Efficacy of a C1-C2 Self-sustained Natural Apophyseal Glide (SNAG) in the Management of Cervicogenic Headache

Toby Hall, Kim Robinson, Ho Tak Chan, Lene Christensen, Britta Odenthal, Cherie Wells

DOI: 10.2519/jospt.2007.2379

STUDY DESIGN: Randomized, double-blind, placebo controlled trial. OBJECTIVES: To determine the effect of a C1-C2 self-sustained natural apophyseal glide (SNAG) on cervicogenic headache. BACKGROUND: Cervicogenic headache is a common condition causing significant disability. Recent studies have shown a high incidence of C1-C2 dysfunction, evaluated by the flexion-rotation test (FRT), in subjects with cervicogenic headache. To manage this dysfunction, Mulligan has described a C1-C2 self-SNAG, though no studies have investigated the efficacy of this intervention approach. METHODS: A sample of 32 subjects (mean ± SD age, 36 ± 3 years) with cervicogenic headache and FRT limitation were randomized into a C1-C2 self-SNAG or placebo group. After an initial instruction and practice visit in the clinic, interven­tions consisted of exercises applied independently by the subject twice daily at home on a continual basis. FRT range was measured twice, before and immediately after the instruction and practice visit. Headache symptoms were determined by a headache index over time, assessed by question­naire preintervention, at 4 weeks postintervention, and at 12 months postintervention. RESULTS: No differences were found in baseline measures between groups. Immedi­ately after the initial instruction and practice visit performed with the supervision of the therapist, FRT range increased by 15° (SD, 9) for the C1-C2 self-SNAG group (P<.001), which was significantly more than 5° (SD, 5) for the placebo intervention (P<.001). There was also a significant interaction for the variable headache index between group and time (P<.001), indicating that group difference was dependent on time. There was no difference in headache index scores at baseline between groups. Headache index scores were substantially less in the C1-C2 self-SNAG group (mean ± SD points at 4 weeks, 31 ± 9; mean ± SD points at 12 months, 24 ± 9) compared to the placebo group (mean ± SD points at 4 weeks, 51 ± 15; mean ± SD points at 12 months, 44 ± 13) at 4 weeks (P<.001) and 12 months (P<.001), with an overall (±SD) reduction of 54% (±17%) for the individu­als in the C1-C2 self-SNAG group. CONCLUSIONS: These results provide evidence for the efficacy of the C1-C2 self-SNAG technique in the management of individuals with cervicogenic headache.  

J Orthop Sports Phys Ther. 2007;37(3):100-107. doi:10.2519/jospt.2007.2379  

KEY WORDS: atlantoaxial joint, cervical spine, flexion-rotation test, joint mobilization, Mulligan

This study provides evidence for the efficacy of the C1-C2 self-sustained natural apophyseal glide (SNAG) technique on the management of individuals with cervicogenic headache.

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