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The purpose was to present a total description, distribution, and ranking of chronic pain conditions in the general population. This was based on structured clinical examinations of a random sample from a population-based survey (HUNT3) with a calculated oversampling of participants with chronic pain. Supplemented with access to hospital reports, the examination was performed by experienced physicians and psychologists using a consistent definition of chronic pain as well as ICD-10- and the new ICD-11-classification. The main findings were that a higher proportion of the 551 participants had chronic pain assessed by clinical examination (399) than by self-report in a survey the same day (337). Among those with examination-verified chronic pain estimated from HUNT3 to represent 27.9% of the general population, 63% had chronic primary pain, 81% musculoskeletal pain, and 77% more than one chronic pain condition. When separating chronic primary from chronic secondary pain according to ICD-11, the weighted prevalence was 17.7% for chronic pain conditions of unknown and 10.2% of known cause. When all the participants’ conditions were accounted for, the most prevalent were nonspecific low back (10.8%) and neck pain (7.6%). Participants with chronic primary pain did not have significantly more psychopathology than those with chronic secondary pain: 14.5% vs. 12.5%. Perspective: Since this study confirms the high prevalence in self-report surveys and indicates that two thirds of chronic pain conditions cannot be explained by underlying diseases, this huge health and societal problem should be solved primarily on a public health level directed towards prevention and rehabilitation.

Objectives The aim of the study was to explore the experiences of participants in non-pharmacological group-based treatments delivered as part of a randomised controlled trial at Norwegian tertiary care pain centres. Methods Individual semi-structured interviews with 15 persons were conducted. The data were analysed with a descriptive thematic cross-case analysis based on the method of systematic text condensation. Results All participants talked about some aspects of the group-based treatments as a positive experience, but mainly the outcome was in line with their expectations; they hoped it would reduce their pain but did not expect it. There were no clear-cut differences in the experiences between the participants from the two different intervention groups. The content was experienced as both relevant and interesting but also to introduce concepts that were difficult to grasp and understand. Similarly, the experiences of participating in a group-based treatment were mostly stimulating but could also be challenging because of an expectancy of sharing personal stories. Although experiencing few changes to their pain they came away with techniques and lessons that were valuable to them. Conclusions In this study, taking part in group-based treatment was perceived as giving positive and valuable lessons, due to relevant content and learning from the professionals and fellow participants, but without any clear indication of reduced pain. Approval from ethical committee number 10260 REK Midt. Trial registration number ClinicalTrials.gov NCT04057144.

Background: The multidimensional array of clinical features and prognostic factors makes it difficult to optimize management within the heterogeneity of patients with common musculoskeletal pain. This study aimed to identify phenotypes across prognostic factors and musculoskeletal complaints. Concurrent and external validity were assessed against an established instrument and a new sample, respectively, and treatment outcome was described. Methods: We conducted a longitudinal observational study of 435 patients (aged 18–67 years) seeking treatment for nonspecific complaints in the neck, shoulder, low back or multisite/complex pain in primary health care physiotherapy in Norway. Latent class analysis was used to identify phenotypes based on 11 common prognostic factors within four biopsychosocial domains; pain, beliefs and thoughts, psychological and activity and lifestyle. Results: Five distinct phenotypes were identified. Phenotype 1 (n = 77, 17.7%) and 2 (n = 142, 32.6%) were characterized by the lowest scores across all biopsychosocial domains. Phenotype 2 showed somewhat higher levels of symptoms across the biopsychosocial domains. Phenotype 3 (n = 89, 20.5%) and 4 (n = 78, 17.9%) were more affected across all domains, but phenotype 3 and 4 had opposite patterns in the psychological and pain domains. Phenotype 5 (n = 49, 11.3%) were characterized by worse symptoms across all domains, indicating a complex phenotype. The identified phenotypes had good external and concurrent validity, also differentiating for the phenotypes in function and health-related quality of life outcome at 3-month follow-up. Conclusion: The phenotypes may inform the development of targeted interventions aimed at improving the treatment efficiency in patients with common musculoskeletal disorders. Significance: This observational prospective study identified five distinct and clinically meaningful phenotypes based on biopsychosocial prognostic factors across common musculoskeletal pain. These phenotypes were independent of primary pain location, showed good external validity, and clear variation in treatment outcome. The findings are particularly valuable as they describe the heterogeneity of patients with musculoskeletal pain and points to a need for more targeted interventions in common musculoskeletal disorders to improve treatment outcome. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC ®

