The impact of psychosocial factors on neck pain and disability outcomes among primary care patients: results from the UCLA Neck Pain Study

Purpose. The purpose of this study is to estimate the associations of psychosocial factors with pain and disability outcomes among neck-pain patients enrolled in a randomized clinical trial of chiropractic treatments.

Methods. Neck-pain patients were randomized to one of 8 modes of chiropractic treatment. Health status and psychosocial variables were measured at baseline. Changes in neck pain severity and disability from baseline to 6 months were the primary outcome variables. Multivariable regression models were used to estimate effects of psychosocial variables adjusted for potential confounders.

Results. Of 960 eligible patients, 336 were enrolled and 80% were followed up through 6 months. Coping strategies involving self-assurance resulted in better disability outcomes, whereas getting angry or frustrated resulted in worse pain and disability outcomes. Participants with high levels of social support from individuals were more likely to experience clinically meaningful reductions in pain and disability. No consistent relations of internal health locus of control, and physical and psychological job demands with improvements in pain and disability were detected.

Conclusions. We found some evidence that certain coping strategies and types of social support are associated with pain and disability outcomes in this population of largely subacute and chronic neck-pain patients.     

The association between cognitive factors,pain and disability in patients with idiopathic chronic neck pain

Purpose.?The aim of this study was to establish the relationship between known cognitive factors and levels of pain and disability in patients with idiopathic chronic neck pain.

Method.?Ninety-four patients referred for physiotherapy because of chronic neck pain completed measures of pain, disability, catastrophising, pain-related fear, pain vigilance and awareness and self-efficacy beliefs. Hierarchical multiple regression analyses were then performed to establish whether the cognitive factors were significant determinants of levels of pain and disability.

Results.?The cognitive measures were significantly related to levels of pain and disability, explaining 23% of the variance in pain intensity and 30% of the variance in disability. Specifically, greater catastrophising (β?=?0.37, p?<?0.05) and lower pain vigilance and awareness (β?=???0.32, p?<?0.05) were associated with greater pain intensity. Moreover, greater catastrophising (β?=?0.26, p?<?0.05) and lower functional self-efficacy beliefs (β?=???0.34, p?<?0.001) were significantly associated with greater levels of disability.

Conclusions.?Cognitive factors were strongly related to levels of pain and disability in patients with chronic neck pain. In view of this, targeting the modification of these cognitive factors should be an integral part of therapy when treating patients with idiopathic chronic neck pain.     

Psychometric properties of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain

Cleland JA, Childs JD, Whitman JM. Psychometric properties of the Neck Disability Index and numeric pain rating scale in patients with mechanical neck pain.

Objective

To examine the psychometric properties including test-retest reliability, construct validity, and minimum levels of detectable and clinically important change for the Neck Disability Index (NDI) and the numeric rating scale (NRS) for pain in a cohort of patients with neck pain.

Design

Single-group repeated-measures design.

Setting

Outpatient physical therapy (PT) clinics.

Participants

Patients (N=137) presenting to PT with a primary report of neck pain.

Interventions

Not applicable.

Main Outcome Measures

All patients completed the NDI and the NRS at the baseline examination and at a follow-up. At the time of the follow-up, all patients also completed the global rating of change, which was used to dichotomize patients as improved or stable. Baseline and follow-up scores were used to determine the test-retest reliability, construct validity, and minimal levels of detectable and clinically important change for both the NDI and NRS.

Results

Test-retest reliability was calculated using an intraclass correlation coefficient (ICC) (NDI ICC=.50; 95% confidence interval [CI], .25-.67; NRS ICC=.76; 95% CI, .51-.87). The area under the curve was .83 (95% CI, .75-.90) for the NDI score and .85 (95% CI, .78-.93) for the NRS score for determining between stable and improved patients. Thresholds for the minimum clinically important difference (MCID) for the NDI were 19-percentage points and 1.3 for the NRS.

