Is a Cervical Adjustment Safe?

Cervical manipulation, also known as a cervical adjustment, neck manipulation, or high-velocity low-amplitude thrust (HVLAT) manipulation, is a common treatment for neck pain, headaches, jaw pain, and upper extremity pain to name a few. It involves applying a controlled force to the cervical spine, typically by an osteopath, chiropractor, physical therapist, and is sometimes used by other healthcare professionals.

The safety of HVLAT cervical manipulation has been the subject of much debate in the medical community. Some studies, and mainly anecdotal evidence, have suggested that cervical manipulation may be associated with an increased risk of stroke and other serious complications, while others have found no such link.

We have two arteries that supply blood flow to our brain, the carotid arteries in the front of your neck, and the vertebral arteries in the back. The vertebral arteries actually course through your C2-C6 vertebrae. This lead to individuals thinking we are adding too much strain on the vertebral artery when we perform a cervical manipulation, because by moving the cervical vertebrae, we are also stretching the vertebral artery. However, our body is incredibly resilient and the vertebral artery is designed to moved and stretched. We even add more stress on the vertebral artery by using our cervical range of motion than we do from a cervical manipulation (1, 2). That means that at times it is more dangerous to look over our blind spot while driving than it is to have a qualified and skilled provider adjust our neck! The stretch on the vertebral artery during a cervical manipulation is 6.2% greater than at rest. When using your full cervical range of motion, the strain on the vertebral artery is up to 12.5% greater than rest (1). Essentially meaning that by looking over our blind spot, we are adding twice the stress on our vertebral artery than from a cervical manipulation. Now, we all know that looking over your blind spot is not inherently dangerous, and neither is a cervical manipulation. If red flags are ruled out and done by a skilled clinician, cervical manipulations are safe.

One reason this is a cause of debate is because while some anecdotal evidence makes providers think that cervical manipulation can cause stroke, scientific research states otherwise. The key is that one of the first symptoms of a vertebral artery dissection is neck pain or headaches. This shows the importance of having a provider rule out serious causes of neck pain or headaches. Because neck pain or headaches are one of the first symptoms, naturally, patients seeking treatment will see a manual therapist, such as a chiropractor. If there has ever been a stroke that happened after a cervical adjustment, it is because the stroke was already in progress, and the provider did not do their due diligence in ruling out a stroke.

One of the most widely cited studies on the topic of strokes and cervical adjustments is a 2008 paper by Cassidy et al., which found that there is no evidence of excess risk of vertebra-basilar artery stroke associated with chiropractic care. However, in this study, there was actually a strong association between strokes and primary care physician visits. As stated earlier, this is likely because one of the first symptoms of a stroke could be neck pain or headaches. In fact, it is stated in the research article:

“We also found strong associations between PCP visits and subsequent VBA stroke. A plausible explanation for this is that patients with head and neck pain due to vertebral artery dissection seek care for these symptoms, which precede more than 80% of VBA strokes” (2, 3).

Because 80% of stroke patients may have headaches or neck pain prior to their stroke, it is crucial for providers to rule out a stroke when treating a headache or neck pain patient.

In 2010, Murphy et al. published a study in which they reviewed the medical literature on cervical manipulation and stroke. They found that there is a small but statistically significant increased risk of stroke associated with cervical manipulation. However, the reasoning for these findings needs to be stressed. Those that had a stroke were going to have a stroke independent of having a cervical manipulation. It is noted in the study that those that eventually had a stroke already had a vertebral artery dissection in progress (5). Meaning, the cervical manipulation did not cause the stroke, but the providers did not do their job of examining the patient for a possible blood flow issue. The stoke that these patients experienced was going to happen regardless of whether or not a cervical manipulation was done.

Studies have said that serious adverse events happened 1 in 5 million manipulations (6, 7). The risk of a minor adverse event, such as stiffness, pain, or headaches, happened in less than 1-2% of cases (2, 7-10). To put that in perspective, the risk of an adverse event from Ibuprofen is 25%, and serious adverse event in up to 4% of cases (11, 12). There are over 100,000 hospitalizations and 16,000 deaths yearly – from ibuprofen! One study even states that cervical manipulation is much safer than NSAIDs for neck pain (13). Ibuprofen can be bought over the counter and is given out like candy. If medication is given out so freely, why is it that non-pharmaceutical treatments that have been demonstrated safe are held to such scrutiny?

