Dysphagia

https://doi.org/10.1007/s00455-020-10137-8

ORIGINAL ARTICLE

Whiplash‑Associated Dysphagia and Dysphonia: A Scoping Review

D. B. Stone1,2,3   · E. C. Ward4 · S. R. Knijnik1,5,6 · H. Bogaardt1 · J. M. Elliott1,3,7

Received: 30 December 2019 / Accepted: 15 May 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Swallowing and voice complaints after a whiplash injury have been observed and reported in several studies; however,
variability in study design complicates current understanding of whether dysphagia and dysphonia should be recognised as
potential adverse outcomes. A scoping review was conducted across six databases from 1950 to March 2019. A total of 18
studies were included for review. Data regarding study purpose, design, outcome measures, participant characteristics and
outcomes reported were extracted. Level of evidence (LOE) was assessed by the American Speech-Language Language
Association (ASHA)’s LOE system. All studies were exploratory, with 68% rated as poor (< 3) on quality ratings. Nearly half
(n = 6) were single case reports. Only three studies investigated some type of swallow-related outcome specifically within
the study aim/s. Incidence of swallow-related problems ranged from 2 to 29%, with unspecified complaints of “swallowing
difficulty”, “dysphagia” and fatigue and pain whilst chewing reported. Neither swallowing biomechanics nor the underlying
pathophysiology of swallow or voice complaints was investigated in any study. Four case studies presented post-whiplash
voice complaints; two of which described loss of pitch range. Others described hoarseness, loss of control and weak phona-
tion. Most studies only mentioned swallow- or voice-related deficits when reporting a wider set of post-injury symptoma-
tology and six did not describe the outcome measure used to identify the swallow and voice-related problems reported.
The existing literature is limited and of low quality, contributing to an unclear picture of the true incidence and underlying
mechanisms of whiplash-related dysphagia and dysphonia.

Keywords  Dysphagia · Deglutition · Dysphonia · Voice · Swallowing · Whiplash · Whiplash-associated disorders

Introduction

The sudden and rapid acceleration and deceleration forces

during a motor vehicle collision (MVC) may give rise to
Electronic supplementary material  The online version of this hyperextension and flexion of the cervical spine [1, 2] and a
article (https​://doi.org/10.1007/s0045​5-020-10137​-8) contains so-called “whiplash injury”. In the absence of spinal fracture
supplementary material, which is available to authorized users.

5
* D. B. Stone The Federal University of Health Sciences of Porto Alegre,
daniellebstone@gmail.com Porto Alegre, Brazil
6
1 The Pontifical Catholic University of Rio Grande do Sul,
Faculty of Medicine and Health, School of Health Sciences,
Porto Alegre, Brazil
The University of Sydney, Sydney, NSW, Australia
7
2 Department of Physical Therapy and Human Movement
Speech Pathology Department, Royal North Shore Hospital,
Sciences, Feinberg School of Medicine, Northwestern
Northern Sydney Local Health District, St Leonards,
University, Chicago, IL, USA
NSW 2065, Australia
3
Neuromuscular Imaging Research Laboratory, Kolling
Institute at the Northern Sydney Local Health District,
Sydney, Australia
4
School of Health and Rehabilitation Sciences, The University
of Queensland and Centre for Functioning and Health
Research (CFAHR) Metro South Hospital and Health
Services, Brisbane, QLD, Australia

