Research Review By Dr. Demetry Assimakopoulos©


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Date Posted:

July 2016

Study Title:

Upper Cervical and Upper Thoracic Manipulation vs. Mobilization and Exercise in Patients with Cervicogenic Headache: A Multi-Center Randomized Clinical Trial


Dunning JR, Butts, B, Mourad F et al.

Author's Affiliations:

Alabama Physical Therapy & Acupuncture, Montgomery AL, USA; Nova Southeastern University, Ft. Lauderdale FL, USA; Univesrsidad Rey, Juan Carlo Alcornoc, Spain; Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcon, Spain; Long Island University, Brooklyn, NY, USA; Department of Physical Therapy, Franklyn Pierce University, Manchester, NH, USA.

Publication Information:

BMC Musculoskeletal Disorders 2016; 17: 64-76.

Background Information:

Cervicogenic headaches (CGH) are defined by the presence of unilateral headache pain that is re-created by applying pressure over the ipsilateral upper cervical spinal structures. Patients with CGH commonly exhibit limited cervical spine range of motion, and worsening headache after neck movement or prolonged postures (1, 2). A CGH episode is often, but not always, accompanied by neck pain (3).

The prevalence of CGH is approximately 20% of the total headache population (4, 5). Interestingly, the prevalence increases to as high as 53% in patients suffering from headache after a whiplash injury (5).

Bronfort et al. (6) reported that spinal manipulation and mobilization often lead to positive outcomes in this population. However, they failed to determine whether cervical spine manipulation resulted in superior outcomes to mobilization. Thus, the authors of this randomized controlled trial sought to determine if spinal manipulation provides superior outcomes to mobilization for the management of CGH.

Pertinent Results:

A total of 110 patients were included. Subjects were randomly assigned to either an upper cervical/upper thoracic spine manipulation (SMT) group or to a group who received a combination of upper cervical/upper thoracic spine mobilization and exercise (mob/ex). Six-to-eight treatment sessions were provided. Treatment was directed mainly to the C1-C2 and T1-T2 spinal levels. The average number of completed treatment sessions was not significantly different between the two groups (7.17 treatments for the SMT group, and 6.90 treatments for the mob/ex group). There was a 97% follow-up rate.

Both groups demonstrated clinical improvement. However, the SMT group demonstrated statistically significant greater improvements in neck pain intensity, weekly headache frequency, headache duration and disability at the 1-week, 4-week and 3-month follow-up periods. There was a significant between-group percentage change in headache intensity (36.58%) and disability (35.56%) from baseline to 3-month follow-up in favor of SMT. The SMT group also reported more dramatic changes in self-perceived overall improvement, and significantly less medication usage at all follow-up periods. No major adverse events were reported in either group.

Clinical Application & Conclusions:

Upper cervical and upper thoracic SMT treatment resulted in greater improvement in cervicogenic headache (CGH) intensity, disability, headache frequency, headache duration, perceived improvement and medication intake than a combination of spinal mobilization and exercise at 3-month follow-up.

The results of this study, however, require a bit of perspective: while only the SMT group showed statistically significant changes in headache features, BOTH GROUPS demonstrated clinically significant changes in all of the above-mentioned variables. These results DO NOT mean that mobilization does not work. Rather, they provide the message that if SMT cannot be used for some reason (i.e. patient or doctor preference), then using mobilization and exercise as an alternative to manipulation can still provide clinically meaningful results.

We as clinicians might utilize a variable combination of spinal mobilization, manipulation and rehabilitation to treat patients suffering from CGH. You might be able to elicit a positive change in your patients’ headache symptoms by beginning your treatment plan with mobilization and exercise, and later moving on to using a full spinal manipulation when the patient feels comfortable and ready to receive that therapy. Either way, you are providing the patient with a beneficial and evidence-based treatment for CGH. Remember, you must pick the right treatment, for the right patient, at the right time!

Study Methods:

This was a multi-centered, randomized control trial.

Subject Inclusion Criteria (3):
  • Age 18-65
  • Unilateral headache, without side-shift, beginning in the occipital region, with eventual referral to the ipsilateral oculo-tempo-frontal region
  • Pain triggered by neck movement and/or sustained awkward neck positions
  • ≤ 32° of passive right or left rotation during the Flexion-Rotation Test (CROM)
  • Pain recreated by digital pressure over C0-C3
  • Moderate-to-severe, non-throbbing and non-lancinating headache pain
  • Headache frequency of at least 1 CGH episode per week, for a minimum of 3 months
  • Minimum headache intensity pain score of 2/10
  • Minimum disability score of ≥ 20% (i.e. ≥ 10 points on the NDI)
  • Confirmatory diagnostic anaesthetic block was not required
Subject Exclusion Criteria:
  • Other primary headache (i.e. TTH, migraine, etc.) or bilateral headache
  • Presence of red flags
  • ≥ 2 positive neurological signs, consistent with nerve root compression
  • Diagnosis of cervical spinal stenosis
  • Bilateral upper extremity symptoms
  • Evidence of CNS involvement
  • History of whiplash injury within the previous 6 weeks
  • Prior surgery to the head/neck
  • Undergone previous treatment for head and/or neck pain from any practitioner within the previous month
  • Undergone physical therapy or chiropractic treatment for head/neck pain within the previous 3 months
  • Had pending legal action regarding the headache and/or neck pain
Twelve physical therapists administered treatment. They had an average 10.3 years of clinical experience. Each therapist completed a post-graduate certification program in manual techniques, and completed a 4-hour training session in an attempt to ensure treatment standardization.

