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

The utilization of dry needling and an upper extremity exercise program for individuals with cervicogenic headaches: A pilot study

OBJECTIVE

To investigate whether a combination of dry-needling treatments and upper extremity neuromuscular reeducation exercises can significantly improve neck pain and/or headache-related disability, joint position error, cervical range of motion, and pain pressure threshold in individuals suffering from cervicogenic headache (CGH).

METHODS

This study is a quasi-experimental design. Seven participants met the inclusion criteria and received dry needling to three muscles that reproduced the participant's headache symptoms and completed the Neck Disability Index (NDI), Headache Disability Inventory (HDI), Visual Analog Scale (VAS), and Numeric Pain Rating Scale (NPRS). Participants performed an exercise regimen designed to address strength and mobility of cervical and scapulothoracic musculature.

RESULTS

There were significant improvements seen in cervical range of motion and neck pain-related disability (NDI) during the 4-week treatment period.

CONCLUSION

Dry needling and neuromuscular re-education (NMR) exercises could be effective components of treatment for individuals suffering from CGH to reduce disability and pain.

Cervicogenic Headaches: A Literature Review and Proposed Multifaceted Approach to Diagnosis and Management

Cervicogenic headaches are a secondary headache disorder attributable to cervical spine dysfunction resulting in head pain with or without neck pain. Diagnosis of this condition has been complicated by varied clinical presentations, causations, and differing diagnostic criteria. In this article, we aim to clarify the approach to diagnosing cervicogenic headaches by providing an overview of cervicogenic headaches, clinical case examples, and a practical diagnostic algorithm based on the most current criteria. A standardized approach will aid in confirmation of the diagnosis of cervicogenic headaches and facilitate further research into this condition.

Reliability and measurement properties of upper cervical flexion-extension range of motion testing in people with cervicogenic headache and asymptomatic controls

OBJECTIVE

The objective was to determine reliability of sagittal plane range of motion (ROM) assessment in a healthy population and in people with cervicogenic headache (CGH).

METHODS

Upper cervical flexion/extension ROM was measured using an iPhone magnetometer sensor and retraction/protraction ROM measured by linear displacement. Two independent raters evaluated these movements in 33 subjects with CGH and 33 age and gender matched asymptomatic healthy controls on two occasions. Measurement procedures were standardized; and the order of testing randomized. Reliability, standard error of measurement (SEM) and minimum detectable change (MDC) were calculated.

RESULTS

Subjects comprised 30 females and 36 males. The iPhone method demonstrated high reliability (ICC >0.82) with SEM values ranging from 0.62 to 1.0 and MDC values ranging from 1.70 to 4.81 respectively. Evaluation of linear displacement demonstrated moderate reliability (ICC >64). with SEM values ranging from 0.38 to 1.91 and MDC values ranging from 1.05 to 1.63 respectively. Compared to healthy controls, upper cervical flexion, retraction and protraction ROM was significantly less in the CGH group with mean difference of 6.50°, 1.52 cm and 2.34 cm respectively.

DISCUSSION

Upper cervical spine sagittal plane ROM can be measured with moderate to high reliability and was found to be more restricted in people with CGH.

Comparative effectiveness of cervical vs thoracic spinal-thrust manipulation for care of cervicogenic headache: A randomized controlled trial

BACKGROUND

There is ample evidence supporting the use of different manipulative therapy techniques for Cervicogenic Headache (CgH). However, no technique can be singled as the best available treatment for patients with CgH. Therefore, the objective of the study is to find and compare the clinical effects of cervical spine over thoracic spine manipulation and conventional physiotherapy in patients with CgH.

DESIGN, SETTING, AND PARTICIPANTS

It is a prospective, randomized controlled study conducted between July 2020 and January 2023 at the University hospital. N = 96 eligible patients with CgH were selected based on selection criteria and they were divided into cervical spine manipulation (CSM; n = 32), thoracic spine manipulation (TSM; n = 32) and conventional physiotherapy (CPT; n = 32) groups, and received the respective treatment for four weeks. Primary (CgH frequency) and secondary CgH pain intensity, CgH disability, neck pain frequency, neck pain intensity, neck pain threshold, cervical flexion rotation test (CFRT), neck disability index (NDI) and quality of life (QoL) scores were measured. The effects of treatment at various intervals were analyzed using a 3 × 4 linear mixed model analysis (LMM), with treatment group (cervical spine manipulation, thoracic spine manipulation, and conventional physiotherapy) and time intervals (baseline, 4 weeks, 8 weeks, and 6 months), and the statistical significance level was set at P < 0.05.

RESULTS

The reports of the CSM, TSM and CPT groups were compared between the groups. Four weeks following treatment CSM group showed more significant changes in primary (CgH frequency) and secondary (CgH pain intensity, CgH disability, neck pain frequency, pain intensity, pain threshold, CFRT, NDI and QoL) than the TSM and CPT groups (p = 0.001). The same gradual improvement was seen in the CSM group when compared to TSM and CPT groups (p = 0.001) in the above variables at 8 weeks and 6 months follow-up.

CONCLUSION

The reports of the current randomized clinical study found that CSM resulted in significantly better improvements in pain parameters (intensity, frequency and threshold) functional disability and quality of life in patients with CgH than thoracic spine manipulation and conventional physiotherapy.

TRIAL REGISTRATION

Clinical trial registration: CTRI/2020/06/026092 trial was registered prospectively on 24/06/2020.

Cervicogenic headache - How to recognize and treat

Cervicogenic headache, described almost 100 years ago, only had its clinical awakening at the end of the century with the work of Professor Sjaastad. Its classic definition is the induction of trigeminal symptoms from cervical disorders, thanks to trigeminocervical convergence mechanisms. For this reason, it can manifest several features typical of migraine, leading to diagnostic errors. Classically, subjects complain of fixed unilateral headaches, with cervical onset and trigeminal irradiation, associated with reduced neck mobility and flexion strength. The headache is mild to moderate, described as pulsatile or compressive, accompanied by nausea, vomiting, photophobia, phonophobia, and may present autonomic symptoms and dizziness. The pain duration varies from one day to weeks, and its frequency is unpredictable. A history of whiplash injury is common. The differential diagnosis encompasses migraine and tension-type headache. Management includes physiotherapy rehabilitation, anesthetic blocks, and selectively surgical procedures. In this article, all these aspects were extensively covered.

Immediate effects of superficial dry needling of the trigeminal nerve innervation field for participants with cervicogenic headache. A randomized controlled trial

BACKGROUND

Cervicogenic headache (CGH) is a common condition with a neuroanatomical basis involving the trigeminal nerve. Dry needling (DN) is a safe and effective treatment for CGH but most studies involve deep DN to cervical musculature.

OBJECTIVE

The aim of this study was to investigate immediate effects of superficial DN of the trigeminal nerve innervation field on numeric pain rating scale (NPRS), flexion-rotation test (FRT), cervical range of motion (AROM), and pain-pressure threshold (PPT) of right (R) and left (L) supraorbital (SO), and right (R) and left (L) greater occipital (GO) nerves in participants with CGH.

METHODS

A parallel controlled randomized design involving 30 participants with CGH received either superficial DN (N = 17) or sham DN (N = 13). Participants and outcome assessors were blind to group assignment. Wilcoxon signed rank analyzed within-group effects and Mann-Whitney U analyzed between-group.

RESULTS

Statistically significant between-group differences were observed for NPRS (P < .001) and AROM (P < .006) favoring DN and were clinically meaningful. Right and left Flexion rotation tests (FRT) outcomes were non-significant (P = .137) but clinically meaningful. No differences were observed for PPT over: R SO (P = .187); L SO (P = .052); R GO (P = .187); or L GO (P = .052). Between-group effect sizes across variables were moderate to large (0.53-1.4) but confidence intervals were wide.

CONCLUSION

Superficial DN targeting the innervation field of the trigeminal nerve improves clinical outcomes in patients with CGH. Only the immediate effects were analyzed and the sample size was small. Larger, longer-term assessments are needed comparing superficial DN of the trigeminal innervation field and other conservative interventions for CGH.

