Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

Thoracic spinal postures and mobility in patients with cervicogenic headache versus asymptomatic healthy controls: A longitudinal study

INTRODUCTION

Studies analyzing postures and mobility of the thoracic spine in the context of cervicogenic headache are missing. Insight in these parameters is needed since the cervical and thoracic spine are biomechanically related.

OBJECTIVE

To compare self-perceived optimal and habitual postures, active-assisted maximal range of motion, and repositioning error of the upper-thoracic and lower-thoracic spine between a cervicogenic headache-group and matched healthy control-group before and after a 30 min-laptop-task.

METHODS

A non-randomized longitudinal design was used to compare thoracic postures and mobility between 18 participants with cervicogenic headache (29-51 years) and 18 matched healthy controls (26-52 years). Outcomes were: self-perceived optimal and habitual postures, active-assisted maximal range of motion, and repositioning error of the upper-thoracic and lower-thoracic spine evaluated in sitting with a 3D-Vicon motion analysis system.

RESULTS

Habitual upper-thoracic postures in the cervicogenic headache-group were significantly (p = .04) less located toward the maximal range of motion for flexion compared to the control-group, self-perceived optimal upper-thoracic posture was significantly (p = .004) more extended in the cervicogenic headache-group compared to the control-group, and self-perceived optimal lower-thoracic posture could not be reestablished in the cervicogenic headache-group after the laptop-task (p = .009).

CONCLUSION

Thoracic postures differ between a cervicogenic headache-group and control-group. These differences were detected by expressing the habitual thoracic posture relative to its maximal range of motion, and by analyzing the possibility of repositioning the thoracic spine after a headache provoking activity. Longitudinal studies are needed to determine the contribution of these musculoskeletal dysfunctions to the pathophysiology of cervicogenic headache.

What is the Status Quo of Patient-Centred Physiotherapy Management of People with Headache within a Biopsychosocial Model? - A Narrative Review

PURPOSE OF REVIEW

Patient-centred care (PCC) is deemed essential in the rehabilitation of musculoskeletal pain. Integrating such care within a biopsychosocial framework, enables to address all facets of the individual pain experience, and to manage the individual instead of the condition. This narrative review describes the status quo of PCC physiotherapy management of people with headache within a biopsychosocial model. PubMed, EMBASE, Web of Science, Scopus were searched (update 07.05.2024). The search-query comprised terminology relating to "headache", "patient-centred", "biopsychosocial", "physiotherapy". Additional eligibility criteria were reviews, trials, cohort, case report, case-control studies in English, Dutch, French.

RECENT FINDINGS

Gaps are exposed in patient-centred physiotherapy management of migraine, tension-type headache, and cervicogenic headache. While a biopsychosocial approach is advised to manage migraine and tension-type headache, its use in clinical practice is not reflected by the literature. A biopsychosocial approach is not advised in cervicogenic headache. Psychosocial-lifestyle interventions are mainly delivered by health-care providers other than physiotherapists. Additionally, psychologically-informed practice is barely introduced in physiotherapy headache management. Though, managing the social context within a biopsychosocial framework is advised, the implementation by physiotherapists is unclear. Comparable conclusions apply to PCC. PCC is recommended for the physiotherapy management of primary and secondary headache. Such recommendation remains however theoretical, not reaching clinical implementation. Yet, a shift from the traditional disease-centred model of care towards PCC is ongoing and should be continued in physiotherapy management. With this implementation, clinical and economical studies are needed to evaluate its effectiveness.

Impact of healthcare interventions on distress following acute musculoskeletal/orthopaedic injury: a scoping review of systematic reviews

BACKGROUND

Musculoskeletal injuries can cause distress, and distress is associated with delayed recovery. Numerous interventions have been developed to facilitate recovery from injury, and several systematic reviews evaluate the efficacy of these interventions for reducing psychological distress.

OBJECTIVES

This scoping review aims to map the synthesised evidence for the relationship between treatment interventions and distress-related outcomes following acute injury. The objectives were (1) to describe the types of interventions that have been evaluated in relation to distress-related outcomes following accidental injury, (2) to examine the scope of distress-related outcomes that have been measured in relation to these interventions and (3) to explore the range of clinical professions that deliver these interventions.

DESIGN

We searched nine electronic databases and grey literature (to 21 April 2022). We included any systematic review reporting on the relationship between interventions delivered in the time following injury and distress-related outcomes. Data relevant to the specific objectives of this scoping review were extracted and described using narrative synthesis.

RESULTS

From 8412 systematic reviews imported for screening, 8266 unique records were screened. 179 were selected for full-text review. 84 systematic reviews were included in the study. Interventional types were pharmacological, psychological, exercise based, physical/manual therapies, virtual reality based, multimodal and workplace based. Interventions were delivered digitally, face to face and using virtual reality by a variety of healthcare professionals, including doctors, nurses, psychologists and physiotherapists. The most frequently reported distress-related variables included anxiety, depression, post-traumatic stress disorder diagnosis.

CONCLUSION

A wide range of interventions may help to mitigate distress following acute accidental musculoskeletal or orthopaedic injury. Even interventions that were not designed to reduce distress were found to improve distress-related outcomes. In view of the important role of distress in recovery from injury, it is recommended that distress-related variables are measured as core outcomes in the evaluation of treatments for acute injuries.

Cross-sectional experimental assessment of pain modulation as part of multidimensional profiling of people with cervicogenic headache: protocol for a feasibility study

BACKGROUND

An endogenous pain modulation profile, reflecting antinociceptive and pronociceptive mechanisms, may help to direct management by targeting the involved pain mechanism. For individuals with cervicogenic headache (CeH), the characteristics of such profiles were never investigated. However, the individual nature of experiencing pain demands profiling within a multidimensional framework including psychosocial lifestyle characteristics. The objective of the current protocol is to assess the pain modulation profile, which includes psychosocial lifestyle characteristics among people with CeH.

