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Neck pain in women: effect of tailored treatment and impact of work environment
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Nacksmärta hos kvinnor : effekten av individanpassad rehabilitering och betydelsen av arbetsmiljöfaktorer (Swedish)
Abstract [en]

Introduction: Musculoskeletal pain is a common problem in the working population. In Sweden, 40% of women and 30% of men report suffering from neck and shoulder pain weekly. The underlying cause for neck pain is often not known and the treatment is commonly guided by the individual’s symptoms. However, there is a lack of knowledge on how to receive the best effect based on the individual’s symptoms and functional limitations, and therefore this has been scarcely evaluated in research. Furthermore, the impact of work exposure and stress on long-term treatment for persons with neck pain is not clear.

Aims: To develop (paper 1) and to evaluate a decision model for tailored treatment in women with neck pain (paper 2). Moreover, to determine if risk factors at work and stress influence intermediate and long-term treatment results (paper 3). Further, to investigate if changes in self-reported pain and disabilities are associated with changes of physical test outcomes of the neck and shoulder region after treatment (paper 4).

Methods: In an RCT, 120 working women with non-specific neck pain were randomized to three different groups – tailored treatment (TT), non-tailored treatment (NTT) or treatment-as-usual (TAU) for an 11 weeks intervention with short-term, intermediate-term and long-term follow-ups. The TT group was guided by a decision model with cut-off levels to indicate impairments. The NTT group received two established treatment components randomly from those not indicated, and TAU group did not receive any treatment within the study. The RCT primary outcomes were self-reported neck pain and neck disability. A linear mixed model was used for analysing the effects. One week after the end of intervention work exposure and stress were assessed at a work-place visit and associations to treatment results were tested for, and mixed models were used to estimate longitudinal associations. Associations between self-reported neck problems and physical outcomes were estimated with univariate and multiple regressions analysis.

Results: No differences between TT and NTT were revealed for neck pain and disability. In comparison to TAU, the TT and NTT groups both showed improvements at short-term follow-up, but not at intermediate and long-term follow-up. High stress level and low self-estimated control at work were associated with more pain and disability at the intermediate and long-term follow-ups. After intervention and at the intermediate-term follow-up, reduced neck pain, disability and frequency of symptoms were associated with increased peak speed of head rotation and cervical range of motion.

Conclusion: Tailored treatment according to the decision model was not superior to the non-tailored treatment in women with non-specific neck pain. One explanation for this can be the weak relationships found between neck pain and disability and physical test outcomes. Further, perceived stress and psychosocial work exposure were associated with self-reported neck problems and should be taken into account to optimize the effects in neck pain rehabilitation.

Abstract [sv]

Bakgrund: Nack- och skulder-smärta är ett vanligt tillstånd som förekommer över hela världen. I Sverige skattar 30-40% besvär från nacke och skuldror mätt under en veckas tid. Generellt rapporterar kvinnor mer nack- och skulder-besvär än män. I avhandlingen är det ospecifik nacksmärta som har studerats, det inkluderar inte t.ex. Whiplash-skador, diskbråck eller andra mer specifika diagnoser. Den bakomliggande orsaken till ospecifik nacksmärta är, precis som beteckningen antyder, ofta inte känd och individens symptom och funktion är istället vägledande i undersökning och behandling samt utvärdering av behandling. Studier har visat att i jämförelse med friska har individer med ospecifika nackbesvär ofta sämre muskulär nackstyrka, minskad rörlighet i nacken och är något långsammare vid test av huvudrörelser. Behandlingen riktar sig ofta mot något av dessa fynd med bl.a. styrketräning av nackmuskler och/eller manuella tekniker för rörelseökning. Studier har dock visat att behandlingen endast ger måttliga resultat och att de positiva resultaten bara är kortvariga. I kliniken försöker man individanpassa behandlingen utifrån patientens behov men det finns väldigt lite forskning om detta utan studier utvärderar likadan behandling för hela grupper. Det saknas fortfarande kunskaper om hur man på bästa sätt individanpassar behandling så att den blir skräddarsydd utifrån individens symptom och funktion samt utvärderar detta.

