Research Review: Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy

In the next installment of the Research Review Series, we discuss a recent randomized controlled study investigating the effectiveness of a manual therapy program specifically tailored to increase the intervertebral foramen (IVF) versus a general manual therapy program in patients presenting with cervical radiculopathy3.

Study Design

Participant and assessor blinded randomized clinical trial.


Thirty-six subjects were included in the study following inclusion/exclusion criteria (18 in both the experimental and control group). There were no significant differences between groups with regards to age (47.8 v. 42.8), weight (76.3 kg v. 80.9 kg), symptom duration (5.7 weeks v. 5.4), NDI (32.0 v. 34.8), Quick DASH (42.3 v. 42.8), Cervical NPRS (4.1 v. 4.3), Upper Limb NPRS (4.6 v. 4.8), or Cervicothoracic mobility.

Inclusion Criteria: (1) between 18 and 65 years of age, (2) pain, paresthesia, or numbness in 1 upper limb, with cervical or periscapular pain of less than 3 months in duration, (3) at least 1 neurological sign of a lower motor neuron lesion in a cervical spine nerve root or spinal nerve, and (4) positive responses to at least 3 of the 4 clinical tests in the Clinical Prediction Rule proposed by Wainner et al4.

Exclusion Criteria: (1) prior surgery to the cervicothoracic spine, (2) bilateral symptoms, (3) signs of upper motor neuron impairments, (4) cervical spine injection in the previous 4 weeks, (5) current use of steroidal anti-inflammatory drugs, or (6) financial compensation for the cervical condition.


Outcome Measures: Neck Disability Index (NDI), Shortened Version of the Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), Cervical Numeric Pain-Rating Scale (CNPRS), Upper Limb Numeric Pain-Rating Scale (ULNPRS), and Cervicothoracic Mobility utilizing the CROM device.

Randomization: An independent research assistant not involved in data collection generated a randomization list prior to the start of the study, using a random-number generator. Group allocations were concealed in sealed, opaque, sequentially numbered envelopes, and blocked randomization was used to make sure that two equal groups were obtained. The two programs were given in different clinics and the evaluation sessions took place outside the treating clinics in order to reduce potential contamination bias.

Interventions: Each patient received treatment sessions during a 4-week period and performed a home exercise program. The patients in the Control Group (CG) received 4 manual therapy techniques at each treatment session. The manual therapy techniques were chosen by the physical therapist according to the results of the biomechanical examination, but could not be used to specifically increase the affected IVF. These techniques could be cervical rotations, lateral glides in neutral, posteroanterior glides, posteroinferior medial glides, or anterosuperior anterior glides. Each manual therapy technique was performed for 10 repetitions of 30 seconds, with a force grade of 3 to 4. Following the mobilization techniques, a 5-minute global (nonspecific) static manual cervical traction was applied. In addition to the manual therapy program, a home exercise program was also included, but none of the exercises could be used to specifically increase the IVF.

Contrary to the CG, the Experimental Group (EG) utilized interventions that were supposed to directly influence the IVF in order to treat the symptoms of cervical radiculopathy. Of the 4 mobilization techniques used at each treatment session, 2 were mandatory techniques thought to increase the size of the IVF on the same side and at the same presumed level as the radiculopathy (global contralateral rotation mobilization and ipsilateral lateral glide in a flexed position). Additionally, the third exercise of the HEP was a repeated movement that is known to increase the size of the IVF (cervical spine rotation in the direction contralateral to the affected side, performed for 10 repetitions, 10 times per day).


Both groups showed significant improvement in NDI, QuickDASH, CNPRS, ULNPRS scores from baseline to week 4 and to 8 weeks. With regards to cervicothoracic mobility, both groups had significant improvement in cervical extension and side-bending. With these improvements, there was no significant group-by-time interaction found between the two groups in any of the measures. In agreement with this finding, the proportion of success did not significantly differ between groups at week 4 or at week 8.


The most significant limitation in this study is the lack of a true control group, which received “standard treatment” (i.e. a non-manual therapy group). Secondly, the only outcome measure that was adequately powered based on sample size was the primary outcome of NDI score.

