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Keith Wobeser, PT, OCS, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship 

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

Mobilization vs Manipulation for Neck and Back Pain — Is There a Difference? It Depends on
How You Study Them.
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Mobilization vs Manipulation for Neck and Back Pain - Is There a Difference? It Depends on How You Study Them.

February 13, 2018

Keith Wobeser PT, OCS, COMT
MAPS Faculty, Fellow in Training,
MAPS Orthopedic Manual Therapy Fellowship

Chris Showalter PT, OCS, FAAOMPT
Program Director, MAPS Orthopedic Manual Therapy Fellowship

 Research Commentary

Low back pain (LBP) and neck pain (NP) are common complaints treated with physical therapy.  LBP alone is estimated to cost $50 billion annually in the U.S. (1).  The National Center for Health Statistics reported that in 2011 approximately 28.8% of the population 18 years and older reported low back pain in the last 3 months, and 15.8% reported some form of neck pain (2).

Manual therapy, encompassing both thrust manipulation (aka manipulation) and non-thrust manipulation (aka mobilization), is a common approach in the conservative treatment of spinal pain. There have been numerous studies showing the effectiveness of treating non-specific low back and neck pain with manual therapy and exercise (3, 4, 5, 6), and Manual Therapy has also been shown to be a cost-effective treatment approach (7).

Manipulation and mobilization are also common approaches to the treatment of low back and neck pain, however, there is conflicting evidence in the literature as to which approach is more effective (8, 9, 10, 11).  Another question is whether clinician choice of a specific applied intervention, either manipulation or mobilization, would affect outcomes in pain or disability (9,12,13).

Pragmatic vs Prescriptive Study Designs

Research into mobilization and manipulation can be essentially divided into two types, pragmatic and prescriptive studies.

Pragmatic Studies:  This type of study design allows for the examiner to choose the intervention (mobilization or manipulation) as well the spinal level in which the technique is to be applied, effectively mirroring the clinic setting and the patient population usually seen in a clinical practice. This allows the clinician to determine the appropriate intervention as part of a thorough assessment, utilize clinical reasoning and develop an informed plan of care for that specific patient. In pragmatic studies, because of inherent broad inclusion criteria (the characteristics that a patient must have to be included in the study) there is less focus on internal validity. Studies with higher internal validity are more likely to have the independent variable (the variable being tested) cause the measured change, rather than by external variables. Pragmatic studies are often used to compare competing interventions.

Prescriptive Studies.  In prescriptive study designs, the specific intervention and the targeted spinal level is specifically prescribed within the study.  There is no independent clinical choice by the therpapist. Prescriptive studies have much narrower inclusion criteria and higher internal validity compared to pragmatic studies.  Interventions are specifically dosed and are focused on the effect of the isolated treatment.

This month’s Research Commentary discusses a recent systematic review (SR) and meta-analysis that analyzed pragmatic and prescriptive studies designed to differentiate mobilization and manipulation treatments upon neck and low back pain and disability.  Prior to the publication of “The impact of pragmatic vs. prescriptive study designs on the outcomes of low back and neck pain when using mobilization or manipulation techniques: a systematic review and meta-analysis” by Daniel Roenz, et al. in November 2017, there had been no systematic review or meta-analysis comparing mobilization versus manipulation using either pragmatic or prescriptive designs to treat LBP or CP. The article can be found here:

Systematic Review and Meta-Analysis By Daniel Roenz, et. al 2017 

Methods:  An electronic data search was performed in MEDLINE and CINAHL from dates of inception to December 2016.

1) Search Terms that were used in the study included:

• Mobilization

• Manipulation

• low back pain

• cervical pain

• clinician choice

• disability and

• pain

The above keywords were used in different combinations to try to capture as many papers as possible.  Authors of relevant articles were contacted to obtain any additional articles, and reference lists from collected articles were also searched.  All six researchers had to reach a consensus as to whether the article should be included in the meta-analysis or systematic review.

2) The Inclusion Criteria for the study included the following:

- written in English

- RCT comparing mobilization to manipulation in isolation, using patients with either low     back or cervical pain and measured with outcome scales of either pain or disability


3) Treatment Definitions

· Mobilization was defined as low velocity spinal mobilization

· Manipulation was defined as high velocity low amplitude thrust (HVLA) manipulation. 


