Cervical Manipulation: A PT's Perspective

Cervical Spine Manipulation: A Physical Therapist's Perspective

A number of medical professionals use Cervical Spine (Neck) Manipulation for the treatment of neck pain, headaches and mobility deficits. These include; Osteopathic Physicians, Allopathic Medical Physicians, Chiropractors and Orthopedic Manual Physical Therapists. Among all the techniques a Physical Therapist (PT) uses, Spinal Manipulation is recommended as a first line treatment in recent professional guidelines. The American Physical Therapy Association has defined manipulation as; a manual therapy technique comprising a continuum of skilled passive movements to the joints and/or related soft tissue that are applied at varying speeds and amplitudes, including a small-amplitude/ high- velocity therapeutic movement. (Guide to Physical Therapist Practice, Rev 2nd Ed. Alexandria, Va: American Physical Therapy Association; 2003). Spinal Manipulation has been part of daily practice since our profession began, somewhere in the 1920’s and 1930’s, and it is well within our scope of practice to this day and even now considered an entry level skill. It should also be mentioned here that much of the research to date that supports, and refutes, the use of Spinal Manipulation has been done by Physical Therapists.
The effects of cervical spinal manipulation are still being studied, no definitive conclusions have been made. Cervical spinal manipulation may improve joint range of motion,  reduce pain in various ways, increase or decrease activity of certain muscles through nervous system stimulation, improve muscle performance, which may all help reduce disability. None of these effects, however, are established as fact and other manual therapy interventions have been shown to be similar if not equal in effectiveness. Some practical reasons for using of cervical spine manipulation for patients with neck pain and mobility deficits are;
  1. It is quick and comfortable
  2. It is usually pain free
  3. The effects can be immediate
  4. Multiple joints can treated with a single thrust
  5. It is safe
A major concern with most patients, and professionals, when it comes to cervical manipulation is safety. There are potential risks associated with it, and the most alarming one is the risk of vertebrobasilar stroke (VBA). Safety has always been a debate in regards to this topic, and as of late nothing has changed ( see http://alteredhaemodynamics.blogspot.co.uk/ andhttp://rogerkerry.posterous.com/should-cervical-manipulations-be-abandoned). Briefly, there are two things you need to know about this topic of VBA stroke associated with cervical manipulation. First, there is no evidence to support the claim of increased VBA stroke risk with cervical manipulation when compared to seeing your primary care physician for an office visit.
In fact, being treated by a Chiropractor has no more association with stroke risk versus seeing a primary care physician, and it is likely that patients who did seek treatment around the time of their stroke had some pathology already in process. It has been estimated that complications with VBA due to manipulation are very low, possibly even greater than 1 in a million.. If anyone wants to discuss risks of certain treatments in the medical community, well, the risks of using nonsteroidal anti-inflammatory drugs is greater. The risk of gastrointestinal bleeding from nonsteroidal anti-inflammatory drugs is significantly high and it has been estimated that a large number of hospitalizations and over 7000 deaths each year may be attributed to these medications. In the literature there is no documented case of a physical therapist inducing a VBA stroke in the USA, UK, Canada and several other countries. Secondly, neck pain and headaches are common but they also occur in patients prior to a VBA stroke. There is a lack of valid and reliable physical tests to detect patients who are at risk for having a VBA stroke with treatment. Instead of relying on age old tests to screen patients for risk, it may be more beneficial to get a better overall picture of the health of the patient. Screening blood pressure, performing a cranial nerve and eye examination and a comprehensive patient interview can help to determine if a patient has symptoms that may be related to VBA stroke.
Considerable variability exists between cervical spinal manipulation methods. Chiropractors have some major differences in technique when compared to an Osteopath or Manual Physical Therapist, but there is often some overlap in techniques due to biomechanical principles that are shared in physical medicine. There are several training institutes that teach Manipulation, two such programs are; Spinal Manipulation Institute www.spinalmanipulation.org founded by Dr. James Dunning,  and the Institute of Orthopedic Manual Therapy www.iomtwoburn.com  instructed by Martin Langaas, OMT. If you are a professional reading this post these are great programs to learn safe, effective manipulation techniques as well as the appropriate framework to use it in. If you are a patient with neck pain seeking help and advice, finding a professional trained by these institutes will be beneficial to you. One thing that should always be included before using any manipulation technique (or manual treatment for the matter) is a thorough patient interview followed by a physical examination.For more information on evaluation see;
A physical therapist who is well trained in spinal manipulation techniques and has been trained in good clinical reasoning will help you tremendously.
Contributed by Dr. Thomas Perreault, PT, DPT, OCS, Cert. SMT
Guide to Physical Therapist Practice, Rev 2nd Ed. Alexandria, Va: American Physical Therapy Association; 2003.
Kerry R, Taylor AJ. Cervical arterial Dysfunction assessment and manual therapy. Manual Therapy 2006;11:243-253
Dunning JR, Cleland JA, Waldrop MA, et al. Upper cervical and upper thoracic thrust manipulation versus nonthrust mobilization in patients with mechanical neck pain: a multicenter randomized clinical trial. J Orthop Sports Phys Ther. 2012;42:5-18
Cassidy JD, Boyle E. Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-controlled and case-crossover study. Spine (Phila PA 1976). 2008;33:s176-183
Garcia Rodriguez LA, Barreales Tolosa L. Risk of upper gastrointestinal complications among users of traditional NSAIDS and COXIBs in the General Population. Gastroenterlogy 2007 Feb;132(2):498-506. Epub 2006 Dec 3.
Krauss JR, Evjenth O, Creighton D. Translatoric Spinal Manipulation for Physical Therapists. 2006


  1. Very imformative article! Easy to read and understand. Answered one of my questions on cervical issues.
    Thank you!

  2. Chiropractors would like you to believe that the incidence of stroke following neck manipulation is extremely small. Overall, the chiropractic profession has downplayed the risk of stroke through cervical manipulation.
    chiropractors nj


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