Introduction

Cervical Manipulation and Other Interventions

Risk of Adverse Effects

Manipulation versus Mobilization

Sample Intervention (Chronic Neck Pain)

Research Corner

Cervical (Mechanical) Pain and Radiculopathy 

Cervicogenic Headache

Cervical Manipulation and Shoulder Dysfunction

Cervical Manipulation and Elbow Dysfunction

Cervical Manipulation Jaw

Systemic Response

Joint Manipulation: Cervical Spine

PACE

<h3>Introduction</h3>
This course describes joint manipulation techniques for the cervical spine (neck manipulation).&#xA0;Various synonyms and definitions have been used to describe the term &quot;manipulation&quot;. The Brookbush Institute uses one conventional definition of the term &quot;manipulations;&quot; implying low-amplitude (relatively small motions), high-velocity (quick) techniques, intended to target and reduce the stiffness of <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> joints or segments, that exhibit a decrease in passive accessory range of motion (a.k.a. stiffness during <a id="arthrokinematics" data-tip="1701" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic motion</a> and specifically <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> or <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a>). 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 &quot;multiple joints&quot; 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.&#xA0;
Note, that the term &quot;mobilization&quot; 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 <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> 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 <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach for cervicothoracic dysfunction, and <a href="https://brookbushinstitute.com/courses/upper-body-dysfunction-ubd" title="Upper Body Dysfunction" target="_blank" rel="noopener">upper body dysfunction (UBD)</a> including cervicogenic headache, shoulder impingement syndrome (SIS), <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylitis (tennis elbow), chronic thoracic pain, chronic neck pain, and acromioclavicular dysfunction, and <a id="movement-impairment" data-tip="1578" target="_blank" href="/glossary-term/movement-impairment" class="glossary">postural dysfunctions</a> including rounded shoulder <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, thoracic kyphosis, or an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt. Some evidence and clinical outcomes even suggest that addressing cervical dysfunction and forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> 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 <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a>, systematic, <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a>, patient-centered, patient-centered, and outcome-driven approach.&#xA0;
<h3>Techniques Covered in this Course:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/video/upper-cervical-manipulation" target="_blank" rel="noopener">Upper-cervical Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/cervical-spine-manipulation" target="_blank" rel="noopener">Mid-cervical Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/cervicothoracic-junction-manipulation" target="_blank" rel="noopener">Cervicothoracic Junction Manipulation</a></li>
</ul>
Sample Intervention (Chronic Neck Pain)
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/levator-scapulae-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Levator Scapulae</a></li>
 <li><a href="https://brookbushinstitute.com/video/upper-trapezius-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Upper Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/video/splenius-cervicis-splenius-capitis-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Splenii Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-extensor-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Deep Cervical Extensor Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/scalene-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Scalene Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/sternocleidomastoid-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Sternocleidomastoid Release</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/upper-cervical-manipulation" target="_blank" rel="noopener">Upper-cervical Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/cervical-spine-manipulation" target="_blank" rel="noopener">Mid-cervical Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/cervicothoracic-junction-manipulation" target="_blank" rel="noopener">Cervicothoracic Junction Manipulation</a></li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-isolated-activation" target="_blank" rel="noopener">Deep Cervical Flexor Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-isolated-activation-2" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
 </ul>
 </li>
 <li>Core Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-activation-and-progressions-for-stabilization-2" target="_blank" rel="noopener">Quadruped with DCF Activation</a></li>
 </ul>
 </li>
</ul>
<h3>Related Courses</h3>
Additional Joint Mobilization Courses
<ul>
 <li><a href="https://brookbushinstitute.com/courses/manipulations-cervical-spine" title="Cervical manipulation" target="_blank" rel="noopener">Joint Manipulation: Cervical Spine</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-thoracic-spine" title="Thoracic Manipulation" target="_blank" rel="noopener">Joint Manipulation: Thoracic Spine</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" title="Lumbar Manipulation" target="_blank" rel="noopener">Joint Manipulation: Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-wrist-and-elbow" title="Elbow Manipulation" target="_blank" rel="noopener">Joint Manipulation: Elbow (Radial Head) and Wrist</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-foot-ankle-and-tibiofibular-joint" title="Foot Manipulation" target="_blank" rel="noopener">Joint Manipulation: Ankle, Midfoot, and Tibiofibular Joint</a></li>
</ul>
For an introduction to joint mobilizations and manipulations:
<ul>
 <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
 <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>

Course Description: Cervical Spine Manipulation

<h2>For Cervicothoracic Dysfunction and <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper-Body Dysfunction</a>:</h2>
For an introduction to joint mobilizations and manipulations:
<ul>
 <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
 <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>
<h3>Techniques Covered in this Course:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/video/upper-cervical-manipulation" target="_blank" rel="noopener">Upper-cervical Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/cervical-spine-manipulation" target="_blank" rel="noopener">Mid-cervical Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/cervicothoracic-junction-manipulation" target="_blank" rel="noopener">Cervicothoracic Junction Manipulation</a></li>
</ul>
<h3>Signs of correlated dysfunction:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment:</a>
 <ul>
 <li>Forward Head</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-11-shoulders-elevate" target="_blank" rel="noopener">Shoulders Elevate</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-10-arms-fall" target="_blank" rel="noopener">Arms Fall</a></li>
 </ul>
 </li>
 <li>
 <h4><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry</a></h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/cervical-lateral-flexion-goniometry" target="_blank" rel="noopener">Cervical </a><a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">Lateral</a> Flexion &lt; 35 - 45&#xB0;
 <ul>
 <li>Note: Gross movement exams may be beneficial for identifying asymmetry, significant restriction, and pain with movement; however, cervical rotation, flexion, and extension are not <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> <a id="goniometry" data-tip="1524" target="_blank" href="/glossary-term/goniometry" class="glossary">goniometric</a> <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>.</li>
 </ul>
 </li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/introduction-manual-muscle-testing-active-population" target="_blank" rel="noopener">Manual </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing MMT:
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-endurance-test" target="_blank" rel="noopener">Deep Cervical Flexor Endurance Test</a>: Weak or With Compensation (cervical protraction)</li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> MMT: Weak or With Compensation (scapular protraction or elevation)</li>
 <li><a href="https://brookbushinstitute.com/video/lower-trapezius-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Lower Trapezius MMT</a>: Weak or With Compensation (scapular protraction or elevation)</li>
 </ul>
 </li>
</ul>

<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/levator-scapulae-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Levator Scapulae</a></li>
 <li><a href="https://brookbushinstitute.com/video/upper-trapezius-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Upper Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/video/splenius-cervicis-splenius-capitis-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Splenii Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-extensor-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Deep Cervical Extensor Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/scalene-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Scalene Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/sternocleidomastoid-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Sternocleidomastoid Release</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/upper-cervical-manipulation" target="_blank" rel="noopener">Upper-cervical Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/cervical-spine-manipulation" target="_blank" rel="noopener">Mid-cervical Manipulation</a></li>
 <li><a href="https://brookbushinstitute.com/video/cervicothoracic-junction-manipulation" target="_blank" rel="noopener">Cervicothoracic Junction Manipulation</a></li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-isolated-activation" target="_blank" rel="noopener">Deep Cervical Flexor Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-isolated-activation-2" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
 </ul>
 </li>
 <li>Core Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-activation-and-progressions-for-stabilization-2" target="_blank" rel="noopener">Quadruped with DCF Activation</a></li>
 </ul>
 </li>
</ul>

<ul>
 <li>Outcomes:&#xA0;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&#xA0;<a href="https://brookbushinstitute.com/glossary-term/superior" target="_blank" rel="noopener">superior</a>&#xA0;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.</li>
 <li>Headache:&#xA0;Cervical manipulation as part of an&#xA0;<a href="https://brookbushinstitute.com/glossary-term/integration" target="_blank" rel="noopener">integrated</a>&#xA0;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.</li>
 <li>Shoulder:&#xA0;Cervical manipulation (as well as cervicothoracic and thoracic manipulation) may decrease&#xA0;<a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a>&#xA0;pain, improve&#xA0;<a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a>&#xA0;ROM, increase&#xA0;<a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a>&#xA0;muscle activity and reduce&#xA0;<a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a>&#xA0;muscle fatigue.</li>
 <li>TMJ:&#xA0;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.</li>
 <li>Elbow:&#xA0;Cervical manipulation may affect elbow pain via systemic effects, and should be partly considered as an adjunct to elbow dysfunction interventions.</li>
 <li>Comparison:&#xA0;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.</li>
 <li>Integration:&#xA0;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&#xA0;<a href="https://brookbushinstitute.com/glossary-term/fibromyalgia" target="_blank" rel="noopener">fibromyalgia</a>, 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 &#x201C;supported by research.&#x201D;</li>
 <li>Risk of Adverse Events:&#xA0;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.</li>
 <li>Screening for Risk:&#xA0;No tests or prognostic indicators have been identified that would reliably screen individuals for risk of severe adverse reactions.</li>
</ul>

