Literature Support for Mechanical Back Pain

Literature Support for Mechanical Back Pain

A recent study in the European Spine Journal caught my attention because of it’s relevance to patients with chronic spine pain after trauma. This journal is considered to be one of the most highly regarded spine journals published. The paper was submitted by Dr. Panjabi from the Department of Orthopedics at Yale. He is considered the most respected and published researcher on the topic of human biomechanics with over 263 published articles. The study was titled A Hypothesis of Chronic Back Pain:Ligament Subfailure
Injuries Lead to Muscle Control Dysfunction. It was in the July 27th , 2005 edition of the journal. The ligament subfailure he refers to is related to several ligaments of the spine including the disc and facet capsules. He suggests that subfailure (partial tears that are not visible on radiographs) are the source of chronic back pain due to muscle control dysfunction. To me this sounds a lot like a chiropractic lesion.

Dr. Panjabi notes the following sequential steps:

1) Single or multiple traumas result in subfailure of the ligaments and mechanoreceptors that are within the ligaments.(In lay terms, mechanoreceptors are nerve endings that sense mechanical stimulus)

2) The damaged mechanoreceptors send corrupted signals which, in turn, result in corrupted muscle responses.

3) This lack of coordination and recruitment of muscles causes abnormal stresses and strains in ligaments, mechanoreceptors, muscles and facet joints.

4) Poor healing of the spinal ligaments results in accelerated degenerative changes in the disc and facet (spondylosis and arthrosis).

5) Over time, this may lead to chronic back pain via inflammation of the neural tissues.

The important point here is that the entire process begins with “abnormal mechanics of the spine” that causes abnormal messages to be sent to the spinal cord.

Dr. Panjabi points out that the tissue source for the mechanorecptors is the spinal column ligaments, facet capsule and disc annulus. This is particularly important in whiplash related injuries because it has been well documented that the primary injury from the trauma is exactly these structures. Also important is that he points out that the muscles will heal relatively quickly due to the abundant blood supply and therefore are not be the primary cause of chronic back pain. On the other hand, he points out that ligaments heal poorly and will result in tissue degeneration over time. “Thus, the ligament injuries are more likely to be the major cause of chronic back pain” .

I liked this study for a number of reasons.

1) It is published in a highly recognizable journal by a world class researcher from Connecticut.

2) It acknowledges that ligamentous subfailure, the kind not visible by conventional imaging methods, is a significant injury resulting in short and long term pain and dysfunction.

3) It points to a neurological explanation that is now widely accepted in the medical and
chiropractic professions.

4) It is particularly pertinent for the population of patients seen in our offices.

5) It suggests that the long term sequella to these injuries is accelerated degenerative changes and worsening of the pain.

6) It supports the chiropractic approaches to management by identifying the primary source of the problem as being mechanical in origin. Thus, the most appropriate treatment will be one that uses mechanical forces to restore function. In other words, CHIROPRACTIC.

It is likely that many more similar papers will be published over the next several years on this topic. Dr. Panjabi is usually leading the field and other researchers follow his lead. Over time, this “ hypothesis” will be validated by further clinical trials.

