http://informahealthcare.com/ptp ISSN: 0959-3985 (print), 1532-5040 (electronic) Physiother Theory Pract, Early Online: 1–8 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2014.963904

RESEARCH REPORT

Effectiveness of mobilization therapy and exercises in mechanical neck pain G. Shankar Ganesh, MPT, Patitapaban Mohanty, PhD, Monalisa Pattnaik, MPT, and Chittaranjan Mishra, MPT

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Department of Physiotherapy, Swami Vivekanand National Institute of Rehabilitation Training and Research, Olatpur, Cuttack, Orissa, India

Abstract

Keywords

Objectives: While studies have looked into the effects of Maitland mobilization on symptom relief, to date, no work has specifically looked at the effects of Mulligan mobilization. The objective of this work was to compare the effectiveness of Maitland and Mulligan’s mobilization and exercises on pain response, range of motion (ROM) and functional ability in patients with mechanical neck pain. Methods: A total sample of 60 subjects (21–45 years of age) with complaints of insidious onset of mechanical pain that has lasted for less than 12 weeks and reduced ROM were randomly assigned to: group I – Maitland mobilization and exercises; group – II Mulligan mobilization and exercises; and group-III exercises only, and assessed for dependent variables by a blinded examiner. Results: Post measurement readings revealed statistical significance with time (p50.00) and no significance between groups (p40.05) indicating no group is superior to another after treatment and at follow-up. The effect sizes between the treatment groups were small. Conclusion: Our results showed that manual therapy interventions were no better than supervised exercises in reducing pain, improving ROM and neck disability.

Exercise, musculo skeletal manipulations, neck pain

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

Address correspondence to G. Shankar Ganesh, Department of Physiotherapy, Swami Vivekanand National Institute of Rehabilitation Training and Research, P.O. Bairoi, Olatpur 754010, Cuttack, Orissa, India. E-mail: [email protected]

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

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

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

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

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surgery or trauma; (2) progressive neurological deficits; (3) cervical myelopathy; (4) vascular diseases of head and neck; (5) previous physical therapy/chiropractic care for shoulder or neck; (6) cervical nerve root pathology; (7) severity and irritability of symptoms; and (8) other red flags to manual therapy. The sample size was calculated and determined at 72 participants (24 in each group) to find a between-group difference in pain of at least 1.5 points [visual analog scale (VAS), 11-point scale (0–10)], with power established at 80% and significance level at 0.05. Participants were recruited through printed advertisements displayed in our institute, sub-centers of our institute and the nearest medical college hospital. The physicians and physiotherapists who were posted in the out-patient department of the above-mentioned places were requested to refer patients complaining of acute neck pain to the place of study. One-hundred forty-one participants (m ¼ 60; f ¼ 81) responded to the advertisement and referral. All the respondents underwent physical examination by the first and second authors and were included into the study if they satisfied the inclusion and exclusion criteria. Forty-two participants (m ¼ 15; f ¼ 27) were excluded and 19 participants (m ¼ 6; f ¼ 13) expressed their inability to attend therapy regularly and were excluded. The participants recruited were from geographically different units within the state and were randomized into three different groups, designated as groups I, II and III. Nine participants (all females) were eliminated due to noncompliance with the intervention program, five participants (m ¼ 1; f ¼ 4) withdrew from the study for personal reasons and six participants (all females) were lost in follow-up. Sixty participants (22 females and 38 males) with a mean age of 41.7 years (SD: 9.8) participated and completed the study (Figure 1). Informed consent was obtained from each participant, and the procedure was approved by the institute ethics committee. Participants were permitted to continue medication prescribed at baseline as required. Outcome measures The following outcome measures were studied. Pain intensity measured by VAS VAS was used to measure subjective pain intensity. The VAS has been shown to be valid and reliable and has a reasonable degree of reproducibility (Revill, Robinson, Rosen, and Hogg, 1976). Each participant subjectively estimated his/her pain level by moving the pointing device along the uncalibrated scale, between 0 and 10. Cervical ROM by 180 degrees universal goniometer Cervical ROM was assessed using a universal goniometer with a measuring scale marked out at a one degree interval. For cervical ROM measurements, the technique suggested by Cipriano (1985) was followed. Goniometric measurement has been found to have greater intra-tester reliability in both clinical and research settings (Rothstein, Miller, and Roettger, 1983). Cervical ROM measurements on the cervical spine evaluated by the same examiner have good to high reliability (Youdas, Carey, and Ganrent, 1991). Neck disability index This functional scale is composed of 10 sections (containing 10 functional activities). Each section has six options, with scoring from 0 to 5 where the participant had to mark in only one box that applied to them. This test has been shown to be reliable, valid and a responsive functional outcome measure for evaluation of patients with cervical pain (Vernon and Mior, 1991). The final score was then transformed into a percentage score.

