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Joint Manipulation: Cervical Spine Audio

Joint manipulations for the cervical spine. Types of manipulations, manipulations vs. mobilizations of the spine and cervical spine. Optimal intervention for forward head, shoulders elevate, arms fall, cervicogenic headache, radiculopathy, posture, jaw, shoulder, and elbow dysfunction. The risk of adverse events, accuracy vs sensitivity, screening, reliability, and validity of cervical spine manips. 

Joint Manipulation: Cervical Spine

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This course describes joint manipulation techniques for the cervical spine (neck manipulation). Various synonyms and definitions have been used to describe the term "manipulation". The Brookbush Institute uses one conventional definition of the term "manipulations;" implying low-amplitude (relatively small motions), high-velocity (quick) techniques, intended to target and reduce the stiffness of specific joints or segments, that exhibit a decrease in passive accessory range of motion (a.k.a. stiffness during arthrokinematic motion and specifically glide or slide). Research does imply that manipulations likely affect multiple joints simultaneously; however, the Brookbush Institute asserts that efforts to target the stiffest joints or segments will increase the likelihood that the stiffest segments are included in the "multiple joints" affected.

The Brookbush Institute has carefully selected manipulation techniques with the intent to increase the probability of practitioner success. That is, techniques have been chosen that are relatively easy to teach, reliably improve outcomes, and are the most commonly used. The Brookbush Institute does not wish to assert that these manipulation techniques are the only techniques that are effective, and/or that these are the best techniques for every outcome measure. It is possible that a highly complex, and/or advanced technique, may result in better outcomes, or that a particular pathology is better addressed with a relatively rarely used technique.

Note, that the term "mobilization" is reserved for low-velocity techniques that are taught in a separate set of courses.

This course includes mobilization techniques that intend to improve excessive stiffness of the cervical spine and upper thoracic spine stiffness, improve spine range of motion (ROM) restrictions, and reduce cervicothoracic and upper extremity dysfunction. For example, cervical dysfunction has been correlated with lateral epicondylitis, and manipulations of the cervical spine have been correlated with reduced pain and improved function, such as increased grip strength. These techniques may also be used in an integrated approach for cervicothoracic dysfunction, and 

 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.) to develop an evidence-based, systematic, integrated, patient-centered, patient-centered, and outcome-driven approach.

Joint Manipulation: Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis

Joint Manipulation: Elbow (Radial Head) and Wrist

Joint Manipulation: Ankle, Midfoot, and Tibiofibular Joint

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 for Continuing Education Credits for:

Course Description: Cervical Spine Manipulation

Research summary of the systemic response from cervical spine joint manipulations found in the Brookbush Institute online course "Joint Manipulation: Cervical Spine"

Course Study Guide: Joint Manipulation: Cervical Spine

Signs of Correlated Dysfunction

Introduction

 Cervical manipulations are effective for improving general pain, pain pressure threshold, range of motion, motor control, and function in individuals with mechanical neck pain. Further, studies imply that 

 outcomes may be achieved using a combination of manual cervical manipulation and thoracic manipulation, perhaps in conjunction with other effective techniques such as cervicothoracic junction manipulation, stretching, and exercise.

 care plan, may be effective for the treatment of a variety of different headache types, however, cervical manipulations alone are likely less effective or not effective for some headache types.

 Cervical manipulation (as well as cervicothoracic and thoracic manipulation) may decrease 

 Upper cervical manipulations are effective for those exhibiting TMJ dysfunction and pain; however, cervical manipulations may be less effective for asymptomatic individuals, and lower cervical manipulation may not be effective for TMJ disorders.

 Cervical manipulation may affect elbow pain via systemic effects, and should be partly considered as an adjunct to elbow dysfunction interventions.

 Research comparing cervical manipulation to other interventions suggests that manipulations are at least as effective for pain, more effective for improving ROM than most interventions, and result in better long-term outcomes than pharmacological intervention.

 Research demonstrates that the combination of cervical manipulation, exercise, and potentially low-level laser and/or pharmacological intervention is more effective than any of these interventions alone. The effectiveness of combined treatments has been investigated for the treatment of headaches, neck pain, and 

, and has demonstrated both better short-term and long-term outcomes. Note, further study is needed before a combination of techniques for preventative care could be deemed “supported by research.”

 The risk of adverse events from cervical manipulations is incredibly low; hundreds of times lower than the risk of adverse events from a medical error or anti-inflammatory drugs. There is no evidence that cervical manipulation places unusual stress or strain on cervical, vertebral or basilar arteries, there may be some evidence that advanced atherosclerotic disease is a contraindication, and research suggests that the most likely factor contributing to the correlation between manipulation and serious adverse events in patients seeking care for serious events in progress.

 No tests or prognostic indicators have been identified that would reliably screen individuals for risk of severe adverse reactions.

Research Summary

Manipulation of the cervical spine has been correlated with improvements in cervicogenic headache, neck, shoulder, elbow, and jaw dysfunction.

Cervical (Mechanical) Pain and Radiculopathy 

Cervicogenic Headache

Cervical Manipulation and Shoulder Dysfunction

Cervical Manipulation and Elbow Dysfunction

Cervical Manipulation Jaw

Cervical Spine Manipulations

Cervical manipulations result in a variety of sympathoexcitatory, neurophysiological and cortical responses, separate but potentially contributing to the mechanical changes that are often the intent of cervical manipulation. Sympathoexcitatory effects, the effects that may be correlated with increased activity of the sympathetic nervous system, have been demonstrated in several studies. An RCT mentioned above by Jiang et al. demonstrated that skin temperature of the upper extremity increased more from manual manipulation than traction or control conditions (8). An RCT by Win et al. demonstrated that cervical manipulation resulted in larger changes in systolic blood pressure and heart rate variability in individuals with neck pain when compared to asymptomatic individuals (38). And, a sham-controlled trial by Goertz et al. demonstrated that although cervical manipulation may have short-term effects on blood pressure, resting blood pressure was not reduced after 6 weeks of regular cervical manipulation (39). These findings are congruent with findings from studies investigating mobilizations and the manipulation of the other joints, demonstrating that these techniques have a significant, but short-term effect, on various sympathoexcitatory outcome measures.

