Highlights
- Combination of manual therapy and exercise shows moderate improvement in function and large pain reduction compared with no treatment in mainly chronic neck pain.
- Compared with placebo, manual therapy with exercise yields moderate functional gains but little or no pain reduction.
- Evidence certainty is generally low to moderate due to performance bias and imprecision; adverse events are minor and non-serious.
- Future well-powered trials with detailed intervention reporting, particularly in acute and subacute neck pain, are needed.
Background
Neck pain is a common musculoskeletal condition with high prevalence and significant impact on quality of life and function. Evidence supports manual therapy and exercise as effective single-modality treatments for neck pain of various chronicity. However, their combined efficacy remains incompletely understood, particularly compared with placebo or no treatment. Understanding the benefits and harms of manual therapy combined with exercise is essential for informed clinical decision-making and guideline development.
Key Content
Methodological Overview of the Evidence
A 2025 Cochrane systematic review by Chacko et al. (PMID: 41363159) synthesized data from nine randomized controlled trials (RCTs) comprising 694 adults with acute to chronic neck pain, predominantly chronic (> 8 weeks). Seven studies compared manual therapy combined with exercise against no treatment and two against placebo interventions. Participants averaged 46 years, with 76% female, and baseline pain severity around 4.75/10. Risk-of-bias assessment revealed significant selection (44%), performance (100%), detection (100%), and reporting (78%) biases, inherent challenges in manual therapy trials due to intervention nature and reliance on self-reported outcomes.
Clinical Outcomes
Short-term Pain Intensity:
- Compared to placebo, manual therapy plus exercise showed little or no meaningful pain reduction (mean difference [MD] -0.91 points on a 0–10 scale; 95% confidence interval [CI] ranging from 1.85 points improvement to 0.04 points worsening; low-certainty evidence).
- Compared to no treatment, the intervention yielded a large pain reduction (MD -2.44; 95% CI -3.23 to -1.65; low-certainty evidence).
Functional Disability/Function:
- Manual therapy plus exercise provided a moderate functional improvement over placebo (improvement of 10.20 points on a 0–100 function scale; standardized mean difference [SMD] 0.77; low-certainty evidence).
- Compared with no treatment, there was a moderate improvement in function (MD -13.84 points; 95% CI -25.24 to -2.44; low-certainty evidence).
Health-Related Quality of Life:
- Limited data suggested little or no improvement versus placebo (MD 2.00 points on SF-12); moderate improvement when compared with no treatment (MD 24.80 points on SF-36; low-certainty evidence).
Participant-Reported Treatment Success and Adverse Events:
- Data insufficient to draw conclusions on treatment success in placebo-controlled trials; evidence uncertain for no treatment comparisons.
- Non-serious adverse events (transient soreness, headache, dizziness) occurred equally in intervention compared to controls, with no serious events reported.
Related Evidence from Other Systematic Reviews
Additional meta-analyses (2023–2025) concur that combined manual therapy and exercise outperform exercise alone in pain and disability reduction, though differences versus manual therapy alone are minimal. Subgroup analyses highlight benefits in chronic non-specific neck pain but underscore heterogeneity and methodological limitations. Physiotherapeutic interventions for upper cross syndrome and cervicogenic headache also emphasize multimodal approaches including manual therapy with exercise for symptomatic relief and functional gains.
Mechanistic and Translational Insights
Manual therapy likely exerts analgesic effects through biomechanical and neurophysiological mechanisms, including modulation of nociceptive input, muscle spasm reduction, and improved joint mobility. Exercise complements these effects by enhancing muscular strength, motor control, and posture, facilitating sustained functional improvements. The synergy of manual therapy with exercise reflects the biopsychosocial model, targeting both tissue mechanics and neuromuscular control.
Expert Commentary
The current evidence base is constrained by inherent performance and detection biases, largely due to challenges in blinding manual therapy and subjective outcome measures. Despite this, the consistency of functional improvements and pain reduction compared to no treatment supports clinical use. The lack of significant pain reduction compared to placebo may reflect placebo effects, natural history, or insufficient treatment dosing. Clinicians should consider combining manual therapy and exercise as part of a multimodal strategy tailored to patient preferences and presentation.
Clinical guidelines increasingly advocate for combined manual therapy and exercise as first-line conservative management, particularly for chronic neck pain. However, reporting deficiencies in intervention fidelity, dose, and adherence in trials limit replicability and clinical translation. Enhanced methodological rigor and pragmatic effectiveness trials focusing on acute and subacute presentations are critical future directions.
Conclusion
Manual therapy combined with exercise provides clinically meaningful improvements in functional capacity and pain reduction in adults with predominantly chronic neck pain compared with no treatment, with a low risk of minor adverse events. Compared to placebo, benefits are limited primarily to function, with pain outcomes showing little difference. These findings, predominantly at short-term follow-up, underscore the value of combined conservative interventions while highlighting the need for standardized reporting, assessment of long-term outcomes, and investigation in acute stages of neck pain.
Future research should prioritize adequately powered RCTs with rigorous intervention characterization and explore patient-centered outcomes including treatment success, adherence, and quality of life. Integrating mechanistic studies will enhance understanding of therapeutic effects and inform personalized rehabilitation strategies.
References
- Chacko N, Gross AR, Miller J, et al. Manual therapy with exercise for neck pain. Cochrane Database Syst Rev. 2025;12(12):CD011225. doi:10.1002/14651858.CD011225.pub2. PMID: 41363159; PMCID: PMC12687410.
- Gross A, et al. Manual physical therapy for neck disorders: an umbrella review. J Man Manip Ther. 2025;33(1):18-35. doi:10.1080/10669817.2024.2425788.
- Jiménez-Jiménez M, et al. The efficacy of manual therapy and therapeutic exercise for reducing chronic non-specific neck pain: A systematic review and meta-analysis. J Back Musculoskelet Rehabil. 2025;38(3):407-419. doi:10.1177/10538127241304110.
- Lewis J, et al. Comparative efficacy of exercise versus passive physical therapy in improving nonspecific neck pain: a multilevel network meta-analysis and dose-response analysis. Spine J. 2025;25(11):2357-2368. doi:10.1016/j.spinee.2025.07.006.
