Cervical manipulation versus thoracic or cervicothoracic manipulations for the management of neck pain: a systematic review and meta-analysis

Key points

1. 01Six RCTs were included; no subgroup showed a statistically significant and clinically important difference between cervical and thoracic or cervicothoracic manipulation
2. 02Pain intensity showed no significant between-group difference in most subgroups; one subgroup favored cervical manipulation plus exercise but did not exceed the minimum clinically important difference
3. 03Disability showed statistically significant changes in two subgroups but neither exceeded the MCID, and they pointed in opposite directions
4. 04No cervical ROM improvement was clinically meaningful in any subgroup or plane of motion
5. 05No serious adverse events were reported in the four studies that assessed them; one study noted adverse events in 3% of participants

How it was conducted

Design

Systematic review and meta-analysis of randomized controlled trials

Databases searched

PubMed, PEDro, Cochrane Library, CINAHL, Web of Science from inception to May 2023

Participants

Patients diagnosed with neck pain (mechanical, chronic mechanical, or unspecified); sample sizes ranged from 20 to 186 per study

Interventions

Cervical thrust (HVLA) or non-thrust manipulation versus thoracic, cervicothoracic, or combined manipulation; some groups also received exercise

Outcomes

Pain intensity (VAS or NPRS), disability (Neck Disability Index), and cervical range of motion (CROM device)

Quality assessment

PEDro scale for methodological quality; GRADE for certainty of evidence

What they found

• Cervical vs thoracic manipulation - pain intensity: MD -0.32 (95% CI -0.92, 0.28), very low certainty
• Cervical plus exercise vs thoracic plus exercise - pain intensity: MD -2.00 (95% CI -3.00, -1.00), 1 study, 20 patients, statistically significant but below MCID, very low certainty
• Cervical vs cervicothoracic manipulation - pain intensity: MD 0.41 (95% CI -0.49, 1.30), very low certainty
• Cervical plus exercise vs thoracic plus exercise - disability (NDI): MD -2.60 (95% CI -5.04, -0.16), 1 study, statistically significant but below MCID, very low certainty
• Cervical vs cervicothoracic manipulation - disability (NDI): MD 5.76 (95% CI 3.46, 8.06), statistically significant but below MCID, moderate certainty
• Cervical vs thoracic manipulation - ROM flexion: MD 0.68 (95% CI -2.55, 3.90), very low certainty
• Cervical vs thoracic manipulation - ROM extension: MD 1.12 (95% CI -3.28, 5.51), very low certainty
• Cervical vs cervicothoracic - ROM right lateral flexion: MD 3.90 (95% CI 0.09, 7.71), low certainty
• Heterogeneity for cervical vs cervicothoracic pain subgroup: I-squared = 82%
• Adverse events reported in 3% of patients in one study (Martinez-Segura et al. 2012); no severe events in any of the four studies that assessed them

Limitations

• Only six RCTs were included, resulting in small pooled sample sizes and limited statistical power
• Some subgroups contained only one study, making interpretation unreliable and requiring single-study inconsistency downgrading
• None of the included studies required cervical ROM restriction as an inclusion criterion, meaning patients without ROM deficits were included and results may not apply to those with restricted motion
• Quantitative analysis used post-intervention scores rather than within-group change scores due to unavailable variability data, which may affect precision of effect estimates

Why it matters

For patients

If you have neck pain, thoracic spinal manipulation appears to work about as well as cervical manipulation for reducing pain and improving movement, and may carry a lower risk of the rare but serious complications linked to direct cervical techniques.

For clinicians

These findings support using thoracic or cervicothoracic manipulation as an alternative to cervical manipulation for neck pain, particularly when risk of cervical arterial adverse events is a concern; combining both approaches does not appear to add benefit over cervical manipulation alone.

For readers

This meta-analysis addresses a clinically important safety question and finds no meaningful superiority of cervical manipulation, but the overall certainty of evidence is low to very low, limiting firm conclusions.