_________________________________________________________________________ Neck Pain in Adults
In patients with chronic neck pain, exercise-induced hypoalgesia after isometric exercises seems less dependent on exercise intensity than aerobic exercises, which may increase adherence. Isometric exercise has potential as a rehabilitation component to target central mechanisms of pain [236]. PSYCHOSOCIAL INTERVENTIONS People with chronic pain are not passive; they actively attempt to change the causes of pain and their behavior in response to pain. For many patients, such change without therapeutic help is unachievable, and repeated misdirected efforts to resolve their pain problem can drive a cycle of pain, depression, and disability. Psychological interventions are designed to promote adaptive pain management and reduce the consequences [238]. As such, psychosocial interventions are used in select patients with acute or chronic pain. Examples include cognitive- behavioral therapy (CBT), relaxation training, mindfulness training, and sleep hygiene training. Cognitive-Behavioral Therapy CBT is widely used in the treatment of pain-related functional impairments and disabilities. In general, CBT is a skills- training intervention that emphasizes identifying and changing maladaptive cognitions, emotions, and behaviors, and can be delivered in individual or group-based sessions [79]. In fear-avoidance, CBT targets pain catastrophizing and avoidant beliefs (maladaptive cognitions), fear (a maladaptive emotion), and avoidant (maladaptive) behaviors by helping the patient develop and apply coping strategies that enhance problem-solving for successfully confronting and self-managing health-related threats posed by pain. Core elements of this approach are [79; 239]: • Graded homework assignments • Cognitive restructuring (i.e., learning how to challenge maladaptive cognitions) • Relaxation training (e.g., diaphragmatic breathing, progressive muscle relaxation, imagery) • Time-based activity pacing (paced by time and not task completion) • Extinguishing pain behaviors (i.e., verbal and nonverbal expressions of pain) Other strategies taught to patients include distraction (diverting attention away from pain), reinterpretation (changing thoughts about pain), dissociation (separating pain from other sensations), coping self-statements (affirming self- messages), and emotional disclosure (expressive writing) [239]. CBT is widely endorsed for patients with subacute or chronic spinal pain and comorbid psychosocial conditions. CBT can lead to long-term improvements in pain intensity, disability, quality of life, pain-related coping, depressed mood, and health care-seeking behaviors. The favorable effects of CBT on pain outcomes are supported by functional imaging studies [79; 240].
Two systematic reviews found inconsistent evidence of pain reduction with CBT. In chronic neck pain, changes in pain and disability were only found when CBT was compared with no treatment, and no effects on kinesiophobia were found. In subacute neck pain, CBT showed benefit in pain relief but not disability compared with other interventions, but the size of these effects was not clinically meaningful. These conclusions were stated as based on low-quality evidence, which might change with new data [241]. A broader review of psychological interventions evaluated recent-onset and persistent neck pain separately [242]. In persistent (three to six months) neck pain with or without radiculopathy, researchers found no clear evidence supporting CBT or relaxation training for reducing pain intensity or disability; however, they did find that Jyoti (candle or light) meditation may help reduce neck pain intensity and bothersomeness. In persistent post-whiplash pain, evidence to support the efficacy of biofeedback or relaxation training was not found, and evidence for using CBT was conflicting. Adding progressive goal attainment to functional restoration physiotherapy may benefit these patients. In recent-onset (less than three months) neck or post-whiplash pain, there was no evidence for or against using psychological interventions. The limited evidence support for psychological interventions may reflect interventions that are ineffective or poorly conceptualized or implemented [242]. In another study, a physiotherapist-led cognitive-behavioral intervention was effective in modifying cognitive risk factors in patients with chronic neck pain. These patients showed larger increases in functional self-efficacy, greater reductions in pain intensity and pain-related fear, and a greater proportion attained clinically meaningful reductions in pain and disability compared with patients randomized to a progressive neck exercise program. Both were delivered in group format [243]. One randomized controlled study compared two brief cognitive-behavioral programs that included sessions of multimodal exercises [244]. Fifteen patients underwent four sessions of CBT based on the NeckPix—a measure of pain- related fears of a specific set of activities of daily living. Another 15 patients received four sessions of CBT based on the Tampa Scale of Kinesiophobia—a patient self-report questionnaire designed to evaluate fear of movement, fear of physical activity, and fear avoidance. Following CBT, both groups attended 10 sessions of multimodal exercises for five weeks’ duration [244]. No changes were found in neck disability index at the end of CBT, while a significant improvement was found for both groups at the end of motor training. Similarly, there was no change in quality of life after CBT, and a significant change at the end of motor training, with a partial loss at follow-up. From CBT sessions to follow-up, both groups showed progressive reduction in kinesiophobia [244].
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