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Whiplash Related Neck Pain

by Dr Simon Petrides MB BS DO DM-SMed Dip Sports Med FFSEM (UK&I)
Musculoskeletal & Sports Physician | The Blackberry Clinic, Milton Keynes

It’s Not Improving So What Next?
This article addresses the issues concerning whiplash related neck pain. There is also extensive discussion on the injection procedures that can be carried out to relieve chronic persistent whiplash related pain.

Our knowledge regarding specific anatomical components injured during the process of whiplash is incomplete, but MRI and autopsy examination has shown significant damage to cervical ligaments, facet joints and discs in people suffering from a whiplash type injury, otherwise known as a cervical acceleration deceleration (CAD) injury. There is evidence to suggest that a significant proportion of patients have pain originating in the cervical facet joints and capsular ligaments  (Lord 1995, Lord 1996).

Whiplash injuries resulting in chronic pain are extremely prevalent in the UK and US. The resulting cost to the NHS and to the Department of Work & Pensions is huge.

Between 5% and 8% of whiplash sufferers develop longstanding symptoms severe enough to affect their ability to work (Lovell 2002, Freeman 1999, Sterner 2004). Studies using medial branch block and radiofrequency neurolysis of facet joint sensory nerves have demonstrated the existence of the facet joint pain in whiplash injury.

Artificial reconstruction of the whiplash injury during rear end collisions demonstrated injury to the anterior longitudinal ligaments and annular fibres in the middle and lower cervical spine (Ivancic 2004, Panjabi 2004). Other studies have shown the facet capsules at C5 - C7 were found to be at risk due to excessive motion during impact (Ito S, 2004).

These studies have led to the conjecture that microscopic injuries of the cervical ligaments may affect mechanoreceptors and nociceptors leading to chronic pain after a certain period of time.

Significant decreases have been reported in ligament strength following simulated whiplash injury supporting the evidence that in patients with whiplash syndrome, there is significant pain relief to be gained following medial branch facet block, and/or radiofrequency neurolysis of the relevant zygapophyseal joint afferent nerves fibres (Lord 1995, Lord 1996).

Any reduction in ligament strength is likely to lead to relative instability at intervertebral segments and further injury to the disc annulus, posterior longitudinal ligament, ligament flavum and other surrounding ligaments, muscles and connective tissue.

Non-Whiplash Neck Pain
There are a few epidemiological studies reporting an accurate prevalence of neck pain, however it is estimated to be in the region of 34% of the general population. Chronic neck pain lasting more than six months is estimated at approximately 14% (Bovim 1994, Makela 1991).

In 1933. Ghormley coined the term facet syndrome to describe a collection of symptoms and signs associated with degenerative change of the lumbar spine (Ghormley 1933). The term cervical facet syndrome implies “axial pain secondary to involvement of the posterior elements of the cervical spine”. This may or may not be associated with referred pain.

The facet joints have been found to be a possible source of neck pain by specific medial branch block.

Clinical Signs & Symptoms
The clinical features that are often associated with pain of cervical facet joint origin include tenderness to palpation over the joints or paraspinal muscles. This is often detectable as dysfunction, “subluxation” or “fixation” as detected by osteopaths, chiropractors and physiotherapists with the relevant manual skills. Pain is usually experienced on extension or rotation in a capsular or non-capsular pattern, and in pure facet joint pain there is an absence of neurological deficit.

The use of MRI, CT and X-ray are usually not helpful, with the exception of ruling out other more serious sources of pain and also to exclude disc protrusion, vertebral fracture or subluxation. Although the signs of disc narrowing and foraminal encroachment, osteophytes and other degenerative changes are frequently associated with the level of pain there is not any proven relationship in view of the fact that these changes are equally prevalent in people without neck pain (Friedenberg 1963).

This is not to say that the degenerative levels are not related causally to the level of pain, and anecdotally they often are: ‘Absence of evidence is not evidence of absence.’

It has been shown that between 26% and 65% of patients with neck pain following an injury have at least one symptomatic facet joint in the cervical spine (Aprill 1992).

