The Biomechanics Behind Whiplash Associated Disorder: Difference between revisions

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'''What is it?'''


Whiplash Associated Disorder (WAD) is a term that is used to describe injuries in and around the neck obtained from deceleration-acceleration movements that occur abruptly, such as from a motor vehicle collision<ref name=":0">1.      Pastakia K, Kumar S. Acute whiplash associated disorders (WAD). Open Access Emergency Med. 2011; 3:29-32. </ref>. The prognosis of WAD tends to be unknown and unpredictable, there can be two types of cases, acute or chronic. <ref name=":1">Stace R. and Gwilym S. Whiplash associated disorder: a review of current pain concepts. Bone & Joint. 2015; 4:360</ref> Acute cases normally have a full recovery whereas chronic cases lead to long term pain as well as future disability. <ref name=":1" />  Most whiplash associated disorders are minor soft tissue injuries lacking evidence for fractures.<ref>Bragg KJ, Varacallo M. Cervical Sprain. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK541016/</nowiki> (Accessed 10 April 2021)</ref>  
== What is it? ==
----
[[Whiplash Associated Disorders|Whiplash Associated Disorder]] (WAD) is a term that is used to describe injuries in and around the neck obtained from deceleration-acceleration movements that occur abruptly, such as from a motor vehicle collision.<ref name=":0">1.      Pastakia K, Kumar S. Acute whiplash associated disorders (WAD). Open Access Emergency Med. 2011; 3:29-32. </ref> The prognosis of WAD tends to be unknown and unpredictable, there can be two types of cases, acute or chronic. Acute cases normally have a full recovery whereas chronic cases lead to long term pain as well as future disability. <ref name=":1">Stace R. and Gwilym S. Whiplash associated disorder: a review of current pain concepts. Bone & Joint. 2015; 4:360</ref>  Most whiplash associated disorders are minor soft tissue injuries lacking evidence for fractures.<ref>Bragg KJ, Varacallo M. Cervical Sprain. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK541016/</nowiki> (Accessed 10 April 2021)</ref>
'''Quebec Classification'''


The Quebec Task Force produced a mechanism used to classify patients suffering from whiplash associated disorder, based on the severity of both signs and symptoms.<ref name=":2">Steven J. MD, Richard A. Patrick, D.L. Convery, K. Keller R.B. Singer, D.E. <sup>*</sup> The Quebec Task Force Classification for Spinal Disorders and the Severity, Treatment, and Outcomes of Sciatica and Lumbar Spinal Stenosis, Spine.1996;21:2885-2892</ref>  There are different grades ranging from I to IV, these are described below.
'''Quebec Classification'''


·     Grade I: Patient experiences neck pain, stiffness or tenderness.
The [[Quebec task force Classification of Grades of WAD|Quebec Task Force]] produced a mechanism used to classify patients suffering from whiplash associated disorder, based on the severity of both signs and symptoms.<ref name=":2">Steven J. MD, Richard A. Patrick, D.L. Convery, K. Keller R.B. Singer, D.E. <sup>*</sup> The Quebec Task Force Classification for Spinal Disorders and the Severity, Treatment, and Outcomes of Sciatica and Lumbar Spinal Stenosis, Spine.1996;21:2885-2892</ref>  There are different grades ranging from I to IV, these are described below.


·     Grade II: Patient exhibits musculoskeletal signs which include decreased range of motion and point tenderness.
Grade I: Patient experiences neck pain, stiffness or tenderness.


·     Grade III: Patient shows neurologic signs which may include sensory deficits as well as muscle weakness.
Grade II: Patient exhibits musculoskeletal signs which include decreased range of motion and point tenderness.


