Co-development of an evidence-informed, theoretically driven exercise programme for people with chronic non-specific neck pain (the EPIC-Neck programme - “Exercise Prescription Improved through Co-design”)

Abstract

Background

Guidelines recommend neck exercise as a key intervention for chronic non-specific neck pain, yet current exercise programmes show modest effects and poor patient engagement. This study aimed to co-develop a neck exercise programme that maximizes effectiveness and engagement.

Methods

Intervention Mapping steps 1–4 were employed with input from a diverse patient group (n = 17). In Step 1, outcomes/changes that the intervention aims to improve were synthesized from literature and patient workshops.

To maximise engagement, Step 2 identified target behaviours (performance objectives), and their determinants from clinical guidelines, literature, and patient workshops. In Step 3, change techniques for each determinant were selected using the Theory and Techniques Tool and patient workshops. Techniques were organized into a logic model and framed within a “best fit” existing behaviour change theory to guide clinical practice.

To maximise effectiveness, Step 2 identified exercise objectives from systematic reviews and expert consensus, describing the mechanisms through which exercise affects outcomes. Step 3 identified the most effective exercises and tailoring strategies to optimise exercise objectives.

Resources to support delivery in clinical practice were co-developed with patients and physiotherapists in Step 4.

Results

The EPIC-Neck intervention aims to improve outcomes including pain, disability, function, sleep, mental well-being and relationship impact, based on individual patient needs. A biopsychosocial exercise prescription framework informs exercise tailoring to optimize neuromuscular function, pain self-efficacy, night pain, cognitive control, social support; and reduce catastrophic thinking/fear avoidance, depending on a patients desired outcome.

Patients need to achieve four performance objectives to manage neck pain effectively with exercise: (1) performing specific neck exercises, (2) independently adapting and progressing their neck exercises, (3) using specific neck exercises during flare-ups, and (4) initiating general exercise. To maximise engagement, a facilitation guide was developed based on the Process Model of Lifestyle Behaviour Change. The guide addresses 35 determinants using 24 change techniques, including goal setting, motivation enhancement, social support, action planning, self-monitoring, problem-solving support, shared decision-making, and patient-centred communication.

Conclusion

This study co-developed an evidence-informed, theoretically driven exercise programme designed to enhance both effectiveness and patient engagement. Future work will assess its feasibility and acceptability to patients and physiotherapists, and in the long-term establish its clinical and cost-effectiveness.

Background

Each year, neck pain accounts for 20.4 million years lived with disability globally [1], representing a major personal and socioeconomic burden [2]. This burden is highest among those with chronic non-specific neck pain [3], who experience recurring moderate to severe pain and disability [4, 5]. Although clinical guidelines recommend neck exercises to alleviate these episodes [6, 7], their effectiveness remains modest [8, 9], and many people continue to experience significant pain despite following prescribed exercises [10]. This suggests that, although other factors may also contribute, current neck exercise programmes need improvement.

Current neck exercise programmes need optimisation to better address outcomes like pain and disability. In other spinal disorders, tailoring exercises to target specific assessment findings and mediators (e.g., strength) improves outcomes. A recent meta-analysis found that matched interventions produced a small-to-moderate effect size (SMD 0.30 [95% CI 0.04, 0.56], P =.02) compared to unmatched interventions (SMD 0.19 [95% CI −0.03, 0.40]) [11]. While this approach is rarely applied to neck pain [12, 13], it offers a promising strategy to enhance outcomes beyond the modest effects typically reported. Experts recommend using a framework that tailors neck exercise to examination findings, goals and outcomes [14], but no such framework exists for chronic non-specific neck pain.

The effectiveness of neck exercise on outcomes like pain and disability is linked to adherence to the prescribed exercise regime [15], which is often poor [9, 16, 17]. Cochrane reviews suggest adherence can be improved with behaviour change strategies [8, 18, 19], though these are often missing [13]. Training to enhance physiotherapist skills in supporting behaviour change may also increase adherence and improve patient outcomes [20]. Effective treatment of neck pain also involves the engagement of patients in various behaviours beyond adherence, such as independently adjusting exercise dosage [14]. Therefore, neck exercise programmes need behavioural strategies to enhance engagement with all key behaviours, including adherence.

In summary, more work is needed to optimise neck exercises for greater patient engagement and intervention effectiveness. Cochrane reviews suggest that this could be achieved by redeveloping exercises using complex intervention frameworks [8, 19]. These frameworks guide developers in using evidence-informed strategies that account for behavioural, psychological, social, and technical factors affecting patient engagement with exercise and treatment outcomes. However, such frameworks have not yet been applied to improve neck exercise programmes.

