Journal of Manual & Manipulative Therapy

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Effects of SNAG mobilization combined with a

self-SNAG home-exercise for the treatment of
cervicogenic headache: a pilot study

Jean-Philippe Paquin, Yannick Tousignant-Laflamme & Jean-Pierre Dumas

To cite this article: Jean-Philippe Paquin, Yannick Tousignant-Laflamme & Jean-Pierre Dumas
(2021) Effects of SNAG mobilization combined with a self-SNAG home-exercise for the treatment
of cervicogenic headache: a pilot study, Journal of Manual & Manipulative Therapy, 29:4, 244-254,
DOI: 10.1080/10669817.2020.1864960

To link to this article: https://doi.org/10.1080/10669817.2020.1864960

Published online: 05 Feb 2021.

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JOURNAL OF MANUAL & MANIPULATIVE THERAPY
2021, VOL. 29, NO. 4, 244–254
https://doi.org/10.1080/10669817.2020.1864960

Effects of SNAG mobilization combined with a self-SNAG home-exercise for the

treatment of cervicogenic headache: a pilot study
Jean-Philippe Paquina, Yannick Tousignant-Laflamme b,c
and Jean-Pierre Dumasb
a
Faculty of Medicine and Health Sciences, Université De Sherbrooke, Sherbrooke, QC, Canada; bSchool of Rehabilitation, Faculty of
Medicine and Health Sciences, Université De Sherbrooke, Sherbrooke, QC, Canada; cResearch Center of the CHUS (CRCHUS), Centre
Hospitalier Universitaire De Sherbrooke (CHUS), Sherbrooke, Qc, Canada

ABSTRACT KEYWORDS
Introduction: Cervicogenic headache (CGH) may originate from the C1-C2 zygapophyseal Cervicogenic headache;
joints. CGH is often associated with loss of range of motion (ROM), specific to this segment, snag; cervical flexion-
and measurable by the cervical flexion-rotation test (CFRT). The main purposes of the study rotation test; mulligan;
were: 1) to investigate the immediate effect of C1-C2 rotation SNAG mobilizations plus C1-C2 mobilization with movement
self-SNAG rotation exercise for patients with CGH and 2) to explore the link between the CFRT
results and treatment response.
Methods: A prospective quasi-experimental single-arm design was used where patients with
CGH received eight physical therapy treatments using a C1-C2 rotational SNAG technique
combined with a C1-C2 self-SNAG rotation exercise over a four-week period. Outcome mea­
sures were pain intensity/frequency and duration, active cervical ROM, CFRT, neck-related and
headache-related self-perceived physical function, fear-avoidance beliefs, pain catastrophizing
and kinesiophobia.
Results: The intervention produced strong effects on pain intensity, CFRT, physical function
and pain catastrophizing. Moderate improvement was noted on active cervical ROM and on
fear-avoidance beliefs and kinesiophobia. No link was found between pre-intervention CFRT
ROM and treatment response.
Conclusion: SNAG mobilization combined with a self-SNAG exercise resulted in favorable
outcomes for the treatment of CGH on patient-important and biomechanical outcomes, as
well as pain-related cognitive-affective factors.

Introduction Patients with CGH commonly seek physiotherapy

care to alleviate their symptoms [16]. Different man­
Headache is a highly prevalent painful symptom affect­
ual therapy techniques and exercises can be used to
ing up to 90% of the general population. Cervicogenic
address C1-C2 range of motion deficits to relieve
headache (CGH), a subtype of headache caused by a
symptoms at the source [17, 18–24]. The use of
disorder involving any structure of the neck, including
Sustained Natural Apophyseal Glide (SNAG) is
bony, muscular and other soft tissue elements [1],
recommended in recent clinical practice guidelines
represents 15% to 20% of all chronic headaches [2]
[25]. It is a mobilization technique which consists in
and 53% of persistent headaches following a whiplash
applying a direct force on the C1-C2 segment dur­
injury [3]. Persons with chronic CGH may experience
ing active rotation of the neck by the patient The
emotional distress, limitations in their daily activities,
technique can be applied manually by the therapist
or restricted social participation [4].
(SNAG) and also by the patient (self-SNAG), using a
Although the specific mechanisms of CGH remain
strap or towel [26].
uncertain, some evidence suggests that the asso­
In that sense, different studies investigating the
ciated symptoms might be linked to referred pain
effect of C1-C2 SNAG or self-SNAG on CGH have
arising from dysfunction at the C1-C2 zygapophyseal
demonstrated a beneficial effect on symptoms, on
joints [5, 6]. Moreover, CGH related to C1-C2 dysfunc­
perceived physical function related to neck pain, on
tion is often associated with loss of range of motion at
headache severity and on mechanical impairment of
this specific cervical segment, which can be assessed
C1-C2 segments [18, , 21, 23, 24]. However, no study
by the cervical flexion-rotation test (CFRT) [7]. The
has verified the effect of the combination of SNAG
CRFT is considered positive when showing a loss of
mobilizations plus self-SNAG exercises on CGH (symp­
rotation of 8º to 10º on one side. CFRT has been
tom intensity), or pain-related cognitive-affective fac­
widely validated for the diagnosis of C1-C2-related
tors (such as fear-avoidance beliefs, pain
CGH [8, 9, 10, 11–15].

