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BackgroundAlthough commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH.MethodsOne hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable.ResultsThe 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001).ConclusionsSix to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months.Trial registrationNCT01580280 April 16, 2012.

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Shoulder impingement is a progressive orthopedic condition that occurs as a result of altered biomechanics and/or structural abnormalities. An effective nonoperative treatment for impingement syndrome is aimed at addressing the underlying causative factor or factors that are identified after a complete and thorough evaluation. The clinician devises an effective rehabilitation program to regain full glenohumeral range of motion, reestablish dynamic rotator cuff stability, and implement a progression of resistive exercises to fully restore strength and local muscular endurance in the rotator cuff and scapular stabilizers. The clinician can introduce stresses and forces via sport-specific drills and functional activities to allow a return to activity.

The repetitive nature of throwing manifests characteristic adaptive changes to the shoulder, scapulothoracic, and hip/pelvis complexes that result in a set of unique physical traits in the overhead throwing athlete. An effective rehabilitation program is dependent upon an accurate evaluation and differential diagnosis to determine the causative factors for the athlete's pathologic features. The treatment program should be individualized with specific strengthening and flexibility exercises to achieve the dynamic stability that is required for overhead function. In this article we describe the characteristics of the throwing shoulder, along with a multiphased rehabilitation program that allows for the restoration of strength, mobility, endurance, and power and is aimed toward a return to unrestricted sporting activity. We also describe exercises that link the upper and lower extremities because of the importance of core control and leg strength in the development of power during the act of throwing. Additionally, proper throwing mechanics, utilization of pitch counts, appropriate rest, and proper off-season conditioning will help decrease overall injury risk in the overhead throwing athlete.