ORIGINAL ARTICLE
Risk factors of chronic neck pain: A prospective study among
middle-aged employees
S. Kääriä1, M. Laaksonen1, O. Rahkonen1, E. Lahelma1, P. Leino-Arjas2
1 Department of Public Health, Hjelt Institute, University of Helsinki, Helsinki, Finland
2 Finnish Institute of Occupational Health, Helsinki, Finland
Correspondence
Sanna Kääriä
Tel.: +358,400,555,024; fax: +358 5419 0061.
E-mail: sanna-mari.kaaria@helsinki.fi
Funding sources
Helsinki Health Study is supported by grant
from the Finnish Work Environment Fund
(#106065) and the Academy of Finland
(#1121748, #1129225, #1135630).
Conflicts of interest
None declared
Accepted for publication
30 October 2011
doi:10.1002/j.1532-2149.2011.00065.x
1. Introduction
Neck pain (NP) is one of the most common muscu-
loskeletal health problems in the general population
(Fejer et al., 2006) and among employees (Aas et al.,
2011). The mean lifetime prevalence of NP has been
estimated to be about 50% and the 1-month preva-
lence 25% (Fejer et al., 2006). Although acute epi-
sodes of NP may resolve completely, pain recurrence
and chronicity frequently occur. Poor recovery from
acute NP is more common than previously thought
(Hush et al., 2011). Chronic NP has been found in
Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters
Abstract
Objective: To study the associations of sociodemographic factors,
working conditions, lifestyle and previous pain in the spine with new onset
chronic neck pain (NP).
Methods: The participants were municipal employees free of chronic NP
at baseline, aged 40, 45, 50, 55 or 60 years (n = 5277, 80% women).
Self-reported data on occupational class, working conditions, body mass
index, smoking, exercise, mental well-being, sleep problems, NP and low
back pain (LBP) were obtained from baseline questionnaire surveys in
2000–2002. The question on chronic NP was repeated in a follow-up in
2007. Logistic regression analysis was used.
Results: The incidence of chronic NP was 15% in women and 9% in
men. In multivariable analysis among women, acute NP [odds ratio (OR)
3.8, 95% confidence interval (CI) 2.9–5.1], chronic LBP (1.6, 1.2–2.2),
reporting current workplace bullying (OR 1.6, 95% CI 1.1–2.4), earlier
bullying at the present workplace (1.6, 1.2–2.0), and earlier bullying in
another workplace (1.8, 1.3–2.4), frequent sleep problems (1.5, 1.2–2.0),
overweight (1.2, 1.0–1.5), and obesity (1.4, 1.1–1.8) predicted chronic NP
at follow-up. Men with acute NP (2.3, 1.4–3.8), chronic LBP (2.3, 1.2–4.3),
manual occupational class (1.8, 1.1–3.1) and high work-related emotional
exhaustion (1.9, 1.1–3.3) at baseline had an increased risk of new onset
chronic NP.
Conclusions: We found potentially modifiable predictors of chronic NP
among employees: workplace bullying, sleep problems, and high body
mass index in women, and work-related emotional exhaustion in men. In
both genders, previous acute NP and chronic LBP were predictive of
chronic NP.
60% to 80% of employees 1 year after the initial
episode (Carroll et al., 2008a). NP often leads to activ-
ity limitations, and indirect costs due to sickness
absence or long-term work disability are considerable
(Cote et al., 2008b).
Similar to low back pain, most cases of NP are non-
specific, i.e., no obvious somatic pathology causing the
pain can be identified (Borghouts et al., 1998). A
range of risk factors for NP related to physical work-
load, psychosocial factors, and health-related beha-
viours have been reported in the literature, mostly
based on cross-sectional or case-control studies. In
911
Risk factors of chronic neck pain
their reviews, Ariens et al. (2000, 2001) found some
evidence for an association between NP and sitting,
twisting or bending of the trunk, high job demands,
low job control, low co-worker support, high and low
skill discretion, and low job satisfaction. Associations
of NP with distress and anxiety have often been
reported (Linton, 2000). In a systematic review
including 14 prospective studies, 45 risk factors for NP
were identified, and evidence regarding pain onset
was assessed to be strong for female gender, older age
in men, high job demands, low support at work, being
an ex-smoker, and a history of low back disorders and
neck injuries (McLean et al., 2010). Evidence for other
risk factors was limited.
Among the Finnish adult population, the prevalence
of chronic neck syndrome was associated with a history
of injury to the back, neck, or shoulder, and with
mental and physical stress at work (Makela et al.,
1991). Determinants of incident chronic NP have rarely
been considered. However, it has been suggested that
the development of chronic NP may be particularly
dependent on psychosocial factors (Young Casey et al.,
2008).
Of psychosocial factors at work, the relationship of
job demands and job control with NP has been exam-
ined also in prospective studies (McCarthy et al., 2009),
while other psychosocial workplace factors have
received less attention. Workplace bullying or harass-
ment at work refers to repeated insulting behaviour
and practices that lead the victims to feel upset, threat-
ened and humiliated. Workplace bullying is associated
with mental and depressive symptoms, and other
health problems including sleep problems (Finne et al.,
2011; Lahelma et al., 2011; Lallukka et al., 2011),
which also may be connected to NP (Strine and
Hootman, 2007).
We conducted a prospective study among middle-
aged (municipal) employees examining sociodemo-
graphic factors, physical workload, and psychosocial
working conditions such as job demands and control,
workplace bullying and emotional exhaustion related
to work, general mental well-being, sleep problems,
and health-related behaviours as risk factors for new
onset chronic NP. In addition, the role of previous pain
in the spine (low back pain and acute NP) among
women and men was examined.
2. Materials and methods
This study was based on data derived from the Hels-
inki Health Study cohort (Lahelma et al., 2005),
including middle-aged employees of the City of Hels-
inki, which with its nearly 40,000 employees is the
912 Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters
S. Kääriä et al.
largest single employer in Finland. The main employ-
ment sectors include public administration, social and
health care, education and cultural services, public
