Manual Therapy for Recent – Onset or Persistent Neck Pain: A Review of Clinical Effectiveness and Guidelines (2025)

Fredin and Lorås 2017²²Combined Exercise + Manual therapy versus Exercise
Pain (VAS or NRS on a scale of 0 to 10)

No statistically significant differences found between groups at immediate post treatment (SMD -0.15; 95% CI, -0.30 to 0.00) , 6 months (SMD -0.05; 95% CI, -0.35 to 0.24) and 12 months (SMD 0.15; 95% CI, -0.17 to 0.46)

Disability (NDI or NPQ on a scale of 0 to 100; )

No statistically significant differences found between groups immediate post-treatment (SMD 0.02; 95% CI, -0.26 to 0.30),6 months (SMD 0.01; 95% CI, -0.19 to 0.21), and 12 months ( SMD -0.09; 95% CI, -0.41 to 0.22)

QoL (physical component; SF 36 or SF 12 on a scale of 0 to 100)

No statistically significant differences were found between groups immediate post-treatment (SMD 0.14; 95% CI -0.20 to 0.48), 6 months (SMD 0.06; 95% CI, -0.14 to 0.26) and 12 months ( SMD 0.17, 95% CI, -0.15 to 0.49)

QoL (mental component; SF 36 or SF 12 on a scale of 0 to 100)

No statistically significant differences were found between groups immediate post-treatment (SMD 0.22; 95% CI -0.04 to 0.47), 6 months (SMD 0.05; 95% CI, -0.15 to 0.25) and 12 months ( SMD 0.05, 95% CI, -0.27 to 0.37)

AEs: Five of the included studies reported no serious adverse events occurred; mild AEs included muscle and joint soreness, headache, back pain, nausea, dizziness and upper extremity symptoms.

“Based on the studies included in this review, it is concluded that combined treatment consisting of MT and ET does not seem to be more effective (moderate-to-low level of evidence), than ET alone in reducing neck pain at rest, neck disability, quality of life for adult patients with grade I and II neck pain”(p.69)²²Shekelle et al. 2017¹⁸

No pooling of data was performed
Five RCTs on SMT (including mobilization) for acute neck pain
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SMT + NSAID (azapropazone) compared to NSAID alone in 1 RCT (n=52); 68% of patients in SMT+ NSAID group reported reduction in pain post-treatment, effect not statistically significant at one or three weeks
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1 RCT (n=30) compared mobilization + neck collar, TNS + neck collar and neck collar alone; at 1 week follow-up no significant differences between the three groups
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1 RCT (n=36) randomized patients to receive SMT ipsilateral to side of neck pain, contralateral to side of pain and placebo ultrasound; statistically significant improvement in VAS scores in group receiving ipsilateral SMT
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1 RCT (n=45) patients allocated to physical therapy (TENS, superficial thermotherapy & STT) with or without thoracic spine manipulation; group receiving manipulation demonstrated statistically significant difference in NPRS and NPQ scores measured four weeks after baseline
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1 RCT (n=45) patients allocated to physical therapy (electro/thermal therapy) with or without thoracic spine manipulation; manipulation group reported statistically significant difference in VAS scores (at end of last treatment, two week, and four week follow-up) and NPQ (end of last treatment and two week follow-up)
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No included RCT reported adverse events

“We rated the evidence as low that SMT improves outcomes in patients with acute neck pain due to study quality concerns and imprecision of results (too few studies).”(p.6)¹⁸Yang et al. 2017¹⁹ICT vs. placebo group (exercise, manual therapy and physical therapy modalities, sham ICT)

Statistically significant reduction in pain scores after completion of treatments (SMD -0.26; 95% CI, -0.46 to -0.07; I² = 58%; 7 RCTs, n= 401), but not at final follow-up (SMD -0.57; 95% CI, -1.46 to 0.32; I² = 83%; 3 RCTs, n = 189)
No statistically significant reduction in NDI scores after completion of treatments (SMD -0.10; 95% CI, 95% -0.33 to 0.13; I²=0%; 4 RCTs, n =298) or final follow-up (SMD -0.26; 95% CI, -1.08 to 0.55; I² = 76%; 2RCTs, n = 163)
Four RCTs reported adverse events; mild increase in pain most commonly reported; no serious adverse events (e.g., neurological deficit) reported