METHODS AND ANALYSIS

A protocol is described to map pain modulation profiles in people with CeH. A cross-sectional non-randomised experimental design will be used to assess feasibility of mapping these profiles. The pain modulation profile is composed based on results on the Depression, Anxiety, Stress Scale, Pittsburgh Sleep Quality Index, Headache Impact Test and on responses to temporal summation of pain (pinprick), conditioned pain modulation and widespread hyperalgesia (mechanical pressure pain threshold and cuff algometry). Primary analyses will report results relating to outcomes on feasibility. Secondary analyses will involve an analysis of proportions (%) of the different psychosocial lifestyle profiles and pain profiles.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Ethics Committee Research UZ/KU Leuven (Registration number B3222024001434) on 30 May 2024. Results will be published in peer-reviewed journals, at scientific conferences and, through press releases. Protocol V.3. protocol date: 3 June 2024.

Effects of cervical stabilization training in patients with headache: A single-blinded randomized controlled trial

BACKGROUND

This study aimed to investigate the effects of Cervical Stabilization Training (CST) on the headache, neck pain and cervical musculoskeletal system in patients with headache compared to the control group.

METHODS

A total of 90 female patients with migraine, tension-type headache and cervicogenic headache (CGH) participated in this study. The patients were divided into the cervical stabilization training group (CSTG) and the control group (CG). The CSTG performed the CST three times a week for 8 weeks while the CG continued their ongoing medical treatment. The pain intensity was assessed by Visual Analogue Scale, forward head posture by craniovertebral angle measurement, the endurance of deep cervical flexor muscles by craniocervical flexion test and the endurance of cervical muscles by flexor and extensor endurance tests before and after 8 weeks. In addition, disability levels, health-related quality of life, sleep quality and mood were assessed by the Migraine Disability Assessment questionnaire, Neck Disability Index (NDI), Short Form 36 Quality of Life Scale, the Pittsburgh Sleep Quality Index and Beck Depression Scale, respectively.

RESULTS

Headache frequency, duration and intensity, neck pain intensity and forward head posture reduced while activation and performance of deep cervical flexor muscles, the endurance of cervical flexor and extensor muscles increased in the CSTG (p < 0.05). Furthermore, the disability levels, quality of life, sleep quality and mood also improved in the CSTG (p < 0.05).

CONCLUSIONS

This study suggests that CST reduces headaches and neck pain by improving the cervical musculoskeletal system in patients with headache.

SIGNIFICANCE

The CST improved the headache frequency, duration and intensity, neck pain intensity, cervical posture, activation of deep cervical flexor muscles and endurance of cervical muscles in patients with headache. In addition, improvements in the cervical musculoskeletal system contributed to a reduction in the intensity of headaches and neck pain. Therefore, CST may be preferred in the treatment of headaches, especially with coexisting neck pain.

Personalized Multimodal Lifestyle Intervention as the Best-Evidenced Treatment for Chronic Pain: State-of-the-Art Clinical Perspective

Chronic pain is the most prevalent disease worldwide, leading to substantial disability and socioeconomic burden. Therefore, it can be regarded as a public health disease and major challenge to scientists, clinicians and affected individuals. Behavioral lifestyle factors, such as, physical (in)activity, stress, poor sleep and an unhealthy diet are increasingly recognized as perpetuating factors for chronic pain. Yet, current management options for patients with chronic pain often do not address lifestyle factors in a personalized multimodal fashion. This state-of-the-art clinical perspective aims to address this gap by discussing how clinicians can simultaneously incorporate various lifestyle factors into a personalized multimodal lifestyle intervention for individuals with chronic pain. To do so the available evidence on (multimodal) lifestyle interventions targeting physical (in)activity, stress, sleep and nutritional factors, specifically, was reviewed and synthetized from a clinical point of view. First, advise is provided on how to design a personalized multimodal lifestyle approach for a specific patient. Subsequently, best-evidence recommendations on how to integrate physical (in)activity, stress, sleep and nutritional factors as treatment targets into a personalized multimodal lifestyle approach are outlined. Evidence supporting such a personalized multimodal lifestyle approach is growing, but further studies are needed.

The Efficacy of Manual Therapy and Pressure Biofeedback-Guided Deep Cervical Flexor Muscle Strength Training on Pain and Functional Limitations in Individuals with Cervicogenic Headaches: A Randomized Comparative Study

Objective

This study aimed to compare the efficacy of manual therapy and pressure biofeedback-guided DCFM strength training on pain intensity and functional limitations in individuals with CGH. Trial Design. A double-blinded, two-arm parallel group randomized comparative design.

Methods

After applying the eligibility criteria, sixty out of eighty-nine CGH patients were recruited from King Saud University Medical Center in Riyadh and randomly allocated to intervention groups using simple random sampling. Group 1 underwent pressure biofeedback-guided DCFM strength training and conventional treatment, while Group 2 received manual therapy and conventional treatment for three consecutive weeks. The main outcome measures were scores on the visual analog scale (VAS) and the headache disability index (HDI). One assessor and two physical therapists were blinded to group allocation.

Results

Sixty out of eighty participants aged 29-40 years were randomized into intervention groups (n = 30/group; age (mean ± standard deviation): group 1 = 35.0 ± 2.82; group 2 = 34.87 ± 2.60), and their data were analyzed. A significant improvement (95% CI, p < 0.05) was observed within each group when comparing the VAS and HDI scores between baseline and postintervention. In contrast, between-group comparisons for the outcome score of VAS and HDI revealed nonsignificant differences in the first, second, and third weeks after intervention, except for the VAS score, which showed a significant difference in weeks 2 and 3 after intervention. Cohen's d-value indicated that the intervention effect size for reducing pain was larger in group 1 than in group 2 at weeks 2 and 3.

Conclusion

Compared with manual therapy, pressure biofeedback-guided DCFM strength training showed a greater reduction in pain intensity (assessed using the VAS) at weeks two and three. However, both treatments were equally effective in lowering headache-related functional limitations in patients with CGH. This trial is registered with ClinicalTrial.gov PRS (Identifier ID: NCT05692232).

Effectiveness of therapeutic exercise for the management of cervicogenic headache: A systematic review

OBJECTIVE

The main aim of this systematic review is to evaluate the effectiveness of therapeutic exercise for managing pain and disability in patients with cervicogenic headache (CEH).

METHODS

A protocol for this systematic review was published in PROSPERO (CRD42019122703). PRISMA and AMSTAR2 standards were followed. Based on an extensive systematic search in five databases (EMBASE, MEDLINE, CINHAL, PsychInfo and SportDISCUS) and the CENTRAL trial register, two reviewers carefully and independently assessed, selected results, collected data, rated the risk of bias (RoB) of included studies with the Cochrane risk of bias tool, synthesized the available evidence, and rated it using GRADE methodology.

