First, I think it is important to examine the current literature with manual techniques at the cervical spine, then speculate what we need to further investigate. Bronfort et al, demonstrated the benefit of home exercise or manual therapy when compared to medication management.1 This study does have some limitations, including time spent with the therapist varied and lack of blinding of the subjects. I truly enjoyed Walker et al. study, which examines the effects of manual therapy and exercise for mechanical neck pain. This study had a meaningful format to me as as time between groups was normalized with a therapist, and treatments administered were similar to ones I use in clinic (thrust or non thrust cervical mobilization, stretching, and muscle energy along with an exercise program of cervical retraction, deep neck flexor strengthening and cervical rotation ROM exercises) making this easier to generalize to my patient population.5 They also utilize similar outcome measures as we do in clinic, again, making it easier to relate the results to my practice. This article demonstrates statistically significant affects in reducing neck pain and disability with using manual therapy and exercise. Manual therapy and exercise is a safe treatment option to reduce pain for patients with or without upper extremity symptoms.5 Lastly, combined manual therapy and exercise are shown to be more effective than one of these alone.6,7
Probably the more interesting question: what is the difference between manipulation and mobilization with patients? In my practice, a few decisions happen before I administer manipulation. First, they need to be cleared for red, and yellow flags. As discussed previously, upper cervical stability needs to be assessed with at minimum the sharp purser test due to its +LR of 17.3 at detecting upper cervical instability.3 For a patient with fearful guarding of the cervical spine, I do not administer a manipulation – especially if the position is painful. Once a patient is deemed safe for both interventions, we are back to the question of: is manipulation more effective than mobilization? In the lumbar spine, this question is clearly answered with durable evidence to show that manipulation is more effective than mobilization under the CPR guidelines. We even have excellent literature to support thoracic spine thrust for patients with acute cervical spine pain. Where Cleland et. al, demonstrated significantly better outcomes at with shorter disability and less pain after thoracic thrust was preformed.2 Puentedura did complete a CPR study that showed patients with 3 of the 4 following criteria had improvement in symptoms from 39% to 90%.13 The criteria are listed as the following:
-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
-Pain with posteroanterior spring testing of the middle cervical spine.
This study gives us a preliminary framework for finding who is appropriate for thrust manipulation, but does not compare results to mobilization. Boyles et. al showed no statistical difference between cervical spine thrust vs. non thrust in outcomes or GROC scores.10 Thus leaving us with a lack of solid literature showing the difference in outcomes between the two, but the overall understanding that manual therapy as a whole is effective in treating neck pain and manipulation can be a beneficial option.
I do think we have a need for more future literature to investigate benefit of cervical spine manipulation. We have found end range manipulation can mediate dorsal horn C-fiber input, which can create hypoalgesic responses.8 Relating this concept to Cleland et. al study in 2005, which showed an immediate reduction in perceived neck pain after thoracic manipulation.9 It is possible that this immediate change in from the elicited hypoalgesic response. There is definitely a need for further investigation. There are a few things that we know over the decade of research, the mechanical model is ineffective to treat spine pain, but research still demonstrates the benefit of manual work at cervical and thoracic spine for management of neck pan. Now, we must ask ourselves, are we affecting movement of cervical spine, or tapping into an afferent input creating hypoalgesic responses or in other commonly utilized terms modifying a centrally mediated response – it is my guess that further literature will tell!
In the meantime, the take point with manual work is to utilize a test-retest model with treatment sessions. First, a discussion with a patient what their expectations are, then finding areas of impairment within the spine and addressing them to the best of your ability utilizing evidence to guide you. Fine tuning each treatment to a patient’s response elicits the most meaningful results to a treatment session and allows patients to see immediate effect of the administered treatment. In conclusion, the following should be strongly considered for the management of mechanical neck pain: thoracic spine manipulation, cervical spine mobilization or manipulation and adjunct therapeutic exercises targeted at mobility.
Original post: July 28, 2013
1) Bronfort, G., Evans, R., Anderson, A. V, Svendsen, K. H., Bracha, Y., & Grimm, R. H. (2012). Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Annals of internal medicine, 156(1 Pt 1), 1–10. doi:10.7326/0003-4819-156-1-201201030-00002
2) Cleland, J. a, Glynn, P., Whitman, J. M., Eberhart, S. L., MacDonald, C., & Childs, J. D. (2007). Short-term effects of thrust versus nonthrust mobilization/manipulation directed at the thoracic spine in patients with neck pain: a randomized clinical trial. Physical therapy, 87(4), 431–40. doi:10.2522/ptj.20060217
3) Uitvlugt G, Indebaum S. Clinical Assessment of Atlantoaxial Instability Using the Sharp-Purser Test. Arthritis Rheum. 1988; 31: 918-922.
4) Adèr, H. J., Vet, H. C. W. De, Koes, B. W., Vondeling, H., & Bouter, L. M. (2003). Primary care, 326(April), 1–6.
5) Walker, M. J., Boyles, R. E., Young, B. a, Strunce, J. B., Garber, M. B., Whitman, J. M., … Wainner, R. S. (2008). The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial. Spine, 33(22), 2371–8. doi:10.1097/BRS.0b013e318183391
6) Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;27:1835–43, discussion 43.
7) Bronfort G, Evans R, Nelson B, et al. A randomized clinical trial of exercise and spinal manipulation for patients with chronic neck pain. Spine 2001;26: 788–97, discussion 98–9.
8) George Steven, Bishop Mark, Bialosky JE, Zeppieri G, Robinson M. Immediate Effects of Spinal Manipulation on Thermal Pain Sensitivity: An Experimental Study. BMC Musculoskeletal Disorders. 2006. 7:68.
9) Cleland, J. a, Childs, J. D., McRae, M., Palmer, J. a, & Stowell, T. (2005). Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual therapy, 10(2), 127–35. doi:10.1016/
10) Boyles, R. E., Walker, M. J., Young, B. a, Strunce, J., & Wainner, R. S. (2010). The addition of cervical thrust manipulations to a manual physical therapy approach in patients treated for mechanical neck pain: a secondary analysis. The Journal of orthopaedic and sports physical therapy, 40(3), 133–40. doi:10.2519/
11) Walker, M. J., Boyles, R. E., Young, B. a, Strunce, J. B., Garber, M. B., Whitman, J. M., … Wainner, R. S. (2008). The effectiveness of manual physical therapy and exercise for mechanical neck pain: a randomized clinical trial. Spine, 33(22), 2371–8. doi:10.1097/BRS.0b013e318183391e
12) IngeborgBCKorthals-deBos,JanLHoving,MauritsWvanTulder,MaureenPMHRutten-van Mölken, Herman J Adèr, Henrica C W de Vet, Bart W Koes, Hindrik Vondeling, Lex M Bouter. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. BMJ. 2003; 326.
13) Puentedura, E. J., Cleland, J. a, Landers, M. R., Mintken, P. E., Louw, A., & Fernández-de-Las-Peñas, C. (2012). Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. The Journal of orthopaedic and sports physical therapy, 42(7), 577–92. doi:10.2519/