ASSOCIATION BETWEEN PSYCHOLOGICAL AND WORK-

RELATED RISK FACTORS FOR SELF REPORTED NECK PAIN

AND DISABILITY AMONG UNIVERSITY FEMALES.

A Synopsis Submitted by

ALEENA SHEHZADI

70058519

Doctor of Physical Therapy

Supervisor: Dr Nayab

University Institute of Physical Therapy

Faculty of Allied Health Sciences

THE UNIVERSITY OF LAHORE

Gujrat Campus

(2017- 2023)
Ref. No. ___________________ Date: ________________

Student Name: _________________ Session: ________________

Reg. no: _______________________ Course: ________________

____________________

Convener

Dr. Farooq Islam

HOD/Assistant Professor

_____________ _____________

Member Member

Dr. Khushboo Gulzar Dr. Nayab

Lecturer Lecturer

______________

Member

Mr. Asim Raza

Assistant Professor (Biostatistics)

FACULTY OF ALLIED HEALTH SCIENCES

THE UNIVERSITY OF LAHORE

Gujrat Campus
 The University of Lahore
Faculty of Allied Health Sciences
University Institute of Physical Therapy

LETTER FROM BIOSTATISTICIAN

This is to certify that I have thoroughly reviewed the synopsis of Aleena Shehzadi
(70058519) for Doctor of Physical Therapy (2017-2023) on the topic

I found it satisfactory for presenting in Board of Study titled for defense.

______________

Mr. Asim Raza

Assistant Professor (Biostatistics)

