MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The effectiveness of manipulation versus mobilization for the management of spinal conditions, including cervicogenic headache, is conflicting, and a pragmatic approach comparing manipulation to mobilization has not been examined in a patient population with cervicogenic headache.

This study evaluated the effectiveness of manipulation compared to mobilization applied in a pragmatic fashion for patients with cervicogenic headache.

Forty-five (26 females) patients with cervicogenic headache were randomly assigned to receive either pragmatically selected manipulation or mobilization. Outcomes were measured at baseline, the second visit, discharge, and 1-month follow-up. The endpoints of the study included the Neck Disability Index (NDI), Numeric Pain Rating Scale (NPRS), the Headache Impact Test (HIT-6), the Global Rating of Change (GRC), the Patient Acceptable Symptoms Scale (PASS). The primary outcome measures were the effects of treatment on disability and pain. They were examined with a mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization) as the between-subjects variable and time (baseline, 48 hours, discharge, and follow-up) as the within-subjects variable.

The interaction for the mixed model ANOVA was not statistically significant for NDI (p = 0.91), NPRS (p = 0.81), or HIT (p = 0.89). There was no significant difference between groups for the GRC or PASS.

The authors concluded that manipulation has similar effects on disability, pain, GRC, and cervical range of motion as mobilization when applied in a pragmatic fashion for patients with cervicogenic headaches.

Essentially, this study is an equivalence trial comparing one treatment to another. As such it would need a much larger sample size than the 45 patients enrolled by the investigators. If, however, we ignored this major flaw and assumed the results are valid, they would be consistent with both manipulation and mobilization being pure placebos.

I can imagine that many chiropractors find this conclusion unacceptable. Therefore, let me offer an alternative: both approaches were equally effective. Therefore, mobilization, which is associated with far fewer risks, is preferable. This means that patients suffering from cervicogenic headache should see an osteopath who is less likely to use manipulation than a chiropractor.

And again, I can imagine that many chiropractors find this conclusion unacceptable.

13 Responses to Manipulation versus mobilization for the management of cervicogenic headache

  • 1. All interventions were done by physios trained at Maitland techniques. This has nothing to do with Chiropractic or Osteopathic SMT, strangely you failed to mention that in your comments.

    2. On what grounds do you claim manipulations have greater risk than mobilizations to the cervical spine? I would love to see the reference. After all both have no side effect registrar system…

    3. Both groups were given the same new exercises regime… could this confuse the statistics?

    4. The suggestion you can get similar results (in terms of pain not in ROM improvement) between manipulation and mobilization is well recorded. That is why good clinicians use both techniques when appropriate.

    5. The no. 1 problem with this study were the inclusion/exclusion criteria. In my practice if I can not reproduce the headache using standardized orthopedic tests, I don’t accept patients for treatment and send them to look elsewhere. I tend to believe if this was implemented here it would have been far more difficult to recruit patients and the results were probably better.

    • 1) is a manual treatment done by a physio different from that performed by a chiro? if you think so, provide evidence, please.
      2) I have written dozens of blog posts on this; help yourself.
      3) no
      4) “when appropriate”? it seems to me that results like the ones from this study suggest that they are not appropriate.
      5) your belief is not evidence.

  • Please explain how this was a pragmatic trial.

    “Following the baseline examination, patients were randomly assigned to receive mobilization or manipulation directed at the upper cervical spine plus exercise.”

    “A second therapist who was blinded to the baseline examination findings opened the envelope and proceeded with treatment according to the group assignment.”

    • ask the authors
      in my view, the term is not well-defined

      • Want a pragmatic study?

        Here are n subjects with cervicogenic headaches. Treat them as you would in clinic. We will analyze the data and see if one approach is better than the others.

        Granted one will have to lay out some parameters.

        Regarding the study, they tried.

        • the way you describe the study, its results would be meaningless.
          even pragmatic trials can include randomization, blinding, and other ways of minimizing biases.

          • If you tell the PT what manual therapy they can and cannot do, that’s not pragmatic.

            solving problems in a sensible way that suits the conditions that really exist now, rather than obeying fixed theories, ideas, or rules: Cambridge

            My suggestion is pragmatic.

            I never said there couldn’t be randomization.

          • … and I did not call this study ‘pragmatic’

  • Dear Dr Ernst (sorry for the random seeming comment) but I haven’t checked in on the skeptic movement in a long time. I’m interested to see now it is very divided on the issue of treatment for trans people, which – full disclosure – I support. I was wondering if you could post some thoughts on this? Many thanks, apologies for lack of relevancy to the article

    • not my area of expertise, sorry

    • My experience of treating trans people has been limited to the occasional case of testicular or prostate cancer. Gender reassignment surgery creates all sorts of problems when it comes to treating a localised prostate cancer in particular, as it makes both prostatectomy and standard radiotherapy so hazardous as to be virtually impossible.

  • I am not surprised that the results between mobilisation and manipulation were similar. I have observed this same result when comparing neck pain and low back pain. What appears to provide much longer positive outcomes with skeletal caused ailments, is when improved skeletal alignment towards average normal is performed. Regarding headache, this manuscript describing a chiropractic method, tested by physiotherapists suggests much better long term outcomes. Some would challenge the use of imaging but in my opinion, it reduces risk and improve outcomes. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7988315/

    • “I am not surprised that the results between mobilisation and manipulation were similar. I have observed this same result when comparing neck pain and low back pain.”
      If that is true, it means mobilisation is preferable, as I state in the post.

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