The aim of this study was to co-develop (with patients and clinicians) the EPIC-Neck programme (“Exercise Prescription Improved through Co-design”) for individuals with chronic non-specific neck pain. By applying a complex intervention development framework, the EPIC-Neck programme integrates evidence-based behaviour change strategies and tailored exercise prescription to maximise both patient engagement with important exercise behaviours and intervention effectiveness.

Methods

Intervention development framework

The EPIC-Neck programme was developed using Intervention Mapping Steps 1–4 [21] (Fig. 1). Intervention Mapping was chosen because it aligns fully with the expert consensus guidance for complex intervention development, meeting 100% of its recommended criteria [22]. It has been used to develop clinically and cost effective interventions [23, 24] and musculoskeletal self-management interventions [25,26,27,28,29,30].

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To ensure the EPIC-Neck programme was both maximally engaging and effective, Steps 2 A and 3 A focused on developing a behaviour change process that maximises patient engagement with key exercise behaviours including exercise adherence and Steps 2B and 3B focused on creating an exercise prescription process that maximises effectiveness.

The intervention development process is reported following recommended guidance [31].

Patient and public involvement and engagement (PPIE)

The EPIC-Neck programme was co-developed with a Patient and Public Involvement and Engagement (PPIE) group (n = 17) that was diverse in age (30–70 + years), gender, ethnic background (White British, White Other, Asian Pakistani, Asian Indian, Black African, Black Caribbean), socioeconomic status (deprivation deciles 1–10), and physical activity levels (from inactive to active). Public involvement in this project followed the National Institute for Health and Care Research (NIHR) definition: research conducted “with” or “by” members of the public, rather than “to,” “about,” or “for” them—an active partnership that shapes and influences research [32]. PPIE members were not research participants, but collaborators who contributed as part of the study team, particularly during the development of the intervention. They were recruited via clinic advertisements, social media, and word of mouth. PPIE demographics and contributions are summarised using the GRIPP2-SF public involvement reporting checklist (Appendix 2) [33]. For further information on PPIE, see the UK Standards for Public Involvement [34], NIHR Learning for Involvement [35], and NIHR Briefing Notes for Researchers [32].

Step 1 – Identifying the outcomes the EPIC-Neck programme intends to improve

The objective of Step 1 was to conduct a needs assessment to identify the most important patient outcomes that the EPIC-Neck programme would target [21]. Over 30 neck pain outcomes were initially synthesised from three key literature sources: a concept mapping study of neck pain burden [4], a conceptual model from the Bone and Joint Decade Task Force [36], and a meta-synthesis of patients’ experiences of living with neck pain [37]. A half-day face-to-face workshop was then held with the PPIE group, during which the literature-derived outcomes were presented. The PPIE group identified additional outcomes (n > 30) and expanded or clarified points. In a prioritisation exercise using dot voting [38], the highest-ranked outcomes were sleep (30 votes), financial burden (14 votes), musculoskeletal pain (14 votes), limitations in exercise and leisure (12 votes), mood (12 votes), and relationships with family (11 votes). This was followed by an iterative process of discussion and refinement between the Study Team (n = 5, comprising expert clinicians, a behavioural psychologist, and intervention development specialists) and the PPIE group. Together, they organized the prioritised outcomes into short- and long-term categories, with ongoing feedback and adjustments leading to a final agreed-upon list.

Step 2 A – Identifying the target behaviour(s), behavioural performance objectives and determinants (behaviour change process - maximising patient engagement)

Step 2 A comprised of three objectives to develop a behaviour change process to maximise patient engagement with key exercise behaviours. Objective one was to define the target behaviour(s) needed to improve the outcomes identified in Step 1. Objective two was to specify the behavioural performance objectives which outline what a patient needs to do to successfully achieve the target behaviour(s) [21]. An initial candidate list of target behaviour(s) and performance objectives were taken from neck and chronic pain guidelines [6, 7, 39, 40], relevant musculoskeletal literature [41,42,43,44,45] and expert consensus on neck pain exercise prescription [14]. The expert panel comprised 37 international experts—including physiotherapists, chiropractors, and academics—from 10 countries, with professional backgrounds spanning clinical practice, research, and education in neck exercise rehabilitation, and representing diverse work settings such as healthcare, academia, private practice, and sport; most held advanced degrees (over 40% with PhDs), substantial academic outputs (including H-indices > 40 and > 200 publications), or extensive clinical experience (over 40% with 21 + years qualified or senior clinical roles).The PPIE workshops, held over two half-day, face-to-face sessions, followed an iterative process. Initial discussions focused on participants’ experiences with neck-specific exercises, identifying helpful behaviours that contributed to positive outcomes, as well as any gaps or issues that could be addressed with new behaviours or performance objectives. The study team then reviewed the candidate list of target behaviours and performance objectives from the initial PPIE discussions and literature, developing proposed definitions. Subsequent workshops refined these definitions, incorporated new ones, and identified potential barriers and facilitators. The study team reviewed the definitions once more for further refinement, continuing the iterative process. Workshop discussions were audio-recorded and facilitated by clinicians and academics experienced in conducting workshops. A researcher reviewed audio recordings to make notes on key messages and discussions from workshops, which were then reshared and rediscussed in subsequent workshops for further feedback and updates.