CONTACT Pr Yannick Tousignant-Laflamme Yannick.Tousignant-Laflamme@USherbrooke.ca School of Rehabilitation, Faculty of Medicine and

Health Sciences, Université De Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Qc, Canada, J1H 5N4
© 2021 Informa UK Limited, trading as Taylor & Francis Group

catastrophizing and kinesiophobia), nor has explored
the association between the CFRT results and the
treatment response to explore its prognostic ability.
The study’s main purposes were to:
1) investigate the immediate effect of treatments
combining C1-C2 rotation SNAG mobilizations and a
C1-C2 self-SNAG rotation exercise program on pain
(headache frequency, duration and intensity), cervical
mobility (active range of motion in flexion, extension,
side flexion and rotation and passive C1-C2 rotation),
neck-related and headache-related self-perceived dis­
ability, fear-avoidance beliefs, pain catastrophizing and
kinesiophobia; and
2) explore the association between the results of the
CFRT and treatment response on pain intensity and
perceived disability.
Methods
Study design and participants
We employed a prospective quasi-experimental
design (pre-post without control group comparison).
Patients with CGH were recruited from advertise­
ments and local physician referrals around the area
of Drummondville (Quebec, Canada) from January to
May 2018. Potential participants were first screened
through phone interview. Thereafter, patients under­
went a physical examination to further verify inclu­
sion and exclusion criteria and confirm their
eligibility. Inclusion criteria were: 1) age between 18
to 65 years old, 2) HA in temporal relation to the onset
of the cervical disorder or appearance of the lesion, 3)
HA aggravated or provoked by neck movements or
postures, 4) HA associated with neck, shoulder and/or
upper limb pain, 5) HA frequency ≥ 1 per week for ≥
1 month, 5) average pain intensity ≥ 3/10 on VAS and
6) pain on palpation of paravertebral tissue of the
cervical spine. Exclusion criteria were: 1) History of
neck surgery, 2) Reported diagnosis of another type
of HA that causes two or more episodes per month
(ex: migraine), 3) Currently receiving another form of
physical intervention, 4) Other chronic pain syndrome
(ie: fibromyalgia, systematic inflammatory disease), 5)
Inability to tolerate the flexion-rotation test, the SNAG
mobilization, or the self-SNAG technique and 6)
Presence of contraindications to cervical manual ther­
apy. The initial assessment, including the physical
examination, was performed by a registered PT (first
author).
Inclusion criteria were based on the international clas­
sification of headache disorders by the Headache
Classification Committee of the International Headache
Society (IHS) (IHS, 2013) and the diagnostic criteria pro­
posed by the Cervicogenic Headache International Study
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 245
Group (CHISG). Contraindications were based on the
International Framework for Examination of the Cervical
Region for potential of Cervical Arterial Dysfunction prior
to Orthopedic Manual Therapy Intervention by the
International Federation of Orthopedic Manipulative
Physical Therapists (IFOMPT) [27] (see Appendix 1).
Informed consent was obtained for all participants
according to The Helsinki Accords. The study was
approved by the Ethics Review Board of the Clinical
Research Center of the Center intégré universitaire de
santé et des services sociaux de l’Estrie – Center
Hospitalier Universitaire de Sherbrooke (reference
number: 2018–2642).
Intervention
The intervention took place in a private practice multi­
disciplinary clinic in Drummondville (Quebec, Canada)
between March and October of 2018. All interventions
were provided by the same licensed physical therapist,
an experienced (8-years) clinician trained in Mulligan
techniques with a fellowship in manipulative therapy
(JPP, first author).
The intervention consisted of 8 physical therapy
treatments (2x/week) given over a 4-week period.
During each visit, all participants received a C1-C2 rota­
tional SNAG technique, as described by Mulligan [28].
During the technique, the therapist placed both thumbs
on the posterior arch of C1 (on the opposite side of the
rotation) and pushed anteriorly. Then, the patient was
asked to actively rotate, as far as possible, without pain,
while the therapist kept pressure on C1 during the
movement. The mobilization was maintained for 10 sec­
onds at end-range, repeated 10 times per set for a total
of 3 sets per treatment. The therapist applied overpres­
sure at end-range if the participant could tolerate it
(Figure 1). Each patient was also given a home exercise
program which consisted of C1-C2 self-SNAG in rotation.
The home-exercise was performed using a towel, which
was used to apply and maintain a pressure on the
posterior arch of C1 while they would actively rotate
their cervical spine, mimicking the C1-C2 rotational
SNAG technique. End-range position was maintained
for 10 seconds, before returning to neutral position.
Participants were instructed in the self-SNAG during
the first appointment and the exercise was reviewed
during subsequent visits [28]. The patients were asked
to perform the exercise twice a day for 10 repetitions
each time, for a total of 20 repetitions per day (Figure 1).
Written instructions and a video of the exercise to be
performed was sent to all participants to improve the
quality and compliance of the home exercise.
Adherence to the exercise program was monitored
with a daily logbook that was completed by the patient.
No further intervention was provided.
246 J.-P. PAQUIN ET AL.

