Does adding manual therapy improve long-term outcomes in patients with chronic neck pain? A systematic review and meta-analysis

Chronic neck pain (CNP) is a prevalent, recurrent disorder imposing substantial physical, psychological, and economic burdens. However, the long-term effects of manual therapy (MT) remain unclear. This study was designed to evaluate the durable efficacy and safety of MT for the management of CNP.

Randomized controlled trials (RCTs) evaluating manual therapy for CNP were retrieved from Chinese and English databases from inception through October 29, 2024 (updated to June 30, 2026). The Cochrane Risk of Bias Assessment tool 2.0 was used to assess the risk of bias. Data were analyzed using Review Manager 5.4 software. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Eighteen RCTs were included. Manual therapy may provide pain relief (mean difference [MD] = −1.01 points, 95% confidence interval [CI]: −1.54, −0.49; P < 0.001) and functional improvement (MD = −3.78%, 95% CI: −5.26, −2.31; P < 0.001) for at least three months post-treatment. Moreover, when combined with active control (e.g., NSAIDs, exercise, or physical therapy), these benefits may persist for up to six months (MD = −1.20 points, 95% CI: −1.74, −0.66; P < 0.001; MD = −5.55%, 95% CI: −8.73, −2.37; P = 0.0006). Although overall quality-of-life results were inconsistent, physical health may improve for up to six months (MD = 9.63 points, 95% CI: 5.84, 13.43; P < 0.001). Five studies reported adverse event rates ranging from 3.3% to 41.3%; however, but they were mild and transient.

Moderate- to very-low- quality evidence indicates that manual therapy may provide pain relief and functional improvement lasting at least 3 months post-treatment in patients with CNP compared with placebo therapy, no-treatment, or active control. When combined with active control, these effects may persist for up to six months and demonstrate an acceptable safety profile.

The study protocol was registered with the International Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/PROSPERO/, CRD42025632884).