Persistent pain and disability in whiplash-associated disorders (WAD) grades II and III are common. In two randomized controlled trials (RCTs) of neck-specific exercises (NSE), we have seen promising results in chronic WAD, with a sustained clinically important reduction in pain and disability. NSE can also be delivered through internet support (NSEIT) and a few visits to a physiotherapist, saving time and cost for both patients and providers. NSE have been shown to have positive effects in other neck pain disorders and we will evaluate the diffusion of the exercises to other patients. The aims of the proposed study are to evaluate an implementation strategy for NSEIT and NSE in primary health care and to evaluate the effectiveness of NSEIT and NSE in clinical practice.The proposed study is a prospective cluster-randomized mixed-design study with hybrid 2 trial design. Reg. physiotherapists working in twenty physiotherapy clinics will be included. The primary implementation outcome is proportion of patients with neck pain receiving neck-specific exercise. Secondary outcomes are; physiotherapists attitudes to implementation of evidence-based practice, their self-efficacy and confidence in performing NSEIT/NSE, number of patients visits, and use of additional or other exercises or treatment. To further evaluate the implementation strategy, two qualitative studies will be performed with a sample of the physiotherapists. The primary outcome in the patient effectiveness evaluation is self-reported neck disability according to the Neck Disability Index (NDI). Secondary outcomes are pain intensity in the neck, arm, and head; dizziness; work- and health-related issues; and patient’s improvement or deterioration over time. All measurements will be conducted at baseline and at 3 and 12 months. Physiotherapists´ self-efficacy and confidence in diagnosing and treating patients with neck pain will also be evaluated directly after their instruction in NSEIT/NSE.This trial will evaluate the implementation strategy in terms of adoption of and adherence to NSEIT and NSE in clinical primary health care, and measure diffusion of the method to other patients. In parallel, the effectiveness of the method will be evaluated. The results may guide physiotherapists and health care providers to sustainable and effective implementation of effective exercise programs.ClinicalTrials.gov, NCT05198258, initial release date January 20, 2022.The randomized trial is registered on  There is usually a considerable time lag from results in health research to implementation and use in clinical practice. Time to implementation is commonly reported to be up to 20 years . For patSeveral theories, frameworks, and taxonomies to promote and facilitate the uptake of evidence in practice are currently available , 14. NonIn a prior study, NSE was implemented in primary care . A one-dIn implementing interventions, there are several factors that must be considered. One factor is how the characteristics of the intervention are perceived by the potential adopters, and if they see a relative advantage in comparison with current practice . IndividEducation is an important component of implementation strategies, but a comprehensive strategy including many meetings with a facilitator has been found to be too time consuming . In the The RE-AIM framework was developed to identify and evaluate a broad aspect of important factors to translate research results into clinical practice , 31. TheIn randomized controlled trials, the intervention follows a strict protocol directed to a specific diagnosis and excludes other treatments or exercise intervention during the study period. This is important in evaluating its effectiveness—that is, whether the method is delivered as intended and has the same effect as in the RCTs , 12. NSEThe aims of the proposed study are to evaluate an implementation strategy for NSEIT and NSE in primary health care and to evaluate the effectiveness of the programs in clinical practice.Reach: To what extent do patients with WAD receive NSEIT/NSE in primary care?Effectiveness: Is the NSEIT/NSE program effective at decreasing disability and pain in patients with WAD or non-specific neck pain in primary care? Will the results be the same as in the RCTs at 3 and 12 months of follow-up?Adoption: To what extent do the physiotherapists apply the NSEIT/NSE for patients with WAD or non-specific neck pain?Implementation: To what extent is the intervention delivered according to the NSE protocol (fidelity)?Maintenance: To what extent will physiotherapists continue to use NSEIT/NSE at 12 months of follow-up?These research questions will be investigated according to the RE-AIM framework:We propose a prospective cluster-randomized mixed-design study evaluating the implementation strategy and effectiveness of the NSEIT/NSE. The study is based on hybrid 2 trial design, as described by Curran et al. , where bTwenty physiotherapy clinics in primary health care in Sweden will be included. Twenty-five patients with neck pain will be consecutively recruited from each clinic, for a total of 500 patients. The flow diagram can be seen in Fig. Physiotherapy clinics in primary health care with ≥3 registered physiotherapists working at the clinic.No exclusion criteria for registered physiotherapists in the clinics that are recruited in the study.The physiotherapists will include patients ≥18 years old with neck pain. Patients will be required to have internet access by phone, tablet, or computer, be able to read and understand Swedish, and be interested in participating in the study.Physiotherapists should exclude patients with “red flags”: symptoms that suggest a serious illness or spinal abnormality, including serious trauma to the neck and no X-ray, preceding neck surgery, osteoporosis, myelopathy, history of cancer, unexplained weight loss, current fever, history of infections, constant and progressive non-mechanical pain, insidious progression of pain, signs of spinal cord compression .Barriers to implement evidence-based interventions in physiotherapy have been identified and are, for example, lack of time, lack of high-quality research, confusion, and misperceptions of the new method . IdentifClinicalTrial.gov Registry.The 20 physiotherapy clinics will be randomized to 2 groups, stratified for the number of physiotherapists working at the clinic (≥4 physiotherapists or 3 physiotherapist). A computerized block randomization list, conducted by a statistician and allocated by a project team member, will be used. The randomization will be performed by an independent researcher. The researcher sends an e-mail to all physiotherapists at the clinic, containing information about the randomization group. Due to the nature of the study can the physiotherapist not be blinded. Any change in the protocol will be communicated with the ethics committee and if approved appropriate changes will be made in the In the first step, physiotherapy clinics will be recruited through contact with health care providers and research coordinators in county councils in Sweden. In the second step, an oral on-line presentation describing the study will be given to those health care providers that express interest in the study. If the eligible physiotherapy clinic confirms participation via e-mail after the presentation, physiotherapists will be included after written informed consent. Registered physiotherapists working at the included physiotherapy clinics will screen patients for eligibility by taking a detailed medical history and careful clinical examination, following the regulations for registered physiotherapists in Sweden  and group B (the control group) will receive on-line theoretical education including 3 hours of practical training by the project leaders. The standardized theoretical instruction includes three 45-minute on-line lectures Table . It willThe internet-based exercise program, NSEIT, is available on-line by phone, tablet, or computer via the Swedish National Support and Treatment Services, INERA. Since 2016, all regions in Sweden have been connected to the Support and Treatment services, a web-based e-health solution to enhance digitalization in health care. The platform is accessed through Health Care Guide 1177 and patients logging in using BankID. The physiotherapists logging in to the Support and Treatment services will choose exercises and information from two different programs, WAD ExerciseIT (for patients with whiplash-associated disorders) and Neck ExerciseIT (for patients with non-specific neck pain). The two programs contain the same neck-specific exercises and the same information about persistent pain, the benefits of exercise directed to the deep neck muscles, strategies for dealing with neck pain relapse, ergonomic advice related to the neck, complementary exercises for shoulder muscles and the low back, and strategies for continuing exercise