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Cervicogenic Headache – Manual Therapy & The Mulligan Concept

Presented by: Gaetano G Milazzo – BSc GDPhysio GDManipPhysio MBiomedE

Will commence LIVE from Sydney, Australia at 8pm AEST

Andrew Ellis BSc (Ex. Sci), M. Phty

World Health Webinars CEO

World Health Webinars Host

Musculoskeletal Physiotherapist Sydney CBD

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Gaetano G Milazzo

• International Chairperson Mulligan Concept

Teachers Association

• 40 years of experience

• Postgraduate teaching both in Australia and

overseas

Consultant Musculoskeletal Physiotherapist

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Cervicogenic Headache – Manual Therapy & The Mulligan

Concept

CGH: Presentation Objectives

Review the clinical signs and symptoms of cervicogenic

headaches (CGH)

Review the principles of the Mulligan Concept

Describe the application of the Mulligan Concept to the

management of CGH.

Therapist applied procedures

Self-treatment procedures

8

CGH: Presentation Objectives

The main objective is to provide you with more treatment options,

to more effectively manage your CGH patients

While the Mulligan Concept is a well accepted

and researched manual therapy procedure,

for the management of CGH, it is not the

only procedure available

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No one technique, procedure, or intervention,

will benefit all patients

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Headache Classification

The International Headache Society (IHS) has classified headache

disorders into one of three groups:

1. Primary: migraine, tension type headaches, cluster

headaches etc.

2. Secondary: this group includes headaches from

cervicogenic origin (Cervicogenic Headaches - CGH).

3. Other: includes cranial neuralgias etc.

For the purposes of this presentation, we can generally

subdivide headache causes as being either mechanical

or non-mechanical.

10

Headache Incidence

Mechanical Headache

One month prevalence of 50.5%

Tension (48.0 %)

Cervicogenic (2.5%)

Non-mechanical headaches

One month prevalence of 49.5%

Migraine (4.0 %)

Other forms (45.5%)

(i.e.. Cluster, TMJ, sinus) .

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Headaches by area mapping

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References // Web site: www.bmulligan.com

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Cervical dysfunction and headaches

As a clinician you will need to make a decision as to the origin of the

patient’s headache (Jull 2013): Options -

Cervicogenic headache: cervical dysfunction directly related

to symptoms

Mixed headache: cervicogenic +migraine/tension type

Not cervicogenic headache:

migraine or tension type headache

but co-existing musculoskeletal signs/symptoms.

.

14

Cervicogenic headache (CGH)

Cervicogenic Headache is described as a referred pain, perceived

in any region of the head, caused by a primary nociceptive source

in the musculoskeletal tissues, innervated by the upper cervical

nerves.

The anatomical basis for cervicogenic headache is convergence in

the trigeminocervical nucleus, between the afferents from the

head, and afferents from the upper 3 cervical spinal segments.

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Cervicogenic Headaches Diagnosis

Sjaastad et. al. (1998) described the diagnostic criteria for

cervicogenic headaches.

He identified two criteria subsets: Major and Moderate

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CGH Diagnosis - Sjaastad et. al. (1998)

Major criteria

Symptoms and signs of neck involvement

Precipitation of comparable head pain by:

Neck movement

Awkward postures

External pressure over upper cervical spine on

symptomatic side

Restriction of cervical movement

Ipsilateral neck, shoulder or arm pain.

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CGH Diagnosis- Sjaastad et. al. (1998)

Moderate criteria:

Confirmatory evidence by diagnostic blocks

Unilaterality of head pain (no side shift)

Head pain characteristics of:

Moderate to severe intensity

Non-throbbing, non-lancing pain

Episodes of varying duration

Fluctuating/continuous pain.

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CGH Headaches

Look at Pattern of Symptoms and Physical Impairment.

