Manual physical therapy for neck disorders: an umbrella review

ABSTRACT

Introduction

Neck pain is a common musculoskeletal disorder, with a prevalence rate (age-standardized) of 27.0 per 1000 in 2019. Approximately 50–85% of individuals with acute neck pain do not experience complete resolution of symptoms, experiencing chronic pain. Manual therapy is a widely employed treatment approach for nonspecific neck pain (NSNP), cervical radiculopathy (CR) and cervicogenic headaches (CGH). This umbrella review synthesized systematic reviews examining manual physical therapy for individuals with cervical disorders.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed with Prospero registration (CRD42022327434). Four databases were searched from January 2016 to May 2023 for systematic reviews with or without meta-analysis examining manual therapy for individuals with neck pain of any stage. Interventions included any manual physical therapy of the cervical or thoracic spine as well as neuromobilization of the upper quarter. Primary outcomes included pain and disability. Two reviewers screened for eligibility and completed data extraction. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR 2) tool.

Results

A total of 35 SRs were included: 15 NSNP, 7 cervical radiculopathy, 9 CGH and 4 samples with combined diagnoses. AMSTAR 2 ratings of the SRs support high confidence in results for 10 reviews, moderate confidence in 12 reviews and low to critically low confidence in 13 reviews. For NSNP, there was high confidence in the results showing manual therapy combined with exercise was superior to either treatment in isolation. In cervical radiculopathy, neural mobilization, distraction, soft tissue treatment and mobilization/manipulation to cervical and thoracic spine were supported with moderate confidence in results. For CGH, there was high confidence in the results supporting the use of cervical spine mobilization/manipulation, soft tissue mobilization, and manual therapy combined with exercise. Original authors of SRs reported varying quality of primary studies with lack of consistent high quality/low risk of bias designs.

Conclusion

Manual therapy plus exercise, cervical or thoracic mobilization and manipulation, neuromobilization, and other types of manual therapy were supported as effective interventions in the management of pain and disability for individuals with NSNP, CGH, or CR in the short-term.

Introduction

Non-specific neck pain (NSNP), cervical radiculopathy (CR), and cervicogenic headaches (CGH) collectively contribute to the global burden of musculoskeletal disorders. Manual therapy is one of the most common conservative interventions used for the management of these conditions [1]. According to the Orthopaedic Manual Physical Therapy Description of Advanced Specialty Practice, manual therapy techniques are defined as ‘Skilled hand movements intended to improve tissue extensibility; increase range of motion; induce relaxation; mobilize or manipulate soft tissues and joints; modulate pain; and reduce soft tissue swelling, inflammation, or restriction.’ [2]. Manual therapy has been associated with biomechanical and neurophysiological effects at peripheral, spinal, and supraspinal levels. Manual therapy has been shown to modify spinal excitability, suppress motor neuron pool activity, reduce inflammatory mediators, muscle activity at rest, temporal summation, and modulate cortical activity [3]. Research suggests that manual therapy can also contribute to pain reduction, improved range of motion, and enhanced functional outcomes in individuals with neck disorders [4].

Studies have shown that manual therapy can be effective for both acute and chronic neck pain, including conditions like NSNP, CR, and CGH [5]. Additionally, manual therapy may have benefits beyond pain relief, influencing factors such as disability, fear of movement, and psychosocial well-being [6]. Manual therapy is commonly integrated into physical therapy approaches and is tailored to individual patient characteristics and clinical presentations [7]. While the evidence base for manual therapy in neck disorders is voluminous, the effectiveness of manual therapy remains unclear, as do the clinical indications and optimal dosage in the treatment of neck disorders. Clinical practice guidelines have included recommendation statements for the use of manual therapy [5]; however, these guidelines are outdated and updated reviews are necessary to inform future recommendation statements. In addition, there are several systematic reviews with contradictory results [4,8–10].

The principal aim of this umbrella review is to systematically analyze and integrate findings from existing systematic reviews and meta-analyses, exploring the effects of manual therapy compared to other physical therapy interventions, medical interventions, or control conditions on pain, function, disability, fear of movement, and psychosocial impairment in individuals with NSNP, CR, and CGH. By consolidating evidence across a spectrum of interventions and outcomes, this review seeks to provide a holistic understanding of manual therapy’s relative effectiveness in managing these diverse cervical conditions.

Methods

Eligibility criteria

Inclusion criteria

Peer-reviewed systematic reviews with or without meta-analyses published from January 2016 through May 2023 were included if they examined manual therapy for individuals with neck pain. An update to the Clinical Practice Guideline for neck pain was published in 2017, therefore we began our search the year prior to this publication [5]. There were no limits placed on the studies included in the systematic reviews.

Exclusion criteria

The following were excluded from the study: literature reviews, scoping reviews, primary studies, interventions delivered exclusively by providers that did not include physical therapists, and interventions that were not manual physical therapy techniques provided for reasons other than musculoskeletal neck pain conditions. Articles that only included outcomes beyond the defined outcomes of interest were also excluded.

Data sources and search strategy

This study was an umbrella review or systematic review of systematic reviews and meta-analyses following methodology described by Smith et al. [11] The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the identification number CRD42022327434. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. One update was made to modify authors.

The search strategy was developed by a medical librarian (SH). The strategy was built from the PICO question, in patients with neck pain is manual therapy effective as compared to other physical therapy interventions, medical interventions, or a control for improving pain, disability or fear? The databases searched were Medline, EMBASE, CINAHL, and Web of Science from 1 January 2016 to May 2022. A hand search was also performed of each included paper to identify additional studies. A second updated search using the same databases and search strategy was completed from March 2022 to May 2023. The search terms used are displayed in online supplemental material.

Selection process

All search strategy results were added to Covidence, a web-based collaboration software platform that streamlines the production of systematic and other literature reviews (www.covidence.org; 2022–2023). Following removal of duplicates, study selection was conducted by two reviewers who independently assessed each article title and abstract for possible inclusion in the first round of selection. In the second round, two reviewers independently read the full text of relevant reviews. Disagreements were resolved by a 3rd reviewer for each round.

Our research question was constructed using the following format: population (individuals with acute to chronic neck pain disorders), intervention (manual therapy: cervical or thoracic mobilization or manipulation, soft tissue mobilization, neuromobilization or neurodynamic intervention), comparator (Control groups, other physical therapy interventions, medical management, usual care) and outcomes (pain, function, disability, psychosocial impairment).

