Disability and Rehabilitation

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/idre20

Short-term effects of spinal thrust joint

manipulation on postural sway in patients with
chronic mechanical neck pain: a randomized
controlled trial

Raúl Romero del Rey , Manuel Saavedra Hernández , Cleofás Rodríguez

Blanco , Luis Palomeque del Cerro & Raquel Alarcón Rodríguez

To cite this article: Raúl Romero del Rey , Manuel Saavedra Hernández , Cleofás Rodríguez
Blanco , Luis Palomeque del Cerro & Raquel Alarcón Rodríguez (2020): Short-term effects of
spinal thrust joint manipulation on postural sway in patients with chronic mechanical neck pain: a
randomized controlled trial, Disability and Rehabilitation, DOI: 10.1080/09638288.2020.1798517

To link to this article: https://doi.org/10.1080/09638288.2020.1798517

Published online: 30 Jul 2020.

Submit your article to this journal

Article views: 7

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=idre20
DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2020.1798517

ORIGINAL ARTICLE

Short-term effects of spinal thrust joint manipulation on postural sway in patients

with chronic mechanical neck pain: a randomized controlled trial

l Romero del Reya , Manuel Saavedra Hern
andeza,b, Cleof
as Rodr
ıguez Blancoc, Luis Palomeque del Cerrob,d
Rau

n Rodr
ıgueza
and Raquel Alarco
a
Department of Nursing, Physiotherapy and Medicine, University of Almer
ıa, Almer
ıa, Spain; bEscuela de Osteopat
ıa de Madrid, Madrid, Spain;
c
Department of Physical Therapy, Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla, Sevilla, Spain; dDepartment of Physical
Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorc
on, Spain

ABSTRACT ARTICLE HISTORY

Purpose: Our aim was to compare the efficacy of spinal manipulation of the upper cervical spine (C1-C2) Received 13 February 2020
on postural sway in patients with chronic mechanical neck pain with the application of a combination of Revised 4 June 2020
cervical (C3-C4), cervicothoracic (C7-T1) and thoracic spine (T5-T6) thrust joint manipulation. Accepted 16 July 2020
Methods: One hundred eighty-six (n ¼ 186) individuals with chronic mechanical neck pain were rando-
KEYWORDS
mised to receive an upper cervical spine manipulation (n ¼ 93) or three different spinal manipulation Neck pain; spinal
techniques applied to the cervical spine, cervicothoracic joint and thoracic spine (n ¼ 93). Measures manipulation; spine;
included the assessment of stabilometric parameters using the Medicapteurs S-Plate platform. postural balance;
Secondarily, neck pain was analysed using the Numeric Pain Rating Scale. musculoskeletal
Results: We observe a decrease in the length of the centre of pressure path, average speed, medio-lateral manipulations
and antero-posterior displacement with statistically significant results (p < 0.05) in the upper cervical
manipulation group. Both interventions are equally effective in reducing neck pain after fifteen
days (p < 0.001).
Conclusion: The application of upper cervical thrust joint manipulation is more effective in improving sta-
bilometric parameters in patients with chronic mechanical neck pain.

Trial registration: The study was registered in the Australian and New Zealand Clinical Trial Registry (no.
ACTRN12619000546156).

ä IMPLICATIONS FOR REHABILITATION

 Patients who suffer from neck pain exhibit increased postural sway than asymptomatic subjects.
 Both spinal manipulation treatments applied in this study are equally effective in reducing neck pain.
 Spinal manipulation treatment on the upper cervical spine improves postural stability parameters.

