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.


  1. Dr. Ball, what are your thoughts on the techniques being utilized in these chiropractic, end-range manipulative techniques? How do you feel these techniques compare to mid-range osteopathic HVLA, and is there any research you are aware of investigating these techniques? Thanks!

  2. I am not aware of any study the examines the effectiveness or safety of chiropractic versus osteopathic techniques, but that's an interesting question. Don't hold your breath though. In the United States, that would be a difficult study to do secondary to a paucity of dual-trained practitioners without serious and significant bias in one direction or another (either by profession or certification). I could see somewhere like Brazil being a better proving ground for that question because chiropractic (and I believe also osteopathic) is actually an advanced degree/certification earned ONLY AFTER completion of physical therapist studies. (I'm looking at you, University of San Paulo . . .).

    If you're asking for my personal opinion however, although I understand what is meant by "mid-range" manipulation, I think it's clever word play that allows some PT's to skirt the chiropractic legal term "paraphysiological range (which lacks a clear and universally agreed upon objective clinical definition). In all manipulative techniques, a barrier is reached and breached. In combined leverage techniques the approach to the barrier is approached by sequential loading in three dimensions with one of three leavers is much more dominant manner. This is versus osteopathic techniques where the barrier is approached and loaded with more (arguably "balanced) tri-planar finesse. Regardless, some type of resistance is reached by the sum total of loading.

    If your clinical philosophy is to improve alignment at a particular segment, you're probably likely to want to use more combined leverage techniques, versus a clinical philosophy focused upon joint movement and non-biomechanic effect where specificity of target may be philosophically more important. Personally, although I spent a year in a residency program biased toward target and vector-specific techniques (and I do use them in clinic), I find osteopathic-style and high-impulse-thrust techniques more comfortable to administer and receive, but that's just me. My wife (a Maitland trained COMT) would argue that the osteopathic and high-impulse techniques I prefer are sloppy of specificity, and I would argue that her Maitland techniques and NAIOMT techniques I mastered in residency are sometimes unnecessarily uncomfortable for the patient . . . we're probably both right.

    You may however be missing the point of my blog post however, the only reported case of a patient with a PT correlated TIA occurred with LOWER CERVICAL MOBILIZATION, not manipulation of either chiropractic or osteopathic style. I doubt the outcome would have been different with chiropractic versus osteopathic style manipulation in that case . . . but I WONDER if a technique delivered in a matter of milliseconds would have been less likely to have resulted in the iatrogenic thrombus liberation injury that several minutes of mobilization did.

    Andrew M. Ball, PT, DPT, PhD, OCS, CMTPT

  3. Dr. Andrew Ball, PT, DPT, PhDAugust 24, 2013 at 10:36 PM

    A few grammatical errors make that post hard to follow, but I hope you get the point.

  4. Great points Drew, I have a few things to add. I've often stated on my blog and in my courses that every manipulative profession thinks they are the most specific, safest practitioners and the others are hacks. The truth is osteopathic "mid-range" which technically I was trained in by Dr. Laurie Hartman, and chiropractic paraphysiologic range, and any other technique using planes to take up "slack" are one in the same. Very few professions do Cyriax style high velocity long lever manips these days. It's all just semantics and ways to elevate your profession above the others.