Effect of Body Mind Exercises and Specific Neck Exercises in Chronic Mechanical Neck Pain
Phase: NA
Conditions: Neck Pain Musculoskeletal
Sponsor: Cairo University

Study Protocol 
 
 
Official Title: Effect of  Body Mind Exercises and Specific Neck Exercises  
in Chronic Mechanical Neck Pain. 
 
ClinicalTrials.gov Identifier (NCT): Pending. 
 
Document Type: Study Protocol 
 
Document Date: March 6, 2026 
 
Principal Investigator: Ramy Gnady I Komir 
 
Institution: Faculty of Physical Therapy, Cairo University, Egypt 

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Effect of  Body Mind Exercises and Specific Neck 
Exercises  in Chronic Mechanical Neck Pain. 
 
 
 
 
By 
 
 
RAMY GNADY IBRAHIM KOMIR 
 
 
 
 
 
 
 
 
 
 
 
 
 
A Protocol Submitted in Partial Fulfillment of the Requirements 
for the Doctoral Degree in Physical Therapy for 
Musculoskeletal Disorders and Its Surgeries 
Faculty of Physical Therapy 
Cairo University 
2025 
 
 
Supervisors 

2 
 
PROF. DR. SALWA FADL ABD EL MAJEED 
Professor of Physical Therapy for Musculoskeletal Disorders and Its 
Surgeries, Faculty of Physical Therapy, Cairo University. 
 
 
 
 
 
 
DR. MOAAZ RAGAB RIYAD 
Lecturer in Physical Therapy for Musculoskeletal Disorders and Its 
Surgeries, Faculty of Physical Therapy, Cairo University. 

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CHAPTER I 
INTRODUCTION 
Chronic mechanical neck pain is one of the most prevalent musculoskeletal 
disorders globally, lacking a clearly identifiable pathology or specific anatomical 
cause (Alagingi, 2022). The condition is associated with high levels of pain 
intensity, functional limitation, and psychosocial factors like fear avoidance and 
catastrophizing, which contribute to poor prognosis (Mansell et al., 2021). It 
affects approximately 25.8% of the population, with 5% experiencing disability 
(Cohen, 2015, Hoy et al., 2010). 
Exercise therapy is a widely recommended conservative treatment approach 
in clinical practice guidelines for managing chronic mechanical neck pain 
(Blanpied et al., 2017; Côté et al., 2016). Among various types, two main 
categories have emerged: general exercises (e.g., aerobic or body-mind exercises 
like brisk walking, cycling, stationary rowing, jogging, running, yoga and tai chi), 
and specific exercises (targeting deep neck flexors, extensors, and 
scapulothoracic stabilizers) (Li et al., 2019; Blomgren et al., 2018). 
General exercises are easily accessible, can be performed individually or in 
groups, and provide additional psychological and social benefits (Miyamoto et 
al., 2019). However, their direct biomechanical effect on the cervical musculature 
may be limited compared to specific exercises, which target known muscular 
imbalances such as reduced activation of deep stabilizers and over activity of 
superficial neck muscles (Lauche et al., 2016; Ylinen et al., 2004). 
Despite the widespread use of both approaches, the current evidence is 
inconclusive regarding which is superior in improving pain and function. A recent 
systematic review and meta-analysis concluded that general exercises are not 
superior to specific exercises in reducing pain and disability in the short, 

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medium, or long term, but also highlighted the low quality of available studies 
and the need for high-quality randomized controlled trials (Vieira Rosa et al., 
2024). 
Statement of the Problem 
Does the addition of Body mind exercise, specific neck exercises or both 
to conventional physical therapy reduce pain, disability, improve neck range of 
motion, isometric neck muscle strength and quality of life in patients with chronic 
mechanical neck pain? 
Purpose of the Study 
To investigate the effect of addition of body mind exercise, specific neck 
exercises or both to conventional physical therapy in patients with chronic 
mechanical neck pain on neck pain severity, functional disability, neck flexion 
range of motion, isometric neck muscle strength and quality of life. 
Significance of the Study 
Body mind exercises (mindful aerobic exercises) has been identified as a 
beneficial intervention for managing chronic mechanical neck pain. A recent 
systematic review and meta-analysis of randomized controlled trials found that 
body mind exercises (mindful aerobic exercises) significantly reduced pain 
intensity and disability in individuals with chronic mechanical neck pain, 
particularly when combined with other therapies such as strengthening exercises 
or acupuncture (De Oliveira-Souza et al., 2024). 
Another systematic review focusing on patients with chronic mechanical neck 
pain highlighted that moderate-intensity aerobic exercises, performed three times 
per week for 30–45 minutes, led to improvements in pain, function, and disability 
levels (Paraskevopoulos et al., 2023). These findings underscore the importance 