·     Grade IV: Patient shows neck dislocation or fracture. <ref name=":0" /> <ref name=":2" />
Grade III: Patient shows neurologic signs which may include sensory deficits as well as muscle weakness.
----


'''Pathophysiology'''
Grade IV: Patient shows neck dislocation or fracture. <ref name=":0" /> <ref name=":2" />


The mechanism of injury in whiplash associated disorder occurs in 3 stages. In the first stage, both the upper and lower spine experience flexion, causing a loss of cervical lordosis. <ref name=":3">Gastown Physio Pilates. Whiplash Associated Disorder. Available from: <nowiki>https://gastownphysiopilates.com/blogs/3-whiplash</nowiki> (Accessed 28 March 2021)</ref> In stage two, extension of the lower vertebrae leads to extension in the upper vertebrae which causes the cervical spine to adopt an S-shaped curve. <ref name=":4">Chen HB, Yang KH, Wang ZG. Biomechanics of whiplash injury. 2009;5:305-14.</ref> Finally, in stage three extension moments acting on both ends cause the entire neck region to be extended with an intense shearing force causing compression of facet joint capsules. <ref name=":3" /><ref name=":4" />
== Pathophysiology ==
----
The mechanism of injury in whiplash associated disorder occurs in three stages<ref name=":3">Gastown Physio Pilates. Whiplash Associated Disorder. Available from: <nowiki>https://gastownphysiopilates.com/blogs/3-whiplash</nowiki> (Accessed 28 March 2021)</ref><ref name=":4">Chen HB, Yang KH, Wang ZG. Biomechanics of whiplash injury. 2009;5:305-14.</ref>:


'''Kinematics During Rear Impact'''
* In the first stage, both the upper and lower spine experience flexion, causing a loss of cervical lordosis.
* In stage two, extension of the lower vertebrae gradually leads to extension in the upper vertebrae which causes the cervical spine to adopt an S-shaped curve. The lower vertebrae is subjected to an extension moment, whereas at the upper levels a flexion moment occurs.
* Finally, in stage three the neck is completely extended with a shearing force causing compression of facet joint capsules.


We must be able to understand the biomechanics during rear impact to be able to assess the severity of injury it can cause. From the perspective of the driver the impact vehicle is rapidly accelerated forward causing the seat to interact with them, this occurs in the seatback causing the thorax to drive anteriorly. <ref name=":5">Stemper BD, Corner BD. Whiplash-Associated Disorders: Occupant Kinematics and Neck Morphology. Journal of Orthopaedic & Sports Physical Therapy.2016;46:834-844</ref> As the thorax is accelerated forward the inertia of the body deforms the seatback which deflects it towards the rear of the car. In time the seatback overcomes inertial loads from the torso and rebounds forward. <ref name=":5" /> This drives the person’s body forward and into the seatbelt. This causes the head-neck complex to sustain inertial loading during the initial stages of the impact.<ref name=":6">De Pauw R, Coppieters I, Kregel J, De Meulemeester K, Danneels L, Cagnie B. Does muscle morphology change in chronic neck pain patients? - A systematic review. 2016 Apr;22:42-9.</ref>  The specific loading that occurs will have a structural response on the cervical spine, but this would be dependent on the input acceleration applied at the cervicothoracic junction as well as the interaction of the head and its spinal components.<ref name=":5" /><sup>)</sup><ref name=":6" />
== Kinematics During Rear Impact ==
----
It is important to understand the biomechanics during rear impact to be able to assess the severity of injury it can cause. From the perspective of the driver the impact vehicle is rapidly accelerating forward causing the seat to interact with them, driving the thorax anteriorly. <ref name=":5">Stemper BD, Corner BD. Whiplash-Associated Disorders: Occupant Kinematics and Neck Morphology. Journal of Orthopaedic & Sports Physical Therapy.2016;46:834-844</ref> With forward acceleration of the thorax, the inertia of the body causes deformation of the seatback, deflecting it towards the rear of the car. In time, inertial loads from the torso are overcome by the seatback, leading it to rebound forward. <ref name=":5" /> This drives the person’s body forward and into the seatbelt.  


'''Clinical Evidence'''
During the primary phase of the impact, the head-neck complex is subjected to inertial loading.<ref name=":6">De Pauw R, Coppieters I, Kregel J, De Meulemeester K, Danneels L, Cagnie B. Does muscle morphology change in chronic neck pain patients? - A systematic review. 2016 Apr;22:42-9.</ref>  The specific loading that occurs will have a structural response on the cervical spine, but this would be influenced by the characteristics of the input acceleration applied at the cervicothoracic junction as well as the interaction of the head and its spinal components.<ref name=":5" /><ref name=":6" />