Background There are large variations in symptoms and prognostic factors among patients sharing the same musculoskeletal (MSK) diagnosis, making traditional diagnostic labelling not very helpful in informing treatment or prognosis. Recently, we identified five MSK phenotypes across common MSK pain locations through latent class analysis (LCA). The aim of this study was to explore the one-year recovery trajectories for pain and functional limitations in the phenotypes and describe these in relation to the course of traditional diagnostic MSK groups. Methods We conducted a longitudinal observational study of 147 patients with neck, back, shoulder or complex pain in primary health care physiotherapy. Data on pain intensity and function were collected at baseline (week 0) and 1, 2, 3, 4, 6, 8, 12, 26 and 52 weeks of follow up using web-based questionnaires and mobile text messages. Recovery trajectories were described separately for the traditional diagnostic MSK groups based on pain location and the same patients categorized in phenotype groups based on prognostic factors shared among the MSK diagnostic groups. Results There was a general improvement in function throughout the year of follow-up for the MSK groups, while there was a more modest decrease for pain intensity. The MSK diagnoses were dispersed across all five phenotypes, where the phenotypes showed clearly different trajectories for recovery and course of symptoms over 12 months follow-up. This variation was not captured by the single trajectory for site specific MSK diagnoses. Conclusion Prognostic subgrouping revealed more diverse patterns in pain and function recovery over 1 year than observed in the same patients classified by traditional diagnostic groups and may better reflect the diversity in recovery of common MSK disorders. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

That certain psychological factors are negatively associated with function in patients with chronic pain is well established. However, few studies have evaluated these factors in individuals with chronic pain from the general population. The aims of this study were to: 1) evaluate the unique associations between catastrophizing and perceived solicitous responses and psychological function, physical function, and insomnia severity in individuals with neuropathic pain, osteoarthritis, or spinal pain in the general population; and 2) determine if diagnosis moderates the associations found. Five hundred fifty-one individuals from the general population underwent examinations with a physician and physiotherapist, and a total of 334 individuals were diagnosed with either neuropathic pain (n = 34), osteoarthritis (n = 78), or spinal pain (n = 222). Results showed that catastrophizing was significantly associated with reduced psychological and physical function, explaining 24% and 2% of the variance respectively, whereas catastrophizing as well as perceived solicitous responding were significantly and uniquely associated with insomnia severity, explaining 8% of the variance. Perceived solicitous responding was significantly negatively associated with insomnia severity. Moderator analyses indicated that: 1) the association between catastrophizing and psychological function was greater among individuals with spinal pain and neuropathic pain than those with osteoarthritis, and 2) the association between catastrophizing and insomnia was greater among individuals with spinal pain and osteoarthritis than those with neuropathic pain. No statistically significant interactions including perceived solicitous responses were found. The findings support earlier findings of an association between catastrophizing and function among individuals with chronic pain in the general population, and suggest that diagnosis may serve a moderating role in some of these associations. Perspective When examining persons with pain in the general population, catastrophizing is associated with several aspects of function, and diagnosis serves as a moderator for these associations. The replication of these associations in the general population support their reliability and generalizability.

Background Group-based transdiagnostic occupational rehabilitation programs including participants with mental and somatic disorders have emerged in clinical practice. Knowledge is sparse on subsequent participation in competitive work. This study aimed to investigate trajectories for (re)entry to work for predefined subgroups in a diagnostically heterogeneous sample of sick-listed participants after completing occupational rehabilitation. Methods A cohort of 212 participants aged 18–69 on long-term sick leave (> 8 weeks) with chronic pain, chronic fatigue and/or common mental disorders was followed for one year after completing a 3½-week rehabilitation intervention based on Acceptance and Commitment Therapy. Self-reported, clinical and registry data were used to study the associations between predefined biopsychosocial predictors and trajectories for (re)entry to competitive work (≥ 1 day per week on average over 8 weeks). Generalized estimating equations analysis was used to investigate trajectories. Results For all biopsychosocial subgroups (re)entry to work increased over time. Baseline employment, partial sick leave and higher expectation of return to work (RTW) predicted higher probability of having (re)entered work at any given time after discharge. The odds of increasing reentry over time (statistical interaction with time) was weaker for the group receiving the benefit work assessment allowance compared with those receiving sickness benefit (OR = 0.92, p = 0.048) or for those on partial sick leave compared with full sick leave (OR 0.77, p