Figure 1.

Main Outcome Measures (CROM) while the patient was seated on a chair.
Patients were advised to perform the neck movement
All outcome measures were assessed during the
with as much range as possible. Movement quality was
initial assessment (T0: baseline) and one month
visually monitored by the assessor. The CROM device
after completion of final treatment (T1: + 4 weeks).
showed moderate to good reliability and good validity
The primary outcome of this clinical design study
in the assessment of active ROM [30–32].
was pain intensity (severity, duration, and fre­
quency), while secondary outcomes were: ROM, per­
ceived disability, and psychosocial factors (fear-
Cervical Flexion-Rotation Test
avoidance beliefs, pain catastrophizing and kinesio­
phobia). All outcome measures are detailed below The CFRT was performed on all patients, as described
and synthesized in Table 1. by 33. This test demonstrated good construct and
content validity in the measurement of C1-C2 passive
rotation [33], good inter-rater reliability (92%) (8), high
Pain severity sensitivity (75% – 100%) [9, 13a] and specificity (85% –
94%) [11, 13] for the diagnosis of C1-C2-related CGH.
The authors measured overall average headache
Hence, it is considered as a routine diagnostic test by
intensity (our main dependent variable) using a
PTs in the assessment procedures for patients present­
10-cm visual analogue scale (VAS); the minimal clin­
ing with headache [34].
ical important difference (MCID) for the VAS is 2/10)
ROM (rotation) during the CFRT was measured by
[29]. Average episode frequency (number of epi­
the HALO goniometer with the device fixed to the
sodes per day) and duration (in hours) were
head with a Velcro strap. The HALO goniometer
obtained through direct questioning at the first
demonstrated good reliability and validity in the
and final visits.
assessment of ROM at the shoulder [35,36]. It was
Pain severity was also measured daily via the log­
also used in a previous study to measure ROM during
book, where participants reported HA intensity (VAS)
the CFRT in subjects with temporomandibular disor­
and duration (hours) for each episode. The frequency
ders [37]. This device was used in replacement of the
of episodes was obtained by dividing the number of
CROM for technical reasons: the position and fixation
episodes by the number of days for each week of
of the CROM device on the head made it impossible to
measurement.
execute the CFRT or could impair the test’s precision.
The result of the CFRT test was interpreted as dichot­
omous data, considered positive when a side-to-side
Active Range of Motion
difference of 8º or more was present [14]. The MCID for
Cervical active ROM was assessed pre-and post-inter­ this test is 4.7º for a right rotation and 7º for a left
vention using the Cervical Range of Motion Device rotation [10].

