Activity Patterns and Stress—Prognostic Factors for Pain Persistence and Disability in Acute Neck Pain: A 1‐Year Prospective Cohort Study

BACKGROUND: Neck pain (NP) is a common global health problem, and persistent symptoms are often linked to psychological stress. How individuals respond to pain during daily activities is captured by activity patterns (eustress persistence, distress persistence, activity pacing and fear avoidance). These behavioural responses reflect different ways of managing pain-related activities and have been linked to variations in stress, pain intensity and disability. This study examined whether these factors serve as prognostic factors of pain and disability 1 year after the onset of acute NP. METHODS: In this observational cohort study, 125 participants were assessed at ≤ 1 month (T1), 3 months (T2), 6 months (T3) and 12 months (T4) after acute NP onset. Stress was measured objectively (hair cortisol) and subjectively (Stress and Coping Inventory). Activity patterns were assessed with the Avoidance-Endurance Fast Screen. Linear mixed-effects models were fitted using frequentist and Bayesian approaches. RESULTS: Pain intensity showed prognostic value at T1-T3 for higher pain intensity and disability at T4. Subjective stress was associated with higher pain intensity only at T3, with disability at all measured time points (T1-T3). Objective stress at T2 and T3 was associated with higher pain at T4, with disability only at T3. Among activity patterns, only distress persistence at T3 was associated with higher pain intensity at T4. DISCUSSION: Early pain intensity, longer-lasting stress and distress persistence were associated with symptom persistence, although effect sizes were small. These results may support patient-centred pain management. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05468684 SIGNIFICANCE STATEMENT: This study identifies prognostic factors for pain and disability 1 year after acute neck pain onset by combining pain intensity, subjective stress, hair cortisol and activity patterns across multiple time points. Early pain intensity and persistent stress showed prognostic value for long-term outcomes. Importantly, distress persistence emerged as a prognostic activity pattern, extending the field beyond the predominant focus on fear avoidance. For physiotherapists, this highlights the value of monitoring pain, stress and behavioural responses to support informed, person-centred care.