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ISSN: 0959-3985 (print), 1532-5040 (electronic)
Physiother Theory Pract, 2015; 31(2): 99106
! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2014.963904

RESEARCH REPORT

Effectiveness of mobilization therapy and exercises in mechanical neck


pain
G. Shankar Ganesh, MPT, Patitapaban Mohanty, PhD, Monalisa Pattnaik, MPT, and Chittaranjan Mishra, MPT
Department of Physiotherapy, Swami Vivekanand National Institute of Rehabilitation Training and Research, Olatpur, Cuttack, Orissa, India

Abstract

Keywords

Objectives: While studies have looked into the effects of Maitland mobilization on symptom
relief, to date, no work has specifically looked at the effects of Mulligan mobilization. The
objective of this work was to compare the effectiveness of Maitland and Mulligans mobilization
and exercises on pain response, range of motion (ROM) and functional ability in patients
with mechanical neck pain. Methods: A total sample of 60 subjects (2145 years of age) with
complaints of insidious onset of mechanical pain that has lasted for less than 12 weeks
and reduced ROM were randomly assigned to: group I Maitland mobilization and exercises;
group II Mulligan mobilization and exercises; and group-III exercises only, and assessed for
dependent variables by a blinded examiner. Results: Post measurement readings revealed
statistical significance with time (p50.00) and no significance between groups (p40.05)
indicating no group is superior to another after treatment and at follow-up. The effect sizes
between the treatment groups were small. Conclusion: Our results showed that manual therapy
interventions were no better than supervised exercises in reducing pain, improving ROM and
neck disability.

Exercise, musculo skeletal manipulations,


neck pain

Introduction
Mechanical neck pain is defined as a generalized neck pain with
or without shoulder pain with mechanical characteristics including: symptoms produced by maintained neck postures, movement,
or by palpation of the cervical muscles (Fernandez-de-las-Penas,
Alonso-Blanco, and Miangolarra, 2007). The main feature of
mechanical neck pain is pain in the cervical region, often
accompanied by restriction of range of motion (ROM) and
functional limitation. Neck pain and its related disability cause an
important socioeconomic burden to the society (Cote, Cassidy,
and Carroll, 2000) and is the second largest cause of time off
work, after low back pain (Albright et al, 2001).
Guidelines by Albright et al. (2001) found no evidence for
EMG biofeedback, thermotherapy, massage, electrical stimulation, therapeutic exercises or combined interventions for acute
neck pain. Manipulations, mobilizations and exercise are favored
over traditional care in reducing acute neck pain at short-term
follow-up. A systematic review by Gross et al. (2007) studied
whether conservative treatments (e.g. manual therapies, physical
medicine methods, medication and patient education) relieved
pain or improved function/disability, patient satisfaction and
global perceived effect in adults with mechanical neck disorders.
The results of this review revealed that exercises combined with

Address correspondence to G. Shankar Ganesh, Department of


Physiotherapy, Swami Vivekanand National Institute of Rehabilitation
Training and Research, P.O. Bairoi, Olatpur 754010, Cuttack, Orissa,
India. E-mail: shankarpt@rediffmail.com

History
Received 6 February 2014
Revised 23 July 2014
Accepted 24 July 2014
Published online 26 September 2014

mobilization/manipulation demonstrated either intermediate or


long-term benefits. Recent Cochrane reviews by Gross et al.
(2010) and Kay et al. (2012) concluded manipulation, mobilization or exercise is beneficial in patients suffering from neck pain
when applied as single-modal treatment approaches.
Different forms and techniques in manual therapy exist, a
common feature being the use of hands during therapy and
include both manipulation and mobilization (Maitland,
Hengeveld, Banks, and English, 2001). Studies have shown that
manual therapy techniques provide effective relief for neck pain
(Bronfort, Haas, Evans, and Bouter, 2004; Gross et al, 2004;
Sarigiovannis and Hollins, 2005). These techniques include
manipulation (i.e. a high velocity thrust directed at the joints of
the spine) and mobilization techniques that do not involve a high
velocity thrust. Professionals debate whether the use of neck
manipulation does more harm than good (Refshauge et al, 2002).
Manipulation is associated with a small risk of serious cerebrovascular injury (Smith et al, 2003), whereas mobilization is
generally considered to be a safer technique (Rivett, Shirley,
Magarey, and Refshauge, 2006). Very few studies have looked
into the effectiveness of manual therapy on acute neck pain (Bonk
et al, 2000; Giebel, Edelmann, and Huser, 1997; McKinney,
Dornan, and Ryan, 1989; Mealy, Brennan, and Fenelon, 1986),
and some have found that cervical mobilization using Maitland
technique relieves pain and normalizes function (McKinney,
Dornan, and Ryan, 1989; Mealy, Brennan, and Fenelon, 1986).
High-quality evidence suggests greater short-term pain relief from
manual therapy than exercise alone, but no long-term differences
was found for acute neck pain (Miller et al, 2010). The
heterogeneity of interventions investigated in these studies
ranging from manipulation and eclectic mobilization to
strengthening, collar and no treatment makes it difficult to

100

G. S. Ganesh et al.

interpret the evidence and the effectiveness of specific mobilization technique.


