Cervical Manipulation Information Sheet

A Guide for Canadian Manipulative Physiotherapists When Communicating

Risks, Benefits and Procedures of High-Velocity, Low Amplitude (HVLA) Cervical
Manipulation to Patients.

This information sheet outlines the benefits, risks and procedures of a cervical manipulation that should be communicated to
patients by manipulative physiotherapists to fulfill the requirements of informed consent. The content was generated by (1)
a review of all levels of evidence pertaining to cervical manipulation and (2) a consensus exercise with a panel of Canadian
experts in the field of manipulative physiotherapy (including legal and licensing experts). The sheet has been formatted into
a clinician section, and a patient section.

INFORMATION FOR CLINICIANS

This document is intended to help the clinicians to fulfill the ‘verbal information’ criteria by providing a tool on
which to base a shared discussion with the patient. This document should not be provided to the patient as
‘written information.’ In addition, it is recommended that due to the possibility, albeit low, of severe outcomes
with HVLA cervical manipulation, those practitioners utilizing the technique are able to confirm appropriate
training. Currently this would include the Canadian Physiotherapy Association’s Orthopaedic division level 4
or 5 courses, a Diploma in manual and manipulative physiotherapy, a Master’s in manipulative physiotherapy
from a Canadian university or the equivalent from another country.

Consideration of Canadian Law

Obtaining informed consent is mandatory. It is strongly recommended that both verbal and written information be provided to the patient
and that he/she be allowed time to weigh the benefits and risks. Note that according to Canadian Law the risks of stroke and death must be
communicated as they are considered to be material to each patient. Material risk is defined as risk information that will influence a person’s
consent to treatment and these risks carry grave consequences should they materialize (Rosovsky, 1997)1. It should be noted that material risk
can vary from person to person depending on what is “material” to each patient, eg. loss of finger function would be a material risk to a pianist
but may not be assessed at the same level for another person. Physiotherapists are required to know and adhere to the legislation governing
their practice in the province in which they practice.

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What is the Effectiveness of a Cervical Manipulation?
• There is evidence in the scientific literature that HVLA cervical manipulation/mobilization combined with exercises has
beneficial effects on reducing pain, improving function and achieving patient satisfaction when compared to a control2.
However it is recognized that there will be variations in individual responses to HVLA manipulation.
• There are studies predicting who is likely to be immediate responders to cervical manipulation3-5. The results are too
extensive to be listed here. Please see the references provided. Note that the Tseng study was conducted using
physiotherapists, while the others used chiropractic care.

Risk Information
The precise risk to each person is difficult to determine. Currently, the best estimates of risk of stroke related to
HVLA cervical manipulation are generated by three case control studies and are as follows:
• From Rothwell et al, 20016, cases of stroke less than 45 yrs of age are 5x more likely to 1.) have had a chiropractic visit within 1
week of their stroke OR7 (95% CI)8 = 5.03 (1.32-43.87), p=0.006 and 2.) to have had > 3 visits to a chiropractor with a cervical
diagnosis in the month before their stroke, OR (95%CI)= 4.98 (1.34-18.57), p=0.017.
• From Smith et al, 20039 controlled for neck pain, cases of stroke were 6x more likely to have had a chiropractic manipulation
within 30 days of their stroke OR (95%CI)=6.60 (1.40-30.00), p=0.015.
• From Cassidy et al, 200810 cases of stroke less than 45 yrs of age, 1.) 5x more likely to have had a chiropractic visit with a
cervical diagnosis within 3 days of their stroke. OR (95%CI = 5.0 (1.38-18.6) and 2.) 3x more likely to have had a chiropractic
visit with a cervical diagnosis within 30 days of their stroke. OR (95%CI) = 3.27 (1.16-8.35)
Clinicians should note these studies are on chiropractic techniques. There are no studies which show HVLA manipulation,
performed by a physiotherapist to be an independent variable to stroke/death nor are there studies demonstrating that differences in
the manipulation technique exist between practitioners. At the time of writing, there is no clear scientific evidence to indicate that
neck manipulation causes any of the adverse events listed, due to limitations of the research studies to provide proof. However it is
important to acknowledge that there are many case reports of stroke or death linked temporally to a manipulation.