Background Epidemiological studies of chronic pain frequently report high prevalence estimates. However, there is little information about the development and natural course of chronic pain. Methods We followed a random sample of participants from a population‐based study (HUNT 3) with annual measures over 4 years. Results Among those without chronic pain at baseline, the probability of developing moderate to severe chronic pain (cumulative incidence) during the first year was 5%, a pain status that was maintained among 38% at the second follow‐up. The probability of developing chronic pain diminished substantially for those who maintained a status of no chronic pain over several years. Subjects with moderate to severe chronic pain at baseline had an 8% probability of recovery into no chronic pain, a status that was maintained for 52% on the second follow‐up. The probability of recovery diminished substantially as a status of chronic pain was prolonged for several years. Pain severity, widespread pain, pain catastrophizing, depression and sleep were significant predictors of future moderate to severe chronic pain, both among subjects with and without chronic pain at baseline. Conclusion These findings suggest that the prognosis is fairly good after a new onset of chronic pain. When the pain has lasted for several years, the prognosis becomes poor. The same social and psychological factors predict new onset and the prognosis of chronic pain. Significance The development and recovery of chronic pain is highly dependent on previous pain. The prognosis of chronic pain may be predicted well when considering its duration in combination with other clinical, social and psychological factors. Targeting modifiable prognostic factors may be particularly important for newly developed chronic pain. Locked until 13.5.2019 due to copyright restrictions. This is the peer reviewed version of the following article: [Development and course of chronic pain over 4 years in the general population: The HUNT pain study], which has been published in final form at [https://doi.org/10.1002/ejp.1243]. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving.

BACKGROUND: Specific stabilizing exercises activating deep local muscles in coordination with global muscles are recommended in the treatment of pregnancy-related lumbopelvic pain. Some studies have suggested that recruitment of the deepest abdominal muscle, transversus abdominis, is crucial in the development and improvement of lumbopelvic pain.OBJECTIVE: This exploratory study aimed to describe the development of pain, disability and transversus abdominis recruitment before, during and after an individually designed intervention including an exercise program for women with persisting lumbopelvic pain after delivery.DESIGN: A multiple-baseline, single-subject experimental design was applied.METHODS: Sixteen women with lumbopelvic pain after delivery were included and received tailored exercise therapy, including ultrasound-guided activation of deep muscles, strengthening and stretching exercises and advice. Pain, disability and ultrasound-recorded activation of transversus abdominis was registered weekly. Treatment and testing was performed in a primary care setting in Trondheim, Norway.RESULTS: All sixteen included women reported reduced pain and decreased disability over the intervention period. The magnitude of transversus abdominis activation varied substantially between individuals and tests. While there was a statistically significant correlation between change in pain and change in disability, no correlation was observed between change in transversus abdominis activation and change in symptoms.LIMITATIONS: This is an exploratory study and results cannot be generalized without replication in controlled studies.CONCLUSIONS: Pain and disability due to persistent low back and pelvic pain after delivery were reduced after specific, individual adapted exercise including deep and superficial lumbopelvic muscles. Changes in pain and disability were not associated with changes in transversus abdominis activation.

