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Hi everyone,
Please review the patient case, and the article “Efficacy of a C1-C2 Self-sustained Natural Apophyseal Glide (SNAG) in the Management of Cervicogenic Headache.” Please answer some or all of the questions below.
The primary talking points will be regarding the C1-C2 SNAG article, however, for additional information regarding my patient case, please familiarize yourself with the article on cervicogenic dizziness.
SNAG Article Questions:
– To find these articles, I use the following search string: “manual therapy AND cervicogenic headache AND cervicogenic dizziness”. Would you change anything regarding this search strategy?
– Before reading this article, what were your views regarding SNAGs? After reading this article, has your opinion regarding this technique changed?
– What do you make of the authors’ findings? And are there any glaring limitations?
Cervicogenic Dizziness Article Question:
– Have you ever treated cervicogenic dizziness? If so, what techniques or interventions have you found helpful?
Thanks!
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1) Search terms – I think it depends on what your PICO question was but given the patient case, it seems like a good search strategy. How many articles did it yield? I feel like that’s usually a good indicator of strategy – if it’s a ton of articles OR just one it’s not great. Only thing I might have added or played around with would be “cervicalgia” or “cervical spine pain”
2a) SNAGs pre article: I like using SNAGs when indicated in the clinic. I think proper technique can be tricky for patients to learn, but clinically speaking they seem to be helpful. I haven’t read much research on them though.
2b) SNAGs post article: Despite some limitations, the study seems to positively influence my practice with support of SNAGs for Cervicogenic headaches.3) Findings/limitations: The authors conclusion of SNAGs being beneficial for treating cervicogenic headache seems to be supported by the data. I think it’s interesting patients were only taught the exercise once and then expected to do it (and do it correctly) daily for a year. I’m not sure you can convey value or ensure correct form from just one visit. They also did not account for the patients seeking other treatments (PT, medication, Chiro, etc) during the year. I’m also not entirely convinced that SNAGs on their own are all that fantastic – if you’re trying to restore ROM and improve joint mobility, don’t you need to follow that up with some neuromuscular re-ed? I’m skeptical of the big improvements they saw from just one exercise.
4) Cervicogenic dizziness: Yes – I tend to treat upper cervical dysfunctions manually (SOR, distraction, mobilization) and follow it with proprioception based exercises (using a laser with targets on the wall) and/or deep cervical flexor training if indicated.
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SNAG Article Questions:
1: I think this was a fair search strategy. It’s broad, and even so, the initial search brought back narrow but helpful results.2a: I have always liked SNAGs in my experience. I use them a lot when cervical ROM is a goal. I do find them somewhat difficult to teach for some patients.
2b: This article seemed to demonstrate significant improvements in ROM and function immediately, in the short term, and in the long term.3: I thought this was a pretty well-done study. Appropriate blinding, a reasonable placebo intervention, and no glaring biases shown. Helen makes a good point about assessing exercise performance, but I feel this would have produced a different error if it was an issue.
Dizziness: I have only treated 1 patient with cervicogenic dizziness. She didn’t have a ROM restriction at the upper cervical region, but the CFRT did reproduce her dizziness. I focused on METs in the CFRT position as well as some motor control training with the laser pointer. This seemed to be helpful, but it is my only experience.
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SNAG Article Questions:
– To find these articles, I use the following search string: “manual therapy AND cervicogenic headache AND cervicogenic dizziness”. Would you change anything regarding this search strategy?
I think it all depends on what you find and if it was applicable to your patient. Like Helen said, if you found a good mix of articles and were able to skim through titles and abstracts to find what you needed, your search terms were successful.
– Before reading this article, what were your views regarding SNAGs? After reading this article, has your opinion regarding this technique changed?
I’ve used SNAGs for a variety of patients and found them beneficial for improving cervical rotation. I feel like this article only made me feel more comfortable in suggesting it as an exercises due to being efficient and easy for pt’s to do to themselves.
– What do you make of the authors’ findings? And are there any glaring limitations?
