A dissertation submitted in partial compliance with the requirements for the Masters Degree in Technology: Chiropractic at Technikon Natal, 2002. / Tension-type headache is generally accepted as the most common form of headache and has been shown to have a great impact on work and social activities (Shwartz et al. 1998). Tension-type headache occurs in 39% of people who suffer from headache symptoms with a higher incidence among females, and a peak in the 25-44 year old age group (Wong et al. 1995). The purpose of this study was to investigate the relative effectiveness of 1000mg acetaminophen (paracetamol) combined with 130mg caffeine as opposed to cervical manipulation as a treatment for tension-type headache. / M

M.Tech. (Chiropractic) / The purpose of the study was to compare the effectiveness of a cervical support pillow in conjunction with correcting abnormal cervical spine biomechanical function (by intervention of high-speed, low-amplitude spinal manipulation in the cervical spine) versus correcting abnormal cervical spine biomechanical function alone, to determine which is the most effective treatment protocol for cervicogenic headache. Thirty-two subjects suffering from frequent, chronic headaches who fulfilled the International Headache Society criteria for cervicogenic headache participated in the investigation. These subjects were recruited from 70 headache sufferers who responded to newspaper and poster advertisements. Patients were randomly assigned to one of two groups as they enrolled for participation. The sixteen patients in group one received cervical spine manipulation twice a week for three weeks. The other sixteen patients received cervical spine manipulation twice a week for three weeks and used a cervical support pillow for sleeping over the three-week period. The main outcome measures included the following: Patients completed a daily headache diary. This monitored the change from week one to week three in analgesic use per day, headache intensity per episode, headache frequency per week and number of headache hours experienced per day. Cervical active range of motion readings were taken at all consultations prior to treatment, using a goniometer. A Neck Pain and Disability Index (Vernon- Mior) Questionnaire and a Numerical Pain Rating Scale 101 were completed by each patient at the initial, second, fourth and sixth visits. In conclusion, it cannot be denied that the combination of a cervical support pillow and correction of cervical spine joint complex dysfunction using standard chiropractic manipulative techniques is a more effective treatment protocol for the management of cervicogenic headache, as it has a far greater benefit with regard to improving the ranges of motion of the cervical spine and a similar effect in improving patient's perception of pain intensity, headache frequency, headache duration and level of functional disability as related to cervicogenic headache, than manipulation of joint complex dysfunction in the cervical spine alone. The short-term symptomatic relief and long-term goals of chiropractic management for cervicogenic headache with specific chiropractic spinal manipulative therapy may be improved by combining the use of a cervical support pillow to this already beneficial and effective protocol.

M.Tech. (Chiropractic) / The object of this study was to compare two chiropractic treatment approaches to each other in the management of migraine without aura. It was hypothesised that a combination of upper cervical and upper thoracic chiropractic manipulative therapy would be more effective than upper cervical chiropractic manipulative therapy alone. Migraine without aura was diagnosed according to the criteria of the International Headache Society (1988) and based on a structured case history, physical examination as well as regional orthopaedic and neurological examinations. Forty-one (41) subjects were randomly allocated to one of the two treatment groups in this single blind, randomised trial. Thirty-three patients completed the trial. Both groups received their respective chiropractic manipulative treatments twice a week for a total period of four weeks. During this time and a period of eight weeks thereafter, each patient kept a daily headache diary, noting migraine frequency, duration, headache intensity and associated analgesic pill consumption. Statistical analysis of the collected data involved inter-group comparisons of the above mentioned variables using Mann-Whitney Rank Sum tests, and intra-group comparisons of the above. mentioned variables using Wilcoxon Signed Rank tests at a 95% level of confidence. Intra-group analysis of the data revealed statistically significant (P < 0.05) decreases in migraine frequency and headache intensity for both groups. Migraine duration followed a similar pattern but for a sudden increase in duration in the third month for the group receiving a combination of upper cervical and upper thoracic chiropractic manipulative therapy. Inter-group analysis of the data established no statistically significant differences (P > 0.05) between the two treatment groups before or during the study. Throughout the study, there was a notable difference in average analgesic pill consumption between the two groups. The results indicate that both chiropractic manipulative therapy approaches had positive effects on the frequency, duration and headache intensity of migraines without aura. The effect of chiropractic manipulative therapy on the associated analgesic pill consumption is speculative, since there was no pre-treatment assessment of analgesic pill consumption. The sudden increase in migraine duration during the third month for the group that received both upper cervical and upper thoracic manipulation may be due to this treatment being less effective than upper cervical manipulation alone. The significance of this sudden increase will need to be established by future studies. Neither one of the two chiropractic treatment protocols applied in this study fared significantly better than the other. It is suggested that future studies consider any disability associated with migraines without aura. A pre-treatment trial period would provide reliable pre-treatment statistics for the variables investigated during such a trial and larger samples would represent the overall migraineur population better. It is suggested that a third group, receiving only chiropractic manipulative therapy to the upper thoracic spine, also be included.

