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Aims: Back pain and neck/shoulder pain are common among nurses. The aim of this study was to investigate the association between nurses' exposure to a demanding psychosocial work environment during the first three years after graduation and the occurrence of severe back pain and neck/shoulder pain in the longer term, 11-15 years later., Methods: The Longitudinal Analysis of Nursing Education (LANE) study (nursing graduates from 26 Swedish universities in the years 2002, 2004 and 2006) was used to create two risk cohorts of nurses not reporting severe back pain ( n =1764) or neck/shoulder pain ( n =1707). Nurses exposed to a demanding psychosocial work environment for one, two or three of the first three years in their career were compared to nurses not having a demanding psychosocial work environment for any of these three years regarding the incidence of severe back pain or neck/shoulder pain at follow-up, 11-15 years later. Relative risks (RR) with 95% confidence intervals (CI) were calculated using binomial regression., Results: The RR (95% CI) of having severe back pain for nurses who had a demanding psychosocial work environment for one of the three years was 1.36 (0.82-2.28) and 2.08 (1.21-3.57) for two of the three years and 2.82 (1.43-5.55) for all three years. Corresponding RRs (95% CIs) for severe neck/shoulder pain were 1.35 (0.87-2.10), 1.49 (0.88-2.51) and 1.41 (0.62-3.20), respectively., Conclusions: Nurses who were repeatedly exposed to a demanding psychosocial work environment early in their career reported severe back pain to a higher extent in the longer term., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Objectives: Long-duration activity-limiting neck/back pain is common, but the knowledge of what work and lifestyle factors that influence the prognosis is sparse. The objective was therefore to evaluate if two factors, good self-perceived work ability and no daily smoking, are associated with a favourable prognosis of long-duration activity-limiting neck/back pain in a working population, and if these exposures have a synergistic prognostic effect., Design: A prospective cohort study based on three subsamples from the Stockholm Public Health Cohort., Settings: A working population in Stockholm County, Sweden., Participants: Individuals, 18-61 years old, reporting long-duration activity-limiting neck/back pain the previous 6 months at baseline in 2010 (n=5177)., Measures: The exposures were: self-perceived work ability (categorised into good, moderate and poor) and daily smoking (no/yes). The outcome in 2014 was 'absence of long-duration activity-limiting neck/back pain' the previous 6 months representing a favourable prognosis of reported problems at baseline in 2010. Risk ratios (RRs) and risk differences (RDs) with 95% CI was estimated by general linear regressions, and the synergistic effect was estimated by the synergy index (SI) with 95% CI., Results: Participants with moderate or good work ability, respectively, had an adjusted RR for a favourable prognosis of 1.37 (95% CI 1.11 to 1.69), and 1.80 (1.49 to 2.17) in comparison with participants with poor work ability. The corresponding adjusted RD were 0.07 (0.02 to 0.11) and 0.17 (0.12 to 0.22). Participants not smoking on daily basis had an adjusted RR of 1.21 (1.02 to 1.42), and an adjusted RD of 0.05 (0.01 to 0.10) for a favourable outcome compared with daily smokers. The adjusted SI was 0.92 (0.60 to 1.43)., Conclusion: For participants with long-duration activity-limiting neck/back pain, moderate or good self-perceived work ability and not being a daily smoker were associated with a favourable prognosis but having both exposures seemed to have no synergistic prognostic effect., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Neck and back pain are musculoskeletal conditions with serious individual and societal consequences. Current evidence about the prognostic value for neck and back pain is limited and conflicting. This prospective cohort study aimed to assess the association between leisure-time physical activity (LPA) and improvement of neck and/or back pain in a working population receiving manual therapy or general care in one of two randomized controlled trials (RCTs)., Methods: Analyses of data from two RCTs evaluating the effect of manual therapies for neck and/or back pain was conducted. Participants (n = 1 464) answered questionnaires about frequency and effort level of LPA at baseline. LPA on moderate or vigorous levels was compared to no or low/irregular moderate and vigorous levels. Pain intensity was assessed with numerical scales at baseline and 3-, 6-, and 12-month follow-up. The outcome was minimal clinically important improvement in pain intensity, defined as ≥2 points improvement in mean pain intensity at follow-up. Crude- and adjusted risk ratios (RR) with 95% confidence intervals (CI) were calculated with Poisson regression analysis and stratified by pain location., Results: Participants with neck and/or back pain performing vigorous LPA showed a minimal clinically important improvement after 12 months compared to the control group; RR 1.35 (95% CI; 1.06-1.73). No effect was observed at 3 or 6 months. Moderate LPA did not improve pain intensity in any follow-up. Stratified analyses revealed that the effect of vigorous LPA at 12 months in back pain was RR 1.83 (95% CI; 1.26-2.66) and neck pain RR 1.06 (95% CI; 0.75-1.49)., Conclusions: Persons with neck and/or back pain receiving manual therapy or general evidence-based care have greater chance of improvement after 12 months if they prior to treatment frequently practice vigorous LPA. When analyzed separately, the effect was only present for back pain., Trial Registration: Registration in Current Controlled Trials (ISRCTN), Stockholm Manual Intervention Trial (MINT), ISRCTN92249294 BJORN-trial, ISRCTN56954776., (© 2021. The Author(s).)