University Institute of Physical Therapy

Faculty of Allied Health Sciences

The University of Lahore,

Gujrat Campus
 INTRODUCTION:
Neck pain is a musculoskeletal condition with high prevalence that may affect the physical,
social, and psychological aspects of the individual, contributing to the increase in costs in society
and business.(1) Neck pain is becoming increasingly common throughout the world. It has a
considerable impact on individuals and their families, communities, health-care systems, and
businesses.(2) By definition, neck pain is pain perceived as arising in a region bounded
superiorly by the superior nuchal line, laterally by the lateral margins of the neck, and inferiorly
by an imaginary transverse line through the T1 spinous process.(3) Neck pain is a multifactorial
disease, there are a number of risk factors which can contribute to its development. There is,
however, more evidence for some risk factors, such as lack of physical activity, duration of daily
computer use, perceived stress and being female. (4). The pain may arise from any of the
structures in the neck. These include the intervertebral discs and annuli, ligaments, muscles, facet
joints, dura and nerve roots. There are a large number of potential (specific) causes of neck pain.
These vary from trauma, infections, tumors, congenital disorders and inflammation. In the large
majority of cases, however, no specific underlying pathology can be established and the
complaints are labelled as non-specific neck pain.(5)
For neck pain it is assumed that there are several risk factors contributing to its development.
Risk factors can be work-related or nonwork-related, and they can be divided roughly into 3
categories (i.e., physical, psychosocial, and individual risk factors).(6) With an increase in the
usage of computers for academic or business purposes, neck pain has become the most prevalent
disorder in office workers who are intensive computer users. Approximately 42% to 69% of
office workers are reported to have experienced neck pain during the past 12 months. For
occupational characteristics such as sustained posture and repetitive use of the upper extremities,
hours of computer 6 usage, work environment, incomplete work-rest cycle control, neck pain
typically is prolonged and not treated properly. Naturally, the chronicity and recurrence of pain is
frequent, resulting in a high economic cost, extensive social burden, and the lower quality of life
for these individuals. Therefore, a specific intervention and management tool for providing
regular care is needed.(7) Myofascial pain is a common cause of neck pain that involves discrete
or diffuse areas of sensitivity within one or more muscle. The causes of myofascial pain are
poorly understood, but muscle pain can develop secondary to biomechanical imbalances, trauma,
emotional stress, and even endocrine and hormonal abnormalities. The treatment of myofascial
pain should be multimodal and should include correcting underlying structural and postural
imbalances, physical therapy (for example, massage and range of motion exercises), drugs, and
psychotherapy (including cognitive behavioral therapy and biofeedback).(8) Work related neck
disorders are common problems in office workers, especially among those who are intensive
computer users however it is generally agreed that the etiology of work related neck disorders is
multidimensional which is associated with, and influenced by, a complex array of individual,
physical and psychosocial factors. Among these various risk factors, work-related psychosocial
factors appear to play a major role. The psychosocial demands may be highly correlated with
physical demands, which also indicate a confounding effect of physical factors on the relation
between work-related psychosocial variables and the occurrence of neck pain.(9) Physical risk
factors (such as prolonged sitting and neck flexion) have been identified as predictive of neck
pain in the study of a mixed population of workers from various industry, health and professional
settings. These and other physical factors (such as posture and neck muscle endurance) have not
been prospectively investigated specifically in office workers. Physical risk factors are useful to
investigate as they are potentially reversible with exercise-based intervention. It has been argued
that both physical and psychosocial contributors to work-related neck pain need to be assessed
together in longitudinal designs, to evaluate their relative contribution to the onset of work-
related musculoskeletal pain.(10). Psychological factors such as stress, anxiety, depression and
cognitive factors might play some role in changing the central pain. Stress is related to pain and
disability. Perceived stress is a risk factor for neck pain). Anxiety is related to different kinds of
chronic pain (e.g., neck pain), as well as disability. Neck pain has been found to be comorbid
with anxiety. The relationship between depression and neck pain appears to be bidirectional.
Mood disorders, especially depression, have been found to be related to chronic neck pain and
disabilities. Cognitive factors (i.e., attitudes, cognitive style, and fear-avoidance beliefs) have
been linked to increased pain, such as neck pain and disability. Pain cognitions, like
catastrophizing and self-perceived poor health, are related to pain and disability.(4) During
psychological challenge, active coping behavior includes a cardiovascular response pattern in
which blood flow to muscles increases. It has been hypothesized that factors involved in the
regulation of muscle blood vessels may activate nociceptors. However, it is also possible that the
pain may originate from tendons or periostea or other components outside the muscle tissue.(11)
Cognitive behavioral therapy (CBT) is one of the most common psychological treatments used in
the treatment of chronic pain conditions. CBT works by means of modifying maladaptive and
dysfunctional thoughts (e.g., catastrophizing, kinesiophobia) and improving mood (e.g., anxiety
and depression), leading to gradual changes in cognition and illness behavior. The psychological
component may be more effective if it specifically targets individual psychological factors. (12)
Several occupational studies have related neck pain to a repetitive or continuing work load and to
unfavorable psychosocial working conditions. Neck pain is less disabling than low back pain.
Nevertheless, it may still have a considerable impact on the health and quality of life of
individuals and on the society as a whole.(13)  The prevalence of neck pain is higher in females
than in males, and the literature is mixed as to whether it peaks or plateaus in middle age. (14)
The cause of the various cervical disorders is not fully understood, treatments for chronic neck
disorders vary from traditional means for pain management and manipulative therapy to group
gymnastics, neck-specific strengthening exercises, and ergonomic changes at work.
Strengthening exercises have been used for the treatment of neck pain, but only a few controlled
intervention studies have been conducted to examine active therapy for neck problems. The
active treatment consisted of 24 sessions of proprioceptive exercises, relaxation, and behavioral
support. The control treatment included a lecture regarding care of the neck with a
recommendation to exercise.(15)  Physiotherapists often give advice about changing lifestyles
with an emphasis on posture, in addition to teaching specific exercises.(16) Workers may have
increased neck pain at their workplace. They may have problems remaining productive at their
jobs, placing their employment at risk. Chronic neck pain is a serious condition that must be
treated aggressively. Modifications in the work environment have the potential to prevent neck
pain from becoming chronic. For example, a chair design matched to the task at work may
prevent the onset of neck pain for the individual who has to sit all day working at a machine.
Workers who use sewing machines are at risk for developing neck and shoulder pain because of
persistent abduction of the arms. The use of a chair with a height adjustment and curved seat
decreases the incidence of neck pain over 1 month, compared with chairs with flat seats. This
study proves that an appropriate work environment can have a good effect on controlling pain.
(17) Musculoskeletal neck pain is reportedly caused by myofascial trigger points (MTrPs) in the
neck and shoulder. MTrPs are hypersensitive spots in palpable taut bands of skeletal muscle
fibers, and recent clinical studies have reported that patients with chronic neck pain have a larger
number of MTrPs in the upper trapezius muscle than healthy subjects. These studies suggest that
MTrPs are responsible for chronic neck pain.(18) Clinical practice guidelines for the
management of NSNP advocate the use of exercises however, there is no consensus as to what
type of exercise is most beneficial. General exercise and specific neck exercises (SNE) have
been recommended. SNE targeting the deep neck flexors and extensors are effective for reverting
some of these neuromuscular disturbances resulting in improved neuromuscular function.
However, whether SNE are more effective than other types of exercises for reducing pain and
disability in NSNP needs to be established.(19) Exercises were categorized as motor control
(submaximal effort exercises for the deep cervical muscles, improving co-ordination and
sequential spinal control); segmental (exercises for the superficial cervical muscles improving
the ability of the neck to produce, transfer and absorb force); pillar (exercises intended to
develop the ability of the spine to maintain a neutral position) or upper limb (exercises intended
to change the neuromuscular performance of the shoulder or shoulder girdle musculature). (20)
The majority of neck pain guidelines on diagnosis and treatment of patients with neck pain
recommend a combination of manual therapy, exercise and education as the preferred evidence-
based physiotherapy treatments. Massage might be beneficial and psychological (behavioral)
treatment and multidisciplinary treatment are effective in some of patients. Physiotherapists often
offer ‘manual therapy’, aiming to improve spinal joint motion and restore range of motion.
Manual therapy consists of various techniques, including mobilizations and manipulations.
Mobilizations are defined as using low-grade/velocity, small amplitude or large-amplitude
passive movement techniques within the patient’s range of motion and within the patient’s
control. Manipulation is defined as a localized high-velocity and low amplitude force directed at
specific cervical or thoracic spinal segments near the end of the patient’s range of motion and
without their control. (21) Therapeutic exercise (TEX), manual therapy (MT), massage, physical
modalities (e.g., ultrasound and transcutaneous electrical nerve stimulation), and TPE are the
most commonly used physical therapy treatments for CNSNP. although studies have also
demonstrated that these therapies are more effective when used in combination. The treatment
duration of combined interventions, however, is usually longer than that of individual
interventions, on occasion even twice as long. A growing body of evidence suggests that
psychological factors are associated with musculoskeletal pain and that factors, such as pain
catastrophizing can predict poor outcomes, especially in cases of back and neck pain(22) In order
to improve patients’ functional status and quality of life, it is important to understand which
structures are capable of producing pain and disability. Over the past decade, numerous studies
have shown an association between reduction in the strength and endurance capacity of the
cervical muscles and neck pain. (23)

