Key messages

• A combination of manual therapy with exercise may show a moderate increase in function, but little or no reduction in neck pain when compared against a placebo (sham) treatment.

• The combination of manual therapy with exercise may result in a large reduction in neck pain and a moderate increase in function and health-related quality of life when compared against no treatment.

• There may be little or no difference in non-serious adverse (unwanted or harmful) events, such as treatment soreness, headache, or dizziness.

What is neck pain?

Neck pain is a common condition that can be disabling and leads to substantial economic costs. Symptoms can be acute (< 4 weeks), subacute (4 to 12 weeks), or persisting (> 12 weeks). Neck pain can cause weakness or numbness in the arms and may include referral of pain to the head, upper back, and arms. Neck pain can stem from bones, joints, nerves, muscles, or soft tissues, and be influenced by social, psychological, and personal factors.

How is neck pain treated?

Treatment for neck pain includes manual therapy combined with exercise. Manual therapy consists of hands-on techniques used to mobilise or manipulate soft tissues, joints, or nerves. The exercise component may include stretching, strengthening, motor control, cardiovascular, and mind-body exercises (e.g. yoga).

What did we want to find out?

We wanted to know the benefits and risks of manual therapy with exercise.

What did we do?

We searched for studies that examined manual therapy with exercise compared with a placebo treatment or no treatment in adults with neck pain. We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods, consistency of findings, and study sizes.

What did we find?

We found nine studies that involved 694 adults. Studies took place in North America, Europe, Asia, and the Pacific.

Manual therapy with exercise versus placebo treatment at short-term follow-up (closest to four weeks).

• Pain (9% actual benefit): People who use manual therapy with exercise may show little to no improvement of 0.91 points on a 0- to 10-point scale, where a lower score means less pain.

• Function (10% actual benefit): People who use manual therapy with exercise may improve by 10.20 points on a 0- to 100-point scale, where a lower score means better function.

• Health-related quality of life (2% actual benefit): People who use manual therapy with exercise may show little to no improvement of 2 points on a 0- to 100-point scale, where a lower score means better quality of life.

• Participant-reported treatment success and adverse events were not reported.

Manual therapy with exercise versus no treatment for short-term follow-up.

• Pain (24% actual benefit): People who use manual therapy with exercise may improve by 2.44 points on a 0- to 10-point scale, where a lower score means less pain.

• Function (14% actual benefit): People who use manual therapy with exercise may improve by 13.84 points on a 0- to 100-point scale, where a lower score means better function.

• Health-related quality of life (24% actual benefit): People who use manual therapy with exercise may improve by 24.80 points on a 0- to 100-point scale, where a lower score means better quality of life.

• Participant-reported treatment success had very uncertain evidence when using manual therapy with exercise.

• Non-serious adverse events: There was a 2% increase in risk of non-serious transient adverse events such as soreness, headache, or dizziness. This means 2 out of 100 people reported non-serious adverse events in the treatment group and 1 out of 100 people reported non-serious adverse events in the no treatment group.

• Serious adverse events were not reported.

What are the limitations of the evidence?

Our confidence in the evidence was low for the following reasons. It is possible that people in the studies were aware of which treatment they were getting. However, this is a limitation that can't be changed in most rehabilitation studies. Reporting of outcomes of interest at short-term and long-term follow-up was incomplete across studies. These biases may have resulted in either an over or underestimation of the size of the effect reported. The occurrence of adverse events was not commonly reported. The number of participants in most studies was small. Focused planning of studies with larger numbers of participants and consistent reporting of type, intensity, frequency, and duration of manual therapy with exercise is needed. Future studies are needed on acute and subacute neck pain due to uncertainties in the currently available evidence.

How up-to-date is this evidence?

This review updates our previous non-Cochrane review. The evidence is current to March 2025.