Clinical Implications

According to a systematic review conducted by Boyles et al.1, the use of manual therapy (muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization) in addition to therapeutic exercise is effective in regards to increasing function, as well as AROM, while decreasing levels of pain and disability. However, often times, addressing a painful condition with a patho-anatomical approach is inadequate. As is demonstrated in this study, manual therapy in addition to a HEP provides decreased pain and improved function in the short-term and long-term, but the specific technique does not matter for cervical radiculopathy in general. This is where a patient response or bio-psychosocial approach should be utilized in order to drive treatment interventions/techniques instead of pathology-specific interventions. By utilizing an approach to identify and treat the patient’s comparable sign2, each patient’s complaints will be addressed without relying on the variable results of a patho-anatomical based treatment.


  1. Boyles R, et al. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review.Journal of Manual and Manipulative Therapy. 2011; 19(3): 135-142.
  2. Cook CE, et al. The relationship between chief complaint and comparable sign in patients with spinal pain: An exploratory study. Manual Therapy. 2015 [Epub Ahead of Print]
  3. Langevin P, Desmeules F, Lamothe M, Robitaille S, Roy J-S. Comparison of 2 Manual Therapy and Exercise Protocols for Cervical Radiculopathy: A Randomized Clinical Trial Evaluating Short-Term Effects. Journal of Orthopaedic & Sports Physical Therapy. 2015; 45(1): 4–17. doi:10.2519/jospt.2015.5211.
  4. Wainner CR, et al. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine. 2003;28(1):52–62.

Neck Pain Best Practice: Treatment-Based Classification

The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education

Among one of the most common musculoskeletal complaints, neck pain has been estimated to effect between 22% and 77% of individuals in their lifetime according to the Neck Pain Clinical Practice Guidelines published by Childs et al. While this pain is typically self-limiting and resolves with time, Bovim et al found that 30% of patients reporting neck pain will ultimately develop chronic symptoms of greater than 6 months in duration. In addition to this study, researchers also found that between 37% (Cote et al) and 44% (Hurwitz et al) of those who experience neck pain will report lingering symptoms for at least 12 months. Unfortunately, even after successful treatment, there has been a reported recurrence rate of 50-85% within the first 1-5 years following resolution of symptoms (Halderman et al). Neck pain is multi-factorial in nature with patients reporting varying symptoms depending on pathology, psychosocial influences/fear-avoidance, and age. Because of the varying clinical presentations of this particular group of patients, an individualized treatment plan developed based on their specific impairments/symptoms should be implemented.

The primary goal of classification is to determine the treatment approach most likely to yield the best clinical outcome for an individual patient and secondarily to determine the patient’s appropriateness for physical therapy. Taking after the treatment-based classification system proposed by Delitto et al for low back pain, Childs et al developed a similar system for disorders of the cervical spine. The first step in this classification scheme is determining the patient’s appropriateness for physical therapy. In general, this stage encompasses screening for ‘red flags’ (cervical myelopathy, cancer, ligamentous instability, fracture, and vascular compromise) as well as non-musculoskeletal causes of neck pain (i.e. cardiac event). This preliminary stage of the process is integral in ruling out significant pathology that needs further radiological imaging and/or surgical intervention prior to beginning a course of physical therapy. During this stage, two specific clinical prediction rules (CPR) can be utilized in order to improve your ability to make the best clinical judgment in this important preliminary stage in the examination process (Cervical Myelopathy and Fracture). After successfully clearing your patient from the presence of serious pathology, the patient’s psychosocial profile should be screened for the presence of any ‘yellow flags’ that may alter your treatment approach (catastrophizing, high fear-avoidance beliefs, ect.). These patients may benefit from a graded exercise, graduated exposure, and/or a pain science education approach in conjunction with the treatment-based classification system groupings.

