Sympathetic cervical spondylosis (SCS) refers to the manifestation of cervical spondylosis accompanied by sympathetic symptoms, such as panic and palpitations, chest tightness, dizziness and nausea, in addition to the typical symptoms of cervical spondylosis (1, 2). The manifestation of these symptoms is typically reported by patients diagnosed with cervical spondylosis (CS), and there is considerable heterogeneity in the presentation of symptoms among individuals affected. Furthermore, SCS is subjective in nature, in contrast to CS, which is objective and quantifiable (3). Consequently, the diagnosis and treatment of SCS remain the subject of considerable controversy (4). The nomenclature and medical terminology for SCS are therefore subject to variation in the literature. Some authors refer to it as “posterior cervical sympathetic syndrome” or “Barré-Liéou syndrome” (5), some scholars call it “cervical vertigo” (6) or “cervical angina” (7).

In recent years, there has been an observable acceleration in the rhythm of work and life in general. This phenomenon has coincided with a notable increase in the prevalence of “low-head people,” which has resulted in a corresponding increase in the incidence of cervical spondylosis, particularly among younger people. As with CS, SCS can lead to severe morbidity, but there is frequently an absence of clinician attention, which can be problematic for patients and have a severely deleterious effect on their quality of life (3, 8). Another epidemiological feature of SCS is that it is often not diagnosed or misdiagnosed. The broad spectrum of symptoms, which affect multiple systems and organs, results in patients consulting a wide range of medical specialties, including gastroenterology, neurology, cardiovascular medicine, and otolaryngology, and the absence of a definitive diagnosis often results in inadequate treatment, leading to patient dissatisfaction (9). Clinical studies have shown that approximately 49.1% of patients with cervical spondylosis have depression and anxiety, patients with anxiety and depression have longer-lasting pain and more severe symptoms, and when the treatment effect is not obvious, it further aggravates the patient’s psychological burden, resulting in a vicious cycle of the disease (10, 11). SCS is more complex and is not taken seriously by clinicians; coupled with the lack of obvious treatment effects, patients tend to be more prone to adverse emotional and psychological reactions. The intricacy of the disease’s manifestations profoundly impacts patients’ physical and mental well-being and quality of life, thereby underscoring the imperative for effective and safe therapeutic interventions, which are pivotal health care concerns on a global scale.

The biomechanical equilibrium of the cervical spine is maintained by static and dynamic systems: the static system consists of adjacent vertebrae and their intervertebral discs, joints, ligaments, etc., which play important roles in stabilizing the cervical spine and supporting the skull; the dynamic system is mainly the cervical musculature, collectively referred to as the cervical muscles, which is the primitive driving force of the activities of the cervical spine and is the necessary condition for maintaining the position of the head and neck (12). As a result, maintaining a poor posture for a long period of time leads to neck muscle groups in high-load exercise, excessive muscle tension and stiffness, decreased muscle oxidative metabolism capacity, increased lactic acid levels, pathological changes in the neck muscle groups, disequilibrium of the static system, and the acceleration of soreness and stiffness in the neck muscles (13–15). Spasticity and laxity of tension in the neck muscle groups lead to instability of the intervertebral joints, causing disequilibrium in the dynamic system (13). Therefore, adjusting the muscles and joints, reconstructing the dynamic equilibrium of the cervical spine, and improving the static equilibrium compensation to restore the dynamic equilibrium of the cervical spine can be considered the optimal direction and the best choice for the treatment of SCS at present.

Several studies have shown that physiotherapy and manipulation can alleviate symptoms associated with the sympathetic nervous system (16–18). Chinese spine manipulation (also called “Chinese osteopathy”) is an important part of Chinese massage techniques. The categorization of manipulative techniques is typically dependent on their characteristics and mechanisms of application. Typically, such techniques are divided into three categories: rotation, traction, or a combination of both (19). Cervical rotational manipulation is a prevalent treatment modality for neck pain, with evidence suggesting its efficacy in autonomic function and sensory systems, as well as in pain reduction (20, 21). This approach is endorsed by clinical guidelines (22) and is widely accepted and used as complementary and alternative medicine (23–25). Chinese cervical spine manipulation currently refers to traditional oblique cervical spine manipulation, which involves resetting the entire cervical spine. In fact, oblique cervical spine manipulation has been shown to increase the risk of intervertebral disc and facet joint damage compared with rotational cervical spine manipulation (26). The cervical spine lesions are multivariable and multisegmental, so traditional oblique cervical spine manipulation does not target the lesion segments for treatment. Compared with the conventional cervical oblique wrenching technique, the cervical fixed-point rotation manipulations employed in this study accurately identify diseased cervical segments through a combination of physical examination and imaging techniques. Then, through manipulations, targeted adjustments are made, thereby ensuring a more precise realignment of the biomechanical equilibrium of the cervical spine, both internally and externally.

