Joint Mobilization: Cervical and Thoracic Spine

Introduction

This course describes joint mobilizations for the cervical spine and thoracic spine. Several terms and definitions have been used to describe the "mobilizations" (e.g. mobilisations) that are taught in this course. The Brookbush Institute uses a conventional definition of "mobilization" that includes low amplitude, low-velocity, oscillatory techniques intended to reduce the stiffness of joints exhibiting a decrease in passive accessory range of motion (a.k.a. arthrokinematic motion and specifically glide or slide). Note, the term "manipulation" is reserved for high-velocity techniques taught in a separate set of courses. Further, the types of mobilizations taught in this course are posterior to anterior (PA) and include both unilateral posterior to anterior (UPA) mobilizations directing force over facet joints, and central posterior to anterior (CPA) mobilizations directing force over the spinous process. These mobilization techniques likely represent the most commonly recommended techniques due in part to their relatively high reliability and efficacy.

This course includes mobilization techniques that intend to improve excessive stiffness of the cervical spine and thoracic spine, improve restrictions in spine range of motion (ROM), and reduce cervicothoracic and upper extremity dysfunction. For example, cervical dysfunction has been correlated with lateral epicondylitis, and mobilizations of the cervical spine have been correlated with a reduction in pain and improvements in function, such as increased grip strength. These techniques may also be used in an integrated approach for cervicothoracic dysfunction, and upper body dysfunction (UBD) including cervicogenic headache, shoulder impingement syndrome (SIS), lateral epicondylitis (tennis elbow), chronic thoracic pain, chronic neck pain, and acromioclavicular dysfunction, and postural dysfunctions including rounded shoulder posture, forward head posture, thoracic kyphosis, or an anterior pelvic tilt. Some evidence and clinical outcomes even suggest that addressing cervical dysfunction and forward head posture can improve long-term outcomes for low back pain patients.

The techniques in this course are recommended for all clinical human movement professionals (physical therapists, physical therapy assistants, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.) with the intent of developing an evidence-based, systematic, integrated, patient-centered, and outcome-driven approach.

Techniques Covered in this Course:

• Cervical Mobilization (Manual)
• Thoracic Mobilization (Manual)

Related Courses

Additional Joint Mobilization Courses

• Joint Mobilizations: Ankle and Tibiofibular Joints
• Joint Mobilizations: Knee and Hip Joints
• Joint Mobilizations: Lumbar Spine and Sacroiliac Joints
• Joint Mobilizations: Cervical and Thoracic Spine
• Joint Mobilizations: Shoulder, Sternoclavicular, and Acromioclavicular Joints
• Joint Mobilizations: Elbow and Proximal Radioulnar Joints

For an introduction to joint mobilizations and manipulations:

• Joint Mobilization and Manipulation: Introduction
• Joint Mobilization and Manipulation: Reliability
• Joint Mobilizations and Manipulations: Effects
• Joint Mobilization and Manipulation: Risk of Adverse Effects
• Joint Mobilizations and Manipulations: Evidence-based Teaching and Learning

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Occupational Therapists - Intermediate
• Physical Therapists
• Physical Therapy Assistants

This Course Includes:

• AI Tutor
• Study Guide
• Text and Illustrations
• Audio Voice-over
• Research Review
• Technique Videos
• Sample Routine
• Practice Exam
• Pre-approved Final Exam

