Accepted Manuscript Repositioning error, pressure pain threshold, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain Sofia Sá, MSc, Anabela G. Silva, PhD PII:

S2468-7812(17)30085-1

DOI:

10.1016/j.msksp.2017.04.011

Reference:

MSKSP 81

To appear in:

Musculoskeletal Science and Practice

Received Date: 5 October 2016 Revised Date:

6 April 2017

Accepted Date: 29 April 2017

Please cite this article as: Sá, S., Silva, A.G., Repositioning error, pressure pain threshold, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain, Musculoskeletal Science and Practice (2017), doi: 10.1016/j.msksp.2017.04.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Title: Repositioning error, pressure pain threshold, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain

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Short title: Functional changes in adolescents neck pain

Authors: Sofia Sá1, MSc; Anabela G. Silva1,2, PhD

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Affiliations 1

School of Health Sciences, University of Aveiro, Portugal

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Address: Escola Superior de Saúde da Universidade de Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro - Portugal

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Center for Health Technology and Services Research (CINTESIS.UA), Universidade

Corresponding author:

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de Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro - Portugal

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Anabela G. Silva (PhD)

School of Health Sciences, University of Aveiro, Portugal

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Address: Escola Superior de Saúde da Universidade de Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro - Portugal Telephone: +351234247119, extension: 27120 Fax: +351 234 401597 e-mail: [email protected]

Manuscript being submitted for: original article This work received no funding. Authors declare no conflicts of interest.

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What’s already known about this topic? •

Adults with chronic neck pain have impaired proprioception and increased pain sensitivity when compared to matched asymptomatic controls Adolescents with chronic pain have increased anxiety and catastrophizing levels which seem to predict disability

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What does this study add?

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•

This study suggests that impaired repositioning sense and decreased pressure

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pain thresholds are a feature of chronic neck pain in adolescents This study suggests that increased levels of anxiety and catastrophizing are present in adolescents with chronic neck pain and are associated with pain

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intensity, frequency and duration and with disability due to neck pain

ACCEPTED MANUSCRIPT Title: Repositioning error, pressure pain threshold, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain

Abstract

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Background: Impaired proprioception, increased pain sensitivity, higher levels of anxiety and catastrophizing are present in adults with chronic idiopathic neck pain. Despite the high prevalence of neck pain, studies in adolescents are scarce.

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Objectives: The main aim was to compare pressure pain thresholds (PPTs) and joint repositioning error (JRE) between adolescents with chronic idiopathic neck pain and

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adolescents without neck pain. Secondary aims were to compare these groups for catastrophizing and anxiety and to investigate the association between PPTs, JRE and psychosocial variables and pain characteristics.

Methods: 80 adolescents (40 with and 40 without chronic neck pain) were assessed for: neck repositioning error, neck, upper trapezius and tibialis anterior PPTs, anxiety

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and catastrophizing. Neck pain was characterized in terms of intensity, frequency, duration and associated disability. MANCOVA was used for between group

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comparisons and Pearson and Spearman coefficients for correlational analysis. Results: Adolescents with neck pain showed higher levels of catastrophizing (p<0.001)

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and anxiety (trait: p<0.001; state: p=0.028), lower PPTs (p<0.001) and higher JRE (p<0.001) than asymptomatic controls. Pain intensity, frequency and duration were moderately correlated with anxiety, and disability was moderately correlated with anxiety (r between 0.43 and 0.50, p<0.05) and catastrophizing (r=0.40, p<0.05). Conclusions: This study suggests that functional changes and maladaptive cognitive processes are present in adolescents with neck pain aged 16 to 18 years old. These findings need to be replicated in future studies.