LITERATURE REVIEW
Adam P. Goode et al study on topic Prevalence, practice patterns, and evidence for chronic neck
pain in 02 November 2010 according to the study the estimated prevalence of chronic neck pain
in 2006 among noninstitutionalized individuals for the state of North Carolina was 2.2% (95%
confidence interval [95% CI] 1.7–2.6). Individuals with chronic neck pain were middle-aged
(mean age 48.9 years) and the majority of subjects were women (56%) and non-Hispanic white
(81%). The subjects saw a mean of 5.21 (95% CI 4.8–5.6) provider types and had a mean of 21
visits. The types of treatments subjects reported varied, with treatments such as electrotherapy
stimulation (30.3%), corsets or braces (20.9%), massage (28.1%), ultrasound (27.3%), heat
(57.0%), and cold (47.4%) having unclear or little benefit based on the current best available
reviews. (24)
Côté, Pierre DC, MSc et al study on topic The Saskatchewan Health and Back Pain Survey
the Prevalence of Neck Pain and Related Disability in Saskatchewan Adults in August 1, 1998
according to the study the age-standardized lifetime prevalence of neck pain is 66.7% (95%
confidence interval, 63.8-69.5), and the point prevalence is 22.2% (95% confidence interval,
19.7-24.7). The age-standardized 6-month prevalence of low-intensity and low-disability neck
pain is 39.7% (95% confidence interval, 36.7-42.7), whereas it is 10.1% (95% confidence
interval, 8.2-11.9) for high-intensity and low-disability neck pain and 4.6% (95% confidence
interval, 3.3-5.8) for significantly disabling neck pain. The prevalence of low-intensity and low-
disability neck pain decreases with age. More women experience high-disability neck pain than
men. Wave analysis suggests that the point prevalence and 6-month prevalence of high-intensity
and low-disability neck pain are overestimated in this survey.(25)
T. T. W. Chiu et al study on topic A Study on the Prevalence of and Risk Factors for Neck Pain
Among University Academic Staff in Hong Kong in June 2002 according to the study the 1-year
prevalence of neck pain among after being an academic staff was 46.7%. A significant
association was found between gender and neck pain (p = 0.02). The percentage of female
academic staff with neck pain (62%) was higher than that in male staff (38%). This matched the
results of other studies, which demonstrated that neck pain was more prevalent in women. There
was a significant association between head posture during computer processing and neck pain
(p = 0.02). Among those with neck pain during computer processing, 60.5% had a forward head
posture. However, a low correlation between psychosocial factors and neck pain was
demonstrated (r = 0.343). Academic staff in tertiary institutions could be considered as a high-
risk group of job-related neck pain.(26)
Bovim G et al study on topic Neck pain in the general population in 01 Jun 1994 according to
this study Overall, 34.4% of the responders had experienced neck pain within the last year. A
total of 13.8% reported neck pain that lasted for more than 6 months.(27)
Fatemeh Ehsani et al study on topic Neck pain in Iranian school teachers: Prevalence and risk
factors in 4April, 2007 according to this a response rate of 95% (n=586) was obtained from the
620 teachers for data analyses. Almost 38% of respondents were from primary schools and 62%
from high schools. Three hundred and eighty-seven (66%) of the participants were female, and
197 (34%) were male in this study. There was a significant association and increased prevalence
of NP with a number of risk factors such as; being female, age, general health, length of
employment, regular exercise and job satisfaction (P<0.05 in all instances).(28)
Kyeong Min Son et al study on topic Prevalence and Risk Factor of Neck Pain in Elderly Korean
Community Residents in 2 May 2013 according to this study the lifetime prevalence of neck pain
was 20.8% with women having a higher prevalence. The prevalence did not increase with age,
and the majority of individuals had low-intensity/low-disability pain. Subjects with neck pain
had a significantly worse SF-12 score in all domains except for mental health. The prevalence of
neck pain was significantly associated with female gender, obesity and smoking. (29)
Nunes et al study on topic Neck pain prevalence and associated occupational factors in
Portuguese office workers in September 2021 according to the study The prevalence of neck pain
was 56.1%. An average of 35.6% of the office workers with neck pain reported pain in more than
three body segments. The significantly risk factors were “age between 50 and 65” [OR: 1.92
(1.26–2.91) P = 0.002], “working without break for 2 h” [OR: 1.82 (1.00–3.31) P = 0.05], “more
than 3 h” [OR: 2.41 (1.35–4.10) P = 0.003], screen localization not centered” [OR: 2.01 (1.01–
4.00) P = 0.045], and “use of computer mouse more than 50% of the worktime” [OR: 2.05
(1.14–3.71) P = 0.017].(30)

