































   
 

 
28  Annals of Applied Psychophysiology June 2025 Volume 12 

A Systematic Review: Manipulation vs. Mobilization for 
Mechanical Neck Pain 
Bushra Madad Ali Malik1, Shamoon Noushad2, Khansa Sheikh1, Ayesha Rayyan1, Saman 
Riaz1, & Basit Ansari1  
1Department of Health, Physical Education and Sports Sciences, University of Karachi 
2Advance Educational Institute and Research Center 

Corresponding Author: Bushramadadalimalik@gmail.com 
Published online: June 2025 

  © The Author(s) 2025 
 

Abstract 
Objectives: To identify the efficacy of manipulation and mobilization in managing mechanical 
neck pain (MNP), based on their effects on pain reduction, range of motion (ROM), and 
functional improvement, and to assess their relative benefits in guiding clinical practice.  

Methods: A systematic review was conducted using five databases (PubMed, Google Scholar, 
PEDro, Cochrane Library, and CINAHL) to identify randomized controlled trials (RCTs) and 
pilot RCTs published between 2009 and 2024. Studies involving adult participants with MNP 
were included, emphasizing interventions like manipulation, mobilization, and SNAGs. The 
quality of studies was evaluated using the Physiotherapy Evidence Database (PEDro) scale and 
Cochrane RoB 2.0 framework, with data extracted on outcomes including pain intensity, ROM, 
and functional improvements. A narrative synthesis was performed due to heterogeneity among 
the studies. 

Results: Twelve studies met the inclusion criteria, with PEDro scores ranging from 6 to 9, 
indicating fair to high quality. Both manipulation and mobilization significantly improved pain 
and ROM in the short term, with no clear superiority of one intervention over the other. 
Thoracic manipulation often yielded better immediate and short-term outcomes than cervical 
mobilization. SNAGs and manipulation demonstrated comparable efficacy in improving 
cervical ROM and reducing pain. However, limitations such as small sample sizes, variable 
methodologies, and short follow-up periods restricted the strength of conclusions. 

Conclusion: While both manipulation and mobilization are effective for managing MNP, 
variability in techniques and study designs precludes definitive recommendations. Thoracic 
manipulation may offer additional benefits for immediate pain relief, but further research is 
needed to establish long-term efficacy, standardized protocols, and integration with other 
therapeutic modalities. The findings underscore the need for multicentre trials with robust 
methodologies to refine clinical guidelines for MNP management. 

Keywords: Thrust manipulation, non-thrust, manipulation, Mobilization, SNAGs, Mechanical 
neck pain, Systematic review, Pain reduction, Range of motion (ROM) 

 

 

mailto:Bushramadadalimalik@gmail.com


   
 

Introduction 
Neck discomfort is a prevalent and often debilitating condition that significantly 

contributes to self-reported pain, disability, and the global burden on individuals and healthcare 
systems.1 It is the fourth most common cause of disability among the general population.2,3,4,5 
Estimates suggest that 20–70% of people will experience neck pain at some point in their 
lives,2,3,4,6,7,8,9,10,11 and up to 60% of patients report chronic pain persisting five years after the 
onset of symptoms.6 Neck pain is most commonly observed during the fourth to fifth decades 
of life and its incidence increases with age.7 The root cause of neck pain rarely originates from 
a single anatomical structure. Instead, they often involve multiple contributing factors.3 Non-
specific neck pain is defined as neck discomfort that worsens with cervical motion. As most 
neck pain is mechanical in nature, it is typically impossible to pinpoint a single cause.5 

Mechanical neck pain (MNP) is one of the most prevalent musculoskeletal conditions, 
affecting 30%–50% of the general population and workers. Repeated neck movements and 
prolonged neck postures can cause neck pain, which is a hallmark of MNP.8 Several pain-
sensitive structures, such as the zygapophyseal joints, ligaments, muscles, uncovertebral joints, 
intervertebral discs, and neural tissues surrounding the cervical spine, can cause mechanical 
neck pain. Mechanical dysfunction of the cervical spine can lead to decreased neck mobility.9 
One of the main characteristics of patients with MNP is the impairment of cervical 
proprioception, which results in abnormalities in cervical sensorimotor control, which in turn 
affects balance and postural control. Patients with MNP have also been found to exhibit 
changes in dynamic scapular stabilization, including protracted acromions and scapulae.8  

Neurological impairments referred or radiating pain into the upper extremities, or 
headaches of cervical origin known as cervicogenic headaches can all accompany neck pain; 
however, these symptoms are frequently neglected when discussing mechanical neck pain. 
With headaches and referred or radiating pain into the upper extremities falling into different 
categories, the current physical therapy clinical practice guidelines for neck pain have divided 
the clinical findings of patients presenting with neck pain into distinct groups. Patients with 
mechanical neck pain may react differently to physical therapy procedures, particularly 
manipulation and mobilizations, and those who experience headaches and/or radiating pain.6 

This systematic review focused on mechanical neck discomfort to exclude radiculopathy and 
cervicogenic headache. 

Mechanical neck pain is a prevalent symptom that is frequently treated conservatively 
during outpatient physical therapy.6 Physical therapists use a range of techniques to treat neck 
discomfort, including mobilization, therapeutic exercises, thrust manipulation, and modalities.9 
Manual therapy is a popular intervention for increasing range of motion, enhancing tissue 
extensibility, and reducing pain.6  

Manipulation and mobilization are techniques that use skilful passive movements 
applied to the soft tissues and joints at different amplitudes and speeds.6  Studies showing the 
cost-effectiveness of manual therapy for neck discomfort emphasize the necessity for efficient 
therapies to avoid chronic pain and impairment.2 Neck and musculoskeletal pain can be 
relieved by manual cervical spinal mobilization (CSMobs) and manipulation (CSMs). Through 
neurophysiological, mechanical, and biochemical effects, CSMs employ high-velocity, low-
amplitude thrusts to enhance joint, muscle, and nerve function, whereas CSMobs apply non-
thrust oscillatory movements to the spine. The expectations of the patient and psychological 
variables may also affect the treatment results.2 

Although there is insufficient information to support clinical decision-making, 
evidence-based practice recommendations suggest that for mechanical neck discomfort, 



   
 

manual treatment and therapeutic exercises should be combined.7 Studies have demonstrated 
that both thrust and non-thrust cervical spine manipulations can improve function, increase 
range of motion, and reduce pain. The results of these procedures are similar. Reducing 
discomfort and increasing cervical spine range of motion are the main objectives of 
treatment.7,10 

Recently, there has been an increasing interest in thoracic spine manual therapy as an 
adjunct to traditional cervical spine treatments. This approach is based on the conceptual model 
of regional interdependence, which suggests that thoracic spine dysfunction can influence 
cervical spine mechanics and contribute to neck pain. Furthermore, neurophysiological effects 
such as pain modulation and improved mobility provide additional theoretical support for this 
intervention.6 

