In Patients with Spinal Dysfunctions, is Spinal Mobilization More Effective than Therapeutic

Exercise in Terms of Range of Motion, Function, and Perceived Pain?

Justin O’Dowd

PTH 662

3/22/2022
IS SPINAL MOBILIZATION MORE EFFECTIVE THAN THERAPEUTIC EXERCISE? 1

Physical therapists frequently encounter patients that come in with some variation of a

spinal dysfunction due to the spine being the focal point of all movement. To treat these patients,

physical therapists may utilize many different skills and techniques. Oftentimes, there are multiple

ways to treat an impairment. Because of this, a special emphasis is put on a therapist’s ability to

correctly select an appropriate intervention. With so many possible interventions at their disposal,

it can be difficult to choose which one to use. This brought up the clinical question, “In patients

with spinal dysfunctions, is spinal mobilization more effective than therapeutic exercise in terms of

range of motion, function, and perceived pain?” The goal of this paper is to illustrate the instances

in which spinal mobilization is more effective than therapeutic exercise using evidence through

multiple peer-reviewed articles.

One area where spinal mobilizations are more effective than therapeutic exercise is range

of motion. A study conducted by Ashraf et al1 compared the effectiveness of spinal mobilization

with leg movement to McKenzie Extension Exercises in patients with lumbar radiculopathy. This

study is pertinent to the clinical question because it examines both spinal mobilization and

therapeutic exercise to determine if one is favorable over the other with treating a dysfunction in

the spine. In this study, 60 participants (ages 28 to 50) with lumbar radiculopathy were divided into

an interventional group treated with spinal mobilization with leg movement (SMWLM), and a

control group treated with McKenzie Extension Exercises. The subjects completed 1 session

consisting of 30 repetitions for 3 days per week. The following measurements were taken pre- and

post-intervention: pain intensity using the Numeric Pain Rating Scale (NPRS), functional mobility

using the Modified Oswestry Disability Index (ODI), and range of motion (flexion, extension,

lateral flexion, rotation) by goniometry. For data analysis, Wilcoxon Signed Rank Test was used

for comparison within groups, and Mann-Whitney Test was used for comparison between the
IS SPINAL MOBILIZATION MORE EFFECTIVE THAN THERAPEUTIC EXERCISE? 2

groups. The results indicate that pain intensity decreased significantly on the NPRS (p < 0.05) and

improvement in function with modified ODI scoring (p < 0.05) and range of motion through

goniometry (p < 0.05) in both groups. While the reduction in pain and improved function was the

same in both groups, the lumbar range of motion had a greater increase in the interventional group

consisting of SMWLM (p < 0.05).1 Although this study showed favorable results for spinal

mobilization over therapeutic exercise regarding range of motion, it should be noted that this study

received a Physiotherapy Evidence Database (PEDro) score of 5/10. The items that were included

in this study were random and concealed allocation, baseline comparability, between-group

comparisons, and point estimates and variability. Items excluded from this study included

eligibility criteria, blind subjects, therapists, and assessors, adequate follow-up, and intention-to-

treat analysis.2 This PEDro score indicates that there was moderate quality of evidence, but this

study had a fair number of limitations, as well. The quality of evidence could have benefited if it

included blind subjects, therapists, and assessors.

This study revealed that spinal mobilization and therapeutic exercise are equally effective

at reducing pain and improving function with patients suffering from lumbar radiculopathy.