Maitland mobilization is one of the most common manual
therapy approaches used by physiotherapists (Gracey,
McDonough, and Baxter, 2002). Maitland mobilization is a
passive oscillatory technique, applied over the hypomobile
vertebra level, and the methods are considered valid (Tuttle,
2005). The Mulligan concept is now an integral component of
many manual physiotherapists clinical practice. The concept has
its foundation built on Kaltenborns principles of restoring the
accessory component of physiological joint movement. This is a
manual therapy technique that consists of applying a sustained
pressure over a cervical hypomobile symptomatic level in weightbearing position (Mulligan, 1999) while the patient moves
actively. The clinical acceptance (convention) of the cervical
sustained natural apophyseal glide (SNAG) is evidenced by the
fact that it formed an integral component of many continuing
education courses, in addition to its description in an increasing
number of clinical texts (Boyling and Palastanga, 1994, Grieve,
1991; Petty and Moore, 1998). However, despite claims of
miraculous results using cervical SNAGs (Mulligan, 1999), crossreferencing of retrieved literature found no empirical evidence
for the efficacy of cervical SNAGs. Literature on the efficacy of
Mulligans techniques is lacking and dominated by descriptive
or case report publications (Exelby, 2001; Hetherington, 1996;
Lincoln, 2000; Miller, 2000; OBrien and Vicenzino, 1998;
Vicenzino and Wright, 1995; Wilson, 2001).
Other evidence points that therapeutic exercises alone reduces
neck pain in the medium and long term (Chiu, Lam, and Hedley,
2005), with strengthening exercise being the most consistently
beneficial program (Ahlgren et al, 2001). The evidence (Takala,
Viikari-Juntura, and Tynkkynen, 1994; Viljanen et al, 2003) is
ambiguous about the advantage of exercise over no treatment, but
suggests exercise is better than a placebo of clinical contact (Chiu,
Lam, and Hedley, 2005).
Although studies showing exercises in isolation or in combination with manual therapy appears to be to be effective in acute
neck pain, it is difficult to draw firm conclusions from these trials
(Bronfort, Haas, Evans, and Bouter, 2004). Further, no work has
specifically looked at the effects of one particular mobilization
approach over another till date and no randomized trial have used
a Mulligan technique in the management of neck pain. This
provided the focus for this work, and the objective of this study
was to compare the effectiveness of three interventions on pain
response, ROM and functional ability in patients with mechanical
neck pain: (1) exercises with Maitland mobilization; (2) exercises
with Mulligan mobilization; and (3) a group receiving exercises
only.

Methods
Design
A prospective repeated-measures design was used to determine
the effectiveness of three interventions during a two-week
program. This phase was followed by a home exercise program
for four weeks. Patient outcomes were again collected at 12 weeks
after treatment. Participants who met the following criteria were
recruited for the study: (1) complaints of insidious onset of neck
pain that have lasted for less than 12 weeks; (2) reduced ROM in
extension, side flexion and rotation; (3) neck symptoms
reproduced during passive accessory movements (central and
unilateral posteroanterior (PA) mobilization); (4) not receiving
any drugs other than stable doses of analgesics or non-steroidal
anti-inflammatory drugs; and (5) willingness to adhere to
treatment and measurement regimens. The participants with the
following criteria were excluded: (1) previous cervical spine

Physiother Theory Pract, 2015; 31(2): 99106

surgery or trauma; (2) progressive neurological deficits; (3)


cervical myelopathy; (4) vascular diseases of head and neck; (5)
previous physical therapy/chiropractic care for shoulder or neck;
(6) cervical nerve root pathology; (7) severity and irritability of
symptoms; and (8) other red flags to manual therapy.
The sample size was calculated and determined at 72
participants (24 in each group) to find a between-group difference
in pain of at least 1.5 points [visual analog scale (VAS), 11-point
scale (010)], with power established at 80% and significance
level at 0.05. Participants were recruited through printed advertisements displayed in our institute, sub-centers of our institute
and the nearest medical college hospital. The physicians and
physiotherapists who were posted in the out-patient department of
the above-mentioned places were requested to refer patients
complaining of acute neck pain to the place of study. One-hundred
forty-one participants (m 60; f 81) responded to the advertisement and referral. All the respondents underwent physical
examination by the first and second authors and were included
into the study if they satisfied the inclusion and exclusion criteria.
Forty-two participants (m 15; f 27) were excluded and 19
participants (m 6; f 13) expressed their inability to attend
therapy regularly and were excluded. The participants recruited
were from geographically different units within the state and were
randomized into three different groups, designated as groups I, II
and III. Nine participants (all females) were eliminated due to
noncompliance with the intervention program, five participants
(m 1; f 4) withdrew from the study for personal reasons and
six participants (all females) were lost in follow-up. Sixty
participants (22 females and 38 males) with a mean age of 41.7
years (SD: 9.8) participated and completed the study (Figure 1).
Informed consent was obtained from each participant, and the
procedure was approved by the institute ethics committee.
Participants were permitted to continue medication prescribed at
baseline as required.
Outcome measures
The following outcome measures were studied.
Pain intensity measured by VAS
VAS was used to measure subjective pain intensity. The VAS has
been shown to be valid and reliable and has a reasonable degree
of reproducibility (Revill, Robinson, Rosen, and Hogg, 1976).
Each participant subjectively estimated his/her pain level by
moving the pointing device along the uncalibrated scale, between
0 and 10.
Cervical ROM by 180 degrees universal goniometer
Cervical ROM was assessed using a universal goniometer with a
measuring scale marked out at a one degree interval. For cervical
ROM measurements, the technique suggested by Cipriano (1985)
was followed. Goniometric measurement has been found to have
greater intra-tester reliability in both clinical and research settings
(Rothstein, Miller, and Roettger, 1983). Cervical ROM measurements on the cervical spine evaluated by the same examiner have
good to high reliability (Youdas, Carey, and Ganrent, 1991).
Neck disability index
This functional scale is composed of 10 sections (containing 10
functional activities). Each section has six options, with scoring
from 0 to 5 where the participant had to mark in only one box that
applied to them. This test has been shown to be reliable, valid and
a responsive functional outcome measure for evaluation of
patients with cervical pain (Vernon and Mior, 1991). The final
score was then transformed into a percentage score.

