Cervicogenic Headache:
A Case Report of Spinal Manipulative Therapy
By:
Don Ross Sanchez
Doctoral Candidate
University of New Mexico School of Medicine
Division of Physical Therapy
Class of 2014
Advisor:
James Dexter, PT, MA
Printed Name of Advisor: _____________________________
Signature:________________________ Date:______________
Approved by the Division of Physical Therapy, School of Medicine,
University of New Mexico in partial fulfillment of the requirements for
the degree of Doctor of Physical Therapy.
Contents Abstract :... 4 Background/Purpose: …... 4 Case Description ... 4 Outcomes:…... 5 Discussion :... 5
Section 1: Background and Purpose of the PICO question: ... 6
Section 2: Case Description: ... 7
Initial Evaluation (12/19/12): ... 7
History: ... 7
Work History: ... 8
Prior Medical History:... 8
Exercise:... 8
Prior Level of Function:…... 9
Pain Assessment:... 9 Posture: ... 9 Cervical AROM:….. ... 9 Special Tests:... 9 Joint Mobility: ………..………. 10
Functional Outcome Measure: ..……… 10
Assessment: ..……….. 10
Clinical Judgments and Problems List: ..………. 10
Visit #2 (8/12/13)... 12 Visit #3 (8/19/13) ... 12 Visit #4 (8/26/13) ... 13 Visit #5 (9/23/13) ... 13 2
Visit #6 (10/7/13)... 14
Visit #7 (11/4/13) ... 15
Visit #8 (11/18/13) ………..……….……….. 15
Section 3: Evidence Based Analysis... 17
Discussion: ... 24 Conclusion:... 26 References ... 28 Appendix 1 ... 29 Appendix 2 ………... 38 Appendix 3 ... 43 Appendix 4 ... 49 Appendix 5 ... 55 Appendix 6 ... 61 Appendix 7 ... 66 Appendix 8 ... 70 Appendix 9 ... 74
Abstract
Background and Purpose:
Cervicogenic headache (CGH) is a secondary headache characterized by unilateral headache and symptoms and signs of neck involvement. It is often worsened by neck movement, sustained awkward head position or external pressure over the upper cervical or occipital region on the symptomatic side
(Chaibi, 2012). The reported prevalence of CGH varies from 13.8% to 17.8% of the headache population in different epidemiological studies (Vavrek, 2010). CGH is difficult to treat because the etiology and pathophysiology are not well understood. Current physical therapy practice relies on a variety of modalities to treat patients with CGH, including spinal manipulative therapy (SMT). The current body of evidence has been aimed at determining the effectiveness of SMT for the management of CGH. The following case study seeks to answer the following PICO question: In adult patients with cervicogenic headache, how effective is cervical manipulation compared to other conservative treatment in controlling incidence, intensity, and duration of cervicogenic headache?
Case Description
This case study looked at a 34-year-old man diagnosed with head injuries and cervicalgia in 2013 with suspected onset 6 months prior from military active duty. Over the past 6 months, the patient had been experiencing sharp, unilateral headaches lasting from hours to days at a time. The patient was referred to
(854.00) and cervicalgia (723.1). After physical examination, the physical therapist identified signs and symptoms consistent with cervicogenic headache. The
following goals were set for the patient after his initial evaluation:
1. Patient will be independent with cervical exercises and postural correction. 2. Patient will increase pain free cervical AROM to WNL’s
3. Patient will increase Patient Specific Functional Scale by 3-point average for sitting, standing, and exercise. Initial score: 3.0
4. Patient will report decreased frequency of headache from 4-5x/week to >1x/week.
Outcome
The patient was able to meet all the goals except for goal 3, which was 90% met. The patient had good outcomes for decreasing frequency of headache and increasing AROM and functional rating.
Discussion
As a whole, the evidence for this PICO question was insufficient to offer evidence-based support for the application of SMT for CGH. Current research lacks
methodological quality and fails to sufficiently report adverse events associated with SMT of the cervical spine. This case study was relevant because it showed the significance and importance of using evidence-based practice to guide clinical assessment of CGH and treatment.
Section 1: Background and Purpose of the PICO question
Globally, the estimate of those with an active headache disorder is 46% of the adult population. According to a recent study by Stewart et al, headache is the most common pain condition causing loss of productive time the US work force Of all headaches, cervicogenic headache (CGH) accounts for 13-18% of the
headache population (Vavrek, 2009). In CGH, pain is localized to the neck and occipital regions and may project to the forehead, orbital regions, vertex, or ears and special neck movements or sustained neck postures aggravate pain.
(Goodman, 2009). Historically, CGH has been difficult to diagnose and treat because the etiology and pathophysiology are not well understood. Current
treatment for CGH ranges from invasive surgeries to pharmaceutical intervention to conservative management with physical therapy, osteopaths and chiropractors. Among the interventions offered by the latter, spinal manipulative therapy (SMT) of the cervical and thoracic spine has emerged as a management approach for relief of pain, intensity and duration of CGH. Because CGH is a relatively new diagnosis, with its own set of diagnostic criteria, practitioners must weigh current research and consider anecdotal data along with patient beliefs and values when providing
treatment. The patient in this clinical setting is a 34-year-old male who was diagnosed with head injury and carvicalgia in 2013 originating from active duty in 2012. The patient came to the clinic with complaints of sharp, unilateral headaches lasting from hours to days at a time accompanied by left shoulder pain. This patient presented with as a motivating case study with an interesting set of issues to
address. This case study prompted the PICO question:
In adult patients with cervicogenic headache, how effective is cervical manipulation compared to other conservative treatment in controlling incidence, intensity, and duration of cervicogenic headache?
Upon performing a literature review, research showed inconsistent and variable improvements for patients suffering from CGH when treated with SMT. Research also iterated the importance of improving the methodological quality of RCT’s that are currently performed (Gross, 2010). Although there is not a single best
approach for managing and treating CGH, the evidence suggests that a multimodal approach may be effective for relief of chronic symptoms (Carlesso, 2010). The outcomes of this case study are important for clinicians who see populations with CGH. Since current evidence does not supply sufficient data or methodological quality to confirm a best approach, case studies may assist in supplying anecdotal data for future studies to be based. It is important to have tools and strategies to treat these patients in particular as their condition is often debilitating and can result in loss of wages and productivity as well as impact the healthcare system in the form of costly, and often long term, medical interventions.
