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BMJ Open. 2019 May 28;9(5):e025219. doi: 10.1136/bmjopen-2018-025219.

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

Author information

Graduate Studies, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.
Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada.
Radiology, McMaster University Faculty of Engineering, Hamilton, Ontario, Canada.
Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada.
Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada.



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.


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


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).


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.


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.


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.




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.

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