Manual Therapy 19 (2014) 281e287

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Manual Therapy
journal homepage: www.elsevier.com/math

Systematic review

The effects of spinal mobilizations on the sympathetic nervous

system: A systematic review
Laura Kingston*, Leica Claydon, Steve Tumilty
Centre for Physiotherapy Research, University of Otago, 325 Great King Street, Dunedin 9016, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: The activity of the sympathetic nervous system is of importance to manual therapists, since the expe-
Received 12 July 2012 rience of pain is associated with sympathetic activity. There has been little exploration into the effects of
Received in revised form mobilizing vertebral segments below the cervical spine. In addition to this, a synthesis of the evidence for
2 April 2014
changes in sympathetic outcome measures has not been completed.
Accepted 3 April 2014
The primary aim of this review was to investigate the effects of spinal mobilizations compared to a
control or placebo on sympathetic outcome measures. The secondary aim was to establish the level of
Keywords:
change, either excitatory or inhibitory, in sympathetic outcome measures. Five electronic databases (Ovid
Spinal manipulation
Best evidence
Medline, Embase, AMED, PEDro, and the Cochrane library; from database inception to May 2012) were
Sympathetic nervous system searched for randomized controlled trials. Two independent raters applied inclusion criteria and rated
Sympathetic outcome measures studies for methodological quality. Seven studies met the inclusion criteria.
Skin conductance All studies demonstrated a consistent increase in sympathetic outcome measures, indicative of sym-
pathetic excitation, irrespective of the segments mobilized. Synthesis of the results established strong
evidence (multiple high-quality randomised controlled trials (RCTs) for a positive change in skin
conductance, respiratory rate, blood pressure, and heart rate among the healthy population. As only one
study investigated changes in a symptomatic population, there was limited evidence (one RCT) for an
increase in skin conductance and decrease in skin temperature. Evidence from this systematic review
supports a sympatho-excitatory response to spinal mobilizations irrespective of the segment mobilized.
Ó 2014 Elsevier Ltd. All rights reserved.

1. Introduction Gate-control mechanisms (Melzack and Wall, 1965) together

Manual therapy (MT) techniques, which encompass a broad
range of procedures, are commonly used to treat joint restriction
and improve pain outcomes by therapists throughout the world. A
common form of MT is passive joint mobilization, often referred to
as “mobilizations”. For the purposes of this review, spinal mobili-
zations will refer to graded passive, oscillatory movements applied
to the spine, that move it to the end of its available range (Maitland
et al., 2001). Other forms of MT commonly used in the clinical
setting include high-velocity low-amplitude (HVLA) thrust ma-
nipulations and mobilizations with movement (MWM’s). To avoid
grouping the effect of different forms of MT techniques together,
HVLA thrust manipulations and MWMs will not be considered in
this review.
* Corresponding author. Tel.: þ64 211363822.
E-mail address: Kingston_laura@hotmail.com (L. Kingston).
with other biomechanical effects (Evans, 2002) formed early hy-
potheses on the mechanisms of therapeutic effects following MT
interventions. There is general agreement that the response of the
sympathetic nervous system (SNS) is part of a much greater, cen-
trally co-ordinated response to spinal mobilizations. Many authors
have postulated that an area of the mid brain, the dorsal peri-
acqueductal grey area (dPAG), is instrumental in evoking this ac-
tivity (Lovick, 1985; Evans, 2002). Other authors have used an
anatomical explanation to account for the increase in sympathetic
outflow. This theory relates to the anatomical positioning of the
sympathetic trunk and paravertebral ganglia (Petersen et al., 1993),
which is also the basis for theories on regional bias (different
sympathetic response dependent on the region of the spine). For
example, Harris and Wagnon (1987) demonstrated an increase in
peripheral skin temperature (indicating inhibition of the SNS)
following manipulation of cervical and lumbar vertebrae and a
decrease in peripheral temperature (indicating excitation of the
SNS) following manipulation of thoracic vertebrae.

