Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache

Effective teaching of manual skills to physiotherapy students: a randomised clinical trial

CONTEXT

To date, despite the relevance of manual skills laboratories in physiotherapy education, evidence on the effectiveness of different teaching methods is limited.

OBJECTIVES

Peyton's four-step and the 'See one, do one' approaches were compared for their effectiveness in teaching manual skills.

METHODS

A cluster randomised controlled trial was performed among final-year, right-handed physiotherapy students, without prior experience in manual therapy or skills laboratories. The manual technique of C1-C2 passive right rotation was taught by different experienced physiotherapist using Peyton's four-step approach (intervention group) and the 'See one, do one' approach (control group). Participants, teachers and assessors were blinded to the aims of the study. Primary outcomes were quality of performance at the end of the skills laboratories, and after 1 week and 1 month. Secondary outcomes were time required to teach, time required to perform the procedure and student satisfaction.

RESULTS

A total of 39 students were included in the study (21 in the intervention group and 18 in the control group). Their main characteristics were homogeneous at baseline. The intervention group showed better quality of performance in the short, medium and long terms (F_1,111  = 35.91, p < 0.001). Both groups demonstrated decreased quality of performance over time (F_2,111  = 12.91, p < 0.001). The intervention group reported significantly greater mean ± standard deviation satisfaction (4.31 ± 1.23) than the control group (4.03 ± 1.31) (p < 0.001). Although there was no significant difference between the two methods in the time required for teaching, the time required by the intervention group to perform the procedure was significantly lower immediately after the skills laboratories and over time (p < 0.001).

CONCLUSIONS

Peyton's four-step approach is more effective than the 'See one, do one' approach in skills laboratories aimed at developing physiotherapy student competence in C1-C2 passive mobilisation.

Effect of Mulligan Concept Lumbar SNAG on Chronic Nonspecific Low Back Pain

OBJECTIVE

The purpose of this study was to investigate the outcomes of adding lumbar sustained natural apophyseal glide (SNAG) to a conventional therapy program for chronic nonspecific low back pain (LBP).

METHODS

Forty-two participants with chronic nonspecific LBP were randomly divided into 2 groups. The study group (aged 27.1 ± 8.3, 20 men, 3 women) received a conventional physical therapy program consisted of stretching and strengthening exercises plus SNAG (based on the Mulligan concept) on the affected lumbar levels, and the control group (aged 28.9 ± 7.7, 13 men, 6 women) received the same conventional program without SNAG 3 times per week for 1 month. Outcome measures were repositioning error (the primary outcome), pain, and function measured by an isokinetic dynamometer, visual analog scale, and the Oswestry Disability Index. Measurements were recorded before and after the end of the treatment period.

RESULTS

The comparison between pretreatment and posttreatment test scores indicated that both study and control groups had significant improvement in all dependent variables (P > .001). However, adding SNAG to the conventional program resulted in higher improvement in terms of repositioning error, pain, and function (P = .02, .002, .008) respectively.

CONCLUSIONS

This preliminary study indicated improvement in both groups. Adding SNAG to conventional programs in the treatment of chronic nonspecific LBP may result in greater improvement of repositioning error, pain reduction, and improved function.

The influence of home exercise programs for patients with non-specific or specific neck pain: a systematic review of the literature

STUDY DESIGN

Systematic review of randomized controlled trials (RCT).

OBJECTIVES

To examine the effects of a therapeutic home exercise program (HEP) for patients with neck pain (associated with whiplash, non-specific, or specific neck pain, with or without radiculopathy, or cervicogenic headache) on pain, function, and disability. Our secondary aim was to describe the design, dosage, and adherence of the prescribed HEPs.

BACKGROUND

Neck pain is a leading cause of disability that affects 22-70% of the population. Different techniques have been found effective for the treatment of neck pain. However, there is conflicting evidence to support the role of a therapeutic HEP to reduce pain, disability, and improve function and quality of life (QOL).

METHODS

A systematic review in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement for reporting systematic reviews. The full-text review utilized the Maastricht-Amsterdam assessment tool to assess quality among RCTs.

RESULTS

A total of 1927 subjects included within seven full-text articles met our specific search strategy. It was found that HEPs with a focus on strength and endurance-training exercises, as well as self- mobilization, have a positive effect when used in combination with other conservative treatments or alone.

