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CHIROPRACTIC MANIPULATIVE THERAPY AND PROPRIOCEPTIVE
NECK EXERCISES FOR THE TREATMENT OF CHRONIC MECHANICAL
NECK PAIN AND ITS EFFECT ON HEAD REPOSITIONING ACCURACY
A dissertation submitted to the Faculty of Health Sciences, University of Johannesburg, as

a partial fulfilment of the requirements for the Masters degree in Technology in Chiropractic
by:
Lana Panagis
(Student Number: 200672208)
Supervisor: ____________________________ _________________

Dr. M. Moodley Date
M Tech Chiropractic (UJ)
DECLARATION
I declare that this dissertation is my own, unaided work. It is being submitted for the
Masters Degree in Technology in the program Chiropractic at the University of
Johannesburg. It has not been submitted before for any degree of examination in any other
Tertiary Institute.
________________________
Lana Panagis
On this________ day of ________ 2013
ii
AFFIDAVIT:
MASTER’S AND DOCTORAL STUDENTS
TO WHOM IT MAY CONCERN
This serves to confirm that I, Lana Panagis ID Number 8608280039084
Student number 200672208 enrolled for the Qualification MTech Chiropractic
Faculty Health Sciences Herewith declare that my academic work is in line with the Plagiarism Policy of the
University of Johannesburg which I am familiar with. I further declare that the work presented in
CHIROPRACTIC MANIPULATIVE THERAPY AND PROPRIOCEPTIVE NECK EXERCISES FOR THE
TREATMENT OF CHRONIC MECHANICAL NECK PAIN AND ITS EFFECT ON HEAD REPOSITIONING
ACCURACY (minor dissertation/dissertation/thesis) is authentic and original unless clearly indicated
otherwise and in such instances full reference to the source is acknowledged and I do not pretend to receive
any credit for such acknowledged quotations, and that there is no copyright infringement in my work. I
declare that no unethical research practices were used or material gained through dishonesty. I understand
that plagiarism is a serious offence and that should I contravene the Plagiarism Policy notwithstanding
signing this affidavit, I may be found guilty of a serious criminal offence (perjury) that would amongst other
consequences compel the UJ to inform all other tertiary institutions of the offence and to issue a
corresponding certificate of reprehensible academic conduct to whomever request such a certificate from the
institution.
Signed at _____________________on this ______________day of _______________ 20___.

Signature___________________________ Print name__________________________
STAMP COMMISSIONER OF OATHS

Affidavit certified by a Commissioner of Oaths
This affidavit conforms with the requirements of the JUSTICES OF THE PEASE AND COMMISSIONERS OF OATHS ACT 16 OF 1963
and the applicable Regulations published in the GG GNR 1258 of 21 July 1972; GN 903 of 10 July 1998; GN 109 of 2 February 2001 as
amended.
iii
DEDICATION
To my father and mother, thank you for always being there for me. Your provision, support
and love over the last six years means so much to me. Thank you for providing me with the
amazing opportunity to enrich my life with this degree. I cannot say thank you enough for
your love and support.
To Anrie Potgieter, my best friend, who helped me through many tough times, was always
willing and able to help me and kept motivating me to finish this dissertation. Thank you so
much for your support.
To Shaun Michael Sewry, my loving boyfriend and best friend, thank you for all your
understanding, love and support during this entire process. Without your motivation and
support, I would not have come as far as I have. Thank you for always loving and
supporting me.
To Jesus Christ, my Lord and Saviour, without you none of this would be possible. Thank
you for always listening and answering my prayers and for your never-ending love.
iv
ACKNOWLEDGMENTS
Dr. Malany Moodley, my supervisor, thank you for the enormous amount of work and
energy you spent on getting me through this process. Your input and help was much
appreciated and your input was invaluable.
To all my chiropractic friends, thank you for your friendship and for joining me on this
interesting journey.
To all the participants who partook in this research, thank you for your time and patience.
Without you it would not have been possible.
v
ABSTRACT
Mechanical neck pain is the most common type of cervical spine pain encountered. It is
also referred to as simple or non-specific neck pain and is common in all groups of people
(Plaugher, 1993). A majority of individuals with neck pain do not experience a resolution in
their pain and disability and this thus results in chronicity (Cote, Cassidy, Carrol and
Kristman, 2004).
Chiropractic manipulative therapy (CMT) is a specific form of articular manipulation,

especially of the vertebral column. This is performed either manually, mechanically,
actively or passively in order to restore normal articular alignment and function (Gatterman,
2005). Proprioceptive neck exercises are designed to retrain the cervical musculature to
regain its position sense in space. Specific exercises are designed to locate the head to a
neutral position and then to do a series of movements in other planes, and then to return
the head to the neutral position (Revel, Minguet, Gergoy, Valliant and Manuel, 1994).
Chiropractic manipulative therapy does have documented positive effects on the

proprioceptive system within the cervical spine (Palmgren, 2006) as does proprioceptive
exercises (Sarig-Bahat, 2003; Revel, Minguet, Gergoy, Vaillant, Manuel, 1994). The
desired effects of combining both these treatments would be to increase the response rate
in patients suffering from chronic mechanical neck pain.
The aim of this study was to compare the effects of Chiropractic manipulative therapy
(CMT) and proprioceptive neck exercises as stand-alone treatment protocols, as well as a
combination treatment protocol with regards to neck pain, disability, cervical spine range of
motion and Head Repositioning Accuracy (HRA).
Participants were recruited from the University of Johannesburg Chiropractic Day Clinic.
They were eligible to participate in the study once they met the inclusion and exclusion
criteria. Participants were recruited by means of advertisements that were placed around
the respective campuses of the University of Johannesburg as well as by word of mouth.
vi
Thirty participants, who presented with chronic mechanical neck pain, volunteered for this
randomised comparative clinical study. The participants, aged between 18 - 40, were
randomly divided into three groups of ten, with a half female to male ratio. Group 1
received Chiropractic manipulative therapy to the restricted joints in the cervical spine,
Group 2 received proprioceptive neck exercises and Group 3 received a combination of
both treatments. Participants were treated for a total of 6 visits over a three week period.
Subjective and objective measurements were taken at the beginning of visits 1, 4 and at a
final visit 7 during which only measurements were taken.
Subjective measurements consisted of the Vernon-Mior Neck Pain and Disability Index
(VMNPDI) and the Numerical Pain Rating Scale (NPRS) to assess the participants‟ neck
pain and disability as well as their perception of pain. Objective measurements were
obtained by using the Cervical Range of Motion device (CROM) as well as measuring the
Head Repositioning Accuracy (HRA) as described by Revel, Andre-Deshays and Minguet
(1991).
Based on the results of the study, it could be concluded that both Group 1 (Chiropractic
manipulative therapy to the restricted joints in the cervical spine) and Group 3 (a
combination of cervical spine manipulation and proprioceptive neck exercises) can be used
effectively to treat chronic mechanical neck pain and improve HRA. Group 1, 2 and 3
showed statistical improvements in certain areas and clinical improvements in all areas
over time. It could not be statistically concluded whether one treatment is superior to the
other, although clinically, Group 1 and Group 3 seemed to be more effective. Considering
that Group 3 is a combination of cervical spine manipulation and proprioceptive neck
exercises, it could be considered as a valid treatment protocol for chronic mechanical neck
pain and improving HRA and could thus be used in a clinical setting.
vii
TABLE OF CONTENTS
DECLARATION ................................................................................................................. ii
AFFIDAVIT ........................................................................................................................ iii
DEDICATION .................................................................................................................... iv
ACKNOWLEDGEMENTS .................................................................................................. v
ABSTRACT ....................................................................................................................... vi
TABLE OF CONTENTS ................................................................................................. viii
LIST OF APPENDICES.................................................................................................... xii
LIST OF FIGURES .......................................................................................................... xiii
LIST OF TABLES ............................................................................................................ xv
CHAPTER ONE: INTRODUCTION .................................................................................... 1

1.1 General Introduction ................................................................................................. 1
1.2 Aim of the Study ....................................................................................................... 1
1.3 Benefits of the Study ................................................................................................. 1
CHAPTER TWO: LITERATURE REVIEW ......................................................................... 3

2.1 Introduction ................................................................................................................ 3
2.2 Functional Anatomy of the Cervical Spine ................................................................ 3
2.2.1 Typical cervical vertebra .................................................................................... 3
2.2.2 Atypical cervical vertebra ................................................................................... 5
2.2.3 The intervertebral disc ....................................................................................... 7
2.2.4 Zygapophyseal joints ......................................................................................... 9
2.2.5 Zygapophyseal joint capsule ........................................................................... 10
2.2.6 Innervation of the zygapophyseal joints of the cervical spine .......................... 10
2.2.7 Ligaments of the cervical spine ....................................................................... 13
2.2.8 Muscles of the cervical spine .......................................................................... 16
2.2.9 Spinal nerves, nerve roots and the spinal cord ................................................ 24
2.3 Biomechanics of the Cervical Spine ....................................................................... 26
2.3.1 Biomechanics of the upper cervical spine ........................................................ 26
2.3.2 Biomechanics of the lower cervical spine ....................................................... 30
viii
2.3.3 Biomechanics of the uncovertebral joints ....................................................... 32
2.3.4 Biomechanics of the intervertebral disc .......................................................... 32
2.4 Chronic Mechanical Neck Pain .............................................................................. 33
2.4.1 Introduction ..................................................................................................... 33
2.4.2 Aetiology ......................................................................................................... 33
2.4.3 Clinical presentation ....................................................................................... 35
2.4.4 Pain referral .................................................................................................... 35
2.5 Manual Therapy ..................................................................................................... 36
2.5.1 The chiropractic subluxation ........................................................................... 36
2.5.2 The Vertebral Subluxation Complex ............................................................... 37
2.5.3 Chiropractic manipulative therapy .................................................................... 41
2.5.4 The effects of chiropractic manipulative therapy ............................................. 43
2.6 Proprioception ........................................................................................................ 46
2.6.1 The neuroanatomical components of the proprioceptive system .................... 48
2.6.2 Pathway of proprioception .............................................................................. 50
2.6.3 Joint Position Sense Function/ Head Repositioning Accuracy ......................... 54
2.6.4 The effects of altered neck proprioception ....................................................... 55
2.6.5 Proprioceptive neck exercises ........................................................................ 56
2.7 Conclusion ............................................................................................................. 59
CHAPTER THREE: METHODOLOGY ............................................................................. 61

3.1 Introduction ............................................................................................................ 61
3.2 Study Design ......................................................................................................... 61
3.3 Participant Recruitment .......................................................................................... 61
3.4 Sample Selection and Size .................................................................................... 61
3.4.1 Inclusion criteria .............................................................................................. 61
3.4.2 Exclusion criteria ............................................................................................ 62
3.5 Group Randomisation ............................................................................................ 62
3.6 Treatment Approach .............................................................................................. 63
3.6.1 First visit ......................................................................................................... 63
3.6.2 Follow-up visits ............................................................................................... 63
3.6.3 Treatments ...................................................................................................... 64
ix
3.7 Subjective Data ...................................................................................................... 65
3.7.1 The Numerical Pain Rating Scale ................................................................... 65
3.7.2 Vernon-Mior Neck Pain and Disability Index ................................................... 65
3.8 Objective Data ....................................................................................................... 67
3.8.1 Cervical Spine Range of Motion ..................................................................... 67
3.8.2 Head Repositioning Accuracy ......................................................................... 70
3.9 Data Analysis ......................................................................................................... 72
3.10 Ethical Considerations ......................................................................................... 73
CHAPTER FOUR: RESULTS .......................................................................................... 74

4.1 Introduction ............................................................................................................ 74
4.2 Demographic Data Analysis ................................................................................... 75
4.3 Subjective Data Analysis ....................................................................................... 76
4.3.1 Evaluation of Numerical Pain Rating Scale readings ...................................... 76
4.3.2 Evaluation of Vernon-Mior Neck Pain and Disability Index ............................. 81
4.4 Objective Data Analysis ......................................................................................... 86
4.4.1 Evaluation of Cervical Spine Range of Motion readings ................................. 86
4.4.2 Evaluation of Head Repositioning Accuracy ................................................. 116
CHAPTER FIVE: DISCUSSION ..................................................................................... 126

5.1 Introduction .......................................................................................................... 126
5.2 Demographic Data Analysis ................................................................................. 126
5.2.1 Age and gender distribution .......................................................................... 126
5.3 Analysis of Subjective Data ................................................................................. 126
5.3.1 Numerical Pain Rating Scale ........................................................................ 126
5.3.2 Vernon-Mior Neck Pain and Disability Index ................................................. 128
5.3.3 Discussion of the subjective data ................................................................. 130
5.4 Objective Data Analysis ....................................................................................... 132
5.4.1 Cervical Range of Motion measuring instrument .......................................... 132
5.4.2 Discussion of the ranges of motion ............................................................... 141
5.4.3 Head Repositioning Accuracy ....................................................................... 145
5.4.4 Discussion of Head Repositioning Accuracy ................................................. 147
x
5.5 Conclusion ........................................................................................................... 149
CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS ...................................... 150

6.1 Conclusion ............................................................................................................ 150
6.2 Recommendations ................................................................................................ 151
REFERENCES ............................................................................................................... 153
xi
LIST OF APPENDICES
APPENDIX A: ADVERTISEMENT
APPENDIX B: INFORMATION AND CONSENT FORM
APPENDIX C: CASE HISTORY FORM
APPENDIX D: PHYSICAL EXAMINATION FORM
APPENDIX E: CERVICAL SPINE REGIONAL EXAMINATION FORM
APPENDIX F: SOAP NOTE FORM
APPENDIX G: NUMERICAL PAIN RATING SCALE
APPENDIX H: VERNON-MIOR NECK PAIN AND DISABILITY INDEX
APPENDIX I: CROM RECORDING SHEET
APPENDIX J: HRA RECORDING SHEET
APPENDIX K: PROPRIOCEPTIVE NECK EXERCISES
APPENDIX L: CONTRAINDICATIONS TO CHIROPRACTIC ADJUSTMENT
APPENDIX M: MOTION PALPATION TECHNIQUES
APPENDIX N: CERVICAL SPINE ADJUSTMENTS
xii
LIST OF FIGURES
Figure 2.1: An Illustration of a Typical Vertebra .......................................................... 4

Figure 2.2: Illustration of the Atlas and Axis ................................................................ 6
Figure 2.3: Structure and Function of the IVD ............................................................. 8
Figure 2.4: Ligaments of the Upper Cervical Spine ................................................... 13
Figure 2.5: Ligaments of the Lower Cervical Spine ................................................... 15
Figure 2.6: Superficial Muscles of the Neck .............................................................. 16
Figure 2.7: Anterior Vertebral Muscles ...................................................................... 18
Figure 2.8: Superficial Muscles of the Neck .............................................................. 19
Figure 2.9: Intermediate Layer of Intrinsic Back Muscles .......................................... 21
Figure 2.10: Suboccipital Muscles ............................................................................... 23
Figure 2.11: Cross-Section of the Spinal Cord ............................................................ 26
Figure 2.12: Sensory Receptors of the Skin ................................................................ 50
Figure 2.13: Components and Destinations of the Proprioceptive System ................. 52
Figure 2.14: The Discriminatory General Sensory Pathways ...................................... 53
Figure 3.1: The CROM Goniometer .......................................................................... 68
Figure 3.2: Flexion and Extension Readings with the CROM Goniometer ............... 68
Figure 3.3: Lateral Flexion Readings with the CROM Goniometer ........................... 69
Figure 3.4: Rotation Readings with the CROM Goniometer ..................................... 70
Figure 3.5: Laser Pointer Device Attached to the Top of a Helmet ........................... 71
Figure 3.6: Maximal Rotation to the Right ................................................................. 71
Figure 3.7: HRA Recording Sheet ............................................................................. 72
Figure 4.1: NPRS Mean Values for the 1st, 4th and 7th Visits ..................................... 79
Figure 4.2: VMNPDI Mean Values on the 1st, 4th and 7th Visits ................................. 84
Figure 4.3: CROM Flexion Mean Values on the 1st, 4th and 7th Visits ....................... 89
Figure 4.4: CROM Extension Mean Values on the 1st, 4th and 7th Visits ................... 94
Figure 4.5: CROM Right Lateral Flexion Mean Values on the 1st, 4th and 7th Visits .. 99
Figure 4.6: CROM Left Lateral Flexion Mean Values on the 1st, 4th and 7th Visits .. 104
Figure 4.7: CROM Right Rotation Mean Values on the 1st, 4th and 7th Visits .......... 109
Figure 4.8: CROM Left Rotation Mean Values on the 1st, 4th and 7th Visits ............ 114
Figure 4.9: HRA Right Rotation Mean Values on the 1st, 4th and 7th Visits ............. 119
xiii
Figure 4.10: HRA Left Rotation Mean Values on the 1st, 4th and 7th Visits ................ 124
xiv
LIST OF TABLES
Table 2.1: Anatomy of the Upper Cervical Ligaments .............................................. 13

Table 2.2: Anatomy of the Lower Cervical Ligaments .............................................. 15
Table 2.3: Superficial Muscles of the Neck .............................................................. 17
Table 2.4: Anterior Vertebral Muscles ...................................................................... 18
Table 2.5: Lateral Vertebral Muscles ....................................................................... 20
Table 2.6: Intermediate Layer of Intrinsic Back Muscles .......................................... 22
Table 2.7: Suboccipital Muscles ............................................................................... 23
Table 4.1: Comparison of the Demographic Data Between the Groups .................. 75
Table 4.2: Intragroup Analysis of Group 1 ............................................................... 76
Table 4.5: Intergroup Analysis of NPRS .................................................................. 78
Table 4.6: NPRS Mean Values ................................................................................ 80
Table 4.10: Intergroup Analysis of VMNPDI .............................................................. 83
Table 4.11: VMNPDI Mean Values ............................................................................ 85
Table 4.15: Intergroup Analysis of Cervical Spine Flexion ......................................... 88
Table 4.16: CROM Flexion Mean Values ................................................................... 90
Table 4.20: Intergroup Analysis of Cervical Spine Extension .................................... 93
Table 4.21: CROM Extension Mean Values .............................................................. 95
xv
Table 4.25: Intergroup Analysis of Cervical Spine Right Lateral Flexion ................... 98
Table 4.26: CROM Right Lateral Flexion Mean Values ........................................... 100
Table 4.27: Intragroup Analysis of Group 1 ............................................................. 101
Table 4.30: Intergroup Analysis of Cervical Spine Left Lateral Flexion .................... 103
Table 4.31: CROM Left Lateral Flexion Mean Values .............................................. 105
Table 4.33: Intragroup Analysis Group 2 ................................................................. 107
Table 4.35: Intergroup Analysis of Cervical Spine Right Rotation ........................... 108
Table 4.36: CROM Right Rotation Mean Values ..................................................... 110
Table 4.40: Intergroup Analysis of Cervical Spine Left Rotation .............................. 113
Table 4.41: CROM Left Rotation Mean Values ........................................................ 115
Table 4.42: Intragroup Analysis Group 1 ................................................................. 116
Table 4.45: Intergroup Analysis of Head Repositioning Accuracy Right Rotation ... 118
Table 4.46: HRA Right Rotation Mean Values ......................................................... 120
Table 4.50: Intergroup Analysis of Head Repositioning Accuracy Left Rotation ...... 123
Table 4.51: HRA Left Rotation Mean Values ........................................................... 125
xvi
CHAPTER ONE: INTRODUCTION
1.1 General Introduction
Neck pain occurs commonly in the general population. Kinesthetic sensibility is defined as
the ability to judge joint position, which is important in the coordinated movements of the
head, trunk and extremities (Cheng, 2009). Any dysfunction of this kinesthetic sensibility
will result in movement irregularities, errors in movement, muscle spindle discharge
changes and also affects the central output of the nervous system (Cheng, 2009).
Mechanical neck pain can affect anyone who maintains a poor posture or position for a
long period of time. It affects the cervical spine, cervical musculature and also the
proprioceptive organs found within these structures. The cervical musculature contains
many proprioceptors, which are muscle spindles that relay information about changes in
muscle length to the central nervous system (Humphreys, 2008).
Chiropractic manipulative therapy does have documented positive effects on the

proprioceptive system within the cervical spine (Palmgren, 2006) as does proprioceptive
exercises (Sarig-Bahat, 2003; Revel, Minguet, Gergoy, Vaillant, Manuel, 1994). The
desired effects of combining both these treatments would be to increase the response rate
in patients suffering from chronic mechanical neck pain.
1.2 Aim of the Study
The aim of this study was to compare the effects of Chiropractic manipulative therapy and
proprioceptive neck exercises with regards to pain, disability, cervical range of motion and
head repositioning accuracy on patients with chronic mechanical neck pain.
1.3 Benefits of the Study
This study would be beneficial in determining which treatment protocol in the form of
Chiropractic manipulative therapy to the cervical spine or proprioceptive neck exercises
1
would be better suited for the treatment of chronic mechanical neck pain. Research has
shown that proprioceptive exercises and Chiropractic manipulative therapy can positively
affect proprioceptive deficits and neck pain on their own. Thus the results of this study, by
combining the two treatments, may provide Doctors of Chiropractic with an additional
treatment protocol for chronic mechanical neck pain.
With respect to the above introduction, Chapter Two will review the literature done on the
anatomy and biomechanics of the cervical vertebral column, chronic mechanical neck pain,
proprioceptive neck exercises and head repositioning accuracy; followed by Chapter Three
which will focus on the methodology relevant to this study. Chapter Four reports the
findings with Chapter Five discussing these results. Chapter Six will provide possible
conclusions and recommendations for the future studies on this topic.
2
CHAPTER TWO: LITERATURE REVIEW
2.1 Introduction
This chapter details previously published research and literature that is relevant to serve as
background information for this particular study.
2.2 Functional Anatomy of the Cervical Spine
The cervical spine consists of seven vertebrae. The relative disc thickness compared to the
size of the vertebral body, the near horizontal plane of the articular facets and the reduced
amount of surrounding body mass, allows the cervical spine region to have the greatest
range of motion and variety of movements of all the other vertebral regions (Moore and
Dalley, 2006).
The cervical spine can be divided into two distinct segments, the upper and lower cervical
spine. The upper cervical spine consists of the occiput, atlas (first cervical vertebrae) and
the atlas (second cervical vertebrae). The upper cervical region forms the primary upper
cervical curve and controls the neutral position of the head in an upright posture. The lower
cervical spine consists of the third to seventh cervical vertebrae. The lower cervical region
forms the secondary cervical curve and along with the upper cervical region, allows for
positioning and movements of the head (Middleditch and Oliver, 2005).
2.2.1 Typical cervical vertebra
The third to the seventh cervical vertebrae are considered typical cervical vertebrae. A
vertebral body, vertebral arch and seven vertebral processes are structures that make up a
typical cervical vertebra (Moore and Dalley, 2006).
The vertebral body gives strength to the vertebral column and supports the weight of the
head. It consists of vascular, trabecular bone enclosed by a thin external layer of compact
bone. Both the superior and inferior surfaces of the vertebral body are covered by hyaline
3
cartilage (vertebral end-plates). The epiphyseal rim is attached to the periphery of the
vertebral body and serves as a growth zone, provides protection to the vertebral body and
also permits diffusion of fluid between the intervertebral (IV) discs and the capillaries within
the vertebral body (Moore and Dalley, 2006).
Figure 2.1: An Illustration of a Typical Vertebra (Netter, 2006)
The vertebral body is small and wider from side to side than anteroposteriorly and has a
roughly oval anterior structure of the typical cervical vertebrae. The superior surface of the
vertebral body is concave and the borders of these transversely elongated bodies are
elevated posteriorly and especially laterally but they are depressed anteriorly. The inferior
surface of the superiorly placed vertebral body is convex and its borders are reciprocally
shaped. The elevated superolateral margin of the vertebral body is called the uncus of the
body (uncinate process) (Moore and Dalley, 2006).
Posterior to the vertebral body lies the vertebral arch, which consists of two pedicles and
laminae. The pedicles are short, stout cylindrical processes that project posteriorly from the
vertebral body to meet two broad, flat plates of bone, called lamina, which unite in the
midline. The vertebral arch and the posterior surface of the vertebral body form the walls of
the vertebral foramen. The succession of vertebral foramina in the vertebral column forms
the vertebral canal, which contains the spinal cord and the roots of the spinal nerves that
emerge from it, along with the meninges, fat and vessels that serve and surround them
(Moore and Dalley, 2006).
4
Vertebral notches are indentations that are observed in lateral views of the vertebrae on
the superior and inferior surfaces of the pedicles. The intervertebral foramina are formed
by superior and inferior vertebral notches of adjacent vertebrae, along with the IV discs
connecting them. The intervertebral foramina house the spinal (posterior root) ganglia and
the cervical spinal nerves and accompanying vessels pass through these foramina. Seven
processes arise from the arch of a typical cervical vertebrae. The spinous process projects
posteriorly from the vertebral arch at the junction of the laminae medially. Two transverse
processes (TVP) project posterolaterally from the junctions of the pedicles and laminae.
The medial portion of the TVP‟s each house a transverse foramen, through which the
vertebral artery and its accompanying veins pass. Four articular processes
(zygapophyses), two superior and two inferior, also arise from the junction of the pedicles
and laminae, each bearing an articular surface (facet). The four articular processes are in
apposition with the corresponding processes of the vertebrae superior and inferior to them,
forming the zygapophyseal (facet) joints. These processes, through their participation in
these joints, determine the types of movements permitted and restricted between the
adjacent vertebrae of each region (Moore and Dalley, 2006).
The facet joints are true synovial joints in that they have a thin ligamentous capsule, that
seals the joint and hyaline cartilage that covers their articular surfaces. The facet joints
capsules are innervated by the medial branches of the adjacent posterior rami of the
segmental levels above and below (Murpy, 2000). The synovium, as well as the capsule
have substance P-sensitive nerves in addition to nociceptors (Souza, 1998).
2.2.2 Atypical cervical vertebra
The first and second cervical vertebrae differ in structure from the lower cervical vertebrae.
The atlas (C1) is the first cervical vertebrae. It articulates superiorly with the occiput and
inferiorly with the axis (C2), the second cervical vertebrae (Middleditch and Oliver, 2005).
a. Atlas: C1
5
The atlas differs from all the other cervical vertebrae in that it does not have a vertebral
body or a spinous process, but consists of two lateral masses that are joined together by
an anterior and posterior arch (Middleditch and Oliver, 2005).
The lateral masses of this ring-shaped bone, serve the place of a vertebral body by bearing
the weight of the cranium. The TVPs of the altas arise from the lateral masses, resulting in
them being more laterally placed than those of the typical cervical vertebrae. The concave
superior articular surfaces of the lateral masses receive two large cranial protuberances
called the occipital condyles, which occur on each side of the foramen magnum. Anterior
and posterior arches, each bearing a tubercle in the centre of its external aspect, extend
between the two lateral masses, forming a complete ring. The posterior arch, which
corresponds to the lamina of a typical vertebrae, has on its superior surface, a wide groove
for the vertebral artery (Moore and Dalley, 2006).
Figure 2.2: Illustration of the Atlas and Axis (Netter, 2006)
6
b. Axis: C2
The axis is the strongest of the cervical vertebrae (Moore and Dalley, 2006). The axis
provides a pivot around which the atlas and cranium rotate (Middleditch and Oliver, 2005).
The axis has two large, flat bearing surfaces, the superior articular facets, on which the
atlas rotates. The dens (odontoid process) is a blunt tooth-like structure that projects
superiorly from the body of the axis. Both the dens and the spinal cord are encircled by the
atlas. The dens lies anterior to the spinal cord and serves as a pivot point. The dens is held
in position against the posterior aspect of the anterior arch of the atlas by the transverse
ligament of the atlas. The axis has a large bifid spinous process (Moore and Dalley, 2006).
c. Vertebra prominens: C7
The seventh cervical vertebra (C7) is the transitional zone between the cervical and
thoracic spine. While the spinous processes of the third to sixth (C3 – C6) cervical
vertebrae are short and usually bifid, C7 is a prominent vertebrae characterized by a long
spinous. As a result of this prominent spinous process, C7 is called the vertebra prominens
(Moore and Dalley, 2006).
2.2.3 The intervertebral disc
The articulating surfaces of adjacent vertebrae are connected by intervertebral discs (IVD)
and ligaments. The IVDs provide strong attachments between the vertebral bodies, uniting
them into a continuous semi-rigid column and forming the inferior half of the anterior border
of the intervertebral (IV) foramen. Apart from permitting movement between adjacent
vertebrae, the IVDs serve as shock absorbers due to their resilient deformability. Each IVD
consists of an annulus fibrosus, an outer fibrous part composed of concentric lamellae of
fibrocartliage, a gelatinous central nucleus pulposus and a vertebral end plate (Moore and
Dalley, 2006).
The cervical IVDs differ in structure from the lumbar IVDs in that they are smaller and the
nucleus pulposus is less distinct from the annulus fibrosus (Middleditch and Oliver, 2005).
7
There is no IVD between C1 and C2 vertebrae, thus IVDs in the cervical spine lie between
C2 to C7 vertebrae. The cervical IVDs are thicker anteriorly, which contributes to the
anterior convexity of the cervical spine (Moore and Dalley, 2006).
Figure 2.3: Structure and Function of the IVD (Moore and Dalley, 2006)
a. Annulus fibrosus
The annulus fibrosus is a fibrous ring consisting of concentric lamellae of fibrocartilage,

