Comparative Analysis of Manual Therapy vs. Exercise for Neck Pain Disability

Thesis Abstract

This study investigates the comparative effectiveness of manual therapy versus structured exercise on neck pain disability, addressing the persistent clinical question of which modality yields superior functional outcomes and patient-reported improvements in neck pain populations. The aim is to determine whether manual therapy provides additional short- and medium-term benefits over standardized exercise programs, and to identify moderating factors such as baseline disability, psychosocial variables, and pain catastrophizing. Specific objectives include (1) comparing changes in neck disability index (NDI) and pain intensity (0–10 numeric rating scale) at 6, 12, and 24 weeks; (2) evaluating neck range of motion, muscle strength, and proprioceptive accuracy as objective physical outcomes; (3) examining adherence to treatment protocols and patient satisfaction; (4) exploring whether psychosocial variables (depression, anxiety, fear avoidance) mediate treatment effects; and (5) assessing cost-effectiveness from a payer perspective. Employing a randomized, parallel-group design, the trial will recruit 240 adults aged 18–65 with subacute to chronic mechanical neck pain from three metropolitan physiotherapy clinics. Participants will be stratified by baseline NDI (<20 vs ?20) and randomized to either a manual therapy arm (high-velocity, low-amplitude thrusts and mobilization techniques applied by licensed physiotherapists, combined with up to two home self-management sessions weekly) or an exercise arm (supervised motor control exercise plus cervical endurance and mobility training, with progressive home exercise). Data will be collected at baseline, 6 weeks, 12 weeks, and 24 weeks. Primary outcome is the Neck Disability Index (NDI); secondary outcomes include numeric pain rating scale (NPRS), cervical range of motion (CROM) measured with a digital inclinometer, isometric neck muscle strength, proprioceptive accuracy via joint position error tests, and patient satisfaction using a global perception of improvement scale. Instruments include validated measures NDI, NPRS, the Fear-Avoidance Beliefs Questionnaire, the Hospital Anxiety and Depression Scale, and the EuroQol-5D for health-related quality of life. Data will be analyzed using mixed-effects linear models to assess group-by-time interactions for continuous outcomes, with intention-to-treat principles and multiple imputation for missing data. Mediation analyses will test psychosocial variables as pathways of effect, and cost-effectiveness will be evaluated using incremental cost-effectiveness ratios (ICERs) and quality-adjusted life years (QALYs) derived from EQ-5D data. Sensitivity analyses will consider per-protocol populations and alternative model specifications. Theoretical underpinnings integrate the Biopsychosocial Model of pain and the Theory of Motor Control, with manual therapy linked to neurophysiological modulation and exercise to neuromuscular re-education. Anticipated results include greater short-term reductions in pain and disability in the manual therapy group at 6 weeks, with sustained improvements in function in the combined metrics at 12 and 24 weeks, contingent on adherence and psychosocial factors. It is expected that both interventions will produce clinically meaningful improvements, but the magnitude and durability of effects will differ across subgroups defined by baseline disability and psychosocial status. The study contributes to knowledge by providing high-quality, pragmatic comparative data on two commonly used interventions for neck pain, clarifying their relative effectiveness, mechanisms, and cost implications. Potential limitations include heterogeneity of manual therapy techniques across therapists, varying adherence to home exercise programs, and generalizability constrained to outpatient physiotherapy settings. Findings will inform clinical guidelines for personalized neck pain management, suggesting that patients with high psychosocial risk may benefit from integrated programs combining manual therapy with motor control exercise and cognitive-behavioral strategies. Policy implications include allocation of resources toward evidence-based rehabilitation pathways and the development of standardized protocol frameworks to optimize outcome consistency across settings.