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ACCEPTED MANUSCRIPT Key words: Chronic neck pain, adolescents, pressure pain threshold, repositioning

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error, catastrophizing, anxiety

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Introduction Neck pain is the most prevalent musculoskeletal pain syndrome affecting young people (Aartun et al. 2014; Hoftun et al. 2011). In a study with 7373 adolescents aged 13 to 18 years old, neck pain prevalence was 14.3% in the group of adolescents aged 13 to 15

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years old and 20.9% in the group aged 16 to 18 years old while low back pain

prevalence was 10.9% and 17.5%, respectively (Hoftun et al. 2011). A systematic review of studies on neck pain prevalence in adolescents aged 16 to 18 years old

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showed that it increased from 22.9% in 1991 to 29.2% in 1999 and remained relatively stable from 1999 to 2011. In contrast, the prevalence of concomitant neck and low

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back pain increased from 6.9% in 1999 to 10.1% in 1999 and to 15.9% in 2011, while the prevalence of low back pain alone remained relatively constant (Ståhl et al. 2014). Furthermore, a prospective study suggests that the combination of pain in the neck and pain at other body sites is more common than pain in the neck only (Aartun et al.

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2014).

Neck pain associated changes in adults are relatively well characterized and can be

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used to inform assessment and treatment guidelines (Childs et al. 2008), but studies in adolescents with neck pain are scarce. Similarly to adults with neck pain, studies have

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shown that adolescents with neck pain have decreased endurance capacity of the neck flexor and extensor muscles (Oliveira & Silva 2016) and that depressed mood is a significant correlate of neck/shoulder pain (Pollock et al. 2011). In contrast to most studies in adults (Silva et al. 2009; Silva et al. 2010), it has been suggested that adolescents with neck pain show decreased forward head posture or no association between head posture and neck pain (Oliveira & Silva 2016; Richards et al. 2016), suggesting that neck pain associated changes in adolescents may differ from those found in adults. A reason for potential differences between adults and adolescents

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ACCEPTED MANUSCRIPT could be differences in pain characteristics, as adolescents seem to report pain of lower intensity and shorter duration (Aartun et al. 2014; Svedmark et al. 2016). The deep muscles of the neck are very rich in proprioceptors and seem to play a relevant role in cervical joint position sense (Kulkarni et al. 2001; Boyd-Clark et al.

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2002), but their function is impaired in the presence of both experimental and clinical

pain (Djupsjöbacka 2008). A method to quantify deep tissue pain such as muscles is the measurement of pressure pain thresholds (PPTs) (Svedmark et al. 2016), which

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seems to be influenced by psychosocial variables. For example, an association

between lower PPTs and increased levels of catastrophizing and between lower PPTs

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and increased levels of anxiety have been reported for young adults with chronic neck pain (Muñoz-García et al. 2016) and for university students with temporomandibular disorders (Vedolin et al. 2009), respectively. In contrast, the association between PPTs and pain characteristics is conflicting (Walton et al. 2016). To our knowledge no study investigated whether impaired cervical position sense, increased pain sensitivity,

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anxiety or catastrophizing are a feature of adolescents with neck pain. The main aim of this study was to compare PPTs and joint repositioning error (JRE) between adolescents with chronic idiopathic neck pain and adolescents without neck pain aged

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16 to 18 years old pain. Secondary aims were to compare these groups for catastrophizing and anxiety and to investigate the association between PPTs, JRE and

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psychosocial variables and pain characteristics. We hypothesized that adolescents aged 16 to 18 years old have higher JRE errors, lower PPTs and higher levels of anxiety and catastrophizing when compared against an age and sex matched group of asymptomatic participants. We also hypothesized that JRE and PPT are not correlated with pain characteristics, while increased anxiety and catastrophizing levels will be associated with increased pain intensity and disability.

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Methods

Ethical Approval Statement This study received Ethical approval from the Ethics Committee of xxxx University (n. º

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1/2015). Before entering the study participants and their legal guardians (if participants were 17 years old or less) had to give their written informed consent. Data collection

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took place in April and May 2015.