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

Cervical Spine Manipulations

Research investigating cervical manipulation most often correlates treatment with outcomes related to chronic neck pain, mechanical neck pain, and radiculopathy. An RCT by Walker et al. demonstrated that chiropractic care including cervical manipulation was more effective than sham treatment for mechanical neck pain, including larger improvements in pain, function, and treatment satisfaction (1). Another RCT by Passmore et al. demonstrated that cervical manipulation increased range of motion, and positively impacted motor control and performance of Fitt&apos;s task (requiring cervical rotation) (2). An RCT by Krauss et al. demonstrated that cervicothoracic junction manipulation improved cervical range of motion (ROM) and mid-cervical pain (3). In a <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> by Peterson et al., patients with cervical herniation confirmed by MRI, and radicular symptoms, received cervical manipulations 3 - 5 times per week for the first 2 - 4 weeks, and 1 - 3 manipulations thereafter until symptoms resolved. Improvements were reported by 55.3% of patients at 2 weeks, 68.9% at 1 month and 85.7% at 3 months, with no adverse events (133). Further, a comparison study by Mart&#xED;nez-Segura et al. demonstrated that both cervical and thoracic manipulation were equally effective for improving pain pressure threshold, neck pain intensity, and cervical ROM in participants with <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> chronic neck pain (4), and an RCT by Saavedra-Hern&#xE1;ndez demonstrated that cervical and thoracic spine manipulation combined resulted in better outcomes (5). An RCT by Gorrell et al. comparing manipulation techniques demonstrated that manual manipulation plus stretching resulted in better outcomes than stretching and &quot;Activator IV&quot; manipulation, or stretching alone, including better improvements in cervical pain, <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> flexion, and rotation ROM (6). In an RCT by Jiang et al., cervical manipulation resulted in larger improvements than <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a>, including larger systemic effects (discussed below) (7). Last, in an RCT by Bronfort et al., the combination of therapeutic exercise and cervical manipulation was found to be more effective than either alone for reducing symptoms of chronic neck pain (8). Saavedra-Hern&#xE1;ndez et al. attempted to develop a clinical prediction rule, demonstrating that pain intensity greater than 4.5 points; cervical extension less than 46&#xB0;; the presence of <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a> at T1; a negative upper limb <a id="tension" data-tip="1229" target="_blank" href="/glossary-term/tension" class="glossary">tension</a> <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> and female sex were were correlated with a higher rate of success from cervical manipulation, with 4 out of 5 variables present increasing the likelihood of success from 61.7% to 75.4% (137). The efficacy of this clinical prediction rule should be confirmed with further research. In summary, these studies demonstrate that cervical manipulation is effective for improving general pain, pain pressure threshold, range of motion, motor control, and function in individuals with chronic, mechanical, and radiating neck pain. Further, these studies imply that <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes may be achieved using a combination of manual cervical manipulation and thoracic manipulation, and further benefits may be achieved with the addition of cervicothoracic junction manipulation, stretching, and exercise.
<table>
 <tbody>
 <tr>
 <td>
 <h3>Posture:</h3>
 Manipulation alone is likely ineffective for improving cervical <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>. Fisher et al. demonstrated that a single manipulation to the cervical spine was not sufficient to influence <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> sway in individuals with nonspecific neck pain (134). Further, a study by Shilton et al. demonstrated that 4 weeks of regular cervical and thoracic manipulation resulted in a trend toward improved cervical lordosis angle that did not reach statistical significance (135). This study should likely be repeated with a larger sample size to determine if the trend was an actual result, and further, standing and dynamic measure of cervical <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> should be added. In this study, cervical lordosis angle was measured using a fluoroscopy machine that may have influenced sitting <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>. The findings of these studies are somewhat odd, considering the very positive research demonstrating the efficacy of cervical and thoracic spine joint mobilizations for improving <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>. This may be due to the mobilization studies including a combination of techniques. Based on the studies discussed here, and the studies covered in the <a href="https://brookbushinstitute.com/article/joint-mobilization-cervical-and-thoracic-spine/" target="_blank" rel="noopener">Joint Mobilization: Cervical and Thoracic Spine</a> course, it is likely reasonable to conclude that manipulations alone are not sufficient for improving posture; however, mobilization/manipulation in combination with soft-tissue techniques and exercise may have a significant effect.
 </td>
 </tr>
 </tbody>
</table>

Although most studies have demonstrated that manipulation has a positive effect on headaches, some consideration must be given to the origin of the headache and our limited ability to differentiate headache types. Not all headaches are cervicogenic, but many headaches are &quot;mixed&quot; with cervicogenic symptoms contributing to the patient&apos;s overall experience. Research generally implies that cervical manipulation improves headache frequency, intensity, or duration, but these findings are not ubiquitous across all studies. In a pilot controlled study by Rolle et al. osteopathic manipulation reduced headache frequency by 33% when compared to sham therapy (<a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> rhythmic impulse) (9). An RCT by Tuchin et al. demonstrated that spinal manipulative therapy resulted in a significant decrease in migraine frequency, duration, disability, and medication use when compared to controls (10). A study by Vernon et al. demonstrated that chiropractic manipulation reduced weekly headache frequency by 46%, and further, that the addition of a self-acupressure pillow for home-care did not significantly alter outcomes (11). A study by Heikkil&#xE4; et al. demonstrated that a combination of treatment including cervical manipulations was more effective than other combinations that included NSAIDs and acupuncture, for the treatment of dizziness believed to have cervicogenic origins (12). Further, a study by Haas et al. suggests a dose-response relationship exists, demonstrating that chiropractic care (manipulation, soft-tissue, and modalities) 3-4 times per week was better than 1 visit per week, 4 visits per week was better than 3 visits per week at 4-week follow-up; however, 3 and 4 visits per week lead to roughly equal results at 12 weeks (13). These high-quality studies provide strong evidence that manipulations may have a positive effect on headaches; however, additional studies are not as supportive. An RCT by Bove et al. demonstrated that soft-tissue therapy and manipulation, and soft-tissue and laser therapy (sham), resulted in similar outcomes after 8 treatment sessions (4 weeks), suggesting manipulation may not be an effective addition to soft tissue therapy for episodic tension-type headache (14). And, an RCT that terminated early (on day 3) by Vernon et al., demonstrated a combination of amitriptyline and chiropractic spinal manipulation was effective in reducing tension-type headaches, but neither treatment alone resulted in a significant change (15). These studies imply that cervical manipulation, as part of an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> care plan, may be effective for the treatment of headaches, however, cervical manipulations alone are likely less or not effective for some headache types. Note, although direct comparison is not possible, the research investigating the effectiveness of <a href="https://brookbushinstitute.com/article/static-manual-release-suboccipitals-sternocleidomastoid-scm-scalenes-and-deep-cervical-extensors-multifidi" target="_blank" rel="noopener">cervical </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> static manual <a id="release" data-tip="1248" target="_blank" href="/glossary-term/release" class="glossary">release</a> and <a href="https://brookbushinstitute.com/article/joint-mobilization-cervical-and-thoracic-spine/" target="_blank" rel="noopener">cervical mobilizations</a> for the treatment of cervicogenic headache is ubiquitously positive and maybe a better &quot;first option&quot;.

Cervical manipulations have also demonstrated efficacy for improving outcomes for the treatment of <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> dysfunction. A study by Wassinger et al. demonstrated that cervical, cervicothoracic and thoracic manipulation significantly decreased acute shoulder pain and pain pressure threshold over the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> following experimentally (exercise) induced pain (16). An RCT by Winters et al. demonstrated that manipulation was the <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> treatment option for treating <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> girdle disorders, while corticosteroid injection was a better option for synovial <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> disorders (17). An RCT by de Camargo et al. demonstrated that cervical manipulation directed toward the C5/C6 segment increased EMG and reduced fatigue to the <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoids</a> in individuals with mechanical neck pain (18). Last, a study by Mintken et al. may be an appropriate summary of research findings regarding shoulder dysfunction and cervical manipulation. The study indicated cervical and thoracic spine manipulation would be beneficial for shoulder pain patients exhibiting one or more of the following signs (clinical prediction rule): pain-free <a href="https://brookbushinstitute.com/video/shoulder-flexion-goniometry" target="_blank" rel="noopener">shoulder flexion</a> &lt;127&#xB0;, <a href="https://brookbushinstitute.com/video/shoulder-internal-rotation-goniometry" target="_blank" rel="noopener">shoulder internal rotation</a> &lt;53&#xB0;, negative <a href="https://brookbushinstitute.com/video/neer-impingement-test" target="_blank" rel="noopener">Neer test</a>, not taking medications for shoulder pain, and symptoms for less than 90 days (more signs increased the odds of successful outcomes) (19). In summary, research suggests that cervical manipulation (as well as cervicothoracic and thoracic manipulation) may decrease <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> pain, improve <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> ROM, increase <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and reduce <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> fatigue when shoulder dysfunction is mechanical, with relatively recent onset (3 months or less) and has not progressed to levels of pain that would motivate a patient to seek prescription medication.