1. Choi, W., & Heo, S. (2019). Short-term Benefits of Mobilization for Patients with Non-Specific Neck Pains: Executive Function and Neck Pain Intensity. Journal of International Academy of Physical Therapy Research, 10(2), 1803-1809.
2. Shah, S., Shakil-ur-Rehman, S., & Ahmad, S. (2015). The effects of spinal mobilization with and without manual traction in patients with cervical radiculopathy. JIIMC, 10(1), 132-134.
3. Rodríguez-Sanz, D., Calvo-Lobo, C., Unda-Solano, F., Sanz-Corbalán, I., Romero-Morales, C., & López-López, D. (2017). Cervical Lateral Glide Neural Mobilization Is Effective in Treating Cervicobrachial Pain: A Randomized Waiting List Controlled Clinical Trial. Pain Medicine, 18(12), 2492-2503.
4. Hayat, A. S. K. F. U. (2017, April). Effectiveness of Maitland’s Mobilization vs. Mulligan Mobilization in Patients with Cervical Radiculopathy. In Islamabad Congress of Ophthalmology (Vol. 15, No. 2, p. 160).
5. Ranganath, P. N., Dowle, P., & Chandrasekhar, P. (2018). Effectiveness of MWM, Neurodynamics and Conventional Therapy Versus Neurodynamics and Conventional Therapy in Unilateral Cervical Radiculopathy: A Randomized Control Trial. Indian Journal of Physiotherapy & Occupational Therapy, 12(3).
6. Oh, H. T., & Hwangbo, G. (2018). The effect of short-term upper thoracic self-mobilization using a Kaltenborn wedge on pain and cervical dysfunction in patients with neck pain. Journal of physical therapy science, 30(4), 486-489.
7. Said, S. M., Ali, O. I., Abo Elazm, S. N., & Abdelraoof, N. A. (2017). Mulligan self mobilization versus Mulligan snags on cervical position sense.
8. Sönmezer, E., Tüzün, E. H., Eker, L., & Yüksel, İ. (2018). Effectiveness of mobilization therapy for treating cervical myofascial pain syndrome. Journal of Exercise Therapy and Rehabilitation, 5(1), 25-32.
9. Lascurain-Aguirrebeña, I., Newham, D. J., Casado-Zumeta, X., Lertxundi, A., & Critchley, D. J. (2018). Immediate effects of cervical mobilisations on global perceived effect, movement associated pain and neck kinematics in patients with non-specific neck pain. A double blind placebo randomised controlled trial. Musculoskeletal Science and Practice, 38, 83-90.
   • Posture
10. Gong, W. (2015). The effects of cervical joint manipulation, based on passive motion analysis, on cervical lordosis, forward head posture, and cervical ROM in university students with abnormal posture of the cervical spine. Journal of physical therapy science, 27(5), 1609-1611.
11. Kim, S. Y., Kim, N. S., & Kim, L. J. (2015). Effects of cervical sustained natural apophyseal glide on forward head posture and respiratory function. Journal of physical therapy science, 27(6), 1851-1854.
12. Lee, K. J., Roh, J. S., Choi, H. S., Cynn, H. S., Choi, K. H., & Kim, T. H. (2015). Effect of active intervention after Kaltenborn's cervical joint mobilization on the cervical spine alignment and muscle activity in patients with forward head posture. Journal of the Korean Society of Physical Medicine, 10(2), 17-27.
13. Cho, J., Lee, E., & Lee, S. (2017). Upper thoracic spine mobilization and mobility exercise versus upper cervical spine mobilization and stabilization exercise in individuals with forward head posture: a randomized clinical trial. BMC musculoskeletal disorders, 18(1), 525.
14. Lee, J., Lee, Y., Kim, H., & Lee, J. (2013). The effects of cervical mobilization combined with thoracic mobilization on forward head posture of neck pain patients. Journal of Physical Therapy Science, 25(1), 7-9.
15. Cho, J., Lee, E., & Lee, S. (2018). Upper cervical and upper thoracic spine mobilization versus deep cervical flexors exercise in individuals with forward head posture: A randomized clinical trial investigating their effectiveness. Journal of back and musculoskeletal rehabilitation, (Preprint), 1-8.
    • Cervicogenic Headache
16. Schoensee, S. K., Jensen, G., Nicholson, G., Gossman, M., & Katholi, C. (1995). The effect of mobilization on cervical headaches. Journal of Orthopaedic & Sports Physical Therapy, 21(4), 184-196.