http://dx.doi.org/10.1016/j.math.2014.04.004
1356-689X/Ó 2014 Elsevier Ltd. All rights reserved.
282 L. Kingston et al. / Manual Therapy 19 (2014) 281e287
The proposal of a multi-system, centrally co-ordinated response
is based on observations from numerous studies (Vicenzino et al.,
1998; Evans, 2002). Increases in heart rate (HR), blood pressure
(BP) and respiratory rate (RR) following stimulation of the dPAG in
animal models have been observed (Burnett and Gebhart, 1991).
These changes occurred concurrently with sympathetic excitation
and hypoalgesia (Lovick, 1985). Diminished pressure pain thresh-
olds have been consistently demonstrated following different
forms of MT with concurrent sympathetic excitation (McGuiness
et al., 1997; Sterling et al., 2001; Cleland et al., 2002; Cleland and
McRae., 2002).
In a review Schmid et al. (2008) found significant support for
central involvement in diminished pressure-pain thresholds
following cervical spine mobilizations. However, this review was
limited to studies that investigated cervical segments only. There is
ambiguity in the literature regarding the sympathetic response of
other forms of MT, such as HVLA thrust manipulations, in different
regions of the spine (‘regional bias’) (Kappler and Kelso, 1984;
Harris and Wagnon, 1987; Welch and Boone, 2008). The majority
of studies that have reported on this have been poorly controlled
and employed different techniques. However, it raises the possi-
bility that regional biases might also be present, following spinal
mobilizations. To the best of the authors’ knowledge a systematic
review of the sympathetic response following spinal mobilizations
in different regions of the spine has not been completed. Systematic
reviews of RCTs constitute ‘best evidence’ in terms of the validity or
rigour of the evidence for a particular treatment. Hence, they are
used by clinicians and policy makers to guide decision making.
The primary aim of this review was to evaluate RCTs investi-
gating the effects of spinal mobilizations on SNS outcome mea-
sures, in both healthy and patient populations. The second aim was
to establish the currently available level of evidence (Heymans
et al., 2004) that supports a change in sympathetic outcome
measures.
2. Methods
This systematic review has been completed in accordance with
internationally recommended guidance; the Preferred Reporting
Item for Systematic Reviews and Meta-Analyses (PRISMA) (www.
prisma-statement.org).
2.1. Literature search
The following electronic databases were searched for eligible
trials (from database inception to May 2012): Ovid Medline,
Embase, AMED, PEDro and the Cochrane library. Reference lists
were also examined to identify any articles not captured in the
electronic database search.
The search was restricted to RCTs conducted on humans and
reported in English language. None of the study authors were
contacted to identify additional studies; only published material
was included.
2.2. Eligibility criteria
RCTs that investigated at least one sympathetic outcome BP, HR,
RR, skin conductance (SC) and skin temperature (ST) during or
immediately following spinal mobilization were included. Spinal
mobilizations were accepted in the form of passive accessory
movements (Schmid et al., 2008). The control interventions
considered acceptable were: no treatment, and/or placebo inter-
vention. Both male and female volunteers between the ages of 18e
65 years, in either a healthy or symptomatic population were
considered eligible.
Investigations involving MWMs, and HVLA thrust manipula-
tions were excluded from this review. Trials that investigated
longer-term effects (i.e. more than 24 h) of spinal mobilizations on
the SNS were also excluded.
2.3. Selection of studies
Potentially relevant articles were obtained in full text, and
screened independently by two authors (LK and LC) for inclusion
and exclusion criteria.
2.4. Data extraction
Two authors (LK and ST) independently extracted data from the
studies, using a standardized form (Table 1). Inconsistencies were
resolved by discussion between the two authors. Corresponding
authors listed on the included articles were contacted for primary
data to complete a meta-analysis, however the study data were not
available.
2.5. RCT rating
The Cochrane Collaboration’s recommended tool for assessing
risk of bias (RoB) was included in this review (Alderson et al., 2004).
The RoB assessment tool incorporates six primary sources for bias,
and was used independently by two authors (LK and ST) to classify
the risk of bias in each study as a “high risk”, “low risk” or “unclear
risk”. Differences in opinions were discussed and an agreement on
judgements reached; it was not necessary to consult with the third
author. Refer to Table 2 for an overview of these judgements.
PEDro, which is the Physiotherapy Evidence Database, contains
randomized trials, systematic reviews and clinical practice guide-
lines in physiotherapy. The PEDro rating scale is an 11-point rating
scale used to help individuals quickly assess the internal validity
(criteria 2e9) and statistical interpretability of results from a trial
(criteria 10e11). A score of six or above is considered a high-quality
trial, while a score of below six is considered a low-quality trial
(Gravare Silbernagel et al., 2001; Roos et al., 2004; Martinez-
Silvestrin et al., 2005). The maximum score achievable on the
PEDro scale is 10/10; as the first criterion, which assesses the
external validity of a trial, is not included in the final score. Each
study was independently rated on this scale by two authors (LK and
ST); disagreements were resolved by discussion and an agreement
was reached for differing scores (Table 3).
Results of combined studies were also summarized using a best-
evidence synthesis (Heymans et al., 2004). The level of evidence for
specific SNS outcome measures was ranked according to the
following criteria:
 “Strong” evidence: generally consistent findings in multiple
high-quality RCTs.
 “Moderate” evidence: generally consistent findings in one high-
quality RCT, plus one or more low-quality RCTs, or by generally
consistent findings in multiple low-quality RCTs.
 “Limited” or “conflicting” evidence: only one RCT (either high or
low quality) or inconsistent findings in multiple RCTs.
 “No” evidence: no RCTs.
3. Results
3.1. Search strategy
The combined database search in MEDLINE, AMED and Embase
yielded five RCTs eligible for inclusion in this review. Searches in
PEDro and the Cochrane Controlled Trials register did not add any
Table 1
Data extracted from studies reviewed.