Objectives: The prevalence of neck/back pain (NBP) is high worldwide. Limited number of studies have investigated workers with occasional NBP regarding the risk of developing long-duration activity limiting NBP (LNBP). The objectives were to assess (1) the effect of poor work ability and sleep disturbances in persons with occasional NBP on the risk of LNBP, and (2) the interaction effect of these exposures., Design: Cohort study based on three subsamples from the Stockholm Public Health Cohort., Settings: The working population in Stockholm County., Participants: Persons aged 18-60 years, reporting occasional NBP the past 6 months at baseline year 2010 (n=16 460)., Measures: Work ability was assessed with items from the Work Ability Index, perceived mental and/or physical work ability. Sleep disturbances were self-reported current mild/severe disturbances. The outcome in year 2014 was reporting NBP the previous 6 months, occurring ≥couple of days per week and resulting in decreased work ability/restricted other daily activities. The additive effect of having both poor work ability and sleep disturbances was modelled with a dummy variable, including both exposures. Poisson log-linear regression was used to calculate risk ratios (RRs) and 95% CIs., Results: At follow-up, 9% had developed LNBP. Poor work ability and sleep disturbances were independent risk factors for LNBP; adjusted RR 1.7 (95% CI: 1.4 to 2.0) and 1.4 (95% CI: 1.2 to 1.5), respectively. No additive interaction was observed., Conclusion: Workers with occasional NBP who have poor work ability and/or sleep disturbances are at risk of developing LNBP. Having both conditions does not exceed additive risk., Competing Interests: Competing interests: Drs ES and LWH are scientific consultants at the Scandinavian College of Naprapathic Manual Medicine and members of their Scientific Board., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate the cost-effectiveness of deep tissue massage ('massage'), strengthening and stretching exercises ('exercises') or a combination of both ('combined therapy') in comparison with advice to stay active ('advice') for subacute and persistent neck pain, from a societal perspective., Methods: We conducted a cost-effectiveness analysis alongside a four-arm randomized controlled trial of 619 participants followed-up for one year. Health-related quality of life was measured using EQ-5D-3L and costs were calculated from baseline to one year. The interventions were ranked according to quality adjusted life years (QALYs) in a cost-consequence analysis. Thereafter, an incremental cost per QALY was calculated., Results: In the cost-consequence analysis, in comparison with advice, exercises resulted in higher QALY gains, and massage and the combined therapy were more costly and less beneficial. Exercises may be a cost-effective treatment compared with advice to stay active if society is willing to pay 17 640 EUR per QALY. However, differences in QALY gains were minimal; on average, participants in the massage group, spent a year in a state of health valued at 0.88, exercises: 0.89, combined therapy: 0.88 and, advice: 0.88., Conclusions: Exercises are cost-effective compared to advice given that the societal willingness to pay is above 17 640 EUR per year in full health gained. Massage and a combined therapy are not cost-effective. While exercise appeared to have the best cost/benefit profile, even this treatment had only a modest benefit and treatment innovation is needed. Advice to stay active remains as a good therapeutic alternative from an economical perspective., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To compare the effectiveness of deep tissue massage, supervised strengthening and stretching exercises, and a combined therapy (exercise followed by massage) (index groups), with advice to stay active (control group)., Methods: Randomized controlled trial of 619 adults with subacute or persistent neck pain allocated to massage (n = 145), exercise (n = 160), combined therapy (n = 169) or advice (n = 147). Primary outcomes were minimal clinically important improvements in neck pain intensity and pain-related disability based on adapted questions from the Chronic Pain Questionnaire. Secondary outcomes were perceived recovery and sickness absence. Outcomes were measured at seven, 12, 26 and 52 weeks., Results: We found improvement in pain intensity favouring massage and combined therapy compared to advice; at seven weeks (RR = 1.36; 95%CI:1.04-1.77) and 26 weeks (RR = 1.23; 95%CI:0.97-1.56); and seven (RR = 1.39; 95%CI:1.08-1.81) and 12 weeks (RR = 1.28; 95%CI:1.02-1.60) respectively, but not at later follow-ups. Exercise showed higher improvement of pain intensity at 26 weeks (RR = 1.31; 95%CI:1.04-1.65). Perceived recovery was higher in the index groups than in the advice group at all follow-ups. We found no consistent differences in pain related disability or sickness absence., Conclusions: In this study, at 12-months follow-up, none of the index therapies were more effective than advice in terms of pain intensity in the long term or in terms of pain-related disability in the short or long term. However, the index therapies led to higher incidence of improvement in pain intensity in the short term, and higher incidence of favorable perceived recovery in the short and in the long term than advice., Trial Registration: ISRCTN01453590. Registered 3 July 2014., Competing Interests: Declaration of competing interest Nothing to declare., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: The effect of a healthy lifestyle on the prognosis of neck pain is unknown. This study aimed to investigate if a healthy lifestyle behaviour influences the risk of long-duration troublesome neck pain among men and women with occasional neck pain., Design: Longitudinal cohort study., Settings: General population, and a subsample of the working population, in Stockholm County, Sweden., Participants: This study involved 5342 men and 7298 women, age 18 to 84, from the Stockholm Public Health Cohort, reporting occasional neck pain at baseline in 2006., Measures: Baseline information about leisure physical activity, smoking, alcohol consumption and consumption of fruits and vegetables were dichotomised into recommendations for healthy/not healthy behaviour. The exposure, a healthy lifestyle behaviour, was categorised into four levels according to the number of healthy behaviours (HB) met. Generalised linear models were applied to assess the exposure on the outcome long-duration troublesome neck pain (activity-limiting neck pain ≥2 days/week during the past 6 months), at follow-up in 2010., Results: The adjusted risk of long-duration troublesome neck pain decreased with increasing adherence to a healthy lifestyle behaviour among both men and women (trend test: p<0.05). Compared with the reference category, none or one HB, the risk decreased by 24% (risk ratio 0.76, 95% CI 0.58 to 0.98) among men and by 34% (0.66, 0.54 to 0.81) among women, with three or four HBs. The same comparison showed an absolute reduction of the outcome by 3% in men (risk difference -0.03, 95% CI -0.05 to -0.01) and 5% in women (-0.05,-0.08 to -0.03). Similar results were found in the working population subsample., Conclusion: Adhering to a healthy lifestyle behaviour decreased the risk of long-duration troublesome neck pain among men and women with occasional neck pain. The results add to previous research and supports the importance of promoting a healthy lifestyle behaviour., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The objectives of this study were to describe the 1-year trajectories of disabling subacute or persistent neck pain and to investigate whether baseline age, sex, pain characteristics, and depressive symptoms are associated with such trajectories., Study Design and Setting: Participants (n=617) included in a randomized controlled trial provided weekly pain intensity ratings by responding to text messages over 1 year. We used latent class mixed model analyses to identify clusters of individual trajectories. Thereafter, we used logistic regression to determine the association between baseline age, sex, pain characteristics, depressive symptoms and treatment, and trajectories of neck pain., Results: Six different clusters of trajectories were identified. Most participants (73%) followed a trajectory of decreasing pain throughout follow-up. The remaining experienced unfavorable trajectories: persistent pain of high intensity (22%) and slightly (3%) or highly (2%) fluctuating levels of pain reaching high levels of pain intensity. Pain intensity at baseline: odds ratio (OR): 3.76 (95% confidence interval [CI]: 2.49-5.68), depressive symptoms: OR: 3.46 (95% CI: 2.01-5.95), younger age: OR: 2.29 (95% CI: 1.48-3.54), female sex: OR: 1.51 (95% CI: 1.01-2.26), and sudden onset of pain: OR: 1.74 (95% CI: 1.13-2.69) were associated with unfavorable trajectories., Conclusions: Most individuals with disabling subacute or chronic neck pain show improvement in pain intensity over a year. However, a quarter present unfavorable trajectories. High pain intensity at baseline, depressive symptoms, younger age, female sex, and sudden onset of pain are factors associated with unfavorable trajectories.

