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Research report

  1. 1. John ǀ Cussen 0655457 0655457 Whiplash ǀ Rehabilitation ǀ Device Research ǀ Report
  2. 2. M a y | 2010 Contents Introduction ......................................................................................................... 2 Secondary ǀ research .......................................................................................... 3 Literary ǀ research ............................................................................................ 3 Patents ............................................................................................................ 4 Australian Patent .......................................................................................... 5 United States Patent .................................................................................... 6 Canadian Patent ........................................................................................... 8 Primary ǀ research ............................................................................................... 9 Focus ǀ groups ................................................................................................. 9 Observations ................................................................................................. 10 Behaviour ǀ mapping ...................................................................................... 11 Interviews ǀ questionnaires ............................................................................ 12 User trials ǀ Product–in-use ........................................................................... 15 Market ǀ analysis ............................................................................................ 17 Personality ǀ profiling ..................................................................................... 18 Style ǀ analysis ............................................................................................... 19 Appendices ....................................................................................................... 20 Interview with Professor Michele Sterling ...................................................... 21 Pictures.......................................................................................................... 23 Neck-brace experiment questions: ................................................................ 25 References........................................................................................................ 26 Journals ......................................................................................................... 28 Page |1
  3. 3. M a y | 2010 Introduction The author has chosen physiotherapy as his field of study. The aim is to create a device for rehabilitation at home for patients suffering from whiplash. Whiplash is an injury caused by or related to a sudden distortion of the neck. The injury is commonly associated with motor vehicle accidents, usually when the vehicle has been hit from the rear. The injury can relate from aches and pains in the neck to serious back problems. Symptoms include:  Neck pain  Headache  Shoulder pain  Low back pain  Difficulty swallowing  Blurred vision  Ringing in the ears  Nausea  Fatigue or weakness  Irritability  Dizziness  Vertigo A 2004 survey by Daniel G. Baldyga showed that almost 10% of all whiplash victims became totally disabled for long periods after the initial injury. This survey also found that 60% of whiplash victims needed long-term treatment for recurrence of the injury. The survey also suggested that almost a quarter of whiplash patients feel the effects of the injury for up to 6 months after the initial Page |2
  4. 4. M a y | 2010 injury. Whiplash patients are usually scheduled for a single session of physiotherapy each week. During this session the ‘Stabilizer Bio-Feedback’ is used as treatment. Once this session ends there is an array of exercises that the patient is given to do at home. However if not done properly these exercises can cause as much as they can help. It is for this reason that the authors believes a device needs to be created that instils confidence in both physio and patient that the rehabilitation can be correctly continued outside of the designated physio sessions. Secondary ǀ research Literary ǀ research Literary research has mostly consisted of books and publications regarding neck stress and whiplash. The author acquired a booklist containing over 75 books with information on the above from a physiotherapist specialising on neuro and physio treatment. One of the stand out books was ‘Whiplash Headache and Neck Pain’ by Gwen Jull. The book deals with the initial evaluation and diagnosis of the injury and the different ways in which the injury should be dealt with, how much rest to get, exercises to do etc. Using Jull as a reference the author looked into different publications specialising in whiplash related injuries. The journal of Rehabilitation Medicine, 2005 included two very interesting publications, ‘Do dorsal head contact forces have the potential to Page |3
