Thoracic Spine Mobilization Added to Physiotherapy Eased Neck Pain in Randomized Trial

Adding upper and mid-thoracic spine mobilization to standard physiotherapy produced greater reductions in pain and disability than standard physiotherapy alone among adults with mechanical neck pain, according to a randomized controlled trial conducted at a rehabilitation center in Bangladesh. The trial, published in the Bulletin of Faculty of Physical Therapy, enrolled 79 participants and randomized them one-to-one to receive either thoracic spine mobilization combined with usual physiotherapy or usual physiotherapy only. Over four weeks of treatment, both groups improved, but the group receiving the thoracic intervention showed statistically greater gains in pain intensity, neck-related disability, and cervical flexion range of motion.

Mechanical neck pain is defined as pain located in the cervical spine or the cervicothoracic junction that is elicited or increased by cervical motion or by palpation of the cervical musculature. Specific pathoanatomical causes are usually unidentifiable, although the location and presentation of symptoms often vary depending on which cervical zygapophyseal joints, ligaments, or nerve root levels are involved. Patients frequently report pain, numbness, tingling, and weakness in the upper extremity, which can produce significant functional restrictions. Physiotherapy for the condition typically aims to resolve pain, increase range of motion, and improve soft tissue extensibility, and manual therapy approaches such as spinal mobilization, spinal manipulation, and massage play a prominent role in treatment plans.

The motivation for the new trial rests partly on a gap in the existing evidence. A 2014 systematic review comparing thoracic manipulation or thoracic mobilization in patients with mechanical neck pain included 14 studies, all of which demonstrated positive outcomes on cervical pain levels, disability, or range of motion following treatment. However, the vast majority of those studies used thoracic manipulation rather than the gentler mobilization technique. A more recent systematic review and meta-analysis from 2019 reported that thoracic manipulation was more beneficial than either thoracic or cervical mobilization. The authors of the current study note that randomized trials directly comparing thoracic mobilization with usual physiotherapy remain relatively few, particularly in Bangladesh, which justified the new investigation.

The study was a single-site, prospective, parallel-groups, patient and assessor-blinded randomized controlled clinical trial carried out at the outpatient physiotherapy unit of the Centre for the Rehabilitation of the Paralysed in Savar, Dhaka. It was approved by the Institutional Review Board of the Bangladesh Health Professions Institute, adhered to Bangladesh Medical Research Council and World Health Organization research guidelines, and was registered with the Central Trial Registry of India under registration number CTRI/2020/06/026090 on 20 June 2020. Reporting followed the CONSORT statement and the TIDieR checklist, and the authors state that no changes to methods were made after the trial commenced. Informed consent was obtained from all participants, who retained the right to withdraw at any time without affecting their clinical treatment.

Participant enrollment and data collection took place between June and September 2020. Of 106 patients assessed for eligibility, 19 chose not to participate and 8 were excluded for other reasons based on the eligibility criteria, leaving 79 patients who were randomly assigned to the thoracic mobilization group (n = 40) or the usual physiotherapy group (n = 39). Eligible participants had a confirmed diagnosis of mechanical neck pain and were aged 20 to 55 years, an age range chosen because of the peak prevalence of neck and other spinal pain in this demographic in South Asia. Individuals with contraindications or red flags for physiotherapy, such as malignancy or vascular problems, were excluded, as were those with concurrent pathologies in the upper cervical region or upper extremities, an inability to adhere to medication, or previous neck surgery. Participants taking medication were asked to keep their current levels unchanged. No adverse effects were reported in any patient.

The randomization process was conducted by a person not affiliated with the study using computer-generated random numbers, with allocation concealed from the researcher and participants screened using sealed envelopes. Both patient and outcome assessor blinding procedures were maintained throughout the study. Ten physiotherapists specializing in musculoskeletal disorders, each with more than two years of experience and an even split of five men and five women, delivered the interventions. Both groups received 12 treatment sessions over four weeks, at a rate of three sessions per week, with the usual physiotherapy protocol determined by the clinical practice guidelines of the host institution’s physiotherapy department. Therapists in the trial group additionally applied upper and mid-thoracic mobilization following an in-service training session covering patient positioning, exercise types, dosage, and repetitions. Participants in both groups were instructed not to take part in any other neck pain intervention during the study period.