17. Pilling, M., Davidson, I., Todd, C., Crooks, K., & Newington, L. (2018). A pre-test, post-test intervention study (with embedded waiting list control) to assess the feasibility (efficacy; acceptability; and methodology) of mobilization of C0-C3 cervical segments to reduce headache in migaineurs.
18. Mohamed, A. A., Shendy, W. S., Semary, M., Mourad, H. S., Battecha, K. H., Soliman, E. S., … & Mohamed, G. I. (2019). Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache. Journal of physical therapy science, 31(4), 376-381.
19. Hall, T., Chan, H. T., Christensen, L., Odenthal, B., Wells, C., & Robinson, K. (2007). Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. journal of orthopaedic & sports physical therapy, 37(3), 100-107.
20. La Touche, R., París-Alemany, A., Mannheimer, J. S., Angulo-Díaz-Parreño, S., Bishop, M. D., Lopéz-Valverde-Centeno, A., … & Fernández-Carnero, J. (2013). Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervico-craniofacial pain?: A randomized-controlled trial. The Clinical journal of pain, 29(3), 205-215.
21. Borusiak, P., Biedermann, H., Boßerhoff, S., & Opp, J. (2010). Lack of efficacy of manual therapy in children and adolescents with suspected cervicogenic headache: Results of a prospective, randomized, placebo‐controlled, and blinded trial. Headache: The Journal of Head and Face Pain, 50(2), 224-230.
22. Fernández‐de‐las‐Peñas, C., Cleland, J. A., Palomeque‐del‐Cerro, L., Caminero, A. B., Guillem‐Mesado, A., & Jiménez‐García, R. (2011). Development of a Clinical Prediction Rule for Identifying Women With Tension‐Type Headache Who Are Likely to Achieve Short‐Term Success With Joint Mobilization and Muscle Trigger Point Therapy. Headache: The Journal of Head and Face Pain, 51(2), 246-261.
    • Cervical Mobilization and Shoulder
23. Huang, S. J., Wei, M. J., & Wang, T. J. (2018). Effectiveness of Cervical Mobilization in Patients With Non-Specific Shoulder/Arm Pain: A Preliminary Study. 物理治療, 43(2), 119-119.
24. Wang, S. S., & Meadows, J. (2010). Immediate and carryover changes of C5-6 joint mobilization on shoulder external rotator muscle strength. Journal of manipulative and physiological therapeutics, 33(2), 102-108.
25. Seo, Y., Lee, J., & Han, D. (2015). The effects of spinal mobilization with arm movements on shoulder muscle strengthening. Journal of physical therapy science, 27(1), 11-13.
    • Cervical Mobilization and Elbow
26. Chaudhery, J. K., & Dabholkar, A. (2017). Efficacy of spinal mobilization with arm movements (SMWAMS) in mechanical neck pain patients: Case-controlled trial. International Journal of Therapies and Rehabilitation Research, 6(1), 18.
27. Cleland, J. A., Flynn, T. W., & Palmer, J. A. (2005). Incorporation of manual therapy directed at the cervicothoracic spine in patients with lateral epicondylalgia: a pilot clinical trial. Journal of manual & manipulative therapy, 13(3), 143-151.
28. Mohanty, P. P., Arora, J., & Pattnaik, M. (2016). Effect of Cervicothoracic Mobilization in Distal Radius Fractures after Plaster Removal. J Nov Physiother Phys Rehabil, 3(1), 046-052.
29. Botelho, M. B., & Andrade, B. B. (2012). Effect of cervical spine manipulative therapy on judo athletes' grip strength. Journal of manipulative and physiological therapeutics, 35(1), 38-44.
    • Cervical Mobilization and the Jaw (20)
30. Pedroni, C. R., Oliveira, A. S., & Bérzin, F. (2005). Immediate effect of cervical mobilization in temporomandibular disorder patients. Brazilian Journal of Oral Sciences, 4(15), 911-918.
31. Calixtre, L. B., Grüninger, B. L. D. S., Haik, M. N., Alburquerque-Sendín, F., & Oliveira, A. B. (2016). Effects of cervical mobilization and exercise on pain, movement and function in subjects with temporomandibular disorders: a single group pre-post test. Journal of Applied Oral Science, 24(3), 188-197.