Utilization of the Cervical Flexion Rotation Test to Confirm Rotation Directional Preference in People With Neck Pain: A Case Series

Despite the prevalence of neck pain, evidence is lacking regarding the relationship of pathophysiology to function in people with neck conditions. Although movement-based diagnoses based on directional preference (DP) are described for lumbar spinal conditions, how these diagnoses guide interventions is not supported in the Cervical Spine Clinical Practice Guidelines. To date, there are no case studies in the literature that demonstrate the efficacy of cervical spine management based on a rotation DP. This case series highlights patient response to repeated end-range neck movements to inform DP and how the cervical flexion rotation test (CFRT) was used as a clinical baseline to assess mechanical and symptomatic changes. Three consecutive patients were evaluated by a physical therapist fellow trained in orthopedic manual physical therapy and diplomaed in mechanical diagnosis and therapy. The patients' baseline pain ranged from 3 to 7/10 on the Numerical Pain Rating Scale (NPRS), and disability scores ranged from 20% to 52.6% on patient-reported outcome (PRO) measures. All three cases demonstrated a limited and painful CFRT. Examination procedures included repeated end-range movement testing in the sagittal and frontal and transverse planes. Across five to six visits in five to eight weeks, a decrease in the primary outcome measures from baseline to discharge were observed: NPRS, 50-85%; PRO, 60-82%. The CFRT may be a key baseline when screening patients with neck pain for DP. Following repeated end-range sagittal and frontal plane movements, the rapid change in the CFRT following targeted upper cervical rotation techniques confirmed a rotation DP.

The cervical spine in tension type headache

INTRODUCTION

The concept that headaches may originate in the cervical spine has been discussed over decades and is still a matter of debate. The cervical spine has been traditionally linked to cervicogenic headache; however, current evidence supports the presence of cervical musculoskeletal dysfunctions also in tension-type headache.

PURPOSE

This position paper discusses the most updated clinical and evidence-based data about the cervical spine in tension-type headache.

IMPLICATIONS

Subjects with tension-type headache exhibit concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, positive flexion-rotation test and also cervical motor control disturbances. In addition, the referred pain elicited by manual examination of the upper cervical joints and muscle trigger points reproduces the pain pattern in tension-type headache. Current data supports that the cervical spine can be also involved in tension-type headache, and not just in cervicogenic headache. Several physical therapies including upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling) and exercises targeting the cervical spine are proposed for managing tension-type headache; however, the effectiveness of these interventions depends on a proper clinical reasoning since not all will be equally effective for all individuals with tension-type headache. Based on current evidence, we propose to use the terms cervical "component" and cervical "source" when discussing about headache. In such a scenario, in cervicogenic headache the neck can be the cause (source) of the headache whereas in tension-type headache the neck will have a component on the pain pattern, but it will be not the cause since it is a primary headache.

Cervical musculoskeletal impairments and pain sensitivity in migraine patients

INTRODUCTION

Currently, examination of migraine patients relies on a clinical interview investigating symptoms characteristics. Despite this, to help identify distinct migraine subtypes and allow a personalized treatment approach, biomarkers to profile distinct migraine subtypes should be utilized in clinical and research settings. Therefore, there is a need to include physical and psychophysical examinations aimed at assessing migraine features quantitatively.

PURPOSE

This paper aimed to discuss if increased pressure pain sensitivity and impaired cervical musculoskeletal function could be considered 1) as quantitative features of migraine and 2) if they could be used as biomarkers to profile migraine patients in distinct subtypes.

IMPLICATION

Increased pain sensitivity and cervical musculoskeletal impairments have been suggested as quantitative biomarkers to phenotype and subgroup migraine patients in clinical and research settings. This could provide the first step for a mechanistically-driven and personalized treatment approach according to migraine phenotypes.

Cervicogenic headache

INTRODUCTION

Cervicogenic headache, first proposed as a distinct headache in 1983, is a secondary headache to a primary cervical musculoskeletal disorder. Research into physical impairments was integral to clinical diagnosis and to develop and test research informed conservative management as the first line approach.

PURPOSE

This narrative presents an overview of the body of cervicogenic headache research from our laboratory which was undertaken in the context of a broad program of research into neck pain disorders.

IMPLICATIONS

Early research validated manual examination of the upper cervical segments against anaesthetic nerve blocks, which was vital to clinical diagnosis of cervicogenic headache. Further studies identified reduced cervical motion, altered motor control of the neck flexors, reduced strength of flexor and extensor muscles, and occasional presentation of mechanosensitivity of the upper cervical dura. Single measures are variable and not reliable in diagnosis. We proved that a pattern of reduced motion, upper cervical joint signs and impaired deep neck flexor function accurately identified cervicogenic headache and differentiated it from migraine and tension-type headache. The pattern was validated against placebo controlled diagnostic nerve blocks. A large multicentre clinical trial determined that a combined program of manipulative therapy and motor control exercise is effective in the management of cervicogenic headache and outcomes are maintained in the long term. More specific research into cervical related sensorimotor controlled is warranted in cervicogenic headache. Further adequately powered clinical trials of current research informed multimodal programs are advocated to further strengthen the evidence base for conservative management of cervicogenic headache.

Headache production during physical examination in patients with and without headache attributed to a whiplash injury: A case-control study

BACKGROUND

Provocation of headache on physical examination of the neck may reflect a role of cervical structures in the presence of acute whiplash-associated headache (WAH).

OBJECTIVE

To determine differences in headache provocation during physical tests in people with and without WAH after a whiplash injury.

DESIGN

Case-control study.

METHODS

Forty-seven people with acute whiplash-associated disorders participated, 28 with WAH. Passive accessory intervertebral movement over the tubercle of C1, the spinous processes of C2-C3 and facet joints of C0-C4, the flexion-rotation test (FRT), manual palpation of cranio-cervical muscles and the upper limb neurodynamic test + cranio-cervical flexion were assessed bilaterally twice by a blinded examiner; headache provocation was determined. Cohen's kappa and Chi-squared were determined to evaluate the intra-rater reliability of test results and differences between groups, respectively. A logistic regression model was also performed.

RESULTS

Intra-rater reliability of headache provocation was good or excellent for most tests. Significant differences between groups were found with higher positive tests in WAH for the assessment of C2 (68%), the most painful side of C0-C1 (57%), C1-C2 (75%) and C2-C3 (53%), most (79%) and least (25%) restricted sides of the FRT, and manual palpation of the most painful side for the trapezius (53%), masseter (50%) and temporalis (46%) muscles. Provocation of headache during the assessment of C2 and C1-C2 on the most painful side demonstrated the highest association with WAH.

CONCLUSION

Mechanical provocation of headache is more frequent in people with WAH than in those without headache soon after a whiplash injury.

Migraine patients with and without neck pain: Differences in clinical characteristics, sensitization, musculoskeletal impairments, and psychological burden

AIMS

This study aims to assess differences in clinical characteristics across healthy controls and migraine patients with (MNP) and without (MwoNP) neck pain.

METHOD

This study assessed: headache frequency; headache disability index (HDI); central sensitization inventory (CSI); Hospital Anxiety (HADS-A) and Depression (HADS-D) scale; active range of motion (AROM); flexion rotation test (FRT); activation pressure score (APS); number of active/latent myofascial trigger points (MTrPs) in head/neck muscles; number of positive cervical vertebral segments (C1/C2) who reproduce migraine pain; wind-up ratio (WUR); mechanical pain threshold (MPT) and static pressure pain threshold (sPPT) over the trigeminal area; sPPT and dynamic PPT (dPPT) over the cervical area; sPPTs and MPT over the hand.

RESULTS

Compared to controls, MNP had: worse CSI, HADS-A, and HADS-D (all, p < 0.002); reduced AROM (flexion, extension, left lateral-flexion, and right-rotation), FRT, APS, and a higher number of MTrPs and positive cervical vertebral segments (all, p < 0.020); reduced trigeminal MPT and sPPT, cervical sPPT and dPPT, hand MPT and sPPT (all, p < 0.006). Compared to controls, MwoNP had: worse CSI, and HADS-A (all, p < 0.002); reduced AROM (flexion, and left lateral-flexion), FRT, APS, and a higher number of MTrPs and positive cervical vertebral segments (all, p < 0.017); reduced trigeminal MPT and cervical dPPT (all, p < 0.007). Compared to MwoNP, MNP had higher headache frequency, worse HDI and CSI (all, p < 0.006); reduced AROM (flexion, and right rotation) (all, p < 0.037); reduced cervical dPPT (all, p < 0.002).

