If you’re wondering, "What, Precisely, is the Biomechanical Goal of Performing a Mid-Cervical HVLA Manipulation?," you’ve come to the right place.

To become proficient, and then an expert, in performing cervical manipulations, it is necessary to grasp what you are trying to accomplish on a biomechanical level. This improves safety, which is the most important factor. However, it also improves efficacy and overall patient outcome. If you can properly conceptualize the biomechanical goal of manipulating the mid-cervical spine, you can abandon the rigid thought process of performing a manipulation exactly the same way each time.

Click here for our full course list + upcoming dates.

The general biomechanical goal and safety guidelines should be followed during each manipulation to ensure safety and efficacy. However, this does not mean every manipulation must be performed the same way. There are general safety precautions and biomechanical rules to follow, but aside from this, each person’s joints are different and require slightly different manipulative forces. Some patients may be more comfortable in supine, some in sitting, etc. This is why developing proficiency in multiple techniques, along with soft hands and a good feel for a person’s joints, is necessary to becoming really good at manipulation. Strictly following rules will limit your efficacy and can lead to poor patient outcomes. Each patient is different, treat them that way.

The mid-cervical spine, C3-C7, has normal mechanics of side-bending (SB) and rotation (ROT) to the same side. The only reason we can SB our necks and still keep our eyes looking forward is that C1-C2 rotates in the opposite direction of the SB and ROT of C3-C7. It’s awesome how our body works. So cool! Another biomechanical aspect of the cervical joint facets is that they sit at about 45 degrees, with an upward slope from P🡪A. Everyone is a slightly different. These are essential mechanical factors to comprehend in order to become a proficient cervical manipulator.

Think About C4 SB and ROT to the R on C5: Focus on Applying Force to the Posterior Aspect of the C4 Transverse Process.

OK, think about the R C4 inferior facet sitting on top of the R C5 superior facet. Remember, joints are spoken about in ResearchLand (that’s my invented word, feel free to use it) as segments, one vertebra on top of another. This is necessary to properly understand the intricacies of arthrokinematic movement. So, when we speak about the movement of the C4 vertebra, we are talking about the movement of C4 in relation to C5.

When we SB our cervical spine to the R, the R C4 inferior facet slides down and back on the R C5 superior facet. At the same time, the L C4 inferior facet slides up and forward on the L superior C5 facet. These arthrokinematic glides occur at about 45 degrees in a cephalic direction from P🡪A. If the joint gets stuck in this position for some reason, we now have a C4 that is rotated to the R on C5. The vertebrae, however, cannot slide directly in an A🡪P or P🡪A direction. They rotate around the spinal cord. So, if the R inferior C4 facet is sliding down and back on the R superior C5 facet, the R inferior C4 facet is also moving in a medial direction, down-back-medial toward the center of the spinal cord. For this reason, think about applying the force in an A🡪P direction, towards the patient’s opposite knee. At the same time, add in a 45-degree angle from P🡪A, in the cephalic direction.

It is not applicable to apply force through the anterior aspect of the cervical spine secondary to neurovasculature in the area. The external and internal jugular, along with the carotid artery and brachial plexus nerves, are just a few of the structures located anterior to the transverse processes in the cervical spine. Typically, the sternocleidomastoid (SCM) attachment, just behind the ear, is a good marker. If you are standing, go from the inferior aspect of the mastoid process directly toward the ground. That is about the line of the transverse processes (TP) of your cervical vertebrae.

If you dig your fingers in there and find the most firm and painful spot to palpate, that is the lateral aspect of a cervical TP. We want to push on the posterior aspect of the transverse processes in between the spinous process (SP) and the TP. This is commonly referred to as the articular pillar of the cervical spine. This keeps us away from any major neurovascular structures and allows us to push vertebrae back into anatomic position in a safe and effective manner.

