Comparative Effects of Mulligan’s Mobilization, Spinal Manipulation, and Conventional Massage Therapy in Cervicogenic Headache—A Prospective, Randomized, Controlled Trial. (2022)

PICO

Patient/Population

History of chronic CGH (>3 months) and in the age group of 18 years to 60 years (n=84)

Intervention

  • Hotpack + Mulligan mobilization therapy (SNAG) + home neck isometric exercises daily
  • Hotpack + Spinal manipulation therapy
    + home neck isometric exercises daily

Comparison

  • Control group
    Hotpack +
    Conventional Massage Therapy
    + home neck isometric exercises daily

Outcomes

  • CGH frequency
  • CGH pain
  • CGH disability
  • Neck pain frequency
  • Neck pain intensity
  • Neck pain threshold
  • Flexion–rotation
  • Neck disability
  • Quality of life

Translatability:   (3/3) Easy                                    

Comments: “Mulligan’s mobilization with the SNAG approach provided better outcomes in cervicogenic headache than those of spinal manipulation therapy and conventional massage therapy. “
Limitations: “First, although the sample size was calculated through the power analysis method, the authors felt the sample size was small and was a potential for type 2 error. Second, both genders were included in the study, but since the data were not analyzed separately during data interpretation, these gender differences might have an impact on the study outcomes. Additionally, due to the nature of the intervention, it was not possible to blind the therapist who administered the intervention to the participants. Third, there is a lack of a placebo or sham group in this study to identify the real effects of treatment groups….Fourth, the duration of the application of different mobilization approaches was not similar, which may affect the outcome of the results. It was also not possible to guarantee that the participants filled out the medical log book every day rather than after a week or four weeks.”

Appraisals:

Trustworthiness – The study contains no serious weaknesses. Based on this result you should conclude that the trustworthiness of the study is high (90%). This means there is a 10% chance that alternative explanations for the effect found are possible. The effect size was not reported and 95% CI was OK. (by CAT)

Metrics and
Journal Details:
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BTB

Intervention – 1

  • Hot pack
  • Mulligan’s sustained natural apophyseal glide (SNAG)

Dose

  • 5 min of hydrocollator hot pack
  • 10 repetitions for about 8 min

Periodicity

  • 4 times a week for 4 weeks

Local/Technic:

  • Hot Pack on the neck and upper back region to relax the muscles.
  • “Each patient was asked to sit comfortably, and the treating therapist stood beside the patient. The patient’s head was free and cradled between the therapist’s right forearm and body, and the therapist stood at the patient’s right side. The therapist then placed his right index, middle, and ring fingers at the base of the occiput and kept his right little finger over the spinous process of C2. Next, with the lateral border of his left thenar eminence, gentle pressure was applied in a ventral and upward direction (45 degrees) over the right little finger. The contacting hand was relaxed, and the source of the power of gliding was delivered from the left hand. At the same time, pressure was applied by the left index finger to move the lower vertebra forward, and the slack was taken up. Gliding was applied rhythmically (three times per second) ten times, and the width of the gliding started from the middle to the end. The therapist continuously glided the joint and asked the patient to actively move their head towards the side of dysfunction and pain. When the patient moved their head, the therapist glided the spinous process ventrally and maintained the SNAG technique for 10 s….At the end of the mobilization, the patient was asked to passively rotate their neck and over press at the end range.”

    Intervention – 2

    • Hot pack
    • Spinal Manipulation Therapy (SMT)

    Dose

    • 5 min of hydrocollator hot pack
    • “The range of rotation depends upon the level of the target vertebrae.”

    Periodicity

    • 4 times a week for 4 weeks

    Local/Technic:

    • Hot Pacck on the neck and upper back region to relax the muscles.
    • “This technique was provided by a trained manipulative therapist after assessing each participant at each visit through physical examination and proper palpation techniques. He identified and documented the sites of dysfunction in the cervical region and manipulated the region based on the study recommendations. SMT was not continued if the participant elicited any new contraindications or in the absence of symptoms, such as absence of pain or joint dysfunction. The participant was asked to lie comfortably in a supine position, with arms and legs inside and neck in neutral position. The therapist stood at the head of the patient, and the patient’s head was held like a cradle. One hand of the therapist was over the chin of the patient, the other hand was placed on the posterior aspect of the occiput, and the manipulation was performed in right and left directions. The movement was first away from the pain, and then the movement was towards the pain. SMT is a bimanual technique where the pre-manipulation rotation of 30°–45° is done away from the side of pain and manipulation is done towards the side of pain, with high velocity and low amplitude thrust.”

    Intervention – 3

    • Hot pack
    • Conventional Massage Therapy (CMT)

    Dose

    • 5 min of hydrocollator hot pack
    • 15 min

    Periodicity

    • 4 times a week for 4 weeks

    Local/Technic:

    “The patient was asked to lie in a supine position, and the external occipital protuberance of the occiput was rested on a folded towel. The therapist stood at the head of the patient, and circular kneading was given on both sides of the cervical vertebra from C7 to C1 using the tip of the middle finger. This maneuver was performed three times for each cervical vertebra, from distal to proximal. Next, the head was rotated to the opposite side, and the same maneuver was performed on the levator scapula, sternocleidomastoid, scalene, and upper trapezius muscles from insertion to origin. This technique was also performed on the contralateral side and was repeated three times. Finally, the same circular kneading was applied over the longissimus capitis, splenius capitis, semispinalis capitis, and suboccipital muscles in the centripetal direction and was repeated three times” (using a Himalaya massage cream—Gold, New Delhi, India).

    Intervention – 4

    • Home neck isometric exercises

    Dose

    • Resistance was held for 10 s and repeated 15 times

    Periodicity

    • Daily, 3 times each day, even after 4 weeks study

    Local/Technic:

    “All the participants in three groups were taught and instructed to do the neck isometric exercises at home. Participant kept their palm over their forehead and resisted forward neck movement. Similarly, resistance was given on the back and both sides of the head, and the same maneuver was repeated. The participants were instructed to continue these exercises even after four weeks.”

    Citation: Nambi G, Alghadier M, Ebrahim EE, Vellaiyan A, Tedla JS, Reddy RS, Kakaraparthi VN, Aldhafian OR, Alshahrani NN, Saleh AK. Comparative Effects of Mulligan’s Mobilization, Spinal Manipulation, and Conventional Massage Therapy in Cervicogenic Headache-A Prospective, Randomized, Controlled Trial. Healthcare (Basel). 2022 Dec 29;11(1):107. doi: 10.3390/healthcare11010107.

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