transportation, and environmental and technical
maintenance, and they cover more than 200 different
occupations.
The baseline mail survey was conducted among all
employees who reached the age of 40, 45, 50, 55 or 60
years in 2000, 2001 and 2002. Of the 13,344 eligible
participants, 8960 (80% women) responded to the
survey (response rate 67%). The response rate was
somewhat lower among men, younger employees,
lower occupational classes and women with medically
confirmed sickness absence. According to non-
response analysis the associations of the background
characteristics and health status, measured by sickness
absence during the study year, were similar among
participants and non-participants (Laaksonen et al.,
2008).
A follow-up survey was conducted in 2007 among
the respondents to the baseline survey. Thus, the
follow-up period varied from 5 to 7 years. Altogether,
127 of the baseline respondents had died before the
follow-up and they were excluded from the sample.
The response rate to the follow-up survey was 83%
(n = 7332). In the present study, only participants
without chronic NP at the baseline were included
(n = 5277).
2.1 Outcome
NP was inquired with the following question at base-
line and at follow-up: ‘Have you ever had pain in the
neck, and if yes, how long was the longest episode?’
Responses to questions were categorized into no NP,
acute NP (duration ⱕ 3 months) and chronic NP (dura-
tion > 3 months). The definitions of acute and chronic
pain were based on the recommendation of the Inter-
national Association for the Study of Pain (IASP, 1986),
where acute pain refers to short-term pain, lasting a
maximum of 3 months, and chronic pain to pain that
has persisted for more than 3 months. Incident chronic
NP was defined as not having had chronic NP at the
baseline but reporting it at the follow-up. As previous
literature suggests that the incidence of NP may vary
between women and men, the analyses were stratified
by gender (McLean et al., 2010). Stratification by
gender is also recommended in studies of risk factors for
musculoskeletal disorders (Messing et al., 2009).
2.2 Potential risk factors
Data on potential risk factors were taken from the
baseline questionnaires. The variable low back pain was
S. Kääriä et al.
created by combining two questions. The first
inquired: ‘Have you ever had local low back pain, and
if yes, how long was the longest episode?’ A similar
question was asked about sciatica. Responses to these
two questions were categorized as follows: (1) no low
back pain (neither local nor sciatic pain); (2) acute low
back pain (duration ⱕ 3 months) if persons reported
acute local low back pain or/and acute sciatica; and (3)
chronic low back pain (duration > 3 months) if
persons reported chronic local low back pain or/and
chronic sciatica.
Occupational class was categorized into professionals
and managers, semi-professionals, routine non-
manual employees, and manual workers. Information
on physical workload was obtained from an inventory of
characteristics of work and working environment
developed at the Finnish Institute of Occupational
Health (Piirainen et al., 2003). Four items indicating
physical characteristics of work were included:
uncomfortable postures, repetitive trunk rotation,
repetitive movements and heavy physical work. These
items were dichotomized, and a summary score of
physical workload was calculated based on the four
items (Cronbach’s a 0.76).
Karasek’s job demand-control inventory (Karasek
and Theorell, 1990) was used in assessing job demands
and control. Nine questions measured job demands
(Cronbach’s a 0.75) and nine questions measured job
control (Cronbach’s a 0.76). Both scores were divided
into quartiles. Work-related emotional exhaustion was
measured using a 6-item scale, which is constructed at
the Finnish Institute of Occupational Health on the
basis of emotional exhaustion subscale of the Maslach
Burnout Inventory (Kalimo et al., 1993). The scale
consists of questions about feelings of being emotion-
ally overextended and exhausted by one’s work (e.g., I
feel used up at the end of the workday) with a 5-point
response scale (1 = never to 5 = very often). A sum
score was calculated and categorized into three classes:
low (1–10), medium (11–17) and high level of exhaus-
tion (18–30). Workplace bullying was defined as follows:
‘Mental violence or workplace bullying refers to isola-
tion of a work team member, underestimation of his/
her work performance, threatening, talking behind the
back or other pressurizing’. It was then asked ‘Have you
been subject to such bullying?’ The response alterna-
tives were: (1) no; (2) yes, currently; (3) yes, previously
in this workplace but not anymore; (4) yes, previously
in another workplace; and (5) cannot say.
Common mental disorders were assessed using the
General Health Questionnaire 12-item version (Gold-
berg et al., 1997). A cut-off point of three or more
symptoms was used to define common mental disor-
Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters
Risk factors of chronic neck pain
ders. The 4-item Jenkins Sleep Questionnaire was
used to assess sleep problems during the past 4 weeks
(Jenkins et al., 1988). The scale includes items on
‘having trouble falling asleep,’ ‘waking up several
times per night’, ‘having trouble staying asleep’ and
‘waking up after the usual amount of sleep feeling
tired and worn out’, with a 6-point response
scale (1 = never to 6 = every night). The answers to
each item were summed and divided by the
number of the completed items. The final score was
then categorized as no sleep problems; rare to occa-
sional (any of the problems 1–14 times); and fre-
quent (any of the problems at least 15 times) sleep
problems.
Body mass index (BMI, kg/m2) was calculated based
on self-reports of height and weight, and categorized
to <24.9 (normal weight), 25.0–29.9 (overweight) and
ⱖ30.0 (obese). Smoking was categorized into never
smokers, ex-smokers and current smokers. weekly
leisure time physical activity during the past 12 months
was asked in four grades of intensity exemplified with
common activities that people often do (Kujala et al.,
1998). Based on approximate metabolic equivalent
tasks (METs), (Ainsworth et al., 2000) the participants
were classified into four groups: inactive (under 14
MET hours per week), moderate (14–50 MET hours
