1. Universidad de Granada, Granada, España.
Study conducted at Universidad de Granada, Granada, Spain.
Correspondence: Calle Mainake, 7. 29670. San Pedro de Alcántara, Málaga, Spain. email@example.com
EFFECTS OF SPINAL MANIPULATION IN PATIENTS WITH
MECHANICAL NECK PAIN
EFEITO DA MANIPULAÇÃO VERTEBRAL EM PACIENTES COM CERVICALGIA MECÂNICA
EFECTOS DE LA MANIPULACIÓN VERTEBRAL EN PACIENTES CON CERVICALGIA MECÁNICA
Original article/artigO Original/artículO Original
Objective: To analyse changes in the range of motion (ROM) and pain after spinal manipulation of the cervical spine and thoracic spine in
subjects with mechanical neck pain. Methods: Spinal manipulations were performed in the cervical and thoracic spine with the Gonstead
and Diversified DTV techniques. To assess cervical ROM an inclinometer was used. Cervical pain was assessed by Visual Analogue
Scale (VAS). The participation of 73 patients was obtained. Ages ranged from 18 to 63 years, with an average of 42.27 years. The sub
jects of this study were characterized by having mechanical neck pain and restricted cervical ROM. Results: We observed a reduction
in the intensity of pain perceived by patients and increased cervical ROM. There were significant differences between pre-treatment
values (first visit) and the fifth and tenth visits (p<0.01), and between the fifth and tenth visits (p<0.01) in all parameters except in the
cervical extension of 70º. Conclusions: The results of this study suggest that spinal manipulation of the cervical and thoracic regions
with the Gonstead and Diversified DTV techniques could subjectively reduce pain and produce considerable increase in cervical ROM
in adults with mechanical neck pain.
Keywords: Neck pain; Range of motion; Chiropractic; Spinal manipulation; Cervical vertebrae.
Objetivo: Analisar as alterações da amplitude de movimento (ADM) e da dor após manipulação da coluna cervical e dorsal, em indivíduos
com cervicalgia mecânica. Métodos: Foram realizadas manipulações na coluna cervical e dorsal com as técnicas Gonstead e Diversificada
DTV. Para avaliar a ADM cervical, utilizou-se o instrumento inclinômetro. A dor na coluna cervical foi avaliada por meio da Escala Visual Ana
lógica (EVA). Obteve-se a participação de 73 pacientes. As idades oscilaram entre 18 e 63 anos, com média de 42,27 anos. Os indivíduos
do estudo foram caracterizados por apresentar cervicalgia mecânica e restrição da ADM cervical. Resultados: Constatou-se redução da
intensidade da dor percebida pelos pacientes e aumento da ADM cervical. Houve diferenças significativas entre os valores pré-tratamento
(primeira consulta) e na quinta e décima consultas (p<0,01) e entre a quinta e décima consultas (p<0,01) em todos os parâmetros, exceto
na extensão cervical de 70º. Conclusão: Os resultados deste estudo sugerem que a manipulação vertebral da coluna cervical e dorsal com
as técnicas Gonstead e Diversificada DTV poderiam ocasionar redução subjetiva da dor e produzir aumento considerável na ADM cervical
em adultos com cervicalgia mecânica.
Descritores: Cervicalgia; Amplitude de movimento articular; Quiroprática; Manipulação da coluna; Vértebras cervicais.
Objetivos: Analizar las alteraciones en la amplitud de movimiento (ADM) y algias tras la manipulación vertebral en la columna cervical
y dorsal, en sujetos con cervicalgia mecánica. Métodos: Fueron realizadas manipulaciones en la columna cervical y dorsal con las
técnicas Gonstead y Diversificada DTV. Para evaluar la ADM cervical se utilizó un inclinómetro. El dolor en la columna cervical, fue
evaluado mediante la Escala Visual Analógica (EVA). Se obtuvo la participación de 73 pacientes. Las edades oscilaron entre los 18 y
los 63 años, con una edad promedio de 42,27 años. Los sujetos de esta investigación se caracterizaron por presentar cervicalgia me
cánica y restricción en la ADM cervical. Resultados: Se observó una reducción en la intensidad del dolor percibida por los pacientes y
un aumento en la ADM cervical, obteniéndose diferencias significativas entre los valores pretratamiento (primera cita) y las citas quinta
y décima (p<0,01), y entre las citas quinta y décima (p<0,01) en todos los parámetros excepto en extensión cervical 70º. Conclusión:
Los resultados de este estudio sugieren que la manipulación vertebral, con las técnicas Gonstead y Diversificada DTV, en la columna
cervical y dorsal, podría provocar una reducción subjetiva del dolor y producir un aumento considerable en la ADM cervical en adultos
con cervicalgia mecánica.
