Mobilization Techniques for Nonspecific Neck Pain: Effects on Cervical Endurance and Function

Neck Pain Musculoskeletal, Nonspecific Neck Pain

Nonspecific Neck Pain, Manual Therapy, Positional Release Technique, Instrument-Assisted Soft Tissue Mobilization, Cervical Muscle Endurance, Physiotherapy, Randomized Controlled Trial, Office Workers

This clinical study investigates the comparative effects of two manual therapy mobilization techniques, Positional Release Technique (PRT) and Instrument-Assisted Soft Tissue Mobilization (İASTM), on cervical muscle endurance and functional performance in individuals with nonspecific neck pain. Nonspecific neck pain is a common musculoskeletal condition among office workers and students, often associated with poor posture, prolonged sitting, and repetitive strain. It leads to reduced muscle endurance, impaired functional capacity, and decreased quality of life. Early and effective management strategies are essential to prevent chronicity and disability. A total of 51 participants will be recruited and randomly assigned into three groups: Group 1 will receive PRT combined with a standardized home exercise program, Group 2 will receive İASTM combined with the same home exercise program, and Group 3 will serve as the control group receiving only conventional home exercise. The interventions will be delivered over a period of 4 weeks, with three sessions per week, under the supervision of trained physiotherapists. The home exercise program includes stretching, strengthening, and posture correction exercises designed to support cervical spine health. The primary outcomes of the study are cervical muscle endurance and functional performance, measured using validated clinical tests. Secondary outcomes include pain intensity assessed by the Visual Analog Scale (VAS), functional disability measured by the Neck Disability Index (NDI), health-related quality of life assessed by the SF-12 questionnaire, and work-related performance indicators. Assessments will be conducted at baseline and after 4 weeks of intervention. Randomization and blinding procedures will be applied to minimize bias, and standardized protocols will ensure consistency across groups. The main objective of this study is to determine whether the early application of PRT or İASTM, in combination with home exercise, provides superior improvements in cervical muscle endurance, pain reduction, and functional outcomes compared to exercise alone. By comparing these two mobilization techniques, the study aims to contribute evidence-based knowledge to physiotherapy practice and guide clinicians in selecting effective manual therapy approaches for nonspecific neck pain. The findings are expected to support clinical decision-making, improve patient care, and enhance rehabilitation strategies for individuals suffering from neck pain in occupational and daily life contexts.

A.Rationale and Aim of the Study With the increasing digitalization of modern life, prolonged desk-based working hours have caused individuals to remain in forward-head and sedentary postures for extended periods. This condition may lead to muscle tension in the cervical region, decreased endurance, and mild functional limitations. Since these early-stage alterations are often not recognized before progressing into clinically significant pain, they have been reported to increase the risk of developing myofascial dysfunctions over time. Therefore, early management of non-specific neck pain is important in terms of reducing both functional impairments and long-term healthcare burden. Mobilization-based approaches are commonly used methods for improving deep cervical flexor endurance, postural control, and cervical stability. While Positional Release Technique (PRT) aims to reduce muscle tension through positional relaxation, Instrument-Assisted Soft Tissue Mobilization (IASTM) is a practical and increasingly widespread technique used in the mobilization of tissue restrictions. Although findings suggest that both approaches may contribute to cervical function and symptom management, studies comparing these two techniques in desk-based workers are limited. Since most existing studies in the literature focus on chronic pain populations, their early preventive effects have not been sufficiently investigated. Therefore, comparing the effects of PRT and IASTM in individuals presenting signs of non-specific neck pain has the potential to fill an important gap in clinical practice. The aim of this study is to comparatively investigate the effects of Positional Release Technique (PRT) and Instrument-Assisted Soft Tissue Mobilization (IASTM), when combined with exercise programs, on muscle endurance, functional status, pain, quality of life, and work performance in desk-based workers with non-specific neck pain. This study aims to identify preventive mobilization approaches that can be implemented in the