Section 2: Case Description
Initial Evaluation (08/05/13)
History:
injuries (854.00) and cervicalgia (723.1). Patient reported initially begin
experiencing headaches while serving in the military 2 years prior. The patient reported an insidious onset of symptoms but believes that carrying a rucksack on long marches led to the headaches and neck pain. Head injury was sustained in 2010 when patient fell off truck while loading supplies, patient reports no LOC from fall and no lasting impairments. The patient reported an increase in headache frequency and duration over the past 6 months averaging 3-4 headaches per week. The patient reported increased pain and shooting headache with certain head and neck positions, particularly when working in the computer at work or turning head to check traffic while driving. Patient reported no relief with over-the-counter medication and had no prior conservative treatment.
Work history:
Patient worked active duty for the military from 2008-20012 as served as a truck driver. Duties performed ranged from vehicle maintenance, physical training, educational courses, and truck driving.
Patient currently works full-time as an accountant for the Forest Service and spends the greater part of the day on a computer.
Prior Medical History:
Arthralgia, OCD, panic disorder, anxiety, irritable bowel syndrome, thyroid nodule, alcohol abuse, low back pain, HTN, asthma, lesions of ulnar nerve.
Exercise:
The patient uses elliptical machine and swims 2-3 times per week and uses
Prior Level of Function:
Independent in all aspects.
Pain Assessment:
Patient reports unilateral headache on R side with occasional L sided headaches as well. Pain is sharp and can last hours to days at a time. Pain is worse with increased head turning and with long durations of working on the computer. Patient tender to palpation to right upper trapezius, right scalenes, and right splenius capitis.
Posture:
Mild forward head posture with slightly excessive thoracic kyphosis.
Cervical AROM:
Left rotation: 45 deg Right rotation: 45 deg Left side bend: 23 deg Right side bend: 7 deg Flexion: 75% normal Extension: 50% normal
(+) Quadrant
Joint Mobility:
AA hypermobility L>R Decreased mobility C2 R>L C3-5 stiffness L>R
Functional Outcome Measure:
Patient Specific Functional Scale: patient identified sitting, standing and exercising as the top 3 functionally limited activities. Score: 3.0
Note: Patient demonstrated no signs or symptoms of vertebral artery occlusion.
Assessment:
Diagnosis: the patient was referred with diagnoses of head injuries (854.00) and cervicalgia (723.1)
Narrative Assessment: The patient’s physical evaluation revealed impaired joint mobility and AROM of the cervical spine as well increased tenderness with
palpation to the right cervical musculature. The patient’s signs and symptoms are consistent with cervicogenic headache. Patient would benefit from skilled therapy intervention for increasing joint mobility and AROM of the cervical spine, relieving tender musculature and decreasing frequency, intensity and duration of
headaches.
Clinical Judgments and Problems List:
2. Decreased joint mobility of cervical spine
3. Increased tenderness to palpation of cervical musculature on right side. 4. Positive Quadrant test consistent with positioning pain for CGH.
5. Frequent unilateral headaches lasting hours to days
6. Poor posture contributing to cervical pain and decreased AROM Activity Restrictions:
1. Decreased ability to sit at desk and perform work
2. Decreased ability to stand for long periods of time due to headache intensity 3. Decreased ability to exercise due to headache pain.
Goals:
1. Patient will demonstrate independent postural correction
2. Patient will increase pain free cervical AROM and joint mobility to WNL’s 3. Patient will increase Patient Specific Functional Scale by 3-point average for
sitting, standing, and exercise. Current: 3.0
4. Patient will report no greater than 1 incidence of headache per week. Intervention:
Patient was educated in postural exercises for head, neck and spine. Patient was asked to stand with back facing a wall. Head and shoulders were to contact wall. Head to assume a chin tuck position to elongate posterior musculature. Patient was also instructed on upper trap stretch and scalene stretch. Patient was instructed to perform postural exercise at least two times per hour while awake. Stretches were to be performed once a day.
Manual stretching was performed in supine to right upper trap, right scalenes, and right splenius capitis.
Mid-thoracic extension HVLAM prone, no cavitation
T1-2 extension lateral flexion HVLAM prone, no cavitation.
Patient reported feeling “looser” and demonstrated increases of 11 degrees of L cervical rotation and 5 degree loss of R cervical rotation.
Visit #2 (8/12/13)
Subjective: Patient stated neck feels more relaxed than initial evaluation. Still having 2-3 headaches per week. Currently without headache.
Objective: Treatment performed: Manual therapy:
HVLAM seated and prone to T1-2 facets left and right, no cavitation
HVLAM left and right AA and C3-4 in supine with neck in lateral flexion, cavitation at C3-4. No cavitation at AA.
Supine cervical traction; 30lbs with 30/10 sec hold/relax x 17 minutes
Assessment: Patient demonstrates increased pain free cervical AROM (visual assessment). However, L rotation (AA) still stiff.
Plan: Continue with HEP and weekly treatment sessions. Next session, reassess cervical AROM.
Visit #3 (8/19/13)
Subjective: Patient stated neck feels looser. Complains of right trap tightness. Stated continues to have 2-3 headaches this week but duration and intensity are less. Reported that HEP seems to be helping with pain relief.
Objective: Treatment performed: Manual Therapy: HVLAM in prone to T1-2 facet, no cavitation
HVLAM in supine with lateral neck flexion to left and right AA and C3-4, no
Trigger point release to left upper trap. Re-assessment of cervical AROM: L rotation: 50 deg
R rot: 55 deg
L side bend: 35 deg R side bend: 25 deg
Assessment: Measurable increase in cervical AROM. However, L rotation (AA) still stiff. Patient demonstrates progress toward all goals.
Plan: Continue weekly treatment sessions. Will revisit cervical traction next session.
Visit #4 (8/26/13)
Subjective: Patient reports neck continues to feel improved. Reports 2 headaches this week with “medium” duration and intensity. Patient currently has headache and would like to use traction. Continues to complain of left upper trap tightness.
Objective: Treatment performed: Manual therapy: Patient performed L scalene and upper trap stretching Seated first rib inferior glides
Supine cervical traction; 30 lbs, 30/10 sec hold/relax x 15 minutes. Patient reported good relief of symptoms.
Assessment: Patient continues to require cues for posture. Assessment of cervical AROM appears improved and continues to be pain free.
Patient reports increased stiffness in neck but that HEP continues to help with pain relief. Reports headaches two times per week with “medium” duration and
intensity.
Objective: Treatment performed: Manual therapy and cervical traction: Manual stretching to L upper traps, L scalenes, and sub-occipitals HVLAM in supine to left and right AA with cavitation
HVLAM in supine with lateral flexion to C4-5 with cavitation Cervical traction; 27 lbs with 30/10 hold/relax x 17 minutes
Assessment: Patient appears to benefit from above treatment for reduction of neck pain and stiffness.