Think about pushing the downslid segment of C4 on the R, back up onto the top of C5, so the two vertebrae are in proper alignment. The force should be directed in an anterior / superior / medial direction. So, push the posterior aspect of C4 TP, at a 45-degree cephalic angle, toward the seated patient’s L knee. Think about turning C4 to the L on C5 and follow that 45-degree angle joint line. This is not an easy idea to conceptualize, but once you get it, something clicks in your brain, and manipulation becomes much simpler and more effective. It’s like an epiphany, of sorts.

Since the normal mechanics of C3-C7 are SB and ROT to the SAME side, we always place the spinal segment to be manipulated in SB and ROT to the OPPOSITE side. This puts the vertebral artery (VA) on slack through the transverse foramina at the joint where the force will be delivered. Opposing the R C4 inferior facet with the R C5 superior facet keeps the VA from getting kinked as it passes through the transverse foramina from C5 to C4. The VA is going through the transverse foramina of C6 to C1 and then into the brainstem. The VA has a stress failure point of about 130% of its resting length. This means that the average VA can stretch 130% of its resting length before anything bad happens to it that may cause an embolus and subsequent CVA. A skilled manipulator stretches the VA far less than that with any given manipulation. The average VA stretch during a skilled manipulation is about 10-15%. Passive, end-range cervical ROM places far more stress on the VA than does a skilled manipulator.

Think about how the VA goes through the transverse foramina and think about opposing the R C4 inferior facet with the R superior C5 facet so the VA is not getting kinked through the transverse foramina. We want to tension the cervical spine ligaments down from the Occiput to C4 and up to C5 from the thoracic spine. If this is accomplished, minimal force is needed to get the R inferior C4 facet back up onto the R superior C5 facet. This aligns the transverse foramina and takes any abnormal tension off the vertebral artery, soft tissue, and nerve roots. This also places the R C4/C5 joint capsule on slack as the bony structure of the R inferior C4 and the R superior facet surfaces come into alignment. If this can be accomplished, a fast, small amplitude force in the proper direction will stretch the R C4/C5 capsule fast enough to create a negative pressure inside the capsule that results in a cavitation and reduction of the C4/C5 segment to neutral.

If we stretch the capsule quickly enough, we increase the volume of the capsule, which has an enclosed liquid, synovial fluid. This increase in joint capsule volume rapidly decreases the pressure on the synovial fluid. Gas is more soluble in fluid at low temperature and high pressure. Quickly stretching the capsule increases the temperature and decreases the pressure. This allows nitrogen and CO2 that are dissolved in aqueous solution to change phases from liquid to gas. This is what creates the cavitation sound. We can see this in real time with fMRI, and it is really cool. This phenomenon is called tribonucleation. You see an air bubble form inside the joint. This creates negative pressure inside the joint capsule and provides internal distraction. A cavitation also releases endogenous opioids such as beta endorphin and other substances that create microvascular vasodilation.

Manipulation is the hardest thing to learn that we are able to perform, by far. Manipulation is much more of a physical skill than is DN. Just like with any physical process or sport, repetition is the only way to become proficient at what you are doing. I have a good friend of mine who is a DC, and he says that he was always told in school that it takes 5 years after you get out of school, manipulating the entire time, to get really good at it. I totally believe this, as it took me numerous years following grad school to feel really proficient with my manipulative skills. Do not get frustrated, learn from your failures, and focus on becoming the best manipulator you can be.

References

Achalandabaso, A., Plaza-Manzano, G., Lomas-Vega, R., Martínez-Amat, A., Camacho, M. V., Gassó, M., … Molina, F. (2014). Tissue Damage Markers after a Spinal Manipulation in Healthy Subjects: A Preliminary Report of a Randomized Controlled Trial. Disease Markers, 2014, 1–7. https://doi.org/10.1155/2014/815379

Annen, M., Peterson, C., Leemann, S., Schmid, C., Anklin, B., & Humphreys, B. K. (2016). Comparison of Outcomes in MRI Confirmed Lumbar Disc Herniation Patients With and Without Modic Changes Treated With High Velocity, Low Amplitude Spinal Manipulation. Journal of Manipulative and Physiological Therapeutics, 39(3), 200–209. https://doi.org/10.1016/j.jmpt.2016.02.012

