The primary aim of this study is to determine if a Contextual Factors-Enriched Standard
Care (CFs+SC) approach is an effective treatment for MNP in terms of reducing pain and
improving function. We hypothesize that a 4-week Contextual Factors-Enriched Standard
Care will be superior to Standard Care alone in terms of patient-reported disability and
pain, with measurements conducted using the Argentine version of the Northwick Park Neck
Pain Questionnaire (NPQ-AR) and the Numerical Pain Rating Scale (NPRS), respectively.
The secondary aims are:
To determine whether CFs+SC is more effective than SC in terms of active range of
motion (ROM) enhancement, global perceived effect (GROC), and satisfaction with
treatment after the 4-week intervention.
To determine if a CFs+SC approach is effective in treating MNP in terms of
disability improvement, pain reduction, active ROM enhancement, global perceived
effect (GROC), and satisfaction with treatment 12 weeks after a 4-week treatment
plan.
To explore differences in treatment credibility and expectations between the CFs+SC
group and the SC group at both the 2-week and 4-week intervals.
To investigate whether individuals identified with at least one negative
psychosocial condition (such as anxiety, fear of movement, stress, catastrophizing,
and depression) will experience greater benefits from the CFs+SC intervention
compared to those without negative psychosocial conditions.
Consecutive patients meeting all inclusion criteria and none of the exclusion criteria
will be randomly assigned in a 1:1 ratio to either the CFs+SC group or the SC alone
group. Randomization will employ a blocked design with variable block lengths (2:4) and
will be stratified based on baseline pain ('mild-moderate' or 'severe,' determined by
whether they report between 3 and 7 points or ≥ 8 points on the baseline NPRS,
respectively) and participants' expectations ('high' or 'low') regarding the
effectiveness of standard care treatment.
The randomization process will be generated and conducted by SS and PP, who will not be
involved in data analysis or patient enrollment. The website www.randomization.com will
be used for this process. To maintain allocation concealment during the study,
sequential, numbered, and sealed opaque envelopes will be utilized. Patients will be
allocated to one of two groups: a CFs+SC group and the SC group. Due to the nature of the
study, blinding of both therapists and patients will not be feasible. The person in
charge of data statistical analysis (FV) and the evaluators who will assess all
participants' pre- and post-intervention assessments (MLL and AR) will be blinded to the
allocated intervention.
Both groups will undergo 4 weeks of standard care twice weekly following established
clinical practice guidelines, and including exercises, mobilization, manual therapy,
education, and a neck wellness home care guide. In the intervention group, CFs will be
enhanced, encompassing the physical, psychological, and social elements inherent in the
clinical encounter, based on existing evidence.
At the onset of treatment, patients will receive a schedule outlining the dates of the
next 8 visits. One day before each session, an individual not involved in the study will
send a text message (SMS) reminder. Should a scheduled session be missed, it will be
rescheduled. However, patients who miss two consecutive scheduled sessions will be deemed
dropouts and analyzed using the intention-to-treat (ITT) approach, with the last observed
value taken into consideration. Additionally, participants will be asked to refrain from
undergoing any other treatments until the end of the 12-week follow-up period. During
this period, participants are only permitted to adhere to the NWHCG. If a participant
reports undergoing any other treatments, they will be considered as dropouts and analyzed
using the ITT approach.
Physiotherapists will undergo a comprehensive training program comprising 8 hours of
formal instruction, tailored to provide the necessary skills and proficiency for both
therapeutic contexts under investigation. To ensure treatment fidelity, a Manual of
Treatment (MOT) was developed. Therapist adherence to the MOT will be evaluated through
self-assessment ratings provided by the therapists themselves. After each session,
therapists will rate their adherence to the manual using a form specifically designed for
this study. Additionally, monthly audits will assess compliance with the MOT, and
frequent meetings with providers will be held to mitigate any deviations in provider
adherence to the MOT, ensuring its consistency over time.
The sample size for this study was determined using a linear mixed effects model to
account for within-subject correlation arising from repeated measures over time. The
model includes fixed effects, such as treatment group (CF+SC and SC groups), and time
points (baseline, 4 weeks, and 12 weeks after treatment), along with the interaction
between treatment group and time to assess potential changes in treatment effects over
time. Random effects for individual subjects were also included to address repeated
measures within the same subjects. Based on an assumed medium effect size (f2 = 0.15),
80% power, and a significance level of 0.05 (two-tailed), the estimated sample size
required for this study was calculated to be 85 subjects. To accommodate a projected
dropout rate of 10%, the sample size was adjusted, resulting in a final target sample
size of 94 subjects (47 participants per group).
Outcomes will be analyzed on an ITT basis, with reporting of sample characteristics and
descriptive statistics. Linear mixed models will be used for primary analysis to verify
the differences between the average effects of interventions (CFs+SC and SC) in
reassessments carried out 4 weeks after random allocation and 12 weeks after treatment.
The differences between groups will be calculated by interaction terms of groups versus
time. All statistical procedures will be performed using SPSS, developed by SPSS Inc.,
Chicago, IL, USA.
Trial procedures and evaluations will be conducted by trained personnel (MLL, AR, MM, GD,
and FR) using paper-based Case Report Forms (CRFs), with implemented quality control
measures. Subsequently, MM, GD, and FR will enter the data into an electronic database
using MAWE® Data Collection Tools (www.mawetools.com). An independent data monitoring
committee (MFA, SS, FV, and PP) will oversee the entire data collection process to ensure
its quality and integrity. Monitoring of the study will be overseen by MFA and FV,
encompassing verification of adherence to predefined inclusion and exclusion criteria,
monitoring overall study progress, and ensuring accurate data recording in CRFs. Auditing
responsibilities will be carried out weekly by the principal investigator to ensure
completeness and accuracy across critical study components, including participant consent
forms, paper forms, and recruitment rates.
The trial will be conducted in compliance with the principles of the Declaration of
Helsinki, Good Clinical Practice, and all applicable regulatory requirements. Ethical
approval has been obtained from the Institutional Review Board (IRB) (#11695, approved on
15/03/2024). The principal investigator and researchers affirm no financial or other
competing interests. Access to final trial data will be provided to designated
individuals and authorized personnel, with any contractual restrictions transparently
disclosed. Upon trial completion, results will be published in peer-reviewed journals,
following authorship guidelines established by the ICMJE and CRediT framework.