Recovery from nonspecific neck pain in office workers

Abstract

BACKGROUND:

Neck pain has an episodic course with varying time for recovery and identification of individuals likely to recover is important.

OBJECTIVE:

The aim of this study was twofold: 1a) to explore the duration of recovery from nonspecific neck pain, and 1b) to investigate the relation between recovery duration and age, and 2) to evaluate whether the NHBOW can predict duration of recovery from non-specific neck pain.

METHODS:

One hundred and three from 342 office workers reported non-specific neck pain, with information collected on pain intensity and disability every month for 12 months. The time to recovery was measured from the onset of neck pain to full recovery. The 103 office workers were divided into two groups using the NHBOW score. Kaplan-Meier survival curves were used to describe the median time to recovery. The survival curves of the two NHBOW groups were compared using Cox regression analysis.

RESULTS:

The median time to recovery from neck pain was 2 months. The duration of recovery was not significantly related with age of participants. There was no significant difference in time to recovery from neck pain between the NHBOW low-score group and the high-score group.

CONCLUSION:

This study showed that the NHBOW was unable to predict duration of recovery from nonspecific neck pain in office workers.

Keywords

Health literacy office worker recovery prognosis

1. Introduction

Neck pain is prevalent among office workers with 42%–69% of office workers reporting neck pain and 34%–49% of office workers developing new onset of neck pain every year [1, 2, 3, 4, 5, 6]. Although the pain levels of neck pain may improve over time, up to 50% of neck pain patients do not recover completely over a 1-year period. Moreover, three-quarters of all patients who recovered from neck pain relapse within 1–5 years. For the majority of those with neck pain (50%–80%), the course seems to be persistent or recurrent (that is, with remissions and exacerbations) over years and months [7]. In the Netherlands, the economic cost of neck pain in 1996 was estimated at 686 million US dollars [8, 9]. In Thailand, the economic cost of neck pain among office workers was approximately 198 million US dollars in 2006 [10]. Neck pain is usually associated with significant disability and chronicity, leading to personal suffering and impaired quality of work and life in general [1, 8].

An important component of clinical decision making for any condition is prognosis [11]. Prognosis enables estimation of the probability that a state of health, such as change in pain or disability, will occur in the future, and is ideal for educating patients regarding anticipated outcome as well as prioritizing individuals for intervention [12, 13]. From a review, it appeared that there were few studies focusing on prognostic factors related to neck pain. The most frequently reported prognostic factors are age, gender, a long duration of the current episode of neck pain, previous history of neck pain problems, previous history of other musculoskeletal disorders, exercise, and physical job demands [11, 14, 15, 16]. Guzman et al. [17] described neck pain as an episodic occurrence over lifetime with variable recovery in between episodes. There are indications that the clinical course of neck pain is similar to that of low back pain, with a pattern of intermittent episodes of pain and disability over a period of years [18]. Leaver et al. [19] found that 52% of neck pain participants experienced full recovery from neck pain during the 3-month follow-up period. The median time from commencement of treatment to recovery of pain was 45 days. Of those who recovered, 55% and 75% recovered within 3 weeks and 4 weeks of commencing treatment, respectively.

Neck pain in workers is assumed to be of multifactorial origin. The risk factors of neck pain should be classified as either modifiable or not modifiable, depending on the feasibility of changing the relevant factor. Of particular importance are modifiable factors that could have a large positive impact on the prevention and recovery of neck pain [17]. One effective way of dealing with musculoskeletal disorders is self-management based on the biopsychosocial model [20, 21]. This model is widely accepted in the care of chronic musculoskeletal disorders as improving self-efficacy and wellness behaviors [22, 23]. Self-management requires patients to have adequate health literacy. The Neck pain-specific Health Behavior in Office Workers (NHBOW) is a health behavior questionnaire for office workers. The NHBOW was developed to identify office workers at risk for developing non-specific neck pain. The total score of the NHBOW ranges from 0 to 24, with higher scores indicating better health behaviors and lower risk to develop non-specific neck pain. Office workers with high scores also possess better health behaviors, health outcomes, and self-management skills than those with low scores of health literacy [34]. Moreover, items 1–6 of the NHBOW consider modifiable factors that could have impact on the prevention and recovery of neck pain. Our earlier study showed that NHBOW can predict office workers who are at risk of developing non-specific neck pain. In the present study, we hypothesized that office workers with higher scores of NHBOW have better health behaviors, which may enable them to exhibit shorter durations of recovery from non-specific neck pain. The aim of this study in office workers was twofold: 1a) to explore the duration of recovery from non-specific neck pain and 1b) to investigate the relation between recovery duration and age, and 2) to evaluate whether the NHBOW can predict duration of recovery from non-specific neck pain.