after the treatment period. WAD ExerciseIT contains information about whiplash injury and Neck ExerciseIT has information about non-specific neck pain and stretching exercises. The physiotherapists will choose and individually progressively assign the neck-specific exercises during the treatment period. In the RCT study, each patient had 4 meetings with the physiotherapist, at weeks 1, 2, 3, and 7, to ensure that the patient performed the exercises as intended . At weekPhysiotherapists will also be able to use the NSE in their clinic for patients who need or would like supervised training; all the NSE exercises and information will be available on paper. The patients will receive the same information and exercise as in the NSEIT program, but it will be delivered by a physiotherapist. Patients will not be withdrawn if they receive any other physiotherapy treatment  in combination with the NSEIT/NSE.Outcome measurements will be recorded at baseline and after 3 and 12 months. See Fig. Background data on each physiotherapist will be collected and include age, sex, years working as physiotherapist, and post-secondary education in physiotherapy.The primary outcome will be the proportion of patients with neck pain receiving neck-specific exercise during the intervention period. Data will be collected from each included physiotherapy clinic, based on each physiotherapist’s registered ICD-10 code  in the medical record.The Evidence-Based Practice Attitude Scale (EBPAS) will be used to assess the physiotherapists’ attitudes to implementation of evidence-based practice  and willThe secondary outcome measures will also include questions about each physiotherapist’s experience of the neck-specific program: the number of times the physiotherapist had contact with the patient  and information about additional or other exercises and/or treatment for neck pain will be collected via the medical record and/or the web-based support and treatment platform INERA, and/or through the Swedish Classification of Health Interventions .Background data will be collected, including age, sex, symptom duration, and whiplash injury or other reason for neck pain.The primary outcome measure that will be collected is neck-specific function as measured by the Neck Disability Index (NDI) .The secondary outcome measurements will be pain intensity  in the neck, head, and arm, and dizziness  in the past week, using a numeric rating scale  ; answersTo further evaluate the implementation strategy, two qualitative studies will be conducted. Data will be collected from semi-structured focus group discussions with a purposeful sample of physiotherapists who have participated in the study. Physiotherapists from both groups—group A with increased implementation support, and group B with no further support after the first three on-line instructional sessions and one practical instructional session—will be included. Physiotherapists of both sexes and varied ages and professional experiences will be sought. Six focus group discussions with 3–5 physiotherapists in each group will be held 1–2 months after the implementation activity and approximately 1 year after. The focus group discussions will be conducted digitally as a video conference meeting with a secure digital system (Visiba care). Data will be analyzed with qualitative content analysis and an inductive approach for category development, and alternatively with a deductive-inductive approach .The interview guides will include questions about, for example, the physiotherapist’s experiences instructing patients in neck-specific training, which patients they have treated using the neck-specific exercises programs, experiences dealing with patients with neck pain after the implementation of neck-specific exercises, and experiences with implementation support.Data regarding the implementation strategy will be analyzed using a parametric t-test and a linear mixed model or repeated-measures ANOVA or the non-parametric Mann-Whitney U test and Kruskal-Wallis test, depending on the data. Analyses will evaluate differences between groups A and B and changes in variables over time.Data regarding the effectiveness of NSEIT and NSE will be analyzed with a linear mixed model or repeated-measures ANOVA or Kruskal-Wallis, depending on the data. NDI, pain intensity, headache, and dizziness will be evaluated as dependent variables with time as an independent fixed factor . The results will be compared with the results from the RCT studies [ studies , 12.All analyses will be conducted in collaboration with a statistician. Data will be analyzed according to intention to treat and supplemented with per protocol analysis. An analysis will be done of the missing data. Imputation methods may be used when deemed to have additional value. Subgroup analyses of age, gender, neck pain intensity, headache, and dizziness may possibly be performed.The effect of neck-specific exercises in the present study for WAD grades II and III and for patients with other neck-pain disorders will also be evaluated and compared with the results in the RCT studies , 12.Sample size and power regarding group differences were calculated by a statistician. The aim of the study is to evaluate both implementation and effectiveness. The sample size calculation to evaluate implementation was based on the assumption that 15% more patients will receive neck-specific exercises in the intervention group (40% in the intervention group and 25% in the control group). The required sample size under individual randomization will be 150 patients in each arm. With 10 physiotherapy clinics (clusters) in each arm , intra-cluster correlation of 0.02 and a cluster size of 21 patients, a total of 420 patients will be recruited for 80% power and a significance level of 0.05. To ensure that enough people are in each group after dropouts, a total of 500 patients will be included, 25 patients from each cluster.Sample size calculation to evaluate effectiveness was based on a clinically relevant improvement of 7% in the NDI, an effect size of 0.2 (Cohen’s f) or 0.4 (Cohen’s d), a correlation among repeated measures of 0.3, and the need for a total of 56 participants for 80% power and a significance level of 0.05. With an expected dropout rate of 20%, a total of 70 participating patients will be needed. The total number of patients may be more than 70 because patients will be recruited at each clinic.Repeated-measure ANOVA or a linear mixed model will be used to examine changes in the patient-reported outcomes over time . The results will be compared with the results from the RCT studies , 12. PatAll data will be monitored by the project team, independent on the study sponsor. To ensure participant confidentiality will a unique identifier be assigned to each participant after enrolment. Data will be stored on a secure website in the County Council of Sörmland. The website is password protected and will only be accessible by the project team. The results will be presented at the group level, and no connection to the individual person can be made. Outcome assessors and data analysts will be blinded for intervention allocation by having a researcher not involved in the analyses recode the groups using two random numbers.The results of the study will be disseminated through scientific papers, seminars and popular science reports and stakeholder. Authorship guidelines include actively contributing to scientific papers and professional writers will not be used.Planning of the study began in January 2021. The trial started in April, 05, 2022 and we estimate that patients will be enrolled in the study in 2022–2023, with follow-up continuing until December 2024 (Fig. Neck-specific exercises have been evaluated in two RCTs, showing reduced disability and neck pain in individuals with persistent WAD , 9, 12. The limitations of the present study are related to the pragmatic approach. To study the implementation process and the adoption, diffusion, and maintenance of the NSEIT/NSE in clinical practice we could not follow as strict a protocol as in an RCT, which means we have less control over the study. The physiotherapists will select patients whose condition they have deemed to be improved by neck-specific exercises. Because all patients will be evaluated as one group, with no comparison with other treatments or exercise methods, threats to internal validity exist; that is, threats to confidence that the results are trustworthy. However, we will compare the results with the findings in our previous RCTs. Threats to the study’s external validity arise from the fact that only neck-pain patients and physiotherapy clinics that are interested in participating in the study will be evaluated. With these concerns in mind, the results can be generalized to physiotherapy clinics in primary care, as many different regions and physiotherapy clinics will participate in the study.