    • Effects on Muscle Activity (12, 14, 28, 29)
32. Sterling, M., Jull, G., & Wright, A. (2001). Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity. Manual therapy, 6(2), 72-81.
33. Jesus-Moraleida, F. R., Ferreira, P. H., Pereira, L. S., Vasconcelos, C. M., & Ferreira, M. L. (2011). Ultrasonographic analysis of the neck flexor muscles in patients with chronic neck pain and changes after cervical spine mobilization. Journal of manipulative and physiological therapeutics, 34(8), 514-524.
    • Systemic Response to Cervical Mobilization
34. Valera-Calero, A., Lluch, E., Gallego-Izquierdo, T., Malfliet, A., & Pecos-Martín, D. (2019). Endocrine response after cervical manipulation and mobilization in people with chronic mechanical neck pain: a randomized controlled trial. European journal of physical and rehabilitation medicine.
35. Yung, E. Y., Oh, C., Wong, M. S., Grimes, J. K., Barton, E. M., Ali, M. I., & Cameron, D. (2017). The immediate cardiovascular response to joint mobilization of the neck-a randomized, placebo-controlled trial in pain-free adults. Musculoskeletal Science and Practice, 28, 71-78.
36. Vicenzino, B., Cartwright, T., Collins, D., & Wright, A. (1998). Cardiovascular and respiratory changes produced by lateral glide mobilization of the cervical spine. Manual Therapy, 3(2), 67-71.
37. McGuiness, J., Vicenzino, B., & Wright, A. (1997). Influence of a cervical mobilization technique on respiratory and cardiovascular function. Manual Therapy, 2(4), 216-220.
38. Moulson, A., & Watson, T. (2006). A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population. Manual therapy, 11(3), 214-224.
39. Chiu, T. W., & Wright, A. (1996). To compare the effects of different rates of application of a cervical mobilisation technique on sympathetic outflow to the upper limb in normal subjects. Manual Therapy, 1(4), 198-203.
40. Vicenzino, B., Cartwright, T., Collins, D., & Wright, A. (1999). An investigation of stress and pain perception during manual therapy in asymptomatic subjects. European Journal of Pain, 3(1), 13-18.
41. Alonso-Perez, J. L., Lopez-Lopez, A., La Touche, R., Lerma-Lara, S., Suarez, E., Rojas, J., … & Fernández-Carnero, J. (2017). Hypoalgesic effects of three different manual therapy techniques on cervical spine and psychological interaction: A randomized clinical trial. Journal of bodywork and movement therapies, 21(4), 798-803.
    • Mobilizations compared to other interventions
42. Ganesh, G. S., Mohanty, P., Pattnaik, M., & Mishra, C. (2015). Effectiveness of mobilization therapy and exercises in mechanical neck pain. Physiotherapy Theory and practice, 31(2), 99-106.
43. Vinodkumar, A., & Desai, P. (2016). Efficacy of Mobilization versus Strength Training in Patients with Chronic Cervicogenic Headache. Indian Journal of Physiotherapy and Occupational Therapy-An International Journal, 10(3), 1-6.
44. Kim, S. H., Choi, J. H., & Lee, K. W. (2016). Immediate effects of active stretching versus passive mobilization of the upper cervical spine on patients with neck pain and ROM. Korean Society of Physical Medicine, 11(4), 27-32.
45. Riaz, F., Haider, R., Qamar, M. M., Basharat, A., Manzoor, A., Rasul, A., … & Ahmad, W. (2018). Effects of static stretching in comparison with Kaltenborn mobilization technique in nonspecific neck pain. BLDE University Journal of Health Sciences, 3(2), 85.
46. Ganesh, G. S., Singh, H., Mushtaq, S., Mohanty, P., & Pattnaik, M. (2016). Effect of cervical mobilization and ischemic compression therapy on contralateral cervical side flexion and pressure pain threshold in latent upper trapezius trigger points. Journal of bodywork and movement therapies, 20(3), 477-483.
47. Khan, M. R., Shafi, H., Amjad, I., & Siddiqui, F. A. (2015). Efficacy of Cervical Spine Mobilization Versus Peripheral Nerve Slider Techniques (Neurodynamics) in Cervicobrachial Pain Syndrome. Journal of International Inovative Medical Council, 10(4), 473-479.