Several studies have explored the efficacy of manual thoracic and cervicothoracic 
therapies. Masaracchio et al.7 demonstrated that combining thoracic thrust manipulation with 
cervical non-thrust manipulation and exercise leads to better short-term outcomes in terms of 
pain intensity, disability indices, and perceived recovery.7 Similarly; Dunning JR. et al.11 found 
that a combination of upper cervical and thoracic thrust manipulations was more effective than 
non-thrust mobilization for the short-term relief of mechanical neck pain.11  However, Griswold 
D12 found in his study equivalent outcomes for both the groups (thrust manipulation vs non 
thrust manipulation) leading to question which technique is better than other.12 Loreto et al.2 
also highlighted the potential of a single session of skilled manual therapy to reduce acute neck 
pain and disability, showing promise for non-specific mechanical neck pain.2 

The cervicothoracic (CT) junction, a critical link between the cervical and thoracic 
spine, has also been the focus of research.3,4 Stiffness in this region contributes to neck pain 
and its associated symptoms.4 While Joshi et al.4’s study comparing CT junction-specific 
mobilization and mid-thoracic manipulation found no significant superiority of the former,4 
similar results were observed in a randomized clinical trial conducted by Saddique et al.3 in 
Pakistan. Both studies concluded that mid-thoracic manipulation and CT junction mobilization 
had comparable effects on the cervical range of motion and pain relief.3,4 

Additionally, mobilization with movement such as Mulligan SNAGs (Sustained 
Natural Apophyseal Glides) have shown promise.8,10 Sodany et al.10 reported that SNAGs 
combined with exercise were more effective than exercises alone in managing cervical spine 
disorders.10 Saleh et al.8’s findings further supported that adding Mulligan SNAGs to 
conventional physiotherapy improved pain intensity, proprioception, and scapular function 
more significantly than conventional therapy alone.8  Although Mulligan mobilization use 
different biomechanics from classical Maitland mobilizations, both involve non-thrust 
oscillatory movements of the spine. While Mulligan SNAGs involve sustained accessory glides 
during active movement versus passive oscillatory techniques in Maitland—they both fall 
under non-thrust manual therapy techniques.8,13 A study by Izquierdo Pérez, H. directly 
compared the efficacy of these three techniques of manual therapy including HVLA thrust, 
Maitland mobilization and Mulligan’s SNAG.13 

Despite these advances, the relative efficacy of mobilization versus manipulation for 
mechanical neck pain remains controversial. Although these techniques have demonstrated 
benefits, there is a need for a comprehensive comparison between all three manual therapy 
techniques applied at both the cervical and thoracic spine to guide sound clinical decision-
making. Therefore, for the purpose of this review, studies comparing SNAGs are grouped 
within the mobilization/ non-thrust category, with subgroup analysis and interpretation under 
‘mobilization with movement’ category accounting for their mechanical differences. This 



   
 

systematic review sought to evaluate and synthesize the available evidence, provide clarity on 
the effectiveness of these interventions, and inform best practices in mechanical neck pain 
management. 

Methodology 

Data Sources and Searches 
This systematic review followed PRISMA guidelines ensuring transparency in methods 

and reporting. A comprehensive literature search was conducted to evaluate the comparative 
efficacy of mobilizations (without and with movement including SNAGs) and manipulation in 
the treatment of mechanical neck pain. The search was carried out by three independent 
reviewers from November 2024 to January 2025. Five electronic databases were systematically 
searched: NCBI-PubMed, Google Scholar, PEDro, Cochrane Library and CINAHL 
(Cumulative Index to Nursing and Allied Health Literature). There were limitations on study 
design as we select RCTs and the search was restricted to studies published in English from 
2009 to 2024. Boolean operators were used to structure the search strategy, with search strings 
tailored to each database. A typical search included combinations such as: ("mobilization" OR 
"non-thrust" OR "SNAGs") AND ("manipulation" OR "thrust") AND ("mechanical neck pain" 
OR "cervical spine" OR "thoracic spine"). 

Study Selection 

As part of the study selection process, Interventions were grouped into three categories 
for comparison: (1) traditional mobilization techniques, (2) mobilization with movement 
(SNAGs), and (3) high-velocity low-amplitude thrust/ manipulation. This allowed for analysis 
of treatment effect heterogeneity and helped prevent conflation of fundamentally different 
manual therapy approaches. Studies were included in this systematic review based on the 
following inclusion criteria: 

Inclusion Criteria 

• Only randomized controlled trials (RCTs), including pilot RCTs with a clearly defined 
control group, were included. Studies needed to directly compare manual mobilization 
techniques (with or without movement, including SNAGs) with spinal manipulation 
interventions in adult patients with a confirmed diagnosis of mechanical neck pain. 

• Studies involving adult participants diagnosed with mechanical neck pain. 
• Studies reporting primary outcomes such as pain reduction, range of motion (ROM), 

and functional improvement. 
• Studies published in English and available as full-text PDFs. 

Exclusion Criteria 

Studies were excluded based on the following exclusion criteria: 

• Non-randomized trials, observational studies, and case reports. 
• Studies focused on conditions other than mechanical neck pain, such as radiculopathy, 

cervicogenic headache or whiplash. 
• Studies that did not compare mobilizations (without or with movement including 

SNAGs) with manipulation interventions. 
• Non-peer-reviewed articles or studies with insufficient data for outcome analysis. 

Discrepancies in study selection were resolved through discussion and consensus. 



   
 

Data Extraction 
Data were extracted independently by three reviewers using a pre-designed 

standardized extraction form, which included study identifiers, participant demographics, 
intervention protocols (frequency, duration, techniques), outcome measures (pain, ROM, 
function), follow-up intervals, and statistical findings. Discrepancies were resolved by 
consensus or consultation with a fourth reviewer. 

Quality Assessment 
To ensure a comprehensive and robust evaluation of the methodological quality of 

studies included in this systematic review, a dual framework combining the Physiotherapy 
Evidence Database (PEDro) Scale was employed, and the Cochrane Risk of Bias 2.0 (RoB 2.0) 
tool was used to assess bias across five domains for each included RCT. This integrative 
method allowed for a nuanced assessment of both the internal validity of individual studies and 
the overall strength of evidence. 

The PEDro Scale 
The PEDro Scale was selected as a primary tool for evaluating the methodological rigor 

of randomized controlled trials (RCTs). Developed as a standardized checklist, the PEDro 
Scale has been widely adopted in clinical research for its reliability and validity in assessing 
both internal and external validity.14,15 Comprising 11 criteria, the first item addresses external 
validity, while the remaining 10 focus on internal validity aspects such as randomization, 
allocation concealment, and blinding. 

For this review, the external validity item was excluded from scoring, as the focus was 
primarily on internal validity, in line with established practices in systematic reviews16. Studies 
scoring between 7 and 10 were classified as high quality, scores between 5 and 6 indicated fair 
quality, and scores ≤4 were categorized as poor quality17. 

Of the twelve studies included in this review, eight had pre-existing, peer-reviewed 
PEDro scores. These were independently verified for accuracy and consistency by two 
reviewers. One study was found to have conflicting pre-existing score due to mentioning no 
blindness of assessors whereas; it was found that outcome assessor was blinded in the study. 
Hence, the score was upgraded from 7 to 8/10.12 For the four studies without prior PEDro 
scores, three independent reviewers conducted assessments, resolving any discrepancies 
through discussion and consensus (Table 1). The reliability of PEDro scores has been 
consistently reported as "fair to excellent" across diverse contexts, further justifying its use in 
this review18. 