Plan: Reduce frequency to 2 times per month. Will instruct patient on use of home traction on next visit.
Visit #6 (10/7/13)
Subjective: Patient reported continued neck pain. Continues to perform HEP and has started swimming again. States that headaches are improving with decreased duration and intensity.
Objective: Treatment performed: Manual therapy and cervical traction HVLAM in supine to left and right AA with cavitation
HVLAM in supine with lateral flexion to C4-5 with cavitation Trial of home, door-hung cervical traction unit.
Assessment: Patient appears to benefit from manual therapy and cervical traction for reduction of neck pain and stiffness. Recommend purchase of home traction unit.
Plan: Continue with two times a month sessions. Will order patient a home cervical
Visit #7 (11/4/13)
Subjective: Patient reports improved neck pain and that neck feels looser. Reports only one headache this week with “medium” duration and intensity. Reports to still performing HEP and swimming. Feels HEP and exercise are helping. Patient has not received cervical traction unit yet.
Objective: Treatment performed: Manual therapy: Trigger point release to left upper trap.
HVLAM in supine to left and right AA with cavitation
HVLAM in supine with lateral flexion to C5-6 with cavitation Cervical traction; 30 lbs. with 30/10 hold/relax x 15 minutes
Assessment: Patient appears to be taking an active role in rehabilitation. Patient continues to benefit from manual therapy and cervical traction for reduction of neck pain and stiffness. Patient reporting less frequent headaches with improved rating of intensity and duration.
Plan: Will re-evaluate cervical AROM on next visit. Anticipate that patient will receive home traction unit by next visit.
Visit #8 (11/18/13)
Subjective: Patient reports that neck is feeling better. Reports having 1 headache this week with “medium” intensity and duration. States that neck feels like it is moving better. Patient has received home traction unit and reports to using 2 times this week. Patient feels ready to begin management from home with HEP, exercise and traction.
R rot: 68 deg
L side bend: 45 deg R side bend: 37 deg Flexion: 90%
Extension: 75% *All ROM pain free (-) quadrant
(-) compression
Assessment: Patient has benefitted from manual therapy and cervical traction to reduce neck stiffness and pain and is experiencing decreased frequency, duration, and intensity of headaches.
Plan: Patient will call to schedule additional appointments if needed. If patient does not call to reschedule appointment in 30 days, patient will be discharged from PT. Review of goals:
1. Patient will demonstrate independent postural correction
Outcome: Patient able to demonstrate independent postural corrections for relief of neck pain. Status: Goal met.
2. Patient will increase pain free cervical AROM and joint mobility to WNL’s
Outcome: Patient increased all cervical AROM from initial evaluation to WFL and is pain free. Status: Goal met.
3. Patient will increase Patient Specific Functional Scale by 3-point average for sitting, standing, and exercise. Current: 3.0
Outcome: Patient score on Patient Specific Functional Scale at end of treatment: 5.67, a 90 % improvement.
4. Patient will report no greater than 1 incidence of headache per week.
headache per week with improved duration and intensity.
This patient had good outcomes with a treatment approach tailored around manipulation therapy. With the treatments administered by the therapist, the patient was able to achieve improved cervical AROM and, importantly, reduce frequency, duration and intensity of cervicogenic headaches. The patient did not achieve a headache-free outcome; however, felt that management could be achieved with a home exercise program and exercise. The patient never called back to schedule additional visits and was therefore discharged from physical therapy services.
Section 3: Evidence Based Analysis
The breadth of research for treatment of cervicogenic headache with the use of spinal manipulative therapy is fairly extensive. The pool of research ranges from high to low levels of evidence. In researching the data for this study, four
bibliographical databases were searched. The databases searched were: PUBMED, CINAHL, PEDRO, and SPORTDISCUSS. Search terms used included: physical therapy and cervicogenic headache, spinal manipulative therapy and cervicogenic headache, cervicogenic headache, physical therapy and headache. Figure 1 shows the search method and the decision tree for selecting articles.
Evidence Scale. There were 4 systematic reviews; the first looked into manual therapies for CGH, the second at SMT for CGH, the third examined adverse events associated with SMT and the fourth aimed and comparing mobilizations to manipulations for neck pain. There were 2 Randomized Controlled Trials with Oxford Level of Evidence scores of 1b and Pedro Scores of 8/10. There was one case study used with an Oxford Level of 3b and a Pedro Score of 3/10. There was one diagnostic RCT with Oxford Level 2c. Finally, an outcomes research article was used that illustrated an evidence-based approach to CGH. The studies identified were all related to this case study and proved to be valuable data for following the treatment of this report.
Table 1 gives the analysis of types of articles, levels of evidence, purpose, outcome measures and results. Included in the appendix of this paper is an analysis of each article, as well as a one page summary of the articles.
# Study Oxford Level of Evidence /PEDro score Cochrane Method Used
Purpose of Study Outcome Measures/ Types of Studies Included Results Accept Results to Answer Clinical Question 1 Chaibi, A., Russell, MB, 2012
1a Not stated The stated purpose was to assess the efficacy of manual therapies for cervicogenic headache.
The study used 7 RCT’s ranging from 50-81 points on a 100-point scale.
The results showed that patients have a positive response to SMT and that PT and SMT may be an effective treatment in the management of CGH. The treatments offered from study to study are feasible options for a typical clinical setting. The primary skill set is manual therapy,
specifically SMT. The primary consideration is the patient’s preference to SMT.
Yes
2 Posadzki P, Ernst E., 2011
1a Yes The objective of this SR was to assess the effectiveness of spinal manipulations as a treatment option for cervicogenic headaches. 9 RCT’s were
investigated. The primary outcome of interest was pain management. This study did not sufficiently describe the selection process from study to study. However the authors acknowledge a relatively heterogeneous population across RCT’s
Results were mostly homogenous from study to study suggesting that SMT is effective in treating CGH. However the data is not conclusive and there continues to be unanswered questions regarding adverse effects of SMT. This article points out many important factors; primarily the lack of reported adverse reactions. W hile the quality methodology is poor, the RCT’s are inconclusive in determining if SMT is a valid treatment option for CGH.
Yes
3 Carlesso, LC, et al, 2010
1a Yes The goal of this SR was to synthesize the literature that has reported adverse events related to both cervical manipulation and mobilization 14 RCT’s were selected for review. Primary outcome of interest was any adverse event(s) associated with SMT.
