Main Article Content

Mark Spriggs
Denise Foukes


Cervical Spine, Radiography, Diagnostic Imaging


Introduction: Neck pain is a common health complaint in the UK and the second most common complaint seen by chiropractors worldwide. Spinal manipulative therapy (SMT) is an effective treatment intervention for patients with neck pain. The risks of SMT of the cervical spine (cSMT) are well documented in the literature; however, investigations into patient risk factors are lacking. Debate exists within the profession regarding the appropriate use of x-rays for spinal complaints with screening for contraindications to cSMT seen by some as inappropriate. This retrospective review of records and service evaluation examines how frequently lateral cervical spine x-rays alter treatment options in 1 chiropractic practice.

Methods: Data from 626 patient records were retrospectively reviewed from a private chiropractic clinic in the UK. Of the 626 new patients, 293 (47%) had x-rays of their cervical spine before commencing treatment. Patient x-rays and x-ray reports were reviewed for contraindications to cSMT.

Results: Of the 293 cervical spine x-rays, 177 (60%) revealed contraindications to cSMT over the 4 years of data collection. Thus, 28% of the 626 new patients who attended the clinic during that time period had their treatment option altered due to findings of contraindications on lateral cervical spine x-rays. Data analysis found that of those x-rays with contraindications, 46% had more than 1 contraindication present in the same patient. Extrapolating these data to the entire new patient population who attended the clinic, 15% of patients per annum had their treatment options altered as a direct result of x-rays findings.

Conclusion: The study found that 60% of cervical spine x-rays revealed contraindications to cSMT over the entire study period. Approximately 30% of lateral cervical spine x-rays revealed contraindications to cSMT, subsequently altering the treatment options of patients. This study adds supporting evidence to the validity of x-rays in chiropractic clinical practice in reducing risks of adverse events from cSMT and increasing patient safety.


Download data is not yet available.
Abstract 503 | CERVICAL SPINE RADIOGRAPHS Downloads 210


1. Henschke N, Kamper SJ, Maher CG. The epidemiology and economic consequences of pain. Mayo Clin Proc. 2015;90(1):139-147. doi:10.1016/j.mayocp.2014.09.010
2. Safiri S, Kolahi AA, Hoy D, et al. Global, regional, and national burden of neck pain in the general population, 1990-2017: Systematic analysis of the Global Burden of Disease Study 2017. BMJ. 2020;368. doi:10.1136/bmj.m791 /pmc/articles/PMC7249252/
3. Beliveau PJH, Wong JJ, Sutton DA, et al. The chiropractic profession: A scoping review of utilization rates, reasons for seeking care, patient profiles, and care provided. Chiropr Man Ther. 2017;25(1):1-17. doi:10.1186/s12998-017-0165-8
4. GCC. Counterfactual for Revalidation Report to the General Chiropractic Council. Econ Eur House, Chancery. 2010;(July)
5. Wong JJ, Shearer HM, Mior S, et al. Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the OPTIMa collaboration. Spine J. 2016;16(12):1598-1630. doi:10.1016/j.spinee.2015.08.024
6. Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of Neck Pain: Noninvasive Interventions. Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. J Manipulative Physiol Ther. 2009;32(2 SUPPL.) doi:10.1016/j.jmpt.2008.11.017
7. Swait G, Finch R. What are the risks of manual treatment of the spine? A scoping review for clinicians. Chiropr Man Ther. 2017;25. doi:10.1186/s12998-017-0168-5
8. Rushton A, Rivett D, Carlesso L, Flynn T, Hing W, Kerry R. International framework for examination of the cervical region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy intervention. Man Ther. 2014;19(3):222-228. doi:10.1016/j.math.2013.11.005
9. Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976) 2008;33(4 Suppl):S176-83. doi:10.1097/BRS.0b013e3181644600
10. Ernst E. Safety of chiropractic manipulation of the cervical spine. Spine (Phila Pa 1976) 2008;33(5):576-577; author reply 577. doi:10.1097/BRS.0b013e318165988f