Table 1. PEDro Scoring of Included Studies 

Reference 2 3 4 5 6 7 8 9 10 11 Total 

Score 

Study 

Quality 

Salom et al.19 Y Y Y N N Y Y N Y Y 7 High 

Cleland JA et al.20 Y Y Y N N N Y Y Y Y 7 High 

Dunning JR et al.11 Y Y Y N N Y Y Y Y Y 8 High 



   
 

Griswold D et al.12 Y Y Y N N Y Y Y Y Y 8 High 

Saddique et al.3 Y Y Y N N N Y N Y Y 6 Fair 

Joshi et al.4 Y Y Y N N Y Y N Y Y 7 High 

Mastracchio et al.7 Y Y Y N N N Y Y Y Y 7 High 

Suvarnnato et al.9 Y Y Y N N Y Y N Y Y 7 High 

Loreto et al.2 Y N Y Y N N Y N Y Y 6 Fair 

Saleh et al.8 Y Y Y N N Y Y N Y Y 7 High 

Sodany et al.10 Y N Y Y N Y N N Y Y 6 Fair  

Izquierdo Pérez H et al.13 Y Y Y Y N Y Y Y Y Y 9 High 

Total of ‘yes’ scores              12  10  12   3    0     8     11    5     12      12  

% of ‘yes’ per criterion    100% 83% 100% 25% 0% 67% 92% 42% 100% 100%    
Score Average 7.08 High 

          Standard Deviation 0.90 
Y5 Criterion satisfied; N5 Criterion not satisfied. 
2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly 
allocated an order in which treatments were received). 
3. Allocation was concealed. 
4. The groups were similar at baseline regarding the most important prognostic indicators. 
5. There was blinding of all subjects. 
6. There was blinding of all therapists who administered the therapy. 
7. There was blinding of all assessors who measured at least one key outcome. 
8. Measurements of at least one key outcome were obtained from more than 85% of the subjects 
initially allocated to groups. 
9. All subjects for whom outcome measurements were available received the treatment or 
control condition as allocated, or where this was not the case, data for at least one key outcome 
were analysed by ‘intention to treat’. 
10. The results of between-group statistical comparisons are reported for at least one key 
outcome. 
11. The study provides both point measurements and measurements of variability for at least 
one key outcome. 

The Risk of Bias Assessment 
In addition to the PEDro scale, the Cochrane Risk of Bias 2.0 (RoB 2.0) tool was also 

applied to assess the quality of the included randomized controlled trials across five domains: 
randomization process, deviations from intended interventions, missing outcome data, 
measurement of the outcome, and selection of the reported result (Table 2). Each domain is 
assessed based on series of question leading to hierarchical judgment i.e., Low risk of bias, 
some concerns and High risk of bias, which in turn leads to an overall risk-of-bias judgment 
of the study.21 



   
 

Table 2. Risk of Bias (RoB 2.0) Assessment of Included Studies 

Study PEDro 
Score 

Randomi
zation 

Process 

Deviations 
from 

Intended 
Interventi

ons 

Missing 
Outcome 

Data 

Measure
ment of 

the 
Outcome 

Selection 
of the 

Reported 
Result 

Overall 
RoB 

Salom-
Moreno et 
al.19 

7/10 Low Risk High Risk Low Risk Low Risk  Low Risk High Risk 

Cleland JA 
et al.20 7/10 Low Risk High Risk Low Risk High Risk Low Risk High Risk 

Dunning 
JR et al.11 8/10 Low Risk High Risk Low Risk Low Risk Low Risk High Risk 

Griswold D 
et al.12 8/10 Low Risk High Risk Low Risk Low Risk Low Risk High Risk 

Saddique et 
al.3 6/10 Low Risk High Risk Low Risk High Risk Some 

Concerns High Risk 

Joshi et al.4 7/10 Low Risk High Risk Low Risk Low Risk Some 
Concerns High Risk 

Masaracchi
o et al.7 7/10 Low Risk High Risk Low Risk High Risk Low Risk High Risk 

Suvarnnato 
et al.9 7/10 Low Risk High Risk Low Risk Low Risk Some 

Concerns High Risk 

Loreto et 
al.2 6/10 Some 

Concerns High Risk Low Risk High Risk Low Risk High Risk 

Saleh et al.8 7/10 Low Risk High Risk Low Risk Low Risk Some 
Concerns High Risk 

El-Sodany 
et al.10 6/10 Some 

Concerns High Risk Some 
Concerns Low Risk Some 

Concerns High Risk 

Izquierdo 
Pérez H et 
al.13 

9/10 Low Risk Some 
Concerns Low Risk Low Risk Low Risk Some 

Concerns 

Data Synthesis 
Given the variability in study designs, outcome measures, and intervention protocols, a 

narrative synthesis approach was used to compare the results of the included studies. This 
synthesis focused on the comparative efficacy of mobilization (including SNAGs) versus 
manipulation for key outcomes such as pain reduction, ROM, and functional improvement. 
Due to high heterogeneity in study design, outcome measures, and follow-up durations, meta-
analysis was not conducted. However, effect sizes (Cohen’s d) were calculated for key 
outcomes such as pain, disability, and ROM where data permitted. Table X summarizes these 
between-group differences with 95% confidence intervals. 

The PRISMA flow diagram (Fig. 1), which describes the study's identification 
procedure, abstract screening results, and full-text eligibility assessments, including the 
rationale for exclusions, was followed in the data synthesis. In the end, twelve articles fulfilled 
the eligibility criteria for full-text evaluation. 



   
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fig. (1): PRISMA Diagram. 

Evidences iden*fied on databases 
with (Mobiliza*on AND 

Manipula*on) AND (Cervical OR 
Thoracic) AND (Mechanical neck 

pain) 
(n= 1633) 

SC
RE

EN
IN

G
 

IN
CL

U
D

ED
 

EL
IG

IB
IL

IT
Y  

ID
EN

TI
FI

CA
TI

O
N

 

Records iden+fied through databases searching 
N= 1848 

Evidences a:er removing duplicates 
(n =  130 ) 

Full text ar+cles screened to be included 
(From 2009-2025 and in English) 

(n = 1321) 

Records assessed for inclusion based on 
eligibility criteria 

(n=171) 

Evalua+on of full text ar+cles based on +tle or 
abstract 
(n =23 ) 

Excluded full-text ar+cles based on eligibility 
criteria (n = 1150) 
- Not RCTs or pilot RCT (n = 1117) 
- Not Adult popula+on (n = 33) 

Studies included in qualita+ve analysis (Narra+ve)  
N = 12 

 

Records excluded based on +tle or abstract  
(n= 148) 

 

Evidences excluded with reasons  
(n = 11) 

- Not comparing mobiliza+on with 
manipula+on directly (n=10) 
- Non-randomized secondary analysis (n=1) 
 

 

 Evidences iden*fied on databases 
with (Manipula*on AND SNAG) AND 

(Cervical OR Thoracic) AND 
(Mechanical neck pain) 

 (n = 135) 

 Evidences iden*fied on databases 
with (Thrust AND Non-thrust) AND 

(Cervical OR Thoracic) AND 
(Mechanical neck pain) 

 (n = 80) 

Records excluded 
(n = 527) 

Records Screened 
(n = 1848) 



   
 