Introduction of proprioceptive information, especially the suboccipital muscles,

Mechanical neck pain is a perceived pain in the cervical spine
that is exacerbated by cervical movements and/or sustained pos-
tures [1]. This definition does not necessarily imply that the main
cause of the pain is in the indicated region, so it only refers to
the location of the pain [2,3]. It is a serious health problem in
developed countries with a mean annual prevalence of 37.2% [4].
Normally, patients with mechanical neck pain achieve resolution
of their symptoms within 2 months, but about 50% will still have
some symptoms a year after their first appearance and become a
chronic problem (>3 months duration) [5].
Patients with mechanical neck pain may present limitation in
cervical range of motion, shoulder and neck pain, headache, dizzi-
ness, nausea [6] and/or alterations in the sensory-motor system,
which may affect postural sway [7–9]. Postural control is possible
due to the correct integration of stimuli from the visual, vestibular
and somatosensory systems [10]. Postural sway can be analysed
by measuring the oscillations of a subject’s centre of pressure
(COP) [7,11].
In this respect, the cervical spine is of great importance [12].
Firstly, this is because the cervical musculature is a major source
which contain a large number of mechanoreceptors [13]. In add-
ition, these muscles also have relationships with the central ner-
vous system, vestibular system and visual system [10], which
explains why a proprioceptive information disorder in the cervical
spine may affect sensory integration [13]. On the other hand, pain
may be the cause of an increase in presynaptic inhibition of mus-
cular input and may affect the central sensory modulation of pro-
prioceptive information that comes from neuromuscular spindles
[14]. As a result, this may cause a decrease in motor control, and
subsequently, a decrease in postural stability.
Physical therapists often use spinal manipulations to decrease
pain [15–17] and improve proprioception [18] when musculoskel-
etal disorders are present, normalising alterations in the informa-
tion coming from the somatosensory system [19,20]. Some
studies have shown that both manipulation of the upper cervical
spine (UCS) [21,22] as well as the application of three different
manipulation techniques on the cervical spine, cervicothoracic
joint and thoracic spine are effective techniques for the treatment
of chronic mechanical neck pain (CMNP) [23]. However, these
authors do not assess its effectiveness in postural swaying.

CONTACT Ra
ul Romero del Rey raulromerodelrey@gmail.com Calle Santa B
arbara, 3, Almer
ıa, 04009, Spain
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 R. ROMERO DEL REY ET AL.
Figure 1. Flowchart diagram according to CONSORT Statement for the report of randomized controlled trials.
Moreover, previous studies have observed an improvement in
postural sway after the application of spinal manipulation on the
UCS [24,25], but these have been performed in asymptom-
atic patients.
In accordance with the above, our aim was to compare the
efficacy of spinal manipulation of the upper cervical spine (C1-C2)
on postural sway in patients with CMNP with the application of a
combination of cervical (C3-C4), cervicothoracic (C7-T1) and thor-
acic spine (T5-T6) thrust joint manipulation.
Methods
Design
We conducted a randomized clinical trial in which patients from a
private physical therapy clinic were recruited. Each patient signed
the informed consent form before the start of the study, which
was made according with the Declaration of Helsinki.
Participants
One hundred eighty-six patients (n ¼ 186) diagnosed with CMNP
were recruited between May 2019 and August 2019. Of the total
number of subjects enrolled, 16 were excluded for different rea-
sons (Figure 1). Inclusion criteria were: (1) symptom persistence
for more than 12 weeks; (2) age from 18 to 55 years; (3) localized
pain in the cervical spine; (4) symptoms are caused by cervical
movement or sustained postures. Exclusion criteria were: (1) stage
acute of symptoms; (2) any contraindication to cervical spinal
manipulation (fracture, osteoporosis, joint infections or vertebro-
basilar insufficiency); (3) patients with previous neck trauma or
cervical spine surgery; (4) patients diagnosed with cervical radicul-
opathy; (5) patients diagnosed with fibromyalgia; (6) have been
treated with manual therapy in the last 3 months; (7) receiving
other treatment while the study is in progress.
Intervention
The study was carried out on two separate days, with a period of
15 days between them. On the first day, the patient entered a
room where an examiner, a physiotherapist with experience han-
dling stabilometric platforms, proceeded to collect their demo-
graphic and clinical data. Once the target variables were
recorded, the participant entered a second room where another
physiotherapist applied the randomly assigned treatment. After