early stages and to establish an evidence-based decision-making framework for physiotherapy practice \[1,2\]. B.Hypotheses H0 (Null Hypothesis): There is no significant difference between the groups receiving PRT and IASTM in terms of muscle endurance, functional status, pain, quality of life, and work performance in individuals with non-specific neck pain. H1 (Alternative Hypothesis): There is a significant difference between the groups receiving PRT and IASTM in terms of muscle endurance, functional status, pain, quality of life, and work performance in individuals with non-specific neck pain. C. Main Study Form C.1.1. General Information Non-specific neck pain (NSNP) is a common musculoskeletal disorder among desk-based working adults and may negatively affect work performance, daily functionality, and quality of life. Prolonged hours spent in a forward-head posture while using computers, sedentary lifestyle, and inadequate workplace ergonomics contribute to muscle tension, trigger point formation, and early functional limitations in the cervical region. Approximately 60% of office workers in Türkiye experience neck pain at some point in their lives; this condition results in work absenteeism and additional burden on the healthcare system. In most individuals, neck pain begins during a "subclinical" stage. Although severe pain may not yet be perceived, active trigger points, soft tissue stiffness, and reduced deep cervical flexor endurance can be identified in muscles such as the upper trapezius, scalene, and levator scapulae. If early intervention is not implemented during this stage, symptoms may become chronic and create long-term negative effects on functional status, quality of life, and occupational adaptation. Manual therapy methods, particularly Positional Release Technique (PRT) and Instrument-Assisted Soft Tissue Mobilization (IASTM), have been found effective in reducing muscle tension and supporting tissue healing during the subclinical stage. PRT provides proprioceptive inhibition by positioning muscles into passive comfort positions, whereas IASTM increases tissue mobility through controlled microtrauma. When both methods are supported with home exercise programs, they enhance postural awareness and muscular endurance. However, no study in the literature has comparatively investigated the effectiveness of these techniques in office workers with non-specific neck pain. This study aims to determine which early preventive physiotherapy approach is more effective and to propose a practical and evidence-based model for supporting cervical health in desk-based workers \[3\]. Positional Release Technique (PRT) Positional Release Technique (PRT) is a non-invasive manual therapy method used to reduce muscle hypertonicity in myofascial trigger points. The technique is based on identifying the tender point through palpation, passively positioning the muscle into its shortened natural comfort position (generally through a combination of lateral flexion, rotation, and slight extension), and maintaining this position for 90 seconds. During this position, proprioceptive inhibition is stimulated, Golgi tendon organs are activated, muscle spindle tension is neutralized, and the spinal reflex arc is modulated, thereby reducing muscle tone to physiological levels \[4,5\]. The role of PRT in non-specific neck pain is mainly limited to the inhibition of early muscle hypertonicity; however, when integrated with exercise programs, it promotes long-term proprioceptive feedback and supports postural alignment \[6\]. PRT will be individually administered by a physiotherapist in the supine position, and session duration will range between 45-60 minutes. The procedure will be performed as follows: Target muscles (upper trapezius, levator scapulae, sternocleidomastoid, and scalene muscles) will be examined through palpation and sensitive trigger points will be identified. Each trigger point will be passively positioned into a comfort position (combination of lateral flexion, rotation, and shoulder depression) until tenderness significantly decreases, and maintained for 90 seconds. Following the hold period, the participant will be slowly returned to the neutral position; 2-3 repetitions will be performed for each point. During weeks 1-2, the hold duration will be 90 seconds, and during weeks 3-4, it will be increased to 120 seconds. This protocol targets trigger points associated with prolonged sitting in desk-based workers, enhances proprioceptive awareness, corrects muscle fiber orientation, and improves tolerance to repetitive stress \[9\]. Its advantages include ease of integration and low risk \[4\]. Randomized controlled studies have confirmed the effects of PRT on cervical muscle endurance, functional status (NDI), and subjective symptoms. El-Khateeb et al. reported that adding PRT to standard treatment in individuals with mechanical neck pain resulted in