11. Ernst E. Manipulation of the cervical spine: a systematic review of case reports of serious adverse events, 1995-2001. Med J Aust. 2002;176(8):376-380. doi:10.5694/j.1326-5377.2002.tb04459.x
12. Kranenburg HA, Schmitt MA, Puentedura EJ, Luijckx GJR, Van der Schans CP. Response to – Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: A systematic review. Musculoskelet Sci Pract. 2017;30(May):e95. doi:10.1016/j.msksp.2017.05.008
13. Puentedura EJ, March J, Anders J, et al. Safety of cervical spine manipulation: Are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports. J Man Manip Ther. 2012;20(2):66-74. doi:10.1179/2042618611Y.0000000022
14. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. 2001;32(5):1054-1060. doi:10.1161/01.str.32.5.1054
15. Scholten-Peeters GGM, van Trijffel E, Hutting N, Castien RF, Rooker S, Verhagen AP. Risk reduction of serious complications from manual therapy: Are we reducing the risk?. Correspondence to: International Framework for Examination of the Cervical Region for Potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention by A. Rushton et al. Man Ther. 2014;19(6):e5-e6. doi:10.1016/j.math.2014.01.007
16. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J R Soc Med. 2001;94(3):107-110. doi:10.1177/014107680109400302
17. Bolton J, Thiel H. Adverse effects of spinal manipulation. J R Soc Med. 2007;100(10):446-446. doi:10.1258/jrsm.100.10.446
18. Carnes D, Mullinger B, Underwood M. Defining adverse events in manual therapies: A modified delphi consensus study. Int J Osteopath Med. 2010;13(3):94-98. doi:10.1016/j.ijosm.2010.03.001
19. Kranenburg HA, Schmitt MA, Puentedura EJ, Luijckx GJ, van der Schans CP. Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: A systematic review. Musculoskelet Sci Pract. 2017;28:32-38. doi:10.1016/j.msksp.2017.01.008
20. Senstad O, Leboeuf-Yde C, Borchgrevink C. Frequency and characteristics of side effects of spinal manipulative therapy. Spine (Phila Pa 1976) 1997;22(4):435-441. doi:10.1097/00007632-199702150-00017
21. Senstad O, Leboeuf-Yde C, Borchgrevink CF. Side-effects of chiropractic spinal manipulation: Types frequency, discomfort and course. Scand J Prim Health Care. 1996;14(1):50-53. doi:10.3109/02813439608997068
22. Barrett AJ, Breen AC. Adverse effects of spinal manipulation. J R Soc Med. 2000;93(5):258-259. doi:10.1177/014107680009300511
23. Leboeuf-Yde C, Hennius B, Leufvenmark P, Thunmn M. Side effects of chiropractic treatment: a prospective study. J Manipulative Physiol Ther. 1997;20(8):511-515.
24. Stevinson C, Honan W, Cooke B, Ernst E. Neurological complications of cervical spine manipulation. J R Soc Med. 2001;94(3):107-110. doi:10.1177/014107680109400302
25. Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol. 2002;249(8):1098-1104. doi:10.1007/s00415-002-0783-4
26. Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. Adverse reactions to chiropractic treatment and their effects on satisfaction and clinical outcomes among patients enrolled in the UCLA Neck Pain Study. J Manipulative Physiol Ther. 2004;27(1):16-25. doi:10.1016/j.jmpt.2003.11.002
27. Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM. Does cervical manipulative therapy cause vertebral artery dissection and stroke? Neurologist. 2008;14(1):66-73. doi:10.1097/NRL.0b013e318164e53d
28. Cagnie B, Vinck E, Beernaert A, Cambier D. How common are side effects of spinal manipulation and can these side effects be predicted? Man Ther. 2004;9(3):151-156. doi:10.1016/j.math.2004.03.001
29. Jenkins H, Xiaoming Z, Bull P. Prevalence of Congenital Anomalies Contraindicating Spinal Manipulative Therapy within a Chiropractic Patient Population. Chiropr J Aust. 2010;40(2):69-76.
30. Wand BM, Heine PJ, O’Connell NE, Cassidy JD, Bronfort G, Hartvigsen J. Should we abandon cervical spine manipulation for mechanical neck pain? BMJ. 2012;345(7869) doi:10.1136/bmj.e3679
31. Joanna Briggs Institute. Critical Appraisal Checklist for Systematic Reviews and Research Synthesis. The Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews. Published 2020. Accessed May 23, 2021.