Authors Participants Intervention Control/Comparator Outcome Results

Petersen et al. (1993) 16 Healthy (male) subjects GIII central PA C5 Placebo procedure Skin conductance SC: Significant increase in intervention procedure compared to
(oscillatory technique) Control procedure Skin temperature placebo and control procedures. An increase in the order of
50e60% during intervention steadily decreasing to that of
placebo after. Placebo consistently increased in the order of 30%
during the intervention and 15e20% after.
ST: Significant decrease in intervention procedure compared to
control (change in the order of 1%), no significant difference
between placebo and intervention procedure.
Chiu and Wright (1996) 16 Healthy (male) subjects GIII central PA C5 @ 2 Hz GIII central PA Skin Conductance SC: Significant increase in 2 Hz group compared to control

L. Kingston et al. / Manual Therapy 19 (2014) 281e287

(oscillatory technique) C5 @ 0.5 Hz Placebo Skin temperature and 0.5 Hz. 2 Hz group increased in the order of 50e60%.
ST: No significant difference in ST between 3 groups.
McGuiness et al. (1997) 23 Healthy (male & GIII central PA C5 Placebo procedure Respiratory rate Significant increases in all outcomes in intervention group
female) subjects (oscillatory technique) Control procedure Blood pressure compared to control and placebo procedures. RR increased
Heart rate in the intervention group during treatment by 44%, Diastolic
BP increased by 12.5% and systolic BP increased by 4.5%. HR
increased in the order of 10.5%.
Vicenzino et al. (1998) 24 Healthy subjects GIII left lateral glide C5 Placebo procedure Respiratory rate Significant increase in all outcomes of the intervention
(oscillatory technique) Control procedure Heart rate procedure compared to control and placebo procedures. RR
Blood pressure increased in the intervention group 36% compared to an increase
of 13% and 14% in the placebo and control group respectively.
HR increased in the intervention group 13% compared to
2% and 1% in the placebo and control group respectively. BP
increased in the intervention group by 14% compared to 1% in
the both the placebo and control group.
(Sterling et al., 2001) 30 subjects GIII unilateral PA on Placebo procedure Skin temperature SC: Significant increase in intervention procedure compared
(male & female) e cervical symptomatic side Control procedure Skin conductance to placebo and control procedure. 16% change increase from
pain > 3months (oscillatory technique) Pressure pain baseline in the intervention group.
and dysfunction C5/6 threshold ST: significant decrease in intervention procedure of 1.3 to 2.5%
Thermal pain
threshold
EMG
VAS
Perry and Green (2008) 45 healthy (male) subjects GIII unilateral (left) PA L4/5 @ 2 Hz Placebo group Skin conductance SC: Significant side-specific increase on ipsilateral side in the
(oscillatory technique) Control group intervention group, compared to placebo and control group. 13%
increase from baseline during the intervention.
Jowsey and Perry (2010) 36 healthy (male & GIII rotatory mobilisation T4 @ 0.5 Hz Placebo group Skin conductance SC: Significant side-specific increase in the intervention group
female) subjects (oscillatory technique) compared to the placebo group. Increase in mean percentage
change of 5.74% during the intervention compared to placebo
and 16.84% post intervention compared to placebo.

283
284 L. Kingston et al. / Manual Therapy 19 (2014) 281e287

Table 2
PEDro scores for each study.

References Criteria 1 Criteria 2 Criteria 3 Criteria 4 Criteria 5 Criteria 6 Criteria 7 Criteria 8 Criteria 9 Criteria 10 Criteria 11 Total

Petersen et al., 1993 Y Y N Y Y N Y N N Y Y 6/10 (high)

Chiu and Wright 1996 Y Y N Y Y N Y N N Y Y 6/10(high)
McGuiness et al., 1997 Y Y N Y Y N Y N N Y Y 6/10 (high)
Vicenzino et al., 1998 Y Y N Y Y N Y N N Y Y 6/10 (low)
Sterling et al., 2001 Y Y N Y Y N Y N N Y Y 6/10(high)
Perry and Green 2008 Y Y Y Y Y N Y Y N Y Y 8/10 (high)
Jowsey and Perry 2010 Y Y N Y Y N Y Y N Y Y 7/10 (high)

