Efficacy of three different Conservative Interventions in the management of Cervicogenic Headache

 

Veena Kirthika. S¹*, Kowsalya. J¹, Padmanabhan. K¹, Jibi Paul¹, Selvaraj Sudhakar¹,

Mohan Kumar. G¹, Senthil Selvam. P²

¹Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute, Maduravoyal, Chennai – 600095.

²School of Physiotherapy, Vels Institute of Science, Technology and Advanced Studies, Chennai, Tamil Nadu.

 

ABSTRACT:

Objective of The Study: To compare the efficacy of kinesio taping (KT), Trigger point (TrP) therapy and mulligan’s sustained natural apophyseal glide (SNAG) for the treatment of cervicogenic headache (CH). Background of The Study: Cervicogenic headache (CH) is a referred pain originating from neck and perceived in one or more regions on face or neck. Although many interventions are reported in the literature, there is a need to find out the most effective intervention. Hence this study compared the effects of Kinesio taping (KT), Trigger point (TrP) therapy and Mulligan’s SNAG in the treatment of cervicogenic headache (CH). Methodology: This experimental comparative pre post test study was conducted at the outpatient physiotherapy department among 30 subjects with cervicogenic headache. Study duration was four weeks. Subjects were selected by simple random sampling method based on inclusion and exclusion criteria. The subjects were randomly divided into 3 groups. Group A was intervented with kinesio taping (KT), Group B was treated with trigger point therapy (TrP), Group C was treated with mulligan’s SNAG. Stretching exercise for neck muscles was given as a common intervention for all the Groups. Results: On comparing the mean values of Group A, Group B and Group C on visual analog scale (VAS), HDI and cervical extension range of motion, showed significant difference in the post test mean values. Mulligan SNAG (Group C) with a lower mean value on VAS and HDI and a higher mean value on cervical extension range of motion was effective than kinesiotaping (Group A) and Trigger point therapy (Group B)

 

 

 

INTRODUCTION:

Headache affects 80-90 percent of the population⁽¹⁾. It affects 2.2 - 2.5% of the adult population and affect women four times more than men⁽²⁾. The International Health Society (IHS) identified 14 different types of headache. Cervicogenic headache (CH) is considered as a secondary headache⁽³⁾. The term cervicogenic headache (CH) has been first introduced by Norwegian Physician Dr. Ottar Sjaastad in 1983⁽⁴⁾. Cervicogenic headache (CH) is a referred pain originating from the neck and perceived in one or more regions on head and/or face⁽⁵⁾.

 

The Cervicogenic Headache International Study Group (CHISG) has a list of clinically relevant diagnostic criteria that include pain with neck movement or sustained improper positioning, restricted cervical range of motion(ROM), and ipsilateral shoulder and arm pain⁽⁶⁾. The symptoms of cervicogenic headache may arise from any of the components of the cervical spine, including vertebra, disks, or soft tissue, though some research has shown that cervicogenic headache pain most commonly arises from the second and third cervical spine(C2/3) facet joints, followed by C5/6 facet joints⁽⁷⁾. Cervicogenic headache is often unilateral, but it can be bilateral. It affects mostly the occipital region, the frontal region, or the retro-orbital region⁽⁸⁾. Clinically, the presence of upper cervical joint restrictions and tenderness detected by manual examination and accompanied by impairment of the deep cervical flexors and/or scapular postural muscles indicate that the headache is cervical in origin⁽⁹⁾. The invasive treatment techniques consist of injections, dry needling, and surgery⁽¹⁰⁾. The non-invasive treatment techniques consist of transcutaneous electrical nerve stimulation (TENS), massage, exercise, manipulation, or mobilization⁽¹¹⁾.

 

Kinesio Taping (KT) was originally developed in Japan by chiropractor Kenzo Kase. It is made up of an elastic polymer strand wrapped by 100% cotton fibres and it can be stretched to 140% of its original length⁽¹²⁾. Kinesio Taping may exerts its effect by increasing local circulation, reducing local edema by decreasing exudative substances, improving circulation of blood by facilitating the muscle, providing a positional stimulus to the skin, muscle, or fascial structures, providing proper afferent input to the central nervous system, limiting range of motion of the affected tissues⁽¹³⁾. Trigger point therapy is primarily used for the treatment of musculoskeletal disorder. Trigger point therapy is an alternative therapy, the benefits of which include a focus on detecting and releasing trigger points^(14,15). SNAG is one of the Mulligan concept techniques performed from a weight-bearing position, with the mobilizing force applied over the affected spinous process while the patient is enacting the painful or limited movement. SNAG, when indicated, can provide immediate pain relief and improvement in range of motion (ROM).^(16,17). Hence this study compared the effects of Kinesio taping (KT), Trigger point (TrP) therapy and Mulligan’s SNAG, which were combined with common interventions like conventional stretching exercises so that a better combination of treat ment protocol can be adopted in the treatment of cervicogenic headache (CH).