Kinematics and kinetics have been studied using crash dummies, human cadavers, human volunteers, and computer models. Collectively these studies have shown that during rear-end collisions the cervical spine initially undergoes a horizontal shear or retraction. <ref name=":7">Curatolo M, Bogduk N, Ivancic PC, McLean SA, Siegmund GP, Winkelstein BA. The role of tissue damage in whiplash-associated disorders: discussion paper 1. Spine. 2011;36:309-15</ref>The studies showed different tissues and joints that could be damaged/injured during impact.  
== Clinical Evidence ==
Crash dummies, human cadavers, human volunteers and computer models have all been used to study the kinematics and kinetics of whiplash associated disorder. These studies have demonstrated that the cervical spine is subjected to a horizontal [[shear]] or retraction during the initial stages of rear-end collisions. <ref name=":7">Curatolo M, Bogduk N, Ivancic PC, McLean SA, Siegmund GP, Winkelstein BA. The role of tissue damage in whiplash-associated disorders: discussion paper 1. Spine. 2011;36:309-15</ref> The studies showed different tissues and joints that could be damaged/injured during impact.  


* '''Anterior Longitudinal Ligaments and Discs'''
*'''Anterior Longitudinal Ligament and Discs'''
Starting with anterior longitudinal ligaments, the studies identified tears as well as rim lesions of the anterior anulus fibrosus that were produced in cadavers subjected to whiplash injuries <ref name=":7" /><sup>.</sup> Strains in the anulus fibrosus of lower cervical discs can exceed physiologic limits. These observations provide a basis for tears of the anterior disc or the anterior longitudinal ligament being a source of nociception after whiplash injury.<ref name=":7" /> 
Starting with [[anterior longitudinal ligament]], cadaveric studies of whiplash injuries have found tears as well as rim lesions of the anterior anulus fibrosus. <ref name=":7" /> The strains that occur in the anulus fibrosus of lower [[Cervical Anatomy|cervical]] discs have been found to exceed physiological limits. These findings suggest a potential pathologic mechanism for tears of the anterior disc or of the anterior longitudinal ligament being a source of nociception following whiplash injury.<ref name=":7" /> 


* '''Dorsal Root Ganglion'''  
* '''Dorsal Root Ganglion'''  
The dorsal ganglia can become damaged from a whiplash injury. They are at risk for injury because of the rapid changes that occur in the canal pressure, which are caused due to the rapid head motions from the impact.<ref name=":7" /> This knowledge offers potential mechanism of how neck and shoulder pain may result from nerve root trauma caused due to whiplash. 
The dorsal ganglia can become damaged from a whiplash injury. They are at risk for injury because of the rapid changes that occur in the canal pressure, which are caused due to the rapid head motions from the impact.<ref name=":7" /> This knowledge offers a potential mechanism of how neck and shoulder pain may result from nerve root trauma caused due to whiplash. 


* '''Vertebral Artery'''  
* '''Vertebral Artery'''
A retrospective analysis of 500 whiplash patients indicated that the incidence of cervical arterial dissections was significantly higher than in controls. Vertebral artery injury originates from an intimal tear, most commonly at cervical spine 1 and 2, which is the primary site of cervical axial rotation.<ref name=":7" /><ref name=":8">Hauser V, Zangger P, Winter Y, et al. Late sequelae of whiplash injury with dissection of cervical arteries. ''Eur Neurol.'' 2010;64:214–218</ref> Coupled cervical spine extension and axial rotation beyond the physiologic limit has been hypothesized to cause vertebral artery injury<sup>.</sup><ref name=":8" /> It is supported by biomechanical research, indicating elongation-induced vertebral artery injury may occur due to non-physiologic coupled neck motions during an automobile collision. <ref name=":7" />
 
The incidence of cervical arterial dissections was found to be significantly greater in those who experienced whiplash compared to healthy controls, in a retrospective analysis of 500 whiplash patients. It is thought that vertebral artery injury may occur from an intimal tear. These occur most often at the C1-C2, which is the principal location of cervical axial rotation. <ref name=":7" /><ref name=":8">Hauser V, Zangger P, Winter Y, et al. Late sequelae of whiplash injury with dissection of cervical arteries. ''Eur Neurol.'' 2010;64:214–218</ref> [[Vertebral Artery|Vertebral artery]] injury has been suggested to be caused by cervical spine extension combined with axial rotation occurring beyond the physiological limit. <ref name=":8" /> Previous biomechanical work provides evidence for this non-physiological coupled neck motion causing vertebral artery injury due to elongation during vehicle collisions. <ref name=":7" />


