Thrust Joint Manipulation and Reverse SNAGS (Sustained Natural Apophyseal Glides) in Cervicogenic Headache
Condition: Cervicogenic Headache
MeSH terms: Post-Traumatic Headache; Headache
Study type: Interventional

Summary: 
      The purpose of the study was to compare the effect of upper cervical thrust joint
      manipulation and reverse Sustained Natural apophyseal Glide on intensity of pain, pain
      pressure threshold, range of motion and headache disability in patients with cervicogenic
      headache. A randomized control trial was conducted at Max Rehab and Physical therapy center,
      Islamabad. The sample size was calculated through open epi tool is 16. The participants were
      divided in two groups, 8 participants in experimental group and 8 participants in control
      group. The study duration was six months. Sampling technique applied was Purposive sampling
      for recruitment and group randomization using sealed envelope method. Only 20 to 40 years
      participants with cervicogenic headache and associated symptoms were included in the study.
      Tools used in this study are Numeric pain rating Scale (NPRS), Algometer, Inclinometer and
      headache disability index (HDI). Data analyzed through Statistical Package for the Social
      Sciences (SPSS) version 23.
    

Detailed description: 
      In 1983 the term "cervicogenic headache" was introduced in an article in the medical
      literature. The diagnostic criteria of cervicogenic headache was revised in 1998. The
      international headache society classified the types of headaches based on their source and
      characteristics. Studies showed that out of 47% of the patients suffering from headache. 38%
      are tension-type ; 10% are migraine ; 3% chronic headache and 2.5 to 4.1 % are cervicogenic
      headaches.The prevalence of cervicogenic headache (CH) after the whiplash is as high as
      fifty-three percent.Literature revealed that due to varying use of diagnostic measures it is
      difficult to find out the true prevalence of cervicogenic headache but it ranges from minimum
      0.7% to maximum 13.8% in population.

      The headache which is originated from the cervical spine and pain is referred to the head
      region is termed as Cervicogenic headache.So, the source of pain is a cervical region located
      near the base of the skull, pain is referred from the neck region which travels towards the
      occulo-frontal and temporal areas of the head.Cervicogenic headache is four times more
      prevalent in females than males. Females suffer more from cervicogenic head due to hormonal
      imbalances and poor posture. Poor posture includes the forward headache posture which affects
      the normal biomechanics of the cervical spine and increases the stress on the neck region.

      The possible cause of cervicogenic headache is said to be the supply of the upper three
      cervical nerves and its various distributions.Upper three cervical nerves innervate the
      atlantoaxial joint, atlantooccipital joint, facet joint (C2-C3), suboccipital, paravertebral.
      upper posterior neck musculature, upper cervical ligaments, spinal dura mater, the vertebral
      artery, intervertebral disc (C2-C3), trapezius, and sternocleidomastoid muscles. Any of these
      structures is the possible source of pain and it should be diagnosed first. According to the
      criteria of the International headache society (IHS) impairment in the function of upper
      cervical muscles is the source of cervicogenic headache.Patients suffering from cervicogenic
      headaches show a decrease in their quality of life and also compromised physical abilities as
      compared to other types of headaches.

      A multifaced approach is required to treat the patients suffering from cervicogenic
      headaches. Most commonly pharmacological, non-pharmacological, physical therapy, anesthetic
      blockade, and sometimes surgical approach is used. A successful intervention requires a
      multidisciplinary team of physicians including a pain specialist, anesthesiologist, physical
      therapist, a psychologist to provide a suitable treatment. For the long-lasting effect of the
      nerve blocks and neurolytic procedures, physical therapy and rehabilitation are required.

      Different physical therapy treatments including thrust joint manipulation, mobilizations,
      exercise program, postural education, or modification used as an effective intervention of
      cervicogenic headache. A combination of these treatments is used to subside the symptoms of
      CH.

      Literature review:

      A systematic and evidence-based search of relevant literature was performed by utilizing
      PubMed and Google Scholar as search engines and the key words used were sustained natural
      apophyseal glides, thrust joint manipulation, mulligan, and reverse sustained natural
      apophyseal glides. The purpose of the literature review is to find out the pre-existing
      literature regarding the Reverse SNAGS and TJM interventions for cervicogenic headache.