 

METHODOLOGY:

This experimental comparative pre post test study was conducted at the outpatient Physiotherapy department, Faculty of Physiotherapy, DR MGR educational and research institute. The study was approved by the institutional review board (A-31/Physio/IRB/2018-2019) Study duration was four weeks. Subjects were selected by simple random sampling method. Inclusion criteria were both male and female subjects between the age group 18-45, headache with neck stiffness or pain, cervical spine dysfunction. Exclusion criteria were surgical interventions of the head, neck or thoracic spine, congenital conditions of the cervical spine, severe osteoporosis, Temporomandibular joint dysfunction related headaches, migraine. Goinometer, kinesio tape, scissor were the materials used. Outcome measure used were visual analogue score (VAS), headache disability index (HDI), cervical extension range of motion (ROM).

 

PROCEDURE:

30 subjects with cervicogenic headache were randomly divided into three groups, with 10 subjects in each group. Group A was intervened with kinesio taping (KT), Group B received trigger point (TrP) therapy and Group C was given mulligan’s SNAG. All the three groups received passive stretching exercises for the neck muscles as a common intervention.

 

Kinesio Taping in Group A:

Two strips (I and Y) of the tape was used; Y strip(orange) starts from thoracic vertebrae 3-5 to the occiput of the skull, it is placed over the posterior cervical extensor muscles and applied from the insertion to origin with paper-off tension. The patient was asked to flex the neck (maximum flexion), then the base of Y strip was applied over the spinous process of T3-T5 and with no tension the tails of Y strip of the tape runs along the spine, one on the right side and other on the left side. The overlying strip is a space-tape (black) placed perpendicular to the Y-strip over the mid cervical region (C3- C6). With the same position (neck flexion) of the patient, the middle paper packing of I strip was torn and applied with tension horizontally then the tension was released at the ends. Then a pressure was applied using the knuckles on the tape to stimulate its adhesive effect.

 

Trigger Point Therapy in Group B:

For the Trigger point therapy group, pressure was progressively applied and increased over the TrP until the finger encountered an increase in tissue resistance (tissue barrier). When pressure was applied to the trigger point, the chemical/pressure cycle is interrupted, which helps to stop the contraction and the pain in the muscle. The muscle is heated and kneaded during treatment, which helps to increase circulation and to remove the metabolic waste products and the muscle fibers become lengthened and stretched which decreases the pressure component of the pain cycle.

 

Mulligan’s SNAGs in Group C:

The subject was seated in a supportive low back chair, thus the cervical spine was in a vertical position (i.e. weight bearing position) and the therapist stood behind the patient. The right index, middle, and ring fingers wrap around the base of occiput, and the middle phalanx of little finger was placed over the spinous process of C2 vertebra. A gentle pressure was then applied by the therapist in a ventral direction on the spinous process of C2 vertebra while the skull remains neutral. This was quietly taken forward until end range is felt and this position was maintained for at least 10sec.

 

Common Intervention:

The stretching exercises were given to all the three groups as a common intervention. Stretching exercises for neck muscles such as rectus capitis anterior, rectus capitis lateralis, longus colli, longus cervicis, semispinalis, splenius capitis, splenius cervicis, sternomastoid, scalene, upper trapezius, levator scapulae and pectoralis major, rhomboids and serratus anterior muscles was done. The duration of stretching was 15s with 5 repetitions initially. Later progression was made by increasing the duration from 30s and repetition by 10 times.

 

DATA ANALYSIS:

The collected data were tabulated and analyzed using both descriptive and inferential statistics. All the parameters were assessed using statistical package for social science (SPSS) version 24. One Way ANOVA includes of following tests (Test of Homogeneity of Variance, ANOVA, Post Hoc test Tukey HSD) (multiple comparison) was adopted to find statistical difference between three groups.

 

 

Table-1 Comparison of Pre and Post VAS values using Test of Homogeneity of Variance and One way Anova Test between Group A, Group B and Group C

TEST	GROUP A		GROUP B		GROUP C		df		F value	significance
	MEAN	S.D	MEAN	S.D	MEAN	S.D	df1	df2
PRE	6.40	1.50	6.20	1.39	6.10	1.44	2	27	.111	.896
POST	3.50	1.50	4.10	1.37	2.20	.788	2	27	.592	.007

 

 

Fig-1 Comparison of Pre and Post VAS score between Group A, Group B and Group

 

Table- 2 Comparison of Pre and Post HDI score using Test of Homogeneity of Variance and One way Anova Test between Group A, Group B and Group C

TEST	GROUP A		GROUP B		GROUP C		Df		F value	significance
	MEAN	S.D	MEAN	S.D	MEAN	S.D	df1	df2
PRE	50.80	10.42	55.40	9.14	52.80	9.39	2	27	.569	.573
POST	40.80	9.19	44.80	7.25	36.80	7.43	2	27	2.49	.010

 

 

Fig- 2 Comparison of Pre and Post HDI score using Test of Homogeneity of Variance and One way Anova Test between Group A, Group B and Group C

 

Table- 3 Comparison of Pre and Post Cervical Extension ROM score using Test of Homogeneity of Variance and One way Anova Test between Group A , Group B and Group C

TEST	GROUP A		GROUP B		GROUP C		df		F value	significance
	MEAN	S.D	MEAN	S.D	MEAN	S.D	df1	df2
PRE	30.00	5.77	29.00	6.14	31.80	7.61	2	27	.181	.836
POST	36.00	4.59	34.00	6.99	40.00	5.27	2	27	2.86	.014

 

Fig-3 Comparison of Pre and Post Cervical Extension ROM score using Test of Homogeneity of Variance and One way Anova Test between Group A , Group B and Group C

 

RESULT:

On comparing the mean values of Group A, Group B and Group C on visual analog scale (VAS), HDI and cervical extension range of motion, showed significant difference in the post test mean values. Mulligan SNAG (Group C) with a lower mean value on VAS and HDI and a higher mean value on cervical extension range of motion was effective than kinesiotaping (Group A) and Trigger point therapy (Group B).