Prescribing of opioid medication has increased over the past 20 years. Most occurs in primary care for chronic pain. There is little evidence that these drugs are effective for this indication. There are concerns about the continuing prescribing of opioids, particularly in the long term and at high doses.To explore GPs’ experiences of prescribing opioids, problems encountered, and factors militating against good prescribing practice.Qualitative interviews with GPs who prescribe opioids in primary care in North East Wales.Semi-structured interviews with 20 GPs were transcribed and subjected to thematic analysis utilising the framework approach.Participating GPs identified a range of problems associated with prescribed opioids. They were concerned about limited effectiveness of the drugs and what they perceived as addiction resulting from their use. They identified healthcare system factors that were obstacles to good prescribing practice such as lack of continuity of care, poor access to secondary care pain management support, and, most importantly, constant time pressure. They reported adverse effects on relationships with patients. Unrealistic expectations that pain could be eliminated resulted in pressure to prescribe stronger drugs and increased doses. It led to difficulties in establishing and maintaining trust and in persuading patients to agree to, and to carry out, dose reductions.Themes emerging from this study suggest that GPs lack appropriate control of opioid prescribing. There is a need to develop methods to help patients and GPs to work together to manage chronic pain safely. Opioid medication is frequently prescribed in primary care but is known to be largely ineffective in the long-term treatment of chronic pain. This study found that GPs are concerned by this situation and experience pressures to initiate, continue, or increase opioids against their better judgement. The factors they identified that make appropriate prescribing difficult to achieve must be addressed if long-term opioid prescribing is to be reduced. Prescribed opioids are an issue of widespread concern in the UK, with focus on avoiding the severe problems encountered in the US. Most opioid prescribing is for chronic non-cancer pain (CNCP) despite a lack of evidence of effectiveness for this indication and evidence of the risk of harms from using these drugs. There is epidemiological evidence that shows opioids for CNCP are associated with worse functioning and quality of life, and clinical experience suggests that this is particularly prevalent in patients on high doses.There has been a large increase in prescribing of opioids in the UK since 1990. Of greater concern is the increased prescribing of stronger opioids and higher doses, and the increase in numbers of people prescribed these drugs long term, which might be overlooked in a downturn in total numbers of prescriptions or items issued. Not enough is known about patients who are prescribed high doses of opioids long term. They may gain no benefit from their medication, while being at significant risk of harm.Although overall opioid prescribing may have begun to decrease, rates are still much higher than they were 25 years ago. In addition, little is known about the reasons for continued high levels of opioid prescribing. Previous studies have shown that conversations with patients about opioids are experienced by GPs as difficult and a cause of conflict. There is a need for a better understanding of the prescribing of opioid medication from the perspective of GPs.Studies of opioid prescribing in the UK published to date have reported aggregated data including the following: the number of prescriptions; the number of individuals receiving prescriptions; and total quantities prescribed at a population level. There is a need to examine prescribing at the individual patient level.The aim of this study was to explore GPs’ experiences of prescribing opioids in primary care, problems they encountered, and factors militating against good prescribing practice.The qualitative face-to-face interview study was conducted in North East Wales. related to the current research.) Two reminder emails were sent at 2-week intervals with a follow-up telephone call to practice managers after a further 2 weeks. Recruitment was completed in January 2020. Potential participants received an information sheet that included the following information:Participants were GPs who worked at least one session per week in primary care. With an aim to recruit 20 participants, 167 GPs from 39 practices were invited to participate via email in October 2019. , which was based on the study aims and objectives, and refined by the study team . The interviews began with a framing statement and an open-ended question asking GP participants to talk about their experience of opioid prescribing. The prompts and probes in the topic guide helped elicit further information relevant to the study aims.et al, using Microsoft Excel. All transcriptions were read by SG and JB, who agreed to a preliminary coding, which was applied to three transcripts independently. The results were compared and a meeting with the wider group refined the coding, which was then applied to rest of the data by SG. Further interpretation workshops involving senior research team  refined and agreed to the final themes (see Supplementary Table 2).All interviews were audio-recorded with consent and transcribed verbatim. Interpretative analysis was carried out, following the five stages of the framework approach, described by Ritchie and Spencer, and Gale Twenty face-to-face interviews (8–31 minutes long) of GP participants, from 18 different practices, were completed from November 2019–January 2020. It was agreed by the team that data saturation had been achieved.Following the framework approach, the following five main themes emerged from the analysis:General experiences of prescribing opioidsFactors affecting good prescribing practiceGPs’ interactions with their patientsLack of controlExpert support to GPs.Most GP participants reported that they had misgivings about opioid medication use in primary care and that they had patients in their practice whose opioid use caused them concern. They identified these drugs as being associated with a wide range of problems. They frequently referred to very long-term prescribing of opioids; prescription of opioids alongside other sedative drugs, gabapentinoids and diazepam being specifically mentioned; negative side effects, particularly in long-term use; patients being prescribed high doses; and the lack of alternative interventions for pain. Other issues identified included the following: the use of pain medication to treat a different problem such as relieving anxiety; opioid-induced hyperalgesia; risks to older patients; inappropriate prescription for conditions such as fibromyalgia; and a culture of reliance on drug interventions. The GP participants frequently reported doubts about aspects of their current prescribing practice and some described a reluctance to initiate or increase opioid doses:'For many years I’ve worried about the over-usage of opioids ... They have effects above and beyond any potential painkilling effect. […] We know these drugs don’t really help very much, can make things worse, but it’s a difficult case to argue.' (GP13)Some of the GP participants identified addiction as a major problem associated with prescribed opioids. They were aware of an increase in use in recent years and some referred to the consequences of overprescribing in the US. The intrinsically addictive nature of the drugs was cited; the problems encountered with patients prescribed them were ascribed to addiction. Patient requests, particularly when repeated, to increase doses, and the converse reluctance to decrease doses when advised, were often cited as evidence of addiction, reinforcing the need to control doses:'Slipping through the net are the drug-seekers, the addicts, the addicts with intention, or no intention.' (GP19)'I think you can't start stripping people of medication that they’ve become dependent on.' (GP14)'I think because the patients demand medication it would seem likely that we’re no longer treating pain, we are treating an addiction, basically.' (GP15)The GP participants were concerned by the observed ineffectiveness of opioids; that long-term use often did not reduce pain symptoms. Many spoke about the limits to effectiveness, with benefits waning over time, and some identified a ceiling effect, whereby there was a point when increased doses brought no increase in benefits. They were also concerned about the negative effects experienced by patients when their drugs ceased to provide benefits and about the lack of available alternatives to opioids:'… realising that actually, they don’t get better. They don’t improve symptom-wise.' (GP4)'... my understanding is that the … it’s very rarely effective to increase or escalate medication if it’s not working.' (GP15)'When the family realises that, actually, the higher doses are not helping that much and they may be contributing to side effects.' (GP9)GP participants were specifically asked if they were aware of any of their patients who were using high doses of opioids and who experienced good levels of pain relief without reduced levels of functioning and impaired quality of life. None of them were able to provide instances of high-dose patients doing well. Several did not answer the question and several others answered a different question; for example, describing patients who were not on high doses or who had improved after reducing doses. Some drew a distinction between doing well and being content with their opioid regimen.There were frequent references by most GP participants to the effects on prescribing practice of working within a system that creates constant time pressure. Time-limited appointments were cited as a barrier to dealing with complex problems and difficult-to-treat patients. They reported not having sufficient time for good management and monitoring of patients. Staff shortages exacerbated these difficulties, some GPs reporting having time to do little more than deal with immediate problems. It was suggested that because of time pressures simple options, such as repeatedly prescribing drugs, were more likely to be taken than the exploration of alternatives:'… right now, because we’re barely able to provide a basic appointment at the moment, we don’t really have any appointments to bring them for repeated review.' (GP16)'I think the problem with the way it works in clinical practice is that it’s very hard to keep track of your patients. There are so many people on opioids and so many other issues that you present with that you don’t have the time to monitor.' (GP2)'So, you will have the 10 minutes to address the main problem and the pain that comes as a result of it, which is a difficult and tricky one. So, I think it does feel, a lot of times, that the easiest option is to escalate whatever painkillers they're on. That would work, at least psychologically, to some extent.' (GP19)Most GP participants reported a range of constraints, associated with a fragmented healthcare system, which affected the ability to deliver good practice, either in general or in relation to the treatment of pain and the prescribing of opioids. Negative external factors were reported including the following: the influence of the pharmaceutical industry, past and present; policy directives; and the difficulties in accessing secondary care services and, in particular, long waiting times for those services. There were references to patients discharged from secondary care on drugs and doses that were difficult to discontinue or reduce. This was also true of patients in primary care who were already on high doses when either inherited from their previous GP or transferred from another practice. Lack of continuity of care within practices, with patients being treated by several clinicians, was seen as making consistent strategies for managing prescribing difficult and tending to facilitate increasing doses:'I trained as a junior doctor, a house officer from 2008. At that time opioids were actually being promoted for non-cancer pain.' (GP4)'Regarding the opioids, the challenge I find is that these patients, often in modern primary care they are seen by various different clinicians. It’s probably easier to give in when we don't see the patient in continuity, right?' (GP9)'My own experience of being a GP for about 20 years, I’ve come across more patients on opiates from secondary care and other GPs than I’ve started.' (GP20)'… we inherit sometimes patients here that come from other surgeries or historically, have been on significant amounts of