forming the circumference of the IVD. It has several concentric fibrocartilage lamellae,
which are convex externally and opposing layers are angled in the opposite oblique
direction. Fibres become less obliquely angled towards the periphery, so they are almost
vertical at the edge of the disc and are almost horizontal near the core, therefore these
fibres act as a coiled spring (Levange and Norkin, 2005). The annuli insert into the smooth,
rounded epiphyseal rims on the articular surfaces of the vertebral body above to the one
below. The fibers forming each lamella run obliquely from one vertebrae to another,
typically running at right angles to those of the adjacent ones (Moore and Dalley, 2006).
The inner lamellae attach loosely to the vertebral end plate, and the fibres are attached
tightly at the periphery (Levange and Norkin, 2005). This arrangement allows for some
movement between the adjacent vertebrae, while providing a strong bond between them
(Moore and Dalley, 2006). Fibres near the circumference blend into anterior and posterior
longitudinal ligaments (Levange and Norkin, 2005).
8
b. Nucleus pulposus
The nucleus pulposus is the central core of the IVD and is located posteriorly within the
IVD. It is avascular and receives its nourishment by diffusion from blood vessels at the
periphery of the annulus fibrosus and vertebral body. The semi-fluid nature of the nucleus
pulposus is responsible for much of the flexibility and resilience of the IVD and of the
vertebral column as a whole (Moore and Dalley, 2006). The nucleus pulposus is strongly
hydrophilic and contains eighty-eight percent water. The disc is devoid of blood vessels
and nerves; therefore imbibition must occur in order for the majority of fluid received from
the disc to be absorbed (Levange and Norkin, 2005). When the nucleus pulposus is
compressed, it becomes broader and the disc loses water, but retains sodium and
potassium. This increase in electrolyte concentration creates an osmotic gradient, which
will result in rehydration when the IVD is unloaded (Levange and Norkin, 2005).
c. Vertebral end plate
The vertebral end plates are cartilaginous in nature and prevent the vertebral bodies from
undergoing pressure atrophy. They also ensure that the annulus fibrosus and nucleus
pulposus are contained within their anatomic borders. The vertebral end plates ensure
proper nutrition of the IVD, as they are very porous and permit imbibition via osmotic action
(Levange and Norkin, 2005).
2.2.4 Zygapophyseal joints
The joints of the vertebral arches are the zygapophyseal joints (facet joints). These
articulations are plane synovial joints between the superior and the inferior articular
processes (zygapophyses) of adjacent vertebrae. Each articulating surface of the facet
joints is covered by a thin layer of articulating hyaline cartilage. The zygapophyseal joints
permit gliding movements between the articular processes; the shape and disposition of
the articular surfaces will determine the types of movement possible (Moore and Dalley,
2006). The inferior articular processes (facets) of a typical cervical vertebrae face forwards
and downwards and articulate with the superior facets of the vertebrae below, which face
9
upwards and backwards. These joints allow flexion, extension, rotation and lateral flexion
to occur. The facet planes lie at approximately forty five degrees to the vertical. The upper
facet joints are more horizontally placed and lie approximately fifty five degrees to the
vertical, while the lower facet joints lie at approximately twenty five degrees to the vertical
(Middleditch and Oliver, 2005).
Each facet joint is surrounded by a thin, loose joint (articular) capsule and in the cervical
spine this capsule is especially thin and loose, reflecting the wide range of movement. The
joint capsule is attached to the margins of the articular surfaces of the articular processes
of adjacent vertebrae. Accessory ligaments unite the laminae, TVPs and spinous
processes and help stabilise the joints (Moore and Dalley, 2006). Zygapophyseal joints
also transmit a sensation of proprioception, which provides an awareness of movement
and position of the neck. The synovial membrane is relatively insensitive. Pain fibers are
numerous in the fibrous layer and associated ligaments, which can result in considerable
pain when the joints are injured (Moore and Dalley, 2006).
2.2.5 Zygapophyseal joint capsule
The joint capsule is composed of an outer fibrous layer or membrane, which in turn is lined
by a serous synovial membrane. The joint capsule spans and encloses the articular cavity
of the zygapophyseal joints. Synovial fluid is secreted by the synovial membrane and thus
serves a lubricating function between the articulating surfaces of the facet joints within the
joint capsule. The zygapophyseal joint capsules are innervated by articular branches that
arise from the medial branches of the posterior rami of the spinal nerves, each articular
branch supplies two adjacent joints; therefore each joint is innervated by two nerves
(Moore and Dalley, 2006). Zygapophyseal joint capsules are as a result highly innervated
and may, therefore, be a primary source of pain (Middleditch and Oliver, 2005).
2.2.6 Innervation of the zygapophyseal joints of the cervical spine
The zygapophyseal joints are richly innervated and are supplied by both myelinated and
unmyelinated nerve fibers with three types of nerve endings. These nerve endings consist
10
of fine free fibers, complex unencapsulated endings and small encapsulated endings
(Hirsch, Ingelmark and Miller, 1963) and (Middleditch and Oliver, 2005).
Mechanoreceptors are biological transducers that react to a mechanical stimulus and

convert it into electrical energy. The different types of mechanoreceptors send information
to the central nervous system regarding joint activity (Porterfield and DeRosa, 1998).
Wyke (1985) has classified four types of receptor nerve endings that are found in synovial
joints. Each receptor has individual characteristic behavioural properties and their
distribution varies in different joints and different regions of each joint capsule. Types I, II
and III are corpuscular mechanoreceptors and type IV are non-corpuscular nociceptive
(pain) receptors.
a. Type I
Type I receptors are small globular mechanoreceptors which are located in the peripheral
layers of the fibrous apophyseal joint capsule. These receptors are particularly numerous
in the cervical spine. They are low threshold, adapt slowly and are sensitive to mechanical
stress. Some type I receptors will discharge continuously at low frequencies as a result of
pressure differences inside and outside the joint capsules, as well as when stress is
applied to the joint capsule by surrounding muscles and ligaments. These receptors
contribute to awareness of joint position in both active and static joints. Type I receptors
have an inhibitory effect on the trans-synaptic centripetal flow of nociceptive afferent
activity from type IV receptors and therefore, are important in pain suppression
b. Type II
Type II receptors are larger than type I and are found mainly in the deeper layers of the
capsule and on the surface of intra-articular fat pads, where they also often lie in close
association with blood vessels. Type II receptors are also more numerous in the cervical
apophyseal joint capsules. These receptors are low threshold, adapt rapidly and do not
11
discharge at rest. They discharge at the beginning and end of movement and are sensitive
to acceleration and deceleration. These receptors are reflexogenic and do not respond to
changes in joint position or movement. Type II receptors discharge in response to vibratory
stimulation and have transient inhibitory effects on the centripetal nociceptive afferent
activity, thus aiding in pain suppression (Middleditch and Oliver, 2005).
Type I and Type II receptor systems operate in both normal and abnormal circumstances.
The reduction in pain that is achieved by some treatment techniques, for example, passive
oscillatory mobilisation, traction and massage is thought to be in part due to stimulation of
type I and II mechanoreceptors, which have an inhibitory effect on afferent nociceptive
activity (Middleditch and Oliver, 2005).
c. Type III
Type III receptors occur only in intra- and extra-articular ligaments of peripheral joints.
These receptors are thus not present in the capsules or ligaments of vertebral joints
d. Type IV
Type IV receptors are distributed throughout the tissues of the spine but there are no
nociceptive nerve endings in the synovial membrane, articular cartilage and menisci. The
type IV receptor system is a three-dimensional plexus of unmyelinated nerve fibers. It is
nociceptive (pain-provoking), high threshold and non-adaptive. This system is activated
when its nerve endings are depolarised by high mechanical stress (e.g. abnormal posture,
fractures, dislocations) or exposure to chemical irritants (e.g. histamine, bradykinins, lactic
acid) which accumulate in the tissue fluid of acutely and chronically inflamed joints. These
nociceptors are also activated by thermal stimuli (temperatures of approximately fourty four
degrees Celsius or above) (Middleditch and Oliver, 2005). Non-nervous tissue can
stimulate the nociceptive nerve endings by releasing chemical irritants and these receptors
can thus provide sensory information to the central nervous system with regards to tissue
injury. Although these receptors send information to the central nervous system about
12
potential tissue injury, they are also are important in contributing to the inflammatory and
repair processes (Middleditch and Oliver, 2005).
2.2.7 Ligaments of the cervical spine
A ligament is a dense regular connective tissue, the collagen fibers are parallel to each
other, tightly packed and aligned with the forces applied to the tissues. A ligament is
flexible but extremely strong. A ligament connects bone to bone (Martini, 2006).
Figure 2.4: Ligaments of the Upper Cervical Spine (Moore and Dalley, 2006)
Table 2.1: Anatomy of the Upper Cervical Ligaments (Moore and Dalley, 2006)
Name of Ligament Attachments Function
Anterior atlanto- From the anterior arch of the atlas (C1) Limits extension of the
occipital membrane to the anterior margin of the foramen occiput on C1.
magnum.
Posterior atlanto- From the posterior arch of C1 to the Limits flexion of the occiput
occipital membrane posterior margin of the foramen on C1.
magnum.
Tectorial membrane From the posterior aspect of the Limits flexion and extension
vertebral body of the axis (C2), crossing of C1 on the occiput.
13
over the dens to attach to the superior
aspect of the occiput.
Alar ligaments From the posterolateral aspect of the Limits contralateral axial
dens to the medial surface of the rotation.
occipital condyle on the same side.
Accessory atlanto- From the base of the dens to the Strengthens the
axial ligaments inferomedial surface of each lateral posteromedial aspect of the
mass on the same side. capsule of the lateral
atlantoaxial joints.
Apical ligament of the From the posterosuperior aspect of the Prevents vertical translation
dens dens to the anterior margin of the and anterior shear of the
foramen magnum. occiput.
Cruciform ligament: Superior longitudinal band: Superior longitudinal band:
 Superior From the transverse ligament to the Keeps the transverse

longitudinal basilar part of the occipital bone. ligament in place and
band anchors C1 to the dens.
Transverse ligament of C1:
 Transverse
Transverse ligament of C1:
ligament of C1 From the medial tubercle of one lateral
 Inferior mass of C1, to the medial tubercle of Forms a diarthrodial joint with
longitudinal the opposite lateral mass of C1. the dens and allows C1 to
band pivot on C2.
Inferior longitudinal band:
Inferior longitudinal band:
From the transverse ligament to the
body of C2. Prevents the transverse
ligament moving superiorly.
14
Figure 2.5: Ligaments of the Lower Cervical Spine (Moore and Dalley, 2006)
Table 2.2: Anatomy of the Lower Cervical Ligaments (Moore and Dalley, 2006)
Name of Ligament Attachments Function
Anterior longitudinal Covers the anterior aspect of the Limits extension of the
ligament vertebral bodies and IVD‟s from the cervical spine.
occiput to the sacrum.
Posterior Covers the posterior aspect of the Prevents posterior IVD

longitudinal ligament vertebral bodies and IVDs from the protrusion.
posterior aspect of the body of C2 to the
sacrum.
Ligament flava (left Runs from the anteroinferior aspect of Aids in extension of the spine
and right) the lamina of the vertebra above to the and limits spinal flexion.
posterosuperior aspect of the lamina of
the vertebra below.
15
Ligamentum nuchae Anteriorly runs between the cervical Limits flexion.
spinous processes to the skin of the back
of the neck posteriorly.
Interspinous Runs between the spinous processes of Limits flexion.

ligaments each pair of vertebra from C2-C3 to L4-
L5.
Intertransverse Runs from one transverse process to the Limits lateral flexion.
ligaments transverse process of the vertebra below.
2.2.8 Muscles of the cervical spine
Figure 2.6: Superficial Muscles of the Neck (Netter, 2006)
16
Table 2.3: Superficial Muscles of the Neck (Moore and Dalley, 2006)
Muscle Superior Inferior Innervation Main Action

Attachment Attachment
Sternocleid Lateral surface of Sternal head: Spinal Unilateral: Laterally

o-mastoid mastoid process of anterior surface of accessory flexes the neck
(SCM) temporal bone and manubrium of nerve (CN XI, ipsilaterally.
lateral half of sternum motor);
Bilateral:
superior nuchal line.
Clavicular head: C2 and C3
Extends and flexes
superior surface of nerves (pain
the neck.
medial third of and
clavicle proprioceptio
n).
Trapezius Medial third of Lateral third of Spinal Unilateral: Lateral

superior nuchal line, clavicle, acromion accessory flexion to the same
external occipital and spine of nerve (CN XI, side.
protuberance, scapula. motor);
Bilateral: Extends
nuchal ligament,
C2 and C3 neck.
spinous processes
nerves (pain
of C7 – T12. Superior fibers:
and
Elevate pectoral
proprioceptio
girdle.
n).
Middle fibers: Retract
scapula.
Inferior fibers:
Depress shoulders.
Superior and inferior

fibers: Rotate scapula
upward.
17
Figure 2.7: Anterior Vertebral Muscles (Netter, 2006)
Table 2.4: Anterior Vertebral Muscles (Moore and Dalley, 2006)

Longus colli Anterior tubercle of Bodies of C5-T3; Anterior rami Unilateral: flexes
C1; bodies of C1- TVP‟s of C3-C5. of C2-C6 neck with rotation to
C3 and TVP‟s of spinal opposite side.
C3-C6. nerves.
Longus Basilar part of Anterior tubercles of Anterior rami Flex head.

capitis occipital bone. C3-C6 TVP‟s. of C1-C3
18
spinal
nerves.
Rectus Base of skull just Anterior surface of Branches Flex head.

capitis anterior to occipital lateral mass of C1. from loop
anterior condyle. between C1
and C2
spinal
nerves.
Anterior TVP‟s of C4-C6. 1st rib. Cervical Flex head.

scalene spinal nerves
C4-C6.
Figure 2.8: Superficial Muscles of the Neck (Netter, 2006)
19
Table 2.5: Lateral Vertebral Muscles (Moore and Dalley, 2006)

Rectus Jugular process of TVP of C1. Branches Flexes head and

capitis occipital bone. from loop helps to stabilise it.
lateralis between C1
and C2
spinal
nerves.
Splenius Inferior half of Lateral aspect of Posterior Laterally flexes and

capitis nuchal ligament and mastoid process rami of rotates head and
spinous processes and lateral third of middle neck to same side.
of superior six superior nuchal line. cervical Bilateral: extend head
thoracic vertebrae. spinal and neck.
nerves.
Splenius Nuchal ligament Tubercles of TVP‟s Posterior Laterally flexes and

cervicis and spinous of C1-C3 or C4. rami of rotates head and
processes of C7-T3 cervical neck to same side.
or T4. spinal Bilateral: extend head
nerves. and neck.
Levator Posterior tubercles Superior part of Dorsal Elevates scapula and

scapulae of TVP‟s C1-C4. medial border of scapular tilts its glenoid cavity
scapula. nerve C5 and inferiorly by rotating
cervical scapula.
spinal nerves
C3 and C4.
Middle Posterior tubercles Superior surface of Anterior rami Flexes neck laterally;
scalene of TVP‟s C4-C6. 1st rib; posterior of cervical elevates 1st rib during
groove for spinal
20
subclavian artery. nerves. forced inspiration.
Posterior Posterior tubercles External border of Anterior rami Flexes neck laterally;
scalene of TVP‟s C4-C6. 2nd rib. of cervical elevates 2nd rib
spinal nerves during forced
C7 and C8. inspiration.
Figure 2.9: Intermediate Layer of Intrinsic Back Muscles (Netter, 2006)
21
Table 2.6: Intermediate Layer of Intrinsic Back Muscles (Moore and Dalley, 2006)

Erector Arises by a broad Fibers run Posterior Unilateral: laterally

spinae: tendon from superiorly to rami of spinal flex vertebral column.
posterior part of: cervical TVP‟s. nerves.
Iliocostalis Bilateral: extend
iliac crest and
vertebral column and
cervicis sacrum, sacroiliac
head; as back and
ligaments, sacral
Fibers run neck is flexed,
and inferior
Longissimus superiorly to controls movement
lumbar spinous
cervical TVP‟s and by gradually
cervicis and processes and
to mastoid process lengthening their
supraspinous
capitis of temporal bone. fibers.
ligament.
Spinalis Fibers run

superiorly to
cervicis and
spinous processes
capitis in upper thoracic
region and to
cranium.
22
Figure 2.10: Suboccipital Muscles (Moore and Dalley, 2006)
Table 2.7: Suboccipital Muscles (Moore and Dalley, 2006)

Rectus Spinous process of Lateral part of Posterior Postural and

capitis C2. inferior nuchal line ramus of C1, proprioception.
posterior of occipital bone. the
Extension of head on
major suboccipital
C1.
nerve.
Rectus Posterior tubercle of Medial part of
Rotation (ipsilateral)
capitis posterior arch of inferior nuchal line
of head on C1 and
posterior C1. of occipital bone.
C2.
minor
Obliquus Spinous process of TVP of C1. Postural and

capitis
23
inferior C2. proprioception.
Rotation (ipsilateral)
of head on C1 and
C2.
Obliquus TVP of C1. Occipital bone Postural and

