neck pain is a common musculoskeletal disorder in modern society that can produce severe 
 pain . 67% of the population suffers from it at least once in a lifetime and the prevalence 
 is about 23%1 . the pain exacerbates and 
 fades periodically , and many patients do not fully recover from the symptoms2 . neck pain occurs in the upper thoracic 
 spine area including the shoulder , and it is mechanical pain caused by bad postures and 
 habits in most cases3 . according to 
 sharon , the upper thoracic spine is involved in the physiologic motion of the neck4 . the decreased movement of the upper 
 cervical spine can cause excessive movement of the lower cervical spine , increase fatigue in 
 the sternocleidomastoid , anterior scalenus , and upper trapezius , cause changes of neck 
 postures and breathing patterns , and a decrease in the range of motion5 . patients with chronic neck pain experience functional 
 impairments including weakening of deep bending neck muscles due to the activation of neck 
 surface muscles6 , increased deformity of 
 the forward head posture7 , proprioception 
 impairment8 , and poor balance9 . in addition , decreased movement of the 
 cervical spine restricts the range of motion of the spine and decreases breathing 
 function10 , 11 . slightly bent positions like the forward head posture may cause 
 mechanical neck pain , cause a greater load by affecting the mobilization order of the 
 muscles operating when the arm is raised , and restrict the range of motion12 . these changes reduce the ability to 
 maintain balance and increase the risk of falls and injury of the musculoskeletal 
 system9 . physiotherapists are using methods such as electrotherapy , therapeutic exercise , and manual 
 therapy to intervene in the neck pain13 . 
 in a cochrane review study of neck pain , stretching exercises for the neck and upper limbs , 
 strengthening exercises , static and dynamic stabilization exercises maitland mobilization 
 grade 3 and 4 treatment for the cervical spine and upper spine significantly decreases neck 
 disability index ( ndi ) , the pain index15 , 
 and increases the range of motion16 . in 
 addition , an the intervention combining therapeutic exercise and manual therapy was 
 significantly more effective compared to manual therapy alone17 . recent evidence - based studies report that treatment combining 
 therapeutic exercise and manual therapy is more effective18 , but research of combined interventions is sparse . the purpose of 
 this study was to apply joint mobilization and therapeutic exercise to the cervical spine 
 and upper spine , investigate the effects on functional impairments caused by the neck pain , 
 and examine differences between groups by comparing the intervention group with the group to 
 which only therapeutic exercises were applied . this study was implemented with non - specific neck pain patients with no medical findings 
 who had visited the cheongju st . all participants received verbal and written information about the study and signed a 
 consent form . the patients who had undergone or would have surgery in the spine , and those who 
 had neurological damage , a cervical spine fracture , osteoporosis , arthritis , a malignant 
 neoplasm , a vascular disease , or a psychiatric problem were excluded . the subjects were 
 randomly assigned to one of two groups of nine people each . group i was the therapeutic 
 exercise group , and group ii was the group to which joint mobilization was applied in 
 combination with therapeutic exercise ( table 
 1table 1.general characteristics of the subjects ( n=18)group igroup iigender ( female)99age ( years)58.0  1.659.0  2.4height ( cm)158.0  3.9157.0  4.7weight ( kg)58.0  4.659.0  6.6values are expressed as mean  sd . * significant difference between pre - post test ( p<0.05 ) . group i ( therapeautic exercise ) , group ii ( mobilization & therapeautic 
 exercise ) ) . the pretest included the visual analog scale ( vas ) , neck disability index 
 ( ndi ) , active cervical range of motion ( acrom ) , static balance ability , muscle tone of the 
 upper trapezius , and respiratory function . after the pretest , group i performed therapeutic 
 exercise and group ii performed both therapeutic exercise and joint mobilization for 60 
 minutes a day , three times a week for two weeks under the guidance of a physical therapist . the participants did not receive any other interventions associated with the neck pain while 
 this research was being conducted . the post - test was carried out with the same protocol as 
 the pretest after two weeks . values are expressed as mean  sd . * significant difference between pre - post test ( p<0.05 ) . group i ( therapeautic exercise ) , group ii ( mobilization & therapeautic 
 exercise ) therapeutic exercises involved enhancing mobility , stability and muscular strength of the 
 neck , improving proprioception , and performing reeducation of movement , and the intensity of 