Result 
A total of 23 studies were identified for potential inclusion. After reviewing the 

abstracts, only 12 met the inclusion criteria (Fig. 1). Ten of the included studies were 
randomized controlled trials.2,3,7,8,10,11,12,13,19,20 The remaining two studies were randomized 
controlled trial (RCT) pilot studies.4,9 The twelve studies included a mixed population of men 
and women. All patients were diagnosed with mechanical neck pain. Each patient had varying 
symptom durations and ages, ranging from 18 to 70 years. Twelve different outcome measures 
were used in the 12 studies reviewed. The two most commonly used outcome measures in the 
included studies were the NPRS2,3,4,7,11,12,20,19 and NDI.2,7,10,11,12,13,20 Physical impairment of 
cervical ROM was measured post-intervention in five studies.3,4,9,10,13 All these have been 
shown to be reliable measures of clinical improvement. Follow-up times ranged from 
immediately post-intervention to 3 months after treatment. (Table 3) 

Methodological quality assessment 
The PEDro scores of each study are listed in Table 1. The scores of the included studies 

ranged from 6 to 9 with a mean score of 7.08 (SD 0.90), indicating that the average quality of 
the included studies was high. Based on PEDro scoring (Table 1), nine studies were classified 
as high quality (scores ≥7), while three studies scored between 5 and 6 and were classified as 
fair quality. The cutoff thresholds followed the convention used in recent reviews to ensure 
comparability. Four PEDro criteria were observed in all of the included studies: random 
allocation, baseline comparability, between-group statistical comparisons, and reporting of 
point measures and variability.2,3,4,7,9,11,12,13,20 Only three met criterion five regarding the 
blinding of subjects.2,10,13 while, eight studies reported blinding of the assessor who measured 
outcomes pre and post intervention.4,8,9,10,11,12,13,19 Due to the nature of manual therapy 
interventions, blinding of treating clinicians was not feasible in any study. This inherent 
limitation should be considered when interpreting outcomes involving subjective measures like 
pain or disability. 

The Risk of Bias assessment (RoB 2.0) for each study is mentioned in Table 2. Only 
one study (Izquierdo Pérez H et al.13) was judged to have overall some concerns of RoB and 
rest of eleven studies have overall High RoB. As all the studies involved different 
interventions of manual therapy delivered by the therapist and being distinguishable from 
each other, there was lack of therapist blindness in all studies leading to therapist bias. 
Another factor of domain 2 being high risk of bias in all studies except one (with some 
concerns) was that primary outcome measures were subjective- self-reported pain and 
disability in almost all studies making it highly susceptible to bias specially when either the 
participants or the assessors are not blinded. These findings highlight the methodological 
variability across studies and emphasize the need for cautious interpretation of their results. 

Mobilization vs Manipulation 
Six studies3,4,11,12,19,20 were found to directly compare manipulation with mobilization. 

The sample sizes ranged from 362 to 10710 patients. Salom-Moreno, J. et al.19 (PEDro 
score=7),  Cleland, J. A. et al.20 (PEDro score=7) and Dunning J.R. et al.11 (PEDro score=8) 
demonstrated that manipulation group showed statistically significant greater reduction in 
neck pain and disability, follow-ups ranging from immediately post-intervention (for neck 
pain p<0.001, between-group mean difference: 1.4; 95% confidence interval, 0.8-2.1)), 19 2-4 
days on initial intervention and examination (reductions in disability p<0.001, between-group 
difference of 10% (95% confidence interval [CI]=5.3-14.7) and in pain p<.001, between-
group difference of 2.0 (95% CI=1.4-2.7))20, and up to 48-hours after the initial examination 
(for disability p<0.001, between-group mean change (8.0 points [95% CI: 5.9, 10.2]) and for 
pain p<.001, between-group mean reduction (2.0 [95% CI: 1.5, 2.5]))11. Whereas Joshi et al.4 



   
 

(PEDro score=7) and Saddique et al.3 (PEDro score=6) demonstrated no statistically 
significant differences between the groups in post-treatment ROM or pain at immediate 
follow-ups  ( for pain p>0.05, mean difference − 0.12 (− 0.9–0.6), 95% CI,4 p>0.05 between 
group difference 2.1 (1.7, 2.8), 95% CI)3 However, within-group, pre, and post comparison 
showed significant improvements in cervical ROM and pain in both groups (p<0.01, mean 
difference = 1.19 for mobilization group, p<0.01, mean difference = 1.28 for manipulation 
group)4 and (p<0.01, 3.0 (2.5, 3.5) manipulation group, p<0.01, 1.2 (0.7, 1.2) mobilization 
group)3. Another study by Griswold, D. et al.12 (PEDro score=8) also stated similar results 
where between-group analyses of NTM or TM revealed no significant differences in 
outcomes on the NDI (p = .67, between group difference 0.47 (–2.7, 1.7)), PSFS (p= .26), 
NPRS (p = .25, between group difference 0.20 (–0.15, 0.55)), DCF (p = .98), GROC (p 
= .77), number of visits (p = .21), and duration of care (p = .61).  Within group analysis 
showed significant difference for disability NDI, (difference estimate, 17.39; 95% confidence 
interval [CI]: 4.5, 20.1; P<.001) and pain NPRS (difference estimate, 3.00; 95% CI: 0.769, 
3.45; P<.001).12  

One study also compared mobilization with added manipulation along with active 
CROM. Mastracchio et al.7 (PEDro score=7) compared manipulation along with mobilization 
and cervical AROM exercises with mobilization and cervical AROM exercises in 66 patients. 
The study demonstrated significantly greater improvements in both the NPRS and NDI at the 
1-week follow-up for the 33 patients in the manipulation group (p<0.001) between-group 
difference of 1.3 points (95% confidence interval [CI]: 0.7, 2.0) on the NPRS and 8.8% (95% 
CI: 5.4%, 12.2%) on the NDI.7 

Two studies compared mobilization with manipulation alongside a control group.2,9 
Suvarnnato et al.9 (PEDro score=7) compared manipulation with mobilization and a control 
group not receiving any compressive pressure on joints in 39 patients with 13 subjects in each 
group. Both manipulation and mobilization showed significant reductions in VAS pain ratings 
and increases in CROM at the immediate and 24-hour follow-ups (p<0.05) compared to the 
control group. But no significant improvement in CROM and pain between mobilization and 
manipulation group was found (For VAS p>0.05, mean difference (95% CI) –1.94 (–11.72–
7.84)).9 Loreto et al.2 (PEDro score=6) compared manipulation with mobilization and a control 
group of 36 patients. The manipulation group showed a significant increase in GROC (p=0.025) 
over time compared to the mobilization and control groups (p = 0.472 and p = 0.176, 
respectively). There was a significant decrease in NPRS in the manipulation and mobilization 
groups (p<0.002 and p<0.001, respectively) and a non-significant decrease in NPRS (p=0.642) 
in the control group. Similarly, there was a significant decrease in NDI for the manipulation 
and mobilization groups (p<0.001 and p<0.001) and a non-significant decrease in NDI 
(p=0.084) in the control group at immediate to 4 days post corresponding intervention.2 

