, underreporting of pathoanatomical lesions during standard autopsy is probably common. These findings may have clinical relevance in the management of road traffic trauma survivors with potentially similar pathoanatomy.

Psychiatry of Whiplash Neck Injury
Br J Psychiatry 2002 (May);   180:   441–448 ~ FULL TEXT

This paper comes to radically different conclusions by focusing on all of those injured in MVAs (rather than just the whiplash cases) and defining the similarities between those with soft-tissue and boney injuries. They found that: (1) Claiming compensation was not a predictor of psychological outcome in any of the injury groups; (2) That whiplash is more likely to be litigated because of the unpleasantness of the acute symptoms, that the sufferer is an innocent victim, and that the liability of the other driver will not be disputed; (3) and that the anger associated with being an innocent victim, and (being trapped within a) slowly progressing litigation is one of several social variables influencing overall quality of life following the accident.
NOTE: This paper helps to dispell the inaccurate conclusion that compensation drives outcomes in whiplash cases, made by New England Journal of Medicine 2000 (Apr 20) by eliminating insurer's bias.

Responses to a Clinical Test of Mechanical Provocation of Nerve Tissue
in Whiplash Associated Disorder

Manual Therapy 2002 (May);   7 (2):   89–94

Only the whiplash subjects whose arm pain was reproduced by the BPPT demonstrated differences between the symptomatic and asymptomatic sides. These generalized hyperalgesic responses to the BPPT support the hypothesis of central nervous system hypersensitivity as contributing to persistent pain experienced by WAD patients.

Central Hypersensitivity In Chronic Pain After Whiplash Injury
Clin J Pain. 2001 (Dec);   17 (4):   306–315

The authors found a hypersensitivity to peripheral stimulation in whiplash patients. Hypersensitivity was observed after cutaneous and muscular stimulation, at both neck and lower limb. Because hypersensitivity was observed in healthy tissues, it resulted from alterations in the central processing of sensory stimuli (central hypersensitivity). Central hypersensitivity was not dependent on a nociceptive input arising from the painful and tender muscles.

Prognosis Following a Second Whiplash Injury
Injury 2000 (May);   31 (4):   249–251

Five percent of the population have suffered a whiplash injury. Of these, 43% suffer long–term symptoms. We undertook a retrospective study of 79 patients who had suffered two whiplash injuries.

Effect of Eliminating Compensation for Pain and Suffering on the
Outcome of Insurance Claims for Whiplash Injury

New England Journal of Medicine 2000 (Apr 20);   342 (16):   1179–1186 ~ FULL TEXT

The incidence and prognosis of whiplash injury from motor vehicle collisions may be related to eligibility for compensation for pain and suffering. On January 1, 1995, the tort–compensation system for traffic injuries, which included payments for pain and suffering, in Saskatchewan, Canada, was changed to a no–fault system, which did not include such payments. To determine whether this change was associated with a decrease in claims and improved recovery after whiplash injury, we studied a population–based cohort of persons who filed insurance claims for traffic injuries between July 1, 1994, and December 31, 1995.
NOTE: The following paper helps to dispell these inaccurate conclusion that compensation drives outcomes in whiplash cases ( Br J Psychiatry 2002 (May);   180:   441–448 ) by eliminating insurer's bias.

Is It Safe to Adjust the Cervical Spine in the Presence of a Herniated Disc?
Dynamic Chiropractic – June 12, 2000

I am often asked by chiropractors, medical doctors and patients if manipulation of the cervical spine is safe in the presence of a cervical herniated nucleus pulposis (CHNP). I usually answer that in most circumstances it not only is safe, but it is often an essential aspect of treatment. I will clarify what this means and provide some of the evidence that supports this notion. I will also illustrate that in most of cases that require treatment, manipulation alone is not a sufficient approach, but that some form of rehabilitation is necessary.

Cervical Nonorganic Signs: A New Clinical Tool to Assess Abnormal
Illness Behavior in Neck Pain Patients: A Pilot Study

Arch Phys Med Rehabil 2000 (Feb);   81 (2):   170–175

For many years, the lumbar nonorganic signs (developed by Waddell and colleagues) have been a useful screening tool in the assessment of abnormal illness behavior in the low back pain population. For the first time, a group of cervical nonorganic signs have been developed, standardized, and proven reliable.

