NON-PHARMACOLOGICAL MANAGEMENT OF PERSISTENT HEADACHES ASSOCIATED WITH NECK PAIN: A CLINICAL PRACTICE GUIDELINE FROM THE ONTARIO PROTOCOL FOR TRAFFIC INJURY MANAGEMENT (OPTIMA) COLLABORATION
 
   

Non-pharmacological Management of Persistent Headaches Associated
with Neck Pain: A Clinical Practice Guideline from the Ontario
Protocol for Traffic Injury Management (OPTIMa) Collaboration

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   European Journal of Pain 2019 (Jul);   23 (6):   1051–1070 ~ FULL TEXT

Pierre Côté, Hainan Yu, Heather M. Shearer, Kristi Randhawa, Jessica J. Wong, Silvano Mior et al.

Canada Research Chair in Disability Prevention and Rehabilitation,
University of Ontario Institute of Technology (UOIT),
Oshawa, Ontario, Canada.


OBJECTIVES:   To develop an evidence-based guideline for the non-pharmacological management of persistent headaches associated with neck pain (i.e., tension-type or cervicogenic).

METHODS:   This guideline is based on systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of clinical benefits, cost-effectiveness, societal and ethical values, and patient experiences when formulating recommendations. Target audience includes clinicians; target population is adults with persistent headaches associated with neck pain.

RESULTS:   When managing patients with headaches associated with neck pain, clinicians should (a) rule out major structural or other pathologies, or migraine as the cause of headaches; (b) classify headaches associated with neck pain as tension-type headache or cervicogenic headache once other sources of headache pathology has been ruled out; (c) provide care in partnership with the patient and involve the patient in care planning and decision making; (d) provide care in addition to structured patient education; (e) consider low-load endurance craniocervical and cervicoscapular exercises for tension-type headaches (episodic or chronic) or cervicogenic headaches >3 months duration; (f) consider general exercise, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage for chronic tension-type headaches; (g) do not offer manipulation of the cervical spine as the sole form of treatment for episodic or chronic tension-type headaches; (h) consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine for cervicogenic headaches >3 months duration. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises; and (i) reassess the patient at every visit to assess outcomes and determine whether a referral is indicated.

CONCLUSIONS:   Our evidence-based guideline provides recommendations for the conservative management of persistent headaches associated with neck pain. The impact of the guideline in clinical practice requires validation.

SIGNIFICANCE:   Neck pain and headaches are very common comorbidities in the population. Tension-type and cervicogenic headaches can be treated effectively with specific exercises. Manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches. The management of tension-type and cervicogenic headaches should be patient-centred



From the FULL TEXT Article:

INTRODUCTION

Neck pain and headaches are common comorbidities. In Canada, individuals with disabling neck pain are 10 times more likely to suffer from co-morbid headaches than those without neck pain (Côté, Cassidy, & Carroll, 2000). Moreover, more than 80% of individuals who experience headaches after a motor vehicle collision also experience neck pain (Cassidy et al., 2000).

In 2008, the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders recognized the link between neck pain and headaches (Guzman et al., 2008). The Task Force defined neck pain as an unpleasant and emotional experience in the cervical spine and proposed a classification that ranges from neck pain that is not associated with major structural pathology or interference with activities of daily living (Grade I) to neck pain caused by major structural pathology (Grade IV) (Guzman et al., 2008). Each grade of neck pain can be associated with headaches. However, the Task Force did not explicitly define the type of headaches that are associated with neck pain.

The International Classification of Headache Disorders (ICHD-3) suggests that two types of headaches are linked to the cervical spine: tension-type headaches and cervicogenic headaches (Headache Classification Subcommittee of the International Headache Society, 2018). Tension-type headache (frequent episodic or chronic) is defined as being typically bilateral, pressing or tightening in quality and of mild to moderate intensity, lasting minutes to days or unremitting on average for at least three months (Headache Classification Subcommittee of the International Headache Society, 2018). The pain does not worsen with routine physical activity and is not or may be associated with nausea, though photophobia or phonophobia may be present. It can be associated with pericranial tenderness on manual palpation of the head and neck muscles (Fernandez-de-las-Penas, Alonso-Blanco, San-Roman, & Miangolarra-Page, 2006; Fernandez-de- Las-Penas, Cuadrado, & Pareja, 2007; Sohn, Choi, Lee, & Jun, 2010). Cervicogenic headaches are caused by a disorder of the cervical spine (bony, disc and/or soft-tissue structures) and are usually accompanied by neck pain (Headache Classification Subcommittee of the International Headache Society, 2018; Sjaastad & Bakketeig, 2008; Sjaastad, Fredriksen, & Pfaffenrath, 1998).