While the findings from this SR are inconclusive, there are a few key variables to note. First, the incidence of AE in current literature regarding SMT is grossly underreported. This failure to report leads the authors to conclude that more stringent reporting of AE is required in RCT’s as well as in other literature. Second, there were no Catastrophic events reported across any eligible study, however this does not exclude the
Yes
techniques across professions.
possibility that minor adverse events are occurring and underreported. 4 Gross A, Miller J, D'Sylva J, et al., 2010
1a Yes This objective of review was to assess whether manipulation or mobilization improves pain, function/disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without cervicogenic headache or radicular findings.
27 RCT’s were selected for this review. Outcome measures of interest were pain relief, function, disability, and patient satisfaction, GPE, QoL. No
restrictions were set on type of tool used to assess the outcome measures. Most used validated tools to collect data.
This SR identified implications for practice that may be used to guide treatment, they are: cervical manipulation and mobilizations provide similar pain relief, functional improvement, and patient satisfaction; cervical manipulation may provide short term but not long term pain relief; thoracic manipulation alone or in combination with electro- thermal or individualized physiotherapy treatments may improve pain and function; anterior-posterior mobilizations may be superior to transverse, oscillatory and rotational mobilizations.
Yes
5 Zito, G, Jull, G, Story, I., 2006
2c n/a This study examined the presence of cervical musculoskeletal impairment in 77 subjects (27 with cervicogenic headache, 25 with migraine + aura, and 22 control subjects). The aim was to investigate the sensitivity of multiple tests, as a group, to determine if there is a pattern of musculoskeletal dysfunction. Assessments included a photographic measure of posture, range of movement, cervical manual examination, pressure pain thresholds, muscle length, performance in the cranio-cervical flexion test and cervical kinesthetic sense.
The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension (P = 0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid
normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.
6 van Duijn, J, van Duijn, AJ, Nitsch, W., 2007 3b 2/10
n/a The purpose of this study was to describe the physical therapy differential diagnosis, management with SMT, and outcomes of a patient with cervicogenic headache. Self-report outcome measures included the VAS for headache pain and intensity and the NDI.
At time of discharge, the patient had reported no headaches for three weeks. Her NDI score had decreased to 3/50 from an initial level of 20/50, which indicated that a clinically meaningful change had occurred based on the minimal clinically important difference of 7 points. The VAS pain scale score ranged from 0-5 (mm) with some daily variation, compared to a maximal initial level of 80 (mm), which represented a true change based on a minimal detectable change of 28 (mm). Yes 7 Jull, G., et al. 2002 1b 8/10
n/a The purpose of this study was to determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headaches when used alone or in combination, as compared with a control group.
The primary outcome was a change in headache frequency. Other outcomes included changes in headache intensity and duration, the Northwick Park Neck Pain Index, medication intake, and patient satisfaction. Physical outcomes included pain on neck movement, upper cervical joint tenderness, a cranio-cervical flexion muscle test, and a photographic measure of posture.
At the 12-month follow-up assessment, both manipulative therapy and specific exercise had significantly reduced headache frequency and intensity, and the neck pain and effects were maintained (P < 0.05 for all). The combined therapies was not significantly superior to either therapy alone, but 10% more patients gained relief with the combination. Effect sizes were at least moderate and clinically relevant. The clinical significance of this study suggests that manual therapy is a viable option for the management of CGH and should be considered as a viable option for the treatment of CGH. Furthermore, exercise therapy remains a valuable modality in the treatment of CGH and should not be excluded as a treatment option for CGH.
Yes
8 Page, P., 2011
5 n/a The purpose of this clinical suggestion is to review the
literature on
Relevant background was presented, gaps in current knowledge we addressed and the need
As with other musculoskeletal dysfunctions, a multi-modal physical therapy intervention is recommended to address individual impairments including modalities, manual therapy, and
Yes
cervicogenic headache (CGH) and develop an evidence-led approach to assessment and clinical management.
for further research was acknowledged. The clinical importance was clearly discussed. The need for this study arises from the incidence of CGH and the paucity of evidence to direct efficient, evidence-based treatment and management.
therapeutic exercise. It’s important for sports physical therapists to make an accurate diagnosis and provide an appropriate intervention to return the athlete with CGHs to sports as soon as possible. 9 Vavrek D, Haas M, Peterso n D., 2010 1b 8/10
n/a The purpose of this RCT was to investigate relationships between objective physical examination measures with self- reported cervicogenic headache outcomes Of 80 subjects, 40 were randomized to 8 treatments (SMT or light massage control) and 8 PE over 8 weeks. PE included motion
palpation of the cervical and upper thoracic regions, active cervical ROM and associated pain, and algometric pain threshold evaluated over articular pillars. Self-reported outcomes included CGH and neck pain and disability, # of CGH headaches, and related disability days. models.
At baseline, number of CGH and disability days were strongly associated with cervical active ROM (P < .001 to .037). Neck pain and disability were strongly associated with ROM-elicited pain (P < .001 to .035) but not later in the study. After the final treatment, pain thresholds were strongly associated with week 12 neck pain and disability and CGH disability and disability days (P ≤ .001 to .048). This article gives little additional
understanding as to the identifying markers for Physical examination to identify CGH. The clinical significance is unchanged from previous
strategies to diagnose CGH; which is to cluster signs and symptoms and apply knowledge of physiology to diagnose CGH in the clinic.
Yes
Discussion:
While some RCT’s suggest that physical therapy and SMT might be an effective treatment in the management of CGH (Chaibi, Russell, 2012); others suggest that the methodological quality of current RCT’s is flawed and cannot be
regarded as an evidence-based approach to treatment (Posadski, Ernst, 2011). With the current literature being somewhat polarized in it’s conclusions,
practitioners must be pragmatic and use clinical judgment along with a strong foundation of physiology and anatomy when examining the conclusions that are drawn about the efficacy of SMT for the treatment of patients with CGH.