further articles. Searching the reference lists of key articles yielded
a further two articles (Petersen et al., 1993; McGuiness et al., 1997)
that were eligible for inclusion, and were not captured in the
electronic search.
3.2. Study characteristics
Five studies were of crossover design, on a healthy population,
that compared the intervention to both a placebo and a control
condition. Just one study was conducted on a patient population
(Sterling et al., 2001). Five of the seven studies included in this
review applied spinal mobilization to the cervical spine (Petersen
et al., 1993; Chiu and Wright, 1996; McGuiness et al., 1997;
Vincenzino et al., 1998; Sterling et al., 2001), one to the thoracic
spine (Jowsey and Perry, 2010), and one applied the mobilisation to
the lumbar spine (Perry and Green, 2008). All studies measured
changes in sympathetic output during and/or immediately
following each intervention using sympathetic outcome measures.
See Table 1 for a comprehensive summary of the data extracted and
the outcome measures used.
3.3. Synthesis of results
All studies ranked high on the PEDro rating scale, and are
detailed in Table 2. Six of the seven studies reviewed did not pro-
vide adequate explanations of allocation concealment. Therefore, a
regarding the risk of bias that this procedure might have introduced
could not be reached. Furthermore, the risk of attrition bias, and
random sequence generation bias, could not be assessed from the
information provided, in five and four of the studies respectively.
Refer to Table 3 for a breakdown of the RoB judgements.
Primary data was not available to complete a meta-analysis; one
corresponding author replied to say the data was no longer avail-
able and the other corresponding author did not respond to the
email. Overall, best-evidence synthesis indicated that there was
strong evidence for statistically significant changes in SC, RR, HR,
and BP among the healthy population, following spinal mobi-
lisation (Petersen et al., 1993; McGuiness et al., 1997; Vicenzino
et al., 1998; Perry and Green, 2008; Jowsey and Perry, 2010).
Limited evidence for significant changes in SC and ST among the
symptomatic population was established (Sterling et al., 2001). All
changes were excitatory in nature (i.e. there was an increase in RR,
HR, BP and SC, and a decrease in ST following spinal mobilization,
compared to controls and placebo intervention), indicating sym-
pathetic up-regulation in both the healthy and symptomatic pop-
ulation. This was the same whether the mobilizations were applied
to the cervical, thoracic, or lumbar spine.
3.4. Additional information yielded from individual studies
One study Chiu and Wright (1996) compared the effects of
different rates of mobilization on sympathetic outflow rather than
comparing mobilization to placebo and control. These authors
found that a higher rate of mobilization (2 Hz) led to significant
increase in SC compared to a lower rate (0.5 Hz), and to a control
condition. No significant differences in skin temperature were
identified between the two intervention groups and the control
group.
One study Perry and Green (2008) found that a unilaterally
applied posterior-anterior mobilisation at 2 Hz to the left L4/5
zygopophyseal joint results in side-specific peripheral SNS changes
(increase in skin conductance) in the lower limbs compared to
placebo and control.
4. Discussion
The primary aim of this review was to evaluate the literature
pertaining to the effects of spinal mobilizations on SNS outcome
measures, in both healthy and symptomatic populations, irre-
spective of segmental level. The second aim was to establish the
level of evidence for a change in sympathetic outcome measures.
Each of the high-quality RCTs included in this review established
a statistically significant change, consistent with sympathetic
excitation, in a variety of sympathetic outcome measures. These
changes were observed following spinal mobilizations, and were
compared to placebo and/or control interventions. Therefore, there