Several studies have demonstrated a relationship between cervical manipulation and the treatment of elbow dysfunction. Studies by Fern&#xE1;ndez-De-Las-Pe&#xF1;as and colleagues demonstrate that cervical manipulation may improve elbow pain pressure threshold (without changes in heat or cold pressure thresholds), and improve pain-free grip strength but not maximal grip strength, in patients with <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia (LE) (20 - 22). An RCT by Vicenzino et al. demonstrated that cervical manipulation improved LE symptoms, including general pain, pain pressure threshold, pain-free grip strength, and neurodynamics (23). In another RCT by Vincenzino et al., participants with LE who received cervical manipulation exhibited immediate hypoalgesic and sympathoexcitatory effects (discussed below under &quot;Systemic Response&quot;) beyond that noted in placebo or control groups (24). In a comparison study, Fern&#xE1;ndez-Carnero et al. demonstrated that cervical manipulation produced larger changes in analgesic effects than thoracic manipulation, and both techniques were equally effective for improving grip strength (22). Bautista-Aguirre et al. demonstrated that cervical and/or thoracic manipulations improved mechanosensitivity of the elbow and grip strength in non-specific chronic neck pain patients; however, there were also improvements in the placebo group resulting in statistically insignificant differences (25). A trend was present in the data; this study should be repeated with larger sample size and more <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> outcome measures. Suter et al. demonstrated that cervical manipulation decreased elbow flexor inhibition in individuals with chronic neck pain (26). And, Haavik et al. demonstrated that cervical manipulation improved elbow joint position sense, and further, that the results were more significant in those with a history of neck pain (27). The only study that could be located that countered any of the above findings was an RCT by Bracht et al., demonstrating that the cervical manipulation group did not exhibit significantly different changes in PPT, EMG, and grip force control (28) These findings may suggest that more research is needed investigating the mechanism of change in the studies above, or that this study may be an outlier that failed to reach statistical significance for this population. Although research demonstrating reduced elbow pain in individuals with a history of neck pain may seem like a non-sequitur, Berglund et al. demonstrated that 70% of subjects with <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> elbow pain indicated pain in the cervical or thoracic spine, compared to just 16% of a matched control group (29). These studies suggest that cervical manipulation may improve elbow pain, grip strength, and elbow reposition sense, which may be due in part to a correlation between neck and elbow dysfunction.

Upper cervical manipulation may be beneficial for treating temporomandibular joint (TMJ) issues, however, the findings are not as consistent as those demonstrated for other joints, further, lower cervical manipulations may not be effective. Oliveira-Campelo et al. demonstrated that atlanto-occipital thrust manipulation, as well as <a href="https://brookbushinstitute.com/video/suboccipital-manual-static-release" target="_blank" rel="noopener">suboccipital soft tissue release</a>, led to an immediate increase in pain pressure threshold over <a id="latent-trigger-point" data-tip="1133" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">latent trigger points</a> in the masseter and temporalis muscles and increased TMJ ROM (30). Mansilla-Ferragut et al. demonstrated that atlantoaxial joint thrust manipulation resulted in an increase in pain pressure threshold and TMJ ROM in women with mechanical neck pain (31). Haavik et al. even demonstrated that upper cervical manipulation increased maximal bite force in asymptomatic individuals (32). In addition to these studies investigating high-velocity manipulations, research investigating low-velocity cervical mobilizations has demonstrated efficacy for improving pain pressure threshold, pain VAS scores, and TMJ ROM (33- 35). However, not all studies have demonstrated an effect. In a blinded RCT by Packer et al., T1 cervicothoracic manipulation did not have a significant effect on pain or TMJ ROM for a group of patients with TMJ disorder (36). Last, an RCT by George et al. demonstrated that Active <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> Technique (ART), cervical manipulation, and controls did not result in significantly different outcomes for mouth opening and pain pressure threshold in asymptomatic individuals (37). These studies suggest that upper cervical manipulations are effective for reducing 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 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 <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a>, 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 <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> 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 <a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> 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 <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> changes. Fern&#xE1;ndez-de-las-Pe&#xF1;as demonstrated that cervicothoracic junction manipulation decreased pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> over C5/C6 zygoapophyseal joints (40). Ruiz-S&#xE1;ez demonstrated that cervical manipulation directed at C3/C4 resulted in a decrease in pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of <a id="latent-trigger-point" data-tip="1133" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">latent trigger points</a> in the <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a> (41). Further, in two studies by Fern&#xE1;ndez-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 <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> 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 <a href="https://brookbushinstitute.com/article/gluteus-medius" target="_blank" rel="noopener">gluteus medius</a> and <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> (42). And, Coronado et al. demonstrated that both cervical and shoulder thrust manipulation resulted in changes in both local (<a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a>) and <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> (<a href="https://brookbushinstitute.com/article/tibialis-anterior" target="_blank" rel="noopener">tibialis anterior</a>) 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 <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> changes and not just local effects.
Additional studies suggest further central <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> changes. Dishman et al. demonstrated that cervical and lumbar manipulation resulted in transient suppression of motoneuron <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a>, as assessed by the <a href="https://brookbushinstitute.com/article/tibialis-anterior" target="_blank" rel="noopener">tibialis anterior</a> 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 <a href="https://brookbushinstitute.com/article/soleus" target="_blank" rel="noopener">soleus</a>, 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 <a href="https://brookbushinstitute.com/article/tibialis-anterior" target="_blank" rel="noopener">tibialis anterior</a> muscles, suggesting that manipulation may alter sensorimotor <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a> (48 - 49). A study by Christiansen et al., also demonstrated increased cortical <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a> and increased <a href="https://brookbushinstitute.com/article/soleus" target="_blank" rel="noopener">ankle plantar flexor strength</a> 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 <a id="integration" data-tip="1472" target="_blank" href="/glossary-term/integration" class="glossary">integration</a>, 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 <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> 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 <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and strength are also commonly cited phenomena resulting from cervical manipulation. Summarizing the studies above; Fern&#xE1;ndez-Carnero et al. and Vicenzino et al. noted an increase in pain-free grip strength in individuals with <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia (20, 22 - 24), de Carmargo noted an increase in EMG amplitude signal and fatigue resistance in <a href="https://brookbushinstitute.com/article/deltoids" target="_blank" rel="noopener">deltoid</a> muscles (18), and Niazi et al. and Christiansen et al. noted increases in <a href="https://brookbushinstitute.com/article/soleus" target="_blank" rel="noopener">ankle plantar flexor strength</a> (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 <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> (53). And, An RCT by Pires et al. demonstrated that cervical manipulation resulted in a short-term relative decrease in right and left SCM <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> 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 &quot;normalize&quot; activity, rather than result in a ubiquitous change in activity in one direction.
<ul>
 <li>Systematic responses to cervical manipulation:
 <ul>
 <li>Sympathoexcitatory effects (skin conductance, skin temperature, blood pressure, heart rate variability, etc.)</li>
 <li>Proximal and <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> analgesic effects</li>
 <li>Inhibition of H-reflex</li>
 <li>Increased cortical excitability</li>
 <li>Potential increase in kinesthesia and motor control</li>
 <li>Normalization of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and increased performance</li>
 </ul>
 </li>
</ul>

<h3>Cervical Manipulation Versus Other Interventions</h3>
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 <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> 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 <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> 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 <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> 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 <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">kinesiology</a> 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 <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> 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 <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> 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 Heikkil&#xE4; 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 <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> 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 <a id="base-of-support" data-tip="1198" target="_blank" href="/glossary-term/base-of-support" class="glossary">Bos</a> 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.
<h3>Cervical Manipulation and Other Interventions</h3>
Research demonstrates that an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> 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 <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> 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, <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> 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 <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> intervention (70). Moustafa et al. demonstrated that the addition of cervical manipulation to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> program also resulted in better outcomes for patients with <a id="fibromyalgia" data-tip="1135" target="_blank" href="/glossary-term/fibromyalgia" class="glossary">fibromyalgia</a> (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 <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> (74). The potential impact of a preventative program should warrant further study, including interventions based on <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, 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 <a id="fibromyalgia" data-tip="1135" target="_blank" href="/glossary-term/fibromyalgia" class="glossary">fibromyalgia</a>, 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&apos;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 <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> 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 <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> 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 <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a>, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, or <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>. 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 Dvo&#x159;&#xE1;k 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 <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> 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 <a id="connective-tissue-cell" data-tip="1368" target="_blank" href="/glossary-term/connective-tissue-cell" class="glossary">connective tissue</a> 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 <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> 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&apos;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 <a href="https://brookbushinstitute.com/article/special-tests-upper-cervical-spine-stability-vertebrobasilar-insufficiency-vbi" target="_blank" rel="noopener">special tests for upper cervical spine </a><a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a> 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 <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a>, but not <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> (104 - 109). This <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> 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 <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (110), which may contribute to the low <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>. 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 <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> cases, Haldeman et al. could not identify a single prognostic indicator that achieved statistically significant <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> 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 <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> 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 <a id="cohort-study" data-tip="1416" target="_blank" href="/glossary-term/cohort-study" class="glossary">cohort</a> (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.