Outcomes

Outcomes of interest were established during PROSPERO registration. Primary outcomes included pain (visual analog scale, numerical pain rating scale), range of motion, disability (neck disability index, headache impact test), and psychosocial impairment (kinesiophobia, pain-related catastrophizing). Secondary outcomes included other measurements of these constructs and medical-based outcomes including medication usage, health status and health-care utilization.

Data extraction/data items

One author independently extracted data from each included review. A second reviewer examined data extraction for completeness and accuracy. The following data were extracted from each review: Number of studies included, total sample size, study objective, sample diagnosis, sample characteristics, stage of condition, specifics of manual therapy, outcomes, results including measures of effect, conclusions, quality/risk of bias reported. Template can be shared upon request to corresponding author.

Study quality and risk of bias assessment

Two reviewers independently analyzed quality using the AMSTAR 2 [12] and a third reviewer resolved disputes. The AMSTAR 2 is a 16-item measurement tool to assess systematic reviews. The checklist includes yes, no, partial yes, and/or not applicable. Critical domains were tracked to allow for interpretation of overall confidence in results according to recommendations from Shea et al. [12]

Appraisal of individual component studies was beyond the scope of this umbrella review, however, the quality ratings or risk of bias reported by the original authors of each included systematic review were recorded.

Analysis

All data were summarized as reported. No statistical or meta-analysis was performed. The existing results from each study were extracted, reviewed and reported in a systematic format. Results were organized by the diagnostic classifications of nonspecific neck pain (NSNP), cervicogenic headaches, cervical radiculopathy, and combined neck pain samples. A second reviewer ensured the accuracy of data extraction and reporting.

Results

Study selection

The study selection process is detailed in the Flow Diagram (Figure 1). The electronic literature search (CINAHL, Embase, Medline, Web of Science) resulted in 4797 studies after duplicates were removed. The title and abstract screening resulted in the exclusion of 4706 articles due to irrelevant title, study design, population/diagnosis, intervention and/or outcome of interest. Ninety-one full-text articles were reviewed and 56 were excluded for reasons noted in Figure 1. A total of 35 articles were included in the review.

Figure 1.

PRISMA flow diagram.

Study characteristics

The 35 included systematic reviews had a total of 701 studies examined. Authors looked for duplication of reporting on individual trials and noted nine articles were reported in multiple systematic reviews. Twenty-three of the systematic reviews included meta-analysis. Systematic review summaries were organized by diagnostic category (nonspecific neck pain, n = 15; cervical radiculopathy, n = 7; cervicogenic headache (CGH), n = 9; combined neck pain samples, n = 4). The population of whiplash-associated disorder (WAD) was not examined by itself in any review, however, all four articles listed in the multiple diagnosis category did include WAD.

While some reviews did not fully describe sample characteristics, the majority reported age ranges from 18 to 65 with a mean age of anywhere from 27 to 50 years old. Only two reviews included a sample age range over the age of 65. Nearly all studies reporting sex had more females than males (range: 60–73% female). Only one review looked exclusively at acute neck pain while five examined only chronic neck pain populations. The remaining reviews had a mix of symptom duration or were unclear in summarizing the stage of condition for their sample.

Some studies used terminology of thrust manipulation, spinal thrust manipulation, high-velocity low amplitude thrust, spinal manipulative thrust, or spinal manipulation to represent manipulative techniques. In an effort to standardize language used in this manuscript, authors chose to use the term manipulation in reporting these findings and chose to use the term mobilization for the non-thrust techniques; the term neural mobilization was used to include extremity techniques like sliders/tensioners [3,13,14].

Quality reporting and risk of bias

The AMSTAR 2 tool was used to appraise included systematic reviews (Supplemental material). Unlike the original AMSTAR, this tool suggests reporting without quantifying a total score. However, there are 7/16 items that are considered to be critical domains (Items 2, 4, 7, 9, 11, 13 and 15) [12]. Shea et al. suggest a qualitative interpretation of overall confidence based on the number of critical weaknesses. A critical weakness was defined as a ‘No’ answer to one of the critical domains. All other items are considered non-critical weaknesses. Using the guidance of Shea et al., high and moderate confidence in results can only be given to those reports with no critical flaws/weaknesses. High confidence is given to those with 0–1 non-critical weaknesses (answering ‘No’ in a non-critical domain); Moderate confidence is related to more than one non-critical weakness reported. If there is one critical flaw with or without noncritical weaknesses, the overall confidence rating is low, while more than one critical flaw implies critically low overall confidence [12].

Overall confidence ratings for the articles included in this umbrella review indicate high confidence in results for 10 reviews, moderate confidence in 12 reviews, low confidence in seven reviews and critically low confidence in six reviews. The majority of reviews did not include funding reports for included studies (n = 32); several reviews did not investigate for publication bias (n = 12) with MA (critical domain), report duplication of data extraction (n = 8), report risk of bias clearly alongside meta-analysis results (n = 8) (critical domain), or explain heterogeneity of results (n = 7). See full details in the supplemental material.

Each included review reported a summary of the quality of evidence and risk of bias for articles included in their original review. A summary of quality and bias as reported by original authors is included in the results tables (Tables 1–4). The language used to report findings from PEDro, GRADE or other quality/bias assessments was inconsistent across reviews included in this study. Due to lack of consistency, Tables 1–4 include language as the original authors wrote it.

Table 1.

Nonspecific neck pain (NSNP) (n = 15).