the intervention, the patient left the centre where the study took
place. Finally, 15 days later, the patient returned to the first room,
where their pain intensity and postural stability were meas-
ured again.
All the interventions were conducted by a physiotherapist with
more than 9 years of experience with patients and specialized in
performing treatments with spinal manipulations. The participants
received treatment the same day as their initial evaluation. The
application of the techniques took no longer than 5 min and was
performed in the following way:
 Upper cervical spine manipulation group: Patients in this group
were treated with spinal manipulation on the UCS (C1-C2) as
described by Dunning et al. [26] (Figure 2).
 Cervico-Thoracic spine manipulations group: The patients
included in this group received a combination of different
spinal manipulations on the thoracic spine (T5-T6), mid-cer-
vical spine (C3-C4) and cervicothoracic junction (C7-T1) as
described by Saavedra et al. [23] (Figure 3).
All techniques were performed in both directions, except the
thoracic spine manipulation. Up to two attempts were allowed for
each technique in order to obtain cavitation.
Figure 2. Atlantoaxial joint manipulation technique applied in the UCS group.
Figure 3. Spinal thrust joint manipulation techniques applied in the CTS group. (A) Thoracic spine manipulation; (B) Mid-cervical spine manipulation; (C) Cervico-thor-
acic junction manipulation.
EFFECTS OF SPINAL MANIPULATION IN POSTURAL SWAY 3
Outcome measures
Firstly, the demographic and clinical data of the patients were col-
lected (gender, age, weight and height). Subsequently, several
baseline measurements of self-report were collected, including a
numerical pain rating scale to assess pain [27] and a body dia-
gram to identify pain location. When all these variables were col-
lected, postural sway was assessed.
Postural sway
The stabilometric analysis was conducted using the Medicapteurs
S-Plate platform according to the recommendations set by the
Posturology Association of France [11]. The participants were
asked to maintain a stance with two feet on the pressure platform
and try to maintain the most natural position possible, without
shoes on and with their eyes open. A positioner was used to
place their heels 10 cm apart with the medial edge of their feet
forming a 30 angle. The examiner stayed behind the participants,
out of sight, to not affect the results in any way. Three consecu-
tive measurements were taken, and only the third measurement
was recorded. The total time of the measurement period was
approximately 70 s, divided into three stages: 10 s, before begin-
ning the analysis to position the participant’s feet correctly on the
platform; 52 s of stabilometric analysis; 5 s rest, after the analysis
finished to prevent any unwanted anticipatory movement near
the end of the stabilometric analysis.
Variations in COP have been shown to be very reliable for ana-
lysing postural stability [28]. The most widely used stabilometric
measurements in other studies by other authors and those which
we have used in this study include the following:
 Length of COP path: Determines the length of the COP path
during stabilometric measurement. Expressed in milli-
metres [11].
 Area of COP path. This is the area of the confidence ellipse,
which contains 90% of the relative positions of the COP. It is
a rigorous measurement in the dispersion of positions. This
parameter evaluates the effectiveness of the postural system
in keeping the centre of gravity as close as possible to its
average balance position. Expressed in square milli-
metres [11].
 Average speed: The average speed that the COP path reaches
during measurement. It allows us to obtain information
about stability control and energy expenditure. Expressed in
4 R. ROMERO DEL REY ET AL.