      According to a systematic review and meta-analysis conducted in 2019 on cervicogenic headache
      to find out the effectiveness of mobilization and manipulation compared to other conservative
      interventions in reducing pain and disability. So, it was concluded that both mobilization
      and manipulation are effective in cervicogenic headache but there were few limitations in the
      study that only nine studies were included and more quality research are required. Further
      research is required to observe the long-term effect and other interventions for clinical
      effectiveness.

      An overview of systematic reviews was conducted in 2019 on the physical therapy interventions
      for cervicogenic headache. Results from the reviews stated that manipulation, mobilization,
      and other conservative interventions were effective in decreasing the frequency of pain and
      disability in patients suffering from cervicogenic headaches.

      According to a randomized control trial conducted in 2019 on cervicogenic headache. The
      purpose of the study was to determine the effectiveness of headache sustained natural
      apophyseal glide (SNAG) and SNAG rotation separately as well as in combination in patients
      suffering from cervicogenic headache to reduce the headache and improve activity limitation.
      The results of the study showed that group that received both SNAG and SNAG rotation
      technique is effective in reducing cervicogenic headache.

      A randomized control trail in 2018 on cervicogenic headaches. The purpose of the study was to
      compare the effectiveness of SNAG and reverse SNAG on patients suffering from cervicogenic
      headache. Results showed that headache SNAG was more effective than reverse SNAG in treating
      patients suffering from cervicogenic headache. The major limitation of the study was limited
      sample size and lack of quantitative equipment for measuring the change.

      In recent studies, results reported that Sustained Natural Apophyseal Glides and Thrust Joint
      Manipulation (TJM) were effective in the management of Cervicogenic Headache. However, they
      did not report if manipulation resulted in superior outcomes compared to mobilization for the
      management of this population, or secondly no literature was found regarding the reverse
      SNAGs as an intervention for cervicogenic headache. The purpose of this study is to compare
      the effects of reverse SNAG and TJM in patients with cervicogenic headache regarding the
      improvement of headache, pain, pain pressure threshold, and cervical range of motion
    

Intervention name(s): Thrust Joint Manipulation; Reverse Sustained Natural apophyseal glides
Intervention type(s): Other; Other
Intervention description(s): Experimental group included TJM, Cervical hot pack, strengthening exercises and home plan; 3 sessions of manipulation per week and total of 4 weeks. Measurement will be taken at base level and after the last session, i.e. Pain intensity, pain pressure threshold, ROM, and disability.
These exercises included. Cervical Flexion, Extension Rotation, lateral flexion and back strengthening exercises. These all exercises were performed 3 x 15 Repetitions with 10 sec hold. This protocol was for 4 weeks and 3 sessions per week.
Home plan exercises includes Craniocervical Flexion, Craniocervical Extension, Rotation Exercise, Lateral Flexion Exercise, Chin Tuck in and Shoulder blade exercise were advised to perform 3 x 10 Repetition with 10 - 30 sec hold.; Control group included Moist Hot Pack (Cervical contour- 8.25 x 10 x 2) for 10 Mins, Reverse SNAGS (10 Repetitions holding for 10 sec in each glide with a rest time of 30 seconds in between), Strengthening exercise and home plan. 3 sessions of mobilization per week and total of 4 weeks. Measurement will be taken at base level and after the last session, i.e. Pain intensity, pain pressure threshold, ROM, and disability.
These exercises included. Cervical Flexion, Extension Rotation, lateral flexion and back strengthening exercises. These all exercises were performed 3 x 15 Repetitions with 10 sec hold. This protocol was for 4 weeks and 3 sessions per week.
Home plan exercises includes Craniocervical Flexion, Craniocervical Extension, Rotation Exercise, Lateral Flexion Exercise, Chin Tuck in and Shoulder blade exercise were advised to perform 3 x 10 Repetition with 10 - 30 sec hold
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Thrust joint manipulation; Reverse sustained natural apophyseal glides; Cervicogenic headache; Mobilization and Manipulation