Neck pain syndromes cause alterations in the ability to do functional activities and can exhibit complex limits and changes of cervical use and movement. However, biological factors should not be considered in isolation as the incidence and the ongoing maintenance of painful neck syndromes also includes factors to do with a person's psychology. Relevant disturbances of psychological functioning should be noted by a physiotherapist so that appropriate referral could be suggested and so that treatment and management can be given with this in mind. The patient's behaviour in reaction to their neck pain may be significantly determined by their psychological status.
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.
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.
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.
The underlying biological changes which occur in the central nervous system during pain syndromes are thought to be responsible for sensory abnormalities, although some think that these factors are minor compared to psychological ones or that malingering is common. However, there is some evidence that the increased reactivity in neck pains has been shown not to be the result of psychological factors. The barrage of incoming pain stimuli into the central nervous system from the damaged areas is accepted as the cause of increased sensory sensitivity, with psychological factors playing a minor role.
