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A 2021 Delphi study of international experts agreed upon two crucial findings for any evidence-based chiropractic practice. The team found cervicogenic headaches (CGH) responded favorably to upper cervical spine mobilization, and migraines are best treated with lifestyle advice and patient education. (1) These findings add to the arsenal of tools we can deploy to treat these patients. This ChiroUp blog will teach you how to perform these techniques and distribute the essential tools to every patient.

In February 2021, Paquin et al. (2) found similar results for CGH using a specific type of cervical mobilization—SNAGs. These specific mobilizations combined with patient self-SNAG exercises provide excellent clinical outcomes and pain reduction. (2) Evidence-based chiropractors may use this type of mobilization as an adjunct or alternative to HVLA.

Check out this video blog demonstration of the SNAGs utilized in this study.

What are SNAGs…

The use of SNAG (sustained natural apophyseal glide) mobilizations may increase patient compliance and improve your clinical outcomes. A recent publication by Mohamed et al. (2019) utilized cervical SNAGs to treat cervicogenic headaches and dizziness related to upper cervical joint dysfunction. The incorporation of two particular SNAGs provided significant symptomatic relief:

“Sustained natural apophyseal glide mobilizations used in the study were effective in reducing cervicogenic headache and dizziness in all groups with a greater improvement in the combined group. The use of cervical SNAG mobilizations is encouraged as a noninvasive intervention depending on the therapist’s assessment, findings, and clinical reasoning.” (3)

Sustained natural apophyseal glide (SNAG) is a treatment technique developed by Mulligan. (4) SNAG movements are primarily for self-care or at-home exercise plans. The patient will actively move in the direction of symptoms until the end range. At the end range, a towel or strap provides gentle overpressure to increase ROM in the desired direction. This movement should be pain-free, with minimal use of force. 

SNAGs effectively decrease symptoms, including cervicogenic headache and vertigo. (5-7)

How can I incorporate SNAGs into my practice? 

First, don’t forget about what works for headaches and migraines. Spinal manipulation is one of the most effective tools that evidence-based chiropractors employ for headaches.

 

HEADACHES

  • A survey of 381 chiropractors found that over 80% of plans for recent-onset headache (less than three months duration) required less than ten visits scheduled at 1-2 visits per week for less than eight total weeks. (8)
  • One randomized controlled trial demonstrated that 6-8 of SMT sessions produced good outcomes for CGH. (9)
  • A Spine Journal study found that spinal manipulation cuts the number of CGH symptomatic days in half, and the number of treatments has a linear dose-response to improvement (10).

MIGRAINE

  • Several clinical trials and research studies suggest that spinal manipulation is an appropriate treatment for migraine headaches. A Harvard study found that SMT reduced migraine days as well as pain intensity. On average, adding SMT to usual medical careleads to approximately two fewer migraine days per month. Another paper demonstrated a “significant reduction” of migraine intensity in almost half of those receiving spinal manipulation. Nearly ¼ of migraine patients reported greater than 90% fewer attacks.

Consider using this infographic with your next patient suffering from Migraine headaches.

Second, consider the exercises for C1-C2 SNAG rotation and Headache SNAG in your treatment plans. 

Headache SNAG

Begin seated or standing. Grasp a rolled towel with both hands. Place the towel behind your neck, just below your skull. Gently pull the towel forward while slowly bringing your chin into your throat as to create a double chin. At the same time, imagine “growing taller” to elongate your neck. Hold this position for one second then return to the starting position. Stop if you feel sharp pain or any other unusual symptom. Perform as directed.

C1-C2 SNAG Rotation

Begin seated or standing. Grasp a (lengthy) rolled towel with both hands. With the hand on your unaffected side, hold the towel at the level of your chest. With the other hand, wrap the towel around the back of your neck. Actively rotate your head until you feel pain or lack of motion. With gentle pressure, use the towel to pull your head into slightly more rotation. Hold this position for one second then return to the starting position. Stop if you feel sharp pain or any other unusual symptom. Perform as directed.

Take Your Patient Education To The Next Level

Create customized treatment plans with exercises like above with ChiroUp! Your patients will be able to access their exercises via printout, email, and even a mobile app.

References
  1. De Pauw R, Dewitte V, de Hertogh W, Cnockaert E, Chys M, Cagnie B. Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study. Musculoskelet Sci Pract. 2021 Jan 26;52:102325. doi: 10.1016/j.msksp.2021.102325. Epub ahead of print. PMID: 33548766.
  2. Paquin JP, Tousignant-Laflamme Y, Dumas JP. Effects of SNAG mobilization combined with a self-SNAG home-exercise for the treatment of cervicogenic headache: a pilot study. J Man Manip Ther. 2021 Feb 5:1-11. doi: 10.1080/10669817.2020.1864960. Epub ahead of print. PMID: 33541242.
  3. Mohamed AA, Shendy WS, Semary M, Mourad HS, Battecha KH, Soliman ES, Sayed SHE, Mohamed GI. Combined use of cervical headache snag and cervical snag half rotation techniques in the treatment of cervicogenic headache. J Phys Ther Sci.2019 Apr;31(4):376-381.
  4. Mulligan BR: Mobilisations with movement and other techniques, 4th ed. Brühl: H. Müller-Frank, 1999, p 1145. Racicki S, Gerwin S, Diclaudio S, et al.: Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. J Manual Manip Ther, 2013, 21: 113–124.
  5. Gross A, Kay TM, Paquin JP, et al. Cervical Overview Group: Exercises for mechanical neck disorders. Cochrane Database Syst Rev, 2015, 1: CD004250.
  6. Lystad RP, Bell G, Bonnevie-Svendsen M, et al.: Manual therapy with and without vestibular rehabilitation for cervicogenic dizziness: a systematic review. Chiropr Man Therap, 2011, 19: 21.
  7. Moore C, Leaver A, Sibbritt D, Adams J. The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey. BMC Neurol. 2018;18(1):171. Published 2018 Oct 17.
  8. Dunning JR, et al. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskelet Disord. 2016 Feb 6;17(1):64
  9. Haas M. et al. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine J. 2018 Feb 23.

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