The Effect of Mobilization On Cervical Headaches

The Effect of Mobilization on Cervical
Headaches
Sydney Kim Schoensee, MS, PT, OCS '
Gail lensen, PhD, PT *
Garvice Nicholson, MS, PT, 0CS3
Marilyn Gossman, PhD, PT, FAPTA4
Charles Katholi, PhD
H
eadache is a common Headaches of cervical origin are often treated with mobilization. Mobilization of the upper
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clinical phenomenon. cervical spine, occiput-C3, and effect on frequency, duration, and intensity of cervical headaches
Headaches have been were studied utilizing an A-B-A single case design. Ten subjects who met the operational criteria of
classified into numer- cervical headaches completed the study. A headache log was used to document headache frequency,
ous types
,. based on duration, and intensity throughout all three phases (A-6-A). The baseline phase (A) lasted approxi-
their signs, symptoms, and etiology. mately 1 month, and no intervention was performed. The intervention phase (B) consisted of 9-12
Headaches which are believed to treatment sessions, two times per week for 3-4 weeks. Visual analysis of data plots revealed a
Copyright © 1995 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
originate from structures in the neck decrease in headache frequency, duration, and intensity from the baseline phase to the treatment
have been given various names, rang- phase. This improvement continued through the second A phase for frequency but leveled off for
ing from broad terms such as "cervi- both duration and intensity. A one-way analysis of variance supported the findings from the visual
cal" (6,10,12,27,53), "occipital" (33, analysis. In these 10 subjects, mobilization had a therapeutic effect on cervical headaches.
50), and "cervicogenic" (15,43,48) to
Key Words: cervical spine, headaches, mobilization
specific terms such as third nerve oc-
'Coordinator for Clinical Education, Baptist Medical Centers at Montclair, Birmingham, AL. This study was sub
cipital headache (3). Cervical head-
mitred in partial fulfillment of the requirements for the master of science degree in physical therapy at the Uni-
ache is a symptom that potentially versity of Alabama at Birmingham, Birmingham, AL. Address for correspondence: 133 Dixon Ave, Birmingham,
can arise from dysfunction of the
Journal of Orthopaedic & Sports Physical Therapy®
A1 35209.
joints, muscles, ligaments, and other 'Associate Professor, Department of Physical Therapy, Creighton University, Omaha, NE
soft tissues of the neck (3,27). The 'Associate Professor, Division of Physical Therapy; Clinical Director of Rehabilitation Services, The Kirklin
Clinic; University of Alabama at Birmingham, Birmingham, AL
exact criteria and description of "cer- 4Professor and Director, Division of Physical Therapy, University of Alabama at Birmingham, Birmingham, A1
vical headache" remain controversial 'Associate Professor, Department of Biomathematics and Biostatistics, University of Alabama at Birmingham,
because of the overlapping character- Birmingham, A1
istics seen with other types of head-
aches, such as tension and migraine
headaches. Lewit (35) reported the 203 patients with cervical spine disor- ing of a "tight band around their
incidence of migraine attacks was as ders, 96 of whom had cervical head- heads" or occasional shooting or stab-
high as 33% in subjects with cervical ache. She developed a cervical head- bing pains in their heads or behind
headaches. Several authors agree, ache profile from an analysis of these their eyes (26). Cervical headache
however, that cervical headaches have 96 patients. The profile revealed often is associated with prolonged
their origin from the cervical level of headaches were either unilateral or neck flexion or poor habitual static
C3 or above (6,l O,27,35,43). bilateral and affected any area of the postures (26,35). A common history
The clinical portrayal of a patient head or face, but most commonly is that of trauma, but the headaches
with a cervical headache is variable. were present in the occipital (6,23), can also be related to prolonged pos-
This variability contributes to the dif- frontal (6,l2), or retro-orbital areas tural and functional strain (10.26).
ficulty practitioners have in making a (26). Suboccipital neck pain was also Other common signs and symptoms
diagnosis of cervical headache. In an common with the headaches (23,45). reported with cervical headache in-
attempt to determine the most com- The most common description of clude dizziness (2,6,11,26), nausea
mon characteristics of cervical head- pain is that of a moderate ache (6, (6,11,26), lightheadedness, inability
ache, Jull (26) reviewed a series of 26). but some patients report a feel- to concentrate, and visual distur-
Volume 21 Number 4 April 1995 JOSPT