It is estimated that 2,331,334,700 of the world's population experience tension-type headaches in 2017 (Global Burden of Disease 2017 Collaborators, 2018). Cervicogenic headaches are also common in the general population. In Denmark, the point prevalence of cervicogenic headaches is 2.5% in individuals between the ages of 20 and 59 and 17.8% of people who report at least five headache days per month suffer from cervicogenic headaches (Nilsson, 1995).

The clinical management of headaches associated with neck pain is often challenging. Evidence suggests that cervical spine exercises or manual therapy may be effective in the management of tension-type or cervicogenic headaches (Varatharajan et al., 2016). Moreover, available clinical practice guidelines recommend that reassurance, acupuncture, exercise, physical therapy (e.g., massage, spinal manipulation, hot and cold packs, ultrasound and electrical stimulation) and psychological interventions can be used to treat tension-type headaches (Becker, Findlay, Moga, Scott, & Harstall, 2015; Bendtsen et al., 2010; Carville, Padhi, Reason, Underwood, & Group, 2012).

Similarly, existing guidelines recommend that exercise, spinal manipulation and cervical mobilization can be considered for the treatment of cervicogenic headaches (Becker et al., 2015; Duncan, Watson, & Stein, 2008). However, the four guidelines currently available need to be updated because their recommendations were informed by evidence published more than five years ago (Clark, Donovan, & Schoettker, 2006; Qaseem, Snow, Owens, & Shekelle, 2010). Therefore, a highquality evidence-based clinical practice guideline informed by the current evidence is recommended to inform the management of headaches associated with neck pain.



METHODS

      Scope and purpose of the guideline

We used the best available evidence to develop a clinical practice guideline for the non-pharmacological management of persistent headaches associated with neck pain. The target population is adults (18 years of age or older) with persistent (>3 months duration) headaches associated with neck pain. These headaches include tension-type headache or cervicogenic headache (Table 1) (Headache Classification Subcommittee of the International Headache Society, 2018; Sjaastad & Bakketeig, 2008; Sjaastad et al., 1998; Varatharajan et al., 2016).

Non-pharmacological interventions included acupuncture, exercise, manual therapy, multimodal care, passive physical modalities, soft-tissue therapies, structured patient education and work disability prevention interventions, excluding medications (interventions defined in Supporting information Table S1). The target audience is clinicians (medical doctors, physiotherapists, nurse practitioners, chiropractors, kinesiologists, psychologists, massage therapists, osteopaths and naprapaths) who provide care for patients with headaches associated with neck pain in primary, secondary and tertiary healthcare settings. The clinical management recommended in this guideline aims to (a) accelerate recovery; (b) reduce the intensity of symptoms; (c) promote early restoration of function; (d) prevent chronic pain and disability; (e) improve health-related quality of life; (f) reduce recurrences; and (g) promote active participation of patients in their care. Moreover, this guideline aims to promote uniform high-quality care for individuals with headaches associated with neck pain.

This guideline was developed by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration, which is a multidisciplinary team of expert clinicians (from medical, dental, physiotherapy, chiropractic, psychological, occupational therapy and nursing disciplines), academics and scientists (epidemiologists, clinical epidemiologists, library sciences and health economists), a patient liaison, a consumer advocate, a retired judge and automobile insurance industry experts. The OPTIMa Collaboration was mandated by the funding organization to develop an evidence-based clinical practice guideline for headaches associated with neck pain.

      Systematic reviews

We updated the systematic reviews from the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (Hurwitz et al., 2008). This update included six systematic reviews (published in one article) examining the effectiveness and safety of non-invasive interventions for the management of headaches associated with neck pain (Varatharajan et al., 2016). We also conducted one systematic review examining cost-effectiveness of the non-invasive interventions (data extraction completed but not published). We registered the systematic reviews with the International Prospective Register of Systematic Reviews (PROSPERO; exercise: CRD42013004848, manual therapy: CRD42013004901, acupuncture: CRD42013004687, multimodal care: CRD42013006940) (National Institute for Health Research n.d.).

The systematic reviews included studies examining the effectiveness of non-pharmacological interventions for the management of persistent headaches associated with neck pain (Table 1; Supporting information Table S1) (Headache Classification Subcommittee of the International Headache Society, 2018; Sjaastad & Bakketeig, 2008; Sjaastad et al., 1998). We excluded studies of migraine (with or without aura), traumatic brain injuries and underlying pathological processes. Eligible comparators for non-pharmacological interventions included other interventions, placebo/sham interventions, non-intervention effects associated with wait listing or no intervention. The clinical outcomes of interest included self-rated recovery, functional recovery, disability, pain intensity, health-related quality of life, psychological outcomes or adverse events. Eligible study designs included randomized controlled trials (RCTs), cohort studies and case–control studies published in English. Only full economic evaluations that jointly analysed costs and health outcomes were eligible for inclusion in the cost-effectiveness review.

