Mobilização para Dor Radicular Cervical

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468 | july 2025 | volume 55 | number 7 | journal of orthopaedic & sports physical therapy
[ literature review ]
socioeconomic challenges by affecting work 
capabilities, quality of life, and exerting 
pressure on health care resources.41
Diagnosing cervical radiculopathy is a 
multifaceted process. Magnetic resonance 
imaging and nerve conduction studies are 
frequently recommended for detecting 
structural and functional anomalies, which, 
when combined with clinical symptoms, 
strengthen the diagnosis.13 Additional 
assessments, such as evaluating sensory, 
motor, and reflex dysfunctions or the 
presence of pain radiating from the neck 
to the upper limb, are common but not 
conclusive in isolation.36
Therapeutic interventions for cervical 
radiculopathy include pharmacological 
treatments and physical therapies, such as 
manual therapy.34 Guidelines suggest some 
benefits of manual therapies like articular 
or neural mobilization, although the rec-
ommendation is low certainty. Systematic 
reviews have highlighted promising out-
comes from manual therapies, including 
neurodynamic mobilization, in treating 
cervical radiculopathy.13,34 The empirical 
evidence supporting its efficacy requires 
further analysis.37,53,72
Recognizing the gaps in the existing lit-
erature, we aimed to evaluate the effective-
ness of articular and neural mobilization 
1Escuela Universitaria de Fisioterapia de la ONCE, Universidad Autónoma de Madrid, Madrid, Spain. 2Department of Radiology, Rehabilitation and Physiotherapy, Faculty of 
Nursery, Physiotherapy and Podiatry, Complutense University of Madrid, Madrid, Spain. 3Grupo In Physio, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos 
(IdISSC), Madrid, Spain. ORCID: García-Juez, 0000-0002-9844-3031; Navarro-Santana, 0000-0002-6065-9283; Valera-Calero, 0000-0002-3379-8392; Varas-de-la-Fuente, 
0000-0002-3749-3924; Plaza-Manzano, 0000-0002-7861-0584. This meta-analysis was prospectively registered in the Open Science Framework (OSF) registry (https://doi.
org/10.17605/OSF.IO/ZV7HA). This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors certify that 
they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address 
correspondence to Marcos José Navarro-Santana, Pl. de Ramón y Cajal, 3, 28040 Madrid, Spain. E-mail: marconav@ucm.es t Copyright ©2025 JOSPT®, Inc
C
ervical radicular pain, also known as cervicobrachial pain, 
involves upper-quadrant symptoms linked to the cervical spine, 
suggesting neuropathic conditions like cervical radiculopathy. 
The pain may arise from issues with cervical discs, facet joints, or 
muscle imbalances with associated myofascial trigger points, and from 
neurogenic origins.29 The estimated incidence of cervical radiculopathy 
is between 83.2 and 179 per 100 000 individuals, presenting significant 
Effectiveness of Articular and Neural 
Mobilization for Managing Cervical 
Radicular Pain: A Systematic Review 
With Network Meta-Analysis
SUSANA GARCÍA-JUEZ, PT, PhD Candidate1 • MARCOS JOSÉ NAVARRO-SANTANA, PT, PhD2,3 
JUAN ANTONIO VALERA-CALERO, PT, PhD2,3 • DANIEL ALBERT-LUCENA, PT, PhD2 
ANA BEATRIZ VARAS-DE-LA-FUENTE, PT, PhD1 • GUSTAVO PLAZA-MANZANO, PT, PhD2,3
	t OBJECTIVE: To evaluate the impact of articular 
and neural mobilization on pain intensity and dis-
ability in patients with cervical radicular pain.
	t DESIGN: Intervention systematic review with 
network meta-analysis.
	t LITERATURE RESEARCH: The MEDLINE, 
SciELO, PubMed, PEDro, Scopus, Web of Science, 
and Cochrane databases were searched up to 
February 2024.
	t STUDY SELECTION CRITERIA: Randomized 
controlled trials studying the effects of articular or 
neural mobilization in adults with cervical radicular 
pain were included.
	t DATA SYNTHESIS: A frequentist network 
meta-analysis was used to assess pain intensity 
and disability. The risk of bias and the certainty of 
the evidence were evaluated using Version 2 of the 
Cochrane Risk of Bias (RoB 2) tool and the Grading 
of Recommendations Assessment, Development, 
and Evaluation (GRADE) approach, respectively.
	t RESULTS: Out of 777 reports, 50 were analyzed 
quantitatively. The combination of articular and 
neural mobilization with usual care was most 
effective in reducing short-term pain intensity 
compared to wait and see, sham, or placebo 
interventions (mean difference [MD], −3.23; 95% 
confidence interval [CI]: −4.33, −2.12) and to 
standard care alone (MD, −1.52; 95% CI: −2.31, 
−0.73). There were significant improvements in 
pain-related disability with neural mobilization plus 
usual care, surpassing wait and see, sham, pla-
cebo interventions (standardized mean difference 
[SMD], −1.57; 95% CI: −2.53, −0.61), and usual 
care alone (SMD, −1.31; 95% CI: −1.88, −0.73). 
Risk of bias and heterogeneity of included trials 
downgraded the certainty of evidence.
	t CONCLUSION: Combining mobilization 
techniques with standard care may be considered 
in clinical practice, although with care due to the 
moderate to very low certainty of the evidence. 
J Orthop Sports Phys Ther 2025;55(7):468-481. 
Epub 16 May 2025. doi:10.2519/jospt.2025.12757
	t KEY WORDS: cervical radiculopathy, 
cervicobrachial pain, mobilization, network 
meta-analysis, neurodynamic
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https://doi.org/10.17605/OSF.IO/ZV7HA
https://doi.org/10.17605/OSF.IO/ZV7HA
mailto:marconav@ucm.es
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journal of orthopaedic & sports physical therapy | volume 55 | number 7 | july 2025 | 469
interventions, either combined with usual 
care or as stand-alone treatments, in allevi-
ating pain and disability among individuals 
with cervical radiculopathy.
