Letters to the Editor

Long-term Benefits of Manipulation for Neck Pain


Am Fam Physician. 2021 Mar 1;103(5):261-262.

Original Article: Neck Pain: Initial Evaluation and Management

Issue Date: August 1, 2020

See additional reader comments at: https://www.aafp.org/afp/2020/0801/p150.html

To the Editor: As a member of the American Academy of Family Physicians and an osteopathic physician, I was greatly interested in the article on neck pain by Drs. Childress and Stuek. I disagreed with the description of the effectiveness of manipulation for the treatment of neck pain, which is directly opposite to the results found in a Cochrane review.1

The article states that manipulation produced short-term pain relief, but that long-term benefits were minimal or inconsistent. However, the Cochrane review stated that, “Cervical manipulation for acute/subacute neck pain was more effective than varied combinations of analgesics, muscle relaxants and nonsteroidal anti-inflammatory drugs for improving pain and function at up to long-term follow-up. For chronic cervicogenic headache, cervical manipulation provided greater benefit than light massage in improving pain and function at short-term and intermediate-term follow-up. For chronic [cervicogenic headache], cervical manipulation may be superior to transcutaneous electrical nerve stimulation (TENS) in improving pain at short-term follow-up.” And, “…for subacute and chronic neck pain, cervical mobilisation appeared similar to pulsed ultrasound, TENS, acupuncture and massage in improving pain, function, quality of life, and patient satisfaction up to intermediate-term follow-up.”1

The article states that the benefit did not extend beyond follow-up. However, the Cochrane review stated that at follow-up the pain and function were improved. I would appreciate the authors' comments on the inconsistency between their article's conclusion and those of the Cochrane review, in addition to further review of the relevant literature. Thank you for your attention to this matter.

Author disclosure: No relevant financial affiliations.


1. Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;(9):CD004249.

In Reply: It was not our goal to discourage the use of cervical manipulation by skilled clinicians. The comments in our article reflect those made by the Cochrane review authors in their summary, “results for cervical manipulation and mobilisation versus control are few and diverse.”1 In a controlled setting, analgesics, muscle relaxants, and nonsteroidal anti-inflammatory drugs provide reliable and consistent relief for chronic neck pain.2 Similarly, in the comparison of mobilization to pulsed ultrasonography, transcutaneous electrical nerve stimulation, acupuncture, and massage, the Cochrane authors noted that none of the studies addressing these questions were high quality (80% of the included studies were low or very low quality), and conclusions were limited to short-term and intermediate-term follow-up.

Author disclosure: No financial affiliations disclosed.


1. Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;(9):CD004249.

2. Binder AI. Neck pain. BMJ Clin Evid. 2008;2008:1103.

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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