Several studies have compared mobilizations and manipulations, many of them are <a id="randomized-control-trial" data-tip="1406" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled</a> trials (RCTs). An RCT by Mart&#xED;nez-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 <a href="https://brookbushinstitute.com/article/joint-mobilization-cervical-and-thoracic-spine" target="_blank" rel="noopener">Joint Mobilization: Cervical and Thoracic Spine</a> course) to cervical <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> and strengthening exercises for the treatment of <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> 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 <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to exercise alone for neck pain.
Studies comparing the long-term effects (&gt; 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, <a href="https://brookbushinstitute.com/video/deep-cervical-flexor-endurance-test" target="_blank" rel="noopener">deep cervical flexor endurance</a>, 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.
<table>
 <tbody>
 <tr>
 <td>Note: The reduction in significant differences in the long-term comparison of mobilizations and manipulations may be expected, as the length of the study approaches the mean (average) recovery time for a diagnosis. That is, there is likely less improvement to be made; and therefore, smaller changes are made by any intervention as full recovery and discharge are approached. To address these issues, it may be more worthwhile to investigate which modality results in the earliest return to full function and full recovery, or which modality results in the fewest mean number of sessions required to reach full recovery (discharge). Although some of the studies above did investigate some of these issues, the number of sessions or follow-up time was preset, that is, time was not the dependent variable.</td>
 </tr>
 </tbody>
</table>
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 <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> 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&apos;s goal and anxiety, and is within the skill-set and scope of the practitioner.

Video Demonstration

Mid-cervical Manipulation

Upper Cervical Manipulation

Cervicothoracic Junction Manipulation

Bibliography

© 2019 Brent Brookbush
Questions, comments and critiques welcomed and encouraged

Copyright

A-Band - Refers to the part of the muscle cell that looks darker under a microscope.  This area of the cell is darker due to parallel arrangement of thicker filaments (myosin) and overlap with the thinner filaments (actin).
<ul>
 	<li>As a muscle contracts, the A-band is where actin and myosin interact.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Accuracy - the proportion of individuals correctly identified by the test results.
<ul>
 	<li>For example, a special test with perfect accuracy would imply a test has 100% specificity, 100% sensitivity, 100% positive predictive value and 100% negative predictive values.</li>
</ul>

Action Potential - A rapid change in voltage, resulting in a wave of excitation, that may result in stimulation of a nerve or muscle cell.
<ul>
 	<li>In order for an action potential to be initiated, the resting membrane voltage must exceed the excitation threshold, which then results in a cascade of depolarization and the "wave of excitation." Any stimulus below that threshold will not result in an action potential, and a stimulus greater than the threshold will not increase a single action potential, but may result in additional action potentials.  In this way, the action potential functions more like an on/off switch (all or none), and less like a dimmer switch.</li>
</ul>

A single-joint movement pattern (most often) designed to load a specific under-active muscle(s), while minimizing the contribution of over-active synergists via specific cues/joint motions.
<ul>
 	<li style="text-align: left;">Activation techniques/exercises are performed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction.</li>
 	<li style="text-align: left;">Activation techniques/exercises cannot be multi-joint movement patterns due to relative flexibility, altered reciprocal inhibition, and synergistic dominance resulting in compensation patterns.</li>
</ul>
Example, <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/activation/gluteus-medius-activation-progression/" target="_blank">gluteus medius activation</a> involves resisted hip abduction while minimizing the contribution of the TFL via hip extension.

Active stretching is a term used to describe a stretch that involves an active contraction of opposing musculature to lengthen a muscle to its end range. Generally these stretches are held for 2-5 seconds and repeated for 8-15 repetitions.

Adenosine triphosphatase (ATPase): is the enzyme responsible for catalyzing (initiating and accelerating) the decomposition of ATP to ADP.
<ul>
 	<li>This dephosphorylation (breakdown) reaction releases energy for processes like muscular contraction.</li>
</ul>

Adenosine triphosphate (ATP): The molecule that functions as a universal energy-transfer molecule, providing most of the energy associated with muscular contraction and human movement. ATP is composed of an adenine group, a ribose group, and three molecules of inorganic phosphates.
<ul>
 	<li>Energy is provided when hydrolysis results in the cleaving of a phophate group; resulting in adenosine diphosphate, an inorganigic phosphate group, and energy.</li>
</ul>

Algometry - measuring the amount of pressure to result in sensitivity or pain, using an algometer.
<ul>
 	<li>Generally, research uses algometry to establish a minimum pain pressure threshold (PPT), in which a lower PPT implies more sensitivity and pain, and a higher PPT implies less sensitivity and pain. PPT is a common outcome measure in trigger point research.</li>
</ul>
<a href="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg"><img class="aligncenter wp-image-140177" src="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg" alt="Image of an Algometer" width="500" height="333" /></a>

All-or-none principle - a nerve or muscle cell's response to a stimulus is independent of the strength of the stimulus. If that stimulus exceeds the threshold potential (threshold of an action potential), the nerve or muscle fiber will respond completely; otherwise, there is no response.

Example, when a motor unit in the biceps brachii is stimulated it contracts the same way whether a 10 lb or 50 lb dumbbell is lifted.  It is actually the number of muscle cells and the size of the motor unit that determines force output.

&nbsp;

The transition period between eccentric load and concentric contraction during a repetition of an exercise.  This term is most often used in reference to power/plyometric exercises, in which a shorter amortization phase is believed to be beneficial.  The shorter amortization phase may better use the stored energy from the elastic deformation of connective tissue and enhance synchronization of myotatic (stretch) reflex with maximum voluntary contraction.

Example, the athlete was cued to spend as little time as possible in the bottom of their squat stance (the amortization phase) during a set of box jumps.

Muscles that oppose the prime mover and synergists for a given joint action.

That is, all the muscles that can perform the opposing joint action.

Example: The triceps and anconeus are antagonists during elbow flexion.

An anatomical direction; toward the front

Example, the face is on the anterior aspect of the head

Appendicular Skeleton - referring to the bones the bones of the arms and legs, as well as the bones that support them. This includes the pelvis, clavicle and scapula. There are approximately 126 bones in the appendicular skeleton.
<ul>
 	<li>Etymology - Appendicular, as in appendage, "that which is appended to something as a proper part," 1640s, from <a class="crossreference" href="https://www.etymonline.com/word/append?ref=etymonline_crossreference">append</a> + <a class="crossreference" href="https://www.etymonline.com/word/-age?ref=etymonline_crossreference">-age</a>. - <a href="https://www.etymonline.com/word/appendage" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Appendicular skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/axial-skeleton/" target="_blank" rel="noopener">axial skeleton</a>".

A reflexive decrease in muscle activity due to joint dyskinesis.
For example, a reduction in deep cervical flexor activity as a result of cervical spine dyskinesis.

Arthrokinematic Motion - Small amplitude motions between bone surfaces at a joint.  The arthrokinematic motions are roll, glide (slide or translation), spin, compression and distraction (traction). Arthrokinematic motions accompany osteokinematic motions to maintain joint congruence.
<ul>
 	<li>Example, arthrokinematic motion of the talus includes posterior glide on the tibia during ankle dorsiflexion.</li>
</ul>
Synonyms include: arthrokinematics, passive accessory motion, joint play and component motion

&nbsp;

Assessment - is the act of assessing, i.e. determining the importance, size, or value of -

In most cases, the results of an assessment are compared to normative data. If the individual exhibits values that are within normal parameters, it may be assumed that the aspect of health or motion assessed is not contributing to the patient's complaint, symptoms or movement impairment. If the results fall outside of normal parameters, it may indicate that the aspect of health or motion assessed is contributing to, or being affected by the patient/client's complaint, symptoms, or movement impairment. In some cases, the results of an assessment are compared to an "ideal model." In this case, deviations from the ideal are noted as potential issues. For example, deviations noted in the <a title="Introduction to the Overhead Squat Assessment" href="https://brentbrookbush.com/online-courses/articles/assessment/introduction-overhead-squat-assessment/" target="_blank">Overhead Squat Assessment</a> are compared to an "ideal model" of posture and motion.

Assessments used by human movement professionals can be divided into three broad categories:
<ul>
 	<li>"Clear" the Patient/Client for Intervention - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.
<ul>
 	<li>For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A Calf Squeeze (Thompson) Test is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.</li>
</ul>
</li>
 	<li>Highlight Contraindications - Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.
<ul>
 	<li>For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.</li>
</ul>
</li>
 	<li>Refine Exercise/Intervention Selection: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.
<ul>
 	<li>Most movement assessments fall into this category. For example, a positive <a href="https://brentbrookbush.com/vimeo_videos/elys-test-rectus-femoris-flexibility-assessment/" target="_blank">Ely's Test</a> may indicate a need to release and/or lengthen the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rectus-femoris/" target="_blank">rectus femoris</a>.</li>
</ul>
</li>
</ul>
Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to Refine Exercise/Intervention Selection, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"

Axial Skeleton - referring to the bones of the head, neck, trunk and spinal column (does not include pelvis). There are approximately 80 bones in the axial skeleton.
<ul>
 	<li>Etymology - Axial, as in "axis", referring to "imaginary motionless straight line around which a body (such as the Earth) rotates," from Latin axis "axle, pivot, axis of the earth or sky" - <a href="https://www.etymonline.com/word/axis" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Axial skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/appendicular-skeleton/" target="_blank" rel="noopener">appendicular skeleton</a>".

