Effect of cervical manipulation on vertebral artery and cerebral haemodynamics in patients with chronic neck pain: a crossover randomised controlled trial

Nicholas Moser, Silvano Mior, Michael Noseworthy, Pierre Côté, Greg Wells, Michael Behr, John Triano, Nicholas Moser, Silvano Mior, Michael Noseworthy, Pierre Côté, Greg Wells, Michael Behr, John Triano

Abstract

Objective: It is hypothesised that cervical manipulation may increase the risk of cerebrovascular accidents. We aimed to determine whether cervical spine manipulation is associated with changes in vertebral artery and cerebrovascular haemodynamics measured with MRI compared with neutral neck position and maximum neck rotation in patients with chronic neck pain.

Setting: The Imaging Research Centre at St. Joseph's Hospital in Hamilton, Ontario, Canada.

Participants: Twenty patients were included. The mean age was 32 years (SD ±12.5), mean neck pain duration was 5.3 years (SD ±5.7) and mean neck disability index score was 13/50 (SD ±6.4).

Interventions: Following baseline measurement of cerebrovascular haemodynamics, we randomised participants to: (1) maximal neck rotation followed by cervical manipulation or (2) cervical manipulation followed by maximal neck rotation. The primary outcome, vertebral arteries and cerebral haemodynamics, was measured after each intervention and was obtained by measuring three-dimensional T1-weighted high-resolution anatomical images, arterial spin labelling and phase-contrast flow encoded MRI. Our secondary outcome was functional connectivity within the default mode network measured with resting state functional MRI.

Results: Compared with neutral neck position, we found a significant change in contralateral blood flow following maximal neck rotation. There was also a significant change in contralateral vertebral artery blood velocity following maximal neck rotation and cervical manipulation. We found no significant changes within the cerebral haemodynamics following cervical manipulation or maximal neck rotation. However, we observed significant increases in functional connectivity in the posterior cerebrum and cerebellum (resting state MRI) after manipulation and maximum rotation.

Conclusion: Our results are in accordance with previous work, which has shown a decrease in blood flow and velocity in the contralateral vertebral artery with head rotation. This may explain why we also observed a decrease in blood velocity with manipulation because it involves neck rotation. Our work is the first to show that cervical manipulation does not result in brain perfusion changes compared with a neutral neck position or maximal neck rotation. The changes observed were found to not be clinically meaningful and suggests that cervical manipulation may not increase the risk of cerebrovascular events through a haemodynamic mechanism.

Trial registration number: NCT02667821.

Keywords: BOLD fMRI; chronic neck pain; fMRI; neck pain; spinal manipulation; stroke; vertebral artery; vertebral artery dissection.

Conflict of interest statement

Competing interests: Conflicts of interest were reported for this study include the following: JT is an occasional lecturer on behalf of NCMIC and CCPA, and MN received an honorarium for lecture on behalf of Bayer.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Protocol flow and method process.