METHODS
r
eporting of our review adhered 
to the Preferred Reporting Items 
for Systematic Reviews and Net-
work Meta-Analysis (PRISMA-NMA) 
checklist.10,26 The review protocol was 
prospectively registered at the Open 
Science Framework registry (https://doi.
org/10.17605/OSF.IO/ZV7HA).
TIDieR Checklist
The Template for Intervention Descrip-
tion and Replication (TIDieR) checklist 
provides a structured framework to report 
key details of interventions, including 
the rationale, materials, procedures, and 
delivery, ensuring replicability and trans-
parency. By using this checklist, researchers 
can improve the quality of reporting, 
which is crucial for the interpretation, 
replication, and implementation of the 
interventions in practice. The checklist 
was applied independently by 2 authors 
in our review.24
Systematic Literature Search
Electronic literature searches were con-
ducted on MEDLINE, SciELO, PubMed, 
PEDro, Cochrane Library, SCOPUS, and 
Web of Science databases from their 
inception to February 20, 2024. When 
databases allowed limits, searches were 
restricted to randomized clinical trials. 
We also screened the reference lists of the 
papers that were identified in database 
searches for other potentially eligible tri-
als. Bibliographic database search strate-
gies were conducted with the assistance 
of an experienced health science librar-
ian. The search strategy for each database 
is available in SUPPLEMENTAL APPENDIXincorporating network meta-analysis: PRISMA-
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Selection Criteria
We included randomized clinical trials 
where at least 1 group received some form 
of articular or neurodynamic mobilization 
in individuals with cervical radicular pain 
or cervical radiculopathy. Due to the het-
erogeneity in terminology, we included 
the following terms: cervical radicu-
lopathy, cervical disc herniation, cervical 
stenosis, brachial plexus injuries, and 
cervical radiculopathy due to spondy-
losis. The selection criteria included ran-
domized clinical trials that followed the 
PICO research framework (SUPPLEMENTARY 
APPENDIX 2):
• Population: Adults with cervical radic-
ulopathy or cervical radicular pain.
• Intervention: Any form of manual ther-
apy (neurodynamic or articular mobili-
zation), excluding massage therapy or 
soft tissue manipulations, either alone 
or combined with other treatments.
• Comparator: Acceptable comparators 
included any type of placebo, sham 
treatment, no intervention, or any 
type of intervention different from 
neural or articular mobilization.
• Outcomes: Any outcome measure such 
as pain or related disability.
Screening and Selection Process
The process of screening and selecting 
trials was conducted independently by 2 
authors. The initial step involved remov-
ing duplicate papers. Following this, the 
title and abstract of each paper were ex-
amined to assess potential eligibility. The 
third step involved a thorough reading of 
the full text of trials that were potentially 
eligible. The authors were tasked with 
reaching a consensus on those trials that 
could potentially be included. In instanc-
es where a discrepancy arose, a third au-
thor made the final decision on whether 
to include the study or not.
Data Extraction
Data from each trial, encompassing 
aspects such as design, sample size, pop-
ulation, interventions, outcomes, and 
follow-ups, were independently extracted 
by 2 authors using a standardized form. 
Discrepancies were resolved via consen-
sus, or a third author if consensus was not 
reached. We extracted the sample size, 
means, and standard deviations for each 
trial. When the trial reported only stan-
dard errors or interval confidence, they 
were converted to standard deviations. 
When necessary, the mean scores and 
standard deviations were estimated from 
graphs. If the trial presented nonpara-
metric values (median and interquartile 
range), they were converted to means 
and standard deviations accordingly.39,73 
A pooled data group was established 
to consolidate findings from trials that 
featured multiple groups when the com-
bination was similar in the same group 
node. Specifically, this was performed for 
those trials that incorporated more than 1 
group undergoing neural mobilization or 
had more than 1 comparative group (eg, 
usual care). This approach was taken to 
ensure a comprehensive analysis and to 
account for the variability in treatment 
modalities and comparative measures 
within individual trials.
Assessing Risk of Bias
The assessment of the risk of bias (RoB) 
and the evaluation of the methodologi-
cal quality of the trials included in the 
review were conducted independently by 
2 authors. The tools employed for these 
assessments were version 2 of Cochrane 
Risk of Bias (RoB 2)69 assessment tool 
and the Physiotherapy Evidence Data-
base (PEDro) scale,14 respectively.40
RoB 2 was used to assess the RoB 
of randomized clinical trials. The tool 
evaluates 5 domains: the randomization 
process, deviations from intended inter-
ventions, missing outcome data, outcome 
measurement, and selection of reported 
results. Each domain contains signaling 
questions to gather relevant information, 
which an algorithm uses to judge the RoB 
as “Low,” “High,” or “Some concerns.”69
The PEDro scale was used to gauge 
the methodological quality verifying the 
random allocation, concealed allocation, 
similarity between groups at baseline, 
blinding of participants, blinding of ther-
apists, blinding of assessors, dropouts, 
intention-to-treat statistical analysis, sta-
tistical comparison between groups, and 
point measures and variability data. A trial 
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https://doi.org/10.17605/OSF.IO/ZV7HA
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470 | july 2025 | volume 55 | number 7 | journal of orthopaedic & sports physical therapy
[ literature review ]
was classified high quality if it achieved a 
PEDro score of at least 5 points out of 10.40
Certainty of Evidence
The Grading of Recommendations Assess-
ment, Development, and Evaluation 
(GRADE) methodology for network 
meta-analysis was used to determine 
level of evidence of direct, indirect, and 
network meta-analysis evidence.28,55 This 
approach classified the level of evidence 
into high, moderate, low, or very low 
based on the presence of within-study 
bias, reporting bias, indirectness, impre-
cision, heterogeneity, and incoherence.40 
This evaluation was conducted using 
CINeMA software to automate each 
aspect of the evaluation according to the 
GRADE methodology.52
The reasons for downgrading the level 
of evidence included several criteria pro-
vided by the CINeMA system. For RoB, 
CINeMA grouped trials into low, moder-
ate, and high RoB categories. We applied 