Mobilization and neck pain

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

Excluded parcipants n=42 (m=15, f= 27)

Paent who fulfilled the inclusion & exclusion criteria

Paent who did not consent for study n= 19 (m= 6, f=13)

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Randomly assigned aer informed consent n = 80 (m=39,f= 41)

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

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

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

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

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

n=20 (m=13, f=7) Patient withdrawal from study (n = 5)

2 weeks ofi ntervenon

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

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

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

Follow-up after 6 weeks n= 20 (m=14, f=6)

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

Patient lost in follow-up (n = 6)

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

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

Procedure All assessments were made by an assessor blinded to the protocol, and all participant data were collected before randomization. The randomization was done by a random number table. Each treatment allocation was placed in a sealed, sequentially numbered opaque envelope. Each envelope given to participants was opened by an individual blinded to upcoming treatment assignments. Two manipulative physiotherapists with more than 18 years of clinical experience working in our institute participated and performed the spinal mobilizations. Both the clinicians treated their own participants. Another physiotherapist with more than 10 years of experience in musculoskeletal physiotherapy and trained in manual therapy supervised the exercises. All three clinicians had post graduate training in manual therapy and underwent Mulligan training by a certified Mulligan teacher. All the outcome measures, baseline, post interventional and follow-up were performed by one of the authors who were blinded to group allocation. Group I – 20 participants (f ¼ 6; m ¼ 14) received Maitland mobilization to the cervical spine for a period of two weeks (five days a week, one session per day) along with exercises prescribed for the group III participants. Treatment by Maitland technique

attempts to gauge the effectiveness of intervention by assessing the segmental movement that is limited by the patient’s symptoms. Participants received Maitland mobilization targeted to impairments identified during the physical examination. The participant was positioned in prone, and the treating therapist stood at the level of the head of the patients with his thumbs in opposition placed at the level of the facet or the spinous process of the corresponding cervical vertebra. A PA oscillatory pressure was applied, through the thumbs, over the process of the hypomobile vertebra. The following grades were used: grades I and II where pain occurred before the motion barrier; and grades III and IV where the motion barrier was encountered before pain. This oscillatory mobilization was performed at a rate of 2–3 oscillations per second with metronome control and a frequency of 3–4 mobilization of the joint lasting approximately 30 s each. The rest time between each mobilization was one minute. Group II – 20 participants (f ¼ 9; m ¼ 11) received Mulligan SNAGs for a period of five sessions per week for two weeks and the exercises prescribed to group III. Mulligan proposed that minor positional fault to a joint can lead to restrictions in physiological movement. Mulligan mobilization (cervical SNAG) was applied with the participant in a seated position. With one thumb (reinforced by the other) placed on the spinous process or

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Table 1. Mean (SD) values of outcome variables. Outcome measure [Mean (SD)] Group I II III

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

VAS 6.7 2.4 2.2 5.7 1.8 1.5 5.9 1.9 1.2

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

NDI (in %)

Extn (in deg)