Syftet med avhandlingen var att undersöka om en intervention med skräddarsydd behandling (som också innehöll specifik aktiv träning) utifrån en beslutsmodell med fysiska tester och frågor om symtom är effektivt för att uppnå positiva effekter i självskattad smärta och funktion (artikel 1 och 2).  Den skräddarsydda behandlingen jämfördes mot en grupp som fick samma upplägg men inte skräddarsydd behandling. Vidare undersöktes om båda dessa behandlingsgrupper var effektivare än en grupp som inte fick någon behandling i studien. Dessutom undersöktes om påverkan från arbetsmiljön i form av fysisk och psykosocial belastning samt upplevd stress påverkade behandlingsresultaten efter interventionen (artikel 3). Slutligen undersöktes om de fysiska testerna och den självskattade smärtan, funktionen och symptomen hade koppling till varandra dels före interventionen och dels i termer av förändringar efter interventionen (artikel 4).

Metod: I en randomiserad kontrollerad interventionsstudie (RCT) inkluderades 120 kvinnor i åldrarna 20-65, alla i arbete, och som hade ospecifika nackbesvär.  De lottades till tre grupper, (1) skräddarsydd behandling (Tailore treatment, TT), (2) icke-skräddarsydd behandling (Non-tailored treatment, NTT) och (3) en kontrollgrupp (Treatment-as-usual, TAU) som inte fick någon behandling i studien men var fria att söka vård på egen hand. Kvinnorna i TT-gruppen fick behandlings-komponenter utifrån testresultaten i beslutsmodellen. Det kunde läggas till någon behandlingskomponent om det visade sig behövas utifrån individens behov i vardagen. Detta undersöktes genom en strukturerad intervju-teknik som kallas Problem Elicitation Technique (PET). Kvinnorna i NTT-gruppen fick två lottade behandlings-komponenter som inte matchade deras behov utifrån testerna i beslutsmodellen. För båda behandlings-grupperna var interventionen 11 veckor med inbokade behandlingstillfällen 2-3 gånger per vecka, samtliga tillfällen vägledda av fysioterapeut. Data för alla tre grupper samlades in innan interventionen samt 3, 9 och 15 månader efter start av interventionen. Gruppskillnaderna analyserades med en ”linear mixed model”. En vecka efter intervention gjordes ett arbetsplatsbesök hos individerna i alla tre grupper. En erfaren ergonom observerade individernas fysiska arbetsbelastning med ett ergonomiskt bedömningsinstrument, Quick Exposure Check (QEC), och individerna skattade också den psykosociala arbetsmiljön i ett frågeformulär, QPS Nordic, samt upplevd stress. För att undersöka om den fysiska och psykosociala arbetsbelastningen samt stress påverkade resultaten från interventionen analyserades data med linjär regression och mixed model. För att undersöka om de fysiska testerna och den självskattade smärtan, funktionen och symptomen hade något samband användes linjär regressionsanalys.

Resultat: Att skräddarsy behandlingen utifrån den testade beslutsmodellen var inte effektivare än att inte skräddarsy. I jämförelse med kontrollgruppen självskattade båda behandlingsgrupperna mindre smärta, bättre funktion och mindre symptom efter interventionen. I de länge uppföljningarna (9 och 15 månader) var dock skillnaderna mellan grupperna inte längre signifikanta förutom att båda behandlingsgrupperna, till skillnad från kontrollgruppen, upplevde sig bättre än innan behandling. Det visade sig att upplevd hög stressnivå och låg kontroll på arbetet hade samband med mer självskattad nacksmärta, sämre funktion och lägre arbetsproduktivitet. De fysiska testerna och självskattade nackbesvär hade bara svaga samband. På baslinjenivå, innan interventionen, fanns det samband mellan hög nackstyrka och låg självskattad funktion och låg frekvens på symptomen, samt mellan att vara långsam i testet av snabba huvudrörelser och hög smärta. Efter interventionen hade individernas förändring i självskattad smärta fortfarande bara samband med snabba huvudrörelser. Förbättring i självskattad funktion och symptom hade samband till ökad hastighet i snabba huvudrörelser och ökat rörelseutslag nackrotation.

