Effect of Attentional Focus Order in Home Exercise for Neck Pain

Effectiveness of Differently Sequenced Attentional Focus Instructions in a Home Exercise Program for Non-Specific Neck Pain: A Randomized Controlled Single-Blind Trial

According to the International Association for the Study of Pain's 2017 terminology, neck pain is described as an unpleasant sensory and emotional experience originating in the cervical region and potentially radiating toward the scapular area, typically linked to actual or potential tissue injury. Although research on how attentional focus instructions influence postural control remains limited, existing findings suggest that the sequence in which these instructions are delivered can impact sensory processing during postural control assessments. These observations raise compelling questions about the potential benefits of using attentional focus strategies in a structured, sequential manner during neck pain treatment. To date, however, no study has investigated how varying the order of attentional focus cues within a home exercise program affects individuals with non-specific neck pain. This study aimed to fill that gap by evaluating the clinical effectiveness of a home-based exercise protocol utilizing attentional focus instructions in different sequences. The primary outcome was disability level, measured by the Neck Disability Index (NDI). Secondary outcomes included pain intensity assessed via the Visual Analog Scale (VAS), craniovertebral angle (CVA) via photogrammetry, pressure pain threshold (PPT), cervical joint range of motion, dizziness-related disability (Dizziness Handicap Inventory), and the endurance of neck flexor and extensor muscles.

Inclusion Criteria:

• Aged between 18 and 40 years
• A craniovertebral angle of 53 degrees or less
• A Visual Analog Scale score greater than 3 for pain in the neck and shoulder areas
• Experiencing head and neck pain for a duration exceeding three months
• A Neck Disability Index score ranging from 5 to 24
• A positive result on the cervical flexion-rotation test
• A body mass index within the range of 18.5 to 25 kg/m²
• No history of injury to the neck, trunk, or upper and lower extremities in the past six months

Exclusion Criteria:

• A positive result on the Spurling test
• Reduced or absent reflex responses in the upper extremities,
• Referred pain scoring greater than 7 on the Visual Analog Scale in the affected dermatome
• Diagnosis of cervical spinal stenosis
• Diagnosis of an autoimmune disorder
• Previous surgical intervention in the cervical or shoulder region
• A positive result on the Vertebrobasilar insufficiency test
• Presence of any musculoskeletal deformity or abnormality
• Inability to carry out functional activities due to visual, auditory, vestibular, or neurological impairments
• Neck pain associated with malignancy or structural abnormalities
• Clinical presentation consistent with a capsular pattern suggestive of arthritis, or the presence of a severe psychological disorder
• Current pregnancy
• Participation in any form of exercise-based treatment or physiotherapy within the last three months