SENSORY, MOTOR, AND PSYCHOSOCIAL CHARACTERISTICS OF INDIVIDUALS WITH CHRONIC NECK PAIN: A CASE–CONTROL STUDY

Sensory, Motor, and Psychosocial Characteristics
of Individuals with Chronic Neck Pain:
A Case–Control Study

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:
  Frankp@chiro.org

FROM:   Physical Therapy 2021 (Mar 26); pzab104 ~ FULL TEXT

  OPEN ACCESS   

É P Rampazo, V R da Silva, A L M de Andrade, C G N Back, P M Madeleine, L Arendt–Nielsen, Richard Eloin Liebano

Physiotherapeutic Resources Laboratory,
Department of Physical Therapy,
Federal University of São Carlos (UFSCar),
São Carlos/SP, Brazil.


Objective:   Given the complex and unclear etiology of neck pain, it is important to understand the differences in central sensitization as well as psychosocial factors in individuals with chronic neck pain and healthy controls. The purpose of this study was to benchmark differences in central sensitization, psychosocial factors, and range of motion between people with nonspecific chronic neck pain and healthy controls and to analyze the correlation between pain intensity, neck disability, and psychosocial factors in people with chronic neck pain.

Methods:   Thirty individuals with chronic neck pain and 30 healthy controls were included in this case–control study. Outcome measures were as follows: central sensitization (pressure pain threshold, temporal summation, and conditioned pain modulation), psychosocial factors (depressive symptoms, pain catastrophizing, and quality of life), and active cervical range of motion.

Results:   People with neck pain had lower local pressure pain threshold, a decrease in conditioned pain modulation, more depressive symptoms, greater pain catastrophizing, lower quality of life, and reduced range of motion for neck rotation when compared with healthy controls. In people with neck pain, moderate correlations were observed between pain intensity and quality of life (p = –0.479), disability and pain catastrophizing (p = 0.379), and disability and quality of life (p = –0.456).

Conclusions:   People with neck pain have local hyperalgesia, impaired conditioning pain modulation, depressive symptoms, pain catastrophizing, low quality of life, and reduced active range of motion during neck rotation, which should be taken into account during assessment and treatment.

Impact:   This study shows that important outcomes, such as central sensitization and psychosocial factors, should be considered during assessment and treatment of individuals with nonspecific chronic neck pain. In addition, pain intensity and neck disability are correlated with psychosocial factors.

Keywords:   Chronic Pain; Neck Disability; Neck Pain; Pain Modulation; Pain Threshold; Pressure Pain Threshold.



From the FULL TEXT Article:

Introduction

The incidence and prevalence of neck pain has risen in recent years, the latter increasing with age. [1, 2] This musculoskeletal disorder may be associated with whiplash injuries, myofascial pain syndrome or degenerative abnormalities such as osteoarthritis and cervical spondylolysis. [3–5] Chronic neck pain is generally persistent and can cause functional disability, [6] limiting activity [7] and lowering quality of life. [6, 8]

Central sensitization (CS) is defined as “increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input.” [9] Many individuals with chronic pain, such as fibromyalgia, [10, 11] rheumatoid arthritis, [12] osteoarthritis, [13] low back pain, [14] and whiplash [11, 15] have presented an involvement of central sensitization and impaired endogenous pain modulation. Nevertheless, in individuals with nonspecific chronic neck pain, the presence of CS is not clear, the available literature provides an inconclusive message and more studies are required. [16] Then, to investigate the presence of central sensitization in nonspecific chronic neck pain compared to healthy controls may lead to more effective therapeutic approaches.

Previous studies have investigated deep tissue hyperalgesia in patients with chronic neck pain compared to healthy controls and evaluated the pressure pain threshold (PPT) in only one or two points on the neck. [17–20] Further, these studies have considered populations consisting of women, [21] adolescents, [22] elderly women, [23] female office workers [24] or patients with chronic whiplash. [25] We found only one study that has investigated the hyperalgesia considering more points on the neck and shoulder girdle area, however, only computers users were recruited. [26] Consequently, there is a lack of studies investigating local hyperalgesia in a larger area of the neck and upper back region in patients with nonspecific chronic neck pain compared to healthy controls.

