Exercise and manipulative therapy for cervicogenic headache and neck pain
A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache
From: Spine. 2002 Sep 1;27(17):1835-43
A multicenter, randomized controlled trial with unblinded treatment and blinded outcome assessment was conducted. The treatment period was 6 weeks with follow-up assessment after treatment, then at 3, 6, and 12 months. To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache (neck related headache) when used alone and in combination, as compared with a control group.
Headaches related to the neck and arising from cervical musculoskeletal disorders are common. Conservative therapies are recommended as the first treatment of choice. Evidence for the effectiveness of manipulative therapy is inconclusive and available only for the short term. There is no evidence for exercise, and no study has investigated the effect of combined therapies for cervicogenic headache.
In patients with cervicogenic headache, manipulative therapy and a low load exercise regimen each reduced headache frequency and intensity more than no physical therapy. A combination of manipulative therapy and exercise was not better than each individual therapy for these outcomes.
200 participants who met the diagnostic criteria for cervicogenic headache were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and 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 craniocervical flexion muscle test, and a photographic measure of posture. The therapeutic exercise used low load endurance exercises to train muscle control of the neck and scapular region.
There were no differences in headache-related and demographic characteristics between the groups at baseline. The loss to follow-up evaluation was 3.5%. 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. 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.
Commentary by Michael Yelland, MBBS, FRACGP
The study by Jull et al is the most rigorous attempt to date to assess the effects of physical therapies on the common clinical problem of cervicogenic headache. Its multicentre design, as well as some flexibility in the number and content of treatment sessions, increase the generalisability of the results to clinical practice. 12 month follow up adequately tested the durability of responses. Blinding was possible only for outcome assessment, but the success of this blinding was not reported.
The results indicate a superior effect of manipulative and exercise therapies used alone and in combination compared with a control condition. On balance, it seems that combined therapy offers slightly more than either therapy alone. The results are
consistent with a review, which showed that multimodal manual therapy, including exercise, is superior to certain physical medicine modalities, rest, and control treatments for cervicogenic headache.
It is impossible to determine the contribution of the non-specific effect of repeated contact with therapists. A course of 8–12 treatment sessions over a 6 week period was given to active treatment groups, but not to the control group. None the less, active treatments worked, and 2 active treatments worked a little better than one. No explanation for the limits on the number of treatment sessions was provided. Only 12–21% of patients in the active treatment groups sought additional treatment in the follow up period, suggesting that ≤ 12 treatments is sufficient. However, is < 8 treatments effective? A small trial of manipulation for cervicogenic headache showed significant improvements from baseline with 6 treatments, but these were not better than the active comparator of laser and deep friction massage; there was no non-intervention group.
Practising clinicians should take note of the trial’s selection criteria of unilateral or predominantly unilateral headache with neck pain and upper cervical tenderness to guide their selection of patients who may benefit from these treatments. Should there be
angst about the potential (small) risk of complications of cervical manipulation, exercise therapy alone would still be effective, or the manual therapy component could be limited to low velocity mobilisation.