RESULTS

A total of 12 manuscripts, reporting on 11 studies were included. Most studies showed a high risk of bias (63,63%). Additionally, a great deal of heterogeneity was observed regarding interventions, comparisons, and outcomes and thus, results could not be synthesized in meta-analyses. The quality of the evidence was found to be from low to very low. Significant differences with large effect sizes were found when comparing multimodal exercise vs. control groups on headache outcomes (SMD = 0.73; 95%CI [0.31, 1.14] for headache intensity and SMD = 0.98; 95%CI [0.56, 1.41], for headache frequency).

CONCLUSIONS

Findings indicate that therapeutic exercise may be effective to achieve clinically relevant reductions in headache intensity and frequency as well as disability for patients suffering from cervicogenic headache. However, more high-quality research is needed to gain confidence in this finding and possibly determine optimal types and dosage of therapeutic exercise.

International Framework for Examination of the Cervical Region for Potential of Vascular Pathologies of the Neck Prior to Musculoskeletal Intervention: International IFOMPT Cervical Framework

SYNOPSIS: This position statement, stemming from the International IFOMPT (International Federation of Orthopaedic Manipulative Physical Therapists) Cervical Framework, was developed based upon the best contemporary evidence and expert opinion to assist clinicians during their clinical reasoning process when considering presentations involving the head and neck. Developed through rigorous consensus methods, the International IFOMPT Cervical Framework guides assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned interventions. Within the cervical spine, events and presentations of vascular pathologies of the neck are rare but are an important consideration as part of patient examination. Vascular pathologies may be recognizable if the appropriate questions are asked during the patient history-taking process, if interpretation of elicited data enables recognition of this potential, and if the physical examination can be adapted to explore any potential vasculogenic hypothesis. J Orthop Sports Phys Ther 2023;53(1):7-22. Epub: 14 September 2022. doi:10.2519/jospt.2022.11147.

Translating the new International IFOMPT Cervical Framework into a framework flowchart for clinical practice and education

BACKGROUND

In 2020, a revised version of the International IFOMPT Cervical Framework was published. This framework provides both physical therapists and educators the necessary information to guide the assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned Orthopaedic Manual Therapy (OMT) interventions.

OBJECTIVE

The objective was to develop a framework flowchart which is useful in clinical practice and education to assist physical therapists to improve the safety of OMT, and apply this in a case report.

METHODS

The framework was developed in co-creation with manual therapy experts, researchers, educators in manual therapy, patients, medical specialists and the Manual Therapy Association in The Netherlands and Belgium. Manual therapists and patients tested the framework for intelligibility and usefulness.

RESULTS

A framework flowchart is developed and presented, that is easy to use in both clinical practice and education. It is a visual representation of the sequence of steps and decisions needed during the process. A case description of a patient with neck pain and headache is added to illustrate the clinical usefulness of the framework flowchart.

CONCLUSION

The framework flowchart helps physical therapists in their clinical reasoning to provide safe OMT interventions.

Exploring multidimensional characteristics in cervicogenic headache: Relations between pain processing, lifestyle, and psychosocial factors

OBJECTIVE

Although multidimensional interventions including physiotherapy, psychology, and education are generally recommended in managing headache, and to prevent chronification, such approach is lacking in cervicogenic headache (CeH). Therefore, exploring CeH within a biopsychosocial framework is deemed an essential first step.

METHODS

Non-randomized cross-sectional design to compare pain processing, lifestyle, and psychosocial characteristics between 18 participants with CeH (CeH group) (40.2 ± 10.9 years) and 18 matched controls (control group) (39.2 ± 13.1 years). Pain processing characteristics included degree of central sensitization (Central Sensitization Inventory), and (extra)-cephalic pressure pain thresholds (kPa/cm²/s). Lifestyle characteristics included sleep quality (Pittsburgh Sleep Quality Index), physical activity, screen time, and sedentary time (hours a week). Psychosocial characteristics included degree of depression, anxiety and stress (Depression Anxiety Stress Scale-21), and quality of life (Headache Impact Test-6).

RESULTS

Pain processing characteristics: More (p = .04) participants in the CeH group showed higher degrees of central sensitization compared to the control group. Lower (p < .05) (extra)-cephalic pressure pain thresholds were revealed in the CeH group compared to the control group for each muscle. Lifestyle and psychosocial characteristics: Compared to the control group, sleep quality and headache-related quality of life were worse (p < .0001) in the CeH group. Severe to extreme stress was experienced by more participants in the CeH group (p = .02). Further, significant relations between pain processing and (1) lifestyle characteristics and (2) psychosocial characteristics were seen in the CeH group.

CONCLUSION

Exploring multidimensional characteristics in CeH exposed relations between pain processing, lifestyle, and psychosocial characteristics. These novel findings fill a gap in the current scientific literature, and highlight the need for outcome research targeting lifestyle and psychosocial factors.

Effectiveness of different physiotherapy interventions in the management of cervicogenic headache: a pilot randomized controlled trial

BACKGROUND

Cervicogenic headache is a secondary headache which leads to decreased functional activity, quality of life and functional disability.

OBJECTIVE

To determine the feasibility and acceptability of different physiotherapy interventions in the management of cervicogenic headache and to determine sample size for a full trial.

TRIAL DESIGN

A pilot randomized controlled trial.

SETTINGS

Various physiotherapy outpatient department.

METHODS

Participants suffering from cervicogenic headache with age 20- 60 years were randomly allocated into four groups. Sessions were given over 4 weeks 4 times a week (16 sessions). The primary outcomes were feasibility of participant recruitment, assessment procedure, retention, adherence, and acceptability. The secondary outcomes were headache impact test-6 for a headache disability, headache diary for headache intensity, frequency, duration, and neck disability index for neck pain, disability measured at baseline, 4th week, and follow up after 1 month.

RESULT

178 subjects were screened based on selection criteria. Out of them, 93 (52%) were eligible and 80 (86%) participated in the study. 96.25% of participants completed the final 8-week assessment. Overall 93.75% of participants completed the entire assessment item across all time points. 95% completed all treatment sessions. 97.5-100% of participants were satisfied with the treatment protocol. No adverse effects were reported by participants. Based on the data obtained from the pilot trial, sample size was determined as 35 participants in each group.