CONCLUSION

MNP had worse headache characteristics, more pronounced cervical musculoskeletal impairments, enhanced signs and symptoms related to sensitization, and worse psychological burden compared to MwoNP.

Headache and orofacial pain: A traffic-light prognosis-based management approach for the musculoskeletal practice

Introduction

Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.

Purpose

The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.

Implications

Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

Comparative Effects of Mulligan's Mobilization, Spinal Manipulation, and Conventional Massage Therapy in Cervicogenic Headache-A Prospective, Randomized, Controlled Trial

Background: There is ample evidence supporting the use of manual therapy techniques for the treatment of cervicogenic headache (CGH). Objective: The objective of this study was to find and compare the effects of different manual therapy approaches to cervicogenic headache. Methods: A randomized, controlled study was conducted on 84 CGH participants at the university hospital. The participants were divided into a Mulligan mobilization therapy group (MMT; n = 28), a spinal manipulation therapy group (SMT; n = 28), and a control group (Control; n = 28); they received the respective treatments for four weeks. The primary outcome (CGH frequency) and secondary outcomes (CGH pain intensity, CGH disability, neck pain frequency, pain intensity, pain threshold, flexion rotation (right and left), neck disability index, and quality of life scores) were measured at baseline, after 4 weeks, after 8 weeks, and at a 6-month follow-up. The one-way ANOVA test and repeated measures analysis of variance (rANOVA) test were performed to find the difference between the inter- and intra-treatment group effects. Results: Four weeks following training, the MMT group showed a statistically significant difference in the primary (CGH frequency) and secondary (CGH pain intensity, CGH disability, neck pain frequency, neck pain intensity, flexion rotation test, neck disability index, and quality of life) scores than those of the SMT and control groups (p < 0.001). The same difference was seen in the above variables at 8 weeks and at the 6-month follow-up. At the same time, the neck pain threshold level did not show any difference at the 4-week and the 8-week follow-up (p ≥ 0.05) but showed statistical difference at the 6-month follow-up. Conclusion: The study concluded that Mulligan’s mobilization therapy provided better outcomes in cervicogenic headache than those of spinal manipulation therapy and conventional massage therapy.

Inter-rater reliability, discriminatory and predictive validity of neck movement control tests in office workers with headache and/or neck pain

BACKGROUND

Movement control tests (MCTs) are clinical tests to evaluate impairment of movement and associated neuromuscular control and are commonly used to evaluate people with neck pain or headache conditions. The aim of this study was to establish inter-rater reliability as well as discriminatory and predictive validity for seven MCTs of the upper (UCS) and lower cervical spine (LCS) in office workers with headache or neck pain.

METHODS

Seven MCTs of the UCS (3) and LCS (4) were performed at baseline on 140 office workers which were included in a cluster randomized controlled trial. The occurrences of headache and neck pain were established at baseline (discriminatory validity) and at a 15-month follow-up (predictive validity). Inter-rater-reliability was established in a separate cross-sectional study.

RESULTS

MCTs showed slight to almost perfect inter-rater reliability but limited discriminatory (baseline) and limited to small predictive validity (15-month follow up) for different subgroups of office workers with headache and/or neck pain. MCTs of the UCS showed limited discriminatory validity, especially for rotation in participants with headache and neck pain compared to those with headache only (Negative Likelihood-ratio: 0.82, 95% CI: 0.69-0.98). Participants with neck pain only and ≥1/4 positive MCTs for the sagittal plane had an increased risk for future neck pain (Relative risk: 3.33, 95% CI: 1.05-10.56).

DISCUSSION

MCTs of the UCS and LCS are reliable but have only limited to small validity to predict future headache events in office workers. Insufficient sagittal plane movement control may predict neck pain relapses in the future.

Cervicogenic headache, an easy diagnosis? A systematic review and meta-analysis of diagnostic studies

BACKGROUND

The diagnosis of cervicogenic headache (CGH) remains a challenge for clinicians as the diagnostic value of detailed history and clinical findings remains unclear.

OBJECTIVES

To update and evaluate available evidence of the prevalence and the diagnostic accuracy of the detailed history and clinical findings for CGH in adults with headache.

DESIGN

Systematic review with meta-analysis.

METHODS

CINAHL, Cochrane Central, Embase, PEDro and PubMed were searched for studies before March 2022 that reported detailed history and/or clinical findings related to the diagnosis of cervicogenic headache. Study selection, risk of bias assessment (QUADAS-2 and PROBAST), and data extraction were performed. Meta-analyses for the cervical flexion-rotation test (CFRT) was performed. Certainty of the evidence was assessed with the GRADE approach.

RESULTS

Eleven studies were included. Moderate certainty evidence indicated that the CFRT differentiated CGH from lower cervical facet-induced headache, migraine, concomitant headaches or asymptomatic subjects (Se 83.0% [95%CI:70.0%-92.0%]; Sp 83.0% [95%CI:71.0%-91.0%]; positive LR 5.0 [95%CI:2.6-9.5]; negative LR 0.2 [95%CI:0.1-0.4]; n = 4 studies; n = 182 participants). Several diagnostic classifications and test clusters based on headache history and clinical findings can be useful, despite uncertain accuracy, in formulating the diagnosis of CGH.

CONCLUSION

Evidence support to undertake an evaluation of headache history and signs and symptoms and a physical examination of the patient neck to diagnose CGH. During the physical examination, a positive or negative CFRT probably has a small to moderate effect on the probability of a patient having a CGH. The diagnostic value of the other findings remains unclear.

TRIAL REGISTRATION

#CRD42020201772.

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.

Response rate and comparison of clinical features associated with positive or negative responses to a scapular positioning test in patients with neck pain and altered scapular alignment: a cross-sectional study

Objective

To investigate the frequency and clinical aspects of patients with neck pain who responded and did not respond to scapular repositioning and to determine the clinical features associated with a positive response.

Design

Cross-sectional study.

Setting

Research unit, Department of Physical Therapy, Chiang Mai University.

Participants

Volunteers with non-specific neck pain aged 18–59 years were recruited between May 2020 and February 2021 from hospitals, clinics, university and community.

Outcome measures

Clinical data documented were neck pain (intensity, duration and disability), the presence of headache, type of scapular dysfunction, cervical musculoskeletal impairment (range of motion (ROM), flexion rotation test (FRT) and location of any symptomatic cervical joint dysfunction), upper limb functional limitation and self-reported disability. Manual scapular repositioning was performed on the side of neck pain. Participants were categorised as responsive or non-responsive based on a change in pain and/or cervical rotation range.

Results

A total of 219 people with neck pain responded to advertisements, of which 144 were eligible. Of the eligible participants, 107 (74.3%) demonstrated a clinically relevant improvement in either neck pain or rotation range or both following the scapular repositioning and 37 (25.7%) had no relevant improvement. The responsive group had a high incidence of scapular downward rotation, greater neck pain intensity, headache and cervical musculoskeletal impairment (reduced ROM, positive FRT and symptomatic C1-3 dysfunction) compared with the non-responsive group (p<0.05). A logistic regression model revealed that features strongly associated with a positive response were the presence of headache (Exp(B)=6.0, 95% CI 2.3 to 15.8), scapular downward rotation (Exp(B)=5.3, 95% CI 2.3 to 12.6) and a positive FRT (Exp(B)=4.0, 95% CI 1.5 to 10.6).

Conclusion

Almost 75% of neck pain patients with altered scapular alignment responded to scapular repositioning. The predominance of upper cervical dysfunction with a downwardly rotated scapular in this group suggests a role of poor axioscapular muscle function which might benefit from rehabilitation.

Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis

BACKGROUND

Migraine and cervicogenic headache (CGH) are common headache disorders, although the large overlap of symptoms between them makes differential diagnosis challenging. To strengthen differential diagnosis, physical testing has been used to examine for the presence of musculoskeletal impairments in both conditions. This review aimed to systematically evaluate differences in physical examination findings between people with migraine, CGH and asymptomatic individuals.

METHODS

The databases MEDLINE, PubMed, CINAHL, Web of Science, Scopus, EMBASE were searched from inception until January 2020. Risk of bias was assessed with the Downs and Black Scale for non-randomized controlled trials, and with the Quality Assessment of Diagnostic Accuracy Studies tool for diagnostic accuracy studies. When possible, meta-analyses with random effect models was performed.