“ ICT was beneficial in reducing pain scores immediately after treatment; however, this effect had diminished by the final follow-up. In addition, ICT let to no functional improvement in the daily life of patients immediately after treatment or at the final follow-up.”(p.963)¹⁹Yao et al. 2017²⁰Pain
Short-term pain:

SMT group had statistically significant reduction in VAS score(MD -1.14; 95% CI, -2.12 to -0.16; 7 RCTs, n=554)
SMT group had no statistical reduction in NPRS score (MD -0.30, 95% CI, -0.80 to 0.20; 10 RCTs, n= 1,502)

Intermediate-term pain:

No statistical difference in VAS score (MD 0.26; 95% CI, -0.54 to 1.06; 2 RCTs, n=149)
SMT group had statistically significant reduction in NPRS score(MD -0.29; 95% CI, -0.53 to -0.05; 6 RCTs, n=916)

Long-term pain:

No statistical difference in VAS score (MD -0.68; 95% CI, -1.63 to 0.27; 1 RCT, n=88) or NPRS score (MD =0.08; 95% CI, -0.24 to 0.40; 5 RCTs, n=670)

Function
Short-term function:

Statistically significant reduction in NDI score (MD -2.10; 95% CI, -2.98 to -1.21; 8 RCTs, n=1,145)

Intermediate-term function:

Statistically significant reduction in NDI score (MD -1.45; 95% CI, -2.55 to -0.35; 7 RCTs, n=987)

Long-term function:

No difference in NDI scores (MD -0.95; 95% CI, -2.42 to 0.51; 5 RCTs, n=758)

Adverse Events

Ten RCTs included AEs as an outcome measure
Four out of ten RCTs reported no serious AEs occurred; six reported AEs occurred
One patient in the SMT group was withdrawn from the RCT due to an unspecified serious adverse event
Other reported AEs including headache, fatigue, nausea and dizziness

“The results do not support the existing evidences for the clinical value of Eastern or Western manipulative therapy for neck pain for short-term follow-up to MCIDS.”(p.543)²⁰Miake-Lye et al. 2016¹⁰6 SRs included on neck pain; 3 exclusively on neck pain and 3 which also included low back, headache or shoulder pain

For chronic neck pain, one SR reported a benefit on pain in comparison with inactive therapies but there is limited evidence for effectiveness over TCM
In one SR on acute and chronic neck and shoulder, statistically significant immediate effect reported for neck pain (SMD 1.79; 95% CI, 1.01 to 2.57)
In comparison to placebo, one SR reported reduction in pain intensity post treatment in patients with acute/subacute or unknown duration of nonspecific neck pain
Three SRs reported that effects of massage on neck pain are unclear

“Findings from high-quality systematic reviews describe potential benefits of massage for pain indications including labor, shoulder, neck, back, cancer, fibromyalgia, and temporomandibular disorder.”(p.20)¹⁰

“These reviews all described the need for more research before any conclusions could be drawn for topics including tendinitis, labor, neck pain, headache, and other musculoskeletal conditions.”(p.16)¹⁰

Southerst et al. 2016¹⁵

Clinical appropriateness assessed and no pooling of data was performed
2 RCTs on manual therapy and exercise
First RCT (n=272) compared HEA, SMT and medication
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No statistically significant differences between HEA and SMT for pain (NRS), disability (NDI) and physical or mental quality of life(SF-36) at 12 week follow-up; satisfaction score statistically significant at 12 week follow-up
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Forty percent of the SMT group and 46% in the HEA group reported nonserious AEs
Second RCT (n=270), compared ET, ET+SMT and HEA
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ET+SMT in comparison to HEA had statistically significant differences in pain, disability, global perceived effect and 12 weeks but not at 52 weeks; satisfaction scores statistically significant at 12 and 52 weeks
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ET + SMT in comparison to ET had a statistically significant effect on disability and physical component of SF-36 at 12 week follow-up; no statistically significant differences reported for any outcome at 52 weeks
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98.9% of ET+SMT , 96.6% of ET group and 33.3% of HEA groups reported non-serious AEs

“Our review suggests that patients with recent neck pain Grade I/II have similar outcomes whether they are managed with home exercises, multi-modal manual therapy, or medication (ie, NSAIDs or acetaminophen).”(p.1520)¹⁵Wong et al. 2016¹⁶

Clinical appropriateness assessed and no pooling of data was performed
One included SR included 1 RCT on osteopathic manipulative treatment (HVLA thrust, MET, STT) in comparison to NSAIDs (30 mg intramuscular ketorolac tromethamine)
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MD of 1.1( 95 % CI, 0.2 to 1.9) on 10-point NRS favoured manual therapy
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One patient in the OMT group reported AE in comparison to eight in NSAIDs group

Note: Discrepancy noted between results presented in evidence table and summary of evidence with respect to the RCT on manual therapy. The results presented here are based on data from the evidence table.

