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

Stationary Cycling Just As Good As Pilates For Chronic Low Back Pain?

The Pilates instructors reading this post along with those of you who do Pilates aren't gonna like me a lot, not with a heading like the one above. But before you get upset, please let me be clear, I have nothing against anyone doing Pilates or any Pilates instructors. I'm just sharing what I read from a published study.

This study compared the effects of specific trunk exercises (or Pilates) versus stationary cycling on subjects with chronic non specific low back pain. 

One group was randomized to undergo specific trunk exercises (SEG) for 8 weeks while the other group did stationary cycling (CEG). The SEG group performed Pilates with attention to muscle control, posture and breathing. 

THE CEG group were informed that they were performing a style of cycling called Pilates Pedal. This is to reduce bias so that their group will not wonder why their exercise program did not include trunk specific exercises. Look at the diagram below, you will see that the CEG group just did a mixture of mixed resistance cycling and no core exercises.

Pain was reduced in both groups after exercises compared to the start of the study. Even though disability was significantly lower in the SEG group compared to the CEG group after 8 weeks, the overall data pattern suggested no long term differences between both groups 6 months later.

Fear-avoidance beliefs (FAB) or activity avoidance behavior scores were lower in the SEG group at 8 weeks only, the CEG group had lower FAB scores at 6 months.

The authors concluded that an 8-week supervised group of Pilates had only better short term but not long term clinically meaningful improvements compared to stationary bike cycling.  

If a patient with chronic non specific low back pain stick to either Pilates or stationary cycling (or any exercise program  for that matter), similar improvements will be achieved as long as a minimal level of adherence is maintained.

If you look in detail at the baseline scores for pain and disability, you will notice they were mild to moderate. Hence, results from this study may not be transferable to those with severe back pain and disability.

Pilates or stationary bike cycling (or any general exercise), your choice really, as along as you stick to it, will help with your recurrent low back pain. Find exercises you enjoy and keep at it.

Reference

Marshall PWM, Kennedy S, Brooks C et al (2013). Pilates Exercise Or Stationary Cycling For Chronic Nonspecific Low Back Pain. Does It Matter? A Randomized Controlled Trial With 6-Month Follow-up. Spine. 38(15): 952-959. DOI: 10.1097/BRS.0b013e318297c1c5.

*thanks to Byron Tan who got me the article. Email me if you like to have a look at the article

Transverse Abdominis and Low Back Pain

I remember being a second year physiotherapy student in the early 90's when we had a special tutorial on how to assess and strengthen the Transverse Abdominis (TA). While in crook lying, you move your leg (bent knee fall out), leg straightening etc and had to maintain the TA contraction.

This was just before a young Paul Hodges and his supervisor Carolyn Richardson (both very famous physiotherapists) published his article on the TA. His research compared the timing of TA and Multifidus in people with low back pain (LBP) for 18 months or more against healthy subjects with no LBP.

Using fine wire and surface EMG, the participants had to move their leg or shoulder and their timing of TA and Multifidus muscles measured. Those with LBP had delayed activation of their TA/ Multifidus.

Hodges suggested that the TA was the likely to be the main cause of LBP as it is the most important and deepest muscle in the abdomen. It looks and works like a corset to stabilise the back.

This article made the allied healthcare/ fitness industry conclude that the TA was a trunk stabilising muscle that was very important to strengthen for those with LBP. Patients who had LBP had weaknesses in their TA which led to instability in the spine.

Because of Hodges' research, many other research on LBP went in that direction. However, out of the seven systematic reviews found, six of them now showed no increase in benefit in such TA based exercises over general exercises. Further research is probably not going to significantly alter this.

As I wrote last week, this early work by Hodges, Richardson and Gwen Jull was quickly adopted by the fitness industry (though Joseph Pilates never intended this). The Allied Health/ Physiotherapy community started assessing the TA via palpation, ultrasound etc and coming up with various rehabilitation exercises for it as well. There are various continuing education courses teaching this approach still.

Although research says this may help, it is no better than general graded exercise and we know that LBP is also associated with obesity and mental health (Maher et al, 2016).

There is even research advising those who have been trained to brace/ hollow their 'core' should be discouraged from doing this as this may create abnormal movement patterns creating more stress on the spine (Lederman et al, 2010).

Brace or hollow your core?

So rather than getting our patients to feel for a deep muscle (like the TA and Multifidus) in a low load movement, it would make more sense for us to get patients to do an exercise/ activity they enjoy that gives them similar benefits.


References

Hodges PA and Richardson CA (1998). Delayed Postural Contraction Of Transversus Abdominis In Low Back Pain Associated With Movement Of The Lower Limb. J Sp Disorders. 11(1): 46-56.

May S and Johnson R (2006). Stabilisation Exercises For Low Back Pain: A Systematic Review. Physiotherapy. 94(3): 179-189. DOI: 10.1016/j.physio.2007.08.010

Maher CG, Underwood M et al (2016). Non-specific Low Back Pain. The Lancet. 389(10070): 736-747. DOI: 10.1016/S0140-6736(16)30970-9

Lederman E (2010). The Myth Of Core Stability. J of Bodywork, Mvt Ther. 14(1); 84-98. DOI: 10.1016/jbmt.2009.08.001

Saragitto B, Maher CG et al (2016). Motor Control Exercise For Nonspecific Low Back Pain. A Cochrane Review. Spine 41(16): 1288-1295. DOI: 10.1097/BRS.0000000000001645

10 Helpful Facts About Low Back Pain

Favia Dubyk on her hangboard

Last week I discussed the myths about low back pain (LBP). This week I will write about 10 helpful facts about LBP once anything sinister and serious pathology are excluded. A positive mindset regarding LBP definitely helps with lower pain levels, disability and seeking healthcare.