Participants

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Participants were recruited from the 10th, 11th and 12th grades at the Secondary School of XXXXX, in the academic year of 2014/2015. The present study was powered to detect a difference of 2.7º for JRE and of 4.5 N/cm2 for PPTs (alpha=0.05 and power=80%). Sample size was determined using an equation from Kirkwood and Sterne (2003) to calculate sample size for comparing two means from two independent

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samples. Between group differences and variance were based on a previous study of our lab for PPTs (findings not published) and on the findings of Roren et al. (2009) for JRE. The higher sample size calculation retrieved was for PPTs (n=39 in each group)

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and, therefore, 40 participants were recruited.

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Screening of participants was performed by SS who interviewed potential participants in order to determine whether they met the inclusion and exclusion criteria. Equal number of students with and without chronic idiopathic neck pain was recruited from each class. Chronic idiopathic neck pain was defined as: pain felt dorsally between the inferior margin of the occiput and T1 not related to trauma or any known pathology that was present at least once a week during the last 3 months (Bogduk & McGuirk 2006). Asymptomatic participants had no current neck pain and reported that they had never had neck pain. Participants were excluded if they reported any of the following 5

ACCEPTED MANUSCRIPT conditions: 1) a history of cervical trauma or surgery; 2) congenital anomalies involving the spine (cervical, thoracic or lumbar); 3) bony abnormalities such as scoliosis; 4) any systemic arthritis; or 5) any disorder of the central nervous system. Inclusion and

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exclusion criteria were established by self-report.

Procedures

Participants attended for assessment on one occasion where they had their neck pain

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characteristics assessed and measures of anxiety, catastrophizing, PPTs and JRE,

taken as specified below. All measurements were taken in the school facilities by XXX,

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a physiotherapist with more than 10 years of clinical practice.

Assessment of neck pain characteristics and of pain at other body sites Neck pain intensity at the moment, frequency in the previous week, duration, location and associated disability were assessed. Neck pain intensity was measured using a 10

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cm visual analogue scale (VAS) anchored with “no pain” and “worst pain imaginable”. Pain frequency and duration were assessed using forced choice questions developed for this study. Neck pain location was assessed using an upper body chart (a figure of

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the upper body) where participants were asked to mark their neck pain location. Pain

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location was posteriorly categorised as: upper neck pain (if in the upper half of the neck) or lower neck pain (if in the lower half of the neck). A disability index adapted from Hoftun et al. (2011) was used to assess to what extent neck pain interfered with the adolescents’ everyday life. Participants were asked to indicate if they agreed with one or more of the following statements: (1) I have difficulties falling asleep because of neck pain and/or neck pain disturbs my sleep; (2) because of neck pain I have difficulties sitting during a lesson; (3) neck pain disturbs me if I walk more than 1 km and; (4) neck pain disturbs me during physical exercise class; (5) because of neck pain

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ACCEPTED MANUSCRIPT I have difficulties doing daily activities in leisure time; (6) neck pain disturbs me in other activities, specify which. In addition, both participants with and without neck pain were asked whether they felt pain at other body sites and those who did were asked to mark them on a full body

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chart. For analysis purposes, the body chart was divided into 8 regions: shoulders,

elbows, wrists/hands, mid back, low back, hips, knees and ankles/feet, and the number

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of painful body regions was counted.

Trait and state anxiety

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Trait and state anxiety were assessed with the xxx version of the Staite-Trait Anxiety Inventory (STAIC) (Silva & Campos 1998). This instrument distinguishes between a tendency to anxious behavior rooted in the personality (trait) and the short term anxiety common to some situations (state), each measured using a 20-item scale. Each scale

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prompts the participant to rate each of the 20 statements from hardly ever true to often true. A separate score is produced for the State Scale and the Trait Scale. Scores range from 20 to 80 for each scale and higher scores are associated with higher levels

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Campos 1998).

