Manual therapy and neck-specific exercise are equally effective for treating non-specific neck pain but only when exercise adherence is maximised: A randomised controlled trial

Key Points

1. Manual therapy was more effective than neck-specific exercise in treating non-specific chronic neck pain when comparing overall responder rates.
2. However, when exercise adherence reached 95% or higher, both interventions showed equal effectiveness.

BACKGROUND AND OBJECTIVE

Non-specific neck pain is a prevalent condition that contributes significantly to disability worldwide. Current clinical practice guidelines recommend using both manual therapy and specific exercise for treatment, but uncertainty remains about their relative effectiveness.

This study aimed to assess the relative effectiveness of manual therapy versus a progressive, tailored neck-specific exercise program for treating non-specific chronic neck pain. The researchers also examined the relationship between exercise adherence and treatment outcomes.

Non-specific neck pain is a prevalent condition that contributes significantly to disability worldwide.

When prescribing exercise, clinicians should consider patient adherence as an important variable affecting the outcome.

METHODS

• The researchers recruited 65 participants who had non-specific chronic neck pain. They were randomly allocated to receive either manual therapy or neck-specific exercise.

• Each group had four weekly 30-minute face-to-face meetings with a physiotherapist.

• During these 30-minute sessions, the manual therapy group received manual therapy. The exercise group received instruction and supervision on how to do the exercises. They were also instructed to do 20-minute exercise sessions every day for four weeks. These consisted of 13 exercises targeting neck flexor and extensor muscles (see video 1). The exercises were progressed and individualized over the four weeks based on feedback in the meetings. The exercise group also received video recordings of the prescribed exercises by a mobile messaging application. The patients documented their adherence to the exercise program.

VIDEO 1 - NECK EXERCISES

• Outcomes were measured at baseline, two weeks, four weeks, and 16 weeks. Measures included pain intensity, disability (using the Neck Disability Index), patient-perceived improvement (using the Global Rating of Change scale), quality of life, kinesiophobia, and the craniocervical flexion test to assess deep neck flexor muscle function.

• Patients were categorized as either "responders" or "non-responders" based on achieving minimum clinically important differences in at least two of three measures: 24-hour neck pain intensity, disability, and patient-perceived improvement.

RESULTS

• Both groups improved on measures related to pain intensity, disability, pain catastrophization, kinesiophobia, and quality of life.

• Patients in the manual therapy group were more likely to be classified as responders than patients in the exercise group at all measured time points.

• However, when the analysis included only patients in the exercise group whose adherence was 95% or greater (n=18), there were no longer significant differences in effectiveness between the two interventions. The exercise group with high adherence (≥95%) demonstrated better improvement in the craniocervical flexion test, indicating better deep neck flexor muscle function, compared to the manual therapy group.

• The mean adherence rate in the exercise group was 95%, with 62% of patients reporting 100% adherence. Higher adherence was linked to greater reductions in disability and pain intensity and increased the likelihood of being classified as a responder at all time points.

LIMITATIONS

• The treatment interventions lasted only four weeks, which may have underestimated the effectiveness of both treatments, particularly the exercise program, which previous studies have implemented over 8-14 weeks.

• The study participants had received previous treatments before recruitment, which may have already provided some benefit and reduced room for improvement.

• The follow-up period was limited to 12 weeks post-treatment, so long-term effects beyond this period remain unknown.

• There was no control group that did not receive any treatment, so it is unknown whether the improvements seen in both groups were due to nonspecific effects or natural progression.

CLINICAL IMPLICATIONS

Non-specific neck pain is a common condition that is often treated with either manual therapy or specific exercise (1,2). However, current research cannot provide clear evidence about which treatment is superior. It is thought that the benefits of exercise may be underestimated by the studies because exercise adherence is less than optimal (3,4).

This study sought to assess the relative effectiveness of manual therapy and exercise therapy for neck pain, and to determine the effect of exercise adherence on the benefits conferred by exercise.

The study found that manual therapy and exercise had mostly similar outcomes when exercise adherence was above 95%, with the exception that the exercise group had better deep neck flexor function. When exercise adherence was lower, the manual therapy group had better outcomes.

Exercise adherence remained less than optimal even though patients received weekly face-to-face meetings with physiotherapists demonstrating the exercises, and video recordings showing the exercises. When prescribing exercise, clinicians should consider patient adherence as an important variable affecting the outcome.

+STUDY REFERENCE

Villanueva-Ruiz I, Falla D, Saez M, Araolaza-Arrieta M, Azkue J, Arbillaga-Etxarri A, Lersundi A, Lascurain-Aguirrebeña I (2025) Manual therapy and neck-specific exercise are equally effective for treating non-specific neck pain but only when exercise adherence is maximised: A randomised controlled trial. Musculoskeletal Science and Practice, 77, 103319.

SUPPORTING REFERENCE

1. Safiri, S., Kolahi, A.-A., Hoy, D., Buchbinder, R., Mansournia, M.A., Bettampadi, D., Ashrafi-Asgarabad, A., Almasi-Hashiani, A., Smith, E., Sepidarkish, M., Cross, M., Qorbani, M., Moradi-Lakeh, M., Woolf, A.D., March, L., Collins, G., Ferreira, M.L., 2020. Global, regional, and national burden of neck pain in the general population, 1990-2017: systematic analysis of the Global Burden of Disease Study 2017. Br. Med. J. 368, m791.
2. Bier, J.D., Scholten-Peeters, W.G.M., Staal, J.B., Pool, J., van Tulder, M.W., Beekman, E., Knoop, J., Meerhoff, G., Verhagen, A.P., 2018. Clinical practice guideline for physical therapy assessment and treatment in patients with nonspecific neck pain. Phys. Ther. 98 (3), 162–171.
3. Castellini, G., Pillastrini, P., Vanti, C., Bargeri, S., Giagio, S., Bordignon, E., Fasciani, F., Marzioni, F., Innocenti, T., Chiarotto, A., Gianola, S., Bertozzi, L., 2022. Some conservative interventions are more effective than others for people with chronic non-specific neck pain: a systematic review and network meta-analysis. J. Physiother. S1836–9553 (22), 00086.
4. Mueller, J., Weinig, J., Niederer, D., Tenberg, S., Mueller, S., 2023. Resistance, motor control and mindfulness-based exercises are effective for treating chronic non-specific neck pain: a systematic review with meta-analysis and dose-response meta-regression. J. Orthop. Sports Phys. Ther. 1–39.