Manual Therapy, Physical Therapy, or Continued Care by the General Practitioner for Patients With Neck Pain Long-Term Results From a Pragmatic Randomized Clinical Trial Jan L. Hoving, PhD,*w Henrica C. W. de Vet, PhD,* Bart W. Koes, PhD,z Henk van Mameren, MD, PhD,y Walter L. J. M. Deville´, MD, PhD,z Danie¨lle A. W. M. van der Windt, PhD,* Willem J. J. Assendelft, MD, PhD,J Jan J. M. Pool, PT,* Rob J. P. M. Scholten, MD, PhD,** Ingeborg B. C. Korthals–de Bos, PhD,* and Lex M. Bouter, PhD* Objectives: The authors’ goals were to compare the effectiveness of manual therapy (MT; mainly spinal mobilization), physical therapy (PT; mainly exercise therapy), and continued care by the general practitioner (GP; analgesics, counseling and education) over a period of 1 year. Methods: One hundred eighty-three patients suffering for at least 2 weeks from nonspecific neck pain were randomized to receive a 6-week treatment strategy of MT once a week, PT twice a week, or GP care once every 2 weeks. The primary outcome measures were perceived recovery, severity of physical dysfunc- tioning, pain intensity, and functional disability. Results: The differences between groups considered over 1 year were statistically significant (repeated measurements analyses P <0.001 to P = 0.02) for all outcomes but borderline for the Neck Disability Index (P = 0.06). Higher improvement scores were observed for MT for all outcomes, followed by PT and GP care. The success rate, based on perceived recovery after 13 weeks, was 72% for MT, which was significantly higher than the success rate for continued GP care (42%, P = 0.001) but not significantly higher compared with PT treatment (59%, P = 0.16). The difference between PT and GP approached statistical significance (P = 0.06). After 1 year the success rates were 75%, 63%, and 56%, respectively, and no longer significantly different. Conclusions: Short-term results (at 7 weeks) have shown that MT speeded recovery compared with GP care and, to a lesser extent, also compared with PT. In the long-term, GP treatment and PT caught up with MT, and differences between the three treatment groups decreased and lost statistical significance at the 13-week and 52-week follow-up. Key Words: neck pain, manual therapy, physical therapy, general practice, long-term effects, randomized clinical trial (Clin J Pain 2006;22:370–377) N eck pain is one of the most common, painful musculoskeletal conditions. Point prevalences have been reported to vary between 10% and 22%, 1–5 and lifetime prevalences as high as 67% and 71% have been reported. 3,4 Neck pain complaints are often self-limiting within a few weeks of onset, but they can also severely limit daily functioning and result in prolonged sick leave and disability. However, the natural course of neck pain remains unclear. 6 In The Netherlands, most patients receive conservative treatment from a general practitioner (GP) or a physical therapist. 5,7 Physical therapy (PT) may include exercise therapy, stretching, traction, massage, electrotherapies, thermal agents, ultrasound, and educa- tion. Physical therapists also perform manual techniques on the cervical spine. Some of the manual therapy (MT) techniques require extensive training before they can be performed in a safe and skillful manner. In The Nether- lands, physical therapists can further specialize in MT theory and techniques during a 3- to 4-year part-time course and register themselves as manual therapists. 8 There is surprisingly little information available from randomized clinical trials (RCTs) on the effectiveness of Copyright r 2006 by Lippincott Williams & Wilkins Received for publication January 30, 2005; revised July 3, 2005; accepted July 23, 2005. From the *Institute for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands; wDepart- ment of Clinical Epidemiology, Cabrini Hospital, and Monash University, Department of Epidemiology and Preventive Medicine, Malvern, Victoria, Australia; zDepartment of General Practice, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands; yDepartment of Anatomy and Embryology, Faculty of Medicine, Maastricht University, Maastricht, The Netherlands; zNIVEL Netherlands Institute for Health Services Research, Utrecht, The Netherlands; JDepartment of General Practice and Nursing Homes Sciences, Leiden University Medical Center, Leiden, The Netherlands; and **Dutch Cochrane Centre, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Supported by grants from the Netherlands Organization for Scientific Research (NWO grant 904-66-068) and from the Fund for Investigative Medicine of the Health Insurance Council (grant OG 95-008). Reprints: Prof Dr Henrica C. W. de Vet, Institute for Research in Extramural Medicine, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands (e-mail: hcw.devet@vumc.nl). ORIGINAL ARTICLE 370 Clin J Pain  Volume 22, Number 4, May 2006