Objective three aimed to produce a list of determinants (barriers and facilitators) that influence a patient’s ability to meet behavioural performance objectives. Candidate determinants were initially identified from the musculoskeletal literature [18, 41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65] and a PPIE workshop (see objective 1). Audio recordings of the workshop were reviewed to note potential determinants, though no formal thematic analysis was performed. Findings from the literature and PPIE workshops were triangulated and discussed at a second workshop for clarification and to resolve discrepancies. The final determinants were then organised into categories and potential mechanisms of action using the COM-B model [66] (a behaviour change framework that proposes three necessary components for any behaviour to occur: Capability, Opportunity, and Motivation) and the Theoretical Domains Framework V2 [67] (an integrative framework developed to facilitate the investigation of determinants of behaviour change and the design of behaviour change interventions) to support the selection of change techniques in Step 3 A.

Step 3 A – Specifying change techniques and their practical application (behaviour change process - maximising patient engagement)

Step 3 A comprised of two objectives to develop a behaviour change process to maximise patient engagement with exercise. Objective one was to specify change techniques for each determinant identified in Step 2 A. Change techniques are behavioural, social or psychological strategies that address barriers and facilitators, helping individuals achieve performance objectives [21]. Evidence-based change techniques were specified using an intervention matrix that maps techniques to determinants/mechanisms of action. The Theory and Techniques Tool [68] was used to identify likely candidate change techniques for each determinant (this tool identifies change techniques that are suitable for use with 26 mechanisms of action, based on evidence reviews and expert consensus). Additional candidate techniques were sourced from the musculoskeletal literature [44, 69,70,71,72], the taxonomy of Behaviour Change Techniques (BCTs) [73], the Study team and the PPIE group.

Two workshops with the PPIE group were conducted. In the first workshop, clinicians and researchers facilitated small group discussions to brainstorm potential change techniques, which were then compared with findings from the Theory and Techniques Tool and relevant literature. The discussions were audio-recorded and analysed to compile the list of techniques. In the second workshop, the identified techniques were reviewed with the PPIE group to resolve disagreements, expand on areas with limited evidence, and refine the list.

The list of change techniques was then further refined by incorporating those with consensus between the Theory and Techniques Tool, PPIE group, and literature. A final set of techniques was developed through a review by a behavioural science expert (CG) and a physiotherapist (JP), ensuring their applicability and feasibility for a physiotherapist-delivered intervention for chronic neck pain, while also considering any additional relevant techniques. The final techniques, along with their determinants and mechanisms of action, were used to develop a logic model of change.

Objective two aimed to plan and structure the practical application/operationalisation of change techniques using a theory of behaviour change that incorporated most of the determinants and mechanisms of action. The theory guided the development of an Exercise Behaviour Change Facilitation Guide, outlining the steps physiotherapists should take in clinical practice to maximise patient engagement with neck exercise and facilitate implementation in clinical settings. The proposed implementation/delivery plan was reviewed and refined with the PPIE group during a half-day face-to-face workshop.

Step 2B - Constructing exercise objectives (exercise prescription process – maximising effectiveness)

To develop an exercise prescription process that maximises effectiveness, the objective of Step 2B was to construct “exercise objectives”. These objectives specify what an exercise needs to change (mediators) to achieve desired outcomes, outlining the mechanisms of change pathways through which these mediators influence outcomes. A preliminary list of exercise objectives was developed by reviewing mediators reported in musculoskeletal pain intervention studies [74,75,76,77,78,79,80,81,82], beyond just exercise-based trials, due to limited literature specific to exercise. The study team, drawing on expert consensus in neck exercise prescription [14], then selected mediators considered either amenable to change through exercise or likely to influence how exercise is prescribed. This list was subsequently refined through team discussion and expert review. This refined list was then presented to the PPIE group, where discussions focused on objectives with limited or conflicting evidence in the literature. Feedback from these discussions informed further refinements to the objectives, which were subsequently reviewed and finalised by the Study team, including their definitions.