bances (6,10,11). Additionally, vascu- zygapophysialjoint as the origin of I-IV), but never exceed the joint's
lar or autonomic-response-mediated pain was performed by blocks of the normal range of motion (18).
symptoms can occur (26). Upper cer- third occipital nerve proximal to its Many authors have reported the
vical joint restrictions and tenderness articular branches to the C2-3 zyg- effectiveness of mobilization in reduc-
are present and can be detected by apophysial joint. Subjects experi- ing or alleviating headaches (10,27,
manual examination (6.1 1,26). Jull enced relief from their headache for 41,51), but few controlled clinical
reported 100% accuracy in detecting the duration of the anesthetic, and studies of mobilization have been
symptomatic abnormal joints in the this effect was reproducible. reported. Vernon (52), in a retro-
upper cervical spine as validated with The most effective form of treat- spective and prospective study, stud-
radiologicalcontrolled diagnostic ment for cervical headache has not ied two groups of subjects (current
nerve blocks (28). Often, objective been established, but a variety of in- and former patients) with benign
tests, such as radiographs, show no vasive and noninvasive treatments chronic headaches to determine the
joint abnormalities. Conversely, a b have been reported. Invasive tech- effects of manipulation on head-
normal radiographs are not always niques include injections and sur- aches. Outcomes were measured by a
associated with neck pain (9.45). This gery. questionnaire which collected infor-
lack of correlation may be, in part, Noninvasive techniques for treat- mation about headache frequency,
because of the complex biomechan- ment of cervical headaches include duration, and severity. Subjects re-
ics of this area (54). In this study, we transcutaneous electrical nerve stimu- ported the pretreatment and post-
investigated the effects of manual lation (TENS) (6), massage (6). exer- treatment status of their headaches.
examination and treatment with pas- cise (6,50), manipulation (6,13,37,50, Results of both groups showed statis-
sive joint mobilization on subjects 5 l ) , or mobilization (lO,27,51,53). tically significant outcomes in de-
who had symptoms of cervical head- Transcutaneous electrical nerve stim- creasing headache frequency, dura-
aches. tion, and severity. Turk and Ratkolb
The etiology of cervical head- (51), in a study of 100 patients with

aches has been related to articular chronic headaches treated by mobili-
dysfunction specifically involving the The etiology of zation and manipulation, reported an
first through third cervical vertebrae absence of headaches in 25% and an
and their surrounding structures (6, cervical headaches has improvement in 40% of the patients
40,52,53). The controversy lies in de- 6 months after completing treatment.
termining from which of these joints
been related to The remaining 35% of the patients
headaches most commonly arise. Cer- articular dysfunction. reported an improvement which
vical dysfunction often can result lasted for approximately 1 month.
from trauma, including whiplash in- Parker et al (41). in a controlled

juries or falls. Norris and Watt (38) trial of cervical manipulation for mi-
found that the most common com- ulation and massage often have palli- p i n e headaches, studied three
plaint in posttraumatic whiplash pa- ative effects, but have been criticized groups. The control group received
tients was neck pain and stiffness fol- as not addressing the primary patho- mobili7ation administered by a physi-
lowed by occipital headache. Ehni logical lesion, only the symptoms (6). cian or physical therapist, wherea-
and Benner (13) hypothesized ar- Of the noninvasive treatments, the the other two groups received manip
throsis of the C1-2 joint was the cause most common are mobilization ulation, one by chiropractors and the
of headaches in a series of seven pa- and/or manipulation (6,10,27,37,50, other by either a physician or a phys-
tients who demonstrated unilateral 51.53). ical therapist. Results showed that all
degenerative disease (arthrosis) of Mobilization and manipulation three groups improved with decreawd
this joint because treatment address- are similar terms that frequently are frequency, duration, and intensity of
ing the arthrosis resulted in partial to used interchangeably in the litera- their headaches. The cervical manipu-
complete relief of symptoms. ture. Both terms refer to passive lation groups were found to be no
Other authors believe that dys- movement techniques used to restore more effective than the mobili7ation
function of C2-3 zygapophysial joints normal motion to a joint (18.37). group (41).
is the primary cause of cervical head- Manipulation is defined as a small A prospective clinical controlled
aches (3,23,51). Bogduk et al (3) amplitude, high velocity thrust (grade trial by Jensen et al (22) compared
found 7 of 10 patient- had occipital V) applied at the limit of the avail- manual therapy and cold pack treat-
or suboccipital headaches originating able range of motion (ROM) (18,37). ments on a group of 19 subjects with
from the third occipital nerve as it Mobilization implies passive move- posttraumatic headaches. Manual
arises from the C2-3 zygapophysial ment-, usually rhythmic in nature, therapy consisted of mobilization and
joint (3). Confirmation of the C2-3 which vary in amplitude (grades muscle energy techniques applied to
JOSPT Volume 21 Number 4 April 19%