Background Physiotherapists (PTs) in primary health care manage patients with large variation in medical diagnosis, age, functional status, disability and prognosis. Lack of knowledge and systematically collected data from patients treated by PTs in primary health care has prompted this longitudinal observational physiotherapy project. This paper aims to describe a method for developing a database of patients managed by PTs in primary health care, with the main purpose to study patients’ characteristics, treatment courses and prognostic factors for favourable outcome. Methods This is a longitudinal observational project, following patients through their physiotherapy treatment periods in primary health care in Norway and until one year after inclusion. The project involves both private practitioners and municipally employed PTs working in primary health care in nine municipalities in Norway. The patients are recruited to three different cohorts depending on age and whether they are referred to a private practitioner or a municipally employed PT. All data are recorded electronically, transferred and stored securely. For all patients we have included extensive questionnaires to obtain information about demographics, disability and function, pain-related variables, psychosocial factors, treatments and evaluation of treatment as well as response to clinical tests. The PTs have access to use their own patients’ data. We have also prepared for linkage to national patient registers and data collected in population-based studies to be able to gather further important data. Discussion This project will have important implications for physiotherapy services in primary health care. The database contains more than 3000 patients, and data collection is ongoing. Data collected so far suggest that the patients included are representative of the larger population of patients treated by private practitioners or municipally employed PTs in Norway. This large scale prospective physiotherapy project will provide knowledge about the patient groups, applied treatments and short- and long-term outcome of the patients. Trial registration ClinicalTrials.gov Identifier: NCT03626389 . Registered on August 13th 2018 (retrospectively registered).

Norway is a member of the European Pain Federation (EFIC). The national pain society works to support the needs of patients with pain, including those with acute pain, chronic pain, cancer pain, pain in later life, and at the end of life. In this chapter of European Pain Management we describe first the geography and history of the country as it relates to the recent demographics of the population, the prevalence of pain and needs for pain management, the pain workforce and its organization, the system pain specialists work within, and specific issues that have been tackled to improve the delivery of pain care. An example of recent innovation is also described.

Most occupational rehabilitation programmes target specific disorders. Crossover between programmes for mental and somatic disorders has been discussed and it has been pointed out that interventions may be applicable across different diagnostic categories. This study aimed to investigate the feasibility of introducing a novel transdiagnostic occupational rehabilitation programme that was delivered in groups mixing participants with chronic pain, chronic fatigue and common mental disorders.

Introduction: The current study examined if adaptive working memory training (Cogmed QM) has the potential to improve inhibitory control, working memory capacity, and perceptions of memory functioning in a group of patients currently on sick leave due to symptoms of pain, insomnia, fatigue, depression and anxiety. Participants who were referred to a vocational rehabilitation center volunteered to take part in the study. Methods: Participants were randomly assigned to either a training condition (N = 25) or a control condition (N = 29). Participants in the training condition received working memory training in addition to the clinical intervention offered as part of the rehabilitation program, while participants in the control condition received treatment as usual i.e., the rehabilitation program only. Inhibitory control was measured by The Stop Signal Task, working memory was assessed by the Spatial Working Memory Test, while perceptions of memory functioning were assessed by The Everyday Memory Questionnaire-Revised. Results: Participants in the training group showed a significant improvement on the post-tests of inhibitory control when compared with the comparison group (p = 0.025). The groups did not differ on the post-tests of working memory. Both groups reported less memory problems at post-testing, but there was no sizeable difference between the two groups. Conclusions: Results indicate that working memory training does not improve general working memory capacity per se. Nor does it seem to give any added effects in terms of targeting and improving self-perceived memory functioning. Results do, however, provide evidence to suggest that inhibitory control is accessible and susceptible to modification by adaptive working memory training. Copyright © 2017 Aasvik, Woodhouse, Stiles, Jacobsen, Landmark, Glette, Borchgrevink and Landrø. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