RESULTS

From 19,682 articles, 62 studies were included in this review and 41 were included in the meta-analyses. The results revealed: a) decreased range of motion [°] (ROM) on the flexion-rotation test (FRT) (17.67, 95%CI:13.69,21.65) and reduced neck flexion strength [N] (23.81, 95%CI:8.78,38.85) in CGH compared to migraine; b) compared to controls, migraineurs exhibit reduced flexion ROM [°] (- 2.85, 95%CI:-5.12,-0.58), lateral flexion ROM [°] (- 2.17, 95% CI:-3.75,-0.59) and FRT [°] (- 8.96, 95%CI:-13.22,-4.69), reduced cervical lordosis angle [°] (- 0.89, 95%CI:-1.72,-0.07), reduced pressure pain thresholds over the cranio-cervical region [kg/cm²], reduced neck extension strength [N] (- 11.13, 95%CI:-16.66,-5.6) and increased activity [%] of the trapezius (6.18, 95%CI:2.65,9.71) and anterior scalene muscles (2.87, 95%CI:0.81,4.94) during performance of the cranio-cervical flexion test; c) compared to controls, CGH patients exhibit decreased neck flexion (- 33.70, 95%CI:-47.23,-20.16) and extension (- 55.78, 95%CI:-77.56,-34.00) strength [N].

CONCLUSION

The FRT and neck flexion strength could support the differential diagnosis of CGH from migraine. Several physical tests were found to differentiate both headache types from asymptomatic individuals. Nevertheless, additional high-quality studies are required to corroborate these findings.

STUDY REGISTRATION

Following indications of Prisma-P guidelines, this protocol was registered in PROSPERO on 21/05/2019 with the number CRD42019135269 . All amendments performed during the review were registered in PROSPERO, indicating the date and what and why was changed.

Effects of combining manual therapy, neck muscle exercises, and therapeutic pain neuroscience education in patients with migraine: a study protocol for a randomized clinical trial

BACKGROUND

Non-pharmacological approaches for the management of migraine exhibit low to moderate effectiveness due to a lack of high-quality randomized clinical trials. In fact, previous studies applied isolated techniques, which were not representative of common clinical practice. A multimodal approach for migraine may benefit these patients more than isolated approaches. This randomized clinical trial aims to determine the effectiveness of a multimodal protocol combining manual therapy, exercise, and therapeutic pain neuroscience education versus the application of manual therapy or pain neuroscience education alone in patients with migraine.

METHODS

This clinical trial will include 75 individuals of both sexes, aged between 18 and 55 years, with migraine. Participants will be randomized into three groups: the therapeutic pain neuroscience education (TPNE; n = 25) group, the manual therapy (MT; n = 25) group, and the multimodal (MM; n = 25) group. The TPNE group will receive one orientation session on migraine and pain self-management, and recommendations for daily active stretching and walking, with subsequent therapist monitoring. The MT group will receive manual therapies targeting musculoskeletal disorders of the cervical spine. The MM group will receive manual therapies targeting musculoskeletal disorders of the cervical spine, active neck exercises, and therapeutic pain neuroscience education. The treatment period will last 12 weeks. The primary outcome will be the headache impact, measured using the Headache Impact Test (HIT-6). Secondary outcomes will include migraine frequency and intensity, cervical mobility and strength parameters, neck pain-related disability, kinesiophobia, cutaneous allodynia, pain-related catastrophizing, quality of life, and self-perception of change. All outcomes will be evaluated at the fourth, eighth, and twelfth weeks of the treatment period. Primary and secondary clinical outcomes, such as headache impact, frequency, and intensity, will also be evaluated at the 1-, 2-, and 4-month follow-ups.

DISCUSSION

The results of this randomized clinical trial may provide high-quality clinical evidence of the effects of non-pharmacological treatment options for the management of migraine.

TRIAL REGISTRATION

This study was registered under the access code RBR-7s22c75 in the Registro Brasileiro de Ensaios Clínicos (ReBEC) in December 2020.

The association between specific temporomandibular disorders and cervicogenic headache

BACKGROUND AND AIMS

Upper neck signs, symptoms and hypomobility have been shown to present with a higher prevalence in patients with temporomandibular disorders (TMDs). However, there is currently no evidence of an association between specific TMDs and cervicogenic headache (CGH). Therefore, the aim of this study was to evaluate the odds ratio and the relative risk of CGH in patients with specific TMDs.

METHOD

116 participants, including 74 patients with TMD (pain-related/intraarticular/mixed TMD) and 42 healthy controls took part in this study. The TMD diagnosis was made by senior faculty members of the Dental School according to the Diagnostic Criteria for TMD, while the cervical diagnosis was made by a qualified senior physical therapist. The analysis comprised the evaluation of the odds ratio of CGH among patients with TMD and the relative risk (RR) for CGH during 14-24 months of follow-up.

RESULTS

Significantly higher odds ratios of cervicogenic headache were found among pain-related and mixed TMD (12.17 and 10.76, respectively) versus healthy controls. During the 14-24 months of follow-up, there was no significant difference of relative risk for CGH among patients with TMD versus healthy controls.

SUMMARY AND CONCLUSIONS

The results support a clear clinical association between painful TMD (pain-related and mixed TMD) and cervicogenic headache.

Effects of SNAG mobilization combined with a self-SNAG home-exercise for the treatment of cervicogenic headache: a pilot study

INTRODUCTION

Cervicogenic headache (CGH) may originate from the C1-C2 zygapophyseal joints. CGH is often associated with loss of range of motion (ROM), specific to this segment, and measurable by the cervical flexion-rotation test (CFRT). The main purposes of the study were: 1) to investigate the immediate effect of C1-C2 rotation SNAG mobilizations plus C1-C2 self-SNAG rotation exercise for patients with CGH and 2) to explore the link between the CFRT results and treatment response.

METHODS

A prospective quasi-experimental single-arm design was used where patients with CGH received eight physical therapy treatments using a C1-C2 rotational SNAG technique combined with a C1-C2 self-SNAG rotation exercise over a four-week period. Outcome measures were pain intensity/frequency and duration, active cervical ROM, CFRT, neck-related and headache-related self-perceived physical function, fear-avoidance beliefs, pain catastrophizing and kinesiophobia.

RESULTS

The intervention produced strong effects on pain intensity, CFRT, physical function and pain catastrophizing. Moderate improvement was noted on active cervical ROM and on fear-avoidance beliefs and kinesiophobia. No link was found between pre-intervention CFRT ROM and treatment response.

CONCLUSION

SNAG mobilization combined with a self-SNAG exercise resulted in favorable outcomes for the treatment of CGH on patient-important and biomechanical outcomes, as well as pain-related cognitive-affective factors.

The C0-C2 axial rotation test - Reliability and correlation with the flexion rotation test in people with cervicogenic headache and migraine

OBJECTIVES

The C0-C2 axial rotation test is a measure of upper cervical range of motion (UCROM), reported to be reliable in a headache free population. The objective was to determine the intra- and inter-rater reliability of the C0-C2 axial rotation test in people with a diagnosis of cervicogenic headache (CGH) or episodic migraine.

METHODS

Two therapists independently evaluated UCROM during the C0-C2 axial rotation test and flexion-rotation test (FRT) with an iPhone in 70 subjects (mean age 37.7 SD 11.6 years) with a diagnosis of CGH (35 subjects) or episodic migraine (35 subjects) on two occasions. Measurement procedures were standardized; and the order of testing randomized.

RESULTS

Reliability of the C0-C2 axial rotation test was moderate to high (ICC > 0.70). The standard error of measurement and minimum detectable change for this test were at most 2°. In subjects with CGH mean UCROM to the most restricted side was 9.3° (1.9) and 8.8° (2.1) for rater 1 and 2 respectively. While in patients with episodic migraine mean UCROM to the restricted side was 13.7° (1.6) and 13.6° (2.0) for rater 1 and 2 respectively.

DISCUSSION

The C0-C2 axial rotation test has at least moderate levels of reliability and correlates well with mobility determined by the FRT.

The presence of aura is not related to changes in the cervical performance and mobility of patients with migraine

BACKGROUND

Migraine may be associated with neck impairment and migraine chronicity is related to greater disability. However, whether other subclassifications of migraine, such as migraine with aura, are related to neck impairment is currently unknown. The aim of this study was to assess the musculoskeletal aspects of the neck in patients with migraine with and without aura.