32. Aromataris E, Fernandez R, Godfrey CM, Holly C, Khalil H, Tungpunkom P. Summarizing systematic reviews: Methodological development, conduct and reporting of an umbrella review approach. Int J Evid Based Healthc. 2015;13(3):132-140. doi:10.1097/XEB.0000000000000055
33. Beck RW, Holt KR, Fox MA, et al. Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. J Manip Physiol Ther. 2004;27(9):554-559. doi:10.1016/j.jmpt.2004.10.008
34. Harrison DE, Harrison DD, Kent C, Betz JW. Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) For Biomechanical Assessment of Spinal Subluxation In Chiropractic Clinical Practice. 1st ed.; 2009.
35. Young KJ, Bakkum BW. The Hangover: The Early and Lasting Effects of the Controversial Incorporation of X-Ray Technology into Chiropractic. Aust New Zeal Soc Hist Med. 2016;18(1):111-136.
36. Young KJ. Gimme that old time religion: The influence of the healthcare belief system of chiropractic’s early leaders on the development of x-ray imaging in the profession. Chiropr Man Ther. 2014;22(1):1-34. doi:10.1186/s12998-014-0036-5
37. Young KJ. Historical influence on the practice of chiropractic radiology: Part II - Thematic analysis on the opinion of diplomates of the American Chiropractic College of Radiology about the future. Young Chiropr Man Ther. 2017;25(15):1-11. doi:10.1186/s12998-017-0145-z
38. ACA ACA. American Chiropractic Association Releases Choosing Wisely® List of Tests, Procedures to Question. Published 2017.
39. Ammendolia C, Hogg-Johnson S, Pennick V, Glazier R, Bombardier C. Implementing evidence-based guidelines for radiography in acute low back pain: a pilot study in a chiropractic community. J Manipulative Physiol Ther. 2004;27(3):170-179. doi:10.1016/j.jmpt.2003.12.021
40. Bussières AE, Taylor JAM, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther. 2008;31(1):33-88. doi:10.1016/j.jmpt.2007.11.003
41. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-491.
42. Pengel LHM, Herbert RD, Maher CG, Refshauge KM. Acute low back pain: systematic review of its prognosis. BMJ. 2003;327(7410):323. doi:10.1136/bmj.327.7410.323
43. Koes BW, van Tulder MW, Ostelo R, Kim Burton A, Waddell G. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine (Phila Pa 1976) 2001;26(22):2504.
44. Dixon J. Progress and Problems in Back Pain Research. Rheumatol Rehabil. 1973;12(50):165-175.
45. Fry J. Back Pain and Soft Tissue Rheumatism. In: Advisory Services Colloquia, No. 1. Advisory Services (Clinical & General); 1972:8.
46. Harrison DE, Betz JW, Harrison DD, Haas JW, Oakley PA, Meyer DW. CBP Structural Rehabilitation of the Lumbar Spine. 1st ed. Harrison Chiropractic Biophysics Seminars Inc; 2007.
47. Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice. BMJ. 1994;308(6928):577-580.
48. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363-370. doi:10.1056/NEJM200102013440508
49. Kääriä S, Luukkonen R, Riihimäki H, Kirjonen J, Leino-Arjas P. Persistence of low back pain reporting among a cohort of employees in a metal corporation: a study with 5-, 10-, and 28-year follow-ups. Pain. 2006;120(1-2):131-137. doi:10.1016/J.PAIN.2005.10.020
50. Balagué F, Troussier B, Salminen J. Non-specific low back pain in children and adolescents: risk factors. Eur Spine J. 1999;8(6):429-438. doi:10.1007/S005860050201
51. Baranto A, Hellström M, Cederlund C, Nyman R, Swärd L. Back pain and MRI changes in the thoraco-lumbar spine of top athletes in four different sports: a 15-year follow-up study. Knee Surg Sports Traumatol Arthrosc. 2009;17(9):1125-1134. doi:10.1007/S00167-009-0767-3
52. Harreby M, Nygaard B, Jessen T, et al. Risk factors for low back pain in a cohort of 1389 Danish school children: an epidemiologic study. Eur Spine J. 1999;8(6):444-450. doi:10.1007/S005860050203
53. Harreby M, Neergaard K, Hesselsoe G, Kjer J. Are radiologic changes in the thoracic and lumbar spine of adolescents risk factors for low back pain in adults?: A 25-year prospective cohort study of 640 school children. Spine (Phila Pa 1976) 1995;20(21):2298-2302. doi:10.1097/00007632-199511000-00007
54. Newcomer K, Sinaki M. Low back pain and its relationship to back strength and physical activity in children. Acta Paediatr. 1996;85(12):1433-1439. doi:10.1111/J.1651-2227.1996.TB13948.X
55. Thomas LC, Rivett DA, Bateman G, Stanwell P, Levi CR. Effect of Selected Manual Therapy Interventions for Mechanical Neck Pain on Vertebral and Internal Carotid Arterial Blood Flow and Cerebral Inflow. Phys Ther. 2013;93(11):1563-1574. doi:10.2522/ptj.20120477
56. Power C, Frank J, Hertzman C, Schierhout G, Li L. Predictors of low back pain onset in a prospective British study. Am J Public Health. 2001;91(10):1671-1678. doi:10.2105/AJPH.91.10.1671
57. Ferrara LA. The Biomechanics of Cervical Spondylosis. Adv Orthop. 2012;2012:1-5. doi:10.1155/2012/493605
58. Shedid D, Benzel EC. Cervical spondylosis anatomy: pathophysiology and biomechanics. Neurosurgery. 2007;60(1 Supp1 1):S7-13. doi:10.1227/01.NEU.0000215430.86569.C4
59. Connell MD, Wiesel SW. Natural history and pathogenesis of cervical disk disease. Orthop Clin North Am. 1992;23(3):369-380.
60. Beck RW, Holt KR, Fox MA, Hurtgen-Grace KL. Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. J Manipulative Physiol Ther. 2004;27(9):554-559. doi:10.1016/j.jmpt.2004.10.008
61. Haynes-Mazion LM. Contraindications to Chiropractic Manipulation with Specific Technique Alternatives.; 1995.
62. Ammendolia C. Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population (multiple letters) J Manipulative Physiol Ther. 2005;28(5):375-376. doi:10.1016/j.jmpt.2005.04.013
63. Imbos N, Langworthy J, Wilson F, Regelink G. Practice characteristics of chiropractors in The Netherlands. Clin Chiropr. 2005;8(1):7-12. doi:10.1016/j.clch.2004.10.004
64. GCC. Fitness to Practise Annual Report 2019-20. GOsC. Published online 2020:9-11. file:///C:/Users/kseki/Downloads/fitness-to-practice-2019-20-03-linked (1)pdf
65. UNSCEAR. Sources and Effects of Ionizing Radiation, United Nations Scientific Committee on the Effects of Atomic Radiation UNSCEAR 2000 Report to the General Assembly, with Scientific Annexes. Vol I.; 2000.
66. Doss M. Linear no-threshold model vs. radiation hormesis. Dose-Response. 2013;11(4):480-497. doi:10.2203/dose-response.13-005.Doss
67. Oakley PA, Harrison DE. Death of the ALARA Radiation Protection Principle as Used in the Medical Sector. Dose-Response. 2020;18(2) doi:10.1177/1559325820921641
68. Vaiserman A, Koliada A, Zabuga O, Socol Y. Health Impacts of Low-Dose Ionizing Radiation: Current Scientific Debates and Regulatory Issues. Dose-Response. 2018;16(3) doi:10.1177/1559325818796331
69. Schultz C, Fairley R, Murphy L, Doss M. The Risk of Cancer from CT Scans and Other Sources of Low-Dose Radiation: A Critical Appraisal of Methodologic Quality. Prehosp Disaster Med. 2020;35(1):3-16. doi:10.1017/S1049023X1900520X
70. Oakley PA, Cuttler JM, Harrison DE. X-Ray Imaging is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation : Radiography Increases Benefits and Reduces Risks. Dose-Response. 2018;16(2):0-6. doi:10.1177/1559325818781437
71. Oakley PA, Harrison DE. X-Ray Hesitancy: Patients’ Radiophobic Concerns Over Medical X-rays. Dose-Response. 2020;18(3) doi:10.1177/1559325820959542
72. Oakley PA, Harrison DE. Radiophobic Fear-Mongering, Misappropriation of Medical References and Dismissing Relevant Data Forms the False Stance for Advocating Against the Use of Routine and Repeat Radiography in Chiropractic and Manual Therapy. Dose-Response. 2021;19(1) doi:10.1177/1559325820984626
73. Oakley P. Radiogenic Cancer Risks from Chiropractic X- rays are Zero: 10 Reasons to Take Routine Radiographs in Clinical Practice Best Practices Radiogenic Cancer Risks from Chiropractic X-rays are Zero : 10 Reasons to Take Routine Radiographs in Clinical Practice. Ann Vertebr Subluxation Res. 2018;2018(March):48-56.
