The complex (virtual) reality and illness perceptions of people with neck pain

Neck pain is a common condition that hinders people's daily functioning. The care of people with non-specific neck pain requires a personalised biopsychosocial approach. However, integrating psychological factors in therapeutic interventions remains a challenge. Understanding psychological mechanisms underlying the persistence of neck pain can support healthcare professionals in offering more rational and personalised (self)management strategies. This PhD-thesis advances this knowledge by providing deeper insights into several underlying psychological mechanisms in people with non-specific neck pain. Part 1 examines the role of associative learning and attentional focus in movement-related pain. Part 2 focuses on illness perceptions and the impact of personalised, psychologically-informed physiotherapy. Part 1: Using Virtual Reality to understand and influence pain-related movement restrictions. Associative Learning and Fear Two studies (Chapters 2 and 3) evaluated whether associative learning influences movement-evoked neck pain. Associative learning suggests that neutral stimuli coupled with pain may eventually elicit pain responses. VR was used to create an illusion of moving more or moving less than the actual movement, to test whether this illusion influenced pain-free range of motion (ROM). Results showed that the ROM when neck pain occurs can be influenced by our visual perception of the amount of rotation, but only in certain VR- conditions (e.g., 30% visual feedback manipulation), with stronger effects in individuals with fear of movement. These findings suggest that non-painful stimuli associated with pain can trigger protective responses, particularly in those fearful of movement, supporting a role for associative learning in neck pain. Focus of Attention In Chapter 4 we investigated whether an internal or external attentional focus influences maximum ROM in 54 participants. An external focus was induced by asking participants to spot birds in a VR-environment, while an internal focus involved direct instructions to move the neck in the rotation and flexion-extension direction. Results showed that external focus improved ROM in rotation but not in flexion-extension. This suggests that directing attention externally can improve certain movement patterns. Part 2: Illness perceptions and its role in personalised psychologically-informed physiotherapy Chapter 5 presents a qualitative study of 20 individuals with chronic disabling neck pain, exploring their illness perceptions and the origins of these perceptions. Five key themes emerged: ‘How my neck pain journey began and why it continued’, ‘Labelling my condition’, ‘Impact: multiple symptoms that require attention and action’, ‘Coping with neck pain’ and ‘Along the road: perceptions and experiences’. People with neck pain are open to the influence of both biological and psychosocial factors on their pain experience. However, they reported that they had received predominantly biomedical messages from healthcare professionals regarding the labelling of their condition, leading to confusion, frustration and reduced control. These results underline the importance of further implementing a biopsychosocial approach in clinical practice. Chapter 6 evaluated an intervention addressing unhelpful illness perceptions and dysfunctional movement behaviour in 14 patients with chronic or recurrent neck pain. Using a single-case experimental design, repeated measures tracked changes across baseline, intervention and follow-up on overall effect, pain and functioning. Mediation analysis showed that changes in illness perceptions—particularly regarding consequences, personal control, identity, concern, and emotional response—explained an important part of the treatment effect. These findings support addressing unhelpful illness perceptions and dysfunctional movement behaviour as essential components in conservative treatment for people with chronic neck pain. Conclusion This thesis shows that a learning perspective is useful to influence perceptions of people with neck pain. For instance, cognitive learning strategies could involve educating the patient about their condition, while experiential learning strategies could involve guided functional exercises to change their pain perception. These strategies seem promising in improving the care of people with persistent neck pain.