With regards to pain reduction, one RCT demonstrated that osteopathic manipulative treatment including a HVLA thrust and soft tissue technique has a statistically significant but clinically non-significant effect in comparison to intramuscular ketorolac tromethamine. A greater percentage of patients in the NSAID group reported adverse events.Wong et al.2016⁹14 RCTs on manual therapy interventions classified as exploratory or evaluation studies; no pooling of data performed
Exploratory Studies
NAD Grades I-II of variable duration

1 RCT (n= 31) found no difference in pain intensity (Neck Pain Disability Scale) or self-perceived recovery between one session of strain-counterstrain and sham counterstrain
See Also
Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review

Recent-onset NAD Grades I-II

2 RCTs found evidence supporting thoracic spine manipulation
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Thoracic manipulation vs. cervical mobilization and home exercise in 1 RCT (n= 66)
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SMT group had statistically significant between group difference (experimental minus comparison) on NRS (1.5; 95% CI, 1.06 to 1.94), NDI (8.8; 95% CI, 6.21 to 11.39) , and GROC (2.0; 95% CI, 1.0 to 3.0)
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Thoracic spine thrust compared to non-thrust mobilization/manipulation in 1 RCT (n=60)
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Statistically significant mean differences between groups with respect to disability (NDI 10.03% on 0 to 100%; 95% CI, 5.3 to 14.7), pain (2.03% on 10-point NPRS; 95% CI, 1.4 to 2.7) and GROC( 1.5 on scale from -7 to 7; 95% CI, 0.48 to 2.5); clinically significant effect on pain (>2/10 on NPRS) and disability(>10% on NDI); no serious AEs reported

Persistent NAD grades I-II

2 RCTs concluded that type of mobilization did not impact outcomes
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First RCT (n=60); no difference in pain (VAS) or GPE between patients receiving one session of non-targeted mobilization of the cervical spine; no AEs reported
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Second RCT (n=60); statistically significant reduction in pain (VAS) in most painful movement in patients receiving central posterior-anterior cervical mobilization in comparison to randomly directed mobilization (9.2; 95% CI, 0.3 to 18.0) but not for global perceived recovery; no AEs reported
Efficacy of spinal manipulation is unclear from 2 RCTs
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First RCT (n=80); no difference in pain (NPRS) or disability (NDI) in patients receiving cervical and cervico-thoracic SMT in comparison to kinesiotape; no serious adverse events reported; 7.5% of SMT group experienced minor increase in neck pain or fatigue
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Second RCT (n=108); no statistically significant differences in VAS scores between patients receiving thoracic SMT in comparison to placebo thoracic SMT

Evaluation studies
Recent-onset NAD grades I-II

Cervical manipulation vs. mobilization; 1RCT (n=182); no statistically significant differences between groups with regards to pain(NRS), disability (NDI), time to recovery, health-related QoL(SF-12), GPE, and incidence of AEs; no serious neurovascular event reported; most common minor adverse events were increased neck pain (29.4%) and headache (22.0%)
Integrated neuromuscular inhibition technique (INIT) was compared to muscle energy technique (MET) in 1 RCT (n=60); statistically significant differences were reported with respect to pain (10cm VAS) and disability (NDI 0-50);
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Mean difference at 2 weeks (INIT minus MET): pain (0.73; 95% CI, 0.52 to 0.93) and disability ( 4.72; 95% CI, 2.76 to 6.68)
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Mean difference at 4 weeks (INIT minus MET): pain (0.98; 95% CI, 0.78 to 1.18) and disability( 4.75; 95% CI, 2.82 to 6.68)