METHODS

Consecutive patients diagnosed with migraine were recruited from a tertiary headache clinic. The patients were divided into two groups according to the presence (MA, n = 37) and absence of aura (MoA, n = 88). The self-report of neck pain and neck disability was assessed using the Neck Disability Index (NDI). The patients underwent the flexion rotation test (FRT) and craniocervical flexion test (CCFT).

RESULTS

There was no association between the presence of aura and neck pain (χ²: 1.32, p = 0.25). No differences in the extent of neck disability (MA: 10.73, SD: 6.22; MoA: 9.63, SD:8.13, p = 0.25) or disability severity (χ² = 6.17, p = 0.10) were found between groups. The FRT did not differ between the groups (MA: 35.07°, SD: 7.90 and MoA: 34.60°, SD: 8.70, t = -0.22, p = 0.83) and there was no association between positive FRT and aura (χ² = 0.004, p = 0.56). The absence of difference between groups was also verified in the CCFT test (U = 1648.0, p = 0.89).

CONCLUSION

There was no association between aura and neck pain disability, reduced upper cervical spine mobility or reduced neck muscle performance. No differences in the neck impairment level between patients with and without aura during the clinical assessment of the cervical spine are expected.

Upper cervical range of rotation during the flexion-rotation test is age dependent: an observational study

Background:

The flexion-rotation test (FRT) is widely used to detect movement dysfunction in the spinal segment C1/C2, especially in patients with cervicogenic headache. The current published literature indicates that range recorded during the FRT is not age dependent. This is questionable, considering the well documented relationship between aging and degeneration in the cervical spine and loss of cervical movement in older people. The present study therefore aims to examine the influence of age on FRT mobility, and to provide normative values for different age groups. An additional aim is to examine the influence of age on the ratio between lower and upper cervical rotation mobility.

Methods:

For this cross-sectional, observational study, healthy subjects aged from 18 to 90 years were recruited. The upper cervical range of rotation during the FRT was measured using a digital goniometer. Personal data including age, weight, height, and lifestyle factors were also assessed.

Results:

A total of 230 (124 male) healthy, asymptomatic subjects, aged between 18 and 87 years were included. Regression analysis showed that 27.91% (p < 0.0001) of the variance in FRT mobility can be explained by age alone, while 41.28% (p < 0.0001) of the variance in FRT mobility can be explained by age and total cervical range of motion (ROM). Normative values for different age decades were calculated using regression analysis. No significant influence of age on the ratio between ROM of lower and upper cervical rotation was found. There was no relevant impact of personal (gender, height, and weight) and lifestyle (smartphone and PC use) factors on ROM during the FRT.

Conclusion:

Upper cervical rotation mobility determined by the FRT correlates strongly with age; hence, the results of the FRT have to be interpreted taking into account the individual age of the tested subject. The ratio between lower and upper cervical rotation mobility is maintained in all age groups.

Biomechanics of the upper cervical spine ligaments in axial rotation and flexion-extension: Considerations into the clinical framework

Context:

The motion of the upper cervical spine (UCS) has a great interest for analyzing the biomechanical features of this joint complex, especially in case of instability. Although investigators have analyzed numerous kinematics and musculoskeletal characteristics, there are still little data available regarding several suboccipital ligaments such as occipito-atlantal, atlantoaxial, and cruciform ligaments.

Objective:

The aim of this study is to quantify the length and moment arm magnitudes of suboccipital ligaments and to integrate data into specific 3D-model, including musculoskeletal and motion representation.

Materials and Methods:

Based on a recent method, suboccipital ligaments were identified using UCS anatomical modeling. Biomechanical characteristics of these anatomical structures were assessed for sagittal and transversal displacements regarding length and moment arm alterations.

Results:

Outcomes data indicated length alterations >25% for occipito-atlantal, atlanto-axial and apical ligaments. The length alteration of unique ligaments was negligible. Length variation was dependent on the motion direction considered. Regarding moment arm, larger magnitudes were observed for posterior ligaments, and consistent alteration was depicted for these structures.

Conclusion:

These outcomes supply relevant biomechanical characteristics of the UCS ligaments in flexion-extension and axial rotation by quantifying length and moment arm magnitude. Moreover, 3D anatomical modeling and motion representation can help in the process of understanding of musculoskeletal behaviors of the craniovertebral junction.

"Short- and mid-term effects of adding upper cervical manual therapy to a conventional physical therapy program in patients with chronic mechanical neck pain. Randomized controlled clinical trial."

OBJECTIVE

To evaluate the effect of adding an Upper Cervical Translatoric Mobilization (UCTM) or an Inhibitory Suboccipital Technique (IST) to a physiotherapy treatment in the symptomatology and function of mechanical chronic neck pain patients.

DESIGN

Randomized controlled trial.

SETTING

Primary Care Center in Cornellà, Spain.

SUBJECTS

78 patients (64 women), with mean age (SD) of 59.96 (13.30) years with mechanical chronic neck pain were divided in three groups: control, IST and UCTM groups.

INTERVENTIONS

All groups received 15 physiotherapy sessions for three weeks. The UCTM and IST groups added 5 minutes of the assigned technique during six sessions.

MAIN MEASURES

Neck disability index (NDI) and numeric pain rating scale (NPRS) for neck pain were measured baseline, three-weeks and 15-weeks follow-up.

RESULTS

NDI (SD) at baseline, three-weeks and 15-weeks were 11.62 (7.08), 9.65 (6.25), 7.58 (5.64) for the control group, 14.38 (6.92), 8.50 (6.11), 7.12 (4.98) for the IST group and 13.19(7.23), 5.35(6.10), 4.35(2.76) for the UCTM group. NPRS (SD) at baseline, three-weeks and 15-weeks were 58.69 (19.46), 45.19 (23.43), 44.58 (24.08) for the control group; 64.08 (19.26), 42.19 (19.69), 34 (21.14) for the IST group; and 67.65 (20.65), 36.23 (20.10), 39.85 (25.44) for the UCTM group.

CONCLUSIONS

Compared with no treatment, both forms of mobilization were associated with reduced disability at three weeks, and UCTM remained better than control at 15 weeks; there were no significant differences between the two mobilization groups.

TRIAL REGISTRATION

This study was registered in Clinicaltrials.gov (NCT02832232).

Concurrent validity and reliability of measuring range of motion during the cervical flexion rotation test with a novel digital goniometer

BACKGROUND

Headache is a common and costly health problem. Although the pathogenesis of headache is heterogeneous, reported contributing factors are dysfunctions of the upper cervical spine. The flexion rotation test (FRT) is a commonly used diagnostic test to detect upper cervical movement impairment. A digital goniometer may support precise measurement of movement impairment in the upper cervical spine. However, its reliability and validity is not assessed, yet. The aim of this study was to investigate the reliability and validity of the digital goniometer compared to an ultrasound-based movement analysis system.

METHODS

Two separate cross-sectional studies were conducted using the digital goniometer EasyAngle (Meloq AB, Stockholm, Sweden) for a) investigating the concurrent validity of upper cervical range of motion (ROM) during the FRT and b) determining the inter- and intra-rater reliability in the target population of patients with head and neck pain. Sixty-two participants, 39 with and 23 without head and neck pain, were recruited for the concurrent validity study. For the reliability study, a total of 50 participants were recruited. Intraclass correlation coefficients (ICC) and Bland Altmann plots were used to assess validity and ICC values, Bland Altmann plots as well as Kappa coefficients were used for estimating intra-rater and inter-rater reliability.

RESULTS

Concurrent validity was strong with an ICC (2,1) of 0.97 for ROM to either side (95%CI = 0.95-0.98). Bland Altman Plots revealed a mean difference between measurement systems of 0.5° for the left and 0.11° for the right side. The inter-rater ICC (2,1) was 0.66 (95%CI 0.47-0.79, p <  0.001, SEM 6.6°), indicating good reliability. The limits of agreement were between 10.25° and - 11.89°, the mean difference between both raters was - 0.82°. Intra-rater reliability for the measurement of ROM during the FRT was between 0.96 (ICC 3,1) for rater 1 and 0.94 (ICC 3,1) for rater 2.