74. Siegel JA, Pennington CW, Sacks B, Welsh JS. The Birth of the Illegitimate Linear No-Threshold Model: An Invalid Paradigm for Estimating Risk Following Low-dose Radiation Exposure. Am J Clin Oncol Cancer Clin Trials. 2018;41(2):173-177. doi:10.1097/COC.0000000000000244
75. Sacks B, Meyerson G, Siegel JA. Epidemiology Without Biology: False Paradigms, Unfounded Assumptions, and Specious Statistics in Radiation Science (with Commentaries by Inge Schmitz-Feuerhake and Christopher Busby and a Reply by the Authors) Biol Theory. 2016;11(2):69-101. doi:10.1007/s13752-016-0244-4
76. Siegel JA, Penningtin C. The Mismeasure of Radiation. Skept Mag. 2015;20(4):46-64.
77. Siegel JA, Pennington CW, Sacks B. Subjecting Radiologic Imaging to the Linear No-Threshold Hypothesis: A Non Sequitur of Non-Trivial Proportion. J Nucl Med. 2017;58(1):1-6. doi:10.2967/jnumed.116.180182
78. Bull PW. Relative and Absolute Contraindications to Spinal Manipulative Therapy Found on Spinal X-Rays. World Fed Chiropr Congr (7th 2003) Published online 2003:376-376. Accessed May 16, 2021.
79. Pryor M, McCoy M. Radiographic findings that may alter treatment identified on radiographs of patient receiving chiropractic care in a teaching clinic. J Chiropr Educ. 2006;27(9):554-559.
80. Jenkins H, Zheng X, Bull P. Prevelence of congenital anomalies contraindicating spinal manipulative therapy within a chiropractic patient population. Chiropr J Aust. 2010;(40):69-76.
81. Yochum TR, Rowe LJ. Congenital Anomalies and Normal Variants. In: Essentials of Skeletal Radiology. 3rd ed. Lippincott Williams & Wilkins; 2005:283.
82. Gatterman MI. Complications of and Contraindications to Spinal Manipulative Therapy. In: Chiropractic Management of Spine Related Disorders. Williams & Wilkins; 1990:55-69.
83. Oakley PA, Cuttler JM, Harrison DE. X-Ray Imaging is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation : Radiography Increases Benefits and Reduces Risks. 2018;(March):0-6. doi:10.1177/1559325818781437
84. Rivett D, Thomas L, Bolton P. Invited Clinical Commentary Pre-manipulative testing : where do we go from here ? New Zeal J Physiother Physiother. 2005;33(November):3-78.
85. Thiel H, Rix G. Is it time to stop functional pre-manipulation testing of the cervical spine? Man Ther. 2005;10(2):154-158. doi:10.1016/j.math.2004.06.004
86. Mcaviney J, Schulz D, Bock R, Harrison DE, Holland B. Determining the Relationship between cervical lordosis and neck complaints. J Manipulative Physiol Ther. 2005;28(3):187-193. doi:10.1016/j.jmpt.2005.02.015
87. McAviney J, Schulz D, Bock R, Harrison DE, Holland B. Determining the relationship between cervical lordosis and neck complaints. J Manipulative Physiol Ther. 2005;28(3):187-193. doi:10.1016/j.jmpt.2005.02.015
88. Harrison DD, Harrison DE, Janik TJ, et al. Modeling of the Sagittal Cervical Spine as a Method to Discriminate Hypolordosis Results of Elliptical and Circular Modeling in 72 Asymptomatic Pain Subjects. Spine (Phila Pa 1976) 2004;29(22):2485-2492.