Symptoms:

Unilateral head and neck pain

Side consistency – does not change sides

Aggravated by neck postures and movements

Impairment:

Unilateral reduced cervical ROM (rotation)

Painful spinal segment and related soft tissues on palpation/movement tests

Impaired cervical muscle function (deep neck flexors)

Jull et al 2007, Amiri et al 2007, Vince and Luna 1999)

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Cervicogenic Headaches

Mechanical dysfunction in the upper cervical spinal segments

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Hall et al (Manual Therapy 2010) Showed that the most symptomatic level associated with CGH is C1/2

CGH Headaches

Single clinical signs lack specificity for accurate CGH diagnosis, as this can be present in different forms of headaches.

Jull 2013: If you have:

Reduced range of motion

Painful segmental joint dysfunction

Impaired cervical muscle function

These combined factors result in

Sensitivity of 100%

Specificity of 94.4%

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Reliability of criteria - Vincent et. al. (1999)

Cervicogenic Headache could be differentiated from

Migraine with:

100% sensitivity and specificity, if 7 of the CGH criteria

were present

Cervicogenic Headache could be differentiated from Tension

Headaches with

100% sensitivity and 86.2% specificity if 7 of the CGH

criteria were present.

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Neurology of CGH Headache

Occiput / C1 segment

Posterior primary ramus C1 –

greater occipital nerve

C1/2 segment

Posterior primary ramus C2 –

lesser occipital nerve

C2/3 segment

Projects to “trigeminal nucleus”

in hypothalamus

23

Specific injection into any upper 3 cervical segments

have been demonstrated to relieve mechanical

headaches symptoms (Bogduk/April 2002).

Trigeminocervical Nucleus

The trigeminocervical nucleus is a bidirectional pathway.

Pain originating in the head can refer to the neck

Pain originating in the neck can refer to the head

Bartsch & Goadsby 2003

Bogduk & Govid 2009

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Bogduk and Govid 2009

Research shows there is overlap of areas, so area of pain may not guide

segmental source of pain: Cooper et al (Pain Medicine 2007)

Manual Therapy has been shown to be effective

in the management of CGH

Two references of note:

Jull et al 2002

Hall et al 2007

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A randomized controlled trial of exercise and

manipulative therapy for cervicogenic headache (Jull et.

al. 2002)

Multicenter trial throughout Australia

200 participants

6 weeks treatment with one of:

Manipulative therapy

Specific exercise

Combined manipulative therapy and exercise

Control

Reviewed at 3, 6 and 12 months.

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Jull et al (2002) - Outcomes

Both manipulative therapy and specific exercise groups

displayed significant reduction of headache compared to

controls

Frequency p<0.05

Intensity p<0.05

Combining treatments - 10% more patients gained relief with

combined therapies.

Consider using techniques other than just passive treatments

Include combined treatments

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Hall et al 2007 - Efficacy of Self SNAG

Research into the

Management of

Cervicogenic Headache

with self SNAG

Hall, T. Chan, H. et. Al. JOSPT Vol.

37, No. 3 March 2007

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The Mulligan Concept

1. The Principles of the Mulligan Concept

2. The Techniques:

Therapist applied techniques

Patient (self-treatment) procedures

Insufficient time in this presentation to discuss proposed

mechanisms of action.

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Developed by Mr Brian Mulligan FNZSP

(Hon.), Dip MT

Brian has been described as “one of the 7

most influential persons in OMT”

His premise: Pain and/or loss of function

(dysfunction) in the articular system can be

directly related to a mechanical causes, or

what Mulligan describes as a “Positional

Fault”

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Articular Dysfunction

Can be related to:

1. Restriction/s due to the soft tissues (passive, active and

neural)

2. Restriction/s due to an intra-articular derangement

3. Combinations of both**

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Mulligan Concept: The beginnings!

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Passive mobilisation (correcting positional fault) +

Active motion = pain relief and improved function.

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Mulligan Concept texts

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Comprehensive Technique Manual in 2014

Probably the manual therapy concept with the most amount of current

research.


His treatment Concept is anecdotally guided by 2 of

Brian’s favourite pneumonics:

1. P I L L

2. C R O C K S

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P.I.L.L.