Step 3B – Selecting and tailoring exercises (exercise prescription process – maximising effectiveness)

Step 3B comprised three objectives to develop an exercise prescription process to maximise effectiveness of neck exercise. Objective one was to identify the most effective neck exercise and dosage for the outcomes determined in Step 1. Exercises were identified from systematic reviews [9, 13, 83], expert consensus [14] and Study team expertise. Objective two was to describe how to tailor these exercises to meet the exercise objectives outlined in Step 2B, using insights from the literature, expert consensus [14], and the Study team’s knowledge. Objective three was to create an Exercise Prescription Framework to assist physiotherapists in clinical practice with exercise prescription. This framework was developed using the findings from Steps 1, 2B, and 3B.

Step 4 – Co-creation of intervention resources and training materials

Step 4 comprised of two objectives. Objective one was to create supporting resources for patients to assist with delivery and engagement with the EPIC-Neck programme. The content was guided by the intervention matrix, logic model, Exercise Behaviour Change Facilitation Guide and Exercise Prescription Framework. Resources were developed collaboratively by the PPIE group, the Study team, creative design experts, and mobile application developers. The Study team initially drafted the resources, which were reviewed by PPIE members for readability (suitable for reading age 9–11) and clarity. Revised drafts were then given to design experts and developers to create the final resources. This process involved five iterative workshops (1–3 h each) with the PPIE group and design experts to refine the resources, ensuring representation of various English language and digital literacy levels.

Objective two was to develop a physiotherapist training programme and supporting resources to enable physiotherapists to effectively deliver the EPIC-Neck programme. The content was guided by the logic model, Exercise Behaviour Change Facilitation Guide, and Exercise Prescription Framework. During a workshop with 20 + physiotherapists, these frameworks were presented and explained. Small group discussions followed, where barriers and facilitators to delivering the programme in clinical practice, as well as physiotherapists’ learning needs, were explored. Insights from these discussions were triangulated with existing literature [84,85,86] and the Study team’s experience to ensure comprehensive understanding of the challenges and training needs. Based on these findings, the training programme was tailored to address the identified barriers and optimise the delivery of the intervention. Additionally, the workshop provided an opportunity to refine the intervention itself, with feedback from physiotherapists used to adjust the facilitation guide and exercise prescription framework to better align with practical considerations for clinical delivery.

Results

Step 1 – EPIC-Neck programme outcomes

The EPIC-Neck programme is designed to be flexible and individually tailored, with desired short-term outcomes identified collaboratively based on each participant’s symptoms, clinical assessment, and personal goals. Potential outcomes include pain, pain-related disability, activity limitations (such as hobbies, activities of daily living, and work), sleep quality, mental well-being, and personal relationships. The programme incorporates strategies to address these domains. The PPIE group and Study team theorised that improvements across these short-term outcomes could lead to reduced long-term personal and societal financial burdens and lower healthcare utilisation (see Appendix 1, Figure A1 for logic model).

Step 2 A – EPIC-Neck programme overarching target behaviour, behavioural performance objectives and determinants (behaviour change process – maximising patient engagement)

The overarching target behaviour was defined as “people with chronic non-specific neck pain engaging with a home exercise programme that facilitates long-term self-management”. The PPIE group contributed two key insights: the EPIC-Neck programme should promote home-based exercise and should enable individuals to independently manage their symptoms, reducing their reliance on healthcare professionals. To perform the above target behaviour, a person with neck pain needs to meet four subsidiary behavioural performance objectives:

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Performance Objective 1 – To perform physiotherapist prescribed neck exercises.

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Performance Objective 2 – To self-adjust neck exercise and dosage variables and independently progress or regress exercise.

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Performance Objective 3 – To use neck specific exercises to reduce the severity and duration of flare-ups.

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Performance Objective 4 – To commence long-term general exercise and understand the benefits and risks of continuing their neck specific exercises for secondary prevention.

Performing physiotherapist prescribed exercise (adherence) was identified as a behavioural performance objective (Performance Objective 1) (PPIE [6, 39, 40]),. Thirty determinants affecting a person’s ability to perform physiotherapist prescribed neck exercise were identified via patient workshops and existing literature [42, 43, 53]), spanning all COM-B model domains and 20 mechanisms of action (Table 1 & Appendix 1, Table A1).

