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Robert J. Fluegel, PT, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT, Fellowship Program Director

Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)

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Chronic Cervicognic Dizziness: Maitland and Mulligan Mobilization (Non-Thrust) BOTH Result in Immediate and Sustained Relief EVEN OUT TO ONE YEAR

January 27, 2015


Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director


Chronic Cervicogenic Dizziness:  Maitland and Mulligan Mobilizations (Non-Thrust)

BOTH Result in Immediate and Sustained Relief EVEN OUT TO ONE YEAR

Dizziness and poor balance are commonplace in the community, especially in older patients. The English Longitudinal Study of Ageing (ELSA) assessed 2,925 adults aged 65 and over, and found that 21.5% had impaired balance and 11.1% experienced dizziness (Stevens 2008). Fortunately, manual therapy treatment for such conditions, in particular Maitland and Mulligan mobilizations, are known to be effective.


This month’s Research Commentary discusses a one year follow-up study, which compares Maitland and Mulligan non-thrust mobilizations in chronic cervicogenic dizziness. The initial study was featured in our February 6, 2014 Commentary and is summarized below. 


In the new study, “Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomized trial” (Reid 2015) the authors concluded “Both Maitland and Mulligan mobilizations have long-term beneficial effects in the treatment of cervicogenic dizziness”.


What causes cervicogenic dizzinesss? 


·       Equilibrium and balance are controlled by incorporation of signals from multiple systems, including the visual system, the vestibular system, and proprioceptors in the neck, trunk and lower limbs (Kristjansson 2009).


·       Balance is controlled subconsciously in normal circumstances, but when there is a conflict of information from the various inputs, patients can experience dizziness (Richmond 2001)


·       Cervicogenic dizziness is often related to upper cervical degeneration or a neck injury, such as whiplash. It is believed to result from a disturbance in sensory information coming from the cervical spine (Wrisley 2000).


Manual Therapy Treatment Options for Cervicogenic Dizziness

The role of two types of mobilization (non-thrust) in the management of cervicogenic dizziness were investigated in the Reid 2014 study entitled, “Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial”

The study randomized 86 participants, with identified cervicogenic dizziness, into three groups, namely:

1)     Sustained natural apophyseal glides (SNAGs) as described by Mulligan

2)     Joint mobilizations as described by Maitland

3)     Deactivated Laser (Placebo Control)

Participants (mean age 62 years) with chronic cervicogenic dizziness were randomized to receive Mulligan SNAGs or Maitland passive joint mobilizations (PJMs) with range-of-motion (ROM) exercises, or a placebo comprising Deactivated Laser for 2-6 sessions over a 6 week period of treatment.  The 2014 study measured the immediate effects of the interventions, and the effects at 12 weeks, while the 2015 study measured the effects at 1 year post treatment. 

The outcome measures used were:

1)     Intensity of dizziness measured using a 100mm visual analog scale (VAS)

2)     Frequency of dizziness

3)     Dizziness Handicap Index (DHI)

4)     Intensity of cervical pain using a 100mm VAS

5)     Global Perceived Effect (GPE)


Reid 2014 Study Results

·       Improved Intensity and Frequency of Dizziness--Both Mulligan and Maitland Effective

Both SNAGs (Mulligan), and Maitland intervention groups had reduced intensity AND reduced frequency of dizziness compared to the placebo group.  This reduction occurred immediately post treatment, and the effects were maintained for 12 weeks.  There was no significant difference in outcomes between SNAGs and Maitland.


·       Dizziness Handicap Inventory (DHI) Improved--Both Mulligan and Maitland Effective 

Baseline DHI scores prior to treatment both the Maitland and SNAGs groups were 31-60 (moderate effect on emotional, social and physical lives).  Both SNAGs and Maitland groups had decreased DHI scores (immediately post treatment) of 1-30 indicating only mild handicap.  Only the Maitland group DHI scores met the Minimal Important Change (MIC) at 12 weeks and were significantly lower than placebo, as well as being lower than SNAGs.


·       Intensity of Cervical Pain (VAS)—Only Maitland Effective

Only the Maitland group had significantly (p < 0.05) lower pain scores than placebo at 12 weeks.

The SNAGs group had a non-significant trend to lower pain scores than placebo at 12 weeks, when 10 SNAGs subjects with VAS scores < 20mm were excluded from the data…leaving only 19 participants within the data set.


·       Global Perceived Effect (GPE)—Both Maitland and Mulligan Effective

Both the SNAGs and Maitland groups had significantly (p < 0.05) higher GPE ratings post treatment and at 12 weeks. The GPE ratings for both were “4” indicating “great” benefit.


·       Adverse Effects—None Reported for Maitland Group

No adverse effects were reported in the Maitland group. Four participants in the SNAG group reported mild transient pain in the lower cervical spine, lasting less than 24 hours.



The Reid 2015 study provides evidence of the LONG TERM effectiveness of BOTH Maitland and Mulligan manual therapy treatments for patients suffering from cerviogenic dizziness.  The Reid 2014 study, demonstrated the effectiveness of both manual therapy treatments for patients suffering from cervicogenic dizziness not just immediately post intervention, but also at 12 weeks.  The 2014 study also demonstrated that Maitland is more effective than SNAGs at reducing pain associated with cervicogenic conditions.