Table 3
Risk of bias judgements.

Authors Risk of bias

Random sequence Allocation Performance Detection Attrition Reporting Other

generation bias concealment bias bias bias bias bias bias

Petersen et al., 1993 L ? L ? ? L L

Chiu and Wright 1996
McGuiness et al., 1997
Vicenzino et al., 1998
Sterling et al., 2001
Perry and Green 2008
Jowsey and Perry 2010
? ? L L ? L L
? ? L L ? L L
? ? L L ? L L
L ? L L ? L L
L L L L L L L
? ? L L L L L

L ¼ Low risk bias, ? ¼ Unclear risk bias, H ¼ High risk bias.

 L. Kingston et al. / Manual Therapy 19 (2014) 281e287
is compelling evidence that spinal mobilizations result in an in-
crease in sympathetic activity, irrespective of the segment mobi-
lized. In contrast to the findings of the current review, a recent
study (Welch and Boone, 2008) investigated the sympathetic
response of the cervical and thoracic spine, following HVLA thrust
manipulations on forty volunteers. Manipulations of cervical spine
in Welch and Boone’s (2008) study resulted in a sympathetic
inhibitory response; while manipulations of the thoracic spine
elicited a sympathetic excitatory response. The authors concluded
that the results provided evidence for a segmental bias. However,
this review found a consistent trend towards sympathetic excita-
tion, irrespective of the region of the spine that received the
mobilization. This may represent a different response of the SNS to
spinal mobilizations compared to HVLA thrust manipulations.
However, the authors feel that this is unlikely, due to insufficient
reporting on the study by Welch and Boone (2008), which means
that the study cannot be repeated. Overall there seems to be poor
support from high-quality RCTs for the theory of a segmental bias.
This review revealed convincing evidence that the sympathetic
response to spinal mobilizations is excitatory in nature, irrespective
of the level of the spine mobilized.
4.1. Context of this research
Undoubtedly, the current findings are of significant interest to
all manual therapists. The studies included in this review provide
compelling evidence that spinal mobilizations elicit sympathetic
excitation. To establish the clinical relevance of these findings
they will be examined in the context of pain modulating
theories.
Sympathetic excitation and concurrent hypoalgesia is postu-
lated to be mediated via the dPAG in humans (Sterling et al., 2001;
Evans, 2002), through neural descending pathways. It is speculated
that mobilization of a spinal segment stimulates receptors present
in joints, capsules, tendons and connective tissues, which are
capable of directly or indirectly activating dPAG mechanisms
(Pickar, 2002; Schmid et al., 2008). Results from studies in this
systematic review have consistently demonstrated increases in
sympathetic activity, such as HR and SC, together with diminished
pressure-pain thresholds and improved motor function (Petersen
et al., 1993; McGuiness et al., 1997; Vicenzino et al., 1998; Sterling
et al., 2001) consistent with dPAG-mediated effects (Kuraishi
et al., 1991; Wright, 1995).
Another indicator of a multi-system response identified by
studies in this review is peripheral vasoconstriction. This is
demonstrated by a significant increase in BP (McGuiness et al.,
1997; Vicenzino et al., 1998) together with a significant
decrease in the skin temperature of peripheral limbs (Petersen
et al., 1993; Chiu and Wright, 1996; Sterling et al., 2001). Pe-
ripheral vascular control, which directly influences BP, is modu-
lated by the dPAG (Carrive, 1993). Considering the above
observations, it could be assumed that sympatho-excitation is a
centrally evoked response, likely to be modulated at least in part,
through dPAG pathways.
