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 Table of Contents  
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 112-116

Effect of mckenzie method on pain and function in patients with cervicogenic headache

1 Dr. D. Y. Patil College of Physiotherapy, Dr. D.Y. Patil Vidyapeeth, Pune, India
2 Smt. Kashibai Navale College of Physiotherapy, Pune, India

Date of Submission29-Jun-2020
Date of Acceptance11-Apr-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Dr. Seema Saini
Department of Musculoskeletal Physiotherapy, Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_51_20

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Background: Individuals with cervicogenic headache (CGH) go through problems in activity of daily living, limitedsocial involvement, and emotional distress. CGH patients score the “worse” in the physical function category when compared to migraine patients. Aims: The aim was to study the effect of McKenzie complemented with conventional treatment on cervical rotation and headache in patients with CGH. Settings and Design: This was an experimental study design and systematic sampling method was used to collect data. The study setting was an Smt. Kashibai Navale General Hospital, Physiotherapy Outpatient Department, Pune, India. Methodology: Thirty subjects were selected with CGH which fulfills the criteria given by the CGH International Study Group. They were divided into two groups of 15 each. One group was given conventional treatment and the other was given conventional combined with McKenzie Method. Flexion–rotation test (FRT), Visual Analog Scale, Neck Disability Index (NDI), and Headache Disability Index were used as outcome measures. Statistical Analysis Used: T-test was applied to see the difference in pre and post values for all variables in both the groups. All data were analyzed using the Statistical Package for the Social Sciences 21 with level of significance for all statistical tests set at P ≤ 0.05. Results: The results showed that FRT has a statistically significant difference in both the groups. Headache disability showed a significant improvement in both the groups with statistically significant difference P < 0.05, the improvement being greater in the experimental group than in the conventional group. Conclusion: This study showed that when the McKenzie method is complemented with the conventional treatment, it shows better improvement in function of the cervical dysfunctions that cause CGH and reduce the intensity of headache.

Keywords: Cervical dysfunction, cervicogenic headache, flexion–rotation test, headache disability index, McKenzie method

How to cite this article:
Saini S, Pamnani V, Palekar TJ. Effect of mckenzie method on pain and function in patients with cervicogenic headache. J Orthop Traumatol Rehabil 2021;13:112-6

How to cite this URL:
Saini S, Pamnani V, Palekar TJ. Effect of mckenzie method on pain and function in patients with cervicogenic headache. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Nov 27];13:112-6. Available from: https://www.jotr.in/text.asp?2021/13/2/112/333566

  Introduction Top

The World Cervicogenic Headache (CGH) Society has defined CGH as referred pain perceived in any part of the head and caused by a primary nociceptive source in the musculoskeletal tissues which are innervated by the cervical nerves.[1],[2],[3],[4]

A research found that about 70% of people with recurrent intermittent headache report neck symptoms correlated with their headache, which may promote care in the cervical area.[5],[6],[7]

While it is suggested that the cervical spine can contribute to various types of headache such as migraine and tension-type headache, studies estimate that only 14%–18% of chronic headaches are cervicogenic, i.e., headaches that are actually caused by musculoskeletal dysfunction in the cervical spine.[8]

Individuals with CGH experience significant limitations in their daily activities, social participation and emotional distress. CGH patients score the “worse” in the physical function category when compared to migraine patients.[9]

There should always be clinical, laboratory, and/or imaging evidence of a disorder or lesion within the cervical spine or neck soft tissues known to be, or generally accepted as, a valid cause of headache, referred to from a source in the neck and perceived in one or more regions of the head and/or face. Attributes include pain in the neck, tenderness of the focal neck, history of neck trauma, mechanical exacerbation of pain, unilaterality, coexisting shoulder pain, reduced range of neck movement, nausea, vomiting, and photophobia. These may be CGH characteristics, but they do not define the relationship between the disorder and the headache source.[10],[11]

There is sufficient evidence that the selected physical examination tests for the diagnosis ofCGH show high levels of reliability and diagnostic precision. For the diagnosis of CGH, the cervical flexion–rotation test (FRT) showed both the highest reliability and the strongest diagnostic accuracy.[12],[13]