89. Harrison DE, Harrison DD, Janik TJ, William Jones E, Cailliet R, Normand M. Comparison of axial and flexural stresses in lordosis and three buckled configurations of the cervical spine. Clin Biomech. 2001;16(4):276-284. doi:10.1016/S0268-0033(01)00006-7
90. Harrison DE, Jones EW, Janik TJ, Harrison DD. Evaluation of axial and flexural stresses in the vertebral body cortex and trabecular bone in lordosis and two sagittal cervical translation configurations with an elliptical shell model. J Manipulative Physiol Ther. 2002;25(6):391-401. doi:10.1067/mmt.2002.126128
91. Johansson MP, Baann Liane MS, Bendix T, Kasch H, Kongsted A. Does cervical kyphosis relate to symptoms following whiplash injury? Man Ther. 2011;16(4):378-383. doi:10.1016/j.math.2011.01.004
92. Katsuura A, Hukuda S, Saruhashi Y, Mori K. Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels. Eur Spine J. 2001;10(4):320-324. doi:10.1007/s005860000243
93. Faldini C, Pagkrati S, Leonetti D, Miscione MT, Giannini S. Sagittal segmental alignment as predictor of adjacent-level degeneration after a Cloward procedure. Clin Orthop Relat Res. 2011;469(3):674-681. doi:10.1007/s11999-010-1614-z
94. Bogduk N, Amevo B, Aprill C. Abnormal instantaneous axes of rotation in patients with neck pain. Spine (Phila Pa 1976) 1992;17(7):748-756. doi:10.1097/00007632-199207000-00004
95. Bogduk N, Mercer S. Biomechanics of the cervical spine. I: Normal kinematics. Clin Biomech. 2000;15(9):633-648. doi:10.1016/S0268-0033(00)00034-6
96. Steilen D, Hauser R, Woldin B, Sawyer S. Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability. Open Orthop J. 2014;8(1):326-345. doi:10.2174/1874325001408010326
97. Bulut MD, Alpayci M, Şenköy E, et al. Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis. Med Sci Monit. 2016;22:495-500. doi:10.12659/MSM.897500
98. Katz EA, Katz SB, Fedorchuk CA, Lightstone DF, Banach CJ, Podoll JD. Increase in cerebral blood flow indicated by increased cerebral arterial area and pixel intensity on brain magnetic resonance angiogram following correction of cervical lordosis. Published online 2019. doi:10.4103/bc.bc_25_18
99. Cai X, Razmara A, Paulus JK, et al. Case misclassification in studies of spinal manipulation and arterial dissection. J Stroke Cerebrovasc Dis. 2014;23(8):2031-2035. doi:10.1016/j.jstrokecerebrovasdis.2014.03.007
100. Dziewas R, Konrad C, Dräger B, et al. Cervical artery dissection--clinical features, risk factors, therapy and outcome in 126 patients. J Neurol. 2003;250(10):1179-1184. doi:10.1007/s00415-003-0174-5
101. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9):1424-1428. doi:10.1212/01.WNL.0000063305.61050.E6
102. Olszewski J, Majak J, Pietkiewicz P, Luszcz C, Repetowski M. The association between positional vertebral and basilar artery flow lesion and prevalence of vertigo in patients with cervical spondylosis. Otolaryngol - Head Neck Surg. 2006;134(4):680-684. doi:10.1016/j.otohns.2005.11.023
103. Wood A. X-Ray Documentation for BCA Members.; 2017.
104. Harrison DE, Harrison DD, Kent C, J B. Practicing Chiropractor’s Committee on Radiology Protocols (PCCRP) For Biomechanical Assessment of Spinal Subluxation In Chiropractic Clinical Practice. International Chiropractors Association (ICA) and accepted for inclusion into the National Guideline Clearinghouse; 2009.