5 
 
of incorporating aerobic exercises into treatment plans for chronic mechanical 
neck pain to enhance patient outcomes. 
Spinal stabilization exercises are popular for treating and preventing 
musculoskeletal neck disorders by the activation of deep muscles and controlling 
the over activity of surface muscles. (Ibrahim Elnaggar et al., 2022) 
Ibrahim Elnaggar et al., (2022) compared the efficacy of cervical 
stabilization exercises and scapular stabilization exercises on neck pain severity, 
neck functional disability and neck mobility in treatment of patients with chronic 
mechanical neck pain. They found that cervical and scapular stabilization 
provided significant improvement in all the measured variables. 
Incorporating both cervical and scapular stabilization exercises into 
rehabilitation programs can provide comprehensive benefits for individuals 
suffering from neck disorders. These exercises not only alleviate pain but also 
restore functional movement patterns, contributing to long-term musculoskeletal 
health (Tian et al., 2025). 
This study addresses a crucial clinical question raised by a recent systematic 
review. Whether general or specific exercises are more beneficial in the treatment 
of chronic mechanical neck pain (Vieira Rosa et al., 2024). By using a 
randomized controlled trial design with well-defined outcome measures, this 
study aims to provide higher quality evidence to inform clinical guidelines and 
individualized treatment decisions (Vieira Rosa et al., 2024). 
A secondary analysis of data from a randomized controlled trial reported 
that combining moderate general exercises and neck-specific exercise 
improved the work ability of patients with neck pain more than neck-specific 
exercise alone. The combination should be recommended in health promotion 
programs and will be investigated in the current study (Daher A, 2021). 

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Hypotheses 
1. There will be no significant difference between body mind exercises, 
specific neck exercises or both on neck pain severity in patients with 
chronic mechanical neck pain. 
2. There will be no significant difference between body mind exercises and 
specific neck exercises or both on functional disability in patients with 
chronic mechanical neck pain. 
3. There will be no significant difference between body mind exercises and 
specific neck exercises or both on neck flexion range of motion in patients 
with chronic mechanical neck pain. 
4. There will be no significant difference between body mind exercises and 
specific neck exercises or both on neck extension range of motion in 
patients with chronic mechanical neck pain. 
5. There will be no significant difference between body mind exercises and 
specific neck exercises or both on neck right lateral flexion range of motion 
in patients with chronic mechanical neck pain. 
6. There will be no significant difference between body mind exercises and 
specific neck exercises or both on neck left lateral flexion range of motion 
in patients with chronic mechanical neck pain. 
7. There will be no significant difference between body mind exercises and 
specific neck exercises or both on neck right rotation range of motion in 
patients with chronic mechanical neck pain. 
8. There will be no significant difference between body mind exercises and 
specific neck exercises or both on neck left rotation range of motion in 
patients with chronic mechanical neck pain. 
9. There will be no significant difference between body mind exercises and 
specific neck exercises or both on isometric neck flexor muscles strength 
in patients with chronic mechanical neck pain. 

