Annals of Internal Medicine 2002 (May 21); 136 (10): 713–722 ~ FULL TEXT
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,
In this randomized, controlled trial, researchers compared the effectiveness of manual therapy, physical therapy (PT) and continued care by a general practitioner (GP) in patients with nonspecific neck pain. The success rate at seven weeks was twice as high for the manual therapy group (68.3 percent) compared to the continued care group (general practitioner). Manual therapy scored better than physical therapy on all outcome measures. Additionally, patients receiving manual therapy had fewer absences from work than patients receiving physical therapy or continued care. The magnitude of the differences between manual therapy and the other treatments (PT or GP) was most pronounced for perceived recovery.
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.
From the FULL TEXT Article:
Neck pain is a common problem in the general population,
with point prevalences between 10% and
15%. [1–3] It is most common at approximately 50 years of age and is more common in women than in
men. [1, 2, 4–6] Neck pain can be severely disabling
and costly, and little is known about its clinical course. [7–9] Limited range of motion and a subjective feeling
of stiffness may accompany neck pain, which is often
precipitated or aggravated by neck movements or sustained
neck postures. Headache, brachialgia, dizziness,
and other signs and symptoms may also be present in
combination with neck pain. [10, 11] Although history
taking and diagnostic examination can suggest a potential
cause, in most cases the pathologic basis for neck
pain is unclear and the pain is labeled nonspecific.
Conservative treatment methods that are frequently
used in general practice include analgesics, rest, or referral
to a physical therapist or manual therapist. [12, 13]
Physical therapy may include passive treatment, such as
massage, interferential current, or heat applications, and
active treatment, such as exercise therapies. Physical
therapists can specialize in passive manual (or “handson”)
techniques, including mobilization or manipulation
(high-velocity thrust techniques), also referred to as
manual therapy. [14–19]
According to the International
Federation of Orthopedic Manipulative Therapies, “Orthopedic
manipulative (manual) therapy is a specialization
within physical therapy and provides comprehensive
conservative management for pain and other
symptoms of neuro-musculo-articular dysfunction in
the spine and extremities” (unpublished data). Today,
many different manual therapy approaches are applied
by various health professionals, including medical doctors,
physical therapists, massage therapists, manual
therapists, chiropractors, and osteopathic doctors. Reviews
of trials involving manual therapy or physical therapy
show that most interventions in these categories are
characterized by a combination of passive and active
components. [20–23] Although a combination of manual
therapy or physical therapy that includes exercises
appears to be effective for neck pain, these therapies
have not been studied in sufficient detail to draw firm
conclusions, and the methodologic quality of most trials
on neck pain is rather low. [20–23]
Koes and colleagues [24, 25] performed a randomized
trial on back and neck pain and found promising
results for manual therapy and physical therapy in subgroup
analyses of patients with neck pain. In our randomized,
controlled trial, we compared the effectiveness
of manual therapy, physical therapy, and continued care
by a general practitioner in patients with nonspecific
Patients with nonspecific neck pain whose clinical
presentation did not warrant referral for further diagnostic
screening were referred to one of four research centers
by 42 general practitioners for study selection. We
excluded patients whose history, signs, and symptoms
suggested a potential nonbenign cause (including previous
surgery of the neck) or evidence of a specific pathologic
condition, such as malignancy, neurologic disease,
fracture, herniated disc, or systemic rheumatic disease.
Two research assistants who were experienced physical
therapists and were blinded to treatment allocation performed
physical examinations at baseline and follow-up.
They used standardized inclusion and exclusion criteria
and performed a short neurologic examination (Appendix
Table 1, available at www.annals.org) and range-ofmotion
assessment. The eligibility criteria were age between
18 and 70 years, pain or stiffness in the neck for
at least 2 weeks, neck symptoms reproducible during
physical examination, willingness to adhere to treatment
and measurement regimens, no physical therapy or
manual therapy for neck pain during the previous 6
months, no involvement in litigation, and written informed
consent. Patients with concurrent headaches,
nonradicular pain in the upper extremities, and low
back pain were not excluded, but neck pain had to be
the main symptom for all patients.