Sammanfattning: För kvinnor i arbete med ospecifika nackbesvär var det inte mer effektivt att skräddarsy behandling/träning utifrån en beslutsmodell jämfört med att slumpmässigt välja ut behandlingskomponenter från samma behandlingsarsenal. En förklaring kan vara att det fanns endast låga samband mellan självskattad smärta och funktion och de fysiska testerna. Upplevd stress och kontroll i arbetet visade sig ha samband med självskattad smärta, funktion och arbetsproduktivitet och bör tas i beaktande i framtida interventioner för individer med nacksmärta.

 

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2017. , 49 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1916
Keyword [en]
neck pain, neck disability, treatment, work exposure, stress
National Category
Physiotherapy
Research subject
physiotherapy
Identifiers
URN: urn:nbn:se:umu:diva-139394ISBN: 978-91-7601-766-1 (print)OAI: oai:DiVA.org:umu-139394DiVA: diva2:1140550
Public defence
2017-10-06, Vårdvetarhuset, Aulan, Umeå, 09:00
Opponent
Supervisors
Funder
AFA Insurance, 090288Forte, Swedish Research Council for Health, Working Life and Welfare, 2009-1403
Available from: 2017-09-15 Created: 2017-09-12 Last updated: 2017-09-26Bibliographically approved
List of papers
1. Effects of tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests: a study protocol of a randomized controlled trial
Open this publication in new window or tab >>Effects of tailored neck-shoulder pain treatment based on a decision model guided by clinical assessments and standardized functional tests: a study protocol of a randomized controlled trial
2012 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 13, 75Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: A major problem with rehabilitation interventions for neck pain is that the condition may have multiple causes, thus a single treatment approach is seldom efficient. The present study protocol outlines a single blinded randomised controlled trial evaluating the effect of tailored treatment for neck-shoulder pain. The treatment is based on a decision model guided by standardized clinical assessment and functional tests with cut-off values. Our main hypothesis is that the tailored treatment has better short, intermediate and long-term effects than either non-tailored treatment or treatment-as-usual (TAU) on pain and function. We sub-sequentially hypothesize that tailored and non-tailored treatment both have better effect than TAU.

METHODS: 120 working women with minimum six weeks of nonspecific neck-shoulder pain aged 20-65, are allocated by minimisation with the factors age, duration of pain, pain intensity and disability in to the groups tailored treatment (T), non-tailored treatment (NT) or treatment-as-usual (TAU). Treatment is given to the groups T and NT for 11 weeks (27 sessions evenly distributed). An extensive presentation of the tests and treatment decision model is provided. The main treatment components are manual therapy, cranio-cervical flexion exercise and strength training, EMG-biofeedback training, treatment for cervicogenic headache, neck motor control training. A decision algorithm based on the baseline assessment determines the treatment components given to the each participant of T- and NT-groups. Primary outcome measures are physical functioning (Neck Disability Index) and average pain intensity last week (Numeric Rating Scale). Secondary outcomes are general improvement (Patient Global Impression of Change scale), symptoms (Profile Fitness Mapping neck questionnaire), capacity to work in the last 6 weeks (quality and quantity) and pressure pain threshold of m. trapezius. Primary and secondary outcomes will be reported for each group with effect size and its precision.

DISCUSSION: We have chosen not to include women with psychological ill-health and focus on biomedical aspects of neck pain. Future studies should aim at including psychosocial aspects in a widened treatment decision model. No important adverse events or side-effects are expected.

Trial registration: Current Controlled Trials registration ISRCTN49348025.