The final stage of this classification scheme involves determining the correct treatment category for the patient based on their clinical presentation. The classification system for neck pain can be broken into 5 distinct categories (Mobility, Centralization, Exercise & Conditioning, Pain Control, and Headache). The Mobility group receives cervical and/or thoracic manipulative and mobilization interventions in conjunction with cervical exercises (active range of motion, deep cervical flexors, ect.). Identifying these patients can be improved by implementing the CPR for cervical manipulation and the CPR for thoracic manipulation in addition to your clinical expertise and the criteria proposed by Childs et al. Those in the centralization group should receive interventions to create centralization of their symptoms either through the use of their specific directional preference via repeated movements or through the use of manual/mechanical cervical traction. Furthermore, the identification of individuals who will specifically benefit from cervical traction can be aided through the use of the CPR developed by Raney et al. Patients who will benefit from general conditioning and exercise typically display lower pain/disability scores and have a longer duration of symptoms and benefit from targeted strengthening and endurance interventions to improve muscular imbalances and/or deficits. The pain control grouping consists of non-aggravating manual techniques, therapeutic modalities, and activity modification. However, the patient should be progressed to a more active classification category as soon as tolerated. Finally, the headache group is treated with manual therapy techniques directed at the cervical and thoracic spine (manipulation, sub-occipital release, ect.) in addition to upper extremity strengthening. As stated in Chad Cook, PT, PhD, MBA, FAAOMPT’s course, “Manual Therapy for the Cervical Spine: An Evidence-Based Approach”, the process of classification is ongoing, and it is assumed that a patient’s presentation will change with time and treatment. Due to this continual change in presentation, ongoing reassessment is required in order to determine the most appropriate sub-group and subsequent intervention at any point in time during the patient’s course of treatment.

While this is a relatively new classification system, there is some evidence available supporting its effectiveness. In 2007, Fritz et al performed a preliminary investigation into the utility of this particular treatment approach. Baseline patient characteristics and evaluations were performed on 274 patients and subjects were split into two groups (those matched to their classification group and those unmatched). Overall, 113 patients received matched interventions and 161 patients received unmatched interventions. Patients receiving matched interventions showed greater changes in both Neck Disability Index (NDI) scores and pain rating scores compared to their unmatched counterparts. Additionally, 72.5% of patients in the matched group achieved the minimal detectible change in NDI, whereas those in the unmatched group only achieved this feat in 53.8% of patients. Along with this outcome data, the authors found a kappa value of 0.95 for classification determination and 0.96 for the treatment matching decision, both of which are in very strong agreement. In conjunction with this randomized controlled trial, Heintz and Hegedus published a case report of a patient presenting with mechanical neck pain who was successfully treated with the aforementioned treatment-based classification system. Over this patient’s 6-week treatment (38 days), pain was reduced from 4-10/10 to 0/10 with only a complaint of stiffness at end-range and their NDI score decreased from 52% (severe disability) to 6% (no disability). Obviously, this is only one patient, but it does add evidence to the effectiveness of this particular treatment approach. While the research regarding this treatment approach is in its infancy, the current evidence available provides preliminary support to its effectiveness in treating patients presenting with mechanical neck pain.

Research Review: Effect of Manual Therapy on Vertebral and Internal Carotid Blood Flow

In the next installment of my Research Review series for MedBridge Education, we will discuss a recent study that appeared in Physical Therapy Journal conducted by Thomas et al. The authors investigated the changes in vertebral and internal carotid blood flow during selective positions that are commonly associated with manual therapy techniques were assumed. This study provides additional evidence toward understanding the role of neck position on blood inflow to the brain.

Study Design

Experimental, observational magnetic resonance imaging (MRI) study.


Twenty participants (10 male, 10 female) with a mean age of 33.1 years were recruited into the study. All participants had normal anatomy of their craniocervical arterial circulation, however three participants (15%) had dominance of one vertebral artery.

Inclusion Criteria: Healthy subjects, between the ages of 18 and 65 years old, no reported mechanical neck pain or headache.