Heart rate variability (HRV) is a frequently employed metric for assessing autonomic nervous system (ANS) function, and an individual’s responsiveness to HRV-related parameters can often be indicative of their ANS function in maintaining cardiovascular homeostasis (27). The ANS is a neural control system that controls many aspects of respiration, heart rate, and digestion; the sympathetic nervous system (SNS) is a branch of the ANS, and cardiac exogenous sympathetic nerves are mediated through the cervical and cervicothoracic nerves (28–30). Measurements of HRV therefore reflect the activity of the SNS and the parasympathetic nervous system (PNS) (27, 31). Sympathetic cervical spondylosis patients often suffer from symptoms such as chest tightness, panic, and palpitations due to sympathetic nerve stimulation. Currently, an objective and scientific basis for evaluating the efficacy of conservative sympathetic treatment is lacking, and HRV measurements reflect sympathetic nerve activity, which has the advantages of being noninvasive, quantitative, and reproducible; thus, HRV can be used as an indicator for evaluating sympathetic cervical spondylosis. There are more parameters and various measurement indices of the HRV, which include detection indices in the time domain, frequency domain and nonlinear analysis. Among them, time domain and frequency domain analyses are most commonly used. The HRV was generally assessed via the standard deviation of the R–R intervals (SDNN) based on previous studies, high-frequency (HF) values with the root mean square of the neighboring R–R interval differences (RMSSD) and 50 milliseconds as a percentage of the total number of heartbeats (pNN50) as markers of parasympathetic activity (32). HRV time-domain analysis was performed numerically with R-R intervals, and the standard deviation of the mean of the R-R intervals per 5-min segment (SDANN) reflected changes in heart rate, which is a sensitive indicator of sympathetic function but is also influenced by the vagus nerve. Frequency domain analysis is based on low-frequency (LF) and high-frequency (HF) detection, and the ratio of HF/LF reflects the balance between vagal and sympathetic nerves. Time domain analysis can directly reflect the height of the HRV, and a decrease in the HRV suggests an increase in sympathetic nerve tone. Frequency domain analysis reflects the relative tension of the sympathetic and parasympathetic nerves and the balance between them.

We reviewed the literature and reported reports of the use of Chinese medicine and acupuncture to explore the correlation between sympathetic cervical spondylosis and HRV, but no studies have analyzed the correlation between sympathetic cervical spondylosis, HRV and anxiety through Tui Na manipulation in China. We aimed to demonstrate that Tui Na manipulation can improve cardiovascular symptoms in patients with sympathetic cervical spondylosis, explore the correlation between HRV and sympathetic cervical spondylosis, alleviate anxiety, and improve the quality of life. Moreover, we hope these findings will confirm the safety and effectiveness of this therapy and facilitate its clinical promotion.

Symptoms such as palpitations and panic in SCS patients have been found to be the result of stimulation of sympathetic nerves in the posterior longitudinal ligament and intervertebral plexus (34, 35). Several studies have shown that the posterior longitudinal ligament is rich in sensory nerve fibers and is connected to the sympathetic nerves by synapses (18, 36, 37). When these sensory nerve fibers are stimulated, the excitability of the sympathetic fibers is enhanced (38, 39). The stimulation of sympathetic nerves has been demonstrated to result in the release of monoamine transmitters, such as NPY. These neurotransmitters modulate blood vessels and induce the release of substance P from sensory nerves, which in turn promotes the dilation of large arteries and further enhances stimulation (38, 40). As a consequence of these stimuli, the sympathetic nerves may trigger the relevant organ systems, thus engendering sympathetic symptoms, including dizziness, palpitations, and tinnitus (41). Consequently, the cervical sympathetic nerves exert a broad regulatory influence on the visceral organs (42). Given the intricacies inherent to SCS, coupled with the dearth of an unequivocal pharmacological resolution, massage therapy, an integral component of complementary and alternative medicine, is garnering heightened interest from those afflicted by SCS. This predilection stems from massage therapy’s safety profile, affordability, and accessibility, making it a viable therapeutic alternative.