CONCLUSIONS

Home exercise programs that utilize either self-mobilizations within an augmented HEP to address specific spinal levels, or strengthening, and/or endurance exercise are effective at reducing neck pain, function, and disability and improving QOL. The benefit of HEPs in combination with other conservative interventions yields some benefit with a range of effect sizes.

Exercises for mechanical neck disorders: A Cochrane review update

BACKGROUND

Neck pain (NP) is disabling and costly.

OBJECTIVES

To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality of life (QoL) and global perceived effect (GPE) in adults with NP.

METHODS

We searched computerised databases up to May 2014 for randomized controlled trials (RCTs) comparing exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radiculopathy. Two reviewers independently conducted selection, data abstraction and assessed risk of bias. Meta-analyses were performed to establish pooled standardised mean differences (SMDp). The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body of evidence.

MAIN RESULTS

The following exercises (27 trials) were supported by 'Moderate GRADE' evidence: For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp -0.45 [95%CI: -0.72 to -0.18]) and function improvement; 4) cervico-scapulothoracic strengthening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp -14.90 [95%CI: -22.40 to -7.39]). 5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST). For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure biofeedback for small/moderate improvement of pain, function and GPE (IP/LT).

AUTHORS' CONCLUSIONS

Specific strengthening exercises of the neck, scapulothoracic and shoulder for chronic NP and chronic CGH are beneficial. Future research should explore optimal dosage.

Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Headache: Any Scientific Evidence?

Cervical mobilization and manipulation are frequently used to treat patients diagnosed with cervicogenic headache (CEH); however, there is conflicting evidence on the efficacy of these manual therapy techniques. The purpose of this review is to investigate the effects of cervical mobilization and manipulation on pain intensity and headache frequency, compared to traditional physical therapy interventions in patients diagnosed with CEH. A total of 66 relevant studies were originally identified through a review of the literature, and the 25 most suitable articles were fully evaluated via a careful review of the text. Ultimately, 10 studies met the inclusion criteria: (1) randomized controlled trial (RCT) or open RCT; the study contained at least two separate groups of subjects that were randomly assigned either to a cervical spine mobilization or manipulation or a group that served as a comparison; (2) subjects must have had a diagnosis of CEH; (3) the treatment group received either spinal mobilization or spinal manipulation, while the control group received another physical therapy intervention or placebo control; and (4) the study included headache pain and frequency as outcome measurements. Seven of the 10 studies had statistically significant findings that subjects who received mobilization or manipulation interventions experienced improved outcomes or reported fewer symptoms than control subjects. These results suggest that mobilization or manipulation of the cervical spine may be beneficial for individuals who suffer from CEH, although heterogeneity of the studies makes it difficult to generalize the findings.

Manual Therapy and Exercise for a Patient With Neck-Tongue Syndrome: A Case Report

STUDY DESIGN

Case report.

BACKGROUND

Neck-tongue syndrome (NTS) is defined as neck and/or head pain accompanied by ipsilateral dysesthesia of the tongue with sudden rotation of the head. Proposed causes include compression or irritation of the C2 nerve root as it courses behind the atlantoaxial joint or hypertrophy of the inferior oblique muscle. The primary purpose of this case report was to describe the conservative physical therapy treatment of a patient with uncomplicated NTS.

CASE DESCRIPTION

The patient was a 13-year-old girl who reported insidious onset of sharp pain in the neck, numbness/tingling of the ipsilateral tongue/face, and tinnitus with cervical rotation. Symptoms occurred several times a week for approximately 10 seconds. Examination revealed impaired function, increased forward head posture, decreased cervical range of motion, and positive neurodynamic assessment. The patient's treatment included manual therapy and exercise for postural stabilization.

OUTCOMES

Following 8 visits, pain of the neck and tongue numbness had resolved. Score on the Patient-Specific Functional Scale (PSFS), cervical range of motion, and posture had also improved. At the 22-month follow-up, infrequent, momentary symptoms in the neck and dysesthesia of the tongue were reported. The PSFS remained the same. Objective measures were normal.

DISCUSSION

This case report describes the physical therapy management of an individual with NTS. The management strategy followed a protocol similar to that used for cervicogenic headaches, due to the involvement of the upper cervical spine with both NTS and cervicogenic headache and the lack of evidence for the treatment of NTS. Level of Evidence Therapy, level 4.