Exclusion Criteria: Diagnosed inflammatory joint disease, any history of serious cervical spine trauma (i.e. fractures), any congenital disorder recognized as being associated with hypermobility or instability of the upper cervical spine, diagnosed vertebrobasilar artery insufficiency (VBI), claustrophobia or discomfort in confined spaces (standard contraindication for MRI), and any contraindication identified by the local health authority MRI safety screening questionnaire.


Experimental Conditions: While the MRI was being performed, the patients’ cervical spine was positioned in 9 distinctly different positions that simulate positions used in manual therapy techniques. These positions included: neutral position, left rotation, right rotation, left rotation with distraction, right rotation with distraction, left rotation localized to C1–C2, right rotation localized to C1–C2, distraction, and post-test neutral.

Outcome Measures: Blood flow in craniocervical arteries was measured with MRI using a phase-contrast flow quantification sequence. The arterial plane of section was selected to intersect the top of the atlas loop of the vertebral arteries at the level of the C1 vertebra, with imaging extending to just below the atlas loop. Average blood flow volume measured in milliliters per second was used as the primary test variable and was analyzed in neutral and each of the neck positions for each artery. The average blood flow volume in each artery then was compared between the neutral position and each of the experimental neck positions. Additionally, total blood supply to the brain was determined from the sum of average flow volume (mL/s) in both vertebral and both internal carotid arteries. A meaningful difference between the neutral position and any of the experimental conditions was determined to be > 10%.


Average inflow to the brain in neutral was 6.98 mL/s and was not significantly changed by any of the test positions. According to the data collected, the lowest total blood inflow level was recorded during left rotation (6.52 mL/a). There was no significant difference in flow in any of the 4 arteries in any position from neutral, despite large individual variations. Although mean values of average flow volume were not significant for any position, there were certain individuals with marked flow changes in some positions. Flow generally decreased slightly for both the end-range rotation and distraction positions but increased in the other positions in comparison to neutral. Flow changes were all less than 10%, which is considered to be the normal variation for cerebral inflow.


Secondary to restraints of the MRI and positioning of patients, full end-range rotation may not have been achieved. Additionally, some of the hand positions had to be altered from typical manual therapy techniques due to the constraints of the MRI set-up. None of the tested positions also included the thrust manipulation commonly used concurrently during a manual therapy procedure. Most notably, the results of this study should be cautioned as no subjects were included that presented with neck pain and/or headache symptoms.

Clinical Implications

Cervical manipulation is a polarizing topic amongst physical therapists and healthcare professionals as a whole. Many believe the risks are not worth the clinical benefits it provides to individuals suffering from mechanical neck pain. This study investigated blood flow to the brain during positions commonly associated with manipulative techniques and found only marginal changes in blood flow with multiple positions. What this study is not able to do (and wasn’t designed to do) is confirm the utility of positional tests for identifying those with blood flow restrictions or confirm that cervical thrust procedures do not involve blood flow changes (the subjects were healthy and there was no thrust used in this study). This sophisticated study adds nicely to the literature but clinicians still face the conundrum of identifying who may and my not be at risk during a thrust manipulation. Prior to intervening with cervical manipulative techniques, clinicians are urged to follow a thorough evaluation framework similar to that proposed by Flynn et al and the International Federation of Orthopaedic Manipulative Physical Therapists. Cervical manipulation should be implemented with caution and following a thorough subjective and physical examination when indicated by individual patient presentation.

Thomas LC, Rivett DA, Bateman G, Stanwell P, Levi CR. Effect of Selected Manual Therapy Interventions for Mechanical Neck Pain on Vertebral and Internal Carotid Arterial Blood Flow and Cerebral Inflow. Physical Therapy. 2013; 93(11): 1563–1574.