“Average RoB” rule to summarize the 
overall concern level for each relative 
treatment effect. For reporting bias, the 
assessment was based on publication 
bias (using funnel plot and Egger’s test) 
and selective reporting, with judgments 
categorized as “suspected” or “unde-
tected.” Imprecision was evaluated based 
on the 95% confidence intervals (CIs), 
and judgments were assigned depend-
ing on whether these intervals included 
clinically important effects or the line of 
no effect. For heterogeneity, CINeMA 
evaluated the variability of treatment 
effects using prediction intervals and the 
I2 statistic, which quantifies the percent-
age of total variation across studies due 
to heterogeneity rather than chance. A 
high I2 value (I2>70% indicating sub-
stantial heterogeneity), combined with 
wide prediction intervals that extended 
into clinically important effects in both 
directions, or the prediction intervals 
extended into clinically important or 
unimportant effects. Finally, incoher-
ence was assessed by comparing direct 
and indirect evidence using the sepa-
rating indirect from direct evidence 
method, with semiautomatic evaluation 
performed by CINeMA software, and 
judgments were based on the signifi-
cance of any observed inconsistencies.52
Data Synthesis and Analysis
Assumption of Transitivity and Geom-
etry of the Network The transitivity 
assumption was assessed, conceptualized 
as the equilibrium in the distribution of 
potential effect modifiers across different 
Records identified from 
Databases, N = 759:
PubMed, n = 72 
Cochrane, n = 188 
Scopus, n = 298 
Medline (EBSCO), n = 52 
WOS, n = 60 
SciELO, n = 1 
PEDro, n = 88 
screening: 
Duplicate records removed, 
n = 287
No full text, n = 21 
Records screened, n = 451 Records excluded, n = 396 
Reports assessed for eligibility, 
n = 55 
Reports excluded, n = 14: 
Cervical traction without 
mobilization group, n = 3 
No RCT, n = 3 
Not an allowed comparison (same 
intervention), n = 3 
Not disability or pain 
outcomes, n = 2 
Unknown manual therapy 
technique, n = 1 
Absence of manual therapy 
technique, n =1Insufficient data, n=1 
Records identified from: 
Websites, n = 8
Citation searching, n = 10
Reports assessed for eligibility,
n = 18
Reports excluded, n = 8: 
Not an allowed comparison (same 
intervention, n = 3 
Duplicate publication, n = 2 
Cervical traction without 
mobilization group, n = 1 
Absence of manual therapy 
technique, n = 1 
TENS intervention without 
mobilization, n = 1 
Studies included in qualitative 
review, n = 51 
Studies included in meta-
analysis, 
n = 50 
Identification of studies via databases and registers Identification of studies via other methods 
n
oitacifit
ne
dI
 
S
cr
ee
n
in
g
 
In
cl
u
d
ed
 
Records removed before 
FIGURE 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. Abbreviations: PEDro, Physiotherapy Evidence Database; RCT, 
randomized controlled trial; TENS, Transcutaneous Electrical Nerve Stimulation; WOS, Web of Science.
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journal of orthopaedic & sports physical therapy | volume 55 | number 7 | july 2025 | 471
pairwise comparisons. This assessment of 
transitivity involved examining these ele-
ments in the context of individual trials, 
interventions, pairwise comparisons, and 
specific networks (for instance, the out-
come and follow-up period). Following 
this, we graphically represented the inter-
connections among treatments using a net-
work plot, specifically for each primary 
outcome at the short-term follow-up.
Summary of the Network The nodes 
involved in the network meta-analysis 
were articular mobilization alone; artic-
ular mobilization combined with usual 
care; articular and neural mobilization 
alone; articular and neural mobilization 
combined with usual care; neural mobi-
lization alone; neural mobilization com-
bined with usual care; and comparisons 
with usual care, wait and see, placebo, or 
sham interventions.
Statistical Analysis The network meta-
analysis was conducted using a frequen-
tist model and the “R” software version 
4.2.2 with the package “netmeta,” “metafor,” 
and CINeMA software. The meta- 
analysis was conducted using the random-
effect model under the assumption of 
significant heterogeneity. The hetero-
geneity of the trials was assessed with 
CINeMA through the prediction interval.
The between-groups mean differences 
(MDs) and standard error were used to 
calculate the network meta-analysis for 
pain intensity. Regarding disability, MDs 
were converted to standardized mean dif-
ference (SMD). A random-effects model 
was used to determine the overall effect 
size (SMD or MD). An effect size (SMD) 
of 0.8 or greater was considered large, 
between 0.5 and 0.8 as moderate and 
between 0.2 and 0.5 as small.15 In general, 
P valuesand Bamhair7 Low Some concerns Low Low Low Some concerns
Anwar et al8 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Barot and Shukia9 Low Some concerns Low Some concerns Some concerns Some concerns
Calvo-Lobo et al14 Low Some concerns Low Low Low Some concerns
Coppieters et al16 Low Some concerns Low Low Some concerns Some concerns
Coppieters et al17 Low Some concerns Low Low Some concerns Some cioncerns
Cui et al18 Low Some concerns Low Low Low Some concerns
Eldesoky et al19 Low Some concerns Low Some concerns Some concerns Some concerns
Godek et al21 Low Some concerns Low Some concerns Some concerns Some concerns
Hassan et al23 Low Some concerns Low Low Some concerns Some concerns
Hungund et al25 Low Some concerns Low Some concerns Low Some concerns
Ibrahim et al27 Low Some concerns Low Low Some concerns Some concerns
Kayiran and Turhan30 Low Some concerns Low Low Some concerns Some concerns
Khan et al31 Low Some concerns Low Some concerns Some concerns Some concerns
Khatwani et al32 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Kim et al33 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Kumar35 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Leonelli et al38 Low Some concerns Low Low Some concerns Some concerns
Marks et al42 Low Some concerns Low Some concerns Some concerns Some concerns
Nambi et al44 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Nar45 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Nee et al46 Low Low Low Some concerns Low Some concerns
Ojoawo et al48 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Ojoawo and Olabode49 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Pandey et al50 Some concerns Some concerns Low Some concerns Some concerns Some concerns
(Table continues on next page.)
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journal of orthopaedic & sports physical therapy | volume 55 | number 7 | july 2025 | 473
DieR checklist. Cohen’s kappa statistic for 
agreement between researchers was 0.92 
for extracted quantitative data.