The planned sample size, based on an a priori power analysis using an effect size of 0.50, an alpha of 0.05, and 80 percent power, was 64 participants per group, or 128 in total. Despite extensive recruitment efforts, only 79 participants were enrolled, a shortfall the authors acknowledge as a limitation of the study. Outcome measures included a 10-centimeter Visual Analogue Scale for pain intensity, cervical range of motion measured with a universal goniometer, the McGill Pain Questionnaire covering sensory, affective, and intensity dimensions of pain, and the Neck Disability Index, a 10-item questionnaire scored from 0 to 50 with higher scores indicating greater disability. Assessments were performed at baseline and after the 12 treatment sessions, with the same study team member collecting pre- and post-treatment data to minimize bias.

The results showed marked improvement in both groups, with a statistical edge for the thoracic mobilization group. Mean pain intensity on the Visual Analogue Scale fell from 8.78, with a standard deviation of 1.16, at baseline to 0.80, with a standard deviation of 0.92, at post-test in the trial group, while the control group declined from 7.93, with a standard deviation of 1.51, to 1.32, with a standard deviation of 1.05. Baseline pain was somewhat higher in the trial group. The baseline Neck Disability Index was similar between groups, at 40.18 in the trial group and 39.51 in the control group on the 50-point scale. Between-group analysis showed statistically significant differences favoring the trial group in pain, the Neck Disability Index, and cervical flexion range of motion. For the McGill Pain Questionnaire, the control group consistently showed a significantly higher mean rank than the trial group for each pain trait, and within-group analysis showed significant reductions in pain characteristics in both groups from baseline to post-intervention.

The authors suggest several possible mechanisms for why thoracic mobilization might add benefit. Improvements in muscle stiffness and joint mobility associated with spinal mobilization have been attributed to disrupting soft tissue adhesions or meniscoid release in spinal intervertebral joints. Other mechanistic theories propose that mobilization and manipulation procedures activate descending inhibitory mechanisms that produce hypoalgesic effects, induce reflex pain inhibition and muscle relaxation, inhibit presynaptic pain pathways, and activate endogenous opiates. Thoracic mobilization combined with usual physiotherapy may also help restore more natural intervertebral joint biomechanics, reduce mechanical stress, and optimize joint force distribution in the cervical spine, thereby enhancing range of motion and decreasing disability. The authors also note that thoracic extensors play a crucial role in cervical spine stabilization and that dysfunction of these muscles has been linked to mechanical neck pain. An interesting observation from the study was that greater improvements in range of motion occurred in patients who had experienced more severe pain.

The trial has limitations that temper how broadly its findings can be applied. Patients were recruited from a single site, albeit the largest rehabilitation center in Bangladesh, which may or may not represent the wider mechanical neck pain population in other countries. The study also lacked short-term or long-term follow-up, meaning the durability of the observed improvements beyond the immediate post-treatment assessment remains unknown, and the authors recommend that future trials of thoracic mobilization incorporate follow-up assessments. The enrolled sample was also smaller than the calculated target of 128 participants. Within those constraints, the authors conclude that upper and mid-thoracic spine mobilization combined with usual physiotherapy was more effective than usual physiotherapy alone in this patient group, and they suggest that this combination deserves greater consideration as part of a comprehensive treatment plan for patients with mechanical neck pain.

Subject of Research: A randomized controlled trial of upper and mid-thoracic spine mobilization combined with usual physiotherapy for mechanical neck pain

Article Title: Effectiveness of upper and mid-thoracic spine mobilization in individuals with mechanical neck pain: a randomized control trial

Article References: Hassan, M. N., Akter, P., Firdawsi, Z., Rimmer, J. H., Hossain, M. F., Hossain, M. A., & Reed, W. R. (2026). Effectiveness of upper and mid-thoracic spine mobilization in individuals with mechanical neck pain: a randomized control trial. Bulletin of Faculty of Physical Therapy, 31(1), Article 33. https://doi.org/10.1186/s43161-026-00370-x

Image Credits: AI Generated

DOI: 10.1186/s43161-026-00370-x

Keywords: mechanical neck pain, thoracic spine mobilization, randomized controlled trial, physiotherapy, manual therapy, neck disability, range of motion, visual analogue scale, McGill Pain Questionnaire, Bangladesh, spinal manipulation, rehabilitation