significant reductions in VAS scores, improvements in NDI scores, and increased pressure pain thresholds (p\<0.001); this effect exceeded the minimum clinically important difference (MCID) threshold within a 4-week protocol \[4\]. Meseguer et al. (2006) reported that a single session of PRT applied to upper trapezius trigger points significantly reduced local pain threshold and that the effect was maintained for 24 hours (p\<0.001) \[6\]. Wong (2012) reviewed that PRT reduced palpation tenderness and increased muscle strength in healthy individuals; improvements in NFET holding duration associated with proprioceptive modulation were also emphasized \[4\]. Gohil et al. reported reductions in VAS scores and NDI scores in myofascial trigger points (p\<0.05) \[10\]. These studies confirm that PRT is an effective early preventive tool for reducing screen-related fatigue in desk-based populations through three sessions per week and for creating synergistic effects when combined with exercise programs \[7\]. Overall, PRT provides sustained muscle inhibition in subclinical cervical dysfunctions and preserves functional reserve \[4,8\]. Instrument-Assisted Soft Tissue Mobilization (IASTM - Graston Technique) Instrument-Assisted Soft Tissue Mobilization (IASTM) is a non-invasive manual therapy method that uses stainless steel instruments to apply controlled microtrauma to soft tissues in order to resolve fibrotic restrictions and accelerate tissue healing. The technique is based on moving the instrument along the muscle fiber direction at a 30-60° angle using lubricant cream. During application, a localized inflammatory response is stimulated, collagen remodeling occurs, adhesions are reduced, and tissue mobility increases \[11,12\]. The role of IASTM in non-specific neck pain is mainly related to resolving soft tissue restrictions during the early stages; when integrated with exercise programs, increased circulation and proprioceptive feedback become more sustainable and support postural alignment \[13\]. IASTM will be individually administered by a physiotherapist in supine and prone positions, and session duration will range between 45-60 minutes. The procedure will be performed as follows: Target muscles (upper trapezius, levator scapulae, sternocleidomastoid, scalene, and pectoralis minor muscles) will be examined through palpation, and fibrotic bands and restricted areas will be identified. Each region will receive 60-90 seconds of instrument strokes, and total manual contact duration will be maintained for approximately 8-12 minutes. Mild local redness and tenderness are expected following treatment. During weeks 1-2, mild-to-moderate pressure will be applied; during weeks 3-4, both pressure and duration will be increased. This protocol targets fibrotic restrictions associated with prolonged sitting in desk-based workers, increases tissue mobility, improves range of motion, and enhances tolerance to repetitive stress \[16\]. Its advantages include rapid application and low risk (mild tenderness \<10%) \[11\]. Randomized controlled studies have demonstrated the effects of IASTM on cervical muscle endurance, functional status, and subjective symptoms. Kim et al. (2021) reported through meta-analysis that adding IASTM to standard treatment for soft tissue injuries resulted in significant reductions in VAS scores and improvements in NDI scores (p\<0.001); this effect exceeded the clinically important difference threshold in 4-week protocols \[13\]. Lee et al. (2020) reported that a 4-week IASTM intervention in office workers with non-specific neck pain demonstrated superiority over the control group in terms of VAS, NDI, and SF-12 scores (p\<0.01) \[16\]. Cheatham et al. (2016) reviewed that IASTM increased tissue mobility and improved proprioceptive feedback, emphasizing increases in NFET holding duration \[11\]. Seffrin et al. (2019) reported that IASTM produced large effect sizes in pain reduction and range of motion improvements in chronic neck pain \[15\]. These studies confirm that IASTM is an effective early preventive tool for reducing screen-related fatigue in desk-based populations through three sessions per week and for creating synergistic effects when combined with exercise programs \[13,16\].Inclusion Criteria Being a healthy individual between 18-40 years of age Performing desk-based work (office/remote work) for at least 6 hours per day Being physically active and having no neck pain (NPRS score 0-2) Providing voluntary consent to participate in the study Exclusion Criteria History of neck trauma, surgery, cardiovascular, metabolic, neurological disease, or rheumatoid arthritis within the last 6 months Participation in a manual therapy or physiotherapy program within the last 6 months Presence of severe malignancy, rheumatoid arthritis, or cardiovascular disease Pregnancy or breastfeeding C.1.2.2. Methods to Be Used in the Study 1. Laboratory