In a large study of 500 patients with chronic spine pain the prevalence of the facet joint being the origin of the pain was determined using comparative controlled local anaesthetic blocks, but which indicated that cervical facet joint pain had a prevalence of 55%.

Discogenic Pain
In 1993, Bogduk demonstrated that 41% of patients had a painful disc and facet joint at the same segment and an additional 23% had a painful facet joint but not a painful disc at the same segment. This demonstrates that the disc and facet joint are the most likely structures to be injured in whiplash and other injuries. Along with other studies, the apparent prevalence of facet joint pain after whiplash is 54%, making the facet/zygapopohyseal joint the most common cause of chronic pain after whiplash injury in the various populations that have been studied (Bogduk, 1993, Barnsley 1995).

The most common levels involved seem to be C2/3 and C5/6 (Lord 1996).

Clinical Anatomy
The cervical spine consists of seven vertebrae which provide mobility and stability to the head. The atlas articulates with the occiput superiorly and inferiorly with the axis at C2. The atlas does not have a body but the body has become part of C2 and is called the dens or odontoid peg. The atlas has an anterior and posterior arch with two lateral masses and two transverse processes. The transverse processes enclose the vertebral artery which travels through a foramen. There are superior and inferior articular processes with uniquely shaped facets which articulate with the occiput and C2.

The axis has a large vertebral body which contains the dens which articulates with the anterior arch of the atlas and this is held in place by the transverse ligament. The axis is comprised of a vertebral body, pedicles, laminae and transverse processes and it has convex superior articular facets.  

The remaining vertebrae, C3 to C7 are similar to each other but different from C1 and C2. Their vertebral bodies are concave on the upper surface, convex on the inferior surface. On the superior surface the bodies are raised laterally into uncinate processes which articulate with areas on the inferior aspect of the vertebra above. These “uncovertebral” joints are known as the joints of Luschka. The spinous process of C3 to C5 are usually bifid compared to C6 and C7,  C7 being the more prominent vertebra (verebra prominens).

The cervical facet joints are synovial with fibrous capsules. They are more lax in the lower cervical spine, allowing for gliding. The joints are at an angle of 45 degrees from horizontal and 85 degrees from the sagittal plane. The fibrous facet joint capsules are innervated by mechanoreceptors and by free nerve endings (McLain 1994).

The facet joints are innervated by both the ventral and dorsal rami. The OA and AA joint are innervated by the ventral rami of the 1st and 2nd cervical spinal nerves. The dorsal ramus of the 3rd cervical nerve gives off two branches which innervate the C2/3 facet joint. The medial branch of the dorsal ramus is known as the 3rd occipital nerve and this is frequently targeted for radiofrequency ablation therapy after whiplash injury.  

The cervical facet joints from C3/4 to C7/T1 are supplied by the medial branches of the dorsal rami that arise one level higher, at the same level and one level below the joint. The medial branches divide into articular branches as they pass around the waist of the articular pillar.

The discs in the cervical spine have a nucleus pulposus, an annulus fibrosus and two end plates either side of the disc are attached to the vertebral bodies.

The annular fibres are prone to injury with rotational force because of the orientation of the lamellae (Bogduk 1991).

The middle and outer third of the annulus is innervated by noceceptors and there have been inflammatory mediators found in the disc which may be a cause of pain (Bogduk 1988, Mendel 1992, Franson 1992).

Several ligaments provide stability and proprioception (Panjabi 1991). The transverse ligament which is the main part of the cruciate ligament arises from tubercles on the atlas and stretches across its anterior ring to hold the dens against the anterior arch. There is a synovial cavity located between the dens and the transverse process, thus rotation of the atlas on the dens is possible. The transverse ligament is the most important ligament in prevention of anterior translation of the atlas on the axis (Fielding 1974).

The ALAR ligaments run from the lateral dens to medial occipital condyles and to the atlas. They limit axial rotation and side flexion. If they are damaged in whiplash injury the joint becomes hypermobile and this can lead to irritation of the vertebral arteries and may be responsible for some of the symptoms of whiplash syndrome such as headache, neck pain and dizziness.