  5. 5. M a y | 2010 identify impairments during graded crainiocervical flexor muscle contractions’ and ’Smooth pursuit neck torsion test in whiplash associated orders – relationship to self reports of neck pain and disability, dizziness and anxiety’. Another important specialist the author found helpful was Professor Michele Sterling PhD MPhty Bphty from the University of Queensland, Australia. She was involved in the both ‘Do dorsal head contact forces have the potential to identify impairments during graded crainiocervical flexor muscle contractions’ and ’Smooth pursuit neck torsion test in whiplash associated orders – relationship to self reports of neck pain and disability, dizziness and anxiety’. One of her own publications ‘Whiplash (grade II) and cervical radiculopathy share a similar sensory presentation: an investigation using quantitative sensory testing’ featured in Clinical Journal of Pain, offered an insight into the effects of a whiplash injury on the different systems in the body, most notably the nervous system. Having read her publications and researched her patents the author subsequently contacted Professor Sterling and she was more than happy to answer the questions posed to her, answers from which were very helpful. Patents The author has also carried out patent searches related to the area of research; the following are patents from Australia and the USA for similar Bio-Feedback products. Page |4
  6. 6. M a y | 2010 Australian Patent no. 657277 1 Application details Australian application no.: 85932/91 Patent application Type: standard Serial no.: 657277 Application status: SEALED Paid to date: 18-10-2009 First IPC mark: A61 5/22 (2006.01) Currently under opposition: No proceeding type(s) Invention title: Exercise monitoring device Inventor(s): Jull, Gwendolen Anne; Richardson, Carolyn Anne Agent name: Fisher & Kelly Address for legal service: 349 Coronation Drive Milton QLD 4064 Filing date: 1991-10-18 Australian OPI date: 1993- 02-25 OPI published in journal Effective date of patent: 1991-10-18 Expiry date: 2011-10-18 Page |5
  7. 7. M a y | 2010 United States Patent no. 5338276 2 Application Details: Application number: 783299 Filing date: October 1991 Summary of The Invention The invention provides in one aspect an exercise monitoring device including a pressure pad, an air pump, feedback means and an air line associated with the pressure pad, air pump and feedback means to permit inflation of the pressure pad for monitoring purposes. The pressure pad may be of any suitable form and thus comprise a flexible bladder or bag preferably formed of non-resilient or non-stretchable material inclusive of plastics material such as vinyl, leather or fabrics like cotton or wool. Although the pressure pad may comprise a single air chamber it is preferred that there are provided a plurality of air chambers separated by boundaries only permitting restricted air access between adjacent air chambers. It is preferred to utilise a plurality of air chambers having restricted air access between the chambers as this allows appropriate monitoring of variable changes (eg rotation) of the patient's body position unlike a single air chamber. Page |6
  8. 8. M a y | 2010 In another embodiment, the pressure pad may be formed of a plurality of completely separate air chambers whereby each chamber has its own air line to provide a plurality of air lines all communicating with a common manifold. In a preferred embodiment therefore the pressure pad may comprise an air bag which is suitably plate like in shape having a pair of opposed walls wherein adjacent parts of each wall may be fused or welded together so as to form the abovementioned boundaries with openings or air passages between each boundary to provide access of air between adjacent air chambers. The air pump may be of any suitable kind and suitably comprises an air bulb or pressure bulb which may be actuated or pressurised manually. However this does not preclude the use of other air pumps such as piston pumps or diaphragm pumps for example. The feedback means may be of any suitable type that permits monitoring or metering of the pressure biofeedback which is transmitted by the pressure pad. This may include an analogue