This case report describes successful outpatient physical therapy intervention (including High Velocity Low Amplitude Thrust (HVLAT) spinal manipulation) of a 43 year-old female patient with neck pain who did not fit ideal clinical prediction rule criteria for thoracic or cervical manipulation following an initial unsuccessful course of physical therapy. Following patient report of “0% improvement” in a physical therapy clinic that did not include HVLAT, patient care was transferred to a different clinic and the patient received physical therapy care that included HVLAT for 10 sessions. During that time, neck disability index scores decreased from 76% to 18%, meeting previously established criteria for minimally detectable change as well as clinically meaningful change. Cranio-cervical flexion test abilities improved from 18mmHg to 28mmHg, active cervical rotation improved from 45 degrees bilaterally to 85 degrees bilaterally, and neck pain had decreased from 7/10 to 0/10 on a Numeric Pain Rating Scale. Functionally, the patient re-acquired the ability to work an 8 hour shift of manual labor, to turn her head and back out of the driveway with her car, and to sleep through the night without waking in pain. The potential relative importance of non-clinical psychosocial factors in the prediction of outcome in patients who do not ideally fit clinical prediction rules is discussed.