opioids for non-cancer pain.' (GP11)'We keep coming back to higher strength opioids. In the absence of quick access to physiotherapy, in the absence of quick access also to a pain clinic and long appointment waits and so on, it keeps coming back to a medication solution. That’s what patients tend to expect.' (GP13)A factor that GP participants reported as creating difficulties was patients’ beliefs and expectations about pain and the drugs they take for pain. They cited patient expectations that chronic pain could be removed completely; that this could be achieved through drugs; and, if this was not currently happening, it would be achieved through increased doses or stronger drugs. They described difficulty in persuading patients that these expectations could not be fulfilled. They reported that this led to continual pressure for increased doses, different drugs, early prescriptions, and referral to specialist services. The converse of this was a reluctance to decrease doses of drugs that were ineffective or had negative effects, which was frequently driven by the fear that reductions would lead to intolerable worsening of pain:' … it is difficult, pain relief, I think, because patients expect you to give you something to make it completely pain free, something that is safe, that doesn’t give them side effects, and the fact that there isn't something like that, it’s hard for them to understand, isn't it?' (GP11)'We get a lot of requests to increase it, because there is this sort of, I guess, lay belief that the more you take, the more likely it is to work.' (GP12)'You’re constantly being under pressure, “The painkiller doesn’t work, have you got something different? Have you got something stronger?”' (GP2)'It is very difficult in some patients to even talk about trying to reduce the medication so that the medication then becomes sort of patient demanded or patient-led.' (GP15)'It provokes enormous anxiety. I think I would say that was the … First of all it’s, kind of, “You’re trying to take something away from me,” but the impression that you get from the patient is extreme anxiety that they’re going to be in pain that they cannot then address.' (GP17)In dealing with the complex issues around the prescribing of opioids for chronic pain, GP participants described the importance of building good relationships with patients. There were references to the skill, effort, and, above all, time needed to engage with patients to develop mutual trust, understanding, and agreement:'The starting point for me is establishing a really good, mutually trusting relationship with a patient, and then, once I've got them on side, I then start to explain to them the harmful effects of these drugs, and start to try and chip away at them. […] One of the first things I do is start to try and chip away, but that requires quite a lot of consultations to get to that point, quite a lot of explanation, but more importantly, it requires the skill of getting into them, inside them, and getting to the core of the problem.' (GP14)There was also recognition of the dangers of breakdown in relationship when engagement fails. Some spoke of a fear of damaging relationships by discussing opioid issues. For some, the need to maintain good relationships outweighed the need to address opioid-related problems. Some saw unmet expectations and relationship breakdown as potentially leading to patients leaving the practice or making formal complaints:'“Why are you going to take me off this medication?” it will be the first question they ask, and we have several patients, actually, coming from other surgeries because of their experience with the GPs taking them off the medications. So, this can result in poor patient–doctor relationship, can lead to complaints and so we’re on a negative feedback end result.' (GP8)GP participants were specifically asked if they had found reducing or stopping opioids a successful strategy. The majority reported attempting this with a few patients but not making it a widespread practice. Many described the process as being difficult to initiate, with patients finding the concept of improvement through reduction of pain medication hard to accept. Persuading patients to begin and to continue reducing doses and monitoring progress placed large demands on time and resources. There were also reports of strained doctor—patient relationships. A few described successful outcomes with some patients but most reported little or no success. Some reported patients reaching a point where they refused to make further reductions, achieving only partial success.Throughout the interviews GPs described factors giving rise to long-term and high-dose opioid prescribing. A cross-cutting theme of a lack of control or agency emerged from many different and interconnected issues described by the GP participants. 'Addiction' referred to a situation where patients’ drug use was out of control. Opioid ineffectiveness, even in high doses, meant that the symptom of pain could not be controlled. Working under constant time pressures meant that best clinical practice was hard to deliver and GP participants lacked the control to give sufficient time to patients with complex and difficult problems associated with chronic pain and medication use. A lack of continuity of care, particularly between prescribers, made control of an overall clinical strategy hard to achieve. Pressures to meet patient expectations and a fear of damaging relationships inhibited attempts to control medication use. Many GP participants found establishing control by systematically reducing doses was difficult to initiate and carry out successfully. Lack of timely access to other specialist services reinforced lack of control.Many GP participants acknowledged, as a consequence of control issues, it was sometimes easier to prescribe opioids, increase doses, change to stronger drugs, or perpetuate regimens, despite many citing that long-term opioids did not work for chronic pain, and none being able to recall patients on such doses 'doing well'.GP participants identified three services they currently drew on for support with prescribed pain medication, these were as follows: NHS primary care pharmacists; secondary care pain management teams (PMT); and the Prescribed Medication Support Service (PMSS). . Comments about pharmacists and PMSS were positive. Comments about PMTs were mixed, with long waiting lists drawing particularly negative comment.All GP participants made suggestions for future assistance in managing opioid prescribing. These fell into the following four categories:Provision of resource materials for patients, which consists of education and information materials about the limitations of opioids.Introduction of new or improved services, which includes the following: provision of improved psychology services; establishment of patient support groups; more primary care pharmacist support; direct GP access to PMT expertise for advice; earlier patient access to PMT; and a substance misuse-like service.Wide-scale NHS organisational changes, which means greater consistency between primary and secondary care, prescribing protocols, drug formulary changes, and regulation of prescribing.Better pain management training and education for GPs and healthcare workers, and provision of resource materials.The following five main themes emerged from the analysis: general experience of prescribing opioids; factors affecting good prescribing practice; GPs' interactions with their patients; lack of control; and expert support to GPs. The findings have shown that GPs are concerned about opioid prescribing in primary care. They often feel that they are presiding over unsatisfactory opioid regimens, but that there are major obstacles to reducing opioid use among their patients. These obstacles fall broadly into the following three categories: patient factors, such as the perception of addiction or unrealistic expectations of complete relief of chronic pain; system factors, such as time pressures and long waiting lists for secondary care pain management services; and interpersonal factors, such as fear of causing a breakdown in therapeutic relationships or provoking complaints. The consequence is a sense of lack of control over the patient's medication use and their pain management.GP participants’ suggestions to improve the situation broadly match these categories, which are as follows: measures to change patient expectations such as patient educational materials; better and more responsive secondary care services; organisational changes, including greater external controls on their prescribing; and better training for primary care workers.The study used a well-established qualitative method that allowed free exploration of GP experiences and attitudes without the research team making prior assumptions that might influence findings. The strength of the method is that it can result in novel and unexpected findings in areas such as opioid prescribing where there are intractable problems in achieving desired change .All qualitative studies are vulnerable to the criticism that findings only apply to a particular small group of participants at a particular time. A potential weakness of this study is that participants were volunteers who responded to a general invitation to take part. They may, therefore, have had particular interests in or concerns about the topic, which made them unrepresentative. The number of participants in qualitative studies is typically small, and in this case 20, but analysis of interview content is detailed. It is necessary to be cautious when generalising findings but set against this, the data are rich in detail of GP experiences. The themes that have emerged in the study are familiar to GPs and pain medicine professionals. The main strength of the study is that the findings suggest some strategies to improve opioid prescribing in primary care that can be developed and tested in clinical trials. aimed at understanding processes leading to long-term prescribing of opioids, reported similar ambiguities. This was seen as resulting from poor access to specialist services and a lack of alternatives to medication as treatment options. Systems that did not facilitate continuity of patient care were also seen as leading to lack of control over prescribing. Discussions about dose reductions or patient requests for increases led to difficult conversations and sometimes conflict with patients. A Canadian interview study, with aims similar to the present study, showed that family practitioners (FPs) experience unease and uncertainty about opioid prescribing and have concerns about addiction and misuse. It is interesting that, in a different healthcare system, there were also problems around accessing and communicating with specialist services; inadequate provision of resources; doubts about FPs’ capabilities; and inadequate guidance about prescribing for pain. FPs found dose tapering difficult to carry out because of high failure rates and resistance from patients. Again, this often led to difficult conversations and confrontation. As in the present study, there were participants in both these studies who admitted to agreeing to maintain or increase doses in order to avoid conflict with patients.To the best of the authors' knowledge, this is the first study to focus directly on UK GPs' experiences of and attitudes to prescribing opioids for chronic pain. The most important finding is that the GP participants appear to have felt an uncomfortable lack of agency over opioid prescribing, with ambiguity whether the locus of control of opioid prescribing lies with doctor, patient, or neither. A qualitative study with UK GPs and patients, Similar or adapted approaches may help GPs with interactions with patients in chronic pain, and such an intervention is now being developed by the authors.The findings suggest that GPs are likely to be amenable to novel interventions and strategies to reduce the number of patients on ineffective and/or harmful opioid regimens. In the authors' opinion, the GP participants were right to identify major systemic problems, such as insufficient continuity of care to allow pursuit of longer-term treatment strategies, and fragmentation of secondary care services with consequent dislocation from primary care. Unfortunately, these systemic problems are well-recognised and are unlikely to improve in the immediate future. However, the findings suggest some interventions that might be effective within primary care, including better information on pain management for patients and training for primary care staff. Helping GPs with 'difficult' interactions has been explored previously with respect to cancer care and successful interventions have been developed.