capitis between superior proprioception.
superior and inferior nuchal
Extension of head on
lines.
C1.
Lateral flexion of
head.
2.2.9 Spinal nerves, nerve roots and the spinal cord
Thirty-one pairs of spinal nerves arise from the spinal column. They are short nerves that
lie within the intervertebral foramina (Middleditch and Oliver, 2005) and exit the vertebral
column through the intervertebral foramina (Moore and Dalley, 2006). All thirty-one pairs of
spinal nerves are identified by a letter and number (e.g. T4) designating their order of origin
from the consecutive spinal cord segments (C, cervical; T, thoracic; L, lumbar; S, sacral;
Co, coccygeal). Spinal nerves initially arise from the spinal cord as rootlets, which then
converge to form two nerve roots, an anterior (ventral) root and a posterior (dorsal) root. An
anterior (ventral) root consists of motor (efferent) fibers that pass from the nerve cell bodies
in the anterior horn of the spinal cord gray matter to the effector organs located
peripherally. The posterior (dorsal) root consists of sensory (afferent) fibers from the cell
bodies in the spinal sensory or posterior (dorsal) root ganglion (DRG) that extend
peripherally to sensory endings and centrally to the posterior horn of the spinal cord gray
matter (Moore and Dalley, 2006). The DRG is collection of cell bodies of all the sensory
fibers that run in the related nerve and is situated near the junction of the dorsal and
ventral roots as a swelling on the dorsal root (Middleditch and Oliver, 2005).
24
The posterior and anterior nerve roots unite, either within or just proximal to the
intervertebral foramen, to form a mixed spinal nerve. This mixed spinal nerve then
immediately divides into two primary rami (branches), a posterior ramus and an anterior
ramus. The posterior and anterior rami carry both sensory and motor fibers, as do all their
subsequent branches, as they are branches of the mixed spinal nerve. The terms motor
nerve and sensory nerves are deemed relative terms, referring to the majority of fiber types
that are conveyed by a particular nerve (Moore and Dalley, 2006).
The dorsal roots of the spinal nerves relay sensory (afferent) fibres to the dorsal column
nuclei of the spinal cord, the nucleus cutaneous and the nucleus gracillis (Guyton and Hall,
1997).
According to Rexed (1952) the spinal cord consists of ten laminae (Cramer and Darby,
1995):
 Laminae I-II relay and edit pain related input
 Laminae III-V relay tactile information
 Laminae VI relay proprioceptive input and contain motor neurons innervating
autonomic effectors and skeletal muscle
 Laminae X consists of decussating axons
Therefore laminae VI will become activated during head and neck movements and the
participant will be aware of these movements.
25
Figure 2.11: Cross-Section of the Spinal Cord Illustrating the Ten Anatomical
Laminae of the Grey Matter and Ascending Sensory Tracts (in red) in the White
Columns of the Spinal Cord (Guyton, 1997)
2.3 Biomechanics of the Cervical Spine
The cervical spine has the greatest range of motion (ROM) of the total spine. The motion of
flexion, extension, lateral flexion and rotation are permitted in the cervical spine. These
types of motions are determined by the shape and direction of the articulating facets, the
shape of the IVD and the surrounding ligaments structures. These motions are also
accompanied by translations which increase in magnitude from C2 to C7 (Dvorak, Panjabi,
1991; Levange and Norkin, 2005), however the predominant translation occurs in the
sagittal plane during flexion and extension (Levange and Norkin, 2005; Middleditch, 2005).
2.3.1 Biomechanics of the upper cervical spine
a. Movement of the atlanto-occipital joint
The atlanto-occipital joint consists of two concave superior facets of the lateral masses of
the atlas with the two corresponding convex occipital condyles of the skull, forming a joint
with spherical articular surfaces. The superior facets of the atlas run obliquely, anteriorly
26
and medially (Clark, 2005; Levange and Norkin, 2005). The movement of the atlanto-
occipital joints (C0-C1) occurs primarily in the sagittal plane, producing flexion and
extension. There is also a small degree of rotation coupled with lateral flexion (Kapandji,
1974; Middleditch 2005).
i. Flexion and extension of the atlanto-occipital joint
During flexion and extension, the occipital condyles slide on the lateral masses of the atlas.
Flexion is brought about by the occipital condyles gliding posteriorly and superiorly on the
lateral masses of the atlas, as the occipital bone moves away from the posterior arch of the
atlas. Therefore this causes the posterior arches of the atlas and the axis to separate as
flexion of the atlanto-axial joint also occurs. Flexion is limited by tension developed in the
articular capsules, posterior atlanto-occipital membrane and the posterior cervical ligament
(Kapandji, 1974; Middleditch 2005).
During extension, the occipital condyles glide anteriorly on the lateral masses of the atlas
and the occipital bone moves closer to the posterior arch of the atlas. Extension is limited
by contact between the occiput and the posterior rim of the foramen magnum, the apex of
the odontoid process (dens) and by the impact of the occiput on the posterior tubercle of
the atlas (Kapandji, 1974; Middleditch, 2005).
ii. Rotation of the atlanto-occipital joint
Pure rotation does not occur at C0-C1. This motion is therefore a coupled motion in
conjunction with lateral flexion which results in an oblique tilt (Kapandji, 1974). Rotation of
the occiput on the atlas is dependent on rotation of the atlanto-axial joint. When the occiput
rotates to the left, for example, the right occipital condyle displaces anteriorly, relative to
the lateral mass of the right atlas. The lateral atlanto-occipital ligament is placed under
tension and will wrap itself around the dens, as it pulls the right occipital condyle medially
to the left. Rotation of the occiput to the left is therefore associated with a linear
displacement, to the ipsilateral side (left) and lateral flexion on the opposite side (right).
Rotation is limited by the alar ligaments (Kapandji, 1974).
27
iii. Lateral flexion of the atlanto-occipital joint
Lateral flexion performed at the atlanto-occipital joint causes no movement at the atlanto-
axial joint. Therefore, movement is restricted to the occiput and the atlas. Lateral flexion at
the atlanto-occipital joint is composed predominantly by coronal plane rotation and
translation. These two motions tend to occur in opposite directions due to the convex
shape of the occipital condyles and the concave shape of the superior articular facets of
the atlas. Thus the rotation movement occurs in the direction of lateral flexion while
translation occurs in the direction opposite to lateral flexion (Peterson and Bergman, 2002).
Therefore the lateral flexion motion is described as the „slipping‟ of the occipital condyles to
the right, during left lateral flexion and „slipping‟ of the occipital condyles to the left, during
right lateral flexion (Kapandji, 1974).
During lateral flexion to the left, the left occipital condyle and dens approximate, but do not
make contact, as movement is limited by the tension developed in the atlanto-occipital
capsular ligament and the right lateral odonto-occipital ligament (Kapandji, 1974).
b. Movements of the atlanto-axial joint
The atlanto-axial joint is made up of the atlanto-dental joint and two atlanto-axial joints,
these are three synovial joints. The atlanto-axial joint motion is primarily controlled by the
osseous geometry and ligamentous articulations (Kapandji, 1974; Levange and Norkin,
2005). Motion at the atlanto-axial joint includes rotation, lateral flexion as well as flexion
and extension. The primary motion between the atlas and the axis is rotation (Kapandji,
1974; Middleditch and Oliver, 2005).
i. Flexion and extension of the atlanto-axial joint
The articular surface of the atlanto-axial joint is biconvex in shape and therefore flexion and
extension of the atlas occurs as a rocking-type of motion. During flexion, the posterior
arches of the atlas and axis separate as the inferior facet of the lateral mass of the atlas
rolls anteriorly and slides posteriorly on the superior articular facet of the axis (Peterson
28
and Bergmann, 2002).The transverse ligament keeps the anterior arch of the atlas and the
dens of the axis in close contact, preventing opening at the atlanto-dental joint interspace.
The posterior arch of the atlas and the spinous process of the axis separate as the
posterior joint capsule stretches (Kapandji, 1974; Middleditch and Oliver, 2005).
During extension, the opposite occurs, as the posterior arch of the atlas and the spinous
process of the axis come into contact. It must also be noted that the transverse ligament is
a distortable structure and bends downwards during flexion and upwards during extension
(Kapandji, 1974).
ii. Rotation of the atlanto-axial joint
The predominant movement occurring at the atlanto-axial joint is axial rotation (Middleditch
and Oliver, 2005).
In the initial stages, the dens of the axis, which is centrally located, remains stationary. In
rotation to the left, the osteoligamentous ring formed by the atlas and the transverse
ligament moves anti-clockwise about an axis around the dens. The articular capsule on the
left is relaxed, while the articular capsule on the right is stretched. Movement also occurs in
the right and left atlanto-axial joints, which are mechanically linked. During left rotation, the
right lateral mass of the atlas moves forward while the left lateral mass recedes. The
opposite will occur in rotation to the right. However, the articular surface of the atlas is
convex inferiorly and the superior surface of the axis is convex. Thus at zero degrees of
rotation the atlas sits on the axis at its highest point and with rotation there is a vertical
displacement as the atlas slides inferiorly on the convex articular surface of the axis. As a
result the atlas will drop vertically by two or three millimetres, so that the movement is
spiral in nature (Kapandji, 1974).
iii. Lateral flexion of the atlanto-axial joint
Atlanto-axial joint lateral flexion is coupled with rotation, and is somewhat limited. Lateral
flexion of the atlanto-axial joint is therefore not considered as a separate movement
29
(Kapandji, 1974). During lateral flexion, the axis rotates and laterally bends to the side of
lateral flexion. The atlas is caught in a pincer action between the occiput and the axis and
is forced laterally with translation towards the side of preference (Kapandji, 1974).
2.3.2 Biomechanics of the lower cervical spine
a. Movements of the lower cervical spine
The lower cervical spine, C3-C7, shows similar movements of flexion, extension, lateral
flexion and rotation as does the upper cervical spine. Movement is governed by the
osseous geometry of the zygapophyseal facets and uncovertebral joints and the integrity if
the IVDs and as a result, movement occurs as a combination of all segments working
together. Motion at one interspace is generally accompanied by a similar motion at the
other spinal levels. There are two main types of movement, namely, flexion and extension,
and rotation coupled with lateral flexion (Kapandji, 1974; Levange and Norkin, 2005;
Gatterman, 1995).
b. Flexion and extension of the lower cervical spine
During flexion the overlying vertebral body tilts and slides superiorly and anteriorly. This
compresses the intervertebral space anteriorly, driving the nucleus pulposus slightly
posterior which stretches the annulus fibrosus. Flexion is limited by tension developed in
the posterior longitudinal ligament, capsular ligament, the posterior cervical ligaments, the
ligamentum flava and the ligamentum nuchae. There is no impaction of bony elements, to
limit flexion (Kapandji, 1974).
During extension of the lower cervical spine, the overlying vertebral body tilts and slides
inferiorly and posteriorly. This will compress the intervertebral space posteriorly and drives
the nucleus pulposus slightly anterior, stretching the anterior fibres of the annulus fibrosus.
The interspace between the two articular facet surfaces will widen anteriorly, as the
superior articular facet slides inferiorly and posteriorly and will also tilt posteriorly on the
inferior facet. Extension is limited by tension in the anterior longitudinal ligament, by the
30
impact of the posterior arches on the spinous processes and as well as by the impact of
the superior articular process of the lower vertebra on the transverse process of the upper
vertebra (Kapandji, 1974).
Flexion and extension is the greatest at C5-C6 with the least amount of movement found at
C7-T1 (Kapandji, 1974).
c. Rotation and lateral flexion of the lower cervical spine
The oblique positioning of the intervertebral joints of the lower cervical spine prevents pure
rotation or pure lateral flexion (Kapandji, 1974). The articular facets are flat, angled at forty-
five degrees horizontally and ninety degrees to the midsagittal plane. This would lead to
abutting of the zygapophyseal joints and a cessation of motion in pure rotation or lateral
flexion, and as a result, these motions are coupled (Gatterman, 1995; Levange and Norkin,
2005). The superior and inferior surfaces of the articular facets are not strictly flat. They are
slightly convex posteriorly between C6 and C7, while at C3 and C4, they are slightly
concave posteriorly. This increases the obliquity of the facet joints, from C7 to C3.
Therefore, the plane of the C7/T1 facet joint articulation lies almost in line with the vertical
axis. As a result, almost pure rotation will occur at this level. At the C2/C3 level the
obliquity of the plane, through the articular surfaces forms an angle of forty to forty-five
degrees with the vertical axis, therefore indicating almost equal rotation and lateral flexion
occurring at this level (Kapandji, 1974).
During lateral flexion, the inferior articular processes glide posteriorly and inferiorly on the
concave side, while they glide superiorly and anteriorly on the convex side (Kapandji,
1974).
Cervical rotation occurs in a transverse plane about a vertical axis between C2 and C7.
Rotation occurs in the same direction as lateral flexion (Kapandji, 1974).
31
2.3.3 Biomechanics of the uncovertebral joints
The uncovertebral joints function to limit the degree of lateral flexion and flexion, as well as
to provide support to the anterior and lateral aspects of the IVDs (Curl, 1994). During
flexion and extension, when the body of the upper vertebra slides anteriorly (flexion) or
posteriorly (extension), the articular facets of the uncovertebral joints also slide relative to
each other, thus guiding the vertebral body into this anteroposterior movement (Kapandji,
1974).
When undergoing lateral flexion, as part of the coupled motion with rotation, the
uncovertebral joint interspaces form an angle equal to the angle of lateral flexion produced
at that joint level. During lateral flexion, for example to the left, the interspaces of the
uncovertebral joints will open on the right and be stretched, and will close on the left. The
nucleus pulposus will be displaced laterally to the right (in a direction opposite to the side
of lateral flexion) (Kapandji, 1974).
2.3.4 Biomechanics of the intervertebral disc
The IVD‟s permit movement between adjacent vertebrae but also have a resilient
deformability, which allows them to serve as shock absorbers (Moore, 2005). During
flexion, the anterior aspect of the IVD is compressed and tends to bulge while the posterior
annulus fibres are under tensile stress. The nucleus pulposus is driven posteriorly in
flexion. The movement of the IVD and the nucleus pulposus will be reversed, when the
cervical spine is extended (Middleditch and Oliver, 2005).
During the movement of lateral flexion, the annular fibers are compressed and tend to
bulge on the side to which the movement occurs, while those on the opposite side have
their attachments stretched. The IVD height is decreased on side of the movement and the
nucleus pulposus is driven to the opposite side (Middleditch and Oliver, 2005).
In the movement of rotation, half of the annular fibers lie in the direction of rotation, while
the other half lie in the opposite direction. Therefore, during rotation to one side, only half
32
of the annular fibers have their points of attachments separated while the other half have
them brought closer together. Rotation places more strain on the outer annular fibers than
the inner fibers (Middleditch and Oliver, 2005).
2.4 Chronic Mechanical Neck Pain
2.4.1 Introduction
A symptom of pain experienced in the cervical spine, termed cervicalgia, is one of the most
prevalent musculoskeletal conditions found in western society (Cote, Cassidy, Carrol and
Kristman, 2004). Neck pain is caused by abnormal functioning of tissue found in the neck
and may be influenced by a multitude of factors, such as psychological, emotional, social
and cultural (Porterfield and DeRosa, 1995). Most neck pain is not caused by a specific
disease or disorder and is usually called muscular/mechanical/postural neck pain (Ferrari
and Russell, 2003). A majority of individuals with neck pain do not experience a resolution
in their pain and disability and this thus results in chronicity (Cote et al., 2004). Mechanical
neck pain is the most common type of cervical spine pain encountered. It is also referred to
as simple or non-specific neck pain and is common in all groups of people (Plaugher,
1993).
2.4.2 Aetiology
Neck pain is caused by abnormal functioning of cervical organs or tissues (Plaugher and
Lopes, 1993). The exact cause of mechanical neck pain is often unknown. It may include
myofascial trigger points, discogenic or ligaments in the cervical spine, cervical facet
syndrome or bad posture may also contribute to this pain (Plaugher, 1993). The muscles,
ligaments, joint capsules, vertebrae, intervertebral discs and associated neural elements
are all structures which contain nociceptive pain receptors and are therefore considered to
be pain generators of the cervical spine (Cote et al., 2004). Neck pain, although felt in the
neck, can be caused by numerous spinal problems. Muscular tightness in both the neck
and upper back or entrapment of nerves of the cervical vertebrae may result in neck pain.
33
Joint dysfunction in the cervical or upper thoracic spine may also cause neck pain (Binder,
2007).
Mechanical dysfunction is one of the most common causes of chronic neck pain (Pikula,
1999). Neck pain can either be intrinsic or extrinsic in nature. Intrinsic pain is broken down
into mechanical neck pain. This type of neck pain is any pain which originates from the
facet joints or intervertebral discs. Extrinsic conditions are conditions which cause pain in
the cervical spine such as nerve root irritation, compression neuropathies, shoulder
pathologies and cardiovascular conditions (Peloza, 2007). Borenstein, Wiesel and Boden
(2004) defined mechanical neck pain as pain secondary to overuse of a normal anatomic
structure or pain secondary to injury or deformity of an anatomic structure. Mechanical
disorders of the spine are the most common cause of neck pain and are local disorders of
the cervical spine. This limits the structures causing pain, to anatomical structures of the
cervical spine. Mechanical disorders are characteristically exacerbated by certain activities
and relieved by others (Borenstein et al., 2004).
Neck pain is prevalent in occupations associated with a flexed cervical spine posture or
repetitive lifting work. These involve the connective tissues and muscles of the cervical
spine and have been implicated with mechanical neck pain (Jordan, Mehlsen and
Ostergaard, 1997). Constant dysfunction leads to pathological changes, by allowing
disproportionate amounts of weight and pull to be inflicted on the cervical spine
(Christensen, 1996) and cervical muscles may undergo fatigue, due to overuse and poor
posture (Schofferman, 2001). The cervical facet component is estimated to be involved in
up to sixty-five percent of neck pain complaints (Carnes and Vizniak, 2010).
Chronic pain is described as pain experienced for a period of three months or longer and
may be constant, intermittent or variable in intensity (Borenstein, Wiesel and Boden, 1996).
Acute pain usually declines and resolves within a few weeks of onset and is a relatively
common experience. Sometimes, this is not the case and patients do not recover. With
prolonged continuance of the patient‟s symptoms, these patients will develop chronic pain
(Segen, 2002) which is defined as pain for three months or longer (Major, 2003).
34
2.4.3 Clinical presentation
Mechanical neck pain may be defined as pain which is aggravated by movement, relieved
by rest and that is not associated with serious underlying pathology. Patients complaining
of mechanical neck pain may experience symptoms such as a dull aching pain, which may
be sharp in character during inflammatory periods. There may be associated symptoms of
decreased cervical spine range of motion (ROM), muscle hypertonicity, pain and/or
headaches (Hubka and Hall, 1994; Carnes and Vizniak, 2010). Pain is usually localised to
the neck, but may refer to the head, shoulders and interscaplular areas (Segen, 2002).
On observation, the patient may be seen to have postural abnormalities such as: anterior
head carriage, increased or decreased cervical spine lordosis, increased kyphosis,
rounded shoulders, and/or torticollis. During physical examination the patient may show a
painful and/or decreased cervical ROM. Postural changes may also be evident, such as an
antalgic position of the head in comparison to the shoulder position. Active, passive and/or
resisted isometric movements may be limited and/or painful (Carnes and Vizniak, 2010).
Probable causes of mechanical neck pain may include cervical disc injuries/prolapsed,
whiplash, myofascial strains, ligamentous sprains, arthritis of the cervical spine, cervical
spine injury and occupational habits, such as poor posture (Carnes and Vizniak, 2010).
2.4.4 Pain referral
Mechanical cervical spine pain is often multifactorial, with an underlying disorder

exacerbated by fatigue, physical deconditioning and sometimes psychosocial stress or
psychiatric abnormality. Due to this multifactorial origin of neck pain, nociceptive structures
have been isolated as a source of the pain. Structures innervated by nociceptors include
the intervertebral discs, anterior and posterior longitudinal ligaments, facet joints, muscles
and nerve roots (Wyatt, 2004). Pain is produced in the neck by irritation of nociceptors in
the area. It has been demonstrated that the cervical spine has more mechanoreceptors per
surface area than any other region of the spinal column. The upper cervical region is
thought to have the greatest amount of receptors in the spine. Mechanoreceptive
35
innervation has been found in cervical facet joints, ligaments and intervertebral discs as
well as the muscle spindles and the fascia covering muscles (Eriksen, 2004).
Nociceptive information from one structure can cause pain to be referred to cutaneous
regions a distance away. The area of referral from a specific pain generator is related to
their area of embryological origin. Pain generators in the cervical spine include muscles,
ligaments, vertebrae, intervertebral discs and the neural elements. Damage to any of these
structures can potentially cause referred pain to a region much larger than the area
immediately surrounding the damaged tissue. This pain referral is caused by a central
mechanism in the cord, where nociceptive information from a pain generator converges in
an interneuronal pool that has also received primary sensory information from a different
cutanueous region. Neurons within the ascending pain pathway that carry nociceptive
information from cutaneous areas are stimulated. The cerebral cortex then interprets this
as coming from a cutaneous origin, thus resulting in conscious awareness of pain at the
referral site. Somatic referred pain can therefore be defined as any pain generated by a
skeletal or related structure that is felt distant to the structure generating the pain (Darby
and Cramer, 1994).
2.5 Manual Therapy
2.5.1 The chiropractic subluxation
D.D. Palmer, the original founder of chiropractic, proposed that the subluxation of a
vertebra is a slight deviation from its normal relation to the adjacent vertebra (above or
below) and this is said to cause a modification and narrowing of the intervertebral foramina
(Charles and Lantz, 2005). According to Haldeman (2000), this vertebral subluxation can
cause irritation to the spinal nerve root, which in turn causes interference with normal nerve
root function. This will result in pain, loss of motion, muscle spasm and other clinical
symptoms and pathology (Haldeman, 2000). Gatterman defines a subluxation as an
alteration of alignment and movement of a motion segment, even though contact between
the surfaces remains intact. The physiological function of the motion segment may be
altered, without structural changes (Gatterman, 2004).
36
The above statements are chiropractic definitions of a subluxation and not a medical
definition. A medical definition of a subluxation implies an unstable segment, which is less
severe than a dislocation. As a result, the term dysfunction or segmental dysfunction is
commonly preferred. This implies that there are abnormal motion characteristics at the
spinal motion segments (Plaugher, 1993).
2.5.2 The Vertebral Subluxation Complex
The Vertebral Subluxation Complex (VSC) is a theoretical model of motion segment

dysfunction that incorporates the complex interaction of pathological changes in nerve,
muscle, ligamentous, vascular and connective tissue (Leach, 1994).
A motion segment, particularly a spinal motion segment, is considered a functional unit. It

incorporates the articular surfaces of two adjacent vertebrae and the connecting tissues
which bind them together (Gatterman, 2005). The two adjacent vertebrae are joined by an
IVD, two posterior articulations, a number of ligaments and a joint capsule (Leach, 1994).
Within the chiropractic profession, there is a growing consensus that the VSC occurs due
to segmental dysfunction with motion disturbance, inflammation and ischemia. This, as a
result, leads to joint instability, spinal degeneration and stabilisation (Leach, 1994). The
comprehensive theoretical model that is the VSC, is comprised of the interplay between
neuropathology, kinesiopathology, myopathology, histopathology, connective tissue,
vascular, inflammatory, anatomic, physiologic and biochemical changes within the VSC.
These will lead to a collection of signs and symptoms that the patient experiences and that
the practitioner observes (Gatterman, 2004).
a. Kinesiopathology
A motion segment is a three-joint complex and is considered the basic functional unit of
spinal mobility. It may be viewed as a single, compound joint, having three articulations;
these include the IVD and two posterior articulations. Joint movement is therefore
complicated and one must also consider the role of ligamentous, capsular and muscular
37
systems (Leach, 2004). The spine is an integral unit, where a decrease in movement at
one level may lead to compensatory changes in other areas. Therefore no single
component of a motion segment may exist without affecting functions of other levels of the
spine. Apart from specific intersegmental movement, gross range of motion must also be
considered (Gatterman, 2005).
A hypomobile joint is one of the most accepted ideas in chiropractic and is the concept of
restricted movement of the motion segment. All circumstances that lead to immobilisation
cause degenerative changes to some extent and the lack of movement in the
musculoskeletal system leads to initial stiffness and pain, followed by joint degeneration
and eventually fusion may occur (Gatterman, 2005; Leach 2004).
b. Neuropathology
The neurological component of the VSC is considered the cornerstone of Chiropractic

theory and pain is the most significant factor for patients who seek chiropractic care
(Leach, 1994). Early chiropractic paradigms stressed the effects of altered nerve root
function as the cause for secondary somatic or visceral dysfunction (Peterson and
Bergmann, 2002). The segmental nerve is an integral component of each vertebral joint.
Subluxations are speculated to structurally alter the size of the intervertebral foramen (IVF)
thus compressing the neurovascular structures within the IVF, and so impair the function of
the nerve root (Gillette, Kramis, and Roberts, 1991). Degeneration of the spinal
articulations will also affect the associated spinal nerves. Herniated discs, hypertrophy of
the zygapophyseal joints, spurs and osteophytes around the joints of Luschka may impinge
on segmental nerve roots, leading to pain (Leach, 1994). Therefore muscle strength,
reflexes, altered sensations and pain responses are primary indicators of neurological
function (Lantz, 1995).
c. Myopathology
Muscle spindles are adversely affected by immobilisation, showing significant

morphological, physiological and biochemical changes. These changes include shortening,
38
thickening and degeneration of primary muscle spindles endings and potential loss of
cross-striations of the muscle spindles. Muscle spasticity leads to joint contracture, which
will lead to more spasticity and muscular contracture. Physiological alterations include an
increased sensitivity to stretch and elevation of the resting rate of discharge. This leads to
an over-stimulation of the muscle groups resulting in muscle spasm and tender trigger
points. The changes in muscle function are often completely reversible, but the time
required for complete restoration is dependent on the period of immobilisation (Leach,
1994). Muscle spasm may reduce spinal mobility. Mechanisms which cause muscle spasm
are varied and it often exists at multiple spinal levels. When joints are immobilised, the
muscles that surround the associated joints undergo what is termed disuse atrophy and in
turn this contributes to joint degeneration (Lantz, 1995; Plaugher, 1993).
d. Connective tissue pathology
The major changes of connective tissue are seen when the joint is immobilised. These
changes can also be classified as histopathological changes. These microscopic changes
occur when spinal muscles, joints and discs undergo tissue degeneration (Gatterman,
2005).
Connective tissue is composed of collagen fibres embedded in a protein-polysaccharide

matrix, called ground substance. Connective tissue has two major qualities: elastic and
viscous stretch. This allows the connective tissue to increase in length, with a spring-like
behaviour. When it is loaded, connective tissue elongates and when the load is removed,
the tissue returns back to its original shape and length (Gatterman, 2005). According to
Evans, Eggers, Butler and Blumel (1960), when the joint is immobilised, the synovial tissue
undergoes fibrous fatty consolidation, which will produce a fibrous tissue matrix for the
deposition of bone salts and this causes a shrinkage of the articular cartilage (Lantz, 1995)
leading to adhesion formation (Leach, 1994). Leach (1994) showed that the zygapophyseal
joints underwent histopathological changes within four weeks of spinal immobilisation,
osteophytes developed in the articular processes and degenerative changes occurred on
the articular surfaces.
39
e. Vascular pathology
Each motion segmental unit receives a segmental artery that passes through the
intervertebral canal into the spinal canal and then divides into two radicular arteries, the
dorsal and ventral arteries (Lantz, 1995). These segmental arteries supply the spinal
nerves. If these arteries become occluded due to joint immobilisation, the lack of venous
drainage is thought to lead to increased capillary pressure, decreased arterial blood flow
and the production of local ischaemia, inflammation and potential associated joint stiffness
(Peterson and Bergmann, 2002). Compression of these arteries within the IVF will affect
the vascular component before it directly affects the neurological structures (Leach, 1994).
A segmental vein drains each motion segment and the related spinal canal (Peterson and
Bergmann, 2002). Immobilisation may lead to localised venous stasis, which effectively
creates a relative negative pressure at the area of immobilisation. Retrograde venous flow
can then bring toxins into the area that is immobilised. Whenever venous stasis occurs,
there is a reduced rate of removal of metabolic toxins, which in turn leads to inflammation
and ultimately accelerating the degenerative process (Lantz, 1995). This will lead to
inflammation and accelerates the degenerative process. The blood vessels, which supply
nerve tissue, are more prone to compression, resulting in neuroischaemia (Gatterman,
2005).
f. Inflammatory response
The inflammatory response is mediated by the vascular system and is a composed of

cellular and biochemical processes. These processes are initiated by events in the tissues
themselves (Leach, 1994; Lantz, 1995). An inflammatory reaction is initiated by
musculoskeletal dysfunction and this is identical to that of an infection. Pain that
accompanies inflammation may initiate a local reflex muscle contraction, which over time,
may lead to ischemia and therefore more pain (Bergmann and Peterson, 2002).
Inflammation is linked intimately with the immune system and is necessary for proper
healing of tissues during the repair process. Inflammation is usually well regulated, but if
there is marked oedema with an accumulation of primary neutrophils and leukocytes, it
40
may lead to scar formation (Lantz, 1990). Immobilisation of joints clearly leads to an
inflammatory response, which ultimately leads to ossification (Lantz, 1995). Chronic
episodes of inflammation may eventually result in ossification of paraspinal ligaments. The
restoration of motion leads to a decrease in the degenerative process (Lantz, 1990).
Inflammation causes nerves to become hyper-excitable and display different behaviour

from normal nerves. The dorsal root ganglion of normal nerves responds to mechanical
stimulation by the creation of an action potential. These action potentials stop on
termination of the stimulus. However, with inflammation prolonged firing of the ganglia
occurs, long after the stimulus has been removed. This may lead to an increase in muscle
tone, as the nerves remain exposed to inflammatory by-products and remain in a hyper-
excited state (Lantz, 1990; Plaugher). Thus compressive forces need not directly affect the
nerves to affect neurological function (Lantz, 1995).
2.5.3 Chiropractic manipulative therapy
Chiropractic manipulative therapy (CMT) is a specific form of articular manipulation,

especially of the vertebral column. This is performed either manually, mechanically,
actively or passively in order to restore normal articular alignment and function (Gatterman,
2005).
Short lever techniques with specific contacts, characterised by a dynamic thrust of

controlled velocity, amplitude and direction are involved in the therapy of chiropractic spinal
manipulation (Bergmann and Peterson, 2002). This manipulative therapy forces the joint
surfaces beyond the initial barrier of resistance until it reaches the safe anatomical space
of joint play (Leach, 2004). The three-joint complex passes through the normal
physiological range of movement into the paraphysiological space without exceeding the
normal limit of anatomical integrity, thereby removing impingements and returning nerves
to their normal tonicity (Gatterman, 2005).
CMT techniques are applied by hand and various patient positions and hand placements
maximise leverage and the direction of force (Herzog, 2000). Due to the specific nature of
41
the chiropractic adjustment, it protects normal non-subluxated segments from any trauma
resulting from the thrust of an adjustment (Plaugher, 1993).
The clinician controls the direction, magnitude and velocity of the thrust and the ability of
the clinician to control these three factors, once the specific contact with the restricted
segment is made, determines the skill of the CMT delivered to a particular segment.
Contact is made on the paraspinal tissues, which overlies the spinous, transverse and
mamillary processes of the vertebrae being adjusted. The clinician will then deliver a
dynamic thrust in this specified area. Using this short lever arm technique applied directly
over the involved vertebral segment minimises the force that is required to accomplish the
chiropractic adjustment. This decreases the amount of compliant tissue through which the
force of the chiropractic adjustment must be transmitted (Pickar, 2002). Chiropractors
frequently use the above mentioned procedures to manipulate joint and neurophysiological
function in order to decrease pain and increase cervical spine range of motion (Esposito
and Phillipson, 2005).
Any reversible mechanical derangement of the intervertebral joint, which leads to a block in
normal joint motion, is an indication for CMT. A movement restriction is referred to as a
fixation of the joint, joint locking or joint blockage (Gatterman, 2004).
Restoration of the tissue to a normal state is thus achieved by CMT, by altering the
autonomic nervous system regulation and spinal and peripheral nerve conduction
(Plaugher and Lopes, 1993). The ability to sustain these effects is dependent on the body‟s
capacity to accommodate or to repair and restore the pre-injury distribution of loads
through the tissues (Herzog, 2000). Chiropractic is based on the theory that reversible joint
dysfunction of the spine may result in negative effects on the human body which may in
turn initiate the VSC. Chiropractors thus rely on SMT as their primary tool to reverse the
subluxation complex (Gatterman, 2004).
42
2.5.4 The effects of chiropractic manipulative therapy
The removal of the subluxation or fixation and restoration of joint function is the aim of
manual therapy (Gatterman, 2005). The adjustment opens or gaps a joint to increase
space or stretch the tissue that causes a restriction of movement, thus providing a local
mechanical, neurological and vascular effect (Esposito and Philipson, 2005).
a. Mechanical effects
CMT causes changes in joint alignment and dysfunctional joint motion (Gatterman, 2005).
Individual motion segments can buckle, resulting in large vertebral motions which achieve
a new position of stable equilibrium (Pickar, 2002). Motion segment buckling is when the
motion segment concerned, is structurally completely normal, but the motion segment itself
will alter the behaviour of other motion segments within the spine during spinal loading. As
a result, the system of joints undergo unacceptable deformation and can irritate the
surrounding tissues and lead to motion changes (Gatterman, 2005). The mechanical force
of manual therapy is delivered to dysfunctional joints to alter the segmental biomechanics.
The breakdown of contractile and collagen adhesions in the local soft tissue, through
mechanical force application, will provide an increase in available active and passive range
of motion (Gillet, 1963; Kirkaldy-Willis, 1992; Pickar and Wheeler, 2001; Sandoz, 1981).
Regardless of the mechanism of injury, a resulting inflammatory response is triggered

