Cervical Manipulation Eases Neck Pain More Than Mobilization, but Gains Fall Short

Spinal manipulation and spinal mobilization are both recommended by clinical practice guidelines as components of multimodal care for chronic neck pain, yet clinicians have long lacked direct evidence on how the two techniques differ when delivered to the cervical spine. A randomized mechanistic cross-over trial now provides one of the most detailed head-to-head comparisons to date, measuring not only clinical outcomes such as pain and range of motion but also real-time muscle activity, pressure pain thresholds and grip strength. The study, published in Chiropractic & Manual Therapies, recruited eighty-nine individuals with mechanical neck pain and tested both interventions in every participant, separated by a seventy-two-hour washout period.

The results reveal a split picture. Both techniques increased every measured plane of active cervical range of motion, and neither proved superior on that front. Manipulation, however, produced a larger immediate drop in subjective pain intensity than mobilization, and it evoked markedly stronger muscular responses in two key neck muscles during the intervention itself. Crucially, the authors report that none of the statistically significant differences reached the thresholds for clinical importance, and they explicitly caution against drawing conclusions for clinical practice from a mechanistic design of this kind.

The trial was conducted at two biomechanics research laboratories, one at Balgrist University Hospital in Zurich, Switzerland, and the other at the Université du Québec à Trois-Rivières in Canada. Recruitment took place in Zurich between August 2023 and January 2024, and in Trois-Rivières between March 2024 and June 2024. Participants were randomly assigned to receive either a cervical spinal manipulation or a cervical spinal mobilization in the first session, then the other intervention in the second session seventy-two hours later. Randomization was stratified by age and sex to keep the allocation balanced across those strata.

Spinal manipulation was defined in the study as a single high-velocity, low-amplitude thrust delivered within the sagittal plane along a posterior-to-anterior linear vector to the targeted cervical zygapophyseal joint, with the participant lying supine. Mobilization consisted of repeated oscillatory movements applied for thirty seconds to the spinous process of the targeted vertebra, again in a posterior-to-anterior direction, with the participant prone. The same painful cervical level identified during a physical examination was targeted in both sessions. Manipulations were delivered by registered practicing chiropractors, while mobilizations were performed by registered chiropractors and physiotherapists in Zurich and by registered manual therapists in Canada, all trained by an experienced orthopaedic manual physical therapist to ensure a standardized technique.

To capture the forces involved, clinicians worked with a flexible high-resolution pressure mat placed between their contact hand and the participant’s neck, recording at 200 hertz. These force-time profiles allowed the researchers to identify the peak force and the time to peak force for each thrust and each mobilization cycle, which in turn anchored the analysis of muscle activity. Surface electromyography electrodes recorded activity from the sternocleidomastoid, upper trapezius and tibialis anterior muscles on both sides, normalized to each participant’s maximum voluntary contraction. Electromyographic responses were calculated in a window spanning 250 milliseconds before and after each force peak.

The clinical measurements told a consistent story about range of motion. Flexion-extension improved by 4.6 degrees after manipulation and 3.7 degrees after mobilization, lateral-flexion by 4 degrees and 2.6 degrees respectively, and rotation by 1.6 and 1.4 degrees. All of these increases were statistically significant over time, but none differed between the two interventions, and no significant treatment-by-time interaction emerged for any plane. Notably, the flexion-extension and lateral-flexion gains did reach the minimal clinically important difference reported in prior work, making range of motion the one domain where both techniques produced changes large enough to matter clinically.

Pain intensity showed the study’s clearest between-technique contrast. Pain decreased significantly over time after both interventions, but the interaction test indicated a greater improvement following manipulation, with a mean decrease of 0.786 points on the numerical pain rating scale compared with 0.373 points after mobilization. The corresponding effect estimate was β = 0.413 with a 95 percent confidence interval of 0.160 to 0.665 and a p value of 0.002. Yet the authors emphasize that this difference fell short of the minimal clinically important difference of 1.3 points on the same scale, meaning the statistical advantage of manipulation may not translate into a benefit patients would perceive as meaningful.

The neuromechanical findings were striking in magnitude even as their clinical meaning remained uncertain. Muscular response, measured as normalized root mean square electromyographic activity, was significantly higher during manipulation than during mobilization for both the sternocleidomastoid, at 0.144 ± 0.121 versus 0.023 ± 0.013, and the upper trapezius, at 0.083 ± 0.100 versus 0.024 ± 0.025, on both sides of the body. In contrast, the tibialis anterior, a distant leg muscle included as a comparison, showed a higher response during mobilization, at 0.029 ± 0.023 versus 0.017 ± 0.013, though the authors note this increase was very small, around 3 percent, compared with roughly 15 percent for the sternocleidomastoid and 8 percent for the upper trapezius during manipulation. The researchers suggest that the greater muscle response to manipulation may partly reflect its higher peak forces and faster rate of force application, consistent with prior reports of a linear relationship between manipulation peak force and muscle activation.