Overall, it is clear that more research is needed to fully understand the safety of HVLAT cervical manipulation. In the meantime, it is important for healthcare professionals to carefully consider the potential risks and benefits of the treatment for each individual patient, and to discuss these with the patient before proceeding with any cervical manipulation.

It is important to note the effectiveness of cervical manipulation. There is evidence to support cervical manipulation for positive short-term results with those that have neck pain (14-16). Cervical manipulations can immediately help with pain and improve cervical rotation range of motion (17). Cervical and thoracic (upper back) manipulation has been shown to be more effective than mobilizations in the short term for patients with neck pain (18). Thoracic manipulation has been shown to be beneficial for patients with neck pain in multiple studies (18-20). Cervical manipulation can cause immediate relief for patients with cervicogenic headaches (21, 22). One study showed that manipulation of the neck and upper back was more effective than mobilization for up to 3 months follow up (23). For this study, it is possible that these effects were maintained longer than the 3 month follow up, however the study ended at 3 months — meaning, there are some longer term results for neck pain with manipulation. As for jaw pain, multiple studies show that cervical manipulation can help with pain and mouth opening range of motion (24, 25).

Many of these studies only show short-term results, as the results were simply not studied long-term. This is an issue because many providers will say something along the lines of “only worrying about long-term results.” While many will dismiss short-term relief, we still aim to provide our patients with short-term relief. Short-term relief means someone will be able to sleep for the night, return to work, take care of their family, etc., while we work on long-term relief with our other treatment techniques.

Granted, not everybody can receive a spinal manipulation. Contraindications include vascular issues, tumors, tuberculosis, cauda equina syndrome, cervical myelopathy, extreme pain, and lack of a diagnosis. Those that are elderly, suffer hypertension, and/or have a family history of vascular issues can still be manipulated, but it definitely should be treated as a precaution.

It is central to state that we, at Dynamic Physio, do not manipulate all of our patients. Any form of treatment that we offer is only part of our treatment. We do not believe in a one-size-fits-all treatment. Every patient has a thorough examination done and will be treated individually, and based on the highest level of evidence.

It is time to reconsider our distrust of cervical manipulation. This treatment technique can benefit a tremendous number of patients dealing with neck pain, headaches, jaw pain, upper extremity pain, and other conditions.

If we continue to disagree as healthcare providers, the only group that ends up suffering is the patient.

References:

1.     Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. 2002 Oct;25(8):504-10. doi: 10.1067/mmt.2002.127076. PMID: 12381972.

2.     Mitchell JA. Changes in vertebral artery blood flow following normal rotation of the cervical spine. J Manipulative Physiol Ther. 2003 Jul-Aug;26(6):347-51. doi: 10.1016/S0161-4754(03)00074-5. PMID: 12902962.

3.     Cassidy JD, Boyle E, Côté P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S176-83. doi: 10.1097/BRS.0b013e3181644600. Erratum in: Spine (Phila Pa 1976). 2010 Mar 1;35(5):595. PMID: 18204390.

4.     Lee VH, Brown RD Jr, Mandrekar JN, et al. Incidence and outcome of cervical artery dissection: a population-based study. Neurology 2006;67: 1809–12.

5.     Murphy B, Taylor HH, Marshall P. The effect of spinal manipulation on the efficacy of a rehabilitation protocol for patients with chronic neck pain: a pilot study. J Manipulative Physiol Ther. 2010 Mar-Apr;33(3):168-77. doi: 10.1016/j.jmpt.2010.01.014. PMID: 20350669.

6.     Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ. 2001;165:905–6

7.     Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, Gress DR. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003 May 13;60(9):1424-8. doi: 10.1212/01.wnl.0000063305.61050.e6. PMID: 12743225.

8.     Kerry R, Taylor AJ, Mitchell J, McCarthy C, Brew J. Manual therapy and cervical arterial dysfunction, directions for the future: a clinical perspective. J Man Manip Ther. 2008;16(1):39-48. doi: 10.1179/106698108790818620. PMID: 19119383; PMCID: PMC2565074.

9.     Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Man Ther. 2010 Oct;15(5):434-44. doi: 10.1016/j.math.2010.02.006. Epub 2010 Mar 12. PMID: 20227325.

10.  Dittrich R, Rohsbach D, Heidbreder A, Heuschmann P, Nassenstein I, Bachmann R, Ringelstein EB, Kuhlenbäumer G, Nabavi DG. Mild mechanical traumas are possible risk factors for cervical artery dissection. Cerebrovasc Dis. 2007;23(4):275-81. doi: 10.1159/000098327. Epub 2006 Dec 29. PMID: 17192705.

