The effect of education and exercises for neck pain: A randomised controlled telehealth trial with cost-effectiveness analysis.

The two groups will have consistent general advice and exercise components, but contrasting education and sensorimotor retraining components. Both groups will receive guideline-recommended care for persistent neck pain, including education/advice and exercise prescription. In both groups, all treatment sessions will be delivered by an experienced and registered allied health clinician one-on-one via telehealth. All treatment sessions will be completed within the first 12 weeks after randomisation. Intervention A: ‘The ReconNECKt Intervention’: In addition to guideline-recommended care, participants will receive individualised education; goal setting; a graded sensorimotor retraining program; graded movement, loading, and endurance training; and an ongoing self-management plan. Participants will receive prescribed exercises and homework activities to complete at home. ‘The ReconNECKt Intervention’ has been tested in an RCT for persistent low back pain (The RESOLVE Trial; DOI: 10.1001/jama.2022.9930). We have translated the RESOLVE intervention for persistent neck pain. The intervention involves three phases underpinned by the ‘fit for purpose’ model (DOI: 10.1093/ptj/pzac151): 1. Operational understanding: Via pain science education (PSE), which aims to reduce the perceived danger associated with the neck through reconceptualising the neck as fit for purpose and safe to move, using proven conceptual change strategies such as: challenging existing knowledge; refining learning strategies for new concepts; using metaphor; providing experiential examples. 2. Cortical body matrix refinement: Via graded sensory precision training and via graded precision movement training [left/right judgments (implicit motor imagery), viewing videos of other people moving (motor empathy), and imagining themselves performing movements (explicit motor imagery), and actual performance of precision movements (focusing on cervical spine, thoracic spine, and scapular region)]. 3. Graded movement, loading, and endurance training (re-engagement): Rehabilitative exercises in line with functional goals using the same progressive protocol as graded precision movement training. For the PSE component of the intervention (Phase 1), all educational concepts will be covered in all participants, but clinicians will individualise the educational content to the individual. Participants will be mailed a custom-made handbook called ‘Explain Pain for Neck Pain’, which will guide them through the PSE component of the intervention. This handbook will be an adaptation the ‘Resolve Back Pain Handbook’ published by Noigroup (https://www.noigroup.com/product/resolve-back-pain-handbook/). The research team will adapt the content of this handbook for neck pain. The clinician will discuss relevant sections of the handbook with participants during the treatment sessions, providing additional explanations (individualised to each participant’s condition and goals), answering questions, and encouraging reflections. Participants will also receive homework activities to complete between sessions, including educational activities (e.g., readings, videos, quizzes) and a structured exercise program involving cortical body matrix refinement activities (Phase 2) and graded movement, loading, and endurance training (Phase 3). The trial clinician will individualise the exercise/activity program to the participant. The trial clinician will individualise the exercise/activity program to the participant. Selection of graded movements (for Phases 2 and 3) will be individualised based on the participants impairments and functional goals. Graded movements will focus on precise scapular, thoracic, and cervical movements, which will then be progressed to integrate other body movements in line with their functional goals (e.g., precise cervical movements with arms overhead). Following precise movements, load (e.g., anti-gravity movements) and endurance (e.g., isometric or repeated anti-gravity movements) movements will be undertaken in line with their functional goals. Progression criteria will be based on participant competency (i.e., accuracy of left/right judgements, participant self-rated ease of observed/imagined movements, clinician judgement of precision/smoothness of movement performance) and symptom provocation (i.e., no/minimal increased symptoms or behavioural responses such as anxiety/distress during or after training). Participants will have access to an online portal to schedule/attend telehealth sessions as well as complete activities at home between telehealth sessions. Each participant will attend 8 treatment sessions within the maximum of 12 weeks. The first four treatment sessions will be scheduled at approximately weekly intervals, after which clinicians may schedule more time between the final four sessions (e.g., two weeks instead of one), based on participant progress and clinical judgement. The duration of the first two sessions will be between 60-90 minutes, and the remaining six sessions will be up to 60 minutes. Participants will also receive weekly activities to complete at home via the online portal, including their exercise prescription/goals and educational activities (i.e., readings, videos, quizzes). Participants will record their progress with homework activities and exercises via the online portal, which their treating clinician will have access to. Clinicians will also document participant progress with the exercise program during each treatment session. The trial intervention will be provided by allied health clinicians who have undertaken high-level pain science education training. Intervention adherence: Assessed via review of attendance records for telehealth treatment sessions (recorded by treating clinicians), via review of each participant’s online portal activity, and via adherence rating scales completed by participants. Intervention fidelity: All treatment sessions will be video recorded, and a random sample of treatment sessions (minimum of one for each clinician) will be audited for intervention fidelity for each group. Each clinician will only provide one of the trial interventions. Clinicians’ case notes for each session, recorded via standardised templates, will also be used to evaluate intervention fidelity.