CONCLUSIONS

The digital goniometer demonstrated strong concurrent validity and good to strong reliability and can be used in clinical practice to accurately determine movement impairment in the upper cervical spine.

TRIAL REGISTRATION

German Registry of Clinical Trials DRKS00013051 .

Headache and neck

Cervicogenic headache (CEH) is currently identified with different diagnostic criteria. The latest one is the International classification of headache disorders (ICHD), 3rd edition (2018). At the present time, there are not enough published articles with reliable sensitivity and specificity that may support a classification for clinical and research purposes. Current literature suggests improvement to the classification(s). The ICHD criteria should be modified to reach an optimal sensitive and specific level to identify CEH as a secondary headache. The B, C1, and C2 criteria should be implemented with proposed suggestions. The C3 criterion should be upgraded. Criteria such as mechanical precipitation of pain by digital pressure on neck trigger points and specific movements, strictly unilateral pain without side-shift, diffuse unilateral shoulder and arm pain, pain starting posteriorly and spreading anteriorly should be integral part of the classification.

Correlation and Reliability Analyses among the Upper Cervical Rotation-Flexion Test, Upper Cervical Flexion-Extension Test, and Upper Cervical Flexion Angle Measurement Using Radiography

(1) Background: The cervical rotation-flexion test is one method of measuring the range of motion of the upper cervical spine; however, this test has not been investigated in detail. The aim of this study was to investigate the reliability and concurrent validity of the upper cervical rotation-flexion test. (2) Methods: Twenty-five healthy individuals (13 women and 12 men) participated in this study. The participants underwent radiography, the upper cervical flexion-extension test, and the upper cervical rotation-flexion test in a sitting position while wearing a cervical goniometer to measure the upper cervical flexion angle. Three experienced physical therapists administered the upper cervical rotation-flexion test using the cervical device, twice for each participant. Inter-rater and intra-rater reliabilities were evaluated using the intraclass correlation coefficient (95% confidence interval). (3) Results: The inter-rater and intra-rater reliability values of the total scores were excellent. The results of the upper cervical rotation-flexion test significantly correlated with those of the radiographic evaluation of the upper cervical flexion angle (r = 0.80, p < 0.001) and those of the upper cervical flexion-extension test (r = 0.77, p < 0.001). Significant correlations among the three test results were observed. (4) Conclusions: The findings of this study suggest that the upper cervical rotation-flexion test is meaningful for independently measuring the upper cervical flexion angle.

Relationship between specific temporomandibular disorders and impaired upper neck performance

Upper neck impairments are more prevalent in patients with temporomandibular disorders (TMDs) but the differences between specific types of TMDs are unclear. This study evaluated the distribution of such impairments among different forms of TMD. In total, 116 participants (86 women and 30 men, age range 21-75 yr) were investigated. Forty-two individuals had no TMDs and were assigned to the control group. The remaining 74 patients were assigned to one of three groups based on the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) findings: pain-related (n = 37); intra-articular (n = 17); or mixed (combined pain-related and intra-articular) (n = 20). Analyses of impairments included between-group comparisons of key parameters of upper neck performance (active/passive mobility and muscular capabilities) and pain (subjective neck disability and pain sensitivity). Patients in the pain-related and mixed TMD groups were found to have decreased upper neck mobility in the cervical flexion-rotation test compared with patients in intra-articular and control groups, as well as poorer capabilities of the deep neck flexor muscles in the cranio-cervical flexion test compared to the control group. It was concluded that patients with pain-related TMD diagnoses are more likely to experience significant upper-neck hypomobility and poor muscular capabilities than patients with intra-articular diagnoses of TMD.

Validation of a clinical examination to differentiate a cervicogenic source of headache: a diagnostic prediction model using controlled diagnostic blocks

OBJECTIVES

Neck pain commonly accompanies recurrent headaches such as migraine, tension-type and cervicogenic headache. Neck pain may be part of the headache symptom complex or a local source. Patients commonly seek neck treatment to alleviate headache, but this is only indicated when cervical musculoskeletal dysfunction is the source of pain. Clinical presentation of reduced cervical extension, painful cervical joint dysfunction and impaired muscle function collectively has been shown to identify cervicogenic headache among patients with recurrent headaches. The pattern's validity has not been tested against the 'gold standard' of controlled diagnostic blocks. This study assessed the validity of this pattern of cervical musculoskeletal signs to identify a cervical source of headache and neck pain, against controlled diagnostic blocks, in patients with headache and neck pain.

DESIGN

Prospective concurrent validity study that employed a diagnostic model building approach to analysis.

SETTING

Hospital-based multidisciplinary outpatient clinic in Joliet, Illinois.

PARTICIPANTS

A convenience sample of participants who presented to a headache clinic with recurrent headaches associated with neck pain. Sixty participants were enrolled and thirty were included in the analysis.

OUTCOME MEASURES

Participants underwent a clinical examination consisting of relevant tests of cervical musculoskeletal dysfunction. Controlled diagnostic blocks of C2/C3-C3/C4 established a cervical source of neck pain. Penalised logistic regression identified clinical signs to be included in a diagnostic model that best predicted participants' responses to diagnostic blocks.

RESULTS

Ten of thirty participants responded to diagnostic blocks. The full pattern of cervical musculoskeletal signs best predicted participants' responses (expected prediction error = 0.57) and accounted for 65% of the variance in responses.

CONCLUSIONS

This study confirmed the validity of the musculoskeletal pattern to identify a cervical source of headache and neck pain. Adopting this criterion pattern may strengthen cervicogenic headache diagnosis and inform differential diagnosis of neck pain accompanying migraine and tension-type headache.

Can physical testing be used to distinguish between migraine and cervicogenic headache sufferers? A protocol for a systematic review

INTRODUCTION

Differential diagnosis of migraine and cervicogenic headache (CGH) can be challenging given the large overlap of symptoms, commonly leading to misdiagnosis and ineffective treatment. In order to strengthen the differential diagnosis of headache, previous studies have evaluated the utility of physical tests to examine for musculoskeletal impairment, mainly in the cervical spine, which could be provoking or triggering headache. However, no systematic review has attempted to evaluate whether physical tests can differentiate CGH from migraine or both conditions from asymptomatic subjects.

METHODS/ANALYSIS

A systematic review protocol has been designed and is reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). A sensitive topic-based search strategy is planned which will include databases, hand searching of key journals and consultation of relevant leading authors in this field. Terms and keywords will be selected after discussion and agreement. Two independent reviewers will perform the search and select studies according to inclusion and exclusion criteria, including any cohort or observational studies evaluating the topic of this review; a third reviewer will confirm accuracy. A narrative synthesis will be developed for all included studies and, if possible, a meta-analysis will be conducted. The overall quality of the evidence will be assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist for diagnostic accuracy studies and the Downs and Black scale for those studies where the QUADAS-2 checklist cannot be applied.

ETHICS AND DISSEMINATION

Ethical approval is not required since no patient information will be collected. The results will provide a deeper understanding about the possibility of using physical tests to differentiate cervicogenic headache from migraine and from asymptomatic subjects, which has direct relevance for clinicians managing people with headache. The results will be published in a peer-reviewed journal and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42019135269.

Headache symptom modification: the relevance of appropriate manual therapy assessment and management of a patient with features of migraine and cervicogenic headache - a case report

OBJECTIVES

People who suffer from headache frequently present with multiple headache forms and the precise diagnosis of the dominant headache form can be challenging. This case report describes a headache symptom modification approach in the diagnosis and management of a patient presenting with combined features of chronic migraine and cervicogenic headache (CGH).

METHODS

A 28-year-old female presented with combined features of chronic migraine and CGH diagnosed according to guidelines published by the International Headache Society. Her main complaints were frequent and severe headache along with frequent neck pain and disability. Symptom modification based on the Mulligan Concept was utilized for assessment of musculoskeletal dysfunction associated with headache which identified upper cervical articular impairment. Impairments were also identified in craniocervical muscle control and endurance. Interventions comprised six sessions of Mulligan manual therapy to address cervical spine impairments, exercise for craniocervical control and endurance, as well as patient education.

RESULTS

Headache frequency at 6 months follow up was reduced from 16 to 3 days per month and intensity from 72 to 23 on Visual Analogue Scale. Clinically relevant improvements were also found in headache duration, pressure pain thresholds, medication intake and Headache Activities of Daily Living Index post-treatment and continued up to 6 months follow-up without adverse events.

