Manipulation and mobilisation for neck disorders

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Published:  23 September 2015 Authors:  Gross A, Langevin P, Burnie SJ, Bédard-Brochu M, Empey B, Dugas E, Faber-Dobrescu M, Andres C, Graham N, Goldsmith CH, Brønfort G, Hoving JL, LeBlanc F Primary Review Group:  Back and Neck Group Review question

This update assessed the effect of manipulation or mobilisation alone compared with a control or another treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without arm symptoms and headache at immediate- to long-term follow-up.


Neck pain can cause varying levels of disability for the affected individual and is a common musculoskeletal complaint. Neck pain can be accompanied by pain radiating down the arms (radiculopathy) or by headache (cervicogenic headache). Manipulation (adjustments to the spine) and mobilisation (movement imposed on joints and muscles) can be used alone or in combination with other physiotherapies to treat neck pain.

Study characteristics

This updated review includes 51 trials: 18 trials contrasted manipulation or mobilisation against no treatment or pretend treatment; 34 trials compared manipulation or mobilisation against another treatment (electrotherapy, exercise, medication) and various techniques or dosages. [Note one trial included two comparison groups].

Key results

Although other reviews focusing on adverse events suggest that mobilisation is safe and manipulation may result in rare but serious side effects such as stroke, disc herniation or serious neurological deficits, our review noted temporary and benignside effects with both approaches; more than half of the included trials did not report on adverse effects.

 Manipulation or mobilisation versus inactive treatment: For subacute/chronic neck pain, a single manipulation produced temporary pain relief. However, conflicting evidence was found at short-term follow-up for pain reduction with multiple sessions. At short-term and intermediate-term follow-up, multiple sessions of thoracic manipulation were favoured for pain reduction among participants with acute/subacute neck pain, and for functional improvement among those with acuteto chronic neck pain. No additional pain relief was reported when thoracic mobilisation was used.

 Manipulation or mobilisation versus another active treatment: Cervical manipulation produced changes in pain, function, quality of life, global perceived effect and patient satisfaction that were comparable with those attained with cervical mobilisation up to intermediate-term follow-up for patients with neck pain of any duration. Cervical manipulation for acute/subacute neck pain was more effective than varied combinations of analgesics, muscle relaxants and non-steroidal anti-inflammatory drugs for improving pain and function at up to long-term follow-up. For chronic cervicogenic headache, cervical manipulation provided greater benefit than light massage in improving pain and function at short-term and intermediate-term follow-up. For chronic CGH, cervical manipulation may be superior to transcutaneous electrical nerve stimulation (TENS) in improving pain at short-term follow-up. For acute neck pain, cervical manipulation may be more effective than thoracic manipulation in improving pain and function up to intermediate-term follow-up. Finally, for subacute and chronic neck pain, cervical mobilisation appeared similar to pulsed ultrasound, TENS, acupuncture and massage in improving pain, function, quality of life and patient satisfaction up to intermediate-term follow-up. However, combining laser with manipulation may be superior to using manipulation or laser alone.

Quality of the evidence

No high-quality evidence was found, so uncertainty about the effectiveness of mobilisation or manipulation for neck pain remains. Future research is likely to have an important impact on the effect estimate. Authors of this review encountered many challenges, for example, the number of participants in most trials was small, 80% (41/51) of the included studies were of low or very low quality and evidence on the optimum dosage requirement was limited.  

Authors' conclusions: 

Although support can be found for use of thoracic manipulation versus controlfor neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. 

Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

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