Cervical spine manipulation is associated with increased inter-vertebral motion

Authors: Branney, J.N. and Breen, A.C.

Conference: European Chiropractors' Union Convention

Dates: 29-31 May 2014



According to the Neck Pain Task Force, cervical spine manipulation is one of the best treatment options for mechanical neck pain (Hurwitz et al. 2008) and its value in the treatment of neck pain has been further bolstered by the findings from recent randomised clinical trials (Bronfort et al. 2012; Evans et al. 2012; Maiers et al. 2013). Yet, for some, the use of spinal manipulation for neck pain remains controversial due to the unresolved association with vertebral artery dissection and stroke (Ernst 2010), and the apparent lack of efficacious superiority over alternative manual treatments considered to be safer, such as mobilisation (Gross et al. 2010). There has even been a call for the abandonment of cervical spine manipulation (Wand et al. 2012). Contributing to this controversy is the lack of understanding regarding the mechanism of spinal manipulation. Most neck pain is believed to be mechanical in nature (Binder 2008) and spinal manipulation is predicated on the idea that inter-vertebral motion can be changed, but previous attempts to research this have been hampered by the lack of an objective reproducible method of measuring inter-vertebral motion. The recent developments in quantitative fluoroscopy (QF) now make such measurement possible. Therefore this study sought to determine if spinal manipulation for neck pain is associated with changes in cervical inter-vertebral motion (IV-RoM) as measured by QF, and if any changes are related to patient outcomes.


Thirty patients with neck pain and 30 matched controls had their cervical inter-vertebral motion (C1/2 – C5/6) measured in flexion and extension by QF. Patients had spinal manipulative treatment over four weeks and completed pain and disability questionnaires at baseline and follow-up. Controls had no treatment and both groups had QF follow-up assessments at four weeks. The minimum detectable change (MDC) in segmental IV-RoM over four weeks was determined in controls for each level. Fixations were defined as those levels exhibiting segmental IV-RoM at or below the 2.5th percentile for that inter-vertebral level.

Results Repeatability coefficients (2.77sw, where sw = within-subject standard deviation) were calculated from controls to estimate the magnitude of angular motion change at four-week follow-up expected 95% of the time for each inter-vertebral level (Bland and Altman 1996). The repeatability coefficients represent the thresholds for MDC. There was a weak but statistically significant (Rho=0.39, p=0.043) positive correlation between the number of manipulations received and the number of levels that increased in range beyond their MDC. Segments that were targeted with at least four manipulations increased their range more than any change in controls. However, only one segment that was classed as a fixation increased its range above the MDC. While 87% of patients had clinically significant pain reduction there was no relationship between any clinical outcomes and change in IV-RoM.


Cervical spine manipulation was associated with increased inter-vertebral motion in a dose-response manner, but this was not correlated with outcomes. References

Binder, A., 2008. Neck Pain - Clinical Evidence Review. Musculoskeletal Disorders, (08), 1103.

Bland, J. M. and Altman, D. G., 1996. Statistics Notes: Measurement error. British Medical Journal, 313 (744).

Bronfort, G., Evans, R., Anderson, A. V., Svendsen, K. H., Bracha, Y. and Grimm, R. H., 2012. Spinal Manipulation, Medication, or Home Exercise with Advice for Acute and Subacute Neck Pain. Annals of Internal Medicine, 156 (1).

Ernst, E., 2010. Vascular accidents after neck manipulation: cause or coincidence. The International Journal of Clinical Practice, 64 (6), 673-677.

Evans, R., Bronfort, G., Schulz, C., Maiers, M., Bracha, Y., Svendsen, K., Grimm Jr, R., Garvey, T. and Transfeldt, E., 2012. Supervised exercise with and without spinal manipulation perform similarly and better than home exercise for chronic neck pain: a randomized controlled trial. Spine, Ahead of print.

Gross, A., Miller, J., D'Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., Haines, T., Bronfort, G. and Hoving, J. L., 2010. Manipulation or mobilisation for neck pain: A Cochrane Review. Manual Therapy, 15, 315-333.

Hurwitz, E. L., Carragee, E. J., van der Velde, G., Carroll, L. J., Nordin, M., Guzman, J., Peloso, P. M., Holm, L. W., Cote, P., Hogg-Johnson, S., Cassidy, J. D. and Haldeman, S., 2008. Treatment of Neck Pain: Noninvasive Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 33(4S) Neck Pain Task Force (Supplement), S123-S152.

Maiers, M., Bronfort, G., Evans, R., Hartvigsen, J., Svendsen, K., Bracha, Y., Schulz, C., Schulz, K. and Grimm, R., 2013. Spinal manipulative therapy and exercise for seniors with chronic neck pain. The Spine Journal.

Wand, B. M., Heine, P. J. and O’Connell, N. E., 2012. Should we abandon cervical spine manipulation for mechanical neck pain? Yes. BMJ, 344.

Source: Manual

Preferred by: Jonny Branney