the cervical and upper thoracic and may project to the forehead, or- proved by an institutional review
spines. Pain schedules were com- bital region, temples, vertex, or ears; board for human use committees.
pleted before each visit and two 2) pain is precipitated or aggravated
weeks following treatment. Two by specific neck movements or sus- Design
weeks following treatment, the mean tained neck posture(s); and 3) resis-
pain index was reduced by 43% (P < tance to or limitation of active and A single case A-&A design was
.05) in the manual therapy group passive (accessory or physiological) used for each of the 10 subjects in
compared with the cold therapy neck movements in the upper cervi- this study. This allowed the investiga-
group, and p < .02 for the manual cal spine occiput, and/or palpable tor to preserve aspects of clinical
therapy group compared with its pre- tenderness. All subjects had to fulfill practice, and is a design well suited
treatment pain index level. At 5 the first two criteria and had to have to clinical conditions where there is
weeks posttreatment, the manual at least one component of the third variation in patients' signs and symp
therapy group's pain index was still criterion. toms and response to treatment (1,
lower than their pretreatment levels, The subjects, volunteers from the 39). The A phase served as the base-
but not significantly. The group community, were obtained via adver- line period prior to the initiation of
treated with cold therapy showed no tisements in the metropolitan area. treatment. Data were collected on
significant changes in their pain indi- All subjects were screened on the headache frequency, duration, and
ces with treatment (22). phone by the primary investigator to intensity. This phase lasted 4-6
Several studies have demon- determine if they met the first two weeks depending on the variability of
strated that mobilization of the cervi- criteria listed above. Subjects were the headache data. Most subjects did
cal spine can aid or reduce the oc- excluded if they had any of the fol- not have headaches with the exact
currence of cervical headaches (22, lowing conditions or diseases which same frequency, duration, or inten-
41,51,52). Few studies have isolated are contraindicated for mobilization sity. The stability of the baseline (or
treatment to just the upper cervical treatment: Paget's disease, rheuma- lack of) determined the length of the
joints. The purpose of this study was
toid arthritis, ankylosing spondylitis, initial baseline phase. The B phase,
to examine the effect of mobili7ation
spondylolistheses, cervical fractures, or treatment phase, consisted ofjoint
of the upper cervical spine (occiput-
osteoporosis, osteomyelitis, malig- mobilization 2-3 sessions per week
C3) on frequency, duration, and in-
nancy, pregnancy, and spinal cord for 4-5 weeks, totaling 9-1 1 treat-
tensity of cervical headaches. Specifi-
syndromes (37,42). Subjects also were ment sessions. This length of treat-
cally, we hypothesized that mobili-
excluded if they reported any radicu- ment is comparable with other stud-
zation of the upper cervical spine,
lar signs and symptoms into the u p ies (41,52). The subject then entered
where joint hypomobility was identi-
per limbs or exhibited a positive ver- the second A phase, or withdrawal
fied, would reduce or relieve pa-

tients' symptoms of cervical head- tebral artery test during the screening phase, duplicating the first phase,
ache. evaluation. All qualifying subjects lasting approximately 1 month.
were scheduled for a physical screen- Throughout all three phases, data on
ing evaluation by the primary investi- headache frequency, duration, and
METHODS gator to determine if they met the intensity were recorded. Additional
third criterion, limitation of cervical data on active range of motion, ten-
Subjects movement and palpable tenderness derness, and passive physiological
Twelve subjects (between the of the upper cervical spine. The eval- and accessory movements were col-
ages of 20-50) who experienced uation was adapted from the stan- lected on each subject four times
headaches and satisfied the diagnos- dard Maitland evaluation procedure throughout the study and are re-
tic criteria for cervical headache were with an emphasis on the upper cervi- ported elsewhere (46).
recruited for the study. Age was re- cal joints. Subjects who qualified for
stricted between the ages of 20-50 the study were informed they would Instrumentation
because of range of motion and de- be excluded if they received any
generative changes associated with other medical treatment for their Headache frequency, duration,
age (36). The inclusive criteria for headaches during the course of the and intensity were obtained by self
subjects were adapted from the classi- study. Subjects were permitted to report and recorded in a headache
fication criteria for cervical headache continue taking their present medica- log which was issued to each patient
developed by the International Head- tions, but were excluded from the upon entrance to the study. Self-
ache Society (19). These criteria in- study if a new headache medication report data have been used by other
cluded the following: I) pain local- was taken. Dosage of medication was authors (22,41,52) and has been
ized to the neck and occipital region not controlled. The study was a p found to be reliable (41).

R E S E A R C H - - S T U..D-Y
Headache intensity or pain was accessory and physiological move- rotation was assessed with manual stabi-
assessed using a visual analog scale ments of intervertebral and facet liiration of the axis by the therapist's
(VAS), which was a component of joints of occiput-C1 through C2-3. thumb and index finger while the pa-
the headache log. The VAS is a sim- These measurements were repeated tient was sitting. Movement limitation
ple, sensitive (20,47), and reliable at the beginning of each phase and was estimated as: 1 = normal, 2 = lim-
instrument that enables a numerical at the end of the withdrawal phase ited, or 3 = severely limited. Normal
value to be given to express a pa- (for a total of four data points) to was operationally defined as free move-
tient's pain (44). A l k m horizontal determine if any changes occurred ment with little to no resistance
line was used with the descriptor during the course of the study. These present, joint restricted <15% of total
words "no pain" on the left and measurements were taken at approxi- range of motion. For flexion/exten-
"worst pain imaginable" on the right mately the same time of day for each sion, normal range was considered a
side. phase of the study. good chin tuck and ability to extend
Passive joint motion, physiologi- the head on neck approximately 15" in
PROCEDURE cal and accessory, was assessed using each direction. Normal rotation was
procedures commonly used by physi- considered approximately 45" and lat-
Self Report Measures cal therapists. Passive physiological eral flexion approximately 25-35".
movements included testing of upper Limited was defined as partial range of
Headache frequency, duration, cervical flexion and extension and motion present with resistance present,
and intensity data were collected lateral flexion as described by Paris motion restricted 1575% of total
throughout baseline, treatment, and (40). The subject was positioned su- range of motion. Severely limited was
withdrawal phases of the study. To pine, and the head was moved pas- defined as minimal motion present,
decrease variability, headache data sively in a forward and backward nod- joint restricted 75% or greater.
were averaged. For frequency, one ding movement with the investigator's Accessory joint motion was a+
data point represented the total num- hands cradling the head to determine sessed using techniques described by
ber of headaches experienced over upper cervical flexion and extension. Maitland (37). Limitation of acces-
the M a y period. For duration and Lateral flexion was also assessed in the sory joint movement was defined by
intensity, one data point represented supine position by introducing a sideb Maitland as perceived stiffness or the
the average (total hours, or VAS ending movement of the head in rela- amount of perceived passive joint
scores + number of headaches). tion to the neck with the head resting displacement and its resistance to this
Upon entrance to the study, each on the plinth. Passive upper cervical displacement (37). These techniques
subject was issued a headache log
and received verbal and written in-
Motions Number of Observations Kappa SE (K) Z Score P
structions on its use. The date was

