Deep Cervical Flexor and Sensorimotor Training for Chronic Neck Pain

Participants in the experimental group will receive a structured four-week physiotherapy intervention consisting of conventional physical therapy treatment combined with deep cervical flexor muscle training and proprioception (sensorimotor) training. All participants will attend three supervised sessions per week, with each session lasting approximately 45-60 minutes. Conventional physiotherapy will include stretching exercises targeting the sternocleidomastoid, upper trapezius, levator scapulae, scalene, Rhomboids and pectoralis muscles, performed in three repetitions, holding each stretch for thirty seconds, strengthening exercises will be provided Isometrically for the cervical flexors, extensors and at sides using a prescription of three sets of ten repetitions with a ten-second hold and two minutes of rest between sets.

In addition, deep cervical flexor muscle training will be performed according to the protocol of Jull and Falla using a pressure biofeedback unit. Participants will be positioned in a supine crook-lying posture with the neck in a neutral position, and the air bag of the pressure biofeedback unit will be placed beneath the cervical lordosis and inflated to a baseline of 20 mmHg. Patients will be instructed to perform a gentle nodding action, increasing the pressure by 2 mmHg increments up to 30 mmHg. Each increment will be held for ten seconds, repeated in three sets of ten repetitions, with a two-minute rest between sets. To enhance activation of the deep flexors, patients will be instructed to keep their mouth open during the exercise.

Proprioception training will include head relocation practice, oculomotor exercises, and eye-head coordination exercises. Head relocation exercises will be conducted using a laser pointer attached to a helmet, with participants practicing relocating their head to a neutral position or predetermined positions, initially with eyes open using visual feedback and later progressing to eyes closed. Oculomotor exercises will begin with eye movements while keeping the head stationary, progressing to combined head and eye movements following visual targets. Eye-head coordination exercises will involve moving the eyes and head to the same side, followed by movements where the eyes lead and the head follows, and eventually progressing to eyes and head moving in opposite directions. Exercises will be progressed by increasing speed, range, and target difficulty. This proprioceptive training will also be performed three times per week for four weeks.

The control group will receive the conventional physical therapy program alone, without the additional deep cervical flexor or proprioception training components. Outcome measures for both groups will be assessed at baseline and after four weeks, including pain intensity using the Numeric Pain Rating Scale (NPRS), craniovertebral angle measured by the APECS mobile application, cervical range of motion via Digital Inclinometer, Segmental mobility using spinal mouse, neuromotor control using the Craniocervical Flexion Test with a pressure biofeedback unit, proprioception assessed through head repositioning accuracy tests, and respiratory function parameters (FEV1 and peak expiratory flow) measured with the spirometer.

• Change in Cervical Range of Motion (ROM) in Degrees Measured by Digital Inclinometer from Baseline to 4 Weeks [Time frame: 4 weeks]
• Change in Neuromotor Control of the Deep Cervical Flexor Muscles Assessed by Craniocervical Flexion Test (CCFT) from Baseline to 4 Weeks [Time frame: 4 weeks]
• Change in Craniovertebral Angle (CVA) Measured by AI Posture Evaluation and Correction System (APECS) from Baseline to 4 Weeks [Time frame: 4 weeks]
• Change in Cervical Proprioceptive Function Assessed by Head Repositioning Accuracy (HRA) Test in centimetre from Baseline to 4 Weeks [Time frame: 4 weeks]
• Change in Respiratory Function Parameters (FEV1 and PEF) Measured by Spirometer from Baseline to 4 Weeks [Time frame: 4 weeks]