RESEARCH: Cervical Manipulation. What You Need To Know

Thursday, July 30th, 2015
chiropractic neck pain manipulation manual therapy risk stroke research

I have spent some serious time going through research abstracts, compiling lists, and battling with a certain faction of the medical field that is strictly against chiropractic. In particular cervical chiropractic adjustments. The one common thread this group of the medical field seems to always come back to is some imaginary notion that cervical manipulation is dangerous. Not only that it is incredibly dangerous but that it is being performed for very little pay-off in the form of pain relief or reduction of disability. 

Very quickly, and very succinctly….this is simply untrue. 

As I’ve stated many times, the relationship between the chiropractic field and the medical field has improved immensely currently so please understand that I am referring to a part of the medical field that has remained stubborn, ignorant to current research, and a group that time has simply passed them up. Some people just don’t take kindly to change of any sort. 

However, I felt that, if some in the medical field hold this idea, then there may be many more in the public sector that have never been properly updated in their ideas of how good (or bad) chiropractic can be for cervical musculoskeletal complaints. 

It’s in that spirit that I have compiled the following information. It includes studies that have accurately proven the benefits for cervical musculoskeletal complaints, headaches, migraines, and range of motion while also showing some of the research dispelling all claims of any real risk of stroke as a result. 

All of these citations can be searched at PubMed online and read for further clarification if one strikes your interest. Also, at the very end of this page, I have included an article from the British Medical Journal just to put the period on the sentence.

I truly hope the following information can dispel some of the misinformation floating around about chiropractors and helps you in your decision to adopt Chiropractic as part of your regular healthcare treatment regimen.

Research Citations Demonstrating Efficacy of Cervical Manipulation/Mobilization  in Cervical Pain and/or Headaches/Migraines with Citations Demonstrating Little to NO Risk of Vertebral Basilar Artery Dissection.

Cervical Studies

  • Korthals-de Bos IB, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial. Randomized controlled trial British Medical Journal. 2003 Apr 26;326(7395):911.

  • Dewitte V, Beernaert A, Vanthillo B, Barbe T, Danneels L, Cagnie B. Articular dysfunction patterns in patients with mechanical neck pain: A clinical algorithm to guide specific mobilization and manipulation techniques. Man Ther. 2014; 19(1):2-9.


  • Dunning JR, Cleland J, Waldrop M, Arnot C, Young I, 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; 42(1): 5-18.


  • Bronfort G, Evans R, AndersonA, Svendsen K, Bracha Y, Grimm R. Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial. Annals of Internal Medicine. 2012; 156(1): 1-10.


  • Puentedura EJ, Cleland JA, Landers MR, Mintken PE, Louw A, Fernández-de-Las-Peñas C. Development of a clinical prediction rule to identify patients with neck pain likely to benefit from thrust joint manipulation to the cervical spine. J Orthop Sports Phys Ther. 2012; 42(7):577–92.


  • Martínez-Segura R, De-la-Llave-Rincón AI, Ortega-Santiago R, Cleland JA, Fernández-de-Las-Peñas C. Immediate changes in widespread pressure pain sensitivity, neck pain, and cervical range of motion after cervical or thoracic thrust manipulation in patients with bilateral chronic mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2012; Sep; 42(9):806–14.


  • Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. J Manipulative Physiol Ther. 2011; 34(2):131-7.


  • Puentedura EJ, Landers MR, Cleland JA, Mintken PE, Huijbregts P, Fernandez-de-Las-Penas C. Thoracic spine thrust manipulation versus cervical spine thrust manipulation in patients with acute neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2011 ed. 2011; Apr;41(4):208–20.


  • Leaver AM, Maher C, Herbet R, Latimer J, MacAuley J, Jull G. Refshauge K. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. 2010; 91(9): 1313-8.


  • Cleland, JA, Mintken PE, Carpenter K, Fritz JM, Glynn P, Whitman J, Childs JD. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: Multi-center randomized clinical trial. Physical Therapy, 2010; 90(9): 1239-1250.


  • Miller J, Gross A, D’Sylva J, Burnid SJ, Goldsmith CH, Graham N, Haines T, Gronfort G, Hoving JL. Manual therapy and exercise for neck pain: A systematic review. Manual Therapy, 2010; 15: 334-354.


  • Gonzalez-Iglesia J, Fernandez-de-las-Penas C, Cleland JA, Alburquerque-Sendin F, Palmerque-del-Cerro F, Mendez-Sanchez R. Inclusion of thoracic spine thrust manipulation into an electrotherapy/thermal program for the management of patients with acute mechanical neck pain: a randomized trial. Manual Therapy, 2009; 14, 306-313.