References

    1. Albuquerque FC, Hu YC, Dashti SR, et al. . Craniocervical arterial dissections as sequelae of chiropractic manipulation: patterns of injury and management. J Neurosurg 2011;115:1197–205. 10.3171/2011.8.JNS111212
    1. Ernst E. Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995-2001. Med J Aust 2002;176:376–80.
    1. Norris JW, Beletsky V, Nadareishvili ZG. Sudden neck movement and cervical artery dissection. The Canadian Stroke Consortium. CMAJ 2000;163:38–40.
    1. Cassidy JD, Boyle E, Côté P, et al. . Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine 2008;33(4 Suppl):S176–83. 10.1097/BRS.0b013e3181644600
    1. Boyle E, Côté P, Grier AR, et al. . Examining vertebrobasilar artery stroke in two Canadian provinces. Spine 2008;33(4 Suppl):S170–5. 10.1097/BRS.0b013e31816454e0
    1. Côté P, Wong JJ, Sutton D, et al. . Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J 2016;25:2000–22. 10.1007/s00586-016-4467-7
    1. Kjaer P, Kongsted A, Hartvigsen J, et al. . National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy. Eur Spine J 2017;26:2242–57. 10.1007/s00586-017-5121-8
    1. Hurwitz EL, Coulter ID, Adams AH, et al. . Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88:771–6. 10.2105/AJPH.88.5.771
    1. Hurwitz EL, Chiang LM. A comparative analysis of chiropractic and general practitioner patients in North America: findings from the joint Canada/United States Survey of Health, 2002-03. BMC Health Serv Res 2006;6:49 10.1186/1472-6963-6-49
    1. Haldeman S, Carey P, Townsend M, et al. . Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ 2001;165:905–6.
    1. Patijn J. Complications in manual medicine: A review of the literature. J Manual Med 1991;6:89–92.
    1. Smith RA, Estridge MN. Neurological complications of head and neck manipulations: A report of two cases. JAMA 1962;182:528–31.
    1. Frisoni GB, Anzola GP. Vertebrobasilar ischemia after neck motion. Stroke 1991;22:1452–60. 10.1161/01.STR.22.11.1452
    1. Mann T, Refshauge KM. Causes of complications from cervical spine manipulation. Aust J Physiother 2001;47:255–66. 10.1016/S0004-9514(14)60273-7
    1. Schmitt HP. Anatomical structure of the cervical spine with reference to pathology of manipulation complications. Man Med 1991;6:93–101.
    1. Mitchell J. Vertebral Artery Blood flow Velocity Changes Associated with Cervical Spine rotation: A Meta-Analysis of the Evidence with implications for Professional Practice. J Man Manip Ther 2009;17:46–57. 10.1179/106698109790818160
    1. Kawchuk GN, Jhangri GS, Hurwitz EL, et al. . The relation between the spatial distribution of vertebral artery compromise and exposure to cervical manipulation. J Neurol 2008;255:371–7. 10.1007/s00415-008-0667-3
    1. Herzog W, Leonard TR, Symons B, et al. . Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol 2012;22:740–6. 10.1016/j.jelekin.2012.03.005
    1. Dunne JW, Conacher GN, Khangure M, et al. . Dissecting aneurysms of the vertebral arteries following cervical manipulation: a case report. J Neurol Neurosurg Psychiatry 1987;50:349–53. 10.1136/jnnp.50.3.349
    1. Arnold C, Bourassa R, Langer T, et al. . Doppler studies evaluating the effect of a physical therapy screening protocol on vertebral artery blood flow. Man Ther 2004;9:13–21. 10.1016/S1356-689X(03)00087-0
    1. Licht PB, Christensen HW, Højgaard P, et al. . Vertebral artery flow and spinal manipulation: a randomized, controlled and observer-blinded study. J Manipulative Physiol Ther 1998;21:141–4.
    1. Mitchell JA. Changes in vertebral artery blood flow following normal rotation of the cervical spine. J Manipulative Physiol Ther 2003;26:347–51. 10.1016/S0161-4754(03)00074-5
    1. Mitchell J, Keene D, Dyson C, et al. . Is cervical spine rotation, as used in the standard vertebrobasilar insufficiency test, associated with a measureable change in intracranial vertebral artery blood flow? Man Ther 2004;9:220–7. 10.1016/j.math.2004.03.005