11.  Bjorkman DJ. Current status of nonsteroidal anti-inflammatory drug (NSAID) use in the United States: risk factors and frequency of complications. Am J Med. 1999 Dec 13;107(6A):3S-8S; discussion 8S-10S. doi: 10.1016/s0002-9343(99)00362-9. PMID: 10628588.

12.  Graumlich JF. Preventing gastrointestinal complications of NSAIDs. Risk factors, recent advances, and latest strategies. Postgrad Med. 2001 May;109(5):117-20, 123-8. doi: 10.3810/pgm.2001.05.931. PMID: 11381661.

13.  Dabbs V, Lauretti WJ. A risk assessment of cervical manipulation vs. NSAIDs for the treatment of neck pain. J Manipulative Physiol Ther. 1995 Oct;18(8):530-6. PMID: 8583176.

14.  Bitterli J, Graf R, Robert F, Adler R, Mumenthaler M. Zur objectivierung der manualtherapeutischen beeinflussbarkeit des spondylogenen kopfschmerzes. Nervenarzt 1977;48:259e62.

15.  Sloop PR, Smith DS, Goldenberg E, Dore C. Manipulation for chronic neck pain: a double-blind controlled study. Spine 1982;7(6):532e5.

16.  Martinez-Segura R, Fernandez-de-las-Penas C, Ruiz-Saez M, Lopez-Jimenez C, Rodriguez-Blanco C. Immediate effects on neck pain and active range of motion after a single cervical high-velocity low amplitude manipulation in subjects presenting with mechanical neck pain: a randomized controlled trial. Journal of Manipulative and Physiological Therapeutics 2006;29:511e7.

17.  Cassidy JD, Quon JA, LaFrance LJ, Yong-Hing K. The effect of manipulation on pain and range of motion in the cervical spine: a pilot study. J Manipulative Physiol Ther. 1992 Oct;15(8):495-500. Erratum in: J Manipulative Physiol Ther 1992 Nov-Dec;15(9):followi. PMID: 1402409.

18.  Dunning JR, Cleland JA, Waldrop MA, Arnot CF, Young IA, Turner M, Sigurdsson G. 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 Jan;42(1):5-18. doi: 10.2519/jospt.2012.3894. Epub 2011 Sep 30. PMID: 21979312.

19.  Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of a thoracic manipulation in patients with neck pain: a randomized clinical trial. Manual Therapy 2005;10:127e35.

20.  Fernandez-de-las-Penas C, Fernandez-Carnero J, Plaza Fernandez A, Lomas-Vega R, Miangolarra-Page JC. Dorsal manipulation in whiplash injury treatment: a randomized controlled trial. Journal of Whiplash & Related Disorders 2004;3:55e71.

21.  Haas M, Groupp E, Aickin M, Fairweather A, Ganger B, Attwood M, et al. Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. Journal Manipulative and Physiological Therapeutics 2004;27:547e53.

22.  Nilsson N. A randomized controlled trial of the effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther. 1995 Sep;18(7):435-40. PMID: 8568424.

23.  Dunning JR, Butts R, Mourad F, Young I, Fernandez-de-Las Peñas C, Hagins M, Stanislawski T, Donley J, Buck D, Hooks TR, Cleland JA. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskelet Disord. 2016 Feb 6;17:64. doi: 10.1186/s12891-016-0912-3. PMID: 26852024; PMCID: PMC4744384.

24.  Oliveira-Campelo NM, Rubens-Rebelatto J, Martí N-Vallejo FJ, Alburquerque-Sendí N F, Fernández-de-Las-Peñas C. The immediate effects of atlanto-occipital joint manipulation and suboccipital muscle inhibition technique on active mouth opening and pressure pain sensitivity over latent myofascial trigger points in the masticatory muscles. J Orthop Sports Phys Ther. 2010 May;40(5):310-7. doi: 10.2519/jospt.2010.3257. PMID: 20436241.

25.  Mansilla-Ferragut P, Fernández-de-Las Peñas C, Alburquerque-Sendín F, Cleland JA, Boscá-Gandía JJ. Immediate effects of atlanto-occipital joint manipulation on active mouth opening and pressure pain sensitivity in women with mechanical neck pain. J Manipulative Physiol Ther. 2009 Feb;32(2):101-6. doi: 10.1016/j.jmpt.2008.12.003. PMID: 19243721.