Neck Pain & Spinal Manipulation: An Update

Chronic pain in the United States is an overwhelming, epidemic, problem. Of the 238 million adults in the US, 116 million suffer from chronic pain (1, 2). Quantifying the anatomical regions for American’s chronic pain shows that the fourth most common region of the body afflicted with chronic pain is the neck (3):

Hip Pain 07.1%

Finger Pain 07.6%

Shoulder Pain 09.0%

Neck Pain 15.1%

Severe Headache 16.1%

Knee Pain 19.5%

Lower-Back Pain 28.1%

Neck pain is a public health problem associated with disability, reduced health-related quality of life, and substantial health care system costs. A search of the National Library of Medicine of the United States (February 10, 2016) with PubMed, using the key words “neck pain manipulation” locates 759 articles.


In 2009, Mercer Health and Benefits released a study titled (4):

Do Chiropractic Services for the Treatment of Low Back and Neck Pain Improve the Value of Health Benefits Plans?

An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending

A Google Internet search of Mercer states:

“Mercer is a leading global provider of consulting, outsourcing and investment services. Mercer works with clients to solve their most complex benefit and human capital issues, designing and helping manage health, retirement and other benefits. It is a leader in benefit outsourcing. Mercer’s investment services include investment consulting and multi-manager investment management. Mercer’s 18,000 employees are based in more than 40 countries. The company is a wholly owned subsidiary of Marsh & McLennan Companies, Inc., which lists its stock on the New York, Chicago and London stock exchanges.”

Physicians Niteesh Choudhry, MD, PhD, and Arnold Milstein, MD, MPH, are the authors this Mercer report.

Dr. Niteesh Choudhry is from Harvard Medical School where he is an Assistant Professor of Medicine and an Associate Physician in the Division of Pharmaco-epidemiology and Pharmaco-economics. Dr. Arnold Milstein is from Mercer Health and Benefits in San Francisco, California where he is the Medical Director at Pacific Business Group on Health, the largest employer health care purchasing coalition in the US.

In this groundbreaking, authoritative document, Drs. Choudhry and Milstein note that neck pain is extremely common in the United States, and it consumes large amounts of health care resources. They note that about 14% of the US adult population report neck pain in a year. They make the following points:

“Low back and neck pain are extremely common conditions that consume large amounts of health care resources.”

“Chiropractic care, including spinal manipulation and mobilization, are used by almost half of the US patients with persistent back-pain seeking out this modality of treatment.”

“The peer-reviewed scientific literature evaluating the effectiveness of US chiropractic treatment for patients with back and neck pain suggest that these treatments are at least as effective as other widely used treatments.”

“Chiropractic care is more effective than other modalities for treating low back and neck pain.”

“Our findings in combination with existing US studies published in peer-reviewed scientific journals suggests that chiropractic care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered in US health benefit plans.”

“Using data from high-quality randomized controlled European trials and contemporary Unites States based average unit prices payable by commercial insurers, we project that insurance coverage for chiropractic coverage for chiropractic physician care for low back and neck pain for conditions other than fracture and malignancy is likely to drive improved cost-effectiveness of United States care.”

“For neck pain it is also likely to reduce total United States health care spending.”

“In combination with the existing United States-based literature, our findings support the value of health insurance coverage of chiropractic care for low back and neck pain at average fees currently payable by Unites States commercial insurers.”

This article by Mercer Health and Benefits is a unique analysis of the costs and effectiveness of chiropractic care in the management of low back and neck pain as compared to medical care and physiotherapy-led exercise. In the case of neck pain, chiropractic care was the most cost effective service, and its improvement in the quality-adjusted life year showed that if chiropractic care is used in the management of neck pain there would be a savings of $6,035 per person per year. Importantly, these authors indicate that chiropractic care is known to reduce the need for drug treatment.


In 2012, a study was published in the Annals of Internal Medicine, and titled (5):

Spinal Manipulation, Medication, or Home

Exercise With Advice for Acute and Subacute Neck Pain

A Randomized Trial

The authors note that mechanical neck pain is a common condition that affects an estimated 70% of persons at some point in their lives. This study sought to determine the relative efficacy of chiropractic spinal manipulation therapy (SMT), medication, and home exercise with advice (HEA) for acute and subacute neck pain in both the short and long term. This is a randomized, controlled trial using 272 subjects aged 18 to 65 years who had nonspecific neck pain for 2 to 12 weeks. The intervention was 12 weeks of SMT, medication, or HEA.