Methodological Quality
The methodological quality scores ranged 
from 0 to 9 (mean, 6.1; standard deviation, 
1.85) out of a maximum of 10 points. Four 
trials (8%) had excellent (9-10 points) 
quality, 60% (30/50) had good quality, 22% 
(11/50) had fair methodological quality, 
and 10% (5/50) had poor methodological 
quality. The most frequent biases were 
blinding of the therapists, participant’s, 
and assessor’s blinding (TABLE 1). Cohen’s 
kappa statistic for agreement between 
researchers was 0.72. A third author was 
necessary 4 times.
Risk of Bias
The RoB assessment of the included trials 
is displayed in TABLE 2. The most frequent 
causes for assigning “some concerns” were 
the deviations from intended interventions 
Nineteen trials1,2,4,6,8,9,27,30,33,35,38,45,56,59,60,64–67 
(38%, 19/50) compared neural mobiliza-
tion adjunct to usual care with wait and 
see, sham, or placebo intervention;6,66,67 
usual ca re;1,2,4,8,9,27,30,33,35,38,45,56,59,60,64,65 
neural and articular mobilization with 
usual care;59and articular mobilization 
with usual care.6,35 Ten (22%, 10/50) tri-
als14,16,17,31,42,50,60–63 compared neural mobili-
zation alone with usual care;14,16,17,50,60,63 wait 
and see, sham, or placebo intervention;61,62 
neural mobilization with usual care;60and 
articular mobilization alone.31,42 Eight 
(16%, 8/50)7,21,46,51,57,59,68,70 compared neural 
and articular mobilization adjunct to usual 
care with usual care;7,21,51,57,59,68 wait and see, 
sham, or placebo intervention;46neural and 
articular mobilization;57 and articular mo-
bilization adjunct to usual care.70 One trial57 
(2%, 1/50) compared neural and articular 
mobilization with usual care and neural 
and articular mobilization adjunct to usual 
care. Details of the intervention reporting 
can be found in TABLE S5, following the TI-
were excluded for various reasons. Ulti-
mately, 51 trials were included in the sys-
tematic review. One trial was excluded 
from the meta-analysis due to inadequate 
data22 (excluded studies are presented in 
SUPPLEMENTAL TABLE  S1). Finally, 50 tri-
als1–9,14,16–19,21,23,25,27,30–33,35,38,42,44–46,48–51,54,56–
68,70,74,76,77 were included in the network 
meta-analysis (FIGURE 1).
Trial Characteristics
The characteristics of the participants, in-
terventions, and selection criteria of the 
included trials are shown in SUPPLEMENTAL 
TABLES S2, S3, and S4. Four18,31,42,76 (8%, 4/50) 
compared articular mobilization alone 
with usual care,18 neural mobilization,31,42 
and sham mobilization.76 Ten (22%, 10
/50)5,6,19,25,35,44,48,49,54,77 included at least 1 
group with articular mobilization adjunct 
to usual care in comparison with wait and 
see, sham, or placebo intervention;6 usual 
care;5,6,19,25,35,44,48,49,54,77 and neural mobi-
lization in comparison with usual care.6 
TABLE 2 Risk of Bias of Included Studies (continued)
Studies Randomization Process
Deviations From 
Intended Interventions Missing Outcome Data Outcome Measurement
Selection of Reported 
Results Overrall
Panjwani51 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Prabhakar and 
Ramteke54
Some concerns Some concerns Low Low Some concerns Some concerns
Rafiq et al56 Low Some concerns Low Low Low Some concerns
Ragonese57 Low Some concerns Low Low Some concerns Some concerns
Rajalaxmi et al58 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Ranganath et al59 Low Some concerns Low Some concerns Some concerns Some concerns
Raval et al60 Low Low Low Some concerns Some concerns Some concerns
Rodríguez-Sanz et al61 Low Some concerns Low Low Some concerns Some concerns
Rodríguez-Sanz et al62 Low Some concerns Low Low Low Some concerns
Rodríguez-Sanz et al63 Low Some concerns Low Low Low Some concerns
Salt et al64 Low Some concerns Low Low Low Some concerns
Sambyal and Kumar65 Some concerns Some concerns Low Some concerns Some concerns Some concerns
Savva et al66 Low Some concerns Low Low Some concerns Some concerns
Savva et al67 Low Some concerns Low Low Low Some concerns
Shafique et al68 Low Some concerns Low Some concerns Some concerns Some concerns
Sudhakar et al70 Low Some concerns Low Low Some concerns Some concerns
Waqas et al74 Low Some concerns Low Some concerns Some concerns Some concerns
Young et al76 Some concerns Some concerns Low Low Low Some concerns
Zhang et al77 Low Some concerns Low Some concerns Some concerns Some concerns
The yellow color indicates “some concerns.” The green color indicates “low risk of bias”.
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[ literature review ]
DISCUSSION
w
e evaluated the effect of 
articular and neural mobilization 
on cervical radicular pain. We 
found very low– to moderate-certainty 
evidence supporting the positive effects 
of articular and neural mobilization on 
pain, and very low–certainty evidence of 
related disability associated with cervical 
radicular pain, particularly in the short 
term (0-12 weeks follow-up).
Our findings demonstrate a signifi-
cant positive impact of both articular 
and neural mobilization when compared 
Certainty of Evidence (GRADE)
TABLES 3 and 4 displayed the details of 
GRADE assessment showing RoB, inco-
herence, heterogeneity of the results, 
indirectness of evidence, imprecision of 
results, and probability of reporting bias.
Meta-regression
None of the covariates were statisti-
cally significant (P>.05) moderators of 
treatment effects on pain intensity (R2 = 
0.00%, I2 = 93.96%, P = .7485) or disability 
(R2 = 0.00%, I2 = 93.95%, P = .8603). 
More details are presented in SUPPLEMENTAL 
APPENDIX 3.
followed by the selection of reported re-
sults. Cohen’s kappa statistic for agree-
ment between researchers was 0.74. A 
third author was necessary 2 times.