Author/Year	Sample Size: Number of Studies (participants)	Objective	Manual Therapy Description	Meta-Analysis Results	Conclusions	Original Author Reported Quality/Risk of Bias	AMSTAR 2: Overall Confidence Rating
Castellini 2022 [15]	108 studies with 38 that examined at manual therapy. Sample size unclear	Examine efficacy of conservative interventions including manual therapy for chronic neck pain.	Manual therapy broadly	Manual therapy combined with other interventions may provide effective outcomes in pain (short-term/1 month) and disability (intermediate term/3-6 month) for chronic nonspecific neck pain. Less effective long-term (12 month).	Manual therapy (manipulation and mobilization) combined with other conservative interventions was most effective for pain and disability in the short/intermediate – term follow-up, especially when combined with exercise.	Quality: GRADE details in Appendix; vast majority were low to very low certainty of evidence rating with a few moderate and three high quality. Cochrane RoB: 50% low risk, 23% unclear risk and 27% high risk	High
Chaibi 2021 [16]	MA: 6 (446)	Examine spinal manipulation (cervical or thoracic) for acute (<6 wk) neck pain	Manipulation alone or multimodal intervention	Large effect for pain favoring treatments with manipulation compared with controls. A single study that showed that manipulation was significantly better than medicine (30 mg ketorolac) one day post-treatment.	In acute neck pain, manipulation alone or combined with other interventions was effective for pain. Manipulation was superior to other treatments for pain intensity in 5/6 studies.	Cochrane Back and Neck RoBTool: 5 good quality (score 6-12 points), 1 low quality (<6); GRADE: Overall low	Moderate
Coulter 2019 [17]	SR: 47 (4460) MA: 6 (550)	Examine mobilization and manipulation for chronic NSNP	Thrust manipulation and nonthrust mobilization intervention	Manipulation intervention was favored for reducing disability at 3 months but not 1 or 6 months. Manipulation + exercise was favored for pain at 1 month but not 3 or 6 months.	For chronic neck pain, manipulation and mobilization (various types) reduced pain and improved function for chronic nonspecific neck pain compared to other interventions. Multimodal approaches (manipulation with exercise) might have the greatest potential impact.	GRADE: Low to moderate quality Bias: Scottish Intercollegiate Guidelines Network (SIGN) for RCTs reported on only unimodal studies: 18 high quality, 16 acceptable quality, 3 low quality	High
Hidalgo 2017 [4]	SR: 23 (1896)	Examine manual therapy + exercise for NSNP that was acute, subacute, or chronic (excluded studies with mixed stage)	Cervicothoracic mobilization and manipulation; mobilization with movement, SNAGs	No MA	Combining different forms of manual therapy with exercise is better than manual therapy or exercise alone for pain. Mobilization does not need to be applied at the symptomatic level(s) for improvements of pain and function in patients with chronic NP. Manipulation alone or manipulation combined with mobilization and exercise is superior for improving pain, function, and satisfaction compared to usual care, exercise alone or manual therapy alone in patients with chronic neck pain.	Cochrane collaboration back review group (CCBRG) used to only include moderate to high quality studies CCBRG risk of bias: only included studies with low risk of bias	High
Liu 2023 [18]	SR, MA 17 (1190)	Determine the efficacy of manipulation for chronic neck pain.	Manipulation	Manipulation and exercise were more effective than comparison groups (exercise alone or control) for short-term improvement in pain and disability for patients with chronic neck pain.	Manipulation decreased pain and disability in patients with chronic neck pain.	GRADE: Moderate to low quality overall PEDro: 15/17 studies have good methodological quality	Moderate
Masaracchio 2019 [19]	SR, MA 14 (885)	Examine thoracic manipulation for mechanical neck pain	Thoracic manipulation compared to other intervention including range of motion, placebo, or other manual therapy (cervical mobilization or manipulation)	Thoracic manipulation was superior to thoracic mobilization or standard care for pain but no different from cervical manipulation (immediate and short-term). Thoracic manipulation was superior to thoracic mobilization or standard care for disability.	Thoracic manipulation is more beneficial than thoracic mobilization, cervical mobilization, and standard care in the short-term (pain, disability, self-perceived rating of change in function) No difference between thoracic manipulation and cervical manipulation or placebo thoracic manipulation to improve pain and disability.	Cochrane RoB: Average score 9/12 Grade: overall low to moderate quality	Moderate
Nim 2021 [20]	SR: 10 (varied sample sizes from 39-186) Only 6/10 articles had cervical pain (3 chronic, 3 unspecified duration). Neck pain sample was 6 (513)	Compare manipulation of ‘clinically relevant site’ to ‘other spinal location’ for spine pain of any region	Manipulation manually or with an instrument	No MA	Spinal manipulation specific to a level or ‘clinically-relevant’ location did not demonstrate superior outcomes compared to ‘not clinically-relevant’ or nonspecific spinal manipulation.	Cochrane RoB: 1 high risk, 4 moderate, 5 low risk of bias Quality: 9/10 acceptable quality (manuscript defines quality)	High
Roenz 2018 [21]	SR:13 (1313), includes cervical and lumbar MA: 12 studies (977); includes cervical and lumbar Neck Pain only: SR: 11 (1052) MA: 6 (351)	Examine pragmatic versus prescriptive trials using mobilization and manipulation for spinal pain	Mobilization and manipulation	Prescriptive studies tend to favor manipulation over mobilization for short and long-term pain and disability outcomes. There is no difference between mobilization and manipulation for pain and disability outcomes in pragmatic studies.	Manipulation tends to have better outcomes compared to mobilization in prescriptive trials. However, there are no differences between mobilization and manipulation in pragmatic trials.	Cochrane RoB for prescriptive studies: 6 studies moderate to low risk; 2 studies high risk Cochrane RoB for pragmatic studies: 2 moderate to low risk; 3 high risk	Low
Sbardella 2021 [22]	SR: 21 (913)	Compare muscle energy technique (MET) with other manual therapy treatments for acute and chronic neck pain	MET versus other manual therapy techniques	No MA	MET may improve pain and ROM and is best when combined with exercise and other manual therapy interventions	PEDro: High risk of bias in 17 studies, low risk in 5 studies
Thomas 2019 [23]	SR: 26 articles,14 with symptomatic patients (954) Specific to Neck pain population: four articles for asymptomatic and three chronic neck pain	Determine the effect of muscle energy technique (MET) on neck pain and ROM	MET	No MA	MET seems to improve ROM when combined with exercise and stretching.	PEDro: 10/14 articles moderate to high quality (scored at least 6/10)	Low
Tsegay 2023 [24]	SR, MA 8 (457)	Determine the efficacy of thoracic spine manipulation for the treatment of chronic mechanical neck pain.	Thoracic manipulation	Thoracic spine manipulation was more effective in reducing pain and disability in the short-term compared to comparison and control groups.	Thoracic manipulation is effective for reducing neck pain and disability in those with chronic neck pain compared to other interventions.	GRADE: low to moderate evidence overall PEDro: 5 high quality (scored 7+), 2 fair quality, 1 poor quality	Moderate
Wang 2022 [25]	SR, MA 12 (566)	Examine manual soft tissue mobilization/massage in individuals with neck pain >1 month	Soft tissue treatment, massage, and myofascial release compared to any other treatment, placebo, sham, or no treatment	Manual soft tissue work was more effective than control for pain (large effect).	Manual soft tissue mobilization is effective for reducing neck pain in those with neck pain >1 month.	Cochrane RoB: Majority had low RoB in all categories except blinding participants/personnel	Moderate
Wilhelm 2023 [9]	SR, MA 22 (2207)	Examine manual therapy plus exercise in nonspecific neck pain (any stage)	Manual therapy + exercise was the primary intervention vs manual therapy alone, exercise alone, control/sham.	Manual therapy + exercise was superior to control or exercise alone in reducing pain and disability. However, no statistically significant effect was noted for manual therapy plus exercise vs manual therapy alone	Manual therapy with exercise is beneficial for pain and disability in individuals with nonspecific neck pain.	GRADE showed low to moderate certainty for most findings; high certainty for no difference in manual + exercise vs exercise for quality of life Cochrane RoB: 9 low risk, 10 some concerns, 3 high risk	Low
Xu 2023 [26]	SR, MA 15 (725)	Examine manual ischemic compression of trigger points for neck pain and dysfunction	Manual Ischemic compression	No immediate change in pain, PPT or disability with ischemic compression compared to other interventions; however short-term improvement was noted for PPT and disability. Ischemic compression was superior to sham or no treatment.	Ischemic compression could be beneficial in the short-term for PPT and function.	GRADE: very low to moderate levels of evidence PEDro: 8/15 studies high quality (scored 6+/10); 7/15 studies scored 4-5/10	Moderate
Yao 2017 [27]	SR, MA 19 (2,194)	Determine efficacy of eastern and western manipulative therapy for neck pain.	Manipulation and mobilization techniques; manual traction.	Eastern and Western manipulation is favored for short-term pain (VAS), as well as short and intermediate term function and disability.	Some evidence supports manipulation may be effective for short-term pain and disability and intermediate disability, however, it may not be enough to reach clinical significance	GRADE: High to medium quality for all trials Cochrane RoB: 11/19 low risk of bias	Critically Low

