Research Review By Dr. Jeff Muir©


Download MP3

Date Posted:

July 2019

Study Title:

A systematic review with meta‐analysis on functional changes associated with neck pain in adolescents


Andias R & Silva AG

Author's Affiliations:

School of Health Sciences, University of Aveiro, Aveiro, Portugal; Center for Health Technology and Services Research (CINTESIS), Porto, Portugal.

Publication Information:

Musculoskeletal Care 2019; 17: 23–36.

Background Information:

Musculoskeletal pain among adolescents has been reported to be as high as 40% (1), of which neck pain (NP) is among the most prevalent conditions, affecting up to 24% of those aged 14-17 years (2). Such neck pain is generally characterized as being of long duration and intermittent nature, occurring 2-3 times per week on average (3). NP in adolescents is associated with limitation on activities of daily living, school absence, negatively impacted family interactions (4-6) and is a predictor of neck pain in adulthood (7-9).

Adolescents with NP have been shown to have decreased neck flexor and extensor endurance (3), increased superficial muscle activity (10), impaired joint position sense and increased pain sensitivity (11). These observations are similar to adult NP sufferers, although adolescents tend to have NP of lower intensity, frequency and duration (3, 12). Elucidating the mechanisms behind these differences compared to the adult patient population are important in establishing treatment plans and approaches and, as such, a better understanding of NP and the associated changes in adolescents is necessary. The goal of this study was to systematically review the current evidence on the functional changes associated with NP in adolescents regarding factors such as posture, postural control, range of motion (ROM), proprioception, muscle function and sensory threshold.

Pertinent Results:

Included Studies:
Ten studies met the eligibility criteria, nine of which were case-control studies and one of which was a prospective, longitudinal study.

Methodological quality was poor to fair, with study quality varying between 3 and 6 (on a scale of 9) and with no study meeting the criteria for “good quality” (7 or higher).

Seven studies compared posture in adolescents with and without neck pain (NP). Significant heterogeneity was noted across studies (Q = 13; p = 0.00; I2 = 85%), with the pooled results showing no statistically significant difference between forward head posture in patients with or without NP (WMD = 1.1; 95% CI –2.1°, 4.1°).

Two studies evaluated seated head position and cervicothoracic angle, with one study (13) noting no significant difference in head posture in NP sufferers, while another study (14) noted a significantly smaller CT angle in NP sufferers, although this difference was no longer significant when subgrouping for gender.

Finally, one study (14) reported a significantly smaller trunk angle, indicating increased extended posture of the trunk (WMD = −3.0°; 95% CI = −5.9°, −0.2°), a smaller lumbar angle (WMD = −6.4°; 95% CI = −10.8°, −2.1°) and a higher pelvic tilt angle (WMD = 5.3°; 95% CI = 1.5°, 9.1°).

Range of Motion:
Three studies of fair quality assessed range of motion (neck [n=2]; thoracolumbar extension [n=1]). One study (15) noted no differences in ROM in patients with NP vs. those without. Another study (10) noted NP sufferers had greater motion in left lateral bending (WMD = 9.4°; 95% CI = 7.6°, 11.3°) and left rotation (WMD = 5.5°; 95% CI = 4.3°, 6.7°), and less motion in right (WMD = −9.6°; 95% CI = −12°, −7.3°) and left (WMD = −14°; 95% CI = −15.7°, −12.3°) axial rotation. Finally, one study (16) found a significant association for thoracolumbar extension, suggesting that patients with greater extension have an increased probability of NP (thoracic OR = 0.98; 95% CI = 0.96, 1.00; and lumbar OR = 0.96; 95% CI = 0.93, 1.00).

One study (11) of fair quality used a laser pointer to assess joint repositioning error (JPE) and found that NP was associated with a higher joint position error (JPE) (WMD = 1.9°; 95% CI = 0.8°, 2.9°; and 2.4°; 95% CI 1.3°, 3.5° for right and left rotation, respectively).

Muscle Endurance and Strength:
One study (3) of fair quality assessed endurance of the deep flexors and extensors of the neck and found that NP sufferers have lower endurance capacity in both flexors (WMD = −11.4; 95% CI = −21.8, −0.9 s) and extensors (WMD = −42; 95% CI = −77.8, −6.3 s). One additional study (10) of poor quality measured superficial electromyographic activity in the upper trapezius (UT), superficial cervical extensors (CE) and sternocleidomastoid (SCM) musculature and found that NP sufferers have a generally higher level of activity (WMD = 9.74 [95% CI = 5.0, 14.5] in the left UT; 7.3 [3.7, 10.8] in the right CE; 4.9 [0.9, 8.9] in the left CE; 6.6 [1.8, 11.4] in the right SCM; and 6.2 [4.1, 8.4] in the left SCM).

Sensory Threshold:
One study (11) of fair quality found that NP sufferers had a lower pressure pain threshold than those without NP (WMD = −14.2 [95% CI = −17.2, −11.2] N/cm2 in the right UT; −15.6 [−18.5, −12.8] in the left UT; −9.3 [−11.3, −7.2] in the right C1/C2 articular pillar; −10.3 [−12.7, −7.8] in the left C1/C2 articular pillar; −11.1 [−13.8, −8.4] in the right C5/C6 articular pillar; −11.4 [−14.1, −8.7] in the left C5/C6 articular pillar; and −13.4 [−16.8, −10.0] in the tibialis anterior).