Descriptores: Dolor de cuello; Rango del movimiento articular; Quiropráctica; Manipulación espinal; Vértebras cervicales.
, cruz Miguel cenDán Martínez
Received on 02/21/2014, accepted on 09/05/2014.
Mechanical neck pain, i.e. the presence of acute or chronic
pain in the cervical region, is located in the posterior and postero
lateral parts of the neck, and is sometimes accompanied by remote
referred pain to the upper limb or head, or symptoms of vertigo.
It is believed to be caused by a mechanical dysfunction involving
various anatomical structures of the cervical spine, essentially of
musculoskeletal origin, causing restricted movement and pain. The
majority of cases of neck pain originate in mechanical factors: repeti
tive movements, lack of work breaks, static jobs, and holding the
head and/or arms in the same position for long periods of time.
The precise nature of the cause of mechanical neck pain is not
clear; however, it has been attributed to stimulation of the afferent
nociceptive fibers present in the cervical interapophyseal joints,
intervertebral discs, paravertebral muscles, and other soft tissues.
Recent studies have suggested that the cervical interapophyseal
joints may be the main cause of neck pain.
According to the World Health Organization
50% of adults
experience neck pain during their lifetime. The frequent presence
of neck pain in the general population is estimated at between
10% and 15%, with women being more commonly affected than
men. More than a third of patients who visit the doctor with neck
pain present symptoms lasting more than six months, or recur
Reduction in range of movement (ROM) of the neck is a fre-
quent finding in individuals with mechanical neck pain.
Recent studies have suggested that manipulative techniques
focused on the thoracic region may be effective in the treatment
of neck pain.
However, we have not found any scientific evi-
dence in studies evaluating the effect of vertebral manipulation in
adults with mechanical neck pain using the Gonstead technique
in the cervical spine, and the Diversified Double Transverse (DTV)
technique in the thoracic spine.
The aim of this study was to evaluate changes in range of
movement and pain in the cervical spine following vertebral ma-
nipulation in the cervical and thoracic spine.
The subjects were characterized as presenting mechanical neck
pain, defined as specific pain located centrally or bilaterally on the
back of the neck, mainly in the area between the upper nuchal line
and the tip of the first thoracic spinous process. The participation of
73 patients was obtained: 37 women and 36 men. Ages ranged from
18 to 63 years, with an average age of 42.27 years. The study was
approved by the Institutional Review Board. All the subjects signed
the Informed Consent Form. The exclusion criteria were: failure to
attend all the trial visits, having suffered some trauma during the
study period, individuals diagnosed with fracture, dislocation, joint
hypermobility, rupture of the soft tissues, cancer and surgical history
involving the joints studied, as well as those who began during chi
ropractic treatment, use of analgesics, anti-inflammatories, or other
therapeutic treatment for the complaint in question.
The procedures used in the first visit were: anamnesis, physi
cal examination with orthopedic tests on the cervical spine, tendon
reflexes, sensory and motor evaluation of the upper extremities,
vascular tests, vital signs, assessment of ROM/neck pain and evalu
ation of imaging exams of the cervical spine,
by the same person.
For the evaluation of cervical ROM, a manual inclinometer
(TECSYMP) was used, with a measuring range of 0° to 180°. During
the cervical ROM test, the subjects sat in a chair with a backrest, in
a relaxed position, facing forwards (neutral position 0°). The range of
movement between the neutral position and the maximum angular
displacement of the head was recorded. The subjects were asked
to move their heads in maximum flexion, extension, right and left
lateral flexion, and right and left rotation. Three consecutive move
ments performed in each direction, taking the mean value as the
final measurement. The procedure was repeated on the first, fifth
and tenth visits.