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10. There will be no significant difference between body mind exercises and 
specific neck exercises or both on isometric neck extensor muscles strength 
in patients with chronic mechanical neck pain. 
11. There will be no significant difference between body mind exercises and 
specific neck exercises or both on quality of life in patients with chronic 
mechanical neck pain. 
Delimitations 
 
The study will be delimited to 
 
 Eighty patients 
 Male and female patients diagnosed with chronic mechanical neck pain. 
 The participants will be aged 50–65 years. 
 Duration of illness will be greater than 3 months 
 Intervention will last for 6 weeks, with 3 sessions per week. 
 The interventions will include: 
o Conventional therapy: heat, massage, stretching exercises. 
o Body mind exercises (mindful walking). 
o Specific Exercises: Cervical and scapular stabilization exercises. 
o Combined Exercises: Mindful walking, cervical and scapular 
stabilization exercises. 
Assumptions 
 All participants will attend the scheduled sessions and comply with the 
prescribed home exercise program 
 All participants will provide full effort during assessments and follow 
therapist instructions. 
 No participants will receive additional treatment or medication during the 
study period. 

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Definition of Terms 
 Body mind exercise is a fitness activity that integrates physical and 
psychological elements. It emphasizes the coordination of body 
movements and mental processes, aiming to promote physical health while 
also contributing to mental well-being (Dong Y et al 2024). 
 Chronic Mechanical Neck Pain: Neck pain without a clearly identifiable 
cause, persisting for more than 3 months (Alagingi NK., 2022). 
 Functional Disability: Measured by the Neck Disability Index (NDI). 
 Muscle Strength: The strength of neck flexor and extensor muscles, 
evaluated using handheld dynamometry 
 Pain Intensity: Assessed using the Visual Analog Scale (VAS) or 
Numeric Pain Rating Scale (NPRS). 
 Range of Motion (ROM): The degree of movement available at the 
cervical joints. Measured by cervical range of motion (CROM) device. 
 Specific Exercises: Resistance training targeting deep cervical 
flexor/extensor and scapular muscles to improve muscular balance and 
motor control (Blomgren et al., 2018). 
Abbreviations 
 
 NPRS: Numeric Pain Rating Scale 
 NDI: Neck Disability Index 
 ROM: Range of Motion 

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CHAPTER II 
LITERATURE REVIEW 
 
Chronic Mechanical Neck Pain 
Chronic mechanical neck pain is defined as pain in the cervical region 
lasting for more than three months with no identifiable specific pathology such 
as infection, neoplasm, or fracture (Alagingi, 2022). High pain intensity, 
functional disability, and catastrophizing beliefs are known predictors of poor 
prognosis in these patients (Mansell et al., 2021). Risk factors for chronic 
mechanical neck pain include poor posture, prolonged sedentary behavior, 
psychological stress, and weak neck musculature (Blanpied et al., 2017). 
Mechanical neck pain can be effectively managed with a combination of 
conventional therapies, body-mind exercises, and potentially, manual therapy. 
Conventional therapies include physical therapy, which may involve 
exercises, heat or cold therapy, and posture correction. Body-mind exercises 
have also shown promise in improving pain and function. Additionally, 
manual therapy techniques like manipulation and mobilization, especially 
when combined with exercise, can be beneficial (Gross et al., 2015). 
Around 5% of individuals with neck pain suffer from persistent disability, 
highlighting the significant socioeconomic burden of chronic mechanical neck 
pain (Cohen, 2015). The global prevalence of neck pain is approximately 
25.8%, making it one of the leading musculoskeletal disorders worldwide 
(Hoy et al., 2010). 
Assessment Tools in Neck Pain 
Assessment tools for neck pain include physical examinations, imaging 
studies, and self-report questionnaires. Physical examinations assess neck 

10 
 
alignment, range of motion, muscle strength, and tenderness. Imaging studies 
like X-rays, CT scans, and MRI can reveal structural abnormalities or nerve 
compression. Self-report questionnaires, such as the Neck Disability Index 
(NDI), measure pain intensity, disability, and psychosocial impact 
(Misailidou et al., 2010) 
To evaluate cervical range of motion, goniometry and inclinometers are 
common tools due to their reliability and ease of use (Kiatkulanusorn et al., 
2023). The Numeric Pain Rating Scale (NPRS) is widely used for evaluating 
pain intensity due to its simplicity, sensitivity to change, and strong 
psychometric properties (Alghadir et al., 2016). For assessing muscle 
strength, handheld dynamometry has been found to be a reliable method, 
especially in evaluating deep cervical flexor and extensor performance 
(Ghamkhar et al., 2011). The Neck Disability Index (NDI) is a validated 
questionnaire for measuring self-reported functional disability in patients with 
neck pain and is frequently used in clinical trials and practice (Vernon and 
Mior, 1991). 
Treatment of chronic mechanical neck pain 
The most recent systematic reviews concluded that a range of 
interventions for chronic mechanical neck pain, such as electrotherapy, 
massage, psychological intervention, pain education, neck manipulation and 
mobilization or exercise, can have a variable degree of effectiveness 
(Valenza-Peña et al., 2023). 
General exercises 
 