    1. Mitchell J, Kramschuster K. Real-time ultrasound measurements of changes in suboccipital vertebral artery diameter and blood flow velocity associated with cervical spine rotation. Physiother Res Int 2008;13:241–54. 10.1002/pri.400
    1. Rivett DA, Sharples KJ, Milburn PD. Effect of premanipulative tests on vertebral artery and internal carotid artery blood flow: a pilot study. J Manipulative Physiol Ther 1999;22:368–75. 10.1016/S0161-4754(99)70081-3
    1. Rivett DA, Sharples KJ, Milburn PD. Reliability of ultrasonograpahic measurement of vertebral artery blood flow. NZ J Physiother 2003;31:119–28.
    1. Rossitti S, Volkmann R, Lofgren J. Changes of blood flow velocity in the vertebro-basilar circulation during rotation of the head in the normal human. Biomech Sem 1992;6:92–9.
    1. Stevens A. Functional Doppler sonography of the vertebral artery and some considerations about manual techniques. Man Med 1991;6:102–5.
    1. Quesnele JJ, Triano JJ, Noseworthy MD, et al. . Changes in vertebral artery blood flow following various head positions and cervical spine manipulation. J Manipulative Physiol Ther 2014;37:22–31. 10.1016/j.jmpt.2013.07.008
    1. Erhardt JW, Windsor BA, Kerry R, et al. . The immediate effect of atlanto-axial high velocity thrust techniques on blood flow in the vertebral artery: A randomized controlled trial. Man Ther 2015;20:614–22. 10.1016/j.math.2015.02.008
    1. Bakhtadze MA, Vernon H, Karalkin AV, et al. . Cerebral perfusion in patients with chronic neck and upper back pain: preliminary observations. J Manipulative Physiol Ther 2012;35:76–85. 10.1016/j.jmpt.2011.12.006
    1. Barrett KE, Ganong WF. Ganong’s Review of Medical Physiology. 25th ed New York, NY: McGraw-Hill Medical, 2015.
    1. Guzman J, Haldeman S, Carroll LJ, et al. . Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. Spine 2008;33(4 Suppl):S199–213.
    1. Cambridge ED, Triano JJ, Ross JK, et al. . Comparison of force development strategies of spinal manipulation used for thoracic pain. Man Ther 2012;17:241–5. 10.1016/j.math.2012.02.003
    1. Descarreaux M, Dugas C, Raymond J, et al. . Kinetic analysis of expertise in spinal manipulative therapy using an instrumented manikin. J Chiropr Med 2005;4:53–60. 10.1016/S0899-3467(07)60114-1
    1. Cohen E, Triano JJ, McGregor M, et al. . Biomechanical performance of spinal manipulation therapy by newly trained vs. practicing providers: does experience transfer to unfamiliar procedures? J Manipulative Physiol Ther 1995;18:347–52.
    1. Triano JJ, Rogers CM, Combs S, et al. . Developing skilled performance of lumbar spine manipulation. J Manipulative Physiol Ther 2002;25:353–61. 10.1067/mmt.2002.126132
    1. Triano JJ, Rogers CM, Combs S, et al. . Quantitative feedback versus standard training for cervical and thoracic manipulation. J Manipulative Physiol Ther 2003;26:131–8. 10.1016/S0161-4754(02)54105-1
    1. Ho SS, Chan YL, Yeung DK, et al. . Blood flow volume quantification of cerebral ischemia: comparison of three noninvasive imaging techniques of carotid and vertebral arteries. AJR Am J Roentgenol 2002;178:551–6. 10.2214/ajr.178.3.1780551
    1. Lotz J, Meier C, Leppert A, et al. . Cardiovascular flow measurement with phase-contrast MR imaging: basic facts and implementation. Radiographics 2002;22:651–71. 10.1148/radiographics.22.3.g02ma11651
    1. Ioannidis JP, Evans SJ, Gøtzsche PC, et al. . Better reporting of harms in randomized trials: an extension of the CONSORT statement. Ann Intern Med 2004;141:781–8. 10.7326/0003-4819-141-10-200411160-00009
    1. Parkes LM, Rashid W, Chard DT, et al. . Normal cerebral perfusion measurements using arterial spin labeling: reproducibility, stability, and age and gender effects. Magn Reson Med 2004;51:736–43. 10.1002/mrm.20023
    1. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed New Jersey: Lawrence Erlbaum Associates, Publishers, 1988.
    1. Cox RW. AFNI: software for analysis and visualization of functional magnetic resonance neuroimages. Comput Biomed Res 1996;29:162–73. 10.1006/cbmr.1996.0014