It is hypothesized that direct stimulation of the sympathetic
ganglia by mobilization of the vertebrae, is a possible mechanism
for the sympathetic response (Evans, 2002). The middle and
inferior cervical ganglia, which are adjacent to C6 and C7
respectively, have postganglionic axons that project to the heart
(Schmid et al., 2008). A number of authors in this review (Petersen
et al., 1993; Chiu and Wright, 1996; McGuiness et al., 1997;
Vicenzino et al., 1998; Sterling et al., 2001) applied spinal mobi-
lizations to the level of C5/6, potentially activating the adjacent
ganglia, which may account for the increase in HR observed
(Schmid et al., 2008). Many authors have cited the potential
285
stimulation of sympathetic fibres through spinal mobilizations
(Sterling et al., 2001; Evans, 2002), as a legitimate source of
sympathetic excitation. After all, the sympathetic chain and
accompanying ganglia, extend from the upper cervical vertebrae
down to the coccyx (Palastanga et al., 2006). A mobilization to a
vertebral body in any region of the spine could stimulate local
sympathetic fibres, side specific responses identified in two
studies (Perry and Green, 2008; Jowsey and Perry, 2010) provides
some support for this idea.
Finally, there is some speculation that joint oscillation may
stimulate spinal reflex pathways (Dishman and Bulbulian, 2000;
Jowsey and Perry, 2010). Interestingly, the application of an oscil-
latory technique is common to all studies in this review. In each
study, the oscillatory technique resulted in statistically significant
changes in sympathetic outcomes compared to a placebo and/or
control. Further to this, recent research (Moulson and Watson,
2006; Moutzouri et al., 2012) that investigated the effects of a
sustained glide applied to C5/6 and L4, respectively, demonstrated
no significant change to SC between intervention and control
conditions, during the treatment period. Thus supporting the the-
ory that it is the oscillatory component of the technique that is
central to generating the response observed (Jowsey and Perry,
2010).
4.2. Limitations of this review
One of the main limitations in scoring the studies for this review
was the inflexibility of the PEDro rating criteria. All studies were
systematically under-rated for criteria numbers six and nine of the
PEDro rating scale. These criteria pertain to blinding of the therapist
and either an intention to treat analysis or explicit confirmation
that all participants received conditions as allocated. The design of
these studies did not permit blinding of the therapists. The SNS
responses are automatic in nature, and were electronically
measured in each study. Whether or not blinding of the therapist or
the assessor could affect the internal validity in this instance is
debatable.
Five of the seven high quality trials applied spinal mobiliza-
tions to the cervical spine (Petersen et al., 1993; Chiu and Wright,
1996; McGuiness et al., 1997; Vicenzino et al., 1998; Sterling et al.,
2001), therefore only two studies (Perry and Green, 2008; Jowsey
and Perry, 2010) in this review contributed to the finding about
an overall excitatory response regardless of the level of the spine.
Only one study (Sterling et al., 2001) investigated changes in
sympathetic outcome measures in a symptomatic population,
diluting the level of evidence that could be established for this
sub-group.
Another limitation of this review is that only English language
studies were included. There is evidence that English language
studies are more likely to be positive therefore potentially
introducing a language bias (Egger et al., 1997). Also studies were
restricted to those in published format. Publication bias may
have been introduced. There is evidence to suggest that pub-
