• James Dunning, Raymond Butts, Noah Zacharko, Keith Fandry, Ian Young, Kenneth Wheeler, Jennell Day, and César Fernández-de-Las-Peñas.
• Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Madrid, Spain; American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy, Montgomery, AL, USA. Electronic address: j.dunning.2016@alumnos.urjc.es.
• Spine J. 2021 Feb 1; 21 (2): 284-295.

Background ContextSpinal manipulation, spinal mobilization, and exercise are commonly used in individuals with cervicogenic headache (CH). Dry needling is being increasingly used in the management of CH. However, questions remain about the effectiveness of these therapies and how they compare to each other.PurposeThe present study aims to compare the combined effects of spinal manipulation and dry needling with spinal mobilization and exercise on pain and disability in individuals with CH.Study Design/SettingRandomized, multicenter, parallel-group trial.Patient SampleOne hundred forty-two patients (n=142) with CH from 13 outpatient clinics in 10 different states were recruited over a 36-month period.Outcome MeasuresThe primary outcome was headache intensity as measured by the Numeric Pain Rating Scale. Secondary outcomes included headache frequency and duration, disability (Neck Disability Index), medication intake, and the Global Rating of Change (GROC). Follow-up assessments were taken at 1 week, 4 weeks, and 3 months.MethodsPatients were randomized to receive upper cervical and upper thoracic spinal manipulation plus electrical dry needling (n=74) or upper cervical and upper thoracic spinal mobilization and exercise (n=68). In addition, the mobilization group also received a program of craniocervical and peri-scapular resistance exercises; whereas, the spinal manipulation group also received up to eight sessions of perineural electrical dry needling. The treatment period for both groups was 4 weeks. The trial was prospectively registered at ClinicalTrials.gov (NCT02373605). Drs Dunning, Butts and Young are faculty within the AAMT Fellowship and teach postgraduate courses in spinal manipulation, spinal mobilization, dry needling, exercise and differential diagnosis. The other authors declare no conflicts of interest. None of the authors received any funding for this study.ResultsThe 2 × 4 analysis of covariance revealed that individuals with CH who received thrust spinal manipulation and electrical dry needling experienced significantly greater reductions in headache intensity (F=23.464; p<.001), headache frequency (F=13.407; p<.001), and disability (F=10.702; p<.001) than those who received nonthrust mobilization and exercise at a 3-month follow-up. Individuals in the spinal manipulation and electrical dry needling group also experienced shorter duration of headaches (p<.001) at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X2=54.840; p<.001) more patients (n=57, 77%) within the spinal manipulation and electrical dry needling group achieved a successful outcome compared to the mobilization and exercise group (n=10, 15%) at 3-month follow-up. Between-groups effect sizes were large (0.94ConclusionUpper cervical and upper thoracic high-velocity low-amplitude thrust spinal manipulation and electrical dry needling were shown to be more effective than nonthrust mobilization and exercise in patients with CH, and the effects were maintained at 3 months.Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

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