GRADE: Grading of recommendations, assessment, development and evaluations; MA: meta-analysis; MET: Muscle energy technique(s); NSNP: nonspecific neck pain; PEDro: Physiotherapy evidence database; PPT: pressure pain threshold; RoB: risk of bias; ROM: range of motion; SNAGs: sustained natural apophyseal glides; STM: soft tissue mobilization; SR: systematic review; VAS: visual analogue scale. The last column (Reported Quality/Risk of Bias) includes language as reported by original authors.

Table 2.

Cervical radiculopathy (n = 7).

Author/Year	Sample Size: Number of Studies (participants)	Objective	Manual Therapy Description	Meta-Analysis Results	Conclusions	Original Author Reported Quality/Risk of Bias	AMSTAR 2: Overall Confidence Rating
Basson 2017 [28]	40 (1759) total Specific to neck related arm pain: SR: 10 (330) MA: 3 (110)	Examine neural mobilization for neck pain with radiating pain or signs of nerve involvement	Lateral glide, neural mobilization, thoracic mobilization	Significant improvement in nerve related neck and arm pain with cervical lateral glide compared to wait list group, ultrasound, and advice only	Cervical lateral glides can improve nerve related neck and arm pain. Neural mobilization (sliders and tensioners) improve pain compared to exercise, traction and interferential. Neural mobilization can improve disability compared to advice to stay active and may improve disability compared to mobilization or exercise.	‘varying methodological quality’ via MASTARI tool; GRADE: 17 low risk bias; 23 unclear or high risk	Moderate
Borrella-Andres 2021 [29]	SR: 17 (1,183)	Examine manual therapy for cervical radiculopathy	Cervical or thoracic mobilization or manipulation, soft tissue treatment, cervical traction and neural mobilization	No MA	Manual therapy appears to be effective in reducing chronic cervical pain and disability in the short-term.	PEDro: 9 high quality (>5), 3 moderate (4,5); 5 low quality	Moderate
Paraskevopoulos 2023 [30]	SR, MA 7 (323)	Examine neural mobilization in cervical radiculopathy	Median nerve mobilization (slider/glider and tensioner) with cervical traction or other intervention	Neural mobilization is superior to control for improving pain, function and ROM in individuals with cervical radiculopathy. Neural mobilization is not superior to other interventions for these same outcomes.	Neural mobilization does not offer significantly better outcomes on pain, ROM, and function compared to other interventions but may be superior to no treatment.	GRADE: Moderate to low quality overall PEDro: 2 high quality (scored 7+/10); 3 moderate quality (5-6/10) and 2 low quality.	Moderate
Plener 2023 [31]	SR: 59 (4108); 9 trials assessed manual therapy (7 multimodal trials and 2 assessed manual therapy alone)	Evaluate conservative intervention versus no intervention or sham in cervical radiculopathy	Manual therapy in general and thoracic manipulation	No MA	Low to very low certainty supporting manual traction and neural mobilization improve immediate ROM. Very Low certainty that cervical mobilization or thoracic manipulation provide improvement in cervical ROM, pain or disability.	GRADE: used to assess articles with ‘some concerns’ or low RoB. Overall lack of moderate to high quality evidence Cochrane RoB: 24 trials rated ‘some concerns’ or low RoB	Moderate
Romeo 2018 [32]	SR, MA 5 (449); 2 (52) for the manual traction group)	Examine the addition of manual cervical traction to other PT intervention in cervical radiculopathy	Manual cervical traction	Manual traction had significant effect on pain.	Manual traction had significant effects on pain at the short-term compared to the use of physical therapy intervention alone.	GRADE: low to moderate quality PEDro: 4 studies scored at least 6/10 (good quality) 2 articles included for manual traction were low quality	Critically Low
Varangot-Reille 2022 [33]	SR, MA 22 (978)	Examine neural mobilization in neck pain with nerve related symptoms	Neural mobilization, cervical lateral glides	Neural mobilization is superior to no intervention for ROM, disability, function and mechanosensitivity. Neural mobilization is superior to other interventions for mechanosensitivity. No differences between neural mobilization and other treatments for pain, ROM, disability.	Neural mobilization was effective in reducing pain when added to other PT interventions. Neural mobilization is superior to no intervention for several outcomes, but may be equal to other interventions when used in isolation.	GRADE: very low to moderate for outcomes of pain, ROM, disability, function overall PEDro: (22 RCTs) 14 studies good quality, 4 fair, 4 poor Cochrane RoB: Figure shows areas of risk across multiple domains Risk of Bias in non-randomized Studies of Interventions tool (ROBINS-I): 1/1 nonrandomized trial had serious risk of bias	High
Zhu 2016 [34]	MA: 502	Determine the efficacy and safety of cervical spine manipulation for degenerative cervical radiculopathy	Cervical manipulation	Cervical spine manipulation is effective for immediate decrease in pain (VAS) compared to cervical computer traction.	Moderate quality evidence that manipulation may be more effective than intermittent cervical traction for short-term pain reduction.	GRADE: Overall moderate quality PEDro: acceptable (score 5-6)	Critically Low

GRADE: Grading of recommendations, assessment, development and evaluations; MA: meta-analysis; PT: physical therapy; PEDro: Physiotherapy evidence database; RoB: risk of bias; ROM: range of motion; SR: systematic review; VAS: visual analogue scale. The last column (Reported Quality/Risk of Bias) includes language as reported by original authors.