Random Assignment and Data Collection
All patient data were collected before randomization.
Patients were assigned to a treatment group on the
basis of block randomization after prestratification for
symptom severity (severity scores <7 points or ≥7
points on a scale of 0 to 10); age (<40 years or ≥40
years); and, mainly for practical reasons, research center
(four local centers). Randomized permuted blocks of six
patients were generated for each stratum by using a
computer-generated random-sequence table. A researcher
who was not involved in the project prepared
opaque, sequentially numbered sealed envelopes that
contained folded cards indicating one of the three interventions.
The intervention period lasted 6 weeks. Patients
were allowed to perform exercises at home and to continue
medication prescribed at baseline or use over-thecounter
analgesics. Other co-interventions were discouraged
but were registered if they occurred. Within the
boundaries of the protocol, treatment could be reassessed
and adapted to the patient’s condition. The specific
treatment characteristics were registered at each
visit. A maximum number of visits was set for each
intervention group; however, the patients did not have
to complete this maximum number if symptoms had
Our approach to manual therapy was eclectic and
incorporated several techniques used in western Europe,
North America, and Australia, including those described
by Cyriax, Kaltenborn, Maitland, and Mennel (15, 16,
19). In our trial, manual therapy (defined as the use of
passive movements to help restore normal spinal function)
included “hands-on” muscular mobilization techniques
(aimed at improving soft tissue function), specific
articular mobilization techniques (to improve overall
joint function and decrease any restrictions in movement
at single or multiple segmental levels in the cervical
spine), and coordination or stabilization techniques
(to improve postural control, coordination, and movement
patterns by using the stabilizing cervical musculature)
(26). Joint mobilization “is a form of manual therapy
that involves low-velocity passive movements within
or at the limit of joint range of motion”. 
Manual therapists must undergo extensive training to be able to
skillfully perform mobilization techniques. [15, 19] Spinal
manipulations (low-amplitude, high-velocity thrust
techniques) were not included in this protocol. Fortyfive
minute treatment sessions were scheduled once per
week, for a maximum of six treatments. Six experienced
manual therapists acknowledged by the Netherlands
Manual Therapy Association performed the treatment.
The physical therapists used a combination of several
treatment options, but active exercise therapies were
the cornerstone of their strategy. Active exercise therapy
involves participation by the patient and includes active
exercises (to improve strength or range of motion), postural
exercises, stretching, relaxation exercises, and functional
Manual traction or stretching, massage, or physical
therapy methods, such as interferential current or heat
applications, could precede the exercise therapy. Specific
manual mobilization techniques were not included in
this protocol. Thirty-minute treatment sessions were
scheduled twice per week for a maximum of 12 treatments.
The treatment was performed by five experienced
physical therapists. We prevented cross-contamination
with manual therapy by choosing physical
therapists who were not manual therapy specialists.
Continued Care by a General Practitioner
Each patient in this group received standardized
care from his or her general practitioner, including advice
on prognosis, advice on psychosocial issues, advice
on self-care (heat application, home exercises), advice on
ergonomics (for example, size of pillow, work position),
and encouragement to await further recovery. The treatment
protocol was similar to the practice guidelines for
low back pain issued by the Dutch College of General
Practitioners.  Patients received an educational
booklet containing ergonomic advice and exercises. 
Medication, including paracetamol or nonsteroidal antiinflammatory
drugs, was prescribed on a time-contingent
basis if necessary. Ten-minute follow-up visits,
scheduled every 2 weeks, were optional, and referral during
the intervention period was discouraged.
Data were collected at the research center after 3
and 7 weeks. At 7 weeks, treatment results were expected
to be maximal. The patients were repeatedly
asked not to reveal any information about their treatment
allocation to the research assistants. The success of
blinding was evaluated at 7 weeks.
Primary outcome measures focused on perceived recovery,
pain, and functional disability. Patients rated
perceived recovery on a 6–point ordinal transition scale,
ranging from “much worse” to “completely recovered.”