Background: Manual therapy is a commonly used treatment for patients with back and neck pain. Studies have shown that manual therapy-related adverse events are mainly short in duration and mild or moderate by their intensity, affecting up to 50% of the patients. If the presence of adverse events has an impact on the chance to recover from back/neck pain is poorly understood. The aim of this study was to investigate if mild or moderate adverse events after manual therapy has an impact on the chance to recover from back/neck pain in men and women., Methods: A prospective cohort study of 771 patients with at least three treatment sessions in a randomized controlled trial performed in January 2010 - December 2013. Adverse events within 24 h after each treatment were measured with questionnaires and categorized as: no, mild or moderate, based on bothersomeness. Outcome measure was the perceived recovery at seven weeks and at three months follow-up. Odds Ratios (OR) and 95% confidence intervals (CI) were calculated by Logistic regression to investigate the associations between the exposure and outcome, and to test and adjust for potential confounding., Results: There were no statistically significant associations observed between the experience of mild or moderate adverse events and being recovered at the seven weeks follow-up. The only statistically significant association observed at the three months follow-up was for mild adverse events in men with an OR of 2.44, 95% CI: 1.24-4.80 in comparison to men with no adverse events., Conclusion: This study indicates that mild adverse events after manual therapy may be related to a better chance to recover in men., Trial Registration: The study is based on data from a trial registered in Current Controlled Trials (ISRCTN92249294)., Competing Interests: Competing interestsThe authors declare that there is no conflict of interest with any financial organization regarding the material discussed in this manuscript. The financial support for the submitted work was obtained from the Swedish Naprapathic Association (SNA). The funding bodies had no role in the design of the study, collection, analysis, or interpretation of data or in writing the manuscript. ES has a part time position at Karolinska Institutet partly financed by grants from the SNA. None of the authors have any competing interests.