recorded as well as headache onset Passive physiological
time and ending time. Subjects were lntrarater 50 0.72 .097 7.42 <.OM1
asked to rate their headache pain on lnterrater 50 0.38 .I32 2.87 <.01
Passive accessory
the VAS scale with an X at the time lntrarater 80 0.81 .067 12.08 <.0001
their headache occurred. During the lnterrater 80 0.45 .I16 3.87 <.0001
baseline phase, subjects were con-
* Five upper cervical motions were tested: right and leit lateral ilexion, rotation, and combined ileuionleutension.
tacted the first week by telephone to t Eight motions were tested: central postero-anterior glides over C2, CZ spinous process, unilateral glides over right
determine if they had any questions and leh Cl, CZ, C3 articular pillars.
on use of the headache log. Thereaf- * lnterrater measurements were taken immediately following each other. lntrarater measurements were taken 2-3
days apart (N = 10).
ter, they were contacted to set up the
first treatment session and/or to re- TABLE 1. lntratester and intertester reliability for measurements of passive physiological' and passive
mind them to mail in their treatment accessoryt range of motion on normal*.
logs. Subjects mailed their headache
logs biweekly to the primary investi-
gator who examined the logs for Motions Number of Observations Kappa SE (K) Z Score P
completeness of data. Passive physiological 25 0.52 .I60 3.25 c.001
Passive accessory 40 0.79 .097 8.14 <.0001
Passive Mobility Measures * Five upper cervical motions were tested: right and kit lateral ilexion, rotation, and combined ilexion/eutension.
t Eight motions were tested: central postero-anterior glides over C2, C2 spinous process, unilateral glides over right
At the beginning of the baseline and leh Cl, C2, C3 articular pillars.
phase, the principal investigator as- TABLE 2. Intertester reliability for measurements of passive physiologicar and passive accessoryt movements
sessed the subject's passive ROM for on five subjects before treatment phase.
JOSPT Volume 21 Number 4 April 1995

Subject Axe Sex Length of HA (years) Location of HA Type of Pain(s) Aggravating Fadon Associated Symptoms
Suboccipital Throb Neck extension Neck pain
Occipital Tight Reading Difficulty concentrating
Temporal Vicelike Lateral flexion Difficulty swallowing
Suboccipital Pressure Prolonged Neck pain

Temporal Vicelike Sitting Difficulty concentrating
Retro-orbital Travelling Light sensitivity
Suboccipital Ache Sleeping Neck pain

Pressure Reading Nausea
Suboccipital Ache Lateral flexion Neck pain

Retro-orbital Throb Using phone Ringing in ears
Frontal Burning Light sensitivity
Suboccipital Ache Sleeping Neck pain

Throb Turning neck Nausea
Pressure Neck extension Difficulty concentrating
Neck flexion Light sensitivity
Suboccipital Throb Turning neck right Neck pain

Temporal Sharp Sleeping Nausea
Driving Ringing in ears
Suboccipital Ache Reading Neck pain

Parietal Throb Neck extension
Frontal Turning neck left
Suboccipital Tightness Using phone Neck pain

Occipital Squeezing Lateral flexion left Difficulty concentrating
Temporal Throb Sleeping Light sensitivity
Suboccipital Throbbing Using phone Neck pain

Occipital Pressure Turning right Nausea
Temporal Stabbing Sleeping Difficulty concentrating
Light sensitivity
Suboccipital Ache Turning left Neck pain

Temporal Pressure Neck extension Difficulty concentrating
Sleeping Light sensitivity
TABLE 3. Descriptive data on subjects with cervical headaches (HA).
have been used to determine origin arms resting comfortable by his or Reliability
of headache (28) and as treatment her sides. Pressures were applied
techniques (35) for headache from through the thumbs in postereante- Reliability for passive physiologi-
cervical joint dysfunction. An ordinal rior direction as described by Mait- cal and passive accessory movements
scale consisting of three levels (1 = land (37). Postereanterior pressures was established through pilot testing
normal, 2 = limited, and 3 = severely were performed centrally over the of 10 asymptomatic subjects prior to
limited) was used. Normal was de- spinous processes of C2 and C3. Uni- data collection. Measurements for
fined as one that moves freely in nor- lateral postereanterior pressures intrarater reliability were taken 2-3
mal available range. Limited was de- were assessed over the lateral aspect days apart by the primary investiga-
fined as a joint which presents some of C1 approximately 1 inch from tor. Interrater reliability was per-
resistance to movement, but is still midline and over the articular pillars formed comparing the primary inves-
able to move through partial range. of C2 and C3. Finding were re- tigator to an experienced physical
Severely limited was defined as a corded as either normal, limited, or therapist who is an orthopaedic clini-
joint with minimal to no movement severely limited. A patient's pain re- cal specialist. Interrater measure-
with immediate resistance. sponse was noted with an asterisk on ments were taken immediately follow-
The patient was positioned prone the documentation form if pain was ing one another. The order of testers
on a plinth with a face opening and elicited or increased during testing. was varied. Passive accessory testing
188 Volume 21 rn Number 4 rn April 1995 rn JOSPT