  • Hurwitz EL, Carragee EJ, van der Welde G, Carrol LJ, Nordin M, Guzman J, et al. 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 2008; 33(4 supplement) S123-S152.


  • Fernandez-de-las-Penas C, Palomeqque-del-Cerro OL, Rodriguew-Blanco C, Comex-Conesa A, Miangolarra-Page JC. Changes in neck pain and active range of motion after a single thoracic spine manipulation in subjects presenting with mechanical neck pain: a case series. JMPT, 2007; 30(4): 312-320.


  • Reinhold Muller and Lynton GF. “long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. Journal of Manipulative and Physiological Therapeutics. 2005;28:3-11


  • Zhu L, et al.  “Does cervical spine manipulation reduce pain in people with degenerative cervical radiculopathy? A systematic review of the evidence, and a meta-analysis.” Clin Rehabil. 2015 Feb 13.


  • Giles LG, Muller R, “Chronic spinal pain a randomized clinical trial comparing medication, acupuncture, and spinal manipulation.” Spine. 2003;28(14)/1490-1502


  • Bronfort G, et al, “Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis.” Spine. 2004;335-356.


  • Hurwitz E, et al. “A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck pain study.” Am Journal of Public Health. 2002;92:1634-1641.


  • Saayman L, Hay C, Abrahamse H. “Chiropractic manipulative therapy and low-level laser therapy in the management of cervical facet dysfunction: a randomized controlled study. Randomized controlled trial” J Manipulative Physiol Ther. 2011 Mar-Apr;34(3):153-63.


  • Snodgrass SJ, Rivett DA, Sterling M, Vicenzino B. “Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. Randomized controlled trial” J Orthop Sports Phys Ther. 2014 Mar;44(3):141-52.


  • Buzzatti L, et al. “Atlanto-axial facet displacement during rotational high-velocity low-amplitude thrust: An in vitro 3D kinematic analysis.” Man Ther. 2015.


Headache/Migraine Efficacy

  • Nelson CF, Bronfort G, Evans R, et al. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for prophylaxis of migraine headache. Journal of Manipulative and Physiological Therapeutics, Oct. 1998;21(8), pp511-19.


  • Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. Journal of Manipulative and Physiological Therapeutics, Feb. 2000:23(2), pp91-5.


  • Brontfort G, et. al. “Efficacy of spinal manipulation for chronic headache: a systematic review.” J Manipulative Physiol Ther. 2001 Sep;24(7):457-66.


  • Duke University Evidence-based Practice Center. Behavioral and physical treatments for tension-type and cervicogenic headache. Des Moines, IA: Foundation for Chiropractic Education and Research;2001.


Stroke Risk

  • Rothwell D, et al.”Chiropractic manipulation and stroke: a population-based case-control study.” Stroke. 2001;32:1054-1060


  • Kosloff TM, et al.”Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropr Man Therap. 2015.Jun 16;23:19.


  • Whedon JM, et al. “Risk of stroke after chiropractic spinal manipulation in medicare B beneficiaries aged 66 to 99 years with neck pain.” J Manipulative Physiol Ther. 2015 Feb;38(2):93-101.


  • Achalandabaso A, et al. “Tissue damage markers after a spinal manipulation in healthy subjects: a preliminary report of a randomized controlled trial.” Dis Markers. 2014.


  • Haneline M, et al.”An analysis of the etiology of cervical artery dissections: 1994-2003.” Journal of Manipulative and Physiological Therapeutics.2005;28:617-622.


  • Haldeman S, et al.”Clinical perceptions of the risk of vertebral artery dissection after cervical manipulation: the effect of referral bias.”Spine.2002;2:334-342.



  • “Risk of Vertebrobasilar Stroke and Chiropractic Care” by Cassidy et. al. and published in the journal Spine (February 2008)




  • “Chiropractic Manipulation & Cervical Artery Dissection” by Michael T. Haneline, DC, MPH, and Gary Lewkovich, DC, and published in JACA (January/February 2007)


  • “Internal Forces Sustained by the Vertebral Artery During Spinal Manipulative Therapy” by Bruce P. Symons, DC, Tim Leonard, and Walter Herzog, PhD, and published in JMPT (October 2002)


The following information was taken from the American Chiropractic Association’s website and can be referenced at this link.

Benefits and Risks of Neck Pain Treatments

Neck pain will affect about 70% of the population at some point in their lives and is a common reason many individuals seek help from a health care professional. A particular episode of neck-related problems can be mildly irritating, or it could be seriously debilitating.