105. Harrison DE, Harrison DD, Haas JW. CBP Structural Rehabilitation of the Cervical Spine. 1st ed. Harrison Chiropractic Biophysics Seminars Inc; 2002.
106. Panjabi MM, White AA, Johnson RM. Cervical spine mechanics as a function of transection of components. J Biomech. 1975;8(5):327-336. doi:10.1016/0021-9290(75)90085-8
107. Frobin W, Leivseth G, Biggemann M, Brinckmann P. Sagittal plane segmental motion of the cervical spine. A new precision measurement protocol and normal motion data of healthy adults. Clin Biomech. 2002;17(1):21. doi:10.1016/s0268-0033(01)00105-x
108. Penning L. Normal movements of the cervical spine. AJR Am J Roentgenol. 1978;130(2):317-326. doi:10.2214/ajr.130.2.317
109. Penning L. Kinematics of cervical spine injury - A functional radiological hypothesis. Eur Spine J. 1995;4(2):126-132. doi:10.1007/BF00278925
110. Yeo CG, Jeon I, Kim SW. Delayed or Missed Diagnosis of Cervical Instability after Traumatic Injury: Usefulness of Dynamic Flexion and Extension Radiographs. Korean J Spine. 2015;12(3):146-149. doi:10.14245/kjs.2015.12.3.146
111. Harrison DE, Harrison DD, Cailliet R, Troyanovich SJ, Janik TJ, Holland B. Cobb method or harrison posterior tangent method: Which to choose for lateral cervical radiographic analysis. Spine (Phila Pa 1976) 2000;25(16):2072-2078. doi:10.1097/00007632-200008150-00011
112. White A, Panjabi M. The Problem of Clinical Instability in the Human Spine: A Systemic Approach. In: Clinical Biomechanics of the Spine. 2nd ed. Lippincott Williams & Wilkins; 1990:314.
113. Dvorak J, Froehlich D, Penning L, Baumgartner H, Panjabi MM. Functional radiographic diagnosis of the cervical spine: Flexion/extension. Spine (Phila Pa 1976) 1988;13(7):748-755. doi:10.1097/00007632-198807000-00007
114. Dvorak J, Panjabi MM, Grob D, Novotny JE, Antinnes JA. Clinical validation of functional flexion/extension radiographs of the cervical spine. Spine (Phila Pa 1976) 1993;18(1):120-127.
115. Ivancic PC, Dvorak J, Goel VK, Fairchild TA, White III AA, DiAngelo DJ. Cervical Spine Kinematics and Clinical Instability. In: The Cervical Spine. 5th ed. Lippincott Williams & Wilkins; 2012:53-72.
116. Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. Reliability of Centroid, Cobb, and Harrison Posterior Tangent Methods. Spine (Phila Pa 1976) 2001;26(11):e227-e234. doi:10.1097/00007632-200106010-00002
117. Harrison DE, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DD, Holland B. Elliptical modelling fo the sagittal lumbar lordosis and segmental rotation angles as a method to discrominate between normal and low back pain subjects. J Spinal Disord. 1998;11(5):430-439.
118. Harrison DD, Janik TJ, Troyanovich SJ, Harrison DE, Colloca CJ. Evaluations of the assumptions used to derive an ideal normal cervical spine model. J Manipulative Physiol Ther. 1997;20(4):246-256.