meter for example such as an aneroid dial or electronic or electrically operated meter such as a digital read out or a suitably visual display unit or VDU. In one form the feedback means may also include a pressure transducer such as a strain gauge or pressure transducer based on a piezo electric effect or variable resistance effect. In the latter arrangement this may operate with one side or face of a membrane incorporating a circuit having the variable resistance being subject to the pressure change which will result in a change in the electrical resistance of the circuit which is related to or proportional to the change. The pressure transducer may be connected to the pressure pad in any suitable Page |7
  9. 9. M a y | 2010 fashion such as by an air hose. The pressure transducer in turn may then be connected to a digital read out or analogue meter or interfaced with a computer which incorporates the VDU which if desired may be coupled to a printer. The computer may use appropriate software so as to provide a thorough analysis of the output of a patient undergoing an exercise routine which may be contained in a suitable print out from the printer. Preferably for ease and convenience the air bulb is directly coupled to an aneroid dial so that the result on the aneroid dial may be read by the patient undergoing the exercise so as to provide a form of self assessment. There also may be provided valve means so as to adjust the pressure in the pressure pad if required. In one form this may comprise a screw actuated valve associated with an air passage between the aneroid dial and the air bulb. When the valve is in an open position air may not reach the pressure pad but is pumped directly to atmosphere. When the valve is closed or partially closed air may be pumped to the pressure pad so as to inflate the pressure pad. Further opening of the valve may decrease the pressure in the pressure pad as recorded on the aneroid dial when required. Canadian Patent no. 2058233-2 3 Page |8
  10. 10. M a y | 2010 In the patents there is no mention of the products being designed for home use. Only the hand pump device is mentioned as a form of pressure gauge, this is an aspect of the product I hope to develop as the current method can be unreliable. Primary ǀ research Focus ǀ groups Since the beginning of the project in September 2009 the author has been to the West Limerick Neuro and Physio Rehabilitation Clinic in Newcastle West, co. Limerick. On two of these occasions the author has met with two of the physio’s for focus groups where ideas were put on the table, pro’s and con’s discussed and decisions made. Along with the focus group aspect of the meetings the physio’s involved the author in demonstrations of the different exercises and routines the patient is put through during the session, in preparation for continuation of the exercise at home. Seeing the preparation that goes into selecting the exercises for the patient to be doing at home was a very important aspect of these meetings. All that was given to the patient was a set of exercises based around what was done during the session on the ‘Stabilizer Bio-Feedback’ device. The Bio-Feedback device is the only recognised piece of equipment currently available for the treatment of whiplash. Both physios and patients of whiplash expressed mixed emotions when it came to the Bio-Feedback device. The patient confessed to a lack of motivation when Page |9
  11. 11. M a y | 2010 trying to recite exercises learned during physio sessions. The physio was concerned in relation to mis-use of the exercise instructions given which may lead to further aggravation of the injury. 4 Stabilizer Bio Feedback Observations The observations carried out by the author have been to do with two different forms of whiplash treatment the first was the use of lasers on pre-designed charts. This method is used when there is an imbalance or a misalignment of the cranium. The activity involves the attaching of a laser to the patients head with the use of an elastic band and a hair band. Both parties found this particularly difficult as the physio had to securely attach the laser pen to the hair band with the elastic band, this was awkward and time consuming. The patient’s issues were to do with the insecurity of the bond between the pen and the hair, making it difficult to carry out the appropriate exercises. P a g e | 10