The anterior longitudinal and posterior longitudinal ligaments, ALL and PLL are the major stabilisers of the intervertebral joints. The ALL is closely adhered to the discs anteriorly but the PLL is not well developed in the cervical spine. The PLL prevents excessive flexion and distraction (Panjabi 1993).

The supraspinous ligament, interspinous ligament and ligamentum flavum maintain stability between the vertebrae.The supraspinous ligament attaches the tips of the spinous processes to each other and the interspinous ligament runs between the mid portion of the spinous processes. The ligamentum flavum runs between the vertebral arches and controls flexion and anterior translation along with the interspinous ligament (Panjabi 1993 and White 1990).     

The ligamentum flavum also connects and reinforces the facet joint capsules on their anterior aspect. The ligamentum nuchae is a continuation of the supraspinous ligament and has a prominent role in the stabilising of cervical spine. Motion between C2 and C7 is determined by orientation of the facet joints, the discs and the joints of Lushka.

There is a coupling of rotational lateral flexion, for example when the vertebrae side bend to the left they also rotate to the left. This is significantly less in the lower segments due to the difference in facet orientation. Horizontal translation of the vertebral body at more than 3.5 millimetres measured on lateral radiographic fluoroscopic screening during flexion and extension is considered the upper limit of normal (White 1975).

Taking a History
Patients with facet joint pain often present with neck pain, headaches, dizziness and a limited range of motion. The pain is dull and may radiate to the upper trapezius and medial scapula area. Neck pain can refer from the cervical facet joints into the arm in an extra segmental pattern of radiation. A more sharp shooting severe pain in a segmental distribution suggests a radicular origin of the pain.

Physical Findings
Examination in facetogenic pain often reveals a non-capsular pattern of movement limitation associated with local tenderness to palpation over the joints or segmental dysfunction/fixation. Paraspinal muscles are often tender and pain is especially prevalent on extension with combined rotation. In pure facetogenic pain there is an absence of neurological findings.

Referred patterns of pain have been mapped (Dwyer 1990):

  • C2/3 facet joints refer pain to the posterolateral upper cervical region and the head.
  • C3/4 facet joints refer pain to the posterolateral middle cervical region.
  • C4/5 facet joints refer pain to the posterolateral middle and lower cervical region and to the top of the shoulder.
  • C5/6 facet joints refer pain to the posterolateral middle and primarily lower cervical spine and the top and the lateral parts of the shoulder and more caudally the spine of the scapula.
  • C6/7 facet joints refer pain to the top lateral parts of the shoulder which extends to the infraspinous and medial aspect of the scapula.

These pain maps have been shown to be a powerful diagnostic tool when evaluating patients with cervical pain (Aprill 1990). Pain patterns for the occipito-atlantal joints were variable and extended from the top of the skull to the C5 level. Pain patterns for the atlanto-axial joints were located posterolateral to the C1/2 segmental region (Dreyfuss 1994, Star 1992). Blood tests are not routinely indicated in the diagnosis of cervical facet joint pain.  

Radiographs are sometimes helpful, especially if combined with flexion extension views or fluoroscopic screening to rule out excessive translation at intervertebral levels. Horizontal movement of one vertebral body on the next should not be more than 3.5 millimetres and the angular displacement of one body on the next should be less than 11 degrees.

Acute Neck Pain
In the first instance, the object is to reduce pain and inflammation and increase the pain free range of motion. Cold or ice therapy is indicated in the acute stage to decrease blood flow and subsequent haemorrhage into injured tissues. This will result in a reduction of local oedema. Ice application may also reduce muscle spasm. Consequent use of ultrasound or other electrical stimulation may also reduce muscle spasm. Manual therapy, mobilisation and myofascial treatment along with stretching and exercises are also helpful. Passive range of motion treatments followed by active range of movement exercises should progress in a pain free range and finally strengthening and stabilisation using various techniques of dynamic stability, balance and kinetic control should be instigated.  

Surgical intervention is only considered when either non-surgical treatment has failed or for severe injury grossly effecting stability and for subluxations/dislocation, etc.