We searched MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials through Ovid Technologies, Inc., and CINAHL Plus with Full Text through EBSCOhost (Supporting information Table S2A and B). We also searched EconLit through ProQuest, Health Technology Assessment (Cochrane) and National Health Service Economic Evaluation Database (Cochrane) for economic evaluations (Supporting information Table S2A and B). Our searches included publication dates from January 1990 to February or March 2015 (search dates varied between reviews) for non-invasive interventions and 2) to August 2013 for the cost-effectiveness of non-invasive interventions. We updated searches of the six systematic reviews from February or March 2015 (search dates varied between reviews) to 25 February 2017 in MEDLINE to identify any recently published RCTs. Random pairs of independent, trained reviewers screened and critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria (Harbour & Miller, 2001).

Studies with low risk of bias were included in the evidence synthesis (Slavin, 1995). Studies with low risk of bias studies were defined as studies where selection bias, information bias and confounding were deemed unlikely by two independent reviewers to have threatened the internal validity of the study. Minimal clinically important difference thresholds from the literature were used to determine the clinical importance of the results between groups from low risk of bias studies (Carroll, Jones, Ozegovic, & Cassidy, 2012; Farrar, Young, LaMoreaux, Werth, & Poole, 2001; Lauche, Langhorst, Dobos, & Cramer, 2013; McCarthy, Grevitt, Silcocks, & Hobbs, 2007; Sim et al., 2006; Stauffer, Taylor, Watson, Peloso, & Morrison, 2011).

      Development of recommendations

The OPTIMa Collaboration developed the guideline using the principles of patient-centred care and the Ontario Health Technology Advisory Committee framework (Johnson et al., 2009).

Specifically, we developed the evidence-based recommendations according to the following:

  • Overall clinical benefits (i.e., effectiveness and safety of interventions based on our systematic reviews) (Varatharajan et al., 2016);

  • Value for money (i.e., cost-effectiveness of interventions when available based on our systematic review);

  • Consistency with expected societal and ethical values (including persons’ lived experiences with their treatment based on our qualitative research) (Lindsay, Mior, Côté, Carroll, & Shearer, 2016).

The OPTIMa Collaboration included a chair, a project manager, a multidisciplinary Guideline Expert Panel (including a consumer representative and a nurse/qualitative researcher who represented patients’ views), a recommendation subcommittee, a technical team and consultants. The technical team conducted all systematic reviews; the Guideline Expert Panel reviewed and approved the methodological merit, analysis and interpretation of systematic reviews. In collaboration with the recommendation sub-committee, the authors of each systematic review developed draft clinical recommendations. The Guideline Expert Panel reviewed and modified draft recommendations and approved final recommendations. When research evidence was sparse (e.g., red flags), the Guideline Expert Panel used evidence from three other headache guidelines to inform its recommendations (Carville et al., 2012; Duncan et al., 2008; Perry et al., 2017). The translation of scientific evidence into guideline recommendations followed five steps (Table 2). Finally, the technical team integrated recommendations into care pathways and algorithms, which were approved by the Guideline Expert Panel (Figures 1?6).

This guideline adapted the National Institute for Health and Care Excellence methodology to develop the wording of guideline recommendations (Table 3) (Vargas-Schaffer, 2010).

Based on this methodology, we worded recommendations as follows:

  • Offer interventions that are of superior effectiveness compared to other interventions, placebo/sham interventions or no intervention

  • Consider interventions providing similar effectiveness to other interventions

  • Do not offer interventions providing no benefit beyond placebo/sham or are harmful

Using the results from the systematic reviews, the Recommendation Subcommittee interpreted the evidence on the effectiveness and safety of interventions by determining whether an intervention was superior, equal or inferior to placebo/sham or a control intervention. An intervention was deemed to have superior effectiveness if evidence of statistically significant and clinically important benefits was identified in at least one RCT with a low risk of bias. Interventions for which there is inconclusive evidence of effectiveness were not recommended (Supporting information Table S3).

We reported the frequencies and durations of care for recommended interventions based on low risk of bias studies in our systematic reviews. Specifically, for recommended interventions based on one low risk of bias study, we used the frequency and duration of care in that study. For recommended interventions based on more than one low risk of bias study, we computed mean frequency and duration of a specific intervention across studies and recommended the frequency and duration of care (Côté & Soklaridis, 2011; Doshmangir, Doshmangir, & Shaghaghi, 2017).

      External consultation and review of the guideline

This evidence-based clinical practice guideline was developed for the Government of Ontario. The Government invited stakeholders to review and comment on the guideline. Moreover, the Government held a series of public consultations on the clinical practice guideline from 17 to 21 August 2015. The Government will determine its applicability to the Ontario healthcare system. It is recommended that this guideline is updated in five years so that the guideline is based on current evidence (Kung, Miller, & Mackowiak, 2012). The update should use methodology similar to the development of this guideline.