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Independent self-adjustment and progression (or regression) of neck exercise was identified as a behavioural performance objective (Performance Objective 2) (PPIE, expert consensus [14]). Since no musculoskeletal literature has examined determinants for independently adjusting or progressing exercise, potential determinants were inferred from strategies used in self-managing diabetes medication [62] and discussed with the PPIE group, along with their own ideas about barriers to and enablers of Performance Objective 2. Twenty determinants affecting a person’s ability to self-adjust and progress (or regress) exercise were identified via patient workshops and existing literature spanning five COM-B model domains and 13 mechanisms of action (Appendix 1, Table A2).

Using exercise to reduce the severity and duration of a neck pain flare-up was identified as a behavioural performance objective (Performance Objective 3) (PPIE [87,88,89]),. As no musculoskeletal literature has evaluated determinants for flare-up related exercise, potential determinants were inferred from other chronic conditions [56, 60, 62, 65, 90, 91] and discussed with the PPIE group, along with their own ideas about barriers to and enablers of Performance Objective 3. Sixteen determinants affecting a person’s ability to use exercise to reduce the severity and duration of a neck pain flare-up were identified spanning all COM-B model domains and 13 mechanisms of action (Appendix 1, Table A3).

Engaging in long-term general exercise and understanding the benefits and risks of secondary prevention neck exercise was identified as a behavioural performance objective (Performance Objective 4)(PPIE group, expert consensus [14]). The effectiveness of secondary prevention neck exercise (adherence while asymptomatic) in reducing recurrence risk is unclear [92,93,94,95]. The PPIE group indicated they would not engage in secondary prevention exercise if asymptomatic, as long as they could manage flare-ups (Performance Objective 3). It was agreed that patients should be educated about the benefits and risks of secondary prevention neck exercise, with decisions made on an individual basis through shared decision-making. Nonetheless, the PPIE group and study team concurred that all patients should participate in general exercise due to its benefits for managing other chronic diseases and reducing mortality rates [96]. Seven determinants relating to long-term exercise engagement (general or musculoskeletal) were identified via PPIE and review of existing evidence [46, 48, 52, 55, 57, 64], spanning four COM-B model domains and seven mechanisms of action (Appendix 1, Table A4).

Step 3 A – EPIC-Neck programme change techniques and practical application (behaviour change process - maximising patient engagement)

The EPIC-Neck programme includes 52 change techniques across the four behavioural performance objectives. A sample of the Performance Objective 1 intervention matrix specifying determinant change techniques and data sources is shown in Table 2. Full details are provided in Appendix 1, Tables A5-8. Twenty-four change techniques were considered key and used to develop a logic model of change (Appendix 1, Figure A1).

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Theoretical underpinnings

The process model of lifestyle behaviour change was chosen to guide behaviour change processes because it aligned well with the key determinants and change techniques identified [97, 98]. This model proposes three broad processes (motivation, followed by planning and ongoing cycles of self-regulation) that support both initiation and maintenance of behaviour over time, as well as the use of a patient-centred communication style to maximise patient engagement.

To translate this theoretical framework into clinical practice, the Study team developed an Exercise Behaviour Change Facilitation Guide (Fig. 2), outlining how specific change techniques could be delivered across behavioural phases. Through iterative discussions, the team mapped the determinants and change techniques onto the model, resulting in eight key principles that underpin the EPIC-Neck programme. These principles aim to engage patients and support progression through behavioural performance objectives. Behavioural performance objectives are introduced sequentially (1–4), with each new performance objective building on the skills developed from the previous one. For example, a patient cannot adjust or progress their exercise (Performance Objective 2) unless they are doing their exercise (Performance Objective 1).

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Principle 1 - Actively involve the patient

An overarching principle is that the patient is actively involved in their care which is facilitated through patient centred communication techniques [99] (open questions, reflective listening and Ask-Tell-Discuss) and shared decision-making [100].

Principle 2 - Agree intended outcomes

Short- and long-term outcome goals are agreed upon collaboratively before prescribing the exercise programme and introducing the first behavioural performance objective (Performance Objective 1 - performing exercise).