Conclusions

Both the NDI and NRS exhibit fair to moderate test-retest reliability in patients with mechanical neck pain. Both instruments also showed adequate responsiveness in this patient population. However, the MCID required to be certain that the change in scores has surpassed a level that could be contributed to measurement error for the NDI was twice that which has previously been reported. Therefore the ongoing analyses of the properties of the NDI in a patient population with neck pain are warranted.     

Contribution of individual, workplace, psychosocial and physiological factors to neck pain in female office workers

This study investigated the relative contribution of individual, workplace, psychosocial and physiological features associated with neck pain in female office workers towards developing appropriate intervention programs. Workers without disability (Neck Disability Index (NDI) score  8, n = 33); workers with neck pain and disability (NDI  9/100, n = 52) and 22 controls (women who did not work and without neck pain) participated in this study. Two logistic regression models were constructed to test the association between various measures in (1) workers with and without disability, and (2) workers without disability and controls. Measures included those found to be significantly associated with higher NDI in our previous studies: psychosocial domains; individual factors; task demands; quantitative sensory measures and measures of motor function. In the final model, higher score on negative affectivity scale (OR = 4.47), greater activity in the neck flexors during cranio-cervical flexion (OR = 1.44), cold hyperalgesia (OR = 1.27) and longer duration of symptoms (OR = 1.19) remained significantly associated with neck pain in workers. Workers without disability and controls could only be differentiated by greater muscle activity in the cervical flexors and extensors during a typing task. No psychosocial domains remained in either regression model. These results suggest that impairments in the sensory and motor system should be considered in any assessment of the office worker with neck pain and may have stronger influences on the presenting symptoms than workplace and psychosocial features.     

Correlation among physical impairments, pain, disability, and patient satisfaction in patients with chronic neck pain

OBJECTIVE: To investigate the correlations among pain, physical impairments, disability, and patient satisfaction in patients with chronic neck pain. DESIGN: A longitudinal cohort study with 6-month follow-up. SETTING: Institutional practice. PARTICIPANTS: Subjects (N=218) with chronic neck pain. INTERVENTIONS: Subjects were treated with different physiotherapy modalities. MAIN OUTCOME MEASURES: Data were obtained for self-reported disability, verbal numeric pain scale, patient satisfaction, and 2 measures of physical impairments during the initial visit, at 6 weeks, and finally at 6 months. RESULTS: The correlation among 4 sets of measurements varied. Moderate correlation was noted between disability and patient satisfaction ( r range, .50-.65), and between disability and pain ( r range, .55-.63). A fair relationship was found between pain and patient satisfaction ( r range, .43-.48), but only weak relationships were found between physical impairments and pain ( r range, -.08 to -.25). The correlations tended to increase in the follow-up assessments. CONCLUSIONS: No strong correlations were found among disability, patient satisfaction, pain, and physical impairments although the correlations tended to increase in the follow-up assessments. The findings support the suggestion that clinicians should address as many relevant aspects of a presenting clinical entity as possible in the management of chronic neck pain.     

Neck pain and disability: a cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic

This hospital-based cross-sectional cohort study examines the clinical and demographic features of neck pain, disability (using the Northwick Park neck pain questionnaire) and relationships to handicap in employment. Of 173 consecutive referrals to a rheumatology clinic with neck pain, 70% had neck/arm pain without neurological involvement, 13% other conditions, 11% nerve involvement and 5% other spinal pain. 141 patients (mean age 50 years) had mechanical or degenerative neck pain, of which 13% was probably work-related and 13% was trauma-related. 44 had taken sickness absence for an average of 30 weeks. Comorbidities were frequent (lumbar pain 51%). Those in work were significantly less disabled than those not working (p = 0.001) and those off sick (p < 0.01). Those reporting sleep disturbance, tearfulness and crying were significantly more disabled (p = 0.0001) than those who did not. Neck pain in secondary care is complicated by physical and emotional comorbidities. Comprehensive management requires a biopsychosocial model of care.     