CONCLUSION

The results indicate that the trial methodology and intervention are feasible for implementing a full-powered randomized controlled trial to determine the effectiveness of physiotherapy intervention in the management of cervicogenic headache.

The feasibility of gym-based exercise therapy for patients with persistent neck pain

Background and aims Persistent neck pain is common and can be detrimental to the health of those who are affected. This is particularly common after neck trauma, where it poses a challenge to health care providers. In this paper, we present the design and results of a study aimed primarily at assessing the feasibility of a supervised exercise intervention for patients with persistent neck pain after trauma. As a secondary aim, we analyzed the results of the intervention. Methods We designed and conducted a feasibility study using a mixed methods design. Ten patients with persistent neck pain (nine with a history of neck trauma and one with sudden onset of neck pain) were recruited from a specialized pain rehabilitation center and underwent a gym-based individual exercise therapy intervention, supervised by a physical therapist. We assessed the feasibility of the exercise therapy intervention based on the experiences of the patients and physical therapists. We analyzed both quantitative and qualitative results using descriptive statistics, content analysis, and questionnaires. Results The study found the exercise therapy to be a feasible alternative for patients with persistent neck pain. Most of the practical aspects of the intervention and study were executed as planned, and the study was well received by the patients, who found it a valuable part of their rehabilitation. In the quantitative analysis, improvements were observed on the Neck Disability Index, numerical rating scale for pain, EuroQol 5D, and physical activity, with scores on the Neck Disability Index showing a statistically significant improvement. Scores on the Disability Rating Index showed a non-significant deterioration. The qualitative analysis uncovered one overarching theme and four themes for the patients and three themes for the physical therapist. Conclusions The exercise therapy intervention seems to be feasible with favorable outcomes for the patients. The quantitative and qualitative analyses demonstrated exercise therapy to be beneficial from several different perspectives. However, although structured, the training needs customization and individual adaption from a clinical reasoning perspective in order to meet each patient's individual needs. Implications This study shows that supervised gym-based exercise therapy is feasible for patients with severe, persistent neck pain. It facilitates and motivates the execution of a larger, controlled trial, which might then lead to a new and potentially effective addition to the toolbox of all health care providers treating patients with persistent neck pain.

The comparative effects of spinal manipulation, myofascial release and exercise in tension-type headache patients with neck pain: A randomized controlled trial

OBJECTIVES

To evaluate the effects of two manual treatment methods on pain, disability, and pressure pain threshold (PPT) in tension-type headache (TTH) patients with and neck pain.

METHODS

Forty-five patients with TTH were randomly assigned to one of three groups and received eight sessions treatment: manipulation plus exercise (manipulation), suboccipital inhibition plus exercise (myofascial release), and exercise only (control). Headache frequency, pain severity (VAS-headache, VAS-neck pain) and headache and neck disability (HIT-6 and NDI, respectively) were measured at baseline, posttreatment, and at the third month follow-up. PPT was also evaluated on the temporalis muscle.

RESULTS

Manipulation group was statistically better than myofascial release group in terms of headache frequency, headache severity, and PPT scores. Also, manipulation group showed statistically significant improvements in all outcome criteria when compared control group.

CONCLUSIONS

Manipulation and exercise, in addition to pharmacologic treatment in TTH patients with cervical dysfunction appear to be a promising approach.

Effectiveness of chiropractic manipulation versus sham manipulation for recurrent headaches in children aged 7-14 years - a randomised clinical trial

Background

To investigate the effectiveness of chiropractic spinal manipulation versus sham manipulation in children aged 7–14 with recurrent headaches.

Methods

Design: A two-arm, single-blind, superiority randomised controlled trial.

Setting: One chiropractic clinic and one paediatric specialty practice in Denmark, November 2015 to August 2020.

Participants: 199 children aged 7 to 14 years, with at least one episode of headache per week for the previous 6 months and at least one musculoskeletal dysfunction identified.

Interventions: All participants received standard oral and written advice to reduce headaches. In addition, children in the active treatment group received chiropractic spinal manipulation and children in the control group received sham manipulation for a period of 4 months. Number and frequency of treatments were based on the chiropractor’s individual evaluation in the active treatment group; the children in the control group received approximately eight visits during the treatment period.

Primary outcome measures: ‘Number of days with headache’, ‘pain intensity’ and ‘medication’ were reported weekly by text messages, and global perceived effect by text message after 4 months. A planned fixed sequence strategy based on an initial outcome data analysis was used to prioritize outcomes. ‘Number of days with headache’ and ‘pain intensity’ were chosen as equally important outcomes of highest priority, followed by global perceived effect and medication. The significance level for the first two outcomes was fixed to 0.025 to take multiplicity into account.

Results

Chiropractic spinal manipulation resulted in significantly fewer days with headaches (reduction of 0.81 vs. 0.41, p = 0.019, NNT = 7 for 20% improvement) and better global perceived effect (dichotomized into improved/not improved, OR = 2.8 (95% CI: 1.5–5.3), NNT = 5) compared with a sham manipulation procedure. There was no difference between groups for pain intensity during headache episodes. Due to methodological shortcomings, no conclusions could be drawn about medication use.

Conclusions

Chiropractic spinal manipulation resulted in fewer headaches and higher global perceived effect, with only minor side effects. It did not lower the intensity of the headaches.

Since the treatment is easily applicable, of low cost and minor side effects, chiropractic spinal manipulation might be considered as a valuable treatment option for children with recurrent headaches.

Trial registration

ClinicalTrials.gov, identifier NCT02684916, registered 02/18/2016 – retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-020-00360-3.

Osteopathic Manipulative Treatment in Tension Headaches

Tension-type headaches, associated with young age, poor health, sleep disturbances, anxiety, stress, and poor posture, account for 90% of all headaches diagnosed by healthcare professionals. Diagnosis and treatment of the various headache subtypes are often aimed at determining the underlying cause but commonly involve over-the-counter pain medication. Because recurrence is common in tension-type headaches, with a subsequent refractory response to over-the-counter medications, adjunctive and alternative treatment modalities should be further studied. Here we present a case of tension headache initially non-responsive to pain medication but resolved with osteopathic manipulative treatment and lifestyle modifications. Osteopathic considerations and literature are also reviewed in the broader context of headache management.