Persistent NAD grades I-II

1 RCT (n=270); no statistically significant differences in patients receiving SMT with or without exercise; with respect to pain (NRS), disability (NDI), satisfaction, quality of life (SF-36), global perceived effect, and medication use at 12 and 52 weeks; transient mild non-serious adverse events reported in 98.9% of patients in ET +SMT group
*Long’s manipulation + Chinese massage vs. Chinese massage (1RCT; n=63); statistical significant difference between groups immediately post-treatment for pain and disability in patients with persistent ; no serious adverse events reported; 1 patient (3%) in Chinese massage group experienced increased pain
**1 RCT (n=64) compared massage (including Swedish and clinical massage and advice) to a self-care book; statistically significant effect favouring massage on symptom bothersomeness (MD 1.6 on 0-10 NRS; 95% CI, 0.7 to 2.5) and disability (0-50 NDI MD 2.1; 95% CI, 0.03 to 4.0) in the short-term (4 weeks) but not at 10 or 26 weeks; neck functional disability ( Copenhagen Neck Functional Disability Scale 0 - 30) and QoL(SF-36) were not statistically significant at any interval; medication use in self-care group increased by 14% from baseline; no serious adverse events reported; 9 patients reported mild adverse events from massage
1 RCT (n=61); compared cupping massage (CM) to progressive muscle relaxation; statistically significant difference in disability (-2.18 on 0-50 NDI; 95% CI, -4.56 to -0.21) and pain pressure threshold at site of maximum pain (63.55 kPa/s ; 95% CI, 6.33 to 121.56) in favour of CM; no statistically significant differences with respect to pain(VAS), days of interference, interference in daily life, depression (HADS), and QoL; three patients reported adverse events in CM group (muscular tension and pain; pain in shoulder area and prolapsed intervertebral disc [ serious but not related to the intervention])
In 1 RCT (n=81), no statistically significant differences were reported for pain(NPRS), disability (NDI), patient satisfaction and GROC when manual therapy interventions were combined with or without cervical traction

Adverse events

Manipulation, mobilization or traction - rate varied from 0% to 30%; majority were mild to moderate and transient; no serious neurovascular events reported
Soft tissue therapy - most AEs were mild and transient, one patient in cupping group suffered a prolapsed disc

Note:
* Long’s manipulation + TCM massage demonstrated statistically significant effects on pain and disability; summary of evidence reports statistically significant effect on pain but not on disability
** Evidence table demonstrates symptom bothersomeness not statistically significant in the long-term, contradictory to statement in the summary of evidence

“mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and other passive physical modalities (heat, cold, diathermy, hydrotherapy, and ultrasound) are not effective and should not be used to manage neck pain.”(p.1623)⁹Gross et al. 2015⁵Cervical Spine Manipulation
Manipulation vs. inactive control

3 RCTs on single session of manipulation; 1 RCT reported immediate pain relief; 2 RCTs reported no short-term benefit on chronic neck pain with radicular pain or headaches and patients with subacute or chronic neck disorders with associated cervical spondylosis
2 RCTs reported conflicting evidence on the effectiveness of multiple sessions of SMT for subacute and chronic neck pain

Manipulation vs. oral medication

Pain : 3 RCTs compared SMT with medications
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1 RCT; cervical SMT more effective than oral medication (NSAIDs, acetaminophen, opioids, and muscle relaxants) immediate post treatment (SMD -0.34; 95%CI, -0.64 to -0.05) and long-term follow-up (SMD -0.32; 95% CI, -0.61 to -0.02), but not at intermediate-term follow-up( SMD -0.21; 95% CI -0.5 to 0.08)
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2 RCTs on chronic neck pain found no statistically significant differences between groups at immediate post treatment (first RCT; Tenoxicam with ranitidine) and long-term follow-up ( second RCT; celaconxin, rofecoxib or paracetamol)
Function and Disability :
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For patients with acute and subacute neck pain; 1 RCT demonstrated manipulation may have benefit in the short and intermediate-term (SMD -0.30; 95% CI -0.59 to 0.00), but not long-term follow-up (SMD -0.11; 95% CI, -0.40 to 0.18) in comparison to NSAIDs, acetaminophen, opioids, and muscle relaxants
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2 RCTs found no difference between oral medication and SMT post treatment (first RCT; Tenoxicam with ranitidine) and in the long term (second RCT; Celaconxin, rofecoxib or paracetamol)
Global perceived effect(GPE) and patient satisfaction : 1 RCT reported SMT may be superior to oral medications (NSAIDs, acetaminophen, opioids, and muscle relaxants) for GPE and patient satisfaction at the long-term follow-up
QoL : No significant differences between manipulation and oral medication (NSAIDs, acetaminophen, opioids, and muscle relaxants) groups at immediate-, intermediate-, and long-term follow-up

