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

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

Review a Point-by-Point Analysis of this Study

FROM: Ann Intern Med 2002 (May 21);   136 (10):   713–722

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. Jan.Hoving@med.monash.edu.au


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 therapy cannot 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 .”

Return to the NECK PAIN Section

Return to the ARTICLES OF INTEREST Page

Return to the COST-EFFECTIVENESS Section

Return to the CHIROPRACTIC RESEARCH ARTICLES Page

Since 9-05-2002