Ankle-Dorsiflexion Range of Motion After Ankle Self-Stretching Using a Strap

CONTEXT

A variety of ankle self-stretching exercises have been recommended to improve ankle-dorsiflexion range of motion (DFROM) in individuals with limited ankle dorsiflexion. A strap can be applied to stabilize the talus and facilitate anterior glide of the distal tibia at the talocrural joint during ankle self-stretching exercises. Novel ankle self-stretching using a strap (SSS) may be a useful method of improving ankle DFROM.

OBJECTIVE

To compare the effects of 2 ankle-stretching techniques (static stretching versus SSS) on ankle DFROM.

DESIGN

Randomized controlled clinical trial.

SETTING

University research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Thirty-two participants with limited active dorsiflexion (<20°) while sitting (14 women and 18 men) were recruited.

MAIN OUTCOME MEASURE(S)

The participants performed 2 ankle self-stretching techniques (static stretching and SSS) for 3 weeks. Active DFROM (ADFROM), passive DFROM (PDFROM), and the lunge angle were measured. An independent t test was used to compare the improvements in these values before and after the 2 stretching interventions. The level of statistical significance was set at α = .05.

RESULTS

Active DFROM and PDFROM were greater in both stretching groups after the 3-week interventions. However, ADFROM, PDFROM, and the lunge angle were greater in the SSS group than in the static-stretching group (P < .05).

CONCLUSIONS

Ankle SSS is recommended to improve ADFROM, PDFROM, and the lunge angle in individuals with limited DFROM.

The effect of manual therapy with augmentative exercises for neck pain: a randomised clinical trial

OBJECTIVES

To compare the effect of manual therapy (MT) and an augmentative exercise programme (AEP) versus MT and general neck range of motion (ROM) on functional outcomes for patients with neck pain. A secondary objective was to examine changes in self-report measures and quantitative sensory testing (QST) following MT and AEP.

METHODS

This was a randomised clinical trial. Seventy-two patients with neck pain were recruited. All patients received a single session of MT. Patients were randomly assigned to MT+AEP or MT+ROM. Clinical self-report outcome measures for disability and pain, and QST measures (pain and vibration thresholds) were collected at baseline, post MT treatment, at ∼48 hours, and at ∼96 hours. Repeated measures ANOVA and MANOVA were used to analyse within and between-group effects for clinical and QST measures.

RESULTS

There were no between-group differences for disability, pain and QST measures. There was, however, a significant difference between groups for Global Rating of Change (GRoC) scores (P = 0.037). Patients in both groups showed improvements in pain, disability and trapezius pressure-pain threshold (PPT) (all P < 0.001).

DISCUSSION

Augmentative exercise programme does not significantly improve disability, pain or QST measures in patients with chronic neck pain although it may enhance their GRoC scores. Over a 96-hour period, patients benefitted from MT plus exercise whether the exercise was general or specific.

Treatment of Cervicogenic Headache: New Insights on the Treatment of Pain in the Neck

This manuscript served as a companion piece for the original article “Pregabalin for the Management of Cervicogenic Headache; A Double Blind Study” by Guy P. Boudreau and Luc Marchand, which was published in the September 2014 issue ofThe Canadian Journal of Neurological Sciences.1

3D motion reliability of occipital condylar glide testing: From concept to kinematics evidence

BACKGROUND

To date, segmental data analyzing kinematics of occipital condylar testing or mobilization is lacking.

OBJECTIVES

The objective of this study was to assess occipitoatlantal 3D motion components and to analyze inter- and intra-rater reliability during in vitro condylar glide test.

METHODS

To conduct this study, four fresh cadavers were included. Dissection was carried out to ensure technical clusters placement to skull, C1 and C2. During condylar glide test, bone motion data was computed using an optoelectronic system. The reliability of motion kinematics was assessed for three skilled practitioners performing two sessions of 3 trials on two days interval.

FINDINGS

During testing, average absolute motion ROM (±SD) were up to 4.1 ± 2.1°, 0.7 ± 1.3° and 10.3 ± 2.5° for occipitoatlantal lateral bending, axial rotation and flexion-extension, respectively. For position variation, magnitudes were 2.3 ± 1.8 mm, 1.1 ± 1.3 mm and 2.6 ± 0.8 mm for anteroposterior, cephalocaudal and mediolateral displacements. Concerning motion reliability, variation ranged from 0.6° to 3.4° and from 0.3 mm to 1.6 mm for angular displacement and condyle position variation, respectively. In general, good to excellent agreement was observed (ICC ranging from 0.728 to 0.978) for the same operator, while consistency was limited to lateral/side bending and lateral condyle displacement between operators, with respective ICCs of 0.800 and 0.955.