Perceived Disability
Neck pain-related disability was measured with the
French version of the Neck Disability Index question­
naire (NDI) (score ranging from 0–50). The question­
naire was validated for a CGH population, with a MCID
of 5.5 points [38]. Headache-related disability was mea­
sured with the French version of the Henry Ford
Hospital Headache Disability Inventory (HDI) (score
ranging from 0–100, MCID: 29 points) [39].
Pain-Related Cognitive-Emotional Factors
We used three questionnaires to explore different
aspects of cognitive-emotional drivers of pain: a mod­
ified version of the Fear-Avoidance Beliefs
Questionnaire (FABQ), where « back » was replaced
by « neck » (score ranging from 0–96), the Pain
Catastrophizing Scale (PCS) (score ranging from 0–52)
and the Tampa Scale for Kinesiophobia (TSK) (score
ranging from 17–68). French versions were used for
all questionnaires. Although these questionnaires have
never been studied in a CGH population, they are
widely used clinically for the prognosis of other chronic
painful musculoskeletal conditions such as migraine
and neck pain [40–42].
Compliance to self-SNAG exercises
Compliance was assessed by therapist reviewing the
daily logbook. Each participant was asked to annotate
the logbook with details on exercise parameters (time
of day and number of reps).
Data analysis
Sample size calculation
Sample size estimates were based on pain intensity
ratings (primary outcome), which was our main depen­
dent variable. With power set to 80% to detect a
difference in means of 20/100 on the VAS, assuming
a standard deviation of differences of 12,7/100 and the
2-sided level of significance for alpha at 0.05 [based on
a similar study design by [23], a minimum of 6 subjects
was required.
Treatment Effect
All statistical analyses were performed with SPSS® sta­
tistical software (IBM SPSS Statistics for Windows, ver­
sion 26.0; IBM, Chicago, IL) with an alpha level of.05. As
all our main variables were not normally distributed
(based on the Shapiro–Wilk test), non-parametric ana­
lysis were performed (a paired Wilcoxon test) to verify
the pre-post effects. Accordingly, the median and
interquartile range were reported for the main out­
come measures.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 247
Finally, the effect size (ES) was calculated based on
the value of matched-pairs rank biserial r [43] to deter­
mine the magnitude of clinical changes after interven­
tion following the equation below, with 95% of
confidence intervals:
r = (Sf/S) – (Su/S)
where Sf is the sum of favorable ranks, S is the total
sum ranks and Su is the sum of unfavorable ranks. The
effect size was characterized by Cohen [44] as weak,
moderate and strong effects, i.e., r = 0,2 is small, r = 0,5
medium and r = 0,8 large, respectively.
Association between CFRT and treatment
response
Association between CFRT results at initial assessment
(positive or negative) and significant improvement on
pain intensity (>20/100 improvement) and neck-
related disability (>5,5 improvement) were estimated
using the Fisher exact test Figure 3.
Results
Demographics and baseline characteristics of
participants
Baseline demographic information and clinical char­
acteristics of participants are detailed in Table 2. A
total of 38 potential participants contacted the main
investigator for further information regarding the
project. Sixteen (16) were excluded following the tel­
ephone screening and two (2) were excluded follow­
ing initial clinical assessment, mainly because they
were deemed to have another type of HA or other
health conditions. Thus, our sample was comprised of
20 participants in pre- and post-intervention mea­
surements. All 20 participants completed the study
protocol (Figure 2).
Treatment Effect
Overall pain intensity: The average pain intensity during
HA episodes obtained through subjective perception
significantly improved after intervention, as measured
with the VAS (p < 0.00, Z = −3.763) (Table 3). A strong ES
on pain reduction was observed after the treatment (ES
r = 0.957), with a meaningful difference of 66% between
times (baseline versus 4 weeks of intervention).
Active range of motion and CFRT: Active range of
motion in the neck significantly improved for all direc­
tions of movements after the 4 weeks of intervention
(Table 3), with ES varying from moderate to strong for
clinical changes across time (r = 0.608 to r = 0.800).
In addition, ROM measured during the CFRT signifi­
cantly increased (p < 0.01) from T0 to T1 (+25% on affected
side), with 15 participants showing a positive test before
the intervention and only one participant still showing a
248 J.-P. PAQUIN ET AL.

Table 1. Description of outcome measures and definition of improvement.

When measurement was Minimal Clinically Important
Outcome measures Measurement tools performed Measurement method Difference
Pain intensity VAS Pre- and post-intervention and Direct questioning 2.0 [29]
daily Logbook
HA frequency Daily Logbook
HA duration Daily Logbook
Active neck ROM CROM device Pre- and post-intervention In-clinic assessment
CFRT HALO goniometer Pre- and post-intervention In-clinic assessment 4.7 to 7 degrees [9]
Neck-related disability NDI (French Canadian Pre- and post-intervention Self-reported via 5.5 [38]
version) questionnaire
Headache-related HDI (French Canadian Pre- and post-intervention Self-reported via 29 points
disability version) questionnaire
Fear-Avoidance beliefs FABQ (French Canadian Pre- and post-intervention Self-reported via
version) questionnaire
Pain catastrophizing PCS (French Canadian Pre- and post-intervention Self-reported via 38 to 44% [49]
version) questionnaire
Kinesophobia TSK (French Canadian Pre- and post-intervention Self-reported via 5.6 points
version) questionnaire
VAS: Visual Analogue Scale; ROM: Range of Motion; CFRT: Cervical Flexion-Rotation Test; CROM: Cervical Range of Motion device; NDI: Neck Disability Index;
HDI: Headache Disability Inventory; TSK: Tampa Scale for Kinesiophobia; FABQ: modified Fear-Avoidance Beliefs Questionnaire; PCS: Pain Catastrophizing
Scale

