Which treatment works better for chronic neck pain? Manual therapy or instrument-assisted soft tissue mobilization? A randomized controlled trial

Abstract

Aim This study aimed to compare the effects of manual therapy and instrument-assisted soft tissue mobilization (IASTM) on pain intensity, neck-related disability, cervical muscle endurance, and cervical range of motion (ROM) in individuals with chronic neck pain (CNP). Methods This prospective randomized controlled trial included 24 individuals diagnosed with CNP, who were randomly allocated to either a Manual Therapy group or an IASTM group (n = 12 per group). Both groups received supervised physiotherapy interventions three times per week for four weeks. Pain intensity was assessed using the Visual Analog Scale (VAS), disability using the Neck Disability Index (NDI), cervical muscle endurance, and cervical ROM. Results Both groups showed significant improvements in pain intensity, disability, cervical muscle endurance, and cervical ROM after the intervention period (p < 0.05). Between-group analyses demonstrated significantly greater improvements in pain (p = 0.007), disability (p = 0.001), and cervical muscle endurance (p = 0.045) in the Manual Therapy group compared to the IASTM group. No significant between-group differences were observed for cervical ROM outcomes (p > 0.05). Effect size analysis revealed large effects for pain and disability, a moderate effect for cervical muscle endurance, and small effects for ROM measures. Conclusion Both manual therapy and IASTM were effective in improving short-term clinical outcomes in individuals with CNP. However, manual therapy demonstrated superior effects, particularly in reducing pain and disability and enhancing cervical muscle endurance, suggesting greater early clinical benefits compared to IASTM.

Keywords

Introduction

Chronic neck pain (CNP) is a common musculoskeletal disorder that adversely affects quality of life and imposes a significant burden on healthcare systems. Epidemiological studies report that the lifetime prevalence of neck pain is approximately 30%, while CNP affects 10%–24% of the general population.1 Although prevalence varies, neck pain affects individuals across all age groups, and its global frequency continues to rise.2 Neck pain is among the most frequent reasons for healthcare visits and is associated with work absenteeism, sleep disturbances, reduced daily activity levels, and impaired quality of life.3 Neck pain lasting longer than 12 weeks is typically defined as chronic and is often accompanied by recurrent episodes, disability, and substantial socioeconomic burden.4,5 Its etiology is multifactorial, involving biomechanical factors such as degenerative cervical changes, postural abnormalities, muscular strain, trauma, disc pathology, and nerve root irritation, along with psychosocial factors including stress, anxiety, and depression.6
Management of CNP requires a multimodal approach integrating pharmacological and non-pharmacological strategies. Pharmacological options include nonsteroidal anti-inflammatory drugs, opioid analgesics, intramuscular or epidural injections, and antidepressants.7 Non-pharmacological approaches encompass patient education, lifestyle modification, cognitive-behavioral therapy, traction, complementary techniques, and physiotherapy-based rehabilitation.8 International guidelines strongly recommend manual therapy and therapeutic exercise for CNP, with their effectiveness supported by several meta-analyses.9
Manual therapy is a cornerstone of physiotherapy practice owing to its ability to reduce pain, improve cervical mobility, and enhance neuromuscular function.9 Soft tissue techniques aim to release adhesions, increase circulation, reduce hypomobility, and normalize neuromuscular activity through methods such as myofascial release, transverse friction massage, deep tissue techniques, classical massage, and instrument-assisted mobilization.10 The Graston Technique (GT), an instrument-assisted approach, is designed to mobilize fascial restrictions, enhance circulation, and improve muscle function through fibroblast activation and collagen synthesis.9,10 Despite the established benefits of manual therapy in CNP, evidence comparing the superiority or comparative effectiveness of different manual techniques remains limited.11
Therefore, the present study aims to comparatively evaluate the effects of instrument-assisted soft tissue mobilization and traditional manual therapy on pain intensity, neck-related disability, cervical muscle endurance, and cervical range of motion (ROM) in individuals with CNP. By providing comparative clinical data, this study seeks to contribute to evidence-based strategies for the management of CNP.

