The Effects of Spinal Mobilization Added to an Exercise Program in Recreational Tennis Players With Mechanical

The Effects of Spinal Mobilization Added to an Exercise Program on Pain and Physical Fitness in Recreational Tennis Players With Mechanical

This prospective, single-blind, parallel-group randomized controlled trial evaluated whether adding cervical and thoracic spinal mobilization (Maitland concept, grades I-IV) to a structured home therapeutic exercise program improves pain intensity and physical fitness parameters in recreational tennis players with mechanical neck pain. Thirty adults aged 18-45 years with body mass index (BMI) of 18-30 kg/m² and mechanical neck pain (Visual Analog Scale, VAS > 4) lasting more than one week were randomized 1:1 into a Control Group (CG, n=15) performing an unsupervised 21-session home exercise program (one session per day for three weeks) and an Experimental Group (EG, n=15) performing the identical home exercise program plus four therapist-delivered sessions of cervical and upper thoracic spinal mobilization (one at baseline and one per week thereafter, across three weeks). Outcomes assessed at baseline (Week 0) and post-intervention (Week 3) included VAS for pain during physical activity, at rest, and during sleep; cervical range of motion measured with a Cervical Range of Motion (CROM) device; isometric neck muscle strength (handheld dynamometer); pinch and hand grip strength; ruler-drop reaction time; sit-and-reach flexibility; and vertical jump performance assessed with the My Jump Lab application.

Study Overview

• Status: Completed
• Conditions: Pain; Mechanical Neck Pain; Manual Therapy; Therapeutic Exercise; Tennis
• Intervention / Treatment: Behavioral: Behavioral: Home Therapeutic Exercise Program; Procedure: Maitland Cervical and Upper Thoracic Spinal Mobilization

Detailed Description

Design: Prospective, single-blind, randomized controlled, two-arm parallel-group superiority trial. Eligible adults aged 18-45 years (BMI 18-30 kg/m²) who were recreational tennis players (playing tennis at least twice weekly, ≥2 hours/week) and presented with mechanical neck pain (>1 week duration, VAS > 4, reduced cervical range of motion confirmed by the cervical flexion-rotation test, and tenderness on external pressure over at least one cervical joint) were enrolled after providing written informed consent. Participants were allocated 1:1 to one of two groups using simple randomization with sealed opaque envelopes. The outcome assessor was blinded to group allocation (single-blind, assessor masking).

Interventions: Both groups completed an identical structured home exercise program lasting three weeks (21 daily sessions). The program comprised stretching of the upper trapezius, right and left levator scapulae, hamstring, and lumbar extensor muscles (30-second holds, 5 repetitions, 3 sets), isometric resistance exercises for cervical flexion, extension, and right and left lateral flexion (10-second holds with 10-second rests, 5 repetitions, 3 sets), the chin-tuck exercise (10-second holds, 5 repetitions, 3 sets), and the cat-camel exercise (10-second holds in each position, 5 repetitions, 3 sets). Written instructions illustrated by figures were provided to ensure correct execution and adherence. The Experimental Group received the same home program plus a Maitland-concept spinal mobilization protocol delivered by a physiotherapist over four supervised sessions (one at baseline and one per week, total of four sessions across three weeks). Cervical mobilization was applied with the participant prone, the therapist standing at the head, and bilateral thumb pressure applied over the facet joint or spinous process of the targeted hypomobile vertebra; grades I-II were used when pain preceded the motion limit and grades III-IV when the motion limit preceded pain, with oscillations at 2-3 Hz performed for approximately 30 seconds per bout, 3-4 bouts per segment, with 1-minute rest between bouts. Upper thoracic mobilization aimed to increase upper-thoracic extension, applying the same dosage as the cervical mobilization, performed with anterior-to-posterior pressure on the transverse processes of the targeted segments.

Assessments: Pre-intervention (Week 0) and post-intervention (Week 3) measurements were performed in a fixed order with rest intervals. Pain intensity was assessed using a 10 cm Visual Analog Scale (VAS) for pain during physical activity, at rest, and during sleep. Cervical active range of motion (flexion, extension, right and left lateral flexion, right and left rotation) was measured with a Cervical Range of Motion (CROM) device with the participant in upright sitting (three measurements per direction, recorded in degrees). Isometric neck muscle strength for flexion, extension, and bilateral lateral flexion was measured using a handheld dynamometer (JTECH Medical Commander Echo MMT) with the participant seated; the maximum of three 3-second contractions was averaged and recorded in kilograms-force. Hand grip strength (hydraulic hand dynamometer) and pinch grip strength (pinch meter) were measured bilaterally in standardized seated posture with elbow at 90° flexion (mean of three trials, kilograms). Reaction time was assessed bilaterally using the Ruler Drop Test with a 60 cm ruler. Vertical jump height was measured using the validated My Jump Lab smartphone application (iPhone 15 Pro Max on a tripod 20 cm above the floor), with three trials and the highest, lowest, and mean values recorded. Flexibility was measured by the sit-and-reach test (three trials, recorded in centimeters).

