One of the things we tend to take for granted in life is the balance of the curves of the spine. From the first months in utero, to learning to hold our heads up, crawl and then walk, the body is ever so intelligently working towards a spinal shape that will carry us through the rest of our lives – upright, balanced, and with optimal neurological flow. Of course, life tends to complicate this by stress, injury and of course looking down at our technological devices (to mention a few complicating factors). These provide just a few reasons why chiropractic care of the spine matters.
Part of this finely balanced spinal shape is called the sagittal plane, and it consists of the upper part of the spine and neck. We know it matters greatly, but a recent study went the extra mile in order to examine what effect restoring sagittal balance might have on things like cervicogenic headaches, and the pain and disability associated with them. It is an important paper investigating an issue facing many adults.
The study aimed to investigate the feasibility and effect of a multimodal program for improving chronic cervicogenic headache (CGH) by correcting the cervical spine alignment. CGH is defined as a ‘secondary type of headache caused by disorders of the cervical spine or any of its components’ .
The study combined myofascial release with exercise, manual therapy (mobilisation) and a postural correction device targeted at providing traction to the neck area. While it did not specify which types of spinal mobilisation were used, the study is relevant to the chiropractic community as maintenance and restoration of the spine and sagittal spinal alignment is a large part of what we do.
Often CGH is accompanied by neck pain. Prevalence is estimated between 0.17%-2.5% for the general population but escalates to as high as 26.73% for dentists and 53% for whiplash injured persons. There is no universally accepted treatment protocol for CGH, especially in the long term. Hence, the authors of the study wanted to look at whether correcting the cervical alignment and anterior head translation (forward head posture) may improve CGH, indicating this misalignment may give rise to the condition.
The study took in 60 participants who were randomly assigned into either the experimental group or the control group. While the individual providing the treatment had to be informed as to whether they were getting the real intervention or the sham, the assessor of the treatment outcome was blind to the group allocation.
Both the control and the experimental group received myofascial release, cervical mobilisation, and therapeutic exercises. The experimental group also received an additional extension cervical traction orthotic device called denneroll. Participants received their treatments 3 times a week for a total of 30 sessions. All participant outcome assessments were performed at baseline, ten weeks, one and two years after treatment (a PT did the assessment)
100% of participants made the 10-week evaluation, 90% for the one year follow up, and 74% for the two year follow up. Given the length of the program, this is a very high response rate at the one-year mark. No participants were excluded because of a lack of compliance with or intolerance to either treatments. This is notable, as it suggests the intervention may be applicable for a large percentage of people with CGH.
Study adherence was also impressive in over the course of the project, as participants attended 98% of the required visits. This factor is a double-edged sword: it does indicate that participants were happy to keep attending appointments and receiving treatments, but it also may suggest consistent attendance might play a role in the outcomes.
The primary goal of the study was to see whether the experimental group experienced a drop in headaches, pain and disability related to chronic cervicogenic headaches. Here’s what they found:
- Satisfaction of experimental group was high, but lower for the control group (using a scale of 1-5 very satisfied to very dissatisfied).
- There was a significant difference between experimental and control groups in cervical lordosis (forward head carriage) and anterior head translation. A bigger improvement was seen in the experimental group at all follow up periods.
- There was no significant difference between the improvement in CGH management outcomes between both treatment groups and this did not vary at the 10-week evaluation. However, at the 1 and 2 year follow up there was a significant difference in these measures, with the experimental group seeing a greater improvement compared to the control group.
- The experimental group saw improved results in terms of cervical posture, but this didn’t translate into improvement in CGH as both groups improved in similar fashions. However, in the long term, there was a gradual improvement seen in the experimental group while the control group regressed back towards pre-intervention values
What does this all mean though? It is likely that the increase in afferent input following manual therapy from both groups had the effect of stirring up the inhibitory pathways in the central nervous system, thus mitigating pain. This may be the cause of the decrease in headaches in both groups.
It was surprising that the restoration of normal cervical alignment did not have a more significant effect on all outcomes. The research seemed to raise the probability that that malalignment of the cervical spine results in abnormal stresses and strains, and when removed and maintained for a long period of time some of the degenerative changes are gradually improved, leading to an overall improvement in the long term.
Every study has limitations, and this one is no difference. The sample size for each group was approximately half of what is required to offset statistical variance, however it did provide good preliminary data. Again, mobilisation and posture correction wasn’t focused on chiropractic care, however the results do show that restoring the sagittal curve can have positive impacts on pain and disability. It would certainly be nice to see some chiropractic specific data on this issue, but in the mean-time, it certainly validates the importance of caring for and optimising spine and nervous system function.
And that is certainly what we are all about.
- Moustafa IM, Diab A, Shousha T, Harrison DE. Does restoration of sagittal cervical alignment improve cervicogenic headache pain and disability: A 2-year pilot randomized controlled trial. Heliyon. 2021;7(3):e06467.