    1. Holmes CJ, Hoge R, Collins L, et al. . Enhancement of MR images using registration for signal averaging. J Comput Assist Tomogr 1998;22:324–33. 10.1097/00004728-199803000-00032
    1. Jang JH, Kim JH, Jung WH, et al. . Functional connectivity in fronto-subcortical circuitry during the resting state in obsessive-compulsive disorder. Neurosci Lett 2010;474:158–62. 10.1016/j.neulet.2010.03.031
    1. Wang J, Wang L, Zang Y, et al. . Parcellation-dependent small-world brain functional networks: a resting-state fMRI study. Hum Brain Mapp 2009;30:1511–23. 10.1002/hbm.20623
    1. Fleiss JL. The Design and Analysis of Clinical Experiments. Toronto: Wiley, 1986.
    1. Yurdakul M, Tola M. Doppler criteria for identifying proximal vertebral artery stenosis of 50% or more. J Ultrasound Med 2011;30:163–8. 10.7863/jum.2011.30.2.163
    1. Bendick PJ, Glover JL. Vertebrobasilar insufficiency: evaluation by quantitative duplex flow measurements. A preliminary report. J Vasc Surg 1987;5:594–600. 10.1016/0741-5214(87)90226-6
    1. Seidel E, Eicke BM, Tettenborn B, et al. . Reference values for vertebral artery flow volume by duplex sonography in young and elderly adults. Stroke 1999;30:2692–6. 10.1161/01.STR.30.12.2692
    1. Arnetoli G, Amadori A, Stefani P, et al. . Sonography of vertebral arteries in De Kleyn’s position in subjects and in patients with vertebrobasilar transient ischemic attacks. Angiology 1989;40:716–20. 10.1177/000331978904000805
    1. Sakaguchi M, Kitagawa K, Hougaku H, et al. . Mechanical compression of the extracranial vertebral artery during neck rotation. Neurology 2003;61:845–7. 10.1212/
    1. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009;8:668–78. 10.1016/S1474-4422(09)70084-5
    1. Senter HJ, Sarwar M. Nontraumatic dissecting aneurysm of the vertebral artery. Case report. J Neurosurg 1982;56:128–30. 10.3171/jns.1982.56.1.0128
    1. Sherman DG, Hart RG, Easton JD. Abrupt change in head position and cerebral infarction. Stroke 1981;12:2–6. 10.1161/01.STR.12.1.2
    1. Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine 2002;27:49–55.
    1. Josien E. Extracranial vertebral artery dissection: nine cases. J Neurol 1992;239:327–30. 10.1007/BF00867589
    1. Okawara S, Nibbelink D. Vertebral artery occlusion following hyperextension and rotation of the head. Stroke 1974;5:640–2. 10.1161/01.STR.5.5.640
    1. Heinen SJ, Keller EL. The function of the cerebellar uvula in monkey during optokinetic and pursuit eye movements: single-unit responses and lesion effects. Exp Brain Res 1996;110:1–14. 10.1007/BF00241368
    1. Kanwisher N, Yovel G. The fusiform face area: a cortical region specialized for the perception of faces. Philos Trans R Soc Lond B Biol Sci 2006;361:2109–28. 10.1098/rstb.2006.1934
    1. Lamm C, Windischberger C, Leodolter U, et al. . Evidence for premotor cortex activity during dynamic visuospatial imagery from single-trial functional magnetic resonance imaging and event-related slow cortical potentials. Neuroimage 2001;14:268–83. 10.1006/nimg.2001.0850
    1. Cavanna AE, Trimble MR. The precuneus: a review of its functional anatomy and behavioural correlates. Brain 2006;129:564–83. 10.1093/brain/awl004
    1. Sengelhoff C, Nebelsieck J, Nassenstein I, et al. . Neurosonographical follow-up in patients with spontaneous cervical artery dissection. Neurol Res 2008;30:687–9. 10.1179/174313208X319080
    1. Dittrich R, Dziewas R, Ritter MA, et al. . Negative ultrasound findings in patients with cervical artery dissection. Negative ultrasound in CAD. J Neurol 2006;253:424–33. 10.1007/s00415-005-0051-5
    1. Nebelsieck J, Sengelhoff C, Nassenstein I, et al. . Sensitivity of neurovascular ultrasound for the detection of spontaneous cervical artery dissection. J Clin Neurosci 2009;16:79–82. 10.1016/j.jocn.2008.04.005
    1. Oktar SO, Yücel C, Karaosmanoglu D, et al. . Blood-flow volume quantification in internal carotid and vertebral arteries: comparison of 3 different ultrasound techniques with phase-contrast MR imaging. AJNR Am J Neuroradiol 2006;27:363–9.

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