October 19, 2016

How long will my neck hurt? What a PT should consider.

Author: Maggie Henjum

A few areas help me drive prognostic factors from my evaluation. Obviously, duration of symptoms and our SINS rule play a large role in how long patients may hurt, but maybe the strongest predictor in the cervical spine: psychosocial factors. I thoroughly enjoy pain discussion and may get on a small soap box in this post, feel free to cut me off or check out to look at Motion’s facebook page.  If you stay, I do think it is worth our time to have a discussion of how coping mechanisms, avoidance behaviors or underlying depression will play into our treatment and outcomes.  More research is developed in psychosocial  factors and their affect on prognosis in patients with whiplash associated disorders (WAD). From this literature, depression, number of pain related symptoms and catastrophizing symptoms seem to have a direct affect on prognosis and may be important for us to take into consideration.5

Psychosocial factors aren’t the whole picture though. As discussed in an earlier the post, 50-85% population report neck pain 1-5 years after initial onset. So again, who else plays a role in these persistent symptoms?

Two articles by Carroll et. al and Sterling et. al, give an excellent overview of prognostic related factors including the following:

1) Gender: Women in general experience more neck pain, research is split if gender directly affects outcomes as about half of the studies show that female gender has direct affect on poorer outcomes, while half show no difference between genders.1

2) Age: the younger the age, the better outcomes.1

3) Health: Previous pain and poor health showed association with increased intensity of neck pain.1,2

4) Biking: This seems counter-intuitive, as the article also states that general activity has no association with outcomes, but if the activity is regular biking this may weigh in negatively on a patient’s prognosis.1

5) Psychological Health: As discussed above, better psychological health and social support predicts better outcomes. Conversely, passive coping strategies associate with worse outcomes.1 Post traumatic stress syndrome also negatively affects outcomes after WAD.2

6) Initial NDI scores: higher NDI scores at initial indicate a poor prognostic value2


Physical therapists have the optimal position to have conversations with patients about prognosis, coping with pain and fear avoidance behaviors.  Physical therapy is unique as we have more time with each patient and are assisting them in pain management. It should be a topic we discuss with patients openly, unfortunately, I think it is commonly missed. With the time allotted, I discuss psychosocial barriers with each patient and how pain coping behaviors may affect their outcomes. As a therapist should start this conversation, this opens an opportunity to utilize our network of healthcare professionals to help us add or finish this discussion.

So now that we have a better idea of how to derive a prognosis, how do we communicate this effectively? An article by Scholten-Peeters et. al , assessed fear avoidance behaviors in developing chronic neck pain. They acknowledged an excellent point by stating “…patients showing avoidance behavior should be encouraged to confront physical activity, despite pain, to prevent chronic symptoms.7 ” This is counter-intuitive to how therapists often tell patients to “don’t do what hurts.” I am victim to saying this point a few times with patients who demonstrate fear avoidance. But nonetheless, this begs the question if we should ditch that motto all together, or the more thought provoking option of deciding what patient this concept is appropriate for. It is a point I think is important to consider when managing patients with pain. With all these prognostic variables in mind, a proper prognosis can be observed and relayed to the patient.

A small side note about available research is that I do think that we have better literature in the lumbar spine to guide therapists and physicians into proper management of not only the disorder, but pain as well. An excellent article to review is by O’sullivan et al; they did a fantastic job at looking at different models of chronic low back pain (CLBP) management. This article examines the possibility of using a sub-classification system to manage CLBP with an excellent overview of how primary physical then secondary cognitive compensatory patterns may play a role into the chronicity of the condition.4 Unfortunately, we don’t have a matched piece of literature in the cervical spine.  Therefore, a therapist has to assess patients coping mechanisms, external and internal factors, and associate this to the clinical examination to arrive at a prognosis with what we have available.

The purpose of this discussion and post is to point out that more variables play a role into prognosis than “how much it hurts, and tissue healing duration.” A skilled clinician takes into consideration of all variables and weighs them against science to the best of our ability, then properly communicates these with patients with using resources available in literature and surrounding physicians.


Original Post: July 23, 2013



1) Carroll, L. J., Hogg-johnson, S., Velde, G. Van Der, Haldeman, S., Holm, L. W., Carragee, E. J., Cassidy, J. D. (2010). Course and Prognostic Factors for Neck Pain in the General Population Neck Pain and Its Associated Disorders, 33(4), 75–82.

2) Sterling, M., Jull, G., & Kenardy, J. (2006). Physical and psychological factors maintain long-term predictive capacity post-whiplash injury. Pain, 122(1-2), 102–8. doi:10.1016/j.pain.2006.01.014

3) Steven Z. George, Rogelio A. Coronado, and Dennis L. Hart. Depressive Symptoms, Anatomical Region, and Clinical Outcomes for Patients Seeking Outpatient Physical Therapy for Musculoskeletal Pain. Physical Therapy. 2011. 91(3) 358-372.

4) O’Sullivan, P. (2005). Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual therapy, 10(4), 242–55. doi:10.1016/j.math.2005.07.001

5) Peolsson, M., & Gerdle, B. (2004). Coping in patients with chronic whiplash-associated disorders: a descriptive study. Journal of Rehabilitation Medicine, 36(1), 28–35. doi:10.1080/11026480310015530

6) Nederhand, M. J., IJzerman, M. J., Hermens, H. J., Turk, D. C., & Zilvold, G. (2004). Predictive value of fear avoidance in developing chronic neck pain disability: consequences for clinical decision making. Archives of Physical Medicine and Rehabilitation, 85(3), 496–501. doi:10.1016/j.apmr.2003.06.019

7) Scholten-Peeters, G. G. ., Verhagen, A. P., Bekkering, G. E., van der Windt, D. a. W. ., Barnsley, L., Oostendorp, R. a. ., & Hendriks, E. J. . (2003). Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies. Pain, 104(1-2), 303–322. doi:10.1016/S0304-3959(03)00050-2