Table 2. Demographic information and baseline characteristics was 12.00 degrees before the intervention and decreased
of participants.
to 1.00 degree after the intervention.
Age (years) 35.75 (SD: 11.48) Perceived disability: The NDI score significantly
Gender (%)
• Female 90 improved post-intervention (p < 0.00, Z = −3.73)
• Male 10 (Table 3), with 13 participants (65% of the sample)
Headache history (years) 12.34 (SD: 10.52)
Headache frequency (number of episodes/week) 3.9 (SD: 2.26) reaching minimal clinical improvement. The HDI
Pain intensity (/10) 6.73 (SD:1.31) score also significantly improved (p < 0.00, Z = −3.77)
Pain duration (hours) 15.34 (SD: 14.42)
Positive CFRT (%) 75 (Table 3) and 7 participants (35%) reached minimal
Onset (%) clinical important change cutoff. These improvements
• following neck trauma 25
• following prolonged posture 30
were supported by clinical changes observed with the
• unknown 45 strong ES between pre- and post-intervention
Comorbidity (%) (r = 0.962 to 0.974 across questionnaires used).
• Other type of HA (ex: migraine) 15
• Other MSK condition 10 Pain-related cognitive-emotional factors: PCS scores
• Psychological condition (ex: depression) 5 significantly decreased post-intervention (p < 0.00,
CFRT: Cervical Flexion-Rotation Test; HA: Headache; MSK: Musculoskeletal; Z = −3,865) (Table 3), as well as TSK scores (p < 0.01,
SD: Standard Deviation
Z = −2,785) (Table 3). Five (5) participants (25%)
reached the minimal clinical improvement for PCS.
positive test after the intervention. The magnitude of this However, the FABQ scores did not significantly change
change was strong across time (ES r = 0.905). The median following the intervention (p = 0.16, Z = −1,420) (Table
side-to-side difference in patients showing a positive test 3). The ES was strong for PCS (r = 0.986), while

Figure 2. Flowchart
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY 249

Figure 3. a. Pain intensity over time during the intervention period (expressed in median (IQR)), b. Headache frequency over time
during the intervention period (expressed in median (IQR)), c. Headache duration over time during the intervention period
(expressed in median (IQR)).

Table 3. Median values and quartiles 1 and 3 of pain intensity, self-perceived physical function and pain-related cognitive-affective
factors at baseline and post-intervention.
Pre-intervention Post-intervention
(T0: baseline) (T1: +4 weeks) Paired Wilcoxon test Effect-size
Outcome Median (Q1;Q3) Median (Q1;Q3) Z p Matched-paired rank-biserial r
Overall pain intensity 6.80 (6.10;7.25) 2.30 (1.10;3.60) −3.763 .000 0.957
Neck-related perceived physical function 16.00 (11.00;18.00) 6.50 (4.75;9.00) −3.724 .000 0.974
Headache-related perceived physical function 41.00 (29.00;48.50) 16.00 (9.00;26.00) −3.772 .000 0.962
Fear-Avoidance beliefs 23.00 (16.00;32.00) 18.00 (9.00;25.50) −1.420 .156 0.362
Pain catastrophizing 25.00 (14.00; 31.50) 5.00 (3.00; 12.00) −3.865 .000 0.986
Kinesiophobia 30.00 (28.00; 39.00) 28.00 (26.50; 32.50) −2.785 .005 0.726
Active neck ROM: flexion 49.00 (41.50; 54.00) 52.00 (45.75; 56.50) −2.420 0.016 0.649
Active neck ROM: extension 50.50 (47.25; 60.5) 58.00 (51.50; 66.25) −2.462 0.014 0.661
Active neck ROM: right rotation 60.00 (56.50; 62.25) 65.00 (61.50; 70.50) −2.564 0.010 0.706
Active neck ROM: left rotation 62.00 (57.50; 66.50) 68.00 (62.00; 78.00) −3.141 0.002 0.800
Active neck ROM: right side bending 30.00 (25.50; 32.00) 31.00 (27.50; 38.00) −2.205 0.027 0.608
Active neck ROM: left side bending 32.00 (26.25; 38.00) 36.00 (30.00; 40.50) −2.728 0.006 0.800
CFRT ROM: Affected side 28.50 (24.25; 31.25) 38.00 (26.00; 40.25) −3.462 0.001 0.905
CFRT ROM: Non-affected side 41.50 (36.50; 46.00) 39.00 (35.50; 41.25) −1.615 0.106 0.421
ROM: Range Of Motion device; CFRT: Cervical Flexion-Rotation Test; Q1: Quartile 1; Q3: Quartile 3

