Background:Manual therapies are commonly used in the management of neck pain to relieve symptoms, restoremobility and hasten recovery. Common practice in manual therapy is using immediate treatment responses to inform both treatment progression and prognosis. Within-session changes in symptoms have been shown to correlate with self-reported recovery rate. This study sought a detailed profile of the trajectory of recovery of neck pain treated with manual therapy and further information about the predictive value of withinsession improvements. Purpose:The aim of this studywas to describe the clinical course of a new episode of neck pain during a course of manual therapy treatment and to explore whether the early responses to treatment were related to longer term outcomes. Methods:Analysis of treatment responses and recovery in participants from two arms of a manual therapy randomised controlled trial. Participants were 181 people with a new episode of neck pain, treated with a course of mobilisation or manipulation of the neck on four occasions over two weeks. The clinical course during the episode of care was described using average preand post-treatment pain scores (numerical rating scale 0–10) for each occasion of treatment. Repeated measures t-test was used to compare scores within and between sessions. The relationships between immediate treatment effects and time taken to recover and the Global Perceived Effect (GPE) of treatment at 3 months were explored using multivariate regression analyses. Results: On each occasion of treatment, pain scores significantly decreased with the smallest average withinsession change 1.4 (95%CI 1.2 to 1.5). There was also small but statistically significant increases in average pain scores of up to 0.7 (95%CI 0.4 to 1.0) between treatment sessions without regression to the preceding pre-treatment level. The change in pain scores after the first treatment session was independently associated with high GPE scores at three months (B= 0.2, 95%CI 0.01 to 0.4). There were also significant univariate associations between the within-session changes in pain and the time taken to recover from the episode of neck pain. However, these associations were not independent of duration of symptoms, self-rated general health, or the presence of headache. Conclusion(s): These results indicate that people with neck pain who are treated with manual therapy experience a pattern of recovery of symptoms that coincides with the occasions of treatment and features improvement within sessions and slight relapse between sessions. These results also demonstrate that improvements in symptoms within a treatment session are associatedwith a faster rate of recovery from an episode of neck pain and with patient’s overall perception of the benefits of treatment at 3-month follow up. Implications:Manual therapists can use the information in this study to assist their patients’ understanding of the trajectory of their recovery from a new episode of neck pain. In particular, it is helpful for patients to understand that slight relapses between treatment sessions are the normand not necessarily an indicator of poor outcome.These results also assist clinical reasoning in manual therapy practice by demonstrating a predictive value of short term treatment responses.