Keith T Palmer et al study on topic Prevalence and occupational associations of neck pain in the
British population in February 2001 according to this study Among 12 907 respondents, 4348 and
2528 reported neck pain in past year (1421 with pain interfering with normal activities) and week,
respectively. Symptoms were the most prevalent among male construction workers [past week and
year 24% and 38% (pain interfering with activities 11%), respectively], followed by nurses, armed
services members, and the unemployed. Generally, the age-standardized prevalence of neck pain
varied little by occupation. Work with arms above the shoulders for > 1 hours/day was associated with
a significant excess of symptoms [PR 1.3— 1.7 (women) and 1.2— 1.4 (men)], but no associations
existed for typing, lifting, vibratory tool use, or professional driving. Stronger neck-pain associations
were found with frequent headaches (PR 2.3— 2.8) and frequent tiredness or stress (PR 2.2— 2.5)
than with occupational activities.(31)

Lloyd Long Yu Chan MSc, PT et al study on topic The prevalence of neck pain and associated
risk factors among undergraduate students: A large-scale cross-sectional study In March 2020
according to the study the total of 5,195 invitation emails were sent. Of 1,002 respondents,
22.3% reported having current neck pain. Physiotherapy (26.5%) and nursing students (26.1%)
had significantly higher prevalence of neck pain as compared to business students (13.2%).
Anxiety (odds ratio (OR):1.11, 95%CI:1.07–1.16), concurrent low back pain (OR:3.28,
95%CI:2.15–5.00) and senior years of studies (OR:1.19,95%CI:1.01–1.41) were significantly
associated with the presence of neck pain. Taller students (OR:1.02,95%CI:0.99–1.05) and
prolonged smartphone usage (OR:1.05,95%CI:0.99–1.12) appeared to be associated with the
presence of neck pain.(32)
Ehrmann Feldman et al study on topic Risk Factors for the Development of Neck and Upper
Limb Pain in Adolescents in March1, 2002 according to the study The cumulative annual
incidence of neck and upper limb pain was 28.4%. The risk factors for neck and upper limb pain
were working (adjusted odds ratio, 1.89; 95% confidence interval, 1.11–3.32) and lower mental
health score (adjusted odds ratio, 1.68; 95% confidence interval, 1.19–2). Students involved in
childcare were at a higher risk for the development of pain (adjusted odds ratio, 2.25; 95%
confidence interval, 1.18–4.29).(33)