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of anxiety. It has demonstrated good internal consistency (Cronbach α =0.76) (Silva &

Pain Catastrophizing The Pain Catastrophizing Scale (PCS) is composed of 13 statements and participants are prompted to indicate the degree to which they experience each of them when experiencing pain, on 5-point scales with the end points (0) not at all and (4) all the time. The 13 statements are grouped into 3 subscales: rumination (4 items), magnification (3 items) and helplessness (6 items). Total score ranges from 0 to 52 and higher scores are indicative of higher catastrophic thinking (Sullivan et al. 2004). The

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ACCEPTED MANUSCRIPT xxxx version of the PCS demonstrated good internal consistency (Cronbach α =0.91) (Jácome & Cruz 2004).

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Pressure pain threshold (PPT) evaluation An algometer (JTECH Medical Industries, Salt Lake City, US) was used to measure PPT at both the right and left upper trapezius (at the mid distance between the

posterior angle of the acromion and C7), the right and left articular pillar between C1

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and C2 (approximately 1 cm lateral and above the spinous process of C2), the right and left articular pillar of C5/C6 (approximately 1 cm lateral to the mid distance

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between the spinous processes of C5 and C6, which were identified by palpation) and over the right tibialis anterior (lateral to the medial malleolus). Before measurements on these points were taken, PPT measurement was demonstrated in the hand to familiarize the patient with the procedure. Participants were instructed to say “stop”

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when the sensation changed from pressure to pain. All PPTs were measured with the patient in prone, with the head aligned and as relaxed as possible except for the tibialis anterior, which was measured with the patient in supine. Three measurements were taken at each point with a probe of 0.5 cm of diameter and pressure was applied at a

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rate of approximately 3N/s up to a maximum of 60N, which was not exceeded because

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of the risk of tissue damage. The mean value was used for between group comparisons. A 30-second resting period was allowed between each measurement. These procedures were in line with previous studies (De Camargo et al. 2011; Azevedo et al. 2008).

Joint repositioning error The neck repositioning error was measured as described by Revel et al. (1991): a lazer pointer was fixed on the top of a helmet that participants used during measurements;

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ACCEPTED MANUSCRIPT participants were seated in a standard chair placed 90 cm away from a wall where the targed (a A3 sheet of millimetric paper) was fixed and had their eyes closed. Movements used were right and left rotations. Before beginning the test, participants had their head in neutral position, which was marked on the target (corresponded to

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where the light of the laser pointer was on the sheet of paper); from this position participants were asked to fully rotate their head to the left or right and to return to the initial neutral position that was remarked on the target. Between each trial, the examiner manually adjusted the participant’s head to match the original starting

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position and gave no feedback on accuracy. Each participant performed 3 movements to the left and 3 movements to the right (Fig. 1). One familiarization trial for each side

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(one right and one left) was conducted before measurements. The laser method has a good test-retest reliability and a strong correlation with an ultrasound technique (Roren et al. 2009).

Data analysis

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Statistical analysis was performed using SPSS version 22 (IBM, New York). To explore

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differences between groups a multivariate analysis of covariance (MANCOVA) was performed with trait and state anxiety, catastrophizing (total score and the 3 subscales

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score), PPTs and JRE as the dependent variables, group (neck pain vs. no neck pain) as the fixed factor and number of painful body sites (excluding the neck) as the covariate. There was homogeneity of between group variance for the dependent variables (Levene’s test, p>0.05). Normality of data was inconsistent, but nonsignificant for most variables and MANCOVA is claimed to be robust to minor violations of normality (Kirkwood & Sterne 2003). A correlation matrix for all independent variables was performed to assess multicollinearity. The correlation between JRE and PPTs and the psychosocial variables was ≤0.53, suggesting no multicollinearity. Associations between variables (anxiety, catastrophizing, PPTs and JRE and pain 9

ACCEPTED MANUSCRIPT characteristics) were explored using a Spearman correlation coefficient for ordinal variables and a Pearson correlation coefficient for continuous variables and the strength of the correlation was interpreted as low if the coefficient was < 0.3, moderate if it was between 0.3 and 0.5, and strong if it was > 0.5 (Cohen 1988). Significance was

Results

Sample characteristics and neck pain

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set at p<0.05.