Manual therapy is often recommended for the management of CGH, although few randomized controlled trials have assessed its effectiveness in isolation. One trial with strong methodological quality and large sample size found that manual therapy helped to reduce CGH.[14] The McKenzie Method of Mechanical Diagnosis and Therapy is a method to treating spinal and extremity problems. The McKenzie Method was developed in Stockholm in 1985 and was widely used in the 1990s as a modality of therapy for people with mechanical spinal disorders. Now, primary care physiotherapists also use this technique as both screening instrument and plan of treatment. McKenzie recommends a series of cervical exercises to decrease CGH symptoms and maintains correct cervical alignment and management strategy recognizes the biopsychosocial nature of musculoskeletal complaints and encourages effective patient management.[15]

These exercises are based on symptom, frequency, and intensity changes. If CGH is not reduced by an exercise, a new component is added and the prior exercise is discontinued. Therefore, care discretion is given to the patient.[16]

There is little scientific evidence that treatment with McKenzie is effective for the CGH patients. Randomized clinical trials involving CGH patients and comparing the McKenzie procedure with other treatment modalities were not documented in the literature, with the exception of one study on whiplash-associated condition patients.[17]

Hence, the main aim of this study was to find the effect of McKenzie along with conventional treatment on pain and function in patients with CGH.

  Methodology Top

Fifty-two patients were screened through systematic sampling method, out of which 18 patients were excluded from the study due to not fulfilling the inclusion criteria. Four subjects did not give consent to participate in the study. A total of 30 subjects with CGH were recruited according to the inclusion and exclusion criteria into two groups, i.e., experimental group and control group.

Ethical clearance from the institutional ethical committee was obtained. Informed written consent from subjects was obtained. Demographic data, i.e., name, age, gender, occupation, qualification, and contact details of each patient were documented. Patients diagnosed with CGH who fulfilled the criteria given by the CGH International Study Group that states if unilateral head pain without side shift. The pain may occasionally be bilateral and when there is bilateral involvement, pain localized to the occipital, frontal, temporal or orbital regions. Intensity of pain maybe moderate to severe.Intermittent attacks of pain can lasts from hours to days. There can be constant pain or constant pain with superimposed attacks of pain, deep and nonthrobbing pain, head pain is triggered by neck movement, sustained or awkward neck postures. There will also be restricted active and passive neck range of motion and reduced FRT range, neck stiffness, associated signs and symptoms including: Nausea; vomiting; photophobia, phonophobia, and dizziness.[18],[1]

Patients with headache with autonomic involvement or visual disturbance, congenital conditions of the cervical spine, contraindication to manipulative therapy like osteoporosis, recent fracture and malignancy, and inability to tolerate the FRT were excluded from the study.

Rotation range of motion in full cervical flexion (FRT) was determined by using a modified cervical range of motion (MCROM) device (floating compass). Two Velcro straps were fixed to the subject's head, traversing the transverse and coronal planes, respectively. The MCROM was attached to the center of the coronal Velcro strap to measure cervical rotation in maximal flexion.[18],[19],[20]

The function was assessed by using Self-reported Neck Disability Index (NDI) and Headache Disability Index (HDI).


Both the groups received treatment in musculoskeletal physiotherapy outpatient department for 1 week for 30–40 min. Reassessment of pain, cervical rotation range of motion, NDI, and HDI were done every week for 4 weeks.

For the control group, endurance training to deep cervical flexors, longus capitis and colli muscle, scapular strengthening exercises along with isometric training exercises using a low level of rotatory resistance was used to train the cocontraction of the neck flexors and extensors.

Postural correction exercises were given. The subjects were trained to sit with a natural lumbar lordosis while gently retracting and adducting their scapulas and active neck exercises: flexion, extension, rotations, and lateral flexion.

For the experimental group, all the above exercises were given except for active neck exercises which are replaced with suitable McKenzie exercise depending upon the McKenzie syndrome.[10]

Based on the McKenzie's method of assessment, the subjects were categorized into three syndromes, as shown in [Table 1].
Table 1: Based on the McKenzie's method of assessment, the subjects were categorized in three syndromes

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Statistical analysis

Paired t-test was applied to see the difference in pre- and postvalues for all variables in both the groups. All data were analyzed using the Statistical Package for the Social Sciences 21(IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) with a level of significance for all statistical tests set at P ≤ 0.05.

  Results Top

Right-sided pain was the most common in both the groups' number being 9 (60.0%) and 7 (46.7%) in Group A and B, respectively. Bilateral pain occurred in 3 (20%) and 4 (26.7%) subjects in Group A and B, respectively, and 3 (20.0%) people in Group A and 4 (26.7%) subjects in Group B suffered from left-sided pain.