DISCUSSION

This case report illustrates the use of a manual therapy symptom modification approach in the management of headache. Improvement in headache symptoms and disability suggests that the musculoskeletal impairments and headache symptoms were more a feature of CGH rather than migraine. The mechanisms underlying these changes in symptoms and impairments are discussed.

Cervical musculoskeletal impairments in migraine and tension type headache: A systematic review and meta-analysis

AIMS

Neck pain is common in migraine and tension type headache (TTH). This review aimed to examine the evidence for cervical musculoskeletal impairments in these headaches.

METHODS

Databases PubMed (Medline), EMBASE, CINAHL, SCOPUS, and Web of Science were searched from inception to December 2018. Observational studies using a comparator group were included. Risk of bias was assessed using the Appraisal tool for Cross-Sectional Studies. Results were pooled using random effects meta-analysis. Level of evidence for each outcome was assigned based on risk of bias, consistency of results and magnitude of difference between participants with headache and controls. (PROSPERO registration: CRD42018083683).

RESULTS

Of 48 studies included, the majority were rated moderate risk of bias due to possible confounding influences. In total, 17 cervical outcomes were assessed, with confidence in findings ranging from very low to moderate levels. Compared to controls, participants with TTH had greater forward head posture (FHP) (MD = -6.18°, 95% CI [-8.18°, -4.18°]) and less cervical range of motion (ROM) (greatest difference transverse plane MD = -15.0°, 95% CI [-27.7°, -2.3°]. Participants with migraine demonstrated minimally reduced cervical ROM (greatest difference sagittal plane MD = -5.4°, 95% CI [-9.9°, -0.9°]. No differences presented in head posture, strength, craniocervical flexion test performance or joint position error between migraineurs and controls.

CONCLUSIONS

TTH presented with more findings of cervical musculoskeletal impairments than migraine however levels of confidence in findings were low. Future studies should differentiate episodic from chronic headache, identify coexisting musculoskeletal cervical disorders, and describe neck pain behaviour in headache.

Is the presence of neck pain associated with more severe clinical presentation in patients with migraine? A cross-sectional study

Objective

To investigate the association between the presence of self-reported neck pain in patients with migraine and clinical features, upper cervical mobility, and neck muscle performance.

Methods

A total of 142 patients with migraine were recruited and stratified by the presence (n = 99) or absence of self-reported neck pain (n = 43). The clinical examination included the Migraine Disability Assessment, the 12-item Allodynia Symptom Checklist, a flexion rotation test, and the Craniocervical Flexion Test.

Results

Migraine-related disability was reported by more than 80% in both groups ( p = 0.82). However, there was a greater prevalence and severity of cutaneous allodynia observed in the group with neck pain ( p < 0.001). Reduced upper cervical mobility was verified in 67% of the patients with neck pain and in 41% of those without neck pain ( p = 0.005). In addition, 67% of the patients with neck pain and 40% without neck pain were not able to maintain the third stage of the Craniocervical Flexion Test without compensation ( p = 0.003).

Conclusions

The presence of self-reported neck pain in patients with migraine was associated with a poor clinical presentation regarding cutaneous allodynia, neck mobility, and muscle function. However, there were no differences in migraine-related disability.

The diagnostic accuracy of headache measurement instruments: A systematic review and meta-analysis focusing on headaches associated with musculoskeletal symptoms

AIM

To systematically review the available literature on the diagnostic accuracy of questionnaires and measurement instruments for headaches associated with musculoskeletal symptoms.

DESIGN

Articles were eligible for inclusion when the diagnostic accuracy (sensitivity/specificity) was established for measurement instruments for headaches associated with musculoskeletal symptoms in an adult population. The databases searched were PubMed (1966-2018), Cochrane (1898-2018) and Cinahl (1988-2018). Methodological quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for criterion validity. When possible, a meta-analysis was performed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) recommendations were applied to establish the level of evidence per measurement instrument.

RESULTS

From 3450 articles identified, 31 articles were included in this review. Eleven measurement instruments for migraine were identified, of which the ID-Migraine is recommended with a moderate level of evidence and a pooled sensitivity of 0.87 (95% CI: 0.85-0.89) and specificity of 0.75 (95% CI: 0.72-0.78). Six measurement instruments examined both migraine and tension-type headache and only the Headache Screening Questionnaire - Dutch version has a moderate level of evidence with a sensitivity of 0.69 (95% CI 0.55-0.80) and specificity of 0.90 (95% CI 0.77-0.96) for migraine, and a sensitivity of 0.36 (95% CI 0.21-0.54) and specificity of 0.86 (95% CI 0.74-0.92) for tension-type headache. For cervicogenic headache, only the cervical flexion rotation test was identified and had a very low level of evidence with a pooled sensitivity of 0.83 (95% CI 0.72-0.94) and specificity of 0.82 (95% CI 0.73-0.91).

DISCUSSION

The current review is the first to establish an overview of the diagnostic accuracy of measurement instruments for headaches associated with musculoskeletal factors. However, as most measurement instruments were validated in one study, pooling was not always possible. Risk of bias was a serious problem for most studies, decreasing the level of evidence. More research is needed to enhance the level of evidence for existing measurement instruments for multiple headaches.

Reduced flexion rotation test in women with chronic and episodic migraine

OBJECTIVE

To compare flexion rotation test and global active cervical mobility in women with chronic migraine, episodic migraine, and headache-free controls. The influence of neck pain-related disability on the flexion rotation test was also analyzed.

METHODS

Women with chronic migraine (n=25), episodic migraine (n=30), and those who were headache-free (n=30) were evaluated. Upper cervical mobility was measured using the flexion rotation test and global active mobility was assessed using the cervical range of motion device. Neck pain related-disability was assessed using the Neck Disability Index. Statistical analyses were performed using a MANOVA test, prevalence ratios, and linear regression.

RESULTS

Chronic (right, MD: -15°; 95%CI: -21° to -11°; left, MD: -13°; 95%CI: -20° to -12°) and episodic (right, MD: -8°; 95%CI: -13° to -4°; left, MD: -8°; 95%CI: -12° to -5°) migraine groups achieved lower flexion rotation test mobility bilaterally than headache-free women. Only chronic migraine was associated with a lower global cervical range of motion compared to that of headache-free women during flexion, (MD: -8°; 95%CI: -15° to -1°), extension (MD: -13°; 95%CI: -20° to -4°), right lateral flexion (MD: -4°; 95%CI: -9° to -0.2°), left lateral flexion (MD: -6°; 95%CI: -10° to -2°), right rotation (MD: -9°; 95%CI: -15° to -4°), and left rotation (MD: -8°; 95%CI: -13° to -2°). Migraine was associated with a 2.85-fold increase in the risk of a positive flexion rotation test. Flexion Rotation Test was influenced by disability-related neck pain (R²=19.1; p=0.001).

CONCLUSION

Women with migraine have a lower upper cervical range of motion than headache-free women. Women with chronic migraine demonstrated reduced global cervical range of motion when compared to headache-free women. Migraine was associated with in increased likelihood of a positive Flexion Rotation Test. Reduction in mobility was influenced by migraine frequency and disability-related neck pain.

Cervical musculoskeletal dysfunction in headache: How should it be defined?

Neck pain commonly accompanies migraine and tension-type headache, but the literature is divided on whether this neck pain is a headache symptom or is associated with cervical musculoskeletal dysfunction. Clarification is essential for hypotheses on the pathogenesis of these headaches and their variants and for decisions on suitability of local neck treatments, both from research and clinical practice perspectives. Reasons for disparate findings could relate to participant selection in headache studies and/or the bases on which decisions on the presence of cervical musculoskeletal dysfunction are reached. Propositions towards gaining a clearer picture of migraine and tension-type headache related neck pain include first, stricter inclusion criteria and reporting of headache characteristics of study participants. Second, reliance on pain sensitivity or the presence of neck tenderness/trigger points as measures be discarded, as they are not uniquely tied to a musculoskeletal disorder. Instead, place reliance on tests of musculoskeletal (dys)function. Third, the values and interpretation of single measures or tests of impairment/dysfunctions can be non-informative and do not reflect the presentation of cervical musculoskeletal disorders. Rather, a typical presentation includes at a fundamental level, interrelated changes in cervical movement, segmental joint and muscle function. We advocate that these measures be adopted as the core set of related measures to define cervical musculoskeletal dysfunction in headache. This does not deter inclusion of other measures of interest or qualification.