Baarbé, J. K., Yielder, P., Haavik, H., Holmes, M. W. R., & Murphy, B. A. (2018). Subclinical recurrent neck pain and its treatment impacts motor training-induced plasticity of the cerebellum and motor cortex. PLOS ONE, 13(2), e0193413. https://doi.org/10.1371/journal.pone.0193413

Bautista-Aguirre, F., Oliva-Pascual-Vaca, A., Heredia-Rizo, A.M., Bosca-Gandia, J.J., Ricard, F. and Rodriguez-Blanco, C., 2017. Effect of cervical vs. thoracic spinal manipulation on peripheral neural features and grip strength in subjects with chronic mechanical neck pain: a randomized controlled trial. Eur J Phys Rehabil Med, 53(3), pp.333-41

Chaibi, A., Benth, J. Š., Tuchin, P. J., & Russell, M. B. (2017). Adverse events in a chiropractic spinal manipulative therapy single-blinded, placebo, randomized controlled trial for migraineurs. Musculoskeletal Science and Practice, 29, 66–71. https://doi.org/10.1016/j.msksp.2017.03.003

Chesterton, P., Payton, S., & McLaren, S. (2018). Acute effects of centrally- and unilaterally-applied posterior-anterior mobilizations of the lumbar spine on lumbar range of motion, hamstring extensibility and muscle activation. Journal of Back and Musculoskeletal Rehabilitation, 31(6), 1013–1023. https://doi.org/10.3233/BMR-171000

Christiansen, T.L., Niazi, I.K., Holt, K., Nedergaard, R.W., Duehr, J., Allen, K., Marshall, P., Türker, K.S., Hartvigsen, J. and Haavik, H., 2018. The effects of a single session of spinal manipulation on strength and cortical drive in athletes. European journal of applied physiology, 118(4), pp.737-749.

Chu, J., Allen, D. D., Pawlowsky, S., & Smoot, B. (2014). Peripheral response to cervical or thoracic spinal manual therapy: an evidence-based review with meta analysis. Journal of Manual & Manipulative Therapy, 22(4), 220–229. https://doi.org/10.1179/2042618613Y.0000000062

Church EW, Sieg EP, Zalatimo O, Hussain NS, Glantz M, Harbaugh RE. Systematic Review and Meta-analysis of Chiropractic Care and Cervical Artery Dissection: No Evidence for Causation. Cureus. 2016;8(2):e498. Published 2016 Feb 16. doi:10.7759/cureus.498

Coronado, R. A., Gay, C. W., Bialosky, J. E., Carnaby, G. D., Bishop, M. D., & George, S. Z. (2012). Changes in pain sensitivity following spinal manipulation: A systematic review and meta-analysis. Journal of Electromyography and Kinesiology, 22(5), 752–767. https://doi.org/10.1016/j.jelekin.2011.12.013

Coulter, I. D., Crawford, C., Hurwitz, E. L., Vernon, H., Khorsan, R., Suttorp Booth, M., & Herman, P. M. (2018). Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis. The Spine Journal, 18(5), 866–879. https://doi.org/10.1016/j.spinee.2018.01.013

Currie, S. J., Myers, C. A., Durso, C., Enebo, B. A., & Davidson, B. S. (2016). The Neuromuscular Response to Spinal Manipulation in the Presence of Pain. Journal of Manipulative and Physiological Therapeutics, 39(4), 288–293. https://doi.org/10.1016/j.jmpt.2016.02.011

DeVocht, J. W., Vining, R., Smith, D. L., Long, C., Jones, T., & Goertz, C. (2019). Effect of chiropractic manipulative therapy on reaction time in special operations forces military personnel: a randomized controlled trial. Trials, 20(1), 5. https://doi.org/10.1186/s13063-018-3133-2

Deyo, R.A., 2017. The role of spinal manipulation in the treatment of low back pain. Jama, 317(14), pp.1418-1419.

