The effects of neck specific exercise combined with breathing retraining in patients with chronic neck pain

The intervention group will receive 10 mins breathing retraining and 30 mins neck specific exercise in each session. The breathing retraining focuses on diaphragmatic breathing and pursed-lip breathing technique. The subjects will practice the breathing techniques under a slow and comfortable pace with hand guiding and verbal cuing from the physiotherapist. The subjects will practice the technique in different positions such as supine lying, prone baby pose, side lying, upright sitting and standing progressively. The neck specific exercise doing craniocervical flexion with pressure biofeedback unit under the suboccipital area will be taught immediately after the breathing retraining. The training will be separated into two phases to make the subjects do the movement more correctly. Phase 1: Re-education of the craniocervical flexion movement. Craniocervical flexion exercise will be performed in supine crooked lying position, targeting the deep neck flexor muscles, the longus capitus and colli. The subjects will be taught the nodding movement that slides the head in the cephalad direction as if saying “yes”, without moving the lower cervical spine or using the superficial neck muscles. The quality of movement will be confirmed and supervised by the same physiotherapist through verbal and hand cuing. It is expected that the subjects achieve the correct movement within 1-4 sessions. Once the correct craniocervical flexion motion is achieved, the physiotherapist will add phase 2 training program into the session progressively. Phase 2: Holding the increasing ranges of craniocervical flexion according to different pressure of the pressure biofeedback unit (PBU). In the beginning of this phase, a pressure biofeedback unit will be placed under the subjects’ upper cervical spine. As the subjects’ head positioned in the neutral position, the PBU will be inflated to 20mmHg. The PBU, as a movement detecting device, the pressure increases when the subjects’ craniocervical flexion range increase. Targeting 5 incremental stages from 20 to 30 mmHg progressively, the subjects will be instructed to do craniocervical flexion and hold in different ranges for 10 seconds according to their ability. The pressure will be shown to the subjects when they move so they can adjust the range of movement according to the pressure shown. Finally, when the subjects achieve the target pressure, they will be asked to close their eyes and to memorize the range they move. The range and the control of movement quality will be assigned as home program. The subjects have to practice both the breathing technique and the craniocervical flexion exercise 10 times a set, 2 sets a day under good movement quality with self-palpation. A Google sheet which reports the tasks they do has to be filled after the practice for monitoring adherence of the intervention. It is expected that the subjects achieve the goal to hold in all stages of pressure for 10 times and for 10 seconds after the total of 12 sessions training.