Effectiveness and safety of manual therapy when compared with oral pain medication

Key points

1. 01Pooled 9 randomized trials with 779 adults comparing manual therapy against oral or topical pain medication for neck pain.
2. 02Manual therapy was modestly favored for short-term pain (SMD -0.39) and long-term pain (SMD -0.36).
3. 03Adverse events were lower with manual therapy (RR 0.59), but reporting differences between groups limit confidence in this.
4. 04Pain effect sizes were below the minimally important difference of 0.4 SD, so the benefit is real but small.
5. 05Most included trials had high risk of bias and were more than 10 years old.

How it was conducted

Design

Systematic review and meta-analysis of randomized controlled trials, searched CENTRAL, MEDLINE, EMBASE, AMED and CINAHL to March 2023

Participants

779 adults with neck pain across 9 trials (median sample 84.5, median age 45, 59.5% female)

Groups

Manual therapy (manipulation, mobilization, neural mobilization, Chuna manual therapy, or manual therapy plus exercise) versus oral or topical medication (NSAIDs, acetaminophen, opioids, muscle relaxants, or usual care)

Primary outcome

Short-term and long-term pain, plus adverse events and all-cause dropouts

Quality appraisal

Risk of bias assessed with RoB2 and certainty of evidence rated with GRADE

What they found

• Short-term pain favored manual therapy (SMD -0.39; 95% CI -0.66 to -0.11; 8 trials, 676 participants; tau2=0.10; low certainty).
• Long-term pain favored manual therapy (SMD -0.36; 95% CI -0.55 to -0.17; 6 trials, 567 participants; moderate certainty).
• Adverse events were lower with manual therapy (RR 0.59; 95% CI 0.43 to 0.79; 5 trials; low certainty), with pain aggravation more common with manual therapy and gastrointestinal symptoms more common with medication, and no serious adverse events reported.
• All-cause dropouts favored manual therapy (RR 0.68; 8 trials, 745 participants; moderate certainty).
• Both pain effect sizes were below the minimally important difference of 0.4 SD, while the adverse event risk reduction exceeded the 20% threshold favoring manual therapy safety.
• Subgroup analysis found manual therapy alone and manual therapy plus exercise showed a similar direction of effect.

Limitations

• Most included trials had high risk of bias and there was heterogeneity between studies.
• Short-term follow-up was limited to 3 to 12 weeks and most studies were more than 10 years old.
• Adverse event reporting differed between groups, so the safety comparison should be interpreted with caution.
• Only English-language studies were included and screening was done by a single reviewer.

Why it matters

For patients

If you have neck pain and want to avoid medication side effects such as stomach upset, hands-on manual therapy is a reasonable alternative that may ease pain a little better.

For clinicians

Manual therapy is a defensible first-line or alternative option to oral analgesics for neck pain, especially for patients at risk of gastrointestinal effects, though the pain benefit is small.

For readers

Across pooled trials manual therapy modestly outperformed pain medication for neck pain with a better safety signal, but the evidence base is dated and uneven.