The C0-C2 axial rotation test: normal values, intra- and inter-rater reliability and correlation with the flexion rotation test in normal subjects

OBJECTIVES

Impairment in upper cervical spine mobility is associated with cervicogenic headache severity and disability. Measures of such mobility include the flexion-rotation test (FRT), which requires full cervical flexion and may be influenced by lower cervical spine dysfunction. The C0-C2 axial rotation test also evaluates upper cervical mobility but normal values and reliability have not been reported. Our objective is to determine normal values, and intra-rater and inter-rater reliability of the C0-C2 axial rotation test.

METHODS

Two therapists independently evaluated the FRT and C0-C2 axial rotation test with an iPhone compass application on 32 asymptomatic subjects with mean age 40.53 (SD 11.64) years on two occasions. Measurement procedures were standardized; and order of testing randomized.

RESULTS

For the FRT and C0-C2 axial rotation test reliability was high (ICC > 0.88). For rater one, Mean range to the left during the FRT and C0-C2 axial rotation test was 45.0° (6.04) and 14.43° (2.94), respectively, while range to the right was 44.6° (6.57) and 15.44° (2.68). For the FRT and C0-C2 axial rotation test the standard error of measurement was at most 2°, while the minimum detectable change was at most 4°. A strong positive correlation exists between the FRT and C0-C2 axial rotation test (r = 0.84, P < 0.01).

DISCUSSION

The range recorded during the C0-C2 axial rotation test and FRT have high levels of reliability when evaluated using an iPhone. The strong correlation between the FRT and C0-C2 axial rotation test indicate that both may be measuring similar constructs, but each test needs to be referenced to normal values.

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain - a diagnostic case-control study

Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions. Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38). Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004). Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON. Level of Evidence: 3b.

Effectiveness of a specific manual approach to the suboccipital region in patients with chronic mechanical neck pain and rotation deficit in the upper cervical spine: study protocol for a randomized controlled trial

BACKGROUND

Mechanical neck pain is a highly prevalent problem in primary healthcare settings. Many of these patients have restricted mobility of the cervical spine. Several manual techniques have been recommended for restoring cervical mobility, but their effectiveness in these patients is unknown. The aim of the present study is to compare the effectiveness of two types of specific techniques of the upper neck region: the pressure maintained suboccipital inhibition technique (PMSIT) and the translatory dorsal glide mobilization (TDGM) C0-C1 technique, as adjuncts to a protocolized physiotherapy treatment of the neck region in subjects with chronic mechanical neck pain and rotation deficit in the upper cervical spine.

METHODS

A randomized, prospective, double-blind (patient and evaluator) clinical trial. The participants (n = 78) will be randomly distributed into three groups. The Control Group will receive a protocolized treatment for 3 weeks, the Mobilization Group will receive the same protocolized treatment and 6 sessions (2 per week) of the TDGM C0-C1 technique, and the Pressure Group will receive the same protocolized treatment and 6 sessions (2 per week) of the PMSIT technique. The intensity of pain (VAS), neck disability (NDI), the cervical range of motion (CROM), headache intensity (HIT-6) and the rating of clinical change (GROC scale) will be measured. The measurements will be performed at baseline, post-treatment and 3 months after the end of treatment, by the same physiotherapist blinded to the group assigned to the subject.

DISCUSSION

We believe that an approach including manual treatment to upper cervical dysfunction will be more effective in these patients. Furthermore, the PMSIT technique acts mostly on the musculature, while the TDGM technique acts on the joint. We expect to clarify which component is more effective in improving the upper cervical mobility.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02832232 . Registered on July 13th, 2016.

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.

Cervical flexion-rotation test and physiological range of motion - A comparative study of patients with myogenic temporomandibular disorder versus healthy subjects

BACKGROUND

Temporomandibular Disorders (TMD) refer to several common clinical disorders which involve the masticatory muscles, the temporomandibular joint (TMJ) and the adjacent structures. Although neck signs and symptoms are found with higher prevalence in TMD patients compared to the overall population, whether limitation of cervical mobility is an additional positive finding in this cohort is still an open question.

OBJECTIVE

To compare the physiological cervical range of motion (CROM) and the extent of rotation during cervical flexion (flexion-rotation test, FRT) in people with TMD (muscular origin) and healthy control subjects.

METHOD

The range of motion of the neck and FRT was measured in 20 women with myogenic TMD and 20 age matched healthy controls.

RESULTS

Women with myogenic TMD had significantly lower FRT scores compared to their matched healthy women. No difference was found between groups in CROM in any of the planes of movement. The FRT was positive (less than 32°) in 90% of the TMD participants versus 5% in the healthy control but the findings were not correlated with TMD severity.

CONCLUSION

The results point out a potential involvement of the upper cervical joints (c1-c2) in women with myogenic TMD.

Changes in cervical movement impairment and pain following orofacial treatment in patients with chronic arthralgic temporomandibular disorder with pain: A prospective case series

The purpose of this study was to investigate the influence of isolated temporomandibular joint (TMJ) manual therapy on pain and range of motion (ROM) of the TMJ and cervical spine including flexion-rotation test (FRT) in people suffering chronic pain arising from chronic arthralgic temporomandibular disorder (TMD). An experienced clinician managed a case series of 12 patients with TMD (mean duration 28.6 months +/- 26.9). The intervention comprised four-weekly sessions of transverse medial accessory TMJ mobilization and advice. Patients were examined prior to and one-week following the intervention period. Outcome measures included jaw disability (JFLS-20), jaw pain measured by Visual Analogue Scale (VAS), maximal mouth opening ROM, cervical ROM including FRT, and pain during cervical movement. A paired t-test revealed significant improvement following the intervention in disability (p < 0.001), VAS pain score at rest (p < 0.001) and at maximum mouth opening (p < 0.001), jaw opening ROM (p < 0.001), FRT ROM to the left (p = 0.024) and right (p = 0.001). In contrast, no significant change was identified for total cervical ROM (p = 0.905). After the intervention, five patients (41.66%) had no pain at rest or at maximal mouth opening, and all had a negative FRT. The effect sizes indicate a moderate to strong, clinically significant effect for all variables apart from total cervical ROM. While a case series cannot identify a cause and effect relationship, these results provide preliminary evidence for the influence of TMJ manual therapy on measures of TMD including pain, as well as upper but not whole cervical movement and associated pain in patients with a diagnosis of TMJ arthralgia.

A normative study of cervical range of motion measures including the flexion-rotation test in asymptomatic children: side-to-side variability and pain provocation

OBJECTIVES

Cervical movement impairment has been identified as a core component of cervicogenic headache evaluation. However, normal range of motion values in children has been investigated rarely and no study has reported such values for the flexion-rotation test (FRT). The purpose of this study was to identify normal values and side-to-side variation for cervical spine range of motion (ROM) and the FRT, in asymptomatic children aged 6-12 years. Another important purpose was to identify the presence of pain during the FRT.

METHODS

Thirty-four asymptomatic children without history of neck pain or headache (26 females and 8 males, mean age 125.38 months [SD 13.14]) were evaluated. Cervical spine cardinal plane ROM and the FRT were evaluated by a single examiner using a cervical ROM device.

RESULTS

Values for cardinal plane ROM measures are presented. No significant gender difference was found for any ROM measure. Mean difference in ROM for rotation, side flexion, and the FRT were less than one degree. However, intra-individual variation was greater, with lower bound scores of 9.32° for rotation, 5.30° for side flexion, and 10.89° for the FRT. Multiple linear regression analysis indicates that movement in the cardinal planes only explains 19% of the variance in the FRT. Pain scores reported following the FRT were less than 2/10.

DISCUSSION

Children have consistently greater cervical spine ROM than adults. In children, side-to-side variation in rotation and side flexion ROM and range recorded during the FRT indicates that the clinician should be cautious when using range in one direction to determine impairment in another. Range recorded during the FRT is independent of cardinal movement variables, which further adds to the importance of the FRT, as a test that mainly evaluates range of movement of the upper cervical spine.