Which is better for Neck Pain Manual Therapy or Exercise Therapy?

1 Much like back pain, neck pain runs an episodic course, often spanning an individual’s life.2,3 The episodic disability caused by neck pain levies high indirect costs in terms of participation in activities and work.4 It is important to recognise that patients who present neck pain complaints to primary care practitioners usually are prone to recurrence, and that watchful waiting for the episode to end is unlikely to save direct or indirect costs long-term. Treatments to minimise recurrence will do more to protect patients, but which treatments have the highest success rates?

             To explore this question, Ruud Groeneweg and colleagues published a study last April in which exercise therapy was compared to manual therapy. Their study spanned sixteen practices, involved 44 treating clinicians, and treated 181 patients who were mostly referred by general practitioners. Patients ranged in age from 18 to 70 and experienced neck pain for 2 to 52 weeks. The exercise therapy group received physiotherapist-supervised, individualised treatments including strengthening, stretching, manual traction, and massage (but excluding manual mobilisation of the spine). The manual therapy group received treatments according to the Manual Therapy Utrect protocol, which is comparable to grade III mobilisations and to Maitland technique. The manual therapy involved individual assessment to determine prescribed movements and low-velocity, low-intensity, passive joint movements within the joint range of motion. Movements are repeated about six times. All joints of the spine, pelvis, and extremity are mobilised.

             Researchers found the difference between outcomes not clinically significant. When measuring success as a clinically important change in the neck disability index at 52 weeks, the manual therapy group experienced a 60.5% success rate compared to exercise therapy’s 63.1% success rate, with a statistical significance of 0.63. The authors conclude that both manual therapy alone and exercise therapy alone are effective and equally cost-efficient. Their study suggests that the decision between the two would be a matter of personal preference. This conclusion would be somewhat limited in generalisability, because some manual therapy clinicians may practice high-velocity, low-amplitude manipulations which were not available to patients in the current study.

             In addition, and perhaps more importantly, this study may be setting up a false dichotomy. There is a third option to be explored. Would combining this manual therapy or other manual therapies with exercise therapy produce results superior to stand-alone therapies? The answer appears to be “yes.” An earlier systematic review finds that the evidence supports a combined approach of exercise therapy plus mobilisation or manipulation.5 Multiple studies in the review found that adding exercise therapy to manual therapies created additional benefits over either approach in isolation. Additionally, manual therapy, exercise therapy, or a combined approach each provide better outcomes than analgesics and advice, especially at long-term assessments. For clinicians referring to therapists for neck pain, the takeaway message is that best results can be achieved by referring to programs that offer a combined approach rather than an exclusively hands-on or hands-off approach.