Cracking the Cervicogenic Headache Code: Cervical vs. Thoracic Adjustments | Podcast Ep. 433

Foreign hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmay. This week we are back with more research, tons of clinical implications, lots of clinical pearls. You're going to want to pay attention to this episode because it is all around cervical and thoracic adjustments for the care of cervicogenic headaches and it is a randomized controlled trial and it is a good one. Before we dive in, if you are interested in the cervical spine, check out neckcare.com youm probably tuned in to my interview with their CEO Orey a few weeks ago and this is in my opinion the best objective assessment tool of the cervical spine on the market. If you're looking for reliable assessments and exercises, neuromusculoskeletal control, proprioception, range of motion, sensory motor integration, all in probably the slickest package that I have seen to date. Head over to neccare.com and I will drop that link down in the show notes as well. They support this podcast and you should support them. People creating awesome clinical tools should always be supported and neccare is one of them. Link down in the show notes neccare.com but as I said at the top on today's episode, we're talking all about cervicogenic headaches. The title of this study, I'll also drop the link in the show notes so you can check it out, is Comparative effectiveness of Cervical versus Thoracic Spinal Thrust manipulation for care of Cervicogenic headache. And this is a randomized control trial. So anytime we see that rct, that is one of the top tiers of research and it just highlights the fact that there's a lot of. I might not use exactly the right term here, but it's a high quality research study, maybe is the easiest way to say it. Headaches. Of course, as we know, one of the top three reasons people initially visit a chiropractor low back pain number one headache and neck pain numbers two and three. And why? Well, because headaches affect a lot of people. Around the world, 66% of adults will have at least one headache per year. Many will have more than one headache. But literally over half the world every single year has a headache. Now a cervicogenic headache, of course, is a distinct type of headache and accounts for about 20% of all the different headache types. So why does this happen? Well, there's a few theories in terms of the causative factors for these types of headaches. When it's cervicogenic, as you can imagine, there is pain Worsened by movement of the head and neck. How does this happen? The most accepted mechanism, as they highlight, is found between the trigeminal nerve and the C1 through C3 nerves in the trigeminocervical nucleus. And how does this happen? Well, it can kind of be a combination of things. They believe there is musculoskeletal issues, such as vertebral issues, disc issues, paravertebral muscle challenges, imbalances, however you want to define that. And all of this can contribute to the unique clinical feature of a cervicogenic headache, which has the presentation of either unilateral or bilateral headache, limited range of motion of the neck, and pain that radiates to the head or face region. So that's kind of how you know you're dealing with it from a symptom perspective. Now, in terms of diagnosing this, typically based on, as you can imagine, history and clinical assessment. So you'd expect to see pain in the cervical region, you'd expect to see decreased neck movements and range of motion, potential muscle tightness and loss of excitability, contractability and elasticity of the musculature in the head and neck. Additionally, they highlight the fact that the cervical flexion rotation test is considered a valid, reliable and accurate method with an accuracy diagnostic accuracy of over 90% for assessing cervical range of motion with cervicogenic headache. If you're assessing range of motion, I cannot recommend neck care enough, by the way. However, in the management of cervicogenic headache, there's a lot of different methods, right? There's some people that go the pharmacological route not recommended, and there's some people that take the non pharmacological route definitely recommended. And the reason why the pharmacological route is not recommended, One, just simply put, most headache medications have a side effect of refractory or more headaches. So it's just crazy to take the stuff. Two is that there's just side effects, potential damage to liver and kidneys, there can be GI issues, constipation, allergic reactions. All of those are aspects of medication that make it not exactly a top tier choice in most cases most of the time. Now 66% of people are gonna have around the world gonna have a cervicogenic headache at some point during the year. Interestingly, in the United States, about 35% of those individuals will have some sort of care for that headache over the years, Some sort of physiotherapy, as they kind of highlight in this, which can be a wide Berth. Right. But some sort of non pharmacological manual care. So that's a lot of people. If you look at, you know, 100 million people, there's over 300 million in the United States. 