A Symptomatic Classification of Whiplash Injury and the Implications
for Treatment

Journal of Orthopaedic Medicine 1999;   21 (1):   22–25

Whiplash injuries are common. Chiropractic is the only proven effective treatment in chronic cases. Our study enables patients to be classified at initial assessment in order to target those patients who will benefit from such treatment. You may also enjoy this review of this article.

Whiplash Update:
New Research About Chiropractic Utilization in America

Lawrence Nordhoff, DC, QME

It is important for the chiropractic profession to stay current with claim behavior in the United States, including treatment costs, number of office visits, types of injuries, and use of diagnostic procedures. This is particularly true with respect to motor vehicle collision injuries. This information lets doctors of chiropractic evaluate their practice profiles and determine how national figures apply to their practices.

Motion Analysis of Cervical Vertebrae During Whiplash Loading
SPINE (Phila Pa 1976) 1999 (Apr 15);   24 (8):   763–769

There were three distinct patterns of cervical spine motion after impact. In the flexion-extension group, C6 rotated backward before the upper vertebrae in the early phase; thus, the cervical spine showed a flexion position (initial flexion). After C6 reached its maximum rotational angle, C5 was induced to extend. As upper motion segments went into flexion, and the lower segments into extension, the cervical spine took an S-shaped position. In this position, the C5–C6 motion segments showed an open-book motion with an upward-shifted instantaneous axis of rotation.

Whiplash Associated Disorders: Redefining Whiplash and Its Management
by the Quebec Task Force:   A Critical Evaluation

SPINE (Phila Pa 1976) 1998 (May 1);   23 (9):   1043–1049 ~ FULL TEXT

The validity of the conclusions and recommendations of the Quebec Task Force regarding the natural course and epidemiology of whiplash injuries is questionable. This lack of validity stems from the presence of bias, the use of unconventional terminology, and conclusions that are not concurrent with the literature the Task Force accepted for review. Although the Task Force set out to redefine whiplash and its management, striving for the desirable goal of clarification of the numerous contentious issues surrounding the injury, its publications instead have confused the subject further.
You may also want to review the original Quebec Task Force Report on WAD.

Chiropractic Treatment of Chronic 'Whiplash' Injuries
Injury 1996 (Nov);   27 (9):   643–645

Twenty-six (93 per cent) patients improved following chiropractic treatment (U = 34, P < 0.001). The encouraging results from this retrospective study merit the instigation of a prospective randomized controlled trial to compare conventional with chiropractic treatment in chronic 'whiplash' injury.

Conservative Management of Mechanical Neck Pain:
Systematic Overview and Meta-analysis

British Medical Journal 1996 (Nov 23);   313 (7068):   1291–1296 ~ FULL TEXT

Twenty four randomised clinical trials met the selection criteria and were categorised by type of intervention: nine used manual treatments; 12 physical medicine methods; four drug treatment; and three education of patients (four trials investigated more than one form of intervention).

Long-term Outcome After Whiplash Injury: A 2-year Follow-up Considering
Features of Injury Mechanism and Somatic, Radiologic,
and Psychosocial Findings

Medicine (Baltimore) 1995 (Sep);   74 (5):   281–297

Previous studies, however, focused on somatic symptoms on the one hand or considered only psychological or neuropsychological variables on the other hand, often in loosely defined or selected groups of patients. No study so far has analyzed the long-term outcome in a nonselected group of patients using a clear injury definition considering patient history; somatic, radiologic, and neuropsychological findings; and features of the injury mechanisms assessed soon after trauma and during follow-up. With regard to baseline findings the following significant differences were found (on this cohort): Symptomatic patients were older, had higher incidence of rotated or inclined head position at the time of impact, had higher prevalence of pretraumatic headache, showed higher intensity of initial neck pain and headache, complained of a greater number of symptoms, had a higher incidence of symptoms of radicular deficit and higher average scores on a multiple symptom analysis, and displayed more degenerative signs (osteoarthrosis) on X ray.

