The combined effects of manual therapy and exercise on pain and related disability for individuals with nonspecific neck pain: A systematic review with meta-analysis

ABSTRACT

Background

Neck pain is among the most prevalent and costly musculoskeletal disorders. Manual therapy and exercise are two standard treatment approaches to manage neck pain. In addition, clinical practice guidelines recommend a multi-modal approach, including both manual therapy and exercise for the treatment of neck pain; however, the specific effects of these combined interventions have not recently been reported in the literature.

Objective

To perform a systematic review and meta-analysis to determine the effect of manual therapy combined with exercise on pain, disability, and quality of life in individuals with nonspecific neck pain.

Design

Systematic Review and Meta-Analysis

Methods

Electronic database searches were completed in PubMed, CINAHL, Cochrane, EMBASE, Ovid, and SportDiscus, with publication dates of January 2000 to December 2022. The risk of bias in the included articles was completed using the Revised Cochrane Risk of Bias Tool (RoB 2). Raw data were pooled using standardized mean differences and mean differences for pain, disability, and quality of life outcomes, and forest plots were computed in the meta-analysis.

Results

Twenty-two studies were included in the final review. With moderate certainty of evidence, three studies demonstrated no significant difference between manual therapy plus exercise and manual therapy alone in pain (SMD of −0.25 (95% CI: −0.52, 0.02)) or disability (−0.37 (95% CI: −0.92, 0.18)). With a low certainty of evidence, 16 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing pain (−0.95 (95%CI: −1.38, −0.51)). Similarly, with low certainty of evidence, 13 studies demonstrated that manual therapy plus exercise is significantly better than exercise alone for reducing disability (−0.59 (95% CI: −0.90, −0.28)). Four studies demonstrated that manual therapy plus exercise is significantly better than a control intervention for reducing pain (moderate certainty) (−2.15 (95%CI: −3.58, −0.73)) and disability (low certainty) (−2.39 (95% CI: −3.80, −0.98)). With a high certainty of evidence, four studies demonstrated no significant difference between manual therapy plus exercise and exercise alone in quality of life (SMD of −0.02 (95% CI: −0.21, 0.18)).

Conclusion

Based on this systematic review and meta-analysis, a multi-modal treatment approach including exercise and manual therapy appears to provide similar effects as manual therapy alone, but is more effective than exercise alone or other interventions (control, placebo, ‘conventional physical therapy’, etc.) for the treatment of nonspecific neck pain and related disability. Some caution needs to be taken when interpreting these results given the general low to moderate certainty of the quality of the evidence.

KEYWORDS:

• Neck pain
• disability
• manual therapy
• manipulation
• mobilization
• exercise

Acknowledgements

The authorship team would like to thank Amy Lapidow, Research & Instruction Librarian, Tufts University Health Sciences Library for her work with the electronic searches.

Disclosure statement

No potential conflict of interest was reported by the author(s).

PROSPERO registration

CRD42021286865

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10669817.2023.2202895

Additional information

Funding

This project was not supported by grant funding.

Notes on contributors

Mark Wilhelm

Mark Wilhelm PT, DPT, PhD, serves as the Director of Admissions and core faculty in the Doctor of Physical Therapy Program at Tufts University School of Medicine. He completed his Bachelor of Science in Exercise Science from the University of Akron, and his Doctor of Physical Therapy from Walsh University in Ohio. Dr. Wilhelm completed his Doctor of Philosophy in Rehabilitation Sciences from Texas Tech University Health Sciences Center. Dr. Wilhelm’s scholarship includes over 20 peer reviewed journal articles and he has co-authored two book chapters.

Joshua Cleland

Josh Cleland PT, PhD, FAAOMPT, FAPTA, is a professor and core faculty in the Doctor of Physical Therapy Program at Tufts University School of Medicine. He has published over 300 manuscripts in peer-reviewed journals and is an Editor for the Journal of Orthopaedic and Sports Physical Therapy. He is currently an author/editor on four textbooks, one of which has been published in nine different languages. Dr. Cleland is a well-known speaker at both the national and international levels and has delivered more than 225 keynote lectures and presentations in over 25 different countries. He is the recipient of numerous awards from the American Physical Therapy.

Anthony Carroll

Anthony Carroll PT, DPT, OCS, CSCS, FAAOMPT, serves as the assistant director of clinical education. Carroll is a board-certified orthopedic clinical specialist and fellow of the American Academy of Manual Physical Therapists. He has served as a clinical educator in various capacities since 2012, including developing and directing a Manual Fellowship Program, providing clinical training for DPT students, residents, and fellows. He has significant teaching experience in an entry-level DPT program and serving as faculty in both a Sports and Orthopedic Residency Program. In addition, he has experience as a site coordinator of clinical education and course coordinator for integrated clinical experiences. Clinically his expertise is in the treatment of spine and chronic pain disorders.

Mark Marinch

Mark Marinch PT, DPT completed his Bachelor of Science in Interdisciplinary Studies from Utah Tech University in St. George, Utah and his Doctor of Physical Therapy from Tufts University. He practices in Las Vegas.

Margaret Imhoff

Margaret Imhoff PT, DPT, graduated from the Doctor of Physical Therapy Program at Tufts University School of Medicine in December 2022. She completed her Bachelor of Science in Biology & Environmental Studies from Gonzaga University in Spokane, WA. Margaret’s scholarship includes previous peer reviewed journal article on high pressure diesel fuel before making her career change to physical therapy, where she now works as a PT at an outpatient clinic in Oregon.

Nicholas Severini

Nick Severini PT, DPT, CSCS, is a Performance Physical Therapist at SPARK Physiotherapy in Alexandria, VA. He completed his Bachelor of Science in Political Science from James Madison University and his Doctor of Physical Therapy from Tufts University in Boston.

Megan Donaldson

Megan Donaldson PT, PhD, FAAOMPT, is a Professor and serves as the Department Chair of Rehabilitation Sciences at the Medical University of South Carolina. She completed her bachelor’s and master's degrees at D’Youville College and her PhD from Nova Southeastern University and is a Fellow American Academy of Orthopaedic Manual Physical Therapists. She has been a faculty member for 15 years and has over 40 peer-reviewed publications, two book chapters, presents nationally on musculoskeletal health and manual therapy related topics. She currently serves nationally as the American Physical Therapy Association (APTA) as an Ohio Delegate and serves the Ohio Chapter as an Executive Board member. Dr. Donaldson has earned numerous awards for research, education, and professional service to include being named Ohio Physical Therapy Association Outstanding PT Award, and Chamber of Commerce Award Top 20 under 40.