Purpose: The aim was to investigate the feasibility of introducing a novel transdiagnostic occupational rehabilitation program delivered in groups mixing participants with chronic pain, chronic fatigue and common mental disorders. Materials and methods: Observational data on group climate and individual participation were triangulated with qualitative data from focus group interviews on the participants’ experiences with transdiagnostic groups. Results: The study included 222 participants receiving a temporary work disability benefit. Self-reported chronic pain (75%), chronic fatigue (79%), and mental distress (62%) were prevalent and the majority reported overlapping conditions (78%). Program completion among participants was high (96%). Those completing participated actively (95%) in the program. Overall group climate was stable with moderately high engagement. Participants with clinically confirmed mental disorders (22%) showed similar outcomes. Self-reported problems with “working in a group” prior to rehabilitation were not associated with how participants experienced group climate. Qualitative data supported the findings of positive participant experiences with transdiagnostic group settings. Conclusions: Transdiagnostic groups showed high participation rates, moderately high group engagement across symptom profiles and positive participant experiences. Implementing transdiagnostic occupational rehabilitation in groups mixing participants with chronic pain, chronic fatigue and common mental disorders was feasible and acceptable to participants. Implications for rehabilitation Most research has been done on disorder-specific occupational rehabilitation programs, but emerging evidence supports a more generic approach. Transdiagnostic therapies, such as Acceptance and Commitment Therapy (ACT), have shown promising results for both somatic and mental disorders. The feasibility of implementing transdiagnostic rehabilitation groups, their acceptability to participants and the demand for such groups has not been established. This study indicates that it is feasible to introduce a novel transdiagnostic group-based occupational rehabilitation program for mixed groups of sick-listed participants with chronic pain, chronic fatigue and/or common mental disorders. 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

Objectives: To examine if elevated symptoms of insomnia affects neuropsychological functioning in patients with concurrent symptoms of pain, fatigue, and mood disorders. Methods and results: A total of seventy-six subjects participated in this (cross-sectional) study. Based on the cut-off score guidelines from The Insomnia Severity Index subjects were assigned to either a clinical insomnia group (N = 35) or a comparison group (N = 41). Factors such as age, general cognitive functioning, and symptoms of pain, fatigue, depression, and anxiety did not differ between the groups. Both groups completed a questionnaire which assessed subjective memory functioning. In addition they completed a set of neuropsychological tests measuring general cognitive functioning, spatial and verbal working memory, and inhibitory control. Although the subjects with clinical insomnia did not report more memory problems than the comparison group, they presented significant deficiencies on the tests assessing spatial and verbal working memory. There was no difference between the groups in inhibitory control. Conclusions: This study shows that as the symptom severity of insomnia increases and become clinically significant, it has substantial effect on both spatial and verbal-numeric working memory functioning. By differentiating and testing different domains of working memory, this study provides a more detailed and nuanced characterization of working memory deficiencies than the previous studies within this field. The results need to be transferred to clinical practice so that neuropsychologists include assessments of sleep as part of their routine screenings. © The Author 2017. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/)

Low back and neck pain are commonly reported in the general population and represent frequent causes for health care consultations. The main aim of this study was to describe the determinants of health care contact during a 1-year period in a general population with recent onset spinal pain. Methods: From 9056 participants in a general health survey in Norway we identified 219 persons reporting a recent onset (

Transfer from on-site rehabilitation to the participant’s daily environment is considered a weak link in the rehabilitation chain. Various follow-up regimes have been implemented after multidisciplinary rehabilitation, however, consensus is lacking on recommended content, duration and intensity.

Objective To investigate the prognostic importance of a number of sensorimotor and psychological factors for global perceived effect (GPE) after physiotherapy in patients with neck pain. In addition to baseline values, change scores were used as independent variables to identify treatment-modifiable factors. Design Clinical cohort study. Setting Primary and secondary healthcare physiotherapy clinics. Participants Patients ( n = 70) with non-specific neck pain. Intervention Usual care physiotherapy. Methods A three-dimensional motion tracking system was used to measure neck motion and sensorimotor variables, in addition to self-reported outcomes covering personal, somatic and psychological factors at baseline (before treatment) and at 2 months. Logistic regression was used to analyse associations between the prognostic variables and the primary outcome (GPE) at 2 months. Results At baseline, neck motion and motor control, pain duration and functioning were the strongest predictors for GPE, with no effect of psychological factors. Among the change variables, reduced pain intensity [odds ratio (OR) 1.86; 95% confidence interval (CI) 1.31 to 2.62], increased functioning (OR 1.46; 95% CI 1.11 to 1.92), reduced disability (OR 1.12; 95% CI 1.05 to 1.20), reduced kinesiophobia (OR 1.21; 95% CI 1.07 to 1.37), reduced catastrophising (OR 1.09; 95% CI 1.09 to 1.18) and increased self-efficacy (OR 1.12; 95% CI 1.03 to 1.21) were significantly associated with GPE. Conclusions Both baseline values and change in pain intensity and functioning predicted GPE at 2 months. Psychological factors such as kinesiophobia, catastrophising and self-efficacy were only able to predict outcome by their change scores, indicating that these factors are modifiable by common physiotherapy practice and are important for GPE.

