The pain and other symptoms which are involved in neck problems typically cause functional difficulties which show themselves in complicated limitations of movement and activity. However, the pain and neurological aspects cannot be considered on their own as psychological factors are also involved in the generation and maintenance of neck pain conditions. Physiotherapists need to be able to identify important psychological disturbance so that appropriate onward referral can be made and so that the assessment and treatment can be adjusted in the light of these factors. Psychological factors may in some cases be of crucial importance in how the patient is behaving in response to neck pain.
While there is a relationship between psychological factors, pain and disability this is by no means clear and likely to be very complex. These factors have been investigated much more completely for lower back pain and it is likely that the factors which relate to neck pain are individual to that anatomical area to some degree. Chronic neck pain is well known to be associated with psychological distress, with whiplash patients exhibiting mood changes such as depression and anxiety, changes in behaviour and degrees of post-traumatic stress disorder.
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.
The persistence of pain, disability and limitation in functional abilities has been shown to hold up the levels of mental distress. In whiplash associated disorder there has not been shown to be any link between a poorer outcome and depression, anxiety, a self assessment of well being or level of mental ability. Investigation into the concept of fear-avoidance in lower back pain has been extensive and linked with the development of longer term losses in function. The fear-avoidance model postulates that a withdrawal from potentially challenging physical activities due to a fear of damage and pain is important.
Lower back pain and fear-avoidance have been shown to be closely related but this is not likely to be the case with neck pain. Moderate amounts of fear-avoidance have been found in patients with whiplash associated disorder but no connection has been made between this and the outcome, being the same in people who do badly and those who do well. A sudden incident such as a motor vehicle crash is the commonest reason for whiplash injury and patients exhibit levels of post-traumatic stress disorder. A poor outcome in the long term is associated with patient showing moderate stress disorder within a month of the event.
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.
The disturbances in sensory interpretations of incoming stimuli are accepted to be due to underlying changes in the way that the central nervous system is processing pain. However, some workers consider such factors to be entirely psychological or due to malingering. However, evidence does indicate that these factors are not entirely responsible for the increase in sensitivity commonly exhibited. Overall the hypersensitivity in the reaction to incoming stimuli which occurs after whiplash is the result of changes in the biological functioning of the central nervous system cells, with some involvement of psychological factors.
Jonathan Blood Smyth is the Superintendent of Physiotherapists at an NHS hospital in the South-West of the UK. He writes articles about back pain, neck pain, and injury management. If you are looking for physiothrapists in Southampton visit his website.
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