per week in moderately intensive activity only), vig-
orous (14–50 MET hours per week including also vig-
orous activity) and conditioning exercise (over 50
MET hours per week including also vigorous activity)
(Lahti et al., 2010).
2.3 Statistical methods
The incidence proportions in women and men were
first compared and associations with age examined.
Logistic regression analysis was then used to examine
the associations between baseline determinants and
the development of chronic NP during the (5–7
years) follow-up. First, age-adjusted associations of
each determinant with incident chronic NP were cal-
culated. The factors showing an association with
chronic NP [based on odds ratios (ORs) and their
95% confidence intervals (CIs)] were chosen for the
next model. All variables associated with chronic NP
at this step were chosen for the final model. Analyses
were made using SPSS version 17.0 (SPSS Inc.,
Chicago, IL, USA).
2.4 Ethics
The study was approved by the ethics committees at
the Department of Public Health, University of Hels-
inki, and the City of Helsinki Health Authorities.
913
Risk factors of chronic neck pain
3. Results
The incidence of chronic NP during the follow-up was
15% for women and 9% for men. In women, the
incidence peaked at the age groups of 45 (OR when
compared with the 40-year-old women 1.39, 95% CI
1.08–1.80) and 50 years (1.39, 1.08–1.81). In men, the
highest incidence was seen among those aged 60 years
when compared with the 40-year-old (1.27, 0.62–
2.57).
The distribution of the follow-up respondents free
of chronic NP at baseline (4220 women and 1057
men) according to the explanatory variables and the
occurrence of chronic NP at follow-up is given in
Table 1.
In age-adjusted analyses among women, the stron-
gest predictors of incident chronic NP were earlier acute
NP and chronic low back pain (Table 2). Of the other
factors, high physical workload, intermediate and high
work-related emotional exhaustion, experiencing and
having earlier experienced bullying at work, common
mental disorders, rare to occasional and frequent sleep
problems, and overweight and obesity were predictive
of chronic NP. Of these, the following retained their
effect in the final model: acute NP (3.84, 2.92–5.05),
chronic low back pain (1.63, 1.23–2.17), workplace
bullying (ORs between 1.62 and 1.79), frequent sleep
problems (1.54, 1.22–1.95), overweight (1.22, 1.00–
1.48) and obesity (1.54, 1.22–1.95).
Among men, chronic low back pain and acute NP,
manual class as compared with managers and profes-
sionals, high work-related emotional exhaustion and
frequent sleep problems were predictive of chronic NP
in age-adjusted analyses (Table 3). Of these, the fol-
lowing variables remained in the final model: acute NP
(2.30, 1.40–3.78), chronic low back pain (2.29, 1.21–
4.32), manual occupational class (1.82, 1.08–3.09)
and high work-related emotional exhaustion (1.88,
1.07–3.30).
4. Discussion
This prospective survey among employees identified
some predictors for chronic NP that were related to
work and lifestyle. Prior acute NP and chronic low
back pain proved to be major risk factors for subse-
quent chronic NP. The incidence of chronic NP was
higher in women than in men, in line with earlier
studies (Cote et al., 2008a; McLean et al., 2010), and
its predictors varied somewhat by gender. Among
women, we found that workplace bullying, frequent
sleep problems, and overweight or obesity, in addition
to previous acute NP and chronic low back pain, inde-
914 Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters
S. Kääriä et al.
pendently predicted the development of chronic NP.
Similar to women, also among men there was a rela-
tionship of previous acute pain in the neck and
chronic pain in the low back with subsequent chronic
NP. The other variables increasing the risk of chronic
NP in men were manual occupational class and work-
related emotional exhaustion.
Our results confirm earlier findings of the impor-
tance of previous NP (Carroll et al., 2008b) and low
back pain (Eriksen et al., 1999) in increasing the risk
of neck problems. In addition, our results showed that
specifically chronic, not acute, low back pain was a
risk factor of chronic NP. It has been pointed out that
chronic pain in one body site may be a more rare
condition than chronic pain in several sites (Carnes
et al., 2007). This suggests some common underlying
mechanisms linked either to shared environmental
factors or individual susceptibility to pain.
Previous studies have shown limited evidence for an
association of occupational class with NP (Hill et al.,
2004). In a 1-year follow-up study of middle-aged
residents of Malmö City in Sweden, men in skilled
manual and unskilled manual work had an increased
risk of incident NP as compared with high-level non-
manual employees, while in women the risk was
increased only among unskilled manual workers
(Ostergren et al., 2005). In the present study, being a
manual worker predicted chronic NP in men but not in
women. This difference may be due to gender differ-
ences in the distribution of occupations and work tasks
in our cohort.
High physical workload was predictive of chronic NP
in age-adjusted analyses in women but not in men.
However, among women the association disappeared
when further covariates were included in the model. In
systematic reviews, limited evidence has been found
for a relationship of NP with a range of physical work
factors, some of them more specifically depicting load
on the neck and shoulders (McLean et al., 2010). Mod-
erate evidence has been obtained for a relationship of
neck-shoulder disorders connected with physical find-
ings with repetitive work at the shoulder and with neck
flexion allied with repetitiveness (Palmer and Smedley,
2007). To measure physical workload, we used a sum
score with good internal consistency of uncomfortable
work postures, repetitive rotation of the trunk, other
repetitive work movements and generally heavy physi-
cal work. A limitation of our study was self-reported
information on workload. More detailed information
on loading of the neck region was unavailable.
Previous studies on the association of psychosocial
factors at work with incident NP, let alone chronic
pain, are so far limited (Macfarlane et al., 2009). Low
S. Kääriä et al. Risk factors of chronic neck pain