This study aimed to describe the somatic, social, psychological, and work-related factors that characterize participants with a duration of sick leave over and under one year.During 2012, 181 patients on long-term sick leave were consecutively recruited and asked to answer an extensive survey. Several outcomes were reported, addressing work-related factors and somatic, psychological, and social symptoms. In cross-sectional analyses, sick leave duration was dichotomized asorone year, based on Norwegian legislation. Linear and logistic regressions were used to estimate population probabilities and means.The estimated prevalence of pain, fatigue, anxiety, and depression was overall high. There was a tendency towards a higher prevalence of fatigue, anxiety, and depression in those with sick leave duration less than one year, with the exception of sleep problems, which was more frequent in the population with longer duration. Relationship with friends, family, co-workers, and the last workplace were worse in the population with longer duration.Cross-sectional analyses indicated that social and work-related problems are more adverse in patients with longer duration of sick leave, while psychological and somatic symptoms appear less adverse. This is one of the first studies quantitatively demonstrating these differences through comprehensive, simultaneously measured self-report questionnaires.

Background Neck pain is associated with several alterations in neck motion and motor control. Previous studies have investigated single constructs of neck motor control, while few have applied a comprehensive set of tests to investigate cervical motor control. This comparative cross- sectional study aimed to investigate different motor control constructs in neck pain patients and healthy controls. Methods A total of 166 subjects participated in the study, 91 healthy controls (HC) and 75 neck pain patients (NP) with long-lasting moderate to severe neck pain. Neck flexibility, proprioception, head steadiness, trajectory movement control, and postural sway were assessed using a 3D motion tracking system (Liberty). The different constructs of neck motion and motor control were based on tests used in previous studies. Results Neck flexibility was lower in NP compared to HC, indicated by reduced cervical ROM and conjunct motion. Movement velocity was slower in NP compared to HC. Tests of head steadiness showed a stiffer movement pattern in NP compared to HC, indicated by lower head angular velocity. NP patients departed less from a predictable trajectory movement pattern (figure of eight) compared to healthy controls, but there was no difference for unpredictable movement patterns (the Fly test). No differences were found for postural sway in standing with eyes open and eyes closed. However, NP patients had significantly larger postural sway when standing on a balance pad. Proprioception did not differ between the groups. Largest effect sizes (ES) were found for neck flexibility (ES range: 0.2- 0.8) and head steadiness (ES range: 1.3- 2.0). Neck flexibility was the only construct that showed a significant association with current neck pain, while peak velocity was the only variable that showed a significant association with kinesiophobia. Conclusions NP patients showed an overall stiffer and more rigid neck motor control pattern compared to HC, indicated by lower neck flexibility, slower movement velocity, increased head steadiness and more rigid trajectory head motion patterns. Only neck flexibility showed a significant association with clinical features in NP patients. Electronic supplementary material The online version of this article (doi:10.1186/s12891-015-0517-2) contains supplementary material, which is available to authorized users.

In this prospective cohort study we aimed to describe the natural course of acute neck and low back pain in a general population of Norway. We screened 9056 subjects aged 20-67 years who participated in a general health survey for a new episode of neck or low back pain the previous month. The screening identified 219 subjects who formed the cohort for this study. Pain intensity was reported on a numeric rating scale (0-10) at 1, 2, 3, 6, and 12 months after start of the new pain episode. The course of pain was described for neck and low back pain, different baseline pain levels, age groups, and number of pain sites at baseline. Use of medication and health care was described and associations between pain intensity and seeking health care were estimated. Pain declined rapidly within 1 month after a new pain episode, with a reduction of 0.91 (95% confidence interval [CI] 0.50-1.32) for neck pain and 1.40 (95% CI 0.82-1.99) for low back pain with little change thereafter. However, pain remained unchanged over the follow-up year for those with equal pain in the neck and low back areas at baseline and for those reporting 4 or more pain sites at baseline. Only 1 in 5 sought health care for their complaints. Still, the course of pain was comparable to effect sizes reported in interventional studies. This study thus contributes natural course reference data for comparisons of pain outcome in clinical trials and practice.