瑜伽干预颈痛效果的Meta分析

目的 系统评价瑜伽在干预颈痛患者疼痛、功能障碍和关节活动度方面的临床疗效。方法 计算机检索PubMed、The Cochrane Library、Embase、中国知网、万方、维普数据库,收集国内外有关瑜伽干预颈痛的随机对照试验。对所得文献进行筛选、资料提取和偏倚风险评价后,采用RevMan5.3软件对数据进行Meta分析。结果 最终纳入中英文文献6篇,共计384名患者。Meta分析结果显示:瑜伽减轻患者颈部疼痛优于对照组[MD(95%CI)=-1.20(-1.40,-1.00),P<0.01],改善患者颈部功能障碍优于对照组[MD(95%CI)=-5.33(-7.19,-3.47),P<0.01],提升患者颈部前屈[MD(95%CI)=8.04(5.24,10.84),P<0.01]、后伸[MD(95%CI)=8.57(5.41,11.74),P<0.01]活动度优于对照组。亚组分析结果显示:瑜伽在减轻颈椎病、非特异性颈痛患者的疼痛程度方面均优于对照组。 结论 瑜伽干预在改善颈痛患者的疼痛、颈部功能障碍和关节活动度方面具有显著效果。     

Modifiable individual and work-related factors associated with neck pain in 740 office workers: a cross-sectional study

Background

Office workers have the highest incidence of neck pain of all occupations. However, the relationship between symptoms and the risk factors is unclear.

The Immediate Effects of Mobilization Technique on Pain and Range of Motion in Patients Presenting With Unilateral Neck Pain: A Randomized Controlled Trial

Kanlayanaphotporn R, Chiradejnant A, Vachalathiti R. The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial.

Objective

To determine the immediate effects on both pain and active range of motion (ROM) of the unilateral posteroanterior (PA) mobilization technique on the painful side in mechanical neck pain patients presenting with unilateral symptoms.

Design

Triple-blind, randomized controlled trial.

Setting

Outpatient physical therapy, institutional clinic.

Participants

Patients (N=60), 2 physical therapists, and 1 assessor involved in this study.

Interventions

The patients were randomly allocated into either preferred or random mobilization group by using an opaque concealed envelope. The first therapist performed the screening, assessing, prescribing the spinal level(s), and the grade of mobilization. The second therapist performed the mobilization treatment according to their allocated group stated in an envelope. The assessor who was blind to the group allocation conducted the measurements of pain and active cervical ROM.

Main Outcome Measures

Pain intensity, active cervical ROM, and global perceived effect were measured at baseline and 5 minutes posttreatment.

Results

After mobilization, there were no apparent differences in pain and active cervical ROM between groups. However, within-group changes showed significant decreases in neck pain at rest and pain on most painful movement (P<0.001) with a significant increase in active cervical ROM after mobilization on most painful movement (P=0.002).

Conclusions

The results of this study did not provide support for the preference of the unilateral PA mobilization on the painful side to the random mobilization.     

An investigation to determine the association between neck pain and upper limb disability for patients with non-specific neck pain: a secondary analysis

This study investigated the relationship between neck pain and upper limb disability in patients with non-specific neck pain (n = 151) recruited from physiotherapy departments in the United Kingdom. Baseline neck pain/disability was measured using the Northwick Park Neck Pain Questionnaire (NPQ). Baseline upper limb disability was measured using the Disabilities of Arm, Shoulder, Hand questionnaire (DASH). A range of baseline psychosocial variables were measured as potential confounding variables. Pairwise analysis revealed a positive correlation between NPQ score and DASH score (Pearsons’ r = 0.799, p < 0.001). After adjusting for potential confounding variables, stepwise linear regression indicated that increasing upper limb disability was predicted by two baseline variables: higher NPQ scores (B = 0.743) and lower pain self efficacy (PSE) scores (B = −0.489) {R² = 0.713; n = 100, p < 0.001}. This study provides preliminary evidence that patients with severe neck pain/disability also report severe upper limb disability. The relationship between neck pain/disability and upper limb disability was mediated by PSE. Clinically, the presence of severe neck pain or low PSE should direct clinicians towards an assessment of upper limb function. In these cases upper limb disability may need to be addressed as part of the neck management process.     