Table 3.

Cervicogenic headache (CGH) (n = 9).

Author/Year	Sample Size: Number of Studies (participants)	Objective	Manual Therapy Description	Meta-Analysis Results	Conclusions	Original Author Reported Quality/Risk of Bias	AMSTAR 2: Overall Confidence Rating
Bini 2022 [35]	SR: 20 (1439) MA: 6 (628)	Examine manual therapy alone or manual therapy and exercise in the management of CGH (any stage)	Massage, trigger point, manipulation, mobilization	Manual therapy was helpful for HA intensity, frequency and disability. Larger effects were noted in the short-term.	Manual therapy alone or with exercise therapy can reduce cervicogenic HA intensity, frequency and disability in short-term with smaller effects in the long-term.	GRADE: very low quality for HA intensity and frequency at short-term and low quality for HA intensity, frequency and disability at long-term. Cochrane RoB: Overall RoB low in 8 trials, unclear in 6, high in 6 trials	High
Cardoso 2022 [36]	SR 8 (357)	Examine SNAGs for CGH (any stage)	SNAGs	No MA	SNAGs may be helpful for CGH pain and dysfunction in short, medium and long-term.	Quality: PEDro 3 high quality and 5 moderate quality	High
Coelho 2019 [37]	SR: 9 (793) MA: 7 (563)	Examine manual therapy mobilization and manipulation in cervicogenic and other HA types	Mobilization or manipulation	No difference in pain, disability or HA frequency for mobilization/manipulation versus conservative care at 4-48 weeks	Cervical mobilization or manipulation were found to be equally as effective as conservative treatment in reducing pain, disability, and frequency.	Cochrane RoB: 3 studies moderate to low risk bias, 6 studies high risk	Critically Low
Demont 2022 [38]	SR: 14 (1112) MA: 3-5 studies (126-285)	Examine exercise or manual therapy for CGH	Manual therapy	Manual therapy was helpful for CGH pain intensity and frequency compared to sham and no treatment. However, at 12 months, this effect was not seen.	Manual therapy is helpful for CGH in short to medium timeframe.	GRADE: Very low to moderate quality overall PEDro: 7 studies high quality (7+) and 7 moderate quality (5,6)	Low
Fernandez 2020 [39]	SR, MA 7 (403)	Examine spinal manipulation versus other manual therapy for CGH	Cervical or thoracic manipulation versus other forms of manual therapy or multimodal intervention	Short-term effect (2 weeks to 3 months) favors spinal manipulation for pain intensity, disability, pain frequency. No effect for pain duration	Spinal manipulation provides small, superior short-term benefits for pain intensity, frequency and disability, but not pain duration.	PEDro: 5 high quality, 2 moderate GRADE: low to moderate quality at each time period (short/intermediate/long-term follow up)	Moderate
Herranz-Gomez 2021 [40]	SR: 18 (9,188) MA: 8 with CGH (1592)	Examine Manual therapy + exercise for CGH and other HA types	Any manual therapy provided by PT	Significant differences in pain intensity with manual therapy for CGH in short-term but not medium or long-term. No significant differences in frequency of symptoms with manual therapy or exercise in individuals with CGH.	Manual therapy alone resulted in short-term improvement in disability and pain in individuals with CGH. Short and medium term improvement in quality of life and disability with manual therapy for CGH in systematic review results. Combined manual therapy with exercise was favorable in the short and medium term for CGH.	AMSTAR: Only 6/18 studies considered high quality RoB in Systematic Reviews: 6/18 had low risk of bias	High
Luedtke 2016 [41]	SR: 7 (402) Total MA for CGH: 4 (388)	Evaluate PT interventions in CGH	Manual therapy, mobilization, soft tissue techniques, SNAGs	Significant improvement in pain intensity, duration and frequency of HA using manual therapy for CGH	Manual therapy resulted in a reduction in intensity, frequency and duration of CGH. Trigger point therapy reduced intensity of CGH. Mobilization was superior to massage to reduce duration of CGH.	Cochrane RoB tool: 19/26 unclear or high risk of bias GRADE: overall quality of published trials is low	Critically Low
Nunez-Cabaleiro 2022 [42]	SR: 14 (1004)	Examine manual therapy for CGH	Spinal manipulation, SNAGs, trigger point, soft tissue work	No MA	Manual therapy could be effective for CGH. Upper cervical manipulation appears to be the most effective of the manual therapy interventions studied. Soft tissue work appeared to provide short-term results while manipulation helped with long-term results.	Quality: Oxford levels of evidence shows majority level 1 and 21% level II. Jadad indicates 3+ points (out of 5) in 43% and none with 0 points	Low
Varatharajan 2016 [43]	SR: 6 (518)	Examine noninvasive treatment for HA associated with neck pain (acute or chronic)	Soft tissue work, manual therapy	No MA	Manipulation was superior to control (massage and moist heat) for HA intensity. Manual therapy (manipulation or mobilization) was superior to usual care for HA intensity, frequency and disability. Manual therapy (spinal manipulation and mobilization) and exercise were more effective than no intervention but equally effective to one another in improving pain, HA frequency and disability. Medication use decreased at 12 months for manual therapy, exercise, and the combined manual therapy + exercise.	Scottish Intercollegiate Guidelines Network (SIGN): 10/10 studies low risk of bias	Low

CGH: cervicogenic headache; GRADE: Grading of recommendations, assessment, development and evaluations; HA: headache; MA: meta-analysis; PEDro: Physiotherapy evidence database; PT: physical therapy/therapist; RoB: risk of bias; ROM: range of motion; SNAGs: sustained natural apophyseal glides; SR: systematic review. The last column (Reported Quality/Risk of Bias) includes language as reported by original authors.

Table 4.

Combined neck pain samples (n = 4).