13
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and neurological deficit in most cases, the cardinal clini-
cal feature of whiplash is neck pain and reduced mobility
[3–5]. However, the presenting signs and symptoms known
as whiplash-associated disorders (WAD) include but are not
limited to, widespread bodily pain, traumatic distress [6–8]
and dizziness and headache [3]. Importantly, up to 50%
of those exposed to whiplash following MVC experience
persistent symptomatology [9]. The economic and public
health burden of WAD is profound [10, 11]. With a high and
increasing prevalence of WAD worldwide [11], low-levels of
life satisfaction [8, 9] and poor treatment outcomes [12], the
importance of contributing towards a better understanding of
the patient-centred poor-recovery profile is greater than ever.
For over 25-years the Quebec Task Force (QTF) clas-
sification system of WAD [13] has guided assessment and
prognosis by dividing a range of symptoms into 5 grades;
grades 0–III reflecting no physical signs (0), neck stiffness
(I) and reduced neck range of movement and point tender-
ness (II) and grades III and IV encompassing more traumatic
cervical spine injury including fracture and absent reflexes.
However, there remains a lack of general agreement about
the clinical usefulness of this classification [14]. Current
evidence highlights the heterogeneity of the clinical course
[7, 15], demonstrating a myriad of physical and psycho-
logical impairments in those that transition from acute to
chronic WAD-related disability [8]. Although not formally
recognised within the QTF classification system, emerging
evidence suggests that voice and swallow complaints may
be among the potential manifestations of under-recognised
features from whiplash [16].
Previous studies have described voice and swallow prob-
lems in acute and chronic whiplash [16–18]; however, dis-
parity exists in the outcomes used to measure and report
these problems. As such, little is known about the incidence
and pathophysiological mechanisms. Alterations in oro-
pharyngeal volume have been reported in individuals pre-
senting with poor recovery compared with those nominating
recovery and healthy control participants [19, 20]. Albeit
preliminary, a conceivable link between self-reported change
in post-traumatic swallow with oropharyngeal volume has
been offered [16]. The potential impact of a post-traumatic
muscular tensioning has also been raised as an underlying
aetiology in patients with an idiopathic functional dys-
phagia [21]. Considering the likely impact of pharyngeal
and laryngeal tensioning on swallow function [22–24], a
whiplash-induced muscle tension dysphagia and/or dys-
phonia is plausible. Dysphagia in patients with chronic pain
(e.g. fibromyalgia) has been previously suggested [25] and
swallowing and voice symptoms have been described in
laryngeal hypersensitivity syndromes [26, 27]. With this in
mind; swallow and voice deficits following whiplash may
contribute to the extensive symptom profile in those with
poor recovery.
13
D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia
The evidence base is currently insufficient towards accu-
rately informing the nature or extent of dysphagia or voice
changes post-whiplash injury. In addition, patients with
WAD are not often assessed or managed by speech-language
pathologists (SLPs). However, if dysphagia and dysphonia
are found to be potential components of the clinical course,
then early identification and referral of at-risk patients to
SLPs for further assessment and management may ultimately
need to be incorporated into practice guidelines. The aim of
this scoping review was to explore what is currently known
about swallow and voice complaints after whiplash and what
further research is needed to better understand these issues.
Method
Design and Preliminary Search
A rigorous scoping review design [28, 29] was selected due
to (a) the substantial heterogeneity in the available body of
literature, (b) no single clinical question being addressed
and (c) an absence of any previous critique [29, 30]. In line
with indications for scoping review over systematic review
by Munn et al. [30], this study aimed to determine the scope
of literature covering swallow and voice problems related
to whiplash and provide an overview of current themes and
gaps. The scoping review was conducted in accordance with
the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses extension for Scoping Reviews (PRISMA-
ScR) guidelines [28]. However, prior to conducting the
final literature search, an additional step involving a pre-
liminary literature search was conducted to develop the final
search terms and inclusion/exclusion criteria. Examination
of known literature revealed issues relating to swallowing
and voice deficits were often only secondary reports within
highly varied study methodologies. Hence in this prelimi-
nary step, known key papers were identified and their con-
tent and reference lists searched, to determine all possible
keywords related to whiplash and the types of studies with
potential to encompass information on any related swal-
low or voice-related problem. For example, the preliminary
search revealed a large body of literature investigating jaw
range of motion (ROM) and pain, temporomandibular joint
(TMJ) biomechanics and the impact of collisional forces on
jaw function. As jaw dysfunction may have an associated
impact on bolus mastication, this was included in the final
search terms.
Eligibility Criteria
From the information gained from the preliminary search
strategy, the study’s final inclusion and exclusion criteria
were determined a priori and are detailed in Table 1.
D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia
Table 1  Inclusion/exclusion criteria
Inclusion
P Adults > 18 years with whiplash injury or exposure (aka: cervical
flexion extension, cervical hyperextension-hyperflexion, cervical
hyperextension, cervical hyperflexion, cervical acceleration-decel-
eration, cervical deceleration, cervical strain, whiplash-associated
disorder/s, whiplash syndrome or mandibular whiplash)
I n/a
C n/a
O Presenting with one or more of the following symptoms:
 Dysphagia
 Swallowing/deglutition disorder/deficit
 Muscle tension dysphagia
 Difficulty chewing/mastication
 Odynophagia
 Trismus/reduced jaw range of movement/jaw fatigue explicitly
associated with any chewing or swallow-related function/s
Jaw pain if explicitly associated with any chewing or swallow-
related function/s
 Dysphonia
 Voice change
 Voice disorder/disturbance
 Vocal hoarseness, aphonia, vocal strain
D Complete scientific articles
Single case reports
PICO participant, intervention, comparison, outcome, design
A search strategy was designed in Medline and is
detailed in Online Appendix  1. Searches were subse-
quently modified for each database. The following main
subject headings were used: whiplash injuries, mandibular
whiplash, deglutition, deglutition disorders, voice, laryn-
geal diseases and voice disorders. Additional search terms
included: swallowing, swallow, pharynx, oropharynx, lar-
ynx, dysphagia and dysphonia. To capture all potential
swallow and voice deficits in the absence of a previously
established whiplash-associated dysphagia or dysphonia,
the search strategy was inclusive of any possible deficit
relating to swallow and/or voice, including structures such
as cranial nerves and swallow musculature.
Exclusion
Adults whose primary condition is not whiplash injury or exposure
Individuals requiring the following as a result of whiplash injury:
 Spinal surgery
 Tracheostomy
 Intubation
(Note: If voice or swallow complaints were reported to be of concern
prior to tracheostomy or intubation intervention, the study was
included)
Traumatic brain injury or other significant (non-direct nerve injury)
neurological impairment following whiplash
Spinal or jaw fracture
History of traumatic brain injury, stroke or other neurological
disease/disorder; disability, head and neck cancer, head and neck
surgery or gastro-oesophageal disease
Children < 18 years and Infants
n/a
n/a
None of the following: dysphagia, swallow deficit, difficulty chewing/
masticating, odynophagia, jaw or orofacial pain, trismus
None of the following: dysphonia, voice change, voice disturbance,
vocal hoarseness
Jaw range of movement and/or pain unrelated to swallow-related
function
Languages other than: English, Dutch, German, French, Portuguese,
Spanish
Review articles
Book chapters
Commentaries
Letters to the editor
Scoping Review
An electronic literature search of all articles published
between 1950 and March 2019 was conducted independently
by two authors (DS, SRK) on 29 March 2019. Databases
included PUBMED, MEDLINE, SCOPUS, Web of Science,
EBSCO, and EMBASE. Reference lists of all selected arti-
cles were manually searched, with forward and backward
citation chasing, for any relevant publications. Deduplication
was conducted using the Bramer method [31].
Following deduplication, one reviewer (DS) screened
titles for inclusion. Articles where titles were unrelated to
any inclusion criteria were excluded. Two reviewers (DS,
13
 D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia

SRK) independently screened the eligibility of remaining Results

articles based on abstract screen. In the case where screening
was unable to determine if a title and/or abstract met crite-
ria, the article was selected for full-text review. Independent
full-text review was conducted by the same two reviewers
and assessed based on inclusion/exclusion criteria. In cases
where the reviewers’ opinions differed for either abstract or
full-text review, a third reviewer (HB) was used to achieve
consensus.
Initial search yielded a total of 1758 articles for review as
detailed in the PRISMA flow diagram (Fig. 1). Independent
review was conducted for 57 full-texts. A total of 18 arti-
cles met inclusion/exclusion criteria and were included for
review and summarised in Table 2.
Quality Rating

Data Extraction and Synthesis Quality indicator ratings for all parameters, overall quality
rating (total score/7) and stage of research are detailed in
Data including study purpose, design, population (N), time Table 3. All 18 papers were categorised within the explora-
post-whiplash, WAD Grade [32] if specified and outcome tory stage of research as per ASHA LOE system guidelines
measure/s were extracted from each eligible study. If WAD [33]. Six of the 18 papers were single case reports, whilst
grade was not specified, level of injury was reflected in five utilised a case control design. Median quality marker
the inclusion criteria from subject description within the was 2/7, indicating a low level of quality for most studies.
article and was not specifically specified. For the purposes
of clearly synthesising findings, papers were stratified as
Patient Populations
either swallow- or voice- related based on the outcomes or
symptoms described. As no study specifically explored dys-
A total of 15,909 individuals aged between 17 and 75 years
phagia, a wide range of terms that encompassed “swallow-
were described across the 18 included studies (Table 2).
related activities/problems” were accepted, consistent with
Two studies investigated over 7000 participants [34, 35].
the nature of a scoping review. Incidence of dysphagia was
There was significant heterogeneity in the time post-whip-
recorded from studies where an overall percentage was cal-
lash; ranging from immediately following initial injury to
culated. Due to the heterogeneity of outcomes reported, all
9-years post. Most individuals sustained whiplash from an
swallow and voice complaints were listed from each paper
MVC. Only two studies [36, 37] included a small sample
and summarised descriptively.
of subjects who sustained injury from a fall. Seven stud-
ies specified WAD grade as determined by the QTF Task-
Methodological Quality force [32], with the majority of these (n = 5) reporting WAD
grades II–III. For most studies, extent of whiplash injury was
The quality of eligible studies was evaluated using the reflected in the inclusion criteria due to a lack of specifica-
American Speech-Language and Hearing Association tion or grading.
(ASHA)’s Levels of Evidence (LOE) rating tool [33]. The
system was created to determine the extent to which a study
Purpose of the Studies
meets a range of quality indicators and designed specifically
for use in non-randomised studies, including single-case
Six studies [21, 38–42] described a single case presentation.
designs. Considering the types of studies included in this
Of these, 3 [39, 41, 42] described voice-related problems,
review, this system was considered most suitable [33]. Two
two reported pain or sensory complaints related to swal-
independent reviewers (DS and SRK) blindly rated each eli-
lowing [21, 40] and one case described a combination of
gible study across eight indicators, including; study design,
swallow- and voice-related difficulties [38]. One study exam-
blinding, sampling, participant comparability, outcomes,
ined eating behaviours following whiplash as the primary
significance, precision and intention to treat. Studies were
aim [18]. Two specifically investigated chewing behaviour
given one point per indicator if the indicator met the high-
after whiplash [37, 43]. A total of four studies [17, 36, 44,
est descriptor; reflective of a higher quality paper. The final
45] examined the characteristics of jaw-related dysfunction
parameter, intention to treat, is only applicable to controlled
through a range of jaw measurements and symptom-based
studies and therefore in this study, a final quality marker
questionnaires. All these utilised a measure of chewing
maximum score of seven was possible [33]. Each study was
behaviour as part of their battery of assessment, however
then characterised by research stage as either effectiveness,
without explicit investigation of chewing as a primary focus.
efficacy, exploratory or policy [33]. Ratings were compared
The remaining studies examined a larger set of post-injury
between reviewers, with consensus achieved after combined
characteristics to investigate the systemic nature of WAD
review in the case of any discrepancy.