The chiropractic spinal manipulation focused on manipulation of areas of the spine with segmental hypomobility. The primary measurement outcome was participant-rated pain, measured at 2, 4, 8, 12, 26, and 52 weeks after randomization. Secondary measures were self-reported disability, global improvement, medication use, satisfaction, general health status (Short Form-36 Health Survey physical and mental health scales), and adverse events.

Results: For neck pain, chiropractic spinal manipulation had a statistically significant advantage over medication after 8, 12, 26, and 52 weeks, and HEA was superior to medication at 26 weeks. The authors concluded that for participants with acute and subacute neck pain, chiropractic spinal manipulation was more effective than medication in both the short and long term.

The home exercise with advice was provided in two 1-hour sessions. The therapists provided instruction, primarily focusing on simple self-mobilization exercise (gentle controlled movement) of the neck and shoulder joints, including neck retraction, extension, flexion, rotation, lateral bending motions, and scapular retraction, with no resistance. Participants were instructed to do 5 to 10 repetitions of each exercise up to 6 to 8 times per day. A booklet (McKenzie R. Treat Your Own Neck. 3rd ed. Waikanae, New Zealand: Spinal Publications; 2002) of prescribed exercises was provided.

The medication group was provided by a licensed medical physician, with the focus of treatment on prescription medication. The first line of therapy was nonsteroidal anti-inflammatory drugs, acetaminophen, or both.

Participants who did not respond to or could not tolerate first-line therapy received narcotic medications. Muscle relaxants were also used.

The authors made these comments:

“Spinal manipulation therapy was superior to medication at the end of treatment and during follow-up in terms of global improvement, participant satisfaction, and SF-36 –assessed physical function; SMT was also superior to medication in measures of long-term medication use.”

“The SMT and HEA groups performed similarly on most of the secondary outcomes, although SMT performed better than HEA for satisfaction with care in both the short and long term.”

“Spinal manipulation therapy and HEA led to similar short- and long-term outcomes, but participants who received medication seemed to fare worse, with a consistently higher use of pain medication for neck pain throughout the trial’s observation period.”

“Our results suggest that SMT and HEA both constitute viable treatment options for managing acute and subacute mechanical neck pain.”

Thus, the mechanical approaches to acute/subacute neck pain management were shown not only to be significantly more effective than medication, but also significantly safer.

Although the printed words in the article suggest that chiropractic spinal adjusting and home exercise/advice are essentially equal in the management of acute and subacute neck pain, a careful review of the measured markers presented in the article show that chiropractic adjustments were nearly always superior to those from home exercise/advice.

Although the article states several times that the chiropractic adjustments were given over a period of 12 weeks, the actual range of adjustments was 2-23 with a mean of 15.3. This is slightly more than 1 adjustment per week for 12 weeks. In contrast, the home exercise/advice group was seen only 1 or 2 times, but instructed to do neck exercises at home daily. The exercises consisted of 7 isolated maneuvers that required 3 different positions: sitting, supine head supported, and supine head unsupported. Each maneuver required 10 repetitions, and the patient was instructed to repeat all of the maneuvers 6-8 times per day. Performing the exercise maneuvers as prescribed takes approximately 10 minutes per session. As such, the authors are advocating that patients with acute/subacute neck pain exercise 60-80 minutes per day; this is both impractical and unrealistic.

Considering these issues, chiropractic spinal manipulation was more effective and much more practical than pharmacology and home exercise advise in the treatment of these neck pain subjects.


Another study from 2012 was published in the Journal of Orthopaedic & Sports Physical Therapy, and titled (6):

Upper Cervical and Upper Thoracic Thrust Manipulation Versus Nonthrust Mobilization in Patients With Mechanical Neck Pain:

A Multicenter Randomized Clinical Trial

The authors note that a bout 54% of individuals have experienced neck pain within the last 6 months. The economic burden associated with the management of patients with neck pain is high, second only to low back pain in annual workers’ compensation costs in the United States.