Table 4. Contingency tables for Fisher’s tests to explore the (p = 0,709, Z = −0,373 and p = 0,629, Z = −0,483 respec­
association between CFRT results on pain and physical func­ tively) (Table 3). The paired Wilcoxon test revealed a
tion response. statistically significant improvement in HA frequency
Significant improvement on pain (p < 0,000, Z = −3,641) (Table 3). This variable improved
intensity (MCID reached)
every week during the intervention period, with partici­
Yes No Total
Positive CFRT pre-intervention Yes 11 4 15
pants reporting a median of 1,000 episodes per day pre-
No 4 1 5 intervention and 0.345 episode per day during week 4,
Total 15 5 20 which represents a decrease of more than 65%.
Significant improvement on NDI score
(MCID reached)
Yes No Total
Positive CFRT pre-intervention Yes 10 4 15 Adherence with Self-SNAG Exercise
No 3 2 5
Total 13 7 20
All participants reported performing the self-SNAG home
CFRT: Cervical Flexion-Rotation Test; NDI: Neck Disability Index; MCID:
Minimal Clinical Important Difference exercise. However, the mean number of sets performed
was 1.85/day, but participants reported completing the
moderate for TSK (r = 0.726) on time factor differences prescribed number of repetitions for each set. No adverse
(baseline versus 4 weeks of intervention). effect was reported during the technique or home
exercise.

Daily Logbook Measures

Association Between CFRT and Treatment Effect
Median values of pain intensity and HA episode duration
reported in the logbook during the pre-intervention per­ Fifteen (15) participants had a positive CFRT before the
iod were similar to those reported during week 4 intervention. All 15 participants significantly improved
250 J.-P. PAQUIN ET AL.
(surpassed the MCID) on pain intensity ratings as mea­
sured pre-and post-intervention, and 13 significantly
improved (surpassed the MCID) on NDI. The Fisher exact
test failed to demonstrate an association between CFRT
results (positive) and significant improvement (MCID
reached) for both pain intensity (p = 0.634) and neck-
related physical function (p = 0.594).
Participants with a negative CFRT pre-intervention
showed significant improvement on different outcomes:
four (4) participants significantly improved on overall pain
intensity, three (3) significantly improved on CFRT range
of motion (on the less mobile side) while one significantly
worsened, two (2) significantly improved on self-per­
ceived physical function (NDI and HDI scores) and one
(1) improved on pain-related cognitive-affective factors
(FABQ-PA subscale, PCS and TSK) (see Table 4).
Discussion
Main findings
The main purpose of this study was to assess the
immediate effect of treatments combining C1-C2 rota­
tion SNAG mobilizations and a C1-C2 self-SNAG rota­
tion exercise program on pain (headache frequency,
duration and intensity), cervical mobility, neck and
headache-related disability, fear-avoidance beliefs,
pain catastrophizing and kinesiophobia variables.
Significant clinical benefits were found after treatment
for our primary outcome related to pain measurement
(clinical change ES r = 0.957), with 66% of reduction on
VAS scale. This positive improvement (4 points on scale
from differences reported between pre- and post-
intervention was higher when compared to minimal
clinical important difference (MCID: 2/10) [29]. These
results were further supported by strong ES on clinical
changes with the treatment, supporting the use of this
type of intervention for this population.
There is some dissonance when extracting data
from the logbook regarding pain intensity, duration,
and frequency. When analyzing data on a weekly basis,
only HA frequency decreased, while pain intensity and
duration remained stable. This discrepancy might be
explained by an information bias. The VAS measures
pain severity at a very specific time (ie: when exercises
are performed and pain intensity is likely to be heigh­
tened). Thus, when we try to extrapolate changes in
pain severity ratings to overall clinical change
(improvement), we may observe a biased result.
Hence, it may have been more relevant to use a spe­
cific tool that measures global improvement, such as
the Patient Global Rating of Change scale.
Significant benefits were also reported on biome­
chanical outcomes, such as active neck ROM, but more
importantly, on neck rotation during the CFRT in the
affected side (an increase of 25% after intervention).
This positive improvement (9.50° between pre- and
post-intervention was higher when compared to the
minimal clinical important difference (MCID: 7°) [10].
Moderate ES was found for active range of motion in
the neck, but a strong ES (r = 0.905) was shown for
CFRT change. The magnitude of change on this test
supports the use of the Mulligan approach to restore
expected mobility at the C1-C2 segment. Our results
on biomechanical outcomes are consistent with the
pathophysiology of CGH and may support the idea
that addressing C1-C2 ROM deficits is important to
attenuate CGH symptoms.
Important improvements were also noted on self-
perceived physical function in relation to neck pain
and headache. Strong ES were obtained for the NDI
score (r = 0.974) and for the HDI score (r = 0.962), which
supports a significant clinical change with the treat­
ment for self-perceived physical function in relation to
neck pain and HA.
Overall, the change was also significant for pain
catastrophizing (80% improvement on the PCS) and
kinesiophobia (0.07% improvement on the TSK). The
ES was strong for PCS (r = 0.986), while moderate for
TSK (r = 0.726) on time factor differences (baseline
versus 4 weeks of intervention). Fear-Avoidance beliefs
did not significantly change after the intervention.
However, questionnaires used to measure pain-related
cognitive-affective factors did not show significant
fear-avoidance beliefs, kinesiophobia and pain cata­
strophizing in our sample before the intervention.
This should be taken into consideration when inter­
preting the results, since these factors might not have
been an issue at first.
The results of the present study are consistent with
current knowledge on manual therapy mechanisms,
supporting that a mechanical force from a manual
intervention is most likely related to biomechanical
and systemic neurophysiological responses leading to
pain inhibition; the reduction in pain intensity might
be explained by a biomechanical effect (supporting
the idea that restoring C1-C2 mobility would eliminate
the cause of CGH), as well as nonspecific response of
hands-on treatment modalities, which are known to
have effects on the psychological areas of pain [45–47].
Many participants showing a positive CFRT test pre-
intervention, as well as participants showing a nega­
tive response to this same test, significantly improved
post-intervention on patient-important outcomes as
well as biomechanical outcomes. In addition, no asso­
ciation was found between CFRT results as a dichoto­
mous data (positive versus negative) and significant
improvement in pain intensity and function in relation
to neck pain, pre-and post-intervention. The low and
unbalanced number of participants in the two sub­
groups did not allow sufficient statistical power to
adequately explore the question. Future studies are
needed to examine the possible utility of CFRT as a
predictive factor for treatment response.