  12. 12. M a y | 2010 5 Laser pen used for correcting cranium alignment 6 Charts also used in treatment The second observation made by the author was the use of the bio-feedback device. This method involved the patient lying on his/her back with the blue piece of the apparatus behind their head. They then have to hold the pressure gauge aloft in order to read the pressure as they completed the exercise. The exercise involved retracting the chin towards the neck, against the pressure built up in the blue apparatus. This device appeared both problematic and awkward for physiotherapist and patient. The patient described it as ‘uncomfortable’ and ‘difficult to figure out’. The physio described it as ‘awkward’ and ‘more time consuming than necessary’. This view was due to the fact the physio had to stay with the patient for most of the exercise, to ensure it was being done properly but also because the patients arm was becoming fatigued as result of holding the pressure gauge aloft. Behaviour ǀ mapping The patient can have many different characteristics so it is hard to map behaviour. Whiplash is mostly suffered by those involved in car accidents but can also be as result of a fall on a hard surface, a sports injury or just aggravation of muscles with a sharp movement of the neck. On the other side of P a g e | 11
  13. 13. M a y | 2010 the treatment is the physiotherapist. He/she would generally work a regular office day, often dealing with whiplash patients for one hour blocks at a time. The use of the product is often determined by the seriousness of the injury sustained, or the stage of the recovery the patient is at. Interviews ǀ questionnaires At the beginning of research, once the decision had been made to focus on the neck, a questionnaire/social experiment was carried out with a neck brace. The questionnaire involved candidates wearing the brace for a certain frame of time, before rating the product on different qualities. The aim of the experiment was to evaluate the effectiveness of the most basic neck support products. The questionnaire had four questions, each answer was to be given as a rating from 1 – 5 with 1 being weakest and 5 being strongest. There were 12 candidates, 8 male, 4 female, 7 candidates fell in the 17-29 age bracket, 1 in the 30-44, 3 in the 45-59 and 1 in the 60+. For the age group 17-29 the average responses were Q1 moderate-okay, Q2 uncomfortable-noticeable, Q3 couldn’t move-restricted, Q4 supported-sufficient support. For the age group 30-44 Q1 okay, Q2 easy, Q3 slight movement, Q4 sturdy support. For the age group 45-59 Q1 okay, Q2 noticeable, Q3 no difference, Q4 supported-sufficient support. For the age group 60+Q1 difficult, Q2 uncomfortable, Q3 restricted, Q4 limited support. P a g e | 12
  14. 14. M a y | 2010 The social side of the experiment was carried out by the author and involved him wearing a neck brace, while undertaking different activities during the course of a regular day. These activities included reading a book, using a laptop, eating a meal and watching TV. After approximately 5 minutes of wearing the brace it because extremely uncomfortable and come the end of the experiment found his neck muscles to be increasingly strained. During the process of research and information gathering many different therapists were interviewed by the author. The interviews were carried out at different stages of the research; these offered both great insights into the range of rehabilitation equipment already on the market and ideas as to what direction that could be taken to improve this market range. The first official was in the sports arena in UL, he agreed that there was little in the way of equipment for those rehabilitating muscles other than thera-bands, which are prone to misuse. The aspect of the idea that most appealed to him was the thought of a product that would have the ability to be used for both sports injuries and general physiotherapy. He recommended a meeting with more specialised physiotherapists to get a more focused opinion on physical therapy. Next to be interviewed were two physiotherapists based in Newcastle West, co. Limerick. This was at a stage when the project was making a move towards focusing on the neck. They have their own clinic, West Limerick Physiotherapy & Neuro Rehabilitation Clinic in Newcastle West and were able to offer several areas in the physiotherapy where products needed development. Products that ranged from roller tubes for back pain to treatment tables. The biggest problem they stated was cost, there was equipment out there but because of increasing costs smaller practices like theirs were unable to afford P a g e | 13