Research Review: Cervical Mobilization & Thoracic Manipulation versus Cervical Mobilization Alone


A randomized clinical trial recently published in the Journal of Orthopaedic & Sports Physical Therapy by Masaracchio et al evaluated the effectiveness of adding thoracic spine thrust manipulation to a program consisting of cervical spine non-thrust mobilization and cervical ROM exercises in the treatment of mechanical neck pain. While this study only looked into the short-term impact of this intervention strategy, it does provide some very important data that should help to guide our selection of manual techniques when treating these patients… [Continue Reading]

Cervical Manipulation… Is the Juice Worth the Squeeze? (Part 2)

In Part 1, the relative risks and important screening areas prior to cervical manipulation were discussed. In this second installment, the effectiveness and a theoretical framework for utilizing cervical manipulation will be laid out.

According to the Neck Pain Guidelines published by Cleland et al, manual therapy (mobilization and manipulation) was graded both an ‘A’ (strong evidence) and a ‘1’ (evidence from high-quality RCT, prospective, or diagnostic studies) in the treatment of neck pain. These guidelines advocate both manipulative and lower grade mobilization in reducing neck pain and cervicogenic headache symptoms. Published in the same year as the clinical guidelines, Walker et al conducted a RCT looking into the effectiveness of manual therapy and exercise in the management of mechanical neck pain. Those randomized to the manual therapy and exercise group (MTE) received treatments that ranged from cervical manipulation to soft-tissue mobilization and every technique in between. The intervention period lasted for 3 weeks with a total of 6 treatment sessions during this timeframe. At the conclusion of the study, those patients in the MTE group demonstrated statistically superior improvements in NDI scores at all 3 follow-ups, pain reduction at 3 and 6 weeks, perceived patient improvement on the GRC at all follow-ups, and overall treatment success rates were almost two-times as large for the MTE group in comparison to the minimal intervention group. These results bode well for a comprehensive manual therapy approach, but is there evidence to support the use of cervical manipulation in isolation?

Saavedra-Hernández et al recently published a RCT investigating the short-term effects of spinal manipulation in individuals suffering from chronic neck pain. In this study, patients were either randomized to an isolated cervical manipulation program (CMP) or a comprehensive manipulation program (cervical spine, cervicothoracic junction, and thoracic spine). After treatment (7 day follow-up), those in the CMP program demonstrated a decrease in pain from 4.8 to 2.7, NDI from 23.7 to 16.8, and increased ROM in all planes. While these values did reach statistical significance and this does lend evidence in support of cervical manipulation, those in the comprehensive program did achieve a greater reduction in disability than the CMP group. This lends support to a thorough manual therapy approach, but does not necessarily discredit the use of manipulation. With so many options available to the treating clinician, how do we know when to use manipulation?

Tseng et al investigated what predictors helped to identify those patients who would demonstrate immediate reduction in pain intensity, significant perceived improvement, and/or a high satisfaction level following cervical manipulation. After analyzing the outcomes of the 100 patients included and grouping them into either the ‘responder’ or ‘non-responder’ group, 6 variables were determined to be predictors of a positive response. These variables included initial scores on Neck Disability Index < 11.5, having a bilateral involvement pattern, not performing sedentary work greater than 5 h/day, feeling better while moving the neck, did not feel worse when extending the neck, and the diagnosis of spondylosis without radiculopathy. If 4 of these variables were present, the probability of success increased from 60% to 89% following manipulation. More recently, Puentedura et al conducted a similar study attempting to develop a clinical prediction rule identifying those who would respond favorably to cervical manipulation. Eighty-two consecutive patients presenting to an outpatient physical therapy clinic received manipulation of the cervical spine. Of the patients in this study, only 32/82 (39%) reported a favorable outcome. However, of those 32 who met the criteria for a favorable response, there were 4 variables that proved to be predictive. These items included symptom duration less than 38 days, positive expectation that manipulation will help, side-to-side difference in cervical rotation range of motion of 10° or greater, and pain with posteroanterior spring testing of the middle cervical spine. When > 3 of the 4 variables were present, the likelihood of a positive response increased from 39% to 90%. These are overwhelmingly positive findings, but it must be noted that these are merely preliminary findings and further supplemental research needs to be conducted in order to validate Puentedura and colleagues’ findings.

