Effects of Physiotherapy Approaches on Biopsychosocial Outcomes in Chronic Non-Specific Neck Pain

Background and Rationale:

Chronic non-specific neck pain (CNSNP) involves complex interactions between musculoskeletal, neurological, and psychosocial factors. Patients frequently experience reduced cervical mobility, impaired sensorimotor control (such as altered joint position sense), central sensitization, and psychological distress including kinesiophobia and pain catastrophizing. While clinical guidelines strongly recommend exercise therapy and patient education, the optimal combination of specific exercise modalities and neuroscience education remains unclear.

Study Design:

This study is designed as a prospective, single-blind, three-arm randomized controlled trial conducted at Istanbul Medipol University. Eligible participants will be stratified based on Central Sensitization Inventory (CSI) scores (<40, 40-49, ≥50) and randomized using a 1:1:1 allocation ratio into three intervention arms via block randomization (block size of 6). Assesors and data statisticians will be blinded to group assignments.

Intervention Protocols:

Structured Exercise Group (SEG): Participants will receive 24 supervised sessions over 8 weeks (3 sessions/week, ~30 mins). Protocol includes cervical active ROM warming/cooling, stretching, progressive isometric and isotonic resistance exercises with elastic bands (monitored via Borg RPE scale), and craniocervical flexion stabilization exercises using a pressure biofeedback unit.

Sensorimotor Training Group (SMTG): Participants will undertake 24 supervised sessions over 8 weeks (3 sessions/week, ~30 mins). Exercises focus on joint position sense retraining using laser feedback, oculomotor control (smooth pursuit, gaze stability, eye-head coordination), and static/dynamic balance training under varied visual/surface conditions.

Pain Neuroscience Education Group (PNEG): Participants will attend 10 online group sessions via Zoom over 8 weeks (~45 mins/session). In addition to the pain neuroscience education curriculum covering pain neurophysiology, peripheral and central sensitization, neuroplasticity, descending inhibition, and cognitive modification, 1 session will be dedicated to demonstrating home-based neck exercises. Participants will be encouraged to perform home exercises 3 days a week for 10 minutes per session. While exercise engagement is encouraged as part of the education, no forced compliance or routine exercise reminders will be provided. Patient exercise diaries will be requested at the end of each month throughout the intervention period.

Outcome Assessment:

All evaluations are performed at baseline (T0), post-treatment at week 8 (T1), and follow-up at week 12 (T2):

Primary Outcomes: Neck Disability Index (NDI) and Numeric Rating Pain Scale (NPRS) for pain intensity.

Secondary Outcomes: Cervical Range of Motion (Clinometer app), Flexion-Rotation Test (FRT), Joint Position Error (JPE), Pressure Pain Threshold (JTECH digital algometer), Deep Neck Flexor/Extensor Endurance, Patient-Specific Functional Scale (PSFS), Short Form 36 (SF-36), Tampa Scale for Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), Central Sensitization Inventory (CSI), Fear-Avoidance Beliefs Questionnaire (FABQ), Hospital Anxiety and Depression Scale (HADS), Global Rating of Change (GRC), and treatment compliance.

Inclusion criteria

• Diagnosis of chronic non-specific neck pain lasting for more than 90 days
• Age between 18 and 65 years (inclusive)
• History of receiving standard physical therapy in a clinical setting in Turkey, yet experiencing persistent neck pain
• Numeric Pain Rating Scale (NPRS) score ≥ 3/10 at rest and during active cervical movement
• Neck Disability Index (NDI) score ≥ 5/50
• Voluntary agreement to participate and signing of the informed consent form

Exclusion criteria

• Neck pain associated with nerve root involvement or radiculopathy
• History of prior cervical spine surgery
• Physical therapy interventions received within the last 3 months
• Severe spinal pathologies (e.g., fracture, tumor, infection, structural instability)
• Systemic conditions (e.g., rheumatic, neurological, metabolic diseases)
• Presence of vertigo or sensory loss
• History of cancer within the last 5 years