was performed for all joints by the
first tester, followed by the second Frequency
tester. Testing multiple joints allowed
for bilateral comparison of the right
and left joints for each examiner
while simulating a typical passive ac-
cessory joint examination.
The Kappa correlation coefficient
was used to determine reliability for
both passive physiological and acces-
sory joint movements (34). Intrarater
reliability was good for passive physio-
logical movements ( K = .72) and ex-
cellent for passive accessory move-
ments ( K = .81). Interrater reliability
for passive physiological movements
was poor ( K = .38) and fair for pas-
sive accessory movements ( K = .45)

on asymptomatic individuals (Table
1). These findings are comparable
with other studies (8,31).
Additional interrater reliability
testing for assessment of passive phys-
iological and accessory movements

was performed on five symptomatic
subjects prior to their treatment
phase. This testing was performed
because of the low reliability coeffi-
cients found with asymptomatic s u b
jects; the hypothesis being that symp
tomatic subjects would be more
reliable. Symptomatic subjects may Time (Days)
present with greaterjoint stiffness

and/or soft tissue changes, therefore, FIGURE 1. Headache frequency data plots for subjects 1-6 (A = Baseline, B = Treatment, A = Baseline).
making restrictions more obvious to
palpation tests. Interrater reliability Treatment consisted of mobiliza- hooking the index finger onto the
was higher, K = .52 and .79, for pas- tion techniques to the limited or articular pillar), and 6) downslides
sive physiological and passive acces- painful segments ( 0 4 3 , C1-2, C2-3) (a lateral bending and extension
sory movements, respectively (Table found on passive accessory and physi- technique applied in line with the
2). These findings are comparable ological testing (37). Techniques joint plane in a downward direction
with or better than those reported in were varied according to the subject's by the first metacarpal interphalan-
previous studies (€431). presentation of limitations and symp geal joint). The reader is referred to
toms. The mobilizations included these references (37,40) for a more
Treatment central and unilateral posterieante- detailed description of the mobiliza-
nor pressures as described by Mait- tion techniques. These techniques
During the treatment phase or land (37) and the following tech- have been advocated by physical ther-
phase B, the subjects received joint niques described by Paris (40): 1) in- apists in the management of cervical
mobilization 2-3 times per week for a hibitory distraction (sustained pres- headache patients (10,27,37,40).
total of 9-1 1 treatment sessions. The sure with the fingertips at the base of The first treatment session for all
number of sessions varied according the skull), 2) physiological rotation of patients consisted of inhibitive dis-
to the subjects' symptoms and the the C1-2 joint in sitting, 3) occipital traction followed by grade I, I1 (gen-
ability of subjects to attend treatment nod on the atlas, 4) lateral pressures tle) posterieanterior pressures a p
during the allotted time frame. This of the atlas, 5) upslides (a rotational plied unilaterally to the C1-2 and
phase lasted 4-5 weeks. All subjects stretch applied in line with the joint C2-3joints. If the subject did not ex-
completed the full treatment regime. plane in an upward direction by perience any increased soreness or

R- E..S-E ..A .R..---
C H -. ..S.~T.-U.- D -Y. - - -- - .--- -. -----.---------..-.- -- ----------
Frequency determine if any trends existed in the

data. Celeration lines were used to
predict how the data would continue
if they followed the predicted path
determined in the baseline phase
(39). Subsequent points during the
#7
treatment and withdrawal phases
were compared with the baseline.
Statistical analysis consisted of
testing the data for serial dependency
by computing lag one auto correla-
tion coefficients (30,39). Since no
significant serial dependency was
found, the data were subjected to
Time (Days) statistical analysis (30). Data were
combined across the subjects for
each of the dependent measures of
headache duration, frequency, and

intensity and were analvzed bv re-
peated measures one-way analysis of
variance (ANOVA) across the three
.
<
Treatment consisted
of mobilization
FIGURE 2. Headache frequency data plots for subjects 7-10 (A = Baseline, B = Treatment, A = Baseline). techniques to the
limited or painful
headaches from the first treatment, the C2-3 facet joints bilaterally with segments.
then upslides and downslides were one side being more involved than
added to the treatment. Additionally, the other. Additionally, treatment was
increased grades ( N , N + ) of poste- adjusted based on the individual sub-
rieanterior pressures were performed ject's irritability level as defined by phases to determine significant differ-
to the restricted or painful joints as Maitland (37). Mobili7ation move- ences between the three phases of
was established by the pretreatment ments generally were performed us- the study for each measure ( 3 0 3 ) .
accessoryjoint testing. Subsequent ing a force and amplitude short of The passive motion data were
treatments were similar with the addi- spasm and not exceeding patient's tested for differences between pre-
tion of physiological rotations ( u p tolerance. treatment and posttreatment mea-
slides and downslides) introduced to sures. The sign test was used for the
those subjects exhibiting limitations. Data Analysis ordinal data of passive physiological
Limitations in physiological occipital- and accessory movement values. An
atlanto flexion were treated with 0-A Descriptive data of all the sub- alpha level of .05 was used as the cri-
mobili7ation, postereanterior pres- jects were analyzed to determine if terion for statistical significance.
sures to C1 (24), and occipital nod any common and distinct characteris-
(40)- tics existed within the subjects. Mea- RESULTS
Passive accessory/physiological surements of headache duration, fre-
motion testing of the upper cervical quency, and intensity were plotted Twelve subjects entered the
spine was used to help guide clinical for each individual. Visual analysis study, and 10 subjects (3 males and
decision making as to the choice of consisted of calculation of the levels 7 females) completed the study. One
treatment technique(s) and the spe- or means of each phase and the use subject did not complete the study
cific joint(s) which were limited. The of celeration lines. Celeration lines because of hospitalization for appen-
joints most commonly involved were were used on the baseline points to dicitis, and a second subject was not

