The goal of this clinical trial is to learn whether adding breathing training to an exercise program can improve pain, mood, and thinking skills in adults with chronic spinal pain.

The main questions it aims to answer are:

• Does adding breathing training lower pain and its impact on daily life?
• Does it improve symptoms of anxiety and depression?
• Does it improve thinking skills, such as attention and mental flexibility?

Researchers will compare three groups to see if adding breathing training provides additional benefits:

• a group that performs exercise only
• a group that performs exercise combined with breathing training
• a group that receives general advice only

Participants will:

• take part in a 12-week program
• attend one supervised session each week
• complete two home-based (unsupervised) exercise sessions each week (about 30 minutes each)

Participants in the combined group will also:

• learn breathing techniques during supervised sessions using biofeedback (a method that provides real-time feedback on breathing patterns)
• practice breathing exercises at home four times per week (about 10 minutes each) without biofeedback support

This study examined the effects of a structured exercise program, with or without diaphragmatic breathing training, in adults with chronic non-specific musculoskeletal pain of the spine.

Chronic pain was defined as pain persisting for at least 12 weeks or recurring over a prolonged period. Non-specific musculoskeletal pain refers to pain that cannot be attributed to a specific underlying pathology, such as fracture, trauma, or systemic disease, and is not associated with conditions that require surgical treatment.

Participants were recruited from the general population through an open call distributed across academic, clinical, and occupational settings. Individuals who expressed interest were screened for eligibility according to predefined criteria.

Eligible participants were randomly assigned to one of three groups: an exercise-only group, a combined exercise and diaphragmatic breathing group, or a minimal intervention control group. All participants in the intervention groups followed a 12-week program that included supervised and home-based sessions.

The exercise program was designed to improve spinal mobility, functional movement, flexibility, and neuromuscular control through progressive, multi-planar exercises performed in seated and standing positions. The combined intervention group additionally received training in diaphragmatic breathing supported by biofeedback during supervised sessions and practiced breathing exercises independently at home.

The control group received psychoeducation and general recommendations for physical activity, including walking, stretching, and relaxation techniques.

Validated clinical, psychological, and neuropsychological measures were used to assess pain, emotional status, quality of life, cognitive performance, and behavioral responses. These measures were administered at baseline, after completion of the intervention, and at follow-up.

All procedures were conducted according to predefined protocols to ensure consistency across groups.

Inclusion Criteria:

• Medically confirmed diagnosis of chronic non-specific musculoskeletal pain of the spine (neck, upper back, or lower back)
• Pain lasting at least 12 weeks or recurring over time
• Medical clearance to safely participate in the study interventions
• No use of opioid medication during the month before enrollment
• Not currently participating in another physical or psychological treatment for spinal pain
• Ability to understand the study procedures and provide written informed consent

Exclusion Criteria:

• Acute spinal conditions (e.g., recent injury or inflammation)
• Neurological or severe neuromuscular disorders
• Clinically significant psychiatric disorders
• Active substance dependence
• Chronic respiratory disease
• Pregnancy
• Any medical condition that makes participation in the study interventions unsafe
• Insufficient ability to understand the Greek language
• Participation in another therapeutic intervention for spinal pain during the month before or at the time of enrollment

Individual participant data will not be shared due to data protection regulations and confidentiality requirements