CONCLUSIONS

This study shows specific motion patterns involving extension and lateral bending of the occipitoatlantal level for anterior condylar glide test. In addition, condyle position variation demonstrated coupled components in forward and heterolateral directions. However, task seems not to be side specific. In general, reliability of 3D motion components showed good intra-operator agreement and limited inter-operator agreement.

Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis

AIM

We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH).

METHODS

We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality.

RESULTS

Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH ( ITALIC! p < 0.0001; mean reduction -1.11 on a 0-10 visual analog scale (VAS); 95% CI -1.64 to -0.57) and CGH ( ITALIC! p = 0.0002; mean reduction -2.52 on a 0-10 VAS; 95% CI -3.86 to -1.19) pain intensity, CGH frequency ( ITALIC! p < 0.00001; mean reduction -1.34 days per month; 95% CI -1.40 to -1.28), and migraine ( ITALIC! p = 0.0001; mean reduction -22.39 hours without relief; 95% CI -33.90 to -10.88) and CGH ( ITALIC! p < 0.00001; mean reduction -1.68 hours per day; 95% CI -2.09 to -1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity ( ITALIC! p < 0.00001; mean reduction -1.94 on a 0-10 VAS; 95% CI -2.61 to -1.27) and frequency ( ITALIC! p < 0.00001; mean reduction -9.07 days per month; 95% CI -9.52 to -8.62).

DISCUSSION

Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

Exercises for mechanical neck disorders

BACKGROUND

Neck pain is common, disabling and costly. Exercise is one treatment approach.

OBJECTIVES

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

MAIN RESULTS

Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

AUTHORS' CONCLUSIONS

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

Physical therapy treatment in patients suffering from cervicogenic somatic tinnitus: study protocol for a randomized controlled trial

BACKGROUND

Tinnitus occurs in a large part of the general population with prevalences ranging from 10% to 15% in an adult population. One subtype is cervicogenic somatic tinnitus, arising from cervical spine dysfunctions, justifying cervical spine assessment and treatment. This study aims to investigate the effect of a standardized physical therapy treatment, directed to the cervical spine, on tinnitus. Additionally, a second aim is to identify a subgroup within the tinnitus population that benefits from physical therapy treatment.

METHODS AND DESIGN

This study is designed as a randomized controlled trial with delayed treatment design. Patients with severe subjective tinnitus (Tinnitus Functional Index (TFI) between 25 and 90 points), in combination with neck complaints (Neck Bournemouth Questionnaire (NBQ) >14 points) will be recruited from the University Hospital of Antwerp. Patients suffering from tinnitus with clear otological etiologies, severe depression, traumatic cervical spine injury, tumors, cervical spine surgery, or conditions in which physical therapy is contra-indicated, will be excluded.After screening for eligibility, baseline data such as TFI, NBQ, and a set of cervical biomechanical and sensorimotor tests will be collected. Patients are randomized in an immediate therapy group and in a group with a delayed start of therapy by 6 weeks. Patients will receive physical therapy with a maximum of 12 sessions of 30 min for a 6-week program. Data from the TFI and NBQ will be collected at baseline (week 0), at the start of therapy (weeks 0 or 6), at the end of therapy (weeks 6 or 12), 6 weeks after therapy (weeks 12 or 18), and 3 months after therapy (weeks 18 or 24). Secondary outcome measures will be collected at baseline and 6 weeks after the therapy (weeks 12 or 18), as the maximal therapy effect on the cervical spine dysfunctions is expected at that moment.

DISCUSSION

This study is the first to investigate the effect of a standardized physical therapy treatment protocol on somatic tinnitus with a prospective comparative delayed design and with blinded evaluator for baseline, end of therapy, and 6 and 12 weeks after therapy.

TRIAL REGISTRATION

12 September 2013, ClinicalTrials.gov: NCT02016313.

Comparison of mulligan sustained natural apophyseal glides and maitland mobilizations for treatment of cervicogenic dizziness: a randomized controlled trial

BACKGROUND

There is short-term evidence for treatment of cervicogenic dizziness with Mulligan sustained natural apophyseal glides (SNAGs) but no evidence for treatment with Maitland mobilizations.