(per headache) was 5.4 hours (SD +
Duration 3.36), and posttreatment duration
#I m
+
was 3.1 hours (SD 2.48). Mean in-
tensity (per headache) (0-10) pre-
+
treatment was 3.4 (SD 1.50) and
posttreatment was 1.6 (SD + 1.04).
These means represent the levels of
each phase of the study and reveal a
decreasing trend across the three
phases.
Celeration lines revealed upward
or level trends during the baseline
phase in 7 of 10 subjects for fre-
quency. Upward, downward, and
level trends were exhibited for both
duration and intensity, representing
the wide variability of headaches for
each individual.
A one-way ANOVA for repeated
measures on headache frequency,
duration, and intensity (44) was
found to be statistically significant
(Table 4). Follow-up testing (Dun-
can's multiple range test) demon-

strated that the decrease in frequency
was significantly different across each
of the three phases (baseline, treat-
ment, and withdrawal). Duration and
intensity were decreased significantly
between the baseline and treatment
phases and baseline and withdrawal
phases, but no significant changes
FIGURE 3. Headache duration data plots for subjects 1-6 (A = Baseline, B = Treatment, A = Baseline). were found between treatment and
withdrawal phases. The sign test re-
vealed no significant differences in
included because of incomplete data. ted across the three phases for each measurements for either passive phys-
Descriptive data for each subject in- of the 10 subjects (Figures 1-6). Vi- iological or accessoryjoint motion.
cluding age, gender, headache char- sual analysis consisted of inspection
acteristics, medications, and associ- of the data graphs (30) and deter- DISCUSSION
ated symptoms are listed in Table 3. mining the extent to which changes
All subjects had experienced head- in response patterns were present for Headache Data
aches for a minimum of 1 year with each subject (29,39). Visual analysis is
the average being 7.7 years (SD + the most commonly used method of The results from the 10 subjects
6.05). Most of the subjects reported evaluation for single case design stud- indicated improvement in headache
their headaches occurred more than ies (29.39). Visual analysis of the av- frequency, duration, and intensity
2 times per week. The pretreatment, erage levels across three phases re- when mobilization treatments were
or baseline phases, lasted a mean of vealed a downward trend between administered. Subjects' headaches
38 days (30-50). and the follow-up the baseline and treatment phases. showed a downward trend between
period, or withdrawal phase, lasted a Descriptive statistics of the means for all three phases of the study and a
mean of 36 days (30-40). The treat- each of the subjects across each of significant difference between base-
ment period lasted a mean of 35.5 the three phases were calculated. The line and the other two phases. This
days (30-50) and consisted of 9-12 mean frequency (number of HAS t 5 trend is supported by celeration lines
treatment sessions. +
days) was 2.9 (SD 1.08) before in 70% of the subjects. Complete re-
Headache (HA) data for frequen- +
treatment and 1.0 (SD .79) follow- lief was obtained by only subject 2, or
cy, duration, and intensity were plot- ing treatment. Pretreatment duration in 10% of the subjects.

The C2-3joint also may be a
causative factor of pain. Unlike the
atlanto-occipital and the lateral at-
lanto-axial joints which are inner-
vated by the branches from the C1
and C2 ventral rami (4), the C2-3
joint is innervated by branches from
the C3 dorsal rami. The atlanto-oc-
cipital joints and lateral atlanto-axial
joints are innervated by the branches
from the C1 and C2 ventral rami (5).
The C2 ventral rami project inferolat-
erally dorsal to the lateral atlanto-
axial joint. The third occipital nerve,
Time (Days) or medial branch of the C3 dorsal
ramus, curves medially and dorsally
around the superior articular process
of the C3 vertebra and crosses the