Mobilization and neck pain

DOI: 10.3109/09593985.2014.963904

101

Referral n= 141 (m= 60, f=81)


Physical Examinaon

Excluded parcipants n=42


(m=15, f= 27)

Paent who fullled the inclusion


& exclusion criteria

Paent who did not consent for study


n= 19 (m= 6, f=13)

Randomly assigned aer informed consent n =


80 (m=39,f= 41)

Group I
n= 26(m=14, f=12)

Group II
n= 27(m=12, f=15)

Group III
n= 27(m=13, f=14)
Eliminated due to noncompliance with
intervenon (n = 9)

n= 26(m=14, f=12)

n=25 (m=12, f=13)

n=20 (m=13, f=7)


Patient withdrawal from study (n = 5)

2 weeks o ntervenon

n= 24(m=14, f=10)

n= 22(m=11, f=11)

n=20 (m=13, f=7)

Follow-up after 6 weeks


n= 20 (m=14, f=6)

n= 20(m= 11,f=9)

Patient lost in follow-up (n = 6)

n= 20(m=13, f=7)

Figure 1. Flow chart describing the progress of patients through the study.

Procedure
All assessments were made by an assessor blinded to the protocol,
and all participant data were collected before randomization. The
randomization was done by a random number table. Each
treatment allocation was placed in a sealed, sequentially numbered opaque envelope. Each envelope given to participants was
opened by an individual blinded to upcoming treatment
assignments.
Two manipulative physiotherapists with more than 18 years of
clinical experience working in our institute participated and
performed the spinal mobilizations. Both the clinicians treated
their own participants. Another physiotherapist with more than 10
years of experience in musculoskeletal physiotherapy and trained
in manual therapy supervised the exercises. All three clinicians
had post graduate training in manual therapy and underwent
Mulligan training by a certified Mulligan teacher. All the outcome
measures, baseline, post interventional and follow-up were
performed by one of the authors who were blinded to group
allocation.
Group I 20 participants (f 6; m 14) received Maitland
mobilization to the cervical spine for a period of two weeks (five
days a week, one session per day) along with exercises prescribed
for the group III participants. Treatment by Maitland technique

attempts to gauge the effectiveness of intervention by assessing


the segmental movement that is limited by the patients symptoms. Participants received Maitland mobilization targeted to
impairments identified during the physical examination.
The participant was positioned in prone, and the treating
therapist stood at the level of the head of the patients with his
thumbs in opposition placed at the level of the facet or the spinous
process of the corresponding cervical vertebra. A PA oscillatory
pressure was applied, through the thumbs, over the process of the
hypomobile vertebra. The following grades were used: grades I
and II where pain occurred before the motion barrier; and grades
III and IV where the motion barrier was encountered before pain.
This oscillatory mobilization was performed at a rate of 23
oscillations per second with metronome control and a frequency
of 34 mobilization of the joint lasting approximately 30 s each.
The rest time between each mobilization was one minute.
Group II 20 participants (f 9; m 11) received Mulligan
SNAGs for a period of five sessions per week for two weeks and
the exercises prescribed to group III. Mulligan proposed that
minor positional fault to a joint can lead to restrictions in
physiological movement. Mulligan mobilization (cervical SNAG)
was applied with the participant in a seated position. With one
thumb (reinforced by the other) placed on the spinous process or

102

G. S. Ganesh et al.

Physiother Theory Pract, 2015; 31(2): 99106

Table 1. Mean (SD) values of outcome variables.


