Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Non-specific chronic neck pain is a prevalent musculoskeletal dysfunction commonly described as pain in the lateral or posterior aspect of the neck. Neck pain acquires the label of chronicity when the duration of painful symptoms last longer than 12 weeks. Non-specific chronic neck pain (NCNP) has generated a substantial socioeconomic burden, as the number of prevalent cases of neck pain worldwide was estimated to be 288.7 million in 2015. The recurrence, progression, and underlying mechanisms for non-specific chronic neck pain are not well understood in the available evidence-based literature. However, many clinicians have theorized that NCNP may be associated with a deficiency in the proprioceptive abilities of the neck muscles; these muscles play a decisive role in the cervical joint position and motor control of the head.

There have been numerous studies conducted to evaluate the clinical efficacy of manual therapy and therapeutic exercise on patients with non-specific chronic neck pain. However, few research articles have appraised the time of action along with duration of effects for both manual therapy and therapeutic exercise. Manual therapy is known to reduce inflammatory biomarkers and alter activity in the pain processing centers of the brain, whereas therapeutic exercise assists with proper motor pattern reorganization along with structural adaptations to increase muscular strength. The aim of this randomized controlled trial was to compare the effects of these two different treatments for patients with NCNP in different stages of follow-up appointments.

Inclusion criteria for the study required participants between the ages of 18 and 50, with current neck pain that has continued for the past 12 weeks. Participants could only receive their assigned treatment of either manual therapy or therapeutic exercise and were prohibited from combining their assigned treatments with pharmacological adjuncts. A total of 65 participants completed the randomized controlled trial with 22 participants in the manual therapy group, 23 participants in the therapeutic exercise group, and 20 participants in the control group (sham treatment). There were numerous major outcomes analyzed in this study: pain levels using the Visual Analog Scale (VAS), pain pressure threshold (PPT), and level of neck disability utilizing the Neck Disability Index (NDI).

The treatment for the manual therapy group consisted of high thrust manipulation to the upper thoracic spine, mobilization of the upper cervical spine, and providing gentle distraction force to inhibit overactive suboccipital muscles of the neck. The treatment for the therapeutic exercise group consisted of exercises that focused on increased motor recruitment of the deep cervical neck flexor muscles. This therapeutic exercise group then progressed to isometric co-contraction exercises of the deep and superficial neck flexors, finally ending with eccentric motor recruitment of necks flexors and extensors in the final stage of their protocol. Patients assigned to the control group received treatment 1 (manual therapy) or 2 (therapeutic exercise) after completing the study.

The results of this study showed clear clinical efficacy for the therapeutic exercise and manual therapy treatment groups in comparison to the control group for patients with non-specific chronic neck pain. The researchers found that the level of neck disability in patients, measured through the Neck Disability Index (NDI), was more immediately reduced in the therapeutic exercise group compared to the manual therapy group. However, the manual therapy group created a more immediate reduction in patient’s painful symptoms measured through the VAS pain scale and pain pressure threshold.

Clinical Application:

Therapeutic exercise may help to reduce cervical disability in the short term before manual therapy, whereas manual therapy may help reduce pain perception in the short term before therapeutic exercise. This trend should be taken into consideration when crafting a treatment plan for patients with NCNP. However, an evidence-based, multimodal approach combining manual therapy, therapeutic exercise, and pain education could be the best therapeutic weapon for subjects with nonspecific chronic neck pain.


Bernal-Utrera C, Gonzalez-Gerez JJ, Anarte-Lazo E, Rodriguez-Blanco C. Manual therapy versus therapeutic exercise in non-specific chronic neck pain: a randomized controlled trial. Trials. 2020;21(1):682. Published 2020 Jul 28. doi:10.1186/s13063-020-04610-w