The evaluation of pain was carried out using a visual analogue
scale (VAS) of pain, and was performed on the 1
The treatment was based on correcting the segments that presented
highest fixation or limitation of movement in the cervical and thoracic
spines, detected by static and dynamic palpation.
The Gonstead technique (Figure 1) chosen for correction of the
segments with higher fixation or limitation of motion of the cervical
spine was the Cervical Chair (CC) technique. The technique was
performed with the patient sitting in a chair with a backrest, in a
relaxed position, with arms and legs extended and facing forwards.
The chiropractor was positioned behind the patient, favoring
the side of the rotation of the spinous process (right or left) of the
vertebra to be manipulated, with the right leg (in rotations of the spi
nous process to the right) or left (in rotations to the left) backwards.
The contact hand was on the spinous process to the left (rota
tions to the left) or right. The focal point was the right or left edge of
the second finger of the right or left hand. The exact point was the
left (or right) inferior posterior view of the spinous process posterior
inferior view. The third finger of the opposite hand (right or left)
stabilized the opposite transverse apophysis of the segment below
the one being manipulated. A gentle inclination to the left (or right)
was performed until slight tension was achieved, and an impulse
was applied, without rotation of the cervical spine, with a movement
from posterior to anterior, inferior to superior, right to the left (in the
case of rotation of the spinous apophysis to the right) and inwards.
The impulse was high velocity and low amplitude.
DTV Diversified technique
The Diversified technique (Figure 2) chosen for correction of
the segments with higher fixation or limitation of movement in the
thoracic spine was the Double Transverse technique (DTV). The
technique was performed with the patient in the prone position,
with chiropractor next to the rotation of the vertebral body of the
segment to be manipulated. The pisiform of the chiropractor’s lower
hand was in contact with the transverse apophysis of the side of the
rotation of the vertebral body, and the upper hand was in contact
with the spinous apophysis on the opposite side, i.e. on the side
of the rotation of the spinous apophysis. The upper hand stabilized
the segment to be set, and the lower hand corrected it through an
impulse. The direction of the impulse was posterior to anterior, and
inferior to superior.
The impulse was set and held for two to three seconds, and was
performed with high speed and low amplitude.
Data recompilation plan
Data were collected in a private chiropractic center. Chiropractic
adjustments were performed by the investigator of this study, which
has a degree in chiropractic medicine. The chiropractic intervention
was therefore standardized for all the patients.
Figure 1. Gonstead CC Technique.
The values and points/bars represented in the graphs show the
mean ± SEM (standard error of the mean) of the scores obtained
in each of the parameters evaluated on the different visits. Statistical
comparisons were performed using one-way ANOVA for repeated
measurements, followed by the Bonferroni test using the statistical
program Prism 5.0. Data with alpha error below 5% were considered
significant (p < 0.05) and those with an alpha error of less than 1%
(p < 0.01 ) were considered very significant.
Regarding the effects of cervical ROM in flexion, the aver-
ages for the pre-and post-intervention groups were 50.07 and
59.38 degrees, respectively (Figure 3). A significant improvement
(p < 0.01) was obtained, which was dependent on the number of
sessions (Figure 3). Figure 4 shows that the averages for the pre-
and post-intervention groups, in the cervical extension, were 64.59
and 69.86 degrees, while on the 5
visit, maximum improvement
was almost achieved (p < 0.01).
Regarding cervical ROM in right and left later flexion (Figure 5)
and right and left rotation (Figure 6), clear statistical significance
(p < 0.01) was observed in both cases, between the initial values
and the intermediate and final values, with ROM increasing to normal
values (Figures 5 and 6).
Spinal manipulation produced a significant reduction in scores
on the first visit and subsequent visits (Figure 7). Thus, the mean pre
-treatment average for the neck pain was 6.33, with a reduction of al-
most half after five adjustments in the cervical spine, which was further
reduced after ten visits (1.55) (Figure 7). It should be emphasized that
there were significant differences not only between 1
visits (p < 0.01), but differences were also obtained in the scores on
visits (p < 0.01), indicating that the higher the number
of manipulations, the greater the decrease in pain (Figure 7).