4) Article Classification.  Articles were classified as either pragmatic or prescriptive as follows:

· pragmatic if the clinician chose: 1) the intervention and 2) the spinal level OR

· prescriptive if they did not meet both criteria 1) and 2) as described above.


5) Study Bias.  The quality of each study was based on a Cochrane risk of bias tool.  The authors calculated a percentage score from numerical scores calculated for each study. A score of 69% was used a cut off for discerning risk of bias. Any score < 69% indicated high risk of bias.  The Cochrane risk of bias tool uses 5 different types of bias:

-    selection bias - selection of participants is not due to proper randomization and therefore not a true representation of the population being studied

-    performance bias - the risk that participant is knowledgeable of which intervention was received and this affects outcomes

-    detection bias - the risk that knowledge by assessors of which intervention was received, rather than the intervention itself, will affect outcome measurement

-    attrition bias - a systematic error caused by the differences between groups when withdrawals from a study lead to an unequal loss of participants and incomplete outcome data

-    reporting bias - differences between reported and unreported findings. It may also arise when research findings are influenced by the nature or direction of results. Examples would be: ‘positive’ results indicate that an intervention works is more likely to be published, published rapidly, published in English, published more than once, published in high impact journals.


6) Meta Analysis Time Intervals.  The meta-analysis examined pain and disability outcomes over periods of time.  The time intervals that were analyzed were:

·         immediate (within 5 minutes of intervention)

·         1-6 days

·         4 weeks

·         5-11 weeks and

·         3-6 months.



During the data search 29,394 studies were identified, of which thirteen were deemed relevant for the study.  The thirteen studies examined 1,313 participants which were used in the systematic review and twelve of those studies were used for meta-analysis.  One study was eliminated due the inability of the author to identify the original data-set.  All the studies either used a Numeric Pain Rating Scale (NPRS) or a Visual Analog Scale (VAS). Seven studies used outcome measures including neck disability index (NDI), Neck Bournemouth Questionnaire (NBQ) and Oswestry Disability Index (ODI). 


Prescriptive Approach Analysis

Eight of the thirteen studies examining manipulation versus mobilization were classified as prescriptive treatment design.  The clinician did not have a choice of treatment intervention provided and/or use assessment and a subsequent clinical decision to choose the spinal level being treated. There were a total of 579 subjects in the included studies.  Seven of the studies studied the treatment of cervical pain and one study evaluated the treatment of low back pain. The Cochrane risk of bias tool across the 8 prescriptive studies was 67.97% +/- 8.48%, where < 69% was considered high risk of bias.

All eight prescriptive approach studies compared pain outcomes with treatment using manipulation versus mobilization interventions.  Manipulation was shown to be superior with regards to decreased pain over mobilization immediately after treatment, at 1-6 days, 1-4 weeks and at 3-6 months.  There was no statistical differences noted at 5-11 weeks between the mobilization and manipulation.  

Four of the eight prescriptive studies also used disability scores.  There was no difference between mobilizations and manipulations immediately after intervention and at 5-11 weeks. 

Manipulation was shown to be favored in decreasing disability scores at 1-6 days, 1-4 weeks and 3-6 months.


Pragmatic Approach Analysis

Five of the thirteen studies used a pragmatic study model. The clinician had choice in both the intervention provided and the spinal level being treated. There were a total of 734 subjects in the five studies.  Four studies examined mobilization versus manipulation with cervical pain and one study with low back pain. The calculated Cochrane risk of bias tool for the pragmatic studies was 53.75% +/- 16.3%.

Pain scales were used with all 5 studies.  There was no statistical differences between either mobilization or manipulation interventions at any time frame. Three of the pragmatic model studies used disability outcome measures.  Again, there was no statistical difference between the mobilizations or manipulations during any time frame.

The one pragmatic study excluded from the meta-analyses (because the corresponding author could not provide the original data set used to develop forest plots), showed no difference between mobilization or manipulation for pain or disability.



The results of the Roenz 2017 meta-analysis indicated that when the research study uses a PRESCRIPTIVE approach to compare manipulation to mobilization on pain and disability outcome scores, manipulation is favored.