Fact 1: LBP is not a serious life-threatening condition.

Fact 2: Most episodes of LBP improve and LBP does not get worse as we age.

Fact 3: A negative mindset, fear-avoidance behavior, negative recovery expectations, and poor pain coping behaviors are more strongly associated with persistent pain than is tissue damage.

Fact 4: Scans do not determine prognosis of LBP, the likelihood of future LBP disability, and do not improve LBP clinical outcomes.

Fact 5: Graduated exercise and movement in all directions is safe and healthy for the spine.

Fact 6: Spine posture during sitting, standing and lifting does not predict LBP or its persistence.

Fact 7: A weak core does not cause LBP, and some people with LBP tend to overtense their core muscles. while it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren't needed.

Fact 8: Spine movement and loading is safe and builds structural resilience when it is graded.

Fact 9: Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.

Fact 10: Effective care for LBP is relatively cheap and safe. This includes: education that is patient-centered and fosters a positive mindset, and coaching people to optimize their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment.

There you have it. Quite different from what you have been told, read or heard. We seek to help patients confidently take up different postures, movement, graded loading physical activity, social and work engagement so you can live healthily. There are free educational resources to support these processes if you do have low back pain and have not seen us in our clinics.

You can watch this Youtube video or visit this site for more details. This will help reduce stress and build self sufficiency for you to better self mange your LBP and make better informed choices about your care.

In my next post, I will address how strengthening your 'core' (Transverse Abdominis and Multifidus) muscles was rapidly adopted by the Pilates, Physiotherapy and fitness community and if we should continue down that path.


References

Lin I, Wiles L, Waller R et al (2019). What does Best Practice care for Musculoskeletal Pain Look Like? Eleven Consistent Recommendations From High-quality Clinical Practice Guidelines: Systematic Review. BJSM. DOI: 10.1136/bjsports-2018-099878

O' Sullivan PB, Caneiro JP et al (2019). Back To Basics: 10 Facts Every Person Should Know About Back Pain. BJSM. DOI: 10.1136/bjsports-2019-101611.

Shoulder Pain From Swimming? Treat Your Neck

Yes, your shoulder pain is coming from your neck

I had a really interesting case this past week. A patient who's an elite swimmer comes in to our clinic complaining of shoulder pain.

An ultra sound scan and MRI that was done confirms the diagnosis of shoulder subacromial impingement (usually the tendon of the supraspinatus muscle gets irritated from hand above head activities under the acromium).

The doctor my patient saw the the Singapore Sports Institute suggested a steroid (or cortisone) injection to "solve the problem".

R shoulder impingement

Well, the Physiotherapists reading this must be thinking "yeah, what's the big deal". All elite swimmers (or athletes involved with overhead sports like badminton, tennis etc) always get shoulder pain from subacromial impingement at some point of other in their sporting career.

Well, here's the thing, I got the swimmer better just be treating the swimmer's neck. This swimmer did not have any neck pain or signs of nerve root irritation.

I've seen other cases of shoulder impingement when the patient had obvious clues suggesting it was the neck and/ or nerve root irritation causing the shoulder impingement.

This swimmer did not have any neck pain or nerve root irritation signs. The patient did have a forward head posture which can contribute to a C5 nerve root involvement.

Similar to the article referenced below, the swimmer got better very quickly just by cervical retraction, as taught by Gwen Jull. Of course treatment also included other things and not just cervical retraction.

My swimmer went back to full training in three days with no recurrence of symptoms. Good thing my patient said no to the steroid or cortisone injection.

Reference

Pheasant S (2016). Cervical Contribution To Functional Shoulder Impingement: Two Case Reports. Int J Sports Phys Ther. 1196): 980-991.

Treat Your Chronic Neck Pain

Women keep saying that we men don't get it, well that's quite true in some cases. We've written before on why women get neck pain (take a look at the video too).

A sustained forward flexion (or poke chin) posture is associated with increased cervical (neck) compressive loading and creep response (or deformation) in the connective tissue.

Here's more evidence from Australian researchers that people with chronic neck pain demonstrated a reduced ability to keep an upright posture when distracted. This means you may start sitting in your office chair with a good posture but your posture deteriorates when you get distracted (e.g. when your boss calls you or when your workload piles up).

58 female subjects with greater than 3 months on chronic neck pain (and 10 control subjects with no pain) participated in the study. Changes in the participants' cervical and thoracic (neck and upper back) posture were measured every 2 minutes during a 10 minute computer task.They were then split in two different exercise groups.

One group received training of the cranio-cervical flexor muscles - picture below (CCF, for which renowned neck researcher Gwen Jull is known for) while the other group received endurance-strength training of the superficial cervical flexor muscles.

Longus Colli and longus Capitis (from Wikipedia)

The researchers showed that after an exercise program targeted at training the deep neck flexors (CCF), people with chronic neck pain demonstrated an improved ability to maintain a neutral neck posture with prolonged sitting.

So here's why you should come to either of our clinics if you have neck pain. Aized has trained under Gwen Jull and she can definitely help you with your neck pain.

Reference

Falla, D Jull G et al (2007). Effect Of Neck Exercise On Sitting Posture In Patients With Chronic Neck Pain. Physical Therapy 87(4) : pg 408-417.

* Thanks to Ming and Dew for helping me get the article.