millimetres per second. Current research suggests that the Baseline demographic and clinical variables were examined
average speed of the COP is the most reliable stabilometric between groups using independent Mann–Whitney U test for
measurement [11]. continuous data and chi-square tests (X2) of independence for
 Medio-Lateral displacement (ML): This measure average oscil- categorical data.
lations of the COP on the axis of abscissas, in other words, The variables that were analysed (pain intensity, length of COP
the average medio-lateral oscillations in millimetres. Negative path, area of COP path, average speed, ML displacement and AP
values correspond to a left shift and positive values to the displacement) followed a non-normal distribution (p > 0.05).
right. Shows the asymmetry of postural tone [11]. Subsequently, the mean values of the related variables (beginning
 Antero-Posterior displacement (AP): This measures average and end of the treatment) within each group were compared
COP oscillations on the ordinate axis, in other words, the using the Wilcoxon test. Finally, the comparison between-groups
average number of front-to-back oscillations measured in used the Mann–Whitney U test for the nonparametric variable. A
millimetres. It shows the anterior-posterior imbalance of the value of p < 0.005 was considered statistically significant.
individual [11].
Results
Pain intensity
A total of 186 patients with CMNP participated in the study.
The Numerical Pain Rating Scale (NPRS) was applied to measure Participants were randomised into two treatment groups: UCS
pain intensity. It is a scale formed by whole numbers from 0 to manipulation group (n ¼ 93) or CTS manipulations group (n ¼ 93).
10, where 0 represents “no pain” and 10 represents “the worst Table 1 shows that both groups were homogeneous in age,
pain imaginable.” Participants selected the single number that sex, height, weight and pain location, with no statistically signifi-
best represented their pain intensity. Previously, it has been cant differences.
reported that the minimum detectable change for the NPRS in Regarding stabilometric parameters and pain intensity, the ini-
individuals with neck pain is 1.3 points [27]. tial characteristics of the variables in the two groups were similar,
not observing statistically significant differences at the beginning
(Table 2).
Sample size
Table 2 shows data at baseline, post-intervention, within
We needed 93 patients for each of the experimental and control groups and between groups for stabilometric parameters (length
groups (given a 95% CI, alpha error of 5%, and beta error of 20%. of COP path, area of COP path, average speed, ML displacement
We were able to detect an OR of 2). and AP displacement) and pain intensity. Statistically significant
differences were observed between groups for variables referring
Randomization to the length of COP path (p < 0.001), average speed (p < 0.001)
and AP displacement (p < 0.05).
The main researcher used the online Research Randomizer [29] When comparing the stabilometric parameters in the upper
tool (www.randomizer.org) before starting the study to randomly cervical manipulation group at the beginning and end of the
assign the 186 participants to the two study groups. A total of treatment (Table 3), a decrease in the length of the COP path was
186 different codes were generated and randomly distributed in observed, which gave a statistically significant result (p < 0.001).
the two groups. These numbers were then placed in a box. After Regarding the area of COP path, a decrease in average values was
signing the informed consent and collecting the initial variables, observed at the end of treatment, although it was not statistically
the participant took a number from the box to give it to the significant. In the average speed measurement, a decrease was
physiotherapist in charge of implementing all the interventions. In observed in the average score between the values observed at
this way, patients were randomly assigned according to the num- the beginning and at the end of treatment (p < 0.001). In regard
ber picked: UCS manipulation group and Cervico-Thoracic spine to ML displacement, a decrease in COP oscillations was observed,
(CTS) manipulations group. which was a statistically significant result (p ¼ 0.001). In the AP
displacement, a decrease in COP oscillations was also observed,
Blinding with statistically significant results (p < 0.05). Concerning neck
pain, a decrease in the mean values was observed, these results
Before beginning the study, we informed patients that different being statistically significant (p < 0.001).
techniques would be compared. A physiotherapist, blinded to the Table 4 shows comparisons of mean scores measured for stabi-
treatment assignment, was in charge of collecting the variables lometric parameters (length of COP path, area of COP path, aver-
under study. On the other hand, a second physiotherapist who age speed, ML displacement and AP displacement) and pain
was blinded to the findings of the initial examination, was in
charge of applying the corresponding intervention according to Table 1. Physical and clinical baseline characteristics of the sample.
the group assignment.
CTS manipulations group UCS manipulation group
(n ¼ 93) (n ¼ 93)
Data analysis Male 38 (41%) 29 (31%)
Female 55 (59%) 64 (69%)
A database was created with all the variables under study and a Age (years) 32 (SD ¼ 9.7) 34 (SD ¼ 11)
statistical analysis was performed using IBM SPP Statistics 23.0 Weight (kg) 71 (SD ¼ 14) 69 (SD ¼ 15)
Height (cm) 171 (SD ¼ 12) 170 (SD ¼ 9)
[30]. First, a descriptive analysis of the continuous variables
Left-sided neck pain 12 (13%) 11 (12%)
expressed as means and standard deviations was performed. Right-sided neck pain 20 (22%) 9 (10%)
Subsequently, the Kolmogorov–Smirnov test was performed to Bilateral neck pain 61 (65%) 73 (78%)
determine whether the continuous variables followed a normal CTS: cervicothoracic spine; UCS: upper cervical spine.
distribution or not. Data are reported as mean and SD except for gender and location of neck pain.
 EFFECTS OF SPINAL MANIPULATION IN POSTURAL SWAY 5

Table 2. Between – group comparison of the mean differences from baseline to post-treatment.
Measures Group Baseline p-Valuea After 15 days p-Valuea
Postural sway
Length of COP path (mm) CTS 55 (SD ¼ 21) 0.12 62 (SD ¼ 20) <0.001
UCS 51 (SD ¼ 19) 44 (SD ¼ 14)
Area of COP path (mm ) 2
CTS 34 (SD ¼ 33) 0.83 36 (SD ¼ 36) 0.71
UCS 35 (SD ¼ 38) 34 (SD ¼ 38)
Average speed (mm/s) CTS 1.8 (SD ¼ 0.61) 0.06 1.9 (SD ¼ 1.5) <0.001
UCS 1.7 (SD ¼ 0.63) 1.5 (SD ¼ 0.33)
ML displacement (cm) CTS 0.88 (SD ¼ 6.6) 0.10 0.34 (SD ¼6.2) 0.52
UCS 2.42 (SD ¼ 6.9) 0.31 (SD ¼ 6.8)
AP displacement (cm) CTS 16 (SD ¼ 9.5) 0.32 17 (SD ¼ 8.9) <0.05
UCS 15 (SD ¼ 11) 12 (SD ¼ 9.2)
Pain intensity at rest (0-10 points)
CTS 3.8 (SD ¼ 2.1) 0.87 2.8 (SD ¼ 2.4) 0.51
UCS 3.8 (SD ¼ 2.4) 2.7 (SD ¼ 2.7)
CTS: cervicothoracic spine manipulations group; UCS: upper cervical spine manipulation group; COP: centre of pressure; ML: medio-lateral;
AP: antero-posterior.
Values are reported as mean ± SD.
a
p-Value obtained by Mann–Whitney U test.