This study is a randomized clinical trial to compare the short-term effects of upper cervical and upper thoracic high-velocity low-amplitude (HVLA) thrust manipulation to nonthrust mobilization in patients with neck pain. Although upper cervical and upper thoracic HVLA thrust manipulation and nonthrust mobilization are common interventions for the management of neck pain, no studies have directly compared the effects of both upper cervi­cal and upper thoracic HVLA thrust manipulation to nonthrust mobilization in patients with neck pain.

In this study, 107 neck pain participants were evaluated subjectively and objectively, and then randomized to receive either HVLA thrust manipulation or nonthrust mobilization to the upper cervical (C1-2) and upper thoracic (T1-2) spines (n = 56) or nonthrust mobilization (n = 51).

The participants were reexamined 48-hours after the initial examination/treatment and again completed the outcome measures. The effects of treatment on disability, pain, C1-2 passive rotation range of motion, and motor performance of the deep cervical flexors were examined.

The patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipulation experienced significantly greater reductions in dis­ability (50.5%) and pain (58.5%) than those of the nonthrust mobilization group (12.8% and 12.6%, respectively) following treatment. In addition, the HVLA thrust manipulation group had significantly greater improvement in both passive C1-2 rotation range of motion and motor performance of the deep cervical flexor muscles as compared to the group that received nonthrust mobilization.

The authors concluded that the combination of upper cervi­cal and upper thoracic HVLA thrust manipulation is appreciably more effective in the short term than nonthrust mobilization in patients with mechanical neck pain.

The C1-2 articulation has a high frequency of involvement in patients with neck pain and headaches. Disturbances in joint mobility in the upper thoracic spine may be an un­derlying contributor to musculoskeletal disorders in the cervical spine. Decreased mobility in the cer­vicothoracic junction (C7-T2) is associated with mechanical neck pain.

The primary outcome measure used in this study was the patient’s perceived level of disability as measured by the Neck Disability Index (NDI). The NDI is the most widely used condition-specific disability scale for patients with neck pain. The NDI has been demonstrated to be a reliable and valid outcome mea­sure for patients with neck pain.

The authors state:

“A single session of HVLA thrust ma­nipulation directed to both the upper cervical and upper thoracic spines results in greater improvements in disability, pain, atlantoaxial joint ROM, and motor performance of the deep cervical flexor muscles than nonthrust mobilization directed to the same regions.”

“We directed treat­ment to the atlantoaxial joints, because the C1-2 articulation has been found to have a high frequency of symptomatic involvement in patients with neck pain and headaches and previous studies have demonstrated that this ar­ticulation is where the majority of cervi­cal rotation occurs.”

“The results of the current study demonstrated that patients with mechanical neck pain who received the combination of upper cervical and upper thoracic HVLA thrust manipula­tion, experienced greater reduction in pain and disability, showed greater im­provement in passive C1-2 rotation range of motion, and had greater increases in motor performance of the deep cervical flexor muscles, as compared to the group that received nonthrust mobilization at a 48-hour follow-up visit.”

“The combination of HVLA thrust manipulation procedures direct­ed to both the upper cervical and upper thoracic articulations may enhance the overall outcomes of patients with me­chanical neck pain.”

Nonthrust mobilization is not worthless; it clearly helped the patients in this study. However, thrust/cavitation manipulations of the same spinal regions (upper cervical and upper thoracic spines) were significantly superior to mobilization in:

1) Overall successful outcomes

2) Disability reduction

3) Pain reduction

4) Increased cervical range of motion

5) Improvements in motor performance of the deep cervical flexors

Also, this study indicates that upper cervical and upper thoracic spines are biomechanically functionally linked and that the superior results achieved in this study as compared to other studies is as a consequence of adjusting both regions.


In September 2015, researchers and clinicians from the Orthopedic University Hospital Balgrist, University of Zurich, Switzerland, published a study in the Journal of Manipulative and Physiological Therapeutics, titled (7):

Prognostic Factors for Recurrences in Neck Pain Patients Up to 1 Year After Chiropractic Care

This is a prospective cohort study assessing 545 neck pain patients. After a course of chiropractic spinal manipulation, they were followed up for one year regarding recurrence of their neck pain. Nine independent prognostic variables were assessed:

• Age

• Use of pain medication

• Sex