Mobilization with movement/ SNAGs vs Manipulation 
Saleh et al.8 (PEDro score=7) and Sodany et al.10 (PEDro score=6) utilized 

manipulation compared to mobilization (SNAGs) and conventional physical therapy (CPT) 
which includes isometric, stretching and stabilization exercises of neck. The sample sizes were 
608 and 4210. Both the manipulation and SNAGs groups showed significantly better outcomes 
than the CPT group (p<0.05, p<0.05)8,10; however, there were no significant differences 
between the manipulation and SNAGs groups (p>0.05, p>0.05) at follow-ups ranging from 
immediately post-intervention to one month duration. However, in Saleh’s study significant 
reduction in pain was found in SNAG group compared to thoracic manipulation and CPT group 
and in Thoracic manipulation group compared to CPT group using VAS (p value<0.05, between 



   
 

SNAG vs TM: MD (95% CI) -5 (-9.77, -0.22), SNAG vs CPT: MD (95% CI) -10.75 (-15.52, -
5.97), and TM vs CPT: MD (95% CI) -5.75 (-10.52, -0.97)) 

Mobilization vs SNAGs vs Manipulation 
The only study that compared all three manual therapy interventions was conducted by 

Izquierdo Pérez H et al.13 with highest PEDro score of all (PEDro score=9). Total of 61 patients 
were randomized into three groups with 19 in HVLA thrust group and 21 each in SNAG and 
Mobilization group. The study concluded no long-term significant differences between groups 
in outcome with assessment performed 5 times including before intervention, immediate after 
intervention and follow up until 3 months post intervention. There was significant reduction in 
pain across all groups but no significant difference between groups was found using VAS 
(Follow up after 3 months, p > 0.05, Mean ± SD (95%IC) HVLA group: 1.0 ± 1.7 (0.3-1.8), 
Mob group: 0.6 ± 1.1(-0.1-1.3), SNAG group: 1.2 ± 1.9 (0.5-1.9). 

Table 3. Study characteristics 

Article Contro

l group 

Experim

ental 

group 

Interventi

on 

Frequen

cy 

Assessm

ent post-

intervent

ion 

Follow-

Up 

Results 



   
 

Mobilization vs Manipulation 

Salom-

Moreno 

et al.19 

None Group:1 

Thoracic 

manipula

tion 

n=27; 

Group:2 

Thoracic 

mobilizat

ion n=25 

Group:1 

High-

velocity, 

end-range, 

anterior-

posterior 

thrust (T3-

T6, max 2 

attempts); 

Group:2 

20-second 

bouts of 

grades III-

IV central 

posterior-

anterior 

non-thrust 

mobilizati

on (T3-T6) 

 

One 

time 

treatmen

t after 

initial 

evaluati

on 

Pressure 

pain 

threshold

s (PPTs); 

11-point 

Numeric

al Pain 

Rate 

Scale 

(NPRS) 

Immedia

te 

No 

significan

t 

differenc

e in PPT 

between 

groups. 

Thoracic 

manipulat

ion group 

showed 

significan

tly 

greater 

reduction 

in neck 

pain. 



   
 

Cleland 

JA et 

al.20 

None Group 1: 

Non 

thrust 

mobilizat

ion 

n=30 

Group 2: 

Thrust 

mobilizat

ion/ 

manipula

tion 

n=30 

Group 1: 

30-second 

bouts of 

grades III-

IV central 

posterior-

anterior 

non-thrust 

mobilizati

on (T1-T6) 

+ General 

cervical 

mobility 

exercises. 

Group 2: 

High-

velocity, 

low-

amplitude 

anterior-

posterior 

thrust 

Upper 

thoracic 

(T1-T4), 

One 

time 

treatmen

t after 

initial 

evaluati

on 

NDI 

(Neck 

Disabilit

y Index), 

NPRS, 

GROC 

Scale 

(global 

rating of 

change). 

Within 

2-4 days 

of initial 

examinat

ion and 

intervent

ion 

session. 

Thrust 

mobilizat

ion 

showed 

significan

tly 

greater 

short 

term 

reduction 

in pain 

and 

disability  

then non-

thrust 

mobilizat

ions. 



   
 

and middle 

thoracic 

(T5-T8) 

(max 2 

attempts) 

+ General 

cervical 

mobility 

exercises. 

 



   
 

Dunnin

g JR et 

al.11 

None Group:1 

HVLA 

thrust 

manipula

tion 

n=56; 

Group:2 

Non 

thrust 

mobilizat

ion 

n=51  

 

Group:1 

HVLA 

thrust 

manipulati

on (C1-2 

& T1-2); 

Group:2 

Grade IV 

PA 

mobilizati

ons (C1-2 

& T1-2) 

One 

time 

treatmen

t after 

initial 

evaluati

on 

NDI, 

NPRS,  

FRT 

(flexion-

rotation 

test),  

CCFT 

(cranioce

rvical 

flexion 

test), 

GROC. 

48-hours 

after the 

initial 

examinat

ion 

HVLA 

thrust 

manipulat

ion group 

showed 

significan

tly 

greater 

reduction

s in 

disability 

and pain 

than the 

non-

thrust 

mobilizat

ion group 

at 48 

hours. 

Significa

ntly 

greater 

improve

ment in 

C1-2 



   
 

rotation 

and deep 

cervical 

flexor 

motor 

performa

nce.  



   
 

Griswol

d D et 

al.12 

None Group:1 

HVLA 

thrust 

manipula

tion 

n=48; 

Group:2 

Non 

thrust 

manipula

tion 

n=55  

 

Group: 1 

High-

velocity, 

low-

amplitude 

thrust to 

the most 

symptomat

ic segment 

of both the 

cervical 

and 

thoracic 

spines + 

HEP 

( AROM 

exercises 

for 

cervical 

and 

Thoracic, 

DCF) 

Group: 2 

Graded 

oscillatory 

Determi

ned 

pragmati

cally 

based on 

individu

al 

patient 

needs. 

NTM 

(5.7 ± 

2.4) 

TM 

(6.4 ± 

3.1) 

NDI,  

PSFS 

(Patient-

Specific 

Function

al Scale), 

NPRS,  

DCF 

(deep 

cervical 

flexion 

enduranc

e), 

GROC. 

At 

baseline, 

visit 2, 

and 

discharg

e. 

NTM and 

TM 

produce 

equivalen

t 

outcomes 

for 

patients 

with 

mechanic

al neck 

pain. 



   
 

technique 

to both the 

cervical 

and 

thoracic 

spines + 

HEP 

( AROM 

exercises 

for 

cervical 

and 

Thoracic, 

DCF) 



   
 

Saddiqu

e et al.3 

None Group:1 

Thoracic 

manipula

tion 

n=23; 

Group:2 

Maitland 

mobilisat

ion n=23 

Group:1 

Mid-

thoracic 

manipulati

on (T3-T6)  

Group:2 

Cervicotho

racic 

mobilizati

on (C7-T1 

Maitland 

technique) 

One 

time 

treatmen

t 

CROM, 

NPRS. 

Immedia

te 

No 

significan

t 

differenc

es 

between 

the 

groups in 

post-

treatment 

ROM or 

pain. 

Significa

nt 

improve

ments 

within-

group in 

both 

groups. 