*  '''Muscles'''  
*  '''Muscles'''  
Direct injury to muscles can occur from the imposed lengthening during reflex neck muscle activation which is the response caused from the impact.<ref name=":9">Chung YS, Han DH. Vertebrobasilar dissection: a possible role of whiplash injury in its pathogenesis. ''Neurol Res.'' 2002;24:129–138</ref>Biomechanically, muscle fascicle strains in the sternocleidomastoid muscle and in the semispinalis capitis muscle were seen in human subjects<ref>Chen H, King HY, Wang Z. Biomechanics of whiplash injury. Chinese Journal of Traumatology. 2009;12:305-314</ref> The strains were larger than those shown in the injury data showing that lesions to the muscles following a whiplash exposure are due to the acute rather than chronic phase of whiplash injury.<ref name=":9" />
In response to the impact induced lengthening caused by reflex neck muscle activation, direct injury to muscles may occur. <ref name=":9">Chung YS, Han DH. Vertebrobasilar dissection: a possible role of whiplash injury in its pathogenesis. ''Neurol Res.'' 2002;24:129–138</ref> Previous biomechanical studies have found muscle fascicle strains occurring in the [[sternocleidomastoid]] muscle and the [[Semispinalis Capitis|semispinalis capitis]] muscle in human subjects<ref>Chen H, King HY, Wang Z. Biomechanics of whiplash injury. Chinese Journal of Traumatology. 2009;12:305-314</ref> The strains were larger than those shown in the injury data, suggesting that the acute phase of whiplash injury may be the cause of muscle lesions rather than the chronic phase.<ref name=":9" />
----
 
== Physical Management post WAD ==
 
* The mainstay of management for acute WAD is the provision of advice encouraging return to usual activity and exercise, and this approach is advocated in current clinical guidelines<ref>Sterling M. (2014). Physiotherapy management of whiplash-associated disorders (WAD). Journal of Physiotherapy, 60, pp. 5–12 Available from: <nowiki>https://www.sciencedirect.com/science/article/pii/S1836955314000058</nowiki> (last accessed 2.2.2020)</ref>. The most important goals of the interventions are:  1. Reassuring the patient  2. Modulating maladaptive cognition about WAD  3. Activating the patient<ref>Meeus M. et al. Pain Physician. The efficacy of patient education in whiplash associated disorders: a systematic review. 2012 Sep-Oct;15(5):351-61.</ref>
* There is evidence supporting multidisciplinary therapy for effective management of chronic whiplash. This therapy consists of an exercise program. Early mobilization is most effective when other more serious clinical pathologies noted on examination and imaging diagnostics have been ruled out.
* Prognosis is secondary to comorbidities prior to the injury, severity of WAD, age and socioeconomic environment.  Full recovery has been shown to occur in a few days to several weeks. However, disability can be permanent and range from chronic pain to impaired physical function.
 


'''Concluding statement'''
For detailed management, please refer [[Whiplash Associated Disorders|here]].


Biomechanics are important in both assessing and understanding treatment procedures that can be done. By appreciating the biomechanics behind whiplash associated disorder we can analyze better treatments as well as improve techniques that are more specific to how injuries are caused. By looking at the biomechanics we can interpret the lesions caused on the different structures around the neck and prepare better plans as well as researching further on how to prevent such lesions. 
== Conclusion ==
----
By appreciating the biomechanics behind whiplash associated disorder we can analyze better treatments as well as improve techniques that are more specific to how injuries are caused. By looking at the biomechanics we can interpret the lesions caused on the different structures around the neck and prepare better plans as well as researching further on how to prevent such lesions. 