However, lumbar functional range of motion showed greatest improvement with the group treated

by SMWLM.1 The conclusion from this study can have notable clinical implications. The manual

technique performed was a sustained transverse glide to the spinous process with leg movement as

the subject was in a side-lying position. Each patient may be different, but this technique is one that

can be utilized in the clinic when treating a patient with lumbar radiculopathy. This is not to say

that therapeutic exercise will not be used while treating a spinal dysfunction like lumbar

radiculopathy, but with all other outcomes equal (pain and function), this manual technique may

give additional benefits, such as increased range of motion, according to this study.
IS SPINAL MOBILIZATION MORE EFFECTIVE THAN THERAPEUTIC EXERCISE? 3

When discussing spinal dysfunctions, functionality is a major limitation that needs to be

addressed in physical therapy. A study performed by Ulger et al3 investigated this by comparing the

effect of manual therapy and exercise in subjects with chronic low back pain (CLBP). This study is

relevant to the stated clinical question because it provides a direct comparison of manual therapy

versus therapeutic exercise. Even though the subjects used for this study were broadly diagnosed

with CLBP, the findings from this study can still be useful because CLBP may be caused by spinal

dysfunction, in some cases. This study utilized one-hundred thirteen subjects with CLBP that were

randomly split into a spinal stabilization group and manual therapy group. The stabilization group

performed spinal stabilization exercises (transversus abdominus and multifidi strengthening, and

trunk stabilization with various surfaces), while the manual group was treated with soft tissue

mobilizations, muscle-energy techniques, and joint mobilizations and manipulations. Both groups

received therapy 3 times per week which lasted 6 weeks for a total of 18 sessions. Measurements

included pain severity with the visual analog scale (VAS), functional status using ODI, and quality

of life using Short Form 36 (SF-36). To analyze the data, the Mann-Whitney U Test was used to

detect the difference between the groups, and the Wilcoxon Signed Rank Test was used to examine

the changes occurring after the treatment. The results of the intragroup analyses showed that both

treatment groups had similar effects with pain, function, and quality of life (p < 0.05), whereas the

intergroup analyses showed there was a greater reduction in pain, and improvement in functional

status for the manual therapy group (p < 0.05).3 This study received a PEDro score of 5/10 when

looking at the quality of evidence. Items included in this study were eligibility criteria, random

allocation, baseline comparability, blind assessors, between-group comparisons, and point

estimates and variability. The following items were excluded from this study: concealed allocation,

blind subjects and therapists, adequate follow-up, and intention-to-treat analysis.2 This study had
IS SPINAL MOBILIZATION MORE EFFECTIVE THAN THERAPEUTIC EXERCISE? 4

moderate quality of evidence but could have been strengthened with blind subjects and therapists

to eliminate any potential bias.

The primary conclusion of this study was both spinal stabilization exercises and manual

therapy contribute a similar effect on quality of life, but the manual therapy proved to be more

effective with pain reduction and functional parameters in patients with CLBP. These findings

have significant clinical applications because a substantial number of patients that are seen in a

physical therapy clinic suffer from low back pain. Because of this fact, the results from this study

could help physical therapists decide which intervention to use. Therapeutic exercise is certainly a

part of the equation when treating low back pain, however, if pain and functionality are a main

concern with a patient, then a physical therapist could use this study as guidance with selecting the

appropriate intervention.

Lastly, an area that can get overlooked when dealing with spinal dysfunctions is how a

selected intervention can influence a patient’s perception of pain. A study by Bernal-Utrera et al4

compared manual therapy versus therapeutic exercise in non-specific chronic neck pain. This study

is applicable because it examines the short-term and mid-term changes generated by the

interventions stated in the clinical question. Additionally, it explores how each intervention can

impact pain perception. This study divided 69 patients into three groups based off the intervention

that they received. The manual therapy group was treated with 3 different manual therapy

techniques using evidence for neck pain treatment. Each technique was performed once per week

for a total of 3 weeks. The therapeutic exercise group performed progressive exercises including

activating deep cervical flexors, isometric co-contractions of superficial and deep cervical flexors,

and eccentric contractions of cervical flexors and extensors. These exercises were performed once

per day for 3 weeks. The control group received a sham treatment via the therapist placing their
IS SPINAL MOBILIZATION MORE EFFECTIVE THAN THERAPEUTIC EXERCISE? 5

hands on the patient’s neck in supine for 3 minutes without therapeutic intent to treat. Pain was

measured using the VAS and pressure pain threshold, and cervical disability was measured through

the Neck Disability Index. Outcomes were assessed on week 1, week 4 (short-term), and week 12