Table 1 Distribution of the participants according to explanatory variables by occurrence of chronic neck pain at follow-up.
Women Men

Chronic neck pain at follow-up All Chronic neck pain at follow-up All
n = 4220 n = 1057
Yes (n) No (n) Yes (n) No (n)

Age (years)
40 119 801 920 16 169 185
45 160 773 933 19 188 207
50 157 758 915 15 190 205
55 149 840 989 29 263 292
60 54 409 463 18 150 168
Acute neck pain
No 67 1177 1244 26 480 506
Yes 572 2404 2976 71 480 551
Low back pain
No 193 1445 1647 27 392 419
Acute 341 1815 2156 48 471 519
Chronic 104 313 417 21 95 116
Occupational class
Managers and professionals 164 991 1155 37 472 509
Semi-professionals 125 752 877 18 186 204
Routine non-manuals 278 1472 1750 11 99 110
Manual workers 72 366 438 31 203 234
Physical workload score
0 58 436 494 20 224 244
1–2 148 884 1032 18 312 330
3–4 433 2261 2694 59 424 483
Job demands
1 (low) 174 942 1116 33 294 327
2 160 895 1055 24 248 272
3 154 916 1070 21 211 232
4 (high) 151 828 979 19 207 226
Job control
1 (high) 176 985 1161 29 218 247
2 170 891 1061 28 266 294
3 164 903 1067 22 282 304
4 (low) 129 802 931 18 194 212
Work-related emotional exhaustion
Low 152 1185 1337 25 324 349
Intermediate 266 1461 1727 36 409 445
High 221 935 1156 36 227 263
Workplace bullying
No 370 2484 2854 66 712 778
Yes, now 42 146 188 6 42 48
Yes, earlier, at this workplace but not now 95 306 455 6 73 79
Yes, earlier, at different workplace 66 220 66 4 40 44
Do not know 66 371 66 15 93 108
Common mental disorders (GHQ-12)
1–2 456 2833 3289 80 774 854
3+ 183 748 931 17 186 203
Sleep problems
No 274 1898 2172 46 521 567
Rare to occasional 211 1153 1364 30 312 342
Frequent 154 530 684 21 127 148
Body mass index
<24.9 328 2059 2387 47 389 436
25.0–29.9 212 1083 1295 33 447 480
ⱖ30.0 99 439 538 17 124 141
Smoking
Never 325 1920 2245 44 388 432
Ex-smoker 166 897 1063 30 330 360
Current smoker 148 764 912 23 242 265
Leisure time physical activity
Conditioning exercise 63 393 456 18 185 203
Vigorous 126 749 875 23 277 300
Moderate 322 1607 1929 32 268 300
Inactive 128 832 960 24 230 254

GHQ-12, General Health Questionnaire 12-item version.

Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters 915
Risk factors of chronic neck pain S. Kääriä et al.

Table 2 Determinants of new onset chronic NP during follow-up among women.

Adjusted for age, physical workload, emotional exhaustion, bullying,
Adjusted for age GHQ, sleep problems, acute NP, low back pain and body mass index Final model