110
An explanation for
improvement of the
subjects' headaches
after treatment may be
FIGURE 4. Headache duration data plots for subjects 7-10 (A = Baseline, B = Treatment, A = Baseline). that cervical
headaches stem from
The improvement in duration provement of the subjects' headaches degenerative changes
and intensity of headaches did not after treatment may be that cervical
continue through the withdrawal headaches stem from degenerative in the facet joints.
phase, but leveled off below pretreat- changes in the facet joint5 (13,50).
ment levels. Although the changes in Often degenerative changes (DJD) in
duration and intensity were not as the facet joints are theorized to be C2-3 joint (5,50). Additionally, the
dramatic as frequency, the subjects' the causative factor of headaches and C2-3 joint is innervated by articular
headaches did improve in these ar- pain (13,50). Turk and Ratkolb (51) branches from the third occipital
eas. These result5 are comparable found that upon roentgenogram nerve or from a communicating loop
with other studies (41.52). Visual in- analysis, 86% of their subjects with between the C2 dorsal ramus and the
spection revealed improvement for chronic headaches had evident de- third occipital nerve (5). Therefore,
all subjects except #1 and #lo. Cel- generative changes, yet 75% of their the C2-3joint is the only joint in the
eration lines for headache intensity subjects had a diminishing number upper cervical spine where the nerve
exhibited an upward or level trend of headaches after three weeks of which innervates the joint crosses
for seven subjects (1,2,4,6-9), and if mobilization treatment. Pain and directly over the articular surfaces.
a subject did not experience a head- headaches also can occur without Therefore, one may postulate that
ache for the M a y period (subjects evidence of degenerative changes on mobilization would help restore nor-
4,5,7), the duration and intensity X-ray (17,41). Ehni and Benner (13) mal mobility, and thus, reduce firing
points were plotted as zero which believed that patients' pain arose of the pain receptors which are acti-
skewed the celeration lines in a nega- from the DJD of the C1-2 joint stimu- vated when the joint is under exces-
tive fashion. The varying directions of lating the C2 nerve root and trans- sive mechanical stresses (54). Addi-
the celeration lines demonstrate the mitting pain by the anterior ramus of tionally, improving mobility of the
wide variability in these subjects. C2, not from the compression of the joint could therefore activate the
A possible explanation for im- nerve. joints' type I and I1 receptors which
Volume 21 Number 4. April 1995. JOSPT

posttreatment of 100 patients' a b
Intensity sence of headaches in 25%, contin-
#I IM
ued improvement in 40%, and 35%
B
reported relief lasting only 1 month.
_ - - -_--- Variability was also present in the
subject's frequency, duration, and
1Time (Days)
intensity of headaches. This phenom-
enon of variability could be due to a
number of factors including varia-
tions in cervical spine mobility, as
dependent on biomechanical factors.
Biomechanical changes could be a
function of neck postures or activities
which may stress involved structures
of the cervical spine. The subjects
reported sleeping postures, reading,
and neck extension as common fac-
tors which aggravated their head-

aches. These aggravating factors are
consistent with those reported by
other authors (26,35).
The descriptive data of these s u b
jects also revealed a wide variability of
headache symptoms, thus, exhibiting

the complexity of the cervical struc-
tures and their relationship to head-
aches. Of the 10 subjects, headaches
most commonly occurred in the s u b
occipital, temporal, occipital, and
retro-orbital regions. Thew regions,
with the exception of the temporal
area, are common areas of cervical
headaches (6,23,26). Subjects often

FIGURE 5. Headache intensity data plots for subjects 1-6 (A = Baseline, B = Treatment, A = Baseline).
reported more than one area of
headache, or that their headache
inhibit pain (54). Therefore, mobili- ported as a common area of tender- started in the suboccipital area and
zation of this joint could contribute ness with reproduction of headache- radiated up and forward to the tem-
to the attenuation of headaches like symptoms (7,50). poral, occipital, and retro-orbital ar-
caused from cervical joint dysfunc- Often patient. with cervical dys- eas. This pattern is similar to that
tion. function and degenerative changes described by Trevor-Jones (50). The
Our study revealed stiffness or on X-ray are told they must live with most common pain descriptors were
limited motion of the right and left their symptoms. An example was s u b throbbing, pressure, and ache. Asso-
C1-2, C2-3joints as determined by ject 2 who had been diagnosed with ciated symptoms of nausea, light sen-
the passive accessoryjoint mobility DID of the cervical spine and had sitivity, and difficulty concentrating
tests, with the C2-3 joint limitation tried various forms of treatment for were commonly reported by our s u b
more prevalent. Jull (25) also re- years without relief. Mobilization re- jects and have been reported by
ported the C2-3 joint as the most lieved his headaches throughout the other authors (6,12). Neck pain, in-
common area of stiffness. Jirout (23) treatment and withdrawal phases of clusive of the suboccipital area, was
hypothesized that the C2-3 area is the study. Support of the positive ef- reported by all 10 subjects who com-
common for dysfunction as it repre- fect of mobilization of the spine, pleted the study. Other authors have
sent. a transitional area between the even with existing degenerative not reported such pervasive concur-
C1-2 joint, which moves primarily in changes, has been reported by other rence of neck pain with headaches
a horizontal plane and C.34 which authors (17,22,41).Long term prog- (72.2).
moves primarily in a saggital plane nosis is uncertain, although Turk and Psychological factors also can
(23,24). The C2-3joint has been re- Ratkolb (51) reported at 6 months have a role in cervical headaches

-.-
R-E .S,E.A-R-C".H-...S..T U D..Y.---.- -- -...--- --.<------ -". - ---
-7. --v-----.-------."-. -- --- -.- . -. .-- -. -.
the patient, as well as the subject's
Intensity expectations, feelings, and cognitive
responses to treatment, are important
elements of the therapist-patient rela-
tionship which can affect treatment
outcomes (16). These factors may
#7 explain why subjects showed the
greatest improvement during the
treatment phase, when the greatest
amount of one-on-one interaction
occurred. The headache log may
have helped increase the subjects'
awareness of their headaches. This
increased awareness may have re-
Time Ow) sulted in a greater sense of improve-
ment or change in headache fre-
quency, duration, and intensity.
The placebo effect was countered