 exercises was adjusted according to the physical abilities of the individuals . for the joint 
 mobilization , after 
 the painful sites were located by examination , the active movement test was conducted to 
 find where joint mobilization would be applied , and the amount and quality of motion were 
 examined . afterwards , passive physiological intervertebral movement ( ppivm ) testing and 
 passive intervertebral accessory movement ( paivm ) test were conducted to find which joints 
 had restricted or excessive movement , and determine where joint mobilization would be 
 applied . the vas was employed to measure the intensity of pain19 , the ndi was used to measure neck pain disability20 , and crom instrument to assess the 
 cervical range of motion21 . in order to 
 check static balance , myoton pro ( myoton as , estonia ) measured 
 the muscle tone of the upper trapezius22 , 
 and a spirometer ( pony fx spirometer ; cosmed , rome , italy ) measured the respiratory 
 function23 . , an ibm company , 
 chicago , il , usa ) . for the normality test , the shapiro wilk test was conducted , confirming 
 that the data are normally distributed . assuming homogeneity between groups , the independent 
 samples t - test was performed , and the paired sample t - test was conducted for the 
 within - group comparison of the measurements before and after the interventions . in addition , 
 the independent samples t - test was conducted to compare the differences between groups . null 
 hypotheses of no difference were rejected if p - values were less than 0.05 . vas and ndi led to significant changes in both groups , and group ii improved significantly 
 more than group i ( tables 2table 2.visual analog scale of the subjectsgroup igroup iipre4.8  0.44.9  0.3post2.7  0.5 * 1.4  05**significant difference between pre - post test ( p<0.05 ) . significant difference between groups ( p<0.05 ) , 3table 3.neck disability index of the subjectsgroup igroup iipre15.1  2.317.2  3.1post8.9  1.5 * 8.6  1.9**significant difference between pre - post test ( p<0.05 ) . the acrom increased significantly in both groups , and group ii 
 improved significantly more on the right lateral flexion and rightward rotation than group i 
 ( table 4table 4.active cervical range of motion of the subjects ( )group igroup iiflexionpre49.2  8.748.9  4.7post54.2  4.5 56.1  6.8*extensionpre54.9  4.356.4  4.9post 64.3  3.2 * 67.6  3.9*rt . rotationpre60.8  3.259.7  5.1post 67.6  3.6 * 67.7  4.2**significant difference between pre - post test ( p<0.05 ) . both groups improved significantly in static balance , with no difference 
 between groups ( tables 5table 5.center of gravity sway velocities of each group under different conditions 
 ( /s)group igroup iifirm - eyes openpre0.04  0.00.05  0.0 post0.03  0.00.04  0.0firm - eyes closedpre0.15  0.00.15  0.0post0.14  0.00.14 0.10.37  0.1post 0.30  0.1 * 0.32  0.1**significant difference between pre - post test ( p<0.05 ) . significant difference between groups ( p<0.05 ) , 6table 6.center of gravity total sway distances of each group under different conditions 
 ( /s)group igroup iifirm - eyes openpre294.6  64.1304.6  97.9 post270.4  66.4281.9 109.2foam - eyes closedpre618.2  82.7687.3  182.8post 529.1  88.2 * 548.4  172.5**significant difference between pre - post test ( p<0.05)significant difference between groups ( p<0.05 ) ) . muscle tone in the left and right upper trapezius muscle improved 
 significantly in both groups , and there was no difference between groups ( table 7table 7.muscle tone of the subjectsgroup igroup iirt . upper trapeziuspre16.0  1.5 16.0  1.2post13.7  1.3 * 14.2  1.4**significant difference between pre - post test ( p<0.05 ) . significant difference between groups ( p<0.05 ) * significant difference between pre - post test ( p<0.05 ) . significant difference between groups ( p<0.05 ) * significant difference between pre - post test ( p<0.05 ) . significant difference between groups ( p<0.05 ) * significant difference between pre - post test ( p<0.05 ) . significant difference between groups ( p<0.05 ) * significant difference between pre - post test ( p<0.05 ) significant difference between groups ( p<0.05 ) * significant difference between pre - post test ( p<0.05 ) . chronic neck pain patients suffer diverse functional impairments , including a deterioration 
 of balance ability , respiratory function , range of joint motion , and proprioception11 . research related to neck pain suggests 
 that there are more efficient interventions based on evidence through systematic reviews , 
 and the interventions combining manual therapy and therapeutic exercise are described as 
 more effective in recent literature18 . in 
 this study , therapeutic exercises were conducted that are reported to be effective for 
 patients with mechanical neck pain , namely , stretching exercise for the neck and upper 
 limbs , static and dynamic stability exercise , strengthening exercise , and exercise 