Pain-free: both Mobilisation and active

Movement

Instant result

Long Lasting

3

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C.R.O.C.K.S

C - Contraindications

R - Repetitions

O – Overpressure + Load if necessary

C - Co-operation/feedback

K - Knowledge/ pathology and biomechanics

S - Sustain the mobilisation + common sense +

subtle changes

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Mulligan Concept

- What the patient can expect

A Pain Free Technique

Immediate improvement in pain and function

Maintained improvement

Appropriate self-management instruction

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The Clinical Assessment

Perform comprehensive clinical assessment, based on

the Biopsychosocial model.

Process: The Interview

A review of Investigations performed

The physical testing - All systems

Outcomes:

1. Ensure no contraindications to treatment

2. Establish that there is reversible mechanical dysfunction

3. Establish agreed outcomes and expectations

39

Mulligan Concept

– The Clinical Intervention Process

Following a comprehensive clinical assessment.

1. Apply the Mulligan Technique

2. Re-assess the comparable activity/function

3. If improved, perform repetitions

4. Progress patient to self-treatment.

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The Mulligan Concept Techniques

In generic terms, the main Mulligan techniques are described as

either

1. NAG: a passive oscillation - mobilisation along the

treatment plane

2. SNAG/MWM: A Sustained Passive movement applied to

the spine (SNAG) or peripheral segment (MWM)- combined

with active physiological motion, or

3. PRP: Pain Release Phenomena – a pain modulation

procedure

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SNAG : SUSTAINED NATURAL APOPHYSEAL GLIDE

The main technique used in the management of CGH is the SNAG.

SNAG is a sustained passive glide, which is usually applied concurrently with an active physiological

movement.

The glide is applied within the limit of the available pain-free range, and the force is applied along the plane of the facet joint.

The mobilisation force is sustained, while the patient performs an active movement.

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Mulligan Concept

Mobilisation Force

The mobilisation forces used in the Mulligan Concept based

treatment are graded towards the patients tolerance rather than a specific grading structure as in the Nordic or Maitland Systems.

43

As much force as is required, to effect a change –

not necessarily at end of range techniques.

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Grades of Mobilisation

44

Limit of active (or

available

/dysfunction) range

NORDIC

MAITLAND

Stage 1: Piccolo (traction)

Stage II: Take up the slack

Stage III:

Stretch

Grade I

Grade II

Grade III

Grade IV

Grade

IV+

Range of Total Physiological motion

Limit of

anatomical

range

35

25

15

5

-5

-15

-25

33 50 66 100 Force Levels (% maximum)

McLean et al A pilot study of manual force levels required to produce manipulation induced hypoalgesia. Clinical Biomechanics 200217: 304-8

HOW MUCH FORCE?

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Mulligan Concept

Direction of Mobilisation Direction

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STOP if Pain does not decrease and/or

NO increase in ROM

ADJUST GLIDE/FORCE if some

improvement

Good to GO: No pain and increased

ROM


Mulligan Concept approach in the management of CGH

1. Diagnosis

2. Treatment

I. Pain

II. Dysfunction

III. Self-management

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Diagnosis

1. Positive Flexion Rotation Test (FRT)

2. Immediate improvement in symptoms with application of

the technique

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Anatomy review: Cervical Spine Z-joint alignment

White and Panjabi 1978

“Converge toward the eye”

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The Cervical Flexion-Rotation Test (FRT)

With the cervical spine in full flexion, the therapist passively rotates the head to the left and then

to the right. Full flexion must be achieved and maintained before rotation is performed.

If range is limited, then limited

atlanto-axial rotation is considered present.

Normal range approx. 45 deg.

