Pain neuroscience education combined with therapeutic exercises provides added benefit in the treatment of chronic neck pain

Key points

1. 01Combined treatment (exercises plus pain neuroscience education) outperformed exercises alone on pain-disability, catastrophizing, and fear-avoidance beliefs after 6 weeks.
2. 02Both intervention groups improved significantly on all four outcomes compared to a no-treatment control group.
3. 03The largest between-group effect size was seen on the Neck Pain and Disability Scale: combined vs. control ES 5.91.
4. 04Pain self-efficacy improved with both treatments (neither differed from the other, p = 0.99), but both were superior to control.
5. 05No adverse events were reported; adherence was 94% (exercises alone) and 89% (combined group).

How it was conducted

Design

Three-arm randomized controlled trial

Participants

72 adults aged 20-50 with chronic nonspecific neck pain for at least 3 months and moderate pain (30-70 on VAS); recruited from rehabilitation centres in Tehran, Iran

Groups

Therapeutic exercises alone (n=24), combined exercises plus pain neuroscience education (n=24), no-treatment control (n=24)

Duration

6 weeks, 3 sessions per week; no follow-up beyond 6 weeks

Primary outcomes

Neck Pain and Disability Scale (NPAD), Pain Catastrophizing Scale (PCS), Fear-Avoidance Beliefs Questionnaire (FABQ), Pain Self-Efficacy Questionnaire (PSEQ)

Analysis

Repeated Measures ANOVA with Bonferroni post hoc correction; significance set at p = 0.05

What they found

• NPAD (disability): combined group improved from 52.86 to 23.50; exercises-alone from 52.55 to 35.50; control from 54.63 to 53.90. Combined vs. exercises-alone mean difference 5.84 (95% CI 3.09 to 8.67), ES 2.30, p = 0.001. Combined vs. control mean difference 16.09 (95% CI 13.24 to 18.98), ES 5.91, p = 0.001.
• PCS (catastrophizing): combined improved from 21.81 to 10.77; exercises-alone from 21.50 to 15.25; control from 22.63 to 20.59. Combined vs. exercises-alone mean difference 2.07 (95% CI 0.06 to 4.09), ES 1.85, p = 0.041. Combined vs. control mean difference 5.31 (95% CI 3.35 to 7.38), ES 4.17, p = 0.001.
• FABQ (fear-avoidance): combined improved from 50.40 to 29.09; exercises-alone from 48.15 to 37.20; control from 49.00 to 48.13. Combined vs. exercises-alone mean difference 2.92 (95% CI 0.06 to 5.78), ES 2.94, p = 0.044. Combined vs. control mean difference 8.81 (95% CI 6.06 to 11.61), ES 5.83, p = 0.001.
• PSEQ (self-efficacy): combined improved from 23.22 to 44.13; exercises-alone from 25.33 to 40.66; control from 24.62 to 25.20. Combined vs. exercises-alone mean difference -0.68 (95% CI -4.77 to 3.41), ES 0.41, p = 0.99 (not significant). Both intervention groups superior to control: exercises-alone vs. control mean difference 8.08 (95% CI 4.07 to 12.04), ES 2.50, p = 0.001.
• Repeated Measures ANOVA showed significant effect of time (p < 0.001), group (p < 0.001), and time-by-group interaction (p < 0.001) for all four outcomes.
• 7 of 72 patients withdrew before completing the intervention (3 exercises-alone, 2 combined, 2 control).

Limitations

• No follow-up beyond 6 weeks, so durability of benefits is unknown.
• Small sample size (24 per group) may limit generalisability to broader populations.
• No pain-neuroscience-education-alone group was included, preventing isolation of its independent effect.
• Outcomes were limited to psychosocial measures; muscle strength, range of motion, and quality of life were not assessed.

Why it matters

For patients

People with long-standing neck pain may benefit from learning about pain biology alongside exercise, as this combination reduced pain, disability, and the fear of movement more than exercise on its own.

For clinicians

Adding structured pain neuroscience education sessions to a 6-week cervical exercise programme produces statistically and clinically meaningful gains in disability and psychological outcomes compared with exercises alone, supporting a biopsychosocial approach.

For readers

This small RCT provides moderate evidence that pain education augments exercise therapy for chronic neck pain, though longer trials with follow-up are needed to confirm lasting benefit.