Author Names
Dunning, J., Butts, R., Mourad, F., Young, I., Penas, C., Hagins, M., Stanislawski, T., Donley, J., Buck, D., Hooks, T., Cleland, J.
Reviewer Name
Ericka Boeger, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Background: Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH.
Methods: One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable.
Results: The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p <0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001).
Conclusions: Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
Primary outcome: The manipulation group had statistically significant greater improvements in Numeric Pain Rating Scale (NPRS) at the 1-week and 3-month follow-up appointments.
Key Finding #2
Secondary outcomes: The manipulation group had greater reductions in the disability index at all follow-up periods. This group also experienced greater perceived improvement at all follow-up periods (measured by the GRC). The frequency and duration of headaches were significantly lower in the manipulation group, and they also experienced a greater reduction in medication intake.
Key Finding #3
The results listed above suggest that 6-8 therapy sessions (over a 4-week time period) with manipulation of the upper cervical and upper thoracic spines have greater improvements and benefits than mobilization combined with exercise for patients diagnosed with cervicogenic headache.
Please provide your summary of the paper
This summary is a multi-center randomized clinical trial that compared the use of cervical and thoracic manipulation vs mobilization and exercise on headache intensity, frequency, duration, disability index, medication intake, and global rate of change in patients with cervicogenic headaches.
There were 110 participants involved who were diagnosed with cervicogenic headache. They were randomized to the cervical and thoracic manipulation group or the mobilization and exercise group. The main outcome was headache intensity. However, they also measured headache frequency, duration, disability index, medication intake, and global rate of change. They received treatment for 4 weeks (total of 6-8 treatment sessions) and were re-assessed with the above outcome measures at 1 week, 4 weeks, and 3 months. The manipulation group received manipulations targeting the right and left C1-2 articulation and bilateral T1-2 articulations during at least one session and other sessions could include repeating the C1-2 and/or T1-2 manipulations or targeted other spinal manipulations (C0-1, C2-3, C3-7, T2-9, ribs 1-9). The mobilization and exercise group received mobilizations targeting the right and left C1-2 articulation and bilateral T1-2 articulations during at least one session and other sessions could include repeating the C1-2 and/or T1-2 mobilizations or targeted other spinal mobilizations (C0-1, C2-3, C3-7, T2-9, ribs 1-9). The also performed cranio-cervical flexion and shoulder girdle progressive resistance exercises, specifically targeting the lower trapezius and serratus anterior.
The results demonstrated that the manipulation group experienced better outcomes overall, such as statistically significant improvements in NPRS, greater reductions in the disability index, and experienced less frequent headaches at the follow-up appointments. A decrease in medication intake was also greater for the manipulation group. The authors discussed that although the manipulation group demonstrated more significant improvements, the mobilization and exercise group also demonstrated improvements. They also mentioned that the techniques used may not be generalizable to other manual therapy techniques. They pondered why the manipulation group had better outcomes and mentioned that more research should be conducted. However, the current thought is that high-velocity manipulation with impulse duration of <200ms can, “alter afferent discharge rates by stimulating mechanoreceptors and proprioceptors.” It is also thought that manipulation stimulates deep paraspinal musculature receptors, where mobilization is likely more superficial. The decrease in pain following manipulation is thought to be due to biomechanical, spinal or segmental, and central descending inhibitory pain pathways. However, further research needs to be conducted.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study can impact clinical practice by giving therapists an idea of whether manipulation or mobilization and exercise are more effective for patients with cervicogenic headache. This study demonstrated that therapists should consider using spinal manipulations in patients with cervicogenic headache due to the positive outcomes noted at each follow-up appointment and the longer-lasting impact at the 3-month follow-up appointment. However, both groups did make clinical improvements. This is important to consider because all patients respond differently to different treatments. Therefore, the clinician should try different techniques and use the one(s) that the patient responds best to and that offers the best results for each individual.