Aerobic training has been shown to induce exercise-induced hypoalgesia, 
a mechanism that may contribute to pain relief in musculoskeletal disorders 
(Wewege et al., 2021). General exercises include aerobic activities (e.g., 

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walking, cycling) and mind-body interventions (e.g., yoga, tai chi), which aim 
to improve overall physical health, cardiorespiratory fitness, and psychosocial 
well-being (Miyamoto et al., 2019). These exercises are typically performed 
in group settings or independently and require minimal supervision or 
specialized equipment (De Zoete et al., 2019). However, general exercises 
may lack the targeted muscular benefits required to correct cervical movement 
dysfunctions commonly seen in CNSNP (Lauche et al., 2016). Mind-body 
practices have been associated with improved psychological outcomes, such 
as reduced stress, anxiety, and depression, which are often present in 
individuals with chronic mechanical neck pain (Cramer et al., 2013a; 
Cramer et al., 2013b). 
Specific Exercises for Chronic Mechanical Neck Pain 
 
Reduced activation of deep neck flexors and increased reliance on 
superficial muscles, such as the sternocleidomastoid and upper trapezius, are 
commonly observed in patients with chronic mechanical neck pain 
(Sakinepoor et al., 2025). Specific training aims to restore motor control, 
improve postural alignment, and reduce compensatory movement strategies 
(Mera, Natalya et al., 2025). Specific exercises are designed to target 
impaired muscular and motor control patterns associated with chronic 
mechanical neck pain (Blomgren et al., 2018). These include deep cervical 
flexor training, scapulothoracic stabilization, and resistance-based neck 
strengthening (Price et al., 2020). Resistance exercises have demonstrated 
improvements in neck strength, function, and pain levels when applied 
consistently over several weeks (Gross et al., 2016). 

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Comparative Studies: General vs Specific Exercises 
 
Vieira Rosa et al. (2024) conducted a systematic review and meta- 
analysis including 14 articles from 12 randomized controlled trials that 
compared general and specific exercises for chronic mechanical neck pain. 
The review found no significant differences in pain intensity between aerobic 
and specific exercises in the medium term (MD 0.95, 95% CI -1.62 to 3.51) 
or long term (MD 0.32, 95% CI -1.05 to 1.68) (Vieira Rosa et al., 2024). 
Similarly, mind-body exercises were not superior to specific exercises for 
reducing pain in the medium (MD 0.54, 95% CI 0.00 to 1.08) or long term 
(MD 0.06, 95% CI -0.59 to 0.46) (Vieira Rosa et al., 2024). Functional 
disability outcomes also showed no significant differences between groups in 
both the medium (MD 0.01, 95% CI -0.25 to 0.27) and long term (Vieira Rosa 
et al., 2024). The review concluded that although both exercise types may 
provide benefit, the quality of evidence remains very low to low, indicating a 
need for high-quality RCTs (Vieira Rosa et al., 2024). 
Several individual studies included in the meta-analysis echoed these 
findings. Iversen et al. (2018) observed modest improvements in both groups, 
with no significant differences in pain or disability. Similarly, Lauche et al. 
(2016) found comparable effects between tai chi and neck-specific exercises 
in reducing symptoms over 12 weeks. 