48. Copurgensli, C., Gur, G., & Tunay, V. B. (2017). A comparison of the effects of Mulligan's mobilization and Kinesio taping on pain, range of motion, muscle strength, and neck disability in patients with cervical spondylosis: a randomized controlled study. Journal of back and musculoskeletal rehabilitation, 30(1), 51-62.
    • Mobilizations in combination with other interventions
49. Buyukturan, O., Buyukturan, B., Sas, S., Karartı, C., & Ceylan, I. (2018). The Effect of Mulligan Mobilization Technique in Older Adults with Neck Pain: A Randomized Controlled, Double-Blind Study. Pain Research and Management, 2018.
50. Farooq, M. N., Mohseni-Bandpei, M. A., Gilani, S. A., Ashfaq, M., & Mahmood, Q. (2018). The effects of neck mobilization in patients with chronic neck pain: A randomized controlled trial. Journal of bodywork and movement therapies, 22(1), 24-31.
51. Ko, T., Jeong, U., & Lee, K. (2010). Effects of the inclusion thoracic mobilization into cranio-cervical flexor exercise in patients with chronic neck pain. Journal of physical therapy science, 22(1), 87-91.
52. Gong, W. T., Cheun, H. J., & Lee, K. M. (2010). The effect of cervical stabilized exercise and joint mobilization on maximum muscle strength and static muscle endurance of cervical region. Journal of the Korean Data and Information Science Society, 21(1), 33-42.
53. Aquaroli, R. S., Camacho, E. S., Marchi, L., & Pimenta, L. (2016). Manual therapy and segmental stabilization in the treatment of cervical radiculopathy. Fisioterapia em Movimento, 29(1), 45-52.
    • Comparing cervical mobilization techniques (4, 39)
54. Hassan, F., Osama, M., Ghafoor, A., & Yaqoob, M. F. (2019). Effects of oscillatory mobilization as compared to sustained stretch mobilization in the management of cervical radiculopathy: A randomized controlled trial. Journal of back and musculoskeletal rehabilitation, (Preprint), 1-6.
55. Al Shehri, A., Khan, S., Shamsi, S., & Almureef, S. S. (2018). COMPARATIVE STUDY OF MULLIGAN (SNAGS) AND MAITLAND MOBILIZATION IN NECK PAIN. European Journal of Physical Education and Sport Science.
56. Egwu, M. O. (2008). Relative therapeutic efficacy of some vertebral mobilization techniques in the management of unilateral cervical spondylosis: a comparative study. Journal of Physical Therapy Science, 20(2), 103-108.
    • Thoracic Spine (13, 14)
57. Kim, G., Lee, S., & Jeong, H. (2011). Effects of upper thoracic joint mobilization on dynamic stability of patients with chronic neck pain. Journal of Physical Therapy Science, 23(5), 753-756.
58. Hwangbo, P. N., Hwangbo, G., Park, J., & Lee, S. (2014). The effect of thoracic joint mobilization and self-stretching exercise on pulmonary functions of patients with chronic neck pain. Journal of physical therapy science, 26(11), 1783-1786.
59. Jeong, H. J., & Kim, B. J. (2019). The Effect of Thoracic Joint Mobilization on the Changes of the Thoracic Kyphosis Angle and Static and Dynamic Balance. Biomedical Science Letters, 25(2), 149-158.
60. Kirschner, J., Vorwerg, S., Michel, S., Braun, A., Martin, T., & Prill, R. (2017). Effect of a manual-therapeutic segmental mobilization on the mobility of the thoracic spine.
61. Park, J. J., & Chon, S. C. (2018). Effect of Posterior-Anterior Mobilization of the Thoracic Spine on Pain, Respiratory Function, and Thoracic Circumference in Patients With Chronic Low Back Pain. Physical Therapy Korea, 25(4), 37-45.
62. Babina, R., Mohanty, P. P., & Pattnaik, M. (2016). Effect of thoracic mobilization on respiratory parameters in chronic non-specific low back pain: A randomized controlled trial. Journal of back and musculoskeletal rehabilitation, 29(3), 587-595.
63. Jung, J. H., & Moon, D. C. (2015). The effect of thoracic region self-mobilization on chest expansion and pulmonary function. Journal of physical therapy science, 27(9), 2779-2781.
64. Wang, J. S. (2015). Effect of joint mobilization and stretching on respiratory function and spinal movement in very severe COPD with thoracic kyphosis. Journal of physical therapy science, 27(10), 3329-3331.