The ubiquitous criticism of current literature lies in the methodological quality of current studies. Currently there are no set protocols to follow for the collection and reporting of crucial data such as adverse events or SMT as an isolated treatment (as opposed to a multimodal approach). The majority of current RCT’s fail to sufficiently or systematically report adverse events that are experienced by the patient when treated with SMT. This failure to report has led to reviewers calling for consort statement extensions on harms reporting guidelines so that mild and moderate adverse events can be captured (Carlesso, et al, 2010). Another common criticism of the current literature was failure to sufficiently blind either tester of participant. However, as with most manual physical therapy blinding will continue to be a difficult task since a clinician will typically know which intervention is being performed. Finally, while the body of evidence on SMT for CGH is growing, there are relatively few RCT’s or case studies that examine SMT as an isolated treatment and not as a multimodal approach to
While concerns should be raised regarding adverse events associated SMT at the cervical spine, current research reports that no catastrophic outcomes were reported in any of the eligible studies. This includes a prospective study
performed by Thiel et al, which reported the performance of 50,276 cervical manipulations (Carlesso, et al, 2010). With that bit of information clinicians should continue to be aware of catastrophic and mild to moderate adverse events that may arise from the use of SMT. Positive implications for practice report that cervical manipulations produce similar pain relief, functional
improvements, and patient satisfaction to mobilization and provide short-term pain relief (Gross, et al, 2010). One study performed in Australia concluded that SMT in conjunction with exercise can reduce symptoms of CGH, and the effects are maintained over a 12 month period (Jull, et al, 2002). Finally, a case study that was performed in the US demonstrated that a multimodal approach to the management of patients with CGH can be effective (Duijn, Duijn, Nitsch, 2007). In this case study the authors used trust and non-thrust manipulation, soft tissue manipulation and stretching, muscle re-education and patient education in the management of a patient with CGH.
One therapist saw the patient in this case report for eight visits, over the course of three and a half months. The therapist, using special tests, patient history,
knowledge of physiology and symptomology diagnosed the patient with CGH. The patient was treated using a multimodal approach that included cervical SMT, cervical mobilizations, cervical traction, postural exercises, and cervical traction. The decision to use cervical SMT for this patient was made after considering multiple factors. First, the literature has presented compelling evidence to use SMT as part of a multimodal approach to management of CGH. Second, the patient showed no signs of symptoms of vertebral artery occlusion nor did the patient present as a risk for vertebral artery dissection. Third, the patient had had prior cervical manipulations in the past and
requested to have SMT performed. Over the course of treatment the patient was taught self-management with the use of postural exercises, neck stretches, and cervical traction. Therapy sessions consisted of primarily manual therapy, specifically cervical SMT but also included, cervical mobilizations, manual stretching, and cervical traction. The patient initially showed good progress, then had a minor set back after missing scheduled appointments, but ultimately able to reduce frequency, duration, and intensity of headaches as well as return active cervical range of motion to normal limits.
Conclusion:
The evidence for cervical SMT for the management of CGH proved to be suitable to make the decision to proceed with treatment focused of SMT. While the evidence was not overwhelmingly conclusive, a case can be made for
positive benefits and outcomes with minimal risk to the patient. This case report was important because it illustrated how a SMT can aid in the management of CGH if used as part of a multimodal approach to achieve a positive patient outcome. This patient was able to achieve nearly all of his physical therapy goals (the exception being 90% completion of the fourth goal) and discharge from treatment with fewer headaches, decreased duration and frequency of headaches, and improved pain free cervical range of motion. Although the patient was not headache free, there were marked improvements in symptoms. For this case report, the PICO question was; “In adult patients with cervicogenic headache, how effective is cervical manipulation compared to other
conservative treatment in controlling incidence of headache?” For this patient, the answer to this question emerges as SMT being at least as effective as other conservative methods of treatment.
References
Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Man
Ther. 2010 Oct;15(5):434-44.
Chaibi A, Russell MB. Manual therapies for cervicogenic headache: a systematic review. J Headache Pain. 2012 Jul;13(5):351-9.
Goodman CC, Fuller KS, Pathology: Implications for the Physical Therapist third
edition. St. Louis, Missouri: Elsevier Inc.; 2009.
Gross A, Miller J, D'Sylva J, et al. Manipulation or mobilisation for neck pain: a Cochrane Review. Man Ther. 2010 Aug;15(4):315-33.
Jull G, et al. A Randomized Controlled Trial of Exercise and Manipulative
Therapy for Cervicogenic Headache. Spine. 1 September 2002 - Volume 27 - Issue 17 - pp 1835-1843.
Page P, Cervicogenic Headaches: An Evidence-Led Approach To Clinical Management. Int J Sports Phys Ther. Sep 2011; 6(3): 254–266. Posadzki P, Ernst E. Spinal manipulations for cervicogenic headaches: a
systematic review of randomized clinical trials. Headache. 2011 Jul-Aug;51(7):1132-9.
van Duijn J, van Duijn AJ, Nitsch W, Orthopaedic Manual Physical Therapy Including Thrust Manipulation and Exercise in the Management of a Patient with Cervicogenic Headache: A Case Report. J Man Manip Ther. 2007; 15(1): 10–24.
Vavrek D, Haas M, Peterson D. Physical examination and self-reported pain outcomes from a randomized trial on chronic cervicogenic headache. J Manipulative Physiol Ther. 2010 Jun;33(5):338-48.
Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Man Ther. 2006 May;11(2):118-29. Epub 2005 Jul 18.
Appendix 1
Diagnostic Test – Evidence Appraisal Worksheet Citation (use AMA or APA format):
Zito, G, Jull, G, Story, I. Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Man Ther. 2006 May;11(2):118-29.
Level of Evidence (Oxford scale): 2c
Is the purpose and background information sufficient?
Appraisal Criterion Reader’s Comments
Study Purpose
Stated clearly?
Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study?
This study examined the presence of cervical musculoskeletal impairment in 77 subjects (27 with cervicogenic headache, 25 with migraine + aura, and 22 control subjects). The aim was to investigate the sensitivity of multiple tests, as a group, to determine if there is a pattern of
musculoskeletal dysfunction.
Literature
Relevant background presented?
A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic.
Describe the justification of the need for this study
Relevant background information and a review of literature was provided along with current gaps in current knowledge and the clinical importance if the topic. The justification of the need for this study is that the diagnosis must come before the treatment. Knowing key characteristics of the diagnosis improves clinical decision-making and leads to better treatment strategies.
Does the research design have strong internal validity?
Appraisal Criterion Reader’s Comments
Is there a detailed description of:
Setting in which the research was conducted
Is this test
reproducible in your setting?
The sample and how it was obtained
Does this resemble your patient
population and/or is the sample selection biased in anyway
Protocol for the test used including scoring
methods. Could you
reproduce the test from the descriptions given?
the testing that was performed. All measurements were described in detail and could be replicated in another clinical setting. The sample of subjects was obtained through valid and reliable sources. The population was females ranging in age from 18-34 years old. While this is not the sole demographic for
cervocogenic headache, this is a fair representation. This protocol could be replicated with the given descriptions.
Are the results of this diagnostic study valid? Yes
Appraisal Criterion Reader’s Comments
1. Was there an independent,
masked comparison between the diagnostic test of interest and a “gold (reference) standard” diagnostic test?
a. If not, describe what was done, the limitations of this approach, and the
potential consequences for the study’s results
There was an independent masked comparison between groups in that the single examiner was not aware of the diagnoses prior to examination. The “gold standard” for diagnosis of CGH was a diagnosis reached using Sjaastad et al., 1998 criteria. IHS, 2004 criteria for migraine headache. Limitations of this approach are the examiners skill level and the inter-rater reliability of the testing.