We have found few studies that have investigated the central sensitization or psychosocial factors and in some cases the sample was composed only by women [21] or adolescents [22] or computers users26 with neck pain or it was considered only in patients with chronic whiplash. [25] Psychosocial factors play an important role in the chronification of neck pain. [27] Then, the correlation between psychosocial factors and pain intensity or neck disability is also important to promote a better therapeutic approach for patients with neck pain. Some studies have observed that greater pain catastrophizing was associated with greater neck disability [17, 22, 28] or greater pain intensity. [28] However, until this moment we have found no studies that have investigated the correlation between neck disability, pain intensity and depression symptoms or quality of life.

Individuals with neck pain seem to exhibit reduced active ROM. [29–31] A recent study showed that reduced neck mobility was associated with pain intensity, neck disability, fear of movement and central sensitization, however this study was performed only in females. [32] Therefore, more wide studies are needed to confirm this information. The active neck ROM is important variable that should be investigated in individuals with nonspecific chronic neck pain compared healthy controls in order to promote a more effective treatment.

As such, it is important to highlight that investigating central sensitization and psychosocial factors could contribute to more effective assessments and treatment choices for this population in the future. As such, the first aim of this study was to evaluate the possible differences in central sensitization (PPT, temporal summation (TS) of pain, conditioned pain modulation (CPM)), psychosocial factors (ie, depressive symptoms, pain catastrophizing and quality of life) and active neck range of motion (ROM) between individuals with nonspecific chronic neck pain and healthy controls. The second aim was to analyze the correlation between pain intensity, neck disability and psychosocial factors in individuals with nonspecific chronic neck pain. We hypothesized that individuals with nonspecific chronic neck pain would present central sensitization, presence of psychosocial factors, and reduced active neck ROM. In addition, we also hypothesized that psychosocial factors would be correlated with their pain intensity and/or neck disability.



Discussion

The results of this study revealed lower PPT in the neck and shoulder girdle areas, a decrease in CPM, the presence of depressive symptoms, greater pain catastrophizing, lower quality of life, and reduced active ROM for rotation in individuals with chronic neck pain compared to healthy controls. In addition, as hypothesized, greater pain intensity and neck disability were moderately correlated with psychosocial factors.

Similarly to our findings in relation to PPT of the neck, other studies reported a decline in PPT in individuals with chronic NP when compared to controls. [17, 22, 23, 56–58] However, these studies investigated only one or two points on the neck and in our study PPT was measured in twelve points on neck and shoulder girdle areas.

With respect to PPT in TA muscle, our findings are in line with those of other studies that also reported no distant hyperalgesia in individuals with neck pain compared to healthy controls/ [17, 19, 21, 23, 24, 26, 59] By contrast, other studies have observed lower PPT values of the anterior tibialis muscle in individuals with neck pain when compared to healthy individuals. [22, 24, 57, 60] Given the controversial results regarding secondary hyperalgesia in individuals with neck pain, further research is needed to assess the presence of this variable.

In this study, topographical mapping confirmed that individuals with chronic neck pain showed greater pressure pain sensitivity. Additionally, the neck region was more sensitive than the shoulder girdle area in both groups, in agreement with Binderup at al. [43] In contrast with our findings, Ge et al, 2014 reported no significant differences in topographical pressure pain sensitivity maps between computer users with and without chronic pain in the neck. [26] However, it should be noted that the authors analyzed individuals who reported pain on the day of the experiment or in the last 24 hours, whereas individuals in the present study had experienced pain for more than 3 months.

Our findings are in line with other studies that also found no increase in TS in individuals with whiplash–associated disorders25 and musculoskeletal shoulder pain [61] compared to healthy controls. In this study, the effectiveness of CPM decreased in individuals with nonspecific chronic neck pain in relation to healthy controls. These findings indicate changes in the endogenous pain inhibition mechanism also observed in individuals with chronic low back pain. [62] However, in those with chronic neck pain, other studies found no decrease in the effectiveness of CPM in individuals with nonspecific chronic neck pain when compared to healthy controls. [21, 63]

The PPTs, TS of pain and CPM tests were used to investigate the presence of central sensitization in individuals with nonspecific chronic neck pain. As previously mentioned, the results obtained for these outcomes are controversial, however, central sensitization may be present in some individuals with neck pain [26] even though it is not characteristic in this population. [16]

As in our study, other studies displayed the presence of depressive symptoms, [64, 65] pain catastrophizing [17, 22, 64] and lower quality of life [18, 21] in individuals with chronic neck pain compared to controls. Assessing and treating these psychological factors are important in order to optimize the effectiveness of pain therapy for these individuals.