The results of the study showed an increase in cervical mobility,
and a subjective reduction in pain after spinal manipulation through
the Gonstead and Diversified DTV techniques in the cervical and
thoracic spine, in adult patients with mechanical neck pain.
Figure 2. DTV Diversified Technique.
Figure 4. Range of movement of cervical extension. Statistically significant
differences between the 1st visit and the remaining visits (p <0.01).
Range of movement
Figure 3. Range of movement of cervical flexion. Statistically significant
differences between the 1st visit and the remaining visits; and between the
visits (p <0.01).
Range of movement
EFFECTS OF SPINAL MANIPULATION IN PATIENTS WITH MECHANICAL NECK PAIN
Numerous studies have shown that patients with mechanical
neck pain have reduced ROM.
The scores considered
ideal, through the test performed with the inclinometer, for each
movement of the cervical spine in healthy adults, are 60 in cervical
flexion, 70 in extension, 45 in lateral flexion, and 80 in rotation.
The test to assess cervical ROM may be a useful tool for describing
the disability of patients with dysfunction in joints of the cervical
spine, and serves as a basis for evaluating the effectiveness of a
The results of this study demonstrated
that the vertebral manipulations in the cervical and thoracic spine
caused a return to cervical ROM at values very close to those con
The cervical spine is a region where stability is sacrificed in favor
of mobility, so this segment, in particular, is more susceptible to
The mechanical stability of the cervical spine comes from
the osteoligamentous and muscular system. Thus, 20% of the stabi
lization is provided by the osteoligamentous system, acting near the
end of range of movement, while the remaining 80% comes from the
deep muscles of the cervical spine, acting between the beginning
and middle of the range of movement, which is commonly adopted
during the tasks of daily living
Giles and Muller,
in a randomized clinical trial, compared the
effectiveness of spinal manipulation, medications and acupuncture
in patients with cervical and lumbar pain. They concluded that if
there are no contraindications, the manipulation generates a greater
reduction in pain and a greater increase in joint mobility.
Cassidy et al.,
compared spinal manipulation and mobilization.
Figure 7. Intensity of cervical pain in the 1
through a VAS. Significant differences between the 1st visit and the remaining
visits; and between the 5
visits (p <0.01).
Intensity of Pain (0 to 10)
Figure 5. Range of movement of cervical bilateral lateral flexion. Statistically
significant differences between the 1st visit and the remaining visits; and
between the 5
visits (p <0.01).
Range of movement
Figure 6. Range of movement of bilateral cervical rotation. Statistically sig-
nificant differences between the 1st visit and the remaining visits; and the
5th and 10th visits (p <0.01).
Range of movement
They showed that spinal manipulation was more effective than mobili-
zation in reducing pain in patients with mechanical neck pain, but that
both treatments increased the range of cervical movement in similar
form. However, Martínez et al.,
in their research, reported that spinal
manipulation led to an increase in ROM and a greater reduction in
pain, compared with cervical mobilization. Therefore, they concluded
that spinal manipulation was more effective than mobilization.
On the other hand, Hurwitz et al.
suggest that the mobility of
the cervical spine is as effective as manipulation in reducing cervical
noted that in patients with subacute and chronic neck
pain, a better result was obtained, in terms of recovery, in the manual
therapy group (manipulation and/or mobilization) than for physical
therapy or general practitioner (analgesics, education and advice)
at seven weeks of treatment, but not at the end of one year. Hoving
suggest that after treatment with manual therapy, there was
an acceleration in recovery in the short term. General medical treat
ment and physical therapy achieved better long-term outcomes;
however, the differences between the three treatment groups at
12 months of follow-up were small, and not statistically signifi
cant. In addition, Pikula
found a greater reduction in pain and
increased cervical ROM with cervical manipulation, compared with
a placebo group.
Vernon et al.,
also conducted a study comparing spinal manipu-
lation and the placebo effect. Patients with chronic mechanical neck
pain were evaluated for pain threshold to pressure on sensitive points
in the paravertebral zone surrounding a manipulable spinal cord
injury. In the group that received spinal manipulation, there was a sig
nificant change in pain thresholds to pressure. In the placebo group,
no change was found in any of the pain thresholds to pressure.
