MOBILIZATION TECHNIQUES IN THE
MANAGEMENT OF CERVICOGENIC
HEADACHES
Leah Batten
Clinical Problem Solving II
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.
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
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.
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:
1) Severe Headaches
2) Upper neck pain
3) Overall Stiffness
Patient’s Main Goal:
Decrease pain, stiffness and abolish HA’s
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
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:
Grade I: C2-C3 painful
Grade II: C4-C6 pain free
Special Tests
Cervical Distraction: Negative
Cervical Compression: Negative
Neck Disability Index (NDI)
33/50 or 66%
ASSESSMENT (DAY 1)
Functional Limitations
1. Pain
2. Headaches
3. Decreased ROM
Activity Restrictions
1. Unable to work - lead
exercise classes
2. Unable to perform
computer work
Prognosis: GOOD
Therex Performed:
Due to the following factors:
• B supine cervical rotation x 10
• Supine deep neck flexor chin
tucks 2 x 10
 Age
 Health status
 Motivation to recover
* Given as HEP
PATIENT CENTERED GOALS
In 2 weeks patient will…
1) Increase AROM in L rotation, extension and B SB, 7
degrees in order to increase safety with driving
1) Report 50% decrease in neck pain and
headaches in order to return to work
1) Exhibit a decreased NDI score of 25% to illustrate
increased functional capacity of cervical spine
PATIENT CENTERED GOALS
In 4 weeks patient will…
1) Be pain free with sitting at the computer and
driving to work to increase functional
independence
1) Teach group fitness classes with minimal pain 2/10
on the VAS in order to return to full capacity at
work
1) State HA’s are abolished in order to increase
success with ADL’s
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
-
Work Simulation (prior to D/C)
- Overhead lifting
- Education on proper form
Cervical Flexion Test
Scapular Retraction Exercises
Upper trap stretches
Isometric SB, Flex and Ext
“SNAG” MULLIGAN TECHNIQUE?
C1-C2 Self-Sustained Natural
Apophyseal Glide
(SNAG)
Mulligan's manual therapy
technique at peripheral
joints, namely mobilization
with movement (MWM).
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
CLINICAL QUESTION
For a 26 year old female post
MVA, are cervical spine
mobilizations effective in the
management of cervicogenic
headaches, and decreased
ROM?
Efficacy of a C1-C2 Self-sustained Natural Apophyseal
Glide (SNAG) in the Management of Cervicogenic
Headache
TOBY HALL, ET AL. 2007, JOSPT
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
METHODS
Participants: 32 subjects
Inclusion Criteria:
• Unilateral or side dominant headache
• Headache with neck stiffness and or pain
• Aged 18-66 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
METHODS
Treatment Groups:
1) C1-C2 Self-SNAG
2) Placebo
Procedure:
1) Initial instruction & practice (3 practice trials, 2 reps/3 secs)
2) FRT measured before and immediately after instruction
3) HA symptoms assessed by questionnaire pre-intervention,
and then 4 and 12 mos post-intervention (100%
compliance)
4) Interventions of HEP (2 reps/3 secs - 2x daily)
RESULTS
Characteristic
C1-C2 SNAG
Placebo
HA Severity Index
(baseline)
52 ± 10
51 ± 10
HA Severity Index
(4-week)
31 ± 9
51 ± 15
HA Severity Index
(12 mo.)
24 ± 9
44 ± 13
15° increase
5° increase
Flexion Rotation Test
• SNAG: 54% reduction in headache symptoms at 12 mos.!
• Placebo: 13% reduction
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
Mobilization versus massage therapy in the treatment
of cervicogenic headache: A clinical study
ENA S Y OUSSEF, ET A L. 2013, JOURNAL OF BACK AND
MUSCULOSKELETAL REHABILITATION
PURPOSE
To compare the effect of cervical
mobilizations to massage therapy when
treating cervicogenic headaches.
Level of Evidence: Randomized Clinical Trial
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.
METHODS
Treatment Groups:
1) Low velocity passive upper cervical mobilization
techniques
2) Massage Therapy
Procedure:
• Evaluation
 HA intensity, frequency, and duration
 Functional Disability (NDI)
 AROM
• Interventions performed 2x week for 6 weeks for 30-40
minutes each
OUTCOMES
Characteristic
Group 1
Mobilization
Group 2
Massage
Pre-Test
Post-Test
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
1.9
1.7
1.6
3.9
2.9
3.2
1.9
1.5
1.6
3.5
2.5
2.52
NDI
46.7
18.5
48.3
17.5
• HA symptom decreases and ROM increases greater with Mobilization
• NDI no significant difference between groups
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
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!
QUESTIONS?
THANK YOU!
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). 144-164.
http://www.physio-pedia.com/Cervical_Flexion-Rotation_Test. September 4,
2015.
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 2007. Volume 37, Number 3. 100-107.
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.