Whiplash Injury and Chronic Neck Pain
New England Journal of Medicine 1994 (Apr 14):   330 (15)

Whiplash injuries occur in more than 1 million people in the United States every year (1). Although the majority become asymptomatic in a matter of weeks to a few months, 20 to 40 percent have symptoms that are sometimes debilitating and persist for years. This so–called late whiplash syndrome has become one of the most controversial conditions in medicine. Some attribute the persistent symptoms to unresolved injury, whereas others attribute them to underlying psychological factors or the possibility of financial gain.

The Rate of Recovery Following Whiplash Injury
Eur Spine J. 1994;   3 (3):   162–164

Fifty consecutive patients with soft-tissue neck injuries following rear end collisions were studied prospectively to assess their rate of recovery. Patients were seen within 5 days of the accident, after 3 months, 1 year and 2 years, and their symptoms were classified into one of four groups (A, asymptomatic; B, nuisance; C, intrusive; D, disabling). Fourteen of 15 patients (93%) who were asymptomatic after 3 months remained symptom-free after 2 years. Of 35 patients with symptoms after 3 months, 30 (86%) remained symptomatic after 2 years.

Contribution of Central Neuroplasticity to Pathological Pain:
Review of Clinical and Experimental Evidence

Pain 1993 (Mar);   52 (3):   259–285

Peripheral tissue damage or nerve injury often leads to pathological pain processes, such as spontaneous pain, hyperalgesia and allodynia, that persist for years or decades after all possible tissue healing has occurred. Although peripheral neural mechanisms, such as nociceptor sensitization and neuroma formation, contribute to these pathological pain processes, recent evidence indicates that changes in central neural function may also play a significant role.

Cervical Zygapophyseal Joint Pain Patterns Part I:
A Study in Normal Volunteers

SPINE (Phila Pa 1976) 1990 (Jun);   15 (6):   453–457

The pain patterns evoked by stimulation of normal cervical zygapophyseal joints were determined in five volunteers. Under fluoroscopic control, joints at segments C2–3 to C6–7 were stimulated by distending the joint capsule with injections of contrast medium. Each joint produced a clinically distinguishable, characteristic pattern of pain, which enabled the construction of pain charts that putatively could be of value in determining the segmental location of symptomatic joints in patients presenting with cervical zygapophyseal pain.

The Risk of Injury for Children Exposed to Whiplash Trauma
Arthur C. Croft, DC, MS, FACO

Less than two percent of the literature about whiplash is devoted to children. When I wrote the first edition of my textbook in 1988,1 I cited an older German study placing the risk for children at approximately one-sixth the risk of adults. By the time the second edition was published in 1995, a Swedish study had since been published putting the risk proportion in children closer to two-thirds that of adults.2

Long–Term Consequences of Whiplash: Allergy; Breathing, Digestive and
Cardiovascular Disorders; Hypertension and Low Back Pain

Arthur C. Croft, DC, MS, FACO, FACFE
Dynamic Chiropractic – October 16, 2000

A recent paper out of Canada takes an intriguing look into what may be some of the less recognized features of the long–term consequences of whiplash trauma – a condition perhaps more rightfully referred to as cervical acceleration/deceleration (CAD) trauma. The authors, using data obtained by health surveys, attempted to correlate a history of neck injury from motor vehicle crashes (MVC) with chronic neck pain.

Concussion May Be More Serious Than Thought
A mild blow to the head may cause more brain damage than previously thought. California researchers have found that head injuries that cause concussion can lead to changes that resemble brain damage in the comatose, and these changes can last for weeks.

How Have Chiropractors Fared in Recent Years with Whiplash Cases?
Lawrence Nordhoff, DC, QME

Chiropractors have been actively treating whiplash soft-tissue injuries for decades. This article explores how the chiropractic profession has fared in recent years compared to medical doctors and physical therapists. These comparisons will illustrate the percentage of claimants seeing the various providers in five-year increments. This paper shows that the chiropractic profession continues to have a healthy upward growth trend, whereas the number of claimants seeing MDs and PTs has declined or has had little growth in recent years.

Collected article citations on CAD
There are many citations here to consider.