Author/Year	Sample Size: Number of Studies (participants) with sample description	Objective	Manual Therapy Description	Meta-Analysis Results	Conclusions	Original Author Reported Quality/Risk of Bias	AMSTAR 2: Overall Confidence Rating
Fredin 2017 [8]	SR, MA 7 (936) Grade I-II neck pain: Pain affects ADLs and is included in the study Excluded: Grade III neck pain: Has neuro signs and Grade IV neck pain: Major structural pathology *Note WAD is included in this sample based on these categories of pain	Examine combined manual therapy + exercise versus either treatment alone in adult patients with ‘grade I-II neck pain’	Manual therapy including manipulation, mobilization or massage	Manual therapy with exercise improved pain immediately but not at 6 or 12 months. No significant difference in disability or quality of life immediately, at 6 months, or 12 months	Manual therapy + exercise does not seem to be more effective in reducing neck pain intensity (at rest), neck disability or improving quality of life over exercise alone. Results favor combined treatment earlier and exercise later	GRADE: Moderate quality for pain at rest, moderate to low for disability and quality of life outcomes PEDro: 3 studies 6+/10 (high quality) and 4 studies < 6/10 (low quality)	Low
Gross 2015 [44]	SR, MA 51 trials (2920 participants) 18 trials of manipulation/mobilization vs control 34 trials of manipulation/mobilization vs another treatment 1 trial had two comparisons). Included Any stage neck pain, neck pain with or without radicular findings, WAD (I, II, III), CGH	Examine mobilization or manipulation alone vs inactive or active controls for neck pain with or without radicular symptoms and CGH	Manipulation, mobilization	Thoracic manipulation was superior to inactive control for neck pain, function, and quality of life (QoL)	Thoracic manipulation is supported versus control for neck pain, function and QoL. Results for cervical manipulation and mobilization versus control are few and diverse. Findings suggest that manipulation and mobilization present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up	GRADE: 41/51 studies low quality Cochrane RoB tool for manipulation/mobilization vs active comparison: 13 studies low risk and 21 high risk of bias	High
Patel 2012 [45]	SR: 15 trials (810 participants) Includes any stage neck pain, neck pain with or without radicular findings, WAD, CGH	Examine massage for neck pain	Massage techniques	No MA	Massage alone can improve pain and tenderness in the immediate and short-term	GRADE: low or very low quality Cochrane RoB: 4/15 unclear risk; 6/15 high risk	High
Sutton 2016 [46]	SR: 14 studies (18 articles) Includes neck pain (nonspecific), WAD	Examine multimodal care (including manual therapy) for management of WAD and neck pain and associated disorders	Mobilization, manipulation, traction, soft tissue work	No MA	Multimodal packages including manual therapy, exercise and/or education were beneficial to the management of acute or persistent WAD or neck pain and associated disorders. There was not one multimodal arrangement that was superior to another multimodal plan.	Scottish Intercollegiate Guidelines Network (SIGN) criteria used; only studies of at least adequate quality were included in synthesis.	Moderate

CGH: cervicogenic headache; GRADE: Grading of recommendations, assessment, development and evaluations; MA: meta-analysis; PEDro: Physiotherapy evidence database; PPT: pressure pain threshold; QoL: quality of life; RoB: risk of bias; SR: systematic review; WAD: whiplash associated disorder. The last column (Reported Quality/Risk of Bias) includes language as reported by original authors.

Findings of included studies

Data were initially extracted in specific detail to include pooled differences and effect sizes. This data, however, could not be summarized in a meaningful way due to the heterogeneity of samples, interventions, outcomes and follow-up periods. Authors summarized results with as many details as possible to remain succinct and accurate. Results were organized by diagnosis and findings are grouped by the level of confidence in results based on AMSTAR 2 ratings (high, moderate, low to critically low confidence).

Non-specific neck pain

A total of 15 systematic reviews (10 with meta-analyses) examined manual therapy for individuals with mechanical neck pain or NSNP diagnoses. See Table 1.

There was high overall confidence in the results for four of the 15 reviews. Findings indicated manual therapy (mobilization and manipulation) combined with exercise was superior to either treatment in isolation [15,17] for chronic neck pain. Hidalgo et al. [4] examined acute, subacute and chronic presentations noting a combination of manual therapy (manipulation, mobilization, mobilization with movement, sustained natural apophyseal glide (SNAG)) and exercise was superior for pain; Hidalgo et al. [4] also reported manipulation alone or in combination with exercise was superior to usual care, exercise alone or other manual therapy alone in chronic neck pain for the outcomes of pain, function and satisfaction. Nim et al. [20] reported manipulation (manual or instrument assisted) had similar outcomes when performed at a ‘clinically relevant’ or ‘not clinically relevant’ location, however, this sample did examine more than just individuals with neck pain. Pain and disability were the most commonly reported outcomes of interest; the majority of studies supporting the positive benefits of manual therapy noted effects in the immediate and short-term follow-ups.

Moderate confidence in the results was found in six reviews. Results from studies with moderate confidence indicated a large effect on pain for treatments including spinal manipulation with or without other interventions in acute neck pain [16] while a combination of manipulation and exercise was more effective for pain and disability in the chronic neck pain population [18]. Tsegay et al. [24] supported the use of thoracic manipulation for nonspecific mechanical neck pain; Masaracchio et al. [19] reported thoracic manipulation was superior to thoracic or cervical mobilization; however, no difference was found between thoracic manipulation and cervical manipulation in the short-term. Ischemic compression applied to trigger points did not show immediate (same day) change in pain, PPT or disability. However, there was short-term improvement in PPT and disability compared to sham or no treatment.[26]

Five reviews had low or critically low confidence in findings. These reviews supported manipulation [27] and manual therapy and exercise combined [9]. There was also support for muscle energy techniques (MET) when combined with exercise or other manual therapy techniques [22,23]. One author reported prescriptive studies tend to support manipulation while pragmatic studies tend to support mobilization [21].

Cervical radiculopathy

A total of seven systematic reviews (five with meta-analyses) examined manual therapy for individuals with cervical radiculopathy. See Table 2.

Only one review had an AMSTAR rating indicating high confidence in the results: Varangot-Reille et al. found neural mobilization was helpful for ROM, disability, function and mechanosensitivity when compared to no intervention; however, results indicate neural mobilization was no better than other treatments for pain, ROM, or disability. Neural mobilization was superior to other treatments for the outcome of mechanosensitivity [33].

Results from studies with moderate confidence in findings supported cervical lateral glides and neuromobilization [28,29] as well as cervical or thoracic mobilization/manipulation and distraction or soft tissue treatment [28,29]. The findings of Paraskevopoulos et al. also supported the benefit of neural mobilization over no treatment, but there were no differences compared to other treatments [30]. Plenar et al. reported low to very low certainty in the benefit of manual traction and neural mobilization, cervical mobilization or thoracic manipulation [31].

Results from two reviews with critically low confidence in findings supported manual traction (Romeo) and cervical manipulation (superior to mechanical traction) (Zhu) for short-term pain reduction.