Materials and Methods

This study was designed as a prospective and randomized controlled study. The study was conducted between 31 August and 30 October 2025 in accordance with the Declaration of Helsinki and registered at ClinicalTrials.gov (NCT07169084). All participants provided written informed consent after being informed of the study objectives, procedures, and interventions. Outcome assessors were blinded, with allocation determined via www.random.org. However, due to the nature of the interventions, neither the participants nor the physiotherapists administering the programs could be blinded to group assignments. The flow of participants through the study is illustrated in Figure 1.
Within the framework of the International Classification of Functioning, Disability and Health (ICF) by the World Health Organization, neck pain is defined as a prevalent health problem with the potential to adversely impact daily activities, social participation, and quality of life. In the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), the code “M54.2—cervicalgia” is classified as a general category encompassing both acute (≤3 months) and chronic (>3 months) neck pain.12
Participants were recruited from patients referred by a university hospital with clinical symptoms of neck pain. All participants had been diagnosed with CNP by specialists in orthopedics or physical medicine and rehabilitation, based on a symptom duration of at least 12 weeks and a clinical examination excluding specific spinal pathologies or neurological disorders.
Inclusion criteria were: age 18–40 years; diagnosis of CNP (less than or equal to 12 weeks of pain); a visual analog scale (VAS) score ≥ 3 cm (clinically relevant pain);Metin girmek için buraya tıklayın veya dokunun.13 and voluntary participation.
Exclusion criteria were: previous cervical surgery; history of acute trauma, fracture, or dislocation; neurological deficits; inflammatory or systemic rheumatic diseases; malignancy; severe cardiovascular or neurological disorders; participation in a similar cervical rehabilitation program within the previous six months; corticosteroid use; pregnancy; illiteracy; missing three consecutive treatment sessions; development of complications during or after the intervention; or failure to meet the diagnostic criteria for chronic pain.Outcome MeasuresParticipants were randomly assigned to two groups using www.random.org: the Manual Therapy group and the Instrument-Assisted Soft Tissue Mobilization (IASTM) group. All outcomes were assessed at baseline and following completion of the four-week intervention.
Primary outcome measures were pain intensity, assessed with the VAS13, and disability, assessed with the Neck Disability Index (NDI)Metin girmek için buraya tıklayın veya dokunun..14
Secondary outcome measures included cervical muscle endurance, evaluated through standardized flexor and extensor endurance testsMetin girmek için buraya tıklayın veya dokunun.,15 and cervical ROM, measured with a goniometer in flexion, extension, right/left rotation, and lateral flexion.
Pain Intensity: pain intensity was assessed using a 10-cm VAS, anchored by “no pain” and “worst imaginable pain.” The VAS is widely used for musculoskeletal pain and demonstrates high reliability (intraclass correlation coefficient [ICC] = 0.82). The Turkish version has been validatedMetin girmek için buraya tıklayın veya dokunun..13 The minimum clinically important difference (MCID) for neck pain was accepted as 1.4 cm. In this study, the VAS was administered twice at four-week intervals.