Table 3. Pre and post-treatment values in the upper cervical spine manipulation group.
Measures Baseline After 15 days p Valuea
Postural sway
Length of COP path (mm) 51 (SD ¼ 19) 44 (SD ¼ 14) <0.001
Area of COP path (mm2) 35 (SD ¼ 38) 34 (SD ¼ 38) 0.21
Average speed (mm/s) 1.7 (SD ¼ 0.62) 1.5 (SD ¼ 0.34) <0.001
ML displacement (cm) 2.42 (SD ¼ 6.9) 0.31 (SD ¼ 6.8) 0.001
AP displacement (cm) 15 (SD ¼ 11) 12 (SD ¼ 9.2) <0.05
Pain intensity at rest (0  10 points) 3.8 (SD ¼ 2.4) 2.7 (SD ¼ 2.7) <0.001
COP: centre of pressure; ML: medio-lateral; AP: antero-posterior.
Values are reported as mean ± SD.
a
p Value obtained by Wilcoxon test.

Table 4. Pre and post-treatment values in the cervicothoracic spine manipula- pain in patients with CMNP. However, we observed that only
tions group. those participants that received spinal manipulation treatment on
Measures Baseline After 15 days the atlantoaxial joint showed an improvement in the postural sta-
Postural sway bility parameters.
Length of COP path (mm) 55 (SD ¼ 21) 62 (SD ¼ 20) The results have not shown an improvement in postural sway
Area of COP path (mm2) 34 (SD ¼ 33) 36 (SD ¼ 36) in patients that received the combination of three spinal manipu-
Average speed (mm/s) 1.8 (SD ¼ 0.63) 1.9 (SD ¼ 1.5) lations (p > 0.05), we even observed an increase in the values of
ML displacement (cm) 0.88 (SD ¼ 6.6) 0.34 (SD ¼ 6.2)
AP displacement (cm) 16 (SD ¼ 9.5) 17 (SD ¼ 9.2) all the stabilometric parameters with the exception of the ML dis-
Pain intensity at rest (0  10 points) 3.8 (SD ¼ 2.1) 2.8 (SD ¼ 2.4) placement of the COP. It is likely that the proprioceptive informa-
COP: centre of pressure; ML: medio-lateral; AP: antero-posterior. tion provided by spinal manipulation of these vertebral segments
Values are reported as mean ± SD. is not enough to improve postural sway. Nonetheless, we
observed that participants who received manipulation on the UCS
showed a decrease in all the stabilometric variables analysed
intensity at the beginning and end of the in the cervicothoracic 15 days after the treatment, which translates to greater postural
manipulations group. In relation to stabilometric parameters at stability. More specifically, we observed a decrease in the length
the end of the treatment, an increase was observed in the aver- of COP path after the intervention, these results being statistically
age score for the length of COP path, area of COP path, average significant (p < 0.001). Regarding the area of the ellipse formed by
speed and AP displacement. We observed a decrease in ML dis- COP oscillations, there was a decrease in average values 15 days
placement at the end of treatment, although this result was not after treatment. In regards to the parameter that measures the
statistically significant (p > 0.05). On the other hand, a decrease in average speed of the COP oscillations, there was also a decrease
neck pain was observed at the end of the treatment, these results observed after the intervention (p < 0.001), which indicates
being statistically significant (p < 0.001). increased stability control, and, therefore, lower energy expend-
iture [11]. Likewise, we observed a decrease in ML and AP oscilla-
tions after spinal manipulation, with these differences being
Discussion
statistically significant (p ¼ 0.001 y p < 0.05, respectively). This
Our aim was to compare the efficacy of spinal manipulation of decrease in COP oscillations indicates a greater symmetry in pos-
the upper cervical spine (C1-C2) on postural sway in patients with tural tone and a lower level of antero-posterior imbalance in the
CMNP with the application of a combination of cervical (C3-C4), individual [11].
cervicothoracic (C7-T1) and thoracic spine (T5-T6) thrust joint Like us, other authors have observed the impact of UCS
manipulation. We observed that both spinal manipulation in the manipulation on postural sway [24,25]. However, only the results
UCS and spinal manipulation of the cervical, cervicothoracic junc- observed immediately after treatment have been analysed.
tion and thoracic spine are equally effective in decreasing neck Similarly, Smith et al. also observed a decrease in average values
6 R. ROMERO DEL REY ET AL.
obtained on the stabilometric parameters after carrying out spinal
manipulation on the UCS [25]. Likewise, Botella-Rico et al.
observed an immediate improvement in the COP area after occi-
pito-atlanto-axial spinal manipulation. However, unlike our study,
they did not observe a statistically significant variance in ML and
AP oscillations of the COP [24]. This difference may be due to the
fact that in their study, the intervention was carried out on