M.Tech. (Chiropractic) / Cervicogenic Headache is a common musculoskeletal disorder afflicting people worldwide. It causes decreased productivity and mild to severe disability and thus has a large socio-economic impact on society. Much research is needed to improve the successful management of patients afflicted with this disorder. The aim of this study is to compare the effectiveness of spinal manipulation alone and spinal manipulation in conjunction with cervical stabilization exercises in the treatment of cervicogenic headache. Thirty eligible participants conforming to the North American Cervicogenic Headache Society classification of cervicogenic headache were solicited and randomly assigned to two groups of fifteen. Group 1 received spinal manipulative therapy to the full spine. Group 2 received spinal manipulative therapy to the full spine as well as cervical stabilization exercises. Patients were treated eight times over a four-week period with a six-week follow-up consultation thereafter. Objective and subjective measurements were taken at. the first, fourth, eighth and six-week follow-up consultations. Objective measurements consisted of cervical spine range of motion measurements. Subjective measures consisted of the Vernon-Mior neck pain and disability index and the numerical pain rating scale. Both groups displayed numerical improvements in all cervical spine ranges of motion. Both groups had statistically significant improvements in cervical spine right lateral flexion, while group 1 only had a statistically significant improvement in cervical spine left lateral flexion. Both groups displayed statistically significant improvements in the subjective measures. However, neither group had a statistically significant improvement over the other. It can be concluded that neither spinal manipulative therapy nor spinal manipulative therapy in conjunction with cervical stabilization exercises is more effective than the other. Thus rehabilitation of the cervicogenic headache patient yielded no measurable added benefit to spinal manipulative therapy only. However, results indicate that if more rigid or complex application of cervical spine stability training is incorporated, superior results may be achieved.

M.Tech. / The most common cause of chronic cervicogenic headache is believed to be mechanical pain from the muscles, ligaments and joints of the upper cervical spine (Hubka and Hall, 1994). Much controversy and debate surrounds all aspects of cervicogenic headache, including the aetiology and treatment of these headaches. The purpose of the study was to determine the effectiveness of chiropractic spinal manipulation of the upper cervical spine alone as a treatment form for cervicogenic headache, with regards to pain, disability and cervical spine range of motion. Method: This study consisted of a single group of thirty participants between the ages of eighteen and thirty-five, with a half male to female ratio. The potential participants were examined and accepted according to the inclusion and exclusion criteria. The only method of treatment administered to each participant was chiropractic manipulation, delivered to restrictions of the upper cervical spine, from which the objective and subjective findings were based. Procedure: Treatment consisted of seven consultations, with two consultations being performed per week. Objective data and subjective data was taken at the beginning of the first, fourth and seventh consultations. Objective data consisted of cervical range of motion readings taken using a Cervical Range of Motion measuring instrument (CROM). The subjective data collected was in the form of a Vernon-Mior Neck Pain and Disability Index and a Numerical Pain Rating Scale. Spinal manipulative therapy based on restrictions identified during motion palpation was applied at the first six consultations with the seventh consultation consisting of data gathering only. Results: Clinically and statistically, significant improvements in the entire group were noted over the course of the treatment with regards to cervical range of motion, pain and disability. Conclusion: The results show that upper cervical spine manipulation is effective, both clinically and statistically, in decreasing pain and disability and increasing cervical spine vi range of motion in those with cervicogenic headache. As the study consisted of a small group of participants treated as a single group, further study is needed in the form of randomised, controlled clinical trials.