Effects of Mobilization on Pain Intensity
The treatment network consisted of 45 
trials (41 double arm trials and 4 triple 
arm trials) (FIGURE 2). Neural and articu-
lar mobilization with usual care had mod-
erate certainty of evidence for a greater 
effect on pain intensity compared to wait 
and see, placebo, or sham intervention 
(MD, –3.23; 95% CI: –4.33, –2.12) and 
low certainty of evidence for usual care 
(MD, –1.52; 95% CI: –2.31, –0.73). 
Articular mobilization alone, neural mo-
bilization with usual care, and articular 
mobilization with usual care significantly 
reduced (P.05) on disability 
compared to the wait and see, placebo, 
sham intervention, or usual care. Direct 
and indirect effects are presented in TABLE 4. 
Funnel plot asymmetry and the Egger’s test 
(P = .054) suggested a low risk of publica-
tion bias (SUPPLEMENTAL FIGURE S2).
FIGURE 2. Netgraph of pain intensity. The netgraph is represented as follows: node size indicates the number of 
studies, node color represents the risk of bias, edge width corresponds to the sample size, and edge color denotes 
the average indirectness. The green color indicates average indirectness with no concerns. The yellow color 
indicates average risk of bias with some concerns. Abbreviations: AM, articular mobilization alone; AMUC, articular 
mobilization with usual care; NAM, neural and articular mobilization alone; NAMUC, neural and articular 
mobilization with usual care; NM, neural mobilization alone; NMUC, neural mobilization with usual care; UC, usual 
care; WSP, wait and see, sham intervention, or placebo.
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journal of orthopaedic & sports physical therapy | volume 55 | number 7 | july 2025 | 475
use of manual therapy either alone or 
alongside exercise. Our meta-analysis, 
with its substantial sample size, delves 
into the effects of articular and neural 
mobilization on pain intensity and dis-
ability in patients experiencing cervical 
lization techniques in managing pain. 
Our results also underscore the positive 
impact of neural mobilization in treating 
neck disorders characterized by nerve-
related symptoms.37,72 Guidelines34 for 
cervical radiculopathy advocate for the 
to other treatments, including wait and 
see, sham, or placebo interventions, in 
reducing pain and disability. A previous 
systematic review71 reported low-certainty 
evidence supporting the effectiveness of 
combined spinal and neurodynamic mobi-
TABLE 3
Summary of Certainty of Evidence (GRADE Approach With CINeMA Software) for 
Network Meta-analysis on Pain Intensity
Comparison N Direct Effect Indirect Effect NMA Effect RBe RoBc Ind. Impr. H. Inc. Certainty
AM vs AMUC 0 . –0.29 (–1.60, 1.02) –0.29 (–1.60, 1.02) NC SC NC NC MCa NC Very low
AM vs NAM 0 . –1.74 (–3.96, 0.48) –1.74 (–3.96, 0.48) NC SC NC SCb NC NC Low
AM vs NAMUC 0 . 0.14 (–1.24, 1.53) 0.14 (–1.24, 1.53) NC SC NC NC MCa NC Very low
AM vs NMUC 0 . 0.32 (–1.55, 0.91) –0.32 (–1.55, 0.91) NC SC NC NC SCd NC Low
AM vs NM 2 –1.38 (–2.99, 0.24) –0.04 (–1.67, 1.59) –0.71 (–1.86, 0.43) NC SC NC NC SCd
I2: 88.6%
NC
P = .25
Low
AM vs UC 1 –0.46 (–2.35, 1.43) –1.95 (–3.43, –0.46) –1.38 (–2.55, –0.21) NC SC NC NC SCd NC
P = .23
Low
AM vs WSP 1 –3.10 (–5.40, –0.80) –3.08 (–4.60, –1.55) –3.08 (–4.36, –1.81) NC SC NC NC NC NC
P = .99
Moderate
AMUC vs NAM 0 . –1.45 (–3.43, 0.52) –1.45 (–3.43, 0.52) NC SC NC SCb NC NC Low
AMUC vs NAMUC 1 2.47 (0.51, 4.43) –0.16 (–1.22, 0.90) 0.43 (–0.50, 1.36) NC SC NC NC SCd SC
P = .02
Very low
AMUC vs NM 0 . –0.43 (–1.36, 0.51) –0.43 (–1.36, 0.51) NC SC NC NC SCd NC Low
AMUC vs NMUC 2 –0.39 (–2.02, 1.23) 0.06 (–0.76, 0.89) –0.03 (–0.76, 0.71) NC SC NC NC MCa
I2: 76%
NC
P = .62
Very low
AMUC vs UC 9 –1.29 (–1.96, –0.63) –0.02 (–1.55, 1.51) –1.09 (–1.70, –0.48) NC SC NC NC SCd
I2: 89.6%
NC
P = .13
Low
AMUC vs WSP 1 –1.56 (–4.80, 1.68) –2.94 (–4.06, –1.82) –2.80 (–3.86, –1.74) NC SC NC NC NC NC
P = .43
Moderate
NAM vs NMUC 0 . 1.43 (–0.52, 3.37) 1.43 (–0.52, 3.37) NC SC NC SCb NC NC Low
NAM vs NM 0 . 1.03 (–0.99, 3.05) 1.03 (–0.99, 3.05) NC SC NC SCb NC NC Low
NAM vs UC 1 0.80 (–1.39, 2.99) –0.94 (–4.73, 2.85) 0.36 (–1.54, 2.26) NC SC NC SCb SCd NC
P = .44
Very low
NAM vs WSP 0 . –1.34 (–3.42, 0.73) –1.34 (–3.42, 0.73) NC SC NC SCb NC NC Low
NAM vs NAMUC 1 1.50 (–0.62, 3.62) 3.35 (–0.79, 7.49) 1.88 (–0.01, 3.77) NC SC NC SCb NC NC
P = .44
Very low
NAMUC vs NM 0 . –0.86 (–1.89, 0.18) –0.86 (–1.89, 0.18) NC SC NC NC SCd NC Low
NAMUC vs NMUC 1 –0.10 (–1.98, 1.78) –0.56 (–1.55, 0.43) –0.46 (–1.33, 0.42) NC SC NC NC SCd NC
P = .67
Low
NAMUC vs UC 6 –1.39 (–2.34, –0.45) –1.82 (–3.26, –0.38) –1.52 (–2.31, –0.73) NC SC NC NC SCd