(mid-term). To find the intragroup difference, Student’s t-test was used for parametric distributions

and Kruskal-Wallis H for non-parametric distributions. The intergroup difference was analyzed

using One-factor ANOVA for parametric distributions and Kruskal-Wallis H for nonparametric

distributions. The results show that there were no statistically significant differences (p > 0.05)

between the experimental groups against the control group with pain. However, the manual therapy

group showed an improvement in perceived pain before the therapeutic exercise group. The study

also found that therapeutic exercise decreased cervical disability faster than manual therapy.4 This

study received a PEDro score of 7/10, meaning there is good quality of evidence. Items included in

this study were eligibility criteria, random allocation, baseline comparability, blind assessors,

adequate follow-up, intention-to-treat analysis, between-group comparisons, and point estimates

and variability. Items excluded were concealed allocation, and blind subjects and therapists.2 The

quality of evidence could have been improved with blind subjects and therapists.

The major conclusion of this study was that although therapeutic exercise reduced

disability faster than manual therapy, manual therapy was shown to decrease pain perception faster

than therapeutic exercise. There were no statistically significant differences between the

experimental groups and the control group with pain. The authors hypothesized that this could be

caused by the neurophysiological effects of the placebo, which can lead to an immediate short-term

improvement. The results found in this study can have implications for the clinic when treating

patients with chronic neck pain. The psychological aspect of a patient is something that needs to be

considered when a physical therapist treats a patient. This study helped illustrate that spinal
IS SPINAL MOBILIZATION MORE EFFECTIVE THAN THERAPEUTIC EXERCISE? 6

mobilizations can decrease the patient’s perception of pain quicker than therapeutic exercise. One

clinical application of this is patient buy-in. If a patient is painful, a therapist may choose to do a

spinal mobilization to decrease a patient’s pain perception. This could help the patient to buy-in to

the therapist’s plan of care, which can lead to better outcomes in the end. All in all, when treating

patients with spinal dysfunctions, spinal mobilization could help with a patient’s perception of

pain, potentially leading to better overall results.

Understanding what intervention to select when treating a patient can have a significant

impact on the outcomes that a patient may experience. Ashraf et al1 showed that lumbar functional

range of motion improved the most with the group treated with spinal mobilization (SMWLM),

when compared to therapeutic exercise. Ulger et al3 revealed that spinal mobilization was more

effective with pain reduction and functional parameters in patients with CLBP than therapeutic

exercise. Lastly, Bernal-Utrera et al4 concluded that manual therapy decreased a subject’s pain

perception faster than therapeutic exercise. In summary, this literature review illustrated that

performing spinal mobilizations are more effective in terms of range of motion, function, and

perceived pain.
IS SPINAL MOBILIZATION MORE EFFECTIVE THAN THERAPEUTIC EXERCISE? 7

References
1. Ashraf B, Ahmad S, Ashraf K et al. Effectiveness of spinal mobilization with leg movement
versus McKenzie back extension exercises in lumbar radiculopathy. Pakistan J of Med and
Health Sci. 2021;15(5):1436-1440. doi:https://doi.org/10.53350/pjmhs211551436
2. Physiotherapy Evidence Database. PEDro scale. Accessed March 20, 2022. Revised June 21,
1999. https://pedro.org.au/english/resources/pedro-scale/
3. Ulger O, Demirel A, Oz M, Tamer S. The effect of manual therapy and exercise in patients
with chronic low back pain: double blind randomized controlled trial. J Back Musculoskelet
Rehabil. 2017;30(6):1303-1309. doi:10.3233/BMR-169673
4. Bernal-Utrera C, Gonzalez-Gerez JJ, Anarte-Lazo E, Rodriguez-Blanco C. Manual therapy
versus therapeutic exercise in non-specific chronic neck pain: a randomized controlled
trial. Trials. 2020;21(1):682. doi:10.1186/s13063-020-04610-w