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Study Design 
CHAPTER III 
SUBJECTS AND METHODS 
This study will be a randomized controlled trial (RCT) conducted to compare 
the effects of body mind exercises (mindful aerobic exercises), specific neck 
exercises and combined (body mind and specific) exercises in addition to 
conventional therapy on neck pain severity, functional disability, neck range of 
motion, isometric neck muscle strength and quality of life in patients with chronic 
mechanical neck pain. 
The study will follow CONSORT guidelines for randomized trials and will 
be conducted at the outpatient physical therapy clinic of the Faculty of Physical 
Therapy, Cairo University. 
Ethical approval will be obtained from the institutional review board (IRB) 
of the Faculty of Physical Therapy, and the trial will be registered on 
ClinicalTrials.gov before patient enrollment. 
Sample Size Calculation 
 
Sample size was calculated using G*Power software version 3.1.9.7, 
referencing effect size data from a recent RCT comparing general and specific 
exercises in neck pain (Vieira Rosa et al., 2024). A priori power analysis for a 
repeated measures ANOVA (within-between interaction) was used with an effect 
size of 0.25, alpha level (α) = 0.05, and power (1-β) = 0.95. The estimated sample 
size required was 76 participants, which was increased to account for potential 
dropouts as shown in (Figure 1). Thus, the total sample will include 80 patients, 
randomly allocated into four equal groups (n = 20 per group): 

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 Group A: Conventional therapy. 
 Group B: Conventional therapy + Body mind exercises (mindful aerobic 
exercise). 
 Group C: Conventional therapy + specific neck exercises (cervical and 
scapular stabilization exercises) 
 Group D: Conventional therapy + combined (body mind and specific) 
exercises 
 
 
Figure 1 sample size calculation 

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Patients 
 
A total of 80 patients (50-65 years old) with chronic mechanical neck pain will 
be recruited from outpatient orthopedic and physical therapy clinics. All 
participants will provide written informed consent prior to enrollment. 
Inclusion Criteria (Daher et al., 2021) 
 
 Adults aged between 50-65 years 
 Diagnosis of chronic mechanical neck pain (pain duration ≥ 3 months) 
 Pain intensity of at least 3/10 on the NPRS 
 
Exclusion Criteria 
 
 History of cervical surgery 
 Specific neck conditions (fractures, neoplasm, infection) 
 Pregnancy 
 Severe cardiopulmonary disease or other systemic illness affecting 
participation 
Randomization and Blinding 
 
Participants will be randomly allocated into four groups using a computer- 
generated block randomization method. Allocation concealment will be ensured 
using sealed opaque envelopes. The outcome assessor will be blinded to group 
allocation. 
 
 
 
Outcome Measures 
 
All outcomes will be measured at baseline (pre-intervention) and after 6 
weeks (post-intervention). 

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1. Pain Intensity 
 
Measured using the Arabic version of the Numeric Pain Rating Scale 
(NPRS), which has been validated for Arabic-speaking populations (Alghadir et 
al., 2016). Patients will be asked to rate their neck pain intensity on a scale from 
0 (no pain) to 10 (worst possible pain). 
2. Functional Disability 
 
Evaluated using the Arabic version of the Neck Disability Index (NDI), a 
validated 10-item questionnaire assessing how neck pain affects daily activities 
(Algarni et al., 2014; Vernon and Mior, 1991). 
3. Cervical Range of Motion (ROM) 
 
Measured using CROM device to assess flexion, extension, lateral flexion, 
and rotation in both directions. Measurements will be performed with the patient 
in a seated position and will be repeated three times to ensure reliability 
(Kiatkulanusorn S et al., 2023). 
4. Isometric Neck Muscle Strength 
 
Assessed using a handheld dynamometer (HHD) placed at the forehead 
(flexion) and occiput (extension) in seated position. Three maximal isometric 
contractions (5 seconds each) will be performed, and the average value will be 
recorded (Ghamkhar et al., 2011). 
5. Quality of life 
 
The Arabic version of Arabic Version of the RAND 36-Item Health Survey 
1.0 to measure the recovery of quality of life of chronic mechanical neck 
pain patients (Coons et al., 1998). 