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D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia
Fig. 1  Prisma chart Records identified through
database search
Identification
(n=1758)
Records after duplicates
removed (n=974)
Screening
Records screened
(n=974)
Full-text articles assessed for
Eligibility
eligibility
(n=53)
Grey Literature
(n=4)
Inclusion
Articles included for
synthesis
(n=18)
[18, 34, 46], the rate of recovery across a wide set of symp-
toms [47] or the relationship between symptoms and acci-
dent mechanisms [48]. None of the selected studies spe-
cifically investigated dysphonia as a specific study aim. No
study investigated pharyngeal swallow biomechanics.
Swallowing‑Related Complaints After Whiplash
There were 16 studies which reported swallow-related
complaints after whiplash, though more of half [17, 34, 36,
38, 44, 46–49] included this information as part of wider
investigations into post-injury sequalae or within broader
investigations related to jaw dysfunction. Swallowing-
related issues were described using various terms includ-
ing: problems eating, dysphagia, swallowing difficulty,
odynophagia, perceived pain on chewing and food avoidance
(Table 4). The most frequently described swallow-related
deficit was problems related to chewing, closely followed
by the broad descriptor “swallowing difficulty”. Of these,
only seven reported a specific tool used to identify these
Records excluded
(n=921)
- Title (622)
- Abstract (295)
- Language (4)
Full-text articles excluded
(n=39)
- No swallow or voice outcomes; unclear
until full-text review (20)
- Jaw articles unrelated to swallow or
chewing, not obvious on initial screening
(5)
- Review article, incomplete article or book
chapter (5)
- Subjects not only whiplash (4)
- > WAD Grade II (3)
- Tracheostomy or other acute/severe injury
(2)
swallow-related difficulties and included: The Jaw Disabil-
ity Checklist [50], a standardised patient-reported outcome
measure in one study [44], measurement of mandible move-
ments [36] or amplitude of masseter muscles via electro-
myography (EMG) [43] during chewing and a timed chew-
ing endurance test [36, 37, 43, 44] (Table 5). Self-reported
questionnaires designed for the purpose of the study where
swallow-related behaviour was a component of a wider set
of questions related to post-injury symptoms were used in
a further seven studies [17, 18, 34, 37, 44, 45]. Six studies
did not utilise any outcome measure [21, 38, 40, 46, 48, 49].
Specifically, six studies specified an incidence rate
for different swallow-related problems occurring within
their cohort, ranging from 2 to 29% [17, 47], see Table 6.
However, due to the differences in the descriptors used to
calculate incidence, no average across the studies can be
calculated. Three of these studies [46, 48, 49] reported inci-
dence of swallow-related deficit with neither case report or
outcome measurement, where swallow-related complaints
were listed purely in a data table summarising a range of
13
 D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia

Table 2  Eligible studies
Study (year) N Age (mean) years Time post- WAD grade Healthy con- Swallow- Voice-related
whiplash* trol group related