OBJECTIVE

The purpose of this study was to compare the effectiveness of SNAGs and Maitland mobilizations for cervicogenic dizziness.

DESIGN

A double-blind, parallel-arm randomized controlled trial was conducted.

SETTING

The study was conducted at a university in Newcastle, Australia.

PARTICIPANTS

Eighty-six people with cervicogenic dizziness were the study participants.

INTERVENTIONS

Included participants were randomly allocated to receive 1 of 3 interventions: Mulligan SNAGs (including self-administered SNAGs), Maitland mobilizations plus range-of-motion exercises, or placebo.

MEASUREMENTS

The primary outcome measure was intensity of dizziness. Other outcome measures were: frequency of dizziness, the Dizziness Handicap Inventory (DHI), intensity of pain, and global perceived effect (GPE).

RESULTS

Both manual therapy groups had reduced dizziness intensity and frequency posttreatment and at 12 weeks compared with baseline. There was no change in the placebo group. Both manual therapy groups had less dizziness intensity posttreatment (SNAGs: mean difference=-20.7, 95% confidence interval [95% CI]=-33.6, -7.7; mobilizations: mean difference=-15.2, 95% CI=-27.9, -2.4) and at 12 weeks (SNAGs: mean difference=-18.4, 95% CI=-31.3, -5.4; mobilizations: mean difference=-14.4, 95% CI=-27.4, -1.5) compared with the placebo group. Compared with the placebo group, both the SNAG and Maitland mobilization groups had less frequency of dizziness at 12 weeks. There were no differences between the 2 manual therapy interventions for these dizziness measures. For DHI and pain, all 3 groups improved posttreatment and at 12 weeks. Both manual therapy groups reported a higher GPE compared with the placebo group. There were no treatment-related adverse effects lasting longer than 24 hours.

LIMITATIONS

The therapist performing the interventions was not blind to group allocation.

CONCLUSIONS

Both SNAGs and Maitland mobilizations provide comparable immediate and sustained (12 weeks) reductions in intensity and frequency of chronic cervicogenic dizziness.

A pilot study to investigate the short-term effects of specific soft tissue massage on upper cervical movement impairment in patients with cervicogenic headache

OBJECTIVES

Upper cervical movement impairment and muscle dysfunction have been identified as core components of cervicogenic headache (CGH) pathogenesis. The purpose of this single-group pre-post test pilot study was to investigate the short-term effects of a specific soft tissue massage (SSTM) intervention to the cervical spine on range of upper cervical motion.

METHODS

Eight subjects (mean age 28.1 years) with published criteria of CGH (mean history of headache for 7.1 years) were investigated. Range of rotation of the upper cervical spine to the left and right was determined by the flexion-rotation test. Movement was assessed in three phases: pre-intervention, intervention, and post-intervention. The SSTM intervention consisted of an 8-minute soft tissue massage to the cervical muscles bilaterally.

RESULTS

Pre-intervention measures of flexion-rotation test range of motion prior to the intervention over two assessment points were consistent. In contrast, a repeated measures analysis of variance revealed a significant improvement in range of rotation to the left and right after the first (P<0.01), second (P<0.01), but not third intervention (P = 0.19), from an average range of 27.5° at baseline to 45.9° at the third treatment session. After the 2-week post-intervention phase, range of motion remained stable without decline, and was considered full range.

DISCUSSION

This pilot study provides preliminary evidence of the potential for SSTM to improve, at least in the short-term, upper cervical range of motion in people with CGH.

Therapeutic options for cervicogenic headache

The term cervicogenic headache (CeH) describes a syndrome originating from the cervical spine. There are a variety of therapeutic approaches used for the management of CeH, but scientific evidence of their effectiveness is scarce. No medication drug has proven to be effective. The evidence for greater occipital nerve blocks, cervical nerve blockades, facet joint injections and surgical procedures is limited. Several physical therapy interventions are proposed for CeH, with spinal manipulation and soft tissue interventions being the most commonly used. However, the lack of solid evidence of positive effects and risks of serious complications for spinal manipulation should be considered in favor of other physical therapy interventions associated with less risk. The inconsistent results in the literature can be related to the fact that maybe not all therapeutic interventions are appropriate for all patients with CeH or maybe not all patients with CeH will benefit from particular interventions.

