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ISSN: 0959-3985 (print), 1532-5040 (electronic)
Physiother Theory Pract, 2015; 31(2): 99106
! 2015 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2014.963904
RESEARCH REPORT
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 Mulligans 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 (2145 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.
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
History
Received 6 February 2014
Revised 23 July 2014
Accepted 24 July 2014
Published online 26 September 2014
100
G. S. Ganesh et al.
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
DOI: 10.3109/09593985.2014.963904
101
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)
2 weeks o ntervenon
n= 24(m=14, f=10)
n= 22(m=11, f=11)
n= 20(m= 11,f=9)
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 6; m 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
102
G. S. Ganesh et al.
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)
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.
Time (F value)
436.288
207.115
48.615
38.781
32.423
46.330
138.812
(p 0.00)
(p 0.00)
(p 0.00)
(p 0.00)
(p 0.00)
(p 0.00)
(p 0.00)
Group (F value)
3.262 (p 0.056)
1.1668 (p 0.198)
1.505 (p 0.231)
0.742 (p 0.481)
0.415 (p 0.662)
0.173 (p 0.841)
0.124 (p 0.84)
(p 0.579)
(p 0.319)
(p 0.592)
(p 0.199)
(p 0.807)
(p 0.750)
(p 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.
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 26). 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
DOI: 10.3109/09593985.2014.963904
103
Figure 5. Graph showing changes in side flexion ROM (left and right)
across three groups: before, after intervention and at follow-up.
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G. S. Ganesh et al.
Figure 6. Graph showing changes in rotation ROM (left and right) across
three groups: before, after intervention and at follow-up.
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
DOI: 10.3109/09593985.2014.963904
105
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G. S. Ganesh et al.
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