Anagnostara44 (2005) 1 58 1–14 d n/s No X x

Bordoni21 (2016) 1 30 6 m II No X
Brademann45 (1998) 1 58 1–3.5 m n/s No x
Carroll17 (2007) 7763 18 years or over  > 1 m n/s No X
Chirchiglia46 (2019) 1 42 6 m n/s No X
Ferrari40 (2005) 7462 37.34 (mean, male); 1 m n/a No X
36.83 (mean, female)
Gargan53 (1994) 50 32 (mean) 5 d–2 y n/s No X
Gronquist18 (2008) 50 20–68  > 6 m II–III Yes X
Haggman42 (2002) 12 28–50 1–9 y II–III Yes X
Haggman43 (2004) 50 17–58 1–9 y II–III Yes (and non- X
whiplash
TMJ**)
Helliwell47 (1984) 1 64 0–18 m n/s No X x
Hildingson55 (1989) 35 19–67 4–14 d n/s No X
Kalezic49 (2010) 21 39 (mean) 3–13 y II–III Yes X
Lampa50 (2017) 80 34.1 (mean)  < 1 m 0–III Yes X
Pennie52 (1991) 144 n/s n/s n/s No X
Severinsson51 (2010) 119 19–75 1 m, 1 y 0–III No X
Sturzenegger54 (1995) 117 19–51 1y n/s No X
Waddell48 (2005) 1 27 56 m WAD No x
Totals 15,909 16 4

n/s not specified, d days, w weeks, m months, y years

*Time post-whiplash
**temporomandibular joint dysfunction—WAD group compared to a group of participants with TMJ dysfunction unrelated to whiplash

symptoms but not elaborated on. Furthermore, three studies
proposed relationships between swallowing issues and other
symptoms or time post-injury. Carroll et al. [17] reported
that people self-reporting difficulty swallowing after whip-
lash were 3.75 times more likely to also experience jaw pain,
while a study investigating jaw symptoms in the 1st year
after whiplash observed difficulty chewing increased from
4 to 10% of women over a 12-month period. Finally, Gar-
gan et al. [47] reported observing a 16% incidence of self-
reported “dysphagia” within 7 days of injury in their cohort
of 50, noting that this reduced to only 2% after 3-months.
In the most explicit of the three studies investigating
swallow-related difficulties related to whiplash as a primary
aim, Gronquist et al. [18] compared 50 WAD and 50 con-
trol participants and pre- and post-injury complaints, to test
the hypothesis that “eating behavior” would be impaired
following whiplash. A significant difference was found in
self-reported difficulties with jaw opening, biting, chewing
and swallowing and increased reports of; avoidance of tough
food, requiring smaller pieces, needing breaks during meals,
aborting meals and social impact, between those exposed
to whiplash and healthy controls (p < 0.0001) and between
pre- and post-injury complaints (p < 0.0001). The two other
studies [37, 43] reported up to one quarter [37] to more than
half [43] of individuals exposed to whiplash discontinued a
chewing endurance task due to self-reported fatigue. Self-
reported pain was significantly higher and onset of fatigue
was significantly earlier than healthy controls [37]. Further
to this, Kalezic et al. [43] demonstrated a significant increase
in autonomic responses of heart rate and arterial blood pres-
sure during the chewing endurance test.
Voice‑Related and Sensory‑Related Complaints
After Whiplash
Of the 18 studies, four reported on voice-related outcomes
and these are detailed in Tables 5 and 7. Additionally, sen-
sory symptoms following whiplash were highlighted in sev-
eral studies, including a unilateral burning sensation on the
tongue [40], unilateral clicking sensation in the larynx [42]
and pain on swallowing or jaw opening [18, 44].
Underlying Mechanisms
Potential underlying mechanisms for the swallowing and
voice issues observed were discussed in many studies [18,

13
 Table 3  Levels of evidence of eligible studies
Study (year) Design Assessor Sampling Subjects Outcomes Significance Precision Intention to treat Quality Research stage
blinding marker score/7

Anagnostara (2005)44 Case study No No Yes Yes No No N/A 2 Exploratory

Bordoni (2016)21 Case study No No Yes No No No N/A 1 Exploratory
Brademann (1998)45 Case study No No Yes Yes No No N/A 2 Exploratory
Carroll (2007)17 Cross sectional No Yes Yes No Yes Yes N/A 4 Exploratory
Chirchiglia (2019)46 Case study No No Yes No No No N/A 1 Exploratory
Ferrari (2005)40 Cohort No No Yes Yes Yes No N/A 4 Exploratory
D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia

Gargan (1994)53 Cohort Yes No Yes No Yes No N/A 4 Exploratory

Gronquist (2008)18 Case control study No No Yes No Yes No N/A 2 Exploratory
Haggman (2002)42 Case control study No No Yes Yes Yes No N/A 3 Exploratory
Haggman (2004)43 Case control study No No Yes Yes Yes No N/A 3 Exploratory
Helliwell (1984)47 Case study No No No Yes No No N/A 1 Exploratory
Hildingson (1989)55 Case series No No No Yes No No N/A 1 Exploratory
Kalezic (2010)49 Case control study No No Yes Yes Yes Yes N/A 4 Exploratory
Lampa (2017)50 Case control study Yes No Yes Yes Yes No N/A 5 Exploratory
Pennie (1991)52 Case series No No No Yes Yes No N/A 2 Exploratory
Severinsson (2010)51 Cohort No No Yes Yes Yes Yes N/A 5 Exploratory
Sturzenegger 1995)54 Case series No No Yes No Yes Yes N/A 3 Exploratory
Waddell (2005)48 Case study No No Yes Yes No No N/A 2 Exploratory