100 million would be 66 million times 3,180 something million are gonna have a headache over the year. And then 34% of those, which probably going to come out to about 45, 50 million, if my math is good, about 45, 50 million people per year are going to seek care specifically for a cervicogenic headache. So we also know that, you know, they're only a fractional percentage. That's a lot of people. Now one of the most common ways to take care of this are of course, spinal adjustments or manipulation. And the technique usually involves two different regions, the cervical region, of course, and the thoracic region. So this study sought to sort of differentiate those and say, hey, when somebody gets adjusted in the cervical spine, when they get adjusted in the thoracic spine, when maybe they have massage therapy, how does this all play out? So this trial was a parallel group, prospective randomized controlled trial aiming to answer those questions. Everybody in this study was between 18 and 60 years old and had either a unilateral or a bilateral cervicogenic headache. So that was really the population that they looked at to analyze and say, how do these different modalities really affect. And we've taken a look on this podcast at previous research highlighting how thoracic adjustments can impact the cervical spine. This is kind of taking it to the next level. So they had 130 people screened and eight of those individuals had a VAS score or pain score greater than eight. So there were some people, you know, a little decent percentage of these individuals that had a lot of pain going on. They looked at a four week intervention cycle and they found significant change in the cervicogenic headache pain frequency level between the cervical manipulation group and the thoracic manipulation group. And we'll detail exactly how that played out here as we get through some of the findings and discussion. So these researchers found that cervical adjustments or manipulation were superior to thoracic manipulation and massage for improving a variety of different things. One, improving days with cervical genetic headache as well as headache and neck pain disability levels at then and up to six months. Additionally, after four weeks of care with the cervical manipulation, that group had a statistically significant changes in every single, all, every single outcome measure related to the cervicogenic headaches and when compared to the thoracic manipulation and conventional therapy. Which they kind of just said was massage, Cervical manipulation was more effective in reducing the primary outcomes. So literally, which was really the frequency, which was clinically important, the less headaches you have, the more functional you can be and the less disability you're going to have. As you can imagine, some people struggle with headaches literally every single day. And that's just taxing on quality of life. That is a huge life impact and life effect on those individuals. So when you can decrease the frequency and cervical manipulation, cervical adjustments did that to a T. And again, hear me loud and clear, the cervical manipulation group, they improved across all outcome measures. Undefeated across the entire spectrum of outcome measures is awesome. So that's really, really important. Now how does this work? Now that's a good question, right? And there's many theories and here is some of the data and science that they highlight. When an adjustment is delivered to the cervical spine. The thought is, is that there's afferent nerve fiber activity through the stimulation of those joint receptors, as you can imagine. And this can or has the potential at least to improve the action and properties of the neck muscles by activating the alpha motor neuron. Also, it alters the sensory fiber activity by activating the joint receptors, almost like a gate, right? Thereby changing the alpha motor neuron activity levels and subsequent muscle reaction. Because of the high mobility of cervical spine. You know, we have this toothpick that's our neck and we have a big bowling ball on top. Cervical manipulation can stimulate the receptors of the deep neck muscles, really important, and the suboccipital muscles, which thoracic manipulation is unable to do. Of course, other theories for pain modulating effects include biomechanical vertebral, which temporal summation and neural central descending pain inhibitory pathway mechanism. So all of that's on the table and quite frankly it's probably a combination in some form or fashion of all of those items. But it showcases how impactful a cervical adjustment can be on those struggling with headaches. Now, from a clinical perspective, you always have to be careful, right? Somebody has like abject pain in their neck, a headache, and they don't want to move their neck. It's like super scary for that person to believe that an adjustment, a fast motion of their neck is actually going to relieve things as opposed to making it worse. If you don't want to move your neck, the last thing you want somebody doing is quote unquote yanking on your neck. And that's what many people see because they don't understand the science. They're Never going to understand the science. This is deep stuff. And we're still understanding and trying to learn exactly what's going on. So can't expect that. So just the looks of it alone can't, can be intimidating. So it's important to guide that conversation not with the super deep science, but just with. When you're not moving, some of the best thing you can do is movement. Now that needs to be controlled. Movement needs to