Exercises Or Manual Therapy Better For Persistent Neck Pain?

Neck exercise

Assuming you have persistent neck pain, would you prefer to very diligently do 13 exercises (pictured above) or would you prefer to have a physiotherapist treat you with hands on manual therapy? 

Manual therapy

Research by (Villanueva-Ruiz et al, 2025) shows that both help patients with chronic neck pain. Manual therapy in this case refers to both myofascial and joint mobilization techniques (Guo et al, 2022 and Zabala-Mata et al, 2024). Please read on for a twist at the end. 

The authors randomly allocated 65 patients with non specific chronic neck pain into a manual therapy or exercise group. They received 4 treatment sessions of either performing 13 specific neck exercises with supervision (plus home exercises) or manual therapy once a week for 4 weeks.

The following outcomes were measured at baseline, 2, 4 and 12 weeks post treatment. Pain intensity, disability, quality of life, patient-perceived improvement, fear of movement and also the cranio-cervical flexion test (CCFT). 

Patients were also categorized into responders or non-responders according to their pain intensity, disability and their perceived improvement at 4 and 12 weeks post treatment. Commitment to exercise was also recorded.

After reading so far, which group do you think fared better? Note that both groups of patients had 'general physio' before and not gotten better.

Ready for the results? The manual therapy group had much more responders than the exercise group at all follow up periods. Treatment outcome in the exercise group was linked to exercise adherence. So manual therapy is more effective? Here's the twist.

When the researchers looked only at patients who were ≥ 95 percent diligent at doing their home exercises (60 percent of the exercise group), the treatments were equal. 

So, a 4 week manual therapy intervention was more effective than exercises for chronic neck pain patients. However, when exercise adherence was ≥ 95 percent, both interventions were equally effective.

Manual therapy may be superior to doing strengthening exercises for chronic neck pain when patients are not able or not motivated to do their home exercises.

For healthcare professionals whose patients are motivated and are likely to do their strengthening exercises then you can dole out the exercises out and send videos to aid them. For patients who are not compliant with the exercises perhaps due to challenging home or work situations, then manual therapy is evidenced based and effective.

References

Villanueva-Ruiz I, Falla D, Saez M et al (2025). Manual Therapy And Neck-Specific Exercise Are Equally effective For Non-Specific Neck Pain But Only When Exercise Adherence Is Maximized: A Randomized Controlled Trial. Musc Sci Pract.77: 103319. DOI: 10.1016/j.msksp.2025.103319