I2: 32.2%
NC
P = .63
Low
NAMUC vs WSP 1 –1.60 (–3.86, 0.65) –3.74 (–5.01, –2.47) –3.23 (–4.33, –2.12) NC SC NC NC NC SC
P = .10
Moderate
NM vs UC 6 –0.64 (–1.48, 0.21) –0.74 (–2.11, 0.63) –0.66 (–1.38, 0.05) NC SC NC NC SCd
I2: 93.8%
NC
P = .90
Low
NM vs WSP 2 –2.99 (–4.38, –1.60) –1.86 (–3.13, –0.59) –2.37 (–3.31,–1.44) NC SC NC NC NC I2: 6.4% NC
P = .24
Moderate
NM vs NMUC 1 0.69 (–1.25, 2.63) 0.34 (–0.55, 1.23) 0.40 (–0.41, 1.21) NC SC NC NC SCd NC
P = .74
Low
NMUC vs UC 17 –1.06 (–1.53, –0.59) –1.61 (–3.09, –0.13) –1.00 (–1.50, –0.50) NC SC NC NC SCd
I2: 89.3%
NC
P = .44
Low
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476 | july 2025 | volume 55 | number 7 | journal of orthopaedic & sports physical therapy
[ literature review ]
radicular pain. Despite variations in evi-
dence certainty (from low to moderate), 
our analysis demonstrated a significant 
effect on pain. The most substantial 
effect with a narrow CI was observed 
when neural or articular mobilization 
was combined with usual care, surpassing 
the minimal clinically important dif-
ference in shoulder-related pain43 and 
cervical radiculopathy.75 Articular and 
neural mobilization could be beneficial 
in managing pain and associated disabil-
ity, although the evidence ranged from 
very low to moderate certainty, and the 
observed benefits were primarily short-
term, lasting 0 to 12 weeks.
Among the significant observations, 
the distinction in outcomes between 
articular and neural mobilization, espe-
cially when juxtaposed with alternative 
interventions, stands out. Combining artic-
ular with neural mobilization appeared to 
enhance the reduction in symptoms more 
significantly than other treatments. Neural 
mobilization may directly activate differ-
ent pathways to influence pain inhibitory 
mechanisms11 and has the potential to 
reduce intraneural edema. Reducing swell-
ing may enhance outcomes when neural 
mobilization is used in conjunction with 
other interventions.47 However, patient 
expectations, therapeutic alliance, and 
the setting in which care is delivered can 
TABLE 3
Summary of Certainty of Evidence (GRADE Approach With CINeMA Software) for 
Network Meta-analysis on Pain Intensity (continued)
Green color represents NC (no downgrade) or high certainty level of evidence. Blue color represents moderate certainty level of evidence. Yellow color represents 
SC (1-point downgrade) or low certainty level of evidence. Red color represents MC (2-point downgrade) very low certainty level of evidence.
Abbreviations: AM, articular mobilization; AMUC, articular mobilization with usual care; GRADE, Grading of Recommendations Assessment, Development, 
and Evaluation; H, heterogeneity; Impr., imprecision; Inc., incoherence; Ind., indirectness; LR, low risk; MC, major concerns; NAM, neural and articular mobilization; 
NAMUC, neural and articular mobilization with usual care; NC, no concerns; NM, neural mobilization; NMUC, neural mobilization with usual care; RB, 
reporting bias; RoB, within-studies risk of bias; SC, some concerns; UC, usual care; WSP, wait and see, sham, or placebo.
aPrediction interval extends into clinically important effects in both directions with and without substantial heterogeneity (I2>70%).
bConfidence interval extends into clinically important effects.
c>50% moderate or high risk of bias studies into comparison.
dPrediction interval extends into clinically important or unimportant effects with and without substantial heterogeneity (I2>70%).
eReporting bias was considered “undetected” based on funnel plot and Egger’s test.
Comparison N Direct Effect Indirect Effect NMA Effect RBe RoBc Ind. Impr. H. Inc. Certainty
NMUC vs WSP 3 –3.12 (–4.49, –1.75) –2.47 (–3.73, –1.21) –2.77 (–3.70, –1.84) NC SC NC NC NC NC
P = .49
Moderate
UC vs WSP 1 . –0.90 (–3.13, 1.33) –1.86 (–2.85, –0.87) –1.71 (–2.61, –0.80) NC SC NC NC SCd NC
P = .44
Low
FIGURE 3. Netgraph of disability. The netgraph is represented as follows: node size indicates the number of 
studies, node color represents the risk of bias, edge width corresponds to the sample size, and edge color denotes 
the average indirectness. Green color indicates average indirectness with no concerns. Yellow color indicates 
average risk of bias or indirectness with some concerns. Abbreviations: AM, articular mobilization alone; AMUC, 
articular mobilization with usual care; NAM, neural and articular mobilization alone; NAMUC, neural and articular 
mobilization with usual care; NM, neural mobilization alone; NMUC, neural mobilization with usual care; UC, usual 
care; WSP, wait and see, sham intervention, or placebo.