STUDY DESIGN Cross-sectional study. OBJECTIVE To evaluate the association between degree of signal changes in the alar ligaments on MRI with respect to pain and disability. SUMMARY OF BACKGROUND DATA Conflicting evidence exists whether areas of high-signal intensity in the alar ligaments on MRI are associated with pain and disability. METHODS A cross-sectional designed study of 173 subjects including a group with persistent whiplash associated disorder (WAD) Grade II after a car accident (n = 59), a group with chronic nontraumatic neck pain (n = 57) and a group without neck pain or previous neck trauma (n = 57). To assess pain and disability, all participants filled in the Brief Pain Inventory (BPI-intensity and BPI-interference), the European Quality of Life (EQ-5D and EQ VAS) and the Hospital Anxiety and Depression Rating Scale (HADS). High-resolution proton-weighted MR images in three planes were evaluated by two experienced neuroradiologists who were blinded to patient history and group allocation. The alar ligaments were evaluated according to a 4-point grading scale; 0 = low-signal intensity throughout the entire cross-section area, 1 = high-signal intensity in one third or less, 2 = high-signal intensity in one third to two thirds, and 3 = high-signal intensity in two thirds or more of the cross-section area. RESULTS With respect to BPI and HADS, the scores were highest in the WAD group, intermediate in the chronic nontraumatic neck pain group, and lowest among controls. EuroQol scores were lowest in the WAD group, intermediate in the chronic nontraumatic neck pain group, and highest among controls (P < 0.001). There was, however, no significant correlation between the alar ligament changes and measures for pain and disability. CONCLUSION The previously reported assumption that changes in the alar ligaments detected on MRI are associated with pain and disability is not supported by this study. The diagnostic value and the clinical relevance of MR-detectable areas of high intensity in the alar ligaments remain questionable.

Objective: While sensorimotor alterations have been observed in patients with neck pain, it is uncertain whether such changes distinguish whiplash-associated disorders from chronic neck pain without trauma. The aim of this study was to investigate head steadiness during isometric neck flexion in subjects with chronic whiplash-associated disorders (WAD), those with chronic non-traumatic neck pain and healthy subjects. Associations with fatigue and effects of pain and dizziness were also investigated. Methods: Head steadiness in terms of head motion velocity was compared in subjects with whiplash (n=59), non-traumatic neck pain (n=57) and healthy controls (n=57) during 2 40-s isometric neck flexion tests; a high load test and a low load test. Increased velocity was expected to reflect decreased head steadiness. Results: The whiplash group showed significantly decreased head steadiness in the low load task compared with the other 2 groups. The difference was explained largely by severe levels of neck pain and dizziness. No group differences in head steadiness were found in the high load task. Conclusion: Reduced head steadiness during an isometric holding test was observed in a group of patients with whiplash-associated disorders. Decreased head steadiness was related to severe pain and dizziness. © 2010 The Authors. Under the CC BY-NC 4.0 license (https://creativecommons.org/licenses/by-nc/4.0/)

Patients with whiplash associated disorders (WAD) have shown less accuracy in trajectory head motion compared to asymptomatic controls, which comply with clinical observations. The aim of this study was to investigate whether a trajectory head movement task can differ between WAD patients, chronic non-traumatic neck pain (CNP) patients and asymptomatic controls. Study groups included subjects with WAD (n = 35) with persistent neck pain after a car accident, CNP (n = 45), and asymptomatic controls (n = 48). Head motion was recorded from an unsupported standing position using a 3D Fastrak device. A laser pointer was attached to the head and by moving the head the subjects were asked to trace a figure of eight displayed on the wall at three different paces (slow, moderate and fast). The motion signal was decomposed into 1 Hz frequency bands and angular velocity (deg/s) within each frequency band was calculated. Significantly higher angular RMS velocity was found in the WAD group compared to the two other groups for the slow paced test (3-4 and 4-5 Hz frequency bands) and the moderate paced test (3-4 Hz frequency band) indicating irregular and uncoordinated movements. Angular RMS velocity was associated with pain and dizziness, but only with severe symptom levels. In conclusion, irregular head movements during a complex task were found in the WAD group, indicating altered central sensorimotor processing. The irregularities were found within frequency levels observable to clinicians.