Chiropractic Doctors

Alec Khlebopros, DC	Chiropractor in Charlotte, NC
Anthony Howe, DC	Chiropractor in Jonesville, FL
Anthony Staiano D.C.	Chiropractor in Atlanta, GA
Antonio Marotta, DC	Chiropractor in Clifton Park, NY
Andre Broussard, DC	Chiropractor in Lubbock, TX
Bob Woolery, DC	Chiropractor in Vallejo, CA
Belinda Mobley, DC	Chiropractor in Seekonk, MA
Benjamin Heath, DC	Chiropractor in Portland, OR
Brett Kinsler, DC	Chiropractor in Rochester, NY
Carmelo Caratozzolo, DC	Chiropractor in Woodbridge, VA
Chris Rizzo, DC	Chiropractor in Leland, NC
Clayton Clark, DC	Chiropractor in San Antonio, TX
Christopher Connelly, DC	Chiropractor in Stone Mountain, GA
David Young, DC	Chiropractor in Indiana, PA
Edward Lauterbach, DC	Chiropractor in Palmyra, VA
Edward Harriott, DC	Chiropractor in Mission Viejo, CA
Eric M. Patten DC	Chiropractor in Gulfport, MS
Frank Navratil, DC	Chiropractor in Torrance, CA
George Putnam, Jr, DC	Chiropractor in New Orleans, LA
Jay Hafner, DC	Chiropractor in Lakewood, CO
James Rosenberg, DC	Chiropractor in Boise, ID
John Zimmerman, DC	Chiropractor in Diamond Bar, CA
Jonathan Woodward, DC	Chiropractor in Dallas, TX
Jennifer Frost, DC	Chiropractor in Naples, FL
Kevin Fielden, D.C., J. Reed, D.C.	Chiropractor in Johnson City, TN
Kevin Smith, D.C.	Chiropractor in Venetia, PA
Kevin Venerus, DC	Chiropractor in Livonia, MI
Louis J Cavallo	Chiropractor in Longmont, CO
Marieke Zegelaar, DC	Chiropractor in the Netherlands
Matt Freedman, DC	Chiropractor in Eugene, OR
Michael Schrad, DC	Chiropractor in Longmont, CO
Mike Nemastil, DC	Chiropractor in Lexington, KY
Morgan Baker, DC	Chiropractor in Eagan, MN
Noah Edvalson, DC	Chiropractor in Boise, ID
Pamela Betz, DC	Chiropractor in Leland, NC
Peter Gala, DC	Chiropractor in Parker, CO
Randy Conger, DC	Chiropractor in Fort Mill, SC
Richard E. Rogovin, D.C	Chiropractor in Brandon, FL
Ruby Kevala, DC	Chiropractor in Ventura, CA
Rusty Russo DC	Chiropractor in Metairie, LA
Ryan Betzina, DC	Chiropractor in Lakeville, MN
Ryan Suh, DC	Chiropractor in Manhattan, NY
Scott Garber, DC	Chiropractor in Pittsfield, MA
Steven Gillis, DC	Chiropractor in Los Angeles, CA
Scott Cady, DC	Chiropractor in Sunnyvale, CA
Stephane Provencher, DC	Chiropractor in St. Louis, MO
Scott Stiffey, DC	Chiropractor in St. Louis, MO
Scott Swanson, DC	Chiropractor in San Francisco, CA
Trent Artichoker, DC	Chiropractor in Denver, CO
Tony Kim, DC	Chiropractor in Moreno Valley, CA
Todd Lloyd, DC	Chiropractor in Santa Rosa, CA
ChiroHub	ChiroHub for even more chiros

Atlanta Chiropractic Doctors

Alec Khlebopros, DC	Chiropractor in Charlotte, NC
Anthony Howe, DC	Chiropractor in Jonesville, FL
Anthony Staiano D.C.	Chiropractor in Atlanta, GA
Antonio Marotta, DC	Chiropractor in Clifton Park, NY
Andre Broussard, DC	Chiropractor in Lubbock, TX
Bob Woolery, DC	Chiropractor in Vallejo, CA
Belinda Mobley, DC	Chiropractor in Seekonk, MA
Benjamin Heath, DC	Chiropractor in Portland, OR
Brett Kinsler, DC	Chiropractor in Rochester, NY
Carmelo Caratozzolo, DC	Chiropractor in Woodbridge, VA
Chris Rizzo, DC	Chiropractor in Leland, NC
Clayton Clark, DC	Chiropractor in San Antonio, TX
Christopher Connelly, DC	Chiropractor in Stone Mountain, GA
David Young, DC	Chiropractor in Indiana, PA
Edward Lauterbach, DC	Chiropractor in Palmyra, VA
Edward Harriott, DC	Chiropractor in Mission Viejo, CA
Eric M. Patten DC	Chiropractor in Gulfport, MS
Frank Navratil, DC	Chiropractor in Torrance, CA
George Putnam, Jr, DC	Chiropractor in New Orleans, LA
Jay Hafner, DC	Chiropractor in Lakewood, CO
James Rosenberg, DC	Chiropractor in Boise, ID
John Zimmerman, DC	Chiropractor in Diamond Bar, CA
Jonathan Woodward, DC	Chiropractor in Dallas, TX
Jennifer Frost, DC	Chiropractor in Naples, FL
Kevin Fielden, D.C., J. Reed, D.C.	Chiropractor in Johnson City, TN
Kevin Smith, D.C.	Chiropractor in Venetia, PA
Kevin Venerus, DC	Chiropractor in Livonia, MI
Louis J Cavallo	Chiropractor in Longmont, CO
Marieke Zegelaar, DC	Chiropractor in the Netherlands
Matt Freedman, DC	Chiropractor in Eugene, OR
Michael Schrad, DC	Chiropractor in Longmont, CO
Mike Nemastil, DC	Chiropractor in Lexington, KY
Morgan Baker, DC	Chiropractor in Eagan, MN
Noah Edvalson, DC	Chiropractor in Boise, ID
Pamela Betz, DC	Chiropractor in Leland, NC
Peter Gala, DC	Chiropractor in Parker, CO
Randy Conger, DC	Chiropractor in Fort Mill, SC
Richard E. Rogovin, D.C	Chiropractor in Brandon, FL
Ruby Kevala, DC	Chiropractor in Ventura, CA
Rusty Russo DC	Chiropractor in Metairie, LA
Ryan Betzina, DC	Chiropractor in Lakeville, MN
Ryan Suh, DC	Chiropractor in Manhattan, NY
Scott Garber, DC	Chiropractor in Pittsfield, MA
Steven Gillis, DC	Chiropractor in Los Angeles, CA
Scott Cady, DC	Chiropractor in Sunnyvale, CA
Stephane Provencher, DC	Chiropractor in St. Louis, MO
Scott Stiffey, DC	Chiropractor in St. Louis, MO
Scott Swanson, DC	Chiropractor in San Francisco, CA
Trent Artichoker, DC	Chiropractor in Denver, CO
Tony Kim, DC	Chiropractor in Moreno Valley, CA
Todd Lloyd, DC	Chiropractor in Santa Rosa, CA
ChiroHub	ChiroHub for even more chiros