Statistical Analysis: Sample size of 30 (15 per group) was based on study termination criteria. Descriptive statistics included mean ± standard deviation, median with 25th-75th percentiles, and frequencies. Normality was tested with the Shapiro-Wilk test. Within-group changes were analyzed using paired-samples t-tests for normally distributed variables and the Wilcoxon signed-rank test for non-normally distributed variables; between-group comparisons of change scores used independent-samples t-tests or the Mann-Whitney U test as appropriate. Categorical variables were compared using chi-square tests. Statistical significance was set at p < 0.05. Analyses were performed in IBM SPSS Statistics. There was no external funding for this study and the investigators declare no conflicts of interest.

• Study Type: Interventional
• Enrollment (Actual): 30
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Turkey (Türkiye)
  • Istanbul, Turkey (Türkiye)
    • Istinye University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

• Age between 18 and 45 years.
• Body Mass Index (BMI) between 18 and 30 kg/m².
• Recreational tennis player, playing tennis at least 2 days per week and at least 2 hours per week.
• Mechanical neck pain triggered by neck movement or sustained positions on the symptomatic side.
• Reduced cervical range of motion as confirmed by a positive cervical flexion-rotation test.
• Pain elicited by external pressure over at least one cervical zygapophyseal (facet) joint.
• Neck pain of at least 1 week duration, with intensity greater than 4/10 on the Visual Analog Scale (VAS), not associated with any specific medical history.
• Able to communicate in Turkish or English (verbal and written).
• Free from systemic, orthopedic, neurological, chronic, or psychiatric disease.

Exclusion Criteria:

