Mobilization versus manipulations versus sustain apophyseal natural glide techniques and interaction with psychological factors for patients with chronic neck pain: randomized controlled trial

Eur J Phys Rehabil Med. 2015 Apr;51(2):121-32. Epub 2014 Oct 9.


Background: Three different types of manual therapy techniques for patients with neck pain and relationship with psychological factors has not been evaluated.

Aim: To compare the effectiveness high velocity and low amplitude (HVLA) manipulation vs. posteroanterior mobilization (PA mob) vs. sustain appophyseal natural glide (SNAG) in the management of patients with neck pain and to evaluate the interaction with psychological factors.

Study desing: Randomized clinical trial.

Setting: Primary Health Care Center.

Population: Patients with history of chronic neck pain over the last 3 months were recruited.

Methods: Patients were randomly assigned to receive treatment with HVLA (N.=15), with PA mob (N.=16) or with SNAG (N.=17). One session was applied. Pain intensity of neck pain, pressure pain threshold over processus spinosus of C2 (PPT_C2) and cervical range of motion (CROM) were measured pre- and post-intervention. Pain catastrophizing, depression, anxiety and kinesiophobia were assessed in baseline. ANOVAs were performed, with main effects, two-way (treatment x time) and three-way interactions (treatment x psychological variable x time) were examined.

Results: Fourthy-eight patients (mean±SD age, 36.5±8.7 years; 87.5% female). A significant interaction treatment x time was observed for VAS-rest in HVLA and AP mob groups (P<0.05). With more pain relief to HVLA and AP mob groups than SNAG groups but all groups improve the same in CROM. Also, a significant three-way treatment x anxiety x time interaction for VAS in Flexion/Extension was identified (P<0.01), and a trend toward significance was observed for the three way treatment x anxiety x time interaction, with respect to CROM in Lateral-Flexion movement (P<0.05).

Conclusion: The results suggest that an HVLA and PA mob groups relieved pain at rest more than SNAG in patients with Neck pain. Among psychological factors, only trait anxiety seems interact with Manual therapy, mainly high anxiety conditions interact with the Mobilization and SNAG effects but under low anxiety conditions interact with the HVLA effects. Significant mean differences can be observed both in VAS in Flexion/Extension and in CROM in lateral-flexion movement when using mobilization under high anxiety conditions

Clinical rehabilitation impact: The findings provide preliminary evidence to support that three different techniques have similar immediate effects over neck pain and while under high anxiety levels a better outcome is expected after mobilization intervention, under low anxiety levels a better prognosis is expected after manipulation and SNAG intervention.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Analysis of Variance
  • Anxiety / complications
  • Anxiety / etiology
  • Catastrophization / psychology
  • Cervical Vertebrae / physiopathology
  • Chronic Pain / psychology
  • Chronic Pain / rehabilitation*
  • Depression / complications
  • Depression / etiology
  • Female
  • Humans
  • Male
  • Manipulation, Orthopedic / methods
  • Manipulation, Orthopedic / psychology
  • Manipulation, Spinal / methods
  • Manipulation, Spinal / psychology
  • Middle Aged
  • Musculoskeletal Manipulations / methods*
  • Musculoskeletal Manipulations / psychology
  • Neck Pain / psychology
  • Neck Pain / rehabilitation*
  • Outcome and Process Assessment, Health Care / statistics & numerical data
  • Pain Measurement / methods
  • Physical Therapy Modalities
  • Range of Motion, Articular / physiology*
  • Spain
  • Zygapophyseal Joint / physiopathology