Principle 3 - Improve motivation (through importance, safety, self-efficacy and social support)

A patient’s motivation to engage with exercise and achieve behavioural performance objectives is enhanced through three strategies: (1) increasing perceived importance and safety, (2) boosting self-efficacy, and (3) engaging social support. Importance and safety are enhanced through exploration of the bio, psycho and social benefits and safety of neck exercises and each performance objective. Self-efficacy is improved through explanations, demonstrations, practice, feedback, and ensuring that exercise and objectives are tailored to the patient’s ability and gradually progressed. Social support is strengthened by identifying non-healthcare supporters, reinforcing positive support, and addressing negative support through problem-solving.

Principle 4 - Set a plan

Exercise action plans are co-created to specify dosage, timing, location, and the use of social support. Self-efficacy regarding the action plans is evaluated, and potential barriers and facilitators are explored.

Principle 5 - Encourage self-monitoring

Self-monitoring of neck exercise adherence including completion and dosage and self-monitoring of outcomes (neck symptoms), is encouraged.

Principle 6 - Review progress

Progress with exercise adherence and outcomes (especially in terms of patient-set goals) and other behavioural performance objectives is reviewed at follow-up appointments. This review includes re-evaluating motivation factors such as perceived importance and safety, self-efficacy, and social support. Feedback is provided, and problem-solving support is offered (Principle 7). When adequate progress is made, a new performance objective is introduced, applying Principles 3–5. Once all performance objectives have been introduced, the patient’s ability to self-manage and suitability for discharge are assessed (Principle 8).

Principle 7 - Support problem solving

Patients are supported to independently problem-solve at all stages.

Principle 8 - Evaluate self-management and discharge suitability

A patient’s ability to self-manage their prescribed exercise and suitability for discharge is determined collaboratively by assessing motivation, progress towards outcome goals, and the ability to perform all performance objectives and solve problems independently.

Step 2B – EPIC-Neck programme exercise objectives (exercise prescription process – maximising patient engagement)

Neuromuscular function, beliefs, catastrophizing, fear avoidance or fear of movement and self-efficacy were identified as mediators of the outcomes pain, pain-related disability and activity limitations. These mediators were converted into exercise objectives, defining what exercise needed to change in order to improve these outcomes (Appendix 1, Table A9 for full details). Since beliefs, catastrophising and fear avoidance/fear of movement collectively form the Fear Avoidance Model [101], and require similar exercise tailoring strategies (see Step 3B) they were consolidated into a single exercise objective.

As no mediators were found for sleep, mental well-being, and personal relationship outcomes, exercise objectives for these outcomes were developed through discussion with the PPIE group, Study team and by reviewing the non-MSK literature. Night pain [102, 103], cognitive control (the process of achieving goals and problem-solving ability) [104] and social support and understanding from family and friends [68] were proposed as mediators of sleep, mental well-being and personal relationships respectively. The final exercise objectives for each outcome are described in Table 3.

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Step 3B – EPIC-Neck programme exercises and tailoring (exercise prescription process – maximising effectiveness)

The most effective exercises for pain and disability are a combination of motor control and segmental exercises [13]. Motor control exercises focus on retraining the coordination of cervical muscles or sequential spinal movement using minimal effort, such as craniocervical flexion in supine [13]. Segmental exercises target larger superficial muscles to enhance the spine’s ability to generate, transfer, or absorb force through sequential movements, such as cervical flexion with pulley systems or cervical retraction with resistance bands [13]. Since the optimal exercise dosage for pain and disability is not well-defined, the EPIC-Neck programme adopts expert consensus, recommending that dosage be set as an “achievable challenge” tailored to each specific exercise objective [13, 14].

The most effective neck exercises for mental well-being, sleep or relationships have not been evaluated. It is unclear whether motor control and segmental exercises are effective for these outcomes or suitable for exercise objectives of pain self-efficacy or fear/catastrophising. The Study team modified the descriptions of these exercises to address psychosocial objectives and outcomes. Therefore, the EPIC-Neck programme includes two exercise stages: (1) “Normalising Movement” and (2) “Improving Tolerance.”

Stage 1, Normalising Movement, conceptually based on motor control exercises, involves active neck and surrounding region exercises aimed at restoring movement that may be dysfunctional due to factors such as impaired motor control, fear, or low self-efficacy.

Stage 2, Improving Tolerance, conceptually based on segmental exercises, involves active neck and surrounding region exercises designed to progressively enhance the neck’s ability to handle increasing demands. This includes addressing fear by gradually increasing exercise complexity or environmental challenges, improving self-efficacy through increasing exercise intensity or volume tailored to individual capacity, and considering social influences by adapting the exercise delivery to engage supportive networks or address social barriers. These exercises are designed to not only improve physical function but also target the psychological factors that influence engagement with the programme.