Background: Neck pain is common in the general population with one year prevalence varying from 30% to 50%. Neck pain is the fourth leading cause of years lived with disability, which underlines the importance of research to identify effective prevention and treatment strategies based on knowledge of underlyingmechanisms of neck pain. Traditionally, physiotherapists have based their treatments of neck pain patients on functional tests and clinical findings. In the last 10 years studies show that neck pain is associated with several alterations in motor control and neck motion. Purpose: In a longitudinal study design we applied a comprehensive set of tests for motor control to investigate associations between motor control and neck pain. The aim was to investigate if motor control and neck motion changed following physiotherapy treatment and secondly, if changes in motor control were associated with reduced neck pain on an individual level. Methods: Subjects with non-specific neck pain (n= 71) participated in this observational study of neck pain patients in private physiotherapy practice. Neck flexibility, joint position error (JPE), head steadiness, trajectory movement control and postural sway were recorded at baseline before start of treatment, at 2 weeks, and 2 months. Numerical Pain Rating Scale was used tomeasure neck pain at the day of testing. To analyze within subjects effects in motor control and neck pain over time we used fixed effects linear regression analysis. Results:Neck flexibility and peak velocity increased after 2 weeks and 2 months compared to baseline. Neck pain patients improved their trajectory movement control and had less postural sway after 2 weeks and 2 months compared to baseline. Joint position error and conjunct motion did not change during the follow-up period. Changes in neck motion and motor control were largest from baseline to 2 weeks with small changes between 2 weeks and 2 months. Within individual changes were assessed with univariate regression analyses and showed that reduced neck pain was associated with twoneck motion and motor control variables; increased neck flexibility, and altered postural control. Conclusion(s): We found that only increased neck flexibility and altered postural control were associated with decreased neck pain after physiotherapy Treatment. Implications: For clinicians knowledge of the associations between neck pain and motor control on an individual level rather than group level is important. This study shows that few of the variables for motor control were associated with neck pain over a course of 2 months with treatment. While neck pain has been shown to be associated stiffening motion patterns, this study suggests that clinicians should focus treatment on interventions to increase neck flexibility and postural control since these variables were the only variables associated with neck pain reduction.

Background Persistent whiplash associated disorders (WAD) have been associated with alterations in kinesthetic sense and motor control. The evidence is however inconclusive, particularly for differences between WAD patients and patients with chronic non-traumatic neck pain. The aim of this study was to investigate motor control deficits in WAD compared to chronic non-traumatic neck pain and healthy controls in relation to cervical range of motion (ROM), conjunct motion, joint position error and ROM-variability. Methods Participants (n = 173) were recruited to three groups: 59 patients with persistent WAD, 57 patients with chronic non-traumatic neck pain and 57 asymptomatic volunteers. A 3D motion tracking system (Fastrak) was used to record maximal range of motion in the three cardinal planes of the cervical spine (sagittal, frontal and horizontal), and concurrent motion in the two associated cardinal planes relative to each primary plane were used to express conjunct motion. Joint position error was registered as the difference in head positions before and after cervical rotations. Results Reduced conjunct motion was found for WAD and chronic neck pain patients compared to asymptomatic subjects. This was most evident during cervical rotation. Reduced conjunct motion was not explained by current pain or by range of motion in the primary plane. Total conjunct motion during primary rotation was 13.9° (95% CI; 12.2–15.6) for the WAD group, 17.9° (95% CI; 16.1–19.6) for the chronic neck pain group and 25.9° (95% CI; 23.7–28.1) for the asymptomatic group. As expected, maximal cervical range of motion was significantly reduced among the WAD patients compared to both control groups. No group differences were found in maximal ROM-variability or joint position error. Conclusion Altered movement patterns in the cervical spine were found for both pain groups, indicating changes in motor control strategies. The changes were not related to a history of neck trauma, nor to current pain, but more likely due to long-lasting pain. No group differences were found for kinaesthetic sense. © 2008 Woodhouse and Vasseljen; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.