Balance - The ability to maintain a body’s center of mass over its base of support. Balance can be static or dynamic.
<ul>
 	<li>For example, maintaining balance is harder on one leg because the center of mass must stay over a much smaller base of support.</li>
</ul>

A ball and socket joint (also called a spheroid joint or spheroidal joint) is a synovial joint in which the rounded or spherical end of one bone fits into a cup-like depression of another bone. The distal bone is capable of motion around an indefinite number of axes, which have one common center. Examples include the hip and shoulder (glenohumeral joint)

Base of support (BoS) - refers to the area beneath an object or person, and the area within the perimeter created by every point of contact that the object or person makes with the supporting surface. This may include the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/gluteus-maximus/" target="_blank" rel="noopener">glutes</a> of someone sitting on a chair, or the back of someone leaning against a wall.
<ul>
 	<li>For example, during a single leg balance the BoS is the area of the foot in contact with the surface; however, when a person is standing on two feet, the BoS is the area of both feet and the surface between them.</li>
</ul>

Pertaining to both sides

Example, bilateral rows are performed with both arms at the same time.

Case-control Study - a particular form of retrospective study that samples a matched group of people who have, and do not have the outcome being studied. A case-control study is a quasi-experimental design, often used in medicine to aid in determining potential contributing factors (cannot determine causality). In this study type exposure is the dependent variable and outcome is independent.
<ul>
 	<li>Example, in this retrospective case-control, medical records were investigated for trends correlated with cervical pain (1).
<ol>
 	<li>Mäkela, M., Heliövaara, M., Sievers, K., Impivaara, O., Knekt, P., &amp; Aromaa, A. (1991). Prevalence, determinants, and consequences of chronic neck pain in Finland. American journal of epidemiology, 134(11), 1356-1367.</li>
</ol>
</li>
</ul>

An anatomical direction; toward the tail, relative to humans this term is often used to refer to "in the direction of the tale (toward the feet)".

Example, to release the trapezius muscle the therapist used a force directed caudally.

Center of mass (CoM) - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.

Center of gravity (CoG) - point where gravity appears to act. Since the human body is so small compared to the earth, we can assume gravity acts uniformly on the body, and that CoG and CoM are the same.
<ul>
 	<li>Example, the CoM of the human body while lying down or standing straight up is close to our navel. However, it is possible that during a resistance exercise, the combination of the body's weight and the weight of the resistance will place the combined CoM outside the body. For example, during the mid-portion of a <a href="https://brentbrookbush.com/vimeo_videos/back-squat/" target="_blank" rel="noopener">back squat</a> the CoM would be several anterior to the naval.</li>
</ul>

An anatomical direction; toward the head (synonym: cranial)

Example, hip pain was felt with any force directed cephalad.

Cohort Study - a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic), performing a cross-section at intervals through-out a period of time. A cohort study is a quasi-experimental design often used in medicine to aid in determining etiology or a cause-and-effect relationship. In this study type exposure is the independent variable and outcome is dependent.
<ul>
 	<li>Example, the study by Cholewicki et al. (1) investigated Yale Varsity Athletes (the cohort) with 2 and 3 year follow up (longitudinal design) and found that trunk muscle response time to off-loading was predictive of future low back injury.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/core/increased-trunk-muscle-latency-may-cause-rather-than-result-from-low-back-pain/" target="_blank" rel="noopener noreferrer">Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620</a></li>
</ol>

Comparable Sign: A combination of pain, stiffness and/or spasm during examination that is comparable to the patients symptoms.
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

An alternative movement pattern that has been adopted to compensate for dysfunction/impairment in the human movement system.
Example: A lack of calf extensibility may limit dorsiflexion, leading to the knees bowing inward (functional valgus) and excessive forward lean of the torso during a squat.

An arthrokinematic motion - the approximation of joint surfaces; that is, a force that directs one bone surface into another resulting in a reduction in intra-articular volume. Although widely thought of as a "destructive force", it is likely best to consider compression as a naturally occurring, stabilizing force. Any arthrokinematic force in excess (spin, glide, roll, traction) may be viewed as potentially deleterious.

For example, during a squat the femoral head is compressed into the acetabulum by muscular forces, bodyweight and any additional external load.

Concave (Concavity) - Having an outline or surface curved like the interior surface of a bowl or sphere - to cave-in or curve inward.
<ul>
 	<li>Example, the internal surfaces of the pelvis is concave, holding some of the bodies viscera.</li>
</ul>

Concordant Sign - The patient's specific pain, symptom or complaint. 
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

Conductivity: Stimulation results in more than a local effect (1).
<ul>
 	<li>For example, in a muscle cell the stimulation of a motor endplate results in a change in cell membrane polarity that rapidly propagates (is conducted) along the entire length of the muscle cell, stimulating all sacromere.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

A condyloid joint (also called condylar, bicondylar, ellipsoid, or ellipsoidal) is an ovoid articular surface, or condyle, that is received into an elliptical cavity.  These joints permit movement in two planes.  Examples include the knee, metacarpophalangeal joints and metatarsophalangeal joints.

Connective Tissue Cell - One of the four basic types of animal tissue, consisting mostly fibers and ground substance.  These cells are specialized to binds organs together, holds them in place, protect them from external forces, and may fill space in the body's cavities.

Example, the body's muscles are enclosed in durable connective tissue sheets known as the "epimysium", "perimysium", and "endomysium," which and in support and transmitting force.
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Contractility: The ability to shorten (1).
<ul>
 	<li>Contractility: Muscle cells are unique in the amount they can shorten when stimulated; this is this largerly due to the highly organized and unique arrangement of myofilaments (actin and myosin).</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Pertaining to the opposite side

Example, the external oblique muscle performs contralateral rotation; rotation to the opposite side.

Convex (Convexity) - Having an outline or surface curved like the exterior of a circle or sphere - to bulge or curve outward.
<ul>
 	<li>Example, the top of your head is shaped by the convex exterior surface of your skull.</li>
</ul>

Correlational Research - Non-experimental <a href="https://www.questionpro.com/blog/what-is-research/">research</a> method in which the statistical relationship between two variables is investigated.
<ul>
 	<li>In this research by Kwon et al., a correlation was noted between a decrease in extensibility during a hamstring length test (goniometry) and current knee pain (1).</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/correlation-patellofemoral-pain-syndrome-pfps-hamstring-activity/" target="_blank" rel="noopener">Kwon O, Yun M, and Lee W. (2014). Correlation between intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. J. Phys. Ther. Sci. 26: 961-964</a></li>
</ol>

Counter-nutation - posterior rotation of sacrum relative to ilium, and/or anterior rotation of ilium relative to sacrum.
<ul>
 	<li>The pelvic floor muscles are examples of muscle that may counter-nutate the sacrum.</li>
</ul>
[caption id="attachment_126335" align="aligncenter" width="400"]<a href="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png"><img class=" wp-image-126335" src="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png" alt="Nutation and Counter-nutation of the Sacroiliac Joint" width="400" height="967" /></a> Nutation and Counter-nutation of the Sacroiliac Joint[/caption]

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Crossover (Study) Design - A type of longitudinal, repeated measures quasi-experimental design in which each group receives both treatments, but at different times. It is named "crossover" due to the patients "crossing-over" to the other treatment or sham group after a specified period of time.
<ul>
 	<li>This type of study has the advantage of every individual serving as their own control, which may reduce the influence of confounding variables.</li>
 	<li>Unfortunately, the design itself introduces the chances that anyone receiving the experimental variable in the first period will continue to be effected in the second period.</li>
</ul>
In a study by Senna et al., a cross-over design was used to investigate the difference load made on inter-set rest intervals (1).
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/strength-training-research-corner/heavy-vs-light-load-single-joint-exercise-performance-with-different-rest-periods/" target="_blank" rel="noopener">Senna, G.W., Rodrigues, B.M., Sandy, Scudese, Bianco, A, &amp; Dantas, E.H.M. (2017). Heavy vs light load single-joint exercise performance with different intervals. Journal of Human Kinetics, 58, 197-206. </a></li>
</ol>