Disability: neck-related disability was evaluated using the NDI, a reliable and widely utilized instrument for quantifying disability associated with neck painMetin girmek için buraya tıklayın veya dokunun..14 Higher scores indicate greater levels of disability.
Range of Motion: cervical range of motion (flexion, extension, rotation, and lateral flexion) was measured using a standard goniometer. The validity and reliability of goniometric assessment for cervical ROM have been supported in the literature, allowing objective monitoring of cervical mobility.
Cervical endurance: evaluated with standardized tests for deep cervical flexors and postural extensors, recognized as reliable and valid with high inter-rater reliabilityMetin girmek için buraya tıklayın veya dokunun..15InterventionsBoth groups received supervised physiotherapy sessions three times per week for four weeks. In the IASTM group, treatment was applied to the suboccipital muscles, upper trapezius, levator scapulae, cervical paraspinals, and thoracodorsal fascia using specialized instruments. Longitudinal and transverse strokes were used to generate controlled hyperemia without excessive mechanical load. Each session began with a brief warm-up and ended with stretching and activation exercises targeting the deep cervical flexors and scapular stabilizers.
In the manual therapy group, posterior–anterior mobilizations, lateral glides, suboccipital release, and manual traction were administered to hypomobile cervical and upper thoracic segments following Maitland principles. When clinically indicated, scapulothoracic mobilizations and first-rib techniques were incorporated. Interventions were delivered in 2–3 sets with reassessment after each setMetin girmek için buraya tıklayın veya dokunun.,16 and all outcome measures were reassessed at the end of the four-week intervention period.Sample Size CalculationThe a priori sample size was calculated using G*Power v3.1.9.4 (Universität Düsseldorf, Germany) based on the effect size derived from pain intensity (VAS) changes reported by Shewail et al.17 Using this effect size (d ≈ 0.60) with α = 0.05 and a power of 0.80, the minimum required total sample size was estimated as 22 participants. To account for a potential 10% attrition rate, 24 individuals were recruited and randomly allocated equally into two groups (n = 12 per group).Ethical ApprovalThis study was approved by the Non-Interventional Clinical Research Ethics Committee of Istanbul Medipol University (Date: 2025-08-28, No: E-10840098-202.3.02-5805).Statistical AnalysisData analysis was performed using SPSS version 26 (SPSS Inc., USA). The Shapiro–Wilk test was used to assess the normality of data distribution. Between-group comparisons of categorical variables were conducted with the Chi-square test. For continuous variables, parametric tests (Independent Samples t-test for between-group and Paired Samples t-test for within-group analyses) were applied when normality assumptions were met, whereas non-parametric alternatives (Mann–Whitney U and Wilcoxon signed-rank tests, respectively) were used when variables were not normally distributed. A p-value of <0.05 was considered statistically significant. Effect sizes (Cohen’s d) were calculated, with 0.2, 0.5, and 0.8 indicating small, moderate, and large effects.Reporting GuidelinesThis study is reported in accordance with the CONSORT guidelines.