Outcome measure [Mean (SD)]
Group
I
II
III

Time of
measurement
Pre
Post
Follow-up
Pre
Post
Follow-up
Pre
Post
Follow-up

VAS
6.7
2.4
2.2
5.7
1.8
1.5
5.9
1.9
1.2

(2.0)
(1.5)
(1.3)
(0.9)
(1.1)
(1.0)
(1.3)
(1.2)
(0.8)

NDI (in %)

Extn
(in deg)

33.9
17.2
13.2
36
14.9
9.4
34.8
10.2
6.7

34
46
44
31
43
43
35
43
43

(17.7)
(11.7)
(9.9)
(14.7)
(9.5)
(5.3)
(11.5)
(6.0)
(3.5)

(7)
(6)
(5)
(9)
(6)
(5)
(10)
(5)
(6)

S.Fn. Lt
(in deg)
28
37
35
24
34
37
29
36
37

(7)
(7)
(8)
(9)
(8)
(8)
(9)
(7)
(8)

S.Fn. Rt
(in deg)

Rotn. Lt
(in deg)

Rotn. Rt
(in deg)

27
36
36
24
36
36
27
37
36

43
55
53
41
53
54
44
54
54

44
58
58
44
57
55
47
57
57

(10)
(8)
(7)
(10)
(7)
(8)
(11)
(7)
(9)

(12)
(8)
(7)
(11)
(7)
(7)
(9)
(7)
(7)

(11)
(9)
(8)
(8)
(8)
(8)
(9)
(8)
(7)

VAS, visual analogue scale; NDI, neck disability index; Extn, extension; S.Fn.Lt, side flexion to left; S.Fn.Rt, side flexion to right; Rotn.Lt, rotation to
left; Rotn.Rt, rotation to right.

Table 2. ANOVA results testing for effects of intervention.


Variable
VAS
NDI
Extn
S.Fn.Lt
S.Fn.Rt
Rotn.Lt
Rotn.Rt

Time (F value)
436.288
207.115
48.615
38.781
32.423
46.330
138.812

(p 0.00)
(p 0.00)
(p 0.00)
(p 0.00)
(p 0.00)
(p 0.00)
(p 0.00)

Group (F value)
3.262 (p 0.056)
1.1668 (p 0.198)
1.505 (p 0.231)
0.742 (p 0.481)
0.415 (p 0.662)
0.173 (p 0.841)
0.124 (p 0.84)

Time  group (F value)


0.722
1.190
0.702
1.526
0.402
0.480
1.192

(p 0.579)
(p 0.319)
(p 0.592)
(p 0.199)
(p 0.807)
(p 0.750)
(p 0.318)

VAS, visual analogue scale; NDI, neck disability index; Extn, extension; S.Fn.Lt, side flexion to left; S.Fn.Rt, side flexion
to right; Rotn.Lt, rotation to left; and Rotn.Rt, rotation to right.

articular pillar (depending upon the indication) of the upper


vertebra of the implicated functional-spinal unit (FSU), the
therapist applied a sustained passive accessory intervertebral
movement superoanteriorly along the facet plane. This glide
was maintained as the participant moved actively through the
desired range of physiological movement and then while sustaining the end-range position for a few seconds. The glide was
released by the therapist after the patient returned to the starting
position for the active movement. The mobilization was repeated
six times per session for a period of two weeks.
Group III 20 participants (f 7; m 13) received supervised
exercise program consisting of flexibility and strengthening
exercises for a period of five sessions per week for two weeks.
The exercises prescribed were stretching exercises to cervical and
scapular muscles, deep neck flexor strengthening, isometric
exercises for extensors, side flexors (both sides) and rotators
(both sides), anti-gravity strengthening to rhomboids, middle and
lower trapezi and cervical ROM exercises. All exercises were
done with a dosage of one set of 10 repetitions with 6 s hold and
10 s rest between the repetitions.
All participants were provided with a basic regimen of postural
advice and were instructed to continue the strengthening and
stretching exercises at home for a period of four weeks. All
measurements were taken prior to the beginning of the therapy
intervention, at completion of two weeks of treatment and at the
end of the 12th week.
Data analysis
The data were analyzed with Statistical Package for Social
Sciences 16.0 version (SPSS Inc., Chicago, IL). The dependent
variables were analyzed using repeated measures ANOVA. There
was one between factor (group) with three levels (groups: I, II and

III) and one within factor (time) with three levels (pre, post and
follow-up measure). p Value was set at 0.05.

Results
Sixty participants (22 females and 38 males) with a mean age of
41.7 years (SD: 9.8) completed the study. The mean duration of
symptoms in this study sample was 62 d. Table 1 lists the baseline,
post-interventional and follow-up scores of pain, ROM and
disability for all the groups investigated in the study. Table 2 lists
the results of repeated measures ANOVA. The overall results of
the study showed that all of the groups improved over time
compared to baseline (p50.05) (Figures 26). The results
revealed no significant differences between groups, and analyses
of variance also demonstrated no significant group  time interaction effects across groups in improving outcomes (p40.05).
The effect sizes between the groups were small (0.2) (Ferreira and
Herbert, 2008) revealing minimal clinical detectable difference
between the mobilization and exercise groups after intervention
and at follow-up.