These two stages serve as a foundation for selecting exercises, which are then tailored to each exercise objective (Table 3). The EPIC-Neck Programme’s Biopsychosocial Exercise Prescription Framework (Fig. 3) assists physiotherapists in making exercise prescription decisions to optimize outcomes.

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Step 4 – EPIC-Neck programme supporting resources and physiotherapist training

The following supporting resources were developed (Fig. 4).

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Workbook (paper and mobile application)

Educates on neck pain and the four performance objectives, integrating change techniques from Step 3 A, and includes an FAQ section to support problem-solving.

Exercise library

The library includes over 80 candidate neck exercises, presented with pictures, videos, and detailed descriptions, allowing physiotherapists to select and tailor exercises to individual patient needs. This resource was developed using exercises described in existing systematic reviews on neck exercise [13] and informed by the clinical expertise of the Study team.

Exercise diaries

Enables self-monitoring of exercise completion, dosage, and symptoms.

Wall chart

An A2 wipeable chart summarizing each performance objective and key change techniques.

Friends and family leaflet

Offers information on neck pain, exercise, and ways friends and family can support the patient’s self-care.

The physiotherapist training programme was developed through workshops with over 20 physiotherapists (NHS pay band 5-8a, junior to specialist), relevant literature [84,85,86], and discussions among the Study team. It consists of a full day of face-to-face training, including lectures, practical sessions, and extensive role play. Physiotherapists also engage in case scenarios to practice developing exercise programmes, tailoring exercises to align with specific exercise objectives and applying behaviour change techniques. The training is supported by a comprehensive manual outlining the intervention delivery, problem-solving strategies, and key components as defined by the logic model and exercise facilitation guide. Additionally, physiotherapists are provided with prompt sheets to assist them in clinical practice, acting as reminders of the essential components of the intervention. Follow-up “top-up” sessions, offered based on site needs, provide ongoing support through either group-based or one-on-one training. These sessions are designed to address any issues or questions that arise during implementation, with opportunities for peer support and direct communication with the Study team for guidance. The training programme emphasises key areas identified as learning needs during prior workshops, particularly around engaging social support, patient-centred counselling, facilitating problem-solving, and enhancing exercise self-efficacy. It also includes specific guidance on selecting and prescribing exercises based on neuromuscular assessments.

The training programme also included changes techniques used by the facilitator to address physiotherapists barriers in delivering the EPIC-Neck programme. These techniques aimed to support physiotherapists in overcoming challenges they may face in clinical practice. Some of these techniques included encouraging physiotherapists to set personal action plans, using peer support through champions and email discussions, and educating physiotherapists about the benefits of the EPIC-Neck programme, both for patients and the physiotherapist. Full details on barriers to delivery and change strategies are in (Appendix 1, Table A10).

Discussion

The EPIC-Neck programme for chronic non-specific neck pain was developed using a rigorous Intervention Mapping process. This structured approach ensured the programme was evidence-informed, theoretically driven, and created in collaboration with key stakeholders. As a result, the EPIC-Neck programme is designed to be highly engaging and effective, aiming to optimize outcomes and reduce the burden of neck pain.

The intended outcomes of neck exercise

The EPIC-Neck programme aims to improve patient-reported outcomes of pain, pain-related disability, functional limitations, sleep, mental well-being, and relationships, addressing the biological, psychological, and social impacts of chronic non-specific neck pain [4, 36, 37]. Pain, disability, and functional limitations are commonly evaluated in clinical trials [9, 13, 83], but sleep and mental well-being are less common and typically secondary outcomes [120, 121]. The inclusion of social outcomes, such as relationships, has been notably absent [8, 19, 83] despite evidence showing the impact of chronic pain on those around the patient [122]. This may partly reflect the assumption that exercise interventions are unlikely to affect social domains directly. However, our PPIE group highlighted the importance of social involvement in recovery and strongly supported the inclusion of personal relationships as an outcome of interest. We acknowledge that this is an emerging and exploratory concept, but we consider social outcomes potentially modifiable through mechanisms such as improved social support and shared understanding with significant others [68]. Their inclusion offers a more holistic view of how exercise might contribute to recovery and will be further investigated in our feasibility work. The omission of outcomes representing the bio, psycho and social burden of neck pain in clinical trials limits the understanding of intervention effectiveness. As the outcomes were identified using a comprehensive range of stakeholders and data sources, and in the absence of a core outcome set, pain, pain-related disability, functional limitations, sleep, mental well-being and relationships could be used as domains in future trials to evaluate the bio, psycho and social burden of neck pain.