lished studies are more likely to be positive (Easterbrook et al.,
1991).
4.3. Clinical implications and future research
Studies considered in this review have shown there could be
potential to treat distal pain, more proximally. This is due to the
connection between sympathetic excitation and pain modulation,
as discussed in the literature (Petersen et al., 1993; Sterling et al.,
2001; Pickar, 2002). In instances of acute injury, or in the pres-
ence of painful inflammation of the target area, it would be useful
to treat centrally, away from the target area. According to the
286 L. Kingston et al. / Manual Therapy 19 (2014) 281e287
results of this review, it is likely that the response of the SNS would
be the same (i.e. sympathetic excitation), regardless of the level of
the spine that was mobilized. This phenomenon of SNS excitation
following spinal mobilization is significant, and has been demon-
strated to occur concurrently with mechanical nociceptive hypo-
algesia in a non-segmental pattern (Vicenzino et al., 1994, 1996;
Sterling et al., 2001).
Previous high-quality RCTs have focused on the response of the
SNS among healthy volunteers. Future studies that established a
consistent response among the symptomatic population would
directly influence the clinical applicability of this technique. These
trials have also focused primarily on the implications of increased
SNS activity in terms of its endogenous analgesic effects, through
dPAG-mediated pathways (Evans, 2002). Although this is of great
importance, other effects of increased SNS activity that may have an
impact on pain perception, such as vasoregulation, should also be
investigated in future studies. Vasoregulation systems are respon-
sible for vasoconstriction and vasodilation; measures of these
include the reactive hyperaemic response (as an index of the
resistance of artery endothelial function), venoarteriolar and
venarteriolar-myogenic reflexes (Dayon et al., 2008).
A natural progression from spinal mobilizations is MWM’s
and HVLA thrust manipulation (Maitland et al., 2001). Debate
exists surrounding their influence on the SNS (Harris and
Wagnon, 1987; Welch and Boone, 2008). Few high-quality trials
investigating these effects are available, making it difficult to
form a conclusion. Therefore, more high-quality, reproducible
trials, investigating the effects of HVLA thrust manipulations on
SNS activity are required.
5. Conclusion
All studies included in this review were deemed to be of high-
quality, in accordance with the PEDro rating scale. Each study
demonstrated SNS excitation, following spinal mobilization.
Among the healthy population, there is strong evidence for changes
in ST, SC, RR, HR and BP, consistent with sympathetic excitation.
Only one study, which qualified for inclusion in this review,
investigated changes in a symptomatic population. Therefore, the
level of evidence for changes in SC and ST among the patient
population is limited. More studies investigating sympathetic ac-
tivity following spinal mobilizations in a symptomatic population
are necessary. In the clinical context, this has important implica-
tions as sympathetic excitation occurs concurrently with
hypoalgesia.
Appendix I
Database(s): Ovid MEDLINE(R) 1946 to present with daily update search strategy
Number MeSH heading/Key word
1 Manipulation, spinal
2 Limit 1 to English language ad humans
3 Sympathetic nervous system/or vasomotor system/
4 Limit 3 to (English language and humans)
5 Spinal mob*.mp.
6 Limit 5 to (English language and humans)
7 2 and 4
8 Limit 7 to randomized controlled trial
9 4 and 6
10 Limit 9 to randomized controlled trial
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