OR 95% CI OR 95% CI OR 95% CI

Acute NP
No 1.00 1.00 1.00
Yes 4.18 3.22–5.44 3.75 2.85–4.93 3.84 2.92–5.05
Low back pain
No 1.00 1.00 1.00
Acute 1.41 1.17–1.70 0.94 0.77–1.15 0.95 0.77–1.16
Chronic 2.53 1.93–3.31 1.60 1.20–2.13 1.63 1.23–2.17
Occupational class
Managers and professionals 1.00
Semi-professionals 1.01 0.78–1.30
Routine non-manuals 1.13 0.92–1.39
Manual workers 1.16 0.86–1.58
Physical workload score
0 1.00 1.00
1–2 1.25 0.91–1.74 1.13 0.81–1.58
3–4 1.44 1.07–1.93 1.14 0.84–1.54
Job demands
1 (low) 1.00
2 0.97 0.77–1.22
3 0.91 0.72–1.15
4 (high) 0.99 0.78–1.26
Job control
1 (high) 1.00
2 1.07 0.85–1.35
3 1.02 0.81–1.29
4 (low) 0.90 0.70–1.15
Work-related emotional exhaustion
Low 1.00 1.00
Intermediate 1.43 1.15–1.77 1.18 0.94–1.47
High 1.87 1.49–2.34 1.25 0.96–1.62
Workplace bullying
No 1.00 1.00 1.00
Yes, now 1.95 1.36–2.80 1.55 1.06–2.26 1.62 1.11–2.35
Yes, earlier, at this workplace but not now 1.78 1.38–2.28 1.53 1.18–1.99 1.58 1.22–2.04
Yes, earlier, at different workplace 1.98 1.47–2.67 1.77 1.30–2.40 1.79 1.32–2.43
Common mental disorders (GHQ-12)
1–2 1.00 1.00
3+ 1.54 1.28–1.87 1.06 0.85–1.32
Sleep problems
No 1.00 1.00 1.00
Rare to occasional 1.28 1.05–1.55 1.01 0.82–1.24 1.06 0.87–1.30
Frequent 2.05 1.65–2.56 1.40 1.08–1.81 1.54 1.22–1.95
Body mass index
<24.9 1.00 1.00 1.00
25.0–29.9 1.25 1.04–1.52 1.22 1.00–1.48 1.22 1.00–1.48
ⱖ30.0 1.46 1.14–1.87 1.39 1.07–1.80 1.39 1.08–1.80
Smoking
Never 1.00
Ex-smoker 1.06 0.87–1.30
Current smoker 1.11 0.89–1.37
Leisure time physical activity
Conditioning exercise 1.00
Vigorous 1.05 0.76–1.46
Moderate 1.26 0.94–1.69
Inactive 0.98 0.71–1.36

Logistic regression analysis, OR with 95% CI. (n = 4220). CI, confidence interval; GHQ-12, General Health Questionnaire 12-item version; NP, neck pain; OR, odds ratio.

916 Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters
S. Kääriä et al. Risk factors of chronic neck pain

Table 3 Determinants of new onset chronic NP during follow-up among men.

Adjusted for aforementioned, occupational class,
Adjusted for age emotional exhaustion, NP, low back pain and sleep problems Final model

OR 95% CI OR 95% CI OR 95% CI

Acute neck pain

No 1.00 1.00 1.00
Yes 2.80 1.75–4.47 2.35 1.43–3.87 2.30 1.40–3.78
Low back pain
No 1.00 1.00 1.00
Acute 1.50 0.91–2.45 1.06 0.63–1.79 1.07 0.64–1.79
Chronic 3.27 1.76–6.06 2.28 1.19–4.37 2.29 1.21–4.32
Occupational class
Managers and professionals 1.00 1.00 1.00
Semi-professionals 1.26 0.70–2.26 1.24 0.68–2.28 1.23 0.67–2.24
Routine non-manuals 1.50 0.73–3.07 1.54 0.74–3.23 1.46 0.71–3.00
Manual workers 2.03 1.22–3.38 1.88 1.10–3.21 1.82 1.08–3.09
Physical workload score
0 1.00
1–2 0.66 0.34–1.27
3–4 1.62 0.95–2.76
Job demands
1 (low) 1.00
2 0.86 0.49–1.49
3 0.89 0.50–1.59
4 (high) 0.82 0.45–1.49
Job control
1 (high) 1.00
2 0.80 0.46–1.38
3 0.59 0.33–1.05
4 (low) 0.70 0.38–1.30
Work-related emotional exhaustion
Low 1.00 1.00 1.00
Intermediate 1.16 0.68–1.97 1.16 0.66–2.05 1.14 0.66–1.97
High 2.13 1.24–3.65 1.98 1.07–3.68 1.88 1.07–3.30
Workplace bullying
No 1.00
Yes, now 1.55 0.63–3.78
Yes, earlier, at this workplace but not now 0.91 0.38–2.18
Yes, earlier, at different workplace 1.13 0.40–3.26
Common mental disorders (GHQ-12)
1–2 1.00
3+ 0.92 0.53–1.60
Sleep problems
No 1.00 1.00
Rare to occasional 1.12 0.69–1.81 0.80 0.47–1.36
Frequent 1.91 1.10–3.33 1.14 0.61–2.13
Body mass index
<24.9 1.00
25.0–29.9 0.60 0.38-0.96
ⱖ30.0 1.11 0.61–2.02
Smoking
Never 1.00
Ex-smoker 0.79 0.48–1.28
Current smoker 0.85 0.50–1.44
Leisure time physical activity
Conditioning exercise 1.00
Vigorous 0.84 0.44–1.60
Moderate 1.18 0.64–2.20
Inactive 1.05 0.55–2.00

Logistic regression analysis, OR with 95% CI. (n = 1057). CI, confidence interval; GHQ-12, General Health Questionnaire 12-item version; NP, neck pain; OR, odds ratio.

Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters 917
Risk factors of chronic neck pain
job control predicted new onset NP in a 4-year
follow-up in the general working population (Eriksen
et al., 1999). In another 4-year follow-up study of
industrial and service sector employees, high job
demands and low job control were associated with the
onset of NP (Andersen et al., 2003). In contrast,
several indicators of job demands and control did not
predict the onset of NP in a follow-up of employees of
20 Norwegian organizations (Christensen and
Knardahl, 2010). In the Malmö study (Ostergren
et al., 2005), effects of job demands and job control on
incident NP were modest, but job strain was predictive
of NP among women, but not in men. Our results
indicated no associations between job demands or job
control with chronic NP in either gender or conse-
quently the possible effect of job strain was not tested.
Among women, the experience of being bullied was
one of the strongest predictors of chronic NP. This was
true regarding the current job both now and earlier, as
well as previous jobs. We lack prospective studies
examining the associations between bullying and the
development of NP. However, it has been shown earlier
in the current study population that among both
genders repeatedly occurring bullying at the workplace
was associated with acute pain in unspecified bodily
location, but not with chronic pain (Saastamoinen
et al., 2009). Workplace bullying also predicted new
cases of fibromyalgia among hospital employees (Kivi-
maki et al., 2004). It has been suggested that targets of
workplace bullying differ from non-targets in their
personality profile, but the results are heterogeneous
(Lind et al., 2009). A mechanism for an association
between workplace bullying and NP might be via
increased mental distress (Finne et al., 2011), a possible
risk factor of NP (McLean et al., 2010). A Norwegian
study (Eriksen et al., 1999) showed that mental distress
was a predictor of bullying. Such reciprocal relation-
ships might be an explanation for our finding that not
only current but also past bullying experiences were
predictive of chronic NP.
In contrast to our findings in women, no associa-
tions of being bullied with chronic NP were seen in
men. This might reflect gender-related differences in
the occupational status and work tasks. In our sample,
men more often than women were managers and
professionals. According to a review, managers may
experience less aggressive behaviour from other orga-
nizational member such as bullying than other
employees (Einarsen, 2000). Among men, work-
related emotional exhaustion was an important pre-
dictive factor instead. In women, the association
between emotional exhaustion and NP seen in the
age-adjusted analyses disappeared with the inclusion
918 Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters
S. Kääriä et al.
of further covariates in the model. Our finding in men
is in line with a previous cross-sectional study where
mental tiredness at the end of the workday was an
important risk factor of NP among office workers
(Cagnie et al., 2007). In that study, differences in risk
between genders were not considered.
In the adult US population, the risk of NP was
doubled in those with insomnia or trouble with falling
asleep (Strine and Hootman, 2007), while no evidence
for poor sleep as a risk factor for NP was found in a
review of employee populations (Cote et al., 2008b).
The present study showed that frequent sleep prob-
lems predicted chronic NP in women. A similar rela-
tionship was seen among men when only age was
adjusted for, but the association disappeared in further
adjustments. Our finding is supported by a longitudi-
nal study that found an association between poor
sleep and persistent NP (Eriksen et al., 1999). Also, it
has been reported in the current study population that
workplace bullying is strongly associated with sleep
disturbances (Lallukka et al., 2011). Our results
showed, however, that both factors, sleep problems
and workplace bullying, play an independent role in
the development of chronic NP in women.
We found, further, that overweight and obesity were
predictive of chronic NP in women, but not in men. The
possibility of high body mass being a risk factor of NP
has not received much attention among employee
populations. High BMI increased the risk of radiating
NP in a longitudinal study among employees in forest
industry (Viikari-Juntura et al., 2001). Among a
sample of the normal adult Norwegian population,
overweight and obesity increased the risk of incident
chronic neck-shoulder pain in both women and men
after adjustment for exercise, smoking and occupation
(Nilsen et al., 2011). The increase in risk for overweight
was 12% and for obesity about 20% compared with the
normal weight, that is somewhat lower than was found
in our study among female employees. In a represen-
tative sample of elderly people, obesity increased the
risk of chronic NP (McCarthy et al., 2009).
The strengths of our study include sufficiently large
sample size, prospective design, high response rate
particularly in the follow-up survey and possibility to
examine the effects of many potential risk factors
simultaneously. We studied chronic incident NP
instead of acute pain. This was performed in view of
the work life relevance of the outcome and because
the information on chronic pain is likely more reliable.
Recall bias hampers assessment of acute pain episodes
in population surveys while chronic pain often leading
to healthcare use may be more reliably reported
