Effects of Online Exercise Intervention on Physical and Mental Conditions in Young Adults With Chronic Neck Pain
Phase: NA
Conditions: Chronic Non-specific Neck Pain
Sponsor: Beijing Sport University

 
 
 
 
Effects of Online Exercise Intervention 
on Physical and Mental Conditions in 
Young Adults with Chronic Neck Pain 
 
 
2023.08.06 
 

Effects of Online Exercise Intervention on Physical and Mental Conditions in Young Adults with 
Chronic Neck Pain 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 

Visual Analog Scale (VAS) 
Neck Disability Index (NDI) 
Hospital Anxiety and Depression Scale (HADS) 
Work Limitations Questionnaire (WLQ) 
the Modified Brügger’s Exercise (MBE)  
the Modified Proprioceptive Neuromuscular Facilitation Diagonal Flexion Exercise (MPNFDFE) 
Principal investigator:  
Co-Investigators:  
Research team and contact Information:  
Study site: Rehabilitation Medicine Centre, School of Sports Medicine and Rehabilitation, Beijing 
Sport University 
Effects of Online Exercise Intervention on Physical and Mental Conditions in Young Adults with 
Chronic Neck Pain 
The target participants were adults with self-reported non-specific neck pain for more than three 
months. They were recruited through posters and social media in the campus of the Beijing Sport 
University.  
The present study was an assessor blinded randomized controlled trial conducted according to the 
Declaration of Helsinki (World Medical Association, 2013). The Institutional Review Board of the 
Beijing Sport University approved the study (reference number: 2023006H).  
With an anticipated dropout rate of 15%, a total of 39 participants was required. 

Totally 8 weeks, including 1-week baseline testing, 6-week intervention and 1-week post 
intervention testing. 
Participants in both groups completed the same exercise program three times a week for six weeks 
with either face-to-face or online mode of delivery by physiotherapists. 
The primary objective is to study the effectiveness of online and conventional exercise therapy on 
pain level and function in adults with chronic neck pain. There were three primary outcomes, 
including average and maximum neck pain using visual analog scale (VAS), and Neck Disability 
Index (NDI).  
The secondary objectives are investigating the effectiveness of online and conventional exercise 
therapy on mental condition and working efficacy in adults with chronic neck pain. There were 
two secondary outcomes: anxiety and depression measured with the Hospital Anxiety and 
Depression Scale (HADS) and work efficiency assessed with the Work Limitations Questionnaire 
(WLQ). 
Neck pain is one of the most common musculoskeletal disorders causing significant burden in public 
health worldwide (Safiri et al., 2020). In China, neck pain also influences large population, the age 
standardized point prevalence of neck pain was 4532.6 per 100000 persons, which was higher than 
the global age standardized point prevalence of 3551.1 per 100000 persons in 2017 (Safiri et al., 
2020; Wu et al., 2021). The China Mental Health Survey reported that the prevalence of chronic 
back or neck pain among people with any mental disorders was more than twice that of those without 
mental disorder (Xu et al., 2020). It is believed that psychological factors such as stress, distress, 
anxiety, mood and emotions, cognitive function and pain-related behaviors are important factors 
related to chronic neck pain (Kazeminasab et al., 2022). Additionally, because of COVID-19 
pandemic, people's physical activity has been greatly reduced and the prevalence of anxiety and 
depression all over the world is prone to increase. In 2020, the pandemic will lead to an increase of 
27.6% in cases of severe depression and 25.6% in cases of anxiety disorders worldwide (Santomauro 
et al. 2021). In this way, people with chronic neck pain may have a higher risk to develop mental 
disorder.  