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A total of 180 adolescents were screened for inclusion, of which 30 refused to

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participate without reasons (7 with neck pain and 24 without pain). Of the remaining 150, 40 reported neck pain and accepted to participate in the study and another 40 asymptomatic adolescents matched for age and sex to the neck pain group were recruited. Both groups had 21 (52.5%) females and a mean(±SD) age of 17.2±0.56 years old. In the group of adolescents with chronic neck pain, 29 (70.0%) had pain at

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other body sites (low back - n=13; knee – n=6; mid back n=3; arm – n=1; pain in two or more of these body sites – n=6) and in the group without neck pain, 20 (50.0%) had pain at other body sites (low back - n=10; knee – n=3; mid back n=1; arm – n=2; pain

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in two or more of these body sites – n=4). Neck pain characteristics and associated

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disability are presented in Table 1.

Between group comparisons for anxiety, catastrophizing, pressure pain threshold and joint repositioning error The MANCOVA revealed a significant main effect of group (Pillai’s Trace: F (15,63) = 9.56; p <0.001). Pairwise comparisons revealed significant differences between groups for the total score of the pain catastrophizing scale (F (2,77) = 9.69; p <0.001), and subscales of rumination (F (2,77) = 15.38; p <0.001) and helplessness (F (2,77) = 9.35; p <0.001), for trait (F (2,77) = 9.07; p <0.001) and state anxiety (F (2,77) = 3.76; p=0.028), for all PPTs including the tibialis anterior (F (2,77) ≥ 31.22; p <0.001) and for 10

ACCEPTED MANUSCRIPT both the right (F (2,77) = 7.01; p =0.002) and left rotation (F (2,77) = 8.67; p <0.001) JRE. No significant between group differences were found for the subscale of the PCS magnification (F (2,77) = 0.94; p> 0.05).

pain threshold and joint repositioning error

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Association between pain characteristics and catastrophizing, anxiety, pressure

Higher pain intensity and higher pain duration were moderately associated with higher trait anxiety (r=0.32 and r=0.33, respectively; p<0.05). Higher pain frequency was

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moderately associated with both higher trait (r=0.32, p<0.05) and state (r=0.32, p<0.05) anxiety levels. Increased disability due to neck pain was moderately associated with

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higher levels of state and trait anxiety, amplification, helplessness and catastrophizing (r≥0.35, p<0.05).

There is a positive moderate association between pain intensity and pressure pain thresholds at the left C1/C2 articular pillar (r= 0.40; p <0.05) and at the right C5/C6

and JRE (Table 3).

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Discussion

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articular pillar (r= 0.35; p <0.05). No other significant associations were found for PPTs

This study suggests that adolescents with chronic idiopathic neck pain have increased

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pain sensitivity both in the neck and at a distant body site, decreased neck position sense as well as increased trait and state anxiety and catastrophizing than adolescents without neck pain. Additionally, it suggests that increased pain intensity, frequency, duration and disability are moderately associated with increased levels of anxiety; disability is also moderately associated with increased magnification, helplessness and catastrophizing, but the correlation values are relatively low and need to be interpreted with caution. Nevertheless, this study results support further studies investigating functional changes associated with neck pain as well as studies investigating the

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ACCEPTED MANUSCRIPT effectiveness of multimodal interventions targeting anxiety, catastrophizing, proprioception and primary and secondary hyperalgesia in adolescents with neck pain.