Other Treatment Options
The object of this article is not to detail physical treatment and other manual approaches to neck pain but to outline options once these conservative measures have failed or have provided inadequate improvement.

Facet Joint Injections Under Fluoroscopic X-Ray Guidance
Some studies of intra-articular facet joint injections report only minor relief for days to weeks (Moran 1988, Barnsley 1994) while others report substantial relief for weeks to months (Dorey 1983, Fairbank 1981 and Roy 1988). Therefore it is evident that these procedures are worth trying in many situations since anecdotal reports also claim significant improvement with this approach.

Medial Branch Blocks
The sensitivity of a single uncontrolled block has been estimated to be 95% and the specificity 73% (Barnsley 1993). It has been shown that local anaesthetic does not spread beyond the area of the medial branch (Barnsley 1993). This indicates that the block does not anaesthetise any other structures that may be a source of chronic cervical pain, other than the facet joint.

Cervical medial branch blocks are easier to perform than intra-articular blocks, the patient is often lying on the side with a lateral view obtained by fluoroscope. The needle is then introduced onto the middle of the articular pillar and the resulting effect is noted over the consequent four hours. The patient makes a physical record using a pain scale and when it has confirmed that a particular cervical facet joint pain has been obliterated by the medial branch blocks then this diagnostic technique can leave the physician to continue with a more permanent technique known as radiofrequency neurolysis.

Radiofrequency Neurolysis/Ablation
Radiofrequency neurolysis results in denervation of the facet joint by passing a radiofrequency current through the medial branch of the posterior primary ramus (dorsal ramus). This denatures the proteins in the nerve (Zervas 1972). There was also a heating effect produced by a vibration of ions. Afferent transmission of pain along the nerve to the dorsal root ganglion is obliterated. The nerve is not completely destroyed since the medial branch cell bodies in the dorsal root ganglion are not affected, so it has been noted that the nerve may grow back to its target joint in nine to twelve months depending upon the lesion site. This can result in a recurrence of the pain.

There is an option of repeating the medial branch radiofrequency neurolysis with equal effect and without any further side effects. The procedure is not performed bilaterally at multiple segments at the same time because of a risk of cervical muscular fatigue with daily activity (McDonald 1999). In a randomised double blind controlled trial radiofrequency neurolysis was assessed heating the nerve to 80 degrees C for 90 seconds and the patients in the treatment group took an average of 263 days before the pain returned to 50% of the pre-operative level, whereas the patients in the control group perceived this return of pain in just eight days (Lord 1996). In another study, complete relief of pain was reported in 71% of patients after the initial procedure. The total duration of pain relief was 422 days after the initial procedure and 219 days after the repeat procedure (McDonald 1999).  

Greater Occipital Nerve Radio Frequency Neurolysis
Radiofrequency can be used for intractable headache and occipital pain as a result of greater occipital neuralgia and which responds to greater occipital nerve blockade with local anaesthesia. These headaches are often referred to as tension headaches and are related to hypertonicity in the suboccipital musculature, pain refers from the occiput as far as the parietal area and often causes retro-orbital pain.  

Cervial Epidural Injections
Cervical epidurals can be of use in discogenic cervico brachialgia when an MRI has shown a disc protrusion and the clinical signs have demonstrated significant neurological deficit, dural tension and irritation. The most common levels involved are C5/6 and C6/7 resulting in C6 and C7 radiculopathy respectively.

Transforaminal Epidural
Cervical transforaminal epidural injections (nerve blocks) are sometimes carried out under X-ray guidance but there is reluctance on behalf of some pain clinicians to carry out these procedures in view of the higher incidence of intravascular or possibly intra-arterial injection which increases the risk of adverse reactions. Cervical epidurals tend to be the treatment of choice in these cases.

Blind Cervical Nerve Root Injections
There is a recognised technique of injecting onto the transverse process of C7 without X-ray control and this has been shown in small studies to be an effective method of controlling radicular pain from C7 radiculitis. This can be a very effective and safe approach for the acute cervico-brachialgia that exists when patients present with neck and arm pain and the inability to sleep due to the severity and intensity of the pain. These patients often have to sleep with their arm behind their head and often in a sitting position. This is catastrophic when it lasts more than a few days and patients are often desperate for a procedure to relieve their pain.