patients without symptoms, who usually show a lesser COP oscil-
lation than individuals with neck pain [8,13]. On the contrary,
Fisher et al. [31] did not observe statistically significant differences
in stabilometric measurements after applying spinal manipulation
therapy. The main difference with this study is that they applied a
different manipulation to each patient depending on the cervical
level in dysfunction. Furthermore, they only analysed the results
15 min after the intervention while we applied the same tech-
nique to all patients and observed the results over a period
of 15 days.
According to other previous studies [23,32–35], we observed a
decrease in neck pain when spinal manipulation techniques were
applied in both groups. Like us, authors such as Martinez-Segura
et al. [36] or Saavedra et al. [23] also observed no differences
when comparing different spinal manipulation techniques,
decreasing neck pain in all treatment groups. Lohman et al. [37]
have recently conducted a study in which they observed that the
mechanical stimulus provided by cervical spinal manipulation pro-
duced an immediate increase in the blood concentration of noci-
ception-related biomarkers (oxytocin, neurotensin and orexin A).
In our study, participants in both groups received spinal manipu-
lation on the cervical spine so it is possible that this change in
nociception-related biomarkers could explain the similar decrease
in pain in the two groups.
On the other hand, some previous studies have shown that
spinal manipulation techniques could influence the proprioceptive
system [18] and are capable of normalising the alterations of
afferent information in the somatosensory system [19] by chang-
ing the levels of excitability of the alpha motor neuron, and con-
sequently, altering muscular activity [26]. In this way, and as
observed by previous investigations, the effectiveness of spinal
thrust joint manipulation techniques can be explained from a
neuro-physiological point of view rather than a mechanical one
[32,33]. Additionally, due to the high concentration of mechanore-
ceptors in the suboccipital muscles, the occipito-atlanto-axial com-
plex provides a great deal of proprioceptive information in the
cervical region and consequently, a great influence on postural
sway [10,38]. Thus, it is possible that, due to this neuro-physio-
logical mechanism, UCS manipulation is more effective than spinal
manipulation on the mid-cervical spine, cervicothoracic joint and
thoracic spine in improving postural sway in patients with CMNP.
Study limitations
We must consider some limitations regarding our study. First, we
used a sample that was limited to a single private clinic, which
may make the sample non-representative of the population in
general. Secondly, the techniques used in our study were only
performed on patients with CMNP, thus, we do not know their
effect on other clinical situations. Thirdly, the techniques were
performed by only one physiotherapist, which could influence the
results. Future research could focus on the influence of these
manipulation techniques performed by different physiotherapists
on individuals with acute and chronic neck pain. Finally, we did
not investigate the effects of treatment over a period of time
greater than 15 days, we do not know if the effects observed
would continue after this period. In this respect, our recommen-
dation is to carry out further monitoring of the patients and apply
the techniques in different time periods, in terms of observing
the long-term results.
Conclusions
In conclusion, our results indicate that both spinal manipulation
on the UCS and spinal manipulation of the cervical spine, cervico-
thoracic junction and thoracic spine applied together are equally
effective in reducing neck pain. However, spinal manipulation per-
formed on the UCS is more effective in improving stabilometric
parameters in individuals with CMNP.
Acknowledgements
We would like to thank all the patients who made this
study possible.
Ethical approval
The study was approved by the Ethics and Research Commission
of the Department of Nursing, Physiotherapy and Medicine of the
University of Almeria and registered in the Australian and New
Zealand Clinical Trial Registry (no. ACTRN12619000546156).
URL:https://www.anzctr.org.au/Trial/Registration/TrialReview.
aspx?id=377314&isReview=true
No commercial party having a direct financial interest in the
results of the research supporting this article has or will confer a
benefit on the authors or on any organization with which the
authors are associated.
Disclosure statement
The authors report no conflicts of interest.
ORCID
Ra