Farrell, S. F., Khan, S., Osmotherly, P. G., Sterling, M., Cornwall, J., & Rivett, D. A. (2018). Lateral atlantoaxial joint meniscoid volume in individuals with whiplash associated disorder: A case-control study. Musculoskeletal Science and Practice, 33, 46–52. https://doi.org/10.1016/j.msksp.2017.11.004

Fernández-de-las-Peñas, C., Alonso-Blanco, C., Cleland, J. A., Rodríguez-Blanco, C., & Alburquerque-Sendín, F. (2008). Changes in Pressure Pain Thresholds Over C5-C6 Zygapophyseal Joint After a Cervicothoracic Junction Manipulation in Healthy Subjects. Journal of Manipulative and Physiological Therapeutics, 31(5), 332–337. https://doi.org/10.1016/j.jmpt.2008.04.006

Fernández-De-Las-Peñas, C., Pérez-De-Heredia, M., Brea-Rivero, M., & Miangolarra-Page, J. C. (2007). Immediate Effects on Pressure Pain Threshold Following a Single Cervical Spine Manipulation in Healthy Subjects. Journal of Orthopaedic & Sports Physical Therapy, 37(6), 325–329. https://doi.org/10.2519/jospt.2007.2542

Fernandez, M., Moore, C., Tan, J., Lian, D., Nguyen, J., Bacon, A., Christie, B., Shen, I., Waldie, T., Simonet, D. and Bussières, A., 2020. Spinal manipulation for the management of cervicogenic headache: A systematic review and meta‐analysis. European Journal of Pain, 24(9), pp.1687-1702.

Galindez-Ibarbengoetxea, X., Setuain, I., Ramírez-Velez, R., Andersen, L. L., González-Izal, M., Jauregi, A., & Izquierdo, M. (2018). Immediate Effects of Osteopathic Treatment Versus Therapeutic Exercise on Patients With Chronic Cervical Pain. Alternative Therapies in Health and Medicine, 24(3), 24–32. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/29135458

García-Pérez-Juana, D., Fernández-de-las-Peñas, C., Arias-Buría, J. L., Cleland, J. A., Plaza-Manzano, G., & Ortega-Santiago, R. (2018). Changes in Cervicocephalic Kinesthetic Sensibility, Widespread Pressure Pain Sensitivity, and Neck Pain After Cervical Thrust Manipulation in Patients With Chronic Mechanical Neck Pain: A Randomized Clinical Trial. Journal of Manipulative and Physiological Therapeutics, 41(7), 551–560. https://doi.org/10.1016/j.jmpt.2018.02.004

Gyer, G., Michael, J., Inklebarger, J. and Tedla, J.S., 2019. Spinal manipulation therapy: Is it all about the brain? A current review of the neurophysiological effects of manipulation. Journal of integrative medicine, 17(5), pp.328-337.

Haas, M., Bronfort, G., Evans, R., Schulz, C., Vavrek, D., Takaki, L., … Neradilek, M. B. (2018). Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. The Spine Journal. https://doi.org/10.1016/j.spinee.2018.02.019

Haas, M., Bronfort, G., Evans, R., Schulz, C., Vavrek, D., Takaki, L., … Neradilek, M. B. (2018). Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. The Spine Journal. https://doi.org/10.1016/j.spinee.2018.02.019

Haavik, H., Niazi, I.K., Jochumsen, M., Sherwin, D., Flavel, S. and Türker, K.S., 2017. Impact of spinal manipulation on cortical drive to upper and lower limb muscles. Brain sciences, 7(1), p.2.

Haider, R., Bashir, M. S., Adeel, M., Ijaz, M. J., & Ayub, A. (2018). Comparison of conservative exercise therapy with and without Maitland Thoracic Manipulative therapy in patients with subacromial pain: Clinical trial. JPMA. The Journal of the Pakistan Medical Association, 68(3), 381–387. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/29540872

Hartstein, A. J., Lievre, A. J., Grimes, J. K., & Hale, S. A. (2018). Immediate Effects of Thoracic Spine Thrust Manipulation on Neurodynamic Mobility. Journal of Manipulative and Physiological Therapeutics, 41(4), 332–341. https://doi.org/10.1016/j.jmpt.2017.10.006

Harwich, A. S. (2017). Joint Manipulation: Toward a General Theory of High-Velocity, Low-Amplitude Thrust Techniques. Journal of Chiropractic Humanities, 24(1), 15–23. https://doi.org/10.1016/j.echu.2017.01.001

Herzog, W., Leonard, T.R., Symons, B., Tang, C. and Wuest, S., 2012. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. Journal of Electromyography and Kinesiology, 22(5), pp.740-746.