Both the experimental group and the control group showed statistically significant difference in outcome measures Visual Analog Scale (VAS), NDI, HDI, and FRT. The conventional treatment that is the specific therapeutic exercise program chosen for this study was based on the previous evidences that showed the effectiveness of these therapeutic exercises. However, the experimental group and the control group showed a statistically significant difference between the groups with the experimental group showing greater improvement in VAS [Figure1], NDI [Figure 2], and HDI [Figure 3]. Flexion–rotation range showed significant differences in both the groups for both the affected and nonaffected sides when bilateral samples were excluded. There was no statistical difference when compared the right and left side in the patient affected bilaterally.
Figure 1: Visual analog scale

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Figure 2: Neck Disability Index

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Figure 3: Headache Disability Index

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  Discussion Top

Our results correlated with the study conducted by Jull et al. which concluded that manual therapy along with a specific exercise program showed a reduction in pain intensity. Mechanical pain is caused due to abnormal stresses on the normal structure, normal stresses on the abnormal structure, or abnormal stresses on the abnormal structure[14] It has been shown that pain can immediately change motor control of cervical muscles and altered motor control can remain after nociceptive input has ceased. It is probable that retraction exercises may activate the deep cervical flexors while minimizing the superficial flexors, more effectively and functionally than typical strength training (e.g. head-lifting or isometric flexion). McKenzie method is based on directional preference which involves manual therapy, exercise therapy, or both, which are predicated on the discovery of a “directional preference” during the physical examination similar to the movement system impairment-based model of assessment and treatment.[19] Based on this model, the patient is educated, analyzed on posture, and it prescribes the exercises based on the musculoskeletal dysfunction.[11],[20] CGH is a disorder of cervical muscular impairment as much as cervical joint dysfunction. cervical retraction which is the first exercise prescribed in the McKenzie flexion and extension principle causes the lower cervical segments to move toward an extended position, while the upper segments move toward a more flexed position. Neck retractions reduce the mechanical forces on the intervertebral disk (between c2 and c3), leading to decompression effect and pain reduction. Progression of this exercise consists of retraction with patient's overpressure, retraction with clinician's overpressure, retraction/extension, and retraction/extension in supine.[10] The clinicians or the therapist forces cause mobilization or manipulation of the cervical spine thus serving as the mobility component by stretching the dysfunctional tissue (feature of dysfunction syndrome), releases stress on neural structures (derangement or postural syndrome).

Our results showed improvement in both headache disability and NDI in both the groups. Jull et al. in their study discussed that both manipulative therapy and exercise therapy may induce quite local afferent input into the system to modulate pain perception and that studies suggest that the afferent input induced by manipulative therapy procedures may stimulate neural inhibitory systems at various levels in the spinal cord and may also activate descending inhibitory pathways. Another study by Thabe suggested that manual mobilization or manipulation causes the reciprocal inhibition of the cervical flexors and causes reduction of the overactivity of cervical extensors, thus causing better motor control and hence reduction in pain intensity and reduction in disability caused by headache and neck pain. Stimulation of mechanoreceptors present in the joint capsule has shown to cause inhibition in the pain perception at the spinal cord which can also be a possible cause of pain and disability reduction. The reduction in pain intensity is a multimechanism phenomenon and hence requires further research. In a systematic review by Helen A Clare, Roger Adams et al. also concluded that most of the results from individual studies and the pooled results reveal that McKenzie therapy was statistically significantly more effective than other treatments in reducing pain and disability at short-term follow-up which correlates with this study.

This study also showed improvement in the flexion–rotation range that is the cervical function. TOBY HALL in his study stated that flexion–rotation range is restricted in patients with CGH which is suggestive of improvement in the cervical range that will be beneficial for reducing the cervical headache symptoms. Manipulations and mobilizations, i.e., retraction with patient or therapist overpressure, utilized as a progression of retraction exercises, have demonstrated improvement in ranges. In addition, mobilizations are thought to break down the adhesions and stretch and reduce joint stiffness in the surrounding tissues, thus causing improvement in the flexion–rotation range by restoring normal mobility, and thus, reduce firing of the pain receptors which are activated when the joint is under excessive mechanical stresses.

  Conclusion Top

This study showed when the McKenzie method is complemented with the conventional treatment, it shows a better improvement in function of the cervical dysfunctions that cause CGH and reduce the pain intensity of headache when compared to subjects given only conventional treatment. Reduction in pain and improvement in joint function leads to reduced disability of the patients.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther 2007;37:100-7.  Back to cited text no. 15
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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