Wirksamkeit manualtherapeutischer Techniken in Kombination mit vestibulärer Rehabilitation nach sportbedingten Gehirnerschütterungen – Eine systematische Übersichtsarbeit randomisiert kontrollierter Studien

Hintergrund Die Rehabilitation nach leichter, sportbedingter Gehirnerschütterung erfordert eine komplexe Behandlung unter Berücksichtigung der muskuloskelettalen, insbesondere zervikogenen, und vestibulären Beteiligung. Das empfohlene Rehabilitationskonzept der vollständigen Ruhe bis zur Beschwerdefreiheit wird inzwischen neu bewertet. Aktuelle Studien deuten auf positive Auswirkungen einer frühen Mobilisierung und multimodaler Physiotherapie hin. Der medizinische Nutzen ausgewählter manualtherapeutischer Techniken wird in mehreren klinischen Studien untersucht. Bisher konnten jedoch keine eindeutigen Empfehlungen für manualtherapeutische Techniken nach einer Gehirnerschütterung ausgesprochen werden.

Ziel Analyse und Zusammenfassung vorhandener randomisiert kontrollierter Studien (RCTs) zur Untersuchung der Wirksamkeit manualtherapeutischer Techniken in Kombination mit vestibulärer Rehabilitation auf Symptomfreiheit und Wiedererlangung der sportlichen Belastbarkeit bei Patienten nach sportbedingten Gehirnerschütterungen.

Methode Systematische Recherche in den Datenbanken ClinicalTrials.gov, WHO-ICTRP, EBSCO, PubMed und PEDro mit den Suchbegriffen concussion, physiotherapy, manual therapy und mild traumatic brain injury. Eingeschlossen wurden RCTs zur Untersuchung manualtherapeutischer Techniken nach sportbedingten Gehirnerschütterungen oder milden Formen eines Schädelhirntraumas. Die Bewertung der methodischen Qualität erfolgte Anhand der PEDro-Skala.

Ergebnisse Publikationen zu 2 RCTs mit guter und moderater methodischer Qualität (PEDro-Skala: 7–8/10 Punkten) sowie eine Folgestudie wurden inkludiert. Als primärer Outcome-Parameter wurde in allen Studien der Zeitraum der ärztlichen Freigabe zur Rückkehr zum Sport angegeben. Sekundäre Outcome-Parameter bezogen sich auf Symptomfreiheit, Postconcussion Scale, Numeric Pain Rating Scale, Balance Confidence Scale, Dizziness-Handicap-Index, Sport Concussion Assessment Tool 2 und Joint-Position-Error-Test. Die Ergebnisse aller inkludierten Studien ergaben signifikante Unterschiede zugunsten der Interventionsgruppen. Die eingeschlossenen klinischen Studien waren jedoch in Bezug auf Design, Methodik und Auswahl der Techniken heterogen, was einen direkten Vergleich erschwerte.

Schlussfolgerung Abgeschlossene klinische Studien deuten darauf hin, dass manualtherapeutische Techniken als Teil eines multimodalen Rehabilitationsprogramms nach Gehirnerschütterungen und leichten Schädelhirntraumata von Nutzen sein können. Aufgrund der geringen Anzahl an RCTs und deren heterogenen Studiendesigns ist eine Bewertung der Wirksamkeit spezifischer manualtherapeutischer Techniken derzeit nicht möglich. Weitere hochwertige Studien sind erforderlich.

Development and validation of a model predicting post-traumatic headache six months after a motor vehicle collision in adults

IMPORTANCE

The prognosis of post-traumatic headache is poorly understood.

OBJECTIVE

To develop and validate a prognostic model to predict the presence of post-traumatic headache six months after a traffic collision in adults with incident post-traumatic headache.

DESIGN

Secondary analyses of adults with incident post-traumatic headache injured in traffic collisions between November 1997 and December 1999 in Saskatchewan, Canada (development cohort); and between January 2004 and January 2005 in Sweden (validation cohort).

SETTING

The Saskatchewan cohort (development) was population-based (N = 4162). The Swedish cohort (validation) (N = 379) were claimants from two insurance companies covering 20 % of cars driven in Sweden in 2004.

PARTICIPANTS

All adults injured in traffic collisions who completed a baseline questionnaire within 30 days of collision. Excluded were those hospitalized >2 days, lost consciousness >30 min, or reported headache <3/10 on the numerical rating scale. Follow-up rates for both cohorts were approximately 80 %.

PREDICTORS

Baseline sociodemographic, pre-injury, and injury factors.

OUTCOME

Self-reported headache pain intensity ≥3 (numerical rating scale) six months after injury.

RESULTS

Both cohorts were predominantly female (69.7 % in Saskatchewan, 65.2 % in Sweden), with median ages 35.9 years (Saskatchewan), and 38.0 years (Sweden). Predictors were age, work status, headache pain intensity, symptoms in arms or hands, dizziness or unsteadiness, stiffness in neck, pre-existing headache, and lower recovery expectations. With a positive score (i.e., ≥0.75 probability), the model can rule in the presence of post-traumatic headache at six months (development: specificity = 99.8 %, 95 % CI 99.5 %-99.9 %; sensitivity = 1.6 %, 95 % CI 1.0 %-2.6 %; positive likelihood ratio (LR+) = 8.0, 95 % CI 2.7-24.1; negative likelihood ratio (LR-) = 1.0, 95 % CI 1.0-1.0; validation: specificity = 95.5 %, 95 % CI 91.1 %-97.8 %; sensitivity = 27.2 %, 95 % CI 20.4 %-35.2 %); LR+ = 6.0, 95 % CI 2.8-13.2; LR- = 0.8, 95 % CI 0.7-0.8).

CONCLUSIONS AND RELEVANCE

Clinicians can collect patient information on the eight predictors of our model to identify patients that will report ongoing post-traumatic headache six months after a traffic collision. Future research should focus on selecting patients at high risk of poor outcomes (using our model) for inclusion in intervention studies, and determining effective interventions for these patients.