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journal of orthopaedic & sports physical therapy | volume 55 | number 7 | july 2025 | 477
factors—such as the ritual of hands-on 
care, the physical environment, and even 
the language used during therapy ses-
sions—can modulate the placebo and 
nocebo responses, potentially enhancing 
therapeutic outcomes, including pain 
reduction and improved function.11 It is 
also possible this mechanism might have 
an impact on patient-centered outcomes, 
such as pain and disability. Contextual 
significantly influence the efficacy of man-
ual therapy. Factors such as the patient’s 
beliefs about treatment, their previous 
experiences, and the perceived compe-
tence of the therapist contribute to the 
TABLE 4
Summary of Certainty of Evidence (GRADE Approach With CINeMA Software) for 
Network Meta-analysis on Disability
Comparison N Direct Effect Indirect Effect NMA Effect RBg RoBc Ind. Impr. H. Inc. Certainty
AM vs AMUC 0 . –0.55 (–2.10, 0.98) –0.55 (–2.10, 0.98) NC SC NC MCe NC N/A Very low
AM vs NAM 0 . –1.70 (–4.21, 0.80) –1.70 (–4.21, 0.80) NC SC NC MCe NC N/A Very low
AM vs NAMUC 0 . –0.29 (–1.88, 1.30) –0.29 (–1.88, 1.30) NC SC NC MCe NC N/A Very low
AM vs NMUC 0 . 0.19 (–1.26, 1.64) 0.19 (–1.26, 1.64) NC SC NC MCe NC N/A Very low
AM vs NM 1 –1.24 (–3.52, 1.04) 0.31 (–1.51, 2.14) –0.29 (–1.72, 1.13) NC SC NC MCe NC NC
P = .30
Very low
AM vs UC 1 –0.32 (–2.50, 1.86) –1.66 (–3.45, 0.14) –1.12 (–2.50, 0.27) NC SC NC SCb SCd NC
P = .35
Very low
AM vs WSP 1 –1.30 (–3.58, 0.97) –1.43 (–3.27, 0.40) –1.38 (–2.81, 0.04) NC SC NC SCb SCd NC
P = .93
Very low
AMUC vs NAM 0 . –1.15 (–3.35, 1.06) –1.15 (–3.35, 1.06) NC SC NC MCe NC N/A Very low
AMUC vs NAMUC 1 0.74 (–1.55, 3.04) 0.79 (–0.17, 1.75) 0.26 (–0.78, 1.31) NC SC NC SCb SCd NC
P = .64
Very low
AMUC vs NM 0 . 0.26 (–0.88, 1.41) 0.26 (–0.88, 1.41) NC SC NC MCe NC N/A Very low
AMUC vs NMUC 2 0.47 (–1.85, 2.79) 0.01 (–0.83, 0.83) 0.74 (–0.11, 1.63) NC SC NC SCb SCd NC
P = .80
Very low
AMUC vs UC 8 –0.65 (–1.45, 0.15) –0.18 (–1.81, 1.45) –0.56 (–1.28, 0.16) NC SC NC SCb SCd NC
P = .61
Very low
AMUC vs WSP 1 –0.09 (–2.45, 2.26) –1.04 (–2.31, 0.23) –0.83 (–1.94, 0.29) NC SC NC SCb SCd NC
P = .48
Very low
NAM vs NMUC 0 . 1.89 (–0.28, 4.06) 1.89 (–0.28, 4.06) NC SC NC SCb SCd N/A Very low
NAM vs NM 0 . 1.41 (–0.88, 3.69)) 1.41 (–0.88, 3.69) NC SC NC MCe NC N/A Very low
NAM vs UC 1 0.85 (–1.51, 3.21) –0.42 (–5.04, 4.19) 0.59 (–1.52, 2.69) NC SC NC MCe NC NC
P = .44
Very low
NAM vs WSP 0 . 0.32 (–1.95, 2.59) 0.32 (–1.95, 2.59) NC SC NC MCe NC N/A Very low
NAM vs NAMUC 1 1.14 (–1.23, 3.52) 2.40 (–2.13, 6.93) 1.41 (–0.69, 3.52) NC SC NC SCb SCd NC
P = .63
Very low
NAMUC vs NM 0 . –0.01 (–1.23, 1.22) –0.01 (–1.23, 1.22)NC SC NC MCe NC N/A Very low
NAMUC vs NMUC 1 –0.73 (–2.99,1.53) 0.76 (–0.33, 1.86) 0.48 (–0.51, 1.47) NC SC NC SCb SCd NC
P = .24
Very low
NAMUC vs UC 5 –0.77 (–1.80, 0.26) –0.96 (–2.58, 0.65) –0.83 (–1.69, 0.04) NC SC NC SCb SCd NC
P = .84
Very low
NAMUC vs WSP 1 –1.33 (–2.68, 0.01) –0.43 (–2.67, 1.82) –1.09 (–2.25, 0.06) NC SC NC SCb SCd NC
P = .5
Very low
NM vs UC 4 –1.56 (–3.13, 0.01) –0.43 (–1.57, 0.71) –0.82 (–1.75, 0.10) NC SC NC SCb SCd
I2: 98.5%
NC
P = .25
Very low
NM vs WSP 2 –2.30 (–3.92, –0.69) –0.18 (–1.58, 1.22) –1.09 (–2.15, –0.03) NC SC NC NC MCf
I2: 9.9%
SC
P = .05
Very low
NM vs NMUC 1 0.65 (–1.61, 2.92) 0.44 (–0.69, 1.57) 0.48 (–0.53, 1.50) NC SC NC SCb MCf
I2: 93.4%
NC
P = .87
Very low
NMUC vs UC 14 –1.44 (–2.06, –0.82) –0.40 (–2.01, 1.22) –1.31 (–1.88, –0.73) NC SC NC NC SCd
I2: 89.3%
NC
P = .24
Very low
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478 | july 2025 | volume 55 | number 7 | journal of orthopaedic & sports physical therapy
[ literature review ]
A sensitivity analysis considering 
each individual domain of RoB 2 could 
not be performed due to the limita-
tions of the CINeMA software. Future 
studies could address this limitation by 
conducting manual sensitivity analyses 
using statistical software or exploring 
alternative meta-analysis tools that 
support domain-specific RoB 2 assess-
ments. Finally, deviations from the ini-
tial protocol were made. The RoB 1 tool, 
initially used for RoB assessment, was 
updated to RoB 2. The TIDieR check-
list, which was not originally planned, 
was also included based on editorial 
suggestions. Although meta-regression 
analyses were not initially intended, 
they were conducted to explore the 
heterogeneity found and to enhance the 
precision of the results.
Clinical and Research Implications
We recommend (with evidence ranging 
from very low to moderate certainty) 
incorporating neural and articular mobi-
lization alongside standard care to allevi-
ate pain and disability in individuals with 
cervical radiculopathy. This recommen-
dation aligns with previous guidelines 
advocating for manual therapy in treat-
ing cervical radicular pain.13,34 However, 
it remains unclear whether the observed 
Due to the heterogeneity and the 
inability to group these study charac-
teristics, they were not included in the 
meta-regression or subgroup analysis, 
which could influence the results. A minor 
proportion of the randomized controlled 
trials (10%) included were of low quality 
(assessed by the PEDro scale). The RoB 
2 tool classified all trials as having “some 
concerns,” which eventually downgraded 
the overall quality of the meta-analysis 
according to the GRADE assessment. 