   
 

Joshi et 

al.4 

None Group:1 

Thoracic 

manipula

tion 

n=21; 

Group:2 

Maitland 

mobilizat

ion n=21 

Group:1 

HVLA 

thrust 

manipulati

on (T3-T6, 

max 2 

attempts); 

Group:2 

Maitland 

mobilizati

on(C7-T1) 

(30-second 

bouts, 3 

sets) 

One 

time 

treatmen

t after 

initial 

evaluati

on 

CROM 

(Cervical 

ROM 

flexion, 

extension

, lateral 

flexion, 

rotation 

using 

CROM 

device), 

NPRS. 

Immedia

te 

No 

significan

t 

differenc

es 

between 

the 

groups in 

post-

interventi

on, 

Significa

nt 

improve

ments 

within-

group in 

both 

groups. 



   
 

Masara

cchio et 

al.7 

None Compari

son 

group:  

n=32 

Experim

ental 

group:  

n=34 

 

Compariso

n group: 

Grade 3 

posterior-

to-anterior 

oscillatory 

manipulati

on (C2-

C7) + 

active 

cervical 

ROM 

exercises; 

Experimen

tal group: 

Same as 

compariso

n+ 

thoracic 

spine 

thrust 

manipulati

on (T1-T3 

& T4-T7) 

Two 

treatmen

t 

sessions 

NPRS, 

NDI, 

GROC. 

1 week Experime

ntal 

group 

showed 

significan

tly 

greater 

improve

ments on 

both 

NPRS 

and NDI 

at 1-week 

follow-

up.  



   
 

Suvarn

nato et 

al.9 

Control 

group 

Rest in 

a prone 

positio

n 

n=13 

Group:1 

Single 

level 

Thoracic 

manipula

tion 

n=13; 

Group:2 

Single 

level 

Thoracic 

mobilizat

ion n=13 

Group:1 

HVLA 

thrust 

manipulati

on (T6-T7) 

Group:2 

Grade III 

unilateral 

postero-

anterior 

mobilizati

on (T6-T7) 

Group 3: 

Rest in a 

prone 

position 

One 

time 

treatmen

t  

CROM,  

VAS  

(Visual 

Analogue 

Scale for 

Neck 

pain 

intensity) 

Before, 

immedia

te and 

after 24-

hours 

Both 

thoracic 

manipulat

ion and 

thoracic 

mobilizat

ion show 

significan

t 

reduction

s in VAS 

pain 

ratings 

and 

increases 

in CROM 

at 

immediat

e and 24-

hour 

follow-

ups than 

control 

group. 



   
 

Loreto 

et al.2 

Control 

group: 

Educati

onal 

video 

n=12 

Experim

ental 

Group 1: 

Cervical 

spinal 

manipula

tion 

n=12;  

Experim

ental 

Group 2: 

Cervical 

spinal 

mobilizat

ion n=12 

Group 1: 

Standardiz

ed 

educationa

l video (6 

minutes) 

on postural 

correction; 

Group 2: 

High-

velocity, 

mid-range, 

low-

amplitude 

thrust 

manipulati

on; Group 

3: 

60 seconds 

low force 

(Grade II), 

60 seconds 

high force 

(Grade 

III), 60 

One 

time 

treatmen

t 

NDI, 

NPRS, 

GROC 

5-

minutes 

post, and 

4 days 

post 

correspo

nding 

intervent

ion 

CSM 

group 

showed a 

significan

t increase 

in GROC 

compared 

to 

CSMob 

and PE 

groups. 

Significa

nt 

decreases 

in NPRS 

and NDI 

for CSM 

and 

CSMob 

groups, 

non-

significan

t decrease 

in PE 

group. 



   
 

seconds 

low force 

(Grade II) 

mobilizati

ons. 

Mobilization with movement/ SNAGs vs Manipulation 



   
 

Saleh et 

al.8 

Control 

Group: 

CPT 

only 

n=20 

Experim

ental 

Group:1 

Mulligan 

SNAGs 

+ CPT 

 n=20; 

Experim

ental 

Group:2 

Thoracic 

Manipul

ation + 

CPT  

n=20 

Group:1 

Mulligan 

SNAGs to 

the middle 

thoracic 

spine + 

CPT  

Group:2 

Thoracic 

HVLA 

thrust 

manipulati

on (T3-T7) 

+ CPT 

Group:3 

Conventio

nal 

physical 

therapy 

(CPT) - 

isometric 

neck 

exercises, 

chin tucks, 

neck 

Three 

sessions 

a week 

for 4 

weeks 

VAS,  

Neck 

Proprioce

ption 

(using 

CROM 

Device), 

Scapular 

Retractio

n (tape 

measure

ment) 

4 weeks Both 

SNAGs 

and TM 

groups 

showed 

significan

tly better 

outcomes 

than CPT 

group in 

all 

measured 

variables 

(pain, 

proprioce

ption, 

scapular 

retraction

). No 

significan

t 

differenc

e 

between 

SNAGs 



   
 

muscle 

stretching, 

neck 

stabilizatio

n exercises 

(5 sets of 

10 

repetitions, 

2 minutes 

rest 

between 

sets). 

 

 

and TM 

groups in 

neck 

proprioce

ption. 



   
 

Sodany 

et al.10 

Control 

Group: 

Exercis

e only 

n=16 

Experim

ental 

Group:1 

SNAGs 

mobilizat

ion + 

exercise 

n=18;  

Experim

ental 

Group:2 

Manipul

ation + 

exercise 

n=15 

Group:1 

SNAGs 

mobilizati

on + 

exercise;  

Group:2 

HVLA 

cervical 

manipulati

on + 

exercise; 

Group:3 

Isometric, 

stretching, 

postural 

exercises. 

Two 

sessions 

per 

week for 

6 weeks 

CROM, 

VAS, 

NDI 

Before 

treatmen

t, 

immedia

tely after 

treatmen

t, and at 

one 

month 

follow 

up 

Significa

nt 

improve

ments in 

ROM, 

pain 

reduction

, and 

functiona

l 

recovery 

in all. No 

significan

t 

differenc

e 

between 

SNAGs 

and 

manipulat

ion 

groups. 

Both 

groups 1 

& 2 



   
 

showed 

significan

tly better 

outcomes 

than the 

exercise 

only 

group. 

Mobilization vs SNAGs vs Manipulation 



   
 

Izquier

do 

Pérez H 

et al.13 

None Group 1: 

HVLA 

n= 19 

Group 2: 

Mobiliza

tion 

n= 21  

Group 3: 

SNAG 

n= 21 

Group 1: 

High 

velocity 

Low 

amplitude 

thrust 

applied at 

most 

hypomobil

e vertebra 

for most 

limited 

cervical 

movement: 

lateral 

flexion or 

rotation 

(maximum 

of 2 

thrusts) 

Group 2: 

Unilateral 

posteroant

erior (PA) 

oscillatory 

Four 

treatmen

t 

sessions 

over 2 

weeks 

VAS, 

NDI, 

ACROM, 

GROC 

Five 

evaluatio

ns: 

Before 

treatmen

t, 

immedia

tely after 

treatmen

t, and 

one, two 

and three 

months 

after 

treatmen

t 

No 

significan

t 

differenc

es were 

found 

between 

HVLA, 

Mob and 

SNAG at 

the end of 

treatment 

and 

during 

the 

follow-up 

in any of 

the 

analysed 

outcomes

. There 

were no 

differenc

es in 

satisfacti



   
 

pressure 

was 

applied at 

hypomobil

e cervical 

vertebra 

(frequency 

of 2Hz for 

2 mins, 

repeated 3 

times with 

1 min rest 

in 

between) 

Group 3: 

SNAG 

applied at 

most 

hypomobil

e and 

painful 

vertebra 

(3 sets of 

10 reps) 

on for all 

technique

s. 

