1. Mobilization Techniques in the Management of cervicogenic Headaches
Leah Batten
Clinical Problem Solving II

2. Purpose
To describe the physical therapy examination, evaluation, plan of care, and outcomes of a patient who suffered from severe Cervicogenic Headaches, and decreased ROM post motor vehicle accident. To present current research related to mobilization techniques in decreasing headache severity and increasing cervical ROM.

3. Cervicogenic Headaches
“Nocioceptive input originating from an anatomical structure in the cervical spine referred to the occipital region and felt as a headache.”
Accounts for 15% - 20% of all chronic recurrent headaches.
Major Signs & Symptoms
Unilateral headache
Neck pain (C1-C3)
Neck movement restrictions

4. Cervicogenic Headache Assesment
Flexion Rotation Test (FRT):
Assesses dysfunction at the C1-C2 motion segment.
Test Procedure:
Cervical spine is passively fully flexed, to isolate movement to C1-C2.
Rotation ROM is evaluated in this position.
Results:
Normal range of rotation motion in end range flexion has been shown to be 44° to each side.
In contrast, subjects suffering from headache with C1-C2 dysfunction have an average of 17° less rotation.
The C1-C2 motion segment accounts for 50% of rotation of the cervical spine.
Why Cervicogenic Headaches? Cervicogenic headaches, dizziness and ROM deficits are common after MVA. These impairments can be significant during the acute phase, but can also persist long term.

5. Patient information 26 year old female
Health fitness specialist and wellness manager
Involved in a motor vehicle accident
Hit her head, no loss of consciousness
Chief Complaints:
Severe Headaches
Upper neck pain
Overall Stiffness
Patient’s Main Goal:
Decrease pain, stiffness and abolish HA’s

6. Physical therapy EXAM EVAL CRITERIA FINDINGS AROM of Cervical Spine
Extension: 25°, painful
Flexion: 3 fingers to chin, painful
Rotation:
R: 55°, painful
L: 33°, painful
Side-bend:
R: 25°, painful
L: 25°, painful
Strength
Bilateral C4-T1 myotomes 5/5
Posture
Forward Head, Thoracic Kyphosis, Cervical Protrusion
Headache / Pain VAS
Constant; 5/10
PROM same limitations as AROM and painful to contralateral side of movement.

7. Physical therapy EXAM EVAL CRITERIA FINDINGS
Palpation (Supine & Prone)
Occiput: bilateral pain
C1-C3: bilateral pain on spinous processes
C4-C7: pain free
Mobility
Anterior Mob:
Grade I: C2-C3 painful
Grade II: C4-C6 pain free
Unilateral Mob:
Special Tests
Cervical Distraction: Negative
Cervical Compression: Negative
Neck Disability Index (NDI)
33/50 or 66%
The NDI Score of 66% would place her at a severe disability. Minimum Detectable Change of NDI: 5 points or 10%. 25% would her at 24: Moderate disability
0-4points (0-8%) no disability,
5-14points ( 10 – 28%) mild disability,
15-24points (30-48% ) moderate disability,
25-34points (50- 64%) severe disability,
35-50points (70-100%) complete disability

8. Assessment (Day 1) Functional Limitations Pain Headaches Decreased ROM
Activity Restrictions
Unable to work - lead exercise classes
Unable to perform computer work
Prognosis: GOOD
Due to the following factors:
Age
Health status
Motivation to recover
Therex Performed:
B supine cervical rotation x 10
Supine deep neck flexor chin tucks 2 x 10
* Given as HEP

9. Patient Centered GOALs
In 2 weeks patient will…
Increase AROM in L rotation, extension and B SB, 7 degrees in order to increase safety with driving
Report 50% decrease in neck pain and headaches in order to return to work
Exhibit a decreased NDI score of 25% to illustrate increased functional capacity of cervical spine

10. Patient Centered GOALs
In 4 weeks patient will…
Be pain free with sitting at the computer and driving to work to increase functional independence
Teach group fitness classes with minimal pain 2/10 on the VAS in order to return to full capacity at work
State HA’s are abolished in order to increase success with ADL’s
Main limitations to the goals: No evidence based reasoning on 25% decrease in NDI and 50% in VAS.