Cross-sectional Study - a research design that involves gathering data from a population or representative subset at a specific point in time.
<ul>
 	<li>Example, the study by Karimi-Mobarake et al.(1) investigated the prevalence of genu varum and genu valgum among school children 7-11 years old in Iran.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/low-prevalence-of-genu-varum-and-valgum-among-elementary-school-children/" target="_blank" rel="noopener noreferrer">Karimi-Mobarake, M., Kashefipour, A., Yousfnejad, Z. The prevalence of genu varum and genu valgum in primary school children in Iran 2003-2004. (2005) Journal of Medical Science 5(1). 52-54</a></li>
</ol>

Cytokine - A broad and loose category of small proteins that act through receptors, and are especially important to immune function (inflammation).
<ul>
 	<li>Cytokines include substances such as interferon, interleukin, and growth factors, which are secreted by certain cells of the immune system and have an effect on other cells. Their definite distinction from hormones is a topic of continued research.</li>
</ul>
&nbsp;

Dependent variable - in research, this is the variable that is changed by the independent variable, most often this is the "outcome" of the study.
<ul>
 	<li>Example, in the study by Cleland et al. (1), the independent variable is "thoracic manipulation," and the dependent variable is "lower trapezius muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/short-term-effects-lower-thoracic-manipulation-lower-trapezius-muscle-strength/" target="_blank" rel="noopener noreferrer">Cleland J, Selleck B, Stowell T, Brown L, Alberini S, St. Cyr H, Caron T. Short-term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength.  Journal of Manual &amp; Manipulative Therapy. 2004; 12(2): 82-90</a></li>
</ol>

An anatomical direction; further from the trunk or center of the body

Example, the foot is at the distal end of the leg.

An arthrokinematic motion - a force applied to a body part that may result in the separation of joint surfaces, a reduction in intra-articular pressure, and/or an increase in intra-articlar space.

For example, to hang from one's hands (i.g. in preparation for a pull-up) results in a traction force on the glenohumeral joint (shoulder).

An anatomical term of location; back or upper surface

Example, shoe laces may compress tissues on the dorsal surface of the foot

The "drawing-in" maneuver is a common cue used during exercise and rehabilitation programs. A light contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abominis</a> (and potentially the entire <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/core-subsystems/intrinsic-stabilization-subsystem/" target="_blank" rel="noopener">intrinsic stabilization subsystem</a>) achieved by gently pulling the lower abdominal region away from one's waist band. This should have minimal effect on breathing, and should not be confused with a maximal contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abdominis</a> resulting in a "vacuum pose".
<ul>
 	<li>Research often refers to this maneuver as the "abdominal drawing-in maneuver"; abbreviated ADIM.</li>
</ul>
Development and introduction of this cue into practice is based on the pivotal research and resulting text:
<ol>
 	<li>Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004</li>
</ol>

Faulty or abnormal movement; an alteration of normal kinematics.

For example, joint stiffness or a reduction in arthrokinematics motion that results in limited osteokinematic range of motion - inadequate inferior glide of the femoral head resulting in limited abduction of the hip.

The seeping into, or abnormal collection of fluid in a body cavity.

For example, knee effusion describes swelling within the knee joint.

Note: the word "effusion" is used differently in medicine than it is used in reference to the movement (seeping out) of liquids and gases, for example in chemistry.

&nbsp;

A trait of body tissues that allows a tissue to return to its resting length or state after deformation or stretch.
Example:  Muscle is elastic tissue; many muscles will return to their resting length after being stretched to 150% of that length without any appreciable change in tissue quality.

Elasticity: Elasticity refers to the ability of a cell to return to its resting length after being stretched/lengthened.
<ul>
 	<li>Note: this term is often confused with extensibility. Elasticity is not the ability to stretch; it is the ability to return to normal length after being stretched. Muscle tissue, connective tissue and even nerve tissue have varying levels of elasticity.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Epithelial cell - One of the four basic cell types, found lining the body's cavities, blood vessels, organs and constitutes most gland tissue.  These cells are specialized to aid with absorption, secretion, or act as a barrier from foreign objects.
<ol>
 	<li>Saladin, K. S., &amp; Miller, L. (1998). Anatomy &amp; physiology. New York (NY): WCB/McGraw-Hill.</li>
</ol>

Equilibrium - a state in which opposing forces or influences are balanced.
<ul>
 	<li>For example, to maintain a neutral trunk while pushing or pulling a weight in one hand, your core musculature must balance the force by creating an equal amount of force in the opposite direction.</li>
</ul>

The study of causation, or origination. The word is commonly used in the medical professions, where it may refer to the study of why things occur, or the reason behind why things act a certain way.

For example, the etiology of low back pain is a complex subject, with multiple contributing factors and various structures implicated.

<div class="gs_citr" tabindex="0">Evidence-based medicine (practice) is the integration of best research evidence with clinical expertise and patient(client) values (2)."</div>
<ul>
 	<li class="gs_citr" tabindex="0">...the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (clients).  It involves the integration of at least (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve (1).</li>
</ul>
&nbsp;
<ol>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., &amp; Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. Bmj, 312(7023), 71-72.</li>
 	<li class="gs_citr" tabindex="0">Sackett D et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1</li>
</ol>

Excitability: The ability of a cell to change in membrane conductance as a response to stimulation.

<ul>
 	<li>For example, muscle cells are specialized to react to a change in membrane potential with contraction, where as nerve cells are specialized to propagate a change in membrane potential along there axons and communicate that message to other tissues via neurotransmitters.
</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Excitation threshold: The level that a depolarization must reach for an action potential to occur.
<ul>
 	<li>The excitation threshold is a contributing factor to the "all-or-none" response of muscle and nerves cells to a stimulus.</li>
</ul>

Exercise Progression - Modification of an exercise with the intent of promoting adaptation by increasing demand. This can be accomplished by increasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise progression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise, or series of exercises that make it harder to maintain stability with good form.
<ul>
 	<li>Sample Exercise Progression: <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a></li>
</ul>
</li>
</ul>

Exercise regression - The opposite of progression; that is, modification of an exercise with the intent of reducing demand. This can be accomplished by decreasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability. Generally, regressions are used to modify an exercise to the client's current level of ability, with the intent of improving form, motor learning and retention.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise regression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise or series of exercises that make it easier to maintain stability with good form.
<ul>
 	<li>Sample Exercise Regression: <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a></li>
</ul>
</li>
</ul>

Experimental Research - Studies in which the researchers introduce the variable to be studied, with the intent of observing the outcome. This is different than observational research which observes the effect of a variable already present. Many texts also assert that experimental research should include randomization and ideally a control group, as is seen in Randomized Control Trials. Studies in which the variable is introduced by the researchers, but participants are not randomized may be considered Quasi-experimental research.
<ul>
 	<li>In this study by Esformes, the experimental variable was squat depth and the outcome measures observed were various performance measures related to power (1).</li>
</ul>
<ol>
 	<li><a href="https://brookbushinstitute.com/article/back-squat-depth-lower-body-post-activation-potentiation/" target="_blank" rel="noopener">Esformes, J., &amp; Bampouras, T. (2013). Effect of back squat depth on lower-body postactivation potentiation. Journal of Strength and Conditioning Research, 27(11), 2997-3000.</a></li>
</ol>
&nbsp;

Extensibility: The ability of a cell to be stretched or lengthened without damage (1).
<ul>
 	<li>For example, most cells would rupture with even a modest stretch, but muscles can stretch up to 3 times their contracted length.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

False Negative - the proportion of negatives in a group that were assessed incorrectly (assessed as negative when the patient was actually positive)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

False Positive - the proportion of positives in a group that were assessed incorrectly (assessed as positive when the patient was actually negative)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

The function of fascia is to transmit force, provide support, and protect tissues. Fascia can effect motion by:
Transmitting force from one or more muscles (example: the thoracolumbar fascia)
Restricting motion in cases of adaptive shortening and/or adhesion to proximal structures (example: iliotibial band in cases of lower-leg dysfunction)
Elastic recoil after stretching can contribute to force production (example: plyometric exercise)

Note: There is evidence that fascia may house more receptors related to human movement than other tissues. In this way fascia may act as a motherboard for the nervous system

The fascial system does not contract or develop trigger points, and its capacity to adapt to stretching and or strengthening exercise is limited, especially when compared to the adaptive capacity of muscle tissue.

Fibromyalgia - A loosely defined diagnosis that is associated with a combination of widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. Consideration may also be given to the presence of psychosocial stressors and inflammatory disease in the patients history. Newer research suggests that fibromyalgia may be at least in part due to central sensitization of myofascial pain, often associated with trigger points (1 - 4).
<ol>
 	<li>Wolfe, F. (2018). Fibromyalgia Syndrome and Fibromyalgia Syndrome Criteria: Problems in Definition and Validity. Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition.</li>
 	<li>Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., ... &amp; Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis &amp; Rheumatism: Official Journal of the American College of Rheumatology, 33(2), 160-172.</li>
 	<li>Alonso-Blanco, C., Fernandez-de-las-Penas, C., Morales-Cabezas, M., Zarco-Moreno, P., Ge, H. Y., &amp; Florez-García, M. (2011). Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. The Clinical journal of pain, 27(5), 405-413.</li>
 	<li>Staud, R., Nagel, S., Robinson, M. E., &amp; Price, D. D. (2009). Enhanced central pain processing of fibromyalgia patients is maintained by muscle afferent input: a randomized, double-blind, placebo-controlled study. PAIN®, 145(1-2), 96-104.</li>
</ol>
&nbsp;

Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.
Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.

