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. References Bailey, E., Heneghan, N. R., Cassidy, N. J., Falla, D., & Rushton, A. B. (2020). Clinical effectiveness of manipulation and mobilisation interventions for the treatment of non- specific neck pain: Protocol for a systematic review and meta-analysis. BMJ Open, 10(10), e037783. https://doi.org/10.1136/bmjopen-2020-037783 Cleland, J. A., Glynn, P., Whitman, J. M., Eberhart, S. L., MacDonald, C., & Childs, J. D. (2007). Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Physical therapy, 87(4), 431–440. https://doi.org/10.2522/ptj.20060217 De Morton, N. A. (2009). The PEDro scale is a valid measure of the methodological quality of clinical trials: A demographic study. The Australian Journal of Physiotherapy, 55(2), 129–133. https://doi.org/10.1016/S0004-9514(09)70043-1 Dunning, J. R., Cleland, J. A., Waldrop, M. A., Arnot, C., Young, I., Turner, M., & Sigurdsson, G. (2012). Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: A multicenter randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 42(1), 5–18. https://doi.org/10.2519/jospt.2012.3894 El-Sodany, A. M., Alayat, M. S. M., & Zafer, A. M. I. (2014). Sustained natural apophyseal glides mobilization versus manipulation in the treatment of cervical spine disorders: A randomized controlled trial. International Journal of Advanced Research, 2(6), 274–280. Griswold, D., Learman, K., Kolber, M. J., O'Halloran, B., & Cleland, J. A. (2018). Pragmatically Applied Cervical and Thoracic Nonthrust Manipulation Versus Thrust Manipulation for Patients With Mechanical Neck Pain: A Multicenter Randomized Clinical Trial. The Journal of orthopaedic and sports physical therapy, 48(3), 137–145. https://doi.org/10.2519/jospt.2018.7738 Izquierdo Pérez, H., Alonso Perez, J. L., Gil Martinez, A., La Touche, R., Lerma-Lara, S., Commeaux Gonzalez, N., Arribas Perez, H., Bishop, M. D., & Fernández-Carnero, J. (2014). Is one better than another?: A randomized clinical trial of manual therapy for patients with chronic neck pain. Manual therapy, 19(3), 215–221. https://doi.org/10.1016/j.math.2013.12.002 Joshi, S., Balthillaya, G., & Neelapala, Y. R. (2020). Immediate effects of cervicothoracic junction mobilization versus thoracic manipulation on the range of motion and pain in mechanical neck pain with cervicothoracic junction dysfunction: A pilot randomized controlled trial. Chiropractic & Manual Therapies, 28, 1–8. https://doi.org/10.1186/s12998-020-00302-0 Loreto, A., Lohman, E., Gharibvand, L., Lohman, T., & Lee, B. (2024). The effects of cervical spine mobilization versus manipulation on pain, disability, and satisfaction in subjects with non-specific mechanical neck pain. Physical Therapy Rehabilitation Science, 13(3), 261–273. https://doi.org/10.14474/ptrs.2024.13.3.261 https://doi.org/10.1136/bmjopen-2020-037783 https://doi.org/10.2522/ptj.20060217 https://doi.org/10.1016/S0004-9514(09)70043-1 https://doi.org/10.2519/jospt.2012.3894 https://doi.org/10.2519/jospt.2018.7738 https://doi.org/10.1016/j.math.2013.12.002 https://doi.org/10.1186/s12998-020-00302-0 https://doi.org/10.14474/ptrs.2024.13.3.261 Maher, C. G., Sherrington, C., Herbert, R. D., Moseley, A. M., & Elkins, M. (2003). Reliability of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy, 83(8), 713–721. https://doi.org/10.1093/ptj/83.8.713 Masaracchio, M., Cleland, J., Hellman, M., & Hagins, M. (2013). Short-term combined effects of thoracic spine thrust manipulation and cervical spine nonthrust manipulation in individuals with mechanical neck pain: A randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 43(3), 