33.9 17.2 13.2 36 14.9 9.4 34.8 10.2 6.7

34 46 44 31 43 43 35 43 43

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

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

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

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

S.Fn. Rt (in deg)

Rotn. Lt (in deg)

Rotn. Rt (in deg)

27 36 36 24 36 36 27 37 36

43 55 53 41 53 54 44 54 54

44 58 58 44 57 55 47 57 57

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

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

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

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

Table 2. ANOVA results testing for effects of intervention. Variable VAS NDI Extn S.Fn.Lt S.Fn.Rt Rotn.Lt Rotn.Rt

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

(p ¼ 0.00) (p ¼ 0.00) (p ¼ 0.00) (p ¼ 0.00) (p ¼ 0.00) (p ¼ 0.00) (p ¼ 0.00)

Group (F value) 3.262 (p ¼ 0.056) 1.1668 (p ¼ 0.198) 1.505 (p ¼ 0.231) 0.742 (p ¼ 0.481) 0.415 (p ¼ 0.662) 0.173 (p ¼ 0.841) 0.124 (p ¼ 0.84)

Time  group (F value) 0.722 1.190 0.702 1.526 0.402 0.480 1.192

(p ¼ 0.579) (p ¼ 0.319) (p ¼ 0.592) (p ¼ 0.199) (p ¼ 0.807) (p ¼ 0.750) (p ¼ 0.318)

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

articular pillar (depending upon the indication) of the upper vertebra of the implicated functional-spinal unit (FSU), the therapist applied a sustained passive accessory intervertebral movement superoanteriorly along the facet plane. This ‘‘glide’’ was maintained as the participant moved actively through the desired range of physiological movement and then while sustaining the end-range position for a few seconds. The ‘‘glide’’ was released by the therapist after the patient returned to the starting position for the active movement. The mobilization was repeated six times per session for a period of two weeks. Group III – 20 participants (f ¼ 7; m ¼ 13) received supervised exercise program consisting of flexibility and strengthening exercises for a period of five sessions per week for two weeks. The exercises prescribed were stretching exercises to cervical and scapular muscles, deep neck flexor strengthening, isometric exercises for extensors, side flexors (both sides) and rotators (both sides), anti-gravity strengthening to rhomboids, middle and lower trapezi and cervical ROM exercises. All exercises were done with a dosage of one set of 10 repetitions with 6 s hold and 10 s rest between the repetitions. All participants were provided with a basic regimen of postural advice and were instructed to continue the strengthening and stretching exercises at home for a period of four weeks. All measurements were taken prior to the beginning of the therapy intervention, at completion of two weeks of treatment and at the end of the 12th week. Data analysis The data were analyzed with Statistical Package for Social Sciences 16.0 version (SPSS Inc., Chicago, IL). The dependent variables were analyzed using repeated measures ANOVA. There was one between factor (group) with three levels (groups: I, II and

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

Results Sixty participants (22 females and 38 males) with a mean age of 41.7 years (SD: 9.8) completed the study. The mean duration of symptoms in this study sample was 62 d. Table 1 lists the baseline, post-interventional and follow-up scores of pain, ROM and disability for all the groups investigated in the study. Table 2 lists the results of repeated measures ANOVA. The overall results of the study showed that all of the groups improved over time compared to baseline (p50.05) (Figures 2–6). The results revealed no significant differences between groups, and analyses of variance also demonstrated no significant group  time interaction effects across groups in improving outcomes (p40.05). The effect sizes between the groups were small (0.2) (Ferreira and Herbert, 2008) revealing minimal clinical detectable difference between the mobilization and exercise groups after intervention and at follow-up.

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

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DOI: 10.3109/09593985.2014.963904

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Figure 2. Graph showing changes in pain (VAS) across three groups: before, after intervention and at follow-up. Figure 4. Graph showing changes in extension ROM across three groups: before, after intervention and at follow-up.