Cervical manipulation may also result in reflexive analgesic nervous system changes. Fernández-de-las-Peñas demonstrated that cervicothoracic junction manipulation decreased pain pressure sensitivity over C5/C6 zygoapophyseal joints (40). Ruiz-Sáez demonstrated that cervical manipulation directed at C3/C4 resulted in a decrease in pain pressure sensitivity of latent trigger points in the 

 (41). Further, in two studies by Fernández-Carnero, one an RCT, it was demonstrated that cervical manipulation targeted at the C5/C6 joint in a group with LE resulted in an immediate change in pain extensor mass pressure threshold and pain-free grip strength (20, 22). Two RCTs by Vicenzino et al. demonstrated cervical manipulations improved general pain scores, pain pressure threshold, pain-free grip strength, and neurodynamics more than placebo or control groups with LE (23, 24). More distal analgesic effects have also been demonstrated. Srbely et al. demonstrated that cervical manipulation reduced pain pressure threshold in a group of individuals with the identified 

 trigger points (42). And, Coronado et al. demonstrated that both cervical and shoulder thrust manipulation resulted in changes in both local (

) pain pressure threshold and heat pain thresholds (43). These studies imply that at least some of the reduction in pain noted in studies investigating cervical manipulation is the result of systemic nervous system changes and not just local effects.

Additional studies suggest further central nervous system changes. Dishman et al. demonstrated that cervical and lumbar manipulation resulted in transient suppression of motoneuron excitability, as assessed by the 

 H-reflex, with lumbar manipulation resulting in slightly larger effects than cervical manipulation (44). Niazi et al. demonstrated that cervical manipulation resulted in decreased H-reflex and increased maximum voluntary contraction of the 

, attributed to an increase in cortical drive (45). A study by Daligadu et al. used transcranial magnetic stimulation (TMS) to demonstrate that subclinical neck pain patients exhibit altered cerebellar inhibition when compared with healthy controls, and spinal manipulation before a motor sequence learning task changes the cerebellar inhibition pattern to one similar to healthy controls (46). Lelic et al. demonstrated that the alteration to cortical activity following cervical manipulation in individuals with subcortical pain can be largely localized to the prefrontal cortex (47). Two studies by Haavik-Taylor et al. using TMS demonstrated that cervical manipulation resulted in a reduction in the cortical silent period, significantly larger maximum motor evoked potentials, and significantly larger movement related evoked potentials in the abductor pollicis brevis and 

 muscles, suggesting that manipulation may alter sensorimotor integration (48 - 49). A study by Christiansen et al., also demonstrated increased cortical excitability and increased 

 following cervical manipulation in a group of elite Taekwondo athletes (50). Last, in an interesting study by Humphries et al. that may be related to cortical integration, kinesthesia, or disinhibition; lower cervical manipulation resulted in a slight increase in made free-throw percentage in a group of basketball players, although this trend needs further investigation in a larger group (51). These studies suggest that analgesic effects may only be a small piece of a larger nervous system response to manipulation techniques, that includes both changes to motor neurons as well as cortical changes.

As mentioned in several of the studies above, increased muscle activity and strength are also commonly cited phenomena resulting from cervical manipulation. Summarizing the studies above; Fernández-Carnero et al. and Vicenzino et al. noted an increase in pain-free grip strength in individuals with lateral epicondylalgia (20, 22 - 24), de Carmargo noted an increase in EMG amplitude signal and fatigue resistance in 

 muscles (18), and Niazi et al. and Christiansen et al. noted increases in 

 (45, 50). Additionally, Dunning et al. noted that a single C5/6 cervical manipulation elicited an immediate increase in resting EMG activity of the biceps brachii bilaterally, irrespective of whether or not cavitation occurred (52). Further, Herzog et al. demonstrated that cervical, thoracic, lumbar, and sacroiliac joint manipulation resulted in a reflexive decrease in hypertonicity of the 

 (53). And, An RCT by Pires et al. demonstrated that cervical manipulation resulted in a short-term relative decrease in right and left SCM muscle activity during arm elevation (54). These last two studies are interesting, as it suggests that while typically inhibited (under-active) muscles may exhibit an increase in activity post manipulation (disinhibition), typically over-active muscles may exhibit a decrease in activity. That is, mobilization and manipulation may "normalize" activity, rather than result in a ubiquitous change in activity in one direction.

Systematic responses to cervical manipulation:

Sympathoexcitatory effects (skin conductance, skin temperature, blood pressure, heart rate variability, etc.)

Potential increase in kinesthesia and motor control

Normalization of muscle activity and increased performance

Systemic Response

Cervical Manipulation Versus Other Interventions

Research suggests that cervical manipulation may have a larger effect than many, but not all interventions. Several interventions have been compared in only one study. An RCT by Escortell et al. demonstrated that both TENS and manipulation had similar acute effects on neck pain (55). Last, a study by Hamilton et al. demonstrated that neither cervical manipulation nor muscle energy technique was effective for improving the pain pressure threshold of the suboccipital muscles in asymptomatic individuals (56). An RCT by Lin et al. demonstrated that manipulation was superior to a massage for reducing chronic mechanical neck pain, even during follow-up 3 months post-treatment (57). In an RCT by Jiang et al., cervical manipulation resulted in larger improvements than traction in cervical radicular pain and resulted in larger sympathoexcitatory effects (discussed above) (7). Research comparing intervention and using pain as an outcome measure often demonstrate that manipulations are equally as effective as other techniques; however, studies investigating range of motion may suggest manipulations are more beneficial. An RCT by Gorrell et al. demonstrated that manual cervical manipulation resulted in larger improvements in pain and ROM than machine manipulation (6). Another RCT by Saavedra-Hernandez et al. demonstrated that kinesiology taping and cervical manipulation resulted in similar improvements in mechanical neck pain and some ROM measurements; however, the cervical manipulation group exhibited larger gains in cervical rotation (58). This research may suggest that manual cervical manipulation is equally as effective or superior to many other techniques for pain; however, manipulation may be more effective at improving range of motion.

