Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache

Toby Hall, Ho Tak Chan, Lene Christensen, Britta Odenthal, Cherie Wells, Kim Robinson

Research output: Contribution to journalArticlepeer-review

80 Citations (Scopus)


STUDY DESIGN: Randomized, double-blind, placebo controlled trial.

OBJECTIVES: To determine the effect of a C1-C2 self-sustained natural apophyseal glide (SNAG) on cervicogenic headache.

BACKGROUND: Cervicogenic headache is a common condition causing significant disability. Recent studies have shown a high incidence of C1-C2 dysfunction, evaluated by the flexion-rotation test (FRT), in subjects with cervicogenic headache. To manage this dysfunction, Mulligan has described a C1-C2 self-SNAG, though no studies have investigated the efficacy of this intervention approach.

METHODS: A sample of 32 subjects (mean _ SD age, 36 +/- 3 years) with cervicogenic headache and FRT limitation were randomized into a C1-C2 self-SNAG or placebo group. After an initial instruction and practice visit in the clinic, interventions consisted of exercises applied independently by the subject twice daily at home on a continual basis. FRT range was measured twice, before and immediately after the instruction and practice visit. Headache symptoms were determined by a headache index over time, assessed by questionnaire preintervention, at 4 weeks postintervention, and at 12 months postintervention.

RESULTS: No differences were found in baseline measures between groups. Immediately after the initial instruction and practice visit performed with the supervision of the therapist, FRT range increased by 15 degrees (SD, 9) for the C1-C2 self-SNAG group (P < .001), which was significantly more than 5 degrees (SD, 5) for the placebo intervention (P < .001). There was also a significant interaction for the variable headache index between group and time (P < .001), indicating that group difference was dependent on time. There was no difference in headache index scores at baseline between groups. Headache index scores were substantially less in the C1-C2 self-SNAG group (mean +/- SD points at 4 weeks, 31 +/- 9; mean +/- SD points at 12 months, 24 +/- 9) compared to the placebo group (mean +/- SD points at 4 weeks, 51 +/- 15; mean +/- SD points at 12 months, 44 +/- 13) at 4 weeks (P < .001) and 12 months (P < .001), with an overall (+/-SD) reduction of 54% (+/-17%) for the individuals in the C1-C2 self-SNAG group.

CONCLUSIONS: These results provide evidence for the efficacy of the C1-C2 self-SNAG technique in the management of individuals with cervicogenic headache.

Original languageEnglish
Pages (from-to)100-7
Number of pages8
JournalJournal of Orthopaedic and Sports Physical Therapy
Issue number3
Publication statusPublished - Mar 2007


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