Background and Aims: Frequent back, neck and/or shoulder pain (BNSP) are common conditions which pose high burden for the society. Results from previous studies suggest that diabetes and hyperlipidaemia may be associated with a higher risk of getting such conditions, but there is in general, few studies based on longitudinal designs. The aim of this study was therefore to compare the risk of developing frequent BNSP in men and women with and without diabetes and/or hyperlipidaemia., Methods: A longitudinal study based on the Stockholm Public Health Cohort was conducted based on subjects aged 45-84, who were free from pain at the mentioned sites in 2006 and followed up until 2010. The data in the current study is based on questionnaires, except socioeconomic status which was derived from Statistics Sweden. The exposure diabetes and hyperlipidaemia was self-reported and, a categorical variable was created; without any of the conditions, with hyperlipidaemia only, with diabetes only and with both conditions. The outcome frequent BNSP was defined using the following questions in the questionnaire in 2010: "During the past 6months, have you had pain in the neck or upper part of the back?", "During the past 6months, have you had pain in the lower back?", and "During the past 6months, have you had pain in the shoulders/arms?". All questions had three possible response options: no; yes, a couple of days per month or less often and; yes, a couple of days per week or more often. Those who reported weekly pain to at least one of these questions were considered to having frequent BNSP. Binomial regressions were run to calculate the crude and adjusted risk ratio (RR) in men and women separately. Additional analysis was performed in order to control for potential bias derived from individuals lost to follow-up., Results: A total of 10,044 subjects fulfilled the criteria to be included in the study. The mean age of the sample was 60years and evenly distributed by sex. After adjusting for age, body mass index, physical activity, high blood pressure and socioeconomic status, the RR for frequent BNSP among men with diabetes was 1.64 (95% CI: 1.23-2.18) and 1.19 (95% CI: 0.98-1.44) for hyperlipidaemia compared to men with neither diabetes nor hyperlipidaemia. Among women the corresponding RRs were 0.92 (95% CI: 0.60-1.14) and 1.23 (95% CI: 1.03-1.46). Having both diabetes and hyperlipidaemia at baseline was not associated with increased risk of frequent BNSP. Diabetes and hyperlipidaemia seems to be associated with an increased risk for frequent BNSP and the risk may differ between men and women. Behaviours and/or biological underlying mechanisms may explain the results., Conclusions: This study suggests that metabolic diseases such as diabetes and hyperlipidaemia may have an impact on the pathophysiology of frequent BNSP and thus, contributes to the knowledge in musculoskeletal health. Furthermore, it confirms that men and women may differ in terms of risk factors for BNSP., Implications: Health professionals should contemplate the results from this study when planning primary prevention strategies., (Copyright © 2016 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Background: Expectations have been investigated in populations seeking care for neck pain, however not considering potential confounding factors. The aim of this study was to investigate if pretreatment expectations of recovery is a prognostic factor for recovery from neck pain at 7 weeks follow-up in patients seeking manual therapy treatment., Method: The study was based on the Stockholm Manual Intervention Trial, a randomized controlled trial investigating efficiency of three combinations of manual therapy. The patients with neck pain were included in this study (n = 716). Expectations of recovery was measured at baseline; 'How likely is it, according to your judgment, that you are completely recovered from your neck/back problems in 7 weeks'. Patients answered on a 11-point scale, further categorized into low, moderate and high expectations. The outcome was measured at 7 weeks follow-up by a modified version of the Global Perceived Recovery Question. Potential effect measure modifiers and confounders were measured at baseline. Multivariable log binomial regression models were used to analyse the association between expectations and recovery, presented as relative risks and 95% confidence intervals (CI)., Results: High expectations of recovery yielded a 47% increased probability of being recovered at 7 weeks follow-up. High expectations of recovery yielded improved recovery in both men and women separately, but moderate expectations yielded improved recovery only among men., Conclusion: Our results suggest that expectations of recovery is a prognostic factor for recovery in patients with neck pain seeking manual therapy treatment. WHAT DOES THIS STUDY ADD?: We found that high expectations of recovery yielded a higher probability of recovery compared to having low expectations, also when considering potential confounding factors. Expectations seemed to have a more distinct influence on recovery among men., (© 2016 European Pain Federation - EFIC®)

Background: The effect of physical activity on risk and prognosis for neck pain has been studied earlier with inconclusive results. There is a need for large prospective studies on the subject. The aim of this study was to investigate if work related physical activity and physical activity during leisure time are of importance for the risk and prognosis of neck pain in men and women., Methods: We used the Stockholm Public Health Cohort and formed two sub-cohorts of the working population based on data from 2002. Cohort I (risk cohort) included persons without neck pain (n = 4681), and cohort II (prognostic cohort) included persons with occasional neck pain (n = 6820) during the previous six months. Both cohorts were assessed for the outcome long duration troublesome neck pain (LDNP) in 2007. The exposures and potential confounders were assessed through a questionnaire in 2002. The question regarding work related physical activity over the past 12 months had five answering categories ranging from "sedentary" to"heavy". The question regarding leisure physical activity for the past 12 months had five answering categories ranging from "sedentary" to "regular physical activity". LDNP in 2007 was defined as having had troublesome neck pain lasting ≥ 3 consecutive months during the previous five years. Associations between work related physical activity and LDNP, as well as leisure physical activity and LDNP, were investigated by multivariable logistic regression, considering potential confounding factors., Results: In cohort I (risk cohort) we found an association between leisure physical activity and LDNP. In cohort II (prognostic cohort) we found no association between the exposures and the outcome., Conclusion: The results suggest that leisure physical activity has a protective effect on the risk of developing LDNP in a population free from neck pain. It did not, however, affect the prognosis of occasional neck pain. Neither the risk nor the prognosis of neck pain was affected by work related physical activity in this study.

Background: Manual therapy as spinal manipulation, spinal mobilization, stretching and massage are common treatment methods for neck and back pain. The objective was to compare the treatment effect on pain intensity, pain related disability and perceived recovery from a) naprapathic manual therapy (spinal manipulation, spinal mobilization, stretching and massage) to b) naprapathic manual therapy without spinal manipulation and to c) naprapathic manual therapy without stretching for male and female patients seeking care for back and/or neck pain., Method: Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of Naprapathögskolan - the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 1057) were randomized to one of three treatment arms a) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage), b) manual therapy excluding spinal manipulation and c) manual therapy excluding stretching. The primary outcomes were minimal clinically important improvement in pain intensity and pain related disability. Treatments were provided by naprapath students in the seventh semester of eight total semesters. Generalized estimating equations and logistic regression were used to examine the association between the treatments and the outcomes., Results: At 12 weeks follow-up, 64% had a minimal clinically important improvement in pain intensity and 42% in pain related disability. The corresponding chances to be improved at the 52 weeks follow-up were 58% and 40% respectively. No systematic differences in effect when excluding spinal manipulation and stretching respectively from the treatment were found over 1 year follow-up, concerning minimal clinically important improvement in pain intensity (p = 0.41) and pain related disability (p = 0.85) and perceived recovery (p = 0.98). Neither were there disparities in effect when male and female patients were analyzed separately., Conclusion: The effect of manual therapy for male and female patients seeking care for neck and/or back pain at an educational clinic is similar regardless if spinal manipulation or if stretching is excluded from the treatment option., Trial Registration: Current Controlled Trials ISRCTN92249294.