Pressure pain threshold results were notably inconsistent. The right sternocleidomastoid showed a significant interaction, with an increase of 0.176 kilograms after manipulation and a decrease of 0.029 kilograms after mobilization, while the right upper trapezius threshold rose after both interventions, by 0.204 and 0.103 kilograms respectively. The left-sided muscles and the tibialis anterior produced mixed patterns, including a decrease in threshold over time on the right tibialis anterior after both techniques. The authors state plainly that these hemilateral, inconsistent patterns may partly reflect statistical noise rather than intervention-specific physiology, and that none of the differences reached the smallest detectable difference for pressure pain thresholds in cervical muscles. Grip strength likewise showed no consistent change; the small right-sided decrease of 1.13 kilograms after manipulation fell far below the six-kilogram minimal detectable change, and some participants reported discomfort while squeezing the dynamometer.

The trial has important limitations that shape how its findings should be read. Only immediate effects were assessed, leaving longer-term outcomes unknown. Baseline disability was relatively mild in many participants, with 78.7 percent reporting mild to moderate disability on the Neck Disability Index and 20.2 percent reporting moderate to severe disability, so the sample may not fully represent a typical care-seeking clinical population. Participants could not be blinded, since the thrust of manipulation is easily distinguished from oscillatory mobilization, although treatment expectations measured before each session were similar and outcome assessors remained blinded. The authors also flag the possibility of type I error given the number of outcomes analyzed, residual carryover effects despite the washout period, and variability in clinician training across sites. Electromyographic data were usable for only fifty-three of the eighty-seven analyzed participants because of technical issues with the time-event markers. No serious adverse events were reported; one participant experienced dizziness during the physical examination, before any intervention, and was referred for further assessment.

Context matters for interpreting these results. The background section notes that chronic neck pain prevalence rose 77.3 percent between 1990 and 2020 and is projected to rise a further 32.5 percent by 2050, largely due to population aging, and that neck pain ranked eleventh among 369 conditions for years lived with disability in the 2019 Global Burden of Disease study. Against that burden, the question of whether manipulation or mobilization works better is clinically pressing. Prior evidence, including a Cochrane review cited by the authors, has generally found similar clinical effects for the two techniques at short- and intermediate-term follow-up, and the present trial’s finding of equivalent range-of-motion improvements aligns with that picture even as its pain and muscle-activity results point to measurable short-term differences.

The authors conclude that a single treatment of cervical manipulation resulted in greater pain reduction and higher muscular response than cervical mobilization in people with chronic neck pain, while both interventions increased cervical range of motion. But they are unequivocal that, because the statistically significant results did not reach clinical significance, readers should refrain from drawing conclusions regarding clinical practice. They suggest that clinically meaningful effects might emerge with more than one treatment session or within the multimodal approaches, combining exercise, manual therapy and patient education, that current guidelines recommend. Future trials, they write, should compare the two techniques across multiple sessions and determine the clinical relevance and longer-term implications of the immediate neuromechanical differences documented here.

Subject of Research: Immediate clinical and neuromechanical effects of cervical spinal manipulation versus mobilization in chronic neck pain

Article Title: Immediate clinical and neuromechanical effects of cervical spine manipulation compared to cervical spine mobilization among individuals with chronic neck pain: a randomized mechanistic cross-over trial

Article References: Bouqartacha, S., Conconi, D., Schwendenmann, Y., Piché, M., Schweinhardt, P., Descarreaux, M., & Gorrell, L. M. (2026). Immediate clinical and neuromechanical effects of cervical spine manipulation compared to cervical spine mobilization among individuals with chronic neck pain: a randomized mechanistic cross-over trial. Chiropractic & Manual Therapies, 34(1), Article 49. https://doi.org/10.1186/s12998-026-00674-8

Image Credits: AI Generated

DOI: 10.1186/s12998-026-00674-8

Keywords: chronic neck pain, spinal manipulation, spinal mobilization, randomized cross-over trial, electromyography, pressure pain threshold, range of motion, pain intensity, grip strength, manual therapy, chiropractic, neuromechanics