and Clinical Assessment Methods A total of 51 desk-based workers are planned to participate voluntarily in the study. All participants will be informed about the risks and benefits of the study. Participants will be randomly assigned into three groups: Group 1: Home exercise program supported by Positional Release Technique (PRT) Group 2: Home exercise program supported by Instrument-Assisted Soft Tissue Mobilization (IASTM) Group 3: Home exercise program only A researcher-developed assessment form will be used as the data collection tool. Before the study begins, participants will complete a form including demographic information (sex, age, height, weight, education level, weekly desk-working hours) and medical history (chronic disease, previous injury, physical activity level). While distributing the assessment forms, participants will be informed about how to complete the forms, and it will be emphasized that the information obtained will be used solely for scientific purposes. Before the intervention, standard assessment tools will be applied to evaluate cervical parameters, including cervical muscle endurance using the Neck Flexor Endurance Test (NFET), functional status using the Neck Disability Index (NDI), pain severity using the Visual Analog Scale (VAS), quality of life using the SF-12 Quality of Life Scale, work performance using the Work Role Functioning Questionnaire (WRFQ), and joint range of motion using a goniometer. Following the assessment process, all three groups will participate in a 4-week mobilization program in addition to their daily routine activities, performed 3 days per week for approximately 45-60 minutes including warm-up and cool-down sessions. Progression throughout the program will be achieved by increasing mobilization intensity. Cervical parameters will be reassessed after completion of the 4-week intervention period \[17\]. Group 1: Positional Release Technique (PRT) Participants will receive individualized PRT applications for 4 weeks, 3 sessions per week (12 sessions total), with each session lasting 45-60 minutes. During the intervention, trigger point palpation will be performed focusing on the upper trapezius and sternocleidomastoid muscles in the supine position. Subsequently, the head will be positioned into comfort using lateral flexion and rotation, and this position will be maintained for 90 seconds for three repetitions \[18\]. In addition to the sessions, neck and shoulder stretching exercises (30-second × 3-set static stretching for the upper trapezius, levator scapulae, and scalene muscles), deep cervical flexor endurance exercises (chin tuck, 10-second × 10-repetition isometric holds), and scapular stabilization strengthening exercises (3 sets × 10-15 repetitions for the middle trapezius, rhomboids, and serratus anterior) will be performed \[19\]. Exercise training will be planned using home-based video guidance, and the program will continue with progressive increases in hold duration and repetition numbers according to the participant's progress. One-minute rest intervals will be provided between sets, and session duration will be approximately 45 minutes. Group 2: Instrument-Assisted Soft Tissue Mobilization (IASTM) Participants will receive individualized IASTM applications for 4 weeks, 3 sessions per week (12 sessions total), with each session lasting 45-60 minutes. During the intervention, the upper trapezius and sternocleidomastoid muscles will be targeted in the supine position using a stainless-steel instrument applied with lubricant at a 30-60° angle along the muscle fiber direction. Tissue adhesions will be mobilized, and three repetitions will be performed bilaterally for 40-180 seconds up to the threshold of hypermobility \[20,21\]. In addition to the sessions, neck and shoulder stretching exercises (30-second × 3-set static stretching for the upper trapezius, levator scapulae, and scalene muscles), deep cervical flexor endurance exercises (chin tuck, 10-second × 10-repetition isometric holds), and scapular stabilization strengthening exercises (3 sets × 10-15 repetitions for the middle trapezius, rhomboids, and serratus anterior) will be performed \[19\]. Exercise training will be planned using home-based video guidance, and the program will continue with progressive increases in hold duration and repetition numbers according to participant progress. One-minute rest intervals will be provided between sets, and session duration will be approximately 45 minutes. Group 3: Control Group Participants will receive only conventional home exercise programs individually for 4 weeks, 3 sessions per week, with each session lasting 45-60 minutes. The program will include neck and shoulder stretching exercises (30-second × 3-set static stretching for the upper trapezius, levator scapulae, and scalene muscles), deep cervical flexor endurance exercises (chin tuck, 10-second × 10-repetition isometric