Comparative Effectiveness of Cervical vs Thoracic Spinal-thrust Manipulation for Care of Cervicogenic Headache: A Randomized Controlled Trial
SOURCE: PLoS One 2024 (Mar 29); 19 (3): e0300737 ~ FULL TEXT
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Gopal Nambi • Mshari Alghadier • Mudathir Mohamedahmed Eltayeb • Osama R Aldhafian. et al.
Department of Health and Rehabilitation Sciences,
College of Applied Medical Sciences,
Prince Sattam Bin Abdulaziz University,
Al-Kharj, Saudi Arabia.
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.
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.
From the FULL TEXT Article:
Introduction
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Globally, headache disorders affect approximately 66% of the population between the ages of 18 and 65 years at least once a year. Sixty-six percent of men and fifty-seven percent of women report headaches at least once in their lifetime which reduces the quality of life, work productivity and increased costs to society. [1] Cervicogenic headache (CgH) is a distinct form of headache and accounts for 17.8% of all headaches, the prevalence rate is between 15 and 20% among cases of chronic headache. [2] The prevalence rate of CgH is 0.21% in females and 0.13% in males and has various causative factors. [3] It has a significant negative socioeconomic impact and is a burden on the community and public health. [4] The causative factor for the headache is located in the neck region and the pain is made worse by movements of the head and neck. [2] The most accepted mechanism of CgH is found between the trigeminal nerve and C1 –C3 nerves in the trigemino-cervical nucleus. [5] It usually arises from musculoskeletal structures such as the cervical vertebra, intervertebral disc, or paravertebral muscles. The clinical features of CgH include unilateral or bilateral headache, limited range of motion (ROM) of the neck, and radiating pain to the head or face region. [6]
Generally, CgH is diagnosed based on a detailed history and clinical assessment. [7] Physical examinations typically reveal pain in the cervical region–neck pain (NP), decreased neck movements, upper quarter muscle tightness and loss of muscle properties such as excitability, contractility, extensibility and elasticity. [8] The cervical flexion rotation test (CFRT) is a valid, reliable and accurate method with an overall diagnostic accuracy of 91% for assessing cervical range of motion in patients with CgH. [9] The management of CgH consists of pharmacological and non-pharmacological methods, in which the pharmacological means are associated with many side effects such as damage to the liver or kidneys, diarrhea, constipation and allergic reactions. [10] There are also many non-pharmacological treatment modalities available such as; physical modalities, positional release therapy (PRT), muscle strengthening exercises, ergonomic guidance and patient education etc. [11] It has been estimated that 34% of US citizens receive some sort of physiotherapy for CgH each year. [12]
In physiotherapy, joint mobilization and manipulation are the most commonly used treatment modalities for treating patients with CgH. [13] The manipulation technique commonly used to treat CgH targets two different regions in the spine such as the cervical and thoracic spine. Cervical spine manipulation (CSM) and thoracic spine manipulation (TSM) technique uses high velocity, low amplitude thrusts (HVLAT) manoeuvre. Some studies have looked solely at the effects of manipulating the cervical spine in cases of Cervicogenic headache. [6, 14, 15] Dunning JR et al investigated that six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CgH, and the effects were maintained at 3 months. [16] Haas et al. investigated the effectiveness of cervical manipulation in patients with CgH. [17] Similarly, McDevitt AW et al. found that thoracic spine manipulation alone significantly improved neck-related disability in CgH, but had no effect on headache-related disability but participants reported overall improvement in their condition. [18] However, so far no studies have compared and investigated the individual effects of cervical spine manipulation, thoracic spine manipulation or conventional physiotherapy in treating patients with CgH.
Numerous studies have supported the application of various manipulative therapy approaches for the treatment of CgH. [13–18] Nevertheless, evidence is scarce in comparing the individual effects of cervical and thoracic manipulation approaches in Cervicogenic headache, particularly regarding its clinical and functional aspects. Additionally, no studies have attempted to address the shortcomings and gaps observed in the existing literature on the management of CgH, such as a lack of comparison between manipulation in two different regions, poor study designs, quality and small sample sizes. Therefore, our study objective was to compare and investigate the individual effects of cervical and thoracic manipulation techniques on patients with CgH. This randomized clinical trial hypothesized that there would be differences in primary and secondary outcome measures between cervical spine manipulation, thoracic spine manipulation, and conventional physiotherapy for treating patients with CgH.
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