Figure 3. Graph showing changes in NDI across three groups: before, after intervention and at follow-up.

due to: the neuro physiological (Melzac and Wall, 1965); sympathetic (Kandel, Schwartz, and Jessell, 2000); and psychological effects (Coulehan, 1985) of mobilization. Mulligan SNAG mobilization could ameliorate pain by either separating the facet surfaces or releasing the entrapped meniscoid, or by allowing the entrapped meniscoid to return to its intra articular position, or perhaps by stretching adhesions (Hearn and Rivett, 2002). The increase in ROM between the Maitland mobilization and Mulligan mobilization groups were not significant, both clinically and statistically. Reduced segmental movement is associated with neck pain (Dall’Alba et al, 2001). Treatment using Maitland mobilization evaluates the changes in the segmental mobility, at the beginning and end of each treatment session. The treatment is then modified according to the direction and extent of these changes (Tuttle, 2005). It is believed that within session changes are valid predictors of between session changes and there occurs some lasting changes associated with the immediate change (Whittingham and Nillson, 2001). Mechanisms by which Maitland mobilization improved ROM can be attributed to both mechanical and neurophysiological effects. Mechanical effects

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

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

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

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

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mobilization or exercise are beneficial in patients suffering from neck pain when applied as single-modal treatment approaches. The very small effect size favoring mobilization groups over exercise group may be attributed to the ‘‘hands-on approach’’ and opportunities for intensive patient–therapist interaction. The lack of superiority of one technique over another may underline the fact that there is no conclusive evidence regarding specific pathology in the majority of the cases of acute neck pain. An objective of clinical practice is to determine the exact source and cause of pain and then implement measures to stop it. In a recent systematic review, Takasaki and May (2014) concluded that there is no additional benefit of the McKenzie approach compared to a ‘‘wait-and-see’’ or other therapeutic approaches in reducing pain and disability in neck pain. However, the difficulties in identifying the source of neck pain do not necessitate a ‘‘wait and see’’ approach as good practice does not universally mean waiting to find out whose pain resolves, and whose does not. The interventions might have halted the evolution of acute pain to a chronic condition. None of the mobilization group participants had major side effects except local muscle and joint soreness, which rarely leads to even short-term impairment in functional status. There are some potential limitations with the study. The muscle strength of neck and peri-scapular muscles was not measured. The treating therapists were restricted to the use of the studied mobilization approach only and the final sample size per group was reduced to 20. There were 20 drop-outs (m ¼ 1; f ¼ 19) in total from the point of recruitment; 13 in the mobilization groups and 7 in the control group. Eleven participants (all from the mobilization group) (m ¼ 1; f ¼ 10) dropped out since the intervention begun. In no case was the reason related to neck pain or treatment complications. The majority of the women who dropped out were Indian Hindus and there are aspects of the Hindu religion that commonly affect healthcare decisions. Furthermore, healthcare decisions among Indian women are frequently discussed within the immediate family before seeking outside help and men play a major role in health care decisions. Future studies should consider recruiting more Indian women with neck pain into each arm to allow for drop-outs, contamination or other adverse contingencies. This is important as the prevalence of neck pain among women is higher and more women experience greater disability associated with neck pain than men. The results of this study have to be interpreted with caution, as the analysis showed no time and group interaction and approximately 30–70% of people with neck pain improve spontaneously over time (Hoy, Protani, De, and Buchbinder, 2010). An observation group (physician care only) would have served as an optimal control to evaluate whether the results were due to the interventions or improvement over time. Future studies will include a physician care group as this group may better reflect the natural course of neck pain in everyday practice.

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

Declaration of interest The authors report no declarations of interest.

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

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DOI: 10.3109/09593985.2014.963904

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Effectiveness of mobilization therapy and exercises in mechanical neck pain.

While studies have looked into the effects of Maitland mobilization on symptom relief, to date, no work has specifically looked at the effects of Mull...
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