Discussion
We compared the effectiveness of two manual mobilization
techniques with exercises on pain, disability and range of motion
in patients suffering from mechanical neck pain, as involving both
manual therapy and exercise leads to an inability to evaluate the
contribution of each intervention towards patient improvement.
Our results showed that manual therapy interventions were no
better than supervised exercises alone in reducing pain, improving
ROM and neck disability index (NDI).
The results showed a reduction in pain over time in all the
groups. The reduction of pain in the Maitland group is probably

DOI: 10.3109/09593985.2014.963904

Mobilization and neck pain

103

Figure 2. Graph showing changes in pain (VAS) across three groups:


before, after intervention and at follow-up.
Figure 4. Graph showing changes in extension ROM across three groups:
before, after intervention and at follow-up.

Figure 3. Graph showing changes in NDI across three groups: before,


after intervention and at follow-up.

due to: the neuro physiological (Melzac and Wall, 1965);


sympathetic (Kandel, Schwartz, and Jessell, 2000); and psychological effects (Coulehan, 1985) of mobilization. Mulligan SNAG
mobilization could ameliorate pain by either separating the facet
surfaces or releasing the entrapped meniscoid, or by allowing the
entrapped meniscoid to return to its intra articular position, or
perhaps by stretching adhesions (Hearn and Rivett, 2002).
The increase in ROM between the Maitland mobilization and
Mulligan mobilization groups were not significant, both clinically
and statistically. Reduced segmental movement is associated with
neck pain (DallAlba et al, 2001). Treatment using Maitland
mobilization evaluates the changes in the segmental mobility, at
the beginning and end of each treatment session. The treatment is
then modified according to the direction and extent of these
changes (Tuttle, 2005). It is believed that within session changes
are valid predictors of between session changes and there occurs
some lasting changes associated with the immediate change
(Whittingham and Nillson, 2001). Mechanisms by which
Maitland mobilization improved ROM can be attributed to both
mechanical and neurophysiological effects. Mechanical effects

Figure 5. Graph showing changes in side flexion ROM (left and right)
across three groups: before, after intervention and at follow-up.

could involve a permanent or temporary change in the length of


connective tissue structures such as joint capsule of the
zygapophyseal joints, ligaments and muscle. Neurophysiological
mechanisms have been postulated to account for changes in the
mobility observed in response to application of PA forces by
reducing the perception of pain (Zusman, 1986) and a reduction in
muscle activity (Katavich, 1998).
Mulligan (1991, 1999) proposed that the reputed clinical
effectiveness of cervical SNAGs may be biomechanical in nature
and when an increase in pain-free range of movement occurs with
a SNAG it is primarily the correction of the positional fault at the
zygapophyseal joint, although a SNAG can influence the entire
spinal functional unit. Failure of the posterior column joints to
glide properly might result in an altered instantaneous axis of
rotation and increased anterior column stress (White and
Sahrmann, 1994). This best explains why SNAGS, which would
appear to principally affect apophyseal joint function, are often
dramatically effective for patients suffering from anterior column
pathology (Bogduk and Twomey, 1991).

104

G. S. Ganesh et al.

Figure 6. Graph showing changes in rotation ROM (left and right) across
three groups: before, after intervention and at follow-up.

The study results showed that exercises alone were effective in


improving outcomes. Several studies (Hakkinen, Kautiainen,
Hannonen, and Ylinen, 2008; Hallgren, Greenman, and
Rechtien, 1994; McPartland and Brodeur, 1999) have demonstrated that neck muscle atrophy is strongly correlated with neck
pain. Muscle strength decrement may be caused by the inhibitive
effect of pain and changes in muscle structures (Nikander et al,
2006). Muscle weakness especially in deep muscles could affect
the spinal posture condition and lead to postural disorders, which
can increase pain and the subsequent pain can cause further
muscle weakness. Criso and Panjabi (1990) and Panjabi (1992)
hypothesized that muscles that have direct attachments to the
vertebrae are responsible for the segmental stability through the
control of the neutral zone.
Exercises prescribed targeting the neck and shoulder with the
objective of enhancing strength have been found to be very
effective in breaking the pain cycle (Kisner and Colby, 2007) and
increasing motor control (Chiu, Lam, and Hedley, 2005;
Hakkinen, Kautiainen, Hannonen, and Ylinen, 2008; Ylinen
et al, 2003). Studies have experimentally demonstrated that
skeletal adaptations can occur in various skeletal muscle fiber
types at four weeks, if the training intensity is sufficient. The
exercise program prescribed to cervical musculature as well as the
scapula muscles might have increased proximal stability to the
head and neck region (Gebhard, Donaldson, and Brown, 1994).
Furthermore, dynamic exercises as prescribed in this study had a
significant effect on pain reduction due to the positive effect on
stability and function. This is achievable through improved blood
circulation and better muscle glycogen intake (Kisner and Colby,
2007). Strengthening exercises also leads to enhancing the protein
metabolism, which helps in the recovery of a painful muscle and
as the muscle gets stronger, it can better withstand pressure and
stress (Andersen et al, 2008). The stretching exercises prescribed
might have increased the extensibility and flexibility of the soft
tissues, causing a decrease in pain during movement (Bjorklund,
Hamberg, and Crenshaw, 2001) and an improvement in the ROM.
Normal pain free ROM is essential for normal function. The
components of NDI are directly related to the patients pain.
The reduction in NDI scores seen in all participants may be due
to the reduction of pain and improvement in ROM. Vernon and
Mior (1991) showed that the NDI is sensitive to change and
correlates significantly with VAS.
The results of the study are consistent with the reviews of
Gross et al. (2010) and Kay et al. (2012) in that manipulation,