An increase in joint stability via compressive forces resulting from muscular contraction and increased tension in fascial structures (1,2).
<ul>
 	<li>This term is most often used in reference to core intrinsic stabilizers, the thoracolumbar fascia and the sacroiliac joint; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Form closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

The relative contribution of joint shape and structure to the stability of a joint (1,2).
<ul>
 	<li>This term is most often used in reference to the "rough" articulating surfaces of the sacroiliac joint and the wedge shape of the sacrum; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Force closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. Spine, 20(7), 753-758.</li>
</ol>

An arthrokinematic motion - linear motion across a joint surface parallel to the plane of the adjacent joint surface, just as your posterior moves relative to a "slide" in a park.

For example, the glide of facet joint in the spine during spinal flexion and extension, or the posterior glide of the humeral head that must accompany anterior roll to maintain congruence with glenoid fossa during shoulder horizontal adduction.

A plane joint (also called an arthrodial joint, gliding joint or plane articulation) is a synovial joint which allows only gliding movement in the plane of the articular surfaces. The opposed surfaces of the bones are flat or almost flat, with movement generally limited by tight capsules and ligaments. Plane joints are numerous, are most often small, and allow very little motion.  Examples include the carpal joints of the wrist, the tarsal joints of the ankle, and the facet joints of the spine.

"...refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones of the body (1).

&nbsp;
<ol>
 	<li>Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company</li>
</ol>

Ground reaction force (GRF) - The force exerted by the ground on the body in contact with it.

For example, when a runner's foot strikes the ground with a force equal to the mass of the individual times their acceleration due to gravity, momentum and muscular exertion, the ground exerts an equal and opposite force on the runner's foot.
<ul>
 	<li>GRF is often measured in research studies using force plates as a means of quantitatively measuring the force generated by an individual.</li>
</ul>

H-Band - Refers to the central zone of a sarcomere that looks lighter under a microscope.  This area of the sarcomere is a lighter portion of the A-band where there is no overlap between the thinner filaments (actin), and the thicker filaments (myosin).
<ul>
 	<li>Example, when a muscle contracts, actin and myosin cross-bridging occurs in the region of the A-band until the H-band is reached where no overlap occurs.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

A hinge joint (also called a ginglymus) is a synovial joint in which the articular surfaces fit one another in a way that only permits motion in one plane. Examples include the elbow, the knee (unless considered a condyloid joint) and the interphalangeal joints.

Holism (holistic) (biological holism) - (from Greek holos "all, whole, entire") is the idea that systems and their properties should be viewed as wholes, not just as a collection of parts.
<ul>
 	<li>Summarized by Aristotle in his "Metaphysics": "The whole is more than the sum of its parts". However, the term "holism" was introduced into language by the South African statesman Jan Smuts as recently as 1926. (Smuts J. C. 1987 [1926]. Holism and evolution. Cape Town: N &amp; S Press.)</li>
</ul>
Example: The Brookbush Institute promotes a holistic approach to human movement science, in which the muscular, fascial, articular and neural systems are not viewed as separable and all proximal segments are considered.

Hormone: Chemical messengers produced by the endocrine system, transported via tissue fluids such as blood, to stimulate cells to "act."
<ul>
 	<li>Example: Growth hormone is secreted by the pituitary gland in the brain; stimulating growth, cell reproduction and cell regeneration in certain types of cells</li>
</ul>
The English physician E. H. Starling discovered in collaboration with the physiologist W. M. Bayliss secretin, the first hormone, in 1902. (1).
<ol>
 	<li>Henriksen, J. H., &amp; de Muckadell, O. S. (2000). Secretin, its discovery, and the introduction of the hormone concept. Scandinavian journal of clinical and laboratory investigation, 60(6), 463-472.</li>
</ol>

A range of motion achieved by the patient/client that is more than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If an individual can place their forehead on their knees they are likely hypermobile at one, if not several joints

Example 2: 110° of shoulder external rotation would be considered hyper-mobile.

Hyperplasia is an increase in organic tissue size due to an adaptive increase in the number of cells per organ.
<ul>
 	<li>Although muscle hyperplasia has been noted in some animals, human muscle tissue does not seem to have this adaptive ability.</li>
</ul>

A condition of excessive tone of the skeletal muscles; increased resistance of muscle to passive stretching.  May be related to increased neural drive, synergistic dominance, trigger points, reflexive over-activity, and/or muscle length.
Example:  Individuals who exhibit ankle eversion and abduction during an overhead squat assessment likely have hypertonic fibularis (peroneal) muscles.

Muscular hypertrophy is an increase in muscle mass/size due to increase in the volume and cross-sectional area (CSA) of individual muscle cells. The increase in cross-sectional area can be attributed to an an increase in contractile proteins and structural elements (myofibrillar hypertophy), as well as an increase in glycogen storage and elements related to metabolism (sarcoplasmic hypertophy). Hypertrophy is an adaptation of both cardiac and skeletal muscle fibers in response to progressive increases in workload.
<ul>
 	<li>Note: Hypertrophy is not hyperplasia. Hyperplasia is an increase in muscle size due to an adaptive increase in the number of muscle fibers/cells per muscle. This type of adaptation does not occur in human muscle tissue.</li>
</ul>

A range of motion achieved by a patient/client that is less than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If the end range of shoulder external rotation is reached and measured as 75° during goniometric assessment, the client/patient is exhibiting hypomobility of the glenohumeral joint (shoulder).

Hypothesis - a proposed explanation for a phenomenon; "scientific hypotheses" are generally constructed in a way that is testable or falsifiable.
<ul>
 	<li>Example: The hypothesis, "excessive knee valgus may be correlated with future knee pain and injury," has been the subject of several studies published over the last decade.</li>
</ul>

Diminished tone of skeletal muscles; diminished resistance of muscles to passive stretching.   May be related to inhibition, reciprocal inhibition, arthrokinematics inhibition and/or  increased resting length of muscle.
Example:  If your knees cave (hip adduction) during a squat or leg-press it is likely that your gluteus medius is hypotonic.

I-Band - Refers to the part of the muscle cell that looks lighter under a microscope.  This area of the cell is lighter due to parallel arrangement of thinner filaments (actin), and no overlap with the thicker filaments (myosin).
<ul>
 	<li>As a muscle contracts, the I-bands will decrease in width and move closer to one another.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Independent variable - in research, this is the variable or phenomenon being manipulated in the study.
<ul>
 	<li>Example, in the study by Ghanbari et al. (1), the independent variable is "knee joint mobilization", the dependent variable is "quadriceps muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/effect-knee-joint-mobilization-quadriceps-muscle-strength/" target="_blank" rel="noopener noreferrer">Ghanbari A. and Kamalgharibi S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. International Journal of Health and Rehabilitation Sciences. 2(4): 186-191</a></li>
</ol>

An anatomical direction; toward the bottom (below)

Example, the mouth is inferior to the eyes

A reduction in neural drive, muscular activity, and or force output due to altered neuromuscular reflex.  Alterations in neuromuscular reflex may occur due to increases in muscle length (hypothesis: increased excitation threshold), altered reciprocal inhibition in response to increased antagonist tone, and or alterations in joint motion (arthrokinematics inhibition).

Making a whole of parts.

Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.

Intermuscular Coordination - Optimal timing and motor unit recruitment of agonists, antagonists, synergists, neutralizers, stabilizers and fixators.