2. Was the diagnostic test
evaluated in subjects with the range of presentation (i.e., different levels or stages) of the condition?
a. If not, describe the sample and discuss the potential consequence that this limited sample has for the study results
The testing was performed on subjects with varying total length of history ranging from 9 months – 10 years.
3. Did the investigators perform the gold standard diagnostic test on every subject regardless of the result from the diagnostic test of
Gold standard testing was performed on each subject regardless of the results from the diagnostic test of interest.
interest?
a. If not, describe what was done, as well as the limitations of this approach.
4. Was the test (or cluster of tests) evaluated in a second
independent group of subjects? Did the investigators confirm their findings with a new set of subjects?
a. If not, describe the
limitations resulting from the lack of comparison group
The test was not evaluated by a second, independent group of subjects. Findings were not confirmed with a new set of subjects. The limitations resulting from a lack of comparison are in reliable
measurements. There is no data to suggest that these tests are reproducible given different testers in a new location.
5. Were the individuals performing the test masked or blinded to the other test’s results?
a. If not, what are the
potential consequences of this knowledge for this study’s results
There was a single tester who was blinded to the diagnosis of each patient.
Are the valid results of this diagnostic study important? Fairly
Appraisal Criterion Reader’s Comments
6. What were the statistical findings of this study?
a. When appropriate use the calculation forms below to determine these values b. Include: tests of
association With p-values and CI
c. Sensitivity/ specificity d. Positive predictive value/
negative predictive value e. LR + and LR- with CI f. Other stats should be
included here
With the given data, 2 co-variables were found to be diagnostic indicators of CGH vs. migraine and control: 1) upper cervical joint dysfunction at the C1/2 segments paired with 2) pectoralis minor muscle length. Given these two variables the researchers report a sensitivity of 0.8. Given raw data from C1/2 segments (raw data not given for pec minor):
Specificity=0.76
Please see calculation below for PPV, LR-, LR+, Pre/Post-test probability, nomogram.
7. What is the meaning of these statistical findings for your
patient/client’s case? What does this mean to your practice?
This data suggests a fair diagnostic value can be taken when using C1/2 dysfunction along with pectoralis minor muscle length. For practice, evaluating C1/2 and
pectoralis minor are important variables in diagnosing CGH and ultimately the
Can you apply this valid, important evidence about this diagnostic test in caring for your patient/client? What is the external validity? Yes, external validity is fair.
Appraisal Criterion Reader’s Comments
8. Does this test sound appropriate for use (available, affordable) in your clinical setting?
Considering availability and affordability, this test appears appropriate for use in a clinical setting.
9. Are the study subjects similar to your patient/ client?
a. If not, how different? Can you use this test in spite of the differences?
This study is focused on females only. Without further research the implications do not cross to over to male populations. Given the inherent differences in the male and female anatomy, additional diagnostic criteria must be examined in male
subjects.
10. Can you generate a clinically sensible estimate of your patient’s pretest probability of the disorder?
a. Talk about your interpretation of the nomogram
Given the data from this study, the pretest probability is 35%. This appears to be a sensible estimate given the prevalence of the condition. The nomogram gives further diagnostic confidence when applying the C1/2 criteria. Given raw data from
pectoralis testing the probabilities could potentially increase, giving the diagnostic tools greater probability of correct
diagnosis.
11. Would the test and its results, including the posttest
probabilities help your patient? a. If so, how? If not, could
the test actually harm your patient?
Yes. The results give greater confidence to the diagnosis allowing the clinician to guide treatment in an appropriate direction.
12. Does the test fit within your patient’s stated beliefs or
expectations? What are the risks vs. benefits? Cost?
Generally, patients want to know why their bodies feel bad. The conservative testing involved with this research is fairly fast, relatively inexpensive and within the scope of practice of any physical therapist. Risks are low; potentially provoking some CGH associated pain. Benefits are moderately high; correct diagnosis increases
probability of positive outcome.
What is the bottom line?
Appraisal Criterion Reader’s Comments
Summarize your findings and relate this back to clinical significance and
usefulness of this test
This study suggests that C1/2 testing in conjunction with pectoralis minor muscle length testing can be useful in the
diagnosis of CGH. The clinical significance lies in the testing parameters, C1/2 testing and muscle length testing are universal skills in nearly every practice. Additionally, the testing requires no additional cost or risk to the patient making it a viable option for first line diagnosis.
Calculations if needed: given raw data from c1/2 dysfunction (no pec minor data) Target Disorder Diagnostic test results + - Totals + a b a+b - c d c+d
Totals a+c b+d a+b+c+d
Sensitivit y = a / (a + c) = __39___ / (__39___ + __15____) = __39___ / __54____ = __73__%_ Specificit y = d / b + d = __76___ / (__24___ + __76____) = __76___ / __100____ = __76___% Positive Predictive Value = a / (a + b) = __39___ / ___39__+ __25___ = __39___ / __64___ = __61___% Negative Predictive Value = d / (c + d) = __76___ / (__15___ + __76___) = __76___ / __91___ = __84___% Positive Likelihood Ratio = Sensitivity / (100 - specificity) (LR+) = __80___% / (100 - _76___%_) = __80___ / _24____ = __3.33___ Negative Likelihood Ratio = (100 - sensitivity) / specificity 34
(LR-) = (100- _80____%) / _76___% = __20___ / __76___ = _0.26____ Pretest probability (prevalence) = (a+c) / (a+b+c+d) = (_39__ + _15__) / (_39__ + _24__+_15__+_76__) = ___54__ / ___154__ = __35___%
Use the nomogram to determine post-test probability: Draw a line to represent your answer for both a positive test and a negative test.
Here are lines you can drag and expand to put on your graph:
Interpretation of the Nomogram (is this diagnostic test clinically useful?): Given the above statistics a clinician can increase the probability of correct diagnoses by 28% using positive findings from a C1/2 dysfunction test as
diagnostic tool. Conversely a clinician can increase confidence of ruling out CGH from 35% probability to roughly 12% (a difference of 23%) probability by using c1/2 diagnostic criteria.
Adapted from : Jewell, D. Guide to Evidence Based Physical Therapy Practice. Jones and Bartlett Publishers, Sudbury, MA 2008
Zito, G, Jull, G, Story, I. Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache. Man Ther. 2006 May;11(2):118-29.