Atlanta Auto Accident Doctor, Stone Mountain Georgia

CHIROPRACTIC TREATMENT

Chiropractic’s founding principle is that the health of the Nervous System determines the health of the body. Physical and Biochemical Stresses on the Nervous System have a negative impact on the body’s health.
DOCTORS OF CHIROPRACTIC

Doctors of Chiropractic are Board-certified Physicians that have passed a rigorous academic and clinical training standards. They are trained to assess the body for a wide number of conditions and to deliver effective treatments aimed a promoting health and healing. Their focus begins with the health of the nervous system and expands outward.
THE AUTONOMIC NERVOUS SYSTEM

Our bodies perform trillions of tasks each second to keep us alive. These tasks range from tiny biochemical reactions lasting split seconds, to a complex series of events like food digestion, respiration, and wound-healing. Nearly all of these “health events” occur without us even being aware that they are happening. The part of the body that monitors and coordinates the immense amount activity needed to keep us alive and healthy is the Autonomic Nervous System.

The Autonomic Nervous System controls everything in our body down to the tiniest detail. It does this through a complex network of connections between the Brain, the Spinal Cord, Spinal Nerves, and Nerves. That means the connections to-and-from your Brain are vitally important to your health and well-being! If they suffer, your health will inevitably suffer as well.
SPINAL SUBLUXATIONS

Spinal Subluxations are misaligned, poorly-moving vertebrae of the spine. These restricted vertebrae decrease the amount of space available to Spinal Nerves coming off the Spinal Cord. With decreased space, it becomes increasingly likely that the bones of the spine will chafe, irritate, or pinch the nerves leaving the Spinal Cord. When Spinal Nerves are pinched or irritated the vital communication between your brain and body can be disrupted. This can cause organ or tissue malfunction and can disrupt your overall health. As the condition progresses the dysfunction becomes more noticeable in the form of symptoms. Pain is the most recognized symptom of Subluxation, but anything the body does can be affected. That means a wide variety of symptoms can be produced from a single subluxation.

Neurological impairments by poorly-moving or misaligned segments of the spine can be a contributing cause for a great many conditions. Everything from Asthma to IBS to OB-GYN issues have been relieved by Chiropractic Treatment.
CHIROPRACTIC EXAMINATION

A Chiropractic Examination is combination of Orthopedic, Neurologic, and Functional Exams designed to identify Spinal Misalignments (Subluxations), Damaged Spinal Nerve Roots, Damaged Discs, Degenerative Changes to the Spine, as well as identify Muscle, Ligament, and Tendon Problems that may be contributing to a patient’s poor health.
THE CHIROPRACTIC ADJUSTMENT

Subluxations are a physical problem similar to a dislocation or fracture. That means pill or shot can’t fix them because they need to be physically put back into place. That’s what an adjustment does.