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FTR – alternate test procedures

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Research

Hall et al: found that a positive test is less than 32deg; not

influenced by lower cervical joint pain

Hall et al 2010: The degree of impairment of cervical movement

is related to the degree of headache severity

- The greater the restriction, usually the more intense the pain

Buldelmann et al 2013: Also confirmed to be present in

paediatric population with headaches

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FRT research Results

Average range of unilateral rotation

Migraine 39 degrees (SD=6.9)

Asymptomatic 39 degrees (SD=6.5)

Cervicogenic 20 degrees (SD=11.0)

Sensitivity (ability to get +ve result when condition truly present) = 91%

Specificity (ability to get –ve result when condition truly absent) = 90%

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Caution with diagnosis

Do not rely on any one clinical sign, especially motion restriction

alone, for CGH diagnosis.

Research on cranio-cervical rotation (Osmotherly et al 2013)

showed that while the normal range is 21 deg, the variation can

be from 1.7 to 22 degrees even in “normal” non-injured

asymptomatic subjects.

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Management of Cervicogenic Headache –

Three Phases

I Pain Control

• Medication

• Manual therapy • Postural control

II Rehabilitation of Mobility

• Manual therapy

• Self treatment

III Rehabilitation of Postural, Kineasthetic and

Muscular Control

55

Phase I: Pain Control

Manual therapy (mechanical treatment)

Mulligan Concept procedures

Therapist applied procedures

Patient self-treatment

Medication (pharmacological management)

Analgesics, NSAID’s, Muscle relaxants etc

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Phase I: Pain Control

Posture Optimisation

Head on neck alignment

“Neutral pelvis”

Sit and stand tall

Sternum up

Use of lumbar roll if

necessary

Dynamic posture

– apply correct posture principles at home and at work

57

Mulligan Concept techniques for CGH

For dysfunction between Occiput and C2

Headache Techniques

Technique 1: Glide C1/2 anterior on Occiput (Headache SNAG)

Technique 2: Glide Occiput anterior on C1/2 (Reverse

Headache SNAG)

Technique 2: Glide Occiput posterior on C1/2

Upper Cervical traction

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Headache SNAG (anterior glide of C1/2)

Mobilisation:

Anterior sustained glide of C2 (joint plane) through contact on spinous process.

Comments:

Sustain the glide , monitor pain changes. Do not oscillate.

Vary glide as required: flex/ext +/- rotation or traction if needed

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Left hand: Little finger

on C2 spinous process.

Right hand: Applies glide

force.

Reverse Headache SNAG Anterior glide of occiput on relatively fixed C1/2.

Mobilisation:

Sustained anterior translation of

head on relatively stablised

C1/C2.

C1/C2 stabilised by

thumb/forefinger pincer grip

Comments:

No oscillation

Glide is in line with joint plane

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Headache SNAG - modification Posterior glide of the Occiput on relatively fixed C1/2

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Upper Cervical: “Forearm” Traction

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Cervical Belt Traction

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Mulligan Concept - Self-treatment

Self-treatment for Pain Control

Self-treatment for Restoration of Flexibility

No specific Mulligan Concept procedure for exercise

therapy: see work of Jull et al.

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Pain control: CGH self-SNAG

Patient places treatment strap over the level of C2:

positioned below the occiput: tape in line with level with the top teeth.

Technique 1.

Hold head stationary and full tape forward.

Technique 2 .

Hold tape firm and patient gently retracts head against the stabilised C2

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Technique 1

Anterior glide of C1/2 with

strap on relatively fixed

Occiput.

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Technique 2

Posterior glide occiput

(chin retraction) on

relatively fixed C1/2.

Self SNAG for pain control

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Phase II: Rehabilitation of Mobility

Manual therapy

Mobilisation

Manipulation.

Self-mobilisation

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Cervical SNAG: Right rotation in neutral

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Mobilising glide is on C2 –

transverse process.

Use pad of thumb: must be in

line with joint plane.

After glide is applied, patient

performs repetitions of active

rotation to the right (into

direction of restriction).