• People differ in their anatomy and pathology. While these differences are normal, they may or may not increase the risk of
injury and they may or may not be detected by our screening tests.
• Canadian Manipulative Physiotherapists minimize or eliminate rotation in their manipulative technique. (minimize =
wherever possible)
• Two studies have identified predictors of adverse events in people receiving HVLA manipulation11, 12. Please see references.
Both were on chiropractic populations.

Information for Health Care Professionals

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What is the Recommended Cervical Manipulation Protocol?
The following is an overview of the recommended screening, treatment and follow-up to a cervical manipulation.

Screening
• Take a thorough history and physical exam to determine that a HVLA manipulation is an appropriate and optimal choice of
treatment. This includes testing to the best of our ability the integrity of the blood flow to the spinal cord and brain, and stability
of the joints in question
• Ask specific questions to ensure there are no contraindications to HVLA cervical manipulation
• Obtain informed consent for the HVLA manipulation ideally both verbally and in writing. Informed consent should be framed in
the context of patient rights and patient empowerment13. Inform the patient that they can withdraw consent at any time for any
reason
• Confirm verbal consent in the pre-manipulative treatment position and if provided, proceed with treatment
• Provide an opportunity for the patient to ask all questions and answer them to the patient’s satisfaction

Treatment
• Position the patient in a pre-manipulative treatment position and confirm that it is comfortable and pain free
• A movement of high velocity and small amplitude will be applied to the vertebrae beyond its physiological ROM but within its
anatomical limits to produce a separation or sliding of the joint surfaces
• It should be comfortable and pain free, although occasionally there is some discomfort. The treatment will not be done if the
patient cannot relax

Follow-up Care
• Immediately after the treatment, reevaluate the patient to determine the effectiveness of the treatment (to determine whether a
beneficial neuromusculoskeletal response has occurred) and to screen for the development of any new symptoms
• Prescribe exercises to maintain movement and retrain muscle in the area, including information regarding proper postural
alignment and ergonomics as appropriate
• Advise the patient to seek emergency medical attention should any ‘adverse symptoms’1 develop and to inform the therapist if this
occurs
• Manage any post treatment soreness with the application of ice or heat locally to the area
• Follow-up with the patient by phone or in person, within a variable time frame of one to several days

1Seethe ‘What are the Risks of a Cervical Manipulation’ section under the ‘Information for Patients’ for a list of possible
adverse symptoms.

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© Guelph, Ontario 2008
INFORMATION FOR PATIENTS
The following information is provided to assist physiotherapists in the provision of patient education. This is
NOT to be given to the patient as an information pamphlet.

What is a Cervical Manipulation?

• A movement of high velocity and small amplitude applied to the vertebra beyond its physiological ROM but within its
anatomical limits to produce a separation or sliding of the joint surfaces
• Research indicates that cervical manipulation creates a neurophysiological effect, leading to beneficial changes in nerve and
muscle function
• Although not supported by research, clinicians have observed that cervical manipulation creates a mechanical effect, thought
to lengthen tissue due to the ‘creep’ phenomenon, thereby improving joint mobility. Eg. Stretch of joint capsule

Who Can Perform a Cervical Manipulation?

• Cervical manipulation is within the scope of practice of Canadian Physiotherapists. In a number of provinces, spinal
manipulation is considered a ‘Restricted1’, Reserved2, or ‘Controlled3 Act’ and its practice is subject to specific regulatory
standards. As members of a self-regulating profession, only physiotherapists with appropriate training and skill should
include it in their practice

Who is a Candidate for a Cervical Manipulation?

Patients who
• Have achieved a maximum effect from other treatment techniques or there is no further change e.g. graded mobilizations
• Have decreased movement in a joint that is very stiff or stuck
• Have muscle spasm that limits muscle function
• Require relief of mechanical stress to their joints, nerves and surrounding tissues
• Have pain that limits or restricts function in daily activities
• Have collaborated with their physiotherapist in setting the treatment goals that include a cervical manipulation, given their
informed consent, and understand their right to withdraw consent at any time9
1 Under the Alberta Health Professions Act, spinal manipulation is a Restricted Activity. This means only health professionals with the necessary

competence may perform spinal manipulation.