2. Methods

2.1 Study design

This study is a part of a 1-year prospective cohort study in a convenience sample of healthy office workers to investigate the predictive values of the NHBOW on incident non-specific neck pain and duration of recovery from non-specific neck pain in office workers. Office workers without neck pain at baseline were prospectively followed up every month for a 12-month period, and only workers reporting non-specific neck pain in this period were included in to this study.

2.2 Subjects

The study recruited a convenience sample of office workers from large-scale enterprises in Bangkok. Office workers were defined as those working in an office environment with their main tasks involving the use of a computer, reading, phoning, making presentations, and participating in meetings. Other inclusion criteria were: age between 18 and 55 years, working full-time, and having at least five year of experience as an office worker. Exclusion criteria included: reported neck pain in the previous six months with pain intensity greater than 30 mm on a 100-mm visual analog scale; reported pregnancy or a plan to become pregnant in the next 12 months; and history of trauma or accidents or surgery in the neck region. Participants who had been diagnosed with congenital anomaly of the spine, rheumatoid arthritis, infection of the spine and discs, ankylosing spondylitis, spondylolisthesis, spondylosis, tumor, systemic lupus erythymatosus, or osteoporosis were also excluded from the study. Potential participants were screened for the study using a self-administered questionnaire.

Office workers were approached and invited to participate in this study. They were informed about the objectives and details of the study and were asked to provide informed consent upon agreement to participate. At baseline, participants completed the self-administered questionnaire and the NHBOW questionnaire. Participants then received a self-administered diary to record any incidence of neck pain and, if occurring, the intensity of neck pain and disability arising from neck pain. The researcher collected the diaries from participants every month over a 12-month period. The study was approved by the Chulalongkorn University Human Ethics Committee.

2.3 Questionnaire

The self-administered questionnaire comprised three sections designed to gather data on individual, work-related physical, and psychosocial factors. Individual factors included gender, age, marital status, education level, frequency of regular exercise or sport, smoking habits, and number of driving hours per day. Work-related physical factors included current job position, number of working hours, years of working experience, frequency of using a computer, performing various activities during work, and rest breaks. The questionnaire also asked respondents to self-rate the ergonomics of their workstations (desk, chair, and position of monitor) and work environment conditions (ambient temperature, noise level, light intensity, and air circulation). Psychosocial work characteristics were measured using the Job Content Questionnaire (Thai version) [24]. The questionnaire comprises 54 items in the following six areas: psychological demands (12 items), decision latitude (11 items), social support (8 items), physical demands (6 items), job security (5 items), and hazards at work (12 items). Each item has a four-point Likert-type response option ranging from 1, strongly disagree, to 4, strongly agree.

The NHBOW questionnaire (Thai version) comprises six items [34]. Items 1–4 involve the behaviors of office workers during work, while Items 5–6 concern neck-related exercise. Each item has a five-point Likert-type response option ranging from 0, never perform, to 4, always perform, and the total score of the NHBOW ranges from 0 to 24. The cut-off score is less than or equal to 8. Higher scores than 8 indicate better health behavior and a lower risk of developing non-specific neck pain.

2.4 Outcome measure

The area of neck was defined according to the picture of the body from the standardized Nordic questionnaire (Thai version) [25]. Participants answered the yes/no question “Have you experienced any neck pain lasting $>$ 24 hours during the past month?” If they answered “Yes”, follow-up questions about pain intensity measured by a visual analogue scale, and the presence of weakness or numbness in the upper limbs were asked. Those who reported incidence of neck pain were also asked about their disability level as measured by the neck disability index (NDI) (Thai version) [26]. The NDI contains 10 items on a 5-point Likert scale, and the total score of the NDI ranges from 0 to 50, with higher scores indicating more severe disability.