Patients with craniocervical pain have shown reduced performance in the craniocervical flexion test (CCFT). However, there is limited evidence of other possible kinematic alterations not assessed in the context of the CCFT. Previous studies on other functional or planar movements have reported alterations in sensorimotor control  in subjects with neck pain. The objective of this study was to explore the association between sensorimotor control variables associated with craniocervical flexion movement and different characteristics related to pain, age, disability, and fear of movement in individuals with non-traumatic chronic neck pain and asymptomatic controls.This was an observational, cross-sectional study in patients with non-traumatic neck pain and asymptomatic participants. Regression models were used to assess whether descriptive characteristics of the sample, including: (a) age, (b) intensity of pain, (c) neck disability, (d) chronicity of pain, and (e) fear of movement could explain sensorimotor control variables such as ROM, velocity, jerk, head repositioning accuracy, and conjunct motion. All these variables were recorded by means of light inertial measurement unit sensors during the performance of three maximal repetitions of full range craniocervical flexion in the supine position.A total of 211 individuals were screened and 192 participants finished the protocol and were included in the analyses. Participants had an average age of 34.55 ± 13.93 years and included 124 patients with non-traumatic neck pain and 68 asymptomatic subjects. Kinesiophobia partially explained lower craniocervical flexion ROM (p = .01) and lower peak velocity in flexion (P < .001). Age partially explained increased craniocervical extension ROM (P < .001) and lower peak velocity in flexion (P = .03). Chronicity partially explained increased lateral flexion conjunct motion (P = .008). All models showed low values of explained variance (< 32%) and low absolute values of regression coefficients.This study did not find a clear relationship between population characteristics and sensorimotor control variables associated with the craniocervical flexion movement. Kinesiophobia might have some association with reduced ROM in craniocervical flexion, but further research in this field is needed in large samples of patients with higher levels of kinesiophobia pain or disability. Neck pain is a very common musculoskeletal disorder and a major public health burden with high prevalence, incidence, and years lived with disability worldwide . The annPrevious studies have related the onset and perpetuation of craniocervical pain to multiple alterations of the cervical sensorimotor system compared to asymptomatic population, such as reduced muscular strength and endurance of the cervical muscles –8, alterThe craniocervical flexion test (CCFT) specifically assesses the function of the deep neck muscles of the cervical region. , 19, 20.Although CCFT has been frequently investigated in patients with craniocervical pain, it is unclear whether this specific craniocervical flexion movement might be altered in relation to other parameters  than those currently obtained from the CCFT, as well as the relevance of measuring these parameters. Several studies have evaluated the aspects of sensorimotor control in multiple cervical movements rather than during craniocervical flexion –18. HoweIt is possible that kinematic analysis of sensorimotor control of this specific movement may provide relevant information for understanding the mechanisms underlying craniocervical pain or assessing the effects of therapies in relation to changes in patients´ sensorimotor control. Moreover, the kinematics of craniocervical flexion assessed as an independent movement could potentially be used as a alternative form of assessment of the deep cervical flexors, since the limited reliability of the CCFT has recently considered to affect its suitability Therefore, this study aimed to explore whether different characteristics related to pain intensity, age, neck-pain related disability, and fear of movement explain sensorimotor control performance  during the craniocervical flexion movement on a sample of non-traumatic chronic neck pain patients and asymptomatic controls.This was a descriptive, observational, cross-sectional study, including patients with non-traumatic neck pain and a control group of asymptomatic participants based on a previously described study protocol .This study was designed and the findings are reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) .The study was approved by the Research Ethics Committee of CEU San Pablo University (495/21/39). Participants provided informed written consent before being enrolled into the study and they were able to withdraw their consent at any time during the study, in compliance with the WHO standards and the Declaration of Helsinki .The sample was composed of a group of patients with non-traumatic subacute and chronic neck pain and another group of asymptomatic subjects. We recruited a non-probabilistic convenience sample via flyers, online forms through social networks, e-mail, or direct verbal communication at San Pablo-CEU University, the CEU San Pablo University clinic, as well as in private physiotherapy clinics in the Community of Madrid.Patients with neck pain were eligible to be included in the study if they were 18–65 years old and fulfill the following selection criteria: (a) neck pain of at least 1 month of evolution, (b) neck pain from non-specific mechanical origin associated or not with primary headache (e.g. migraine or tension-type headache), shoulder pain, or upper limb pain. Patients with neck pain were excluded if they presented any of the following criteria: (a) complex regional syndrome, (b) previous surgeries in the neck and/or head region, (c) vestibular alterations, (d) otogenic or idiopathic vertigo/dizziness, (e) presence of tumors in the craniocervical region, (f) previous fracture in the head or neck region, (g) osseous deformities in the thoracic, cervical, or cranial region.Asymptomatic subjects should not have any pain in the cervical region during the last year and no previous treatment for neck pain. The exclusion criteria were the same as described for patients with neck pain.Once deemed eligible, subjects were asked to read and sign the informed consent prior to participation and then were invited to participate in the study, consisting of one session in which all variables described below were assessed.Prior to sensorimotor control testing, subject demographic characteristics such as age, gender, weight, height, and dominant side were recorded. In addition, the following pain or descriptive variables were collected for all participants: (a) mean intensity of pain during the last month , (b) neck disability measured using the Spanish version of the Neck Disability Index (NDI) , (c) durSensorimotor control kinematic variables were recorded by means of small (4 cm × 4 cm × 8 cm), light (< 200 g) Inertial Measurement Unit (IMU) sensors , which integrate a 3D accelerometer, a gyroscope, and a magnetometer. This inertial sensor technology has previously shown good to excellent intra-rater and inter-rater reliability in the measurement of general cervical ROM (ICC = 0.93)  and cranAn independent assessor administered testing procedures, blinded to subject group status (neck pain or asymptomatic). Another researcher recorded the demographic variables and was aware of the subject’s pain status. As reported by similar previous research , 38 perfThe kinematics of the craniocervical flexion movement in supine position were evaluated for each subject enrolled in the study. Participants received instructions on testing procedures (see below). During the test, the assessor was able to monitor on real time the values of ROM displayed on a computer screen Fig. .Fig. 1DiBefore starting with the test, participants were asked to sit naturally in a standard chair with the feet well supported on the floor and the neck and head in a neutral comfortable position with their hands resting on their thighs. Patients performed three repetitions of flexion/extension, lateral inclination, and rotations (to both sides), serving as a warm-up exercise before the measurement of craniocervical flexion.Then, the assessor asked the subjects whether they had any questions before starting the test. Then subjects were asked to perform three consecutive active movements of the craniocervical flexion movement in supine position as described in the section below.All