Cervical SNAG: Right rotation in flexion

Bangkok 2013

69

Self-treatment - Rehabilitation of Mobility

Shoulder

blocked

C1 -

T.P. Gentle

ERL

Position hands close to neck –

thumb on forehead to ensure hand

and head move together

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Self-SNAG’s - to restore Rotation C1/2 (R)

Patient places tape over the level of C2; positioned below the occiput, and below ear lobes with the tape level with the top teeth.

Patient gently retracts head against stabilised C2.

NO PAIN, and NO VERTEBRAL ARTERY SYMPTOMS / SIGNS

Patient grasps the left side of the tape with the right hand (for restoration of rotation to the right).

Stabilise neck with the left side of the tape held against the sternum, with the patients elbow over the chair (stops twisting).

Glide with right hand horizontally to move the head to the right = no pain + increased ROM expected

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HEADACHES: SELF SNAGS

Common errors in technique

Not localised

Pulling with the tape

Flexing the head on the neck

Direction of pull of tape is not correct

Glide not maintained until head returns to neutral

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Phase III: Postural, Kinaesthetic and Muscle Re-

education

Phasic muscles (tend to shorten)

Long flexors

Sternocleidomastoids,

Omohyoids

Long extensors

Splenius capitus,

Longus cervicus

Upper trapezius

Deep extensors

Rectus capitus

Obliqus capitus inferior

Postural muscles (tend to

weaken)

Deep neck flexors

Longus coli,

longus capitus,

Strength, endurance and

synergy

lower trapezius

Postural awareness and re-

education

Static and Dynamic Strength and

Endurance

Joint Position Error

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RECORDING TREATMENT

1. Type of procedure: SNAG - central or unilateral

2. Segment mobilised: C2

3. Reaction / response to treatment

4. Reassessment of comparable sign/s

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Troubleshooting

If symptoms remain unchanged after Rx, consider:

Clinical reasoning error

Incorrect joint selection

Poor handling skills

Wrong direction or force

Ineffective communication

75

Non-responders to treatment of CGH

Liebert et al 2013:

History of severe trauma

Genetic history of CGH or other headache type

Neural sensitivity

Minimal presence of upper cervical neck pain and impairment

Immunological comorbidities

Latency of response to treatment

76

The Mulligan Concept How does it Fit in the current Bio Psycho Social model

Bio: Identifies the origin of the “positional fault” (segment)

associated with the pain provocation and functional

impairment. Immediate pain reduction and impairment

improvement.

Pain: No pain provocation – avoids sensitisation of neural

mechanisms.

Psycho: Decrease in fear of pain and movement

Empowerment to self-management

Reduction in somatisation and catastrophising

Social: Return to participation – work, home, sport, leisure

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In conclusion

CGH can be effectively managed utilising the Mulligan

Concept procedures.

Always perform comprehensive clinical assessment

Apply treatment only if there is an immediate benefit

noted with treatment delivery

Explain the condition, the treatment and the patient’s

involvement in the recovery

Benefit of the Concept is based on biomechanical and

neuroscience paradigms.

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SPECIFIC APPLICATION

NEUROSCIENCE PARADIGM

BIOMECHANICAL PARADIGM

DPIS/ non-opioid hypoalgesia

pain SNS

Motor Sensori-motor

Bony realignment (PFs)

Transient bony displacement

level

Painless!!!

localization direction

Applied force

MIND MAP: PROPOSED MWM

MECHANISM (Vicenzino)

o Pre-existing beliefs

o Injury and damage

o Catastophisation

o Fear-avoidance

o Expectations

oPAG – tripartite response

o Sympatho-excitatory

o Motor facilitation

o Non-opioid hypoalgesia

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Course pictures Research abstracts Book chapters

Interviews

Videos

80

Conclusion

Be aware of patients with mixed headaches,

especially where tension and anxiety may be co-

existing conditions.

Treat the patient

Questions?

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Live Q & A With Gaetano Milazzo

Coming up next week

Facebook, Twitter, LinkedIn, Google +

2/09/2013

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Live Q & A With Gaetano Milazzo

Thank you

From Gaetano Milazzo

&

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