Purpose: The estimated prevalence of poor sleep in patients with non-specific chronic low back pain is estimated to 64% in the adult population. The annual cost for musculoskeletal pain and reported poor sleep is estimated to be billions of dollars annually in the US. The aim of this cohort study with one-year follow-up was to explore the role of impaired sleep with daytime consequence on the prognosis of non-specific neck and/or back pain., Methods: Secondary analysis of a randomized controlled trial, including 409 patients., Results: Patients with good sleep at baseline were more likely to experience a minimal clinically important difference in pain [OR 2.03 (95% CI 1.22-3.38)] and disability [OR 1.85 (95% CI 1.04-3.30)] compared to patients with impaired sleep at one-year follow-up., Conclusion: Patients with non-specific neck and/or back pain and self-reported good sleep are more likely to experience a minimal clinically important difference in pain and disability compared to patients with impaired sleep with daytime consequence.

Background: Neck pain is a major health problem in populations worldwide and an economic burden in modern societies due to its high prevalence and costs in terms of health care expenditures and lost productivity. Massage and exercise therapy are widely used management options for neck pain. However, there is a lack of scientific evidence regarding their effectiveness for subacute and long-lasting neck pain. This study protocol describes a randomized controlled trial aiming to determine the effect of massage and/or exercise therapy on subacute and long-lasting neck pain over the course of 1 year., Methods/design: A randomized controlled trial in which at least 600 study participants with subacute or long-lasting nonspecific neck pain will be recruited and randomly allocated to one of four treatment arms: massage therapy (A), exercise therapy (B), exercise therapy plus massage therapy (C) and advice to stay active (D). The study has an E-health approach, and study participants are being recruited through advertising with a mix of traditional and online marketing channels. Web-based self-report questionnaires measure the main outcomes at 7, 12, 26 and 52 weeks after inclusion. The primary outcomes are a clinically important improvement in pain intensity and pain-related disability at follow-up, measured with a modified version of the Chronic Pain Questionnaire (CPQ). The secondary outcomes are global improvement, health-related quality of life (EQ-5D), sick leave, drug consumption and healthcare utilization. Adverse events are measured by questionnaires at return visits to the clinic, and automated text messages (SMSes) survey neck pain intensity and pain-related disability every week over one year., Discussion: The results of this study will provide clinicians and stakeholders much needed knowledge to plan medical care for subacute and long-lasting neck pain disorders., Trial Registration: Current Controlled Trials ISRCTN01453590. Date of registration: 3 July 2014.

Background Context: Detailed knowledge about the interrelationship between neck pain, back pain, and psychological distress is important from a public health prospective, but missing because of lack of large population-based cohort studies., Purpose: To assess and compare the sex-specific recovery rate of spinal pain and psychological distress as single and comorbid conditions, to describe the interrelationship between these conditions at the baseline (2002) and follow-up 5 years later, and to explore the questions of spinal pain as a risk factor for the onset of psychological distress and vice versa., Study Design: A prospective cohort study., Patient Sample: General population in Stockholm county aged 18 to 84 years, n=19,774., Outcome Measures: Spinal pain (modified Nordic Pain Questionnaire) and psychological distress (General Health Questionnaire-12)., Methods: A random sample of the population in Stockholm was approached with postal questionnaires at the baseline and at follow-up., Results: Comorbidity of spinal pain and distress was twice as common among women (11%) than among men (4%) (relative risk=2.4, 95% confidence interval [CI]: 2.1-2.7). Women also more commonly had spinal pain without psychological distress (women, 20%; men, 14%) and vice versa (women, 15%; men, 12%). Comorbidity makes recovery less probable (women, 26%; men, 27%) than having single conditions of spinal pain (women, 41%; men, 44%) or psychological distress (women, 49%; men, 52%). No statistical significant sex differences were seen. Twenty-four percent of the women and 17% of the men with spinal pain without psychological distress at the baseline had psychological distress at follow-up. Corresponding figures for spinal pain among participants with psychological distress without spinal pain at the baseline were 24% and 20%. Spinal pain was a determinant of psychological distress (odds ratio [OR]=2.6, 95% CI: 2.3-2.9) and vice versa (OR=2.0, 95% CI: 1.8-2.2)., Conclusions: Spinal pain and psychological distress as comorbid and single conditions are common in the general population, especially among women. Comorbidity affects recovery negatively both in men and women. This study confirms the bidirectional association between spinal pain and psychological distress in the general population., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To study whether job strain, that is, psychological job demands and decision latitude, and sleep disturbances among persons with occasional neck/shoulder/arm pain (NSAP) are prognostic factors for having experienced at least one episode of troublesome NSAP, and to determine whether sleep disturbances modify the association between job strain and troublesome NSAP., Design: Prospective cohort study., Setting: Stockholm, Sweden., Participants: A population-based cohort of individuals with occasional NSAP (n=6979) who answered surveys in 2006 and 2010., Outcome Measures: Report of at least one episode of troublesome NSAP in 2010., Results: The ORs for troublesome NSAP at follow-up were in individuals exposed to passive jobs 1.2 (95% CI 0.9 to 1.4); to active jobs 1.3 (95% CI 1.1 to 1.5); to high strain 1.5 (95% CI 1.0 to 2.4); to mild sleep disturbances 1.4 (95% CI 1.3 to 1.6) and to severe sleep disturbances 2.2 (95% CI 1.6 to 3.0). High strain and active jobs were associated with having experienced at least one episode of troublesome NSAP during the previous 6 months in persons with sleep disturbances, but not in individuals without sleep disturbances., Conclusions: Our results indicate that high strain, active jobs and sleep disturbances are prognostic factors that should be taken into account when implementing preventive measures to minimise the risk of troublesome NSAP among people of working age. We suggest that sleep disturbances may modify the association between high strain and troublesome NSAP., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: The safety of the manual treatment techniques such as spinal manipulation has been discussed and there is a need for more information about potential adverse events after manual therapy. The aim of this randomized controlled trial was to investigate differences in occurrence of adverse events between three different combinations of manual treatment techniques used by manual therapists (i.e. chiropractors, naprapaths, osteopaths, physicians and physiotherapists) for patients seeking care for back and/or neck pain. In addition women and men were compared regarding the occurrence of adverse events., Methods: Participants were recruited among patients, ages 18-65, seeking care at the educational clinic of the Scandinavian College of Naprapathic Manual Medicine in Stockholm. The patients (n = 767) were randomized to one of three treatment arms 1) manual therapy (i.e. spinal manipulation, spinal mobilization, stretching and massage) (n = 249), 2) manual therapy excluding spinal manipulation (n = 258) and 3) manual therapy excluding stretching (n = 260). Treatments were provided by students in the seventh semester of total eight. Adverse events were measured with a questionnaire after each return visit and categorized in to five levels; 1) short minor, 2) long minor, 3) short moderate, 4) long moderate and 5) serious adverse events, based on the duration and/or severity of the event. Generalized estimating equations were used to examine the association between adverse event and treatments arms., Results: The most common adverse events were soreness in muscles, increased pain and stiffness. No differences were found between the treatment arms concerning the occurrence of adverse event. Fifty-one percent of patients, who received at least three treatments, experienced at least one adverse event after one or more visits. Women more often had short moderate adverse events (OR = 2.19 (95% CI: 1.52-3.15)), and long moderate adverse events (OR = 2.49 (95% CI: 1.77-3.52)) compared to men., Conclusion: Adverse events after manual therapy are common and transient. Excluding spinal manipulation or stretching do not affect the occurrence of adverse events. The most common adverse event is soreness in the muscles. Women reports more adverse events than men., Trial Registration: This trial was registered in a public registry (Current Controlled Trials) (ISRCTN92249294).