119. Béjot Y, Aboa-Eboulé C, Debette S, et al. Characteristics and outcomes of patients with multiple cervical artery dissection. Stroke. 2014;45(1):37-41. doi:10.1161/STROKEAHA.113.001654
120. Engelter ST, Grond-Ginsbach C, Metso TM, et al. Cervical artery dissection trauma and other potential mechanical trigger events. Neurology. 2013;80(21):1950-1957. doi:10.1212/WNL.0b013e318293e2eb
121. Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: A population-based case-control study. Stroke. 2001;32(5):1054-1059. doi:10.1161/01.STR.32.5.1054
122. Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9):1424-1428. doi:10.1212/01.WNL.0000063305.61050.E6
123. Cassidy JD, Boyle E, Côté P, Hogg-johnson S, Bondy SJ. Risk of Carotid Stroke after Chiropractic Care : A Population-Based Case-Crossover Study. Spine (Phila Pa 1976) 2016;33(4S):176-183. doi:10.1016/j.jstrokecerebrovasdis.2016.10.031
124. Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(10):3155-3174. doi:10.1161/STR.0000000000000016
125. Schievink WI. Spontaneous Dissection of the Carotid and Vertebral Arteries. N Engl J Med. 2001;344(12):898-906. doi:10.1056/nejm200103223441206
126. Schwartz NE, Vertinsky AT, Hirsch KG, Albers GW. Clinical and Radiographic Natural History of Cervical Artery Dissections. J Stroke Cerebrovasc Dis. 2009;18(6):416-423. doi:10.1016/j.jstrokecerebrovasdis.2008.11.016
127. Oppenheim JS, Spitzer DE, Segal DH. Nonvascular complications following spinal manipulation. Spine J. 2005;5(6):660-667. doi:10.1016/j.spinee.2005.08.006
128. Oppenheim JS, Spitzer DE, Segal DH. Nonvascular complications following spinal manipulation. Spine J. 2005;5(6):660-666. doi:10.1016/j.spinee.2005.08.006
129. Dvořák J, Loustalot D, Baumgartner H, Antinnes JA. Frequency of complications of manipulation of the spine - A survey among the members of the Swiss Medical Society of Manual Medicine. Eur Spine J. 1993;2(3):136-139. doi:10.1007/BF00301410
130. Rivett DA, Milburn P. A Prospective Study of Complications of Cervical Spine Manipulation. J Man Manip Ther. 1996;4(4):166-170. doi:10.1179/jmt.1996.4.4.166
131. Dvořák J, Orelii F. How dangerous if manipulation of the cervical spine? Man Med. 1985;(2):1-4.
132. Jaskoviak PA. Complications arising from manipulation of the cervical spine. J Manip Physiol Ther. 1980;3(4):213-219.
133. Hanyes MJ. Stroke following cervical manipulation in Perth. Chiropr J Aust. 1994;24(2):42-46.
134. Eriksen K, Rochester RP, Hurwitz EL. Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: A prospective, multicenter, cohort study. BMC Musculoskelet Disord. 2011;12. doi:10.1186/1471-2474-12-219
135. Rajendran D, Bright P, Mullinger B, Froud R. Reporting patterns and predictors of common minor adverse events following osteopathic treatment: Lessons learned from a prospective, patient-administered questionnaire feasibility study in a UK teaching clinic. Eur J Integr Med. 2015;7(6):634-644. doi:10.1016/j.eujim.2015.09.005
136. Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW. The Benefits Outweigh the Risks for Patients Undergoing Chiropractic Care for Neck Pain: A Prospective, Multicenter, Cohort Study. J Manipulative Physiol Ther. 2007;30(6):408-418. doi:10.1016/j.jmpt.2007.04.013
137. Rubinstein S, Leboeuf-Yde C, DL K, TE de K, CE P, MW van T. Predictors of adverse events following chiropractic care for patients with neck pain. J Manip Physiol Ther. 2008;31(2):94-103. doi:10.1016/j.jmpt.2007.12.006
138. Hurwitz EL, Morgenstern H, Vassilaki M, Chiang LM. Frequency and clinical predictors of adverse reactions to chiropractic care in the UCLA neck pain study. Spine (Phila Pa 1976) 2005;30(13):1477-1484. doi:10.1097/01.brs.0000167821.39373.c1
139. Phillips DC (Denis C, Burbules NC. Postpositivism and Educational Research . Rowman and Littlefield Publishers; 2000.
140. NICE. Shared Decision Making (NG197): NICE Guidelines. Natl Inst Heal Care Excell. Published online 2021:1-29. doi:10.1016/j.medcli.2015.10.003
141. Dvorak J, Orelli F. The frequency of complications after manipulation of the cervical spine: case report and epidemiology. Schweizerische Rundschau fur Medizin Praxis Revue suisse de medecine Praxis.1982; 71(2): 64-69.