BACKGROUND: Cervical exercise has been shown to be an effective treatment for neck pain, but there is still a need for more clinical trials evaluating the effectiveness of adding manual therapy to the exercise approach. There is a lack of evidence on the effect of these techniques in patients with neck pain and upper cervical rotation restriction. PURPOSE: To compare the effectiveness of adding manual therapy to a cervical exercise protocol for the treatment of patients with chronic neck pain and upper cervical rotation restriction. METHODS: Single-blind randomized clinical trial. Fifty-eight subjects: 29 for the manual therapy plus exercise (MT+exercise) group and 29 for the exercise group. Neck disability index, pain intensity (0 to 10), pressure pain threshold (kPa), flexion-rotation test (degree), and cervical range of motion (degree) were measured at the beginning and at the end of the intervention, and at 3-and 6-month follow-ups. The MT+exercise group received one 20-min session of manual therapy and exercise once a week for 4 weeks and home exercise. The exercise group received one 20-min session of exercise once a week for 4 weeks and home exercise. RESULTS: The MT+exercise group showed significant better values post-intervention in all variables: neck disability index: 0% patient with moderate, severe, or complete disability compared to 31% in the exercise group (p = 0.000) at 6-months; flexion-rotation test (p = 0.000) and pain intensity (p = 0.000) from the first follow-up to the end of the study; cervical flexion (p = 0.002), extension (p = 0.002), right lateral-flexion (p = 0.000), left lateral-flexion (p = 0.001), right rotation (p = 0.000) and left rotation (p = 0.005) at 6-months of the study, except for flexion, with significative changes from 3-months of follow up; pressure pain threshold from the first follow-up to the end of the study (p values range 0.003 to 0.000). CONCLUSION: Four 20-min sessions of manual therapy and exercise, along with a home-exercise program, was found to be more effective than an exercise protocol and a home-exercise program in improving the neck disability index, flexion-rotation test, pain intensity, and pressure pain threshold, in the short, medium, and medium-long term in patients with chronic neck pain and upper rotation restriction. Cervical range of motion improved with the addition of manual therapy in the medium and medium-long term. The high dropout rate may have compromised the external validity of the study.

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