Purpose: The study sought to examine the gender-specific effects of physical activity level and body mass index on recovery from persistent neck pain (PNP) among citizens of working age in Stockholm, Sweden., Methods: A population-based cohort of 1,730 subjects (18-65) with PNP answered surveys in 2002 and 2007. Prognostic factors were self-reported body mass index (BMI) and physical activity level (PAL) at baseline. Analyses were performed with odds ratios (OR) with corresponding 95 % confidence intervals (95 % CI)., Results: Women reporting higher physical activity level had higher odds of recovering from PNP than women with sedentary leisure time (OR of 1.5, 95 % CI 1.0-2.4), but no associations were found in men. No associations were found between BMI and recovery from PNP in any analyses., Conclusion: Physical activity seems to be associated with recovery from PNP in women and should therefore be encouraged. Future studies should continue investigating physical activity and lifestyle factors in relation to recovery from persistent neck pain, since these modifiable factors may be considered in interventions.

Background: Studies have shown associations between higher income and better health, but income has not been studied in relation to neck pain. The aims of this cohort study were to assess the sex-specific role of disposable income for onset and prognosis of neck pain in the general population and if economic stress influences such potential associations., Methods: Two subcohorts were identified in the Stockholm Public Health Cohort with data from 2002. Cohort I (risk cohort) included persons without neck pain (n=8348). Cohort II (prognostic cohort) included persons with occasional neck pain during the previous 6 months (n=10 523). Both cohorts were assessed for long duration troublesome neck pain (LDNP) in 2007. Individual income was defined as aggregated annual family income in 2002 with each family member assigned a weighted consumption share, based on salary, pensions and social benefits. LDNP in 2007 was defined as having had troublesome neck pain lasting for three or more consecutive months the previous 5 years. Association between income and LDNP, considering potential confounding, was investigated by multivariable logistic regression. Economic stress was tested as effect modifier between income and LDNP., Results: In both cohorts, associations were found between lower income and a higher risk for LDNP. The results were similar between the sexes. Economic stress modified the associations in both cohorts., Conclusions: Low income may be a risk as well as prognostic factor for developing LDNP. Furthermore, the results indicate that economic stress may be an underlying factor to consider when studying associations between income and neck pain.

Background: Neck pain is very common but the occurrence of bothersome neck pain is not well described. Therefore our objective was to report on the prevalence and incidence of, as well as the rate of recovery from, bothersome neck pain in men and women of different ages in the general population., Methods: We used data from a recently conducted population-based cohort study, comprising 23,794 individuals in Stockholm County, Sweden. Study participants were surveyed with a self-administered questionnaire in 2002/2003 and 2007, and information on episodes of neck pain was gathered at baseline and at follow-up. We then measured bothersome neck pain in 2005 and 2006 retrospectively in 2007 using the follow-up questionnaire., Results: The one-year prevalence of bothersome neck pain for at least seven consecutive days was 25% (95% confidence interval (CI): 24-25) among women and 16% (95% CI: 15-16) among men, peaking in individuals aged 30-59 years. The one-year incidence proportion of bothersome neck pain was 7% (95% CI: 6-7) among women, and 4% (95% CI: 4-5) among men. Women recovered more infrequently than men. The one-year incidence proportion of recovery (of at least one year duration) was 11% (95% CI: 10-12) among women and 14% (95% CI: 12-16) among men., Conclusion: Bothersome neck pain is most common in middle-aged individuals. Women are more likely than men to have and to develop bothersome neck pain, and less likely to recover from such pain. Younger men and women have a higher incidence, but recover more often from bothersome neck pain than older individuals.

