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Thoracic manipulation and cervical mobilization for neck pain

Neck pain can lead to pain and stiffness which can be very frustrating to deal with. Many people have heard of having a neck manipulation or 'adjustment' to treat neck pain. Many Physiotherapists are reluctant to perform cervical manipulations due to the very small risks involved (I.e. stroke due to vertebral artery dissection) Smith et al 2003. Instead a treatment technique that can be just as effective is recommended known as a cervical mobilization. Cervical mobilizations involve moving the painful/stiff region of the neck without thrusting at end range.

Hurwitz et al 2005 concluded that there is a higher risk of adverse effects from manipulation compared to mobilization of the neck. This study also concluded that the benefits from mobilization are just as effective as manipulation without the adverse effects (Hurwitz et al, 2005)

If you have concerns about the use of spinal manipulation it is best to speak with your respective health practitioner about the risk/benefit of this technique and get informed consent.

Recent research has indicated that manipulating the thoracic spine is an effective treatment for patients with neck pain (Cleland et al, 2005). More importantly, manipulating the thoarcic spine poses no risk to the vertebral artery. This randomized controlled trial investigated the immediate effects of a single thoracic manipulation on pain levels in patients presenting with neck pain. The study demonstrated that a single thoracic manipulation produced significantly greater immediate relief in patients with mechanical neck pain compared to those in the control group. Thoracic manipulations may elicit similar therapeutic benefits as cervical spine manipulation while minimizing the potential risk associated with cervical manipulation.

The same authors of the above study performed an investigation to determine which patients would most likely benefit from a thoracic manipulation. (Cleland et al 2007) The factors that help to identify these patients are known as clinical prediction rules or CPR's.

The 6 key clinical prediction rules are:

1. No symptoms below the shoulder

2. Pain less than 30 days

3.No pain with neck extension

4. Neck extension less than 30 degrees

5. Reduced upper thoracic kyphosis

6. Fear avoidance beliefs questionnaire pain and activity score less than 12

If a patient had 4 out of 6 CPR variables, the probability of success increased to 93%.


Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005 May; 10(2): 127-35.

Cleland JA, Childs JD, Fritz JM, Whitman JM, Eberhart SL. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education Phys Ther. 2007 Jan;87(1):9-23.

Hurwitz E, MorgensternH, Vassilaki M, Chiang LN. Frequency and clinical predictors of adverse reactions to chiropractic care in the ULCA neck pain study. Spine. 2005 Jul; 30 (13): 1477-84.

Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari, Albers GW, Gress DR. Spinal manipulative therapy is an independent risk factor for vetebral artery dissection. Neurology. 2003 May 13; 60(9): 1424-8

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