  15. 15. M a y | 2010 them. On the second visit to the West Limerick Physiotherapy & Neuro Rehabilitation Clinic the author was given demonstrations for several products and could immediately see the areas either where new products or improvements were needed. They gave a full list of books and publications to read up on, and in particular mentioned Professor Michelle Sterling, an author of several publications who is based in Queensland, Australia. At this point the author successfully contacted Professor Sterling and she has agreed to a Skype interview when she is free, but in the meantime offered to answer any immediate questions. The next interview carried out by the author was with a chartered physiotherapist based in Castletroy, Limerick who has masters in sports physiotherapy, he practices in the United Physiotherapy Clinic at Whitehorns, Castletroy. The author asked him, what he felt were the major flaws in whiplash treatment. He replied ‘after a trauma muscles become sensitised and the pain felt by the affected neck muscles can spread through the nervous system, making it difficult to treat, also with whiplash injuries, an x-ray of a perfectly healthy neck and an x-ray of a neck post whiplash will look the exact same so it can be hard to differentiate between tissue and muscle damage’. ‘Loads on damaged muscles can leave them fatigued, hampering treatment and during certain treatments the front neck muscles (deep neck flexors) become inhibited’. The author then asked him his opinion on his own thoughts that home treatment can be harmful as much as helpful! He agreed, stating that ‘there is a big problem with home exercises as there is no guarantee the exercises are being done properly and the exercises are being done at all’. He suggested maybe some form of a video diary or clicker to indicate number of replications done. He P a g e | 14
  16. 16. M a y | 2010 also talked about Ultrasound treatment, this form of treatment allows the physiotherapist to view the muscles contracting. The author also contacted and visited physiotherapists in St. Camillus, Shelbourne road, Limerick. The physio echoed a lot of the points of view already gathered by the author, but was unable to offer more as they did not deal with whiplash first hand in the clinic. On the visit to St. Camillus the author was referred to their specialist physio clinic, located within a kilometre of the main clinic. The author was familiar with this clinic as he had completed rehabilitation there previously. The physio met there was very helpful and offered her opinions on several of the devices currently in use for whiplash rehabilitation. She felt the laser head-band/chart idea was effective but could be made more user-friendly. She did not have any major trouble with the bio-feedback either but again felt it could be more user- friendly. She did confess though that her patients had more negative feelings towards the bio-feedback than her. User trials ǀ Product–in-use Testing carried out by the author has included trials on different neck braces and on the ‘Stabilizer Bio-Feedback’. This testing helped distinguish the exact issues and flaws with the different treatment devices used for whiplash. Problems with neck braces included height around the neck that caused discomfort, other than this flaw the issues were to do with comfort and restriction of movement; these however were unavoidable with compromising the purpose of the brace. P a g e | 15
  17. 17. M a y | 2010 7 neck-brace front 8 neck-brace back 9 neck-brace side Problems with the ‘Stabilizer Bio-Feedback’ were numerous. There were complaints about the position it had to be used in, the struggle to get the exact required pressure, having to keep the pressure gauge aloft for the duration of the exercise and also the fact the patient couldn’t take the device home to continue recovery. P a g e | 16
  18. 18. M a y | 2010 Videos involving these user trials for both the neck brace and the bio-feedback device are available for viewing on www.johncussen.vox.com Market ǀ analysis At the moment Stabilizer are the only manufacturers of the bio feedback device. As there are no other manufacturers, there are no other variations of the product, meaning the current flaws remain constant. These flaws include a lack of clarity over how exactly to use the product. The pressure is hard to correctly gauge as there is constantly air moving between the tube connecting the pressure pump and gauge to the head rest. The current version also requires two people in order to use the device correctly for the duration of the exercise. The rest which sits under the neck offers no support for the head, which leads to doubt about how to position the device correctly this can also cause further muscle issues. These flaws are mainly due to the fact the device was originally invented for use by patients with back issues. The author feels the following features need to be introduced to the device to aid the physio and the patient.  Ability to use the device anytime, anywhere and in any position.  Easier to use.  Better neck support.  Incorporation of some sort of motivational device.  More cost effective. Currently, there are no other variations of this device on the market, or plans to introduce a new variation into the market. This gives the author reassurance P a g e | 17
