Cervical Pain and Disability – Part Three

Activities of daily functioning are commonly interfered with by neck pain disorders and use of the cervical spine can be altered in complex movement patterns and restrictions. The onset and longer term persistence of neck pain and disability should not be thought of in isolation but rather in conjunction with relevant psychological factors. On assessment a physiotherapist should address any obvious psychological disturbance by suggesting referral to an appropriate specialist, and also adjust their management of the condition to account for such factors. The psychological state of mind of the patient may be a critical factor in their reaction to their neck pain syndrome.

The relationship between disability, pain and psychological factors is of importance but it is very complicated and in many cases not very clear. Research into low back pain has been much more extensive and it is becoming apparent that psychological factors for neck pain may be relatively specific to the neck. Psychological distress is well recognised in chronic neck pain sufferers, with mood alterations such as anxiety and depression present in whiplash cases, along with behavioural changes and varying amounts of post-traumatic stress.

While psychological factors are widely agreed to be relevant in disabling neck pain problems there is poor evidence for how this relationship works. Intuitively one would expect that the disability and pain as a consequence of neck pain would trigger psychological distress, but is there a relationship in the other direction? It is likely that people with long term whiplash symptoms suffer psychological distress secondary to the levels of disability and pain they have to endure from the neck condition. Traits of personality and other variables of psychological functioning have not been linked to the chronicity of pain problems.

There is some evidence that if the symptoms of pain and restriction persist then the psychological distress is also maintained. In whiplash injury psychological factors such as anxiety and depression, self assessed well being and mental abilities have not been shown to be connected with a poor outcome. In lower back pain the levels of fear-avoidance have been investigated and found to be of some importance in predicting disability. Fear-avoidance is the concept that a person’s fear of the pain and potential tissue damage limits their function so they avoid significant and normal activities.

The relationship between neck pain and fear-avoidance is likely not to be as close as it may be in lower back pain. It looks like patients with whiplash may have moderate levels of fear-avoidance but that this is not predictive of outcome, being similar in patients who recover well and those who do less well. As whiplash is a sudden and traumatic event, typically a motor vehicle accident, there is some evidence of the presence of post-traumatic stress disorder being of importance. Moderate levels of this disorder present within four weeks of the injury is strongly predictive of a poor outcome overall.

As post-traumatic stress disorder has been found to be of importance in at least a number of whiplash patients, it may be useful for physiotherapists to include aspects of treatment which include techniques targeted at post-traumatic stress. Overall the biopsychosocial model indicates that pain and disability are related to the interaction of a large number of factors both physical and psychological although the exact contribution of each factor and how they interact is not known. In whiplash the complex changes in sensory interpretations are present early in the syndrome in those who do not recover well and remain until the chronic phase.

In painful syndromes there appear to be biological changes in the neurological system which are responsible for the hypersensitivity which develops in the sensory systems, although some workers attribute these changes to malingering or psychological changes. However, these factors have been shown not to be of great relevance in the generation of heightened sensitivity in neck pain syndromes. The large amounts of pain stimuli entering from the periphery into the central nervous system is recognised as the trigger for the hyperalgesia present in neck pain, with a more limited role for psychological factors.

Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about Physiotherapists, physiotherapy, physiotherapists in Leeds, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.