Looking Back at US Pharmacy’s Past to Help Discern Its Future

Objective: To review specific literature that aimed to predict the future of US pharmacy, beginning in the late 1980s. Data Sources: Articles were identified from searching MEDLINE, CINAHL, Google Scholar, and references of relevant articles. The following combinations of search terms were used: future, pharmacy, prediction, and forecast. Study Selection and Data Extraction: The following inclusion criteria were applied: (1) full-text commentary, review, or original research and (2) focused predominantly on the pharmacy in the United States. Data on predictions for the future of pharmacy were extracted. Data Synthesis: We selected 3 articles published between 1988 and 2006, with each aiming to project the future for the following decade. We examined each prediction in light of the current knowledge. Relevance to Patient Care and Clinical Practice: Educators, practitioners, and other stakeholders should consider reflecting on the changes in pharmacy for the past 3 decades and applying both historical and emerging trends to improve patient care and sustain practice in the third decade of the 21st century and beyond. Conclusion: Most of the predictions for the future of pharmacy from the past 3 decades materialized, with some still in progress (reimbursement for pharmacy services), whereas others manifested in unexpected ways (transition from shortage to excess of pharmacists). Current forces shaping pharmacy include, but are not limited to, growing spending and use of specialty drugs, automation of pharmacy operations, growth of pharmacy in the digital health enterprise, and growing consumer interest in the use of analytical pharmacy that tests drugs before dispensing.

Manual therapy as a prophylactic treatment for migraine: design of a randomized controlled trial

Background

People with migraine often experience disability with serious consequences for their social life and work productivity. The pharmacological prophylactic management of migraine is effective in reducing migraine attacks. However, many people are reluctant to use daily prophylactic medication, leading to a demand for non-pharmacological treatment options. We present the design for and discuss the feasibility of a pragmatic, randomized controlled trial on the effectiveness of a multimodal manual therapy (MT) treatment compared to usual care by the general practitioner (GP) for the prophylactic treatment of migraine.

Methods

Eligible participants will be recruited in primary care using the International Classification of Headache Disorders III criteria for migraine of the International Headache Society. Participants will be randomized to either multimodal MT treatment or usual care provided by the GP. GPs will be asked to treat the usual care group according to the Dutch GP guideline for headache. The multimodal MT intervention will include manual pressure techniques, neck muscle-strength exercises and mobilization of the cervical and thoracic spine.

The trial will consist of a 12-week treatment period and follow-up measurements at 12, 26 and 52 weeks. The primary outcome measure is the number of migraine days per 4 weeks, assessed with a headache diary. Secondary outcome measures are the number of migraine attacks, medication use, disability due to headache, headache intensity, number of participants reporting a 50% migraine reduction, measurement of cervical pressure pain thresholds, presence of allodynia, endurance of cervical flexor muscles, days of absence of work and global perceived effect.

Discussion

The results of the trial will show whether a multimodal MT intervention is an effective non-pharmacological treatment option for people with migraine.

Trial registration

Dutch Trial Register, NL7504. Registered on 7 February 2019.

Cervicovestibular rehabilitation in adult with mild traumatic brain injury: a randomised controlled trial protocol

Background

Mild traumatic brain injury (mTBI) is an acknowledged public health problem. Up to 25% of adult with mTBI present persistent symptoms. Headache, dizziness, nausea and neck pain are the most commonly reported symptoms and are frequently associated with cervical spine and vestibular impairments. The most recent international consensus statement (2017 Berlin consensus) recommends the addition of an individualized rehabilitation approach for mTBI with persistent symptoms. The addition of an individualized rehabilitation approach including the evaluation and treatment of cervical and vestibular impairments leading to symptoms such as neck pain, headache and dizziness is, however, recommended based only on limited scientific evidence. The benefit of such intervention should therefore be further investigated.

Objective

To compare the addition of a 6-week individualized cervicovestibular rehabilitation program to a conventional approach of gradual sub-threshold physical activation (SPA) alone in adults with persistent headache, neck pain and/or dizziness-related following a mTBI on the severity of symptoms and on other indicators of clinical recovery. We hypothesize that such a program will improve all outcomes faster than a conventional approach (between-group differences at 6-week and 12-week).

Methods

In this single-blind, parallel-group randomized controlled trial, 46 adults with subacute (3 to12 weeks post-injury) persistent mTBI symptoms will be randomly assigned to: 1) a 6-week SPA program or 2) SPA combined with a cervicovestibular rehabilitation program. The cervicovestibular rehabilitation program will include education, cervical spine manual therapy and exercises, vestibular rehabilitation and home exercises. All participants will take part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome will be the Post-Concussion Symptoms Scale. The secondary outcomes will be time to clearance to return to function, number of recurrent episodes, Global Rating of Change, Numerical Pain Rating Scale, Neck Disability Index, Headache Disability Inventory and Dizziness Handicap Inventory. A 2-way ANOVA and an intention-to-treat analysis will be used.

Discussion

Controlled trials are needed to determine the best rehabilitation approach for mTBI with persistent symptoms such as neck pain, headache and dizziness. This RCT will be crucial to guide future clinical management recommendations.

Trial registration

ClinicalTrials.gov Identifier - NCT03677661, Registered on September, 15th 2018.

Exercise, headache, and factors associated with headache in chronic whiplash: Analysis of a randomized clinical trial

BACKGROUND

Almost 40% of individuals with chronic whiplash-associated disorders (WAD) report headache after 5 years, making it one of the most common persistent symptoms besides neck pain, but randomized treatment studies are lacking. This study aimed to evaluate the effect of 3 different exercise approaches on headache in chronic WAD grades 2 and 3, and to identify potential factors associated with such headache, and whether they differ depending on 3 different aspects of such headache (current headache, maximum headache, or headache bothersomeness).

METHODS

This was an analysis of a randomized clinical trial of people with chronic WAD and headache (n = 188), who were randomized to either 12 weeks of neck-specific exercise without (NSE) or with a behavioral approach (NSEB) or physical activity prescription (PPA). Data were collected at baseline and at 3, 6, and 12 months. Physical and psychosocial factors were tested for association with headache. Multivariate regression models and linear mixed models were used.