Individuals with neck pain exhibited reduced ROM for neck rotation when compared to healthy controls. Recent reviews concluded that individuals with neck pain seem to exhibit reduced active ROM for flexion, extension and rotation in relation to healthy individuals. [29, 30] It is important to highlight that these differences in findings may be related to the different measuring instruments used. In our investigation, active ROM of the cervical spine was measured with a fleximeter, whereas previous studies used other devices. [29, 30] In addition, some limitations are mentioned by aforementioned reviews [29, 30]: studies with no difference between patients and healthy controls are more likely to keep unpublished than those reporting positive results, inadequate blinding of evaluators may have enlarged the difference in measurements and there is a poor reporting in relation to test methods and evaluator background and training. Then, additional research with better quality and more detailed descriptions of the individuals and methods to obtain more consistent findings are needed.

      Correlation between pain intensity, neck disability and psychosocial factors in individuals with neck pain.

The present study demonstrated that higher pain intensity is correlated with greater neck disability and low quality of life. In contrast with our results, MuñozGarcía et al, 2017 found no correlation between pain intensity and neck disability. [17] Our study also showed that neck disability is correlated with poor quality of life. In addition, the neck disability also is moderately correlated with pain catastrophizing, as reported in other studies with patients with neck pain. [17, 22, 28] Therefore, pain intensity and disability can affect quality of life, while neck disability may influence pain catastrophizing or vice versa, since a causal relation cannot be established. Based on these findings, these aspects should be evaluated, and the therapeutic approach requires more than analgesics and physical treatment modalities (electrophysical agents, manual therapy or exercises) to improve ROM. The presence of central sensitization and psychosocial factors makes it important to adopt a multidisciplinary approach as well as neurophysiological pain education to effectively rehabilitate these individuals.

      Limitations

The PPT at distant sites was only assessed in the middle third of the TA muscle and additional points should be evaluated to analyze the distant hyperalgesia mechanism in this group. Anxiety was not evaluated, and we think it is important to investigate it, and to verify if it is correlated with pain intensity or neck disability. It will provide more information that can be used for a better approach in the assessment and treatment of individuals with nonspecific chronic neck pain.



Conclusions

Local hyperalgesia, impaired conditioning pain modulation, depressive symptoms, pain catastrophizing, poor quality of life and reduced active ROM for neck rotation were observed in individuals with nonspecific chronic neck pain. Additionally, there is a significant correlation between intensity pain, neck disability and psychosocial factors. As such, pain management, neck mobility and psychosocial components should be assessed and taken into account in the therapeutic approach adopted for this population.


Acknowledgements

The authors gratefully acknowledge the individuals of this study


Funding

This study was supported by a grant (É.P.R.) from Fundação de Amparo à Pesquisa do Estado de São Paulo (2017/26447–2).


Disclosure

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.



References:

  1. Blanpied PR, Gross AR, Elliott JM, et al. Neck Pain: Revision 2017. J Orthop Sport Phys Ther 2017; 47: A1–A83.

  2. Safiri S, Kolahi AA, Hoy D, et al.
    Global, Regional, and National Burden of Neck Pain in the
    General Population, 1990–2017: Systematic Analysis of
    the Global Burden of Disease Study 2017

    British Medical Journal 2020 (Mar 26); 368: m791

  3. Borghouts J a, Koes BW, Bouter LM. The clinical course and prognostic factors of non–specific neck pain: a systematic review. Pain 1998; 77: 1–13.

  4. Kroeling P, Gross A, Graham N, et al. Electrotherapy for neck pain. Cochrane database Syst Rev 2013; CD004251.

  5. Kjaer P, Kongsted A, Hartvigsen J, et al.
    National Clinical Guidelines for Non–surgical Treatment
    of Patients with Recent Onset Neck Pain or Cervical Radiculopathy

    European Spine Journal 2017 (Sep); 26 (9): 2242–2257 ~

  6. Wong JJ , Shearer HM , Mior S , et al .
    Are Manual Therapies, Passive Physical Modalities, or Acupuncture
    Effective for the Management of Patients with Whiplash-associated
    Disorders or Neck Pain and Associated Disorders? An Update
    of the Bone and Joint Decade Task Force on Neck Pain and
    Its Associated Disorders by the OPTIMa Collaboration

    Spine J. 2016 (Dec); 16 (12): 1598-1630

  7. Koyuncu E, Ökmen BM, Özkuk K, et al. The effectiveness of balneotherapy in chronic neck pain. Clin Rheumatol 2016; 35: 2549–55.