Success was defined a priori as “completely recovered” or
“much improved”.  In addition, on the basis of the
systematic assessment of spinal mobility, palpation, and
pain reported by the patient, the research assistant rated
the severity of physical dysfunction on a numeric 11–
point scale ranging from 0 (no physical dysfunction) to
10 (maximal dysfunction). Likewise, the patient measured
pain severity in the previous week in three ways on
a numeric 11–point scale (higher scores indicate more
severe pain): “bothersomeness” of pain (affective pain),
average pain, and most severe pain. [31, 32] Functional
disability was measured according to the Neck Disability
Index , which scores 10 activities of daily living on a
scale of 0 to 5. Higher scores indicate more disability
(maximum score, 50 points). Other studies have shown
that the reliability and validity of the Neck Disability
Index are acceptable. [34, 35]
Secondary outcome measures included the severity
of the most important functional limitation, rated by
the patient on a numeric 11–point scale. Range of motion
of the cervical spine was measured by using the
Cybex Electronic Digital Inclinometer 320 (Lumex,
Inc., Ronkonkoma, New York).  General health was
measured according to the self-rated health index (scale,
0 to 100) of the Euro Quality of Life scale. [37, 38]
Patients recorded absences from work and analgesic use
in a diary.
We calculated sample sizes on the basis of the dichotomized
score of the primary outcome measure “perceived
recovery.” A difference of 25% or more in success
rate was considered to be clinically significant. With a
power of 0.8 and a significance level of 0.05, a minimum
of 60 patients per treatment group was required.  Analyses were performed according to the intention to-
treat principle, using SPSS statistical software (SPSS
Inc., Chicago, Illinois).  We also performed an alternative
analysis that excluded patients who had received
any interventions other than the allocated treatments.
The differences in success rates for perceived recovery
(risk differences) were analyzed by applying chisquare
tests (univariate analysis). Likewise, differences in
improvement rates for absence from work and use of
analgesics were analyzed. For the continuous outcome
measures, univariate analyses of variance were applied to
the differences between the baseline measurement and
each of the follow-up measurements (the mean improvement).
Multivariate analyses (multiple logistic regression
and analyses of covariance) were performed to examine
the influence of the following covariates: baseline value
of an outcome measure, therapist, age, severity, research
center, sex, duration of the current episode, previous
episodes of neck pain, headache of cervical origin, radiating
pain below the elbow, and patient preference for
treatment. For all comparisons, a two-tailed P value of
0.05 was considered statistically significant. A statistician
who had no knowledge of the randomization code
performed all analyses.
The Scientific Committee and Medical Ethical
Committee of the Vrije Universiteit Medical Center in
Amsterdam, the Netherlands, approved the protocol.
Role of the Funding Sources
The two grant agencies approved the design of the
trial but had no influence on the conduct and reporting
of the study.
Patient Selection and Follow-up
During a period of 21 months (February 1997 to
October 1998), 223 patients were referred by their general practitioners. Of these, 40 did not meet the selection
criteria (Figure 1). A total of 183 patients were
randomly assigned: 60 to manual therapy, 59 to physical
therapy, and 64 to continued care. One patient withdrew
from the manual therapy group because of lack of
time and also missed the baseline pain measurements.
Values were occasionally missing for some variables in a
few other patients.
Patient Characteristics and Baseline Similarity
All patients had multiple symptoms and signs (Table
1). Mean patient age was 45 years, and approximately
60% were women. Most patients had had neck
pain for 12 weeks or fewer, and many had had previous
episodes of neck pain. Patients rated the “bothersomeness”
of their pain, on average, as 7.6 on a numeric
11–point scale. The mean score for the Neck Disability
Index was 14.5 points (“minimally disabled,” according
to Vernon and Mior ). Only minor baseline differences
were found among the three groups (Table 1).
