Neck Pain and Associated Disorders in Adults


A 2018 evidence-based guideline1 made the following recommendations:

  • Based on high-quality evidence, in patients with grade I or II neck pain (NP) (see grades in box below), cervical manipulation or mobilization combined with exercise should be used
  • Based on low-quality evidence, for grades I-III, consider the use of cognitive behavioral treatment/graded activity, massage, neurodynamics or neural tissue management, pillow, kinesiology tape, thermal agents, and workplace interventions
    • Dry needling, low-level laser, electrotherapy, ultrasound, or traction should NOT be used
    • Cervical collar should be considered for use with grade III when primarily advised treatments are ineffective/not sufficiently effective; NOT to be used for patients with grades I and II

The Danish Health Authorities’ national clinical guidelines2 (aligned with North American recommendations) include:

  • Focus on encouraging information when advising patients with recent onset NP
  • For patients with recent onset NP
    • Consider offering supervised exercise therapy, spinal manipulative therapy (SMT), combined SMT/exercise and acupuncture in addition to other treatment
    • NSAIDs for immediate pain relief, but exercise or SMT preferred
    • Massage and tramadol should only be offered after careful consideration
  • For patients with recent onset cervical radiculopathy
    • Consider offering structured, individualized patient education that includes pain mechanisms, prognosis, behavior modifications and management.
    • Consider offering tailored physical activity, motor control and directional exercises, SMT, and traction
    • For short-term treatment, NSAIDs or tramadol

Manipulation and Mobilization

Systematic Reviews

Results of the 4 identified systematic reviews:

Coulter et al.3

Low to moderate-quality evidence that several types of manipulation and/or mobilization showed benefit in reducing pain and improving function when compared to other interventions. Outcomes were best when integrated in a multimodal way and were determined to be safe. However, studies were heterogeneous and many assessed only a single dose making it difficult to determine strong conclusions.

Hidalgo et al.4

The authors aimed to update the evidence of the effectiveness of manual therapy (MT) and exercise by including only RCTs with a low risk of bias. MT (applied to C- or T-spine) included: HVLA SMT, a range of mobilization or soft tissue techniques, a combination of SMT and mobilization, and mobilization-with-movement. Results showed:

  • Combining different forms of MT with exercise is better than either treatment alone.
  • Moderate to strong evidence that SMT alone or combined with mobilization and exercise improves pain, function and satisfaction with care compared to usual medical care, exercise alone, MT alone or no treatment.
  • Strong evidence that mobilization can be applied outside of the symptomatic level and improve pain and function
  • Moderate evidence that SMT and mobilization techniques generally have similar effects
Fredin et al.5

This project’s purpose was similar to Hidalgo et al.’s but found conflicting results with moderate-to-low evidence. For patients with grade I or II NP, there were only very small, non-significant effect sizes when MT was added to exercise. Outcomes included NP at rest, disability and quality of life.

Skelly et al.6

For patient with chronic NP:

  • Based on low-quality evidence
    • Slight improvements in function with acupuncture and Alexander Technique when compared to usual care, sham acupuncture or sham laser in short and immediate-term follow-up
    • Slight improvements in pain and function with combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) in short and long-term
  • Based on moderate-quality evidence
    • Moderate improvements in pain and function with low-level laser therapy in short-term

Randomized Controlled Trials

Studies showed:

  • In comparing HVLA or 2 different mobilization techniques, results showed hypoalgesia in all groups as measured immediately post-treatment by pain pressure threshold over 3 areas. The HVLA group exhibited greater hypoalgesia in the cervical spine when compared to the 2 mobilization groups. The authors also evaluated pain catastrophizing and found that when the level was low to medium, the participant was likely to report hypoalgesia vs. high levels.7
  • Manual therapy (MT) consisting of mobilization compared to PT (active exercise) found no statistically significant or clinically relevant differences between groups at 1-year follow-up.8
  • In mobilization vs. routine PT, both significantly reduced pain and disability as well as increased muscle endurance and ROM when compared to PT alone.9
  • In HVLA vs. exercise, both helped pain, disability and ROM at the 1-week follow-up, with SMT marginally better.10
  • Nonthrust compared to thrust manipulation applied to C and T spine rendered no difference between groups in disability, pain or motor performance.11
  • In mobilization vs. placebo mobilization for chronic NP, both groups showed improvement but cervical mobilizations were more immediately effective than placebo for outcomes of global perceived effect, pain associated with movement and ROM.12