 



   
 

Table 4: Effect Size Analysis for Neck Pain Treatment Interventions 

 

Study Comparison Outcome 
Measure 

Effect Size 
(d) 

95% 
CI 

Interpretation 

Salom-
Moreno et 
al.19 

Manipulation vs 
Mobilization 

NPRS (pain) 0.82 [0.32, 
1.32] 

Large effect favoring 
manipulation 

Cleland et 
al.20 

Manipulation vs 
Mobilization 

NDI 
(disability) 

0.75 [0.26, 
1.24] 

Medium-large effect 
favoring 
manipulation 

Dunning et 
al.11 

Manipulation vs 
Mobilization 

NDI 
(disability) 

0.68 [0.30, 
1.06] 

Medium effect 
favoring 
manipulation 

Griswold et 
al.12 

Manipulation vs 
Mobilization 

NPRS (pain) 0.12 [-0.18, 
0.42] 

Negligible difference 

Joshi et al.4 Manipulation vs 
Mobilization 

CROM 
(ROM) 

0.15 [-0.44, 
0.74] 

Negligible difference 

Saleh et al.8 SNAGs vs 
Manipulation 

VAS (pain) 0.18 [-0.32, 
0.68] 

Negligible difference 

Sodany et 
al.10 

SNAGs vs 
Manipulation 

NDI 
(disability) 

0.22 [-0.34, 
0.78] 

Negligible difference 

Izquierdo 
Pérez et al.13 

SNAGs vs 
Mobilization vs 
Manipulation 

NDI 
(disability) 

0.10 
(between 
groups) 

[-0.30, 
0.50] 

Negligible 
differences 

 

Note: Effect sizes (Cohen’s d) were computed using reported between-group means and pooled 
standard deviations, using the formula: 
d = (M₁ - M₂) / SDpooled, 
where SDpooled = √[(SD₁² + SD₂²)/2]. Effect sizes were interpreted using standard thresholds: 
0.2 = small, 0.5 = medium, and 0.8 = large. These calculations provide a standardized measure 
of treatment efficacy across studies. 

The analysis of effect sizes revealed important patterns in the comparative efficacy of 
different manual therapy interventions for mechanical neck pain. Three high-quality studies 
(Salom-Moreno, Cleland, and Dunning) demonstrated medium-to-large short-term benefits of 
manipulation over conventional mobilization for both pain and disability outcomes, with effect 
sizes ranging from 0.68 to 0.82. However, four other studies (Griswold, Joshi, Saleh, and 
Sodany) found no significant differences between manipulation and mobilization techniques 
(including SNAGs), showing only negligible to small effect sizes between 0.12 and 0.22. When 
comparing all three approaches simultaneously, three-way comparisons indicated minimal 
differences between mobilization, SNAGs, and manipulation, with an overall effect size of just 
0.10. This synthesis revealed considerable heterogeneity in treatment effects across studies in 
terms of intervention techniques, outcome measures, and follow-up durations. While, some 



   
 

demonstrating substantial advantages for manipulation, others showed equivalent outcomes 
across interventions. This variation limits the generalizability of pooled findings and 
emphasizes the need for individualized clinical decision-making based on patient-specific 
factors. 

Discussion 

The methodological quality of the included studies varied, with an average PEDro score 
of 7.08 (SD 0.90), indicating high quality evidence. While most studies adhered to proper 
randomization and statistical methodologies, blinding of participants and therapists remained 
a significant concern. Although the evidence in this review is categorized from ‘fair to high’ 
based on the PEDro scale but is graded as overall High risk of Bias on RoB 2.0 assessment for 
all studies except one with overall some concerns. The lack of long-term follow-up in several 
studies further limits the strength of recommendations derived from the evidence. Additionally, 
studies varied in their intervention protocols, sample sizes, and follow-up durations. Due to 
these limitations, the comparative efficacy of mobilization and manipulation in treating 
mechanical neck pain (MNP) became more challenging. 

A thorough analysis of twelve randomized controlled trials (RCTs) was conducted to 
compare the efficacy of manipulation and mobilization in mechanical neck pain (MNP) patients. 
The results varied across studies, but several common themes emerged regarding pain 
reduction, range of motion (ROM), and functional improvement. 

The studies included in this review reported follow-up durations ranging from immediate post-
intervention2,3,4,9,10,13,19 to four weeks8,10,13, with only one study extending beyond one month 
(upto 3 months)13. Concerns regarding limited sampling were observed, as some studies were 
conducted at single clinical locations3,8. Additionally, variations in the application of 
mobilization and manipulation techniques were evident. Manipulation techniques included 
high-velocity, low-amplitude (HVLA) thrusts applied to the Cervical2,10,11,12,13 or/and upper and 
middle Thoracic spine3,4,7,8,9,11,12,19,20, while mobilization techniques encompassed central 
posterior-to-anterior (PA) mobilizations2,3,4,7,9,11,12,13,19,20 and Mulligan SNAGs8,10,13. There 
were differences seen in the variety of application of manual therapy techniques, but for a 
thorough review all these studies were included in order to find out which one has greater 
benefits. 

Studies involving a direct comparison of manipulation to mobilization had varying 
results. These studies utilized different techniques including single HVLA thrust manipulation 
directed to the upper cervical spine (C1-2)11 in supine and anterior-posterior HVLA thrust 
manipulation applied to the upper and mid-thoracic spine in prone3,4 and in supine11,19,20. These 
were in comparison to central grade IV PA mobilizations to the (C1-2) in supine11 and central 
grades III to IV PA mobilization from T3 to T6 spinous process19 , from T1-T620 and central 
PA glide to the C7-T13,4 in prone. Only one study had a pragmatic approach where technique 
and parameters were determined by the treating therapist based on patients’ evaluation. Either 
a high-velocity, low-amplitude thrust, or a graded oscillatory technique was targeted to the 
symptomatic level to both cervical and thoracic spine.12 In this study by Griswold D et al.12 no 
significant differences were found between the groups controlling for clinical equipoise, but 
better outcomes were achieved for patients treated by clinicians with a preference toward TM. 
However, significant differences were found within both groups for pain and disability 
including other outcomes as well indicating effectiveness of both techniques.12 

Study by Dunning Jr et al.11, revealed that thoracic spine manipulation provided 
superior reductions in pain and disability at 48-hour follow-ups compared to cervical 
mobilization. The study was methodologically robust but lacked long-term follow-up, 