Honoré, M., Leboeuf-Yde, C. and Gagey, O., 2018. The regional effect of spinal manipulation on the pressure pain threshold in asymptomatic subjects: a systematic literature review. Chiropractic & manual therapies, 26(1), pp.1-18.

Honoré, M., Leboeuf-Yde, C., & Gagey, O. (2018). The regional effect of spinal manipulation on the pressure pain threshold in asymptomatic subjects: a systematic literature review. Chiropractic & Manual Therapies, 26(1), 11. https://doi.org/10.1186/s12998-018-0181-3

Hutting, N., Kerry, R., Coppieters, M. W., & Scholten-Peeters, G. G. M. (2018). Considerations to improve the safety of cervical spine manual therapy. Musculoskeletal Science and Practice, 33, 41–45. https://doi.org/10.1016/j.msksp.2017.11.003

Jatuzis, D., & Valaikiene, J. (2012). Migraine-like presentation of vertebral artery dissection after cervical manipulative therapy. Perspectives in Medicine, 1(1–12), 452–454. https://doi.org/10.1016/J.PERMED.2012.03.010

Jeong, E.-D., Kim, C.-Y., Kim, S.-M., Lee, S.-J., & Kim, H.-D. (2018). Short-term effects of the suboccipital muscle inhibition technique and cranio-cervical flexion exercise on hamstring flexibility, cranio-vertebral angle, and range of motion of the cervical spine in subjects with neck pain: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation, 31(6), 1025–1034. https://doi.org/10.3233/BMR-171016

Joo, S., Lee, Y. and Song, C.H., 2018. Immediate effects of thoracic spinal manipulation on pulmonary function in stroke patients: A preliminary study. Journal of manipulative and physiological therapeutics, 41(7), pp.602-608.

Kim, B. J., Kim, T., Ahn, J., Cho, H., Kim, D., & Yoon, B. (2017). Manipulative rehabilitation applied soon after lumbar disc surgery improves late post-operative functional disability: A preliminary 2-year follow-up study. Journal of Back and Musculoskeletal Rehabilitation, 30(5), 999–1004. https://doi.org/10.3233/BMR-169546

Kolberg, C., Horst, A., Moraes, M. S., Duarte, F. C. K., Riffel, A. P. K., Scheid, T., … Partata, W. A. (2015). Peripheral Oxidative Stress Blood Markers in Patients With Chronic Back or Neck Pain Treated With High-Velocity, Low-Amplitude Manipulation. Journal of Manipulative and Physiological Therapeutics, 38(2), 119–129. https://doi.org/10.1016/j.jmpt.2014.11.003

Kovanur-Sampath, K., Mani, R., Cotter, J., Gisselman, A.S. and Tumilty, S., 2017. Changes in biochemical markers following spinal manipulation-a systematic review and meta-analysis. Musculoskeletal Science and Practice, 29, pp.120-13

Krott, N. L., Bloyinski, G. M., & Cattrysse, E. (2018). 3-Dimensional Cervical Movement Characteristics and the Influence of Thoracic Treatment on a Subgroup of Acute Neck Pain Patients. Journal of Manipulative and Physiological Therapeutics. https://doi.org/10.1016/j.jmpt.2017.11.002

Krott, N. L., Bloyinski, G. M., & Cattrysse, E. (2018). 3-Dimensional Cervical Movement Characteristics and the Influence of Thoracic Treatment on a Subgroup of Acute Neck Pain Patients. Journal of Manipulative and Physiological Therapeutics, 41(4), 304–314. https://doi.org/10.1016/j.jmpt.2017.11.002

Mansfield, C.J., Domnisch, C., Iglar, L., Boucher, L., Onate, J. and Briggs, M., 2020. Systematic review of the diagnostic accuracy, reliability, and safety of the sharp-purser test. Journal of Manual & Manipulative Therapy, 28(2), pp.72-81.