The Chiropractic Adjustment is a specific force delivered into vertebrae or bone to restore it’s normal motion, and return it to its “normal anatomical position.” By getting adjusted you are helping injured nerves and discs heal by taking pressure off of them and changing the biomechanics of the spine. As communication with the brain is fully restored, the health and balance of your body is restored. In addition to helping with pain and other symptoms, Chiropractic Care helps protect and enhance your body’s ability to maintain itself.
EXTREMITY ADJUSTMENTS

Extremity Joints, such as the shoulders, elbows, wrists, fingers, hips, knees, ankles, and tarsal and metatarsal bones of the feet can also become misaligned. As such, each of these joints can be adjusted. The Chiropractic Extremity Adjustment can have a powerful healing effect on problem extremity joints.

If a joint is improperly lined up within the joint space it can change the line of pull for muscles, stress tendons and ligaments as the joint moves improperly through its range of motion, and cause injury, pain, and inflammation.

Extremity adjustments can drastically improve an joint problem treatment option for nearly any extremity issue. Adjustments of the extremities are as specific as those for the spine. Typically the joint needs to be moved in a very specific direction to free it up again. There is a noticable difference in the strength of a joint that is subluxated and one that isn’t and this can be shown with Functional Testing.

This, in conjunction with a Muscle Rehabilitation Program and Lifestyle and Ergonomic Assessment is often the only thing needed for a person to recover from any number of Extremity Conditions.

For those looking for a more wholistic approach, take a look at our

Auto Injury, Atlanta Whilpash Doctor

Daily Procedures Overview This is just an overview, please read each individual section.
1. Start the day with relaxed thought and prayer.
Start off by saying, “This is the day the Lord has made; I will rejoice and be glad in it.”. Spend approximately 20 seconds relaxing; calm your mind, close your eyes, and take 5 deep breathes. Then give thanks for all the blessings God has provided you and your family. Next, think while visualizing what you want your day to be like. Open your eyes and look at your “prayer board”. Ask God, if it is his will, to give you the strengthen and wisdom to accomplish your goals. End by saying the prayer you picked out, thinking about the meanings of the words as you pray. It is important that your prayers and daily actions match.

2. Avoid unhealthy or pain generating factors.
Trauma, smoking, alcohol, poor sleeping, poor ergonomics, pollution, high stress, toxins, poor diet, lack of exercise, obesity, negativity, addictions and many other factors are unhealthy and result in pain. By avoiding the pain triggers or causes of pain, you will have less pain and a healthier body. Stop abusing your body.

3. Promote a health body and tissue building foods.
Your diet is everything you put into your body including; food, drinks, vitamins and pills. It is widely accepted that your diet can cause inflammation and pain. You want to avoid chemicals that cause inflammation or pain and consume only chemicals that promote healthy tissue. Also, remember your body is mostly water, not soda, tea, coffee or juice. Waste elimination, oxygen and sleep also promote healthy tissue. Treat you body like a temple.

4. Promote proper posture, motion, and strengthening.
Your body was made to move. Motion is needed for joint health, muscle health, ligament health, blood flow, organ function, and much more. Remember, “use it or lose it“. Do your daily procedures.

5. Good daily living, developing the habits of happiness and self confidence.
You are in control of your life. Each day work to develop your good habits and break your bad habits. Many times we are addicted to things and do not even know it. Develop the habits of service, gratitude, wellness, opportunity and confidence. Laughter is also very important in developing the happiness habit.

6. Daily mental exercise and building your “Neuro Network”.
Your brain is like a muscle. The more you use it the stronger it gets, the less you use it the weaker it gets. Your “neuro network” is your mental road map. Over your lifetime your brain collects information and uses this information to make judgments and decisions. Use neuroplasticity to build your “neuro network” to serve you well and to break unwanted habits or addictions. Also remember that your thoughts and prayers have power.

7. End the day with relaxed thought or prayer.
Spend approximately 30 seconds relaxing; calm your mind, close your eyes, and take 5 deep breathes. Think of the following words; love, forgiveness, tranquility and faith. Give praise and thanks for the day you had. Think about what you want tomorrow to be like. Ask God for the strengthen and wisdom to do his will. End by saying your personal prayer, thinking about the meanings of the words as you pray.

8. Proper sleep.
Sleep is one of the most important of the body’s functions. Go to sleep with a peaceful mind and pleasant thoughts. Do not fall asleep with the television on. Use your restful sleep strategies.

9. Breaking the pain habit.
What is causing the pain? Tell the pain to go away, and that there is nothing life threatening wrong. Learn to turn off your pain alarm system. Use your pain relief strategies.