Cervicogenic headache

A total of nine systematic reviews (six with meta-analyses) examined manual therapy for individuals with cervicogenic headache. See Table 3.

There were three studies with a high confidence in results. Findings support cervical spine mobilization and manipulation as well as trigger point and soft tissue mobilization in improving HA intensity, frequency and disability in the short-term, with smaller effects in the long-term; this finding supported manual therapy alone or combined with exercise [35]. Another study found manual therapy was helpful for HA pain and disability in the short-term but not the medium or long-term; no differences in HA frequency were reported [40]. These authors also noted a combination of manual therapy and exercise was favorable in the short and medium-term [40] .SNAGs were helpful for pain and dysfunction in the short, medium and long-term [36].

One study with a moderate confidence in the results reported small superior short-term benefits for pain intensity, frequency and disability but not pain duration for spinal manipulation versus other forms of manual therapy or multimodal intervention packages [39].

There were five reviews with low to critically low confidence in findings. One study found no difference in outcomes for cervical mobilization or manipulation versus conservative care [37]. Two studies supported manual therapy including soft tissue techniques and SNAGs for pain intensity and frequency when compared to sham or no treatment [38,41]. Nunez-Cabaleiro et al. [42] reported upper cervical spine manipulation was most effective and soft tissue work was helpful in the short term. Varatharaja et al. [43] reported manipulation, mobilization and manual therapy with exercise were effective for the CGH population.

Combined neck pain samples

A total of four systematic reviews (two with meta-analyses) examined manual therapy across several diagnostic groups including WAD. See Table 4.

Two studies had a high confidence in the results. Gross et al. [46] examined NSNP and WAD reporting benefits with multimodal packages of manual therapy, exercise and education. These authors reported cervical and thoracic mobilization and manipulation, traction and soft tissue work were helpful, mostly in the short to intermediate timeframes. Patel et al. [45] reported massage alone improved pain and tenderness in the immediate and short-term for individuals at any stage of neck pain with or without radicular findings, WAD and/or CGH.

One study with a moderate confidence in the findings reported multimodal packages with manual therapy, exercise and/or education were beneficial to the management of acute or persistent WAD or neck pain with associated disorders [46]. Authors reported there was not one multimodal package that was superior [46].

One review with low confidence in the results examined a population with neck pain that impacts activity of daily living (without neurological signs or major structural pathology); authors reported manual therapy and exercise were not better than exercise alone in long-term follow-up (6 months to 1 year); however, there was more support for the combined intervention in the short-term [8].

Discussion

This umbrella review aimed to systematically analyze and integrate findings from existing systematic reviews and meta-analyses, exploring the effects of manual therapy compared to other physical therapy interventions, medical interventions, or control conditions on pain, function, disability, fear of movement, and psychosocial impairment in individuals with NSNP including CR, CGH, and combined neck pain samples. AMSTAR 2 ratings indicate high confidence in findings for 10 reviews, moderate confidence in 12 reviews and low to critically low confidence in 13 reviews.

Non-specific neck pain (NSNP)

AMSTAR 2 ratings with a high confidence in the results indicated manual therapy combined with exercise was superior to either treatment in isolation for the management of acute and chronic NSNP [15,17].

In acute neck pain, results indicated a moderate level of confidence in supporting the efficacy of spinal manipulation (cervical and/or thoracic), either alone or in combination with other interventions, for pain relief [16]. For chronic neck pain, the review emphasized the potential benefits of manipulation and mobilization, suggesting that multimodal approaches, especially when incorporating exercise, may yield the most significant improvements in pain and function [18]. Treatments such as spinal manipulation plus mobilization/soft tissue manipulation, outperformed manual therapy or exercise alone, emphasizing the potential synergistic effects of a multimodal approach.

Notably, the targeted application of spinal manipulative therapy to specific levels did not demonstrate superior outcomes compared to nonspecific manipulative therapy, challenging traditional assumptions regarding precision in manual therapy interventions; while there was high confidence in these results, it is important to note that this study examined pooled data over multiple areas of spinal pain (results were not exclusive to cervical pain) [20]. Muscle energy techniques, particularly when combined with exercise, emerged as a favorable option for improving range of motion in patients with chronic neck pain, although findings had low to critically low confidence in the results.

For individuals with NSNP, our umbrella review affirms the overall beneficial effects of manual therapy, either in isolation or when combined with other conservative interventions. This holds true across various stages of neck pain, providing clinicians with flexibility in tailoring treatment plans.

Cervical radiculopathy

There is a high confidence in the results supporting neural mobilization, such as sliders and tensioners, to reduce mechanosensitivity in individuals with cervical radiculopathy [33]. Importantly, these findings also indicated the combination of neural mobilization with other physical therapy interventions appear to enhance outcomes, supporting a multimodal approach.

Our synthesis of systematic reviews indicates moderate confidence in the effectiveness of manual therapy in the short-term. Cervical spine mobilization including lateral glides, cervical and thoracic spine manipulation, soft tissue mobilization, cervical traction and neural mobilization techniques effectively improved pain, ROM and disability associated with cervical radiculopathy [28,29]. Manual traction and cervical spine manipulation emerge as potential interventions for immediate pain and disability reduction, although both of these results are based on evidence with critically low confidence in findings [32,34].

For individuals with cervical radiculopathy, our umbrella review affirms the benefit of manual therapy.

Cervicogenic headache

For individuals with cervicogenic headaches, cervical mobilization, manipulation and soft tissue or trigger point work were supported from three studies with a high confidence in the results. These manual therapy interventions were effective in reducing disability and HA frequency/intensity, particularly in the short-term [35,40]. There is also high confidence in the use of SNAGS across various timeframes for short to long-term effects [36] and high confidence in the use of a multi-modal plan of manual therapy and exercise for short to medium-term improvements [40].

Spinal manipulation, including upper cervical manipulation, emerges as a valuable intervention, providing small yet superior short-term benefits in pain intensity, frequency, and disability compared to control groups with moderate confidence in the results [39].

Lower confidence findings also supported cervical mobilization or manipulation, soft tissue techniques and SNAGs [37,38,41,42]. Manual therapy added to exercise was helpful for pain, disability and HA frequency in short and intermediate follow-up with an additional benefit of reducing medication use [43].

Differentiating treatment modalities, such as joint mobilization, manipulation, exercise, trigger point therapy and soft tissue mobilization, can be tailored based on short- or long-term goals for managing individuals with cervicogenic headaches.