Comparison of Findings with Previous Studies
Our results on overall pain and neck-related self-per­
ceived physical function are consistent with other stu­
dies investigating the effect of the SNAG manual
technique or self-SNAG exercise to improve C1-C2
rotation. Significant improvement on pain intensity
(VAS) was observed when using the technique alone
in 3 studies [23,24] and disability due to neck pain
(NDI) was observed when using the technique alone
in 4 studies [22–24]. HA episode duration was also
measured and significantly improved in one of these
studies [24].
Other authors assessed physical function in head­
ache patients with the Headache Impact Test (HIT-6)
[21,22] and the Headache Activities of Daily Living
Index (HADLI) [21] to measure the effectiveness of
the C1-C2 SNAG mobilization technique. In these stu­
dies, SNAG mobilizations demonstrated significant
improvement on both the HIT-6 and HADLI. Finally,
one study reported significant improvements in HA
severity, including pain intensity, frequency and dura­
tion as well as neck-perceived physical function with
the sole use of self-SNAG exercise [18].
Biomechanical impairments were less commonly
reported in previous studies. Significant improvement in
neck active range of motion with the SNAG manual tech­
nique was reported by 23, and 22. Significant improve­
ment on CFRT [restricted side) with the self-SNAG exercise
was reported by 18. The CFRT was also measured pre-and
post-intervention by 21, and showed an improvement of
13º, but no statistical analysis was provided.
Strengths and Limitations
Considering previous studies, the current authors used
the Mulligan approach as practiced in clinical settings,
including in-clinical manual treatment and a home
exercise program to maintain progress and self-suffi­
ciency. The authors also used a specific exercise
dosage (intervention procedures], which is easily
reproducible in a clinical setting or in future studies.
The authors included outcomes measuring different
aspects of pain, as well as biomechanical features
related to CGH. The variety of measurement tools
used in our study allowed us to appreciate the involve­
ment of biomechanics as well as pain, physical func­
tion, and cognitive-affective factors. This is an
important strength of our study when considering
the actual knowledge on CGH pathophysiology, man­
ual therapy mechanisms and chronic pain develop­
ment. The use of a manual approach combining a
hands-on intervention with a home-exercise program
targeting C1-C2 segment seems beneficial for multiple
aspects of pain and disability.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 251
Several limitations should be considered when
interpreting the results of this study. First, no conclu­
sion can be brought forth on the efficacy of the inter­
vention, due to the absence of a control group. Also,
the benefits noted in the current study were only
assessed immediately post-intervention and no long-
term follow-up was performed. Patient sample size is
another important limitation. Although the sample size
required to determine the effect of our intervention on
overall pain was respected, normality of data could not
be reached. This sample size calculation did not
include other important outcomes such as CFRT, self-
perceived physical function and pain-related cogni­
tive-affective factors. Therefore, generalization of
these results is not indicated. Another limitation lies
in the fact that many steps of the project were
entrusted to the same person, including selection of
participants, pre-and post-intervention measurements,
as well as performing the intervention. This could lead
to potential bias in patient response as well as data
collection, and might influence the results.
Implications for practice
The results of the current study contribute to support
the use of Mulligan’s SNAG and self-SNAG in the man­
agement of patients with CGH by showing the poten­
tial benefits of different aspects of pain and physical
impairments.
Implications for research
Self-reported outcome measures used for pain-related
cognitive-affective factors were not specifically vali­