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology, Durban University of Technology, 2010. / Episodic Tension–type headache (ETTH), which has a high prevalence, is the most common headache. Manual therapeutic approaches towards Episodic Tension-Type Headaches (ETTHs) have not been fully explored. However, cervical spine manipulation (CSM) and dry needling are found to be successful modalities for the treatment of tension-type headache (TTH). Therefore, this study aims to determine the effectiveness of CSM alone, dry needling alone and CSM combined with dry needling in the treatment of ETTHs. Objectives The objectives of this study include: determining the effectiveness of CSM alone, dry needling alone and CSM combined with dry needling in terms of objective and subjective data for the treatment of ETTHs. Method Forty five participants suffering from ETTHs, between the ages of eighteen and fifty, were recruited through convenience sampling and were randomly allocated to one of three equal groups (15 per group). The three different groups were: (A); CSM alone, (B); dry needling alone and (C); CSM in addition to dry needling. The study took place over a period of four weeks involving six consultations. Each participant received a headache diary for the duration of the study. At the first consultation the participant received the headache diary and was monitored for one week before the treatments commenced. Thereafter, four treatments were administered over the next two weeks, depending on group allocation. Participants were also monitored with the headache diary for one week after the last treatment. The objective data for each participant consisted of cervical range of motion (CROM) and pressure–pain threshold readings, measured using a CROM goniometer and an algometer respectively. The subjective data for each participant was collected using a headache diary and a headache questionnaire/disability index. SAS version 9.1.3 was used to analyse the data. A p value of <0.05 was considered as statistically significant. Results A decrease in headache duration, frequency, intensity and severity and increases in CROM and algometer measurements were observed in all groups. However, no statistically significant differences were found between the three groups in terms of objective and subjective measurements although, a statistically significant improvement from consultation five to six was found in Group C in terms of headache disability. Conclusion CSM and dry needling, used in isolation or in combination are effective in the treatment of ETTHs although Group C did show superiority over the other groups in the long term with respect to the disability index.

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Durban University of Technology, 2007 / The purpose of this study was to determine the relationship between Myofascial Pain Syndrome (MPS) of the pericranial musculature and the clinical presentation of episodic tension-type headache (ETTH). It set out to determine the extent to which MPS is related to the nature of the ETTH. ETTH is a very prevalent disorder, common to individuals in their third decade, and particularly females. Current literature suggests a multi-factorial aetiology, combining psychological and neuromusculoskeletal mechanisms, to name a few. Due to the many facets of this disorder, it has, for a long time, provided a challenge to the practitioner with regard to patient treatment and management. MPS is a condition that may affect any number of muscles, resulting in motor, sensory and autonomic symptoms. MPS of the pericranial muscles, namely the upper Trapezius, Sternocleidomastoid, Temporalis and Suboccipital muscles, produces a referred pain pattern similar to the pain pattern experienced during an ETTH. The literature states that the pain produced by MPS has been somewhat overlooked and it was thus necessary to further investigate the myofascial component of ETTH. This study was a quantitative, pilot, non-intervention, clinical assessment study, which required forty participants residing in the province of Kwa-Zulu Natal suffering from ETTH. The clinical assessment included a case history and physical and cervical examinations. The participants were requested to complete a headache diary over a period of 14 days. Following this, they returned to the Chiropractic Day Clinic for a second consultation. Data was collected at both consultations and the participant was offered one free treatment. The headache diary and Numerical Pain Rating Scale provided the subjective measurements, while the algometer and Myofascial Diagnostic Scale were used to gather the objective measurements. / M

Submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban University of Technology, Durban, South Africa, 2018. / Background: Cervicogenic headaches are usually chronic, debilitating and tend to be unresponsive to common headache medications. Manual therapy has been shown to be an effective form of management for cervicogenic headache. The Electromechanical Adjusting Instrument is a hand-held device offered as an alternative to manual therapy for musculoskeletal treatment. Aim: The aim of this study was to determine the effectiveness of the Electromechanical Adjusting Instrument compared to cervical spine manipulation in terms of subjective and objective measures in the treatment of cervicogenic headache. Methodology: This study was a randomised single-blinded clinical trial. There were 41 participants between the ages of 18 and 59 years who were randomly divided into two groups of 21 and 20 respectively by means of a randomisation table drawn up by the statistician. Participants in Group A received cervical spine manipulation while those in Group B received the Electromechanical Adjusting Instrument. Subjective headache intensity was determined using a Numerical Pain Rating Scale. The effect of neck pain on the participants’ activities of daily living before and after treatment was assessed using the Neck Disability Index. The effect of the headache on the participants’ activities of daily living before and after treatment was assessed using the Headache Disability Index. Objective cervical range of motion in all six planes of motion was assessed using a CROM goniometer. Participants in both groups received six interventions over a three-week period with a minimum interval of 48 hours between each intervention. The subjective and objectives assessments were taken at baseline, post-third and post-sixth interventions. The data was analysed using the IBM SPSS version 24.0. Repeated measures ANOVA was used to examine the effect on each outcome measure separately of time and treatment group interaction. Profile plots were generated to show the rates of changes in outcomes over time by the intervention group. A p value <0.05 was considered statistically significant. Results: For most of the outcomes, there was no clinical or statistical interaction present, i.e. the intervention effect was similar in both groups irrespective of the intervention. Conclusion: The trends in each of the outcomes suggest that the Electromechanical Adjusting Instrument is as effective as cervical spine manipulation for the treatment of cervicogenic headache / M

M.Tech. / Purpose: Acupuncture has been a controversial issue in the medical world for many years before the sceptic western medicine slowly adopted its idea. Some mechanisms for pain relief were clinically researched and proven to be valid as well as effective in treating tension-type headaches (Stux, Berman and Pomerantz, 2003) The purpose of this study was to assess and compare the effects of cervical spine manipulation and needling of acupuncture points in those patients with tension-type headache and suggest another complimentary treatment to the chiropractic manipulation, especially in those patients where manipulation is contraindicated to manipulation. If found to be effective, various mechanisms have been suggested in the formation of tension headache episodes. Those mechanisms may be alterations within the spinal cord and/or brainstem gating mechanisms as a result of facet joint dysfunction, sensitization of nociceptors in the peripheral structures of the body and psychological factors. Method: This study consisted of two groups, consisting of 16 subjects in each group. All participants were screened for tension-type headaches and accepted based on the inclusion and exclusion criteria. The subjects were between the ages of eighteen and thirty-five. Group 1 received chiropractic manipulation treatment to the most restricted levels in their cervical spine. Group 2 received treatment consisting of needling of acupuncture points to specific predetermined points. Procedure: Each successful candidate was treated six times over a 3 week period which included a total of seven sessions. Before the beginning of the treatment, the successful candidate completed the Vernon-Mior Neck Pain and Disability Index Questionnaire and the Numerical Pain Rating Scale. Readings for cervical spine ranges of motion were then taken with a CROM device. In group 1, chiropractic manipulation was then delivered to the most restricted segments in the cervical spine. In group 2, needling of six predetermined acupuncture points for relieving tension-type headache was performed bilaterally. The same treatment procedure was administered at sessions one through six, the CROM readings and questionnaires were taken in sessions one, three, five and seven. Results: The results were obtained by using the Mann-Whitney U and t-test. No statistically significant differences were identified between the groups, when comparing the 2 treatment methods at the visits. However, both groups showed a statistically significant improvement over time within each group individually for subjective measurements and for right lateral flexion in the objective measurements. Conclusion: The results were inconclusive with regards to the prolonged effects of chiropractic manipulation and needling of acupuncture points on cervical spine range of motion in patients with tension-type headache. However, it was concluded that both methods of treatment had beneficial effects on how the participants perceived their pain and disability. Due to the small group of subjects and relatively short duration of the study, accurate conclusions could not be formulated. The findings obtained were insignificant and further research needs to be performed on the effects of cervical spine manipulation and needling of acupuncture points on those suffering with tension-type headache.