By contrast, when a research study uses a PRAGMATIC approach, mobilization and manipulation are equivalent (no differences) in both pain and disability outcome scores.

Pragmatic studies are more representative of the clinical setting. They allow the therapist to perform assessment and use clinical reasoning in determining which intervention, in this case either mobilization or manipulation, may benefit that patient best.  Pragmatic studies also allow the therapist to choose which spinal level or levels to treat.  This mirrors everyday clinical practice.  Since mobilization and manipulation were equivalent in the treatment of cervical and low back pain and disability, the therapist then has the choice of which intervention to use. Some patients may not be appropriate for manipulation of the upper cervical spine, where there may be the potential for “rare but serious adverse reactions” (5). Given that mobilization and manipulation have an equivalent effect on pain and outcome scores, this allows the therapist to offer a graded mobilization to the patient.  Where state practice acts do not allow the use of manipulation, mobilization can be used with an equivalent result.

To learn more about the risks associated with cervical manipulation review the following previous MAPS Research Commentaries:

Sept 9, 2014
Renewed Controversy in Cervical Spine Thrust Manipulation: How To Minimize the Risks with Cervical Artery Dysfunction Assessment

Oct 15, 2013
Cervical Spine Thrust Manipulation: Minimize the risks with Cervical Artery Dysfunction Assessment

Sep 17, 2013
Cervical Spine Thrust Manipulation: What are the risks?

Prescriptive studies which favored manipulation over mobilization remove any clinical decision-making from the treating therapist. They exhibit high internal validity, which is useful when performing research studies, however they are not reflective of clinical practice. Prescriptive studies are not representative of how physical therapists practice in a clinical setting, and as such, the results may not be generalizable to actual practice. Given that clinical reasoning is considered evidence based practice taken to highest level (14), and essential to physical therapy practice (15), the removal of any clinical decision making may actually be a detriment to effective and safe treatment.  Prescriptive studies with greater internal validity have much narrower inclusion criteria and thus the results may be subjected to sampling bias.  One of the studies included in the prescriptive study data only included subjects that satisfied a clinical prediction rule for manipulation (8).


Take Home Messages

1.    Study design can influence the outcome of the research. 

2.    Pragmatic Studies reflect true clinical practice in which therapists have control over which intervention, mobilization, or manipulation, and the spinal level or levels to be treated. 

3.    When therapists have control over their intervention, apply sound clinical reasoning, and treat the appropriate spinal level, mobilization is equivalent to manipulation for decreasing pain and disability outcomes.

4.    As Chad Cook states in “How about a little love for non-thrust manipulation?”

“…when non-thrust manipulation is performed similarly to how it is designed to be used in clinical practice, by those with skilled hands, it is as useful a technique as thrust manipulation.” (16)

Cheers, and enjoy,

Keith Wobeser PT, COMT

© 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.

Featured Reference

Roenz D, Broccolo J, Brust S, Billings J, Perrott A, Hagadorn J, Cook C, Cleland J. The impact of pragmatic vs. prescriptive study designs on the outcomes of low back and neck pain when using mobilization or manipulation techniques: a systematic review and meta-analysis. J Man Manip Ther. 2017 Nov 1-13


Other References

1 Liliedahl RL et al. Cost of care for common back pain conditions intiated with chiropractic vs medical doctor of osteopaththy as first physician: experience of one Tennessee-based general health insurer. J Manip Physio Ther. 2010 Nov-Dec;33(9): 640-3

2 National Center for Health Statistics. Health, United States 2011: with special features on socioeconomic status and health.  Hyattsville, MD;2012

3 Hildalgo B, Detrembleur C, Hall T et al.  The efficacy fo manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. J Man Manip Ther. 2013;22:59-74

4 Miller, J. et al (2010). Manual therapy and exercise for neck pain: A systematic review. Manual Therapy.

5 Gross, A. et al (2015). Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. The Cochrane Database of Systematic Reviews, 9, CD004249.

6 Celenay, S et al. A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients with Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial L Ortho Sports Phys There. 2016;46 (2):  44-55

7 Pinto D, Robertson MC, Abbott JH, Hansen P, Campbell AJ; Manual therapy, exercise therapy, or both, in addition to usual care, for osteoarthritis of the hip or knee. 2: economic evaluation alongside a randomized controlled trial. Osteoarthritis Cartilage. 2013 Oct;21(10):1504-13.