The primary factors contributing to 
downgrading of evidence certainty were 
RoB and heterogeneity.
Future high-quality clinical trials ex-
ploring the mid- to long-term impacts 
of neural mobilization might present 
alternative findings. Despite concerns 
about potential heterogeneity due to 
variations in methodological quality, diag-
nostic criteria, and the use of imaging, 
the meta-regression revealed that none 
of these factors significantly moderated 
the intervention’s effects on pain and dis-
ability. Therefore, our findings should be 
interpreted with caution, as unmeasured 
or unaccounted factors, including poten-
tial heterogeneity related to the RoB, 
sample characteristics, and intervention 
details, may have influenced the observed 
outcomes.
the clinical effects of interventions.12 
Specifically, in the context of manual 
therapy, up to 88% of the observed effect 
in mobilization could be attributed to non-
specific effects such as patient expectations, 
the therapist’s behavior, and the therapeutic 
setting.20 The success of neural and artic-
ular mobilization is likely less influenced 
by specific mechanical or biological fac-
tors and is more enhanced by the patient’s 
expectations, psychosocial factors, and 
contextual cues, which together amplify 
the therapeutic effect.
Strengths and Limitations
The generalizability of our analysis is 
confined to its acknowledged strengths 
and limitations. Its merits include a thor-
ough literature review, methodological 
precision, comprehensive data extrac-
tion, detailed statistical analysis, and the 
selection of randomized controlled trials 
for several databases. However, it faces 
limitations due to the varied application 
of neural or articular mobilization—dif-
fering in dosage, frequency, and in com-
bination with interventions of varying 
evidence levels. The diversity in neural 
or articular mobilization practices among 
these trials hinders the formulation of 
broad conclusions about its effectiveness 
as a therapeutic measure.
TABLE 4
Summary of Certainty of Evidence (GRADE Approach With CINeMA Software) for 
Network Meta-analysis on Disability (continued)
Green color represents NC (no downgrade) or high certainty level of evidence. Blue color represents moderate certainty level of evidence. Yellow color represents 
SC (1-point downgrade) or low certainty level of evidence. Red color represents MC (2-point downgrade) or very low certainty level of evidence.
Abbreviations: AM, articular mobilization; AMUC, articular mobilization with usual care; H, heterogeneity; Impr., imprecision; Inc., incoherence; Ind., 
indirectness; LR, low risk; MC, major concerns; NAM, neural and articular mobilization; NAMUC, neural and articular mobilization with usual care; NC, no 
concerns; NM, neural mobilization; NMUC, neural mobilization with usual care; RB, reporting bias; RoB, within-studies risk of bias; SC, some concerns; UC, 
usual care; WSP, wait and see, sham, or placebo.
aPrediction interval extends into clinically important effects in both directions with and without substantial heterogeneity (I2>70%).
bConfidence interval extends into clinically important effects.
cSC: >50% some concerns.
dPrediction interval extends into clinically important or unimportant effects with and without substantial heterogeneity (I2>70%).
eConfidence interval extends into clinically important effects in both directions.
fPrediction interval extends into clinically important effects in both directions.
gReporting bias was considered “undetected” based on funnel plot and Egger’s test.
Comparison N Direct Effect Indirect Effect NMA Effect RBg RoBc Ind. Impr. H. Inc. Certainty
NMUC vs WSP 3 –0.98 (–2.30, 0.34) –2.25 (–3.66, –0.84) –1.57 (–2.53, –0.61) NC SC NC NC MCf NC
P = .20
Very low
UC vs WSP 1 . –0.46 (–2.71, 1.80) –0.23 (–1.26, 0.80) –0.27 (–1.20, 0.67) NC SC NC SCb SCd NC
P = .85
Very low
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Biological, mechanical or physical? Conservative 
treatment of cervical radiculopathy. Ortop 
manuscript, (6) providing facilities, and 
(7) providing subjects.
DATA SHARING: Data are available upon 
request. The data that support the 
findings of this study are available from 
the first author.
PATIENT AND PUBLIC INVOLVEMENT: Partici-
pants were not involved in the design, 
conduct, reporting, or dissemination 
plans of our research.
 
REFERENCES
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Effect of combined neural mobilization and 
intermittent traction in patients with cervi-
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versus intermittent cervical traction in unilateral 
cervical radiculopathy on pain, range of motion 
and quality of life - a comparative study. Research 
benefits were exclusively due to mobili-
zation or other therapeutic approaches, 
as no significant differences were found 
between usual care alone and mobiliza-
tion treatments, except when neural and 
articular mobilization was combined 
with usual care specifically for pain 
intensity, not disability. Integrating neural 
and articular mobilization with other 
therapeutic techniques may offer practical 
benefits for clinicians who are aiming 
to reduce pain and improve function. 
Future investigations should include 
large sample size to guarantee a reduc-
tion in imprecision of results and high 
methodological quality to improve the 
overall certainty of evidence.
CONCLUSION
a
rticular and neural mobiliza-
tion had very low to moderate evi-
dence of a positive effect on pain 
and related disability for people with 
cervical radicular pain. The effect was 
observed at short-term only. t
KEY POINTS
FINDINGS: Integrating articular and neural 
mobilization with usual care was the 
most effective strategy for mitigating 
short-term intensity of cervical radicular 
pain. Comparative analyses revealed 
no significant differences in outcomes 
related to pain and disability across 
different modalities and combinations 
of mobilization.
IMPLICATIONS: Incorporating neural 
mobilization with usual care is the 
superior approach for alleviating 
short-term disability related to 
cervical pain.
CAUTION: The certainty of evidence 
ranged from moderate to very low.
STUDY DETAILS
AUTHOR CONTRIBUTIONS: All the authors 
equally contributed on (1) concept/
idea/research design, (2) acquisition 
of data, (3) analysis and interpretation 
of data, (4) writing/review/editing of 
manuscript, (5) final approval of the 
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