Kinematics of the head and associated vertebral artery length changes during high-velocity, low-amplitude cervical spine manipulation

Background Cervical spine manipulation (CSM) is a frequently used treatment for neck pain. Despite its demonstrated efficacy, concerns regarding CSM safety remain. The purpose of this study was to quantify the angular displacements of the head relative to the sternum and the associated vertebral artery (VA) length changes during the thrust phase of CSM. Methods Bilateral rotation and lateral flexion CSM procedures were delivered from C1 to C7 to three male cadaveric donors. For each CSM the force-time profile was recorded using a thin, flexible pressure pad (100-200Hz), to determine the timing of the thrust. Three dimensional displacements of the head relative to the sternum were recorded using an eight-camera motion analysis system (120-240Hz) and angular displacements of the head relative to the sternum were computed in Matlab. Positive kinematic values indicate flexion, left lateral flexion, and left rotation. Ipsilateral refers to the same side as the clinician's contact and contralateral, the opposite. Length changes of the VA were recorded using eight piezoelectric ultrasound crystals, inserted along the entire vessel. VA length changes were calculated as D=(L1-L0)/L0, where L0= length of the whole VA (sum of segmental lengths) or the V3 segment at CSM thrust onset; L1= whole VA or V3 length at peak force during the CSM thrust. Results VA length changes during the thrust phase were greatest with ipsilateral rotation CSM (producing contralateral head rotation): [mean ± SD (range)] whole artery [1.3 ± 1.0 (-0.4 to 3.3%)]; and V3 segment [2.6 ± 3.6 (-0.4 to 11.6%)]. For ipsilateral rotation CSM, head angular displacements relative to the sternum during the thrust were: flexion/extension [1.2 ± 3.4 (-6.6 to 7.6º)]; rotation [-10.2 ± 3.5 (-16.1 to -3.7º)]; and lateral flexion [8.8 ± 3.0 (2.5 to 14.1º)]. Conclusion Mean head angular displacements and VA length changes were small during CSM thrusts. Of the four different CSM measured, mean VA length changes were largest during rotation procedures. This suggests that if clinicians wish to limit VA length changes, consideration should be given to the type of CSM used.

Vertebral artery dissection in term pregnancy after cervical spine manipulation: a case report and review the literature

Background Vertebral artery dissection is an uncommon, but potentially fatal, vascular event. This case aimed to describe the pathogenesis and clinical presentation of vertebral artery dissection in a term pregnant patient. Moreover, we focused on the differential diagnosis, reviewing the available evidence. Case presentation A 39-year-old Caucasian woman presented at 38 + 4 weeks of gestation with a short-term history of vertigo, nausea, and vomiting. Symptoms appeared a few days after cervical spine manipulation by an osteopathic specialist. Urgent magnetic resonance imaging of the head was obtained and revealed an ischemic lesion of the right posterolateral portion of the brain bulb. A subsequent computed tomography angiographic scan of the head and neck showed a right vertebral artery dissection. Based on the correlation of the neurological manifestations and imaging findings, a diagnosis of vertebral artery dissection was established. The patient started low-dose acetylsalicylic acid and prophylactic enoxaparin following an urgent cesarean section. Conclusion Vertebral artery dissection is a rare but potential cause of neurologic impairments in pregnancy and during the postpartum period. It should be considered in the differential diagnosis for women who present with headache and/or vertigo. Women with a history of migraines, hypertension, or autoimmune disorders in pregnancy are at higher risk, as well as following cervical spine manipulations. Prompt diagnosis and management of vertebral artery dissection are essential to ensure favorable outcomes.

Short-term effects of an upper cervical spine traction-manipulation program in patients with cervicogenic dizziness: A case series study

BACKGROUND: Damage on the somatosensory system could cause sensation of dizziness, a condition known as cervicogenic dizziness (CD). Manual physical therapy has shown beneficial effects, relieving the symptoms of cervicogenic dizziness. However, the effect of upper cervical spine manipulation is unknown, as this is a technique that respects the International Federation of Orthopedic Manipulative Physical Therapists (IFOMPT) safety criteria. OBJECTIVE: To assess the effects of upper cervical spine traction-manipulation in subjects with cervicogenic dizziness. METHODS: This was a descriptive case series study. Treatment focused on the upper cervical spine manipulation procedure. Evaluation was performed before and after the treatment. Variables recorded include upper and lower cervical range of motion, Cervical Flexion-Rotation Test (CFRT), dizziness intensity and cervical pain (VAS), self-perceived dizziness measured with Dizziness Handicap Inventory (DHI) and subjective perception of outcome (GROC-scale). RESULTS: Ten subjects were recruited. After the treatment protocol, there was an increased range of movement towards the most restricted side, as measured by the CFRT (p< 0.001), decreased intensity of dizziness (p< 0.001) and intensity of pain (p< 0.001). Functional capacity also improved after the intervention (p< 0.011). CONCLUSION: Upper cervical spine manipulation may decrease dizziness intensity and cervical pain and improve functional ability and upper cervical spine mobility in patients with cervicogenic dizziness.

