An interventional study of Conventional Physiotherapy and Action Observation and Motor Imagery Training in Cervical Disc Herniation, Chronic Pain and Kinesiophobia, sponsored by İrem Çetinkaya. Not yet recruiting. Open to participants aged 18 Years to 65 Years. Per ClinicalTrials.gov, last updated 2026-08-24.
Sponsored by İrem Çetinkaya · Not applicable, Interventional, and Treatment
Cervical disc herniation is a common degenerative spinal disorder associated with chronic neck pain, impaired cervical function, reduced motor control, and decreased quality of life. Although conventional physiotherapy is widely used, innovative rehabilitation strategies that enhance motor learning may improve treatment outcomes. This randomized controlled trial aims to investigate the clinical effectiveness of Action Observation (AO) and Motor Imagery (MI) training as an adjunct to conventional physiotherapy in individuals with cervical disc herniation and chronic neck pain.
Thirty-six participants diagnosed with cervical disc herniation will be randomly assigned to one of two groups. The control group will receive conventional physiotherapy combined with sham observation consisting of neutral nature videos, while the experimental group will receive conventional physiotherapy plus AO and MI training. The intervention period will last six weeks. Clinical outcomes will be assessed before and after the intervention. Primary and secondary outcome measures will include pain intensity, pressure pain threshold, neck disability, kinesiophobia, cervical motor control and endurance, and cervical proprioception using validated assessment tools.
The findings of this study are expected to provide evidence regarding the effectiveness of AO and MI training as complementary rehabilitation approaches for individuals with cervical disc herniation and to support the integration of motor learning-based interventions into clinical physiotherapy practice.
The cervical spine is highly susceptible to mechanical stress and degenerative changes because of its considerable mobility. Degenerative alterations may lead to cervical disc herniation, a condition commonly associated with chronic neck pain, restricted cervical mobility, impaired function, and reduced quality of life. In addition to peripheral musculoskeletal impairments, chronic neck pain has been associated with changes in central nervous system processing, including alterations in proprioception, motor control, muscle activation, and cortical organization.
Action Observation (AO) and Motor Imagery (MI) are non-invasive, low-cost, motor learning-based rehabilitation approaches that target the central nervous system. Motor imagery involves the mental rehearsal of a movement without physical execution, whereas action observation consists of observing goal-directed movements to facilitate activation of motor-related cortical networks. Both approaches are believed to enhance neuroplasticity and improve motor performance by promoting cortical excitability and motor learning.
Previous studies have reported beneficial effects of AO and MI on pain, proprioception, motor control, and functional performance in individuals with musculoskeletal disorders. However, evidence regarding the combined application of AO and MI in individuals with cervical disc herniation remains limited, particularly in randomized controlled trials incorporating a sham intervention. The inclusion of a sham observation group using neutral nature videos is intended to distinguish the specific therapeutic effects of AO and MI from nonspecific effects related to attention and treatment participation.
The present study is designed as a randomized controlled trial to investigate the clinical effectiveness of AO and MI training as an adjunct to conventional physiotherapy in individuals with cervical disc herniation and chronic neck pain. Thirty-six participants will be randomly assigned to one of two groups. The control group will receive conventional physiotherapy combined with sham observation consisting of neutral nature videos, whereas the experimental group will receive conventional physiotherapy in addition to AO and MI training. The intervention period will last six weeks.
Clinical outcomes will be evaluated before and after the intervention. Outcome measures will include pain intensity, pressure pain threshold, neck-related disability, kinesiophobia, cervical proprioception, cervical motor control, and muscular endurance using validated assessment tools. The primary objective is to determine whether the addition of AO and MI training provides greater improvements in these clinical outcomes than conventional physiotherapy with sham observation. The findings are expected to contribute to the evidence supporting motor learning-based rehabilitation strategies and to facilitate the integration of neuroplasticity-oriented interventions into the conservative management of cervical disc herniation.
Adults aged 18 to 65 years. Diagnosis of cervical radiculopathy confirmed by a physician based on clinical examination and magnetic resonance imaging (MRI).
History of chronic neck pain lasting at least 3 months. Sufficient active cervical range of motion to participate in the intervention (flexion and extension ≥20°, lateral flexion ≥15°, and rotation ≥30°).
Neck pain intensity of ≥3 points on the Visual Analog Scale (VAS) and neck disability of ≥10 points on the Neck Disability Index (NDI) at baseline.
Willingness to participate and provision of written informed consent.
Exclusion Criteria:
Inability to comply with the study protocol or cooperate with study procedures. Cognitive impairment (e.g., dementia or learning disability) that would interfere with understanding or completing the intervention or assessments.
History of cervical spine surgery. Acute trauma, fracture, tumor, infection, or other serious pathology involving the cervical spine or shoulder region.
Cervical spinal stenosis, cervical myelopathy, advanced cervical spondylosis, or other significant structural degenerative cervical spine disorders.
Uncontrolled neurological or systemic disease that could influence study participation or outcomes.