 reeducation14 . in addition , as manual 
 therapy , mobilization to reduce pain and improve the movements of the soft tissue exhibiting 
 contracture and restricted motions of joints ( maitland grade iii and iv)13 , 24 
 were applied to group ii . the effect of the two kinds of interventions , and group 
 differences based on those interventions were examined . in this research , a significant 
 reduction in the vas and ndi was observed in both groups , and the comparison between the 
 groups showed that the intervention was more effective in group ii . this result is different 
 from studies that found no difference between groups based on a short - term intervention17 . these differences may result from our 
 smaller number of subjects and differences of individual characteristics . for the acrom , 
 both groups improved significantly overall , and group ii improved more on right lateral 
 flexion and rightward rotation . these results are consistent with studies that reported that 
 mobilization applied to both the neck and spine at the same time improved cranial vertical 
 angle and cranial rotation angle25 and 
 research that showed that endurance exercise of the neck , stabilization exercise , and 
 strength training improved the joint range of motion26 . in this study , static balance was measured under a variety of conditions , including hard or 
 soft bearing surfaces and open or closed eyes . a significant decrease in the sway velocity 
 of the center of gravity and in the sway distance occurred only under eyes closed , and there 
 was no difference between groups . although it was reported that patients with neck pain and 
 forward head posture may exhibit reduced balance ability9 , it was possible to measure the static balance ability most 
 accurately when the soft bearing surface was used and eyes were closed to block the visual 
 feedback . muscle tone of the upper trapezius decreased significantly in both groups , and 
 there was no difference between the groups . this may indicate that the tension and fatigue 
 of the upper trapezius were reduced due to pain reduction , enhancement of mobility of the 
 neck joints , and change in the mobilization sequence of movements caused by afferent 
 information activation of proprioception5 . deterioration of mobility of the spine and thoracic cage was reported in patients of chronic 
 neck pain , and respiratory function was also affected27 . however , in this research , no significant change in the 
 respiratory function was observed . this may be because the patients were not given direct 
 training for functional improvement of breathing muscles , although the range of motion of 
 the cervical and upper thoracic spine was improved through the study interventions . the number of subjects was small , and since the 
 period of intervention was not long , it was difficult to produce a mechanical change of 
 muscles . therefore , future research is required to investigate the effect of joint 
 mobilization and therapeutic exercise on the functional impairments caused by chronic neck 
 pain using diverse subjects and intervention periods , and research on the persistence of the 
 effect also needs to be conducted . in conclusion , joint mobilization and therapeutic exercise for functional impairments 
 caused by chronic neck pain significantly improved several types of functional impairment . in addition , in the group to which both joint mobilization and therapeutic exercise were 
 applied , significantly more improvement in the pain index , neck disability levels , and acrom 
 was seen than in the group that received only therapeutic exercise .
[ purpose ] this study evaluated joint mobilization and therapeutic exercise applied to the 
 cervical spine and upper thoracic spine for functional impairment caused by chronic neck 
 pain . 
 [ subjects and methods ] eighteen study subjects were randomly assigned to two groups 
 of nine people each . 
 therapeutic exercise only was applied to the cervical and upper 
 thoracic spine for group i , while both therapeutic exercise and joint mobilization were 
 applied to group ii . the visual analog scale , neck disability index , active cervical range 
 of motion , static balance capacity , and muscle tone were assessed with a pre - test . 
 the 
 intervention was carried out for 60 minutes a day , three times a week , for two weeks for 
 each group , followed by a post - test using the same protocol as the pre - test . 
 [ results ] the 
 visual analog scale , neck disability index , and active cervical range of motion improved 
 significantly in both groups . 
 group ii improved significantly more on right lateral 
 flexion and rightward rotation . 
 muscle tone improved significantly in the upper trapezius 
 in both groups . 
 [ conclusion ] the joint mobilization and therapeutic exercise for 
 functional impairments caused by chronic neck pain had a significant effect on several 
 types of functional impairment .