When cervical manipulation is compared to exercise the outcomes are similar, with manipulations potentially demonstrating slightly superior results. A study by Coronado et al. demonstrated that cervical manipulation, thoracic manipulation, and exercise resulted in similar outcomes for shoulder pain (43). Galindez-Ibarbengoetxea et al. demonstrated that the immediate effects of manipulation were larger than exercise for chronic cervical pain and cervical ROM (59). And, Moretti et al. demonstrated that manipulative therapy resulted in better short-term and long-term outcomes than traditional physiotherapy (therapeutic exercise) for mechanical cervicobrachialgia (60). The superiority of manipulation techniques has been demonstrated in 2 of the 3 studies discussed here, but the combination of manipulation and exercise is a more important consideration and discussed below.

Studies demonstrate that cervical manipulation and exercise generally result in better outcomes than pharmaceutical interventions. An RCT by McReynolds et al. demonstrated that cervical manipulation performs as well as intramuscular ketorolac (61). A study by Heikkilä et al. demonstrated that a combination of treatment including cervical manipulation was more effective than other combinations including NSAIDs and acupuncture, for the treatment of dizziness believed to have cervicogenic origins (12). An RCT by Bronfort et al. demonstrated that spinal manipulation was superior to home exercise, which was a close second, and that both were better than medication for subacute neck pain (62). In two RCTs by Hoving et al, neck pain was better treated using cervical manipulation and therapeutic exercise than pharmacological treatment and care from a general practitioner, with cervical manipulation demonstrating better outcomes than a therapeutic exercise in the first 7 weeks. (63, 64) Korthals-de Bos et al. performed an economic analysis alongside an RCT to determine the most effective and economical approach for neck pain, determining that the manual therapy group (which included manipulation) outperformed physical therapy (which included exercise), which outperformed general practitioner care (which included medication) (65). These studies suggest that more consideration should be given to referral for conservative care including cervical manipulation, perhaps before the recommendation of prescription medications.

Cervical Manipulation and Other Interventions

Research demonstrates that an integrated approach that includes manipulation results in better outcomes than isolated techniques. Several studies have demonstrated the efficacy of manipulation combined with soft tissue therapy for the treatment of headaches. An RCT by Falla et al. demonstrated that the combination of cervical manipulation and massage was more effective than massage alone for the treatment of tension-type headaches (66). Further, an RCT by Antonia demonstrated that soft-tissue therapy, manipulations, and the combination of soft-tissue and manipulation resulted in similar changes in tension-type headache symptoms; however, the groups that included manipulations exhibited greater changes in cervical ROM (67). Although more research is needed investigating additional combinations of treatment, these high-quality RCTs provide strong evidence for an integrated approach to headache.

The combination of manipulation and therapeutic exercise has also demonstrated efficacy. An RCT by Jull et al. demonstrated that cervicogenic headache responded similarly to manipulative therapy, specific exercise, and combined therapies; however, the combined therapy group had 10% more patients acquire relief from symptoms (68). A prospective RCT by Allan et al. demonstrated that stretching and chiropractic manipulation was more effective than either alone for reducing mechanical neck pain and range of motion, both short-term and long-term (132). Akhter et al. demonstrated that the combination of manual therapy and exercise improved pain and function related to non-specific neck pain better than either intervention alone (69). An RCT by Bronfort et al. demonstrated similar findings as Akhter et al. (8). And, an RCT with a two-year follow-up by Evans et al., demonstrated that the combination of manipulation and therapeutic exercise was the superior intervention (70). Moustafa et al. demonstrated that the addition of cervical manipulation to an integrated program also resulted in better outcomes for patients with fibromyalgia (71). Studies have demonstrated that the addition of supervised exercise and home exercise results in similar outcomes. Another RCT by Evans et al demonstrated that supervised exercise with and without manipulation resulted in similar outcomes, with little additional benefit noted with the addition of home exercise (72). Maiers et al. demonstrated that cervical manipulation with home exercise resulted in greater pain reduction for chronic neck pain after 12 weeks than the combination of supervised exercise and home exercise and exercise alone (73). Note, the studies by Evans et al. and Maiers et al. suggest that the combination of supervised exercise and home exercise did not result in better outcomes than either technique alone; considering the importance of self-management, instruction for home exercise should likely be prioritized. In an interesting attempt at preventative care, an RCT by Martel et al. demonstrated that a preventative program of spinal manipulation with and without home exercise was not effective for reducing the occurrence of cervical pain; however, there was no attempt to tailor interventions based on assessment (74). The potential impact of a preventative program should warrant further study, including interventions based on assessment, and additional combinations of treatment. These studies demonstrate that the combination of manipulation and exercise is a powerful treatment option for headache, neck pain, and fibromyalgia, both short-term and long-term; however, further study is needed before this combination can be recommended for preventative care.

Cervical manipulation is often combined with various pharmacological interventions in practice. An RCT by Boline et al. demonstrated that neither manipulation nor amitriptyline resulted in a significant difference in chronic tension-type headaches; however, the combination of both interventions was effective (75). Nelson et al. demonstrated that there was no advantage to combining amitriptyline and spinal manipulation for the treatment of migraine headache and that spinal manipulation demonstrated the same efficacy as well-established pharmacological treatment options (76). Considering the relatively low risk of many of these pharmacological treatment options and the effectiveness for immediately reducing pain, it may be recommended that manipulations are recommended first and pharmacological treatment recommended on an as-needed basis, based on a patient's personal case.

Additional treatment options have been investigated in conjunction with cervical manipulations. An RCT by Saayman et al. demonstrated that the combination of cervical manipulation and low-level laser therapy was more effective than either technique alone (77). Li et al. demonstrated that cervical manipulation resulted in a significantly higher response rate than TENS for the treatment of cervicogenic headache (78). And, an RCT by Puentedura et al. demonstrated that cervical manipulation was better for neck pain than thoracic manipulation when part of an integrated program (although both exhibited results) (79). The results of these studies may suggest that TENS should be considered a less effective option, low-level laser an adjunct to therapeutic intervention, and cervical manipulation should be part of an integrated approach to cervical dysfunction and headache, even when thoracic manipulation is included in treatment.