(Howe, 1970). Manual therapies directed at minimising the extent of associated
inflammatory exudates are helpful in reducing pain and muscle spasm (Fitz-Ritson, 1990).
CMT may provide sufficient energy to restore a buckled segment to a lower energy level
and thus reduce the mechanical stress or strain on soft and hard paraspinal tissues. This
may restore the mobility and joint play in the zygapophyseal joint (Pickar, 2002).
Early conservative management is directed at limiting the extent of the inflammatory

response (Fitz-Ritson, 1990). As the exudates that form by-products of inflammation, set
the stage for the next step in the connective tissue repair by providing the matrix for the
development of granulation tissue for scar formation. Therefore if immobilisation leads to
43
decreased flexibility, joint mobilisation or manipulation should be directed to restore motion
(Stonebrink, 1990).
Clinical evidence has shown that CMT affects the neuromusculoskeletal system
(Lawrence, 1991). Active and passive range of motion increases and articular adhesions
are broken (Cassidy, Lopes, Yong-Hing, 1992). Joint space increases, which stimulates
the mechanoreceptors and affects segmental muscle tension (Kirkaldy-Willis, 1992) and a
subjective decrease in pain levels has been reported, in other words, reflex pain inhibition
has occurred (Lawrence, 1991). The biomechanical change, caused by chiropractic
manual therapy, may be caused by the effects on the inflow of sensory information to the
central nervous system (CNS). As CMT releases trapped meniscoids or discal material or
normalising a buckled segment, the mechanical input may decrease the nocioceptive input
from the nerve endings in the innervated paraspinal tissues or joint capsules (Picker,
2002).
b. Soft tissue effects
Joint dysfunction may alter the signalling properties of mechanically or chemically sensitive
neurons in the paraspinal soft tissues. It may cause pain, altered muscle function or
alteration of visceromotor activities (Picker, 2002). CMT may therefore increase movement
in dehydrated tissues and promote the imbibition of fluid (Gatterman, 2005).
Spinal structures are richly innervated and the multiple sensory receptors in muscle,
ligament, facet joints, paraspinal skin, the meninges and outer fibres of the IVD, are all
responsive to direct mechanical forces applied during CMT. Each neural receptor in each
spinal structure has different characteristics and sensitivities and stimulation of these
receptors activates central reflex pathways and somato-somatic reflexes, relieving muscle
spasm and increasing range of motion. Chiropractic is thus believed to have a direct effect
on the structures which surround the spine (Haldeman, 2000).
CMT changes the tone and strength of the supporting musculature, by stretching
segmental muscles and causing spindle reflexes, which may reduce hypertonicity
44
(Gatterman, 2005). Chiropractic SMT also breaks up adhesions, which in turn could
account for the instantaneous changes that occur in intersegmental motion once
chiropractic SMT is delivered (Plaugher, 1993).
c. Neurological effects
When joint motion is lost, type I, II and III mechanoreceptors become inactive, thus
allowing the type IV nociceptors to become active and therefore allowing the perception of
pain. CMT will restore joint motion and will result in normal functioning of the type I, II, III
mechanoreceptors, while the type IV nociceptors will be inhibited (Gatterman, 2005).
Manual therapy (or CMT) stimulates the mechanoreceptors associated with synovial joints
and restores their normal function. The mechanical force applied during manual therapy is
below the mechanical threshold of the mechanoreceptors. This proposes that the receptive
nerve endings are affected by manual therapy (Gatterman, 2005). The biomechanical
changes caused as a result of manual therapy affects the nervous system‟s neural activity
by removing the aberrant sensory input or providing new input through the adjustment
(Leach, 1994). This results in a reflex inhibition of pain and reflex muscle relaxation, thus
leading to increased mobility (Cassidy et al., 1992). This is the predominant theory with
regards to the effect that chiropractic SMT (manual therapy) has on altered joint function
(Haldeman, 2000).
The mechanism by which CMT works remains uncertain, but it seems to cause a reflex
effect on pain and muscle tension (Cassidy et al., 1992), while also affecting the primary
afferent neurons from paraspinal tissues, the motor control system and pain processing
centers (Pickar, 2002).
High velocity chiropractic manipulative techniques delivered to dysfunctional joints can

result in decreasing the amplitude of cortical somatosensory responses in the cerebrum.
Somatosensory changes persisted in the CNS for twenty to thirty minutes; following a
single treatment of CMT. The exact mechanism remains relatively unknown with regards to
these changes. The greatest amplitude change was noted in the cortical loop, which links
the basal ganglia, thalamus, pre-motor areas and the primary motor complex. This
45
suggests that CMT of dysfunctional joints alters the transmission of neural signals at a
spinal level as well as at a cortical level too. The decrease in the amplitude of the cortical
somatosensory responses following CMT, reflects a normalisation of afferent input and
may be a mechanism for the improvement of functional ability (Haavik-Taylor and Murphy,
2007).
CMT provides pain relief; however, it is difficult to explain the mechanisms by which this
occurs as there are multiple factors which lead to the origin of spinal pain (Haldeman,
2000; Tseng, Wang, Chen, Hou, Chen and Lieu, 2006). Manual therapy delivered to
mechanically dysfunctional joints may normalise articular afferent input to the nervous
system, re-establish a normal kinaesthetic reflex and normalise nociceptive thresholds, as
well as to decrease pain (Peterson and Bergmann, 2002).
2.6 Proprioception
The dorsomedial pathway provides information on the exact position of the body‟s parts in
space, including the range and direction of movement of the joint in space. Information is
also provided about the shape, size and weight of an object, which is held in the hand. This
is known as proprioception (Kiernan, 1998). When vision is absent, we have an accurate
sense of limb position. This implies that, without visual signals, a human being still knows
the position of different body parts at any time during a movement and has an accurate
location of the body part in space. In order for this to occur the body relies on the
proprioceptive system to achieve such precise placements (Fortier and Basset, 2012).
Charles Sherrington first defined proprioception in 1906, by introducing his classification of

the senses. He classified proprioceptors as those afferent nerve endings that receive and
transmit afferent information about mechanical stimuli generated within the body,
especially from the musculoskeletal framework. Conventionally, proprioception consists of
four senses: the kinaesthetic sense, the sense of tension, the sense of effort, and the
sense of balance. Proprioception is one of the three somatic senses that are functions of
the nervous system collecting sensory information from the body, to the exclusion of the
special senses (sight, hearing, taste, touch, smell, and vestibular). In other words,
46
proprioception is the cumulative neural input to the central nervous system (CNS) from
specialised nerve endings, called mechanoreceptors, located in the joints, capsules,
ligaments, muscles, tendons and skin (Fortier and Basset, 2012).
Proprioception can refer to all neural inputs, which originate from joints, muscles and
tendons. These neural inputs are then projected to the CNS for processing and result in
motor control and the regulation of reflexes (Lephart and Fu, 2000). The CNS is able to
extract and use the proprioceptive information to co-ordinate discrete movement
sequences, by using both velocity and position information, provided by proprioeptive
afferents and muscle spindles (Cordo, Bevan, Gurfinkel, Carlton and Kerr, 1994). The
somatosensory cortex is the highest level of organisation, which processes proprioceptive
information and provides conscious awareness of the joint position in space. This is known
as joint position sense, where joint motion is known as kinaesthesia (Lephart and Fu,
2000).
Afferentation refers to the transmission of afferent nerve impulses along afferent nerve
fibers. Seventy-five to ninety-five percent of joint afferents are related to nociceptors. Only
five to twenty-five percent of afferents are related to mechanoreceptors (Gatterman, 2005;
Seaman and Winterstein, 1998). Under normal conditions, axons transmit coherent, low
intensity signals from joint mechanoreceptors at the site of articulation to the interneurons.
The interneurons will then amplify the signal as they are highly excitable. This amplified
signal is then projected to the motorneurons and pre-ganglionic sympathetic neurons to
produce accurate adaptive motor and sympathetic reflex responses (Slosberg, 1988).
Mechanically dysfunctional, hypomobile joints can act as a source of altered afferent

impulses. Movement is required as the adequate stimulus for proper mechanoreceptor
function, and therefore hypomobile joints will decrease mechanoreceptor activity.
Hypomobile joints will produce an altered afferent input, which will induce a persistent
nociceptive input, as well as an altered and decreased proprioceptive input. This therefore
will produce pain (Gatterman, 2005; Seaman and Winterstein, 1998). When joint
dysfunction or tissue damage occurs, the intensity of the sensory signal is increased and
this produces more impulses per unit of time. This results in high intensity impulses from
47
nociceptors, which will disrupt the normally low intensity sensory input. The altered
amplified sensory pattern is then transmitted and further amplified by the excitable
interneurons, to the motorneurons in the same or adjacent segmental levels. This results in
a constant, excessive, high intensity stimulus. Manifestation of which is muscle spasm,
joint hypomobility and sustained sympathetic hypertonus, with the end result being an
inappropriate efferent response which is excessive, disruptive and maladaptive (Slosberg,
1988).
2.6.1 The neuroanatomical components of the proprioceptive system
a. Receptors of proprioception
There are four types of sensory endings which are located in the ligaments and in the
capsules of synovial joints. Three of these endings are encapsulated and include Pacinian,
Ruffini‟s and tendon stretch receptors (Golgi tendon organs). These receptors provide
information to the central nervous system regarding the position and movements of the
joints. These receptors are primarily involved in proprioception (McLain, 1994; Snell, 1997).
The fourth type of sensory ending is non-encapsulated and transmits pain sensations
(Snell, 1997).
b. Joint Mechanoreceptors
Type I, II and III mechanoreceptor endings have been found in the cervical spine facets.
These receptors are encapsulated and there is no apparent difference in the distribution of
these receptors between the upper and lower cervical spine. The cervical spine facet joint
capsules contain significant densities and distributions of mechanoreceptors (McLain,
1994).
These mechanoreceptors provide proprioceptive information regarding the movement of

the head on the trunk. Input from these mechanoreceptors may only be present during low
speed head movements (Rix and Bagust, 2001).
48
These receptors are responsive to spinal adjustive-like loads. They are not active at rest or
during the application of the pre-load force during an adjustment. The receptor is rapidly
adapting and shows a brief discharge during the application of the impulse force, which is
only twenty-five percent higher than the initial pre-load force (Pickar and Wheeler, 2001).
Mechanoreceptors are classified as ruffini endings, pacini corpuscles and golgi-like

receptors.
i. Ruffini Ending
The Ruffini ending is a Coil-shaped, partial encapsulated, dendritic nerve ending with a
bulbous terminal. It is a slow adapting, low-threshold receptor, which is constantly reactive
during joint motion. Additionally, these endings have been found to react to axial loading
and tensile strain in the ligaments therefore revealing their importance in signaling joint
position and rotation. These characteristics are believed to be of importance in the
regulation of the static joint position and preparatory control of the muscles around the joint
(Hagert, 2010).
ii. Pacini Corpuscle
The Pacini corpuscle also referred to as a lamellated sensory corpuscle, (indicating the
thick, layered capsule that characterises this nerve ending). The Pacini corpuscle differs
from the Ruffini ending, in that it is a rapidly adapting, high-threshold receptor sensitive to
joint acceleration/deceleration that is, it is able to sense mechanical disturbances and it is
sensitive to compressive but not tensile forces. These characteristics make the Pacini
corpuscle ideal for sensing sudden joint movements, and signalling during possibly harmful
joint motions such as distortion and injury in the ligamentous system (Hagert, 2010).
49
iii. Golgi-like Receptor
The “Golgi tendon organs” are found in the myotendinous junctions. The Golgi-type
endings are only active at the extremes of joint motion. Golgi-type endings are important in
monitoring tensile strain during ultimate angles of joint motion (Hagert, 2010).
Figure 2.12: Sensory Receptors of the Skin. (A) Ruffini Corpuscle. (B) Free Nerve
Endings in the Epidermis Where They Lie Between Contiguous Epithelial Cells.
(C) Pacinian Corpuscle. (D) Meissner’s Corpuscle. (E) Merkel’s Corpuscle (Noback,
Strominger, Demarest and Ruggiero, 2005)
2.6.2 Pathway of proprioception
Information regarding discriminative touch and proprioception, from the upper parts of the
body are transmitted via identical pathways (Kiernan, 1998). Both afferent and efferent
fibres are similar in size, therefore to know the nature of the fibre, one needs to know its
50
origin or termination. There are different groups of afferent fibres, namely Group I, II, III and
IV. This classification is based on fibre size, where Group I is the largest and Group IV is
the smallest. Group I and II afferents are mechanoreceptors and Group III and IV are
nociceptors (Gatterman, 2005).
When these mechanoreceptors from the cervical facet joints are stimulated, they send
afferent information which is transmitted to the dorsal horn of grey matter of the spinal
cord. Which then project to lamina 1 and lamina 2 of the dorsal horn of grey matter. These
afferent fibres may descend or ascend one or two spinal cord segments, from their point of
entry, to synapse with cells in the posterior horn of grey matter, at a level distal or proximal
to their point of entry (Bolton, 1998; Snell, 1997). The central axons of these fibres will then
enter the posterior column of white matter within the spinal cord (Missankov, 2001). These
long ascending fibres continue travelling upwards in the posterior column of white matter
as the fasciculus gracillis and fasciculus cuneatus (refer to figure 2.12). The ascending
fibres of the fasciculus cuneatus are only present in the levels of C1-C7 and T1-T6 (Snell,
1997).
In the caudal half of the medulla oblongata, lies the nucleus gracillis and nucleus
cutaneous. This is the site where the ascending fasciculus gracilllis and fasciculus
cuneatus fibres will cross the midline to the opposite side of the medulla oblongata
(Missankov, 2001). These fibres continue to ascend as they join the sensory medial
lemniscus. They will then pass through the medulla oblongata, the pons and the midbrain,
to terminate in the ventral posterolateral nucleus of the thalamus. The fibres then pass
through the posterior limb of the internal capsule to the postcentral gyrus of the cerebral
cortex, which is the sensory area of the brain (Missancov, 2001; Snell, 1997). This area is
the only proprioceptive afferent destination which produces proprioception of the joints and
allows perception (refer to figure 2.12 and 2.13) (Stillman, 2002; Noback, Strominger,
Demarest and Ruggiero, 2005).
Some information is transmitted to the cerebellum, which is the primary localisation for the
complex integration of somato-sensation and proprioception, which are so important for
(subconscious) regulation of postures, balance, and movement and therefore is concerned
51
with the unconscious neuromuscular control of a joint (refer to figure 2.13 and 2.14)
(Stillman, 2002; Noback, Strominger, Demarest and Ruggiero, 2005).
Figure 2.13: Components and destinations of the proprioceptive system. On the left,
proprioceptive afferent pathways from skin, muscle and joint enter the spinal cord
via the dorsal roots. The three derived pathways (1-3) pass to the ventral grey matter
of the spinal cord, the cerebellum, and the sensory cerebral cortex respectively. A
hypothetical pathway for corollary discharges from the upper motor neurones is
also shown (4). The transverse section of the spinal cord on the right provides
greater detail of the spinal connections (Stillman, 2002)
52
Figure 2.14: The Discriminatory General Sensory Pathways Originating in the Spinal
Cord Comprise the Posterior Column-Medial Lemniscus Pathway and the Anterior
Spinothalamic Tract (Noback, Strominger, Demarest and Ruggiero, 2005)
53
2.6.3 Joint Position Sense Function/ Head Repositioning Accuracy
Joint position sense is dependent on mechanoreceptor input, which is derived from the
articular and muscular components of the proprioceptive system. Any angular change in
the joints is determined by this system (Palmgren, Sandström, Lundqvist and Heikkilä,
2006). A method for assessing and evaluating the joint position sense (cervicocephalic
kinaesthesia or head repositioning accuracy [HRA]) of the cervical spine was adapted and
developed by Revel, Andre-Deshays and Minguet (1991) and Loudon, Ruhl and Field
(1997). This system was designed to determine and examine how accurately an individual
could reposition the head, after it was moved away from a starting reference point. This
became known as the Cervicocephalic Kinesthethic Sensibility Test (Teng, Chai, Lai and
Wang, 2007).
During Revel et al. (1991) and Loudon et al (1997) studies, each participant was
blindfolded to eliminate the use of the visual system in providing information regarding joint
position sense during the movement of the head relative to the trunk. This technique of
assessing joint position sense provided a method for evaluating and quantifying the extent
of proprioceptive loss in the cervical spine (Loudon et al., 1997; Revel et al., 1991). This
was done to ensure that there was no interference of the visual and vestibular systems in
joint position sense. Any orientation of the head in space, relative to the trunk relies on
input from the visual and vestibular systems, as well as structures in the cervical spine
responsible for detecting joint position sense (Palmgren et al., 2006).
There are several mechanisms by which neck pain may cause altered somatosensory
input and integration. These include direct trauma sustained to the cervical receptors and
the surround musculature. Chemosensitive nerve endings found in joints and muscles may
become activated by inflammatory mediators and thus results in pain production.
Neuromuscular control can be influenced by the production of pain, as there is an
alteration in the afferent input to the CNS (Field, Treleaven and Jull, 2007).
Research has been conducted on patients with cervical pain, in order to determine joint
position sense (Revel et al., 1991; Sjölander, Michaelson, Jaric and Djupsjöbacka, 2007;
54
Teng et al., 2007). Middle-aged patients with a history of mild chronic neck pain did not
show a decrease in joint position sense when compared to a similarly aged group who had
no history of neck pain. Pain sensation is thus not an interfering factor in altered joint
position sense and the neck pain in itself may not cause an alteration of joint position
sense. However, altered neck proprioception and joint position sense has been
documented in patients with chronic neck pain, but there is no direct evidence of the
relationship between chronic non-traumatic neck pain and neck proprioception (Revel et
al., 1991; Teng et al., 2007). Neck pain is subjective and cannot be easily objectively
quantified, especially if it is subclinical and occurs intermittently. It appears that is it the
pain frequency that is associated with the altered neck proprioception, instead of the
intensity or duration of the pain itself (Lee, Wang, Yao and Wang, 2007).
2.6.4 The effects of altered neck proprioception
Proprioception‟s primary involvement is concerned with postural and occulomotor control.

The functional instability of joints is related to altered joint position sense. This results in
the joints becoming susceptible to repetitive injury and may also result in chronic pain and
degenerative joint disease (Heikkilä and Wenngren, 1998; Palmgren et al., 2006).
The function of controlling head movement by the proprioceptive system is to achieve a

desirable posture and orientation of the head, in order for optimal accuracy to be achieved
while performing tasks with the limbs. If the target‟s exact location is unknown, the head is
moved to an area of the expected target‟s location, while the proprioceptive system
supplies any corrective movements. This cognitive mapping serves to fine tune the posture
and place the head in a specific location so as to ensure that further egocentric manual
tasks can be executed effectively and with precision (Kim, Gillespie and Martin, 2007).
In a study performed on participants with whiplash associated disorders, an error in their