In this study, participants were identified as those with onset non-specific neck pain, i.e. if they answered “Yes” to the question “Have you experienced any neck pain lasting $>$ 24 hours during the past month?”, reported pain intensity greater than 30 mm on a 100-mm visual analogue scale, and had no weakness or numbness in the upper limbs. Participants were followed until they completed the 12-month follow-up, or withdrew from the study. For the outcome measure of recovery from non-specific neck pain, this study sampled two dimensions of recovery: pain intensity and disability. When participants reported being pain-free (VAS $=$ 0) with no disability (NDI $=$ 0) during the past month, they were considered “recovered” at the beginning of that month. Hence, the outcome measure was time to recovery, i.e. the duration from the onset of neck pain to the recovery.

2.5 Statistical analysis

Characteristics of subjects were described using means or proportions. The percentage of missing data for the individual was 0.9%. To retain the statistical power of the database, missing data were handled using the “hot-deck imputation” procedure. A respondent was selected at random from the total sample of the study, and the value for that person was assigned to the case for which information was missing. This procedure was conducted repeatedly for each missing value, until the dataset was complete

The KaplanMeier survival curves were used to describe the median time to recovery of the participants. Participants lost to follow-up were censored at the mid-point between the last completed follow-up and the next follow-up time [27]. Participants not recovered after 12 months were censored at this point. The correlations of the recovery time from non-specific neck pain and age of the participants were analyzed using Pearson correlation. The participants were divided into two groups using the NHBOW score: the low-score group had an NHBOW score lower than or equal to 8, and the high-score group had an NHBOW score higher than 8. The survival curves of these two groups were compared using Cox regression analysis. First, Cox regression analyses were used to identify the association between group of NHBOW score and recovery time from non-specific neck pain. Second, the participants’ age, gender, previous history of neck pain, previous history of neck muscle tension, previous history of low back pain, exercise, psychosocial work characteristics as well as pain intensity and disability at the first neck pain episode were considered to be confounders and were forced into the multivariate analysis. All statistical analyses were performed using SPSS for Window Version 17.0 (SPSS Inc, Chicago, IL, USA).

3. Results

Among the total of 2,510 workers who received invitations, 847 responded. Of these, 505 were excluded because they did not meet the inclusion criteria, giving an eligible population of 342. A total of 342 workers agreed to participate and 335 of those were followed for one year. There were 103 (30.7%) participants who reported non-specific neck pain with mean (SD) VAS and NDI scores of 4.44 (1.19) and 6.79 (3.76), respectively. Participants comprised office workers aged 26 to 55 years. Participants aged between 30 and 39 years (52.4%) showed the highest proportions of those with an episode of non-specific neck pain. Those aged between 26 and 29 years (5.8%) showed the lowest proportion for those with an episode of non-specific neck pain. Four-fifths of the participants with non-specific neck pain (82.5%) were female. Table 1 presents the baseline characteristics of office workers who reported non-specific neck pain. During the remaining follow-up period, 75 participants reported recovery from non-specific neck pain. Twenty eight participants (27.2%) who had not reported recovery from non-specific neck pain were censored at the time of last completed follow-up. Table 2 shows the NHBOW scores at baseline, 6-month, and 12-month of all 103 office workers.

Table 1
Characteristics of the study population of office workers with nonspecific neck pain ( $n=$ 103)

Characteristic	N (%)	Mean $\pm$ SD
Demographic characteristics
Gender
Male	18 (17.5)
Female	85 (82.5)
Age (years)		38.94 $\pm$ 7.5
26–29	6 (5.80)
30–39	54 (52.4)
40–49	29 (28.2)
$\geqslant$ 50	14 (13.6)
At the first neck pain episode
Pain intensity		44.4 $\pm$ 11.9
Disability		6.79 $\pm$ 3.76
Education
Lower than Bachelor’s degree	7 (6.80)
Bachelor’s degree	61 (59.2)
Higher than Bachelor’s degree	35 (34)
Exercise frequency in the past 12 months
Never	22 (21.4)
Sometimes	63 (61.2)
Frequently	18 (17.5)
History of neck pain
Yes	70 (68)
No	33 (32)
History of neck muscle tension
Never	40 (38.8)
Sometimes	39 (37.9)
Frequently	24 (23.3)
Work-related characteristics
Duration of employment (years)		13.41 $\pm$ 7.54
Working hours (hours per day)		7.69 $\pm$ 1.14
Working days (days per week)		5.0 $\pm$ 0.5
Psychosocial work characteristics
Job control		36.14 $\pm$ 4.80
Psychological demand		33.85 $\pm$ 5.23
Physical demand		13.48 $\pm$ 2.88
Job security		17.12 $\pm$ 1.14
Social support		37.56 $\pm$ 5.64
Hazards at work		16.00 $\pm$ 3.20