  8. Alayat MSM, Mohamed AA, Helal OF, et al. Efficacy of high–intensity laser therapy in the treatment of chronic neck pain: a randomized double–blind placebo–control trial. Lasers Med Sci 2016; 31: 687–694.

  9. Nijs J, Leysen L, Vanlauwe J, et al. Treatment of central sensitization in patients with chronic pain: time for change? Expert Opin Pharmacother 2019; 20: 1961–1970.

  10. Sluka KA, Clauw DJ. Neurobiology of fibromyalgia and chronic widespread pain. Neuroscience 2016; 338: 114–129.

  11. Coppieters I, Ickmans K, Cagnie B, et al. Cognitive performance is related to central sensitization and health–related quality of life in patients with chronic whiplash–associated disorders and fibromyalgia. Pain Physician 2015; 18: E389–E402.

  12. Zhang A, Lee YC. Mechanisms for Joint Pain in Rheumatoid Arthritis (RA): from Cytokines to Central Sensitization. Curr Osteoporos Rep 2018; 16: 603–610.

  13. Lluch E, Torres R, Nijs J, et al. Evidence for central sensitization in patients with osteoarthritis pain: A systematic literature review. Eur J Pain (United Kingdom) 2014; 18: 1367–1375.

  14. Nijs J, Apeldoorn A, Hallegraeff H, et al. Comprehensive Review Low Back Pain: Guidelines for the Clinical Classification of Predominant Neuropathic, Nociceptive, or Central Sensitization Pain. Pain Physician 2015; 18: E333–E346.

  15. Van Oosterwijck J, Nijs J, Meeus M, et al. Evidence for central sensitization in chronic whiplash: A systematic literature review. Eur J Pain (United Kingdom) 2013; 17: 299–312.

  16. Malfliet A, Kregel J, Cagnie B, et al. Lack of evidence for central sensitization in idiopathic, nontraumatic neck pain: A systematic review. Pain Physician 2015; 18: 223–235.

  17. Muñoz–García D, López–de–Uralde–Villanueva I, Beltrán–Alacreu H, et al. Patients with Concomitant Chronic Neck Pain and Myofascial Pain in Masticatory Muscles Have More Widespread Pain and Distal Hyperalgesia than Patients with Only Chronic Neck Pain. Pain Med 2017; 18: 526–537.

  18. Yalcinkaya H, Ucok K, Ulasli AM, et al. Do male and female patients with chronic neck pain really have different health–related physical fitness, depression, anxiety and quality of life parameters? Int J Rheum Dis 2017; 20: 1079–1087.

  19. Scott D, Jull G, Sterling M. Widespread sensory hypersensitivity is a feature of chronic whiplashassociated disorder but not chronic idiopathic neck pain. Clin J Pain 2005; 21: 175–181.

  20. Chien A, Sterling M. Sensory hypoaesthesia is a feature of chronic whiplash but not chronic idiopathic neck pain. Man Ther 2010; 15: 48–53.

  21. Coppieters I, De Pauw R, Kregel J, et al. Differences Between Women With Traumatic and Idiopathic Chronic Neck Pain and Women Without Neck Pain: Interrelationships Among Disability, Cognitive Deficits, and Central Sensitization. Phys Ther 2017; 97: 338–353.

  22. Sá S, Silva AG. Repositioning error, pressure pain threshold, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain. Musculoskelet Sci Pract 2017; 30: 18–24.

  23. Uthaikhup S, Prasert R, Paungmali A, et al. Altered pain sensitivity in elderly women with chronic neck pain. PLoS One; 10. Epub ahead of print 3 June 2015. DOI: 10.1371/journal.pone.0128946.

  24. Johnston V, Jimmieson NL, Jull G, et al. Quantitative sensory measures distinguish office workers with varying levels of neck pain and disability. Pain 2008; 137: 257–65.

  25. Ickmans K, Malfliet A, de Kooning M, et al. Lack of gender and age differences in pain measurements following exercise in people with chronic whiplash–associated disorders. Pain Physician 2017; 20: E829–E840.

  26. Ge H–Y, Vangsgaard S, Omland Ø, et al. Mechanistic experimental pain assessment in computer users with and without chronic musculoskeletal pain. BMC Musculoskelet Disord 2014; 15: 412.