The behavioural performance objectives required to successfully enable long-term self-management with neck exercise

A unique aspect of this study was identifying a comprehensive set of behavioural performance objectives necessary for effective self-management using exercise. While adherence to exercise (Performance Objective 1) is well-documented, objectives like self-adjusting and progressing exercises (Performance Objective 2), managing flare-ups with exercise (Performance Objective 3), and incorporating general and secondary prevention exercise (Performance Objective 4) are less commonly addressed in musculoskeletal literature. The concept of independently adjusting and progressing exercise (Performance Objective 2) is emerging [123,124,125,126,127,128] and could potentially reduce reliance on healthcare professionals, enhancing long-term self-management. Additionally, managing flare-ups with exercise (Performance Objective 3) has been minimally explored [129,130,131]. By using Intervention Mapping, this study not only outlines these key behavioural performance objectives but also identifies barriers and strategies to overcome them, thereby optimizing patient engagement.

Exercise behaviour change facilitation guide and biopsychosocial exercise prescription framework

Two major outputs from this development process are the Exercise Behaviour Change Facilitation Guide and the Biopsychosocial Exercise Prescription Framework. These tools offer clinicians a structured approach to prescribing and supporting individually tailored exercises, theoretically enhancing both patient engagement and treatment effectiveness. They provide clarity and consistency in clinical practice and future research, aligning with recommendations from the Global Burden of Disease Neck Pain Collaborators [2, 132]. By detailing the development of the behaviour change and exercise prescription process, these resources can be updated with new knowledge, further improving their impact on patient engagement and treatment effectiveness.

In developing the exercise components, we made a key methodological decision to categorise exercises based on their intended spinal effects rather than broad performance descriptors such as “strengthening.” This contrasts with prior reviews, including de Zoete et al., [83], which grouped interventions by type (e.g., strength, motor control, mind-body). As such, our classification enabled more granular interpretation of programme content and mechanisms — for example, distinguishing segmental exercises embedded within multi-component “strength” programmes. While the findings of de Zoete et al., [83] support motor control, strength, and mind-body approaches, our outputs integrate the core components of motor control and spinal-loading (segmental) exercises, tailored through a biopsychosocial lens.

Strengths and limitations

This study is among the few to detail the theoretical and evidence-based development of an exercise programme for a musculoskeletal disorder. A potential limitation is the reliance on general musculoskeletal literature rather than neck-specific studies, which might affect the validity of the Exercise Behaviour Change Facilitation Guide and the Biopsychosocial Exercise Prescription Framework. However, discussing literature findings with the PPIE group at each stage likely enhanced their validity. Additionally, using broader musculoskeletal literature means these tools could be adapted for other chronic musculoskeletal disorders with minor adjustments.

While Intervention Mapping provides a systematic, step-by-step approach to intervention development, we acknowledge that different groups of experts and patients may make different decisions, leading to a slightly altered intervention [133]. While we have aimed for transparency by thoroughly documenting our decisions and the reasons behind them at each stage, it’s important to recognise that alternative approaches may exist. This detailed documentation ensures clarity about our process, enabling future adjustments based on new evidence, shifts in clinical practice, or different stakeholder involvement.

Implications

Research is now needed to assess the acceptability and feasibility of the EPIC-Neck programme before evaluating its clinical and cost-effectiveness. In the long term, the EPIC-Neck programme and its logic model/approach could be adapted for other chronic musculoskeletal disorders. By using an evidence-informed, theoretically driven, and co-developed approach to exercise prescription, this programme aims to reduce variability among clinicians and studies, leading to more consistent and effective treatments. This consistency could ultimately lower economic and healthcare utilization burdens.

Conclusion

The EPIC-Neck programme, developed using intervention mapping principles, offers a robust, evidence-informed, theoretically driven approach to managing chronic neck pain through tailored exercise. Its innovative tools, including the Exercise Behaviour Change Facilitation Guide and Biopsychosocial Exercise Prescription Framework, support effective and engaging, individualized exercise. Future research will assess its feasibility and acceptability to both patients and physiotherapists, and in the long-term establish its clinical and cost-effectiveness.

Data availability

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

BCTs:

Behaviour Change Techniques

EPIC:

Exercise Prescription Improved through Co-design

MSK:

Musculoskeletal

NIHR:

National Institute for Health and Care Research

PO:

Performance Objective

PPIE:

Patient and Public Involvement and Engagement

T&TT:

Theory and Techniques Tool

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