Physiother Theory Pract, 2015; 31(2): 99106

mobilization or exercise are beneficial in patients suffering from


neck pain when applied as single-modal treatment approaches.
The very small effect size favoring mobilization groups over
exercise group may be attributed to the hands-on approach and
opportunities for intensive patienttherapist interaction. The lack
of superiority of one technique over another may underline the
fact that there is no conclusive evidence regarding specific
pathology in the majority of the cases of acute neck pain. An
objective of clinical practice is to determine the exact source and
cause of pain and then implement measures to stop it. In a recent
systematic review, Takasaki and May (2014) concluded that there
is no additional benefit of the McKenzie approach compared to a
wait-and-see or other therapeutic approaches in reducing pain
and disability in neck pain. However, the difficulties in identifying the source of neck pain do not necessitate a wait and see
approach as good practice does not universally mean waiting to
find out whose pain resolves, and whose does not. The
interventions might have halted the evolution of acute pain to a
chronic condition.
None of the mobilization group participants had major side
effects except local muscle and joint soreness, which rarely leads
to even short-term impairment in functional status. There are
some potential limitations with the study. The muscle strength of
neck and peri-scapular muscles was not measured. The treating
therapists were restricted to the use of the studied mobilization
approach only and the final sample size per group was reduced to
20. There were 20 drop-outs (m 1; f 19) in total from the point
of recruitment; 13 in the mobilization groups and 7 in the control
group. Eleven participants (all from the mobilization group)
(m 1; f 10) dropped out since the intervention begun. In no
case was the reason related to neck pain or treatment complications. The majority of the women who dropped out were Indian
Hindus and there are aspects of the Hindu religion that commonly
affect healthcare decisions. Furthermore, healthcare decisions
among Indian women are frequently discussed within the
immediate family before seeking outside help and men play a
major role in health care decisions. Future studies should consider
recruiting more Indian women with neck pain into each arm to
allow for drop-outs, contamination or other adverse contingencies.
This is important as the prevalence of neck pain among women is
higher and more women experience greater disability associated
with neck pain than men.
The results of this study have to be interpreted with caution, as
the analysis showed no time and group interaction and approximately 3070% of people with neck pain improve spontaneously
over time (Hoy, Protani, De, and Buchbinder, 2010). An
observation group (physician care only) would have served as
an optimal control to evaluate whether the results were due to the
interventions or improvement over time. Future studies will
include a physician care group as this group may better reflect the
natural course of neck pain in everyday practice.

Conclusion
The results of this study suggest that supervised exercises are as
effective as mobilization and exercises combined in reducing neck
pain, improving ROM and related disability among participants
with acute neck pain.

Declaration of interest
The authors report no declarations of interest.

References
Ahlgren C, Waling K, Kadi F, Djupsjobacka M, Thornell LE, Sundelin G
2001 Effects on physical performance and pain from three dynamic

DOI: 10.3109/09593985.2014.963904

training programs for women with work-related trapezius myalgia.