participants completed a questionnaire related to fear of movement, which is also described below. The Spanish version of the Tampa Scale for Kinesiophobia (TSK11)  was usedOne wireless wearable sensor was adhered to the center of the forehead  before starting the test Fig. a.Fig. 2aPlacement of the sensor with these landmarks has shown to be a reliable method for measuring craniocervical flexion ROM in previous research . ParticiAdditionally, the movement was repeated in case the assessor detected signs of compensation, such as lower cervical flexion, neck retraction, or overuse of the superficial flexor muscles.This procedure was verbally explained to participants through the following standardized instructions to ensure same information was explained to all subjects: “Please lie on your back with your knees bent and your feet resting on the table. The starting position will be relaxed with the gaze directed vertically towards the ceiling. Then, please perform an anterior rotation of the head in a controlled manner without moving your neck, such that the head rotates slightly, reaching as far as possible. The posterior side of the head will slide smoothly on the table during the movement and the head should not separate from the table or push into the table during the movement. You must perform this movement three times, returning to the starting position after each one and holding the position of maximum flexion for three seconds in each repetition”.Active craniocervical flexion ROM expressed as the maximal angular displacement (°) achieved in any of the three repetitionsActive craniocervical extension ROM when trying to return to the neutral position from the craniocervical flexion motion, also expressed as the maximal angular displacement (°). This variable represents poorer accuracy when trying to achieve the neutral position. It is different from the variable “Head repositioning accuracy”, since this excessive extension motion was frequently observed immediately before the patient tried to further change the position to come to the point in which they were supposed to have achieved the real neutral position between repetitions.Peak velocity in craniocervical flexion and extension independently, expressed as the maximal angular velocity (°/s): calculated as the discrete derivative of angular orientation applying a standard smooth filtering algorithm.3): calculated as the third discrete derivative of the angular orientation (change in acceleration) [Smoothness of motion expressed as maximal movement jerk peak (º/seration) , 41.Head repositioning accuracy expressed as angular displacement (°): calculated as the absolute repositioning error considering the maximal difference between the neutral starting position (set up at the beginning of each movement) and the positions reached when the patient tried to come back again to the neutral after returning from flexion. The maximal difference observed during all the three repetitions was used for the analysis.Peak conjunct motion (°): calculated as the angular displacement occurring in a different anatomical plane to the one that is being tested .A software application computed and exported the complete ROM of the participants, expressed as angles from the calibrating starting position in the three axes, sampled every 20 ms. In addition, data smoothing filters were applied to avoid peaks and variations not corresponding to the trend of each data set. The analysis of these data allowed for the calculation of the following variables during three repetitions of craniocervical flexion:All data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 24.0  and R Ver. 4.1.3 program. . The level of significance was established at p < 0.05. The distribution of the quantitative variables was tested with the Kolmogorov–Smirnov test with Lillierfors correction, which showed the absence of normality. Quantitative variables are shown as mean ± standard deviation and categorical variables with absolute and relative values (%).Nine multivariate linear regression models were built between each of the sensorimotor control dependent variables  and the secondary variables of age, previous month visual analog scale (VAS), TSK11 score, pain duration, and NDI score. The VAS score was included in the model instead of the group categorical variable (pain or asymptomatic) in order to maintain the power inherent in a continuous variable, which could be lost in a discrete categorical variable with few levels defined . All patThe assumption of linearity between all dependent and independent variables was tested by visual inspection of the correlation graph and a value of the effective degrees of freedom (EDF) close to 1. When this assumption was not met, a generalized additive model (GAM) was applied with the double penalty method in the selection of variables, modelling the variables with the parametric or smoothed model based on fulfilling the assumption. In all models, compliance with concurrency assumptions was tested for the smoothed terms, eliminating those with a value greater than 0.8, and multicollinearity in the parametric terms, eliminating those with a variance inflation factor (VIF) greater than 2. The distribution of residuals and adjusted values around the null value and adequacy of the number of basic functions with a non-significant K index were also checked.In the case of the peak velocity variable, a linear model was applied when the assumptions of linearity, homoscedasticity, normality of the residuals, and absence of autocorrelation were fulfilled, while in the maximum lateral flexion a weighted least square (WLS) model was applied to be able to handle the non-normality of the residuals.2 = 0.076 and an effect size of 0.082. Considering the probability of technical errors related to the automatic record of data from inertial sensors, an additional 20% of patients was estimated (n = 192).The sample size of this study was determined using G*Power, Version 3.1.9.2 , considering the results from a pilot study with 20 subjects: 10 asymptomatic and 10 subjects with neck pain. Sample size was calculated using a linear multiple regression (fixed model), with 0.95 power (1- beta error probability) and an alpha level of 0.05 . ConsideOf a total of 211 participants who were screened, 19 of them were excluded due to previous surgeries in the neck and/or head region (n = 4), vestibular alterations (n = 2), otogenic or idiopathic vertigo/dizziness (n = 9), previous fracture in the head or neck region (n = 1), and osseous deformities in the thoracic, cervical, or cranial region (n = 3).The study involved 192 participants with an average age of 34.55 ± 13.93 years (Table The descriptive data of the sensorimotor control in neck pain patients and asymptomatic controls is represented in Table ref), F values and p values for smooth regression analysis that showed any significant explanatory variable.Significant explanatory variables were found in four of the models . None of the remaining models found any significant explanatory variable. Table A generalized additive model (GAM) for craniocervical flexion ROM using a linear regression adjusted for pain duration, and NDI and a smooth regression model adjusted for age, pain intensity (previous month), and TSK11 only showed TSK11 as a significant explanatory variable of craniocervical flexion ROM Table . The effA linear model showed that age and pain duration significantly explain craniocervical extension ROM Table . SpecifiA smoothed model showed that the variables age and TSK11 scores significantly explained the peak velocity in craniocervical flexion Table . The eff2adj = 0.084).Finally, a linear model showed that pain duration and NDI significantly explained maximum conjunct motion lateral flexion Table . That isThis study has found that sensorimotor characteristics of the craniocervical flexión movement, such as ROM, peak velocity or conjunct motion can partially be explained by the population characteristics of chronicity, age or kinesiophobia. However, the models should be interpreted with caution due to the low values of variance explained and the low absolute values of regression coefficients in the linear regression models. Therefore, the kinematic analysis of craniocervical flexion performed in this study might not be suitable to identify clear variables that could be considered relevant to explain the kinematics of the craniocervical flexion. The characteristics of the population included in this study could also have influenced our results and future research should investigate