Is there a difference in head posture and cervical spine movement in children with and without pediatric headache?

Pediatric headache is an increasingly reported phenomenon. Cervicogenic headache (CGH) is a subgroup of headache, but there is limited information about cervical spine physical examination signs in children with CGH. Therefore, a cross-sectional study was designed to investigate cervical spine physical examination signs including active range of motion (ROM), posture determined by the craniovertebral angle (CVA), and upper cervical ROM determined by the flexion-rotation test (FRT) in children aged between 6 and 12 years. An additional purpose was to determine the degree of pain provoked by the FRT. Thirty children (mean age 120.70 months [SD 15.14]) with features of CGH and 34 (mean age 125.38 months [13.14]) age-matched asymptomatic controls participated in the study. When compared to asymptomatic controls, symptomatic children had a significantly smaller CVA (p < 0.001), significantly less active ROM in all cardinal planes (p < 0.001), and significantly less ROM during the FRT (p < 0.001), especially towards the dominant headache side (p < 0.001). In addition, symptomatic subjects reported more pain during the FRT (p < 0.001) and there was a significant negative correlation (r = -0.758, p < 0.001) between the range recorded during the FRT towards the dominant headache side and FRT pain intensity score. This study found evidence of impaired function of the upper cervical spine in children with CGH and provides evidence of the clinical utility of the FRT when examining children with CGH.

Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review

PURPOSE

The purpose of this systematic review was to assess the effectiveness of conservative physical therapy management of cervicogenic headache (CGH).

INTRODUCTION

CGH affects 22-25% of the adult population with females being four times more affected than men. CGHs are thought to arise from musculoskeletal impairments in the neck with symptoms most commonly consisting of suboccipital neck pain, dizziness, and lightheadedness. Currently, both invasive and non-invasive techniques are available to address these symptoms; however, the efficacy of non-invasive treatment techniques has yet to be established.

METHODS

Computerized searches of CINAHL, ProQuest, PubMed, MEDLINE, and SportDiscus, were performed to obtain a qualitative analysis of the literature. Inclusion criteria were: randomized controlled trial design, population diagnosed with CGH using the International Headache Society classification, at least one baseline measurement and one outcomes measure, and assessment of a conservative technique. Physiotherapy evidence-based database scale was utilized for quality assessment.

RESULTS

One computerized database search and two hand searches yielded six articles. Of the six included randomized controlled trials, all were considered to be of 'good quality' utilizing the physiotherapy evidence-based database scale. The interventions utilized were: therapist-driven cervical manipulation and mobilization, self-applied cervical mobilization, cervico-scapular strengthening, and therapist-driven cervical and thoracic manipulation. With the exception of one study, all reported reduction in pain and disability, as well as improvement in function.

CONCLUSION

Calculated effect sizes allowed comparison of intervention groups between studies. A combination of therapist-driven cervical manipulation and mobilization with cervico-scapular strengthening was most effective for decreasing pain outcomes in those with CGH.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear.

OBJECTIVES

To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

Computerized searches were conducted up to February 2012.

SELECTION CRITERIA

We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses.

MAIN RESULTS

Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.

Evidence-based guidelines for the chiropractic treatment of adults with headache

OBJECTIVE

The purpose of this manuscript is to provide evidence-informed practice recommendations for the chiropractic treatment of headache in adults.

METHODS

Systematic literature searches of controlled clinical trials published through August 2009 relevant to chiropractic practice were conducted using the databases MEDLINE; EMBASE; Allied and Complementary Medicine; the Cumulative Index to Nursing and Allied Health Literature; Manual, Alternative, and Natural Therapy Index System; Alt HealthWatch; Index to Chiropractic Literature; and the Cochrane Library. The number, quality, and consistency of findings were considered to assign an overall strength of evidence (strong, moderate, limited, or conflicting) and to formulate practice recommendations.

RESULTS

Twenty-one articles met inclusion criteria and were used to develop recommendations. Evidence did not exceed a moderate level. For migraine, spinal manipulation and multimodal multidisciplinary interventions including massage are recommended for management of patients with episodic or chronic migraine. For tension-type headache, spinal manipulation cannot be recommended for the management of episodic tension-type headache. A recommendation cannot be made for or against the use of spinal manipulation for patients with chronic tension-type headache. Low-load craniocervical mobilization may be beneficial for longer term management of patients with episodic or chronic tension-type headaches. For cervicogenic headache, spinal manipulation is recommended. Joint mobilization or deep neck flexor exercises may improve symptoms. There is no consistently additive benefit of combining joint mobilization and deep neck flexor exercises for patients with cervicogenic headache. Adverse events were not addressed in most clinical trials; and if they were, there were none or they were minor.