10. Break the habits of stress, depression, fear, anger, anxiety or sadness.
Step away from the situation, take a deep breath and use your coping strategies. “I will not let my emotions effect my health or cause me to make bad decisions.”

I hear and I forget. I see and I remember. I do and I understand. Confucius
Health is the result of thinking and acting in a certain way. Wallace D Wattles

Car ratings Atlanta

The insurance industry designated dozens of new cars and trucks, led by Ford Motor Co. and its Volvo subsidiary, to its annual list of the safe st vehicles Tuesday, helped by the increased use of anti-rollover technology. Ford and Volvo had 16 vehicles in the 2009 model year on the Insurance Institute for Highway Safe ty's list of the safe st new cars , followed by Honda Motor Co. with 13 vehicles. Seventy-two cars , trucks and SUVs received the top safe ty pick designation for 2009, more than double the number of vehicles in the 2008 model year and three times the number in 2007. "The sheer number of this year's winners indicates that automakers have made huge strides to improve crash protection," said Institute president Adrian Lund. The selected vehicles are the best in protecting people in front, side and rear crash tests based on institute evaluations during the year.

The vehicles are required to have electronic stability control, or ESC, to qualify for the award. IIHS said electronic stability control is now standard equipment on virtually all new SUVs and three-quarters of passenger cars for the 2009 model year. ESC is standard on more than one-third of 2009 pickups. Ford was led by the Ford Fusion and Mercury Milan midsize cars with optional ESC; the Ford F-150 pickup, Ford Edge and Ford Flex midsize sport utility vehicles; and the Ford Escape and Mercury Mariner small SUVs.

The list also included the Mazda Tribute, which has the same underpinnings as the Escape and Mariner. Ford CEO Alan Mulally argued last week in Washington that the automaker had made safe ty strides when he testified along with other Big Three executives seeking massive government aid. "Every year, we're going to improve the quality, we're going to improve the fuel efficiency, we're going to improve the safe ty, and we're going to keep improving the productivity so we can offer the consumer the very best value," Mulally told a House committee.

Honda and its Acura unit had vehicles in nearly every category, including top-sellers such as the Honda Accord; the Honda Civic 4-door with optional ESC; and the Acura MDX and RDX midsize SUVs; and the Honda Fit with optional ESC. The Fit is the first mini-car to earn the safe ty award. Volkswagen AG and its Audi brand had nine vehicles on the list, including the Volkswagen Jetta and Passat and the Audi A3, A4 and A6. General Motors Corp. and Toyota Motor Corp. both had eight vehicles on the list. GM's included the Cadillac CTS and the Buick Enclave, Chevrolet Traverse, GMC Acadia and Saturn Outlook large SUVs. Toyota's top performers were the Toyota Corolla with optional ESC, Toyota RAV4, Toyota Tacoma, Toyota Tundra and Scion xB.

Using the awards, consumers can compare vehicles without having to review results from multiple tests. Automakers pay close attention to the institute's findings and frequently note positive ratings in television commercials. The institute has advocated for an early adoption of anti-rollover technology such as ESC ahead of a government requirement for the systems by the 2012 model year. Electronic stability control senses when a driver may lose control and automatically applies brakes to individual wheels to keep the vehicle stable and avoid a rollover. It helps motorists avoid skidding across icy or slick roads or keep control when swerving to avoid an unexpected object in the road.

IIHS said Chrysler LLC was the only major automaker that did not receive a single award. They said Chrysler could have picked up five awards if the head restraints had been improved in the Dodge Avenger and Chrysler Sebring, the Sebring convertible and the Dodge Grand Caravan and Chrysler Town and Country. Chrysler spokesman Cole Quinnell said he could not comment on whether the head restraints might be upgraded in the future. He said Chrysler vehicles are equipped with a variety of safe ty features and the institute's results "are just one of the sources of information about a vehicle's crash performance."

Whiplash Symptoms

Whiplash is a nonmedical term used to describe neck pain following an injury to the soft tissues of your neck (specifically ligaments, tendons, and muscles). It is caused by an abnormal motion or force applied to your neck that causes movement beyond the neck's normal range of motion.

* Whiplash happens in motor vehicle accidents, sporting activities, accidental falls, and assault.

* The term whiplash was first used in 1928, and despite its replacement by synonyms (such as acceleration flexion-extension neck injury and soft tissue cervical hyperextension injury), it continues to be used to describe this common soft tissue neck injury. Your doctor may use the more specific terms of cervical sprain, cervical strain, or hyperextension injury.