Mas Rodriguez, M. F., Berrios, R. A., & Ramos, E. (2016). Spontaneous Bilateral Vertebral Artery Dissection During a Basketball Game: A Case Report. Sports Health, 8(1), 53–56. https://doi.org/10.1177/1941738114547347

Micheli, S., Paciaroni, M., Corea, F., Agnelli, G., Zampolini, M., & Caso, V. (2010). Cervical artery dissection: emerging risk factors. The Open Neurology Journal, 4, 50–55. https://doi.org/10.2174/1874205X01004010050

Molina-Ortega, F., Lomas-Vega, R., Hita-Contreras, F., Plaza Manzano, G., Achalandabaso, A., Ramos-Morcillo, A. J., & Martínez-Amat, A. (2014). Immediate effects of spinal manipulation on nitric oxide, substance P and pain perception. Manual Therapy, 19(5), 411–417. https://doi.org/10.1016/j.math.2014.02.007

Murphy, D. R., Schneider, M. J., Perle, S. M., Bise, C. G., Timko, M., & Haas, M. (2016). Does case misclassification threaten the validity of studies investigating the relationship between neck manipulation and vertebral artery dissection stroke? No. Chiropractic & Manual Therapies, 24(1), 43. https://doi.org/10.1186/s12998-016-0124-9

Nambi, G., Kamal, W., Es, S., Joshi, S. and Trivedi, P., 2018. Spinal manipulation plus laser therapy versus laser therapy alone in the treatment of chronic non-specific low back pain: a randomized controlled study. European Journal of physical and rehabilitation medicine, 54(6), pp.880-889.

Nejati, P., Safarcherati, A., & Karimi, F. (2019). Effectiveness of Exercise Therapy and Manipulation on Sacroiliac Joint Dysfunction: A Randomized Controlled Trial. Pain Physician, 22(1), 53–61. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/30700068

Niraj, G. (2018). Pathophysiology and Management of Abdominal Myofascial Pain Syndrome (AMPS): A Three-Year Prospective Audit of a Management Pathway in 120 Patients. Pain Medicine. https://doi.org/10.1093/pm/pnx343

Plaza-Manzano, G., Molina-Ortega, F., Lomas-Vega, R., Martínez-Amat, A., Achalandabaso, A., & Hita-Contreras, F. (2014). Changes in Biochemical Markers of Pain Perception and Stress Response After Spinal Manipulation. Journal of Orthopaedic & Sports Physical Therapy, 44(4), 231–239. https://doi.org/10.2519/jospt.2014.4996

Reed, W. R., Cranston, J. T., Onifer, S. M., Little, J. W., & Sozio, R. S. (2017). Decreased spontaneous activity and altered evoked nociceptive response of rat thalamic submedius neurons to lumbar vertebra thrust. Experimental Brain Research, 235(9), 2883–2892. https://doi.org/10.1007/s00221-017-5013-5

Rist, P.M., Hernandez, A., Bernstein, C., Kowalski, M., Osypiuk, K., Vining, R., Long, C.R., Goertz, C., Song, R. and Wayne, P.M., 2019. The impact of spinal manipulation on migraine pain and disability: a systematic review and meta‐analysis. Headache: The Journal of Head and Face Pain, 59(4), pp.532-542.