B. Cagnie et al study on topic Individual and work-related risk factors for neck pain among
office workers: a cross sectional study in 8 December, 2006 according to the study The 12 month
prevalence of neck pain in office workers was 45.5%. Multivariate analysis revealed that women
had an almost two-fold risk compared with men (OR = 1.95, 95% CI 1.22–3.13). The odds ratio
for age indicates that persons older than 30 years have 2.61 times more chance of having neck
pain than younger individuals (OR = 2.61, 95% CI 1.32–3.47). Being physically active decreases
the likelihood of having neck pain (OR = 1.85, 95% CI 1.14–2.99). Significant associations were
found between neck pain and often holding the neck in a forward bent posture for a prolonged
time (OR = 2.01, 95% CI 1.20–3.38), often sitting for a prolonged time (OR = 2.06, 95% CI
1.17–3.62) and often making the same movements per minute (OR = 1.63, 95% CI 1.02–2.60).
Mental tiredness at the end of the workday (OR = 2.05, 95% CI 1.29–3.26) and shortage of
personnel (OR = 1.71, 95% CI 1.06–2.76) are significantly associated with neck pain. The results
of this study indicate that physical and psychosocial work factors, as well as individual variables,
are associated with the frequency of neck pain. (9)
Fatemeh Ehsani et al study on topic The Prevalence, Risk Factors and Consequences of Neck
Pain in Office Employees in January 15, 2017 according to study the Immediate, last month, last
six months, last year, and lifetime prevalence of NP were 38.1%, 39.7%, 41.1%, 45.8% and,
62.1%, respectively. The point prevalence of NP was significantly related to age, gender, health
status, job satisfaction, and length of employment (P < 0.05). Elongated working hours on the
computer, taking a prolonged sitting position, and static postures were the most irritating factors,
respectively (P < 0.001). Taking medications and physiotherapy were the most effective
intervention strategies that participants chose for the treatment of NP (60.2%).(34)
Anas Mohammed Alhakami et al study on topic The Prevalence and Associated Factors of Neck
Pain among Ministry of Health Office Workers in Saudi Arabia: A Cross Sectional Study in 16
july, 2022 according to the study A total of 413 subjects (176 females and 237 males)
participated in our study with an average age of 33.6 ± 8 years. The prevalence of neck pain in
our participants was 64% during a twelve-month period. Females were less likely to suffer neck
pain than males (OR = 0.52, 95%CI [0.30,0.87]), and age, BMI, level of education, and
profession were not associated with likelihood of having neck pain. However, reduced working
hours were associated with a reduction in the likelihood of having neck pain (OR = 0.42, 95%CI
[0.33,0.53]).(35)
Hviid Andersen, et al study on topic Physical, Psychosocial, and Individual Risk Factors for
Neck/Shoulder Pain with Pressure Tenderness in the Muscles Among Workers Performing
Monotonous, Repetitive Work in 15 March, 2002 according to the study The prevalence of
neck/shoulder pain with pressure tenderness was 7.0% among participants performing repetitive
work and 3.8% among the referents. We found an association with high repetitiveness
(prevalence ratio 1.8, 95% confidence interval 1.1–2.9), high force (2.0, 1.2–3.3), and high
repetitiveness and high force (2.3, 1.4–4.0). The strongest work-related psychosocial risk was
high job demands (1.8, 1.2–2.7). Increased risk was also associated with neck/shoulder injury
(2.6, 1.6–4.1), female gender (1.8, 1.2–2.8), and low-pressure pain threshold (1.6, 1.1–2.3).
Neck/shoulder pain was strongly associated with reduced health-related quality of life.(36)

Michel Guez et al study on topic the prevalence of neck pain in 08 July, 2009 according to the
study The sample included 8,356 subjects and 6,000 (72%) of them answered. 43% of the
population reported neck pain, more women (48%) than men (38%). Women of working age had
more neck pain than older ones, a phenomenon not seen among men. Chronic neck pain, defined
as continuous pain of more than 6 months' duration, was commoner in women (22%) than men
(16%). More than one fourth of the cases with chronic symptoms had a history of neck or head
trauma and one third of these had sustained a whiplash type of injury. Thus, all types of neck
trauma seem to be associated with chronic neck pain.

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