The study design allowed the manual therapists,
physical therapists, and general practitioners to vary the
number of treatments up to a maximum, to perform
their own evaluations, and to treat individual patients
according to their own findings. However, the specific
treatment options were limited to those listed in the
protocol and the specific treatment characteristics were
recorded (Appendix Table 2, available at www.annals
.org). The median number of visits was 6 (interquartile
range, 5 to 6) in the manual therapy group, 9 (interquartile
range, 7 to 12) in the physical therapy group,
and 2 (interquartile range, 1 to 4) in the continued care
group. Figure 1 shows the protocol deviations and additional
treatments in each group.
Minor, benign, short-term adverse reactions were
reported (Table 2). Headache, pain and tingling in the
upper extremities, and dizziness occurred more frequently
in patients who received manual and physical
therapy than in those who received continued care. Patients
in the manual therapy group were more likely to
report a temporary increase in neck pain that lasted
more than 2 days after receiving therapy.
Evaluation of Blinding
Research assistants remained unaware of the allocated
treatment for 93.4% of patients (n = 170). At 7
weeks, blinding was not successful in 12 patients (2 in
the manual therapy group, 3 in the physical therapy
group, and 7 in the continued care group). In most of
these 12 cases, the patient accidentally mentioned the
In general, the outcome measures showed distinct
differences both within groups (compared with baseline)
and among groups. These differences usually favored
manual therapy more than physical therapy and physical
therapy more than continued care (Figure 2). Adjustment
for covariates (research center, severity, age, sex,
headache, duration of neck pain, previous episodes, and
baseline outcomes of the outcome measure) did not
greatly influence the results. Because only small differences
in outcome were seen among the manual therapists
and among the physical therapists, multilevel analysis
was not necessary. For the continuous outcomes, we
present the adjusted means and confidence intervals. We
did not adjust the percentages of binary outcomes (Table
3) because we preferred to present risk differences
instead of odds ratios.
The success rate at 7 weeks was twice as high for the
manual therapy group (68.3%) as for the continued care
group (35.9%) (difference, 32.4 percentage points [95%
CI, 15.8 to 49.0 percentage points]). Physical dysfunction,
pain, and functional disability were less severe in
the manual therapy group than in the continued care
and physical therapy groups. Some differences in outcome
measures were already statistically significant at 3
At 7 weeks, the success rate was higher for physical
therapy (50.8%) than for continued care (35.9%), but
this difference was not statistically significant. For the
other outcome measures, small but mostly nonsignificant
differences were found in favor of physical therapy
compared with continued care by a general practitioner.
At 3 weeks, more patients worsened with continued care
(n = 9) than with physical therapy (n = 3) or manual
therapy (n = 0). The success rates for manual therapy
were statistically significantly higher than those for physical
therapy. Manual therapy scored better than physical
therapy on all outcome measures, although not all differences
Although disability on the Neck Disability Index
improved in all three groups by at least 5.9 points (continued
care group), the differences among groups were
not statistically significant. Range of motion improved
more markedly for those who received manual therapy
or physical therapy than for those who received continued
care. General health perception on the self-rated
health index of the Euro Quality of Life scale showed a
statistically significant difference in favor of manual
therapy compared with continued care and physical
Patients receiving manual therapy had fewer absences
from work than patients receiving physical therapy
or continued care. Respectively, 13% (6 of 47),
29% (12 of 42), and 26% (12 of 46) of patients were
absent due to neck pain; differences among groups were
not statistically significant. A similar trend was seen for
patients who used analgesics (51% [30 of 59] in the
manual therapy group, 53% [31 of 59] in the physical
therapy group, and 80% [51 of 64] in the continued
care group). Manual therapy and physical therapy each
resulted in statistically significantly less analgesic use
than continued care.
We performed an alternative analysis that excluded
14 patients who received treatment other than that allocated.
Results were similar to those of the intentionto-
treat analyses. For example, at 7 weeks, the success
rates were 70.7% for manual therapy, 50.8% for physical
therapy, and 34.6% for continued care.
We compared the effectiveness of frequently used
treatments for nonspecific neck pain in general practice.
We found that manual therapy was more effective than
continued care, and our results consistently favored
manual therapy on almost all outcome measures. Although
physical therapy scored slightly better than continued
care, most of the differences were not statistically
significant. In addition, although manual therapy
seemed to be more effective than physical therapy, differences
were small for all outcome measures except perceived
recovery and were not always statistically significant.