Table 2

The mean score of the NHBOW at baseline, 6-month and 12-month ( $n=$ 103)

	Baseline	6-month	12-month
	(Mean $\pm$ SD)	(Mean $\pm$ SD)	(Mean $\pm$ SD)
Score of NHBOW	9.84 $\pm$ 3.68	10.86 $\pm$ 3.29	10.68 $\pm$ 3.44

Figure 1.

Kaplan-Meier estimate of the time to recovery from nonspecific neck pain in office workers ( $n=$ 103).

Figure 2.

Kaplan-Meier estimate of the time to recovery from nonspecific neck pain in office workers in the NHBOW high-score group ( $n=$ 44) and NHBOW low-score group ( $n=$ 59).

Table 3

Cox regression for recovery time from nonspecific neck pain with hazard ratios (HR) and 95% confidence intervals

Variable	Unadjusted		Adjusted
	HR (95%CI)	P value	HR (95%CI)	P value
Group of NHBOW
Low-score group	0.881 (0.56 to 1.40)	0.587	0.931 (0.57 to 1.52)	0.776
High-score group	1.000		1.000
Age			0.971 (0.94 to 1.01)	0.122
Gender			0.835 (0.41 to 1.70)	0.619
History of neck pain			1.342 (0.70 to 2.61)	0.387
History of low back pain			0.847 (0.44 to 1.64)	0.624
History of neck muscle tension
Frequently			0.808 (0.40 to 1.66)	0.561
Sometimes			0.496 (0.25 to 1.00)	0.051
Never			1.000
Exercise frequency in the past 12 months
Never			0.538 (0.24 to 1.21)	0.132
Sometimes			0.667 (0.33 to 1.33)	0.250
Frequently			1.000
Psychosocial work characteristics
Decision latitude			1.014 (0.95 to 1.09)	0.692
Psychological demands			0.978 (0.92 to 1.04)	0.458
Physical demands			0.986 (0.88 to 1.10)	0.801
Job security			1.242 (0.94 to 1.64)	0.122
Social support			0.994 (0.94 to 1.06)	0.853
Hazards at work			0.962 (0.88 to 1.05)	0.382
At the first neck pain episode
Pain intensity			0.904 (0.72 to 1.14)	0.384
Disability			1.001 (0.94 to 1.07)	0.980

Recovery from onset non-specific neck pain, determined by recovery on pain intensity and disability took a median time of 2 months (range: 1 to 10 months). The Kaplan-Meier survival curve showed that the cumulative probability of recovery was 35.9% at 1 month. After 2 months, the probability was 53.4%, and this increased to 72.8% at 10 months (Fig. 1). Aging participants (aged 45 years and older) showed a median duration of recovery from non-specific neck pain of 2 months, which was also 2 months for those younger than 45 years. The duration of recovery was not significantly related with age of participants (the correlation coefficient was 0.074). The Cox regression for recovery time of non-specific neck pain showed that the median time to recovery from neck pain in the high-score group was 2 months, and in the low-score group the median time to recovery was 3 months. When comparing the low-score group and the high-score group, there was no significant difference in time to recovery from neck pain (Fig. 2). After adjustment for age, gender, previous history of neck pain, previous history of neck muscle tension, previous history of low back pain, exercise, psychosocial work characteristics as well as pain intensity and disability at the first neck pain episode, there remained no association between the group of NHBOW and duration of recovery (Table 3).