Place, publisher, year, edition, pages
BioMed Central, 2012
Keyword
Neck, trapezius, myalgia, neck-shoulder pain, RCT, individualized treatment, rehabilitation, physiotherapy, tailored
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-56552 (URN)10.1186/1471-2474-13-75 (DOI)000312193600001 ()22607546 (PubMedID)
Available from: 2012-06-20 Created: 2012-06-20 Last updated: 2017-09-13Bibliographically approved
2. Is tailored treatment superior to non-tailored treatment for pain and disability in women with non-specific neck pain?: A randomized controlled trial
Open this publication in new window or tab >>Is tailored treatment superior to non-tailored treatment for pain and disability in women with non-specific neck pain?: A randomized controlled trial
Show others...
2016 (English)In: BMC Musculoskeletal Disorders, ISSN 1471-2474, E-ISSN 1471-2474, Vol. 17, 408Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The evidence for the effect of treatments of neck pain is modest. In the absence of causal treatments, a possibility is to tailor the treatment to the individuals' functional limitations and symptoms. The aim was to evaluate treatment effects of a tailored treatment versus a non-tailored treatment. Our hypothesis was that tailored treatment (TT) would have better effect on pain intensity and disability than either non-tailored treatment (NTT) (same treatment components but applied quasi-randomly) or treatment-as-usual (TAU) (no treatment from the study, no restrictions). We further hypothesized that TT and NTT would both have better effect than TAU.

METHOD: One hundred twenty working women with subacute and chronic non-specific neck pain were allocated to 11 weeks of either TT, NTT or TAU in a randomized controlled trial with follow-ups at 3, 9 and 15 months. The TT was designed from a decision model based on assessment of function and symptoms with defined cut-off levels for the following categories: reduced cervical mobility, impaired neck-shoulder strength and motor control, impaired eye-head-neck control, trapezius myalgia and cervicogenic headache. Primary outcomes were pain and disability. Secondary outcomes were symptoms, general improvement, work productivity, and pressure pain threshold of m. trapezius.

RESULTS: Linear mixed models analysis showed no differences between TT and NTT besides work productivity favoring TT at 9- and 15-months follow-ups. TT and NTT improved significantly more than TAU on pain, disability and symptoms at 3-month follow-up. General improvement also favored TT and NTT over TAU at all follow-ups.

CONCLUSION: Tailored treatment according to our proposed decision model was not more effective than non-tailored treatment in women with subacute and chronic neck pain. Both tailored and non-tailored treatments had better short-term effects than treatment-as-usual, supporting active and specific exercise therapy, although therapist-patient interaction was not controlled for. Better understanding of the importance of functional impairments for pain and disability, in combination with a more precise tailoring of specific treatment components, is needed to progress.

TRIAL REGISTRATION: Current Controlled Trials ISRCTN 49348025. Registered 2 August 2011.

Keyword
Neck-shoulder pain, Trapezius, Individualized treatment, Rehabilitation, Physiotherapy, Cut-off
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-127281 (URN)10.1186/s12891-016-1263-9 (DOI)000395028500001 ()27716128 (PubMedID)
Available from: 2016-11-04 Created: 2016-11-04 Last updated: 2017-09-12Bibliographically approved
3. Impact of workplace exposure and stress on neck pain and disabilities in women: a longitudinal follow-up after a rehabilitation intervention
Open this publication in new window or tab >>Impact of workplace exposure and stress on neck pain and disabilities in women: a longitudinal follow-up after a rehabilitation intervention
Show others...
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Abstract

Introduction: To evaluate if pain, disability and work productivity are influenced by physical and psychosocial work exposures as well as by stress, up to one year after an RCT treatment intervention, and determine whether any such association differed between treatment and control groups.

Methods: Ninety-seven working women suffering non-specific neck pain (n=67 treatment group, n=30 control group) were followed from end of treatment intervention and 9- and 15-months follow-ups respectively. Physical and psychosocial exposure as well as perceived stress was assessed after the treatment intervention. Pain, neck disability and work productivity were assessed at baseline, after intervention 3 months later and at 9- and 15-month follow-ups. Longitudinal assessment was conducted using the exposure level at 3 months as predictor of pain, disability and work productivity at 3, 9 and 15 months, respectively. Mixed models were used to estimate longitudinal associations, accounting for within individual correlation of repeated outcome measures by incorporation of a random intercept. Age and duration of neck pain were adjusted for in all models. To evaluate group differences, interactions between exposures and treatment groups were estimated.