Each patient underwent a thorough history and physical examination at baseline. They also completed the Neck Pain Medical Screening Questionnaire, Neck Pain Rating Scale (0-10 headache intensity), Global Rating of Change Questionnaire (GRC) and the Neck Disability Index (NDI). They also provided information on weekly headache frequency, headache duration (hours) and weekly medication intake. The physical examination included, but was not limited to, passive right and left rotation CROM using the Cervical Flexion-Rotation Test. The primary outcome measure was the patient’s headache intensity at 1-week, 1-month and 3-months following the initial treatment session.

Patients were randomized to either the SMT or mobilization/exercise group, using a computer-generated, randomized number table. Patients were asked to not discuss the particular treatment procedure received with the examining therapist. It was not possible to blind the patients or the treating therapists.

Each patient underwent 6-8 treatment sessions of high-velocity, low-amplitude spinal manipulation (SMT) or a combination of mobilization and exercise (mob/ex).

The manipulation group underwent right and left C1-C2 and T1-2 joint manipulations on at least one occasion over the 6-8 treatment period. Therapists were also free to manipulate other cervical, thoracic or costo-vertebral levels at their discretion. SMT was performed with the patient lying supine. Mobilization, exercise and other modalities were not provided to this group.

Mobilizations were performed on the right and left C1-C2 and T1-2 articulations, on at least one of the 6-8 treatment sessions. During other treatment sessions, the therapists either repeated these mobilization techniques, or targeted other cervicothoracic or costovertebral areas, at their discretion. To avoid a ‘contact’ or ‘attention effect’, therapists were instructed to only mobilize one cervical segment (i.e. right and left) and one thoracic segment during each treatment session. The practitioners provided three 30-second bouts of prone, unilateral grade 4 posterior to anterior (P-A) mobilizations to the applied segment, as described by Maitland (7).

The mobilization group also received supine cranio-cervical flexion exercises, as previously described in Jull et al. (8, 9). For this, the patient was placed supine with their knees bent. Head position was standardized by ensuring that an imaginary line connecting the patient’s forehead and chin was parallel to the ground. An air-filled pressure biofeedback unit was placed in the suboccipital region, and pre-inflated to 20 mmHg (9). The patient was then asked to perform the cranio-cervical flexion action, and attempt to visually target pressures of 22, 24, 26, 28 and 30 mmHg from a resting baseline of 20 mmHg, and hold the position steady for 10 seconds. If substitution of the superficial flexors (SCM or anterior scalene muscles) or neck retraction was noticed before the completion of the 10 second isometric hold, it was regarded as a failure. The last successful target pressure was used to determine each patient’s exercise level, and the patient performed 3 sets of 10 isometric holds. The patients were additionally required to perform 10 minutes of progressive resistance exercises targeting the lower trapezius and serratus anterior (11).

Statistics & Outcome:
Descriptive statistics were compiled and calculated to summarize the data. Treatment effect on headache intensity and disability were examined with a 2x4 mixed-model ANOVA. Separate ANOVAs were performed for headache intensity and NDI. Independent t-test was used to determine the group differences in percentage change from baseline-to-3-month follow-up. Separate Mann-Whitney U tests were performed for headache frequency, GRC, headache duration and medication intake as dependant variables. Bonferroni correction was performed to explain the difference between-groups.

A successful outcome was categorized as a 2-point NPRS decrease in headache intensity. Numbers needed to treat and 95% CI were also calculated at the 3-month follow-up.

Study Strengths / Weaknesses:

  • Multi-centered nature of the study enhances generalizability to multiple populations.
  • Large population sample.
  • Standardization of manual therapy and rehabilitation was attempted, however therapists were free to treat spinal areas other than the upper cervical or upper thoracic regions – this would have ‘de-standardized’ the treatment a little (although there is nothing wrong with pragmatic treatment studies!).
  • While the benefits of spinal manipulation were maintained at 3 months, it is uncertain of the results would have been sustained in the long term.
  • Bilateral upper cervical and upper thoracic manipulations were used. It is uncertain if the results would have been similar if different manipulations had been utilized (i.e. seated, prone, etc).
  • Minor adverse events, such as worsening of symptoms, minor soreness, etc. were not measured (although no major adverse events were reported).
  • The mobilization group could only have received one cervical and one thoracic segment treated during a treatment session. Is it possible that the SMT group received a higher treatment volume?
  • There was no true control group.

Additional References:

  1. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol 2009; 8(10): 959–968.
  2. Sjaastad O, Fredriksen TA & Pfaffenrath V. Cervicogenic headache: diagnostic criteria. The Cervicogenic Headache International Study Group. Headache 1998; 38(6): 442–445.
  3. The International Classification of Headache Disorders: 3rd Edition. Cephalalgia 2013; 33(9): 629-808.
  4. Anthony M. Cervicogenic headache: prevalence and response to local steroid therapy. Clin Exp Rheumatol 2000; 18(2 Suppl 19): S59–S64.
  5. Nilsson N. The prevalence of cervicogenic headache in a random population sample of 20-59 year olds. Spine 1995; 20(17): 1884–1888.
  6. Bronfort G, Haas M, Evans R, Leininger B, Triano J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopath 2010; 18:3. 1-33.
  7. Maitland GD. Vertebral Manipulation. 5th ed. Oxford: Butterworth- Heinemann; 1986.
  8. Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002; 27(17): 1835–1843.
  9. Jull G. Deep cervical flexor muscle dysfunction in whiplash. J Musculoskeletal Pain 2000; 8: 143–154.