A pilot study to determine the consistency of peak forces during cervical spine manipulation utilizing mannequins

Objective Cervical spine manipulation is a complex motor skill used to treat musculoskeletal ailments such as neck pain. There is evidence demonstrating the effectiveness of objective feedback and mannequins for the teaching of spinal manipulation (SM) in the thoracic and lumbar spine. This paper examines the effectiveness of an educational intervention combining both mannequins and force-sensing technology for teaching cervical SM. Methods Fourth-year chiropractic interns were separated into 2 groups: an intervention group and a group trained with the standard curriculum. The intervention included a 60-minute educational session focused on targeting 100 N total peak force cervical manipulations on mannequins, with objective feedback through force-sensing table technology. Pre- and post-CMs were recorded on both a mannequin and a paired student partner, with an attempt to have a target total peak force of 100 N. Results Ninety students were recruited. The invention group (n = 46) scored significantly better at the outcome compared to the control group (n = 44) when manipulating the mannequin (p = .003). These improvements did not carry over when manipulating a paired human partner (p = .067). Conclusion Following a 1-hour cervical SM educational intervention utilizing thrusting on mannequins and force-sensing table technology, students demonstrated improved peak force control for SM delivered on the mannequin. However, this improvement was not carried over to SM delivered on human subjects.

Influence of Cervical Spine Manipulation on Neck Joint Position Sense error in patients with chronic neck pain.

Introduction: Cervical joint dysfunction may interfere with the sensorimotor afferent response, interfering with neck neck Joint Position Sense error (JPS). Objective: The aim of this study was to evaluate the influence of Cervical Spine Manipulation (CSM) on neck JPS error in patients with chronic neck pain. Method: 21 patients with chronic neck pain were divided into 2 groups: Spinal Manipulation Group (MG) or Sham Group (SG) who received 4 sessions of CSM and Sham CSM respectively. JPS was assessed in three different time frames: 1) pre-intervention; 2) Right after the first intervention (post-intervention 1); and 3) After a chronic intervention (post-intervention 2). The outcome measured in this study was the head reposition accuracy test with the Revel’s Test. Results: The JPS showed no significant differences between pre- and post-intervention 1 and 2 for any of the assessed groups. Conclusion: We conclude that, for this sample, neither the CSM nor the Sham CSM statistically changed the JPS error for neither groups. We believe that the changes in JPS after CSM were concealed because the ability of other sensory system information to compensate for inadequacies in any other component. Therefore, more studies have to be done with a stronger methodological rigor, clinical prediction rule for spinal manipulation, bigger sample and a blind assessment.

A rare case of ischaemic stroke following cervical spine manipulation in an adolescent girl

Stroke in children is associated with a multitude of risk factors compared to risk factors of adult stroke such as hypertension, diabetes or atherosclerosis. A 15-year adolescent girl presented with acute onset weakness involving right upper and lower limb. She complained of neck pain and fever 2 days before the onset of hemiparesis for which her parents took her to traditional healer who performed neck manipulation after which she developed vomiting, tingling numbness and weakness of right upper and lower limb. There was no history of preceding headache, ear discharge or any other contributory history. Clinical examination revealed Glasgow Come Scale 12/15, power of grade 2/5 in right upper limb and 3/5 in right lower limb, exaggerated deep reflexes, extensor plantar reflex, right sided ptosis and right sided upper motor neuron facial palsy. CT scan brain showed right cerebellar and occipital infarct with posterior inferior cerebellar artery territory involvement. MRI Brain and MR Angiogram showed wedge shaped infarct involving right posterior inferior cerebellum, inferior vermis, ventral aspect of superior medulla, paracentral pons, right cerebral peduncle, tectum of both halves of midbrain with no internal hemorrhage and no vessel abnormality and right vertebral artery was not visualized. Her coagulation profile and cardiac work up were normal. She was treated with antiplatelet drugs, anticoagulants and physiotherapy following which the child gradually improved over a period of one month. In this case, with a positive history of neck manipulation authors can conclude that the etiology of young stroke wasinduced byneck manipulation. This case has been reported to increase awareness about the ill effects of neck manipulation and counsel parents against performing such procedures for children. Early recognition of pediatric stroke is critical for immediate diagnosis, imaging and treatment with better outcomes.