Prolotherapy is an injection of Glucose (12.5%), Glycerol and Phenol (1%) around the supporting capsular and supraspinous/interspinous ligaments under X-ray control on three separate occasions at weekly intervals. This procedure has been shown to thicken collagen fibres and may help to strengthen and stabilise the intervertebral segments (Hackett,Cyriax, Ongley, Dorman, Reeves etc). Prolotherapy is used frequently by musculoskeletal and some sports physicians in the lumbar spine but it can be of particular use in the cervical spine if mild instability or recurrent or chronic neck pain exists which is refractory to other treatments.

On the basis that neck ligament strength is decreased following whiplash type trauma (Tominaga et al and Panjabi), it seems logical that prolotherapy to thicken ligament tissue would be a rational approach in whiplash type injury. Prolotherapy was shown in a prospective case series on neck pain to reduce sagittal translation at the unstable level and to reduce pain.( Centeno, Elliot et al 2005).

Post Procedure Recovery
The patients should continue with an active rehabilitation programme whilst their pain is improving, the goals being to increase stability, strength and range of motion along with neuromuscular control. Manual therapy may still be required depending upon the progress.

Traction has been shown to be a benefit in several studies and there are useful home traction kits available. Anecdotally this treatment can help where other forms of manual therapy have been ineffective. Traction should be done on a daily basis and consequently traction in an outpatient physiotherapy unit is not cost effective, but home traction units can be extremely useful to provide five minutes of traction twice a day for one to two weeks.

Acupuncture has a role to play in pain relief following whiplash injury and should not be overlooked when considering conservative management in this instance.

Other Approaches
The temporomandibular joint (TMJ) is often considered by osteopaths and chiropractors as being important in neck pain and assessment of this joint can demonstrate asymmetry/dysfunction and malocclusion. It is treated sometimes by occlusal plates from dentists with an interest in this joint. Physiotherapists with an interest in the joint also have several manual and other therapeutic approaches.

Anti-inflammatory and analgesic medication can be used at any point during the recovery phase and there is a recognised effect of using this form of treatment for pain relief. Gabapentin, Pregabalin and other pain modulating drugs can be useful, especially in neuropathic type pains which may be a consequence of neck injury.

Return to Sport
This is an individual process for sports participants and no specific time frame exists, but the safe return to sport is allowed when the patient can illustrate the full pain free range of motion along with full neuromuscular control and a proper neutral spine posture during and in-between sport specific activities.

Despite extensive literature regarding surgical management of cervical spine injury, there is little information concerning the indication for returning to sport after these procedures and also after non-surgical conditions such as neck strain and “stingers”. Full assessment should be made if ligament injury is suspected. The process of using flexion, extension and neutral radiographs should be used if ligament injury is suspected. If any evidence of ligamentous instability exists the patient must be placed in a rigid collar and further images obtained two to four weeks later. Wryneck or “torticollis” may suggest a severe injury, especially if experienced after trauma and may even suggest subluxation or unilateral dislocation. Neurological status must be assessed thoroughly and an expert opinion sought.

Some specialists recommend a cervical MRI scan if symptoms following a stinger type injury persist for more than a few minutes and an EMG if they last for more than two weeks. As a rule any athlete with permanent neurological signs and deficits should be prohibited from participating in further competition. Athletes without spinal cord injuries and with stable fractures should be allowed to return to their normal daily activities.

Paraesthesia or brachial plexus injury may not prohibit return to play once neurological examination returns to normal, but each of these situations regards careful individual assessment. Even after healing of a severe injury has occurred, the altered biomechanics and loss of motion in the surrounding spinal segments may result in severe or devastating future sports related injuries, so return to play must be considered with due caution.

Psychosocial Issues
A cognitive behavioural approach can be useful in chronic neck pain since whiplash injury can often be complicated by involvement in compensation issues. Loss of employment due to disability is also linked with depression and psychosocial issues. Continuation at the workplace should be encouraged at all costs and if modification of the workstation and working environment is required then it should be encouraged.

