Spinal manipulation and perineural electrical dry needling in patients with cervicogenic headache: a multicenter randomized clinical trial.

BACKGROUND CONTEXT: Spinal 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. PURPOSE: The 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/SETTING: Randomized, multicenter, parallel-group trial. PATIENT SAMPLE: One hundred forty-two patients (n=142) with CH from 13 outpatient clinics in 10 different states were recruited over a 36-month period. OUTCOME MEASURES: The 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. METHODS: Patients 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. RESULTS: The 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 (0.94