Many professionals have over-stated the risks associated with manipulations, and/or suggested that manipulations should only be performed after special tests which have failed to establish acceptable levels of validity, reliability, or sensitivity. The propagation of the myth that cervical manipulations are high-risk techniques may be some of the worst thinking demonstrated by professionals in this industry. Many editorials and research publications seemingly disregard probabilities, risk to benefit ratio, risk relative to other interventions, and consideration of confounding variables.

Survey data suggest the occurrence of serious adverse effects is extremely rare. A large survey study by Margarey et al. asked professionals who use cervical manipulations on a regular basis to report adverse events, resulting in data that suggests serious complications occur at a rate of about 1 per 1000 years of practice (80). This rate of occurrence suggests that less than 3% of all practicing manual therapists will have 1 serious incident in a 30-year career. Stevinson et al. asked the Association of British Neurologists to return surveys reporting cases of complications occurring within 24 hours of manipulation over the last 12 months. Of 323 members, 239 responded, 24 reported at least one case within the last 12 months, 35 adverse events were reported, of the adverse events reported only 10 involved stroke or dissection, and only 6 involved worsening neuropathy (81). To add perspective to this research, this implies that of all the cases seen by nearly 240 neurologists over 12 months, only 10 life-threatening incidents occurred following manipulation, from all referring professionals. Haldeman et al. published a study that included all cases of vertebral artery dissection after cervical manipulation (23), from the Canadian Chiropractic Protective Association between 1988-1997, representing 85% of practicing chiropractors in Canada. Based on the survey data, it is estimated that 134,466,765 cervical manipulations were performed during this 10-year period, resulting in a calculated rate of vertebral artery dissection after manipulation 1 out of every 5,846,381 cervical manipulations (82). Another survey study by Dvořák et al. found that non-life-threatening transient side-effects from cervical spine manipulation, such as disturbance of consciousness or radicular signs were more common at a rate of 1 in 16,716, and lumbar spine complications including increased pain and transient sensorimotor deficits with precise radicular distribution were 1 in 20,125 (83). Reinforcing these findings, Theil et al. did a prospective national survey demonstrating that of more than 50,000 cervical manipulations performed, no serious adverse events were noted, minor adverse events occurred less than 5% of the time, with many complaints (for example radicular pain) occurring in less than 0.1% of the time (84). Two additional studies by Rothwell et al. and Kranenburg et al. failed to find any correlation between cervical manipulation and stroke (85, 86). In another study of 283 patients by Cagnie et al. indicated that reactions to spinal manipulation (headache, soreness, fatigue) may be relatively common but are almost always benign in nature and short duration (less than 24 hours) (87). These last studies define minor adverse events in a way that is analogous to complaining about injection site soreness after getting a flu shot. An interesting study by Paanalahti et al. demonstrated that less serious, transient side-effects following manual therapy were fairly common (1 - 10%), the most common being muscle soreness; however, eliminating cervical manipulation and stretching did not change the rate of occurrence (88). These studies suggest that serious complications from manipulation are incredibly rare, that less serious adverse effects occur with more frequency but are still relatively rare, and removing manipulations from manual intervention may not change the rate of occurrence.

Unfortunately, these statistics have not impeded the publication of studies using biased, and in some cases purposefully frightening language. A study by Di Fabio et al. reviewed the literature and found evidence of 32 deaths from arterial dissection and brain stem lesions following cervical manipulation (89). This frightening finding is quickly admonished when the full study is read, and the reader finds that this includes all case studies between 1925 and 1997; implying only 32 reported deaths in 72 years. Puentedura et al. analyzed 10 reported cases of injury following thoracic manipulation, noting that spinal cord injury and pneumothorax have occurred (90). Although this study may imply that practitioners should be aware of red-flags following manipulation, the number of cases is too small to imply that these occurrences are anything but extremely rare. Smith et al. determined that manipulative therapy was an independent risk factor for vertebral artery dissection, but that conclusion is questionable. The researchers examined all patient records from a hospital for 5 years looking for evidence of cervical arterial dissection (CAD) occurring under the age of 60 (and a set of matched controls). The study showed that individuals in the (CAD) group were only 11% (14% versus 3%) more likely than controls to have had cervical manipulation, but were also 36% more likely to have had neck pain than controls (91). It seems more likely that a history of neck pain is the larger concern, and that the increase in cervical manipulations may be due to patients looking for treatment options. If the study by Oppenheim et al. was not published in an environment of fear-mongering, it would be a great example of reporting. Oppenheim et al. identified 18 cases in 6 years of patients that exhibited signs of complications from cervical, thoracic or lumbar manipulation. Of the 18 cases, none were life-threatening; however, most required surgery (92). Although these studies highlight troubling outcomes, the small number of cases likely implies the rate of occurrence in the survey data above is accurate.