4. Discussion

At the end of follow-up, 72.8% of non-specific neck pain office workers reported recovery from their pain. The median time from the onset of neck pain to recovery was 2 months. The NHBOW did not predict duration of recovery from non-specific neck pain in office workers. Leaver et al. [19] reported that the median recovery time of neck pain was 45 days, which was shorter than in this study. However, there are difficulties comparing the recovery time between our study and their study because their participants received physical therapy treatment at four sessions over two weeks. In contrast, our participants did not receive treatment. In the study of Leaver et al. [19], for the participants considered to have recovered from neck pain mean pain intensity remained at 1.5 (SD 1.8) and mean disability at 5.4 (SD 6.4) at the end of their 3-month follow-up, while recovery in our study was considered to be pain free and without disability (VAS $=$ 0, NDI $=$ 0). However, our study reported median time to recovery to be quite similar to the study of Henschke et al. [28] among acute low back pain patients in terms of pain intensity. They reported that median time to recovery from pain after an episode of acute low back pain was 58 days (range: 53 to 63 days) [28]. Our study and the study of Henschke et al. [28] defined recovery as participants who are pain free. Henschke et al. [28] defined “complete recovery” as participants who reported to be pain free, without disability and having returned to work. However, they found that the survival curves for recovery from pain and complete recovery were similar. This may indicate that neck pain and low back pain are musculoskeletal disorders that have rather similar times for recovery. In addition, this study found no association between age and duration of recovery time from non-specific neck pain. The results were similar to the study of Borghouts et al. [29], which described no association between age and worse prognosis, although they did find an association between worse prognosis and women over 50 years.

There was no association between the group of NHBOW and duration of recovery from non-specific neck pain in office workers. Nevertheless, the questions in the NHBOW consider modifiable factors that could have a positive impact on the recovery of neck pain [17]. Patients with good health behavior will be encouraged to pursue self-management for dealing with musculoskeletal disorders. Self-management based on the biopsychosocial model focuses on encouraging patients to be involved with their own treatment as well as preparing patients to manage their health behaviors [20, 21, 30, 31]. The study of Walton et al. [32] suggested that prognosis requires a knowledge of factors across biopsychosocial domains and is generally of high importance for prognosis, involving psychological and behavioral factors beyond purely physical signs. Likewise, Questions 1–4 of NHBOW focus on the behaviors of office workers during work. The study of Bernaards et al. [33] showed that behavioral change was effective in improving recovery from neck/shoulder symptoms and reducing pain in the long term. Questions 5–6 concern neck-related exercise. This was consistent with the study of McLean et al. [14], which demonstrated that regular exercise predicted a good outcome for non-specific neck pain.

In addition, it was interesting that the NHBOW score of participants, most of whom had started to experience neck pain in the first months of the study, slightly increased when the baseline was compared to 6-month and 12-month follow-up. This increase may indicate that the office workers with non-specific neck pain may have changed their behavior to manage neck pain. Hence, this may lead to an increase in the NHBOW score from baseline. Office workers with improving health behaviors are more likely to improve their health outcomes and self-management skill. This may be explained by the pain making participants more aware of their health which may in turn lead them to learn how to deal with the problem and to change their behavior in order to relieve the pain. It should, however, be noted that these interpretations are only speculative and that future research should shed light on this area.

The most important strength of this study is its prospective design; we followed pain intensity and disability every month over a 12-month period with high rates of follow-up. A further strength is that the study builds on earlier evidence reporting the predictive value of the NHBOW in office workers without neck pain. A limitation of the study, however, is that the occurrence and recovery of neck pain was subjective in terms of pain intensity, which may have led to inaccuracy. Another drawback of self-reported data is the risk of overestimation of exposure. Furthermore, some workers may be more sensitive to any somatic disturbance than others. As a result, there is a risk of underreporting or overreporting of the symptom. Future studies should consider inclusion of objective information from physical examination. Another limitation is that duration of time recovery was measured from the onset of neck pain to the recovery, or the completed 12-month follow-up. Hence, participants had unequal durations for follow-up.

5. Conclusion

This study showed that the median recovery duration of office workers suffering from neck pain was 2 months. There was no relation between age and duration of recovery from non-specific neck pain. This study also found that the NHBOW was unable to predict duration of recovery from non-specific neck pain in office workers.

Footnotes

Acknowledgments

This work was funded by the Thailand Research Fund through the Royal Golden Jubilee Ph.D. Program (Grant No. PHD/0221/2553) and the Ratchadaphiseksomphot Endowment Fund of Chulalongkorn University (RES560530271-AS).

Conflict of interest

None to report.

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Recovery from nonspecific neck pain in office workers

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Methods

2.1 Study design

2.2 Subjects

2.3 Questionnaire

2.4 Outcome measure

2.5 Statistical analysis

3. Results

Table 1 Characteristics of the study population of office workers with nonspecific neck pain ( n = 103)

5. Conclusion

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Characteristics of the study population of office workers with nonspecific neck pain ( $n=$ 103)