118–127. https://doi.org/10.2519/jospt.2013.4450 Moseley, A. M., Elkins, M. R., Van der Wees, P. J., & Pinheiro, M. B. (2020). Using research to guide practice: The Physiotherapy Evidence Database (PEDro). Brazilian Journal of Physical Therapy, 24(5), 384–391. https://doi.org/10.1016/j.bjpt.2020.04.006 Saddique, M., Bhutto, M. A., Jahangir, S., Pt, A. S., Shafiq, M. S., Zafar, I., ... & Malik, M. W. (2022). Effectiveness of thoracic manipulation and cervicothoracic mobilisation in decreasing pain and increasing ROM in nonspecific neck pain. Pakistan Journal of Medical & Health Sciences, 16(12), 592. https://doi.org/10.53350/pjmhs20221612592 Saleh, A. M., Abdel-Aal, N. M., & Ibrahem, O. A. (2023). Mobilization with movement versus thoracic manipulation on neck proprioception in mechanical neck pain: A randomized controlled study. Journal of Pharmaceutical Negative Results, 14(3), 3972– 3980. https://doi.org/10.47750/pnr.2023.14.03.526 Salom-Moreno, J., Ortega-Santiago, R., Cleland, J. A., Palacios-Ceña, M., Truyols- Domínguez, S., & Fernández-de-las-Peñas, C. (2014). Immediate changes in neck pain intensity and widespread pressure pain sensitivity in patients with bilateral chronic mechanical neck pain: A randomized controlled trial of thoracic thrust manipulation vs non–thrust mobilization. Journal of Manipulative and Physiological Therapeutics, 37(5), 312–319. https://doi.org/10.1016/j.jmpt.2014.03.007 Suvarnnato, T., Puntumetakul, R., Kaber, D., Boucaut, R., Boonphakob, Y., Arayawichanon, P., & Chatchawan, U. (2013). The effects of thoracic manipulation versus mobilization for chronic neck pain: A randomized controlled trial pilot study. Journal of Physical Therapy Science, 25(7), 865–871. https://doi.org/10.1589/jpts.25.865 Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng H-Y, Corbett MS, Eldridge SM, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; 366: l4898. Verhagen, A. P., De Vet, H. C., De Bie, R. A., Kessels, A. G., Boers, M., Bouter, L. M., & Knipschild, P. G. (1998). The Delphi list: A criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. Journal of Clinical Epidemiology, 51(12), 1235–1241. https://doi.org/10.1016/S0895-4356(98)00131-0 Wu, A. M., Cross, M., Elliott, J. M., Culbreth, G. T., Haile, L. M., Steinmetz, J. D., ... & Pourahmadi, M. (2024). Global, regional, and national burden of neck pain, 1990–2020, and projections to 2050: A systematic analysis of the Global Burden of Disease Study https://doi.org/10.1093/ptj/83.8.713 https://doi.org/10.2519/jospt.2013.4450 https://doi.org/10.1016/j.bjpt.2020.04.006 https://doi.org/10.53350/pjmhs20221612592 https://doi.org/10.47750/pnr.2023.14.03.526 https://doi.org/10.1016/j.jmpt.2014.03.007 https://doi.org/10.1589/jpts.25.865 https://doi.org/10.1016/S0895-4356(98)00131-0 2021. The Lancet Rheumatology, 6(3), e142–e155. https://doi.org/10.1016/S2665- 9913(23)00336-3 Yamato, T. P., Maher, C., Koes, B., & Moseley, A. (2017). The PEDro scale had acceptably high convergent validity, construct validity, and interrater reliability in evaluating methodological quality of pharmaceutical trials. Journal of Clinical Epidemiology, 86, 176–181. https://doi.org/10.1016/j.jclinepi.2017.03.012 Young, J. L., Walker, D., Snyder, S., & Daly, K. (2014). Thoracic manipulation versus mobilization in patients with mechanical neck pain: A systematic review. Journal of Manual & Manipulative Therapy, 22(3), 141–153. https://doi.org/10.1179/2042618613Y.0000000043 https://doi.org/10.1016/S2665-9913(23)00336-3 https://doi.org/10.1016/S2665-9913(23)00336-3 https://doi.org/10.1016/j.jclinepi.2017.03.012 https://doi.org/10.1179/2042618613Y.0000000043