  19. 19. M a y | 2010 that there is a hole in the market that can be filled with a well designed and manufactured product that already has a concrete target market. Personality ǀ profiling The primary user will be the patient, with the secondary being the physiotherapist. Mike, 23, is a young male who is currently doing his masters degree in Biology, in University of Limerick. He is an independent individual who lives away from home and pays his own way in life by virtue of his part-time job. Mike is an active member of his local GAA club and enjoys kick-a-bouts with his friends during free evenings. He also has an active social life. One evening driving home from work Mike is rear ended by another vehicle but doesn’t suffer immediate health issues. A few weeks later however he complains of muscle pains, is referred to a physiotherapist, Linda, and is diagnosed with whiplash. With restricted movement and having to attend physiotherapy sessions once a week, Mike’s life is completely disrupted. He is unable to attend college, work or play any sports. He feels his treatment could be progressing faster, especially if he could continue his rehabilitation after physio sessions at home... Linda, 52, has been working as a physiotherapist for almost 30 years. She owns her own clinic and is used to dealing with whiplash victims, none more so than patients involved in road accidents. She has recently had to let a physiotherapist go because of spiralling expenses so as a result has a heavier workload. As her clinic is based in the city centre she has many whiplash P a g e | 18
  20. 20. M a y | 2010 patients but little time to fit them all in for minimum one session a week. She finds recovery times slow as well and wishes there was only some way she could monitor her patients progress outside of sessions... Style ǀ analysis The styles a device for a neck muscle rehabilitation device would have to follow the typical medical device features. These include the device being a clean soft colour, having little or no ‘fancy tech add-ons’ and being designed to meet all medical requirements especially the strict guidelines of what is and isn’t classed as medical waste. The device should also look comfortable and to wear. The patient will be wearing the device for no longer than 10-15 minutes at any one time but it is still important for the device to carry an appealing aesthetic. P a g e | 19
  21. 21. M a y | 2010 Appendices The following is a list of individuals who have been interviewed, offered advice or contributed to the project during research in any way. Claire Noonan, Physiotherapist, West Limerick Physiotherapy and Neuro Rehabilitation Clinic, Newcastle West Fiona Taylor, Physiotherapist West Limerick Physiotherapy and Neuro Rehabilitation Clinic, Newcastle West Dr Johnson McEvoy, United Physiotherapy Clinic at Whitehorns, Castletroy Dr Cian O’Neill, Course Director, health fitness, University of Limerick Assoc Prof Michele Sterling, Associate Professor, University of Queensland, Australia Niall Deloughry, Lecturer, M&OE Department, UL Dermot McInerney, Lecturer, M&OE Department, UL Muireann McMahon, Lecturer, M&OE Department, UL Sara Cox, Lecturer, M&OE Department, UL Marion McCarthy, Physiotherapist, St.Camillus, Shelbourne Road Sarah Breen, Post-graduate student, Department of physical education and sport sciences, UL Joseph Costello, Post-graduate student, Department of physical education and sport sciences, UL Dr Christy Gillick, Lecturer, M&OE department, UL Dr Colin Fitzpatrick, Lecturer, Electronic Engineering, UL Dr Pepijn Van de Ven, Lecturer, Electronic Engineering, UL P a g e | 20
  22. 22. M a y | 2010 Interview with Professor Michele Sterling Q. The general time frame for recovery from a whiplash injury is said to be 8 to 12 weeks, is this true or a myth depending mostly on the seriousness of the injury sustained? A. This is a myth. Most data now indicates that around 50% will still have symptoms at 12 months (see paper from Bone and Joint Decade) Q.Is there an age group of common whiplash sufferers? A. Not really. Age is sometimes a predictor of outcome and sometimes not. Q. What are the muscles most affected during whiplash? A. Evidence for direct muscle injury/damage is inconclusive (see Siegmund paper). However there are certainly changes in muscle morphology and recruitment patterns that occur in response to either the injury or pain - it’s not clear which, (see Elliott and sterling papers). Q. Is there a minimum force that needs to be applied for a person to suffer neck muscle damage, or does this depends on the physical condition of the person involved? A. A minimum force for injury has never been demonstrated as far as I'm aware. People can be injured in low force/impact collisions. P a g e | 21