RESULTS

The NSE/NSEB groups reported reduced headache both over time and compared to PPA. Up to 51% (NSE) and 61% (NSEB) reported at least 50% reduction in their headache at 12 months. The PPA group was not improved over time. Neck pain and dizziness were associated with headache regardless of aspect of headache. The only associated psychosocial factor was anxiety, which was associated with headache bothersomeness. Other factors were mainly physical, and up to 51% of the variance was explained.

CONCLUSION

Headache in chronic WAD, may be reduced with neck-specific exercise with or without a behavioral approach. Chronic headache was associated with neck pain and dizziness regardless of aspect tested. Other factors associated with headache in chronic WAD were mainly physical rather than psychosocial.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov, no: NCT015285.

Lifestyle and Chronic Pain across the Lifespan: An Inconvenient Truth?

Chronic pain has a tremendous personal and socioeconomic impact and remains difficult to treat. Therefore, it is important to provide an update on the current understanding regarding lifestyle factors in people with chronic pain across the lifespan. Lifestyle factors such as physical (in)activity, sedentary behavior, stress, poor sleep, unhealthy diet, and smoking are associated with chronic pain severity and sustainment. This applies to all age categories, that is, chronic pain across the lifespan. Yet current treatment options often do not or only partly address the many lifestyle factors associated with chronic pain or attempt to address them in a standard format rather than providing an individually tailored multimodal lifestyle intervention. The evidence regarding lifestyle factors is available in adults, but limited in children and older adults having chronic pain, providing important avenues for future research. In conclusion, it is proposed that treatment approaches for people with chronic pain should address all relevant lifestyle factors concomitantly in an individually-tailored multimodal intervention. Ultimately, this should lead to improved outcomes and decrease the psychological and socioeconomic burden of chronic pain. Level of Evidence: IV.

A Neuroscience Perspective of Physical Treatment of Headache and Neck Pain

The most prevalent primary headaches tension-type headache and migraine are frequently associated with neck pain. A wide variety of treatment options is available for people with headache and neck pain. Some of these interventions are recommended in guidelines on headache: self-management strategies, pharmacological and non-pharmacological interventions. Physical treatment is a frequently applied treatment for headache. Although this treatment for headache is predominantly targeted on the cervical spine, the neurophysiological background of this intervention remains unclear. Recent knowledge from neuroscience will enhance clinical reasoning in physical treatment of headache. Therefore, we summarize the neuro- anatomical and—physiological findings on headache and neck pain from experimental research in both animals and humans. Several neurophysiological models (referred pain, central sensitization) are proposed to understand the co-occurrence of headache and neck pain. This information can be of added value in understanding the use of physical treatment as a treatment option for patients with headache and neck pain.

Non-pharmacological management of persistent headaches associated with neck pain: A clinical practice guideline from the Ontario protocol for traffic injury management (OPTIMa) collaboration

OBJECTIVES

To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic).

METHODS

This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain.

RESULTS

When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated.

CONCLUSIONS

Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation.

SIGNIFICANCE

Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred.

Shi's Daoyin Therapy for Neck Pain: A Randomized Controlled Trial

Objective

To compare the immediate and short term effectiveness of Shi's Daoyin therapy (DT) rather than the Melbourne Protocol (MP) in terms of pain, mobility, and isometric strength of cervical muscles in nonacute nonspecific neck pain patients.

Material and Methods

A total of 114 nonacute nonspecific neck pain patients aged 20~50 years were recruited and randomly assigned to be treated by either Shi's DT or the MP. 56 cases and 54 cases received treatment for 3 weeks and were evaluated before and after intervention and at 3-week follow-up in Shi's DT group and MP group, respectively. The outcome measures were Chinese version of the Neck Disability Index (NDI), cervical range of motion (ROM), maximal voluntary isometric force (MVIF), and pain intensity (Numeric Pain Rating Scale, NPRS).

Results

All outcomes of both groups showed statistically significant improvements after the intervention and at 3-week follow-up (P < 0.05), while no statistically significant difference was found in NDI between groups. When followed up after 3 weeks, the ROM in axial rotation was significantly greater in the Shi's DT group (P < 0.05), and the NPRS in the Shi's DT group was significantly lower than the MP group (P < 0.05). At the end of the treatment period, the MVIF in lateral bending in the Shi's DT group had a lower value (P = 0.044) than in the MP group, but there was no significant difference in flexion and extension between the two groups.

Conclusions

Both Shi's DT and MP groups demonstrated an obvious reduction in pain intensity and improvements in neck mobility after a short term follow-up period. The improvement of Shi's DT in disability and pain during functional activities is generally similar to that of the MP for the treatment of nonacute nonspecific neck pain.

Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial

BACKGROUND CONTEXT

The optimal number of visits for the care of cervicogenic headache (CGH) with spinal manipulative therapy (SMT) is unknown.

PURPOSE

The present study aimed to identify the dose-response relationship between visits for SMT and chronic CGH outcomes and to evaluate the efficacy of SMT by comparison with a light-massage control.

STUDY DESIGN/SETTING

This is a two-site, open-label randomized controlled trial.

PATIENT SAMPLE

Participants were 256 adults with chronic CGH.

OUTCOME MEASURES

The primary outcome was days with CGH in the previous 4 weeks evaluated at the 12- and 24-week primary end points. Secondary outcomes included CGH days at remaining end points, pain intensity, disability, perceived improvement, medication use, and patient satisfaction.

METHODS

Participants were randomized to four dose levels of chiropractic SMT: 0, 6, 12, or 18 sessions. They were treated three times per week for 6 weeks and received a focused light-massage control at sessions when SMT was not assigned. Linear dose effects and comparisons with the no-manipulation control group were evaluated at 6, 12, 24, 39, and 52 weeks. The present study was funded by the National Center for Complementary and Integrative Health (R01AT006330) and is registered at ClinicalTrials.gov (NCT01530321). The authors declare no conflicts of interest.

RESULTS

A linear dose-response was observed for all follow-ups, a reduction of approximately 1 CGH day/4 weeks per additional 6 SMT visits (p<.05); a maximal effective dose could not be determined. Cervicogenic headache days/4 weeks were reduced from about 16 to 8 for the highest and most effective dose of 18 SMT visits. Mean differences in CGH days/4 weeks between 18 SMT visits and control were -3.3 (p=.004) and -2.9 (p=.017) at the primary end points, and were similar in magnitude at the remaining end points (p<.05). Differences between other SMT doses and control were smaller in magnitude (p>.05). Cervicogenic headache intensity showed no important improvement nor differed by dose. Other secondary outcomes were generally supportive of the primary outcome.