The magnitude of the differences between manual
therapy and physical therapy, but also between manual
therapy and continued care, were most pronounced for
perceived recovery. Because perceived recovery combines
other outcomes, such as pain, disability, and patient satisfaction, it may be the most responsive outcome measure.
For pain intensity, statistically significant differences
among the treatment groups ranged from 0.9 to
1.5 on a scale of 0 to 10. Although smaller differences
could have been detected with larger sample sizes, they
would not have been clinically relevant.
It is of interest that the postulated objective of manual
therapy, that is, the restoration of normal joint motion,
was achieved, as indicated by the relatively large
increase in the range of motion of the cervical spine.
The differences among groups in scores on the Neck
Disability Index were small (<2 points) and are not
considered clinically important (35). The low disability
scores on the Neck Disability Index at baseline may have
left only a small margin for improvement. Other studies
using the Neck Disability Index have also found that
function may not be severely limited in patients with
nonspecific neck pain (8, 41). We recommend further
investigation of disease-specific outcome measures for
neck pain. Only Koes and colleagues (24, 25) have compared
the effectiveness of manual therapy (manipulation
and mobilization) and physical therapy (exercise, traction,
and other methods) with that of continued care
and a placebo treatment. Our study confirms their findings
that manual therapy and physical therapy are superior
to continued care.
The general practitioners performed a routine examination,
which is common in general practice. Although
we tried to enroll all eligible patients who consulted
their general practitioner with a new episode of neck
pain during the recruitment period, the numbers of patients
recruited by each general practitioner suggest that
potential participants were lost at this point. However,
we feel that our study sample reflects patients with nonspecific
neck pain who were seen in everyday practice.
The natural course of neck pain in everyday practice
might best be reflected by the progress in the continued
care group. Borghouts and colleagues (9), in a systematic
summary of the available evidence, found that patients
with chronic neck pain who received a variety of common
interventions experienced between 37% and 95%
improvement when assessed from 3 weeks to 1 year.
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 effects. 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.
In this trial, manual therapy was performed by
physical therapists with formal training. We believe that
manual therapy has added value because therapists are
knowledgeable about spinal problems, are skilled in performing
specific manual techniques, and are educated
about the potential risks. (42). Active treatment components,
such as those used in the physical therapy strategy,
tend to become more dominant over time as the
patient improves (41, 43). In our study, mobilization,
the passive component of the manual therapy strategy,
formed the main contrast with physical therapy or continued
care and was considered to be the most effective
Our results suggest that in everyday practice, for
every 3 patients referred to manual therapy and every 7
patients referred to physical therapy, 1 additional patient
will completely recover within 7 weeks than would
have recovered after continued care by a general practitioner
(number needed to treat on the basis of perceived
recovery). Although differences were not particularly
large for all outcome measures, manual therapy seems to
be a favorable treatment option for patients with neck
The authors thank Anita Gross for critical review of
the manuscript; Eva Stokx, Luite van Assen, Vera Veldman, and Ingeborg
Korthals-de Bos for data collection and data entry; Frans Krapels for
advice on usual care; and Brigitte Kapteijn and Raymond Swinkels for
advice on physical and manual therapy. They also thank the participating
physical therapists, manual therapists, general practitioners, and patients.
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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 .”
SUMMARIES FOR PATIENTS
Manual Therapy, Physical Therapy, or Care by Primary Care Doctors for Patients with Neck Pain
21 May 2002 | Volume 136 Issue 10 | Page I36
Summaries for Patients are a service provided by Annals to help patients better understand the complicated and often mystifying language of modern medicine.
Summaries for Patients are presented for informational purposes only. These summaries are not a substitute for advice from your own medical provider. If you have questions about this material, or need medical advice about your own health or situation, please contact your physician. The summaries may be reproduced for not-for-profit educational purposes only. Any other uses must be approved by the American College of PhysiciansAmerican Society of Internal Medicine.
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.
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.
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 Trial
- Jan 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.
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