  27. Cohen SP, Hooten WM. Advances in the diagnosis and management of neck pain. Bmj 2017; j3221.

  28. Thompson DP, Urmston M, Oldham JA, et al. The association between cognitive factors, pain and disability in patients with idiopathic chronic neck pain. Disabil Rehabil 2010; 32: 1758–1767.

  29. Hesby BB, Hartvigsen J, Rasmussen H, et al. Electronic measures of movement impairment, repositioning, and posture in people with and without neck pain – A systematic review. Systematic Reviews; 8. Epub ahead of print 27 August 2019. DOI: 10.1186/s13643–019–1125–2.

  30. Stenneberg MS, Rood M, de Bie R, et al. To what degree does active cervical range of motion differ between patients with neck pain, patients with whiplash, and those without neck pain? A systematic review and meta–analysis. Arch Phys Med Rehabil 2017; 98: 1407–1434.

  31. Madeleine P, Prietzel H, Svarrer H, et al. Quantitative posturography in altered sensory conditions: A way to assess balance instability in patients with chronic whiplash injury. Arch Phys Med Rehabil 2004; 85: 432–438.

  32. De Pauw R, Coppieters I, Palmans T, et al. Motor impairment in patients with chronic neck pain: does the traumatic event play a significant role? A case–control study. Spine J 2018; 18: 1406– 1416.

  33. Vandenbroucke JP, von Elm E, Altman DG, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Epidemiology 2007; 18: 805–835.

  34. Cerezo–Téllez E, Torres–Lacomba M, Fuentes–Gallardo I, et al. Effectiveness of dry needling for chronic nonspecific neck pain: a randomized, single–blinded, clinical trial. Pain 2016; 157: 1905– 17.

  35. Ferreira–Valente MA, Pais–Ribeiro JL, Jensen MP. Validity of four pain intensity rating scales. Pain 2011; 152: 2399–2404.

  36. Cook C, Richardson JK, Braga L, et al. Cross–cultural adaptation and validation of the Brazilian Portuguese version of the Neck Disability Index and Neck Pain and Disability Scale. Spine (Phila Pa 1976) 2006; 31: 1621–1627.

  37. Cheung J, Kajaks T, Macdermid JC. The relationship between neck pain and physical activity. Open Orthop J 2013; 7: 521–9.

  38. Dailey DL, Rakel BA, Vance CGT, et al. Transcutaneous electrical nerve stimulation reduces pain, fatigue and hyperalgesia while restoring central inhibition in primary fibromyalgia. Pain 2013; 154: 2554–62.

  39. Celenay ST, Kaya DO, Akbayrak T. Cervical and scapulothoracic stabilization exercises with and without connective tissue massage for chronic mechanical neck pain: A prospective, randomised controlled trial. Man Ther 2016; 21: 144–150.

  40. Bablis P, Pollard H, Bonello R. Neuro Emotional Technique for the treatment of trigger point sensitivity in chronic neck pain sufferers: A controlled clinical trial. Chiropr Osteopat 2008; 16: 4.

  41. Alburquerque–Sendín F, Camargo PR, Vieira A, et al. Bilateral myofascial trigger points and pressure pain thresholds in the shoulder muscles in patients with unilateral shoulder impingement syndrome: a blinded, controlled study. Clin J Pain 2013; 29: 478–486.

  42. Alburquerque–Sendín F, Madeleine P, Fernández–De–Las–Peñas C, et al. Spotlight on topographical pressure pain sensitivity maps: A review. J Pain Res 2018; 11: 215–225.

  43. Binderup AT, Arendt–Nielsen L, Madeleine P. Pressure pain sensitivity maps of the neckshoulder and the low back regions in men and women. BMC Musculoskelet Disord 2010; 11: 234.

  44. Corrêa JB, Costa LOP, Oliveira NTB, et al. Effects of the carrier frequency of interferential current on pain modulation and central hypersensitivity in people with chronic nonspecific low back pain: A randomized placebo–controlled trial. Eur J Pain 2016; 20: 1653–1666.

  45. Shahidi B, Maluf KS. Adaptations in Evoked Pain Sensitivity and Conditioned Pain Modulation after Development of Chronic Neck Pain. Biomed Res Int 2017; 2017: 8985398.

  46. Valencia C, Kindler LL, Fillingim RB, et al. Stability of conditioned pain modulation in two musculoskeletal pain models: Investigating the influence of shoulder pain intensity and gender. BMC Musculoskelet Disord 2013; 14: 182–192.