global cervical joint position sense occurred. This showed that there was an abnormal
cervical afferent input, resulting in an alteration of their balance function and other postural
control deficits, including dizziness or unsteadiness. This suggests that there were
adaptations in the brain stem (which is responsible for receiving and managing this input
55
from these sources); due to the altered cervical spine afferent input conflicting with the
visual and vestibular input (Treleaven, Jull and LowChoy, 2006). The mental perception of
body orientation will be affected as the altered cervical proprioceptive information
converges in the CNS with the vestibular and visual signals. As a result, the body‟s relation
to its surroundings may be misinterpreted (Heikkilä et al., 2000). This will then result in
secondary disturbances to the postural control system, causing dizziness or loss of
balance (Treleaven et al., 2006).
Reflexive postural control mechanisms occur primarily in the head and neck region. These
begin to develop as the foetal spine begins to adapt to a gravity dependant environment.
Hypomobile or restricted joints can alter these postural control mechanisms which are
maintained and monitored by the nervous system (Morningstar, Pettibon, Schlappi and
Ireland, 2005). Proprioceptive deficiency and neck pain may potentially perpetuate each
other (Lee et al., 2007). Restriction of cervical spine motion and changes in the quality of
proprioceptive information from the cervical spine region, may affect postural and
oculomotor control (Heikkilä et al., 2000).
Once the abnormal afferent input is removed; there will be an improvement in the
proprioception and motor response. When comparing non-sterodial anti-inflammatory
therapy to chiropractic SMT, the latter is considered to be the most powerful remedy for
improving cervical joint position sense and decreasing dizziness. Patients suffering from
vertigo or dizziness have a lower cervical position sense accuracy when compared to
asymptomatic individuals. Non-sterodial anti-inflammatory therapy and acupuncture affect
primarily the superficial muscles, where CMT has a greater effect on the joints and their
adjacent tissues. This thus supports the theory that CMT affects the mechanoreceptors
afferent input, implying that the neural input from the cervical spine facet joints is more
important for proprioception and pain sensation (Heikkilä et al., 2000).
2.6.5 Proprioceptive neck exercises
Proprioceptive neck exercises are designed to retrain the cervical musculature to regain its
position sense in space. Specific exercises are designed to locate the head to a neutral
56
position and then to do a series of movements in other planes, and then to return the head
to the neutral position (Revel, Minguet, Gergoy, Valliant and Manuel, 1994).
The purpose of Revel et al. (1994) rehabilitation program was to improve neck
proprioception and to determine whether functional improvement could be accompanied by
a decrease in chronic neck pain and discomfort. The exercises were concerned mainly with
eye-neck co-ordination and included fifteen individual exercise sessions twice a week for
eight weeks with a follow up session on the tenth week. There was a statistical
improvement in the treatment group (p=0.0004), with a decrease in neck pain and an
increase in HRA, even at the ten week follow up. This shows that the proprioceptive
system of the neck, which is mainly involved in cervicocephalic kinaesthesia, has learning
abilities and can be improved by using rehabilitation techniques (Revel et al., 1994).
a. The muscle spindle
It is generally accepted that the receptor primarily responsible for joint position sense is the
muscle spindle, with compound afferent input derived from cutaneous and joint receptors
providing supplementary information to the CNS (Armstrong, McNair and Taylor, 2008).
There are high densities of these spindles in the deeper cervical muscles, particularly in
the middle layer of muscles in the mid-cerival region and at the transitional zones of the
cervico-thoracic and thoraco-lumbar junctions. There are marginally higher muscle spindle
densities in the deep layer of the upper cervical spine when compared to the lower cervical
spine. Additionally, the distribution of the spindles often corresponds to the positions of the
major intramuscular nerve trunks, thus showing a potentially protective role of the muscles
close to these key neural structures (Amonoo-Kuofi, 1983). Differences in the density,
morphology and distribution of the muscle spindles have been observed between the
longus colli and multifidus muscles of the cervical spine. Higher densities of muscle
spindles concentrated in clusters and orientated anterolaterally, away from the vertebral
body, have been observed in the longus colli; when compared with the multifidus muscle
where the spindles are single units distributed close to the lamina of the cervical vertebrae
(Boyd-Clark, Briggs and Galea, 2002). Very high densities of spindles have also been
found in the three small muscles of the sub-occipital triangle, (superior and inferior oblique
57
capitis and rectus capitis posterior major and minor) (Peck, Buxton and Nitz, 1984;
Kulkarni, Chandy and Babu, 2001). These findings suggest that these muscles may act as
sensors of the craniovertebral motion contributing to the fine control of HRA (Armstrong et
al., 2008).
b. The vestibular system
The influence of the vestibular system on eye, head and body posture needs to be
understood when evaluating and rehabilitating HRA or joint position sense. The vestibular
system consists of peripheral and central components. The peripheral component detects
rotational acceleration of the head via the semicircular canals and linear acceleration via
the saccule and utricle. Neurons from these components travel via the eighth cranial nerve
to the four vestibular nuclei in the medulla. The vestibular system provides important
information about the position of the head in space that is integrated with information from
other inputs including the eyes and the neck proprioceptors. This integrated system
accurately determines the position of the head in space and the head relative to the body.
Each of these systems has an independent frame of reference that the CNS has to
interpret and transform into meaningful information about orientation, accounting for the
relationships between the different frames of reference of the sensors (Roberts, 1995). If
one or more of these sensory systems is dysfunctional, it is possible that reduced accuracy
of signal transformations in the CNS may lead to a deficit in orientating and stabilising the
head (Armstrong et al., 2008).
Vestibular receptors transmit signals regarding head angular and linear acceleration and
orientation of the head with respect to the gravitational axis of the CNS (Horak and
Shupert, 2000). Output from the vestibular system influences ocular muscles and postural
muscles, serving the vestibulocular reflex (VOR) and the vestibulospinal reflex (VSR), as
well as the vestibulocollic reflex (VCR) and the cervicocollic reflex (CCR). The VOR
stabilises gaze during head motion, enabling clear vision. The VSR produces
compensatory body movements to stabilise the body in space. The VCR stabilises the
head relative to space and the CCR stabilises the head relative to the trunk (Hain and
Hillman, 2000; Melvill-Jones, 2000). The VCR responds to movement of the head in space
58
by activating neck muscles to stabilise the head (Peterson, Goldberg and Bilotto, 1985;
Wilson, Yamagata and Yates, 1990). Whereas the CCR responds to the stretch of the neck
muscles and reduces the amplitude of head movement relative to the trunk (Melvill-Jones,
2000). The VCR operates in a spatial co-ordinate frame, whereas the CCR operates within
the trunk co-ordinate frame (Peng, Hain and Peterson, 1996). When the head is moved
relative to the trunk, both reflexes work in synchrony; however, when the trunk is moved on
a stable head, the CCR must be suppressed (Melvill-Jones, 2000; Peterson et al., 1985).
The control of posture and stability is dependent on successful transformation of the two
different reference frames of the VCR and CCR and the integration of these signals in the
CNS (Armstrong et al., 2008). There is good evidence that the VCR and the CCR are
strongly influenced by neck proprioceptive information (Keshner and Peterson, 1995).
There are rich anatomical connections with neck and vestibular afferents converging on the
vestibular nuclei neurons (Wilson et al., 1990).
2.7 Conclusion
Individuals suffering from chronic neck pain and impaired HRA and/or occulomotor control
should receive comprehensive kinaesthestic retraining protocols. These protocols focus on
eye/head co-ordination and balance exercises, visual tracking, gaze stability and
repositioning practice. These exercises should begin as soon as possible following injury
and should be relatively pain free (Armstrong et al., 2008). Heikkila and Astrom (1996)
reported improved head and neck repositioning accuracy using a multidisciplinary
rehabilitation programme that included more general exercise and body awareness
training. However Revel et al. (1994) and Sonderlund (2000) demonstrated that HRA may
be retrained over time with specific eye-neck co-ordination exercises, particularly targeting
eye-head coupling and neck co-ordination exercises performed in a supine lying position.
The ability to position our heads accurately during functional tasks relies upon feed-forward
and feedback mechanisms, the predominance of either being related to the task being
performed. The cervical spine muscles have unique arrangements and large densities of
muscle spindles. It seems likely that compared with other sources of position-sense
59
information within the cervical spine, such as the cervical joint capsules and ligaments, the
signals from muscles are most important. The peripheral and central vestibular system
provides and integrates information essential for knowledge of head in space and head on
body position (Armstrong et al., 2008).
The co-ordination between eye and neck motor function strongly suggests that exercises
based on eye-head coupling are more appropriate to facilitate neck proprioception
rehabilitation than usual rehabilitation programs. The functional organisation of the neck
and mainly of its proprioceptive apparatus, support the inclusion of exercises based on eye
neck co-ordination in rehabilitation for chronic neck pain patients. The proprioceptive
system of the neck, which is mainly involved in HRA, has learning abilities and can be
improved by rehabilitation techniques. If HRA improves, there is generally a decrease in
neck pain, suggesting that with better control of head-neck positioning and motion, chronic
neck pain patients could better control pain, at least the part that arises from muscle
tension (Revel et al., 1994; Armstrong et al., 2008).
60
CHAPTER THREE: METHODOLOGY
3.1 Introduction
This chapter serves to elaborate on the structure of this study and the procedures involved.
3.2 Study Design
This study was a randomised comparative clinical study.
3.3 Participant Recruitment
Willing male and or female participants who presented to the University of Johannesburg
Chiropractic Day Clinic with chronic mechanical neck pain were invited to participate in this
study and were recruited by word of mouth and by means of advertisements (Appendix A)
displayed in and around the Chiropractic Day Clinic at the University of Johannesburg,
Doornfontein Campus.
3.4 Sample Selection and Size
Thirty participants that were male or female between the ages of 18 and 40 were recruited
to participate in the study. Participants must have presented with neck pain of six weeks or
longer. Suitable participants drew papers labelled 1, 2 or 3 out of a container which
randomly divided the participants into three groups of ten participants each. Equal male
and female numbers were guaranteed by keeping only a limited amount of spaces open for
each gender in all three groups.
3.4.1 Inclusion criteria
 Participants could have been male or female between 18 and 40 years of age.
 Participants must have presented with chronic mechanical neck pain (pain for
longer than 6 weeks (Segen, 2002).
61
 The participants should have had 2 of the 7 following criteria associated with joint
dysfunction (Peterson and Bergmann 2002):
o Localised joint pain which commonly changes with movement
o Local tissue hypersensitivity
o Decreased range of motion of the joint
o Altered alignment
o Decreased, increased or aberrant movement
o Altered end feel on motion palpation
o Local palpatory muscle rigidity.
 Participants must have had at least one cervical spine restriction which was
confirmed by motion palpation as per Appendix M.
3.4.2 Exclusion criteria
 Participants who are contraindicated for cervical spine chiropractic manipulative

therapy (Appendix L).
 Participants who experienced neck pain due to (Revel, Minguet, Gergoy, Valliant
and Manuel, 1994):
o Inflammatory (rheumatoid arthritis, ankylosing spondylitis)
o Tumoural or Infectious diseases
o Any sign of cervical radiculopathy or cervical myelopathy
 Participants must not have undergone other forms of treatment that could interfere
with this study, for the duration of the study, including other chiropractic treatment
or physical therapies and medication.
3.5 Group Randomisation
Participants that met the inclusion criteria were randomly assigned to three groups of ten
participants each. Participants were assigned to their group by drawing a number from a
box. Group 1 received chiropractic manipulative therapy to any restricted cervical spinal
level; Group 2 received proprioceptive neck exercises; Group 3 received a combination of
both treatments.
62
3.6 Treatment Approach
3.6.1 First visit
This visit involved the following:

 Signing an informed consent form (Appendix B)
 Participants underwent a thorough case history (Appendix C)
 Participants underwent a physical examination (Appendix D)
 Participants underwent a cervical spine regional examination (Appendix E)
 Participants were requested, prior to treatment to complete a Numerical Pain
Rating Scale (Appendix G) and a Vernon-Mior Neck Pain and Disability Index
(Appendix H)
 Before treatment, all the cervical ranges of motion were recorded with the
analogous Cervical Range of Motion (CROM) device (Appendix I)
 Head Repositioning Accuracy (Appendix J) was also measured prior to treatment
 Participants then received either Chiropractic manipulative therapy to the restricted
cervical spinal segments (Appendix N), which was confirmed using motion
palpation techniques (Appendix M) or proprioceptive neck exercises (Appendix K)
or a combination of both, depending on their group allocation and was recorded on
the SOAP note as per Appendix F.
3.6.2 Follow-up visits
Participants were treated twice a week over a three week period. Participants returned for
a seventh follow-up visit where no treatment was administered, only subjective and
objective readings were recorded and data collected.
These visits involved the following:
 Participants were re-assessed before each treatment

 Participants were requested before the fourth and seventh consultation visits to
again complete the Numerical Pain Rating Scale (Appendix G) and a Vernon-Mior
Neck Pain and Disability Index (Appendix H)
63
 All the cervical spine ranges of motion were recorded with the analogous Cervical
Range of Motion (CROM) machine (Appendix I)
 Head Repositioning Accuracy (Appendix J) was measured prior to treatment at the
fourth and seventh consultation visits
 Participants received either chiropractic manipulative therapy to the restricted
cervical spinal segments (Appendix N), confirmed using motion palpation
techniques (Appendix M) or proprioceptive neck exercises (Appendix K) or a
combination of both, depending on their group allocation and was recorded on the
SOAP note as per Appendix F.
3.6.3 Treatments
a. Group 1
Group 1 received cervical spine manipulation over restricted segments. The restricted
segments were identified using motion palpation techniques as per Appendix M.
Chiropractic spinal manipulative therapy applied to the cervical spine varied between the
participants, due to the type of restrictions they presented with during the study. Diversified
chiropractic cervical spine manipulation techniques were used in this study as per
Appendix N.
b. Group 2
Group 2 received proprioceptive neck exercises. These exercises were mainly concerned
with eye-neck co-ordination as per Appendix K and were performed by the participant
under supervision of the examiner at each consultation visit.
c. Group 3
Group 3 received a combination of cervical spine manipulation (Appendix N) to their

respective restrictions which was determined by using motion palpation techniques as per
Appendix M. These participants also received proprioceptive neck exercises (Appendix K)
64
that were performed by the participant under supervision of the examiner at each
consultation visit.
3.7 Subjective Data
3.7.1 The Numerical Pain Rating Scale
The Numerical Pain Rating Scale (NPRS) (Appendix G) is a quantitative scale for pain
intensity. It is designed for subjective assessment of pain severity or intensity, and is
considered valid and reliable (Farrar, Troxel, Stott, Duncombe and Jensen, 2008).
The NPRS is a unidirectional scale from 0 to 10. Participants were asked to grade their
pain level experienced at that particular moment on a scale of 0 to 10. Zero indicating “no
pain” and 10 indicates the “worst imaginable pain” (Mc Dowell and Newell, 1996). The
NPRS measures the participants‟ perception of pain and is scored out of 10. It is the
standard questionnaire used in chronic pain due to its clinical importance with regards to
pain (Farrar, Troxel, Stott, Duncombe and Jensen, 2010). The NRPS is considered valid
and reliable by Bolton and Wilkinson (1998), Yeomans (2000) and Farrar, Troxel, Stott,
Duncombe and Jensen (2008). It is commonly used as a subjective measurement due to
its reliability, ease of use and time effectiveness. The NPRS was answered by participants
before the first, fourth and during the seventh visits. None of the participants were told
his/her scores following completion of the questionnaire, nor were they shown the scores
from previously completed questionnaires.
3.7.2 Vernon-Mior Neck Pain and Disability Index
Vernon-Mior Neck Pain and Disability Index (VMNPDI) (Appendix H) is the most commonly
used questionnaire for the measurement of neck pain and disability. It consists of ten
categories with six potential answers for each category. The VMNPDI provided insight on
the ability of the patient to manage everyday life and how it had been affected by neck
pain. This gave an indication of the intensity and quality of the participants pain (Vernon,
65
2008). It was originally developed to evaluate the activities of daily living in patients with
disabling neck pain and is proven to be valid and reliable (Chin Ci En, 2009).
The instructions for answering the questionnaire appeared at the top of the page.
Participants were required to answer every section and only mark one box in each section
that most accurately described or represented their pain and disability at that point. For
each question, 6 possible statements were given and each was allocated a mark: 0 is
awarded if the first statement is selected and a 5 is awarded if the last statement is
selected, which were then totalled. There is a total possible score of 5 for each section. If
all the sections were completed, a maximum score of 50 (100%) was possible. The scores
are then converted into a percentage using the following formula (Vernon, 2008):
Example: 18 (Total scored) x 100 = 36%
50 (Total possible) 1
If one section was incomplete, scoring was done as follows:
Example: 16 (Total scored) x 100 = 35.5%
45 (Total possible) 1
The following overall ratings were used once interpretation of these total scores occurred:
0 – 20% Minimal disability
20 – 40% Moderate disability
40 – 60% Severe disability
60 – 80% Crippled
80 – 100% Bed bound or exaggerating
66
The VMNPDI was answered by participants before the first, fourth and during the seventh
visits. None of the participants were told his/her scores following completion of the
questionnaire, nor were they shown the scores from previously completed questionnaires.
3.8 Objective Data
3.8.1 Cervical Spine Range of Motion
Changes in total cervical spine range of motion in all planes were measured using the
CROM (Appendix I), the validity and reliability of which has been proven (Piva, 2006). The
CROM has been shown to have some of the best ratings on clinometric aspects such as
reproducibility, responsiveness and validity (de Koning, van den Heuvel, Bart Staal,
Bouwien, Smits-Engelsman and Hendriks, 2008). The CROM is a reproducible method for
assessing changes in mobility after treatment (Palmer and Epler, 1998).
This device was fitted on the head and has three inclinometers attached to it to measure all
cervical spine ranges of motion (Agarwell, Allison and Singer, 2005) (Figure 3.1). The
CROM measures three degrees of movement: flexion and extension, which are measured
in the sagittal plane; right and left lateral flexion, which are measured in the coronal plane
and right and left rotation, which are measured in the transverse plane. The CROM device
measured cervical spine range of motion in degrees from a neutral starting position of the
cervical spine, in flexion, extension, right and left lateral flexion and right and left rotation.
All ranges of motion was assessed to the limit of pain or within a pain free zone and
documented.
Measurements were taken with the CROM before the first and fourth and during the
seventh visits and were recorded on a CROM readings recording sheet (Appendix I). None
of the participants were told their measurements following completion, nor were they
shown the measurements from previous visits.
67
Figure 3.1: The CROM Goniometer (de Koning, van den Heuvel, Bart Staal, Bouwien,
Smits-Engelsman and Hendriks, 2008)
Cervical spine flexion and extension

 The participant was asked to be seated, with his/her trunk as upright as possible
and to maintain this posture throughout the process
 The CROM goniometer was placed on the participants head
 The participant was instructed to flex his/her neck forward maximally and
measurents were recorded off the vertical goniometer
 The participant was then instructed to extend his/her neck backward maximally
and measurements were recorded also off the vertical goniometer.
Figure 3.2: Flexion and Extension Readings with the CROM Goniometer (de Koning
et al., 2008)
68
Cervical spine lateral flexion
 The participant was asked to remain seated, with his/her trunk as upright as
possible and to maintain this posture throughout the process
 With the CROM goniometer still placed on the participants head, the participant
was asked to maximally laterally flex his/her neck to the right and measurements
were taken off the vertical goniometer and the same process was followed for left
lateral flexion.
Figure 3.3: Lateral Flexion Readings with the CROM Goniometer (de Koning et al.,
2008)
Cervical spine rotation

 The participant was asked to remain seated, with his/her trunk as upright as
possible and to maintain this posture throughout the process
 With the CROM goniometer still placed on the participants head, a magnetic collar
fixed around the participants neck was added
 The horizontal goniometer was zeroed by adjusting the goniometer with regards to
the magnetic collar
 The participant was asked to maximally rotate his/her neck to the right and
measurements were taken off the horizontal goniometer and the same process
was followed for left rotation.
69
Figure 3.4: Rotation Readings with the CROM Goniometer (de Koning et al., 2008)
3.8.2 Head Repositioning Accuracy
The methods used and described by Revel, Andre-Deshays and Minguet (1991) were used
to determine the Head Repositioning Accuracy in right and left rotation only and was
measured in milimeters (Appendix J). The laser pointer device was used in a study by
Revel et al. (1991) to determine cervicocephalic kinesthetic sensibility in patients with
cervical spine pain. This device was shown to be a fairly accurate testing tool in a clinical
setting for the evaluation of an alteration in joint position sense accuracy (Revel et al.,
1991). The laser pointer device was used to measure the total displacement from the
starting point, to where the head would stop in its final position during the Head
Repositioning Accuracy test.
All participants were blindfolded to occlude their vision, in order to eliminate the use of the
visual system and as a result, isolating the input regarding joint position sense, to the
proprioceptors in the cervical spine facet joints. A laser pointer device was attached to the
top of a helmet, which was firmly tied to the participants head. The participants were
seated on a chair with a backrest, to allow them to find the most comfortable upright
position. The upper chest and shoulders of the participants were strapped to the back rest
to ensure movement only occured at the head and neck. Participants were placed ninety
centimeters from a target placed on the wall infront of them. Each blindfolded participant
70
was instructed to face the target, with his/her face directed straight ahead and forward, in a
position that felt “neutral” to him/her. They were instructed to memorise their starting
“neutral” position, this acted as their starting reference position, and was called “point
zero”.
Figure 3.5: Laser Pointer Device Attached to the Top of a Helmet
The point at which the light beam of the laser pointer device projected onto the target in
front of the participant, with their head in their “neutral” starting reference position, was
marked with a permanent marker and was labelled as “point zero”. The participant was
then instructed to complete an active maximal rotation to the right and hold for two
seconds. This allowed the participant sufficient time to concentrate on this new reference
position point (Revel et al.,1991). The participant was then instructed to rotate their head
back to the left and to return to their memorised “neutral” starting reference position, as
accurately as possible.
Figure 3.6: Maximal Rotation to the Right
71
The point at which the light beam of the laser pointer device stopped on the target in front
of the participant was marked and labelled as the right rotation final position point. The
same procedure was repeated for left rotation of the head (Revel et al., 1991). The distace
of any overshot of “point zero” of the participants initial “neutral” starting reference position
in right and left rotation was measured in millimeters and recorded on a Head
Repositioning Accuracy recording sheet as per Appendix I. Measuring Head Repositioning
Accuracy using the laser helmet was also validated and proven reliable (Roren, 2009).
Figure 3.7: HRA Recording Sheet with “Point Zero” in the Middle and HRA Left
Rotation on the Left and HRA Right Rotation on the Right
Measurements of Head Repositioning Accuracy were taken before the first and fourth and
during the seventh visits and were recorded on a Head Repositioning Accuracy recording
sheet (Appendix J). None of the participants were told their measurements following
completion, nor were they shown the measurements from previous visits.
3.9 Data Analysis
The data was collected by the researcher after which analysis was done with the help of a
statistician. The results were based on the subjective and objective measurements
gathered during the study. After consultation with Ms. Juliana van Staden from STATKON,
72
it was concluded that the results were analysed using the using non-parametric tests. Inter-
group data was analysed using the Kruskall-Wallis Test. If differences were found between
the groups, the Mann-Whitney U test was then used instead. Intra-group data was
analysed using the Friedman test and if there were differences over time, the Wilcoxon-
Signed Ranks test would rather be used.
3.10 Ethical Considerations
All participants that wished to partake in this particular study were requested to read and
sign the information and consent form specific to this study. The information and consent
form outlined the names of the researcher, purpose of the study and benefits of partaking
in the study, participant assessment and treatment procedure. Any risks, benefits and
discomforts pertaining to the treatments involved were explained and that the participant‟s
safety would be ensured (prevention of harm). The information and consent form also
explained that the participant‟s privacy was protected as only the doctor, patient and
clinician would be in the treatment room and that anonymity would be ensured as the
patient information would be converted into data and therefore cannot be traced back to
the individual. The form also stated that standard doctor/patient confidentiality would be
adhered to at all times when compiling the research dissertation. The participants were
informed that their participation was on a voluntary basis and that they were free to
withdraw from the study at any stage without prejudice. Should the participant have had
any further questions, those would have been explained by the researcher, whose contact
details were made available. The participants were then required to sign the information
and consent form, signifying that they understood all that was required of them for this
particular study.
73
CHAPTER FOUR: RESULTS
4.1 Introduction
The findings obtained from the study are presented in this chapter. The sample group
consisted of thirty participants that were divided into Group 1, Group 2 and Group 3. Group
1 represents the ten participants treated with cervical spine manipulation. Group 2
represents the ten participants treated with proprioceptive neck exercises. Group 3
represents the final ten participants treated with a combination of cervical spine
manipulation and proprioceptive neck exercises. The statistical results only represent a
small group of subjects and therefore no assumptions can be made with respect to the
population as a whole.
The p-value for the tests was set at 0.05 and represented the level of significance of the
results. If the p-value was less than or equal to 0.05 (p ≤ 0.05) there was a statistically
significant finding. If the p-value was greater than 0.05 (p ≥ 0.05) there was no statistically
significant finding. Statistical significance means that a given result is unlikely to have
occurred by chance.
The analyses included:
1. Demographic data analysis consisting of the gender and age of the participants
2. Subjective measurements consisting of the Numerical Pain Rating Scale and the
Vernon-Mior Neck Pain and Disability Index.
3. Objective measurements consisting of cervical spine range of motion measuring
instrument (CROM), which included flexion, extension, left and right lateral flexion and
left and right rotation as well as head repositioning accuracy (HRA), which included
right and left rotation.
74
4.2 Demographic Data Analysis
The population group of this study consisted of fifteen female and fifteen male participants
(n=30). Group 1 consisted of ten participants (n=10); five females and five males. Group 2
consisted of ten participants (n=10); five females and five males. Group 3 also consisted of
ten participants (n=10); also five females and five males. The mean age of Group 1 was
24.80 years, Group 2 was 25.10 years, and of Group 3 was 25.70 years, making the total
population mean 25.20 years.
Table 4.1: Comparison of the Demographic Data Between the Groups
Combined
Data Group 1 Group 2 Group 3 Total
Age distribution
(Years) 24 - 27 23 - 28 23 - 34 23 - 34
Mean age (Years) 24.80 25.10 25.70 25.20
Gender distribution 5 Females 5 Females 5 Females 15 Females
5 Males 5 Males 5 Males 15 Males
75
4.3 Subjective Data Analysis
4.3.1 Evaluation of Numerical Pain Rating Scale readings
a. Intragroup analysis: Group 1 Numerical Pain Rating Scale readings
The Shapiro-Wilks test, that tests for normality was inconclusive, therefore the Friedman
test was used to determine intragroup results between the 1 st and 7th treatments. The
Wilcoxon Signed Ranks test was used to determine intragroup results between the 1 st and
4th and the 4th and the 7th treatments.
The Friedman test was used to compare Group 1‟s 1 st treatment to the 7th treatment. The
results indicated that Group 1 demonstrated a statistically significant improvement over
time (p=0.005).
The Wilcoxon Signed Ranks test revealed that the values demonstrated a statistically
significant improvement for the 1st treatment to the 4th treatment (p=0.005) and for the 4th
treatment to the 7th treatment (p=0.010).
Table 4.2: Intragroup Analysis of Group 1

Visits (Group 1) p-values
1st Visit- 7th Visit 0.005
4th Visit- 7th Visit 0.010
b. Intragroup analysis: Group 2 Numerical Pain Rating Scale readings
time (p=0.005).
76

c. Intragroup analysis: Group 3 Numerical pain Rating Scale readings
time (p=0.005).