Increased pain sensitivity in the neck region in adults with neck pain is consensual. For

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example, Javanshir et al. (2010) measured PPTs in a group of adult participants with chronic neck pain, a group with acute neck pain and an asymptomatic group and

reported that both acute and neck pain participants showed lower PPTs in the articular pillar of C5/C6 (chronic neck pain: mean±sd=11.53 ± 2.61N/cm2; acute neck pain:

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mean±sd=14.22 ± 10.1N/cm2) compared to asymptomatic participants

(mean±sd=20.53 ± 7.51N/cm2). These values are lower than those found in the present

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study, potentially due to the small size of the groups (5 to 7 participants) in Javanshir ‘s study and/or to differences in the sample characteristics (patients referred to physical therapy). The local increased sensitivity to pain can be classified as primary hyperalgesia and is believed to reflect nociceptor sensitization and/or sensitization of

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the spinal cord at the corresponding segmental level (Malfliet et al. 2015). Nevertheless, evidence for increased pain sensitivity at body sites distal to the neck, i.e., secondary hyperalgesia is conflicting. Secondary hyperalgesia is likely due to the

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sensitization of central pain signaling neurons (Treede et al. 1992). A systematic review on the evidence for a central sensitization component in idiopathic neck pain found 6

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studies that compared PPTs in adults with neck pain and asymptomatic controls (Malfliet et al. 2015). The authors of this review concluded that there was mixed evidence for secondary hyperalgesia measured by PPTs as the number of studies providing evidence for and against secondary hyperalgesia was the same. It could be argued that pain at body sites other than the neck could have contributed to the findings of the present study and, therefore, number of other painful body sites was accounted for in the statistical analysis. Furthermore, when applying the criteria to identify central sensitization proposed by Nijs et al. (2014) it could be considered that our sample of adolescents met 2 of the 3 criteria for central sensitization: i) presents 12

ACCEPTED MANUSCRIPT insufficient evidence of injury, pathology, or objective dysfunctions for generating nociceptive input capable of causing the self-reported pain and disability and ii) present diffuse pain distribution (bilateral neck pain is presented by 82.% and pain at other body regions by 70% of the sample). In addition, sleeping problems (reported by 52.5%

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of our sample) are reported as being often present in individuals with central sensitization (Nijs et al. 2014) and psychosocial characteristics, such as

catastrophizing, might contribute to central sensitization (Roussel et al. 2013).

Nevertheless, data suggests that the sample is heterogeneous in terms of pain

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intensity, frequency and duration and presence of pain in other body sites, and future

adolescents with neck pain.

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studies should explore differences in pain sensitization between subgroups of

Regarding repositioning error, these study findings are in line with findings in adults with neck pain. Two systematic reviews of studies comparing neck proprioception

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between adults with neck pain and asymptomatic controls concluded that adults with neck pain are worse than asymptomatic controls at head-to-neutral repositioning tests (Stanton et al. 2016; de Vries et al. 2015), suggesting impaired joint positioning sense,

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one of the components of proprioception. Repositioning errors for rotation-to-neutral varied between 3.3º and 6.1º (de Vries et al. 2015). Neck muscles, in particular the

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small suboccipital deep muscles have a very high density of muscles spindles and are, therefore, essential contributors to neck proprioception (Kulkarni et al., 2001, Liu et al., 2003). Several mechanisms may contribute to the altered neck position sense, including: the effects of pain itself on both nociceptor and mechanoreceptor activity locally, at the spinal cord and within the central nervous system (Le Pera et al. 2001); disturbed sensitivity of the cervical joint and muscles receptors (Johansson et al. 1999) or by inflammatory mediators (Thunberg et al. 2001). In addition, central sensitization (as suggested by the PPTs and other findings of the present study discussed in the previous paragraph), is believed to be associated with reorganization of the 13

ACCEPTED MANUSCRIPT somatosensory cortex in chronic pain syndromes, including changes in the cortical representation of painful body sites (Tsay et al. 2015; Seifert & Maihöfner 2011). This disruption of the body map may also influence proprioception (Tsay et al. 2015). Based on the present study results, pain characteristics seem unrelated to joint position error,

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in line with studies in adults (de Vries et al. 2015).

