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A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache

Jull, Gwendolen, PT, PhD,*; Trott, Patricia, PT, MSc,†; Potter, Helen, PT, MSc,‡; Zito, Guy, PT, Grad Dip Manip Ther; Niere, Ken, PT, Mph,∥; Shirley, Debra, PT, BSc; Emberson, Jonathan, MSc,#; Marschner, Ian, PhD,#; Richardson, Carolyn, PT, PhD*

Randomized Trial
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Study Design. 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.

Objectives. To determine the effectiveness of manipulative therapy and a low-load exercise program for cervicogenic headache when used alone and in combination, as compared with a control group.

Summary of Background Data. Headaches 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.

Methods. In this study, 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.

Results. 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 (P < 0.05 for all). 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.

Conclusion. Manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained.

From the *Department of Physiotherapy, University of Queensland,

the †School of Physiotherapy, University of South Australia,

the ‡School of Physiotherapy, Curtin University, Western Australia,

the §School of Physiotherapy, University of Melbourne,

the ∥School of Physiotherapy, Latrobe University, Victoria,

the ¶School of Physiotherapy, University of Sydney,

and the #NH&MRC Clinical Trials Centre, Sydney, Australia.

The research was undertaken and administered from The University of Queensland, Brisbane, Queensland, Australia.

Supported by grants from the National Health and Medical Research Council (NH&MRC grant 971139), the Physiotherapy Research Foundation, the University of Queensland Foundation, the St Vincent’s Foundation, and the Centre of National Research on Disability and Rehabilitation Medicine.

Acknowledgment date: August 31, 2001.

First revision date: November 19, 2001.

Acceptance date: February 12, 2002.

Address reprint requests to

Gwendolen Jull, PT, PhD

Department of Physiotherapy

School of Health and Rehabilitation Sciences

University of Queensland

Brisbane, Queensland 4072

Australia

E-mail:g.jull@shrs.uq.edu.au

Device status/drug statement: The submitted manuscript does not contain information about medical devices or drugs.

Conflict of interest: No funds were received in support of this work. Although one or more of the authors have received or will receive benefits for personal or profession use from a commercial party related directly or indirectly to the subject of this manuscript, benefits will be directed solely to a research fund, foundation, educational institution, or other nonprofit organization with which the authors have been associated. One or more of the authors have received or will receive benefits (e.g., royalties, stocks, stock options, or decision-making position) for personal or professional use from a commercial party related directly or indirectly to the subject of this manuscript.

© 2002 Lippincott Williams & Wilkins, Inc.