Background: Back and neck pain are very common, disabling and recurrent disorders in the general population and the knowledge of long-term effect of treatments are sparse. The aim of this study was to compare the long-term effects (up to one year) of naprapathic manual therapy and evidence-based advice on staying active regarding non-specific back and/or neck pain. Naprapathy, a health profession mainly practiced in Sweden, Finland, Norway and in the USA, is characterized by a combination of manual musculoskeletal manipulations, aiming to decrease pain and disability in the neuromusculoskeletal system., Methods: Subjects with non-specific pain/disability in the back and/or neck lasting for at least two weeks (n = 409), recruited at public companies in Sweden, were included in this pragmatic randomized controlled trial. The two interventions compared were naprapathic manual therapy such as spinal manipulation/mobilization, massage and stretching, (Index Group), and advice to stay active and on how to cope with pain, provided by a physician (Control Group). Pain intensity, disability and health status were measured by questionnaires., Results: 89% completed the 26-week follow-up and 85% the 52-week follow-up. A higher proportion in the Index Group had a clinically important decrease in pain (risk difference (RD) = 21%, 95% CI: 10-30) and disability (RD = 11%, 95% CI: 4-22) at 26-week, as well as at 52-week follow-ups (pain: RD = 17%, 95% CI: 7-27 and disability: RD = 17%, 95% CI: 5-28). The differences between the groups in pain and disability considered over one year were statistically significant favoring naprapathy (p < or = 0.005). There were also significant differences in improvement in bodily pain and social function (subscales of SF-36 health status) favoring the Index Group., Conclusions: Combined manual therapy, like naprapathy, is effective in the short and in the long term, and might be considered for patients with non-specific back and/or neck pain., Trial Registration: Current Controlled Trials ISRCTN56954776.

Objective: To investigate the associations between smoking and alcohol consumption, and long-term sick leave due to unspecific back or neck pain among employees in the public sector., Design: A 3-year prospective cohort study., Subjects: Approximately 9000 persons in the public sector in Sweden were invited to participate. Of these, 7533 answered a questionnaire and 6532 were included in the study, classified as having "good health for working"., Methods: New periods of sick leave >or= 28 days were consecutively reported from the employers or the occupational health service during a period of 3 years. Rate ratios were estimated by means of Cox proportional hazard regression model., Results: Smoking was associated with an increased risk of long-term sick leave due to unspecific back or neck pain. Compared with people who have never smoked, "ever smokers" had a higher risk (rate ratio = 1.8, 95% confidence interval: 1.3-2.4). Alcohol consumption tended to be associated with a decreased risk, but the results were not statistically significant., Conclusion: Our results suggest that smoking is a risk factor for long-term sick leave due to unspecific back or neck pain. Moderate alcohol consumption tends to have a protective effect, at least among women in the public sector.

Objectives: To compare naprapathic manual therapy with evidence-based care for back or neck pain regarding pain, disability, and perceived recovery. Naprapathy that is common in the Nordic countries and in some states in the United States is characterized by manual manipulations with a focus on soft and connective tissues, aiming to decrease pain and disability in the musculoskeletal system., Methods: Four hundred and nine patients with pain and disability in the back or neck lasting for at least 2 weeks, recruited at 2 large public companies in Sweden in 2005, were included in this randomized controlled trial. The 2 interventions were naprapathy, including spinal manipulation/mobilization, massage, and stretching (Index Group) and support and advice to stay active and how to cope with pain, according to the best scientific evidence available, provided by a physician (Control Group). Pain, disability, and perceived recovery were measured by questionnaires at baseline and after 3, 7, and 12 weeks., Results: At 7-week and 12-week follow-ups, statistically significant differences between the groups were found in all outcomes favoring the Index Group. At 12-week follow-up, a higher proportion in the naprapathy group had improved regarding pain [risk difference (RD)=27%, 95% confidence interval (CI): 17-37], disability (RD=18%, 95% CI: 7-28), and perceived recovery (RD=44%, 95% CI: 35-53). Separate analysis of neck pain and back pain patients showed similar results., Discussion: This trial suggests that combined manual therapy, like naprapathy, might be an alternative to consider for back and neck pain patients.

Objective: To expand the knowledge about the occurrence of life events, and how they affect the risk of low back and neck/shoulder pain., Design: A population-based case-control study., Setting: Men and women 20-59-years old, living in and not working outside the municipality of Norrtälje, Sweden, from November 1993 to November 1997., Participants: Cases (n = 1,148) were defined as all subjects from the study base who sought healthcare for a new episode of low back and/or neck/shoulder pain by any of the care givers in the municipality. Controls (n = 1,700) were selected as a stratified random sample from the study base, considering sex and age. Study subjects were interviewed about life events and critical life changes. Critical life changes were defined as events that brought about a marked psychosocial change. Odds ratios (ORs) associated with different numbers of life events or critical life changes were calculated., Results: Having experienced at least two life events during the preceding 5 years was associated with an increased risk of neck/shoulder pain (OR = 1.6, 95% CI 1.1 to 2.4). At least two critical life changes were associated with an increased risk of neck/shoulder pain (OR = 1.9, 95% CI 1.3 to 2.7). In general, no associations were observed in relation to risk of low back pain., Conclusion: Life events and critical life changes are of importance for the risk of neck/shoulder pain of the kind that people are seeking care for. The study provides useful information for clinical practice and for future aetiological research on neck/shoulder pain.