'''References'''<references />
== References ==
<references />
[[Category:Neurology]]
[[Category:Biomechanics]]
[[Category:Injury]]
[[Category:Neurological - Conditions]]
[[Category:The University of Waterloo Clinical Biomechanics Project]]

Latest revision as of 19:47, 26 December 2023

Original Editors - Camila Trujillo as part of The University of Waterloo Clinical Biomechanics Project

Top Contributors - Rucha Gadgil, Natasha Ivanochko, Camila Trujillo, Kim Jackson, Simisola Ajeyalemi and Habibu Salisu Badamasi  

What is it?[edit | edit source]

Whiplash Associated Disorder (WAD) is a term that is used to describe injuries in and around the neck obtained from deceleration-acceleration movements that occur abruptly, such as from a motor vehicle collision.[1] The prognosis of WAD tends to be unknown and unpredictable, there can be two types of cases, acute or chronic. Acute cases normally have a full recovery whereas chronic cases lead to long term pain as well as future disability. [2]  Most whiplash associated disorders are minor soft tissue injuries lacking evidence for fractures.[3]

Quebec Classification

The Quebec Task Force produced a mechanism used to classify patients suffering from whiplash associated disorder, based on the severity of both signs and symptoms.[4] There are different grades ranging from I to IV, these are described below.

Grade I: Patient experiences neck pain, stiffness or tenderness.

Grade II: Patient exhibits musculoskeletal signs which include decreased range of motion and point tenderness.

Grade III: Patient shows neurologic signs which may include sensory deficits as well as muscle weakness.

Grade IV: Patient shows neck dislocation or fracture. [1] [4]

Pathophysiology[edit | edit source]

The mechanism of injury in whiplash associated disorder occurs in three stages[5][6]:

  • In the first stage, both the upper and lower spine experience flexion, causing a loss of cervical lordosis.
  • In stage two, extension of the lower vertebrae gradually leads to extension in the upper vertebrae which causes the cervical spine to adopt an S-shaped curve. The lower vertebrae is subjected to an extension moment, whereas at the upper levels a flexion moment occurs.
  • Finally, in stage three the neck is completely extended with a shearing force causing compression of facet joint capsules.

Kinematics During Rear Impact[edit | edit source]

It is important to understand the biomechanics during rear impact to be able to assess the severity of injury it can cause. From the perspective of the driver the impact vehicle is rapidly accelerating forward causing the seat to interact with them, driving the thorax anteriorly. [7] With forward acceleration of the thorax, the inertia of the body causes deformation of the seatback, deflecting it towards the rear of the car. In time, inertial loads from the torso are overcome by the seatback, leading it to rebound forward. [7] This drives the person’s body forward and into the seatbelt.

During the primary phase of the impact, the head-neck complex is subjected to inertial loading.[8] The specific loading that occurs will have a structural response on the cervical spine, but this would be influenced by the characteristics of the input acceleration applied at the cervicothoracic junction as well as the interaction of the head and its spinal components.[7][8]

Clinical Evidence[edit | edit source]

Crash dummies, human cadavers, human volunteers and computer models have all been used to study the kinematics and kinetics of whiplash associated disorder. These studies have demonstrated that the cervical spine is subjected to a horizontal shear or retraction during the initial stages of rear-end collisions. [9] The studies showed different tissues and joints that could be damaged/injured during impact.

  • Anterior Longitudinal Ligament and Discs

Starting with anterior longitudinal ligament, cadaveric studies of whiplash injuries have found tears as well as rim lesions of the anterior anulus fibrosus. [9] The strains that occur in the anulus fibrosus of lower cervical discs have been found to exceed physiological limits. These findings suggest a potential pathologic mechanism for tears of the anterior disc or of the anterior longitudinal ligament being a source of nociception following whiplash injury.[9] 

  • Dorsal Root Ganglion

The dorsal ganglia can become damaged from a whiplash injury. They are at risk for injury because of the rapid changes that occur in the canal pressure, which are caused due to the rapid head motions from the impact.[9] This knowledge offers a potential mechanism of how neck and shoulder pain may result from nerve root trauma caused due to whiplash. 

  • Vertebral Artery

The incidence of cervical arterial dissections was found to be significantly greater in those who experienced whiplash compared to healthy controls, in a retrospective analysis of 500 whiplash patients. It is thought that vertebral artery injury may occur from an intimal tear. These occur most often at the C1-C2, which is the principal location of cervical axial rotation. [9][10] Vertebral artery injury has been suggested to be caused by cervical spine extension combined with axial rotation occurring beyond the physiological limit. [10] Previous biomechanical work provides evidence for this non-physiological coupled neck motion causing vertebral artery injury due to elongation during vehicle collisions. [9]