including samples with a larger proportion of neck pain patients presenting higher levels of pain, disability or kinesiophobia. Interestingly, pain intensity and self-reported disability did not partially explain any of the kinematic variables of craniocervical flexion, but other characteristics of the population, specially kinesiophobia, seemed to be more relevant factors that partially explained the kinematics features of the movement. These results agree with previous research that also observed that kinesiophobia showed stronger associations with kinematic measures of neck movement than pain intensity or disability did . A recenMaximum ROM in craniocervical flexion was only significantly explained by kinesiophobia. In this smoothed model, higher scores in the TSK11 were associated with lower values of ROM Fig. . This trIt can be hypothesized that patients in our study with higher fear of movement may perceive the final degrees of craniocervical flexion as a more threatening demand due to the feeling of reaching the end of the ROM, usually perceiving the sensation of tension of the cervical myodural bridge  or stretTo the authors’ knowledge, the possible association between kinesiophobia and reduced ROM in craniocervical flexion have been scarcely investigated, and there has not been an association observed between these variables . StudiesOther factors were investigated in this model, including the intensity or chronicity of pain, age, or the level of disability, but these did not associate with the maximal ROM in craniocervical flexion. To the authors’ knowledge, there is sparse research that has investigated the influence of pain, disability, or psychological variables on the maximal active ROM during the craniocervical flexion movement specifically, nor on any other of the sensorimotor control variables analyzed in this study. In agreement with our results, a study by Rudolfsson et al.  did not Results from previous studies in the analysis of full cervical active ROM during planar movements  have showed good quality of evidence that there is a significantly, clinically relevant decrease in cervical ROM in patients with non-traumatic neck pain when compared to asymptomatic controls . In our The method used in our study to guide participants in order to perform the craniocervical flexion movement is based on several aspects considered when performing the CCFT, in terms of the patient position or the set of verbal instructions provided. A systematic review and meta-analysis by Romeo et al.  recentlyThe analysis of the craniocervical extension ROM in this study does not represent the maximal craniocervical extension participants can reach in an independent motion analysis, but rather the maximal ROM reached when the participant is trying to return to the neutral position from the craniocervical flexion motion. Therefore, we hypothesize that higher values in this variable could be considered as a lack of control when trying to progressively come from flexion to extension when trying to reach the neutral position. Most of the patients performed few degrees of craniocervical extension when returning to the neutral position and then progressively performed a small craniocervical flexion motion to try to more accurately reach the neutral position.The results of this linear model showed that increased age and lower chronicity of pain were significant explanatory variables of higher values of craniocervical extension. However, these results are limited by the low explained variance (15.5%) of the model. Moreover, when looking at the regression coefficients, described as the change in the dependent variable for each one-unit change in the independent variable , the obsTo the authors’ knowledge, no previous research has investigated the factors that can influence this specific craniocervical extension ROM when returning from maximal craniocervical flexion.Velocity and jerk were evaluated both during the movement from neutral to craniocervical flexion (flexion movement) and during the maximal craniocervical flexion to the neutral (extension movement). Only the smoothed model for velocity during craniocervical flexion showed the significant explanatory variables of age (p = 0.028) and kinesiophobia (p < 0.001). However, these results could only explain 15.5% of the variance. Moreover, the smoothed terms partial effect plot for age do not show a clear trend for its interpretation, since it remains stable with alternative small variations across different ages Fig.  shows a These results of this study suggest that the specific assessment of craniocervical flexion velocity or jerk may not be a clinically relevant parameter to assess in patients with neck pain. Future research is needed to further confirm this perception in a population with higher levels of pain or disability. To our knowledge, no previous research has investigated the factors that can explain velocity or jerk variables during the craniocervical flexion movement. However, there is some evidence of alterations of movement velocity or jerk during other global cervical planar or functional movements in patients with mechanical neck pain compared to asymptomatic controls –18.2adj = 0.084), which limits the relevance of these findings. Previous studies have not observed increased conjunct motion in patients with neck pain when assessed during other global cervical movements, or have observed reduced conjunct motion in patients with neck pain [Conjunct motion was analyzed as the maximal ROM achieved in any other plane that is not the flexion–extension sagittal plane during the craniocervical flexion. This variable has been investigated in previous research during other movements and considered as an alteration in sensorimotor control that might reflect protective or learned strategies , 50, 52.eck pain . SimilarNone of the independent variables significantly explained the joint position error when patients returned to the neutral starting position. Head repositioning accuracy during the performance of maximal craniocervical flexion divided in three independent repetitions may not be a clinically relevant variable to assess in patients with neck pain. However, future research is needed to further investigate its influence in large samples of patients with high levels of pain,disability and kinesiophobia. Previous systematic reviews evaluating head repositioning accuracy when returning to a neutral head position following planar movements of rotation or flexion–extension have suggested differences between idiopathic neck pain and healthy groups , 14. HowTo our knowledge, this is the first study to investigate the use of a novel inertial technology to assess further sensorimotor control characteristics during the performance of the craniocervical flexion movement. However, the present study has various limitations. First, associations across variables were investigated through a cross-sectional design, so no inferences can be made in terms of causality. Future data from longitudinal studies could provide more evidence on the possible causal direction of the relationship between variables. Second, the study population characteristics may be limited to young individuals of European descent with low to moderate levels of pain, disability, or kinesiophobia. Future research could investigate larger samples with high levels of these variables. Third, although the instructions to perform the craniocervical flexion movement were standardized, subjects of older age or with a lower educational level may present more difficulties in understanding the correct performance of the movement. Fourth, the muscle activation of deep and superficial muscles while performing the craniocervical flexion was not monitored by electromyography. It is possible that patients could have changed their motor strategies to achieve similar kinematic performance during the movement. Previous research has shown the complexity and variability of neuromuscular adaptations in patients with pain . Fourth,The results of this study did not show a clear relationship between the population characteristics and the sensorimotor control performance. Therefore, the kinematic analysis of craniocervical flexion performed might not be suitable to identify clear variables that could be considered to relevantly explain the kinematics of the craniocervical flexion. Kinesiophobia might show some degree of association with reduced ROM, but further research in large samples of patients with higher levels of chronic pain, disability and kinesiophobia is needed.


