Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial


Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial

Jan Lucas Hoving, PT, PhD; Bart W. Koes, PhD; Henrica C.W. de Vet, PhD;
Danielle A.W.M. van der Windt, PhD; Willem J.J. Assendelft, MD, PhD;
Henk van Mameren, MD, PhD; Walter L.J.M. Devillé, MD, PhD; Jan J.M. Pool, PT;
Rob J.P.M Scholten, MD, PhD; and Lex M. Bouter, PhD

Department of Clinical Epidemiology,
Cabrini Hospital,
Victoria, Australia.


BACKGROUND:   Neck pain is a common problem, but the effectiveness of frequently applied conservative therapies has never been directly compared.

OBJECTIVE:   To determine the effectiveness of manual therapy, physical therapy, and continued care by a general practitioner.

DESIGN:   Randomized, controlled trial.

SETTING:   Outpatient care setting in the Netherlands.

PATIENTS:   183 patients, 18 to 70 years of age, who had had nonspecific neck pain for at least 2 weeks.

INTERVENTION:   6 weeks of manual therapy (specific mobilization techniques) once per week, physical therapy (exercise therapy) twice per week, or continued care by a general practitioner (analgesics, counseling, and education).

MEASUREMENTS:   Treatment was considered successful if the patient reported being “completely recovered” or “much improved” on an ordinal six-point scale. Physical dysfunction, pain intensity, and disability were also measured.

RESULTS:   At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy, and 35.9% for continued care. Statistically significant differences in pain intensity with manual therapy compared with continued care or physical therapy ranged from 0.9 to 1.5 on a scale of 0 to 10. Disability scores also favored manual therapy, but the differences among groups were small. Manual therapy scored consistently better than the other two interventions on most outcome measures. Physical therapy scored better than continued care on some outcome measures, but the differences were not statistically significant.

CONCLUSION:   In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.


Point by Point Review


Thanks to Dan Murphy, D.C. for contributing this summation:

1.   “Manual therapy was more effective than continued physician care, and our results consistantly favored manual therapy on almost all outcome measures.”

2.   “Although physical therapy scored slightly better than continued physician care, most of the differences were NOT statistically significant.”

3.   “The postulated objective of manual therapy for the restoration of normal joint motion was achieved, as indicated by the relatively large increase in range of motion of the cervical spine.”

4.   This study confirms Koes study (1992) that “manual therapy and physical therapy are superior to continued physician care.”

5.   “In the physical therapy and manual therapy groups, the hands-on approach, frequent visits, and opportunities for intensive patient-therapist interaction may have contributed to the observed [superior] effects.”

6.   “The differences in effect between the physical therapy and manual therapy groups, however, suggest that the superiority of manual therapycannot be explained by nonspecific effects alone.”   WOW!

7.   “In our study, mobilization, the passive component of the manual therapy strategy, formed the main contrast with physical therapy OR continued physician care, and was considered to be the most effective component.”   WOW! This is very important, because since the 1993 Mercy Document, passive care has been criticised as leading to “physician dependence”, while this study showed the superiority of passive treatment over the active treatment components!

8.   “The physical therapy patients achieved significantly worse success rates while using twice the number of patient visits as the manual therapy group!”   If you tend to question this conclusion, please note that the principal author of this study is a physical therapist!

9.   “The physical therapy provided was primarily active exercise, while the manual therapy was primarily passive joint mobilization (the first component of spinal adjusting/manipulation).”

10.   “The manual therapy group had no patients worse after 3 weeks of treatment, whereas the physician care group scored 9/64 worse, or 14% worse.”

11.   Finally, “Primary care physicians should consider [referral for] manual therapy when treating patients with neck pain .”


A Summary of the Study from the Annals of Internal Medicine


Manual Therapy, Physical Therapy, or Care by Primary Care Doctors for Patients with Neck Pain

21 May 2002 | Volume 136 Issue 10 | Page I36

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The summary below is from the full report titled “Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain. A Randomized, Controlled Trial.” It is in the 21 May 2002 issue of Annals of Internal Medicine (volume 136, pages 713-722). The authors are JL Hoving, BW Koes, HCW de Vet, DAWM van der Windt, WJJ Assendelft, H van Mameren, WLJM Devillé, JJM Pool, RJPM Scholten, and LM Bouter.

What is the problem and what is known about it so far?


Neck pain is common and can interfere with daily activities. Neck pain usually goes away without treatment, but patients often seek treatment to speed recovery. Treatments include pain medications, rest, manual therapy, and physical therapy. In manual therapy, a trained therapist moves a patient’s neck in specific ways to help improve neck mobility. In physical therapy, a trained therapist assists patients with exercises to improve neck mobility. The main difference between manual therapy and physical therapy is that the therapist moves the patient in manual therapy, while physical therapy requires the patient to do exercises. The best treatment for neck pain is not known.

Why did the researchers do this particular study?


To compare the effectiveness of three treatments for neck pain: routine care by a doctor (rest and medication), manual therapy, or physical therapy.

Who was studied?


183 adults who had had nonspecific neck pain for at least 2 weeks. Nonspecific means that the neck pain was due to strain of muscles and joints rather than to some serious problem such as a broken bone. Forty-two primary care doctors in the Netherlands referred patients to the study.

How was the study done?


The researchers used a computerized coin flip to assign patients to treatment with manual therapy, physical therapy, or continued care by their doctor. One of 6 manual therapists performed the manual therapy for 45 minutes, once per week, for up to 6 weeks. One of 5 physical therapists performed the physical therapy for 30 minutes, twice per week, for up to 6 weeks. The doctors used medications to treat pain and inflammation and gave advice about rest, hot compresses, and home exercises. All patients were allowed to use home exercises, nonprescription medicines, or medicines their doctors had prescribed before referring them to the study. Seven weeks after beginning treatment, patients rated their neck pain on a scale from “much worse” to “completely recovered.” The researchers compared the number of patients in each group who reported feeling “much improved” or “completely recovered.”

What did the researchers find?


In the manual therapy group, 68.3% of patients felt “much improved” or “completely recovered” compared with 50.8% of patients in the physical therapy group and 35.9% of doctor-treated patients. The differences between manual therapy and either physical therapy or treatment by a doctor were large enough to prove that there were true differences between the groups. The results suggested that physical therapy might also be better than treatment by a doctor, but the study was too small to prove this.

What were the limitations of the study?

The results could be different with different therapists or doctors.

What are the implications of the study?

Doctors should consider referring patients with neck pain to manual therapy.

Related articles in Annals:

Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain: A Randomized, Controlled TrialJan Lucas Hoving, Bart W. Koes, Henrica C.W. de Vet, Danielle A.W.M. van der Windt, Willem J.J. Assendelft, Henk van Mameren, Walter L.J.M. Devillé, Jan J.M. Pool, Rob J.P.M Scholten, and Lex M. Bouter

Annals 2002 136: 713-722. (in ) [Abstract] [Summary] [Full Text]