The most frequent cause of whiplash is a car accident. The speed of the cars involved in the accident or the amount of physical damage to the car may not relate to the intensity of neck injury; speeds as low as 15 miles per hour can produce enough energy to cause whiplash in occupants, whether or not they wear seat belts.

* Other common causes of whiplash include contact sport injuries and blows to the head from a falling object or being assaulted.

*Repetitive stress injuries or chronic strain involving the neck (such as using your neck to hold the phone) are a common, non-acute causes.

These signs and symptoms may occur immediately or minutes to hours after the initial injury; the sooner after the injury that symptoms develop, the greater the chance of serious damage.

* Neck pain

* Neck swelling

* Tenderness along the back of your neck

* Muscle spasms (in the side or back of your neck)

* Difficulty moving your neck around

* Headache

* Pain shooting from your neck into either shoulder or arm

Who's at Risk of Developing Chronic Whiplash?

Auto injuries are a common problem seen in clinical practice. Most of the time, a patient will have some temporary discomfort that will resolve within a few weeks. A significant percentage of patients – around 20 to 30% – will develop some kind of chronic pain or disability from their injury. Four recent studies have looked at the issue of chronic pain to see if there are any predictive factors that can help us determine who is at risk of developing long-term problems.

The following is a list of documented risk factors found in these studies:

Gender. One of the four studies4 found that women were more likely than men to be injured in general, which confirms previous studies. Researchers speculate that the lower muscle mass in female necks may increase the risk of injury.

Turned head. Two recent studies have been done on this issue, and they both have found that when the occupant’s head is turned at the moment of impact, the spine is exposed to motion that exceeds the normal physiological range. This can result in ligament tears or damage to the spinal nerve roots.2

Direction of impact. It has been known for years that a rear-end collision is more likely to result in injury than is a frontal collision. Pape et al.1 found in their study that rear-end collisions were a greater risk factor than frontal impacts.

Previous injuries. It’s not surprising that a pre-existing injury to the neck or shoulder could be worsened after an auto collision, and that’s what Pape et al.1 found. In fact, patients with a history of neck and/or shoulder pain were more than twice as likely to have chronic problems three years after the collision.

Muscular tension immediately after the crash. Pape et al.1 found that patients with increased muscular tension soon after the crash were 3.43 times as likely to develop long-term symptoms.

Reduced range of motion. Sterling et al.3 found, as have other studies, that reduced ROM predicts symptoms two to three years after the injury.

Immediate pain and/or numbness. Both Sterling3 and Berglund4 found that patients who reported symptoms immediately after the crash were more likely to develop chronic pain. Immediate numbness indicates that the patient suffered some kind of nerve injury in the collision, and unless these types of injuries are diagnosed and treated quickly, they could easily develop into chronic pain. Berglund4 found that these patients were 6.5 times as likely to develop long-term problems.

The issues of reduced ROM and increased muscular tension are related, and understanding this issue is critical in treating auto injury patients. Upon injury to the disk or ligaments of the spine, an immediate reflex reaction is instigated – causing surrounding muscles to contract. This muscular guarding can be palpated as tension or inflammation. The increased muscular activity has the result of restricting ROM. How do these symptoms predict chronic pain? If the underlying tissue damage – ligament or disk – does not heal properly, long-term pain and restricted motion can result.

These studies help us treat auto injury cases in two ways: first, they demonstrate the need to take a careful and thorough history of the collision. For instance, asking the patient if his or her head was turned at the moment of impact can help us diagnose the injury. Second, by being aware of risk factors, we can focus our attention on those patients more likely to suffer long-term consequences of their injury.

1. Pape E, Brox JI, Hagen KB, et al. Prognostic factors for chronic neck pain in persons with minor or moderate injuries in traffic accidents. Accident Analysis and Prevention 2007 Jan;39(1):135-46.
2. Panjabi MM, Ivancic PC, Maak TG, et al. Multiplanar cervical spine injury due to head-turned rear impact. Spine 2006;31(4):420-429.
3. Sterling M, Jull G, Kenardy J. Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Pain 2006;122:102-108.
4. Berglund A, Bodin L, Jensen I, et al. The influence of prognostic factors on neck pain intensity, disability, anxiety and depression over a 2-year period in subjects with acute whiplash injury. Pain 2006;125(3):244-56.