1 The Health Professions Council in British Columbia defines a Reserved Act as: "tasks and services involving significant risk of harm". These acts

may only be performed by professions to whom they are, on a non-exclusive basis, assigned, and so long as those performing them are acting within
the scope of practice of their profession.
1 Under the Ontario Regulated Health Professions Act, Controlled Acts are the procedures carried out by health professionals that can potentially

cause harm to patients. Spinal manipulation is one of 13 controlled acts.

Information for Health Care Professionals

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What is the Effectiveness of a Cervical Manipulation?
• There is evidence in the scientific literature that cervical manipulation/mobilization combined with exercise has beneficial
effects on reducing pain, improving function and achieving patient satisfaction when compared to a control6. However it is
recognized that there will be variations in individual responses to manipulation

What are the Benefits of a Cervical Manipulation?

Benefits of a neck manipulation may include one or more of the following:
• Increased joint mobility
• Alleviation of muscle spasm
• Decreased symptoms such as pain, headache, dizziness, numbness and pain
• Decreased stress on spinal joints above and below the problem restricted area
• Increased functional level of daily activities
• Improved postural alignment or improved ability to do exercises
• It is often more comfortable for the patient than other techniques

What are the Risks of a Cervical Manipulation?

Although the risk of injury from a cervical manipulation is rare, the following adverse effects associated with
cervical manipulation have been reported in the literature:
• Muscle spasm, pain, damage to a joint and its tissues including discs and ligaments, disorientation, headache, dizziness, vertigo,
loss of consciousness, nausea and vomiting
• Difficulty with the following activities/senses: speaking, swallowing, vision, hearing, smelling, sensation, balance and
coordination
• Spinal cord injury which may include the following: the presence of numbness or tingling, decreased ability to feel temperature or
touch, changes in normal bowel and bladder function, muscle weakness or paralysis
• Stroke
• Death

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© Guelph, Ontario 2008
References
1. Rosovsky LE. The Canadian Law of Consent to Treatment. Markham, ON., Butterworths, Ltd. 1997.
2. Gross AR et al. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol. 2007;
May;34(5):1083-102.
3. Tseng YL,et al. Predictors for the immediate responders to cervical manipulation in patients with neck pain. Man Ther.
2006; Nov;11(4):306- 15.
4. Haymo TW & Bolton JE. Predictors for immediate and global responders to chiropractic manipulation of the cervical spine.
J Manipulative Physiol Ther. 2008; 31(3):172-83.
5. Rubinstein SM., Leboeuf-Yde C., Koekkoek TE., Pfeifle CE., van Tulder, MW. Predictors of a favourable outcome in patients
treated by chiropractors for neck pain. Spine 2008: 33 (14): 1451-8.
6. Rothwell D, Bondy S, Williams L. Chiropractic manipulation and stroke: a population-based case-control study. Stroke 2001;
25: 2180-2186.
7. Odds Ratio definition - The odds ratio is a measure of association in which a value of "1.0" means that there is no
relationship between variables. The value of an odds ratio can be less than or greater than 1.0. The size of any relationship
is measured by the difference (in either direction) from 1.0. An odds ratio less than 1.0 indicates an inverse or negative
association. An odds ratio greater than 1.0 indicates a positive relation. www.etr.org/recapp/research/researchglossary.htm
8. 95% Confidence Interval definition – Identifies the range in the parameter where the true value (unknown) is most likely to
occur. McNeely LM, Warren S. Value of confidence intervals in determining clinical significance. Phys Can 2006; 58: 205-
211.
9. Smith WS, Johnston SC, Skalabrin EJ, Weaver M, Azari P, Albers GW, Gress DR. Spinal manipulative therapy is an
independent risk factor for vertebral artery dissection. Neurology 2003; 60: 1424-1428.
10. Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver FL, Bondy SJ. Risk of Vertebrobasilar stroke and chiropractic
care: Results of a population-based case-control and case-crossover study. Spine 2008; 33: S176-S183.
11. Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW. Predictors of adverse events following
chiropractic care for patients with neck pain. J Manipulative Physiol Ther. 2008 Feb;31(2):94-103.
12. Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. Frequency and clinical predictors of adverse reactions to chiropractic
care in the UCLA neck pain study. Spine 2005 Jul 1;30(13):1477-84.
13. Delany, CM. Respecting patient autonomy and obtaining their informed consent: ethical theory – missing in action.
Physiotherapy 2005; 91:197-203.

Information for Health Care Professionals

© Guelph, Ontario 2008