AUTUMN
Question
What is the effect of a 4-week regimen of Mulligan manual therapy (MMT) plus exercise compared with exercise alone for managing cervicogenic headache? Is MMT plus exercise more effective than sham MMT plus exercise? Are any benefits maintained at 26 weeks of follow-up?
问题：在治疗颈源性头痛方面，为期4周的Mulligan手工疗法（MMT）加运动方案与单独运动方案相比有什么效果？MMT +运动是否比假MMT +运动更有效？在26周的随访中是否有任何益处保持？
Design
A three-armed, parallel-group, randomised clinical trial with concealed allocation, blinded assessment of some outcomes and intention-to-treat analysis.
设计：一项三臂、平行组、随机临床试验，隐蔽分配，对一些结果进行盲法评估和意向治疗分析。
Participants
Ninety-nine people with cervicogenic headache as per International Classification of Headache Disorders (ICHD-3).
参与者：根据国际头痛疾病分类（ICHD-3）， 99例颈源性头痛患者。
Interventions
Participants were randomly allocated to 4 weeks of: MMT with exercise, sham MMT with exercise or exercise alone.
干预措施：参与者被随机分配到4周的MMT加运动，假MMT加运动或单独运动。
Outcome measures
The primary outcome was headache frequency. Secondary outcomes were headache intensity, headache duration, medication intake, headache-related disability, upper cervical rotation range of motion, pressure pain thresholds and patient satisfaction. Outcome measures were collected at baseline and at 4, 13 and 26 weeks.
结局指标：主要结局为头痛频率。次要结局为头痛强度、头痛持续时间、药物摄入、头痛相关残疾、上颈椎旋转活动度、压痛阈值和患者满意度。在基线、4周、13周和26周时收集结果测量值。
Results
MMT plus exercise reduced headache frequency more than exercise alone immediately after the intervention (MD between groups in change from baseline: 2 days/month, 95% CI 2 to 3) and this effect was still evident at 26 weeks (MD 4 days, 95% CI 3 to 4). There were also benefits across all time points in several secondary outcomes: headache intensity, headache duration, headache-related disability, upper cervical rotation and patient satisfaction. Pressure pain thresholds showed benefits at all time points at the zygapophyseal joint and suboccipital areas but not at the upper trapezius. The outcomes in the sham MMT with exercise group were very similar to those of the exercise alone group.
结果：MMT加运动比干预后立即进行运动更能减少头痛频率（组间从基线变化的MD: 2天/月，95% CI 2至3），并且这种效果在26周时仍然明显（MD 4天，95% CI 3至4）。在所有时间点，几个次要结局也有益处：头痛强度、头痛持续时间、头痛相关残疾、上颈椎旋转和患者满意度。压力疼痛阈值在关节突关节和枕下区域的所有时间点显示出益处，但在上斜方肌没有。假MMT联合运动组的结果与单独运动组非常相似。
Conclusion
In people with cervicogenic headache, adding MMT to exercise improved: headache frequency, intensity and duration; headache-related disability; upper cervical rotation; and patient satisfaction. These benefits were not due to placebo effects
结论：在颈源性头痛患者中，在运动中加入MMT可改善头痛的频率、强度和持续时间；headache-related残疾;上颈椎旋转；以及病人的满意度。这些益处不是由于安慰剂效应。
文献内容展示：
1.Interventions 干预措施
Participants in the exercise alone group received a structured exercise program comprising cervical flexion loading exercises,40 scapular retraction in a prone position, passive static self-stretching exercises and active mobility exercises of the neck. The exercise component took 20 minutes/session. The MMT with exercises group pragmatically received additional MMT, which took an additional 10 minutes/session. During the initial consultation, a trial headache sustained natural apophyseal glide (SNAG), reverse headache SNAG, modified headache SNAG and upper cervical traction technique were trialled in sequence to determine which technique, if any, would reduce headache intensity. The next technique in sequence was only applied if no reduction in headache intensity was observed with the application of the first technique. If the headache intensity reduced with a technique, it was repeated as the treatment.
单独运动组的参与者接受了一项有组织的锻炼计划，包括颈椎屈曲负荷锻炼、俯卧位肩胛骨后缩、被动静态自我拉伸锻炼和颈部主动活动锻炼。锻炼部分每次20分钟。试验组接收额外的MMT，每次10分钟。在初次治疗期间，依次试验了持续性头痛自然椎体滑动（SNAG）、反向头痛SNAG、改良头痛SNAG和上颈椎牵引技术，以确定哪种技术（如果有的话）可以减轻头痛强度。只有在应用第一种技术没有观察到头痛强度减少的情况下，才依次应用下一种技术。如果头痛强度通过一种技术降低，则作为治疗重复进行。
2. 试验设计和流程：
3. Primary outcome
Group means and standard deviations for the primary outcome measure – headache frequency – at all time points are presented in Table 2. Between-group differences in change with 95% CIs are presented in Table 3.
At 4 weeks, the mean difference in headache frequency achieved the smallest worthwhile effect threshold for MMT combined with exercise compared with either of the other groups, but the 95% CIs spanned that threshold (Table 3). Therefore, the results at 4 weeks indicated a benefit but the clinical relevance of the benefit was uncertain. At 13 and 26 weeks, these mean differences and 95% CIs achieved or exceeded the smallest worthwhile effect, confirming worthwhile benefits. Differences were negligible between sham MMT plus exercise and exercise alone at all time points
主要结局指标头痛频率在所有时间点的组均值和标准差见表2。95% ci组间变化差异见表3。在第4周时，与其他两组相比，MMT联合运动的头痛频率的平均差异达到了最小的有价值的效果阈值，但95%的ci跨越了该阈值（表3）。因此，第4周的结果表明有益处，但益处的临床相关性尚不确定。在13周和26周时，这些平均差异和95% ci达到或超过了最小的有价值效果，证实了有价值的益处。在所有时间点上，假MMT加运动和单独运动之间的差异可以忽略不计。
4. Secondary outcomes
Headache parameters: Group means and standard deviations for headache intensity, headache duration, headache medication and headache disability at all time points are presented in Table 2.
Between-group differences in change with 95% CI are presented in Table 3
头痛参数：各时间点头痛强度、头痛持续时间、头痛药物和头痛失能的组均值和标准差见表2。
组间变化差异及95% CI见表3
各组在各时间点头痛结局的平均值（SD）
头痛结局变化的组间平均差异（95% CI）
各组在各时间点的平均满意度（SD）
组间满意度的平均差异（95% CI）
各组在各时间点其他结局的中位数（IQR）
其他结局变化的组间中位数差异（95% CI）
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