ASHA level of evidence rating system

Blinding—assessors blinded or not blinded; Sampling—random sampling adequately OR inadequately described or convenience sample described or not described; Subjects—groups compa-
rable or not comparable OR subjects described or not described; Outcomes—at least one primary outcome measure is valid or reliable or validity unknown/appears reasonable or invalid/unreli-
able; Significance—P-value reported; Precision—effect size or confidence interval described

13
 D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia

Table 4  Negative swallow-related outcomes following whiplash

Study Problems Dysphagia Swallowing Pain related to swal- Chewing Food avoidance Difficulty Tongue pain
eating difficulty low-related behaviour problems* coughing

Anagnostara44 √
Bordoni21 √ √
Carroll17 √
Ferrari40 √
Gargan53 √
Gronquist18 √ √ √ √ √
Hildingson55 √
Lampa50 √ √
Pennie52 √
Sturzenegger54 √ √
Kalezic49 √
Haggman42 √
Haggman43 √
Helliwell47 √
Severinsson51 √
Chirchiglia48 √
Totals: N 1 4 5 3 8 1 1 1

Swallow-related outcomes as described by each study

*Self-reported pain and/or fatigue during chewing, longer duration during chewing task or premature discontinuation of chewing task

21, 38–41, 43], however not specifically investigated in any
of the 18 studies included in this review. Anagnostara et al.
[38] described swallowing difficulty and vocal hoarseness in
a case of retropharyngeal hematoma post-whiplash. Oedema
of the pre-vertebral space and bulging of the posterior phar-
yngeal wall was found at the level of the tongue base on
computed tomography (CT) of the neck, which the authors
reported was suggestive of muscular tearing of the longus
colli muscles [38]. They also reported anterior displacement
of the arytenoid cartilages, compression of the parapharyn-
geal space and suggested involvement of pharyngeal muscles
after whiplash, given their location at the anterior border of
the retropharyngeal space.
Several studies [18, 21, 36, 37, 45] discussed the func-
tional relationship between the tongue, atlanto-occipi-
tal joint, cervical joints and hyoid bone after whiplash.
Gronquist et al. [18] supposed jaw dysfunction may be
the result of impaired coordination between jaw and neck
muscles and joints and suggested eating behaviours may
be impaired due to morphological alterations of the oro-
pharyngeal region after whiplash. Bordoni et al. [21] pro-
posed cervical and oropharyngeal tensioning as potential
factors impacting the tongue and described a reportedly
successful case of osteopathic treatment and myofascial
release of the tongue and hyoid region. Improvement in
self-reported cervical pain on swallowing following treat-
ment was considered the result of restoration of physi-
ological length in the fascial system and reduction in
inflammatory status. Four studies [36, 37, 43, 44] sug-
gested a relationship between neck injury and chewing
problems after whiplash, however did not discuss potential
underlying physiology.
For voice-related problems after whiplash, an underlying
superior laryngeal nerve (SLN) paresis was considered a
possible cause of loss of pitch and vocal control and weak
phonation in one case study [39]. Bilateral vocal fold palsy
was identified as the cause of weak phonation in a second
case [41]; considered to be a result of vagal nerve palsy from
shearing and stretching forces at the time of acceleration and
deceleration motions following impact.
The physiology underlying both sensory and motor com-
plaints following whiplash was also discussed. Bordoni et al.
[21] discussed widespread sensory hypersensitivity as a
potential mechanism of tongue tension and pain, specifically,
hyperexcitability in the central nociceptive pathways via the
trigeminal reflex [21], where myofascial release was pro-
posed to reduce trigger point activity in the cervico-occipital
region. Hyperexcitability of the autonomic nervous system
was also used to explain the increased autonomic responses
observed during a chewing endurance test [43] and likened
to the central drivers seen in chronic pain, where the spread
and maintenance of pain leads to lowered pain and sensory
thresholds. To explain the observations of pain during chew-
ing, Haggman et al. [37] discussed the coupling of the jaw
and neck sensorimotor system as a mechanism for the spread
of pain and musculoskeletal dysfunction,

13
 Table 5  Outcome measures in eligible studies
Swallow-related outcomes Voice-related outcomes
Study Self-reported Standard Mandibular Measure- EMG Osteopathic Timed Case report No Voice Nasendoscopy Case report No
questionnaire PROM ments during chewing during assessment chewing outcome range outcome
chewing test measure profile measure

Anagnostara44 √ √ √ √
Bordoni21 √ √ √
Brademann45 √ √ √
D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia

Carroll17 √
Chirchigilla46 √ √
Ferrari40 √
Gargan53 √
Gronquist18 √
Haggmann42 √ √
Haggmann43 √ √
Helliwell47 √ √ √ √
Hildingson55 √
Kalezic49 √ √
Lampa50 √ √ √
Pennie52 √
Severinsson51 √
Sturzenegger46 √
Waddell48 √ √ √
Totals: N 7 1 1 1 2 4 3 6 1 2 4 3

13
 D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia

Table 6  Incidence of swallow-related difficulties Due to large methodological differences, at present the

Study N Swallow-related Incidence (N) %
incidence of swallowing-related issues remains unclear.
descriptor Based on the two large cohort studies, it is possible that
swallowing-related issues may occur for one in every 4 or
Carroll17 5999 Swallowing difficulty 359a 6
5 individuals [17]. However, all studies varied widely in
1128 319b 28.4
sample size, nature and time post-injury and used a variety
Hildingson55 35 Dysphagia 2 5.7
of different and non-specific terms to describe complaints
Gargan53 50 Dysphagia 8c 16
(e.g. “difficulty swallowing”, “problems eating”). Many
1d 2
studies also failed to report exactly how swallowing issues
Pennie52 144 Dysphagia 18 27
were detected, thus limiting any comparison of results
Sturzenegger54 28 Dysphagia 2e 7
across studies.
117 10f 16
In the studies identified there was no specific investi-
Ferrari40 7462 Swallowing difficulty 248g 8.5
gation of swallowing biomechanics conducted. As such,
477h 10.5
there is little information to help clinicians understand how
a
 No jaw pain many people may present with a swallowing deficit or the
b
 New onset jaw pain nature of swallow-related impairments. From the data cur-
c
 Within 7-days rently available there is some early evidence to suggest that
d
 After 3-months issues with jaw function and the impact on chewing may be
e, g
 Male a component of such problems. However, in order to deter-
f, h
 Female mine what other factors may be contributing to eating and
swallowing behaviours as a consequence of whiplash injury,
more rigorous inquiry using validated tools and instrumental
Discussion measures of swallowing are needed. Furthermore, includ-
ing routine assessments of swallowing in future prospec-
A scoping review was conducted to broadly examine the tive investigations would help provide clearer information
nature and incidence of dysphagia and dysphonia follow- regarding symptom presentation and its relationship to the
ing whiplash. A total of 18 studies described a range of clinical course.
swallow and voice-related disturbances; however, for the The review highlighted voice problems post-whiplash
majority these were not the specific focus of the research, across four individual case studies, with a range of param-
often embedded within the reporting of a wider set of eters described and varied mechanisms proposed. Interest-
clinical signs and symptoms. Based on this review of ingly, loss of pitch range was reported in two of four stud-
the existing literature, it can be concluded that the cur- ies [39, 42] and could represent a potential area of future
rent understanding of the incidence, characteristics and/ investigation, particularly given the proposal of a potential
or causes of whiplash-related dysphagia and dysphonia is superior laryngeal nerve involvement [39] and other sugges-
extremely limited. tions of nerve injury [41]. Although spasmodic dysphonia
and muscle tension dysphonia were suspected as an under-
lying mechanism [42], there were no specific perceptual

Table 7  Negative voice-related Study Inci- Outcome measure

outcomes following whiplash dence N
(%)
Self-reported voice complaint Nasendoscopy Imaging

Helliwell47 1 Weak phonation Bilateral vocal fold immobility –

Waddell48 1 Loss of control – –
Break in register in singing
Brademann45 1 Loss of head voice Glottal closure –
Poor vocal fold lengthening,
Sagging vocal fold appearance
Anagnostara44 1 Hoarseness – Arytenoids
displaced
anteriorly