8 Cleland JA, Fritz JM, Kulig K, Davenport TE, Eberhart S, Magel J, Childs JD. Comparison of the effectiveness of three manual physical therapy techniques in a subgroup of patients with low back pain who satisfy a clinical prediction rule: a randomized clinical trial. Spine (Phila Pa 1976). 2009 Dec 1;34(25):2720-9 

9 Kenneth Learman, Chris Showalter, Bryan O’Halloran, Megan Donaldson, Chad Cook.     No Differences in Outcomes in People with Low Back Pain Who Met the Clinical Prediction Rule for Lumbar Spine Manipulation When a Pragmatic Non-Thrust Manipulation Was Used as the Comparator. Physiotherapy Canada 2014; 66(4);359-366

10  Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G,et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. 2010;91:1313–8.

11 Dunning JR, Cleland JA, Waldrop MA, Arnot CF, Young IA, Turner M, Sigurdsson G. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2012 Jan;42(1):5-18. 

12 Bishop M, Bialosky J, et al. The influence of clinical equipoise and patient preferences on outcomes of conservative manual interventions for spinal pain: an experimental study. J Pain Res. 2017; 10: 965–972

13 Kent P, Marks D et al. Does clinician treatment choice improve the outcomes of manual therapy for nonspecific low back pain? A meta-analysis. J Manipulative Physiol Ther. 2005 Jun;28(5):312-22.

14 Sackett D, Rosenberg W, et al. Evidence based medicine: what it is and what it isn’t. BMJ (Clinical Research Ed.), 312(7023), 71-72

15 Baker S, Painter E, et al. Systematic Clinical Reasoning in Physical Therapy (SCRIPT): Tool for the Purposeful Practice of Clinical Reasoning in Orthopedic Manual Physical Therapy. Phys Ther. 2017 Jan 1;97(1):61-70

16 Cook C. How about a little love for non-thrust manipulation? J Man Manip Ther. 2012 Feb; 20(1): 1–2.


View the Complete List of Research Commentaries

Noteworthy Articles
March 05, 2015
5 Systematic Reviews Refute the Clinical Applicability of CPRs

January 27, 2015
Chronic Cervicognic Dizziness: Maitland and Mulligan Mobilization (Non-Thrust) BOTH Result in Immediate and Sustained Relief EVEN OUT TO ONE YEAR

January 06, 2015
Construct validity of Maitland’s “Comparable Sign” is further supported by a new exploratory study in spinal pain patients

December 08, 2014
Even if the patient meets CPR for Low Back Pain Manipulation…you don’t have to thrust! There are NO DIFFERENCES in OUTCOMES when patients received Thrust or Non-Thrust manipulation

September 09, 2014
Renewed Controversy in Cervical Spine Thrust Manipulation: How To Minimize the Risks with Cervical Artery Dysfunction Assessment

June 06, 2014
Mobilization and Manipulation are EQUALLY EFFECTIVE and produce the SAME OUTCOMES in Mechanical LBP

September 17, 2013
Cervical Spine Thrust Manipulation: What are the risks?

August 13, 2013
Regional Interdependence Maybe, Maybe Not, in Shoulder Impingement

June 25, 2013
The fragility of CPRs in predictive modeling…Are they really such robust clinical tools?

October 12, 2012
GROUND-BREAKING NEW STUDY… Mobilization and Manipulation are EQUALLY EFFECTIVE and produce the SAME OUTCOMES in Mechanical LBP

July 10, 2012
Maitland Grade IV Shoulder Mobilizations Significantly Improved Outcomes in Chronic Frozen Shoulder Patients Compared to Standardized PT Care

May 22, 2012
Landmark Study Achieves 3 SIGNIFICANT FIRSTS in the Manual Therapy Management of Mechanical Low Back Pain

April 02, 2012
Maitland Lumbar UPA Joint Mobilizations Significantly Improves SLR Compared to Both Static Stretching and Control Groups

March 01, 2012
4 Systematic Reviews Refute the Clinical Applicability of CPRs

Historical List

View the Complete List of Research Commentaries

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