Measuring practitioner/therapist effects in randomised trials of low back pain and neck pain interventions in primary care settings

In psychological health treatment studies it has been shown that differences between therapists account for some of the non‐specific effect of treatment but this phenomenon has not so far systematically been investigated in musculoskeletal disorders. In this study we evaluated and compared the size and potential influence of the ‘practitioner effect’ (or ‘therapist effect’) in three randomised treatment trials of low back pain and neck pain patients in primary care. We calculated the proportion of variance in outcomes attributable to differences across practitioners, i.e. the practitioner–variance partition coefficient (p–vpc). As measures of outcome, we focused on self‐reported disability as the primary outcome, but we also investigated assessed psychological outcomes. The p–vpc for the disability measures ranged from 2.6% to 7.1% across trials and time points (post treatment and follow up). Estimates differed between treatment subgroups within trials; being highest in treatment subgroups assigned to psychosocial‐based interventions. A ‘practitioner effect’ does exist and is more pronounced in treatments involving greater psychosocial emphasis. This has implications for both practice and research in this clinical area. It highlights the importance of patient–practitioner interactions, and the need to address practitioner effects in designing and analysing outcome studies in low back pain and neck pain in primary care.     

The immediate effects of thoracic transverse mobilization in patients with the primary complaint of mechanical neck pain: a pilot study

Objective:

Posterior-to-anterior (PA) vertebral mobilization to the thoracic spine has been studied as an intervention for neck pain. Our purpose was to explore effects of a different mobilization technique, transverse vertebral pressure, on cervical range of motion (ROM) and pain when applied to the thoracic spine among participants with neck pain.

Methods:

A single-blinded quasi-experimental study with a one-group pretest–posttest design. A transverse group consisted of 21 participants whose neck pain increased with active movements. A non-intervention group of 20 asymptomatic participants was included simply to ensure rater blinding. The treatment group received Grades IV to IV+ transverse mobilizations at T1 through T4 bilaterally. Measurements taken immediately after intervention included pre/post cervical ROM, distant pressure pain threshold (PPT), and a numerical pain rating scale (NPRS). Analysis utilized t-tests and ordinal counterparts.

Results:

The transverse group demonstrated significant gains in extension and bilateral rotation (P≤0·005) but not flexion or side-bend. A total of 57% of mobilized participants reported clinically meaningful decreased pain (P<0·001). Seven participants exceeded the PPT MDC₉₅ of 0·36 kg/cm². The non-intervention group had no significant changes in ROM or NPRS scores.

Discussion:

After 8 minutes of transverse mobilization to the upper thoracic spine, significant gains in cervical extension and bilateral rotation, and decreased pain scores were found. There were no adverse effects. Unlike other mobilization studies, PPT changes at a remote site were statistically but not clinically meaningful. Findings suggest that transverse mobilization would be a productive topic for controlled clinical trials.     

Psychometric properties of the neck disability index amongst patients with chronic neck pain using item response theory

Objective: The Neck Disability Index (NDI) is commonly used for clinical and research assessment for chronic neck pain, yet the original version of this tool has not undergone significant validity testing, and in particular, there has been minimal assessment using Item Response Theory. The goal of the present study was to investigate the psychometric properties of the original version of the NDI in a large sample of individuals with chronic neck pain by defining its internal consistency, construct structure and validity, and its ability to discriminate between different degrees of functional limitation.

Methods: This is a cross-sectional cohort study of 585 consecutive patients with chronic neck pain seen in a university hospital rehabilitation clinic. Internal consistency was evaluated using Cronbach’s alpha, construct structure was evaluated by exploratory factor analysis, and discrimination ability was determined by Item Response Theory.