Background and objectivesOne of the most frequent conditions for which people seek physiotherapy treatment is low back pain (LBP). When the aetiology of low back pain is whittled down to mechanical factors, pelvic tilting becomes apparent. The iliopsoas muscle is the key to relieving LBP in such circumstances, and since it is tightened, we concentrated on stretching it adequately in this study. Proprioceptive neuromuscular facilitation (PNF) and muscle energy technique (MET) are two stretching techniques that we have compared for this purpose. There are many other stretching techniques available, but the evidence has proven these two to be the most effective.MethodsThe participants in the study were those between the ages of 18 and 60 who had exaggerated lumbar lordosis, or LBP, and met the inclusion criteria. There were two groups created: A and B. PNF and traditional physiotherapy was used to manage the participants in group A, and MET and traditional physiotherapy were used to manage the participants in group B. Each group underwent the same pre-and post-tests, which included the Numerical Pain Rating Scale (NPRS) to assess pain intensity; a universal goniometer to measure hip joint extension range of motion (ROM) to assess iliopsoas flexibility; and a side-lying X-ray to measure the lumbosacral angle (LSA) to determine the angle of lumbar lordosis.ResultIn both the stretching interventions, i.e., PNF and MET, there were statistically significant differences in pain, hip extension range of motion, and lumbar lordosis angle (P > 0.0001). However, for the PNF group, the difference between the pre-and post-test was greater than that for the MET group.ConclusionThe current study, which included 100 participants, demonstrated that both PNF and MET are remarkably effective for loosening the tight iliopsoas. A comparison of both techniques showed that the PNF group had benefited significantly more than the MET group. Low back pain (LBP) is frequently experienced by people who are in an activity flag, interfering with their daily jobs and activities -3. ThereThe iliopsoas muscle is the most powerful hip joint flexor. It is known to link the spine to the lower extremities and has been directly linked to back pain . The iliWhen compared to stable individuals, people with iliopsoas tightness exhibit significantly lower iliopsoas strength, constrained hip extension ROM, increased pelvic tilting, and lumbar lordosis . When thThere are several methods for releasing iliopsoas tension, including proprioceptive neuromuscular facilitation (PNF) , muscle After receiving approval from the Institutional Ethics Committee of Datta Meghe Institute of Medical Sciences (DMIMS) (Deemed to be University [DU]) , the study was conducted in the neuro-physiotherapy outpatient department (OPD), and the participants were drawn from the orthopedic and neuro-physiotherapy OPDs of Acharya Vinoba Bhave Rural Hospital Sawangi (Meghe), Wardha, Maharashtra. Informed consent was obtained, arbitrary data was gathered, and a preliminary evaluation was completed to determine whether or not the individuals met the inclusion and exclusion criteria. The inclusion criteria were that the participants had to be of either gender and between the ages of 20 and 65, have LBP , have hyper-lordosis of the lumbar spine , be able to understand and follow instructions, be willing to participate in the study, and be able to complete the outcome measures. People with LBP , hyper-lordosis of the lumbar spine , complaints of radiculopathies with or without neurological deficits, pregnant women, people who have had surgery on their lumbar or thoracic spine, people who have anatomical deformities of the spine or chest wall, and those who are currently enrolled in another research trial for a similar illness and have non-specific LBP were all excluded from the study. The objectives and methods of the study were then explained to the qualified participants. Using the SNOSE method, the participants were randomly assigned to either group A or group B by simple random sampling. The primary researcher, a physiotherapy department intern, conducted the randomization and allocation. The study's enrolment, intervention, and assessment schedule followed the guidelines in the standard protocol items: a suggestion for conducting intervention trials . The floOutcome measuresA physiotherapy undergraduate student who was aware of the study but blinded to the intervention evaluated the following outcome measures before and after the intervention.Numerical Pain Rating ScaleOn a piece of paper, 0-10 markings were made, in which 0 was no pain and 10 was maximum pain. The NPRS assisted in quantifying the patient's low back pain intensity before and after the intervention, as well as any improvement or exacerbation. A 2-point change on the NPRS indicates a clinically significant change that exceeds the measurement error boundaries .Lumbosacral AngleIn order to analyze the difference in the lumbar lordosis, we measured the LSA through an X-ray while the patient was supine  before GoniometryA goniometer is used to measure a joint's range of motion in degrees; in this case, it was used to compare the degree of hip extension before and after the intervention. It has been determined that conventional manual goniometers are reliable for use in clinics for longitudinal examinations .InterventionMeasurements were made before and after the intervention. PNF and traditional physiotherapy were given to the subjects in group A, while MET and traditional physiotherapy were given to the subjects in group B. Each technique was applied three times, and both groups received traditional physiotherapy in the form of a hot pack applied to the low back region prior to treatment for ten minutes.In group A, participants received basic conventional physiotherapy along with bilateral iliopsoas stretching using the PNF hold-relax D1 movement pattern three times in a single session with a break of 2 minutes in between each repetition. The hold-relax technique was used to perform the lower extremity PNF pattern bilaterally using the D1 extension and flexion pattern, which was extension-abduction-internal rotation and flexion-adduction-external rotation. The patient was made to lie on the side of the treatment leg at the edge of the couch with the hip in flexion-adduction-external rotation and the knee flexed and the untreated knee extended. The therapist stood facing the patient and next to the extended leg while adjusting his position in response to the motion of the limb  and GraphPad Prism 7.0 . The student t-test was used to compare groups A (PNF) and B (MET) in order to determine which treatment was most effective for lowering LBP, enhancing iliopsoas flexibility, and reducing lumbar lordosis angle. Within groups A and B, a paired t-test was used to compare pre and post-scores. An unpaired t-test was used to compare the post-mean difference scores between groups A and B. The subject characteristics for both groups are displayed in Table Table LBP is a notable factor in the decline of both the young and elderly population's quality of life. Since LBP is a chronic and serious condition, it must be treated as soon as possible with a thorough evaluation and treatment plan. Iliopsoas tightness causes lumbar hyper-lordosis and is one of the most common causes of LBP. According to Jun-Yong Lee's research, there was a significant difference in iliopsoas muscle tension between the low back pain patient group and the control group. He suggested that during physiotherapy sessions, more focus should be placed on releasing iliopsoas muscle tension . In anotIn this study, the effectiveness of PNF with MET stretching for the iliopsoas muscle in reducing low back pain in people with lumbar hyper-lordosis was tested. The difference between both the procedures is the position of the patient's lower limb, i.e., in PNF it is moved diagonally and in MET it is moved in line with the hip joint flexion axis; another difference is the isotonic contraction used in PNF and the isometric contraction used in MET. Both the PNF and MET groups showed a significant improvement in the study's outcome measures, but the PNF group's improvement was more pronounced. This is consistent with Marvin's observation that the PNF hold-relax group had significant improvements in range, which he believed could be explained by the active mobilization and autogenic inhibition of connective tissue . In the By using voluntary muscle contraction and promoting muscle relaxation to prevent reflexive muscle contractions, PNF stretching techniques increase joint ROM. In order to increase flexibility, stretching techniques like hold-relax, contract-relax, slow reversal, etc., are now frequently used. They all call for the contraction and relaxation of agonist and antagonist muscles in succession. The ideal sequence is three repetitions of a 10-second active push phase followed by a 10-second passive rest phase. Theoretically, PNF stretching should be superior to static stretching methods because they stimulate not just muscle fibers but also sensory receptors in both the antagonist and agonist muscles .The LSA, hip extension ROM, and pain were all improved in the MET group. METs are a set of typically painless mobilization techniques that are used to increase range of motion, decrease muscle spasm, decrease tissue edema, stretch fibrous tissue, and retrain the stabilizing function of inter-segmentally related muscles . AlthougThree outcome measures, namely the NPRS, bilateral hip extension ROM, and LSA, were used to evaluate the effectiveness of both interventions. According to research, a 2-point shift on the NPRS used to measure low back pain indicates a clinically significant shift that exceeds the measurement error margin . LumbosaIn this study, PNF and MET stretching were given thrice in a single session. All three outcome measures significantly improved for both groups. A comparison between the two groups revealed that the PNF group had significantly outperformed the MET group in terms of decreased lumbar lordosis angle, LBP, and increased hip extension range of motion (P 0.05), compared to MET, it had a quicker rate of influence, more people achieved iliopsoas muscle flexibility, and reduced lumbar lordosis angle. Because PNF involves better positioning and recruitment of the muscle that is intended to be stretched, it is more effective than MET.The study has not included a follow-up time because the stretching technique is intended for the instant relief of low back pain, which occurs after sitting for a prolonged period due to iliopsoas tightness. The PNF stretching technique has outshone the MET technique in instantly relieving low back pain. The low back pain will eventually be back whenever the person sits for a prolonged period of time again and again stretching this muscle will relieve the pain.The study could be expanded in the future to include an equal number of male and female patients, examine any other muscle in the body that occasionally experiences tightness, and run for a longer duration to determine the precise length of time required to treat tightness using either technique.Limitations of the study were that only young, healthy people were included in it, a wide age range was taken into consideration for the study population, and unequal numbers of men and women were recruited.In today's lifestyle, especially sedentary ones, low back pain is a major concern. The causes of this back pain vary, but one of the most typical ones is increased lumbar lordosis in inactive people, which is brought on by iliopsoas tightness. The faster the tightness is released, the faster the LBP will resolve. We compared two widely used techniques in this study to determine which was the most effective. The hold-relax proprioceptive neuromuscular facilitation stretching technique and the post-isometric relaxation muscle energy stretching technique for the iliopsoas muscle were compared, and it was determined that both were effective in reducing lumbar lordosis and reducing pain in just one session. However, the latter's outcomes fell short of the former. To determine the precise time needed to treat tightness using either technique, the study could be expanded in the future to include an equal number of male and female patients, examine any other muscle in the body that occasionally experiences tightness, and run for a longer period of time.