Several potential causes of adverse events resulting from cervical manipulation have been investigated; however, a clear causal relationship has not been identified. A review by Haneline et al. provides a good summary, demonstrating that medical literature cannot establish a strong correlation between cervical mobilization and internal carotid artery dissection; noting that cases are both exceedingly rare and that a number of confounding factors exist including connective tissue aberrations, underlying arteriopathy, coexistent infection, and major differences in the way the techniques are performed by different practitioners/professions (93). One of the proposed mechanisms for adverse events is injury or occlusion of cervical arteries. Herzog et al. demonstrated that cervical manipulations did not result in greater strain on the carotid arteries than normal daily activity (94). Quesnele et al. demonstrated that neither head position nor cervical manipulation had any significant effect on blood flow or velocity in the vertebral arteries in healthy young men (95). And, in an RCT by Licht et al. it was demonstrated that cervical manipulation did not result in any significant change in vertebral artery flow velocity in individuals with biomechanical dysfunction (96). Some studies suggest that advanced atherosclerotic disease may be a contraindication. In an animal study (rats) by Qi et al., there was some evidence that severe carotid atherosclerosis plaques may increase risk during cervical manipulation (97). In another animal study (monkeys) by Guan et al., extreme rotation angle and significant atherosclerotic disease affected blood flow of the internal carotid artery; however, manipulation with mild atherosclerotic disease resulted in no change in blood flow (98). There has been some consideration given to worsening herniation with manipulation; however, Huang et al. demonstrated that manipulation, generally being performed on the side opposite the herniation, protects the herniated portion of the disk with ipsilateral flexion (99). The probability that the arterial injury was in progress, resulting in neck pain, motivating the patient to seek professional care, is a confounding variable that is likely supported by the research. As mentioned above Smith et al. determined that history of neck pain had a stronger correlation with CAD than recent manipulation (91). A study by Haldeman et al. investigated a series of cases of stroke, cerebral artery dissection, and cervical spine manipulation therapy, noting that 92% of cases presented with a history of head and/or neck pain, and 25% cases presented with a sudden onset of new and unusual headache and neck pain symptoms that are often associated with other neurological symptoms that may represent a dissection in progress (100). Cassidy et al. demonstrated that vertebrobasilar artery (VBA) stroke is very rare, and again that it is likely that the correlation between (VBA) and manipulation is due to the onset of headache and neck pain from VBA dissection motivating patient's to seek care (101). Attempts have been made to further clarify the definition of an adverse event, and develop prognostic indicators, but to date, there has not been any progress. In summary, there is no evidence that cervical manipulation places unusual stress or strain on cervical, vertebral or basilar arteries, there may be some evidence that advanced atherosclerotic disease is a contraindication, and research suggests that the most likely factor contributing to the correlation between manipulation and serious events is patients seeking care for serious events in progress.

Some professionals have called for the ubiquitous use of 

special tests for upper cervical spine instability and vertebrobasilar insufficiency (VBI)

 (102, 103), despite any evidence that they are sufficiently accurate to be used as screens. The few studies that are available suggest that some of these tests are specific, but not sensitive (104 - 109). This accuracy profile implies these tests may be helpful for diagnosis but would result in far too many false negatives to be useful in preventing cervical manipulations from being used when there is a risk of a severe adverse event. Kranenburg et al., also found these tests exhibit low reliability (110), which may contribute to the low sensitivity. Additionally, attempts have been made to categorize and identify prognostic symptoms. Carnes et al., used questionnaires to inquire with chiropractors about classifying concerning symptoms, but only initial classification was possible, and further study is needed (111). Kranenburg et al. and Chaibi et al. attempted to categorize symptoms associated with adverse effects and create risk/benefit assessments; however, these methods have not been widely adopted (112, 113). In a review of relevant cases, Haldeman et al. could not identify a single prognostic indicator that achieved statistically significant reliability for predicting an increased risk of injury from cervical manipulation (114). Unfortunately, these studies suggest that even if manipulations increase the risk of adverse events for a certain subset of patients, there is currently no accurate means for identifying that subset of individuals.

An incredibly important consideration that is often overlooked is the relative risk of manipulations. That is, what is the risk of manipulations when compared to other interventions for the same condition. Hurwitz et al demonstrated that adverse events (mostly increased pain or headache) were slightly more likely to occur following manipulation than mobilization, with adverse events resulting in a slight decrease in perceived outcome in a group of 280 respondents with neck pain (115). This study may indicate that starting with joint mobilizations is indicated for patients that may be at higher risk. In a prospective study by Rubenstein et al., the benefits of chiropractic care seemed to outweigh the risks, with the majority of neck pain patients exhibiting complete resolution of symptoms by the fourth session, 2/3rds exhibiting complete resolution at 3 and 12 months, less than 30% had any negative complaints following a treatment, less than 8% reported symptoms that could be interpreted as neurological, none of the complaints were of a serious nature, and only 1% of patients reported feeling worse at 3 and 12 months (116). When manipulations and chiropractic care are compared to physician intervention, the relative risks are sobering. A study by Whedon et al. demonstrated the cumulative probability of injury in a group of 66 - 99yo Medicare Part B beneficiaries was 40 incidents/100,000 for chiropractic care, and 153 incidents/100,000 subjects in the primary care cohort (117). Further, Dabbs et al. demonstrated that the best evidence indicates that NSAIDs are several 100 times more dangerous than cervical manipulations, and there is no evidence that NSAIDs are any more effective than manipulation for neck pain (118). Although the first two studies may influence practice, suggesting that mobilization may be a better initial treatment for high-risk patients, and minor adverse reactions should likely be tolerated given impressive outcomes; the last two studies demonstrate sobering statistics and hint at the hypocrisy of some in the medical community. The rate of serious adverse events from physician error and anti-inflammatory medications is potentially 100s of times more prevalent than serious adverse effects from cervical manipulation. It has to make you wonder if the attack on cervical manipulations is just another, not so veiled, attack on the chiropractic profession by physicians.

Risk of Adverse Effects

Several studies have compared mobilizations and manipulations, many of them are randomized controlled trials (RCTs). An RCT by Martínez-Segura et al. demonstrated that a single cervical thrust manipulation was more effective for reducing neck pain at rest and improving active ROM than a non-thrust mobilization technique (119). An RCT by Waqas et al. demonstrated that adding Maitland cervical manipulation (head cradle technique in the videos below) was more effective than adding Maitland cervical mobilizations (similar to the technique taught in the 

Joint Mobilization: Cervical and Thoracic Spine

 course) to cervical traction and strengthening exercises for the treatment of unilateral C6/C7 radiculopathy; however, both were effective (120). An RCT by Cassidy et al. demonstrated that both mobilization and manipulation were effective for increasing ROM; however, manipulations had a significantly larger effect on pain immediately following treatment (121). A multi-centered RCT by Dunning et al. comparing mobilization and manipulation for either the thoracic or cervical spine for the treatment of mechanical neck pain demonstrated that manipulations for either the thoracic or cervical spine resulted in larger improvements than mobilization at 1 and 4-week follow-ups (122). An RCT by El-Sodany et al. demonstrated that cervical manipulation and cervical SNAG mobilization resulted in larger improvements in ROM, pain, and Neck Disability Index scores when compared to exercise alone at 1-month follow-up (123) An RCT by Lopez-Lopez et al. demonstrated that chronic pain improved more with cervical manipulation or mobilization, compared to SNAG mobilization, however, changes in cervical ROM were similar in all groups. Anxiety affected manipulation outcomes when anxiety was low; however, when anxiety was higher mobilization and SNAG mobilization were more affected (124). These studies imply that manipulation likely results in larger short-term improvements in pain and disability up to one month after treatment unless the patient expresses anxiety about manipulation techniques note high levels of general anxiety may respond better to manipulation than mobilization. Further, mobilization and manipulation result in similar changes in ROM, and both are superior to exercise alone for neck pain.