Journal of Rehabilitation Medicine 33: 162169.
Albright J, Allman R, Bonfiglio RP, Conill A, Dobkin B, Guccione AA,
Hasson SM, Russo R, Shekelle P, Susman JL, Brosseau L, Tugwell P,
Wells GA, Robinson VA, Graham ID, Shea BJ, McGowan J, Peterson J,
Poulin L, Tousignant M, Corriveau H, Morin M, Pelland L, Laferrie`re
L, Casimiro L, Tremblay LE 2001 Philadelphia panel evidence-based
clinical practice guidelines on selected rehabilitation interventions for
neck pain. Physical Therapy 81: 17011717.
Andersen LL, Kjr M, Sgaard K, Hansen L, Kryger AI, Sgaard G 2008
Effect of two contrasting types of physical exercise on chronic neck
muscle pain. Arthritis and Rheumatism 59: 8491.
Bjorklund M, Hamberg J, Crenshaw AG 2001 Sensory adaptation after a
2-week stretching regimen of the rectus femoris muscle. Archives of
Physical Medicine and Rehabilitation 82: 12451250.
Bogduk N, Twomey L 1991 Clinical biomechanics of the lumbar spine.
New York, NY, Churchill Livingstone.
Bonk AD, Ferrari R, Giebel GD, Edelmann M, Huser R 2000 Prospective
randomized, controlled study of activity versus collar, and the natural
history for whiplash injury, in Germany. Journal of Musculoskeletal
Pain 8: 123132.
Boyling J, Palastanga N (eds) 1994 Grieves modern manual therapy: The
vertebral column, 2nd edn. Edinburgh, Churchill Livingstone.
Bronfort G, Haas M, Evans RL, Bouter LM 2004 Efficacy of spinal
manipulation and mobilization for low back pain and neck pain:
A systematic review and best evidence synthesis. Spine Journal 4:
335356.
Chiu TT, Lam TH, Hedley AJ 2005 A randomized controlled trial on the
efficacy of exercise for patients with chronic neck pain. Spine 30:
E1E7.
Cipriano JJ 1985 Photographic manual of regional orthopaedic tests.
Baltimore, Williams & Wilkins.
Cote P, Cassidy JD, Carroll L 2000 The factors associated with neck pain
and its related disability in the Saskatchewan population. Spine 25:
11091117.
Coulehan JL 1985 Adjustment, the hands, and healing. Culture Medicine
and Psychiatry 9: 353382.
Criso JJ, Panjabi MM 1990 Postural biomechanical stability and gross
muscular architecture in the spine. In: Winters JM, Woo SLY (eds)
Multiple muscle system, pp 438450. New York, NY, Springer-Verlag.
DallAlba PT, Sterling MM, Treleaven JM, Edwards SL, Jull GA 2001
Cervical range of motion discriminates between asymptomatic persons
and those with whiplash. Spine 26: 20902094.
Exelby L 2001 The locked facet joint: Intervention using mobilisations
with movement. Manual Therapy 6: 116121.
Fernandez-de-las-Penas C, Alonso-Blanco C, Miangolarra JC 2007
Myofascial trigger points in subjects presenting with mechanical
pain: A blinded, controlled study. Manual Therapy 12: 2933.
Ferreira ML, Herbert RD 2008 What does clinically important really
mean? Australian Journal of Physiotherapy 54: 229230.
Gebhard JS, Donaldson DH, Brown CW 1994 Soft-tissue injuries of the
cervical spine. Orthopaedic Reviews Supplementary 2: 917.
Giebel GD, Edelmann M, Huser R 1997 Die distorsion der halswirbelsaule: Fruhfunktionalle vs. ruhigstelle ndebehandlung. Zentralbibliotak
Chiropractic 122: 517521.
Gracey J, McDonough S, Baxter G 2002 Physiotherapy management of
low back pain. Spine 27: 406411.
Grieve G 1991 Mobilization of the Spine, 5th edn. Edinburgh, Churchill
Livingstone.
Gross A, Miller J, DSylva J, Burnie SJ, Goldsmith CH, Graham N,
Haines T, Brnfort G, Hoving JL 2010 Manipulation or mobilization for neck pain: A Cochrane review. Manual Therapy 15:
315333.
Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P, Aker P,
Santaguida P, Myers C; the Cervical Overview Group 2007
Conservative management of mechanical neck disorders: A systematic
review. Journal of Rheumatology 34: 10831102.
Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P,
Bronfort G; Cervical Overview Group 2004 A Cochrane review of
manipulation and mobilization for mechanical neck disorders. Spine
29: 15411548.
Hakkinen A, Kautiainen H, Hannonen P, Ylinen J 2008 Strength training
and stretching versus stretching only in the treatment of patients with
chronic neck pain: A randomized one-year follow-up study. Clinical
Rehabilitation 22: 592600.

