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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.

It is clear that there is an important relationship between pain, disability and psychological variables but this relationship is complex and not obvious. Psychological variables in lower back pain have been much more completely investigated but it seems that the variables in neck pain may be more specific to cervical pain and not the same. People suffering from long term neck pain are known to shown alterations in mood such as depression and anxiety, with patients with whiplash also showing changes in the ways they behave and posttraumatic 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.

Fear-avoidance and pain are likely to have a looser relationship in neck pain syndromes than in lower back pain. Patients with whiplash associated disorder have been shown to have intermediate levels of fear avoidance but that this does not predict how well they do over time as both long term disabled and good recoveries show similar amounts. A whiplash injury is usually the result of a sudden incident such as a road accident and levels of post-traumatic stress disorder have been found in these patients. Within a month of the injury if a patient has a moderate level of this stress disorder then they are likely to do poorly in the long term.

Physiotherapists need to be aware of the presence of post-traumatic stress disorder in whiplash patients as it is a relatively common occurrence and should be able to recognise, assess and have some therapeutic approach to this aspect of the condition. Pain, distress and disability are linked together in the biopsychosocial model, with the large numbers of psychological and physical factors contributing to the presentation of the patient. How these factors interact to produce the overall outcome is not well understood. The sensory hypersensitivity in early whiplash does not predict between good recovery and poor.

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.

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