M.Tech. / Purpose: Heachaches are a very common complaint among society today, and as a result there are a vast number of individuals seeking medical treatment specifically for headaches (Alix and Bates, 1999). The impact that headaches have on a patients quality of life far exceeds that of other conditions such as osteoarthritis and hypertension. Primary headaches such as Cervicogenic, Cluster and Tension-type headaches have no specific underlying cause. However, it has been shown that spinal manipulative therapy (SMT) can be used as an effective tool in the treatment of these primary headaches (Brontford, Assendelft, Evans, Haas, and Bouter, 2001; Khoury, 2000 and Vernon, 1995). A Cervicogenic Headache is defined by the North American Cervicogenic Society (NACHS) as referred pain perceived in any region of the head caused by a primary nociceptive source in the musculoskeletal tissues innervated by cervical nerves. The aim of this study was to determine the efficacy of upper cervical spine manipulation in conjunction with Interferential current and Ultrasound therapy, compared to upper cervical spine manipulations alone as a treatment protocol for Cervicogenic headaches. Method: This study consisted of two groups; both Group 1 and Group 2 consisted of 15 participants with Cervicogenic headaches. The participants were between the ages of 18 and 55 years. Potential participants were examined and accepted based on the inclusion and exclusion criteria. Group 1 received spinal manipulative therapy over restricted segments in the upper cervical spine C1-C3 levels. Group 2 received a combination treatment with Interferential current and Ultrasound therapy over active myofascial trigger points in the Posterior Cervical muscles in conjunction with spinal manipulative therapy over restricted segments in the upper cervical spine C1-C3 levels. Objective and subjective findings were based on the treatments. Procedure: The participants received six treatments in total over a three week period that is two treatments a week for three weeks followed by a seventh consultation visit where only subjective and objective measurements was taken. The participants completed a Numerical Pain Rating Scale and Headache Disability Index Questionnaire. Algometer readings were taken over the most sensitive trigger point in the Posterior Cervical muscles. Group 1 received spinal manipulative therapy over restricted segments in the upper cervical spine and Group 2 received a ten minute combination treatment with Interferential current and Ultrasound therapy over active myofascial trigger points in the Posterior Cervical muscles in conjunction with spinal manipulative therapy over restricted segments in the upper cervical spine. The same treatment procedures were administered over the study; subjective and objective readings were only taken at visits 1, 4 and 7. Results: In terms of objective measurements based on the pressure Algometer readings, a statistically significant difference was revealed within both Group 1 and Group 2 individually over time. No statistically significant difference in muscle sensitivity between the two groups over time was revealed. However, Group 1 showed a larger overall clinically significant difference in Posterior Cervical muscle sensitivity. In terms of subjective measurements based on the Headache Disability Index Questionnaire scores, a statistically significant difference was revealed within both Group 1 and Group 2 individually over time. No statistically significant difference in terms of intensity, duration and frequency of the headaches between the groups over time was revealed. However, Group 1 had a greater clinical reduction in intensity, duration and frequency of headaches when compared to Group 2. In terms of subjective measurements based on the Numerical Pain Rating Scale scores, a statistically significant difference was revealed within both Group 1 and Group 2 individually over time. A statistically significant difference in terms of intensity of the headaches between the groups over time was revealed. The overall clinical improvement was similar for both groups however Group 1 had a slightly greater clinical reduction in headache intensity when compared to Group 1. Conclusion: Both groups showed an overall improvement in the headache symptoms as well as Posterior Cervical muscle sensitivity; however Group 1 showed a greater clinical improvement when compared to Group 2.