Mobilization and neck pain

105

Hallgren RC, Greenman PE, Rechtien JJ 1994 Atrophy of suboccipital


muscles in patients with chronic pain: A pilot study. Journal of the
American Osteopathic Association 94: 10321038.
Hearn A, Rivett DA 2002 Cervical SNAGS: A biomechanical analysis.
Manual Therapy 7: 7179.
Hetherington B 1996 Case study: Lateral ligament strains of the ankle, do
they exist? Manual Therapy 1: 274275.
Hoy DG, Protani M, De R, Buchbinder R 2010 The epidemiology of
neck pain. Best Practice and Research Clinical Rheumatology 24:
783792.
Kandel ER, Schwartz JH, Jessell TM 2000 Principles of neural science,
4th edn. New York, NY, McGraw-Hill.
Katavich L 1998 Differential effects of spinal manipulative therapy on
acute and chronic muscle spasm: A proposal for mechanisms and
efficacy. Manual Therapy 3: 132139.
Kay TM, Gross A, Goldsmith CH, Rutherford S, Voth S, Hoving JL,
Brnfort G, Santaguida PL 2012 Exercises for mechanical
neck disorders. Cochrane Database of Systematic Reviews 8:
CD004250.
Kisner C, Colby LA 2007 Therapeutic exercise: Foundations and
techniques, 5th edn. Philadelphia, PA, FA Davis Co.
Lincoln J 2000 Clinical instability of the upper cervical spine. Manual
Therapy 5: 4146.
Maitland GD, Hengeveld E, Banks K and English K 2001 Maitlands
vertebral manipulation, 6th edn. Oxford, Butterworth-Heinemann.
McKinney LA, Dornan JO, Ryan M 1989 The role of physiotherapy in the
management of acute neck sprains following road-traffic accidents.
Archives of Emergency Medicine 6: 2733.
McPartland JM, Brodeur RR 1999 Rectus capitis posterior minor:
A small but important suboccipital muscle. Journal of Bodywork and
Movement Therapies 3: 3035.
Mealy K, Brennan H, Fenelon GC 1986 Early mobilization of acute
whiplash injuries. British Medical Journal 292: 656657.
Melzac R, Wall PD 1965 Pain mechanisms: A new theory. Science 150:
971979.
Miller J 2000 Mulligan concept Management of Tennis Elbow.
Orthopaedic Division Review May/June: 4546.
Miller J, Gross A, Sylva JD, Burnie SJ, Goldsmith CH, Graham N,
Haines T, Brnfort G, Hoving JL 2010 Manual therapy and
exercise for neck pain: A systematic review. Manual Therapy 15:
334354.
Mulligan B 1991 Vertigo . . . Manual therapy may be needed. Proceedings
of the 7th Biennial Conference of the Manipulative
physiotherapists Association of Australia, Blue Mountains, New
South Wales: 4647.
Mulligan B 1999 Manual Therapy, NAGS, SNAGS, MWMS,
etc, 4th edn. Wellington, Plane View Services.
Nikander R, Malkia E, Parkkari J, Heinonen A, Ylinen J 2006 Doseresponse relationship of specific training to reduce chronic neck pain
and disability. Medicine and Science in Sports and Exercise 30:
20682074.
OBrien T, Vicenzino B 1998 A study of the effects of Mulligans
mobilisation with movement treatment of lateral ankle pain using a
case study design. Manual Therapy 3: 7884.
Panjabi MM 1992 The stabilizing system of the spine: II. Function
dysfunction, adaptation and enhancement. Journal of Spinal Disorders
5: 390397.
Petty N, Moore A 1998 Neuromusculoskeletal examination and assessment: A handbook for therapists. London, Churchill Livingstone.
Refshauge KM, Parry S, Shirley D, Larsen D, Rivett D, Boland R 2002
Professional responsibility in relation to cervical spine manipulation.
Australian Journal of Physiotherapy 48: 171179.
Revill SI, Robinson JO, Rosen M, Hogg MJ 1976 The reliability of linear
analog for evaluating pain. Anaesthesia 31: 11911198.
Rivett D, Shirley D, Magarey M, Refshauge K 2006 Clinical guidelines
for assessing vertebrobasilar insufficiency in the management of
cervical spine disorders. Melbourne, Australian Physiotherapy
Association.
Rothstein JM, Miller PJ, Roettger RF 1983 Goniometric reliability in a
clinical setting: Elbow and knee measurements. Physical Therapy 63:
16111615.
Sarigiovannis P, Hollins B 2005 Effectiveness of manual therapy in the
treatment of non-specific neck pain: A review. Physical Therapy
Reviews 10: 3550.
Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P,
Albers GW, Gress DR 2003 Spinal manipulative therapy is an

106

G. S. Ganesh et al.

independent risk factor for vertebral artery dissection. Neurology 60:


14241428.
Takala EP, Viikari-Juntura E, Tynkkynen EM 1994 Does group
gymnastics at the workplace help in neck pain? A controlled study.
Scandinavian Journal of Rehabilitation Medicine 26: 1720.
Takasaki H, May S 2014 Mechanical diagnosis and therapy has similar
effects on pain and disability as wait and see and other approaches in
people with neck pain: A systematic review. Journal of Physiotherapy
60: 7884.
Tuttle N 2005 Do changes within a manual therapy treatment session
predict between-session changes for patients with cervical spine pain?
Australian Journal of Physiotherapy 51: 4348.
Vernon H, Mior S 1991 The neck disability index: A study of reliability
and validity. Journal of Manipulative and Physiological Therapeutics
14: 409415.
Vicenzino B, Wright A 1995 Effects of a novel manipulative physiotherapy technique on tennis elbow: A single case study. Manual Therapy
1: 3035.
Viljanen M, Malmivaara A, Uitti J, Rinne M, Palmroos P, Laippala P
2003 Effectiveness of dynamic muscle training, relaxation training, or

Physiother Theory Pract, 2015; 31(2): 99106

ordinary activity for chronic neck pain: Randomised controlled trial.


British Medical Journal 327: 475.
White SG, Sahrmann SA 1994 A movement system balance approach to
the management of musculoskeletal pain. In: Grant R (ed) Physical
therapy of the cervical and thoracic spine, p 339. Edinburgh, Churcill
Livingstone.
Whittingham W, Nillson N 2001 Active range of motion in cervical spine
increases after spinal manipulation (toggle recoil). Journal of
Manipulative and Physiological Therapeutics 24: 552555.
Wilson E 2001 The Mulligan concept: NAGS, SNAGS, and mobilisations
with movement. Journal of Bodywork and Movement Therapies 5:
8189.
Ylinen J, Takala EP, Nykanen M, Hakkinen A, Malkia E, Pohjolainen T
2003 Active neck muscle training in the treatment of chronic neck pain
in woman. JAMA 289: 25092516.
Youdas JN, Carey JR, Ganrent TR 1991 Reliability of measurements of
cervical range of motion. Physical Therapy 71: 98104.
Zusman M 1986 Re-appraisal of a proposed neurological mechanism for
the relief of joint pain with passive movements. Physiotherapy Theory
and Practice 1: 6470.

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