I didn’t see anything — looks like a solid paper. I find it interesting that they did a follow up at one year and the people in the placebo group didn’t get better. I think 12 months is a pretty long time to have sought other treatment or tried something new. Those people participated in this study and just did nothing else for a whole year? And if they did try other treatments, it was the missing application of the SNAG that prevented them from better health? I’m not sure what to do with that thought.
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Would you change anything regarding this search strategy?
1) I think it was a great search strategy, especially if it gave you 3 articles that you could easily skim through and apply to your patient. You kept it simple and found exactly what you were looking for with a high-quality article.
Before reading this article, what were your views regarding SNAGs? After reading this article, has your opinion regarding this technique changed?
2) Prior to reading the article, I utilized SNAGs pretty often with upper cervical patients who had pain/limitations with rotation. I like utilizing them in HEPs on the day of the evaluation to immediately start addressing ROM deficits. After reading the article, I feel much more confident in my reasoning to use them, especially with this population of cervicogenic headache/dizziness.
Have you ever treated cervicogenic dizziness? If so, what techniques or interventions have you found helpful?
3) I have treated a couple of patients with cervicogenic headaches/dizziness. My initial treatment focus was addressing ROM deficits with CPA/UPAs and METs, then I transitioned to deep neck flexor training and proprioception exercises (laser with cervical motions + DNF activities) as ROM increased and pain/dizziness decreased.
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SNAG article-
1) You could try doing two different searches (manual and CCH and manual and cervicogenic dizziness) to get more results between the two compared to having both in the same search. But if you felt like you got adequate results with that strategy then I think what you did is fine.
2) Before reading- In terms of research my understanding is that there is evidence for their efficacy for patients with cervicogenic headache and I prescribe them in this population, but also think they can be beneficial to facilitate rotation range of motion in other patients as well.
After reading- still seems like an effective treatment for symptom improvement in those with CGH.
3) The large impact that just 5 self-SNAGs had compared to the placebo is interesting- I am looking forward to discussing with others their thoughts on some of the methods.Cervicogenic dizziness-
1) I have not had anyone with this so far, so don’t have any helpful information to give based on experience. -
I find it interesting that they did a follow up at one year and the people in the placebo group didn’t get better. I think 12 months is a pretty long time to have sought other treatment or tried something new.
Good call Barrett. I didn’t think of this. You would think that natural history would have set in. The subjects of this study were people with chronic headaches though, so maybe that explains that.
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– To find these articles, I use the following search string: “manual therapy AND cervicogenic headache AND cervicogenic dizziness”. Would you change anything regarding this search strategy?
I think that if you are searching for articles about manual therapy in regards to cervicogenic headache and dizziness then it will be a good potential search strategy. I think it all depends on your PICO question. Also, your search may come up with minimal results due to searching for two different diagnoses in one article, cerviocgenic headache and dizziness.
– Before reading this article, what were your views regarding SNAGs? After reading this article, has your opinion regarding this technique changed?
I really like using SNAGs as a treatment for patients with decreased cervical rotation, limited cervical joint mobility, cervical pain, and cervicogenic headaches. Overall, the patients seem to like this intervention after they get the hang of the form.
– What do you make of the authors’ findings? And are there any glaring limitations?
A glaring limitation that I noticed was the compliance in both groups but mainly of the placebo group. Could the the poor compliance be related to the lack of improvement or the lack of improvement be related to poor compliance?
The study had a relatively small number of participants (16 in each group).
The actual treatment itself interests me as it is described as “3 second sustained hold at pain free end range and performed for 2 repetitions.” I am not sure how much stock I place in this dosage.
– Have you ever treated cervicogenic dizziness? If so, what techniques or interventions have you found helpful?
Surprisingly enough, I have not actually treated any patients with cervicogenic dizziness. I have treated patients with cervicogenic headaches and there are a lot of different techniques that seem to be beneficial (STM to SCM and suboccipitals, MT including CPAs/UPAs, Exercises including laser for “joint repositioning training” and proprioception/kinesthesia and some gentle muscle energy techniques in various painfree ROM.
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