holds), and scapular stabilization strengthening exercises (3 sets × 10-15 repetitions for the middle trapezius, rhomboids, and serratus anterior). Exercises will be monitored through home-based video guidance and mobile application reminders. The program will continue with gradual increases in repetition number and hold duration according to baseline performance. One-minute rest intervals will be provided between sets, and session duration will be approximately 45 minutes \[22,23\]. Outcome Measures Neck Flexor Endurance Test (NFET) The Neck Flexor Endurance Test (NFET) is a practical clinical test used to assess the endurance of cervical flexor muscles. Participants lie in a supine position while maintaining cervical retraction and lifting the head approximately 2-3 cm from the surface. Holding time is recorded in seconds using a stopwatch. Normal values range between 30-60 seconds. The test is performed within the natural cervical flexion range (20-30°), and the average of three repetitions is recorded.\[24,25\]. Neck Disability Index (NDI) The Neck Disability Index (NDI) is a 10-item patient-reported questionnaire used to assess neck-related disability. It evaluates pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreational activities. Scores range from 0-50 and are converted into percentages, with lower scores indicating better functional status.\[26,27\]. Visual Analog Scale (VAS) The Visual Analog Scale (VAS) is a simple and non-invasive clinical tool used to assess pain severity subjectively. Participants indicate their pain level on a 10-cm line ranging from 0 ("no pain") to 10 ("worst imaginable pain").\[28,29\]. SF-12 Quality of Life Scale The SF-12 is a 12-item patient-reported questionnaire measuring physical and mental health-related quality of life. Scores are calculated as Physical Component Summary (PCS) and Mental Component Summary (MCS), ranging from 0-100, with higher scores indicating better health status.\[30,31\]. Work Role Functioning Questionnaire (WRFQ) The WRFQ is a 27-item patient-reported questionnaire assessing work performance and role limitations. It evaluates how factors such as fatigue, pain, and concentration affect occupational functioning during the workday.\[32,33\]. Normal Range of Motion (ROM) Normal cervical range of motion represents the maximum active and passive movement achievable in healthy individuals. Measurements will be performed using a universal goniometer in the sitting position. Cervical flexion, extension, lateral flexion, and rotation will each be measured three times, and averages will be recorded.\[34\]. Sample Size Sample size was calculated using the G\*Power 3.1 power analysis program. Based on the minimum clinically important difference (MCID) value of 7.5 points and a standard deviation (SD) of 7.0 for the primary outcome measure, the Neck Disability Index (NDI), the effect size (ES) was calculated as 1.04 (Young et al., 2009). For an ANOVA test with 80% statistical power (1-β = 0.80) and a Type I error probability of α = 0.05, the required total sample size for three groups (PRT, IASTM, and control) was determined as 45 participants (15 participants per group). Considering a potential dropout rate of 10%, the sample size was increased, and a total of 51 participants will be included in the study: Group 1 (PRT) = 17, Group 2 (IASTM) = 17, and Group 3 (control) = 17 \[35\]. 2. Statistical Methods Planned for the Study Statistical analyses of the data obtained from the study will be performed using the Statistical Package for Social Sciences (SPSS) Version 22.0 (SPSS Inc., Chicago, IL, USA). The normality of data distribution will be evaluated using the Shapiro-Wilk test. According to the results of this test, parametric tests will be used for normally distributed data, while non-parametric tests will be applied for data not demonstrating normal distribution. Descriptive statistics will be presented as mean (Mean), standard deviation (SD), and percentage (%). Demographic and clinical characteristics among the three groups (PRT, IASTM, and control) will be compared using one-way ANOVA for quantitative variables and the Chi-square test for qualitative variables. Repeated measures ANOVA and post-hoc Tukey tests will be used to analyze within-group and between-group differences. Results will be evaluated within a 95% confidence interval, and p\<0.05 will be considered statistically significant. References 1. Ehsani F, Mosallanezhad Z, Vahedi G. The Prevalence, Risk Factors and Consequences of Neck Pain in Office Employees. Middle East Journal of Rehabilitation and Health Studies. 2017. doi:10.5812/mejrh.42031 2. Coulter ID, Crawford C, Vernon H, Hurwitz EL, Khorsan R, Booth MS, Herman PM. Manipulation and Mobilization for Treating Chronic Nonspecific Neck Pain: A Systematic Review and Meta-Analysis. Pain Physician. 2018;21(4):E333-E348. 3. 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