Cervical Manipulation vs. mobilization and other manual techniques

Pain:
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2 RCTs on the effectiveness of a single session of SMT; one RCT reported immediate pain relief in comparison to MET and the other reported no significant difference with Activator instrument
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Multiple sessions of SMT was found to be no more effective than mobilization
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SMT was found to be more effective than massage in the short-term and intermediate-term follow-up
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Cervical SMT more effective than thoracic manipulation and combined thoracic and sacroiliac manipulation in the short-term
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No difference when comparing different number of sessions, different types of SMT or when comparing with instrument assisted SMT (Activator)
Function and disability:
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SMT no more effective than mobilization at short-term and intermediate-term follow-up;
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SMT more effective than massage and thoracic manipulation in the short-term and intermediate term
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Twelve SMT sessions in comparison to three provides immediate functional improvement in patients with chronic CGH
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SMT no more effective than activator SMT at any follow-up for patients with subacute and chronic neck pain
Global perceived effect: 2 RCTs showed no differences between SMT and or SMT and activator for GPE at any follow-up interval
Patient satisfaction: No differences between SMT and mobilization for patients with subacute and chronic neck pain
QoL: 2 RCTs demonstrated no significant differences between SMT and mobilization for subacute and chronic or SMT and activator for subacute neck pain

Manipulation vs. exercise or other physical therapy modalities

Pain:
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1 RCT showed no difference in pain relief between a session of SMT vs. one single use kinesiotape application in patients with subacute or chronic neck pain
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5 RCTs assessed multiple sessions of SMT;
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SMT no more effective than exercise at any follow-up interval
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No more effective than low-level laser for subacute and chronic neck pain; but effective when paired with low-level laser
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No difference between low-voltage electrical acupuncture in immediate-term or acupuncture in the long-term
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SMT more effective than TENS for cervicogenic headache in the shortterm
Function and disability:
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1 RCT ; single application of kinesiotape improved function ( SMD 0.46; 95 % CI 0.01 to 0.92) post treatment in comparison to SMT
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No differences found over exercise at any follow-up; low-voltage electrical acupuncture post treatment or acupuncture in the long-term
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Combination of SMT and low-level laser more effective in the short-term
GPE: 1 RCT reported no differences between SMT and HEA at long-term follow-up
Patient satisfaction:1 RCT reported SMT superior to home exercise for patients with acute or subacute neck pain at the long-term follow-up
QoL: No difference between SMT and home exercise at intermediate- and long-term follow-up

Thoracic Spine Manipulation
Thoracic spine manipulation vs. inactive control

Pain:
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1 RCT reported decreased pain in comparison to placebo SMT in patients with chronic neck pain; 2 RCTs reported no differences in comparison to inactive control and the same treatment in both arms
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7 RCTs assessed multiple sessions of thoracic SMT
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Immediate follow-up: 2 RCTs found positive effect on acute pain ( SMT -3.45; 95% CI, -4.13 to -2.79); 2 RCTs found no effect on chronic pain (SMT -0.23; 95% CI -1.15 to 0.69, I²=81%)
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Short-term follow-up: For acute and subacute neck pain , statistically significant effect (SMD -1.46; 95% CI -2.20 to -0.71; I² = 84%); similar effects on chronic neck pain
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Intermediate follow-up: 1 RCT reported benefits in favor of SMT group
Function and disability:
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1 RCT reported single session of thoracic SMT significantly effects function in patients with chronic neck pain
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4 RCTs were concerned with multiple sessions of SMT
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Immediate follow-up: 2 RCTs reported statistically significant effects for SMT on function/disability (SMD -0.52; 95% CI, -0.85 to -0.18) for chronic neck pain
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Short-term follow-up: 4 RCTs reported statistically significant effects on function for neck pain of all durations ( SMD -1.40; 95% CI, -2.24 to -0.55)
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Intermediate follow-up: 1 RCT favoured SMT for chronic neck pain
QoL : 1 RCT favoured SMT for chronic neck pain

Thoracic manipulation vs. mobilization

Pain: 1 RCT; single session of thoracic manipulation comparable to mobilization for chronic non-specific neck pain

Thoracic manipulation vs. exercise

Pain: 1 RCT reported no difference between 4 sessions of thoracic SMT and instructed exercise at long-term follow-up