Objective: To investigate the incidence and course of widespread pain (WP) subsequent to localized pain in subjects with whiplash-associated disorders (WAD); and to investigate the influence of depressive symptoms, neck pain intensity, number of whiplash-associated symptoms, and number of painful body areas on such conditions., Methods: From a large prospective cohort of injury claimants who reported WAD after motor vehicle collision (MVC; n = 7462), we identified a subgroup with only localized head/neck/back pain, and who responded to one or more followup questionnaires mailed at 6 weeks and 4, 6, and 12 months after the MVC (n = 266). Pain drawings were distributed at the followup, and we defined WP as having 9 or more painful areas, including posterior neck, at any of these occasions. Depressive symptoms were assessed with the Center for Epidemiological Studies Depression Scale and pain intensity with on a visual analog scale (VAS)., Results: The cumulative incidence of WP was 21%, and it occurred early after the injury. Continuous WP over the 12 months was rare. The odds for developing WP were greater in those with depressive symptoms (OR 3.2, 95% CI 1.6-6.3), VAS pain intensity 55-100 (OR 3.2, 95% CI 1.3-8.0), reporting > or = 3 pain-associated symptoms (OR 1.9, 95% CI 0.9-3.8), and those reporting 4 or 5 painful body areas (OR 2.6, 95% CI 1.3-5.4)., Conclusion: WP occurred early in the course. Even though the cumulative incidence was 21%, continuous WP was rare. Subjects with WAD who report early depressive symptoms and more severe neck injury symptoms are at risk of developing WP after MVC.

Eva Skillgate,1,2 Oscar Javier Pico-Espinosa,1 Johan Hallqvist,3 Tony Bohman,1 Lena W Holm4 1Unit of Cardiovascular Epidemiology, Musculoskeletal and Sports Injury Epidemiology Center, Institute of Environmental Medicine, Karolinska Institutet, 2Naprapathögskolan - Scandinavian College of Naprapathic Manual Medicine, Stockholm, 3Department of Public Health and Caring Sciences, Uppsala University, Uppsala, 4Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden Background: The role of healthy lifestyle behavior (HLB) in terms of physical activity, alcohol intake, smoking, and diet put together has not yet been explored for the risk of low back pain (LBP) and neck pain (NP). Our aim was to study if an HLB is protective against the onset of long duration troublesome LBP and NP in men and women. Methods: Two cohorts from the Stockholm Public Health Cohort, free from LBP (n=12,483) and NP (n=10,539), respectively, in 2006, were surveyed with questionnaires. Baseline information about physical activity, alcohol intake, diet, and smoking were dichotomized into being healthy/not healthy and combined in a categorical variable according to the number of healthy behaviors present. Binomial regression analyses were used to evaluate the role of HLB for the outcomes 4 years later.Results: When men with three or four healthy lifestyles were compared to men with none or one, the risk ratio (RR) of LBP was 0.63 (95% confidence interval [CI]: 0.39–1.02). The corresponding RR for LBP in women was 0.86 (95% CI: 0.56–1.32). When men with three or four healthy lifestyles were compared to men with none or one, the RR for NP was 1.13 (95% CI: 0.74–1.71). The corresponding RR for NP in women was 0.52 (95% CI: 0.35–0.77). Conclusion: An HLB seems to be protective for long duration troublesome LBP in men, and for long duration troublesome NP in women. Keywords: neck pain, low back pain, lifestyle, physical activity, smoking, alcohol, healthy diet, prevention, musculoskeletal

Purpose: The etiology of neck/shoulder pain is complex. Our purpose was to investigate if respiratory disorders are risk factors for troublesome neck/shoulder pain in people with no or occasional neck/shoulder pain. Methods: This prospective cohort study was based on the Stockholm Public Health Cohorts (SPHC) 2006/2010 and the SPHC 2010/2014. We included adults who at baseline reported no or occasional neck/shoulder pain in the last six months, from the two subsamples (SPHC 06/10 n = 15 155: and SPHC 2010/14 n = 25 273). Exposures were self-reported asthma at baseline in SPHC 06/10 and Chronic Obstructive Pulmonary Disease (COPD) at baseline in SPHC 10/14. The outcome was having experienced at least one period of troublesome neck/shoulder pain which restricted work capacity or hindered daily activities to some or to a high degree during the past six months, asked for four years later. Binomial regression analyses were used to calculate risk ratios (RR) with 95% confidence intervals (95% CI). Results: Adjusted results indicate that those reporting to suffer from asthma at baseline had a higher risk of troublesome neck/shoulder pain at follow-up four years later (RR 1.48, 95% CI 1.10–2.01) as did those reporting to suffer from COPD (RR 2.12 95%CI 1.54–2.93). Conclusion: Our findings indicate that those with no or occasional neck/shoulder pain and reporting to suffer from asthma or COPD increase the risk for troublesome neck/shoulder pain over time. This highlights the importance of taking a multi-morbidity perspective into consideration in health care. Future longitudinal studies are needed to confirm our findings. [ABSTRACT FROM AUTHOR]