Thrust Joint Manipulation and Reverse SNAGS (Sustained Natural Apophyseal Glides) in Cervicogenic Headache
Thrust Joint Manipulation and Reverse SNAGS (Sustained Natural Apophyseal Glides) in Cervicogenic Headache
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.
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
Inclusion Criteria:

 -  Headache frequency of at least 1 per week for a minimum of 3 months

 -  Secondary Headache (cervical spine dysfunction)

 -  International Classification of headache Disorder:

 1. Pain localized in the neck and occiput, which can spread to other areas in the
 head, such as forehead, orbital region, temples, vertex, or ears, usually
 unilateral.

 2. Pain is precipitated or aggravated by specific neck movements or sustained
 postures.

 3. At least one of the following:

 1. Resistance to or limitation of passive neck movements

 2. Changes in neck muscle contour, texture, tone, or response to active and
 passive stretching and contraction

 3. Abnormal tenderness of neck musculature

 Exclusion Criteria:

 -  Other types of headache

 -  Trigger points of upper cervical muscles

 -  Congenital conditions of cervical spine

 -  Cervical Disc herniation

 -  Fracture

 -  Cervical Artery disease

 -  Red flags of Thrust Joint Manipulation