Chiropractic Care for Spinal Whiplash Injuries
David BenEliyahu, DC, DAAPM, DACBSP

Studies on the efficacy of chiropractic care for patients suffering with pain secondary to whiplash injury are appearing in the literature. In 1996, Woodward et al. published a study in Injury on the efficacy of chiropractic treatment of whiplash injuries. [1] The authors of this study were from the Department of Orthopedic Surgery in Bristol, England. In 1994, Gargan and Bannister published a paper on the recovery rate of patients with whiplash injuries and found that if patients were still symptomatic after three months, there was almost a 90% chance they would remain so. [2] No conventional medical treatment has been shown to be effective in these established chronic whiplash injury patients. [3–4] However, most DCs treating whiplash injury patients have empirically found high success rates in the recovery of these types of patients.

The Failure of Standard Orthopedic and Neurologic Tests, Part I
Chiropractors are regularly called upon to evaluate and treat those patients involved in motor vehicle accidents. The chiropractor often faces a significant dilemma when attempting to report findings from the standard orthopedic and neurologic tests. On one hand the doctor realizes that the patient has been injured, however the standard orthopedic and neurologic tests that we learned in school and in postgraduate programs are not sensitive for what the patient actually suffers with.

The Failure of Standard Orthopedic and Neurologic Tests, Part II
Tests which I believe are sensitive to the whiplash-injured patient can be divided into two categories: those which are listed by physical examination, and those which are listed by other diagnostic tests. Examination procedures which are more sensitive to the tissues innervated by the dorsal ramus include: 1) palpation, 2) provocative tests, 3) motion palpation. There are several diagnostic tests which are more sensitive in assessing whiplash trauma. They are: 1) Stress films, 2) Videofluoroscopy, 3) Diagnostic ultrasound


Low Speed Rear End Impact Collisions (LOSRIC)

Jaw Symptoms and Signs and the Connection to Cranial Cervical Symptoms
and Post-traumatic Stress During the First Year After a Whiplash Trauma

Disabil Rehabil. 2010;   32 (24):   1987–1998

Jaw symptoms were initially reported by three men (5%) and three women (4%), and subsequently developed in eight women (10%) during the following year. Jaw signs were noted initially in 53 subjects (37%) and in 28 subjects (24%) after 1 year, without difference between sexes, and more often after low-speed impacts.

Impact of Motor Vehicle Accidents on Neck Pain
and Disability in General Practice

British Journal of General Practice 2008 (Sep);   58 (554):   624–629 ~ FULL TEXT

This study showed that the percentage of patients who had been involved in an MVA and reported continuous neck pain was significantly higher than for those patients with other self-reported causes of neck pain. Reported prevalences of continuous neck pain in patients who had experienced MVAs vary widely in the literature and seem to consist of two different groups of figures – lower prevalence figures of chronic neck pain range between 8% and 24%, [21] while higher reported figures range from 43% up to 66%. [22, 23] Marshall reported that even 80% of patients experienced neck discomfort after an MVA. [12]

Significant Spinal Injury Resulting From Low-level Accelerations:
A Case Series of Roller Coaster Injuries

Arch Phys Med Rehabil. 2005 (Nov);   86 (11):   2126–2130

The results of this study suggest that there is no established minimum threshold of significant spine injury. The greatest explanation for injury from traumatic loading of the spine is individual susceptibility to injury, an unpredictable variable.

Correlating Crash Severity With Injury Risk, Injury Severity, and
Long-term Symptoms In Low Velocity Motor Vehicle Collisions

Med Sci Monit. 2005 (Oct);   11 (10):   RA316–321

A substantial number of injuries are reported in crashes of little or no property damage. Property damage is an unreliable predictor of injury risk or outcome in low velocity crashes. The MIST protocol for prediction of injury does not appear to be valid.

Awareness Affects the Response of Human Subjects Exposed to a Single
Whiplash-Like Perturbation

SPINE (Phila Pa 1976) 2003 (Apr 1);   28 (7):   671–679

The larger retractions observed in surprised females likely produce larger tissue strains and may increase injury potential. Aware human subjects may not replicate the muscle response, kinematic response, or whiplash injury potential of unprepared occupants in real collisions.