Mobilization of Cervical Spine
Cervical mobilization vs. inactive control

Pain: 1 RCT reported no difference in pain when mobilization added to SMT in patients with chronic CGH or degenerative changes post treatment period; 1 RCT favoured inactive control group for patients with subacute /chronic WAD-II

Cervical mobilization vs. medical injection

For patients with neck pain with MFPS, 1 RCT reported mobilization using PNF was more effective than intramuscular lidocaine (SMD -1.05; 95% CI, -1.96 to -0.15) for pain relief, but no significant differences between groups for function

Mobilization of cervical spine vs. mobilization and other manual therapies

Pain:
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3 RCTs comparing a single session of one mobilization technique versus other mobilization techniques demonstrated no significant differences between groups for chronic neck pain
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7 RCTs compared multiple sessions of mobilization;
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Mobilization was found to be more effective than a massage regimen for chronic CGH in 1 RCT, but another found no difference when using effleurage, stroking and petrissage for chronic neck pain
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AP unilateral pressure was found to be more effective in the immediate relief in comparison with rotation or transverse;
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Mobilization was found to be no more effective than Activator for subacute neck pain at all follow-up intervals
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manual therapy to TMJ to in patients with TMJ and cervicogenic headache more effective than manual therapy to cervical spine;
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2 RCTs found no differences when mobilization versus manipulation as an adjunct to physical therapy modalities for subacute or chronic neck pain or MET for chronic neck pain
Function and disability:
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4 RCTs evaluated multiple sessions of mobilization vs. various manual therapies:
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3 RCTs reported no differences in comparison to massage or Activator
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One RCT reported manual therapy to TMJ was more effective than to cervical spine post treatment and intermediate-term in patients with TMJ and cervicogenic headache
Global perceived effect:
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2 RCTs; No significant differences in results when comparing different mobilization techniques in patients with chronic neck pain

Mobilization of cervical spine vs. exercise and other physical therapy modalities

Pain:
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No statistically significant differences were reported between one session of neural dynamic mobilization and pulsed ultrasound
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5 RCTs assessed the effects of multiple sessions of mobilization:
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No difference was found over acupuncture for subacute or chronic neck pain including WAD at long-term follow-up
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No difference over exercise for cervical radiculopathy in the immediate-term;
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No difference over TENS for chronic neck pain
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Possible benefit over extracorporeal shockwave therapy post treatment
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Chuna manual therapy more effective than cervical traction post treatment for disc herniation
Function and disability:
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No significant effect on function when compared to acupuncture, exercise, TENS, and shock wave therapy
Patient satisfaction : One RCT found no significant difference on TENS utilization at intermediate-term follow-up in patients with chronic neck pain
QoL: 1 RCT found no difference versus TENS utilization at immediate- and intermediate-term follow-up in patients with chronic neck and another found no difference in comparison to acupuncture at intermediate-term

Adverse events

AEs reported for manipulation and mobilization were benign and transient; they included neck pain, soreness, headache, stiffness, fatigue, dizziness, paresthesia etc.
No severe AEs were reported in any of the trials

“For individuals with acute/subacute neck pain, thoracic manipulation provided short-term neck pain relief, and for those with acute and chronic neck pain, it further improved function when contrasted with an inactive control.” (p.34)⁵

“For acute/ subacute neck pain, multiple sessions of cervical manipulation provided better pain relief and functional improvement than were attained with certain oral medications such as varied combinations of NSAIDs, analgesics, opioids and muscle relaxants at immediate-, intermediate- and long-term follow-up.”(p.34)⁵

“For individuals with acute and chronic neck pain, cervical manipulation versus mobilisation produced similar results in neck pain reduction, functional improvement, quality of life and global perceived effect at immediate-, short and intermediate-term follow-up. A similar pattern was observed when thoracic mobilisations were contrasted with thoracic manipulation techniques in chronic neck pain. (p.34)⁵

Wei et al. 2015¹⁷

SR included 4 SRs relevant to cervical radiculopathy
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One SR concluded that massage and manipulation may be safe and effective
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The second SR concluded manipulation and massage in conjunction or separate may be effective in treating cervical radiculopathy
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The third SR concluded manual therapies including manipulation, massage, mobilization and acupressure have statistically significant effects on cervical radiculopathy in the short-term, but not in the long-term
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Lastly, cervical SMT is more effective than cervical computer traction for pain in the immediate-term