The Read 2015 study provides additional evidence that both forms of manual therapy treatments were effective AT ONE YEAR POST TREATMENT. 

Ongoing improved outcome measures at one year for both interventions included less frequent dizziness, lower DHI scores, and higher GPE. 



1) BOTH the SNAGs and Maitland mobilizations EQUALLY reduced Intensity AND Frequency of dizziness immediately after intervention AND the effects were maintained for 12 weeks (Reid 2014)

In other words, both interventions effectively improved cervicogenic dizziness immediately following treatment and in the longer term (12 weeks).

3) BOTH the SNAGs and Maitland mobilizations reduced the Disability Handicap Inventory (DHI) scores from the “Moderate handicap” to the “Mild handicap” range (Reid 2014).

In other words patients perceived less handicap after both interventions.

3) ONLY the Maitland mobilizations met the Minimal Important Change (MIC) level at 12 weeks.

In other words ONLY the Maitland mobilizations had a clinically relevant impact at 12 weeks.

4) ONLY the Maitland mobilizations significantly (p < 0.05) REDUCED pain scores at 12 weeks.   

5) BOTH the SNAGs and Maitland mobilizations resulted in significantly (p < 0.05) HIGHER Global Percieved Effect (GPE) immediately post treatment and at 12 weeks

In other words patients perceived “Great Benefit” (GPE of 4) after both interventions even at 12 weeks.

6) Only four SNAGs patients experienced minor (< 24 hrs duration) mild transient adverse effects (pain in the lower cervical spine).  No Maitland patients experienced adverse effects.

7) AT ONE YEAR post treatment (Reid 2015), BOTH SNAGs and Maitland mobilization groups reported long lasting improvements:      

  • Reduced dizziness frequency
  • A lower handicap (DHI scores)
  • Higher global perceived effect (GPE scores)


Cheers and Enjoy

Chris R. Showalter PT, OCS, COMT, FAAOMPT 

© Chris R. Showalter and Maitland Australian Physiotherapy Seminars


Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website ( is permissible.


Article Follows (with weblink to Physical Therapy)

Manual therapy for cervicogenic dizziness: Long-term outcomes of a randomised trial. Reid SA, Callister R, Snodgrass SJ, Katekar MG, Rivett DA. Manual Therapy 2015 Feb;(20)1:148-156


Manual therapy is effective for reducing cervicogenic dizziness, a disabling and persistent problem, in the short term. This study investigated the effects of sustained natural apophyseal glides (SNAGs) and passive joint mobilisations (PJMs) on cervicogenic dizziness compared to a placebo at 12 months post-treatment. Eighty-six participants (mean age 62 years, standard deviation (SD) 12.7) with chronic cervicogenic dizziness were randomised to receive SNAGs with self-SNAGs (n = 29), PJMs with range-of-motion (ROM) exercises (n = 29), or a placebo (n = 28) for 2–6 sessions over 6 weeks. Outcome measures were dizziness intensity, dizziness frequency (rated between 0 [none] and 5 [>once/day]), the Dizziness Handicap Inventory (DHI), pain intensity, head repositioning accuracy (HRA), cervical spine ROM, balance, and global perceived effect (GPE). At 12 months both manual therapy groups had less dizziness frequency (mean difference SNAGs vs placebo −0.7, 95% confidence interval (CI) −1.3, −0.2, p = 0.01; PJMs vs placebo −0.7, −1.2, −0.1, p = 0.02), lower DHI scores (mean difference SNAGs vs placebo −8.9, 95% CI −16.3, −1.6, p = 0.02; PJMs vs placebo −13.6, −20.8, −6.4, p < 0.001) and higher GPE compared to placebo, whereas there were no between-group differences in dizziness intensity, pain intensity or HRA. There was greater ROM in all six directions for the SNAG group and in four directions for the PJM group compared to placebo, and small improvements in balance for the SNAG group compared to placebo. There were no adverse effects. These results provide evidence that both forms of manual therapy have long-term beneficial effects in the treatment of chronic cervicogenic dizziness.

Where to find the Articles:

Epidemiology of balance and dizziness in a national population: findings from the English Longitudinal Study of Ageing. Stevens KN, Lang IA, Guralnik JM, Melzer D. Age Ageing. 2008 May;37(3):300-5

Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial.  Reid SA, Rivett DA, Katekar MG, Callister R. Physical Therapy 2014 Apr;94(4):466-476

Sensorimotor function and dizziness in neck pain: implications for assessment and management. Kristjansson E, Treleaven J. JOSPT. 2009 May;39(5):364-77.

Richmond F, Corneil B. Afferent mechanisms in the upper cervical spine. In: Vernon H, ed. The cranio-cervical syndrome. Toronto, Canada: Butterworth-Heinemann; 2001

Cervicogenic dizziness: a review of diagnosis and treatment.

Wrisley DM, Sparto PJ, Whitney SL, Furman JM. JOSPT. 2000 Dec;30(12):755-66.


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