  •  Muscles

In response to the impact induced lengthening caused by reflex neck muscle activation, direct injury to muscles may occur. [11] Previous biomechanical studies have found muscle fascicle strains occurring in the sternocleidomastoid muscle and the semispinalis capitis muscle in human subjects[12] The strains were larger than those shown in the injury data, suggesting that the acute phase of whiplash injury may be the cause of muscle lesions rather than the chronic phase.[11]

Physical Management post WAD[edit | edit source]

  • The mainstay of management for acute WAD is the provision of advice encouraging return to usual activity and exercise, and this approach is advocated in current clinical guidelines[13]. The most important goals of the interventions are: 1. Reassuring the patient 2. Modulating maladaptive cognition about WAD 3. Activating the patient[14]
  • There is evidence supporting multidisciplinary therapy for effective management of chronic whiplash. This therapy consists of an exercise program. Early mobilization is most effective when other more serious clinical pathologies noted on examination and imaging diagnostics have been ruled out.
  • Prognosis is secondary to comorbidities prior to the injury, severity of WAD, age and socioeconomic environment.  Full recovery has been shown to occur in a few days to several weeks. However, disability can be permanent and range from chronic pain to impaired physical function.


For detailed management, please refer here.

Conclusion[edit | edit source]

By appreciating the biomechanics behind whiplash associated disorder we can analyze better treatments as well as improve techniques that are more specific to how injuries are caused. By looking at the biomechanics we can interpret the lesions caused on the different structures around the neck and prepare better plans as well as researching further on how to prevent such lesions. 

References[edit | edit source]

  1. ↑ 1.0 1.1 1.      Pastakia K, Kumar S. Acute whiplash associated disorders (WAD). Open Access Emergency Med. 2011; 3:29-32. 
  2. ↑ Stace R. and Gwilym S. Whiplash associated disorder: a review of current pain concepts. Bone & Joint. 2015; 4:360
  3. ↑ Bragg KJ, Varacallo M. Cervical Sprain. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541016/ (Accessed 10 April 2021)
  4. ↑ 4.0 4.1 Steven J. MD, Richard A. Patrick, D.L. Convery, K. Keller R.B. Singer, D.E. * The Quebec Task Force Classification for Spinal Disorders and the Severity, Treatment, and Outcomes of Sciatica and Lumbar Spinal Stenosis, Spine.1996;21:2885-2892
  5. ↑ Gastown Physio Pilates. Whiplash Associated Disorder. Available from: https://gastownphysiopilates.com/blogs/3-whiplash (Accessed 28 March 2021)
  6. ↑ Chen HB, Yang KH, Wang ZG. Biomechanics of whiplash injury. 2009;5:305-14.
  7. ↑ 7.0 7.1 7.2 Stemper BD, Corner BD. Whiplash-Associated Disorders: Occupant Kinematics and Neck Morphology. Journal of Orthopaedic & Sports Physical Therapy.2016;46:834-844
  8. ↑ 8.0 8.1 De Pauw R, Coppieters I, Kregel J, De Meulemeester K, Danneels L, Cagnie B. Does muscle morphology change in chronic neck pain patients? - A systematic review. 2016 Apr;22:42-9.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 Curatolo M, Bogduk N, Ivancic PC, McLean SA, Siegmund GP, Winkelstein BA. The role of tissue damage in whiplash-associated disorders: discussion paper 1. Spine. 2011;36:309-15
  10. ↑ 10.0 10.1 Hauser V, Zangger P, Winter Y, et al. Late sequelae of whiplash injury with dissection of cervical arteries. Eur Neurol. 2010;64:214–218
  11. ↑ 11.0 11.1 Chung YS, Han DH. Vertebrobasilar dissection: a possible role of whiplash injury in its pathogenesis. Neurol Res. 2002;24:129–138
  12. ↑ Chen H, King HY, Wang Z. Biomechanics of whiplash injury. Chinese Journal of Traumatology. 2009;12:305-314
  13. ↑ Sterling M. (2014). Physiotherapy management of whiplash-associated disorders (WAD). Journal of Physiotherapy, 60, pp. 5–12 Available from: https://www.sciencedirect.com/science/article/pii/S1836955314000058 (last accessed 2.2.2020)
  14. ↑ Meeus M. et al. Pain Physician. The efficacy of patient education in whiplash associated disorders: a systematic review. 2012 Sep-Oct;15(5):351-61.
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