dated for the CGH population and failed to demon­
strate the presence of these factors in our sample.
However, pain catastrophizing may be involved in
CGH and would therefore warrant further studies.
The current results suggest that the C1-C2 SNAG
technique, combined with self-SNAG exercises, might
have a positive effect on pain catastrophizing and
kinesiophobia. Therefore, such measurement tools
could be validated with the CGH population and be
included in interventional studies.
The association between the C1-C2 rotation
range of motion during the CFRT and treatment
response should be further explored, as this
study’s sample size was not large enough to
reach a level of statistical power that could ade­
quately answer our research question. Another
study with a larger sample size and a precise
methodology might be able to add additional
information, which could lead to a better under­
standing of the CFRT’s value.
252 J.-P. PAQUIN ET AL.
Conclusion
SNAG mobilization combined with a self-SNAG home
exercise resulted in favorable outcomes for the treat­
ment of cervicogenic headache. Beneficial effects were
noted on patient-important outcomes, such as pain
intensity and self-perceived physical function, as well
as biomechanical outcomes, including active range of
motion in the neck with CFRT. Additional results
showed a potential benefit on pain-related cognitive-
affective factors, namely on pain catastrophizing.
Future studies are required to strengthen knowledge
on the benefits of physical therapy in CGH patients for
all aspects of pain [48,49].
Acknowledgments
We thank Clinique Physio-Santé for their infrastructures and
all the participants to this study
Disclosure statement
No potential conflict of interest was reported by the authors.
Notes on contributors
Jean-Philippe Paquin, PT, is a clinical professor at Health
Sciences Department (Physical Therapy Program) of
Université du Québec à Chicoutimi, Qc, Canada. Jean-
Philippe’s fields of interest include manual therapy, thera­
peutic exercise, headache, neck disorders and
neurodynamics.
Yannick Tousignant-Laflamme, PT, PhD, is Professor and
director of the Physical Therapy Program (School of
Rehabilitation) of the Université de Sherbrooke, Qc, Canada.
Yannick’s fields of interest include pain science/manage­
ment, low back pain, and orthopedic physical rehabilitation.
Jean-Pierre Dumas, PT, PhD, is an Associate Professor at the
School of Rehabilitation (Physical Therapy Program) of the
Université de Sherbrooke, Qc, Canada. Jean-Pierre’s fields of
interest include neck disorders, cervicogenic headache and
clinical reasoning.
ORCID
Yannick Tousignant-Laflamme http://orcid.org/0000-
0002-1133-8707
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254 J.-P. PAQUIN ET AL.
Appendices
Appendix 1: List of contraindications to cervical manipula­
tive therapy
● uncontrolled cardiovascular disease (such as hyperten­
sion, hypercholesterolemia, etc.)
● multi-level nerve root pathology
● worsening neurological function
● unremitting, severe, non-mechanical pain
● unremitting night pain
● recent trauma (less than 6 weeks)
● upper motor neuron lesions
● spinal cord damage
● signs and symptoms of vertebrobasilar insufficiency (diz­
ziness, diplopia, dysarthria, dysphagia, drop attacks, nau­
sea, nystagmus, facial numbness, ataxia, vomiting,
hoarseness, loss of short-term memory, vagueness, hypo­
tonia/limb weakness, anhidrosis, hearing disturbances,
malaise, perioral dysesthesia, photophobia, papillary
changes, clumsiness, agitation)
● signs and symptoms of internal carotid insufficiency
(carotidynia, ptosis, transient retinal dysfunction, transi­
ent ischemic attacks, cerebrovascular accidents)
● cranial nerve dysfunction
● hindbrain stroke (e.g. Wallenberg’s syndrome, locked-in
syndrome)
● signs and symptoms of upper cervical instability (bilat­
eral foot and hand dysesthesia, feeling of a lump in
the throat, metallic taste in the mouth, arm and leg
weakness, lack of coordination bilaterally, positive
instability tests)11
● Osteoporosis
● Hyperlaxity Syndrome (ex: Marfan syndrome)
● Down’s Syndrome
● Local infection