Physical and psychological predictors for persistent and recurrent non-specific neck pain: a systematic review

Key points

1. 01High pain catastrophizing and psychological distress consistently predicted future neck disability, pain intensity, and recurrence across multiple studies.
2. 02Psychological distress was supported by moderate certainty of evidence; pain catastrophizing by low certainty, due to one study showing only a small effect size.
3. 03No physical predictor was confirmed: cervical range of motion, neck extension strength, and cold pain threshold over the neck showed no association in multiple studies.
4. 04Physical factors like neck flexion strength and conditioned pain modulation showed promise in single studies but lacked replication.
5. 05All six included studies were phase 1 exploratory cohort studies, limiting the overall certainty of findings.

How it was conducted

Design

Systematic review of six prospective cohort studies; narrative synthesis with forest plots, no meta-analysis feasible due to heterogeneity

Databases searched

PubMed, MEDLINE, EMBASE, CINAHL Plus, PsycInfo; inception to January 31, 2025

Participants

2189 adults with non-specific neck pain who completed follow-up; 64% female, 36% male

Follow-up range

6 months to 16 years across included studies

Risk of bias

Three studies rated high overall risk of bias; three rated moderate overall risk of bias (QUIPS tool)

Certainty of evidence

GRADE tool adapted for prognostic studies; physical predictors rated very low to low; psychological predictors rated low to moderate

What they found

• Pain catastrophizing (PCS): association with neck disability r = 0.32 (p = 0.021) in one study and OR 1.11 (p significant) in another; low certainty of evidence for disability, moderate for pain intensity and incidence.
• Psychological distress (DASS-21): association with neck disability r = 0.44 (p = 0.001) and with pain intensity r = 0.47 (p < 0.001) in one study; moderate certainty of evidence overall.
• BDI-II (depression): OR 3.36 for persistent or recurrent neck disability in one multivariate study.
• PHQ-8 (depression): OR 1.47 for being in the Moderate-Fluctuating Disability trajectory in one study.
• GAD-7 (anxiety): OR 1.34 for being in the Moderate-Fluctuating Disability trajectory in one study.
• GHQ (psychological distress): risk of recurrent neck pain was twice as high in the highest versus lowest quartile of baseline GHQ score (RR = 2.0) in one study.
• Neck flexion strength: a 1 kg reduction in maximal voluntary contraction significantly increased NDI by 0.32 units (p = 0.04) in one study, but two other studies found no association (beta < -0.1).
• Cervical range of motion: no significant association with neck disability reported consistently across three studies (low certainty).
• Isometric neck extension strength: no association with disability reported by three studies (low certainty).
• Cold pain threshold over the neck: no association with disability in three studies (low certainty); positive association with pain intensity in one study only.

Limitations

• All six included studies were phase 1 exploratory cohort studies, which are particularly vulnerable to false positive results and represent the lowest quality of prognostic evidence.
• Three of six studies had high overall risk of bias, mainly due to insufficient reporting of confounding factors and study attrition.
• Most physical predictors were each investigated by only one study, making it impossible to draw conclusions about replication or consistency.
• Population heterogeneity across studies, including mixing of asymptomatic individuals with those in remission, may explain inconsistent findings for physical predictors such as neck flexion strength.

Why it matters

For patients

People with neck pain who experience high levels of worry, distress, or catastrophic thinking about their pain are at greater risk of it becoming long-lasting or recurring, and should discuss psychological support with their clinician early.

For clinicians

Routine early screening for pain catastrophizing and psychological distress (using tools such as PCS, DASS-21, BDI-II, PHQ-8, or GAD-7) is supported by this review to identify patients at higher risk of chronicity, and psychological interventions targeting maladaptive beliefs should be considered as part of management.

For readers

This review fills a gap by examining both physical and psychological predictors together, but the evidence base is currently small and exploratory; high-quality confirmatory cohort studies are needed before firm clinical prediction models can be developed.