While recent scientific studies have found that there are useful treatments for many neck-related problems, no one treatment has been shown to be effective in all cases. Commonly used physical treatments for neck pain include spinal manipulation, mobilization, massage, and therapeutic exercises. Common pharmaceutical treatments include acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxant medications, and narcotic (opioid) pain medications.

All of the commonly used neck pain treatments carry some risk. Most of these risks are mild, but some can be serious.

To outline the benefits and relative risks of these therapies, the American Chiropractic Association (ACA) has prepared this summary of recent scientific findings. This review includes information from a report of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (1). This international, multi- disciplinary team of researchers examined available research studies to determine the best treatments for neck pain. This summary also includes another recent review of the scientific evidence on the potential harms and efficacy of commonly used therapies for neck pain (2). Additional research that describes the efficacy and risks (serious and non- serious) related to these therapies is also reviewed.

Physical Treatments: Manipulation, Mobilization, Massage and Exercise

Manipulation is a therapy in which a trained professional uses his/her hands to gently and quickly move abnormally stiff joints into their normal functional range of motion. Mobilization technique is similar, but it is usually performed more slowly.

Evidence from numerous clinical studies has shown that both manipulation and mobilization of the cervical spine (the neck) result in short-term improvements in pain and physical function, as well as lasting, long-term pain relief. The report by the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders, referenced above, found 17 studies that looked at various manual therapies. It found overall positive evidence for both mobilization and manipulation, particularly when combined with exercise. This led the authors to include mobilization, manipulation and other manual therapies among the “likely helpful” treatments for simple neck pain.

A variety of minor side effects are commonly reported with all manual treatments for neck pain. These include temporary aggravations in symptoms or mild/moderate soreness following manipulation, mobilization, massage, or therapeutic exercises of the cervical spine.

The relation between manual treatments and serious complications is controversial. Numerous case reports have associated cervical spine manipulation with a rare type of stroke that results from a dissection (tear) of the vertebral artery, a blood vessel in the neck. These dissections are likely due to an underlying abnormality of the vascular system that usually can’t be identified in advance, and are probably not directly caused by the manipulation. Unfortunately, the only early sign of an evolving dissection is neck pain and headache, symptoms that may lead people to seek treatment from a doctor of chiropractic or other professional.

The largest study performed to date looked at the medical records of 11 million people in the Canadian Provence of Ontario over a nine year period and found that patients who went to a doctor of chiropractic for neck pain were no more likely to have a stroke following a chiropractic visit than patients who went to their primary care medical physician for neck pain (3).

That study concluded that any observed association between a stroke and a patient’s visit to either a chiropractic physician or a family medical physician was not directly caused by any treatment performed. Instead, any association was likely due to patients with an evolving vertebral artery dissection seeking care for symptoms such as neck pain or headache that sometimes take place before the stroke occurs.

The likelihood of a person having one of these rare vertebral artery strokes is about 1 to 3 per 100,000 people and is similar among both chiropractic patients and the general population.

Pharmaceutical Treatments: Acetaminophen, NSAIDs, Muscle Relaxant Medications and Narcotics

Simple analgesics such as acetaminophen (paracetamol) are commonly used to treat neck-related conditions. While generally safe at recommended doses, acetaminophen is the largest cause of drug overdoses in the United States because of the narrow range between therapeutic dose and toxic dose (4). Every year in the United States, acetaminophen overdoses are responsible for 56,000 emergency room visits, 2,600 hospitalizations, and 458 deaths due to acute liver failure.

NSAIDs are often used to treat neck-related conditions. Common side-effects include nausea, vomiting, and abdominal pain. NSAID use has been associated with a variety of serious adverse effects including bleeding and ulcers in the stomach and intestine, stroke, kidney failure, life-threatening allergic reactions, and liver failure. One study published in The New England Journal of Medicine (5) estimated that at least 103,000 patients are hospitalized per year in the United States for serious gastrointestinal complications due to NSAID use. These authors also estimated that there are 16,500 NSAID-related deaths annually in the United States, making this the 15th most common cause of death. This figure is similar to the annual number of deaths from AIDS, and is considerably greater than the number of deaths from multiple myeloma, asthma, or cervical cancer.

NSAIDs also can have significant cardiovascular side effects. One recent review (6) found that major vascular complications were increased by about a third in patients taking one of the “new generation” coxib NSAIDs. It also found that ibuprofen significantly increased major coronary events. This study found that among 1,000 patients taking a coxib or diclofenac for a year, one would expect three more major vascular events and one additional fatality, compared with placebo.