Results: The NDI demonstrated good internal consistency assessed by Cronbach’s alpha (0.87). The exploratory factor analysis identified only one factor with eigenvalue considered significant (cutoff 1.0). When analyzed by Item Response Theory, eight out of 10 items demonstrated almost ideal difficulty parameter estimates. In addition, eight out of 10 items showed high to perfect estimates of discrimination ability (overall range 0.8 to 2.9).

Conclusions: Amongst patients with chronic neck pain, the NDI was found to have good internal consistency, have unidimensional properties, and an excellent ability to distinguish patients with different levels of perceived disability.

• Implications for Rehabilitation

• The Neck Disability Index has good internal consistency, unidimensional properties, and an excellent ability to distinguish patients with different levels of perceived disability.

• The Neck Disability Index is recommended for use when selecting patients for rehabilitation, setting rehabilitation goals, and measuring the outcome of intervention.

     

Functional activities and psychosocial factors in the rehabilitation of patients with low back pain

A four-week rehabilitation programme for back patients, focusing on functional activities and psychosocial factors in the demands of work and daily living, was evaluated. The programme is a combination of training of functional activities and increased psychological knowledge, body awareness and coping. A total of 40 patients with lumbago or lumbago ischias participated in the program and were compared with a matched control group. The results showed that the patients had significantly more ergonomic and psychosocial problems in their working environment than did the controls. A significant reduction in ratings of low back pain was noted in patients compared with controls after rehabilitation. Increased functional ability and physical fitness were shown in the patient group after rehabilitation. Significantly more patients than controls returned to work after the rehabilitation.     

The psychometric properties of the cervical nonorganic signs in patients with neck pain: an assessment of pain expression

Purpose: Neck pain is a common cause of disability. This study investigated the psychometric properties of the cervical nonorganic signs (CNOS), a tool for assessing abnormal illness behaviors in patients with neck pain.

Methods: The CNOS was administered on patients with neck pain. Reliability and validity analyses were used to evaluate the psychometric properties. Exploratory factor analysis was used to investigate the dimensionality. Correlations with the Short Form-36 were used to investigate the convergent validity.

Results: The results supported the reliability (inter-rater reliability intra-class correlation: 0.920), validity (correlated with body pain (|ρ|=0.31) and vitality (|ρ|?=0.30), and two-factor dimensionality (χ²=^?5.904, p=?0.66; χ²/df?=?0.738; RMSEAConclusion: The CNOS is a reliable and valid instrument for assessing pain and vitality problems. It helps patients to express severe pain and lack of vitality. The rehabilitation discipline could use the scale to understand pain expression and to design proper rehabilitation programs.

• Implications for Rehabilitation

• The cervical nonorganic signs has two domains (pain and vitality).

• The scale is reliable and valid for patients with neck pain.

• Patients with high scores on the pain domain have severe body pain that may interfere with normal social activities.

• Clinicians should understand their suffering and try to help them to alleviate the pain.

     

The processes underpinning reductions in disability among people with chronic neck pain. A preliminary comparison between two distinct types of physiotherapy intervention

Purpose: To establish whether different processes underpin changes in disability in people with neck pain who underwent two types of active physiotherapy intervention.

Materials and methods: This study was a sub-analysis of a randomized controlled trial assessing whether the addition of Interactive Behavioral Modification Therapy (a cognitively informed physiotherapy treatment) to a Progressive Neck Exercise Program improved outcome in patients with chronic neck pain. Regression analyses were performed to determine the extent to which demographics, changes in pain, and changes in certain cognitive factors were related to changes in disability.

Results: In the progressive neck exercise group, changes in levels of pain intensity were the only factor significantly related to change in disability, explaining 33% of the variance. In the interactive behavioral modification therapy group, changes in pain intensity, and catastrophizing together explained 54% of the variance in change in disability. Only changes in catastrophizing displayed a significant β value in the final model.

