Manipulation and Mobilisation for Mechanical Neck Disorders

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

This updated review included 27 trials (1522 participants) that compared manipulation or mobilization against no treatment, sham (pretend) treatments, other treatments (such as medication, acupuncture, heat, electrotherapy, soft tissue massage), or each other. 

There is low quality evidence from three trials (130 participants) that neck manipulation can provide more pain relief for those with acute or chronic neck pain when compared to a control in the short-term following one to four treatment sessions. Low quality evidence from one small (25 participants) dosage trial suggests that nine or 12 sessions of manipulation are superior to three for pain relief at immediate post treatment follow-up and neck-related disability for chronic cervicogenic headache. There is moderate quality evidence from 2 trials (369 participants) that there is little to no difference between manipulation and mobilisation for pain relief, function and patient satisfaction for those with subacute or chronic neck pain at short and intermediate-term follow-up. Very low quality evidence suggests that there is little or no difference between manipulation and other manual therapy techniques, certain medication, and acupuncture for mostly short-term and on one occasion intermediate term follow-up for those with subacute and chronic neck pain (6 trials, 494 participants) and superior to TENS for chronic cervicogenic headache (1 trial, 65 participants).

There is very low to low quality evidence from two trial (133 participants) that thoracic (mid-back) manipulation may provide some immediate reduction in neck pain when provided alone or as an adjunct to electrothermal therapy or individualized physiotherapy for people with acute neck pain or whiplash. When thoracic manipulation was added to cervical manipulation alone, there was very low quality evidence suggesting no added benefit for participants with neck pain of undefined duration.

There is low quality evidence from two trials (71 participants) that a mobilisation is as effective as acupuncture for pain relief and improved function for subacute and chronic neck pain and neural dynamic techniques produce clinically important pain reduction for acute to chronic neck pain. Very low to low quality evidence from three trials (215 participants) suggests certain mobilisation techniques may be superior to others.

Adverse (side) effects were reported in 8 of the 27 studies. Three out of those eight studies reported no side effects. Five studies reported minor and temporary side effects including headache, pain, stiffness, minor discomfort, and dizziness. Rare but serious adverse events, such as stoke or serious neurological deficits, were not reported in any of the trials.

Limitations of this review include the high number of potential biases found in the studies, thus lowering our confidence in the results. The differences in participant and treatment characteristics across the studies infrequently allowed statistical combination of the results.

Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change

Authors' conclusions: 

Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Read the full abstract...

Manipulation and mobilisation are often used, either alone or combined with other treatment approaches, to treat neck pain.


To assess if manipulation or mobilisation improves pain, function/disability, patient satisfaction, quality of life, and global perceived effect in adults with acute/subacute/chronic neck pain with or without cervicogenic headache or radicular findings.

Search strategy: 

CENTRAL (The Cochrane Library 2009, issue 3) and MEDLINE, EMBASE, Manual Alternative and Natural Therapy, CINAHL, and Index to Chiropractic Literature were updated to July 2009.

Selection criteria: 

Randomised controlled trials on manipulation or mobilisation.

Data collection and analysis: 

Two review authors independently selected studies, abstracted data, and assessed risk of bias. Pooled relative risk and standardised mean differences (SMD) were calculated.

Main results: 

We included 27 trials (1522 participants).

Cervical Manipulation for subacute/chronic neck pain : Moderate quality evidence suggested manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low quality evidence showed manipulation alone compared to a control may provide short- term relief following one to four sessions (SMD pooled -0.90 (95%CI: -1.78 to -0.02)) and that nine or 12 sessions were superior to three for pain and disability in cervicogenic headache. Optimal technique and dose need to be determined.

Thoracic Manipulation for acute/chronic neck pain : Low quality evidence supported thoracic manipulation as an additional therapy for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and favoured a single session of thoracic manipulation for immediate pain reduction compared to placebo for chronic neck pain (NNT 5, 29% treatment advantage).

Mobilisation for subacute/chronic neck pain: In addition to the evidence noted above, low quality evidence for subacute and chronic neck pain indicated that 1) a combination of Maitland mobilisation techniques was similar to acupuncture for immediate pain relief and increased function; 2) there was no difference between mobilisation and acupuncture as additional treatments for immediate pain relief and improved function; and 3) neural dynamic mobilisations may produce clinically important reduction of pain immediately post-treatment. Certain mobilisation techniques were superior.