(Miranda et al., 2006).
S. Kääriä et al.
In our study, the time frame for the occurrence of
chronic pain was after the baseline and before the
follow-up survey. Thus, some participants in the index
group of incident chronic NP may have had NP at the
time of responding to the follow-up questionnaire,
whereas in some others the chronic episode may have
resolved by that time point. At baseline, some partici-
pants may have suffered from acute NP that later
became chronic. These employees contributed to the
index group of chronic NP at follow-up. Existing pain
may influence the experience of physical workload
and psychosocial factors. Our analyses, however, took
previous acute pain into account, which reduced the
possible bias.
Information on predictors of pain was based on self-
reports. Such information is typically used in epidemio-
logical studies to assess health behaviours, height,
weight and work-related factors, among others. Poten-
tial data limitations include the possibility of reporting
bias due to selective recall, social desirability or
negative affectivity. Respondents may under-report
smoking or over-report physical activity, or tend to give
negative responses. This is a potential bias affecting the
studied associations. However, although people tend to
underestimate their weight and overestimate their
height, it has been argued that self-reported height and
weight are valid for identifying relationships in epide-
miological studies (Spencer et al., 2002).
In summary, we found some potentially modifiable
risk factors of chronic NP among employees, particu-
larly workplace bullying, sleep problems, and high
BMI in women, and work-related emotional exhaus-
tion in men. The results also underline the importance
of pain history, not only with reference to the neck,
but also to the low back, in evaluating the risk of
future chronic NP.
Acknowledgements
We thank the City of Helsinki, all participating employees,
and members of Helsinki Health Study Group.
References
Aas RW, Tuntland H, Holte KA, Roe C, Lund T, Marklund S,
et al. Workplace interventions for neck pain in workers.
Cochrane Database Syst Rev 2011;13(4):CD008160.
Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz
AM, Strath SJ, et al. Compendium of physical activities: an
update of activity codes and MET intensities. Med Sci
Sports Exerc 2000;32(9 Suppl):S498–504.
Andersen JH, Kaergaard A, Mikkelsen S, Jensen UF, Frost P,
Bonde JP, et al. Risk factors in the onset of neck/shoulder
pain in a prospective study of workers in industrial and
Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters
Risk factors of chronic neck pain
service companies. Occup Environ Med 2003;60(9):649–
54.
Ariens GA, van Mechelen W, Bongers PM, Bouter LM, van
der Wal G. Physical risk factors for neck pain. Scand J
Work Environ Health 2000;26(1):7–19.
Ariens GA, van Mechelen W, Bongers PM, Bouter LM, van
der Wal G. Psychosocial risk factors for neck pain: a sys-
tematic review. Am J Ind Med 2001;39(2):180–93.
Borghouts JA, Koes BW, Bouter LM. The clinical course and
prognostic factors of non-specific neck pain: a systematic
review. Pain 1998;77(1):1–13.
Cagnie B, Danneels L, Van Tiggelen D, De Loose V, Cambier
D. Individual and work related risk factors for neck pain
among office workers: a cross sectional study. Eur Spine J
2007;16(5):679–86.
Carnes D, Parsons S, Ashby D, Breen A, Foster NE, Pincus T,
et al. Chronic musculoskeletal pain rarely presents in a
single body site: results from a UK population study.
Rheumatology (Oxford) 2007;46(7):1168–70.
Carroll LJ, Hogg-Johnson S, Cote P, van der Velde G, Holm
LW, Carragee EJ, et al. Course and prognostic factors for
neck pain in workers: results of the Bone and Joint Decade
2000–2010 Task Force on Neck Pain and Its Associated
Disorders. Spine 2008b;33(4S) (Suppl):S93–100.
Carroll LJ, Hogg-Johnson S, van der Velde G, Haldeman S,
Holm LW, Carragee EJ, et al. Course and prognostic factors
for neck pain in the general population: results of the Bone
and Joint Decade 2000–2010 Task Force on Neck Pain and
Its Associated Disorders. Spine 2008a;33(4 Suppl):S75–82.
Christensen JO, Knardahl S. Work and neck pain: a prospec-
tive study of psychological, social, and mechanical risk
factors. Pain 2010;151(1):162–73.
Cote P, Kristman V, Vidmar M, Van Eerd D, Hogg-Johnson S,
Beaton D, et al. The prevalence and incidence of work
absenteeism involving neck pain: a cohort of Ontario lost-
time claimants. Spine 2008a;33(4 Suppl):S192–8.
Cote P, van der Velde G, Cassidy JD, Carroll LJ,
Hogg-Johnson S, Holm LW, et al. The burden and deter-
minants of neck pain in workers: results of the Bone and
Joint Decade 2000–2010 Task Force on Neck Pain and Its
Associated Disorders. Spine 2008b;33(4S) (Suppl):S60–74.
Einarsen S. Harassment and bullying at work: a review of the
Scandinavian approach. Aggress Violent Behav 2000;
5(4):379–401.
Eriksen W, Natvig B, Knardahl S, Bruusgaard D. Job char-
acteristics as predictors of neck pain. A 4-year prospective
study. J Occup Environ Med 1999;41(10):893–902.
Fejer R, Kyvik KO, Hartvigsen J. The prevalence of neck pain
in the world population: a systematic critical review of the
literature. Eur Spine J 2006;15(6):834–48.
Finne LB, Knardahl S, Lau B. Workplace bullying and mental
distress – a prospective study of Norwegian employees.
Scand J Work Environ Health 2011;37(4):276–87.
Goldberg DP, Gater R, Sartorius N, Ustun TB, Piccinelli M,
Gureje O, et al. The validity of two versions of the GHQ in
the WHO study of mental illness in general health care.