11. Plan of Care Frequency/Duration: 2x a week for 4 weeks Intervention
Specifics
Pain Management
Heat
AROM/PROM of Cervical Spine
Manual Therapy
Cervical Distraction
Soft Tissue Massage
Joint Mobilizations (Passive/Active)
Therex
Cervical Flexion Test
Scapular Retraction Exercises
Upper trap stretches
Isometric SB, Flex and Ext
Work Simulation (prior to D/C)
Overhead lifting
Education on proper form
STM to sub-occipitals, lateral paraspinals, upper trapezius
Cranioflexion Test: : Failed at 20 mmHg, used as treatment. Needed tactile and verbal cues to decrease SCM activation. Progressed from supine to elevated 45 degrees and then to seated. Added overpressure.
Scapular Retraction Exercises: Rows, Extensions, W’s, Prone I’s, Y’s with weights

12. “SNAG” Mulligan Technique?
C1-C2 Self-Sustained Natural Apophyseal Glide
(SNAG)
Mulligan's manual therapy technique at peripheral joints, namely mobilization with movement (MWM).
Thin strap was positioned on the posterior arch of C1 and drawn horizontally forward across the face. The purpose of the strap is to facilitate rotation at C1-C2 in the same direction as found to be limited in ROM.
Possible physiologic mechanism of mobilization: neuro-modulation effect. IN the gate control theory, stimulation of mechanoreceptors within the join capsule and surrounding tissues casues a an inhibition of pain at the spinal cord. In addition, descending pain-inhibitory systems may be activated, mediated by areas such as the periaqueductal gray of midbrain. The end range of positioning in rotation with the C1-C2 self-SNAG may engage these inhibitory systems and decrease pain.

13. Patient outcomes EVAL CRITERIA FINDINGS AROM of Cervical Spine
Extension: Full, pain free
Flexion: full, pain free
Rotation:
R: 81°, pain free
L: 80°, pain free
Side-bend:
R: 50°, pain free
L: 50°, pain free
Headaches / Pain VAS
None; 0/10
Work Simulation
Overhead lifting of +12# pain free
Discharged
At 6 weeks
Neck Disability Index (NDI)
0/50

14. Clinical Question
For a 26 year old female post MVA, are cervical spine mobilizations effective in the management of cervicogenic headaches, and decreased ROM?

15. Efficacy of a C1-C2 Self-sustained Natural Apophyseal Glide (SNAG) in the Management of Cervicogenic Headache
Toby Hall, et al. 2007, JOSPT

16. Level of Evidence: Randomized Double-Blind Placebo Controlled Trial
Purpose
To determine the effect of a C1-C2 self sustained natural apophyseal glide on cervicogenic headaches.
Level of Evidence: Randomized Double-Blind Placebo Controlled Trial

17. methods Participants: 32 subjects Inclusion Criteria:
Unilateral or side dominant headache
Headache with neck stiffness and or pain
Aged yrs.
Positive flexion-rotation test and ROM restriction greater than 10°
Exclusion Criteria:
Headache not of cervical origin
PT/Chiropractic treatment in past 3 mos.
Headache with autonomic involvement, dizziness, visual disturbance
Additional Exclusion Criteria:
Congenital conditions of cervical spine, Contraindication to manipulation therapy, Involvement in litigation or compensation, Inability to tolerate FRT
of cervical joint dysfunction in neck pain and headache patients.

18. methods Treatment Groups: Procedure: C1-C2 Self-SNAG Placebo
Initial instruction & practice (3 practice trials, 2 reps/3 secs)
FRT measured before and immediately after instruction
HA symptoms assessed by questionnaire pre-intervention, and then 4 and 12 mos post-intervention (100% compliance)
Interventions of HEP (2 reps/3 secs - 2x daily)
HA Severity Index: (100 MAX). Composite Score of Intensity, Frequency and Duration.
Placebo – used the strap but pulled forward on C1 with no head rotation.
Exercise Compliance Questionnaire at 4 wks and 12 mos (1 no exercise, 5 daily). Results showed greater compliance with SNAG group.

