0.5 contact hours (30 min)
$19.99
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Pain Management · 9 min · September 27, 2026
From the course: Active vs Passive Multimodal Physiotherapy for Chronic Nonspecific Neck Pain: A Randomized Trial · 0.5 contact hours
This episode reviews a randomized trial in chronic nonspecific neck pain comparing multimodal active and passive physiotherapy, with results on pain, anxiety, depression, and function. It also explores why the active approach may offer added benefits for pain modulation, kinesiophobia, and mental health-related quality of life.
Wang J, Nie S, Wang R, He Y, Li M, Cui X, Lu Z, Zou H, Zhao Y, Xu J, Zhao P. Multimodal Active Physiotherapy Versus Multimodal Passive Physiotherapy for Chronic Nonspecific Neck Pain: A Randomized Controlled Trial on Dual Outcomes of Physical and Mental Health. Pain Res Manag. 2025;2025:3449647. https://doi.org/10.1155/prm/3449647. PMID: 41179651. PMCID: PMC12575025.
Is active physical therapy better than passive treatment for chronic nonspecific neck pain? In one randomized trial, the two approaches produced no clear difference in pain or mood over eight weeks. In that single-blind trial, published in Pain Research and Management in 2025, Wang and colleagues assigned 54 adults either to an eight-week multimodal program built on the patient's own active participation or to a matched program delivered by the therapist and by physical agent modalities. Both groups improved on pain, anxiety and depression, and the groups did not clearly differ on those primary outcomes. The active group improved more on three secondary measures: conditioned pain modulation, fear of movement and mental health-related quality of life. There was no follow-up after treatment ended and no untreated comparison group.
The authors define chronic nonspecific neck pain as pain lasting beyond three months with no identifiable pathology, felt between the superior nuchal line and the first thoracic vertebra, with stiffness and restricted mobility. They note that it commonly occurs alongside anxiety, depression and reduced quality of life, and they describe central sensitization, meaning heightened excitability in central pain pathways, as a key mechanism.
Their rationale follows from that mechanism: if amplified central processing sustains the pain, treatment that engages the patient through guided movement should, in theory, do more than treatment that supplies mechanical input to tissues. They write that passive strategies remain predominant in practice despite limited effectiveness and an association with high recurrence rates, and that the comparative effectiveness of the two approaches in this condition had not been established.
The trial was a single-blind, stratified, parallel-group randomized controlled trial, registered with the Chinese Registry of Clinical Trials (ChiCTR2500104619). Participants, outcome assessors and data analysts did not know group assignment, and the treating therapists took no part in assessment or analysis.
Adults aged 18 to 65 were recruited through social media. Entry required an average baseline pain score between 3 and 7 on an 11-point scale, neck pain at least three times a week for three months or longer, and no shoulder or upper limb symptoms. Of 111 people screened, 54 were randomized, 27 to each group.
Both groups received 16 one-on-one sessions of 60 minutes, twice a week for eight weeks, and both protocols addressed pain relief, cervical mobility, muscular strength and sensorimotor control.
| Component | Active program | Passive program |
|---|---|---|
| Education | Pain neuroscience education: causes of chronic pain, psychosocial influences, the role of active participation | Biomechanical education: cervical anatomy, common causes of neck pain, self-care methods |
| Manual work | Dynamic joint mobilization and myofascial release, with the patient moving during the technique | Passive joint mobilization, soft tissue massage, passive static stretching |
| Other | Progressive cervical functional training | Physical agent modalities |
| Patient role | Active participation throughout | Passive and receptive throughout |
Neither program clearly outperformed the other on pain. Forty-eight of the 54 participants completed the program, and the analysis included everyone randomized.
| Outcome (higher score is worse) | Active: start to end | Passive: start to end |
|---|---|---|
| Pain (0–10) | 4.59 to 2.59 | 4.44 to 2.85 |
| Anxiety (0–21) | 6.33 to 5.04 | 5.96 to 4.56 |
| Depression (0–21) | 3.85 to 2.74 | 4.15 to 3.11 |
Anxiety and depression were measured with the Hospital Anxiety and Depression Scale. The authors reported that each group improved from its own baseline on all three measures by more than chance would explain, with no clear difference between the groups on any of them.
That within-group improvement needs a caveat. When the analysis was adjusted for age, sex, body mass index, total sleep time, sedentary desk time, regular physical activity and medication use, no clear effects of time, group or the two combined remained. Of those covariates, total sleep time was the one the authors reported as influencing anxiety and depression scores.
| Secondary outcome | Comparison between programs |
|---|---|
| Conditioned pain modulation (whether a painful stimulus elsewhere dampens pain sensitivity at the neck) | Favored the active program |
| Fear of movement (scored 17 to 68, higher is more fear) | Favored the active program |
| Mental health-related quality of life | Favored the active program |
| Patient-perceived change | No clear difference |
| Insomnia symptoms | No clear difference |
| Neck function and disability | No clear difference |
On fear of movement, average scores in the active group fell from 38.74 to 29.11, while scores in the passive group moved from 40.22 to 37.29. The authors attributed the difference to the pain neuroscience education in the active protocol and to its broader focus, in contrast with the biomechanical rationale given to the passive group. For conditioned pain modulation, they called for further work on whether the measurement predicts anything clinically useful.
The authors also acknowledged that the active program showed no clear advantage on anxiety or depression, and suggested its exercise intensity may have been too low to affect mood. One participant in the active group withdrew because of acute neck pain, and two in the passive group withdrew, one for skin hypersensitivity and one for cardiac discomfort. The authors reported no clear difference between groups in how often adverse events occurred.
Wang and colleagues concluded that the two approaches were comparable for pain and emotional status, while the active approach offered added benefit for pain modulation, fear of movement and mental health-related quality of life. They proposed that better pain modulation and less fear of movement could lower recurrence over time, which their design could not test, and called for longer follow-up and objective imaging.
For pain relief over eight weeks, Wang and colleagues found the two approaches comparable in their 2025 trial of 54 adults. The active program showed greater improvement in fear of movement, conditioned pain modulation and mental health-related quality of life. Neither group was followed after treatment ended.
Fear of movement improved more in the active group, whose program included pain neuroscience education, and the authors attributed the difference in part to that education. Because the authors compared whole programs, the effect of the education on its own was not measured.
Anxiety and depression scores improved in both groups, with no clear difference between programs. The authors cite evidence that physical therapy has limited direct effect on these symptoms and that cognitive behavioral therapy remains the preferred intervention.
Wang J, Nie S, Wang R, et al. Multimodal active physiotherapy versus multimodal passive physiotherapy for chronic nonspecific neck pain: a randomized controlled trial on dual outcomes of physical and mental health. Pain Res Manag. 2025;2025(1):3449647. doi:10.1155/prm/3449647
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