    • Thoracic mobilization in combination with other techniques
65. Lee, K. S., & Lee, J. H. (2017). Effect of maitland mobilization in cervical and thoracic spine and therapeutic exercise on functional impairment in individuals with chronic neck pain. Journal of physical therapy science, 29(3), 531-535.
66. Yang, S. R., Kim, K., & Park, S. J. (2015). The effect of thoracic spine mobilization and stabilization exercise on the muscular strength and flexibility of the trunk of chronic low back pain patients. Journal of physical therapy science, 27(12), 3851-3854.
67. Mohanty, P. P., & Pattnaik, M. (2016). Mobilisation of the thoracic spine in the management of spondylolisthesis. Journal of bodywork and movement therapies, 20(3), 598-603.
    • Thoracic mobilization effect on muscle activity and systemic response
68. Pecos-Martín, D., de Melo Aroeira, A. E., Silva, R. V., de Tejada Pozo, G. M., Solano, L. R., Plaza-Manzano, G., … & Falla, D. (2017). Immediate effects of thoracic spinal mobilisation on erector spinae muscle activity and pain in patients with thoracic spine pain: a preliminary randomised controlled trial. Physiotherapy, 103(1), 90-97.
69. Jowsey, P., & Perry, J. (2010). Sympathetic nervous system effects in the hands following a grade III postero-anterior rotatory mobilisation technique applied to T4: a randomised, placebo-controlled trial. Manual therapy, 15(3), 248-253.
70. Ghaffar, T., Sajjad, A., & Rasul, A. (2016). Effects of thoracic spine mobilization on vitals and blood oxygen level in healthy individuals. Journal of Islamic International Medical College, 11, 163-166.
71. Araujo, F. X., Schell, M. S., Ferreira, G. E., Pessoa, M. D., Pinho, A. S., Plentz, R. D., & Silva, M. F. (2019). Short-Term Effects of Different Rates of Thoracic Mobilization on Pressure Pain Thresholds in Asymptomatic Individuals: A Randomized Crossover Trial. Journal of Chiropractic Medicine, 18(1), 33-41.
72. Araujo, F. X., Schell, M. S., Ferreira, G. E., Pessoa, M. D. V., de Oliveira, L. R., Borges, B. G., … & Silva, M. F. (2018). Autonomic function and pressure pain threshold following thoracic mobilization in asymptomatic subjects: A randomized controlled trial. Journal of bodywork and movement therapies, 22(2), 313-320.
73. Shukla, R., Sahay, P., Sharma, R., Sarkar, B., & Biswas, A. (2018). Immediate Effects of Unilateral Thoracic Postero-Anterior Pressure Versus Transverse Pressure in Chronic Mechanical Neck Pain: A Comparative Study. Indian Journal of Physiotherapy & Occupational Therapy, 12(1)
    • Additional Research
74. Muhsen, A., Moss, P., Gibson, W., Walker, B., Jacques, A., Schug, S., & Wright, A. (2019). The Association Between Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia. The Clinical journal of pain, 35(5), 435.
75. Yung, E., Oh, C., Wong, M., Grimes, J. K., Barton, E. M., Ali, M. I., & Breakey, A. (2019). Non-thrust cervical manipulations reduce short-term pain and decrease systolic blood pressure during intervention in mechanical neck pain: a randomized clinical trial. Journal of Manual & Manipulative Therapy, 1-12.
76. Nakamaru, K., Aizawa, J., Kawarada, K., Uemura, Y., Koyama, T., & Nitta, O. (2019). Immediate effects of thoracic spine self-mobilization in patients with mechanical neck pain: A randomized controlled trial. Journal of bodywork and movement therapies, 23(2), 417-424.
77. Liebler, E. J., Tufano-Coors, L., Douris, P., Makofsky, H. W., McKenna, R., Michels, C., & Rattray, S. (2001). The effect of thoracic spine mobilization on lower trapezius strength testing. Journal of Manual & Manipulative Therapy, 9(4), 207-212
78. McClatchie, L., Laprade, J., Martin, S., Jaglal, S. B., Richardson, D., & Agur, A. (2009). Mobilizations of the asymptomatic cervical spine can reduce signs of shoulder dysfunction in adults. Manual Therapy, 14(4), 369-374.