We found increased levels of anxiety (trait) and catastrophizing in adolescents with

neck pain compared to those without neck pain, in line with previous studies in adults

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with neck pain (Thompson et al. 2010). However, our study results need to be

interpreted with caution and its clinical relevance requires further investigation as the

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catastrophizing and anxiety levels found in the present study are low when compared to those found in adolescents attending a chronic pain center (Tran et al. 2015) or against reference values (Silva & Campos 1998), respectively. Similarly, the moderate association found between disability due to neck pain and increased levels of anxiety

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and catastrophizing, is also in line with previous studies using large samples of adolescents with chronic pain (without consideration for pain location) (Hoftun et al. 2012; Tran et al. 2015). For example, Tran et al. (2014) found a correlation of 0.48

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between catastrophizing and disability and of 0.30 between anxiety and disability in a sample of 725 adolescents with chronic pain aged 8 to 18 years old. Trait anxiety was

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associated to a higher number of pain characteristics (intensity, frequency and duration) than state anxiety (frequency). A possible explanation is that trait anxiety is a more stable aspect of anxiety, defined as a stable tendency to attend to, experience, and report negative emotions including a manifestation of repeated concerns about body symptoms (Gidron 2013), while state anxiety refers to a temporary condition. The present study results suggest that anxiety and catastrophizing may play a role in neck pain and associated disability.

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ACCEPTED MANUSCRIPT Study limitations This study results need to be seen in light of its limitations. Firstly, participants were recruited from a single school what could limit the generalizability of results, particularly to adolescents with neck pain presenting at pain care centers. Secondly,

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measurements were not taken by a blinded assessor. Nevertheless and in order to minimize bias, the instructions given to participants were standardized. Thirdly, the size of the sample did not allow for subgroup comparisons. However, the group of

adolescents with neck pain was heterogeneous in terms of pain characteristics,

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suggesting the relevance of investigating differences in sensory, motor and

psychosocial variables between subgroups. Finally, the disability index used was not

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specific of adolescents with neck pain and did not allow participants to grade the degree of disability and, therefore, may not have captured accurately the sample characteristics in terms of disability.

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Implications for research and clinical practice

This study results highlight the need to value adolescents complaints and support future studies on the effect of multimodal preventive strategies and treatment programs

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directed at adolescents with neck pain. Furthermore, they suggest that assessing anxiety, catastrophizing, PPTs and JRE can have value to inform treatment strategies

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and treatment progression.

Conclusion

This study suggests that adolescents with neck pain show higher levels of anxiety and catastrophizing, impaired joint position sense and increase pain sensitivity when compared to matched controls without neck pain and that increased levels of anxiety are moderately associated with higher pain intensity, frequency and duration and increased levels of anxiety and catastrophizing are moderately associated with disability. Further studies are needed to verify these findings . 15

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ACCEPTED MANUSCRIPT Legends for tables and illustrations

Table 1 – Neck pain characteristics (n=40).

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Table 2 – Between group comparisons for catastrophizing, anxiety, pressure pain threshold and joint positioning error

Table 3 – Correlation between pain characteristics and catastrophizing, anxiety,

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pressure pain threshold and joint repositioning error for participants with neck pain

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(n=40).

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Figure 1 – Measurement of cervical repositioning error: participant positioning.

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ACCEPTED MANUSCRIPT Table 1 Neck pain characteristics

Results (n=40) 4 (10.00%)

Left

0 (0.00%)

Right+Left

9 (22.50%)

Right Lower neck

Intensity (VAS)

Right

2 (5.00%)

Left

0 (0.00%)

Right+Left

5 (12.50%)

Mean ± SD

3.39 ± 1.84

≤ 1 once a week

24 (60.0%)

2/3 times a week

12 (30.0%)

>3 times a week

4 (10.0%)

3 to 6 months

15 (37.5%)

> 6 months & < 1 year

7 (17.5%)

≥1 & < 2 years

9 (22.5%)

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Duration n (%)

19 (47.50%)

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Frequency

Disability n (%)

0 (0.00%)

Right+Left

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Upper and lower neck

Left

1 (2.50%)