ul Romero del Rey http://orcid.org/0000-0002-5885-5218
References
[1] Bier JD, Scholten-Peeters WG, Staal JB, et al. Clinical prac-
tice guideline for physical therapy assessment and treat-
ment in patients with nonspecific neck pain. Phys Ther.
2018;98(3):162–171.
[2] Bogduk N. The anatomy and pathophysiology of neck pain.
Phys Med Rehabil Clin N Am. 2003;14(3):455–472.
[3] Misailidou V, Malliou P, Beneka A, et al. Assessment of
patients with neck pain: a review of definitions, selection
criteria, and measurement tools. J Chiropr Med. 2010;9(2):
49–59.
[4] Cohen SP, Hooten WM. Advances in the diagnosis and
management of neck pain. BMJ. 2017;358:j3221.
[5] Cohen SP. Epidemiology, diagnosis, and treatment of neck
pain. Mayo Clin Proc. 2015;90(2):284–299.
[6] Blanpied PR, Gross AR, Elliott JM, et al. Neck pain: revision
2017. J Orthop Sports Phys Ther. 2017;47(7):A1–A83.
[7] de Zoete RMJ, Osmotherly PG, Rivett DA, et al.
Sensorimotor control in individuals with idiopathic neck
pain and healthy individuals: a systematic review and
meta-analysis. Arch Phys Med Rehabil. 2017;98(6):
1257–1271.