Receipt of any treatment targeting the cervical region within the previous 6 months (e.g., physiotherapy, injection therapy, or other invasive interventions).
Visual impairment, hearing impairment, or severe vestibular disorders that would prevent participation in the intervention protocol.
Participants in the experimental group will receive an individualized conventional physiotherapy program three times per week for six weeks. In addition, they will receive approximately 20 minutes of Action Observation (AO) and Motor Imagery (MI) training during each treatment session.
Other: Conventional Physiotherapy · Other: Action Observation and Motor Imagery Training
Participants in the control group will receive the same individualized conventional physiotherapy program three times per week for six weeks. In place of Action Observation and Motor Imagery training, they will watch neutral nature videos without motor content for approximately 20 minutes during each session as a sham observation intervention.
Other: Conventional Physiotherapy · Other: Sham Observation
Participants in both study groups will receive an individualized conventional physiotherapy program three times per week for six weeks. The program will include electrotherapy (conventional transcutaneous electrical nerve stimulation or vacuum interferential current applied on alternating sessions), superficial heat therapy, soft tissue mobilization, and a supervised therapeutic exercise program. The exercise program will consist of deep cervical flexor activation exercises, cervical range-of-motion exercises, scapular stabilization exercises, postural correction exercises, and stretching exercises targeting the upper trapezius, levator scapulae, and pectoral muscles. All treatment sessions will be delivered individually by the same physiotherapist, and exercise intensity will be adjusted according to each participant's tolerance and clinical status.
Participants in the experimental group will receive approximately 20 minutes of Action Observation (AO) and Motor Imagery (MI) training in addition to conventional physiotherapy during each treatment session, three times per week for six weeks. During the AO component, participants will observe standardized videos demonstrating correct execution of cervical and scapular movements, including cervical flexion, extension, lateral flexion, rotation, and scapular retraction. Immediately afterward, participants will perform MI under physiotherapist supervision by mentally rehearsing the same movements using both visual imagery (imagining observing themselves performing the movement) and kinesthetic imagery (imagining the sensory experience of performing the movement). All sessions will be delivered individually following a standardized intervention protocol.
Participants in the control group will receive approximately 20 minutes of sham observation in addition to conventional physiotherapy during each treatment session, three times per week for six weeks. Instead of Action Observation and Motor Imagery training, participants will watch neutral nature videos without any human movement or motor-related content. The sham intervention is designed to match the experimental intervention in duration, therapist supervision, and attention while avoiding activation of motor learning processes.
Neck Disability Index
Neck-related disability will be assessed using the Neck Disability Index (NDI). The NDI consists of 10 items addressing pain intensity, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation. Each item is scored from 0 to 5, resulting in a total score ranging from 0 to 50. Higher scores indicate greater neck-related disability.
Time frame: Baseline and immediately after the 6-week intervention
Craniocervical Flexion Test
Deep cervical flexor motor control and endurance will be assessed using the Craniocervical Flexion Test with a pressure biofeedback unit. Participants will perform progressive craniocervical flexion at five pressure levels (22-30 mmHg) from a baseline pressure of 20 mmHg. The highest pressure level successfully achieved and maintained for 10 seconds without compensatory movement will be recorded as the motor control performance. The participant's ability to sustain the target pressure level throughout the test will also be used to evaluate deep cervical flexor muscle endurance. Higher performance reflects better motor control and endurance.
Time frame: Baseline and immediately after the 6-week intervention
Visual Analog Scale for Pain
Neck pain intensity will be assessed using a 10-cm Visual Analog Scale. Participants will mark their perceived pain intensity on a horizontal line ranging from 0, indicating no pain, to 10, indicating the worst imaginable pain. Higher scores indicate greater pain intensity.
Time frame: Baseline and immediately after the 6-week intervention
Pressure Pain Threshold Measured With a Digital Algometer
Pressure pain threshold will be assessed using a digital pressure algometer. Measurements will be performed bilaterally at the level of the C5 vertebra and at the midpoint of the upper trapezius muscle. Pressure will be gradually increased until the participant first reports pain. Three measurements will be obtained from each assessment site, and the mean value will be recorded. Higher values indicate a higher pressure pain threshold and lower mechanical pain sensitivity.
Time frame: Baseline and immediately after the 6-week intervention
Tampa Scale for Kinesiophobia-11
Fear of movement will be assessed using the 11-item Tampa Scale for Kinesiophobia (TSK-11). Each item is scored on a 4-point Likert scale, and the total score ranges from 11 to 44. Higher scores indicate greater pain-related fear of movement.
Time frame: Baseline and immediately after the 6-week intervention
Cervical Joint Position Error
Cervical proprioception will be assessed using the Laser Pointer Assisted Active Repositioning Test. Participants will perform a cervical movement and then attempt to return their head to the initial neutral position. The difference between the initial and repositioned head positions will be recorded as the absolute joint position error in degrees. Lower error values indicate better cervical proprioceptive accuracy.
Time frame: Baseline and immediately after the 6-week intervention
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Plan to share: No
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