Studies comparing the long-term effects (> 1 month) of mobilizations and manipulations suggest differences are minimal. Leaver et al. demonstrated that there was no appreciable difference in time to full recovery (43 days and 45 days) for mechanical neck pain patients, comparing 4 mobilization or manipulation treatment sessions over 2 weeks (125). An RCT by Perez et al., using the same intervention methodology as Leaver et al. (125) demonstrated no differences between interventions at 1 - 3 month follow-ups (126). Two RCTs by Griswold et al. reported no significant difference in outcome measures for neck pain patients comparing mobilization and manipulation, including cervical active ROM, 

, numerical pain rating scale, neck disability index scores, the patient-specific functional scale, or the global rating change scale, number of visits, and duration of care. (127, 128). The results of the UCLA neck-pain study, a large multi-centered RCT (Hurwitz et al.), demonstrated that there was little if any difference between mobilization and manipulation in a multi-modal program for neck pain patients at 6-month follow-up (129). These studies suggest that although early differences between manipulation and mobilization may be noted, by 4 weeks the difference in outcomes is insignificant.

Studies do suggest that long-term treatment of cervicogenic headache may benefit more from manipulation. In a multi-centered RCT by Dunning et al., 8 sessions of cervical manipulation were found to be more effective than cervical mobilization and exercise for the treatment of cervicogenic headache, resulting in less frequent headaches and shorter duration of headaches (130). An older RCT by Parker et al. demonstrated that chiropractic manipulation, physiotherapy manipulation, and physiotherapy mobilization resulted in similar reductions in frequency and duration for migraine sufferers; however, chiropractic manipulation demonstrated slightly better outcomes for pain intensity during migraines (131). These long-term studies suggest that, unlike mechanical neck pain, manipulations may be superior for long-term outcomes related to cervicogenic headache.

In summary, research suggests that manipulation likely has a slight edge on mobilizations for most outcome measures; however, mobilizations are also effective and the difference in outcomes reduces over the length of the treatment period. Further, anxiety may play a role in outcomes, and which technique is most effective for an individual patient. That is, practitioners should choose the technique that is most effective, based on the client's goal and anxiety, and is within the skill-set and scope of the practitioner.

Manipulation versus Mobilization

Mid-cervical Manipulation

Upper Cervical Manipulation

Cervicothoracic Junction Manipulation

Video Demonstration

 Sample Intervention (Chronic Neck Pain)

Walker, B. F., Hebert, J. J., Stomski, N. J., Losco, B., & French, S. D. (2013). Short-term usual chiropractic care for spinal pain: a randomized controlled trial. 

Passmore, S. R., Burke, J. R., Good, C., Lyons, J. L., & Dunn, A. S. (2010). Spinal manipulation impacts cervical spine movement and Fitts' task performance: a single-blind randomized before-after trial. 

Journal of manipulative and physiological therapeutics

Krauss, J., Creighton, D., Ely, J. D., & Podlewska-Ely, J. (2008). The immediate effects of upper thoracic translatoric spinal manipulation on cervical pain and range of motion: a randomized clinical trial. 

Martínez-Segura, R., De-la-Llave-Rincón, A. I., Ortega-Santiago, R., Cleland, J. A., & Fernandez-De-Las-Penas, C. (2012). Immediate changes in widespread pressure pain sensitivity, neck pain, and cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: a randomized clinical trial. 

journal of orthopaedic & sports physical therapy

Saavedra-Hernández, M., Arroyo-Morales, M., Cantarero-Villanueva, I., Fernández-Lao, C., Castro-Sánchez, A. M., Puentedura, E. J., & Fernández-de-las-Peñas, C. (2013). Short-term effects of spinal thrust joint manipulation in patients with chronic neck pain: a randomized clinical trial. 

Gorrell, L. M., Beath, K., & Engel, R. M. (2016). Manual and instrument applied cervical manipulation for mechanical neck pain: a randomized controlled trial. 

Jiang, C. B., Wang, J., Zheng, Z. X., Hou, J. S., Ma, L., & Sun, T. (2012). Efficacy of cervical fixed-point traction manipulation for cervical spondylotic radiculopathy: a randomized controlled trial. 

Zhong xi yi jie he xue bao= Journal of Chinese integrative medicine

Bronfort, G., Evans, R., Nelson, B., Aker, P. D., Goldsmith, C. H., & Vernon, H. (2001). A 

 of exercise and spinal manipulation for patients with chronic neck pain. 

Rolle, G., Tremolizzo, L., Somalvico, F., Ferrarese, C., & Bressan, L. C. (2014). Pilot trial of osteopathic manipulative therapy for patients with frequent episodic tension-type headache. 

The Journal of the American Osteopathic Association

Tuchin, P. J., Pollard, H., & Bonello, R. (2000). A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. 

Vernon, H., Borody, C., Harris, G., Muir, B., Goldin, J., & Dinulos, M. (2015). A randomized pragmatic clinical trial of chiropractic care for headaches with and without a self-acupressure pillow. 

Heikkilä, H., Johansson, M., & Wenngren, B. I. (2000). Effects of acupuncture, cervical manipulation and NSAID therapy on dizziness and impaired head repositioning of suspected cervical origin: a pilot study. 