Rubinstein, S. M., Haldeman, S., & van Tulder, M. W. (2006). An Etiologic Model to Help Explain the Pathogenesis of Cervical Artery Dissection: Implications for Cervical Manipulation. Journal of Manipulative and Physiological Therapeutics, 29(4), 336–338. https://doi.org/10.1016/j.jmpt.2006.03.003

Rustom, D. H., Gupta, D., & Chakrabortty, S. (2013). Epidural lipomatosis: A dilemma in interventional pain management for the use of epidural Steroids. Journal of Anaesthesiology, Clinical Pharmacology, 29(3), 410–411. https://doi.org/10.4103/0970-9185.117070

Sampath, K. K., Botnmark, E., Mani, R., Cotter, J. D., Katare, R., Munasinghe, P. E., & Tumilty, S. (2017). Neuroendocrine Response Following a Thoracic Spinal Manipulation in Healthy Men. Journal of Orthopaedic & Sports Physical Therapy, 47(9), 617–627. https://doi.org/10.2519/jospt.2017.7348

Shibahara, T., Yasaka, M., Wakugawa, Y., Maeda, K., Uwatoko, T., Kuwashiro, T., … Okada, Y. (2017). Improvement and Aggravation of Spontaneous Unruptured Vertebral Artery Dissection. Cerebrovascular Diseases Extra, 7(3), 153–164. https://doi.org/10.1159/000481442

Tal, A., Taeymans, J., Karstens, S., Clijsen, R., Clarys, P., & Rogan, S. (2018). Akute Effekte von TH4- Brustwirbelsäulenmobilisationstechniken auf das sympathische Nervensystem – eine Cross-over-Machbarkeitsstudie. Praxis, 107(21), 1139–1146. https://doi.org/10.1024/1661-8157/a003089

Teodorczyk-Injeyan, J. A., McGregor, M., Triano, J. J., & Injeyan, H. S. (2017). Elevated Production of Nociceptive CC-chemokines and sE-selectin in Patients with Low Back Pain and the Effects of Spinal Manipulation. The Clinical Journal of Pain, 1. https://doi.org/10.1097/AJP.0000000000000507

Vanichkulbodee, A., Issaragrisil, S., & Inboriboon, P. C. (2019). Massage-induced spinal epidural hematoma presenting with delayed paraplegia. The American Journal of Emergency Medicine. https://doi.org/10.1016/j.ajem.2019.01.017

Wang, F., Zhang, J., Feng, W., Liu, Q., Yang, X., Zhang, H., … Zhao, P. (2018). Comparison of human lumbar disc pressure characteristics during simulated spinal manipulation vs. spinal mobilization. Molecular Medicine Reports, 18(6), 5709–5716. https://doi.org/10.3892/mmr.2018.9591

Wirth, B., Gassner, A., de Bruin, E.D., Axén, I., Swanenburg, J., Humphreys, B.K. and Schweinhardt, P., 2019. Neurophysiological effects of high velocity and low amplitude spinal manipulation in symptomatic and asymptomatic humans: a systematic literature review. Spine, 44(15), pp.E914-E926

Wong, A. Y. L., Parent, E. C., Dhillon, S. S., Prasad, N., & Kawchuk, G. N. (2015). Do Participants With Low Back Pain Who Respond to Spinal Manipulative Therapy Differ Biomechanically From Nonresponders, Untreated Controls or Asymptomatic Controls? Spine, 40(17), 1329–1337. https://doi.org/10.1097/BRS.0000000000000981

Wong, A. Y. L., Parent, E. C., Dhillon, S. S., Prasad, N., Samartzis, D., & Kawchuk, G. N. (2019). Differential patient responses to spinal manipulative therapy and their relation to spinal degeneration and post-treatment changes in disc diffusion. European Spine Journal. https://doi.org/10.1007/s00586-018-5851-2

Yang, S.-D., Chen, Q., & Ding, W.-Y. (2018). Cauda Equina Syndrome Due to Vigorous Back Massage With Spinal Manipulation in a Patient With Pre-Existing Lumbar Disc Herniation. American Journal of Physical Medicine & Rehabilitation, 97(4), e23–e26. https://doi.org/10.1097/PHM.0000000000000809

Yoon, J. R., Kim, Y. K., Ko, Y. D., Yun, S. I., Song, D. H., & Chung, M. E. (2018). Spinal Accessory Nerve Injury Induced by Manipulation Therapy: A Case Report. Annals of Rehabilitation Medicine, 42(5), 773–776. https://doi.org/10.5535/arm.2018.42.5.773.