Manipulation and Mobilization of the Cervical Spine: The Results of a Literature Survey and Consensus Panel

Objectives

To review the scientific evidence for both manipulation and mobilization therapies for the cervical spine. This report presents the results from a review of the medical, chiropractic, osteopathic, physical therapy, and dental literature on the efficacy, complications, and indications for manipulation and mobilization of the cervical spine, and the appropriateness ratings of indications for manipulation and mobilization.

Methods

114Articles were identified through searches of computerized databases [MEDLINE [Index Medicus], CHIROLARS [Chiropractic Literature Analyses and Retrieval System] etc.], review of article's bibliographies, and advice from experts. This yielded 362 primary articles on cervical spine manual therapy and 145 articles on complications. Priority was given to research that used randomized, controlled trial [RCT] designs. Second priority was given to non-experimental studies including cohort, case-control, and cross sectional studies. Case series and case reports were given lowest priority. This process produced 108 studies [16 RCTs; 13 cohort; 27 case series; 52 case reports]. A panel of nine experts were provided with the literature review and were then used to complete two rounds of ratings for appropriateness of indications for manipulation and mobilization. The panel was multidisciplinary in composition.

Results

Literature Review. The review provided 67 articles on efficacy; 14 RCTs. For acute neck pain there were three RCTs for mobilization but only one for manipulation. Results varied but mobilization is probably better than collar and rest, but exercises are equally effective and the one trial of manipulation showed an immediate improvement that was not sustained at one week. For subacute and chronic neck pain there was one RCT for mobilization and four for manipulation. Results show short-term pain relief and motion enhancement. A small but significantly significant outcome was shown for manipulation compared to physiotherapy. For headache there were five RCTs, 10 case series, 19 case reports of manipulation, and one RCT for mobilization. For muscle tension headaches the data support but do not prove that manipulation and/or mobilization may provide short-term relief for some patients. Evidence for long-term benefit is less conclusive. For migraine, one RCT and five other studies for manipulation were reviewed. The literature neither supports nor refutes manipulation/mobilization for migraine. For shoulder/arm/hand pain; thoracic outlet syndrome, carpel tunnel, temporomandibular joint [TMJ] disorders; blood pressure and heart rate, cervical spine/intersegmental motion cervical spine curvature, miscellaneous conditions, there is insufficient evidence to refute or support either manipulation or mobilization. Articles document 110 cases of complications published in English relating to manipulation. The vast majority involved vertebrobasilar accidents [VBA]. Based on the available evidence we estimate the rate of complications to be 1 per million manipulations.

Panel Ratings. The panel rated 1,436 indicaiions [clinical scenarios of patients who might be considered for cervical manipulation or mobilization] in the final round, with disagreement on 2% of the indications. They rated 43% as inappropriate for manipulation or mobilization. Appropriate and uncertain indications accounted for 11516% and 41%, respectively. The frequency with which indications occur in a population is unknown and therefore the rate of inappropriate manipulation/mobilization being rendered to patients cannot be determined at this time. [Article copies available from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@ha-worth.com ]