19. RESULTS Characteristic C1-C2 SNAG Placebo HA Severity Index (baseline)
52 ± 10
51 ± 10
HA Severity Index
(4-week)
31 ± 9
51 ± 15
(12 mo.)
24 ± 9
44 ± 13
Flexion Rotation Test
15° increase
5° increase
Rotation increased 15 degrees to 39 degrees vs. only 5 degrees to 32 degrees.
SNAG: 54% reduction in headache symptoms at 12 mos.!
Placebo: 13% reduction

20. Conclusion
The C1-C2 self-SNAG technique is efficient in reducing cervicogenic headache symptoms sustained over a 1-year period.
Limitations:
Small sample size
Did not document if patients sought alternative treatment during the 12 mos.
No long-term measurement of ROM
Since my patient had severe pain initially and we were only able to add the SNAG technique later in therapy - I wanted to look at a study that compared mobilizations to massage therapy …

21. Mobilization versus massage therapy in the treatment of cervicogenic headache: A clinical study
Enas Youssef, et al. 2013, Journal of Back and Musculoskeletal Rehabilitation

22. Level of Evidence: Randomized Clinical Trial
Purpose
To compare the effect of cervical mobilizations to massage therapy when treating cervicogenic headaches.
Level of Evidence: Randomized Clinical Trial

23. Methods Participants: 38 subjects Inclusion Criteria
Recurrent HA and neck pain 2+ mos.
Aged 18-40
Unilaterality of pain
Restricted neck ROM
Exclusion Criteria
Migraine/Cluster HA symptoms
Cervical pathology
Received treatment past 6 mos.

24. Methods Treatment Groups:
Low velocity passive upper cervical mobilization techniques
Massage Therapy
Procedure:
Evaluation
HA intensity, frequency, and duration
Functional Disability (NDI)
AROM
Interventions performed 2x week for 6 weeks for minutes each
*All subjects underwent stretching and active exercises
Group 1: low velocity small oscillatory movements to the upper cervical vertebrae (C1, 2, 3) PA, unilateral and transverse mobiliazations.
Massage Therapy Technique: 6 phases – 1) warm up bilateral pressure of cspine 2) Myofascial release of deltoid, pec, trap 3) Cervical traction 4) Trigger point therapy to trap, SCM suboccipitals, levator scap, temporalis, splenius capitis 5) Stretching/MET of neck flexors followed by passive stretching 6) Effleurage (gliding) and Petrissage (kneading) of cervical region

25. outcomes Characteristic Group 1 Mobilization Group 2 Massage Pre-Test
Post-Test
Headache Symptoms
Intensity
Frequency
Duration
7.1
6.1
3.5
2.2
1.9
1.4
6.8
5.9
3.6
4.3
3.9
1.64
ROM
Flexion
Extension
L Rotation
1.7
1.6
2.9
3.2
1.5
2.5
2.52
NDI
46.7
18.5
48.3
17.5
Headache pain intensity, frequency and duration as well as ROM significantly reduced in BOTH groups however slightly more after mobilization.
HA symptom decreases and ROM increases greater with Mobilization
NDI no significant difference between groups

26. conclusion
While both interventions showed benefits, cervical spine mobilization demonstrated greater results than massage therapy with managing cervicogenic headache symptoms and ROM restrictions.
Limitations
Intervention in this study was limited to 6 weeks
No long-term follow-up
No control group in which to confirm the outcomes of treatment intervention

27. Back to my patient Does this answer my question? YES!
Mobilizations, especially the C1-C2 Self-Sustained Apophyseal Glides (SNAGS) technique are effective interventions for reducing cervicogenic headaches and increasing ROM.
As illustrated with my patient, post-interventions her headaches abolished and her ROM increased!

28. Questions?
Thank you!

29. References
Wayne Hing PhD et al. Mulligan’s mobilisation with movement: a review of the tenets and prescription of MWMs. NZ Journal of Physiotherapy. November 2008, Vol. 36 (3) September 4, Toby Hall et all. Efficacy of a C1-C2 Self-Sustained Natural Apophyseal Glide (SNAG) in the Management of Cervicogenic Headache. Journal of Orthopaedic & Sports Physical Therapy. March Volume 37, Number Enas F. Youssef et al. Mobilization versus massage therapy in the treatment of cervicogenic headache: A clinical study. Journal of Back and Musculoskeletal Rehabilitation 26 (2013) 17–24.