How Crash Severity in Rear Impacts Influences Short- and Long-term
Consequences to the Neck

Accid Anal Prev 2000 (Mar);   32 (2):   187–195

The two crashes which resulted in long-term disabling neck injuries had the highest peak acceleration (15 and 13 x g), but not the highest change of velocity. The crash tests showed that a tow-bar may significantly affect the acceleration of the car as well as that of the occupant. According to real-life crashes, a tow-bar on the struck car increased the risk of long-term consequences by 22% but did not affect the risk of short-term consequences.

A Review and Methodologic Critique of the Literature Refuting
Whiplash Syndrome

SPINE (Phila Pa 1976) 1999 (Jan 1);   24 (1):   86–96

The validity of whiplash syndrome has been a source of debate in the medical literature for many years. Some authors have published articles suggesting that whiplash injuries are impossible at certain collision speeds; others have stated that the problem is psychological, or is feigned as a means to obtain secondary financial gain. These articles contradict the majority of the literature, which shows that whiplash injuries and their sequelae are a highly prevalent problem that affects a significant proportion of the population.

Low Speed Rear End Impacts: Vehicle and Occupant Response
J Manipulative Physiol Ther 1998 (Nov);   21 (1):   629–639

In low impact collisions, there are usually no skid marks, minor or no visible damage to the vehicle. There is a lack of relationship between occupant injury vehicle speed and/or damage. There does not appear to be an absolute speed or damage to a vehicle for a person to experience injury. Crash tests indicate a change of vehicle velocity of 4km/h (2.5 mph) may produce occupant symptoms. Vehicle damage may not occur until 14–15km/h (8.7 mph).

Chronic Cervical Zygapophysial Joint Pain After Whiplash:
A Placebo–Controlled Prevalence Study

SPINE (Phila Pa 1976) 1996 (Aug 1);   21 (15):   1737–1744

The prevalence of cervical zygapophysial joint pain after whiplash has been studied by means of comparative local anesthetic blocks. The concern is that such blocks may be compromised by placebo responses and that prevalence estimates based on such blocks may exaggerate the importance of this condition. In this study, sixty-eight consecutive patients referred for chronic neck pain after whiplash were studied. Those who did not experience pain relief together with the patients with dominant neck pain proceeded to undergo placebo-controlled local anesthetic blocks. Two different local anesthetics and a placebo injection of normal saline were administered in random order and under double-blindfolded conditions. A positive diagnosis was made if the patient's pain was completely and reproducibly relieved by each local anesthetic but not by the placebo injection. Overall, the prevalence of cervical zygapophysial joint pain (C2–C3 or below) was 60% (93% confidence interval, 46%, 73%).

The Prevalence of Chronic Cervical Zygapophysial Joint Pain
After Whiplash

SPINE (Phila Pa 1976) 1995 (Jan 1);   20 (1):   20–26

In a significant proportion of patients with whiplash, chronic, refractory neck pain develops. Provisional data suggest many of these patients have zygapophysial joint pain, but the diagnosis has been established by single, uncontrolled diagnostic block. In this study, fifty consecutive, referred patients with chronic neck pain after whiplash injury were studied using double-blind, controlled, diagnostic blocks of the cervical zygapophysial joints. On separate occasions, the joint was blocked with either lignocaine or bupivacaine in random order. A positive diagnosis was made only if both blocks relieved the patient's pain and bupivacaine provided longer relief. In this population, cervical zygapophysial joint pain was the most common source of chronic neck pain after whiplash.

Making the Case Against Late Whiplash
Arthur C. Croft, DC, MS, FACO, FACFE

It seems that 1999 was a banner year for the whiplash naysayers. In addition to the barriers such literature imposes for advances in automotive safety, it provides an ongoing source of grist for the ever-polarized medicolegal mill. Readers may recall my criticisms of the first Lithuanian paper of 1996 (reference 10), which appeared in DC that year. The authors revisited this problem of late whiplash more recently. Subsequently, a spate of particularly bad literature has appeared (chiefly from a Dr. Ferrari) that uses, as its chief foundation, these two fundamentally flawed misadventures of science. In this article, I'll explore the major problems with the recent (1999) Lithuanian paper and juxtapose them with the 1996 paper.

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