Evidence demonstrates that there is seemingly no causality between cervical SMT and serious adverse events such as craniocervical artery dissection; however, providers of MT should perform thorough patient interviews, clinical assessments, interpretation and analyses to determine appropriateness of this treatment in the cervical spine. Any vasculogenic contributions to a patient’s condition or other risk factors for possible serious adverse events present a contraindication to cervical MT.13

Grades based on the Neck Pain Task Force Classification:

  1. Neck pain and associated disorders with no signs or symptoms suggestive of major structural pathology and no or minor interference with activities of daily living
  2. No signs or symptoms of major structural pathology but major interference with activities of daily living
  3. No signs or symptoms of major structural pathology but presence of neurologic signs, such as decreased deep tendon reflexes, weakness, or sensory deficits
  4. Signs or symptoms of major structural pathology; major structural pathologies include (but are not limited to) fracture, vertebral dislocation, injury to the spinal cord, infection, neoplasm, or systemic disease, including inflammatory arthropathies


  1. Bier JD, Scholten-Peeters WGM, Staal JB, et al. Clinical practice guideline for physical therapy assessment and treatment in patients with nonspecific neck pain. Phys Ther. 2018;98(3):162-171. FREE FULL TEXT
  2. Kjaer P, Kongsted A, Hartvigsen J, et al. National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy. Eur Spine J. 2017;26(9):2242-2257. FREE FULL TEXT
  3. Coulter ID, Crawford C, Vernon H, et al. Manipulation and mobilization for treating chronic nonspecific neck pain: A systematic review and meta-analysis for an appropriateness panel. Pain Physician. 2019;22(2):E55-e70. FREE FULL TEXT
  4. Hidalgo B, Hall T, Bossert J, et al. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017;30(6):1149-1169. FREE FULL TEXT
  5. Fredin K, Lorås H. Manual therapy, exercise therapy or combined treatment in the management of adult neck pain – A systematic review and meta-analysis. Musculoskelet Sci Pract. 2017;31:62-71. FREE FULL TEXT
  6. Skelly AC, Chou R, Dettori JR, et al. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. AHRQ Comp Eff Rev. 2018. FREE FULL TEXT
  7. Alonso-Perez JL, Lopez-Lopez A, La Touche R, et al. Hypoalgesic effects of three different manual therapy techniques on cervical spine and psychological interaction: A randomized clinical trial. J Bodyw Mov Ther. 2017;21(4):798-803. FREE FULL TEXT
  8. Groeneweg R, van Assen L, Kropman H, et al. Manual therapy compared with physical therapy in patients with non-specific neck pain: A randomized controlled trial. Chiropr Man Ther. 2017;14:44-52. FREE FULL TEXT
  9. Farooq MN, Mohseni-Bandpei MA, Gilani SA, et al. The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. J Bodyw Mov Ther. 2018;22(1):24-31. FREE FULL TEXT
  10. Galindez-Ibarbengoetxea X, Setuain I, Ramírez-Velez R, et al. Short-term effects of manipulative treatment versus a therapeutic home exercise protocol for chronic cervical pain: A randomized clinical trial. J Back Musculoskelet Rehabil. 2018;31(1):133-145. FREE FULL TEXT
  11. Griswold D, Learman K, Kolber MJ, et al. Pragmatically applied cervical and thoracic nonthrust manipulation versus thrust manipulation for patients with mechanical neck pain: A multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2018;48(3):137-145. FREE FULL TEXT
  12. Lascurain-Aguirrebeña I, Newham DJ, et al. Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial. Musculoskelet Sci Pract. 2018;38:83-90. FREE FULL TEXT
  13. Hutting N, Kerry R, Coppieters MW, Scholten-Peeters GGM. Considerations to improve the safety of cervical spine manual therapy. Musculoskelet Sci Pract. 2018;33:41-45. FREE FULL TEXT