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Location n (%)

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Upper neck

Right

≥2 & < 5 years

4 (10.0%)

≥ 5 years

5 (12.5%)

Difficulties sleeping

21 (52.5%)

Difficulties sitting

32 (80.0%)

Difficulties walking

4 (10.0%)

Difficulties in leisure activities

16 (40.0%)

Difficulties during exercise class

19 (47.5%)

Difficulties in other activities

4 (10.0%)

Mean ± SD (number of activities

2.40 ± 1.65

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reported per adolescent)

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ACCEPTED MANUSCRIPT Table 2 Results (mean ± SD) Variables

NoNo neck pain (n=40) 2.95 ± 3.57

6.40 ± 3.57

Magnification

3.95 ± 2.19

4.00 ± 2.25

0.936

Helplessness

2.83 ± 3.31

5.93 ± 3.85

<0.001

Catastrofizing (Total)

9.73 ± 7.61

16.33 ± 8.47

<0.001

State anxiety

28.25 ± 10.71

32.05 ± 9.07

0.028

Trait anxiety

33.23 ± 5.36

39.98 ± 10.53

<0.001

Right upper

<0.001

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Anxiety

Rumination

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zing

p

(n=40)

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Catastrofi

Neck pain

34.87 ± 8.10

20.68 ± 5.12

<0.001

36.10 ± 7.63

20.47 ± 5.08

<0.001

24.72 ± 5.21

15.45 ± 4.23

<0.001

26.80 ± 5.67

16.51 ± 5.47

<0.001

27.81 ± 7.02

16.71 ± 5.19

<0.001

31.51 ± 6.11

20.12 ± 6.07

<0.001

54.78 ± 6.98

41.40 ± 8.48

<0.001

Right rotation

3.37 ± 1.94

5.22 ± 2.60

0.002

Left rotation

3.82 ± 2.67

6.22 ± 2.71

<0.001

trapezius Left upper trapezius Right articular pillar

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C1/C2 PPTs

Left articular pillar

(N/cm2)

C1/C2

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Right articular pillar C5/C6

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Left articular pillar C5/C6

Tibialis anterior

JRE (º)

PPTs – pressure pain thresholds; JRE – joint repositioning error.

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ACCEPTED MANUSCRIPT Table 3 Variables

Frequency

Duration

Disability

0.16

0.15

0.02

0.30

Magnification

0.21

-0.08

-0.12

0.40*

Helplessness

0.14

-0.01

0.10

0.35*

Catastrofizing (Total)

0.19

0.06

0.04

0.40*

State anxiety

0.19

0.32*

0.32*

0.32*

0.08

0.06

Catastrophizing Rumination

Anxiety

Trait anxiety

trapezius

pillar C1/C2 PPTs

Left articular

0.50**

-0.16

0.06

0.01

0.08

0.30

0.01

0.06

-0.17

0.40*

0.08

0.27

0.09

0.35*

-0.07

-0.16

0.10

0.21

0.13

0.10

0.09

-0.09

0.03

-0.13

-0.13

-0.14

0.05

-0.04

-0.16

-0.07

-0.19

-0.08

-0.13

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pillar C1/C2

0.33*

0.13

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Right articular

0.43**

0.24

Left upper trapezius

0.001

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Right upper

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Intensity

Right articular pillar C5/C6

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Left articular pillar C5/C6

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Tibialis anterior

Right rotation

JRE

Left rotation

PPTs – pressure pain thresholds; JRE – joint repositioning error; **p <0.01 *p <0.05

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Figure 1

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ACCEPTED MANUSCRIPT Highlights •

Adolescents with neck pain seem to have increased pain sensitivity both locally and at distance; Adolescents with neck pain seem to have impaired joint repositioning sense;

•

Adolescents with neck pain seem to catastrophize and be more anxious than

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•

asymptomatic adolescents •

There is the need for multimodal interventions targeting neck pain in

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adolescents