Most chronic neck pain is non-specific with no identifiable pathoanatomical cause (Beltran-Alacreu 
et al., 2018). Many therapies have been used to treat patients with chronic non-specific neck pain 
but exercise therapy is considered as the integral component of interventions (Blanpied et al., 2017). 
It has also been proved that exercise can reduce the symptoms of depression, anxiety and pain in 
patients with neck pain (Nazari et al., 2018). However, due to the lack of time, money and 
rehabilitation resources, many people cannot receive high quality conventional rehabilitation. Since 
the start of COVID-19 pandemic in 2020, it became more difficult to deliver the conventional form 
of exercise therapy to those patients with chronic neck pain by the physiotherapists.  In response 
to this crisis, telerehabilitation, as a new service mode of delivering rehabilitation, has become 
popular for physiotherapists to treat various musculoskeletal, neurological and cardiopulmonary 
disorders (Havran and Bidelspach, 2021). Telerehabilitation not only alleviates the time cost and 
economic cost of patients, but also reduces the pressure on the medical system (De Biase et al., 
2020). In addition, online rehabilitation can maximize the use of high-quality rehabilitation 
resources, and neck pain patients in remote areas can also receive the cutting-edge and effective 
interventions at home. Recent review on systematic reviews of telerehabilitation in physiotherapy 
provides preliminary evidence that “telerehabilitation in physical therapy could be comparable with 
in-person rehabilitation or better than no rehabilitation for conditions such as osteoarthritis, low-
back pain, hip and knee replacement, and multiple sclerosis and also in the context of cardiac and 
pulmonary rehabilitation” (Seron et al., 2021). However, the efficacy of telerehabilitation for 
patients with chronic non-specific neck pain is still unknown. A Cochrane review protocol on 
telerehabilitation for neck pain has been published but the review results are not available yet 
(Fandim et al., 2021).  
People with chronic neck pain suffer from persistent pain with impaired physical function and 
mental health. The proportion of mental issues among them is much higher than healthy population. 
The purposes of this study were to compare the efficacy of online exercise therapy with conventional 
exercise therapy on pain, function, psychological status and work efficiency of young adults with 
chronic neck pain. 
Objective outcome assessments were taken at baseline prior to randomization and after the 6-week 
intervention period. Additional assessments of the Work Limitations Questionnaire were done after 
two weeks and four weeks of intervention. 

The primary objective is to investigate the effectiveness of online and conventional exercise therapy 
on pain and function in adults with chronic neck pain. One primary outcome was the average and 
maximum neck pain measured by visual analog scale (VAS). Another outcome was the neck 
dysfunction measured by the Neck Disability Index (NDI).  
The secondary objective is to investigate the effectiveness of online and conventional exercise 
therapy on mental condition and working efficacy in adults with chronic neck pain. There were two 
secondary outcomes: anxiety and depression measured with the Hospital Anxiety and Depression 
Scale (HADS), and work efficiency assessed with the Work Limitations Questionnaire (WLQ). 
Randomized clinical trial with 39 adults with self-reported chronic neck pain recruited. They were 
randomly assigned into two groups. The experimental group received online exercise therapy and 
the control group received conventional exercise therapy.  
Participants in both groups completed the same exercise program three times a week for six weeks 
with either face-to-face or online mode of delivery by physiotherapists. The degree of pain was 
assessed by the improvement in average and maximum visual analogue scale (VAS). Neck function 
and work limitations were assessed by the Neck Disability Index (NDI) and Work Limitations 
Questionnaire (WLQ) respectively. The Hospital Anxiety and Depression Scale (HADS) and its 
subscales were used to evaluate anxiety and depressive symptoms. Participants were assessed at 
baseline and at 6 weeks while the changes in WLQ were assessed biweekly. To ensure the 
effectiveness of online exercise therapy, therapists delivered the online exercise 3 times a week for 
6 weeks, with videoconferencing once a week and posting of exercise record on WeChat app twice 
a week. 
The target participants were adults with self-reported non-specific neck pain for more than three 
months. They were recruited through posters and social media in the campus of the Beijing Sport 
University.
The inclusion criteria were: (1) adults between 18 and 50 years of age with neck pain (from occiput 

