Abstract: Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskeletal Disorders. 2016;17:64. Dunning JR, Butts R, Mourad F, et al.

This RCT of 110 patients (mean age 34- manip.; 36 -mob/ex groups respectively) assessed the clinical effectiveness of these interventions over a short duration (3 months) with 6-8 treatment sessions over 1 month time. These authors believe that manipulation (in the right population set) can be more effective than joint mobilization and exercise for cervicogenic headache patients.

It appears this is a good beginning evaluation of this but some methodological controversies persist. For example, these authors had their research clinical partners  “lock” above and below in the thoracic manipulation T1-2 but there was primarily segmental focusing in the C1-2 manipulation technique they described, with the force at C1 on C2 primarily rotational. NAIOMT techniques, often are even more specific to the the relative joint mechanics to improve the safety and effectiveness of the techniques.

These authors feel that the research (1) suggests poor utility of pre manipulative  VBI tests in screening out those who will have an adverse event in response to upper cervical manipulation. NAIOMT coursework continues to use the pre manipulative ‘hold’  (different than isolated VBI testing) and thorough medical history and objective examination to screen for patients who may be at higher risk of an adverse event AND to obtain patient consent for manipulation as per IFOMT 2012 manual therapist recommendations.

The above study also doesn’t detail the type of objective examination the therapist examiners did it their study other than the Cervical Flexion Rotation test which does show good reliability and specificity for cervicogenic headache source in patients with C1-2 dysfunction. The treating therapists also had the option to manipulate or mobilize C0-7, T1-9 and 1st-9th ribs on these same patients.

While this study references (2) research that states there is limited accuracy of upper cervical spine stability tests, the text of that study does note some promise in particular of tectorial membrane, AO membrane, alar and CFRT tests utility. Additional studies have been done to begin to establish the reliability and validity of common upper cervical ligament stability tests with good early results (3,4).

Overall, as manual therapy clinicians we need to continue thoroughly screen and evaluate our patients to determine what manual therapy interventions best suit our patient, our skill level and their presenting condition. The  ongoing research continues to improve our ability to make our selections more precise and effective for our patients.

–Karen Walz, PT, DPT, OCS, COMT, FAAOMPT

Faculty CFI and Examiner NAIOMT

NAIOMT Clinical Fellowship Instructor/Faculty and Examiner

The North American Institute for Orthopaedic Manual Therapy

NAIOMT is a leader in the manual physical therapy continuing education field in promoting the use of eclectic, clinically reasoned, evidence based evaluation and treatment techniques for the low back. See upcoming  manual therapy courses here.

1. Hutting N, Verhagen AP, Vijverman V, Keesenberg MD, Dixon G, Scholten-Peeters GG. Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: a systematic review. Man Ther. 2013;18(3):177–82.
2. Hutting N, et al. Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Phys Ther. 2013 Dec;93(12):1686-95. doi: 10.2522/ptj.20130186. Epub 2013 Jul 25.

3. Osmotherly PG, Rivett DA, Rowe LJ. The anterior shear and distraction tests for craniocervical instability. An evaluation using magnetic resonance imaging. Man Ther.2012;17(5):416-421.
4. Osmotherly PG,Rivett DA, Rowe LJ.Toward understanding normal craniocervical rotation occurring during the rotation stress test for the alar ligaments. Phys Ther. 2013;93(7):986-992.