UPDATE OF SYSTEMATIC REVIEWS

We updated the original search of the literature conducted for the original six systematic reviews (extending from February or March 2015 to 25 February 2017). This search yielded 417 articles (after duplicates removed), of which three RCTs were relevant, and all three had a low risk of bias (Supporting information Table S4). The low risk of bias studies from the updated searches investigated the following interventions: (a) manual therapy (Dunning et al., 2016; Espi-Lopez, Zurriaga-Llorens, Monzani, & Falla, 2016); (b) multimodal care (Dunning et al., 2016); and (c) soft-tissue therapies (Damapong, Kanchanakhan, Eungpinichpong, Putthapitak, & Damapong, 2015). None of these studies provided evidence that conflicted with the original recommendations developed by the OPTIMa Collaboration (i.e., based on original searches conducted in February or March 2015). We only identified one low risk of bias cost-effectiveness study (Witt, Reinhold, Jena, Brinkhaus, & Willich, 2008).



RECOMMENDATIONS

All recommended interventions are supported by evidence of effectiveness, safety and cost-effectiveness (when costeffectiveness data were available), and are consistent with societal and ethical values. Interventions that are not recommended did not satisfy the criteria of one or more key decision determinants (i.e., evidence of effectiveness, safety, cost-effectiveness and/or consistency with societal and ethical values).

      Recommendation 1: evaluation of headaches associated with neck pain

Clinicians should rule out major structural or other pathologies, or migraine as the cause of headaches. Clinicians should classify headaches as tension-type headache or cervicogenic headache.

Clinicians should conduct a clinical evaluation to rule out major structural or other pathologies (e.g., migraines with or without aura, and traumatic brain injuries) as the cause of presenting signs and symptoms. The presence of risk factors for serious pathologies (also termed “red flags”) identified during the history/examination warrants further investigation and referral to the appropriate healthcare professional (Table 4) (Carville et al., 2012; Duncan et al., 2008; Perry et al., 2017). Once major pathology has been ruled out, clinicians should classify headaches as tension-type or cervicogenic headaches, and the patient should receive the appropriate evidence- based interventions (Figures 2, 4 and 6, care pathways).




      Recommendation 2: management of persistent headaches associated with neck pain

Clinicians should provide care in partnership with the patient and involve the patient in care planning and decision making. For headaches associated with neck pain, clinicians should provide care in partnership with the patient and involve the patient in care planning and decision making (Stiggelbout et al., 2012). Clinicians should aim to understand the patient's beliefs and expectations about headaches and address any misunderstandings or apprehension through education and reassurance. Clinicians need to advise patients to stay active or exercise, provide information about pain and its mechanism, reassure patients about the nature and course of headaches, and deliver time-limited care that includes effective interventions (Yu et al., 2016). In the presence of prognostic factors (e.g., psychosocial factors, demographics and headache characteristics) for delayed recovery, clinicians should discuss them with the patient and adjust their care plan accordingly (Probyn et al., 2017).




      Recommendation 3: management of episodic tension-type headaches

For patients with episodic tension-type headaches, clinicians may consider low-load endurance craniocervical and cervicoscapular exercises in addition to structured patient education (Tables 5 and 6, Figures 1,2). In view of evidence of no effectiveness, clinicians should not offer manipulation of the cervical spine.

Structured patient education   Clinicians should provide information about the nature, management and course of episodic tension-type headaches as a framework for initiating the programme of care. This recommendation is based on universal principles of health professions’ standards of practice wherein patients are informed and educated about their condition and participate in the decision-making process (Stiggelbout et al., 2012).

Low-load endurance craniocervical and cervicoscapular exercises   Clinicians may consider low-load endurance craniocervical and cervicoscapular exercises (a maximum of 8 sessions over 6 weeks with resistance in a supervised clinical environment). This involves supervised and home-based low-load endurance exercises to perform a slow and controlled craniocervical flexion against resistance over time to train muscular control of the craniocervical and cervicoscapular region. The exercise programme should be taught to the patient by a healthcare professional. This recommendation is based on one low risk of bias RCT that found adding low-load endurance exercises (6-week supervised period, twice a day for 10 min per session at home, then at least twice per week after supervised period) to physiotherapy (i.e., Western massage, low-velocity passive cervical joint mobilization and instruction on postural correction) is superior to physiotherapy alone for improving headache frequency in the long-term for chronic or episodic tension-type headaches (van Ettekoven & Lucas, 2006).

Editorial Comment:

The following manual therapy conclusion, based on the (Bove & Nilsson, 1998) is incorrect.