Haas, M., Groupp, E., Aickin, M., Fairweather, A., Ganger, B., Attwood, M., … & Baffes, L. (2004). Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. 

Bove, G., & Nilsson, N. (1998). Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. 

Vernon, H., Jansz, G., Goldsmith, C. H., & McDermaid, C. (2009). A randomized, placebo-controlled clinical trial of chiropractic and medical prophylactic treatment of adults with tension-type headache: results from a stopped trial. 

Wassinger, C. A., Rich, D., Cameron, N., Clark, S., Davenport, S., Lingelbach, M., … & Davidson, J. (2016). Cervical & thoracic manipulations: acute effects upon pain pressure threshold and self-reported pain in experimentally induced shoulder pain. 

Winters, J. C., Sobel, J. S., Groenier, K. H., Arendzen, H. J., & Meyboom-de Jong, B. (1997). Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomised, single blind study. 

de Camargo, V. M., Alburquerque-Sendín, F., Bérzin, F., Stefanelli, V. C., de Souza, D. P. R., & Fernández-de-las-Peñas, C. (2011). Immediate effects on electromyographic activity and pressure pain thresholds after a cervical manipulation in mechanical neck pain: a randomized controlled trial. 

Mintken, P. E., Cleland, J. A., Carpenter, K. J., Bieniek, M. L., Keirns, M., & Whitman, J. M. (2010). Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. 

Fernández-Carnero, J., Fernández-de-las-Peñas, C., & Cleland, J. A. (2008). Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. 

Fernández-De-Las-Peñas, C., Pérez-De-Heredia, M., Brea-Rivero, M., & Miangolarra-Page, J. C. (2007). Immediate effects on pressure pain threshold following a single cervical spine manipulation in healthy subjects. 

Journal of Orthopaedic & Sports Physical Therapy

Fernández-Carnero, J., Cleland, J. A., & Arbizu, R. L. T. (2011). Examination of motor and hypoalgesic effects of cervical vs thoracic spine manipulation in patients with lateral epicondylalgia: a clinical trial. 

Vicenzino, B., Collins, D., Benson, H., & Wright, A. (1998). An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation. 

Vicenzino, B., Collins, D., & Wright, A. (1996). The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. 

Bautista-Aguirre, F., Oliva-Pascual-Vaca, A., Heredia-Rizo, A. M., Bosca-Gandia, J. J., Ricard, F., & Rodriguez-Blanco, C. (2017). Effect of cervical vs. thoracic spinal manipulation on peripheral neural features and grip strength in subjects with chronic mechanical neck pain: a randomized controlled trial. 

European journal of physical and rehabilitation medicine

Suter, E., & McMorland, G. (2002). Decrease in elbow flexor inhibition after cervical spine manipulation in patients with chronic neck pain. 

Haavik, H., & Murphy, B. (2011). Subclinical neck pain and the effects of cervical manipulation on elbow joint position sense. 

Bracht, M. A., Coan, A. C. B., Yahya, A., & Santos, M. J. D. (2018). Effects of cervical manipulation on pain, grip force control, and upper extremity muscle activity: a randomized controlled trial. 

Berglund, K. M., Persson, B. H., & Denison, E. (2008). Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. 

Oliveira-Campelo, N. M., Rubens-Rebelatto, J., MartÍn-Vallejo, F. J., Alburquerque-SendÍn, F., & Fernández-de-las-Peñas, C. (2010). The immediate effects of atlanto-occipital joint manipulation and suboccipital muscle inhibition technique on active mouth opening and pressure pain sensitivity over latent myofascial trigger points in the masticatory muscles. 

Journal of orthopaedic & sports physical therapy

Mansilla-Ferragut, P., Fernández-de-las Peñas, C., Alburquerque-Sendín, F., Cleland, J. A., & Boscá-Gandía, J. J. (2009). Immediate effects of atlanto-occipital joint manipulation on active mouth opening and pressure pain sensitivity in women with mechanical neck pain. 

Haavik, H., Özyurt, M., Niazi, I., Holt, K., Nedergaard, R., Yilmaz, G., & Türker, K. (2018). Chiropractic manipulation increases maximal bite force in healthy individuals. 

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. 

Pedroni, C. R., Oliveira, A. S., & Bérzin, F. (2005). Immediate effect of cervical mobilization in temporomandibular disorder patients. 

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. 

Packer, A. C., Pires, P. F., Dibai-Filho, A. V., & Rodrigues-Bigaton, D. (2015). Effect of upper thoracic manipulation on mouth opening and electromyographic activity of masticatory muscles in women with temporomandibular disorder: a randomized clinical trial. 

George, J. W., Fennema, J., Maddox, A., Nessler, M., & Skaggs, C. D. (2007). The effect of cervical spine manual therapy on normal mouth opening in asymptomatic subjects. 

Systemic Response (including 13, 20, 22, 25, 27, 28, )

Win, N. N., Jorgensen, A. M. S., Chen, Y. S., & Haneline, M. T. (2015). Effects of upper and lower cervical spinal manipulative therapy on blood pressure and heart rate variability in volunteers and patients with neck pain: a randomized controlled, cross-over, preliminary study. 

Goertz, C. M., Salsbury, S. A., Vining, R. D., Long, C. R., Pohlman, K. A., Weeks, W. B., & Lamas, G. A. (2016). Effect of spinal manipulation of upper cervical vertebrae on blood pressure: results of a pilot sham-controlled trial. 

Fernández-de-las-Peñas, C., Alonso-Blanco, C., Cleland, J. A., Rodríguez-Blanco, C., & Alburquerque-Sendín, F. (2008). Changes in pressure pain thresholds over C5-C6 zygapophyseal joint after a cervicothoracic junction manipulation in healthy subjects. 

Ruiz-Sáez, M., Fernández-de-las-Peñas, C., Blanco, C. R., Martínez-Segura, R., & García-León, R. (2007). Changes in pressure pain sensitivity in latent myofascial trigger points in the upper trapezius muscle after a cervical spine manipulation in pain-free subjects. 