 

DISCUSSION:

The aim of the study was to find the effectiveness of Kinesio Taping, Trigger point therapy and Mulligan’s SNAG in the treatment of subjects with Cervicogenic Headache.

 

This study supports the findings of Jull, et al – 2002, showed that manual therapy was an effective form of management for Cervicogenic Headache⁽¹⁸⁾. This study agrees the findings of Patra et al, showing that Mulligan’s SNAG’s were an effective treatment in the management of cervicogenic headache⁽¹⁹⁾. The findings of this study confirms the research done by Bronfort, et al–2004, that both neck exercises and spinal manipulation were effective in the short-term and long- term for Cervicogenic Headache⁽²⁰⁾ and Hall, et al – 2007, who demonstrated that SNAG’s were effective in increasing in cervical ROM.⁽²¹⁾

 

The findings of Reid, et al -2008, that SNAG’s had an immediate clinically and significant sustained effect in reducing dizziness, cervical pain and disability caused by cervical dysfunction at post- treatment compared to pre- treatment is also supported⁽²²⁾. This study strongly agrees the findings of El-Sodany, et al – 2014, that SNAG’s mobilization and manipulation were effective and in addition, the combination of mobilization or manipulation with exercise therapy produced greater increase in Cervical Range of Motion and greater reduction of pain in the treatment of cervical spine disorders.⁽²³⁾

The study also agrees with Saleh, H.M., et al – 2016, who concluded that KT improves the outcome of physiotherapy for CH to a greater extent⁽²⁴⁾. This study supports the findings of Dawood, et al – 2013, that the combined therapy of KT or cervical traction posture pump with exercise program are effective in improving the absolute rotatory angle, pain intensity and function neck disability in mechanical neck dysfunction⁽²⁵⁾. The possible mechanism in the development of cervicogenic headache is that the constant position of neck leads to static contraction of neck muscles. The awkward postures, prolonged static positions and repetitive movements may reduce the length of soft tissues which will limit/ restrict the available ROM.⁽²⁶⁾

 

The application of SNAG influences correcting irregular position of articular elements and achieving correct biomechanics of the cervical spine. This technique causes a decrease in excessive reactivity of cervical nuclei in trigeminal nerve and blocks A-beta fibers stimuli that may result in pain relief and also limit the headache disability⁽²⁷⁾. In Kinesio Taping, the tension applied by the real application provides neural feedback to the patients during neck movement, thus facilitating their ability to move the neck with a reduced mechanical irritation of the soft tissues. Kinesio tape provides a proper sensory feedback to the patients, decreasing fear of movement, thus improving neck pain and range of motion.⁽²⁸⁾ The mechanisms of TrP therapy include a reduction of TrP activity, restoration of the length of the muscle sarcomeres, reactive hyperemia within the TrP taut band, temporary elongation of the connective tissues, or reduction of sensitization mechanism associated to TrPs ⁽²⁹⁾.

 

The mean value of Group A (KT) post-test (40.80) of HDI which when compared with Group B (TrP) (44.80) and Group C (SNAG) (36.80), Group C with lesser mean value had better reduction in the headache disability. The mean value of Group A (KT) post-test (3.50) of VAS which when compared with Group B (TrP) (4.10) and Group C (SNAG) (2.20), Group C with lesser mean value had better reduction in the pain intensity. The mean value of Group A (KT) post-test (36) of Cervical Extension ROM which when compared with Group B (TrP) (34) and Group C (SNAG) (40), Group C with greater mean value had better improvement in the cervical extension range of motion. This study revealed that all the three groups improved after intervention. As far as the HDI and VAS is concerned Group C treated with Mulligan’s SNAG showed significant improvement when compared to Group A and Group B. When the Cervical Extension ROM is taken into account, Group A and Group C with have shown significant improvement in the treatment of cervicogenic headache. On the whole, Group C (SNAG) showed better improvement in all the outcome measures when compared to Group A (KT) and Group B (TrP).

 

CONCLUSION:

This study concluded that all the three interventions namely Kinesio Taping, Trigger Point therapy and Mulligan’s SNAG were effective in reducing the disability, pain and improving cervical Extension ROM in subjects with cervicogenic headache. When the three groups were compared, Group C showed better reduction in Headache Disability, Visual Analogue Scale and improved Cervical Extension ROM.

 

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Received on 03.12.2019            Modified on 23.02.2020

Accepted on 13.04.2020         © RJPT All right reserved