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Instrumentation 
 
 NPRS scale (Arabic version) 
 Neck Disability Index (Arabic version) 
 RAND 36-Item Health Survey (Arabic version) 
 CROM for neck ROM 
 Handheld dynamometer for neck isometric muscle strength 
 Stopwatch 
 
Intervention Procedures 
 
All groups will receive 3 treatment sessions per week for a total of 6 weeks 
(18 sessions). Each session will last approximately 60- 90 minutes. 
All groups will receive conventional therapy (Mahesvi, Hafiz & Graha et 
al., 2023) which includes: heat therapy (infrared) for 10 minutes, massage therapy 
10 min, stretching of neck (Scalene, SCM, UFT, Levator scapulae) and pectoral 
muscles 20 min. 
Home program: patients will be instructed to do self-stretching exercises 
according to a given brochure at home. This will monitored for compliance using 
a structured calendar sheet. 
Group A: Conventional physical therapy group (Control group) 
 
Group A will receive conventional therapy (Mahesvi, Hafiz & Graha et 
al., 2023) which includes: heat therapy (infrared) for 10 minutes, massage therapy 
10 min, stretching of neck (Scalene, SCM, UFT, Levator scapulae) and pectoral 
muscles 20 min. 

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Group B: Body mind exercises group (mindful aerobic exercises) 
 
Group B will receive conventional physical therapy (infrared, massage, and 
neck stretching) in addition to Body mind exercises (mindful aerobic 
exercises). The aerobic exercise will be performed at an intensity of at least 60% 
of maximal oxygen consumption (VO₂ max) to effectively improve 
cardiorespiratory fitness. The program will include treadmill walking 30 minutes. 
Participation will be recorded only when conducted under instructor supervision 
(Korshøj M., et al 2017). 
Group C: specific neck exercise group 
 
Group C will receive conventional therapy in addition to specific neck 
exercises. Specific exercises will include: cervical and scapular stabilization (Oz 
HE et al., 2024; Kang et al., 2021). 
Cervical Stabilization Exercises 
 
These exercises focus on activating deep cervical flexors and extensors to 
support spinal stability (Oz HE et al., 2024). The patients in the cervical 
stabilization exercise group will perform cervical stabilization exercises. The 
unilateral/bilateral upper and lower extremity movements with/without an 
external loads will be performed in four different positions: lying in supine, lying 
in prone, in quadrupedal, and in standing. Chin-tuck position will be maintained 
during each movement. The exercise program will be progressed by increasing 
isometric contraction times of the chin-tuck exercises and the repetitions of the 
movements, as shown in (Figure 2 and 3). 

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Figure 2 cervical stabilization exercises adopted from Oz HE et al., (2024). 
 
 
 
Figure 3 progression of cervical stabilization exercises adopted from Oz HE et al., (2024). 
 
Scapular stabilization exercises: 
 
The Scapular stabilization exercises will be comprised of four exercise 
programs. The participants sat on the knees in 90° flexion position, and a Swiss 
ball was propped up between the chest and stomach. Looking from the side, the 
earlobe, acromion of scapula, and pelvis made a straight line (Kang et al., 2021). 

20 
 
A. Scapula retraction exercise: While retracting both the scapula, raise both the 
arms backward. 
B. Scapula mobilization exercise: With thumbs up, raise both the arms sideways 
making a straight line with the shoulders. 
C. Scapula dynamic stabilization exercise I: Raise one arm beside the ear and 
push out the other arm behind the back. Do the same for the opposite side. 
D. Scapula dynamic stabilization exercise II: Raise both the arms beside the ears 
and then push them down bending and maintaining elbows at 90°. Raise both the 
arms beside the ears again and put them down. 
Each exercise was performed with two sets of 15 reps, 10 sec per rep as shown in 
(Figure 4). 
 
 
 
Figure 4 scapular stabilization exercises adopted from Kang et al., (2021). 
 
 Group D : Combined exercise group. 
 
Group D will receive conventional therapy in addition to mindful aerobic 
exercises, cervical and scapular stabilization. 

21 
 
Statistical analysis: 
Data will be analyzed using SPSS version 27 (IBM Corp, Chicago, IL, USA). 
Descriptive statistics (mean ± SD) will be reported for all variables. Normality of 
distribution will be assessed using the Kolmogorov–Smirnov test. Within- 
group comparisons (pre vs post) will be conducted using paired t-tests. 
Between-group differences will be analyzed using one-way ANOVA followed 
by post hoc Tukey’s test. The level of significance will be set at p < 0.05. 

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