CONCLUSIONS

There was a linear dose-response relationship between SMT visits and days with CGH. For the highest and most effective dose of 18 SMT visits, CGH days were reduced by half and about 3 more days per month than for the light-massage control.

Effectiveness of autogenic training on headache: A systematic review

PURPOSE

To investigate the impact of length of autogenic training (AT) use, alone and with the addition of adjunct treatments, on intensity and duration of primary headache in adults age 19 and older.

METHODS

We searched articles published in English and Korean from 1926 to 2016. A search of seven domestic and foreign databases was conducted from September 25, 2016 to December 30, 2016 using the search terms "autogenic training," "autogen," "relaxation," and "headache." The search was documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search yielded a total of 262 papers; a multi-step screening and selection process ultimately yielded six articles of randomized controlled trials (RCTs) for the systematic review. Cochrane's Risk of Bias Tool was used to evaluate the quality of the selected papers.

RESULTS

Five of the six studies demonstrated statistically significant reduction in headache by AT-only or biofeedback-assisted AT. The reviewed studies varied in characteristics of subjects, length of autogenic training and practice, use of adjunct therapies, and use of headache measures.

CONCLUSIONS

The small number of studies retrieved in this review, with their variations in AT interventions used, in AT training/practice time, and headache measures used, did not facilitate rigorous evaluation of the effectiveness of specific AT approaches nor of the optimum length of AT practice for reduction of headache. More research is needed on the effectiveness of AT-only for headache, the most effective duration of autogenic training and practice, and the type(s) of headache for which it is most effective.

Neck-specific exercises with internet-based support compared to neck-specific exercises at a physiotherapy clinic for chronic whiplash-associated disorders: study protocol of a randomized controlled multicentre trial

Background

Globally, neck pain is the fourth most common condition associated with longer periods of living with disability. Annually, approximately 0.3% of the population of Western countries undergo whiplash trauma, and half of those individuals will develop chronic problems with high costs for the individual and society. Evidence for chronic whiplash-associated disorders (WAD) treatment is scarce, though neck-specific training at a physiotherapy clinic twice a week for 12 weeks has demonstrated good results. More efficient, flexible rehabilitation with reduced waiting times and lower costs is needed, ideally replacing lengthy on-site treatment series by healthcare providers. Internet-based care has been shown to be a viable alternative for a variety of diseases and interventions, but studies are lacking on Internet-based interventions for individuals with chronic neck problems. The aim of the trial described here is to compare the effects of an Internet-based neck-specific exercise programme to the same exercises performed at a physiotherapy clinic in regards to self-reported and clinical measures, as well as cost-effectiveness.

Methods

This prospective, randomized controlled trial will involve 140 participants. Measurements will be made at baseline, 3 months (end of treatment), and 15 months (12 months after end of intervention) and will include ratings of pain, disability, satisfaction with care, work ability, quality of life, and cost-effectiveness.

Discussion

The study results may contribute to the development of a more effective rehabilitation, flexible and equal care, shorter waiting times, increased availability, and lower costs for healthcare and society.

Trial registration

ClinicalTrials.gov Protocol ID: NCT03022812, initial release 12/20/2016.

Efficacy of strength training on tension-type headache: A randomised controlled study

Background Strength training has shown effects in reducing neck pain. As neck pain is highly prevalent in tension-type headache (TTH), it is relevant to examine the effect of strength training of the shoulder muscles on TTH patients. Aim To examine the effect of strength training of the shoulder/neck muscles on TTH frequency and duration. Methods Sixty patients with TTH were randomised into strength training or a control group. The strength training group trained ten weeks with elastic resistance bands. The control group performed ergonomic and posture correction. Efficacy was evaluated at follow-up after 19-22 weeks. Results Twenty-three patients completed strength training and 21 completed ergonomic and posture correction (per-protocol). No between-group effect was detected, but within groups numerical reductions were noted in both groups from baseline to follow-up. Frequency of TTH in the strength training group decreased by 11% ( P = 0.041) and duration decreased by10% ( P = 0.036), while the ergonomic and posture correction group showed a significant reduction in frequency of 24% ( P = 0.0033) and a decrease in duration of 27% ( P = 0.041). Conclusion No significant difference between the groups was found and the within-group effects did not reach clinical significance. Combining all the elements into a multifaceted intervention could prove more useful and should be further explored in future studies. Clinical trials registration number NCT02984826.

Neck Pain: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to neck pain. J Orthop Sports Phys Ther. 2017;47(7):A1-A83. doi:10.2519/jospt.2017.0302.

The risk associated with spinal manipulation: an overview of reviews

BACKGROUND

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.

METHODS

We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.

RESULTS

We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.

CONCLUSIONS

It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015030068 .

Dose-response of spinal manipulation for cervicogenic headache: study protocol for a randomized controlled trial

BACKGROUND

Cervicogenic headache is a prevalent and costly pain condition commonly treated by chiropractors. There is evidence to support the effectiveness for spinal manipulation, but the dose of treatment required to achieve maximal relief remains unknown. The purpose of this paper is to describe the methodology for a randomized controlled trial evaluating the dose-response of spinal manipulation for chronic cervicogenic headache in an adult population.

METHODS/DESIGN

This is a mixed-methods, two-site, prospective, parallel groups, observer-blind, randomized controlled trial conducted at university-affiliated research clinics in the Portland, OR and Minneapolis, MN areas. The primary outcome is patient reported headache frequency. Other outcomes include self-reported headache intensity, disability, quality of life, improvement, neck pain intensity and frequency, satisfaction, medication use, outside care, cervical motion, pain pressure thresholds, health care utilization, health care costs, and lost productivity. Qualitative interviews are also conducted to evaluate patients' expectations of treatment.

DISCUSSION

With growing concerns regarding the costs and side effects of commonly used conventional treatments, greater numbers of headache sufferers are seeking other approaches to care. This is the first full-scale randomized controlled trial assessing the dose-response of spinal manipulation therapy on outcomes for cervicogenic headache. The results of this study will provide important evidence for the management of cervicogenic headache in adults.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT01530321).