“In conclusion, current systematic reviews showed potential advantages to CAM for CR in alleviating neck pain or related symptoms.”(p.7)¹⁷Cheng and Huang 2014¹¹Pain
Immediate-Term:

Massage demonstrated statistically significant immediate effect on pain relief in comparison to aggregated active and inactive therapies (SMD 0.49; 95 % CI, 0.07 to 0.92; 13 RCTS, n= 785)
- Massage showed significant effect in comparison to inactive therapies (SMD 1.30; 95% CI, 0.09 to 2.50; n =785) but not active therapies (SMD 0.21; 95% CI -0.22 to 0.64; n=632)
- Massage demonstrated statistically significant immediate effect over TCM ( SMD 0.73; 95% CI, 0.13 to 1.33; n=125)
- No statistically significant difference over traction (SMD 0.61; 95% CI, -0.09 to 1.30; n= 246)
- Acupuncture (SMD -0.52; 95% CI, -0.82 to -0.21; n= 171) and other manual therapies (SMD -0.51; 95% CI - 0.92 to -0.09; n=91) had statistically significant effects on pain relief over massage

Short-term:

No differences were found when massage was compared to acupuncture (SMD -0.10; 95% CI, -0.47 to 0.28; n=111) at 12 weeks and exercise (SMD 0.71; 95% CI, -0.28 to 1.70; n=17) at 6 weeks

Dysfunction
Immediate-term:

No statistically significant difference in NDI scores when compared to inactive therapies ( SMD 0.26; 95% CI, -0.09 to 0.62) or active therapies (SMD -0.7; 95% CI, -0.36 to 0.22)

Adverse Events

2 RCTs reported on AEs; low BP was experienced in 21% of participants in 1 RCT and 28% of participants in another reported mild AEs ( discomfort, pain, soreness, and nausea)

Note: This SR was included in Miake-Lye,¹⁰ but only the outcome of pain was included in the evidence map. Additionally, further details on subgroup analyses were not reported.

“this systematic review found moderate evidence of MT on improving pain in patients with neck pain compared with inactive therapies and limited evidence compared with traditional Chinese medicine due to few eligible studies. These are beneficial evidence of MT for neck pain. Assuming that MT is at least immediately effective and safe, it might be preliminarily recommended as a complementary and alternative treatment for patients with neck pain.”(p.11)¹¹Young et al. 2014²¹Thoracic manipulation vs. thoracic mobilization
1 RCT (n=60); manipulation group had statistically significant effects on pain, disability and perceived recovery at 2-4 day follow-up; no differences between groups with respect to number of side effects; AEs reported included muscle spasms, neck stiffness, headache and radiating symptoms.Thoracic manipulation

4 RCTs compared manipulation + modality vs. modality or modality/education group; thoracic manipulation was found to have statistically significant effects on pain reduction and range of motion
1 RCT comparing manipulation to a placebo intervention found statistically significant immediate pain relief in SMT group
2 studies examined exercise and manipulation
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The first study found statistically significant reductions in pain and disability in the short-term; disability in the long-term; perceived recovery at 4 weeks and 6 months for the manipulation group
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Second study reported only one of the ten patients reported statistically significant effects in function at 4 weeks and 6 months and 40% of patients had statistically significant pain reduction at 4 weeks
One study compared thoracic manipulation to cervical manipulation, but the SR only reported results for the thoracic SMT group: thoracic manipulation group had statistically significant decrease in pain level post treatment
2 studies compared a single session of thoracic SMT with exercise; one RCT reported statistically significant effects on pain and bilateral cervical rotation post treatment and the case series reported patients experienced post treatment pain relief
In comparison to exercise, the manipulation group in one RCT reported statistically significant reductions in pain at the one year follow-up
The prospective cohort study was a clinical prediction rule derivation study to determine patients with mechanical neck pain who are most likely to benefit from thoracic SMT; probability of perceived recovery increased to 93% if four of the criteria were met

Thoracic Mobilization

1 quasi-RCT demonstrated statistically significant effects on pain reduction, disability and muscle endurance in comparison to exercise

“As a result of methodological concerns associated with the current research on the use of thoracic mobilization in the treatment of mechanical neck pain, there is no definitive evidence to support its clinical efficacy. In contrast, there is a significant amount of evidence, although of varied quality, that exists to support the use of thoracic manipulation in the treatment of mechanical neck pain for short-term improvements in neck pain, range of motion, and disability.”(p.152)²¹