– Outcome measure not used for this study

13
D. B. Stone et al.: Whiplash-Associated Dysphagia and Dysphonia
or acoustic voice parameters described and no delineation
made between these two presentations to confidently make
this assumption. With such a small number of participants
and heterogeneity in the measuring and reporting of voice
outcomes in the selected studies of this review, this review
cannot confidently conclude that a post-whiplash dyspho-
nia exists. Despite this, the available literature points to
four individuals who self-reported a range of voice prob-
lems and despite this, no study in this review specifically
set out to examine voice function. Future work is needed,
utilising valid and reliable perceptual, acoustic and instru-
mental measurement to determine whether voice changes
after whiplash is perhaps an under-recognised feature of the
chronic recovery profile and whether they share a similar
underlying pathophysiology to swallow complaints.
In the existing literature, swallow-related problems con-
cerning chewing, fatigue, pain and food avoidance were
described, and changes in voice quality and function were
also observed. In most studies, several explanations were
proposed to explain these complaints. However as yet, no
study has specifically explored underlying cause and the
evidence base remains at the level of clinical opinion only.
Many of the causal mechanisms proposed to date appear
plausible but further research in this area is needed. For
example, the suggested impact of pharyngeal and/or lon-
gus colli muscle involvement in whiplash trauma [38] and
the subsequent impact on swallowing could be grounds
for future work. Although the longus colli is not typically
considered part of the swallowing musculature, dysphagia
and odynophagia are described as key symptoms of longus
colli tendonitis [51, 52]. The longus colli also has a role in
maintaining the cervical spine lordotic curve [53]. Given
the incidence of swallowing difficulties in cases of curvature
change [54], its’ contribution to post-whiplash dysphagia is
plausible [53] but not yet examined.
The link between the jaw, cervical spine and swallow
musculature was also suggested in several studies [18, 21,
36, 37, 45], though unsupported by any experimental inves-
tigations. The whiplash event may render some tissues vul-
nerable to injury [55]. For example, the thyroid cartilage
is anterior to the sixth cervical vertebrae, where excessive
stretch of the anterior soft tissue of the neck during the
injury event may result in nerve injury [39]. Further inves-
tigation into swallow biomechanics post-whiplash and the
possible association with biomechanical consequences of
cervical spine injury is needed to further our understanding
of post-whiplash swallow or voice problems.
Finally, the potential for a centrally-driven component
to explain swallow or voice-related problems provides an
interesting area for future exploration. Sensory disturbances
in the tongue [21, 40], larynx [42] and/or jaw [18, 44] have
been described, albeit briefly, but have not been systemati-
cally investigated as yet. Heightened autonomic responses
in reaction to increased chewing load [43] were suggestive
of hypersensitivity and lowered pain and sensory thresholds.
Given that a cardinal feature of chronic WAD is widespread
pain and higher pain intensity [56] and that dysphagia and dys-
phonia are typical manifestations seen in laryngeal hypersensi-
tivity syndromes [26] the possibility of centrally-driven causal
or contributing factors in post-whiplash swallow and voice
complaints is plausible and worthy of further consideration.
Overall, multiple issues were identified with the quality
of the existing literature, which was rated as low for most
studies. Over 30% of the included studies were single case
reports, where a range of descriptors suggested voice and/or
swallow problems were a direct consequence of injury, how-
ever without use of reliable and valid measurement tools. As
observed in the analysis of the 18 papers, there was great
variability in symptom presentation and the study designs
failed to detail nature and severity across those injured or the
temporal expression and duration of symptoms across the
clinical course. The degree of WAD was also not specified in
most studies and this proves a challenge when trying to make
comparisons and draw clinical inference into potential risk
factors. These and other methodological weaknesses need to
be systematically addressed in future studies. This scoping
review highlighted the need for robust, primary investiga-
tion into swallow and voice deficits following whiplash to
elucidate these interesting preliminary findings.
Limitations
Given the limited information on swallow and voice defi-
cits reported in the selected studies, where many descrip-
tors were embedded within larger data sets, the authors
acknowledge the potential of having missed some informa-
tion reported in papers with similar, brief and heterogenous
reporting. Despite this, best efforts were made to include
all possible terms across our literature review and robustly
search the known literature. Also, to avoid inclusion of
a suspected large number of studies outside the scope of
this review, studies of post-whiplash jaw dysfunction were
excluded if unrelated to swallow or chewing deficits. In
doing so, the authors acknowledge the chance of missing
information that may have been embedded in the excluded
studies. However, full-text review was conducted on any title
or abstract where this was unclear and so this risk was mini-
mised as much as possible.
Conclusion
The studies in this review highlighted a range of swallow-
and voice-related deficits following whiplash. However, the
study designs and heterogeneity across the available litera-
ture provides a challenge in determining the true incidence
13

and nature of whiplash-associated dysphagia and/or dys-
phonia. Further studies using standard and instrumental
measures of swallow and voice function, implemented pro-
spectively over time in large clinical cohorts are needed to
make headway in this field. Understanding the underlying
biomechanics and pathophysiology of the swallowing and
voice changes is also critical to help inform the nature of any
interventions. Until such data are available it is difficult to
determine whether swallow and voice assessment and any
intervention for these issues, is indicated in the management
of this population.
Acknowledgements  The authors would like to acknowledge the exper-
tise of Ms Nicola Wormleaton, Librarian at Royal North Shore Hos-
pital and Ms Yulia Ulyannikova, Librarian for the Faculty of Health
Sciences, The University of Sydney. Their expertise in assistance with
search strategy design was greatly appreciated.
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Publisher’s Note Springer Nature remains neutral with regard to
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D. B. Stone  BAppSc(SpPath), MAppSc, PhD Candidate
E. C. Ward  PhD
S. R. Knijnik  BSpHLSc, MAppSc
H. Bogaardt  PhD
J. M. Elliott  PT, PhD, FAPTA
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