• Neck pain of more than 6 months duration.
• Concomitant sensory loss (paresthesia, hypoesthesia, or anesthesia).
• Pain radiating to the upper extremities (radicular symptoms).
• History of long-term systemic corticosteroid use.
• Regular use of medications affecting musculoskeletal performance or pain perception.
• Sequelae from prior injury or any surgical history involving the cervical or thoracic spine.
• Prior interventional procedures targeting the neck region (e.g., injection therapy).
• Pregnancy or suspected pregnancy.
• During the study: pain greater than 3/10 on VAS during sessions, three consecutive missed sessions, incident illness or trauma, withdrawal request, or failure to meet exercise progression criteria.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Active Comparator: Control Group (CG); Control Group (CG, n=15): Participants performed an unsupervised structured home therapeutic exercise program for three weeks (one session per day; 21 sessions total). The program comprised bilateral stretching of the upper trapezius and levator scapulae muscles, hamstring and lumbar extensor stretching, isometric resistance exercises for cervical flexion, extension, and bilateral lateral flexion, the chin-tuck exercise, and the cat-camel exercise. Written instructions with illustrations were provided	Behavioral: Behavioral: Home Therapeutic Exercise Program; Three weeks (21 daily sessions) of unsupervised home exercises supported by written and illustrated instructions. Components included bilateral upper trapezius and levator scapulae stretching, hamstring and lumbar extensor stretching, isometric cervical flexion / extension / bilateral lateral flexion exercises, chin-tuck exercise, and cat-camel exercise.
Experimental: Experimental: Experimental Group (EG); Experimental Group (EG, n=15): Participants performed the identical home therapeutic exercise program as the Control Group AND received four supervised sessions of Maitland-concept spinal mobilization (cervical and upper thoracic) delivered by a physiotherapist (one session at baseline and one session per week thereafter, total of four sessions across three weeks). Mobilizations used grades I-IV depending on the relationship between pain and motion limit, with oscillations at 2-3 Hz, ~30 seconds per bout, 3-4 bouts per segment, and 1-minute rest between bouts.	Behavioral: Behavioral: Home Therapeutic Exercise Program; Three weeks (21 daily sessions) of unsupervised home exercises supported by written and illustrated instructions. Components included bilateral upper trapezius and levator scapulae stretching, hamstring and lumbar extensor stretching, isometric cervical flexion / extension / bilateral lateral flexion exercises, chin-tuck exercise, and cat-camel exercise.; Procedure: Maitland Cervical and Upper Thoracic Spinal Mobilization; Therapist-delivered passive oscillatory mobilization to hypomobile cervical and upper thoracic segments using grades I-IV per the Maitland concept; oscillation rate 2-3 Hz; ~30-second bouts; 3-4 bouts per segment; 1-minute rest between bouts. Total of four supervised sessions (one at baseline, then once per week) across three weeks.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain intensity - Visual Analog Scale (VAS) during physical activity (0-10 cm)	Self-reported pain intensity rated by the participant on a 10 cm horizontal Visual Analog Scale anchored from "no pain" (0) to "worst imaginable pain" (10), scored to one decimal in centimeters; lower scores indicate less pain. Safety Issue: No.	Baseline (Week 0) and Post-Intervention (Week 3)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain intensity - Visual Analog Scale (VAS) at rest and during sleep (0-10 cm)	Self-reported pain intensity rated separately during rest and sleep on a 10 cm Visual Analog Scale; lower scores indicate less pain. Safety Issue: No.	Baseline (Week 0) and Post-Intervention (Week 3)
Cervical Range of Motion (CROM) - degrees	Active cervical range of motion in flexion, extension, right and left lateral flexion, and right and left rotation measured with a Cervical Range of Motion (CROM) device (three inclinometers with magnetic compass) in upright sitting; results recorded in degrees; higher values indicate greater mobility. Safety Issue: No.	Baseline (Week 0) and Post-Intervention (Week 3)
Isometric Neck Muscle Strength - kilograms-force (kgf)	Maximal isometric strength of cervical flexors, extensors, and right and left lateral flexors measured using a handheld dynamometer (JTECH Medical Commander Echo MMT) with the dynamometer placed on the forehead, external occipital protuberance, or above the right/left ear, respectively; participants performed three 3-second maximal contractions per direction and the mean was recorded in kgf. Safety Issue: No	Baseline (Week 0) and Post-Intervention (Week 3)
Hand Grip Strength - kilograms (kg)	Maximal isometric grip strength of the right and left hands measured using a hydraulic hand dynamometer with the participant seated, shoulder adducted in neutral rotation, elbow at 90° flexion, and forearm/wrist in neutral position; the mean of three trials per hand was recorded in kilograms. Safety Issue: No.	Baseline (Week 0) and Post-Intervention (Week 3)
Pinch Grip Strength - kilograms (kg)	Maximal pinch (key/lateral) strength of the right and left hands between the thumb and index finger measured using a calibrated pinch meter with the participant seated, elbow at 90° flexion, and wrist in neutral; the mean of three trials per hand was recorded in kilograms. Safety Issue: No	Time Frame: Baseline (Week 0) and Post-Intervention (Week 3)
Reaction Time - Ruler Drop Test (centimeters)	Reaction time of the right and left hands measured using the Ruler Drop Test with a 60 cm ruler; the participant attempts to catch the ruler as quickly as possible after an unannounced release, and the catch distance (in centimeters) is recorded. Lower values indicate faster reaction time. Safety Issue: No.	Baseline (Week 0) and Post-Intervention (Week 3)
Vertical Jump Height - centimeters (cm)	Countermovement vertical jump height measured using the validated My Jump Lab smartphone application (iPhone 15 Pro Max mounted on a tripod 20 cm above the floor); participants performed three jumps with hands on the iliac crests; the highest, lowest, and mean jump heights were recorded in centimeters. Higher values indicate greater lower-limb power. Safety Issue: No.	Baseline (Week 0) and Post-Intervention (Week 3)
Sit-and-Reach Test (centimeters)	Flexibility measured with the standard sit-and-reach test (legs extended, knees in extension, feet against a fixed reference platform); reach distance was recorded in centimeters as the mean of three trials. Higher values indicate greater flexibility. Safety Issue: No.	Baseline (Week 0) and Post-Intervention (Week 3)

Collaborators and Investigators

• Sponsor: Istinye University

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2025
• Primary Completion (Actual): July 15, 2025
• Study Completion (Actual): August 1, 2025

Study Registration Dates

• First Submitted: May 3, 2026
• First Submitted That Met QC Criteria: May 3, 2026
• First Posted (Actual): May 8, 2026

Study Record Updates

• Last Update Posted (Actual): May 8, 2026
• Last Update Submitted That Met QC Criteria: May 3, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: pain; therapeutic exercise; Manual therapy; Tennis; Mechanical neck pain
• Additional Relevant MeSH Terms: Neurologic Manifestations; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Pain
• Other Study ID Numbers: tennis neck 25-77

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No