Level of evidence: 2c
Purpose: This study examined the presence of cervical musculoskeletal impairment in 77 subjects (27 with cervicogenic headache, 25 with migraine + aura, and 22 control subjects). The aim was to investigate the sensitivity of multiple tests, as a group, to determine if there is a pattern of musculoskeletal dysfunction.
Methods: Seventy-seven female volunteers aged between 18 and 34 years were invited to join the study. The cross- sectional study was conducted under single blind
conditions in that the principal investigator, an experienced musculoskeletal
physiotherapist, was blind to the diagnostic category of the subjects. The subjects were recruited from neurologists, general medical practitioners and musculoskeletal
physiotherapists or by advertisement. They entered one of three groups, a control group a cervicogenic headache group or a migraine with aura group and comparisons
between the three groups were made. Headache subjects entered their respective groups according to established diagnostic criteria for migraine with aura and cervicogenic headache. Anesthetic blockades were not used as a criterion for
cervicogenic headache as the procedure was considered too invasive and costly for this study and is not readily accessible to most clinicians. The total length of the history of the headache ranged from 9 months to more than 10 years. Young subjects were selected as it is the period of life when vascular symptoms are more frequently
encountered and when the effects of age or disease in the musculoskeletal system are still relatively negligible. The inclusion criteria for control subjects were no history of headache, cervical pain or injury for which they had sought treatment. Headache subjects were deemed ineligible if they had a history of combined forms of headache, were involved in compensation or, in the case of migraine with aura subjects, if they had a history of a neck injury or condition.
Results: The results of this study determined that range of cervical movement was reduced in the cervicogenic headache subjects, albeit significant for flexion and extension only. This finding of reduced movement supports the current criteria for cervicogenic headache.
Bottom Line: This study determined that the presence of upper cervical joint dysfunction most clearly differentiated the cervicogenic headache sufferers from those with migraine with aura and control subjects. The cervicogenic headache group also presented with restriction in cervical motion, a higher frequency of muscle tightness. This data is useful in the treatment of cervicogenic headache because the diagnostic criteria fit the current model of dysfunction in patients with cervicogenic headache.
Appendix 2
Intervention – Evidence Appraisal Worksheet Citation (use AMA or APA format):
van Duijn J, van Duijn AJ, Nitsch W. Orthopaedic Manual Physical Therapy Including Thrust Manipulation and Exercise in the Management of a Patient with Cervicogenic Headache: A Case Report. J Man Manip Ther. 2007; 15(1): 10–24.
Level of Evidence (Oxford scale): 3b
Is the purpose and background information sufficient?
Appraisal Criterion Reader’s Comments
Study Purpose
Stated clearly?
Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis.
A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study? Literature
Relevant background presented?
A review of the literature should provide
background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical
importance of the topic.
Describe the justification of the need for this study
The purpose of this study was to describe the physical therapy differential diagnosis, management, and outcomes of a patient with cervicogenic headache (CGH).
The authors discuss the current literature and the need for further high-level evidence to support or refute the use of cervical manipulation as a viable treatment option for CGH. This study justifies treatment based on current industry standards of diagnosis and treatment.
Does the research design have strong internal validity?
Appraisal Criterion Reader’s Comments
Discuss possible threats to internal validity in the research design. Include:
Assignment Attrition History Instrumentation Maturation Testing Compensatory Equalization of treatments Compensatory rivalry Statistical Regression
Possible threats to internal validity include, follow-up times (6 mos. and 1 yr.) as well as an appeal to authority on the part of the patient. These variables question the validity of true long-term carry-over as well as the subjective feelings of the patient when followed over time.
Are the results of this therapeutic trial valid?
Appraisal Criterion Reader’s Comments
1. Did the investigators randomly assign subjects to treatment groups?
a. If no, describe what was done b. What are the potential
consequences of this assignment process for the study’s results?
This article is a case report. There was single subject who was treated for CGH using thrust and non-thrust manipulation techniques, exercise, and postural correction. There was no blinding in this study.
2. Did the investigators know who was being assigned to which group prior to the allocation?
a. If they were not blind, what are the potential consequences of this knowledge for the study’s results?
Potential consequences are no comparison to a “gold standard” of treatment. The reported outcome comes from the therapist who has gathered the data from the patient.
3. Were the groups similar at the start of the trial? Did they report the
demographics of the study groups? a. If they were not similar – what
differences existed? b. Do you consider these
differences a threat to the research validity? How might the differences between groups affect the results of the study?
There was only one subject in this study. This effectively makes this a 3b level of evidence.
4. Did the subjects know to which treatment group they were assign?
a. If yes, what are the potential consequences of the subjects’ knowledge for this study’s results
Yes. The patient may have felt a need to appeal to the authority of the therapist.
5. Did the investigators know to which treatment group subjects were assigned ?
a. If yes, what are the potential consequences of the subjects’ knowledge for this study’s results
Yes. However, there was a pre-designed treatment plan that the therapist followed. This treatment may not have large carry-over to large pools of patient populations.
6. Were the groups managed equally, apart from the actual experimental treatment?
a. If not, what are the potential consequences of this knowledge for the study’s results?
N/A
7. Was the subject follow-up time sufficiently long to answer the question(s) posed by the research?
a. If not, what are the potential consequences of this knowledge for the study’s results?
Follow-up time was 6mos and 1yr. This was a fair amount of time to examine the “long term” effects of the treatment. However, even longer follow-up would aid in the determination to label the results a positive “long term” outcome.
a. If not how many subjects were lost?
b. What, if anything, did the authors do about this attrition? c. What are the implications of the
attrition and the way it was handled with respect to the study’s findings?
9. Were all patients analyzed in the groups to which they were randomized (i.e. was there an intention to treat analysis)?
a. If not, what did the authors do with the data from these subjects?
b. If the data were excluded, what are the potential consequences for this study’s results?
Yes, no data was excluded.
Are the valid results of this RCT important?
Appraisal Criterion Reader’s Comments
10. What were the statistical findings of this study?
a. When appropriate use the calculation forms below to determine these values b. Include: tests of differences
With p-values and CI
c. Include effect size with p-values and CI
d. Include ARR/ABI and RRR/RBI with p-values and CI
e. Include NNT and CI
f. Other stats should be included here
Statistics were not performed in this study.
11. What is the meaning of these statistical findings for your patient/client’s case? What does this mean to your practice?
Statistics were not performed in this study
12. Do these findings exceed a minimally important difference? Was this brought up or discussed?
a. If the MCID was not met, will you still use this evidence?
Statistics were not performed in this study
Can you apply this valid, important evidence about an
intervention in caring for your patient/client? What is the
external validity?
