Effectiveness of musculoskeletal manipulations in patients with neck pain: a systematic review and network meta-analysis.

Neck pain is common and manual therapies are often recommended as a first-line option, but it has been unclear which specific type of manipulation works best. This review pooled evidence from 101 randomised trials involving 7633 adults with neck pain, comparing approaches such as multimodal treatment (combining more than one technique), manual therapy, mobilisation, soft tissue technique, and manipulation, using a network meta-analysis to compare them even without direct head-to-head trials. Compared with no treatment, several approaches showed reductions in pain intensity, with multimodal treatment ranking as the most effective for both pain and disability, while manipulation alone ranked best for improving neck movement. The findings are interesting because they suggest different approaches may target different outcomes, but the evidence should be read cautiously: most of the underlying trials had a high risk of bias, and certainty ratings ranged from moderate down to very low, meaning these rankings could shift as better evidence emerges.

If you've dealt with neck pain, you've probably heard that hands-on treatments like manual therapy or manipulation are often suggested as a first option. This study looked at a large collection of research, 101 trials involving over 7,600 people, to see which types of these treatments seemed to help the most. The results suggested that combining more than one type of manual treatment (called multimodal treatment) was associated with the greatest reductions in pain and in neck-related disability compared with no treatment, while manipulation alone stood out for improving how far people could move their neck.

These are encouraging patterns, but they come with an important caveat: most of the individual studies feeding into this analysis had a meaningful risk of bias, and the confidence researchers have in these results ranges from moderate down to very low. That means the true benefit could be smaller or larger than reported, and it's not a guarantee of what would happen for any one person.

The findings describe patterns in grouped data, not a personalized treatment recommendation.

This is a summary of research, not medical advice. Talk to your own healthcare provider about anything affecting your care.

This network meta-analysis addresses a long-standing uncertainty in manual therapy practice: among the many hands-on approaches recommended for neck pain, which category of intervention is associated with the greatest improvement, and does the answer differ depending on whether the outcome is pain, disability, or range of motion. Pooling 101 randomised controlled trials (7633 participants) allowed indirect comparisons across manipulation, mobilisation, manual therapy, soft tissue technique, active control, and multimodal treatment. The analysis found multimodal treatment (defined as combined use of two or more manipulation techniques) ranked highest for both pain intensity reduction and neck disability improvement relative to no treatment, while manipulation alone ranked highest for cervical range of motion in flexion and extension.

This raises the possibility that technique selection could reasonably differ depending on whether the clinical priority is pain, function, or mobility, though the review does not establish that combining techniques causes added benefit beyond what single techniques achieve, since this was an indirect network comparison rather than a head-to-head trial of combination versus single-technique protocols. The main limitation affecting applicability is study quality: 61.3% of included trials had high risk of bias, and certainty of evidence ranged from moderate to very low depending on the comparison. The abstract does not report adverse event data in its summarized findings beyond noting it as a prespecified outcome, so safety conclusions cannot be drawn from this synthesis.