Srbely, J. Z., Vernon, H., Lee, D., & Polgar, M. (2013). Immediate effects of spinal manipulative therapy on regional antinociceptive effects in myofascial tissues in healthy young adults. 

Coronado, R. A., Bialosky, J. E., Bishop, M. D., Riley 3rd, J. L., Robinson, M. E., Michener, L. A., & George, S. Z. (2015). The comparative effects of spinal and peripheral thrust manipulation and exercise on pain sensitivity and the relation to clinical outcome: a mechanistic trial using a shoulder pain model. 

Dishman, J. D., & Burke, J. (2003). Spinal reflex excitability changes after cervical and lumbar spinal manipulation: a comparative study. 

Niazi, I. K., Türker, K. S., Flavel, S., Kinget, M., Duehr, J., & Haavik, H. (2015). Changes in H-reflex and V-waves following spinal manipulation. 

Daligadu, J., Haavik, H., Yielder, P. C., Baarbe, J., & Murphy, B. (2013). Alterations in cortical and cerebellar motor processing in subclinical neck pain patients following spinal manipulation. 

Lelic, D., Niazi, I. K., Holt, K., Jochumsen, M., Dremstrup, K., Yielder, P., … & Haavik, H. (2016). Manipulation of dysfunctional spinal joints affects sensorimotor integration in the prefrontal cortex: A brain source localization study. 

Haavik-Taylor, H., & Murphy, B. (2007). Transient modulation of intracortical inhibition following spinal manipulation. 

Haavik, H., Niazi, I., Jochumsen, M., Sherwin, D., Flavel, S., & Türker, K. (2017). Impact of spinal manipulation on cortical drive to upper and lower limb muscles. 

Christiansen, Thomas Lykke, Imran Khan Niazi, Kelly Holt, Rasmus Wiberg Nedergaard, Jens Duehr, Kathryn Allen, Paul Marshall, Kemal S. Türker, Jan Hartvigsen, and Heidi Haavik. "The effects of a single session of spinal manipulation on strength and cortical drive in athletes." 

Humphries, K. M., Ward, J., Coats, J., Nobert, J., Amonette, W., & Dyess, S. (2013). Immediate effects of lower cervical spine manipulation on handgrip strength and free-throw accuracy of asymptomatic basketball players: a pilot study. 

Dunning, J., & Rushton, A. (2009). The effects of cervical high-velocity low-amplitude thrust manipulation on resting electromyographic activity of the biceps brachii muscle. 

Herzog, W., Scheele, D., & Conway, P. J. (1999). Electromyographic responses of back and limb muscles associated with spinal manipulative therapy. 

Pires, P. F., Packer, A. C., Dibai-Filho, A. V., & Rodrigues-Bigaton, D. (2015). Immediate and short-term effects of upper thoracic manipulation on myoelectric activity of sternocleidomastoid muscles in young women with chronic neck pain: A Randomized Blind Clinical Trial. 

Cervical Manipulation versus Other Interventions

Escortell, E. M., Lebrijo, G. P., Pérez, Y. M., del Barco Asúnsolo, A., Riesgo, R. F., & Saa, C. R. (2008). Randomized clinical trial for primary care patients with neck pain: manual therapy versus electrical stimulation. 

Hamilton, L., Boswell, C., & Fryer, G. (2007). The effects of high-velocity, low-amplitude manipulation and muscle energy technique on suboccipital tenderness. 

International journal of osteopathic medicine

Lin, J. H., Shen, T., Chung, R. C. K., & Chiu, T. T. W. (2013). The effectiveness of Long's manipulation on patients with chronic mechanical neck pain: a randomized controlled trial. 

Saavedra-Hernández, M., Castro-Sánchez, A. M., Arroyo-Morales, M., Cleland, J. A., Lara-Palomo, I. C., & Fernandez-De-Las-Penas, C. (2012). Short-term effects of kinesio taping versus cervical thrust manipulation in patients with mechanical neck pain: a randomized clinical trial. 

Galindez-Ibarbengoetxea, X., Setuain, I., Ramírez-Velez, R., Andersen, L. L., González-Izal, M., Jauregi, A., & Izquierdo, M. (2017). Immediate Effects of Osteopathic Treatment Versus Therapeutic Exercise on Patients With Chronic Cervical Pain. 

Alternative Therapies in Health & Medicine

Moretti, B., Vetro, A., Garofalo, R., Moretti, L., Patella, S., Patella, V., & Simone, C. (2004). Manipulative therapy in the treatment of benign cervicobrachialgia of mechanical origin. 

McReynolds, T. M., & Sheridan, B. J. (2005). Intramuscular ketorolac versus osteopathic manipulative treatment in the management of acute neck pain in the emergency department: a randomized clinical trial. 

Journal of the American Osteopathic Association

Bronfort, G., Evans, R., Anderson, A. V., Svendsen, K. H., Bracha, Y., & Grimm, R. H. (2012). Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. 

Joint Manipulation: Cervical Spine

Related Courses:

Course Description: Cervical Spine Manipulation

Course Study Guide: Joint Manipulation: Cervical Spine

Introduction
1 Sub Section

Research Summary

Cervical Spine Manipulations
5 Sub Sections

Systemic Response

Cervical Manipulation and Other Interventions

Risk of Adverse Effects

Manipulation versus Mobilization

Video Demonstration
3 Sub Sections

Sample Intervention (Chronic Neck Pain)

Bibliography

Related Courses:

Comments

Guest

Joint Manipulation: Cervical Spine

Related Courses:

Course Description: Cervical Spine Manipulation

Course Study Guide: Joint Manipulation: Cervical Spine

Introduction1 Sub Section

Research Summary

Cervical Spine Manipulations5 Sub Sections

Systemic Response

Cervical Manipulation and Other Interventions

Risk of Adverse Effects

Manipulation versus Mobilization

Video Demonstration3 Sub Sections

Sample Intervention (Chronic Neck Pain)

Bibliography

Related Courses:

Comments

Guest

Introduction
1 Sub Section

Cervical Spine Manipulations
5 Sub Sections

Video Demonstration
3 Sub Sections