  23. 23. M a y | 2010 Q. I myself suffered a form of whiplash as result of a fall playing sport. How common is a sports related whiplash injury? A. Probably fairly common, but not much research done on this. Probably because whiplash from car crashes costs a lot due to compensation etc. Q. I’ve recently used the bio-feedback rehabilitation device, and found it to be unreliable and sometimes inaccurate, what is your opinion of it? A. Reliability and accuracy improves with improved skills of the tester. The PBU is a clinical tool only - i.e. feedback for the phsyio and the patient. It is not really designed to be a diagnostic tool. Q. Are there any other devices like the bio-feedback for whiplash treatment currently available on the market? A. Not that I'm aware of. Q. Do you know of any devices for home treatment of whiplash injuries? A. Not sure what you mean here? Do you mean exercise devices? If so then no, not that I’m aware of. Q. When doing physio for rehabilitation of my left hand, I was given exercises to do outside of session time at home but found them to be doing as much harm as they were help, do you think this is one of the main reasons injuries are prolonged? P a g e | 22
  24. 24. M a y | 2010 A. In the case of whiplash, a group of patients demonstrate widespread sensory hypersensitivity and cold allodynia that reflect central nervous system hyperexcitability. If any form of exercise aggravates these people's pain, then this will potentially further wind up the CNS and yes do more harm than good. If the exercises a pain free then things should be OK Pictures 10 11 P a g e | 23
  25. 25. M a y | 2010 12 13 14 15 16 17 18 P a g e | 24
  26. 26. M a y | 2010 19 Neck-brace experiment questions: Q. Is the product easy to get on? Q. Is the product comfortable to wear? Q. Is your movement restricted? Q. Does it offer adequate support? Each answer was to be given as a rating from 1 – 5 with 1 being weakest and 5 being strongest. P a g e | 25
  27. 27. M a y | 2010 References 1. http://pericles.ipaustralia.gov.au/ols/auspat/quickSearch.do?queryString= 657277&resultsPerPage=http://patft.uspto.gov/netacgi/nph- Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=/netahtml/PTO/s rchnum.htm&r=1&f=G&l=50&s1=5338276.PN.&OS=PN/5338276&RS=P N/5338276 2. http://patft.uspto.gov/netacgi/nph- Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=/netahtml/PTO/s rchnum.htm&r=1&f=G&l=50&s1=5338276.PN.&OS=PN/5338276&RS=P N/5338276 3. http://brevets-patents.ic.gc.ca/opic- cipo/cpd/eng/patent/2058233/financial_transactions.html?type=number_ search 4. http://healthinfousa.com/chattanooga/biofeedback.jpg 5. Photos – John Cussen 6. Photos – John Cussen 7. Photos – John Cussen 8. Photos – John Cussen 9. Photos – John Cussen 10. Photos – John Cussen 11. Photos – John Cussen 12. Photos – John Cussen P a g e | 26
  28. 28. M a y | 2010 13. http://g-ecx.images- amazon.com/images/G/01/books/promos/Muscles_Lateral_lg.jpg1 14. http://g-ecx.images- amazon.com/images/G/01/books/promos/Muscles_Lateral_lg.jpg2 15. http://g-ecx.images- amazon.com/images/G/01/books/promos/Muscles_Lateral_lg.jpg3 16. http://g-ecx.images- amazon.com/images/G/01/books/promos/Muscles_Lateral_lg.jpg4 17. http://www.a3bs.com/imagelibrary/VR1132_L/anatomical-charts-poster- size/VR1132_L_head-and-neck-chart.jpg1 18. http://www.a3bs.com/imagelibrary/VR1132_L/anatomical-charts-poster- size/VR1132_L_head-and-neck-chart.jpg2 19. http://www.physiostuff.com/repository/product/15/img_9781587793752.jp g 20. http://www.truckinfo.net/trucking/newwhiplashinformation.htm P a g e | 27
  29. 29. M a y | 2010 Journals Whiplash Headache and Neck Pain, Jull, G. The journal of Rehabilitation Medicine, 2005 Do dorsal head contact forces have the potential to identify impairments during graded crainiocervical flexor muscle contractions, Jull, G. Sterling, M Smooth pursuit neck torsion test in whiplash associated orders - relationship to self reports of neck pain & disability, dizziness & anxiety, Jull, G. Sterling, M Publications Whiplash (grade II) and cervical radiculopathy share a similar sensory presentation: an investigation using quantitative sensory testing’ Sterling, M P a g e | 28

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