This study confirms that manipulation can increase local paraspinal
levels of pain threshold. Using a pressure pain threshold gauge, it
was possible to determine this beneficial effect on the deep tissues.
found greater pain reduction and
increased cervical ROM in patients with mechanical neck pain after
vertebral manipulation, in a comparison of ultrasounds. The results
indicated that spinal adjustments were more effective
On the clinical efficacy of chiropractic treatment, the most recent
report, conducted jointly by Mercer Health and Benefits (the world’s
biggest health economy consultant) and Harvard University was
published in 2009, reviewing studies from both the EU and the USA.
Almost half of Americans with spinal pain visit a chiropractor, and
the costs of this disability are as high as $85,000 million. Countless
studies and reviews throughout the world demonstrate that this is
the main cause of absenteeism and the most costly in economic
The Mercer report concludes that chiropractic medicine
is more effective than other treatments for back pain, and the most
effective treatment for neck pain, showing a high cost-effectiveness
benefits in the treatment of both disorders.
The results published to date in relation to cervical spinal dis
recommend chiropractic treatment for neck pain,
headache of cervical origin, and whiplash syndrome. Despite clinical
evidence of the benefits and apparent widespread use of spinal
manipulation, the neurophysiological mechanisms underlying its
effects are not entirely clear, but this does not negate the clinical
effects of spinal manipulation.
According to Ortega Santiago et al.,
neck pain is associated
with mechanical instability, and can be caused by an increase in
nociceptive discharge of the afferent fibers in the vertebral zyg-
apophyseal joints, intervertebral discs, paraspinal muscles, and
Fernández de Las Peñas et al.,
explain that spinal
manipulation can affect the mobility of a hypomobile segment, and
produces increased range of movement. Haavik and Murphy
that the effectiveness of spinal manipulation is due to the fact that
manipulation can increase the range of movement of the joints,
increasing the activity of the proprioceptive fibers and thereby reduc
ing the transmission of pain stimuli, also relieving chronic tension
and spinal nerve irritation caused by joint dysfunction; it relaxes the
muscles due to stretching of the joint capsules, which stimulates
mechanoreceptors, decreasing muscle soreness. In addition, joint
adhesions can be reduced in chronic cases, increasing the pain
threshold in the skin and the pain threshold to pressure in the para
believe the biomechanical changes
caused by spinal manipulation have physiological consequences,
through their effects on the influence of sensory information to the
central nervous system. The afferences to the muscle spindles, and
the afferences to the Golgi tendon organs are stimulated by spinal
manipulation. Sensory nerve fibers of smaller diameter are likely to
become active, although this has not been directly demonstrated.
hypothesized that the reasons underlying the biomechanical
changes in the spine affect the afferent neurons, with a subsequent
change in central processing, and affecting the somatomotor effe
rences and the somatovisceral reflexes.
Spinal manipulation triggers changes in the musculoskeletal
system. Experimental tests indicate that the charge of the impulse of
a spinal manipulation influences the proprioceptive primary afferent
neurons in the paraspinal tissues.
addition, the manipulation can
affect the processing of pain, possibly by altering the central facili
tated state of the spinal cord, and can affect motor control system.
It is likely that more than one mechanism explains the neurophysi-
ological mechanisms of vertebral manipulation.
The subjects of this study had mechanical neck pain and
limited cervical ROM in at least one cervical movement. The re
sults of this study suggest that vertebral manipulation, using the
Gonstead and Diversified DTV techniques, in the cervical and
thoracic spine, could cause a subjective reduction in pain and
produce a considerable increase in cervical ROM in adults with
mechanical neck pain.
Despite the promising results, the limitations of this study
should be emphasized. The population included, has been re
cruited in a single chiropractic center, which could limit the ex-
trapolation of the results, as the subjects may have specific clinical
and demographic characteristics. Other studies with compari
son groups and wider samples, outlining specific methodologies
through the elimination of variables, are necessary to corroborate
the results of this study, before any relationship of cause and ef
fect can be determined.
All authors declare no potential conflict of interest concerning
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