77
d. Intergroup analysis
The Shapiro-Wilks test, that tests for normality were inconclusive, therefore the Kruskal
Wallis tests were used to determine if there is a statistical significance between Group 1, 2
and 3 regarding the Numerical Pain Rating Scale (NPRS).
The intergroup analysis revealed that there was no statistical significance between Group
1, Group 2 and Group 3 at the 1st visit (p=0.539), the 4th visit (p=0.611) and the 7th visit
(p=0.601). This means that the groups started out comparable and that they remained
comparable throughout the study.
Table 4.5: Intergroup Analysis of NPRS

1st Visit 4th Visit 7th Visit
p-values 0.539 0.611 0.601
78
e. Clinical interpretation of mean NPRS values
The NPRS results on the 1st visit, Group 1, Group 2 and Group 3 had mean values of 4.9,
4.9 and 5.5 for Numerical Pain Rating Scale measurements respectively. On the 4 th visit
Group 1, Group 2 and Group 3 had mean values of 2.7, 3.2 and 3.2 respectively. On the
7th visit Group 1, Group 2 and Group 3 had mean values of 1.3, 2 and 1.6 respectively.
6
5.5
4.9 4.9
5
4
NPRS values
3.2 3.2
3 Group 1
2.7
Group 2
2 Group 3
2 1.6
1.3
0
Visit 1 Visit 4 Visit 7
Figure 4.1: NPRS Mean Values for the 1st, 4th and 7th Visits
The mean difference between the 1st and 4th visit for Group 1, Group 2 and Group 3 was
2.2, 1.7 and 2.3 resulting in a mean percentage improvement of 45%, 35% and 42%
consecutively. The mean difference between the 4 th and 7th visit for Group 1, Group 2 and
Group 3 was 1.4, 1.2 and 1.6 resulting in a mean percentage improvement of 52%, 38%
and 50% consecutively. At the end of the study Group 1 had a mean difference of 3.6 and
a mean percentage improvement of 74%. Group 2 had a mean difference of 2.9 and a
mean percentage improvement of 59%. Group 3 had a mean difference of 3.9 and a mean
percentage improvement of 71%.
79
Table 4.6: NPRS Mean Values
Visit Mean Value Mean Percentage

Difference Difference
Group 1 1st Visit 4.9 3.6 74%
7th Visit 1.3
7th Visit 2
7th Visit 1.6
4th Visit 2.7
4th Visit 3.2
4th Visit 3.2
Group 1 4th Visit 2.7 1.4 52%
7th Visit 1.3
7th Visit 2
7th Visit 1.6
80
4.3.2 Evaluation of Vernon-Mior Neck Pain and Disability Index
a. Intragroup analysis: Group 1 Vernon-Mior Neck Pain and Disability Index

readings
Wilcoxon Signed Ranks test was used to determine intragroup results between the 1st and
time (p=0.005).

Group 1 p-values
b. Intragroup analysis: Group 2 Vernon-Mior Neck Pain and Disability Index

readings
time (p=0.023).
81
insignificant improvement for the 1st treatment to the 4th treatment (p=0.089) and for the 4th

Group 2 p-values
c. Intragroup analysis: Group 3 Vernon-Mior Neck Pain and Disability Index

readings
time (p=0.005).

Group 3 p-values
82
The Shapiro-Wilks test, that tests for normality were inconclusive, therefore the Kruskal
and 3 regarding the Vernon-Mior Neck Pain and Disability Index (VMNPDI).
1, Group 2 and Group 3 at the 1st visit (p=0.565) and the 4th visit (p=0.084), but there was
a statistical significance at the 7th visit (p=0.005). This means that the groups started out
comparable, but at the 7th visit there was a statistical difference between the groups.
Table 4.10: Intergroup Analysis of VMNPDI

p-values 0.565 0.084 0.005
83
e. Clinical interpretation of mean VMNPDI values
The VMNPDI results on the 1st visit, Group 1, Group 2 and Group 3 had mean values of
21.2, 18.8 and 16.4 for Vernon-Mior Neck Pain and Disability Index measurements
respectively. On the 4th visit Group 1, Group 2 and Group 3 had mean values of 8.2, 14.8
and 7.4 respectively. On the 7th visit Group 1, Group 2 and Group 3 had mean values of
3.4, 12.8 and 2.6 respectively.
25
21.2
20 18.8
16.4
14.8
VMNPDI values
15
12.8
Group 1
Group 2
10
8.2 Group 3
7.4
5 3.4
2.6
0
Figure 4.2: VMNPDI Mean Values on the 1st, 4th and 7th Visits
13, 4 and 9 resulting in a mean percentage improvement of 61%, 21% and 55%
Group 3 was 4.8, 2 and 4.8 resulting in a mean percentage improvement of 59%, 14% and
65% consecutively. At the end of the study Group 1 had a mean difference of 17.8 and a
mean percentage improvement of 84%. Group 2 had a mean difference of 6 and a mean
percentage improvement of 32%. Group 3 had a mean difference of 13.8 and a mean
84
Table 4.11: VMNPDI Mean Values

Group 1 1st Visit 21.2 17.8 84%
7th Visit 3.4
Group 2 1st Visit 18.8 6 32%
7th Visit 12.8
Group 3 1st Visit 16.4 13.8 84%
7th Visit 2.6
4th Visit 8.2
4th Visit 14.8
4th Visit 7.4
7th Visit 3.4
Group 2 4th Visit 14.8 2 14%
7th Visit 12.8
7th Visit 2.6
85
4.4 Objective Data Analysis
4.4.1 Evaluation of Cervical Spine Range of Motion Readings
a. Cervical spine flexion
i. Intragroup analysis: Group 1 Cervical Spine Flexion Range of Motion
The Friedman test was used to compare group 1‟s 1st treatment to the 7th treatment. The
results indicated that Group 1 demonstrated no statistically significant improvement over
time (p=0.400).
The Wilcoxon Signed Ranks test revealed that the values demonstrated no statistically

Group 1 p-values
ii. Intragroup analysis: Group 2 Cervical Spine Flexion Range of Motion
time (p=0.717).
86

Group 2 p-values
iii. Intragroup analysis: Group 3 Cervical Spine Flexion Range of Motion
results indicated that Group 3 demonstrated statistically significant improvement over time
(p=0.013).
significant improvement for the 1st treatment to the 4th treatment (p=0.040) and no
statistically significant improvement for the 4th treatment to the 7th treatment (p=0.115).

Group 3 p-values
87
iv. Intergroup analysis
The Shapiro-Wilks test, that tests for normality was inconclusive, therefore the Kruskal
and 3 on cervical spine flexion range of motion.
1, Group 2 and Group 3 at the 1st visit (p=0.821), the 4th visit (p=0.168), but there was a
statistical significance at the 7th visit (p=0.026). This means that the groups started out
comparable, but at the 7th visit there was a statistical difference between the groups.
Table 4.15: Intergroup Analysis of Cervical Spine Flexion

p-values 0.821 0.168 0.026
88
v. Clinical interpretation of mean cervical spine flexion measurements values
On the 1st visit, Group 1, Group 2 and Group 3 had mean values of 54.3˚, 55.6˚ and 58.4˚
for cervical spine flexion measurements respectively. On the 4 th visit Group 1, Group 2 and
Group 3 had mean values of 54.4˚, 55.6˚ and 62.2˚ respectively. On the 7th visit Group 1,
Group 2 and Group 3 had mean values of 55.6˚, 55.9˚ and 65˚ respectively.
66 65
64
62.2
CROM values in flexion
62
60
58.4
58 Group 1
55.6 55.6 55.655.9
56 Group 2
54.3 54.4
54 Group 3
52
50
48
Figure 4.3: CROM Flexion Mean Values on the 1st, 4th and 7th Visits
0.1˚, 0˚ and 3.8˚ resulting in a mean percentage improvement of 0.2%, 0% and 7%
Group 3 was 1.2˚, 0.3˚ and 2.8˚ resulting in a mean percentage improvement of 2%, 0.5%
and 5% consecutively. At the end of the study Group 1 had a mean difference of 1.3˚ and a
mean percentage improvement of 2%. Group 2 had a mean difference of 0.3˚ and a mean
percentage improvement of 0.5%. Group 3 had a mean difference of 6.6˚ and a mean
89
Table 4.16: CROM Flexion Mean Values

Group 1 1st Visit 54.3˚ 1.3˚ 2%
7th Visit 55.6˚
Group 2 1st Visit 55.6˚ 0.3˚ 0.50%
7th Visit 55.9˚
Group 3 1st Visit 58.4˚ 6.6˚ 11%
7th Visit 65˚
Group 1 1st Visit 54.3˚ 0.1˚ 0.20%
4th Visit 54.4˚
Group 2 1st Visit 55.6˚ 0˚ 0%
4th Visit 55.6˚
Group 3 1st Visit 58.4˚ 3.8˚ 7%
4th Visit 62.2˚
Group 1 4th Visit 54.4˚ 1.2˚ 2%
7th Visit 55.6˚
Group 2 4th Visit 55.6˚ 0.3˚ 0.50%
7th Visit 55.9˚
Group 3 4th Visit 62.2˚ 2.8˚ 5%
7th Visit 65˚
90
b. Cervical spine extension
i. Intragroup analysis: Group 1 Cervical Spine Extension Range of Motion
Wilcoxon Signed Ranks Test was used to determine intragroup results between the 1 st and
time (p=0.018).
significant improvement for the 1st treatment to the 4th treatment (p=0.027), but no

Group 1 p-values
ii. Intragroup analysis: Group 2 Cervical Spine Extension Range of Motion
time (p=0.007).
91

Group 2 p-values
iii. Intragroup analysis: Group 3 Cervical Spine Extension Range of Motion
The Friedman test was used to compare Group 3‟s 1st treatment to the 7th treatment. The
time (p=0.212).

Group 3 p-values
92
and 3 on cervical spine extension range of motion.
(p=0.457). This means that the groups started out comparable and that they remained like
that throughout the study.
Table 4.20: Intergroup Analysis of Cervical Spine Extension

p-values 0.192 0.378 0.457
93
v. Clinical interpretation of mean cervical spine extension measurements values
On the 1st visit, Group 1, Group 2 and Group 3 had mean values of 66.8˚, 59˚ and 68.4˚ for
cervical spine extension measurements respectively. On the 4th visit Group 1, Group 2 and
Group 3 had mean values of 72.8˚, 67˚ and 73.3˚ respectively. On the 7th visit Group 1,
Group 2 and Group 3 had mean values of 74.8˚, 69.2˚ and 73.7˚ respectively.
80 73.3 74.8 73.7

72.8
68.4 67 69.2
70 66.8
CROM values in extension
59
60
50
Group 1
40
Group 2
30
Group 3
20
10
0
Figure 4.4: CROM Extension Mean Values on the 1st, 4th and 7th Visits
6˚, 8˚ and 4.9˚ resulting in a mean percentage improvement of 9%, 14% and 7%
Group 3 was 2˚, 2.2˚ and 0.4˚ resulting in a mean percentage improvement of 3%, 3% and
0.6% consecutively. At the end of the study Group 1 had a mean difference of 8˚ and a
mean percentage improvement of 12%. Group 2 had a mean difference of 10.2˚ and a
94
Table 4.21: CROM Extension Mean Values

7th Visit 74.8˚
Group 2 1st Visit 59˚ 10.2˚ 17%
7th Visit 69.2˚
Group 3 1st Visit 68.4˚ 5.3˚ 8%
7th Visit 73.7˚
4th Visit 72.8˚
Group 2 1st Visit 59˚ 8˚ 14%
4th Visit 67˚
Group 3 1st Visit 68.4˚ 4.9˚ 7%
4th Visit 73.3˚
Group 1 4th Visit 72.8˚ 2˚ 3%
7th Visit 74.8˚
Group 2 4th Visit 67˚ 2.2˚ 3%
7th Visit 69.2˚
Group 3 4th Visit 73.3˚ 0.4˚ 0.60%
7th Visit 73.7˚
95
c. Cervical spine lateral flexion
i. Intragroup analysis: Group 1 Cervical Spine Right Lateral Flexion Range of Motion
time (p=0.017).

Group 1 p-values
ii. Intragroup analysis: Group 2 Cervical Spine Right Lateral Flexion Range of Motion
time (p=0.027).
96
significant improvement for the 1st treatment to the 4th treatment (p=1.000), but a

Group 2 p-values
iii. Intragroup analysis: Group 3 Cervical Spine Right Lateral Flexion Range of
Motion
time (p=0.462).

Group 3 p-values
97
and 3 on cervical spine right lateral flexion range of motion.
Table 4.25: Intergroup Analysis of Cervical Spine Right Lateral Flexion

p-values 0.435 0.150 0.403
98
v. Clinical interpretation of mean cervical spine right lateral flexion measurements
values
for cervical spine right lateral flexion measurements respectively. On the 4 th visit Group 1,
Group 2 and Group 3 had mean values of 48.2˚, 42.3˚ and 46.5˚ respectively. On the 7th
visit Group 1, Group 2 and Group 3 had mean values of 50.6˚, 45.8˚ and 47.2˚
respectively.
52
50.6
CROM values in right lateral flexion
50
48.2
48 47.2
46.5
45.4 45.7 45.8
46
Group 1
44 Group 2
42.3 42.3
Group 3
42
40
38
Figure 4.5: CROM Right Lateral Flexion Mean Values on the 1st, 4th and 7th Visits
2.8˚, 0˚ and 0.8˚ resulting in a mean percentage improvement of 6%, 0% and 2%
Group 3 was 2.4˚, 2.5˚ and 0.7˚ resulting in a mean percentage improvement of 5%, 8%
and 2% consecutively. At the end of the study Group 1 had a mean difference of 5.2˚ and a
percentage improvement of 8%. Group 3 had a mean difference of 1.5˚ and a mean
99
Table 4.26: CROM Right Lateral Flexion Mean Values

Group 1 1st Visit 45.4˚ 5.2˚ 12%
7th Visit 50.6˚
Group 2 1st Visit 42.3˚ 3.5˚ 8%
7th Visit 45.8˚
Group 3 1st Visit 45.7˚ 1.5˚ 3%
7th Visit 47.2˚
Group 1 1st Visit 45.4˚ 2.8˚ 6%
4th Visit 48.2˚
4th Visit 42.3˚
Group 3 1st Visit 45.7˚ 0.8˚ 2%
4th Visit 46.5˚
Group 1 4th Visit 48.2˚ 2.4˚ 5%
7th Visit 50.6˚
Group 2 4th Visit 42.3˚ 2.5˚ 8%
7th Visit 45.8˚
Group 3 4th Visit 46.5˚ 0.7˚ 2%
7th Visit 47.2˚
100
vi. Intragroup analysis: Group 1 Cervical Spine Left Lateral Flexion Range of Motion
The Shapiro-Wilks test, that tests for normality was inconclusive. While performing the
above parametric tests, it was made clear that the data proved to be statically insignificant
and thus the non-parametric tests (the Friedman test and the Wilcoxon Signed Ranks test)
were not performed.
The Shapiro-Wilks test showed p-values for visit 1, visit 4 and visit 7. The results indicated
that at the 1st treatment, Group 1 demonstrated no statistical significance at the start of the
study (p=0.252). At the 4th treatment, there was a statistically significant improvement
(p=0.012), but the results revealed that at the 7th treatment, there was no statistically
significant improvement over time at the end of the study (p=0.307).

Group 1 p-values
1st Visit 0.252
4th Visit 0.012
7th Visit 0.307
vii. Intragroup analysis: Group 2 Cervical Spine Left Lateral Flexion Range of Motion
were not performed.
that at the 1st treatment, Group 2 demonstrated a statistical significance at the start of the
study (p=0.036). At the 4th treatment, there was also a statistically significant improvement
101
(p=0.008), but the results revealed that at the 7th treatment, there was no statistically
significant improvement over time at the end of the study (p=0.150).

Group 2 p-values
1st Visit 0.036
4th Visit 0.008
7th Visit 0.150
viii. Intragroup analysis: Group 3 Cervical Spine Left Lateral Flexion Range of
Motion
were not performed.
that at the 1st treatment, Group 3 demonstrated no statistical significance at the start of the
study (p=0.107). At the 4th treatment, there was also no statistically significant
improvement (p=0.092) and the results revealed that at the 7th treatment, there was no
statistically significant improvement over time at the end of the study (p=0.103).

Group 3 p-values
1st Visit 0.107
4th Visit 0.092
7th Visit 0.103
102
ix. Intergroup analysis
and 3 on cervical spine left lateral flexion range of motion.
Table 4.30: Intergroup Analysis of Cervical Spine Left Lateral Flexion

p-values 0.653 0.325 0.400
103
x. Clinical interpretation of mean cervical spine left lateral flexion measurements
values
On the 1st visit, Group 1, Group 2 and Group 3 had mean values of 51˚, 47.8˚ and 48.4˚ for
cervical spine left lateral flexion measurements respectively. On the 4th visit Group 1,
Group 2 and Group 3 had mean values of 51.4˚, 47˚ and 50.4˚ respectively. On the 7th visit
Group 1, Group 2 and Group 3 had mean values of 53.4˚, 49˚ and 51.2˚ respectively.
54 53.4
CROM values in left lateral flexion
52 51.4 51.2
51
50.4
50 49
48.4
47.8 Group 1
48 47
Group 2
46 Group 3
44
42
Figure 4.6: CROM Left Lateral Flexion Mean Values on the 1st, 4th and 7th Visits
0.4˚, 0.8˚ and 2˚ resulting in a mean percentage improvement of 1%, 2% and 4%
Group 3 was 2˚, 2˚ and 0.8˚ resulting in a mean percentage improvement of 4%, 4% and
2% consecutively. At the end of the study Group 1 had a mean difference of 2.4˚ and a
104
Table 4.31: CROM Left Lateral Flexion Mean Values

Group 1 1st Visit 51˚ 2.4˚ 5%
7th Visit 53.4˚
Group 2 1st Visit 47.8˚ 1.2˚ 3%
7th Visit 49˚
Group 3 1st Visit 48.4˚ 2.8˚ 6%
7th Visit 51.2˚
Group 1 1st Visit 51˚ 0.4˚ 1%
4th Visit 51.4˚
Group 2 1st Visit 47.8˚ 0.8˚ 2%
4th Visit 47˚
4th Visit 50.4˚
Group 1 4th Visit 51.4˚ 2˚ 4%
7th Visit 53.4˚
Group 2 4th Visit 47˚ 2˚ 4%
7th Visit 49˚
Group 3 4th Visit 50.4˚ 0.8˚ 2%
7th Visit 51.2˚
105
d. Cervical spine rotation
i. Intragroup Analysis: Group 1 Cervical Spine Right Rotation Range of Motion
test was used to determine intragroup results between the 1 st and 7th treatment. The
Wilcoxon Signed Ranks test was used to determine intragroup results between the 1st and
4th and the 4th and the 7th treatment.
time (p=0.012).

Group 1 p-values
ii. Intragroup analysis: Group 2 Cervical Spine Right Rotation Range of Motion
time (p=0.017).
106
Table 4.33: Intragroup Analysis Group 2

Group 2 p-values
iii. Intragroup analysis: Group 3 Cervical Spine Right Rotation Range of Motion
time (p=0.078).

Group 3 p-values
107
and 3 on cervical spine right rotation range of motion.
Table 4.35: Intergroup Analysis of Cervical Spine Right Rotation

p-values 0.522 0.128 0.286
108
v. Clinical interpretation of mean cervical spine right rotation measurements values
for cervical spine right rotation measurements respectively. On the 4th visit Group 1, Group
2 and Group 3 had mean values of 72.8˚, 66.4˚ and 71.6˚ respectively. On the 7th visit
Group 1, Group 2 and Group 3 had mean values of 73.6˚, 69.8˚ and 72˚ respectively.
76
73.6
74 72.8
CROM values in right rotation
71.6 72
72
69.8
70
68 66.8 Group 1
66.4 66.4
66 Group 2
63.8
64 Group 3
62
60
58
Figure 4.7: CROM Right Rotation Mean Values on the 1st, 4th and 7th Visits
6˚, 2.6˚ and 5.2˚ resulting in a mean percentage improvement of 9%, 4% and 8%
Group 3 was 0.8˚, 3.4˚ and 0.4˚ resulting in a mean percentage improvement of 1%, 5%
and 0.6% consecutively. At the end of the study Group 1 had a mean difference of 6.8˚ and
a mean percentage improvement of 10%. Group 2 had a mean difference of 6˚ and a mean
109
Table 4.36: CROM Right Rotation Mean Values

Group 1 1st Visit 66.8˚ 6.8˚ 10%
7th Visit 73.6˚
7th Visit 69.8˚
Group 3 1st Visit 66.4˚ 5.6˚ 8%
7th Visit 72˚
4th Visit 72.8˚
Group 2 1st Visit 63.8˚ 2.6˚ 4%
4th Visit 66.4˚
Group 3 1st Visit 66.4˚ 5.2˚ 8%
4th Visit 71.6˚
Group 1 4th Visit 72.8˚ 0.8˚ 1%
7th Visit 73.6˚
Group 2 4th Visit 66.4˚ 3.4˚ 5%
7th Visit 69.8˚
Group 3 4th Visit 71.6˚ 0.4˚ 0.60%
7th Visit 72˚
110
vi. Intragroup analysis: Group 1 Cervical Spine Left Rotation Range of Motion
time (p=0.109).

Group 1 p-values
vii. Intragroup analysis: Group 2 Cervical Spine Left Rotation Range of Motion
time (p=0.343).
111
Group 2 p-values
viii. Intragroup analysis: Group 3 Cervical Spine Left Rotation Range of Motion
time (p=0.233).

Group 3 p-values
112
ix. Intergroup analysis
and 3 on cervical spine left rotation range of motion.
1, Group 2 and Group 3 at the 1st visit (p=0.074), but there was a statistical significance
between the groups at the 4th visit (p=0.020) and the 7th visit (p=0.039). This means that
the groups started out comparable, but at the 7th visit there was a statistical difference
between the groups.
Table 4.40: Intergroup Analysis of Cervical Spine Left Rotation

p-values 0.074 0.020 0.039
113
x. Clinical interpretation of mean cervical spine left rotation measurements values
for cervical spine left rotation measurements respectively. On the 4 th visit Group 1, Group 2
and Group 3 had mean values of 72.4˚, 67.2˚ and 75.4˚ respectively. On the 7th visit Group
1, Group 2 and Group 3 had mean values of 74.2˚, 68.6˚ and 74.2˚ respectively.
78
76 75.4
CROM values in left rotation
74.2 74.2
74
72.2 72.4
72 70.8
Group 1
70 68.6
Group 2
68 67.2
66.5 Group 3
66
64
62
Figure 4.8: CROM Left Rotation Mean Values on the 1st, 4th and 7th Visits
0.2˚, 0.7˚ and 4.6˚ resulting in a mean percentage improvement of 0.3%, 1% and 7%
Group 3 was 1.8˚, 1.4˚ and -1.2˚ resulting in a mean percentage improvement for Group 1
and 2 of 3% and 2% respectively and a mean percentage decrease of 2% for Group 3. At
the end of the study Group 1 had a mean difference of 2˚ and a mean percentage
improvement of 3%. Group 2 had a mean difference of 2.1˚ and a mean percentage
improvement of 3%. Group 3 had a mean difference of 3.4˚ and a mean percentage
improvement of 5%.
114
Table 4.41: CROM Left Rotation Mean Values

7th Visit 74.2˚
Group 2 1st Visit 66.5˚ 2.1˚ 3%
7th Visit 68.6˚
Group 3 1st Visit 70.8˚ 3.4˚ 5%
7th Visit 74.2˚
Group 1 1st Visit 72.2˚ 0.2˚ 0.30%
4th Visit 72.4˚
Group 2 1st Visit 66.5˚ 0.7˚ 1%
4th Visit 67.2˚
Group 3 1st Visit 70.8˚ 4.6˚ 7%
4th Visit 75.4˚
Group 1 4th Visit 72.4˚ 1.8˚ 3%
7th Visit 74.2˚
Group 2 4th Visit 67.2˚ 1.4˚ 2%
7th Visit 68.6˚
Group 3 4th Visit 75.4˚ -1.2 -2%
7th Visit 74.2˚
115
4.4.2 Evaluation of Head Repositioning Accuracy
a. Intragroup analysis: Group 1 Head Repositioning Accuracy Right Rotation
Wilcoxon Signed Ranks Test was used to determine intragroup results between the 1 st and
time (p=0.185).
Table 4.42: Intragroup Analysis Group 1

Group 1 p-values
b. Intragroup analysis: Group 2 Head Repositioning Accuracy Right Rotation
time (p=0.012).
116

Group 2 p-values
c. Intragroup analysis: Group 3 Head Repositioning Accuracy Right Rotation
time (p=0.203).

Group 3 p-values
117
and 3 on head repositioning accuracy right rotation.
Table 4.45: Intergroup Analysis of Head Repositioning Accuracy Right Rotation

p-values 0.888 0.515 0.525
118
e. Clinical interpretation of mean Head Repositioning Accuracy right rotation
measurements values
On the 1st visit, Group 1, Group 2 and Group 3 had mean values of 81.7, 76 and 69.9 for
head repositioning accuracy right rotation measurements respectively. On the 4 th visit
Group 1, Group 2 and Group 3 had mean values of 57.7, 74.8 and 73.9 respectively. On
the 7th visit Group 1, Group 2 and Group 3 had mean values of 64.7, 46.1 and 54.4
respectively.
90
81.7
CROM values in HRA right rotation
80 76 74.873.9
69.9
70 64.7
57.7
60 54.4
50 46.1
Group 1
40 Group 2
30 Group 3
20
10
0
Figure 4.9: HRA Right Rotation Mean Values on the 1st, 4th and 7th Visits
24, 1.2 and -4 resulting in a mean percentage improvement for Group 1 and Group 2 of
29% and 2% respectively, but a mean percentage decrease in improvement for Group 3 of
6%. The mean difference between the 4th and 7th visit for Group 1, Group 2 and Group 3
was -7, 28.1 and 19.5 resulting in a mean percentage decrease in improvement for Group
1, of 12%, but a mean percentage improvement for Group 2 and 3 of 38% and 26%
respectively. At the end of the study Group 1 had a mean difference of 17 and a mean
119
Table 4.46: HRA Right Rotation Mean Values

7th Visit 64.7
Group 2 1st Visit 76 29.9 39%
7th Visit 46.1
Group 3 1st Visit 69.9 15.5 22%
7th Visit 54.4
4th Visit 57.7
4th Visit 74.8
Group 3 1st Visit 69.9 -4 -6%
4th Visit 73.9
Group 1 4th Visit 57.7 -7 -12%
7th Visit 64.7
Group 2 4th Visit 74.8 28.1 38%
7th Visit 46.1
Group 3 4th Visit 73.9 19.5 26%
7th Visit 54.4
120
f. Intragroup analysis: Group 1 Head Repositioning Accuracy Left Rotation
test was used to determine intragroup results between the 1 st and 7th treatment. The
4th and the 4th and the 7th treatment.
time (p=0.092).