Pain Management Programmes
Pain management is an important part of the treatment of longstanding cervical pain and cognitive behavioural therapy, physical therapy and exercise therapy should all be used concurrently in this approach.

Early Treatment
Early treatment of any musculoskeletal disorders, especially those relating to the cervical and lumbar spine may prevent chronicity, the progression of pain behaviours and fear avoidance resulting in abnormal movement patterns. The resulting muscle weakness and segmental instability can potentiate this progressive downward spiral of deterioration.

Source (in alphabetical order)
Aprill C, Dwyer A, Bogduk N. Cervical zygapophyseal joint pain patterns. II: A clinical evaluation.
Spine. Jun 1990;15(6):458-61.
Aprill C, Bogduk N. The prevalence of cervical zygapophyseal joint pain. A first approximation.
Spine, 17(7):744-7.
Barnsley L, Lord S. Bogduk N. Comparative local anaesthetic blocks in the diagnosis of cervical zygapophysial joint pain. Pain. Oct 1993;55(1):99-106.
Barnsley L, Lors S, Wallis B, Bogduk N. False-positive rates of cervical zygapophysail joint blocks. Clin J. Pain. Jun 1993;9(2):124-30.
Barnsley L, Lord SM, Wallis BJ, Bogduk N. Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zgapophyseal joints. N Engl J Med. Apr 1994;330(15):1047-50.
Bogduk N, Windsor M, Inglis A. The innervation of the cervical intervertebral discs. Spine. Jan 1988;13(1):2-8.
Bogduk N, Marsland A. The cervical zygapophysial joints as a source of neck pain. Spine. Jun 1988;13(6):610-7.
Bogduk N, Twomey L. Clinical Anatomy of the Lumbar Spine. 2nd ed. 2nd ed. New York, NY: Churchill Livingstone; 1991.
Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks.
Pain. Aug 1993;54(2):213-7.
Bovim G, Schrader H, Sand T. Neck pain in the general population.
Spine. Jun 15 1994;19(12):1307-9.
Centeno, Elliot et al .Fluoroscopically guided cervical  prolotherapy for instability with blinded pre and post radiographic reading. Pain Physician 2005;8:67-72 ISSN 1533-3 59
Dory MA. Arthrography of the cervical facet joints. Radiology. Aug 1983;148(2):379-82.
Dreyfuss P, Michaelsen M, Fletcher D. Atlanto-occipital and lateral atlanto-axial joint pain patterns. Spine. May 15 1994;19(10):1125-31.
Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns. I: A study in normal volunteers. Spine. Jun 1990;15(6):453-7.
Fairbank JC, Park WM, McCall IW, O’Brien JP. Apophyseal injection of local anaesthetic as a diagnostic aid in primary low-back pain syndromes. Spine. 6(6):598-605.
Fielding JW, Cochran GB, Lawsing JF 3rd, Hohl M. Tears of the transverse ligament of the atlas. A clinical and biomechanical study. J Bone Joint Surg Am. Dec 1974;56(8):1683-91.
Franson RC, Saal JS, Saal JHA. Human disc phospholipase A2 is inflammatory. Spine. Jun 1992;17(6 Suppl):S129-32.
Freeman MD, Croft AC, Rossignol AM, Weaver DS, Reiser M: A review and methodologic critique of the literature refuting whiplash syndrome. Spine 1999, 24:86-96.
Friedenberg Z, Miller W. Degenerative disc disease of the cervical spine. J. Bone Joint Surg. 1963;45A:1171-78.
Ghormley R. Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA. 1933;101:1773-7.
Hackett, Cyriax, Ongley, Dorman, Reeves – several studies papers and reviews available on request
Ito S, Ivancic PC, Panjabi MM, Cunningham BW: Soft tissue injury threshold during simulated whiplash: a biomechanical investigation. Spine 2004, 29:979-987.
Ivancic PC, Pearson AM, Panjabi MM, Ito S: Injury of the anterior longitudinal ligament during whiplash simulation. Eur Spine J 2004, 13:61-68.
Lord SM, Barnsley L, Bogduk N. Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain: a caution. Neurosurgery 1995, 36:732-739.