CONCLUSIONS

Evidence suggests that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. The type, frequency, dosage, and duration of treatment(s) should be based on guideline recommendations, clinical experience, and findings. Evidence for the use of spinal manipulation as an isolated intervention for patients with tension-type headache remains equivocal.

Normal kinematics of the upper cervical spine during the Flexion-Rotation Test - In vivo measurements using magnetic resonance imaging

The Flexion-Rotation Test (FRT) is proposed to assess mobility primarily at C1-C2. However, there is no in vivo measurement investigating the validity of the FRT. The purpose of this study was 1) to examine measurement reliability of segmental upper cervical movements using magnetic resonance imaging and 2) to investigate the content validity of the FRT. Nineteen asymptomatic female subjects (mean age: 22.2 years) were evaluated with a 0.2-T horizontally open MRI unit. The segmental rotation angles from Occiput-C1 to C3-C4 and the C4 vertebra were assessed with the head maximally rotated to both the right and the left in two conditions - neck in neutral and in flexion. Good reliability of the method of measurement was suggested by error considerations. A repeated measure ANOVA revealed an interaction between the two different neck starting positions and segment levels (P < 0.0001). Post-hoc analysis revealed that there were significant reductions in the flexed position (P < 0.0001) except for at Occiput-C1. While there was only a 16.3% reduction in rotation range at C1-C2, the reduction was 68.1% at C2-C3, 61.4% at C3-C4, and 76.9% at segments below C4, respectively, supporting the content validity of the FRT as a clinical measure of atlanto-axial mobility.

Reliability of manual examination and frequency of symptomatic cervical motion segment dysfunction in cervicogenic headache

This study investigated the reliability of manual examination procedures and the frequency that each or multiple segments in the upper cervical spine above the C4 vertebra were the dominant source of pain in subjects with cervicogenic headache (CGH). Eighty subjects were evaluated, 60 with CGH (39 females, mean age 33 years) and arbitrarily a further 20 asymptomatic subjects (13 females, mean age 34 years) included to reduce examiner bias, but subsequently omitted from data analysis. Two experienced physiotherapists examined on the same day each subject with standard manual examination procedures, independently rating each segment in the upper cervical spine above the C4 vertebra for involvement. Examiners were blind to each other's findings and the subject's clinical status. Standard and adjusted Kappa coefficients were calculated for each segment in symptomatic subjects only. Chi-squared analysis for goodness of fit was used to identify the segment that was most frequently determined the predominant symptomatic segment. Manual examination above the C4 vertebra showed good reliability. The C1/2 segment was most commonly symptomatic, with a positive finding at this segment in 63% of cases. The high frequency of C1/2 involvement in CGH highlights the importance of examination and treatment procedures for this motion segment.

Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test

The aim of this study was to compare the findings of the cervical flexion–rotation test (FRT) between subjects with probable cervicogenic headache (CGH), migraine without aura (Migraine), and multiple headache forms (MHF). An additional aim was to identify the diagnostic accuracy of the FRT in CGH evaluation. Sixty subjects were evaluated: 20 with CGH, 20 with Migraine, and 20 with MHF. Subject and headache symptoms were evaluated by questionnaire. A single-blind examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion using a goniometer. The average range of unilateral rotation to the most restricted side was 25°, 42° and 35° for groups CGH, Migraine and MHF, respectively. The difference between groups was significant (P < 0.001). Range of rotation was significantly reduced in the CGH group when compared to groups Migraine (P < 0.001) and MHF (P = 0.001), with an additional smaller significant difference between groups Migraine and MHF (P = 0.039). A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 85% of the time (P < 0.001), with a positive cut-off value of 30°. Multivariate regression analysis revealed that 44% of the variance in FRT range of motion was explained by the presence of two variables: neck movement or positions provoke headache, and neck symptoms precede headache, but not by other factors associated with migraine. These findings provide further evidence supporting the clinical utility of the FRT in CGH evaluation.