Group 1 p-values
g. Intragroup analysis: Group 2 Head Repositioning Accuracy Left Rotation
time (p=0.036).
121
Group 2 p-values
h. Intragroup analysis: Group 3 Head Repositioning Accuracy Left Rotation
time (p=0.093).

Group 3 p-values
122
i. Intergroup analysis
and 3 on head repositioning accuracy left rotation.
Table 4.50: Intergroup Analysis of Head Repositioning Accuracy Left Rotation

p-values 0.447 0.986 0.442
123
j. Clinical interpretation of mean Head Repositioning Accuracy left rotation
measurements values
On the 1st visit, Group 1, Group 2 and Group 3 had mean values of 86.5, 91 and 102.4 for
head repositioning accuracy left rotation measurements respectively. On the 4 th visit Group
1, Group 2 and Group 3 had mean values of 74.3, 76.3 and 74.5 respectively. On the 7th
visit Group 1, Group 2 and Group 3 had mean values of 69.4, 57.1 and 63.8 respectively.
120
CROM values in HRA left rotation
102.4
100 91
86.5
80 74.376.374.5
69.4
63.8
57.1 Group 1
60
Group 2
40 Group 3
20
0
Figure 4.10: HRA Left Rotation Mean Values on the 1st, 4th and 7th Visits
12.2, 14.7 and 27.9 resulting in a mean percentage improvement of 14%, 16% and 27%
Group 3 was 4.9, 19.2 and 10.7 resulting in a mean percentage improvement of 7%, 25%
and 14% consecutively. At the end of the study Group 1 had a mean difference of 17.1 and
a mean percentage improvement of 20%. Group 2 had a mean difference of 33.9 and a
mean percentage improvement of 37%. Group 3 had a mean difference of 38.6 and a
mean percentage improvement of 38%.
124
Table 4.51: HRA Left Rotation Mean Values

Group 1 1st Visit 86.5 17.1 20%
7th Visit 69.4
7th Visit 57.1
Group 3 1st Visit 102.4 38.6 38%
7th Visit 63.8
Group 1 1st Visit 86.5 12.2 14%
4th Visit 74.3
4th Visit 76.3
Group 3 1st Visit 102.4 27.9 27%
4th Visit 74.5
7th Visit 69.4
Group 2 4th Visit 76.3 19.2 25%
7th Visit 57.1
Group 3 4th Visit 74.5 10.7 14%
7th Visit 63.8
125
CHAPTER 5: DISCUSSION
5.1. Introduction
The results of this study are discussed with reference to the previous results chapter. Any
statistically significant results are highlighted in this chapter. Where it was possible,
relevant results of previous studies and aspects of the above literature review are included.
5.2 Demographic Data Analysis
5.2.1 Age and gender distribution
Participants in this study had to meet the selection criteria of 18 to 40 years of age. Table
4.1 shows that the gender distribution was set at 15 females and 15 males. Table 4.1 also
shows that the average age was 25.20. This ensured that gender related variables were
kept to a minimum.
5.3 Analysis of Subjective Data
The two components of subjective data used in this study were in the form of a Numerical
Pain Rating Scale (NPRS) and a Vernon-Mior Neck Pain and Disability Index (VMNPDI).
These subjective assessments signify what the participants were experiencing, in the form
of neck pain, disability and quality of life, by allocating a quantitative numerical value to the
subjective assessments throughout the study.
5.3.1 Numerical Pain Rating Scale
To discuss the findings of the NPRS, the study was divided into two separate analyses.
They were an intragroup analysis and an intergroup analysis. A direct comparison of
cervical spine manipulation versus proprioceptive neck exercises versus a combination of
cervical spine manipulation and proprioceptive neck exercises may then be made.
126
a. Intragroup analysis
i. Cervical spine manipulation
In comparing the 1st treatment to the 7th, cervical spine manipulation showed to have a
statistical significance with regards to pain perception (p=0.005), this was mirrored when
comparing the 1st treatment to the 4th (p=0.005) and the 4th treatment to the 7th (p=0.010).
The clinical interpretation also showed that cervical spine manipulation had a positive
effect over time, with a decrease of pain perception of 74%, when comparing the beginning
of the study to the end.
ii. Proprioceptive neck exercises
In comparing the 1st treatment to the 7th, proprioceptive neck exercises showed to have a
statistical significance with regards to pain perception (p=0.005), this was mirrored when
The clinical interpretation also showed that proprioceptive neck exercises had a positive
effect over time, with a decrease of pain perception of 59%, when comparing the beginning
of the study to the end.
iii. Combination of cervical spine manipulation and proprioceptive neck exercises
In comparing the 1st treatment to the 7th, the combination of cervical spine manipulation
and proprioceptive neck exercises showed to have a statistical significance with regards to
pain perception (p=0.005), this was mirrored when comparing the 1st treatment to the 4th
(p=0.005) and the 4th treatment to the 7th (p=0.014). The clinical interpretation also showed
that the combination of cervical spine manipulation and proprioceptive neck exercises had
a positive effect over time, with a decrease of pain perception of 71%, when comparing the
beginning of the study to the end.
127
b. Intergroup analysis
Intergroup analysis compared measurements on the 1 st, 4th and 7th sessions, between
Group 1, Group 2 and Group 3 and it resulted in p-values of 0.539, 0.611 and 0.601
consecutively. This showed that there was no statistical significance between the cervical
spine manipulation, proprioceptive neck exercises and the combination of cervical spine
manipulation and proprioceptive neck exercises. However there was a clinical
improvement during the intragroup analysis (74% versus 59% versus 71%), which
indicated that the cervical spine manipulation group showed the most improvement over
the 7 visits.
5.3.2 Vernon-Mior Neck Pain and Disability Index
To discuss the findings of the VMNPDI, the study was divided into two separate analyses.
statistical significance with regards to VMNPDI (p=0.005), this was mirrored when
The clinical interpretation also showed that cervical spine manipulation had a positive
effect over time, with a decrease of VMNPDI of 84%, when comparing the beginning of the
study to the end.
128
statistical significance with regards to VMNPDI (p=0.023), this was not mirrored when
The clinical interpretation also showed that proprioceptive neck exercises had a positive
effect over time, with a decrease of VMNPDI of 32%, when comparing the beginning of the
study to the end.
VMNPDI (p=0.005), this was mirrored when comparing the 1st treatment to the 4th
(p=0.007) and the 4th treatment to the 7th (p=0.014). The clinical interpretation also showed
a positive effect over time, with a decrease of VMNPDI of 84%, when comparing the
manipulation and proprioceptive neck exercises at the 1st and 4th sessions, which means
that the groups started out comparable, but at the 7 th session the groups were non-
comparable. However there was a clinical improvement during the intragroup analysis
(84% versus 32% versus 84%), which indicated that the cervical spine manipulation group
and combination of cervical spine manipulation and proprioceptive neck exercises group
showed the most improvement over the 7 visits.
129
5.3.3 Discussion of the subjective data
The NPRS results showed that there was a statistical significance for each of the three
groups with regards to the results of the intragroup subjective data analysis, showing that
there was a significant reduction in the participants‟ pain perception. But there was no
statistical significance between the three groups with the intergroup subjective data
analysis, which means that all three treatment protocols provided improvements in the
participants‟ perception of pain, and these improvements occurred at a similar rate to one
another. This might be due to the small sample size of the population (Berben, Sereika and
Engberg, 2012). There was a clinical significance however, where the NPRS showed a
significant reduction in the participants‟ perception of pain throughout the study, as seen in
Table 4.6. At the end of the study there was a mean percentage improvement of 74% for
Group 1 (cervical spine manipulation), 59% for Group 2 (proprioceptive neck exercises)
and 71% for Group 3 (combination of cervical spine manipulation and proprioceptive neck
exercises). This indicates that all treatment approaches had an effect in reducing the
participants‟ perception of pain, but that the cervical spine manipulation group (Group 1),
had a more significant effect on pain perception.
The VMNPDI results showed that there was a statistical significance for Group 1 (cervical
spine manipulation), Group 3 (combination of cervical spine manipulation and
proprioceptive neck exercises) and Group 2 (proprioceptive neck exercises) with regards to
the results of the intragroup subjective data analysis, showing that there was a significant
reduction in the participants pain and disability for Group 1, 2 and 3. There was no
statistical significance between the three groups with the intergroup subjective data
analysis at the 1st session, but at the 7th session there was a statistical significance, which
means that all three treatment protocols provided improvements in the participants‟ pain
and disability, and these improvements occurred at a similar rate to one another. This
might be due to the small sample size of the population (Berben et al., 2012). There was a
clinical significance however, where the VMNPDI showed a significant reduction in the
participants‟ pain and disability throughout the study as seen in Table 4.11. At the end of
the study there was a mean percentage improvement of 84% for Group 1 (cervical spine
manipulation), 32% for Group 2 (proprioceptive neck exercises) and 84% for Group 3
130
(combination of cervical spine manipulation and proprioceptive neck exercises). This
indicates that all treatment approaches had an effect in reducing the participants‟ pain and
disability, but that cervical spine manipulation group (Group 1) and combination of cervical
spine manipulation and proprioceptive neck exercises (Group 3) had a more significant
effect on pain and disability.
Chiropractic manipulative therapy (CMT) is effective at reversing mechanical

derangements such as joint approximation and immobilisation, which will result in a
decrease in pain, as there is a restoration of normal functioning to the three joint complex.
Theoretically, CMT is effective in decreasing pain and disability by affecting the
nociceptive, mechanoreceptive and proprioceptive input. CMT achieves this as it has the
potential to remove mechanical sources of pain and stimulation while also generating a
stimulus-induced analgesia (Peterson and Bergmann, 2002).
Proprioceptive neck exercises are designed to retrain the cervical musculature to regain its
position sense in space (Revel et al., 1994). The purpose of Revel et al. (1991)
rehabilitation program was to improve neck proprioception and to determine whether
functional improvement could be accompanied by a decrease in chronic neck pain and
discomfort. In the above study, there was a statistical improvement in the treatment group
(p=0.0004), with a decrease in neck pain and an increase in Head Repositioning Accuracy
(HRA), even at the ten week follow up. This shows that the proprioceptive system of the
neck, which is mainly involved in cervicocephalic kinaesthesia, has learning abilities which
can be improved by using rehabilitation techniques (Revel et al., 1994). By combining CMT
and these above mentioned proprioceptive neck exercises used by Revel et al. (1994),
together they may be a good combination in treating chronic mechanical neck pain.
131
5.4 Objective Data Analysis
5.4.1 Cervical Range of Motion Measuring Instrument
To discuss the findings of the CROM, the study was divided into two separate analyses.
The acceptable range of motion of the cervical spine is, according to Middleditch and
Olivier (2005):
 Flexion/extension of the suboccipital segment: 20-30 degrees

 Flexion/extension of the lower cervical spine: 100-110 degrees
 Flexion/extension of the complete cervical spine: 130 degrees
 Lateral flexion of the complete cervical spine: 45 degrees
 Rotation of the complete cervical spine: 80-90 degrees.
The resting position of the cervical spine is midway between flexion and extension. The
closed packed position results when the joints surfaces are in maximum contact and the
ligaments are in a shortened position, this occurs in full extension. The capsular pattern for
the cervical spine is lateral flexion and rotation and then extension. Therefore if a joint
capsule was involved in an injury, the first movement that would be lost is lateral flexion
and rotation and then extension. Thus, a patient with chronic mechanical neck pain could
present with a capsular pattern, reducing the patient‟s lateral flexion and rotation more than
extension and flexion (Magee, 2008).
132
a. Cervical spine forward flexion range of motion
i. Intragroup analysis
Cervical spine manipulation
In comparing the 1st treatment to the 7th, cervical spine manipulation showed to have no
statistical significance with regards to cervical spine forward flexion range of motion
(p=0.400), this was mirrored when comparing the 1st treatment to the 4th (p=0.596) and the
4th treatment to the 7th (p=0.306). The clinical interpretation also showed that cervical spine
manipulation had a positive effect over time, with an increase in cervical spine forward
flexion range of motion of 2%, when comparing the beginning of the study to the end.
Proprioceptive neck exercises
In comparing the 1st treatment to the 7th, proprioceptive neck exercises showed to have no
statistical significance with regards to cervical spine forward flexion range of motion
(p=0.717), this was mirrored when comparing the 1st treatment to the 4th (p=0.799) and the
4th treatment to the 7th (p=0.343). The clinical interpretation also showed that
proprioceptive neck exercises had a positive effect over time, with an increase in cervical
spine forward flexion range of motion of 0.5%, when comparing the beginning of the study
to the end.
Combination of cervical spine manipulation and proprioceptive neck exercises
cervical spine forward flexion range of motion (p=0.013), this was mirrored when
comparing the 1st treatment to the 4th (p=0.040), but not at the 4th treatment to the 7th
(p=0.115). The clinical interpretation also showed that the combination of cervical spine
manipulation and proprioceptive neck exercises had a positive effect over time, with an
133
increase in cervical spine forward flexion range of motion of 11%, when comparing the
ii. Intergroup Analysis
consecutively. This proves that there was no statistical significance between the cervical
manipulation and proprioceptive neck exercises at the 1st and 4th sessions, which means
that the groups started out comparable, but at 7 th session the groups were non-
comparable. However there was a clinical improvement during the intragroup analysis (2%
versus 0.5% versus 11%), which indicated that the combination of cervical spine
manipulation and proprioceptive neck exercises group showed the most improvement over
the 7 visits.
b. Cervical spine extension range of motion
statistical significance with regards to cervical spine extension range of motion (p=0.018),
this was mirrored when comparing the 1st treatment to the 4th (p=0.027), but not at the 4th
treatment to the 7th (p=0.202). The clinical interpretation also showed that cervical spine
manipulation had a positive effect over time, with an increase in cervical spine extension
range of motion of 12%, when comparing the beginning of the study to the end.
134
statistical significance with regards to cervical spine extension range of motion (p=0.007),
this was mirrored when comparing the 1st treatment to the 4th (p=0.018), but not at the 4th
treatment to the 7th (p=0.104). The clinical interpretation also showed that proprioceptive
neck exercises had a positive effect over time, with an increase in cervical spine extension
and proprioceptive neck exercises showed to have no statistical significance with regards
to cervical spine extension range of motion (p=0.212), this was mirrored when comparing
the 1st treatment to the 4th (p=0.115) and the 4th treatment to the 7th (p=0.496). The clinical
interpretation also showed that the combination of cervical spine manipulation and
spine extension range of motion of 8%, when comparing the beginning of the study to the
end.
ii. Intergroup analysis
improvement during the intragroup analysis (12% versus 17% versus 8%), which indicated
that the proprioceptive neck exercises group showed the most improvement over the 7
visits.
135
c. Cervical spine right and left lateral flexion range of motion
Right lateral flexion
statistical significance with regards to cervical spine right lateral flexion range of motion
(p=0.017), this was mirrored when comparing the 1st treatment to the 4th (p=0.042) and at
the 4th treatment to the 7th (p=0.026). The clinical interpretation also showed that cervical
spine manipulation had a positive effect over time, with an increase in cervical spine right
lateral flexion range of motion of 12%, when comparing the beginning of the study to the
end.
Left lateral flexion
In comparing the 1st treatment, cervical spine manipulation showed to have no statistical
significance with regards to cervical spine left lateral flexion range of motion (p=0.252), this
was not mirrored when comparing 4th treatment which showed a statistical significance
(p=0.012), but there was no statistical significance the 7th treatment (p=0.307). The clinical
interpretation also showed that cervical spine manipulation had a positive effect over time,
with an increase in cervical spine left lateral flexion range of motion of 5%, when
comparing the beginning of the study to the end.
statistical significance with regards to cervical spine right lateral flexion range of motion
(p=0.027), this was not mirrored when comparing the 1st treatment to the 4th (p=1.000), but
136
there was a statistical significance at the 4th treatment to the 7th (p=0.017). The clinical
interpretation also showed that proprioceptive neck exercises had a positive effect over
time, with an increase in cervical spine right lateral flexion range of motion of 8%, when
statistical significance with regards to cervical spine left lateral flexion range of motion
(p=0.036), this was mirrored when comparing the 4th treatment (p=0.008), but not at the 7th
treatment (p=0.150). The clinical interpretation also showed that proprioceptive neck
exercises had a positive effect over time, with an increase in cervical spine left lateral
flexion range of motion of 3%, when comparing the beginning of the study to the end.
to cervical spine right lateral flexion range of motion (p=0.462), this was mirrored when
The clinical interpretation also showed that the combination of cervical spine manipulation
and proprioceptive neck exercises had a positive effect over time, with an increase in
cervical spine right lateral flexion range of motion of 3%, when comparing the beginning of
the study to the end.
In comparing the 1st treatment, the combination of cervical spine manipulation and
proprioceptive neck exercises showed to have no statistical significance with regards to
cervical spine left lateral flexion range of motion (p=0.107), this was mirrored when
137
comparing the 4th treatment (p=0.092) and the 7th treatment (p=0.103). The clinical
interpretation also showed that the combination of cervical spine manipulation and
spine left lateral flexion range of motion of 6%, when comparing the beginning of the study
to the end.
consecutively. This shows that there was no statistical significance between the cervical
that the cervical spine manipulation group showed the most improvement over the 7 visits.
Intergroup analysis compared measurements on the 1st, 4th and 7th sessions, between
that the combination of cervical spine manipulation and proprioceptive neck exercises
group showed the most improvement over the 7 visits.
138
d. Cervical spine right and left rotation range of motion
Right rotation
statistical significance with regards to cervical spine right rotation range of motion
(p=0.012), this was mirrored when comparing the 1st treatment to the 4th (p=0.018) and at
the 4th treatment to the 7th (p=0.046). The clinical interpretation also showed that cervical
spine manipulation had a positive effect over time, with an increase in cervical spine right
rotation range of motion of 10%, when comparing the beginning of the study to the end.
Left rotation
statistical significance with regards to cervical spine left rotation range of motion (p=0.109),
this was mirrored when comparing the 1st treatment to the 4th (p=0.317) and at the 4th
treatment to the 7th (p=0.102). The clinical interpretation also showed that cervical spine
manipulation had a positive effect over time, with an increase in cervical spine left rotation
Right rotation
statistical significance with regards to cervical spine right rotation range of motion
(p=0.017), this was not mirrored when comparing the 1st treatment to the 4th (p=0.170), but
there was a statistical significance at the 4th treatment to the 7th (p=0.040). The clinical
interpretation also showed that proprioceptive neck exercises had a positive effect over
139
time, with an increase in cervical spine right rotation range of motion of 9%, when
Left rotation
In comparing the 1st treatment to the 7th, proprioceptive neck exercises showed to have no
statistical significance with regards to cervical spine left rotation range of motion (p=0.343),
this was mirrored when comparing the 1st treatment to the 4th (p=0.465) and at the 4th
treatment to the 7th (p=0.109). The clinical interpretation also showed that proprioceptive
neck exercises had a positive effect over time, with an increase in cervical spine left
rotation range of motion of 3%, when comparing the beginning of the study to the end.
Right rotation
to cervical spine right rotation range of motion (p=0.078), this was mirrored when
The clinical interpretation also showed that the combination of cervical spine manipulation
and proprioceptive neck exercises had a positive effect over time, with an increase in
cervical spine right rotation range of motion of 8%, when comparing the beginning of the
study to the end.
Left rotation
to cervical spine left rotation range of motion (p=0.233), but there was a statistical
significance when comparing the 1st treatment to the 4th (p=0.026) and this was not
mirrored at the 4th treatment to the 7th (p=0.414). The clinical interpretation also showed
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a positive effect over time, with an increase in cervical spine left range of motion of 5%,
when comparing the beginning of the study to the end.
Right rotation
that the cervical spine manipulation group showed the most improvement over the 7 visits.
Left rotation
consecutively. This shows that there was no statistical significance at the 1st visit which
means that the groups started out comparable, but at the 4 th and 7th visits the groups were
non-comparable. However there was a clinical improvement during the intragroup analysis
(3% versus 3% versus 5%), which indicated that the combination of cervical spine
manipulation and proprioceptive neck exercises group showed the most improvement over
the 7 visits.
5.4.2 Discussion of the ranges of motion
Measures were taken to ensure that there was consistent accuracy during all cervical spine
ROM measurements with the CROM device. These precautionary measures consisted of
ensuring that the CROM device was placed correctly on the participants head as well as it
141
being in the same position before each movement and ensuring that the participants
maintained a correct upright seated position during the cervical ROM, after which a set of
readings were taken. Cervical spine ROM devices were assessed for their reliability in a
study in 2000. Although the CROM device received the most evaluations and even though
it revealed that this device had a superior reliability when compared to other cervical ROM
devices, the reliability was completely dependent on the ability of the operators‟ knowledge
to use the device in the correct manner as well as to take accurate readings (Jordan,
2000). The validity and reliability of the CROM device has been proven (Piva, 2006).
There was statistical significance between the three groups with the intergroup data
analysis, with a statistical significance in flexion at the 7th visit and left rotation at the 4th
and 7th visit, which means that all three treatment protocols provided improvements in the
participants‟ cervical spine range of motion, and these improvements occurred at a similar
rate to one another. This might be due to the small sample size of the population (Berben
et al., 2012).
A clinically significant improvement was seen in flexion ROM in Group 1 with a 2%

increase, Group 2 with a 0.5% increase and in Group 3 with an 11% increase, as seen in
Table 4.16. This indicates that although all three groups did improve, that Group 3 had a
more significant effect on increasing flexion ROM. A clinically significant improvement was
seen in extension ROM in Group 1 with a 12% increase, Group 2 with a 17% increase and
in Group 3 with an 8% increase, as seen in Table 4.21. All three groups resulted in an
increase in extension ROM, however Group 2 had a more significant effect on increasing
extension ROM.
A clinically significant improvement was seen in right lateral flexion ROM in Group 1 with a
12% increase, Group 2 with an 8% increase and in Group 3 with a 3% increase, as seen in
Table 4.26. Group 1 had the most significant increase in right lateral flexion ROM, even
though the other two groups also had a positive increase. A clinically significant
improvement was seen in left lateral flexion ROM in Group 1 with a 5% increase, Group 2
with a 3% increase and in Group 3 with a 6% increase, as seen in Table 4.31. Although all
142
three groups provided for a marginal improvement in increasing left lateral flexion ROM,
Group 3 had the most significant improvement.
A clinically significant improvement was seen in right rotation ROM in Group 1 with a 10%
increase, Group 2 with a 9% increase and in Group 3 with an 8% increase, as seen in
Table 4.36. Group 1 had a more significant improvement in increasing right rotation ROM,
even though the other two groups also showed an improvement in right rotation ROM. A
clinically significant improvement was seen left rotation ROM in Group 1 with a 3%
increase, Group 2 with a 3% increase and in Group 3 with a 5% increase, as seen in Table
4.41. All three groups show a slight improvement in increasing left rotation ROM, but
Group 3 showed to have a more significant improvement in increasing left rotation ROM.
Group 1 (cervical spine manipulation) and Group 3 (combination of cervical spine

manipulation and proprioceptive neck exercises) had the most significant improvement in
increasing cervical spine ROM in flexion, right and left lateral flexion and right and left
rotation. Group 2 (proprioceptive neck exercises) only had a significant improvement in
increasing cervical spine extension ROM.
As mentioned in chapter two, muscle hypertonicity could lead to movement inhibition and
CMT serves to eliminate this muscle hypertonicity on a segmental level (Peterson and
Bergmann, 2002). CMT changes the tone and strength of the supporting musculature, by
stretching segmental muscles and causing spindle reflexes, which may reduce
hypertonicity (Gatterman, 2005). CMT also breaks up adhesions, which in turn could
account for the instantaneous changes that occur in intersegmental motion once CMT is
delivered (Plaugher, 1993). The above statement is confirmed by Martinez-Segura,
Fernandez-de-las-Penas, Ruiz-Saez, Lopez-Jimenez and Rodrigues-Blance (2006), who
stated that when manual therapy is delivered to the restricted segments of the cervical
spine, an expected increase in cervical spine range of motion would occur i.e. flexion,
extension, lateral flexion and rotation. CMT would have restored function to the subluxated
motion segments and would therefore have allowed for the positive clinical changes seen
as an increase in the cervical ROM in both Group 1 and Group 3.
143
Proprioception can refer to all neural inputs, which originate from joints, muscles and
tendons. These neural inputs are then projected to the CNS for processing and result in
motor control and the regulation of reflexes (Lephart and Fu, 2000). Proprioceptive neck
exercises are designed to retrain the cervical musculature to regain its position sense in
space using a rehabilitation program to improve neck proprioception, allowing for functional
improvement and a decrease in chronic neck pain and discomfort. The exercises were
concerned mainly with eye-neck co-ordination (Revel et al., 1994). Proprioception‟s
primary involvement is concerned with postural and occulomotor control. The functional
instability of joints is related to altered joint position sense. This results in the joints
becoming susceptible to repetitive injury and may also result in chronic pain and
degenerative joint disease (Heikkilä and Wenngren, 1998; Palmgren et al., 2006).
Mechanically dysfunctional, hypomobile joints can act as a source of altered afferent