Appraisal Criterion Reader’s Comments
13. Does this intervention sound appropriate for use (available,
affordable) in your clinical setting? Do you have the facilities, skill set, time, and 3rd party coverage to provide this treatment?
This intervention is appropriate for us in a clinical setting. There are minimal tools needed and the cost is relatively low given that there is no additional equipment needed.
14. Are the study subjects similar to your patient/ client?
a. If not, how different? Can you use this intervention in spite of the differences?
This subject appears similar to other patients with this diagnosis.
15. Do the potential benefits outweigh the potential risks using this intervention with your patient/client?
The benefits outweigh the potential risks.
16. Does the intervention fit within your patient/client’s stated values or expectations?
a. If not, what will you do now?
This intervention fits within most patients’ values and expectations. The primary consideration is whether the patient has a aversion to cervical manipulation.
17. Are there any threats to external validity
in this study? There are situational threats to external validity. There were multiple modalities
used to treat (i.e. thrust, non-thrust manipulation, exercise and postural exercises) there is no clear indication that one of these modalities works better than. This must be a consideration when
choosing treatment modalities.
What is the bottom line?
Appraisal Criterion Reader’s Comments
PEDRO score (see scoring at end of form)
2/10
Summarize your findings and relate this back to clinical significance
This is a fair case report that uses data from multiple sources to treat a single patient with CGH. The modalities chosen reflect the best current evidence and should be considered when treating patients with CGH. The largest considerations remaining are whether all modalities are needed or if individual components of this treatment can be effective.
van Duijn J, van Duijn AJ, Nitsch W. Orthopaedic Manual Physical Therapy Including Thrust Manipulation and Exercise in the Management of a Patient with Cervicogenic Headache: A Case Report. J Man Manip Ther. 2007; 15(1): 10–24.
Level of Evidence (Oxford scale): 3b
Purpose: The purpose of this study was to describe the physical therapy differential diagnosis, management, and outcomes of a patient with cervicogenic headache (CGH). Methods: The patient was a 40-year-old woman referred by her physiatrist with com- plaints of cervical pain and ipsilateral temporal headache. The patient presented with increased muscle tone, multiple-level joint hypomobility in the cervical and thoracic spine, muscle weakness, and postural changes. Self-report outcome measures included the Visual Analog Scale for headache pain intensity and the Neck Disability Index. Management consisted of various thrust and non-thrust manipulations, soft tissue mobilizations, postural re-education, and exercise to address postural deficits and cervical and thoracic hypomobility and diminished strength.
Results: At discharge, the patient demonstrated clinically meaningful improvements with regard to pain, disability, and headache. The patient was seen for a total of 16 visits over a 9-week period of time. The initial frequency of treatment was 3 times per week and was gradually decreased to once weekly during Weeks 6-9 to monitor progression of the home program. At time of discharge, the patient had reported no headaches for three weeks. Her NDI score had decreased to 3/50 from an initial level of 20/50, which indicated that a clinically meaningful change had occurred based on the minimal
clinically important difference of 7 points. The VAS pain scale score ranged from 0-5mm with some daily variation, compared to a maximal initial level of 80mm, which
represented a true change based on a minimal detectable change of 28mm. The location of the remaining pain was in the upper thoracic region.
Bottom Line: A multimodal PT treatment approach was used based on evidence in the literature and pathophysiologic hypotheses, and it included the use of non-thrust and thrust manipulation techniques, therapeutic exercise, and postural correction. Clinically meaningful short- and long-term improvements with regard to pain, disability, and headache were reported with at least a temporal relation to this treatment approach. Physical therapy management of the cervical headache patient should address all identified impairments with interventions including non-thrust joint manipulation, HVLA thrust manipulation, soft tissue manipulation and stretching techniques, retraining specific postural muscle groups, and patient education.
Appendix 3
Intervention – Evidence Appraisal Worksheet Citation (use AMA or APA format):
Gwendolen J, et al. A Randomized Controlled Trial of Exercise and Manipulative
Therapy for Cervicogenic Headache. Spine. 1 September 2002 - Volume 27 - Issue 17 - pp 1835-1843.
Level of Evidence (Oxford scale): 1b
Is the purpose and background information sufficient?
Appraisal Criterion Reader’s Comments
Study Purpose
Stated clearly?
Usually stated briefly in abstract and in greater detail in introduction. May be phrased as a question or hypothesis. A clear statement helps you determine if topic is important, relevant and of interest to you. Consider how the study can be applied to PT and/or your own situation. What is the purpose of this study?
Literature
Relevant background presented?
A review of the literature should provide background for the study by synthesizing relevant information such as previous research and gaps in current knowledge, along with the clinical importance of the topic.
Describe the justification of the need for this study
The purpose of this study was to determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic
headaches (CGH) when used alone or in combination, as compared with a control group.
The researchers presented relevant current data for this topic, acknowledged gaps in current knowledge and gave rationale for the clinical importance of this topic. This study aimed to answer the question of modality options for the treatment of CGH.
Does the research design have strong internal validity?
Appraisal Criterion Reader’s Comments
Discuss possible threats to internal validity in the research design. Include: Assignment Attrition History Instrumentation
Attrition, history, compensatory rivalry, are all possible threats to internal validity in this research design. The loss of patients needs to be addressed through intention to treat analysis. History, while not a large factor in this study, needs to be considered as events in certain areas of the country can effect the outcome of the study.
Testing
Compensatory
Equalization of treatments
Compensatory rivalry
Statistical Regression
they belong, making compensatory rivalry a real threat to internal validity.
Are the results of this therapeutic trial valid?
Appraisal Criterion Reader’s Comments
1. Did the investigators randomly assign subjects to treatment groups?
a. If no, describe what was done
b. What are the potential consequences of this assignment process for the study’s results?
Yes, the researchers used a randomized permuted block design. This process allows for reasonable allocation of subjects into each group.
2. Did the investigators know who was being assigned to which group prior to the allocation?
a. If they were not blind, what are the potential
consequences of this knowledge for the study’s results?
No.
3. Were the groups similar at the start of the trial? Did they report the demographics of the study groups?
a. If they were not similar – what differences existed? b. Do you consider these
differences a threat to the research validity? How might the differences between groups affect the results of the study?
Yes, demographics were reported. The between-group differences were not a threat to the research validity nor would they affect the results of the study.
4. Did the subjects know to which treatment group they were assign?
a. If yes, what are the
potential consequences of the subjects’ knowledge for this study’s results
The subjects knew which group they were assigned. Possible compensatory rivalry may have affected the results of the data.