Psychol Med 1997;27(1):191–7.
919
Risk factors of chronic neck pain
Hill J, Lewis M, Papageorgiou AC, Dziedzic K, Croft P. Pre-
dicting persistent neck pain: a 1-year follow-up of a popu-
lation cohort. Spine 2004;29(15):1648–54.
Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM.
Prognosis of acute idiopathic neck pain is poor: a system-
atic review and meta-analysis. Arch Phys Med Rehabil
2011;92(5):824–9.
International Association for the Study of Pain (IASP). Clas-
sification of chronic pain. Pain Suppl 1986;3:S1–226.
Jenkins CD, Stanton BA, Niemcryk SJ, Rose RM. A scale for
the estimation of sleep problems in clinical research. J Clin
Epidemiol 1988;41(4):313–21.
Kalimo R, Olkkonen M, Toppinen S. Ihminen Kehittyvässä
Tuotannossa. 1, Tutkimus- Ja Kehityshanke Teollis-
uudessa. Helsinki: Työterveyslaitos; 1993.
Karasek R, Theorell T. Healthy work: stress, productivity, and
the reconstruction of working life. New York: Basic Books;
1990.
Kivimaki M, Leino-Arjas P, Virtanen M, Elovainio M,
Keltikangas-Jarvinen L, Puttonen S, et al. Work stress and
incidence of newly diagnosed fibromyalgia: prospective
cohort study. J Psychosom Res 2004;57(5):417–22.
Kujala UM, Kaprio J, Sarna S, Koskenvuo M. Relationship of
leisure-time physical activity and mortality: the Finnish
twin cohort. JAMA 1998;279(6):440–4.
Laaksonen M, Aittomaki A, Lallukka T, Rahkonen O,
Saastamoinen P, Silventoinen K, et al. Register-based
study among employees showed small nonparticipation
bias in health surveys and check-ups. J Clin Epidemiol
2008;61(9):900–6.
Lahelma E, Lallukka T, Laaksonen M, Saastamoinen P,
Rahkonen O. Workplace bullying and common mental
disorders: a follow-up study. J Epidemiol Community
Health 2011. doi: 10.1136/jech.2010.115212.
Lahelma E, Martikainen P, Rahkonen O, Roos E, Saastam-
oinen P. Occupational class inequalities across key
domains of health: results from the Helsinki Health Study.
Eur J Public Health 2005;15(5):504–10.
Lahti J, Laaksonen M, Lahelma E, Rahkonen O. The impact
of physical activity on physical health functioning – a
prospective study among middle-aged employees. Prev
Med 2010;50(5–6):246–50.
Lallukka T, Rahkonen O, Lahelma E. Workplace bullying
and subsequent sleep problems – the Helsinki Health
Study. Scand J Work Environ Health 2011;37(3):204–12.
Lind K, Glasø L, Pallesen S, Einarsen S. Personality profiles
among targets and nontargets of workplace bullying.
European Psychologist 2009;14(3):231–7.
Linton SJ. A review of psychological risk factors in back and
neck pain. Spine (Phila Pa 1976) 2000;25(9):1148–56.
Macfarlane GJ, Norrie G, Atherton K, Power C, Jones GT.
The influence of socioeconomic status on the reporting of
regional and widespread musculoskeletal pain: results
from the 1958 British Birth Cohort Study. Ann Rheum Dis
2009;68(10):1591–5.
920 Eur J Pain 16 (2012) 911–920 © 2011 European Federation of International Association for the Study of Pain Chapters
S. Kääriä et al.
Makela M, Heliovaara M, Sievers K, Impivaara O, Knekt P,
Aromaa A. Prevalence, determinants, and consequences of
chronic neck pain in Finland. Am J Epidemiol 1991;
134(11):1356–67.
McCarthy LH, Bigal ME, Katz M, Derby C, Lipton RB.
Chronic pain and obesity in elderly people: results from
the Einstein aging study. J Am Geriatr Soc 2009;
57(1):115–9.
McLean SM, May S, Klaber-Moffett J, Sharp DM, Gardiner E.
Risk factors for the onset of non-specific neck pain: a
systematic review. J Epidemiol Community Health
2010;64(7):565–72.
Messing K, Stock SR, Tissot F. Should studies of risk factors
for musculoskeletal disorders be stratified by gender?
Lessons from the 1998 Quebec Health and Social Survey.
Scand J Work Environ Health 2009;35(2):96–112.
Miranda H, Gold JE, Gore R, Punnett L. Recall of prior
musculoskeletal pain. Scand J Work Environ Health
2006;32(4):294–9.
Nilsen TI, Holtermann A, Mork PJ. Physical exercise, body
mass index, and risk of chronic pain in the low back and
neck/shoulders: longitudinal data from the Nord-
Trondelag Health Study. Am J Epidemiol 2011;174(3):
267–73.
Ostergren PO, Hanson BS, Balogh I, Ektor-Andersen J, Isac-
sson A, Orbaek P, et al. Incidence of shoulder and neck pain
in a working population: effect modification between
mechanical and psychosocial exposures at work? Results
from a one year follow up of the Malmö shoulder and neck
study cohort. J Epidemiol Community Health 2005;
59(9):721–8.
Palmer KT, Smedley J. Work relatedness of chronic neck
pain with physical findings – a systematic review. Scand J
Work Environ Health 2007;33(3):165–91.
Piirainen H, Hirvonen M, Elo A, Huuhtanen P, Kandolin I,
Kauppinen K, et al. The work and health interview study
2003: basic report. Helsinki, Finland: Finish Institute of
Occupational Health; 2003.
Saastamoinen P, Laaksonen M, Leino-Arjas P, Lahelma E.
Psychosocial risk factors of pain among employees. Eur J
Pain 2009;13(1):102–8.
Spencer EA, Appleby PN, Davey GK, Key TJ. Validity of
self-reported height and weight in 4808 EPIC-Oxford par-
ticipants. Public Health Nutr 2002;5(4):561–5.
Strine TW, Hootman JM. US national prevalence and corre-
lates of low back and neck pain among adults. Arthritis
Rheum 2007;57(4):656–65.
Viikari-Juntura E, Martikainen R, Luukkonen R, Mutanen P,
Takala EP, Riihimaki H. Longitudinal study on work
related and individual risk factors affecting radiating neck
pain. Occup Environ Med 2001;58(5):345–52.
Young Casey C, Greenberg MA, Nicassio PM, Harpin RE,
Hubbard D. Transition from acute to chronic pain and
disability: a model including cognitive, affective, and
trauma factors. Pain 2008;134(1–2):69–79.