be understood. Movement. But man, that can make such an impact. And just empathizing with that individual, not surprising them, but just empathizing with them and letting them know this is gonna help get you better. Um, you know that we've seen this happen many times, however you wanna discuss that. But really being able to, I'm going to say, modulate that fear is really, really important now. Thoracic manipulation, thoracic adjustments. Did it do nothing? Absolutely not. They were also. Thoracic adjustments were found to be more effective than conventional PT or massage in improving both the primary and secondary outcomes. So thoracic adjustments were helpful in improving the pain parameters, functional disability, and the quality of life, as they say, significantly. So really, really, really important. So the response to pain reduction with chronic neck pain through the thoracic manipulation, here's kind of what they think about in terms of the mechanism. That there's an induction, so to speak, that it induces reflex inhibition of pain or muscle relaxation reflex. By modifying the discharge of proprioceptive group 1 and 2 afferents. This can activate the descending pathways, resulting in pain reduction in distant areas from the manipulation. And that's really, really. And through these mechanisms, they kind of highlight the fact that thoracic adjustments may induce ventral paraequeductal gray in the brain, which basically is endogenous opioids. It is feel good medication built in, not created in a lab. Right. So that provides pain relief naturally through the brain mechanism as well. Which is really, really interesting when you highlight and kind of look back at what they showcased in terms of how does the cervical manipulation work versus how does the thoracic manipulation or adjustment work? There's overlap, but there's also distinction. So getting in there with both might be a good idea right now. Obviously you want to go through and understand what's going on with the patient and do your examination. And this isn't just a carte blanche, adjust everybody, every single segment. But it is something that you should definitely, and I'd encourage you, if somebody comes in with a cervical issue or a headache issue, check out the thoracic spine, you should always check, in my opinion, the region adjacent to the primary issue because there can be so many compensatory items and you might be able to get additional benefit with your care by checking and adjusting when necessary, those regions of the spine or extra spinal as well that might be adjacent to the primary issue. So I always recommend taking a look at that. So their conclusion was this randomized control trial found that cervical manipulation adjustments was more effective in improving pain parameters. That's intensity, frequency and thresholds, functional disability and quality, quality of life, the whole gamut in patients with cervicogenic headache than thoracic manipulation and conventional therapy. However, thoracic manipulation did outperform conventional physiotherapy and massage. So great information, awesome study. Building upon our knowledge of understanding how an adjustment works and how maybe a combination of adjustments, thoracic and cervical, can really make a significant impact that and it can approach a person in different ways that allow them to find potentially even better relief. Now it's important of course exam all of your patients and make sure that where you're adjusting is the best place based upon case history, based upon examination findings. However, don't hesitate to look at those adjacent regions. Before we wrap up, I want to say a few words about Stop Pain Clinical. They also have a headache topical that is really really great and Stop Pain Clinical supports this podcast. I'll ask you to support them. I'm going to drop a link down in the show notes. You can check them out at Stop A Period in ebc. That's Stop Pain EBC with a dot between the A and the I. So these are exclusively available to healthcare providers, not on Amazon or retail. Long lasting results from sprains, strains, bruises, arthritis, muscle aches, joint pain and back pain and more. Stop Pain Clinical, Paul over there and their entire team, awesome team, awesome product. Highly recommend checking it out. If you have topicals check out Stop Pain Clinical. They have a awesome pack that is put together exclusively for members of this podcast at that link and I'm going to drop it down below starter pack. You can be profitable and get some awesome topicals right from the get go. And finally I will wrap up by saying if you're interested in patient reactivations this year we we have made some massive massive technology upgrades with patient pilot so that you can have patient recall list. All of the automations are there. Bottom line is this if you have a patient list of more than 500 people, 500 people that you've seen in the past sitting in your ehr and you're not doing anything with it. You are missing out on opportunity every single day. We'd love to have a conversation with you. You can check out Patient Pilot and schedule a demo at the smart chiropractor.com again that is the smart chiropractor.com I really appreciate you listening into this podcast. I hope you have a fant fantastic week in practice and I will talk to you soon.

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