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

backgroundNeck pain is a common global health problem and a leading cause of disability, imposing significant personal and societal burdens. Musculoskeletal manipulations are recommended as the first-line treatment for neck pain in clinical practice guidelines, valued for their non-invasive and cost-effectiveness.

objectiveTo determine the most effective musculoskeletal manipulation for neck pain by integrating both direct and indirect evidence through a network meta-analysis, enabling comparisons among interventions even in the absence of direct head-to-head evidence.

designSystematic review and network meta-analysis. DATA SOURCES: Web of Science, the Cochrane Library, Embase, PubMed, Clinical Trials Registry, China National Knowledge Infrastructure, VIP Database and Wanfang Data were searched from January 2013 to May 2025. ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) involving adults (aged ≥18 years) with neck pain receiving musculoskeletal manipulations. DATA EXTRACTION AND SYNTHESIS: Paired reviewers independently extracted data. The primary outcome was pain intensity, assessed using the visual analogue scale or numeric rating scale (with total scores of 10 or 100 points). Secondary outcomes included neck disability measured by the neck disability index (with total scores of 50 or 100 points), cervical range of motion (flexion and extension) measured in degrees using a universal goniometer and adverse events. All included studies were assessed for risk of bias using the RoB 2.0 tool and categorised as 'low', 'some concerns' or 'high'. A frequentist random-effects network meta-analysis was conducted to calculate weighted mean differences with its 95% confidence intervals were calculated. Comparison-adjusted funnel plots were used to assess publication bias when 10 or more studies were included, and the Grading of Recommendations, Assessment, Development and Evaluations approach was applied for the quality of evidence.

resultsA total of 101 RCTs involving 7633 participants were included. Overall, 62 (61.3%) had high risk of bias, 18 (17.8%) had some concerns and 21 (20.7%) had low risk of bias. Moderate to very low-certainty evidence showed significant reduction in neck pain intensity compared with no treatment: multimodal treatment (pooled weighted mean difference (WMD): -36.65, 95% CI -61.02 to -12.28), active control (pooled WMD: -36.62, 95% CI -62.67 to -10.57), manual therapy (pooled WMD: -35.85, 95% CI -59.86 to -11.83), soft tissue technique (pooled WMD: -28.72, 95% CI -51.65 to -4.79) and mobilisation (pooled WMD: -20.23, 95% CI -39.87 to -0.06), with multimodal treatment being the most effective intervention (surface under the cumulative ranking curve (SUCRA)=100%). No publication bias was detected for neck pain intensity. Moreover, multimodal treatment was the most effective for reducing neck disability (SUCRA=96.3%), whereas manipulation was the most effective for improving cervical range of flexion (SUCRA=81.3%) and extension (SUCRA=78.2%).

conclusionMultimodal treatment (the combined use of two or more musculoskeletal manipulations) is the most effective intervention for reducing both neck pain intensity and neck disability. Manipulation is the most effective for improving cervical range of motion.