Discussion

CNP represents a major public health concern, reducing patients’ quality of life, leading to functional limitations, and substantially increasing healthcare expenditures. A wide range of conservative rehabilitation strategies has been employed in its management, including manual therapy and IASTM. Manual therapy, through mobilization and manipulation techniques, primarily aims to modulate pain, enhance ROM, and improve neuromuscular control. By contrast, instrument-assisted approaches achieve comparable therapeutic outcomes by addressing myofascial restrictions and improving inter-tissue gliding properties. Although both modalities have been shown to improve pain, disability, and postural control in multiple randomized controlled trials and systematic reviews, evidence directly comparing their relative effectiveness remains limited. In this randomized controlled trial, both IASTM and manual therapy resulted in significant improvements in pain, disability, cervical muscle endurance, and range of motion in individuals with CNP. However, between-group analyses demonstrated that manual therapy was superior, particularly in reducing pain intensity, decreasing disability levels, and enhancing cervical muscle endurance. These findings suggest that while both interventions are clinically valuable, manual therapy may provide comparatively greater benefits in alleviating pain and reducing disability.
Recent evidence supports the analgesic effects of both manual therapy and IASTM in CNP11, and our results are consistent with this body of literature. Improvements observed in the IASTM group may be attributed to the release of myofascial restrictions, stimulation of fibroblast activity, and remodeling of collagen fibers, thereby enhancing tissue gliding properties. These biomechanical processes are thought to reduce mechanical stress and promote analgesiaMetin girmek için buraya tıklayın veya dokunun..18 In the manual therapy group, a greater reduction in pain was observed, which is consistent with literature proposing that mobilization and manipulation may engage segmental inhibitory pathways and central pain modulation mechanismsMetin girmek için buraya tıklayın veya dokunun..19 The comparatively greater effects of manual therapy observed in our between-group analysis may be attributed to the rapid hypoalgesic neurophysiological responses associated with manipulative techniques.
NP not only manifests as pain but also leads to significant declines in disability by limiting activities of daily living. The functional improvements observed with IASTM may be related to enhanced tissue extensibility and the reduction of myofascial restrictions, which facilitate more efficient movement patterns. Improvements observed in our study align with those reported by Abdel-Aal et al. (2021)Metin girmek için buraya tıklayın veya dokunun.,20 who demonstrated that adding the Graston technique to an exercise program led to greater reductions in pain and improvements in neck disability and range of motion compared to exercise alone. In manual therapy, functional enhancement is likely mediated by increased proprioceptive feedback and improved muscle activation secondary to joint mobilization, a mechanism supported by Dunning et al. (2012)Metin girmek için buraya tıklayın veya dokunun.,21 who showed superior outcomes with manipulation compared to mobilization and exercise in patients with cervicogenic headache. This mechanism aligns with the findings of Dunning et al. (2012)21Metin girmek için buraya tıklayın veya dokunun. who observed reduced functional disability, and with the meta-analysis of Gross et al. (2015)Metin girmek için buraya tıklayın veya dokunun.,19 which supported functional benefits of mobilization and manipulation. The greater improvements in disability levels observed in the manual therapy group suggest that this approach may offer additional benefits not only for reducing pain but also for enhancing overall functional ability.
Reduced cervical muscle endurance is consistently reported in individuals with CNP. The improvements observed with IASTM may be related to increased inter-tissue mobility and subsequent enhancements in muscular performance. This finding supports previous research indicating that Graston therapy combined with exercise leads to greater gains in endurance compared to exercise alone, as demonstrated by Yana et al. (2019)Metin girmek için buraya tıklayın veya dokunun..22 However, the more pronounced improvements seen in the manual therapy group align with the results of Reid et al. (2014)Metin girmek için buraya tıklayın veya dokunun.,23 who reported that mobilization and manipulation enhance proprioceptive responses and facilitate deep cervical flexor activation.
Studies on cervical ROM consistently report marked restrictions in individuals with CNP, underscoring the importance of ROM restoration as a key rehabilitation target. In the present study, significant improvements in flexion, extension, rotation, and lateral flexion were observed in both groups. The present findings appear to be consistent with other research, including the study by Kim et al. (2017)Metin girmek için buraya tıklayın veya dokunun.,24 which demonstrated increased mobility in individuals with mechanical neck pain, and the systematic review by Cheatham and Lee (2016)Metin girmek için buraya tıklayın veya dokunun.,18 which highlighted the effectiveness of IASTM in enhancing mobility. This mechanism is likely related to the release of myofascial adhesions and subsequent improvements in tissue extensibility. The gains achieved with manual therapy may be explained by mobilization of the joint capsule, stimulation of mechanoreceptors, and disruption of the pain–spasm cycle, consistent with the findings of recent studies showing improved joint mobility and neuromuscular modulation following manual interventions.

Limitations

A major limitation of this study is the absence of a control group that received no treatment. Given the well-established benefits of therapeutic interventions in individuals with chronic neck pain, we considered it unethical to include participants who would not receive any form of treatment. Additionally, assessments were conducted only at baseline and at the end of the 4-week intervention period, with no long-term follow-up. Future studies should include extended follow-up assessments to better evaluate the sustainability of treatment effects.

Conclusion

Both manual therapy and IASTM led to meaningful short-term improvements in pain, disability, cervical endurance, and range of motion in individuals with chronic neck pain. However, manual therapy demonstrated comparatively greater benefits, particularly in pain reduction, functional recovery, and muscular endurance, indicating a stronger early therapeutic effect.

Declarations

Abbreviations

References

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