  • It did NOT involve an “inert LASER”

Because I had just finished an acupuncture program, I wrote to Geoffrey Bove, D.C., Ph.D. the day his study was first published online (November 11, 1998) on the CHIROSCI-LIST to ask him:

Below are AMA's abstract, and an additional article from the AMA "Science News Update", on a study of 75 people who received 8 "treatments" in 4 weeks and failed to respond...even though they admit that both groups reduced in symptoms and drug reliance.

Strangely, the placebo group received laser treatment to the neck and back. It is unclear, when they state they used a "a placebo laser treatment "...does that mean the laser was a fake, or was it an operational laser, which they considered a "neutral" treatment?

He responded almost immediately and said:

We cited a paper that demonstrated that laser light therapy could be expected to have no more effect than placebo.
It was an operational laser.

So his “inert” laser was in fact another active treatment.

When you couple that with the actual results of the trial, which found that

“both groups reduced in symptoms and drug reliance”

what you are left with is a study that actually found that both chiropractic care AND laser acupuncture WERE effective. I do not fault Dr. Bove for this error, because at that time (late 90s) the only published literature on laser-acupuncture research was published in Chinese, and so was unavailable to him.

It's now 22 years later, and laser is being widely used in the U.S. as an alternative acupuncture treatment.

My suspicion is that the OPTIMa group probably reviewed the abstract, and NOT the full-text study, because they would have come to the same conclusion that I did, which is that the “placebo of choice” was, in fact, another active treatment.

That is why their conclusion that
“Clinicians should not offer manipulation of the cervical spine” is in error, and should state that both chiropractic and laser actupuncture have been shown to be effective for episodic tension-type headaches.

You may review the article under discussion [1], or the complete e-mail exchange with Dr. Bove [2]on our website.

  1. Manipulation and Tension Headaches in the AMA Journal
    A Chiro.Org Editorial ~ Wednesday, November 11, 1998

  2. Correspondence with the author, Dr. Bove
    A Chiro.Org Editorial ~ Wednesday, November 11, 1998


Manual therapy   Clinicians should not offer manipulation of the cervical spine. This recommendation is based on two low risk of bias RCTs suggesting that cervical manipulation combined with massage led to similar outcomes as inert LASER combined with massage (Bove & Nilsson, 1998) or massage alone (Espi-Lopez et al., 2016).




      Recommendation 4: management of chronic tension-type headaches

For patients with chronic tension-type headaches, clinicians may consider general exercise (including warm-up, neck and shoulder stretching and strengthening, and aerobic exercises), low-load endurance craniocervical and cervicoscapular exercises, multimodal care (combining spinal mobilization, craniocervical exercise and postural correction) or clinical massage in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer manipulation of the cervical spine as the sole form of treatment (recommendation Tables 5 and 6, Figures 3 and 4).

Structured patient education   As described above, clinicians should provide information about the nature, management and course of chronic tension-type headaches as a framework for initiating the programme of care.

Exercise   Clinicians may consider a general clinic- and home-based exercise programme (warm-up, neck and shoulder stretching and strengthening, aerobic exercise) limited to a maximum of 25 sessions over 12 weeks. The exercise programme should be taught and supervised by a healthcare professional. This recommendation is based on one low risk of bias RCT. The RCT by Soderberg et al. suggests that similar outcomes in headache intensity and quality of life post-intervention and at three months are obtained from either general exercise (25 sessions over 10–12 weeks), needle acupuncture, or combined relaxation training and stress coping therapy (Soderberg, Carlsson, & Stener-Victorin, 2006; Soderberg, Carlsson, Stener-Victorin, & Dahlof, 2011).

Clinicians may consider low-load endurance craniocervical and cervicoscapular exercises (a maximum of 8 sessions over 6 weeks with resistance). This involves supervised and home-based low-load endurance exercises against resistance over time to train muscular control of the craniocervical and cervicoscapular region. The exercise programme should be taught to the patient by a healthcare professional. This recommendation is based on one low risk of bias RCT that found adding low-load endurance exercises (6-week supervised period, twice a day for 10 min per session at home, then at least twice per week after supervised period) to physiotherapy (Western massage, lowvelocity passive cervical joint mobilization, instruction on postural correction) is superior to physiotherapy alone for improving headache frequency in the long term for chronic or episodic tension-type headaches (van Ettekoven & Lucas, 2006).

Multimodal care   Clinicians may offer a maximum of nine sessions over eight weeks of multimodal care that includes spinal mobilization, craniocervical exercises and postural correction. This multimodal care programme should be provided to the patient by a healthcare professional. This recommendation is based on one low risk of bias RCT that found a multimodal care programme (cervical and thoracic mobilization, craniocervical exercise and postural correction) (30 min per session for a maximum of nine sessions) is more effective than usual general practitioner (GP) care in reducing symptom intensity related to chronic tension-type headache (Castien, Windt, Grooten, & Dekker, 2011).