Results: High perceived stress was associated with more neck pain, more neck disability and decreased work productivity in both cross-sectional and longitudinal analyses. High ‘control of decision’ was associated with less neck pain, less neck disability and higher work productivity in cross-sectional analyses but only to less disability and higher productivity in longitudinal analyses. Shoulder/arm load was the only physical exposure variable that was statistically significant associated with work productivity in the univariate analyses. Only small differences were observed between treatment and control groups.

Conclusion: High perceived stress and low ‘control of decision’ were associated with more neck pain, increased neck disability and decreased work productivity. Treatment interventions for individuals with neck pain should take into account psychosocial workplace exposures and stress to improve intermediate and long-term results.

Keyword
non-specific neck pain, physiotherapy, shoulder pain, work productivity
National Category
Physiotherapy
Identifiers
urn:nbn:se:umu:diva-139392 (URN)
Funder
AFA Insurance, 090288Forte, Swedish Research Council for Health, Working Life and Welfare, 2009-1403
Available from: 2017-09-11 Created: 2017-09-11 Last updated: 2017-09-13
4. Associations between self-rated and physical test outcomes before and after intervention in women with non-specific neck pain: Cross-sectional and longitudinal analyses
Open this publication in new window or tab >>Associations between self-rated and physical test outcomes before and after intervention in women with non-specific neck pain: Cross-sectional and longitudinal analyses
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Abstract

Non-specific neck pain is common, especially in women. There is often a multifaceted symptom picture while the etiology remains unclear. Consequently, a wide arsenal of treatments exists. While the underlying mechanisms of pain relief are complex, the relationship between individual improvement on physical function and the neck patient’s self-rated status is also obscure. The present aim was to determine the associations between physical test outcomes involving the neck and shoulder region, and self-reported neck problems before and after (Change-scores) a treatment intervention in women with non-specific neck pain.

Methods: Data were obtained for 120 women (aged 47±11 years) with non-specific neck pain who had participated in a previous randomized controlled trial involving physiotherapy treatment. Data were used from all participants at baseline prior to treatment for cross-sectional analysis, and for longitudinal analysis for 69 women at baseline, at the end of treatment after 3 months, and at 9-month follow-up (Change-scores). Associations between self-reported neck problems (pain, disability, symptoms) and physical test outcomes (neck-strength, flexibility, motor control) were estimated with cross-sectional (baseline) and longitudinal (Change-scores) linear regression analyses.

Results: Neck pain was only significantly associated to the physical outcome measure Peak-Speed of cervical rotation, i.e., increased pain related to lower speed. This was true at baseline and for Change-scores at 9 months. Increased neck disability and frequency of symptoms were associated to lower neck strength and Peak-Speed at baseline, and to reduced Peak-Speed and cervical Axial-Range of Motion (A-ROM) at 3 and 9 months, respectively. Peak-Speed and A-ROM were thus the physical test outcomes with associations to changes in neck problems. At the 9-month follow-up, 26% of the variance of frequency of symptom changes was explained by changes in A-ROM and Peak-Speed, which were also inter-correlated (r=0.55).

Conclusion: If changes in physical functioning, tested as cervical mobility and strength, have only a modest relation to the course of self-rated condition in neck disorders, then the specificity and usefulness of various assessments for decision-making, treatment and evaluation might be questioned. This also calls for reconsideration regarding acting mechanisms behind the apparent effect of, e.g., strength training on neck pain disorders.

Keyword
treatment, neck disability, neck symptoms, strength, range of motion
National Category
Physiotherapy
Research subject
physiotherapy
Identifiers
urn:nbn:se:umu:diva-139393 (URN)
Funder
AFA Insurance, 090288Forte, Swedish Research Council for Health, Working Life and Welfare, 2009-1403
Available from: 2017-09-11 Created: 2017-09-11 Last updated: 2017-09-13

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