Example: Role of Muscles during Hip Extension
<ul>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Prime Mover" href="https://brentbrookbush.com/glossary/prime-mover/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Prime Mover&lt;/div&gt;The muscle most responsible for a joint action under load -&lt;br /&gt;&lt;br /&gt;That is, the muscle that can produce the most force for a given joint action. Often this term is used synonymously with the term agonist. The prime mover as defined above, may or may not be the most active muscle for a joint action during activities of daily living.&lt;br /&gt;&lt;br /&gt;Example: the gluteus maximus is the most powerful hip extensor and therefore the prime mover; however, the hamstrings are likely the most active hip extensors during low level activities like walking or standing.">Prime Mover</a>:  <a href="https://player.vimeo.com/external/82855344.hd.mp4?s=54c3e7d98fb9d4e0af8d282c85ba9b3e">Gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Synergists" href="https://brentbrookbush.com/glossary/synergists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Synergists&lt;/div&gt;Muscles that assist the prime mover in performing a joint action.&lt;br /&gt;&lt;br /&gt;That is, all muscles that can perform a joint action that are not the prime mover, are termed synergists.&lt;br /&gt;Example: The rectus abdominis is the prime mover of spinal flexion. All other muscles that can perform spinal flexion are synergists including – external obliques, internal obliques and psoas.">Synergists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/biceps-femoris/">Biceps femoris (long head)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/semitendinosus-and-semimembranosus/">semitendinosus, semimembranosus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">posterior head of adductor magnus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Antagonist" href="https://brentbrookbush.com/glossary/antagonists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Antagonist&lt;/div&gt;Muscles that oppose the prime mover and synergists for a given joint action.&lt;br /&gt;&lt;br /&gt;That is, all the muscles that can perform the opposing joint action.&lt;br /&gt;&lt;br /&gt;Example: The triceps and anconeus are antagonists during elbow flexion.">Antagonists</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/psoas/">Psoas</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/iliacus/">iliacus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/tensor-fascia-latae-tfl/">tensor fascia latae</a> (TFL),<a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-femoris/"> rectus femoris</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">anterior adductors (especially pectineus)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/sartorius/">sartorius</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Neutralizer" href="https://brentbrookbush.com/glossary/neutralizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Neutralizer&lt;/div&gt;Muscles that oppose unwanted joint motions created by the prime mover and/or synergists, and/or muscles that prevent unwanted ancillary motion.&lt;br /&gt;Example: The teres minor and infraspinatus neutralize the internal rotation force created by the pectoralis major during horizontal adduction of the shoulder.">Neutralizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-minimus/">Gluteus minimus</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-medius/">anterior fibers of gluteus medius</a> neutralize external rotation force of <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-maximus/">gluteus maximus</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Stabilizer" href="https://brentbrookbush.com/glossary/stabilizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Stabilizer&lt;/div&gt;Muscles whose primary role is to improve arthrokinematics by maintaining optimal alignment of joint surfaces.&lt;br /&gt;&lt;br /&gt;Most often these muscles are the most intrinsic muscles of a joint, have a larger percentage of Type I muscle fibers and are rich in proprioceptors.&lt;br /&gt;Example: The muscles of the rotator cuff act as stabilizers for most shoulder motions.">Stabilizers</a>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/deep-rotators-of-the-hip/">Deep rotators of hip</a></li>
 	<li><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Fixator" href="https://brentbrookbush.com/glossary/fixators/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Fixator&lt;/div&gt;Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.&lt;br /&gt;Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.">Fixators</a>: <a href="https://brentbrookbush.com/articles/core-subsystems/intrinsic-stabilization-subsystem/">Intrinsic stabilization subsystem</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-abdominis/">rectus abdominis</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/internal-obliques/">internal</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/external-obliques/">external obliques</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/quadratus-lumborum/">quadratus lumborum</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/erector-spinae/">erector spinae</a></li>
</ul>
&nbsp;

Example from: <a href="https://brentbrookbush.com/articles/anatomy-articles/introduction-to-functional-anatomy/kinesiology-of-the-hip/" target="_blank" rel="noopener">Introduction to Functional Anatomy: Kinesiology of the Hip</a>

Intramuscular coordination refers to the coordinated recruitment of motor units within a single muscle. This concept is used to explain increases in maximal strength and power; however, the coordinated and sequential recruitment of motor units is also essential to strength endurance and smooth coordinated motion.  Related terminology may include; motor unit recruitment, preferential recruitment, rate coding, sequence, etc..

Example: It is hypothesized that the "shaking" noted during a novice exercisers attempt at an activity like the <a href="https://brentbrookbush.com/vimeo_videos/ball-crunch-and-progressions/" target="_blank">stability ball crunch</a> may be due to relatively poor intramuscular coordination. Rather than smooth, sequential firing of rectus abdominis motor units, groups of motor units turn on and off in an uncoordinated manner.

Pertaining to the same side

Example, the quadratus lumborum performs ipsilateral flexion; lateral flexion toward the same side as the muscle.

An isoform, or variant, is a member of a set of similar proteins, that originate from the same gene, or gene family.
<ul>
 	<li>Example, the variations in myosin heavy chain proteins (MHC I, MHC IIA, MHC IIB/X) that contribute to the characteristic differences between muscle fiber types.</li>
</ul>

“The Prime Assumption”
Everything crossing a joint will influence joint motion during every joint action.

A concept that has expanded over the past several decades to describe the integration of 4 body systems (muscle, joints, fascia and nerves), as well as, the coordinated function of various body segments (e.g. hip, knee and ankle) to produce motion. Kinetic referring to motion, and chain being an analogy for the interdependent link between systems.

Example, the posterior kinetic chain, refers to the integrated function of nerves, muscles, fascia and joints on the posterior side of the body.

The concept of the kinetic chain was originally adapted from the work of a mechanical engineer named Franz Reuleaux (Kinematics of Machinery (1875)) by Dr. Arthur Steindler in 1955 (Steindler A: Kinesiology of the Human Body. Springfield, IL, Charles C. Thomas Co.. 1955).

Latent Trigger Point - A myofascial trigger point that is not painful at rest, only painful when palpated, and may or may not exhibit a characteristic referral pain pattern when palpated.  Latent trigger points do result in an acute point of sensitivity, in a taut band of muscle, and may restrict range of motion (1).

Note: Based on the clinical experience, the Brookbush Institute suggests that latent trigger points (sometimes refereed to as Tender Points) are more common than active trigger points. Further, they are likely addressed more often than trigger points; being the intended target of many soft-tissue mobility techniques.
<ol>
 	<li>David G. Simons, Janet Travell, Lois S. Simons, Travell &amp; Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens</li>
</ol>

An anatomical direction; further from the midline

Example, the anterior deltoid is lateral to the pectoralis major

Length/Tension Relationship - The amount of force generated by a muscle is dependent on sarcomere length.
<ul>
 	<li>The ability of sarcomere to maximally produce force occurs when sarcomere length results in optimal overlap between actin and myosin. Stretching a sarcomere decreases overlap between actin and myosin filaments and reduces force production (1-3). When length is less than optimal, actin from opposite ends overlap and interfere with cross-bridging, and myosin filament are compressed as they contact the the Z-disk also reducing force (4)</li>
</ul>
<ol>
 	<li>Gordon, A. M., Huxley, A. F., &amp; Julian, F. J. (1966). The variation in isometric tension with sarcomere length in vertebrate muscle fibres. The Journal of physiology, 184(1), 170-192.</li>
 	<li>Edman, K. A. P. (1966). The relation between sarcomere length and active tension in isolated semitendinosus fibres of the frog. The Journal of Physiology, 183(2), 407-417.</li>
 	<li>Lieber, R. L., Loren, G. J., &amp; Friden, J. (1994). In vivo measurement of human wrist extensor muscle sarcomere length changes. Journal of neurophysiology, 71(3), 874-881.</li>
 	<li>Lieber, R. L. (2002). Skeletal muscle structure, function, and plasticity. Lippincott Williams &amp; Wilkins.</li>
</ol>
&nbsp;

Levels of Evidence - Relative to evidence-based practice, levels of evidence are an attempt to describe the strength of the results measured in a clinical trial or research study.  Note: levels of evidence do not supersede the critical evaluation of an experienced professional, and should be viewed as guidelines - a meta-analysis may be poorly constructed (Level IA), and a comparative study (Level III) may employ new technologies and a strong methodology.


The Levels of Evidence used by the Brookbush Institute, as described by Shekelle et al.(1):
<ul>
 	<li class="p1">IA - Evidence from meta-analysis of randomized controlled trials</li>
 	<li class="p1">IB - Evidence from at least one randomized controlled trial</li>
 	<li class="p1">IIA - Evidence from at least one controlled study without randomization</li>
 	<li class="p1">IIB - Evidence from at least one other type of quasi-experimental study</li>
 	<li class="p1">III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</li>
 	<li class="p1">IV - Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both</li>
</ul>
<ol>
 	<li>Shekelle, P. G., Woolf, S. H., Eccles, M., &amp; Grimshaw, J. (1999). Developing clinical guidelines. Western Journal of Medicine, 170(6), 348.</li>
</ol>

Likelihood Ratios - Likilihood ratios are used for assessing the value of performing a diagnostic test. They use sensitivity and specificity to determine whether a test result usefully changes the practitioner's chance (probability) of reaching the correct assessment. Calculation of likelihood ratios is based on Baye's theorem.
<ul>
 	<li>Positive Likelihood Ratio (LR+) - The ratio of a positive test result in people with the pathology to a positive test result in people without the pathology.</li>
 	<li>Negative Likelihood Ratio (LR-) - The ratio of a negative test result in people with the pathology to a negative test result in people without the pathology.</li>
</ul>

Longitudinal Study - a research design that involves observing the same variables, several times over a period of time.
<ul>
 	<li>Example, the study by Hewett et al. (1) is a type of longitudinal study called a "cohort study." This study investigated whether excessive knee valgus during landing was a predictor of knee injury risk in adolescent females over the course of a season.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/research-review-increased-valgus-during-landing-predicts-acl-injury-in-adolescent-female-athletes/" target="_blank" rel="noopener noreferrer">Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., &amp; Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501</a></li>
</ol>

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