Soft-tissue therapy   Clinicians may consider eight 45-min sessions of clinical massage (2 sessions per week over 4 weeks). This recommendation is based on one low risk of bias RCT suggesting that court-type traditional Thai massage (a form of clinical massage) (45 min per session, 2 sessions per week over 4 weeks) and amitriptyline may lead to similar outcomes (Damapong et al., 2015).

Editorial Comment:

The following manual therapy conclusion, based on the Espi-Lopez et al., 2016 is also incorrect.

In fact, the Full-Text conclusion [1] states:

This study confirms the efficacy derived from the application of treatment focused on the upper cervical region for tension-type headache (TTH). Both interventions, massage alone or massage combined with manipulation, showed positive results for headache relief. However, the addition of manipulation was more effective at improving upper cervical and cervical flexion range of motion. Moreover, the addition of manipulation was more effective than massage alone for reducing the impact of headache on the four sub-dimensions of the Headache Disability Inventory (HDI).

That last sentence caught my eye, because improvements in CROM is considered a positive outcome that supports the care provided. So it's unclear how the OPTIMa group came up with the impredssion that:

cervical manipulation combined with massage led to similar outcomes as massage alone

The Espi-Lopez et al. study was accomplished by the Department of Physiotherapy, University of Valencia, Valencia, Spain. I have no idea what their training in manipulation is like, OR how extensive it is compared with standard chiropractic training, but from studying pictures provided in other European manipulation trials by PTs from Europe, the positioning of patients and the contact-points applied to lumbar and sacroiliac regions look nothing like what U.S. DCs are taught, so my general impression is that it is not what we would title as very "specific" to the joint in question.

  1. The Effect of Manipulation Plus Massage therapy Versus Massage Therapy Alone in People with Tension-type Headache. A Randomized Controlled Clinical Trial
    Eur J Phys Rehabil Med. 2016 (Oct); 52 (5): 606–617


Manual therapy   Clinicians should not offer cervical spine manipulation. This recommendation is based on one low risk of bias RCT suggesting that cervical manipulation combined with massage led to similar outcomes as massage alone (Espi-Lopez et al., 2016).




      Recommendation 5: Management of persistent cervicogenic headaches

For patients with cervicogenic headaches >3 months duration, clinicians may consider low-load endurance craniocervical and cervicoscapular exercises or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine in addition to structured patient education. However, there is no added benefit in combining spinal manipulation, spinal mobilization and exercises (Tables 5 and 6, Figures 5 and 6).

Structured patient education   As described above, clinicians should provide information about the nature, management and course of persistent cervicogenic headaches as a framework for initiating the programme of care.

Exercise   Clinicians may consider low-load endurance craniocervical and cervicoscapular exercise with resistance limited to a maximum of eight sessions over six weeks. This involves supervised and home-b ased low-load endurance exercises against resistance over time to train muscular control of the craniocervical and cervicoscapular region. The exercise programme should be taught to the patient by a healthcare professional. This recommendation is based on one low risk of bias RCT suggesting that low-load endurance craniocervical and cervicoscapular exercise (8–12 visits over 6 weeks)is more effective than no intervention in improving headache-related outcomes and neck symptoms for the management of chronic cervicogenic headaches (Jull et al., 2002).

Manual therapy   Clinicians may consider manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine limited to a maximum of 10 sessions over six weeks.

This recommendation is based on three low risk of bias RCTs suggesting that

(a)   spinal manipulation combined with light massage and moist heat (8 or 16 treatments over 8 weeks) is more effective than light massage and moist heat alone in improving headache pain, headache frequency and headache-induced disability (Haas, Schneider, & Vavrek, 2010; Haas, Spegman, Peters on, Aickin, & Vavrek, 2010);

(b)   spinal manipulation and mobilization (8–12 visits over 6 weeks) are more effective than no intervention in improving headache-related outcomes and neck symptoms (Jull et al., 2002); and

(c)   spinal manipulation (6–8 sessions over 4 weeks) is more effective than multimodal care (spinal mobilization and craniocervical flexion exercise) (Dunning et al., 2016).

Multimodal care   Clinicians should not offer a multimodal programme of care that includes a combination of exercise, spinal manipulation and spinal mobilization. This recommendation is based on two low risk of bias RCTs suggesting that (1) combining low-load endurance exercises with spinal manipulation and mobilization is not more clinically beneficial than providing either intervention alone (Jull et al., 2002) and (2) combining craniocervical flexion exercise and spinal mobilization is less effective than spinal manipulation (Dunning et al., 2016).