partially by the use of an additional
baseline after treatment. A stronger
design would be that of an ABAR
design, especially if the first B phase
is successful in relieving headaches as
was the case in subject 2. Another
design would be to use similar treat-

ments with one being a placebo, ie.,
simulated mobilization.
Treatment was limited to the u p
FIGURE 6. Headache intensify data plots for subjects 7-10 (A = Baseline, B = Treatment, A = Baseline).
per cervical levels, and other forms of
treatment were not administered in
conjunction with mobilization. Out-
(17). Four subjects in this study (4, aches could have an associated cervi- come possibly could have been en-
5,7, and 8) related increased head- cal dysfunction as these same subjects hanced by mobilizing lower areas of
aches with increased stress. This may experienced relief with mobilization the cervical and/or thoracic spine.
be because stress results in an in- treatment. Additionally, treatments commonly
crease in muscle activity via the retic- A placebo effect may also have employed by physical therapists, such
ular activating system (49). The pri- been a factor in treatment outcome. as exercises and postural instruction,
mary muscles involved are the The therapist's knowledge, enthusi- possibly could have improved out-
antigravity muscles which maintain asm, and optimism, as perceived by come or maintained gains achieved
the upright posture of the neck (49). with mobilization (32). These meth-
Specifically, the suboccipital muscles ods were not employed in order to
may be activated as they help main- ~e~endi reduce confounding factors in the
tain proper head position in the u p Variabl study.
right posture. Their increased activa- YW
!"'er. The results of this study indicate
tion could stimulate the development Subjects 9 22.80 2.53 13.55 .0001 that the use of mobilization to the
of myofascial trigger points resulting Phases 2 19.00 9.50 50.82 .0001 upper cervical spine within this sam-
hation
in headaches (2 1) . Myofascial trigger ple may only be therapeutic in the
Subjects 9 133.00 14.78 4.06 .0055
points have been postulated to de- Phases 2 33.68 16.84 4.63 .0239 management of cervical headaches.
velop from dysfunction of one of the ntensily Additionally, this study revealed the
upper cervical segments (21). Experi- Subjects 9 25.06 2.78 2.54 .0443 importance of systematic collection of
mentally, noxious stimulation of the Phases 2 15.59 7.79 7.10 ,0053 data, especially the headache data of
muscles supplied by the C1 and C2 * Significance level set at .O5. frequency, duration, and intensity.
dorsal rami has been shown to refer TABLE 4. Results of one-way analysis of variance for The log revealed a wide variability of
pain to the head (14). One could repeated measures on headache frequency, duration, symptoms with subjects with a com-
reason that stress or tension head- and intensity'. mon diagnosis; for example, not all

subjects had headaches every day. ACKNOWLEDGMENTS tion. Cephalalgia 7:147-160, 1987
The log allowed the clinician to o b 16. Gielen F: Discussion of placebo effect
serve the patient's own perception of I thank Judy McDanal, MD, for in physiotherapy based on a noncritical
her support of this study and all of review of the literature. Physiother Can
his or her headaches. The use of self- 41:210-216, 1989
report data, or the headache log, al- my subjects for the time and effort
they gave for participation. 17. Grieve GP: Common Vertebral Joint
lows the clinician to determine if im- Problems, pp 205-208. New York:
provement is taking place as well as a Churchill Livingstone Inc., 1981
means of measuring functional assess- 18. Grieve GP: Mobilization of the Spine
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The Effect of Mobilization On Cervical Headaches

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The Effect of Mobilization on Cervical

Volume 21 Number 4 April 1995 JOSPT

The etiology of cervical head- (51), in a study of 100 patients with

from trauma, including whiplash in- Parker et al (41). in a controlled

JOSPT Volume 21 Number 4 April 19%

fied, would reduce or relieve pa-

Volume 21 Number 4 April 1995 JOSPT

structions on its use. The date was

JOSPT Volume 21 Number 4 April 1995

Suboccipital Pressure Prolonged Neck pain

Suboccipital Ache Sleeping Neck pain

Suboccipital Ache Lateral flexion Neck pain

Suboccipital Ache Sleeping Neck pain

Suboccipital Throb Turning neck right Neck pain

Suboccipital Ache Reading Neck pain

Frontal Turning neck left

Suboccipital Tightness Using phone Neck pain

Suboccipital Throbbing Using phone Neck pain

Suboccipital Ache Turning left Neck pain

TABLE 3. Descriptive data on subjects with cervical headaches (HA).

188 Volume 21 rn Number 4 rn April 1995 rn JOSPT

sive accessory movements ( K = .45)

iological and accessory movements

present with greaterjoint stiffness

JOSPT Volume 21 Number 4 April 1995

Frequency determine if any trends existed in the

headache duration, frequency, and

Volume 21 Number 4 April 1995 JOSPT

can's multiple range test) demon-

JOSPT Volume 21 Number 4 April 1995

of the C3 vertebra and crosses the

Volume 21 Number 4. April 1995. JOSPT

tors which aggravated their head-

headache symptoms, thus, exhibiting

headaches (6,23,26). Subjects often

JOSPT Volume 21 Number 4 April 1995

The placebo effect was countered

design would be to use similar treat-

Volume 21 Number 4 April 1995 JOSPT

16, 1985 1979

Volume 21 Number 4 April 1995 JOSPT

1. B.T. Pagett. Cervical Headache 254-259. [Crossref]

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