Youssef EF, Shanb AA. Journal of Back and Musculoskeletal Rehabilitation. 2013.

Article Summary by Richard Woodland, SPT from Missouri State University, Springfield, MO

This randomized controlled trial evaluated and compared the effectiveness of two common interventions for the treatment of cervicogenic headaches.  The two interventions compared were mobilization, defined as a “low velocity, small or large amplitude, passive movement within the patients range of cervical motion and control”, and massage therapy. Both treatment interventions were combined in the study with therapeutic exercise.

Thirty-eight participants between the age of 18 and 40 with recurrent headache and neck pain for at least 2 months were included in the study. They were randomly assigned into two groups, mobilization combined with exercise and massage combined with exercise. The authors used a list of inclusion criteria which are as follows: “1) unilaterality of pain, 2) reduction in the range of neck movement, 3) ipsilateral shoulder discomfort, 4) ipsilateral arm discomfort, 5) mechanical precipitation of exacerbations/attacks by awkward neck positions or external pressure against sensitive occipital structures”. According to the authors, subjects were excluded from the study if they had “migraine, cluster headache, cervical radiculopathy, entrapment neuropathy, myelopathy, rheumatoid arthritis or previous surgery of the cervical spine, pregnancy, whiplash trauma, or if they had received therapeutic treatment for neck pain or headache during the previous six months”. Objective measures used for pre and post-test assessment were pain intensity as reported on the visual analog scale (VAS), Neck Disability Index (NDI), and cervical active range of motion (AROM) as measured with a tape measure.  The authors supported the use of tape measurements with other references.

The mobilization group subjects received low velocity/high amplitude small oscillatory movements to the upper cervical vertebrae (C1, 2, 3) within normal range. Techniques involved posterior-anterior central vertebral pressure, unilateral and bilateral posterior-anterior vertebral pressure, and transverse vertebral pressure, with sessions lasting 30 to 40 minutes. The massage group received massage therapy with six specific steps during 30 to 40 minute sessions. These steps are as follows: 1) 3 minutes of warm-up consisting of bilateral pressure to the cervical musculature 2) 5 minutes of myofascial release to the pectoral girdle musculature and upper trapezius 3) 2 minutes of manual cervical traction 4) 15 minutes of active trigger point release in the posterior neck musculature 5) 5 minutes of facilitated stretching techniques 6) 3-5 minutes of effleurage and petrissage. All subjects received exercises in the form of active range of motion, isometric and dynamic strengthening, and endurance exercises. The treatment program was applied twice weekly for 6 weeks, with pre-testing and post-testing. The post-testing was performed during a follow-up visit 7 weeks after the treatment.  Results from the study demonstrated a significant difference in all measured variables in favor of cervical mobilization over massage therapy, except for the neck disability index of functional activities. Notable results from the study are the significant decrease in headache duration, intensity, and frequency following mobilization versus massage. These variables had p-values of .008, .00, and .00 respectively.

The authors presented a dialogue wherein they presented differences between their study and previous literature. They addressed the differences in their results compared to others’ and listed the types of mobilizations and exercises used, along with number of follow-up visits, as potential causes for these differences. Limitations were noted, such as the shortness of the intervention and measurements only being performed at baseline and seven weeks after treatment with no further follow-up. Furthermore, the authors stated the need for a control group to confirm the outcomes of treatment intervention.

Personal Commentary:

Mobilization has been a part of the physical therapy world nearly since the beginning of the profession itself. Some references date mobilization and manipulation use in physical therapy as far back as the 1920s (Boissonnault, 2005). Regardless of its long standing place in our profession, mobilization and the use of manual therapy in general has been highly scrutinized as a passive approach to therapy and often discouraged by many frontrunners in the field. Many individuals choose not to use manual techniques such as mobilization because they believe it fosters dependency from patients and leads to an inability of patients to manage future issues on their own.

I agree with these people. Yes, manual therapy, especially mobilizations, can often be misused as the main or sole approach in therapy and this can leave our patients with nothing to fall back on when symptoms return. We, or the skillset we possess, can become the crutch that they lean on for management of their pain. This obviously is an improper model for patient care and one that should be avoided by members of our profession. This being said, I support the use of mobilization in therapy when combined with therapeutic exercise to provide a more complete patient-care experience.

Feng et al. stated that cervicogenic headaches are related to joint dysfunction in the upper cervical segments of C2/3 and C3/4, with dysfunction occurring at the disc or the facet joints. Other studies have shown that mobilization combined with exercise as a treatment approach is beneficial for persistent mechanical neck disorders (Gross et al. 2004). With this supporting evidence, we as PTs shouldn’t be afraid to include manual mobilizations of the cervical spine in our treatment approach. However, when utilizing this in your skillset it is important to remember that it is simply one of many modalities and that it should be used sparingly to avoid patient dependence. When used as a supplement to therapeutic exercise and postural re-education, mobilization can be a quick and effective pain reliever which encourages proper joint kinematics with neck range of motion.


1) Boissonnault, William. No You Don’t, Yes We Do: The Challenge From Chiropractors. Articulations (2005)

2) Feng FL, and Schofferman J. Chronic Neck Pain and Cervicogenic headaches. Curr Treat Options Neurol. 2003; 5: 493-498.

3) Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, et al. A Cochrone Review of Manipulation and Mobilization for Mechanical Neck Disorders. Spine (Phila Pa 1976). 2004; 29(14): 1541-1548.