[8] Silva AG, Cruz AL. Standing balance in patients with whip-
lash-associated neck pain and idiopathic neck pain when
compared with asymptomatic participants: a systematic
review. Physiother Theory Pract. 2013;29(1):1–18.
[9] Ruhe A, Fejer R, Walker B. On the relationship between
pain intensity and postural sway in patients with non-spe-
cific neck pain. J Back Musculoskelet Rehabil. 2013;26(4):
401–409.
[10] Grace Gaerlan M, Alpert PT, Cross C, et al. Postural balance
in young adults: the role of visual, vestibular and somato-
sensory systems. J Am Acad Nurse Pract. 2012;24(6):
375–381.
[11] Gagey P, Weber B. Posturolog
ıa: Regulacio
n y Alteraciones
de la Bipedestacio
n. Barcelona: Masson; 2001. p. 60–77.
[12] Humphreys BK. Cervical outcome measures: testing for pos-
tural stability and balance. J Manipulative Physiol Ther.
2008;31(7):540–546.
[13] Wannaprom N, Treleaven J, Jull G, et al. Neck muscle vibra-
tion produces diverse responses in balance and gait speed
between individuals with and without neck pain.
Musculoskelet Sci Pract. 2018;35:25–29.
[14] Capra NF, Ro JY. Experimental muscle pain produces cen-
tral modulation of proprioceptive signals arising from jaw
muscle spindles. Pain. 2000;86(1–2):151–162.
[15] Taylor HH, Murphy B. Altered central integration of dual
somatosensory input after cervical spine manipulation. J
Manipulative Physiol Ther. 2010;33(3):178–188.
[16] Haldeman S, Carroll L, Cassidy JD, et al. Clinical practice
implications of the Bone and Joint Decade 2000–2010 task
force on neck pain and its associated disorders: from con-
cepts and findings to recommendations. Spine (Phila Pa
1976). 2008;33(Supplement):S5–S7.
[17] Co ^t
e P, Wong JJ, Sutton D, et al. Management of neck pain
and associated disorders: a clinical practice guideline from
the Ontario Protocol for Traffic Injury Management
(OPTIMa) Collaboration. Eur Spine J. 2016;25(7):2000–2022.
[18] Haavik H, Murphy B. The role of spinal manipulation in
addressing disordered sensorimotor integration and altered
motor control. J Electromyogr Kinesiol. 2012;22(5):768–776.
[19] Dunning J, Rushton A. The effects of cervical high-velocity
low-amplitude thrust manipulation on resting electromyo-
graphic activity of the biceps brachii muscle. Man Ther.
2009;14(5):508–513.
[20] Haavik H, Murphy B. Subclinical neck pain and the effects
of cervical manipulation on elbow joint position sense. J
Manipulative Physiol Ther. 2011;34(2):88–97.
[21] Dunning JR, Cleland JA, Waldrop MA, et al. Upper cervical
and upper thoracic thrust manipulation versus nonthrust
mobilization in patients with mechanical neck pain: a mul-
ticenter randomized clinical trial. J Orthop Sports Phys
Ther. 2012;42(1):5–18.
[22] Clements B, Gibbons P, McLaughlin P. The amelioration of
atlanto-axial rotation asymmetry using high velocity low
amplitude manipulation: is the direction of thrust import-
ant? J Osteopath Med. 2001;4(1):8–14.
[23] Saavedra-Hern
andez M, Arroyo-Morales M, Cantarero-
Villanueva I, et al. Short-term effects of spinal thrust joint
manipulation in patients with chronic neck pain: a random-
ized clinical trial. Clin Rehabil. 2013;27(6):504–512.
[24] Botella Rico JM. Evaluacio
n y an
alisis de la influencia de la
t
ecnica de inhibicio
n suboccipital y la gran maniobra
EFFECTS OF SPINAL MANIPULATION IN POSTURAL SWAY 7
abdominal en la est
atica postural: estudio baropodom
etrico
y estabilom
etrico. 2011.
[25] Smith L, Mehta M. The effects of upper cervical complex
high velocity low amplitude thrust technique and sub-
occipital muscle group inhibition techniques on standing
balance. Int J Osteopath Med. 2008;11(4):162.
[26] Dunning JR, Butts R, Mourad F, et al. Upper cervical and
upper thoracic manipulation versus mobilization and exer-
cise in patients with cervicogenic headache: a multi-center
randomized clinical trial. BMC Musculoskelet Disord. 2016;
17(1):64.
[27] Ferreira-Valente MA, Pais-Ribeiro JL, Jensen MP. Validity of
four pain intensity rating scales. Pain. 2011;152(10):
2399–2404.
[28] Fryer G, Morris T, Gibbons P. Paraspinal muscles and inter-
vertebral dysfunction: part two. J Manipulative Physiol
Ther. 2004;27(5):348–357.
[29] Randomizer R. Research randomizer. 2013. [cited 2013 Aug
1]. Available from: www.randomizer.org.
[30] Corp IBM. IBM SPSS. Statistics Statistical Software.
2013. Available from: https://www.ibm.com/analytics/spss-
statistics-software
[31] Fisher AR, Bacon CJ, Mannion J. The effect of cervical spine
manipulation on postural sway in patients with nonspecific
neck pain. J Manipulative Physiol Ther. 2015;38(1):65–73.
[32] Hanney WJ, Puentedura EJ, Kolber MJ, et al. The immediate
effects of manual stretching and cervicothoracic junction
manipulation on cervical range of motion and upper tra-
pezius pressure pain thresholds. J Back Musculoskelet
Rehabil. 2017;30(5):1005–1013.
[33] Gonz
alez-Iglesias J, Fern
andez-de-las-Pen~as C, Cleland JA,
et al. Inclusion of thoracic spine thrust manipulation into
an electro-therapy/thermal program for the management
of patients with acute mechanical neck pain: a randomized
clinical trial. Man Ther. 2009;14(3):306–313.
[34] Langenfeld A, Humphreys BK, de Bie RA, et al. Effect of
manual versus mechanically assisted manipulations of the
thoracic spine in neck pain patients: study protocol of a
randomized controlled trial. Trials. 2015;16(1):233.
[35] Puentedura EJ, Landers MR, Cleland JA, et al. Thoracic
spine thrust manipulation versus cervical spine thrust
manipulation in patients with acute neck pain: a random-
ized clinical trial. J Orthop Sports Phys Ther. 2011;41(4):
208–220.
[36] Mart
ınez-Segura R, de-la-Llave-Rinco
n AI, Ortega-Santiago
R, et al. Fern
andez-De-Las-Pen ~as C. Immediate changes in
widespread pressure pain sensitivity, neck pain, and cer-
vical range of motion after cervical or thoracic thrust
manipulation in patients with bilateral chronic mechanical
neck pain: a randomized clinical trial. J Orthop Sports Phys
Ther. 2012;42(9):806–814.
[37] Lohman EB, Pacheco GR, Gharibvand L, et al. The immedi-
ate effects of cervical spine manipulation on pain and bio-
chemical markers in females with acute non-specific
mechanical neck pain: a randomized clinical trial. J Man
Manip Ther. 2019;27(4):186–196.
[38] Singh NB, Taylor WR, Madigan ML, et al. The spectral con-
tent of postural sway during quiet stance: Influences of
age, vision and somatosensory inputs. J Electromyogr
Kinesiol. 2012;22(1):131–136.