to 7th cervical vertebra) for at least 3 months; (2) a score of  4/50 on the Neck Disability Index. 
Those participants with the following were excluded: (1) adults with a history of previous neck 
surgery, cervical radiculopathy, acute neck injury or fracture; (2) persons who had more than two 
hours of moderate intensity exercise or more than four hours of low intensity exercise in a week; 
and (3) persons who had received any form of physiotherapy treatment in the last 6 months. 
Participants in both groups completed the same exercise program three times a week for six weeks 
with either face-to-face or online mode of delivery by physiotherapists. 
At baseline, the suitable elastic bands (Thera-band®) for performing the exercises were selected by 
testing the 15 repetitions maximum (15RM) of the Modified Brügger’s Exercise (MBE) and the 
Modified Proprioceptive Neuromuscular Facilitation Diagonal Flexion Exercise (MPNFDFE) for 
the participants of both the experimental group and control group. The details of the MBE and 
MPNFDFE were described in supplementary file 1.  
Participants randomized to the control group performed the following exercises three times a week 
for six weeks in a group of 3-5 participants in the laboratory of the Sport Medicine and Rehabilitation 
School of the Beijing Sport University: 
A. Warm-up exercises 
B. Cranio-cervical flexion exercises 
C. Strength-endurance exercises 
D. Scapular stabilization exercises 
E. Stretching exercises 
The details of the exercises were described in supplementary file 2. 
Participants allocated to the experimental group performed the same set of exercise three times a 
week for six weeks in their home, with the following arrangements: 
The participants had weekly online exercise meetings with the physiotherapist in a group of 3-5 
participants using the TENCENT Meeting. Then the participants performed the remaining two 
sessions of exercises themselves weekly. If they had encountered any problems, they could consult 
the physiotherapist during the online session or texting to the physiotherapist using the WeChat app. 
All the participants of the experimental group received a package of exercise pamphlet and a video 
disc containing 17-minute exercise demonstrations by the physiotherapist. 

In this study, the tests and interventions may include physical activities, which may irritate neck pain 
and have little risk of heart attack and other life-threatening conditions. During the test and trial, if 
there are adverse reactions such as acute aggravation of neck pain, the test or intervention will be 
stopped immediately, and emergency treatment will be conducted. If there is any emergency, the 
principal investigator(s) will provide basic life support including chest compressions and ventilation 
until emergency medical staff are on hand. Participant can consult the general practitioners if they 

are experiencing any side effects from taking part in the study and should also inform the Principal 
Investigator. 
Continuous data were expressed as means and standard deviations. Categorical data were shown as 
frequencies or percentages. All statistical analyses were conducted using the IBM SPSS Statistics 
for Windows, Version 24.0 (Armonk, NY: IBM Corp). The normality of continuous data was 
checked with the Shapiro-Wilk test. The change scores of the primary and secondary outcome 
variables from baseline to end of intervention between the two groups were compared using 
independent sample t test. Within-group comparisons were done using paired sample t test. The level 
of significance of all statistical tests was set with two-tailed at 0.05. Per-protocol analysis was used.  
The sample size for the study was calculated to be 32 using the G*Power 3.1.9.2 (Universitat Kiel, 
Germany), with an estimated effect size of group difference of 0.9 in primary outcomes and a level 
of significance of 0.05, statistical power of 80% with two-tailed independent sample t test. The 
estimated effect size was based on previous studies of home exercise on patients with neck pain 
(Zronek et al., 2016). With an anticipated dropout rate of 15%, a total of 39 participants was required. 
Before participating in the study, physiotherapists will explain this study to all participants to ensure 
they are clear about this study. Participants can drop out at any time during this study. Then they will 
complete the informed consent form. All the participants are recruited from Beijing Sport University, 
China, and they are all native Chinese speakers, so the informed consent form is in Chinese 
(simplified). All participants should meet the inclusion criteria, and anyone meets the exclusion 
criteria will be excluded. 
Subject’s names will be kept on a password protected database, and they will be linked only with 
a study identification number for this research. There are no patient identifiers. All data will be 
entered into a computer that is password protected. Data will be stored in a locked office of the 
investigators and usually maintained for a minimum of three years after the completion of the study. 

This is a relatively safe study which has rare risk. Since it is a training for neck muscles, it has 
possibility of muscle strain and worse neck condition. It has little risk of heart attack and other 
life-threatening conditions. 
Benefits to Participants 
This study provides a good exercise plan for the participants which improves their neck functions 
and decreases their neck pain.   
Stage 1, screening, enrollment, ----2 weeks 
Stage 2, treatment phase, ----6 weeks 
Stage 3, data collection and data analysis, -----4weeks 
Stage 4, presentation and publication, ----1 year 
All data about participants that is collected during the course of the research will be kept strictly 
confidential. The data collected with be de-identified before being analysed, and identified data 
including medical history will be confidential and stored separately. However, confidentiality of 
participants’ data is subject to legal limitations (e.g. subpoena, freedom of information claim, or 
mandatory reporting in some professions). All data will be kept in locked filing cabinets as well as 
password protected electronic files. Data will be securely stored for at least three years and may be 
kept indefinitely. 
No potential conflict of interest. 

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