Long-term stability and minimal detectable change of the cervical flexion-rotation test

STUDY DESIGN

Reliability of clinical measurements over time.

OBJECTIVES

To determine the long-term stability and minimal detectable change (MDC) of the flexion-rotation test (FRT) measurements over days in subjects with cervicogenic headache (CGH).

BACKGROUND

The FRT is used by physical therapists to assist in identifying upper cervical movement impairment, as well as to gauge treatment effectiveness. Test-retest reliability for the FRT has been reported, but the stability of range-of-motion measures taken during the FRT over time and the MDC have not been investigated.

METHODS

Fifteen subjects with CGH were evaluated on headache-free days using the FRT by a blinded examiner at baseline, 2, 4, and 14 days later. An additional 10 asymptomatic subjects were included for blinding purposes. On each occasion, the examiner measured range of motion and determined whether the FRT was positive or negative.

RESULTS

For subjects with CGH, there was no significant change in FRT range of motion over days (P>.05). Intraclass correlation coefficients for intratester reliability were 0.95 (95% CI: 0.90 to 0.98) and 0.97 (95% CI: 0.94 to 0.99) for right and left rotation, respectively. MDC90 was 4.7 degrees for right rotation and 7 degrees for left rotation. Examiner interpretation of the FRT was consistent over time, with kappa = 0.92.

CONCLUSIONS

This study provides evidence that FRT measurements are stable over time, and the MDC90 indicates that a change in FRT range of motion of at least 7 degrees is required to be confident that a change has occurred due to an intervention rather than measurement error.

Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review

Adverse events (AE) are a concern for practitioners utilizing cervical manipulation or mobilization. While efficacious, these techniques are associated with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09-3.54) p < 0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85-1.77) p > .05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted.

Effectiveness of manual therapies: the UK evidence report

BACKGROUND

The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions.

METHODS

The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories. The strength/quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs.

RESULTS

By September 2009, 26 categories of conditions were located containing RCT evidence for the use of manual therapy: 13 musculoskeletal conditions, four types of chronic headache and nine non-musculoskeletal conditions. We identified 49 recent relevant systematic reviews and 16 evidence-based clinical guidelines plus an additional 46 RCTs not yet included in systematic reviews and guidelines.Additionally, brief references are made to other effective non-pharmacological, non-invasive physical treatments.

CONCLUSIONS

Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.Massage is effective in adults for chronic low back pain and chronic neck pain. The evidence is inconclusive for knee osteoarthritis, fibromyalgia, myofascial pain syndrome, migraine headache, and premenstrual syndrome. In children, the evidence is inconclusive for asthma and infantile colic.

A primer on selected aspects of evidence-based practice relating to questions of treatment. Part 1: asking questions, finding evidence, and determining validity

The process of evidence-based practice (EBP) guides clinicians in the integration of individual clinical expertise, patient values and expectations, and the best available evidence. Becoming proficient with this process takes time and consistent practice, but should ultimately lead to improved patient outcomes. The EBP process entails 5 steps: (1) formulating an appropriate question, (2) performing an efficient literature search, (3) critically appraising the best available evidence, (4) applying the best evidence to clinical practice, and (5) assessing outcomes of care. This first commentary in a 2-part series will review principles relating to steps 1, 2, and 3 of this 5-step model. The purpose of this commentary is to provide a perspective to assist clinicians in formulating foreground questions, searching for the best available evidence, and determining validity of results in studies of interventions for orthopaedic and sports physical therapy.

A primer on selected aspects of evidence-based practice to questions of treatment. Part 2: interpreting results, application to clinical practice, and self-evaluation

The process of evidence-based practice (EBP) guides clinicians in the integration of individual clinical expertise, patient values and expectations, and the best available evidence. Becoming proficient with this process takes time and consistent practice, but should ultimately lead to improved patient outcomes. The EBP process entails 5 steps: (1) formulating an appropriate question, (2) performing an efficient literature search, (3) critically appraising the best available evidence, (4) applying the best evidence to clinical practice, and (5) assessing outcomes of care. This second commentary in a 2-part series will review principles relating to steps 3 through 5 of this 5-step model. The purpose of this commentary is to provide a perspective to assist clinicians in interpreting results, applying the evidence to patient care, and evaluating proficiency with EBP skills in studies of interventions for orthopaedic and sports physical therapy.