Guest Post! Lonely At The Top: Musings on Upper Cervical Manipulation | Modern Manual Therapy Blog

Guest Post! Lonely At The Top: Musings on Upper Cervical Manipulation

I should start out by disclosing that I live and work in North Carolina, which requires a specific physician order to administer any type of thrust manipulation to the spine (but not extremity joints).

Thrust manipulation, including upper cervical manipulation, was once a much larger part of my practice than it is at present.  Since becoming certified by Myopain Seminars in myofasical trigger point dry needling (CMTPT), I find that the logistics of practice in North Carolina are such that it is far more efficient to begin with muscular trigger point dry needling (peri-neural techniques are not permitted in North Carolina) and then to provide thrust manipulation in later sessions, if still needed (which in my experience, it usually isn’t).

Nevertheless, I am often asked my thoughts on upper cervical manipulation.  I’m not against it, but with so many new-graduates being trained in advanced manual therapy techniques (both thrust and non-thrust), and a growing number of entertaining and theatrical continuing education providers teaching thrust manipulation, I’m not entirely sure if sufficient respect is paid to the risks (albeit small) of ANY manual therapy technique to the cervical spine.  Upper cervical manipulation may pose unique risk, but it can be argued that lower cervical mobilization poses unique (and no less devastating) risk as well.  My short answer when asked by students, residents, co-faculty, and colleagues alike is:

“If you make the decision that it would not be safe to manipulate the patient, you really shouldn’t mobilize them either.”

This is wisdom that perhaps runs counter-current to the culture of your clinic, your orthopaedics professor, or the guru who taught your most recent course in thrust manipulation.  Allow me to explain . . .

It has been hypothesized by some on the continuing education circuit that manual therapy to the lower cervical spine may actually be more dangerous than upper cervical manipulation because atherosclerotic plaque and calcification generally builds in the lower cervical spine.  The message received by most therapists coming out of these courses seems to be “You’re not worried about lower cervical mobilization which is potentially just as (if not more) dangerous, so reset your barometer regarding upper cervical manipulation and don’t be so concerned about either.”  In my view, this is precisely the wrong message.  Too many therapists don’t have sufficient respect for manipulation and mobilization risks in the LOWER cervical spine.  The message, again in my opinion, shouldn’t be “Don’t worry so much about upper cervical manipulation,” but rather, “Let’s worry a bit more about lower cervical mobilization and manipulation.” 

A recent case report in the Journal of Neuroimaging described a 63 year old male who underwent cervical spinal manipulation and developed sudden left-arm numbness and weakness that was not related to the principal concern of critics of cervical manipulation (upper cervical in particular) … iatrogenic dissection of the cervciocranial vessels.  In this case, the patient’s symptoms resulted from an etiology not previously reported in the literature . . . cerebral embolus emanating from an extensively calcified internal carotid artery.  (Dandamundi, et al.  2013).  Non-thrust manipulation is generally considered by physical therapists to be a safer technique than thrust manipulation, but a 2010 article by Sweeny and Doody brings this assumption into question.  The authors surveyed members of the Irish chartered association of manipulative therapy finding that 100% used non-thrust techniques, 27% used high-velocity low-amplitude thrust (HVLAT) techniques, and 9% used thrust techniques on upper cervical segments.  Over the course of 2 years, 20% reported an adverse event associated with non-thrust manipulation (compared to 4% of therapists using HVLAT).  The most serious of these adverse events was associated with a lower-cervical non-thrust technique.  It is, to my knowledge, the only reported case of a transient ischemic attack associated with physical therapy manual therapy of any kind.  Again, this was associated with a non-thrust technique of the lower cervical spine, not HVLAT.  Given this information, I suggest that we should as profession pay at least as much attention to the possible risks of lower cervical manual therapy (considering also that 5 minutes of non-thrust may be more likely to liberate an internal carotid plaque embolus), as we do to HVLAT of the upper or lower spine completed in less than a quarter of a second (Devocht JW, et al. 2013).

I realize that my response up to this point somewhat side-steps the question of upper cervical manipulation specifically, so allow me answer from another perspective . . . 

Clinicians that teach manipulation on the continuing education circuit (and therefore have a biased interest in which evidence to present to course attendees and which to omit) generally put the risk of stroke following neck manipulation at between one in a million to 1 in 3 million, with this “evidence-based” statistic being parroted by followers in a cult-like fashion that lacks any resemblance to true evidence-based clinical decision making.  What is not discussed in these “evidence-based” courses is that these numbers are generally based upon the flawed method of examining insurance and legal claims.  In smaller countries with socialized medicine systems, where it is actually possible to track the number of treatments against injuries, the numbers look much more alarming --- ranging from 1 in 120,000 to 1 in 20,000.  (Bendetti 2003, Olafsdottir 2001, Grod 2001). 

Ultimately it comes down to evidence-based clinical decision making, based upon the best available evidence (not evidence provided with financial bias), the clinical experience of the clinician, and the informed risk/benefit calculation of both practitioner and patient.  There are some very skilled clinicians teaching some great upper cervical techniques out there, (I’d like to think myself among them).  My concern is that decisions to use manual therapy techniques, upper cervical or lower cervical, thrust or non-thrust, are sometimes not taught with accurate statistics for which the clinician and patient to make an accurate and informed decision regarding risk/benefit.  Worse yet, some clinicians are unaware of their flawed calculation and as such are instead seduced by use of a flashy technique that, when it works, results in rapid patient relief.

I use thrust manipulation techniques on the upper and lower cervical spine, and I’ve in fact developed several of my own twists and takes on these techniques, but with so many advanced manual therapy techniques (including instrument assisted manual therapy with an Edge tool or dry needle) that offer similar outcome with potentially decreased risk than the REAL adverse event numbers associated with upper cervical manipulation, my action threshold for upper cervical manipulation (and mobilization) has risen over the past few years.  Yes, I still use upper cervical manipulation, but for me, it’s getting lonelier and lonelier at the top. 

Contributed by Dr. Andrew Ball  PT, DPT, Ph.D, OCS, CMTPT


What do you think? I initially asked for a counterpoint to my teaching, since I also do not do ANY upper cervical thrust manipulation, and also mainly use only downglide translation to mid and lower. I was not aware of any studies showing adverse events to mobilization either, so that was interesting. I do not mobilize or manipulate more than 1-2 times a month these days in lieu of MDT, MWM, and other easier to perform techniques.


Benedetti P, MacPhail W.  Spin Doctors: The chiropractic industry under examination.  The Dundurn Group: Toronto. 2003.

Dandamudi VS, Thaler DE, Malek AM.  (2013)  Cerebral embolis following chiropractic manipulation in a patient with a calcified carotid artery.  Journal of Neuroimaging, 23:429-430.

Devocht JW, et al (2013)  Force-time profile difference in the delivery of simulated toggle-recoil spinal manipulation by students, instructors, and field doctors of chiropractic.  JMMT.  36(6):342-8.

Grod J, et al.  (2001)  Unsubstantiated claims in patient brocures from the larges state, provincial, and national chiropractic and research agencies.  JMMPT. 24, 8.  517.

Olafsdottir, et al. (2001)  Randomized control trial of infantile colic treated with chiropractic spinal manipulation.  Archies of Diseases in Childhood.  84.  138-141

SweeneyA, Doody C. (2010)  Manual therapy for the cervical spine and reported advrse effects: a survey of Irish manipulative physiotherapists.  Manual Therapy.  15(1):32-36.

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