Martine Verwoerd

The main aim of this thesis was to research the prognostic factors involved in the development of chronic non-specific neck pain (NSNP) and to develop a prognostic model that will enable better prediction of which patients are at risk of developing chronic pain. Additionally, this research explores physiotherapists’ knowledge, attitude, and practice behaviors in managing (sub)acute NSNP.

PART 1 of this thesis starts with a systematic review in CHAPTER 2, identifying prognostic factors for the persistence of pain and perceived non-recovery following an episode of NSNP. A comprehensive literature search, encompassing studies up to October 21, 2017, focused on prospective prognostic studies evaluating pain intensity and perceived non-recovery. Quality assessment was conducted using the Quality in Prognostic Studies (QUIPS) tool. Six prospective studies were included out of 2,737 articles screened, analyzing 47 and 43 factors for pain intensity and perceived non-recovery, respectively. Moderate evidence suggested that age over 40 years and accompanying back pain are prognostic for persistent pain intensity. For perceived non-recovery at 12 months, previous neck pain episodes and accompanying headaches showed moderate evidence as prognostic factors. However, the quality of evidence was rated as low to very low.

Following the systematic review revealing low-quality evidence for prognostic factors in non-specific, non-traumatic neck pain, CHAPTER 3 aimed to identify and establish a consensus on potential prognostic factors, particularly those modifiable by physiotherapy. Employing a modified Nominal Group Technique (m-NGT) and a Delphi survey, this study gathered expert input to identify and categorize potential prognostic factors. Conducted from November 2018 to January 2020, the Delphi survey sought expert consensus on the prognostic value of these factors, their modifiability, and measurement methods in clinical practice. The m-NGT meeting initially identified 84 factors, refined to 47 and categorized into 12 groups. The subsequent Delphi survey led to consensus on 25 prognostic factors of chronic idiopathic, non-traumatic neck pain, 19 of which are potentially modifiable through physiotherapy, with a significant number being psychological. This emphasizes the importance of a biopsychosocial approach to further prognostic research.

Transitioning to PART 2, the focus shifts from identifying and finding experts’ consensus on prognostic factors to empirical research. CHAPTER 4 outlined a study protocol for the development and internal validation of a prognostic model. This study aimed to identify independent prognostic factors, both modifiable and non-modifiable, for the development of chronic pain in patients with acute or subacute nonspecific idiopathic, non-traumatic neck pain. This prospective cohort study, conducted between January 2020 and March 2023, involved 30 primary physiotherapy practices and followed patients with a six-month follow-up period, with measurement points at six weeks, three months, and six months. The study uses comprehensive data collection methods, including baseline questionnaires measuring candidate prognostic variables related to symptoms, work, general health, and psychological and behavioral factors. Chronic neck pain was defined as a Numeric Pain Rating Scale (NPRS) score of ≥ 3 at six weeks, three months and six months. The statistical analysis in this study was conducted according to the Prognosis Research Strategy (PROGRESS) framework, specifically type 3 research. Advanced statistical analyses were employed to develop and validate the prognostic model, including univariable and multivariable logistic regression and internal validation techniques like bootstrapping.

CHAPTER 5 describes the results of this prognostic study. A total of 603 participants were included after screening 2,567 patients. Out of the participants, 62 (10%) developed chronic pain. The univariable analyses identified significant prognostic factors of pain chronification, including gender (female), baseline pain intensity, pain duration, pain in different body regions, the onset of headache since the neck pain, higher disability scores, unemployment, higher scores on catastrophizing, illness beliefs about recovery (concerned and duration), depression, distress, and lower treatment beliefs. Vital prognostic factors in the final model included sex, pain intensity, pain in different body regions, headaches, ability to modify posture during work, employment status, and several illness beliefs and psychological measures, including illness beliefs about pain identity and recovery, treatment beliefs, distress, and self-efficacy. The model demonstrated good fit and predictive accuracy with an optimism-corrected AUC of 0.83 and a corrected R2 of 0.24. This study aimed to enhance the understanding of prognostic factors, aiding clinicians in making informed decisions, tailoring individual treatment approaches, and accurately predicting the likelihood of chronic pain development.

CHAPTER 6 aimed to compare the clinical characteristics and recovery rates between patients experiencing their first episode of nonspecific neck pain and those with recurrent episodes. Additionally, the study investigated the differences in daily activities, illness perceptions, and psychological factors between patients with mild pain (1–2 on the Numeric Pain Rating Scale (NPRS)) and those with moderate to severe pain (≥ 3 NPRS) six weeks after their initial presentation in clinical practice. Data from the prognostic study was used. The study cohort included 198 (33%) individuals experiencing their first episode of (sub)acute neck pain and 405 (67%) with recurrent neck pain. Among the 449 responders at six weeks, 278 participants still reported experiencing neck pain, with a mean intensity of 4.2 (SD = 2.0). The findings indicated no clinically meaningful differences in the clinical characteristics or recovery rates at six weeks, three months, and six months between patients experiencing their first episode of NSNP and those with recurrent episodes. However, significant differences emerged in how mild pain (1–2 NPRS) versus moderate to severe pain (≥ 3 NPRS) impacted disability, patient concerns, and self-efficacy at the six-week mark. Patients with higher pain intensity reported greater disability, higher levels of concern, and lower self-efficacy. Specifically, the differences were clinically meaningful with a 1.33-point difference (SD 0.84–1.81) in disability on a 0–7 scale, a -1.25-point difference (SD -1.84 to -0.65) in self-efficacy on a 0–12 scale, and a 1.87-point difference (SD 1.21–2.52) in patient concerns on a 0–10 scale.

PART 3 shifts the focus to physiotherapists working in primary care. CHAPTER 7 aimed to explore physiotherapists’ knowledge, attitudes, and practice behaviors in managing non-specific, non-traumatic, (sub)acute neck pain, focusing on identifying and modifying prognostic factors for chronic pain. This study utilized semi-structured interviews with 13 primary care physiotherapists, employing qualitative content analysis for data interpretation. In-depth interviews were conducted following the Knowledge-Attitude-Practice (KAP) framework. A purposive sample method was used to capture diverse perspectives. Seven main themes emerged from the analysis: (1) Self-estimated Knowledge and Attitude; physiotherapists recognized the impact of psychosocial factors on neck pain and generally shifted from a biomedical to a biopsychosocial approach over time. (2) Role clarity: there were varied perceptions of role boundaries, with some expanding their roles to include psychosocial aspects. (3) Therapeutic relationships, trust, and cooperation were deemed essential. Physiotherapists often adapted their approach to align with patient expectations. (4) Internal barriers to practice, limited knowledge, and skills in dealing with complex psychosocial factors were noted. (5) External barriers to practice: patients’ reluctance to engage in a biopsychosocial approach was a common barrier. (6) Practice behaviors: physiotherapists relied more on experience than structured assessments for psychosocial factors, with a tendency to prioritize physical treatment approaches. (7) Self-reflection: this was considered crucial for professional development and adopting a broader therapeutic perspective. This chapter revealed a complex relationship between physiotherapists’ knowledge, attitudes, and practice behaviors in managing neck pain. Despite a general shift towards a biopsychosocial approach, physiotherapists faced challenges integrating it into their practice, influenced by personal attitudes, patient expectations, and individual competencies. This chapter highlights the need for enhanced training and support in biopsychosocial approaches, emphasizing the role of self-reflection in professional growth and practice improvement.