Generalized findings

In the broader context of generalized neck pain, this umbrella review consolidates evidence on the effectiveness of multimodal approaches, including manual therapy, exercise, and education. While the combination of manual therapy and exercise does not consistently outperform exercise alone in reducing neck pain intensity, the dosage and timing of treatment may influence outcomes. Thoracic manipulation demonstrates efficacy in improving neck pain, function, and quality of life compared to control groups. Multiple sessions of cervical manipulation prove advantageous, surpassing certain medications in providing sustained pain relief and functional improvement. The effectiveness of massage remains uncertain due to limited reporting quality, with potential short-term benefits.

According to Leech et al. manual therapy is one of the most common conservative interventions used for the management of neck pain. [1] Evidence for manual therapy as an intervention for individuals with neck pain is increasing and recommendations regarding its use are strong [5]; however, the optimal type, dose, and timing remain unclear. Most of the included systematic reviews did not describe the manual therapy interventions in sufficient detail for clinical application; what constitutes the most appropriate manual therapy regime remains unclear. An updated definition of orthopedic manual physical therapy is a sub-specialty that incorporates a more contemporary definition of manual therapy including the multi-dimensional, active, patient-centered approach that includes therapeutic exercise, pain neuroscience education, clinical reasoning, hands-on intervention and appropriate physical activity [7]. Notably, this umbrella review highlights the utility of multimodal packages, emphasizing the absence of a one-size-fits-all approach in managing acute or persistent neck pain and associated disorders. Putting these results into the framework of a biopsychosocial approach to care requires clinicians to incorporate a multi-dimensional manual therapy approach. Future studies. including systematic reviews, should intentionally examine and define dosage parameters for manual therapy while including clear descriptions of the multidimensional aspects of each intervention.

Potential limitations of umbrella review

An umbrella review pools together multiple systematic reviews of varying quality. Each systematic review reported the quality and risk of bias for the randomized controlled trials (individual studies) included in their review. There were several reviews noting lack of consistent high-quality and low risk of bias studies. The quality of each individual study impacts the systematic review and/or meta-analysis with implications for interpretation of an umbrella review. Authors of this umbrella review shared the original author reports of quality and bias alongside the AMSTAR 2 findings to allow readers to take this into consideration when reading results. Twenty-two included reviews had high to moderate confidence in results while 13 reviews had low to critically low confidence.

There is a risk of overlapping primary studies included in multiple systematic reviews; with nine articles reported in multiple systematic reviews, it is possible that the interventions studied can be overrepresented in this umbrella review. It is also possible meaningful primary studies were not represented in any of the included systematic reviews. Authors focused on articles that included our defined outcomes of interest; therefore, outcomes beyond the defined outcomes of interest were excluded. While the search was exhaustive, it is possible studies may have been missed using the search strategy. Heterogeneity of comparator interventions, follow-up periods and outcome tools limited the possibility of providing quantitative summaries.

Conclusion

Evidence for manual therapy as an important management strategy for individuals with neck pain is increasing and strengthening. Ongoing investigation through research is necessary to clearly identify optimal dosing and timing. However, a strong recommendation can be made to include manual therapy as an adjunct to other interventions for the management of neck pain in the acute and chronic stages. This umbrella review underscores the multifaceted nature of manual therapy interventions, their nuanced effects across different neck conditions, and the potential benefits of multimodal approaches in enhancing clinical outcomes. Future research should continue to explore optimal intervention combinations, refine treatment protocols, and address the variability in study methodologies to further guide evidence-based practice in managing neck pain and related disorders.

Biographies

Breanna Reynolds, is an Associate Professor at South College School of Physical Therapy. Dr Reynolds has completed post-professional orthopaedic manual therapy residency and fellowship (FAAOMPT) through the Ola Grimsby Institute. She earned a Doctor of Philosophy (PhD) in Physical Therapy (2018) with Nova Southeastern University. Her current research interests include orthopaedic physical therapy (cervical, TMJ), manual therapy and hybrid DPT education. Dr Reynolds maintains clinical practice with Rock Valley Physical Therapy in Illinois. She is an active member of APTA, IPTA and AAOMPT.

Amy McDevitt, is an Associate Professor in the Physical Medicine and Rehabilitation Department at the University of Colorado Anschutz Medical Campus, School of Medicine. She has been practicing as a physical therapist since 2000. Clinically, she practices at the University of Colorado Health, CU Sports Physical Therapy and Rehabilitation. She is a board-certified Orthopaedic Clinical Specialist and a Fellow in the American Academy of Orthopaedic Manual Physical Therapists. She teaches entry-level Doctor of Physical Therapy students. She completed her clinical PhD at the University of Newcastle, Australia. Amy is active in clinical and educational research at the University of Colorado Anschutz Medical Campus and her research interests include musculoskeletal pain, shoulder pain, regional interdependence, dry needling and assessment of clinical reasoning in physical therapist students.

Joseph Kelly, is an associate professor at Bradley University DPT program. He graduated from Washington University in St. Louis with MSPT. He earned a Doctor of Philosophy (PhD) in physical therapy at Nova Southeastern University. His current research interests include the biomechanical measurement of muscle stiffness, orthopedic physical therapy outcomes, and the scholarship of teaching and learning.

Paul Mintken, lives in Denver, CO and is a Professor in the DPT education program at Hawaiʻi Pacific University (HPU). Prior to HPU, Dr. Mintken was faculty in the DPT Program at the University of Colorado for almost 20 years. Dr. Mintken is a board-certified Orthopaedic Clinical Specialist and a Fellow in the American Academy of Orthopaedic and Manual Physical Therapists. Dr. Mintken has received the APTA Excellence in Academic Teaching Award, the James Gould Excellence in Teaching Orthopaedic Physical Therapy Award, the Rose Research Award, the JOSPT Research Award, the Chattanooga Research Award, the Outstanding Physical Therapist Award for the State of Colorado, and the Kaltenborn “teach I Must” award. Dr. Mintken has over 60 peer-reviewed articles. He remains clinically active as a physical therapist at Wardenburg Health Center at the University of Colorado Boulder.

Derek Clewley, is an assistant professor at Duke University School of Medicine in the Doctor of Physical Therapy Division. His area of expertise and training is in orthopaedics and manual physical therapy. He has achieved board certification in orthopaedics and is recognized as a fellow of the American Academy of Orthopaedic Manual Physical Therapists. He is an associate editor of BMC Musculoskeletal Disorders and an AAOMPT Board Member. He has expertise in systematic review methodology. He is most interested in management of neck pain. Dr. Clewley has published more than 30 peer-reviewed papers.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplemental material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10669817.2024.2425788