      Recommendation 6: Reevaluation and discharge

Clinicians should reassess the patient at every visit to determine whether (a) additional care is necessary; (b) the condition is worsening; or (c) the patient has recovered. Patients should be discharged as soon as they report significant recovery. Healthcare professionals should use the self-rated recovery question to measure recovery: “How well do you feel you are recovering from your injuries?” (Carroll, Lis, Weiser, & Torti, 2016; Fischer, Stewart, Bloch, Lorig, & Laurent, 1999). worse, (f) much worse and (g) worse than ever. Patients reporting to be “completely better” or “much improved” should be considered recovered. The self-rated recovery question is a valid and reliable global measure of recovery in patients with headaches (Carroll et al., 2016; Fischer et al., 1999). Patients who have not recovered should follow the care pathway outlined in the guideline (Figures 2, 4 and 6).


DISCUSSION

We developed an evidence-based clinical practice guideline to help clinicians deliver effective interventions for the management of persistent headaches associated with neck pain. The recommendations aim to promote uniform high-quality care based on recent systematic reviews of the literature and synthesis of best available evidence. Implementing the evidence-based recommendations for headaches associated with neck pain will likely improve patient outcomes, reduce regional variations and improve the efficiency of the healthcare system (Anis, Stiell, Stewart, & Laupacis, 1995; Nichol, Stiell, Wells, Juergensen, & Laupacis, 1999; Rutten et al., 2010).

Our guideline identifies clinical interventions that should not be prescribed because their effectiveness is not established. The Guideline Expert Panel did not recommend these interventions to minimize the risk of iatrogenic disability in patients with neck pain (Cassidy, Carroll, Côté, & Frank, 2007; Côté et al., 2005; Côté & Soklaridis, 2011). We found inconclusive evidence on the effectiveness of needle acupuncture for the management of tension-type headaches because the results of multiple high-quality RCTs conflicted with each other (Varatharajan et al., 2016).

The guideline does not recommend passive physical modalities, stand-alone structured patient education or work disability prevention interventions because their effectiveness has not been evaluated in high-quality studies (Varatharajan et al., 2016). Furthermore, multimodal care is a programme of care that includes a combination of individual interventions (e.g., exercise and soft-tissue therapy). Our guideline evaluated the effectiveness of both multimodal and individual interventions based on available evidence. Therefore, one individual intervention can be recommended as part of multimodal care but is recommended against as a stand-alone intervention (and vice versa).

      Summary of recommendations

Clinicians should rule out major structural or other pathologies as the cause of headaches. In the absence of major structural or other pathologies, clinicians should classify headaches associated with neck pain as tension-type or cervicogenic headaches. In the context of shared decision making, clinicians should discuss with the patient the range of effective interventions available for the management of headaches associated with neck pain. In the presence of prognostic factors for delayed recovery, clinicians should discuss them with the patient and adjust their care plan accordingly.

The following clinical interventions can be considered for episodic tension-type headaches: low-load endurance craniocervical and cervicoscapular exercises. For chronic tension-type headaches, clinicians can consider general exercise (warm-up, neck and shoulder stretching and strengthening, aerobic exercises), low-load endurance craniocervical and cervicoscapular exercises, multimodal care (spinal mobilization, craniocervical exercise and postural correction) or clinical massage. For persistent cervicogenic headaches, clinicians can consider low-load endurance craniocervical and cervicoscapular exercises, or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine. It is important to note that all recommended interventions provide small benefits at best.

      Comparison to previous guidelines

There are existing clinical practice guidelines to assist the management of persistent headaches associated with neck pain (Becker et al., 2015; Bendtsen et al., 2010; Carville et al., 2012; Duncan et al., 2008). Overall, our recommendations agree with those of previous clinical practice guidelines (Becker et al., 2015; Bendtsen et al., 2010; Duncan et al., 2008). For the management of tension-type headaches, patient education and reassurance, exercise and massage are recommended (Becker et al., 2015; Bendtsen et al., 2010); cervical spine manipulation is not recommended (Bendtsen et al., 2010). Exercise and manual therapy (manipulation and mobilization) are recommended for the management of cervicogenic headaches (Becker et al., 2015; Duncan et al., 2008).

There are a few important differences between previous guidelines and ours. Specifically, we do not recommend or refute acupuncture for the management of tension-type headaches and do not recommend multimodal care (lowload endurance exercises, spinal manipulation and spinal mobilization) for the management of persistent cervicogenic headaches. These differences are likely because the previous guidelines included studies with a high risk of bias and small sample sizes, and need updating (Carlsson, Augustinsson, Blomstrand, & Sullivan, 1990; Carlsson, Fahlcrantz, & Augustinsson, 1990; Karst et al., 2001; Kassak, Anderson, Assment, & Edina, 1995; Mousavi, Mirbod, & Khorvash, 2011).