Lord SM, Barnsley L, Wallis BJ, McDonald GJ, Bogduk N: Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint p. N Engl Med 1996, 335:1721-1726.
Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine. Aug 1 1996;21(15):1737-44; discussion 1744-5.
Lord SM, Barnsley L, Wallis BJ, et al. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med. Dec 5 1996;335(23):1721-6.
Lovell ME, Galasko CS: Whiplash disorders—a review. Injury 2002, 33:97-101.
McDonald GJ, Lord SM, Bogduk N. Long-term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery. Jul 1999;45(1):61-7; discussion 67-8.
McLain RF. Mechnaoreceptor endings in human cervical facet joints. Spine. Mar 1 1994;19(5):495-501.
Makela M, Heliovaara M, Sievers K, Impivaara O, Knekt P. Aromaa A. Prevalence, determinants, and consequences of chronic neck pain in Finland. Am J Epidemiol. Dec 1 1991;134(11):1356-67.
Mendel T, Wink CS, Zimny ML. Neural elements in human cervical intevertebral discs. Spine. Feb 1992;17(2):132-5.
Moran R, O’Connell D, Walsh MG. The diagnostic value of facet joint injections. Spine. Dec 1988;13(12):1407-10.
Panjabi MM, Oxland TR, Parks EH. Quantitative anatomy of cervical spine ligaments. Part 1. Upper cervical spine. J Spinal Disord. Sep 1991;4(3):270-6.
Panjabi M, Vasavada A, White A. Cervical spine biomechanics. Seminars in Spine Surgery 1993. In: Cervical spine biomechanics. 5. 1993:10-16.
Panjabi MM, Ito S, Pearson AM, Ivancic PC: Injury mechanisms of the cervical intervertebral disc during simulated whiplash. Spine 2004, 29:1217-1225.
Roy DF, Fleury J, Fontaine SB, Dussault RG. Clinical evaluation of cervical facet joint infiltration. Can Assoc Radio/J. Jun 1988;39(2):118-20.
Star MJ, Curd JG, Thorne RP. Atlantoaxial lateral mass osteoarthritis. A frequently overlooked cause of severe occipitocervical pain. Spine. Jun 1992;17(6 Suppl):S71-6.
Sterner Y, Gerdle B: Acute and chronic whiplash disorders—a review. J Rehabil Med 2004, 36:193-209; quiz 210.
White A, Panjabi M. Spinal kinematics in the research status of spinal manipulative therapy. Washington, DC: Department of Health Education and Welfare; 1975.
White A, Panjabi M. The problem of clinical instability in the human spine: a systematic approach. In: Clinical Biomechanics of the Spine. 2nd ed. Philadelphia, Pa: JB Lippincott Co; 1990:277-378.
White AA, Panjabi M. Kinematics of the spine. In: Clinical Biomechanics of the Spine. 2nd ed. Lippincott-Raven; 1990:92-102.
Windsor at al 2006. Facet Joint Syndrome. E medicine.
Zervas NT, Kuwayama A. Pathological characteristics of experimental thermal lesions. Comparison of induction heating and radiofrequency electrocoagulation. J Neurosurg. Oct 1972; 37(4): 418-22.

Learning Outcomes
The author hopes that this article will achieve an understanding by physiotherapists and other manual therapists of treatments that are available and that have been proven to be successful. By the end of this article the reader should be able to understand the importance of locating the tissues causing the symptoms in whiplash pain and be aware of alternative avenues of treatment if conservative physical therapies have been of limited effectiveness.

Practical Application
In day-to-day practice, whiplash injuries are commonly encountered and it is the duty of the physiotherapist to be able to offer a management programme, but also to be aware of other avenues of treatment involving medication and injection therapy.

Areas for Further Learning
Further research is being carried out into the effectiveness of injection treatments in the cervical spine but several procedures have been proven to be of significant effectiveness. Physiotherapists need to be aware of the available therapeutic interventions and can obtain information from the authors of sited papers and other published literature on the subject.