Many clinicians will argue that cervical manipulation should be abandoned in favor of less ‘dangerous’ interventions. The justification is primarily due to a lack of overwhelmingly superior outcomes compared to thoracic manipulation and/or cervical mobilization. While theoretically, these may be considered more conservative, are the outcomes really the same? Puentedura et al evaluated the outcomes of cervical manipulation versus those of thoracic manipulation in a small RCT. At the conclusion of the study, patients randomized to the cervical manipulation + exercise (CME) group demonstrated superior improvement in pain and disability in comparison to the thoracic manipulation + exercise group (TME). Additionally, there were no serious adverse events reported for either group, however the TME group reported significantly more side effects than the CME group (8 side effects versus 1). So, can we honestly say thoracic manipulation is safer and equally effective? This study seems to disagree. While this was a very small study (n = 24) and all subjects were treated by one clinician, it still offers sufficient evidence to compare the two interventions.

The second intervention that is typically used in place of manipulation is a lower grade joint mobilization (grades I-IV). Dunning et al set out to determine whether a combination of thoracic and cervical thrust manipulation was more effective than non-thrust techniques. At follow-up (48 hours post intervention), those in the manipulation group demonstrated superior improvements in disability, pain, atlatoaxial ROM, and motor performance of the deep neck flexor musculature. While this study only included data immediately following treatment, the benefits of manipulation seem to outweigh those of joint mobilization (in the short-term at least). This study is in agreement with an older study (Cassidy et al) that directly compared the short-term effects of cervical manipulation to mobilization. Both groups demonstrated similar improvements in ROM, but the manipulation group yielded superior improvements in pain intensity. However, contrary to the findings of these two studies, there have also been several studies that have found a lack of significant improvements between manipulation and mobilization. Hurwitz et al, Boyles et al, and Leaver et al all found a lack of discernible improvement in patient outcomes between manipulation and mobilization. Additionally, Saavedra-Hernández et al conducted a RCT comparing the effects of cervical manipulation to those of Kinesiotape in patients with mechanical neck pain. Both groups had similar reductions in neck pain and cervical ROM… This does not lend supporting evidence to Kinesiotape, rather it provides evidence against manipulation. Understandably, it is easy to use the findings of these studies as evidence to support the avoidance of manipulation, but what key concept are all of these studies lacking?

Cervical manipulation, actually manipulation in general, is not an intervention that should be used with every patient presenting with a particular diagnosis. There are specific sub-groups where manipulation is highly beneficial and then there are patients that will show no improvement with its use. Look at the Cochrane Review published on spinal manipulation for low back pain (LBP)… It was determined that, when analyzing all of the data, manipulation was no better than other inert interventions. However, based on the most recent developments in sub-grouping and treatment-based classification, matched treatment with regards to manipulation results in a positive likelihood ratio of 13.2. This is why one of the caveats included within the Cochrane Review is that more research needs to be done looking into the benefits of sub-grouping within this patient population. This is the route that cervical manipulation and its subsequent research needs to take (recent studies by Puentedura et al are a step in the right direction). As seen by the early results (improving probability of benefit from 39% to 90%), those patients who are likely to respond deserve to be provided the appropriate intervention. Not all patients need manipulated. In fact, not very many will need cervical manipulation at all, but to eliminate the intervention from those who will likely benefit seems counterproductive to me.

Based on the risk (albeit very minimal) and similar therapeutic effects from other seemingly less provocative interventions, I propose that cervical manipulation should be a potential intervention, but only for specific patient presentations. In general, I believe if you have exhausted other typical treatment approaches and the patient has not responded adequately, it may be time to consider more aggressive methods. My treatments are determined based on patient presentation and response to treatment, but if possible I try to progress from distal to proximal and from low grade to high velocity low amplitude in terms of manual therapy interventions. In addition, motor control, stabilization, and direction preference exercises must not be left out. As seen in several studies throughout this article, benefits are far superior when coupled with appropriate therapeutic exercise… This is further supported by a systematic review conducted by Gross et al who found combined treatment (manual therapy + exercise) to be superior to any treatment in isolation. It is our job as clinicians to develop and implement a comprehensive program utilizing manual therapy, exercise, pain modulation, and our patient’s beliefs and experiences. Use best evidence and clinical reasoning to determine an appropriate plan of care and your patient will demonstrate far superior outcomes compared to any intervention in isolation.