Our recent systematic review found inconclusive evidence on the effectiveness of needle acupuncture for the management of tension-type headaches (Endres et al., 2007; Jena, Witt, Brinkhaus, Wegscheider, & Willich, 2008; Melchart et al., 2005; Varatharajan et al., 2016). Moreover, our recent systematic review identified two high-quality studies which found that combining exercise and spinal mobilization with or without spinal manipulation was not clinically more beneficial than providing either intervention alone for persistent cervicogenic headaches (Dunning et al., 2016; Jull et al., 2002; Varatharajan et al., 2016).

The publication of recent high-quality RCTs allows for a meaningful update of previously published clinical practice guidelines and will improve the ability of clinicians to manage patients with headaches associated with neck pain. The literature searches for the previously published guidelines ended in 2009, 2011 and 2012 (Becker et al., 2015; Bendtsen et al., 2010; Carville et al., 2012; Duncan et al., 2008). Our guideline includes five new high-quality studies (Castien et al., 2011; Damapong et al., 2015; Dunning et al., 2016; Espi-Lopez et al., 2016; Haas, Schneider et al., 2010; Haas, Spegman et al., 2010). One new study enabled us to develop evidence-based recommendations on the use of manual therapies and multimodal care (i.e., cervical and thoracic mobilization, craniocervical exercise and postural correction) for the management of tension-type headaches (Castien et al., 2011). Two new RCTs add evidence that clinical massage is effective (Damapong et al., 2015) and that cervical manipulation is not effective for the management of tension-type headaches (Espi-Lopez et al., 2016). Moreover, recent high-quality evidence strengthens the recommendation that spinal manipulation is effective in reducing pain intensity and disability in patients with persistent cervicogenic headaches (Dunning et al., 2016; Haas, Schneider et al., 2010; Haas, Spegman et al., 2010). Finally, the OPTIMa guideline improves previous clinical practice guidelines by recommending optimal dosage of interventions (frequency and durations of care).

      Dissemination and implementation of this guideline

This guideline could be adapted for local use in other jurisdictions. We recommend that clinicians, insurers and policymakers use the ADAPTE framework to adapt this guideline to their needs and environment (ADAPTE Collaboration (2009), (2010).

Strengths and limitations

This clinical practice guideline is based on comprehensive literature searches, and its recommendations were developed from high-quality evidence. When developing clinical recommendations, the Guideline Expert Panel considered effectiveness, safety, cost-effectiveness and consistency with societal and ethical values. Moreover, the lived experiences of patients with their care were used when developing recommendations (Lindsay et al., 2016). Our recommendations also included consideration of effect sizes; minimal clinically important differences were used to assess the magnitude of benefit of an intervention on patient outcomes. Finally, the Guideline Expert Panel disclosed any conflicts of interest and maintained editorial independence.

Our recommendations were limited by the amount and quality of published evidence (Varatharajan et al., 2016). Specifically, we found no high-quality studies that investigated the effectiveness of passive physical modalities, stand-alone structured patient education and work disability prevention interventions (Varatharajan et al., 2016). We found little evidence to support the cost-effectiveness of non-pharmacological interventions for the management of headaches associated with neck pain. Similarly, evidence is lacking to determine whether recommended interventions are more effective than placebo or sham treatments. Future research should prioritize these two areas of investigation.


ACKNOWLEDGEMENTS

The authors would like to acknowledge the invaluable contributions to this guideline from Lynn Anderson, Carol Cancelliere, Poonam Cardoso, Brenda Gamble, Willie Handler, Viivi Riis, Paula Stern, Thepikaa Varatharajan, Angela Verven and Leslie Verville.


CONFLICTS OF INTEREST

Côté reports grants from Ontario Ministry of Finance and Financial Services Commission of Ontario during the conduct of this study. Dr. Côté reports grants from Ontario Trillium Foundation, Skoll Foundation, Aviva Canada, NCMIC Foundation, ELIB and Mitacs outside the submitted work. Dr. Côté reports funding from Canada Research Chair Program—Canadian Institutes of Health Research during the conduct of this study; personal fees from National Judicial Institute, Société des experts en évaluation medico-légale du Québec and European Spine Society, outside the submitted work. Dr. Mior reports research grants from the Ontario Chiropractic Association and Canadian Chiropractic Association. Dr. Ammendolia reports funding from the Canadian Chiropractic Research Foundation and the Arthritis Society. Dr. Ammendolia is on the speaking bureau for NCMIC. For the remaining authors, none were declared.


AUTHOR CONTRIBUTIONS

All authors have made substantial contributions to all of the following: (a) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; (b) drafting the article or revising it critically for important intellectual content; and (c) final approval of the version to be submitted. All authors discussed the results and commented on the manuscript.



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