Conclusions: Different processes appear to underpin changes in disability in patients undergoing cognitively informed physiotherapy to those undergoing a primarily exercise-based approach.

• Implications for rehabilitation

• Certain cognitive factors are known to be related to levels of disability in patients with chronic neck pain

• Specifically targeting these factors results in more patients making a clinically meaningful reduction in disability

• Different processes appear to underpin reductions in disability when people with neck pain are treated with cognitively informed physiotherapy to when treated with exercise alone, which may account for why more patients improve when treated in this manner.

• Reductions in catastrophizing appear to be particularly important and efforts should be made to assess and treat catastrophic thoughts in people with chronic neck pain.

     

Self‐management of persistent neck pain: A randomized controlled trial of a multi‐component group intervention in primary health care

Studies regarding self‐management of persistent neck pain are infrequent. Objective: to compare treatment effects of (a) a multi‐component pain and stress self‐management group intervention (PASS) and (b) individually administered physical therapy (IAPT) for patients with persistent musculoskeletal tension‐type neck pain. Methods: Persons seeking physical therapy treatment due to persistent tension‐type neck pain at nine primary health care centers in Sweden were randomly assigned to either PASS or IAPT. Before treatment (baseline) and at 10‐ and 20‐weeks the participants completed a self‐assessment questionnaire comprising: the Self‐Efficacy Scale, the Neck Disability Index, the Coping Strategies Questionnaire, the Hospital Anxiety and Depression Scale, the Fear‐Avoidance Beliefs Questionnaire and questions regarding neck pain, analgesics and utilization of health care. Intention‐to‐treat analyses were performed using repeated measures analysis of variance between baseline, 10‐week and 20‐week follow‐up. Results: One hundred and fifty six participants were included (PASS n = 77, IAPT n = 79). On average participants receiving PASS attended seven treatment sessions and participants receiving IAPT 11 sessions over the 20‐week follow‐up period. Repeated measures ANCOVA showed significant time × group interaction effects for ability to control pain , self‐efficacy regarding pain‐interfering activities , disability due to neck pain (p = 0.001) and levels of catastrophic thinking in favour of PASS. Conclusion: PASS had a better effect than IAPT in the treatment of persistent musculoskeletal tension‐type neck pain regarding coping with pain, in terms of patients’ self‐reported pain control, self‐efficacy, disability and catastrophizing, over the 20‐week follow‐up.     

The effectiveness of cervical versus thoracic thrust manipulation for the improvement of pain,disability, and range of motion in patients with mechanical neck pain

Background:

Many patients present to physical therapy with mechanical neck pain. Cervical and thoracic manipulations are being utilized in treating this impairment, but minimal evidence as to which technique is superior exists in the literature.

Objective:

The purpose of this systematic review is to identify whether cervical or thoracic manipulation is more effective at improving pain, range of motion (ROM), and disability in patients with mechanical neck pain.

Methods:

A comprehensive search of published literature from seven search engines (PubMed, ProQuest, PEDro, CINAHL, Healthsource, Cochrane Library, SPORTDiscus) yielded 13 studies that examined the effectiveness of either cervical manipulations, thoracic manipulations, or cervical and thoracic manipulations to relieve the effects of mechanical neck pain. Eleven of the studies included were randomized controlled trials (RCTs), while two were secondary analyses of RCTs. Each study was assessed using the PEDro scale and found to be of fair to high research quality.

Results:

The studies included in this systematic review produced both positive clinical and statistical differences in pain, disability, and ROM following manipulations of the cervical or thoracic spine.

Conclusion:

There is limited high-quality research directly comparing the two interventions, so determining whether cervical or thoracic thrust manipulation is superior cannot be concluded from this systematic review alone. However, based on the results found in this review, cervical and thoracic thrust manipulations are equally valuable in relieving pain, disability, and improving ROM for a patient with mechanical neck pain in the short term.