Thoracic Manipulation → Cervicothoracic Manipulation → Cervical Mobilization (Grade III/IV) → Meet CPR? → Cervical Manipulation (Grade V)

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Cervical Manipulation… Is the Juice Worth the Squeeze? (Part 1)

Neck pain is a debilitating and all too common issue worldwide. According to a systematic review published by Cote et al, the annual prevalence of neck pain in Quebec City is 48%, 27% in Norway, and 34% in the UK. Subsequently, a limitation in activities of daily living was found in between 11-14% of individuals. An additionally alarming statistic is that 50% of these individuals who suffer from neck pain still have symptoms 12 months after onset. Silverstein et al looked at workers compensation claims in the state of Washington between the years of 1990 and 1998. According to their data, 40.1/10,000 full-time equivalents (FTEs) reported claims for soft-tissue neck pain. This same study found that 19.1/10,000 FTEs missed 4 or more days of work secondary to neck pain. This tells us that neck pain is anything but a ‘self limiting’ disorder, but what are we doing to treat these patients?

Treatment approaches differ between clinicians and professions, but many include various forms of exercise, pain modulation, soft-tissue mobilization, joint mobilization, and the ever controversial cervical manipulation…

Cervical manipulation is the staple of the chiropractic profession, but is also utilized by physical therapists, osteopathic physicians, and other healthcare professions. As beneficial as these manipulative techniques appear to be, they are constantly the focus of media and medical scrutiny, but is it warranted? According to Di Fabio et al, between the years of 1925 and 1997, there were 177 cases of serious injury and 32 mortalities associated with cervical spine manipulation (CSM). The most publicized and discussed adverse events come in the forms of Cervical Artery Dissection (CAD) or Vertebral Artery Dissection (VAD). Lee et al performed an epidemiological study attempting to determine the incidence and prognosis of CAD and VAD. The general incidence of VAD is only 0.97 per 100,000 and CAD was only slightly more common at 2.6 per 100,000 people. With such a low incidence, what is the general risk of causing a severe adverse event as a result of manipulation? There have been a few studies published in recent years with reported incidences of <1/5,000,000 manipulations (Jaskoviak et al), 1/50,000 (Gutmann et al), 1/383,750 (Dvorak et al), <1/518,886 (Patijn et al), 1/3,800,000 (Carey et al), and 1/200,000 (Haynes et al). In addition to these older studies, Gouveia et al conducted a systematic review of the literature from 1966 to 2007 and after review of 46 studies, they concluded the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations. Just to clarify, these statistics do not mean that cervical manipulation CAUSED the adverse event, only that the adverse event was associated with a recent manipulation.

Common symptoms associated with VAD include headache and neck pain, so isn’t it reasonable to assume that these strokes are not caused by the aforementioned interventions, but that these patients are just more likely to seek care for their presumed musculoskeletal symptoms? Cassidy et al investigated just that hypothesis. They found that VAD in those < 45 years old was 3 times more likely when recently visiting a chiropractor OR primary care physician (PCP). In those patients > 45 years old, there was no association between a chiropractic visit and VAD, however there was an association between PCP visits and VAD. So are PCPs somehow causing their patients to have cerebrovascular events? Common sense would dictate that these associations are simply due to ‘at risk’ patients seeking help from those qualified to treat them, regardless of intervention. All this being said, could these adverse events be prevented or predicted?