Clinical Application & Conclusions:

The authors note that the lack of high-quality evidence makes definitive conclusions and recommendations for clinical practice difficult. They highlight the need for more, and higher quality, research into this association for neck pain in adolescents. With caution, the authors recommend that assessment of head posture in adolescents with NP is unlikely to be of relevance, but that the inclusion of the other factors (range of motion, muscle strength/endurance, proprioception) may be beneficial.

Study Methods:

Several databases were searched: PubMed, ScienceDirect, Web of Science, PEDro, Scielo, Scopus and Academic Search Premier. Searches included terms such as “neck pain” and “adolescents”, along with specific terms regarding NP.

Eligibility Criteria:
  • Study population age between 12 and 18 years
  • Acute or chronic NP not related to known pathology
  • Comparisons of any of the following variables in adolescents with and without NP: ROM, proprioception, muscle strength/endurance, sensory threshold, posture and/or postural control
  • Full article published in peer-reviewed journal
Data Extraction:
Titles and abstracts were screened by the principal investigator (PI). All authors independently reviewed each eligible study. The PI extracted study characteristics using standard forms; a second reviewer extracted relevant data.

Methodological Quality Assessment:
The Newcastle-Ottawa Scale was used to assess quality of case-control studies. Agreement was measured using Cohen’s kappa.

Data Synthesis and Analysis:
Data were presented as mean ± standard deviation, odds ratio (OR) or percent difference. Weighted mean difference (WMD) and 95% confidence intervals were calculated where appropriate. Standard meta-analytic tests for heterogeneity (Q-value and I2 statistic) were used where data allowed for pooling.

Study Strengths / Weaknesses:

  • Strong, comprehensive search criteria
  • Clinically relevant variables
  • Satisfactory statistical analysis plan
  • Low methodological quality of the included studies
  • Heterogeneity regarding study populations, definitions of NP and measurement instruments/procedures utilized
  • Low number of eligible studies prevented the authors from conducting a more robust meta-analysis

Additional References:

  1. King S, Chambers CT, Huguet A et al. The epidemiology of chronic pain in children and adolescents revisited: A systematic review. Pain 2011; 152(12): 2729–2738.
  2. Scarabottolo C, Pinto RZ, Oliveira C et al. Back and neck pain prevalence and their association with physical inactivity domains in adolescents. European Spine Journal 2017; 26(9): 2274–2280.
  3. Oliveira AC & Silva AG. Neck muscle endurance and head posture: A comparison between adolescents with and without neck pain. Manual Therapy 2016; 22: 62–67.
  4. Huguet A & Miró J The severity of chronic pediatric pain: An epidemiological study. Journal of Pain 2008; 9(3): 226–236.
  5. Konijnenberg A, Uiterwaal C, Kimpen J et al. Children with unexplained chronic pain: Substantial impairment in everyday life. Archives of Disease in Childhood 2005; 90(7): 680–686.
  6. Palermo T. Impact of recurrent and chronic pain on child and family daily functioning: A critical review of the literature. Journal of Developmental and Behavioral Pediatrics 2000; 21(1): 58–69.
  7. Brattberg G. Do pain problems in young school children persist into early adulthood? A 13‐year follow‐up. European Journal of Pain 2004; 8: 187–199.
  8. Fearon P & Hotopf M. Relation between headache in childhood and physical and psychiatric symptoms in adulthood: National birth cohort study. BMJ 2001; 322(7295): 1–6.
  9. Kanchanomai S, Janwantanakul P, Pensri P et al. Risk factors for the onset and persistence of neck pain in undergraduate students: 1‐year prospective cohort study. BMC Public Health 2011; 11(566): 1–8.
  10. Park KN, Kwon OY, Ha SM et al. Comparison of electromyographic activity and range of neck motion in violin students with and without neck pain during playing. Medical Problems of Performing Artists 2012; 27(4): 188–192.
  11. Sa S & Silva AG. Repositioning error, pressure pain threshold, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain. Musculoskeletal Science & Practice 2017; 30: 18–24.
  12. Silva AG, Sa‐Couto P, Queirós A et al. Pain, pain intensity and pain disability in high school students are differently associated with physical activity, screening hours and sleep. BMC Musculoskeletal Disorders 2017; 18(194): 1–11.
  13. Richards KV, Beales DJ, Smith AJ et al. Neck posture clusters and their association with biopsychosocial factors and neck pain in Australian adolescents. Physical Therapy 2016; 96(10): 1576–1587.
  14. Straker LM, O'Sullivan PB, Smith AJ & Perry MC. Relationships between prolonged neck/shoulder pain and sitting spinal posture in male and female adolescents. Manual Therapy 2009; 14(3): 321–329.
  15. Hellstenius W. Recurrent neck pain and headaches in preadolescents associated with mechanical dysfunction of the cervical spine: A cross‐sectional observational study with 131 students. Journal of Manipulative and Physiological Therapeutics 2009; 32(8): 625–634.
  16. Dolphens M, Vansteelandt S, Cagnie B et al. Multivariable modeling of factors associated with spinal pain in young adolescence. European Spine Journal 2016; 25(9): 2809–2821.