impulses. Movement is required as the adequate stimulus for proper mechanoreceptor
function, and therefore hypomobile joints will decrease mechanoreceptor activity.
Hypomobile joints will produce an altered afferent input, which will induce a persistent
nociceptive input, as well as an altered and decreased proprioceptive input. This therefore
will produce pain (Gatterman, 2005; Seaman and Winterstein, 1998).
By providing the participants with proprioceptive neck exercises, the cervical musculature
is retrained to assume its normal neutral position of the head and neck in space, and thus
prevent any joint or muscular dysfunction. This treatment was provided in Group 3, along
with cervical spine manipulation, which together with their added individual benefits could
account for the positive clinical changes seen as an increase in cervical ROM.
144
5.4.3 Head Repositioning Accuracy
HRA right rotation
statistical significance with regards to HRA right rotation (p=0.185), this was mirrored when
comparing the 1st treatment to the 4th (p=0.066) and at the 4th treatment to the 7th
(p=0.415). The clinical interpretation also showed that cervical spine manipulation had a
positive effect over time, with an increase in HRA right rotation of 21%, when comparing
the beginning of the study to the end.
HRA left rotation
statistical significance with regards to HRA left rotation (p=0.092), this was mirrored when
comparing the 1st treatment to the 4th (p=0.283) and at the 4th treatment to the 7th
(p=0.721). The clinical interpretation also showed that cervical spine manipulation had a
positive effect over time, with an increase in HRA left rotation of 20%, when comparing the
HRA right rotation
statistical significance with regards to HRA right rotation (p=0.012), this was not mirrored
when comparing the 1st treatment to the 4th (p=0.721), but there was a statistical
significance at the 4th treatment to the 7th (p=0.037). The clinical interpretation also showed
145
that proprioceptive neck exercises had a positive effect over time, with an increase in HRA
right rotation of 39%, when comparing the beginning of the study to the end.
HRA left rotation
statistical significance with regards to HRA left rotation (p=0.036), this was not mirrored
when comparing the 1st treatment to the 4th (p=0.799) and at the 4th treatment to the 7th
(p=0.285). The clinical interpretation also showed that proprioceptive neck exercises had a
positive effect over time, with an increase in HRA left rotation of 37%, when comparing the
HRA right rotation
to HRA right rotation (p=0.203), this was mirrored when comparing the 1 st treatment to the
4th (p=0.760) and the 4th treatment to the 7th (p=0.508). The clinical interpretation also
showed that the combination of cervical spine manipulation and proprioceptive neck
exercises had a positive effect over time, with an increase in HRA right rotation of 22%,
when comparing the beginning of the study to the end.
HRA left rotation
to HRA left rotation (p=0.093), but there was a statistical significance when comparing the
1st treatment to the 4th (p=0.022), but not at the 4th treatment to the 7th (p=0.646). The
clinical interpretation also showed that the combination of cervical spine manipulation and
146
proprioceptive neck exercises had a positive effect over time, with an increase in HRA left
rotation of 38%, when comparing the beginning of the study to the end.
HRA right rotation
indicated that the proprioceptive neck exercises group showed the most improvement over
the 7 visits.
HRA left rotation
indicated that the combination of cervical spine manipulation and proprioceptive neck
exercises group showed the most improvement over the 7 visits.
5.4.4 Discussion of Head Repositioning Accuracy
There was no statistical significance between the three groups with the intergroup data
analysis, which means that all three treatment protocols provided improvements in the
participants head repositioning accuracy, and these improvements occurred at a similar
147
rate to one another. This might be due to the small sample size of the population (Berben
et al., 2012).
A clinically significant improvement was seen in HRA right rotation in Group 1 with a 21%
improvement, Group 2 with a 39% improvement and in Group 3 with a 22% improvement,
as seen in Table 4.46. This indicates that although all three groups did improve, that Group
2 had a more significant increase in improving HRA in right rotation. A clinically significant
improvement was seen in HRA left rotation in Group 1 with a 20% improvement, Group 2
with a 37% improvement and in Group 3 with a 38% improvement, as seen in Table 4.51
All three groups resulted in an improvement in HRA, but Group 3 had a more significant
increase in improving HRA in left rotation.
As seen in chapter two, the function of controlling head movement by the proprioceptive
system is to achieve a desirable posture and orientation of the head, in order for optimal
accuracy to be achieved while performing tasks with the limbs. If the target‟s exact location
is unknown, the head is moved to an area of the expected target‟s location, while the
proprioceptive system supplies any corrective movements. This cognitive mapping serves
to fine tune the posture and place the head in a specific location so as to ensure that
further egocentric manual tasks can be executed effectively and with precision (Kim,
Gillespie and Martin, 2007). The mental perception of body orientation will be affected as
the altered cervical proprioceptive information converges in the CNS with the vestibular
and visual signals. As a result, the body‟s relation to its surroundings may be
misinterpreted (Heikkilä et al., 2000). This will then result in secondary disturbances to the
postural control system, causing dizziness or loss of balance (Treleaven et al., 2006).
The purpose of Revel et al. (1994) rehabilitation program was to improve neck
proprioception and to determine whether functional improvement could be accompanied by
a decrease in chronic neck pain and discomfort. The exercises were concerned mainly with
eye-neck co-ordination and included fifteen individual exercise sessions twice a week for
eight weeks with a follow up session on the tenth week. There was a statistical
improvement in the treatment group (p=0.0004), with a decrease in neck pain and an
increase in HRA, even at the ten week follow up. This shows that the proprioceptive
148
system of the neck, which is mainly involved in cervicocephalic kinaesthesia, has learning
abilities and can be improved by using rehabilitation techniques (Revel et al., 1994).
Although the treatment period was only over three weeks in this study with participants
receiving individual proprioceptive neck exercises treatment sessions over 6 consultations,
this could be a possible indication for the clinical improvement seen in Group 2 concerning
HRA in right rotation.
Joint position sense is dependent on mechanoreceptor input, which is derived from the
articular and muscular components of the proprioceptive system. Any angular change in
the joints is determined by this system (Palmgren, Sandström, Lundqvist and Heikkilä,
2006). Once the abnormal afferent input is removed; there will be an improvement in the
proprioception and motor response, chiropractic SMT is considered to be the most
powerful remedy for improving cervical joint position sense and decreasing dizziness,
where chiropractic SMT has a greater effect on the joints and their adjacent tissues. This
thus supports the theory that chiropractic SMT affects the mechanoreceptors afferent input,
implying that the neural input from the cervical spine facet joints is more important for
proprioception and pain sensation (Heikkilä et al., 2000). The combination of cervical spine
manipulation and proprioceptive neck exercises could account for the clinical improvement
seen in Group 3 concerning HRA in left rotation.
5.5 Conclusion
Group 1 was treated with cervical spine manipulation over the restricted joint segment/s.
Group 2 was treated with proprioceptive neck exercises. Group 3 was treated with a
combination of cervical spine manipulation and proprioceptive neck exercises. Group 1, 2
and 3 showed to have a statistical improvement (in certain areas) and clinical
improvements (in all areas) over time. All three groups did improve over time in pain
perception (NPRS), pain and disability (VMNPDI), cervical ROM as well as HRA. Both
Group 1 and Group 3 showed more significant clinical improvements throughout this study
and considering that Group 3 is a combination treatment of cervical spine manipulation and
proprioceptive neck exercises, it could be considered a valid treatment protocol for chronic
mechanical neck pain and improving head repositioning accuracy.
149
CHAPTER 6: CONCLUSION AND RECOMMENDATIONS
6.1 Conclusion
The aim of this randomised comparative clinical study was to determine the effect of
cervical spine manipulation, proprioceptive neck exercises and a combination of cervical
spine manipulation and proprioceptive neck exercises, over a three week period, in the
treatment of chronic mechanical neck pain and the effect it has on Head Repositioning
Accuracy (HRA).
At the end of the study, it was concluded that all three groups showed significant clinical
and statistical improvement (the latter only in certain areas) in both their subjective
perception of pain and disability and their objective improvements in cervical spine range of
motion (ROM) and head repositioning accuracy. The lack of statistical significance in the
objective data analysis could be due to the small sample size used in this study.
Clinical results of this study showed that Group 1 (cervical spine manipulation) and Group
3 (combination of cervical spine manipulation and proprioceptive neck exercises) both had
significant improvements with regards to the Numerical Pain Rating Scale (NPRS) and
Vernon-Mior Neck Pain and Disability Index (VMNPDI). Clinical results of this study also
showed that Group 3 had a more significant improvement with regards to cervical ROM,
followed by Group 1 and where Group 2 (proprioceptive neck exercises) had the least
significant improvement. However, the percentage improvements with HRA in right rotation
were far more superior in Group 2 and when comparing HRA in left rotation, Group 3 was
more superior with Group 2 following closely. Group 1 did show improvements in HRA in
both left and right rotation, but it was not as superior as both Group 2 and 3.
Based on these results seen in Chapter 4 and discussed in Chapter 5, it can be concluded
that both chiropractic cervical spine manipulation on its own and a combination of cervical
spine manipulation and proprioceptive neck exercises can be used effectively to treat
chronic mechanical neck pain. It could not be statistically concluded whether one treatment
is superior to another, although clinically a combination of cervical spine manipulation and
150
proprioceptive neck exercises seemed to be more effective and could thus be used in a
clinical setting.
6.2 Recommendations
The following recommendations may aid in improving statistical significance for future
studies in this field:
 A study that consists of a larger sample group would represent the population
more accurately and would therefore provide an adequate clinical study so that
sufficient statistical significance can be achieved
 Isolating gender to male and female only and selecting a specific age group as
inclusion criteria requirements, may produce a different outcome or stronger
statistical results
 Increase the duration of the study and include more treatment sessions to
determine whether proprioceptive neck exercises would have the same effect as a
standalone treatment protocol for chronic mechanical neck pain or if the
combination of cervical spine manipulation and proprioceptive neck exercises
would still be a more effective approach in the treatment of chronic mechanical
neck pain
 Randomising the order of HRA testing in right and left rotation, may negate any
learning effects during the testing process and may further strengthen the results
of the study
 Measurements of overall HRA can be converted into angular displacements and
the results can then be compared to those obtained from the CROM device. This
may prove to be a more effective method of evaluating HRA
 Right and left lateral flexion movements in HRA measurements may also be added
since rotation in the cervical spine is a coupled movement involving rotation and
lateral flexion
 Assess HRA in all cervical ROM in flexion, extension, bilateral lateral flexion and
bilateral rotation and cross reference these reading with CROM readings in the
151
same movements stated above. This may result in a more accurate representation
of the overall changes in HRA
 Conduct the study on acute facet syndromes; this will determine if the combination
of cervical spine manipulation and proprioceptive neck exercises, together, as well
as standalone treatment protocols has an effect on chronic as well as acute
cervical facet syndromes
 Conduct this study on only the side of the acute cervical facet; this will determine if
the cervical range of motion and HRA changes are due to changes within the
acute cervical facet
 Conduct this study on asymptomatic participants to determine their HRA and
whether pain and dysfunction actually has an effect on HRA.
152
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164
APPENDIX A: ADVERTISEMENT
Do you suffer from neck pain?
Receive free Chiropractic treatment!!!

Do you suffer from chronic (6 weeks or longer) NECK PAIN?
Are you between the ages of 18 and 40?
You may qualify to take part in a research study aimed at relieving
your neck pain.
Treatment is free of charge!!
University ofJohannesburg Doornfontein Campus
Chiropractic Clinic
(Gate 7, Sherwell Road, Doornfontein)
Please contact Lana Panagis on 011 559 6493 if you are interested
165
APPENDIX B: INFORMATION AND CONSENT FORM
DEPARTMENT OF CHIROPRACTIC
INFORMATION AND CONSENT FORM
I, Lana Panagis, hereby invite you to participate in my research study. I am currently a

Chiropractic student, completing my Masters Degree at the University of Johannesburg.
The aim of the study is to compare Chiropractic manipulative therapy and

proprioceptive neck exercises both alone, and in a combination treatment to
determine whether there truly is a benefit in combining the two treatments so as to
provide Doctors of Chiropractic with an additional treatment protocol for chronic
mechanical neck pain and to determine the effect it may have on head repositioning
accuracy.
Participants will be recruited by word of mouth and by advertisements placed within

and around the Chiropractic Clinic at Doornfontein Campus. Participants will be
assessed as to whether they fulfil the inclusion and exclusion criteria for this
research study. Participants will be randomly assigned to three groups and receive
Chiropractic manipulative therapy, proprioceptive neck exercises or a combination
of both. The Chiropractic adjustment involves the restoration of normal joint motion.
Abnormal joint motion will be detected by the researcher via motion palpation. The
Chiropractic adjustment is a safe, non-invasive treatment technique.
166
The research study will take place at the University of Johannesburg Chiropractic Day
Clinic. Your privacy will be protected by ensuring your anonymity and confidentiality when
compiling the research dissertation.
All procedures will be explained to you and all participation is entirely on a voluntary basis;
withdrawal at any stage will not cause you any harm. Potential benefits from this study
include relief or a decrease in mechanical cervical pain. Potential discomforts are
the wearing of the Head Repositioning Helmet and sequence of proprioceptive
exercise. Risks that may occur could be slight pain and discomfort of the neck due
to cervical spine manipulation. After this study is complete, I will provide you feedback
regarding the outcomes if you so wish.
I have fully explained the procedures and their purpose. I have asked whether or not any
questions have arisen regarding the procedures and have answered them to the best of
my ability.
Date: _______________________ Researcher: ________________________
I have been fully informed as to the procedures to be followed and have been given a
description of the discomfort risks and benefits expected from the treatment. In signing this
consent form I agree to this form of treatment and understand my rights and that I am free
to withdraw my consent and participation in this study at any time. I understand that if I
have any questions at any time, they will be answered.
Date: _______________________ Participant: _________________________
Should you have any concerns or queries regarding the current study, the following
persons may be contacted.
Researcher: Lana Panagis 082 955 2988
Supervisor: Dr Moodley 083 775 7997
167
APPENDIX C: CASE HISTORY FORM
168
169
170
171
172
APPENDIX D: PHYSICAL EXAMINATION FORM
173
174
175
176
177
178
179
180
APPENDIX E: CERVICAL SPINE REGIONAL EXAMINATION FORM
181
182
183
184
APPENDIX F: SOAP NOTE FORM
185
186
APPENDIX G: NUMERICAL PAIN RATING SCALE
Numerical Pain Rating Scale
Name: _____________________________
File number: ________________________
Date: ______________________________
Place a mark on the pain scale below that represents your pain at this point in time. On a
scale of 0 to 10, 0 means “no pain” and 10 means the “worst possible pain”. The middle of
the scale describes “moderate pain”. A two or three rating would be “mild pain” and a rating
of seven or higher would indicate “severe pain”.
Visit 1
0 1 2 3 4 5 6 7 8 9 10
No pain Moderate pain Worst pain
Visit 4
0 1 2 3 4 5 6 7 8 9 10
Visit 7
0 1 2 3 4 5 6 7 8 9 10
187
APPENDIX H: VERNON-MIOR NECK PAIN AND DISABILITY INDEX
Vernon-Mior Neck Pain and Disability Index (Vernon, 2008).
Name: _____________________________
File number: ________________________
Date: ______________________________
Neck Disability Index
This questionnaire has been designed to give us information as to how your neck pain has
affected your ability to manage in everyday life. Please answer every section and mark in
each section only the one box that applies to you. We realise you may consider that
two or more statements in any one section relate to you, but please just mark the box that
most closely describes your problem.
Section 1: Pain Intensity
o I have no pain at the moment

o The pain is very mild at the moment
o The pain is moderate at the moment
o The pain is fairly severe at the moment
o The pain is very severe at the moment
o The pain is the worst imaginable at the moment
Section 2: Personal Care (Washing, Dressing, etc.)
o I can look after myself normally without causing extra pain

o I can look after myself normally but it causes extra pain
o It is painful to look after myself and I am slow and careful
o I need some help but can manage most of my personal care
o I need help every day in most aspects of self care
o I do not get dressed, I wash with difficulty and stay in bed
188
Section 3: Lifting
o I can lift heavy weights without extra pain

o I can lift heavy weights but it gives extra pain
o Pain prevents me lifting heavy weights off the floor, but I can manage if they are
conveniently placed, for example on a table
o Pain prevents me from lifting heavy weights but I can manage light to medium
weights if they are conveniently positioned
o I can only lift very light weights

o I cannot lift or carry anything
Section 4: Reading
o I can read as much as I want to with no pain in my neck

o I can read as much as I want to with slight pain in my neck
o I can read as much as I want with moderate pain in my neck
o I can‟t read as much as I want because of moderate pain in my neck
o I can hardly read at all because of severe pain in my neck
o I cannot read at all
Section 5: Headaches
o I have no headaches at all

o I have slight headaches, which come infrequently
o I have moderate headaches, which come infrequently
o I have moderate headaches, which come frequently
o I have severe headaches, which come frequently
o I have headaches almost all the time
Section 6: Concentration
o I can concentrate fully when I want to with no difficulty

o I can concentrate fully when I want to with slight difficulty
189
o I have a fair degree of difficulty in concentrating when I want to
o I have a lot of difficulty in concentrating when I want to
o I have a great deal of difficulty in concentrating when I want to
o I cannot concentrate at all
Section 7: Work
o I can do as much work as I want to

o I can only do my usual work, but no more
o I can do most of my usual work, but no more
o I cannot do my usual work
o I can hardly do any work at all
o I can‟t do any work at all
Section 8: Driving
o I can drive my car without any neck pain

o I can drive my car as long as I want with slight pain in my neck
o I can drive my car as long as I want with moderate pain in my neck
o I can‟t drive my car as long as I want because of moderate pain in my neck
o I can hardly drive at all because of severe pain in my neck
o I can‟t drive my car at all
Section 9: Sleeping
o I have no trouble sleeping

o My sleep is slightly disturbed (less than 1 hr sleepless)
o My sleep is mildly disturbed (1-2 hrs sleepless)
o My sleep is moderately disturbed (2-3 hrs sleepless)
o My sleep is greatly disturbed (3-5 hrs sleepless)
o My sleep is completely disturbed (5-7 hrs sleepless)
190
Section 10: Recreation
o I am able to engage in all my recreation activities with no neck pain at all

o I am able to engage in all my recreation activities, with some pain in my neck
o I am able to engage in most, but not all of my usual recreation activities because of
pain in my neck
o I am able to engage in a few of my usual recreation activities because of pain in
my neck
o I can hardly do any recreation activities because of pain in my neck
o I can‟t do any recreation activities at all
Score: /50 Transform to percentage score x 100 = %points
Scoring: For each section the total possible score is 5:
if the first statement is marked the section score = 0, if the last statement is marked it = 5. If
all ten sections are completed the score is calculated as follows:
Example:16 (total scored)
50 (total possible score) x 100 = 32%
If one section is missed or not applicable the score is calculated: 16 (total scored)
45 (total possible score) x 100 = 35.5%
Minimum Detectable Change (90% confidence): 5 points or 10 %points
NDI developed by: Vernon, H. & Mior, S. (1991). The Neck Disability Index: A study of
reliability and validity. Journal of Manipulative and Physiological Therapeutics. 14, 409-415
191
APPENDIX I: CROM RECORDING SHEET
Range of motion readings with CROM measured in degrees
Name: ____________________________
File number: _______________________
Date: _____________________________
Visit 1, 4 and 7
VISIT 1 4 7
FLEXION
EXTENSION
RIGHT
LATERAL FLEXION
LEFT
LATERAL FLEXION
RIGHT
ROTATION
LEFT
ROTATION
192
APPENDIX J: HRA RECORDING SHEET
Head Repositioning Accuracy (HRA) measured in millimetres (mm)
Name: _____________________________
File number: ________________________
Date: ______________________________
Visit 1, 4 and 7
VISIT 1 4 7
RIGHT
ROTATION
ERROR OF
REPOSITIONING
LEFT
ROTATION
ERROR OF
REPOSITIONING
193
APPENDIX K: PROPRIOCEPTIVE NECK EXERCISES
Proprioceptive Neck Exercises (Revel et al., 1994)
Name: _____________________________
File number: ________________________
Date: ______________________________
1. Patient supine
 Slow passive motions of head while patient maintains gaze on a fixed
target
 Patient is asked to concentrate on the different head positions during the
motions
2. Patient sitting and standing

 Exercises to be performed with restricted peripheral vision using goggles
equipped with opaque lenses except for a clear central point of 0.5mm
wide that is adjustable for each patient to have clear foveal vision
194
(a) Active movements of the head (mainly rotations) to follow a small
mobile target
195
(b) Automatic movements of the neck to maintain the gaze on a fixed
target while therapist moves the trunk of the patient
(c) Patient is instructed to fix a target for a few seconds and to memorize
the head-neck position
 Patient closes eyes and performs maximal rotation of the
head, trying to find the initial position and then opens eyes
 This is repeated to relocate as accurately as possible to the
initial head position
196
3. Exercises in a wide range of motion with free eye-head coupling
 Patient is asked to follow a mobile target using alternating slow persuits
and saccades in a horizontal plane
197
APPENDIX L: CONTRAINDICATIONS TO CHIROPRACTIC ADJUSTMENT
Exclusion Criteria
Contra-indications to Chiropractic Adjustments (Gatterman,1990)
1. Vascular complications
 Vertebral artery syndrome
 Aneurysms
2. Tumours
 Primary to the bone
 Secondary (metastasis to the bone)
3. Bone infections
 Tuberculosis of the spine
 Osteomyelitis of the spine
4. Traumatic injuries
 Fractures
 Instabilities
 Dislocation
 Unstable spondylolisthesis
5. Arthritis
 Ankylosing sponylitis
 Rheumatoid arthritis
 Psoriatic arthritis
 Reiter‟s syndrome
 Osteoarthritis
6. Psychological considerations
 Malingering
198
 Hysteria
 Hypochondriasis
 Pain intolerance
 Dependant personality
 Disability Syndromes
7. Neurological complications
 Cervical disc lesions and myelopathy
 Nerve root damage
199
APPENDIX M: MOTION PALPATION TECHNIQUES
(Esposito and Philipson, 2005)
200
201
202
203
APPENDIX N: CERVICAL SPINE ADJUSTMENTS
(Esposito and Philipson, 2005)
204
205
206
207
208
209
210
211

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COPYRIGHT AND CITATION CONSIDERATIONS FOR THIS THESIS/ DISSERTATION

Please include the following information in your citation:

Year of publication, in brackets

Title of thesis, in italics

Type of degree (e.g. D. Phil.; Ph.D.; M.Sc.; M.A. or M.Ed. …etc.)

Name of the University

A dissertation submitted to the Faculty of Health Sciences, University of Johannesburg, as

Supervisor: ____________________________ _________________

On this________ day of ________ 2013

Signed at _____________________on this ______________day of _______________ 20___.

STAMP COMMISSIONER OF OATHS

Chiropractic manipulative therapy (CMT) is a specific form of articular manipulation,

Chiropractic manipulative therapy does have documented positive effects on the

CHAPTER ONE: INTRODUCTION .................................................................................... 1

CHAPTER TWO: LITERATURE REVIEW ......................................................................... 3

CHAPTER THREE: METHODOLOGY ............................................................................. 61

CHAPTER FOUR: RESULTS .......................................................................................... 74

CHAPTER FIVE: DISCUSSION ..................................................................................... 126

CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS ...................................... 150

REFERENCES ............................................................................................................... 153

Figure 2.1: An Illustration of a Typical Vertebra .......................................................... 4

Table 2.1: Anatomy of the Upper Cervical Ligaments .............................................. 13

1.1 General Introduction

Chiropractic manipulative therapy does have documented positive effects on the

1.2 Aim of the Study

1.3 Benefits of the Study

2.2 Functional Anatomy of the Cervical Spine

2.2.1 Typical cervical vertebra

Figure 2.1: An Illustration of a Typical Vertebra (Netter, 2006)

2.2.2 Atypical cervical vertebra

Figure 2.2: Illustration of the Atlas and Axis (Netter, 2006)

2.2.3 The intervertebral disc

The annulus fibrosus is a fibrous ring consisting of concentric lamellae of fibrocartilage,

c. Vertebral end plate

2.2.4 Zygapophyseal joints

2.2.5 Zygapophyseal joint capsule

2.2.6 Innervation of the zygapophyseal joints of the cervical spine

Mechanoreceptors are biological transducers that react to a mechanical stimulus and

2.2.7 Ligaments of the cervical spine

Name of Ligament Attachments Function

Cruciform ligament: Superior longitudinal band: Superior longitudinal band:

 Superior From the transverse ligament to the Keeps the transverse

Name of Ligament Attachments Function

Posterior Covers the posterior aspect of the Prevents posterior IVD

Interspinous Runs between the spinous processes of Limits flexion.

2.2.8 Muscles of the cervical spine

Figure 2.6: Superficial Muscles of the Neck (Netter, 2006)

Muscle Superior Inferior Innervation Main Action

Sternocleid Lateral surface of Sternal head: Spinal Unilateral: Laterally

Trapezius Medial third of Lateral third of Spinal Unilateral: Lateral

Superior and inferior

Table 2.4: Anterior Vertebral Muscles (Moore and Dalley, 2006)

Muscle Superior Inferior Innervation Main Action

Longus Basilar part of Anterior tubercles of Anterior rami Flex head.

Rectus Base of skull just Anterior surface of Branches Flex head.

Anterior TVP‟s of C4-C6. 1st rib. Cervical Flex head.

Figure 2.8: Superficial Muscles of the Neck (Netter, 2006)

Muscle Superior Inferior Innervation Main Action

Rectus Jugular process of TVP of C1. Branches Flexes head and

Splenius Inferior half of Lateral aspect of Posterior Laterally flexes and

Splenius Nuchal ligament Tubercles of TVP‟s Posterior Laterally flexes and

Levator Posterior tubercles Superior part of Dorsal Elevates scapula and

Figure 2.9: Intermediate Layer of Intrinsic Back Muscles (Netter, 2006)

Supervisor: ____________ _

On this day of 2013

Signed at _______on this day of _ 20_.