  47. Yarnitsky D, Bouhassira D, Drewes AM, et al. Recommendations on practice of conditioned pain modulation (CPM) testing. Eur J Pain (United Kingdom) 2015; 19: 805–806.

  48. Yarnitsky D. Conditioned pain modulation (the diffuse noxious inhibitory control–like effect): Its relevance for acute and chronic pain states. Curr Opin Anaesthesiol 2010; 23: 611–615.

  49. Gomes–Oliveira MH, Gorenstein C, Lotufo Neto F, et al. Validation of the Brazilian Portuguese version of the Beck Depression Inventory–II in a community sample. Rev Bras Psiquiatr 2012; 34: 389–94.

  50. Sehn F, Chachamovich E, Vidor LP, et al. Cross–Cultural Adaptation and Validation of the Brazilian Portuguese Version of the Pain Catastrophizing Scale. Pain Med 2012; 13: 1425–1435.

  51. Damásio BF, Andrade TF, Koller SH. Psychometric properties of the Brazilian 12–item shortform health survey version 2 (SF–12v2). Paideia 2015; 25: 29–37.

  52. Silveira MF, Almeida JC, Freire RS, et al. Propriedades psicométricas do instrumento de avaliação da qualidade de vida: 12–item health survey (SF–12). Cien Saude Colet 2013; 18: 1923– 1932.

  53. Dibai–Filho AV, de Oliveira AK, Girasol CE, et al. Additional effect of static ultrasound and diadynamic currents on myofascial trigger points in a manual therapy program for patients with chronic neck pain. Am J Phys Med Rehabil 2017; 96: 243–252.

  54. Walton DM, Levesque L, Payne M, et al. Clinical Pressure Pain Threshold Testing in Neck Pain: Comparing Protocols, Responsiveness, and Association With Psychological Variables. Am Phys Ther 2014; 94: 827–838.

  55. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. New Jersey: Lawrence Erlbaum Associates, 1988.

  56. Szikszay TM, Luedtke K, Harry von P. Increased mechanosensivity of the greater occipital nerve in subjects with side–dominant head and neck pain–a diagnostic case–control study. J Man Manip Ther 2018; 26: 237–248.

  57. Beinert K, Englert V, Taube W. After–effects of neck muscle vibration on sensorimotor function and pain in neck pain patients and healthy controls–a case–control study. Disabil Rehabil 2019; 41: 1906–1913.

  58. Piña–Pozo F, Heredia–Rizo AM, Madeleine P, et al. Local and Widespread Pressure Pain Hyperalgesia Is Not Side Specific in Females with Unilateral Neck Pain that Can Be Reproduced during Passive Neck Rotation. J Clin Med 2019; 8: 1246.

  59. Chien A, Sterling M. Sensory hypoaesthesia is a feature of chronic whiplash but not chronic idiopathic neck pain. Man Ther 2010; 15: 48–53.

  60. Javanshir K, Ortega–Santiago R, Mohseni–Bandpei MA, et al. Exploration of somatosensory impairments in subjects with mechanical idiopathic neck pain: A preliminary study. J Manipulative Physiol Ther 2010; 33: 493–499.

  61. Haik MN, Evans K, Smith A, et al. People with musculoskeletal shoulder pain demonstrate no signs of altered pain processing. Musculoskelet Sci Pract 2019; 39: 32–38.

  62. Correa JB, Pena Costa LO, de Oliveira NT, et al. Central sensitization and changes in conditioned pain modulation in people with chronic nonspecific low back pain: a case–control study. Exp BRAIN Res 2015; 233: 2391–2399.

  63. Chua NHL, Timmerman H, Vissers KC, et al. Multi–modal Quantitative Sensory Testing in Patients with Unilateral Chronic Neck Pain: An Exploratory Study. J Musculoskelet Pain 2012; 20: 292–299.

  64. López–de–Uralde–Villanueva I, Sollano–Vallez E, Del Corral T. Reduction of cervical and respiratory muscle strength in patients with chronic nonspecific neck pain and having moderate to severe disability. Disabil Rehabil 2018; 40: 2495–2504.

  65. Liu F, Fang T, Zhou F, et al. Association of Depression/Anxiety Symptoms with Neck Pain: A Systematic Review and Meta–Analysis of Literature in China. Pain Res Manag 2018; 2018: 3259431.


Return to CHRONIC NECK PAIN

Since 8–20–2020