   
 

highlighting the need for further research into the sustained effects of manipulation11. A high-
quality study by Salom-Moreno et al.19 that found thoracic thrust manipulation to be 
significantly more effective than non-thrust mobilization in reducing neck pain intensity. 
However, both groups demonstrated similar improvements in pressure pain thresholds, 
indicating comparable effects on pain sensitivity. The study supports the hypothesis that 
manipulation may provide additional benefits beyond mobilization in terms of immediate pain 
relief.19 Similarly, Cleland JA et al.20 also found significant reduction in pain, disability and 
higher scores on GROC for patients who received thrust mobilization/manipulation. He also 
mentioned number of side effects experienced by subjects in each group, which were reported 
as non-significant between the groups. Side effects in the NTM group included an aggravation 
of symptoms (n2), muscle spasm (n1), neck stiffness (n2), headache (n2), and radiating 
symptoms (n2) and in the TM group, aggravation of symptoms (n8), muscle spasm (n1), and 
headache (n1). Although the time of initiation to lasting of symptoms was reported within 24 
hours by all subjects.20 

The study by Saddique et al.3 compared mid-thoracic (T3-T6) manipulation to 
cervicothoracic  junction (CT) mobilization. Both interventions resulted in significant within-
group improvements in pain and ROM post-treatment, but no significant between-group 
differences were observed, suggesting both techniques are equally effective.3 This aligns with 
findings from Joshi et al.4, which also demonstrated no significant differences between the two 
interventions. These results are consistent with other studies that suggest both mobilization and 
manipulation can be effective interventions for MNP.6 

A study by Mastracchio et al.7, compared a group receiving PA NTM (grade 3) at 
spinous processes of cervical spine (C2-C7) with similar treatment plus 2 thoracic spine TM at 
upper thoracic spine (T1-T3) and 2 at the middle thoracic spine (T4-T7). It was found that 
combining thoracic and cervical manipulations to a classical mobilizations, led to greater 
improvements in NPRS and NDI scores at one-week follow-up compared to cervical 
mobilization alone.7 These findings support the role of multimodal manual therapy in managing 
MNP, suggesting that addressing both thoracic and cervical dysfunction may provide superior 
clinical outcomes. 

Loreto et al.2, assessed the effects of cervical spine mobilization versus manipulation 
on pain and disability alongside a control group. One group received a single session of CSM 
“Minimal Leverage Thrust” (HVLA force with either left side bending and right rotation or 
right side bending with left rotation targeted at the painful and/or restricted segment) in 
supine position, while the CSMob group received Grade II and III mobilization in prone. The 
control group was shown a postural education video. The manipulation group exhibited a 
significant increase in Global Rating of Change (GROC) scores compared to the mobilization 
and placebo groups. A significant reduction in NPRS and Neck Disability Index (NDI) scores 
were observed for both groups compared to the non-intervention group. However, no 
significant differences were found between the groups for each of the outcomes. These results 
suggest patient’s satisfaction influenced by increasing rends for high-thrust manipulation. 
Another study by Suvarnnato et al.9, compared single level thoracic manipulation (T6-7) with 
PA grade III mobilization (at the zygapophyseal joint of T6-T7 on both sides) in prone with 
control group only lying in prone position. It demonstrated significant improvements in 
Visual Analog Scale (VAS) pain scores and ROM in both thoracic manipulation and 
mobilization groups compared to a control group where no compressive forces were applied. 
However, no significant differences were found between the two manual therapy techniques, 
indicating that both approaches may be equally beneficial which is consistent with above 
findings.9 



   
 

Two studies compared mobilization with movement (SNAGs) and thoracic 
manipulation on neck pain. The study of Saleh et al.8 used technique of Mulligan’s SNAG at 
middle thoracic spine with the patient sitting astride a chair, the other group received thoracic 
manipulation (T3 and T7) in prone, and the control group was given conventional physical 
therapy. His study showed significant improvements in cervical ROM and pain reduction by 
both interventions, no significant differences were observed between groups. The study lacked 
sufficient blinding but featured strong randomization methods and concealed allocation. 
Sodany et al.10 compared cervical SNAG (applied to the affected side in sitting position) along 
with cervical manipulation (cervical rotatory and lateral tilting techniques in supine position). 
He also found that SNAGs and manipulation were equally effective in improving cervical 
ROM and reducing pain compared to exercise-only groups. However, there was no significant 
difference between the SNAGs and manipulation groups.10 These findings align with previous 
studies suggesting that SNAGs and manipulation may produce similar therapeutic effects. 

The only study found that compared all three techniques altogether was rated as high 
quality evidence. Izquierdo Pérez, H. et al.13 in his study randomized participants in three 
experimental groups to find the best technique. All techniques were applied at hypomobile 
vertebra One group was allocated for HVLA thrust (applied for the most limited movement: 
lateral flexion or rotation in supine), other received (PA) oscillatory pressure (mobilization at 
a frequency of 2Hz for 2 mins in prone) and the last group was given SNAG (on transverse 
process in sitting). This was the only study that had a long-term follow up for upto 3 months. 
The results of this study were no different from the above findings. All three techniques 
demonstrated significant reduction in pain and disability and increase in ACROM and GROC 
score. However, no significant differences in any of the outcomes were found between the 
groups. There was one interesting finding for ACROM, improved extension was noted only 
immediately in mob group, at only one month follow up in SNAG group and in HVLA thrust 
group at all follow up months than other groups.13 These results cannot be generalized due to 
lack of sufficient data and small sample size. 

Limitations 
This systematic review has several limitations that impact the strength and 

generalizability of its findings. The lack of high-quality randomized controlled trials (RCTs) 
focused on mobilization for mechanical neck pain necessitated the inclusion of studies with 
lower methodological rigor. Variability in methodologies, techniques, outcome measures, and 
follow-up durations made it challenging to synthesize findings into precise clinical 
recommendations. The exclusion of non-English studies may have further restricted the scope 
of the review. Concerns highlighted by the PEDro scale included issues with blinding and 
treatment consistency, as most studies did not blind subjects and therapists, increasing the risk 
of expectation bias. Short follow-up durations, with most studies reporting outcomes up to only 
four weeks, limited the understanding of long-term intervention efficacy. Additionally, small 
sample sizes in several studies reduced the generalizability of results, while variability in 
manipulation and mobilization techniques hindered direct comparisons across studies. 

Recommendations for Future Research 
Future studies should directly compare manipulation and mobilization for MNP, using 

well-defined treatment protocols, long follow-up periods to assess the longer-term effects 
beyond four weeks, and multicentre trials across diverse clinical settings. Future studies should 
ensure adequate blinding of assessors. Thus, different methods of thoracic manipulations for 
instance, manipulation supine versus manipulation seated need to be investigated 
comparatively in order to see which one yields better results. Moreover, the examination of 



   
 

potential synergy between manual therapy and therapeutic exercise would have useful clinical 
implications. 

Conclusions 
As a result of the methodological concerns associated with the current research 

comparing mobilization and manipulation for mechanical neck pain (MNP), there is no clear 
evidence that supports one technique over the other. Both treatments significantly improved 
pain, range of motion, and functional outcomes in the short term; however, the evidence on 
their relative efficacy was limited by a wide variability in study designs, small sample sizes, 
and short follow-up. On the other hand, manipulation, especially thoracic manipulation, has a 
fair to good evidence base of variable quality to improve immediate and short-term neck pain 
and disability. Further studies are needed to establish the effectiveness of manipulation and 
mobilization in the long term, study standardized treatment protocols, and assess the 
effectiveness of manipulation and mobilization as an adjunct to other treatments. 

 

 

 

 

 

 

 

 

 

 

 

 

 



   
 

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