In a thorough review of 134 case reports of adverse events following cervical manipulation, Puentadura et al tried to determine how many cases could have been prevented and under what circumstances the events typically occurred. Of the cases reported, chiropractors were the practitioners in 93 cases, osteopaths in 11 cases, non-clinicians in 9 cases, physical therapists in 5 cases, a naturopath in 1 case, and unknown practitioners in 15 cases. Chiropractors were involved in the vast majority of cases, but this is likely secondary to their increased utilization of CSM compared to other professions. After evaluation of each case, the investigators determined whether CSM was indicated or unnecessary and whether the event was preventable based on presence of contraindications and/or red flags. According to their data, 44.8% of cases could have been prevented had a thorough examination and history been taken. Additionally, of the 7 deaths included, 4 could have been prevented, 1 was unpreventable, and 2 were unknown (lack of adequate information within case report). At the most recent IFOMPT Conference in Quebec City, a document written by Rushton et al was created to provide a framework for pre-manipulative evaluation. The following lists are typical historical findings in those patients that should be contraindicated from manipulation or are at risk for disorders that may become worse following manipulation:


– Multi-level nerve root pathology
– Worsening neurological function
– Unremitting, severe, non-mechanical pain
– Unremitting night pain (preventing patient from falling asleep)
– Relevant recent trauma
– Upper motor neuron lesions
– Spinal cord damage

Risk Factors of CAD:

– Past history of trauma to cervical spine / cervical vessels
– History of migraine-type headache
– Hypertension
– Hypercholesterolemia / hyperlipidemia
– Cardiac disease, vascular disease, previous cerebrovascular accident or transient ischaemic attack
– Diabetes mellitus
– Blood clotting disorders / alterations in blood properties (e.g. hyperhomocysteinemia)
– Anticoagulant therapy
– Long-term use of steroids
– History of smoking
– Recent infection
– Immediately post partum
– Trivial head or neck trauma
– Absence of a plausible mechanical explanation for the patient’s symptoms

Risk Factors of Upper Cervical Instability:

– History of trauma (e.g. whiplash, rugby neck injury)
– Throat infection
– Congenital collagenous compromise (e.g. syndromes: Down’s, Ehlers-Danlos, Grisel, Morquio)
– Inflammatory arthritides (e.g. rheumatoid arthritis, ankylosing spondylitis)
– Recent neck/head/dental surgery

Outside of the identification of contraindications and red flags through patient history and subjective interview, is there evidence to support the use of pre-manipulation physical evaluation in identifying or reducing the prevalence of adverse events? Carlesso et al conducted a survey of Member Groups and Registered Special Interest Groups within the IFOMPT trying to identify how often clinicians performed pre-manipulation Vertibrobasilar Insufficiency (VBI) testing. Of the surveys that were returned, 77% of respondents did perform pre-manipulative screening for VBI. Unfortunately, despite the prevalence of pre-manipulation physical examination, there may not be evidence to support its efficacy. According to Mitchell et al, the most provocative and reliable positional test for VBI is sustained end-range rotation. This test may be of benefit, however research is lacking regarding how predictive or how reliable this test actually is. This examination is meant to maximize the occlusion of the vertebral artery, but is this too intense for those ‘at risk’ patients? In my opinion, this test puts patients into a much more dangerous position than most manipulative techniques ever will. This test alone may stress the vertebral artery beyond its limit and may predispose patients to the condition we are attempting to screen for. In fact, a biomechanical study conducted by Herzog et al determined that vertebral artery strain was significantly higher during diagnostic and range of motion testing compared to high velocity, low amplitude cervical manipulation.

Cervical manipulation is an effective means to decrease pain and improve function in patients suffering from mechanical neck pain and, based on the current evidence, is a generally safe intervention. The incidence of adverse events is minimal and, through adequate screening and evaluation, most adverse events can be prevented. There is still an inherent risk, as 10.4% of adverse events were unpreventable (Puentadura et al), but as previously mentioned, these are only associations. Many of these cases may have simply been a case of individuals presenting with seemingly mechanical symptoms (neck pain and headache), but were truly demonstrated preliminary symptoms associated with CAD. The well-informed clinician will take into consideration the patient’s prior medical history, current symptomology, comorbid conditions, and physical examination findings prior to performing any intervention aimed at the cervical spine. Through the use of sound clinical reasoning and after taking adequate precautions, I do believe the juice is worth the squeeze and my next post will delve a little more into why.

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