Among the numerous cervical massage techniques, cervical rotational manipulation has garnered favorable feedback in the management of cervical spondylosis (20). As Moser et al. reported, cervical rotation manipulation has been demonstrated to reduce reverse blood flow and velocity within the vertebral artery (43). Guan et al. conducted a series of experiments on animals to ascertain the safety of cervical rotation manipulation (44). The results of these experiments demonstrated that this manipulation technique does not result in damage to blood cells, thus confirming its safety (44). With the application of biological finite element technology in the field of biomechanics, several scholars have found through computational modeling that cervical rotation manipulation changes the stress distribution around the cervical spine and improves the biomechanical equilibrium around the cervical spine (21).

Compared to other traditional cervical spine manipulation techniques, the cervical fixed-point rotation manipulation is highly targeted during operation, with a key feature being its “accuracy.” First, precise localization is essential. During this technique, the practitioner first performs a palpation to determine whether the pathological site is in the muscles (muscle bands) or the cervical spine (joint dislocation), and then confirms the dislocated joint based on imaging diagnostics. Secondly, the timing of the manipulation is precise. During the procedure, the cervical spine should be rotated to its maximum extent or moved to the “trigger point” where resistance is felt, at which point a controlled, slightly increased-amplitude, instantaneous manipulation is performed. Compared to traditional cervical rotation manipulation techniques, the cervical fixed-point rotation manipulation technique is more targeted and precise in addressing the affected cervical segments and muscles, has the effect of correcting joint dislocation, realigning anatomical structures, and relieving muscle spasms, resulting in clearer effects. Clinically, it is primarily used for cervical spondylosis with nerve compression, such as radicular cervical spondylosis and sympathetic cervical spondylosis.

Previous studies of cervical rotational manipulation did not explore the patient’s cervical spine lesion nodes for treatment and consider other systemic diseases, did not truly improve the patient’s symptoms, and mostly assessed the efficacy in the form of questionnaires, which lacked objective and scientific evaluation standards; however, HRV has the advantages of being accurate, noninvasive, simple to operate, and dynamically observable and can be used as an objective standard for evaluating the efficacy of treating patients with SCS. This study is the first to analyze the correlation between heart rate variability and the SCS by means of Tui Na manipulation and to propose an objective and reliable evaluation index.

Despite the proven effectiveness of cervical rotational manipulation in the treatment of cervical spondylosis, its safety remains a concern. Many people are concerned that improper manipulation may cause more damage to the blood vessels and nerves in the neck. Because of the requirements for the angle and strength of the manipulation, more clinical protocols are needed to ensure the safety of the manipulation and to better serve the clinic. In this study, for the first time, the cervical spine was adjusted segmentally and locally through cervical fixed-point rotational manipulation, which was more targeted to the cervical spine of the diseased segments, and manipulative operations and strengths were described during the study to ensure that the manipulative operations were carried out within the safety limits.

However, there are still limitations in this study. Although HRV can be used as an objective criterion for assessing the efficacy of SCS patients, there are episodes and flattening of symptoms in SCS patients, and the assessment is more accurate only when the patient is in the episodic phase with symptoms such as panic attacks and palpitations, so there is a limitation on the time point of assessment. In addition, there are few clinical reports on the correlation between SCS symptoms and HRV, and the reliability of HRV assessment is controversial. Therefore, more attention should be given to the validity and reliability of the HRV in the assessment of efficacy in SCS patients in future clinical studies. Greater emphasis must be placed on the necessity of standardizing and assessing the safety of cervical rotation manipulation. In the future, the employment of biological finite element analysis will facilitate the calculation of more precise manipulation angles and force parameters; this, in turn, should result in a more effective promotion of the cervical method of manipulation, leading to substantial improvements in the quality of life of SCS patients and, by extension, the overall health of the population.

The aim of the present study was to assess the clinical efficacy of cervical fixed-point rotational manipulation in the treatment of SCS using HRV-related parameters, the NDI scale, the NPQ scale and the HAMA scale. Furthermore, this study analyzed the correlation between heart rate variability and the SCS. The results of this study will be used to determine the efficacy of cervical fixed-point rotational manipulation for the treatment of SCS and to examine whether HRV can be used as an evidence-based method for assessing SCS. These results may change the approach to conservative treatment for patients with SCS and enhance patient quality of life.