Skeletal muscle relaxant drugs including benzodiazepines such as Diazepam (Valium®) are often used for treatment of neck pain. The most commonly reported side effects are drowsiness, fatigue, and muscle weakness. Less common side effects include confusion, depression, vertigo, constipation, blurred vision, and amnesia (7).

The use of narcotic (opioid) pain medications frequently leads to nausea, vomiting, constipation, and dizziness. Both muscle relaxants and narcotic pain medications produce drowsiness that may impair working or driving in about 1 in 3 patients. Muscle relaxants and narcotics are associated with significant risk of abuse, addiction, dependence, withdrawal, seizures, potentially fatal injuries to the liver, and potentially fatal overdoses. Overdoses of opioid painkillers are responsible for some 15,000 deaths per year, more than the number of deaths from cocaine and heroin combined (8).

Comparative Effectiveness of Common Treatments

One review article concluded that there is moderate- to high-quality evidence that patients with some types of chronic neck pain have clinically important short-term and long-term improvements from a course of spinal manipulation or mobilization, but similar benefits were not seen from massage (9).

One recent study (10) compared three groups of neck pain patients who were treated with 1) spinal manipulation, 2) an exercise program, or 3) medications, including NSAIDs, acetaminophen, or (in non-responsive patients) narcotic medications and/or muscle relaxants. This study found that the patients who were treated with either spinal manipulation or the exercise program had significantly greater relief of pain in the short term and in the long term (up to one year after treatment ended).

The Bone and Joint Decade Task Force review (1) concluded that therapies that were “likely helpful” for non- traumatic neck pain included manipulation, mobilization, and exercises. They concluded that there was “not enough evidence to make a determination” about the helpfulness of NSAIDs and other drugs.


The current scientific evidence indicates that all commonly used treatments for neck pain have limited evidence of effectiveness. All treatments come with fairly common but mild side effects, and some have rare but potentially serious side effects. In general, the physical treatments (including manipulation, mobilization, massage and exercise) have fairly good evidence of effectiveness and are very rarely associated with any serious complications. Pharmaceutical treatments, although commonly used, have limited evidence of effectiveness for treatment of neck pain, and infrequent but potentially serious complications.

In conclusion, there is good epidemiological evidence that the odds of having a stroke following a visit to a doctor of chiropractic are no greater than the odds of having a stroke following a visit to a primary care doctor (3). In addition, there is biomechanical evidence that cervical manipulation stretches the vertebral arteries less than routine examination procedures (11), making it unlikely that a cervical manipulation can physically cause an arterial dissection. There is evidence that a manual approach to neck pain including manipulation is at least as effective as a conventional approach using NSAIDs and/or opiates (9) with no greater risk of complications.

Neck pain patients who do not present with signs or symptoms of serious underlying disease should be given the choice of whether to pursue manual treatments, pharmaceutical treatments or a combination of both. Shared decision making should be based on complete and unbiased information, and patient preference should be respected.

Further research is needed to provide high-quality information that can be shared with patients to help them make well-informed health decisions.


1. Guzman J, Haldeman S. et al. Clinical Practice Implications of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: From Concepts and Findings to Recommendations. SPINE 2008; 33(4S): S199–S213. 

2. Dagenais S. Summary review of the scientific evidence on the harms and efficacy of commonly used therapies for neck pain, including manual therapies, therapeutic exercises, and medications,

3. Cassidy et. al., Risk of Vertebrobasilar Stroke and Chiropractic Care, SPINE 2008; 33:(4S): S176–S183.

4. June 29-30, 2009: Joint Meeting of the Drug Safety and Risk Management Advisory Committee with the Anesthetic and Life Support Drugs Advisory Committee and the Nonprescription Drugs Advisory Committee: Meeting Announcement ),

5. Wolfe MM, Lichtenstein DR, Singh G: Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs. NEJM 1999; 340:1888.

6. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013 May 29.

7. Data sheet for VALIUM® brand of diazepam tablets.

8. Jones CM, Mack KA, Paulozzi LJ. Pharmaceutical Overdose Deaths, United States, 2010. JAMA. 2013;309(7):657-659.

10. Bronfort G, Evans R, et al. Spinal Manipulation, Medication, or Home Exercise With Advice for Acute and Subacute Neck Pain: A Randomized Trial. Annals of Internal Medicine 2012; 156 (1): 1-10.

11. Herzog W, et al., Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. Journal of Electromyography and Kinesiology 2012; 22(5): 740–746.

In addition, there is this from the British Medical Journal.

Jeff Williams, DC
Creek Stone Integrative Care
Amarillo Pain & Accident Chiropractic Clinic
3501 W. 45th St.
Suite T
Amarillo, TX