An experimental study will be conducted to evaluate the effect of dry needling on the M.
      Obliquus capitis inferior on rotational mobility and headache realted outcome measures in
      patients with cervicogenic headache.

Dry Needling of the M. Obliquus Capitis Inferior on Rotational Mobility and Headache Related Outcome Measures in CH.

Neck Pain, Posterior

Headache

Mobility Limitation

Headache is a common and disabling condition. Several primary and secondary headache forms
      have been described, such as migraine, tension-type headache and cervicogenic headache (CH).
      In patients with CH; we can see a reffered pain pattern to the head, possibly originating
      from a source in the (upper)cervical spine. It has been described that nociceptive input,
      originating from the C1-C3 nervous system may be responsible for pain referal to head and
      neck regions. Recently, the flexion-rotation test (FRT) has been described as one of the most
      usefel clinical tests in the clinical testing and research of CH. Other literature showed
      that the rotational movement during the FRT was diminished in patients with CH and these
      results were correlated to headache intensity. 5,6

      To treat this disabling condition, manual therapy is already known to be an effective
      treatment strategy. However, the additional value of dry needling is still to be discussed.
      Since the M. Obliquus capitis inferior (M. OCI) finds its origin on the apex of the spinous
      processus of C2 and inserts on transverse processus of the atlas (C1); this muscle might be
      anatomically very relevant to influence rotational mobility in the upper cervical spine.
      Additionally, this muscle is responsible for proprioception and accurate positioning of the
      head and neck, due to the presence of a large amount of Golgi bodies and muscle spindles in
      the muscle. Considering the myofascial pain referal pattern of the M. OCI, a referred pain
      pattern to the temporal region may be present when active triggerpoints are present.

      Previous research already showed some preliminary evidence for positive treatment effects by
      dry needling of the M. OCI in patients with cervicogenic dizziness and headache.

      The goal of this study is to evaluate the effect of a single dry needling intervention of the
      M. OCI on rotational mobility and headache related parameters, in a group of cervicogenic
      headache patients with a positive flexion-rotation test (articular mobility test on level
      C1-C2).

      In this experimental study, 40 patients with cervicogenic headache will be recruited.
      Participants are required to have complaints for at least 3 months. Participants are included
      based on online questionnaires, a clinical examination of neck and shoulder, and the
      identification of a MTrP in the M. OCI muscle. All participants will receive information and
      have to sign an informed consent form.

      Participants will be subjected to baseline assessment, which involves questionnaires and
      measurements of the cervical spine.

      Secondly, participants will be randomly allocated to either the dry needling group or a sham
      needling group. The dry needling group will receive a dry needling treatment at the
      identified trigger point location (M. OCI - heterolateral to the restricted rotationside)
      whereas the sham needling group will receive an intervention in which the needle only
      penetrates the skin but not the fascia and muscle tissue.

      Rotational mobility will be evaluated after the needling intervention, afterwards all
      patients will receive a standardized manual therapy treatment (Muscle Energy Technique).
      Afterwards, all baseline measurements will be conducted again. This testing will be repeated
      one week after treatment as well.

Dry Needling

Sham Needling

Effect of Dry Needling of the M. Obliquus Capitis Inferior on Rotational Mobility and Headache Related Outcome Measures in Patients With Cervicogenic Headache: a Randomized, Controlled Experimental Study

Changes in Atlanto-axial rotational mobility after dry needling or sham needling will be assessed by the flexion-rotation test at baseline, immediately after needling (DN or SN); immediately after manual therapy and 1 week after treatment. Measurements will be registered with the digital EasyAngle Goniometer (Meloq).
The change in Atlanto-axial rotational mobility after dry needling will be compared with the change Atlanto-axial rotational mobility after sham needling. Atlanto-axial rotational mobility be expressed in degrees.

Changes in pain score after dry needling, compared to sham needling, as assessed by the numeric rating scale (NRS).
Subjects will have to report their actual pain complaints on a numeric rating scale (NRS) ranging from 0 (no pain) to 10 (worst pain) at baseline, immediately after dry or sham needling + manual therapy and 1 week after the intervention.

Changes in neck disability scores after dry needling, compared to sham needling, will be assessed by the Neck Disability Index. The Neck Disability Index consists of 10 questions, each with 6 answer options with concomitant scores ranging from 0 to 5, which makes the total score of the NDI on 50. A score between 5 and 14 represents a mild disability, whereas a score between 15 and 24 is interpreted as a moderate disability. NDI scores of 25 or higher reflect a severe disability. Subjects will have to report their actual disability complaints at baseline, immediately after dry or sham needling + manual therapy and 1 week after the intervention.

Changes in headache disability scores after dry needling, compared to sham needling, will be assessed by the Headache Disability Index. The Headache Disability Index consists of 25 questions which can be answered with yes (4 points), sometimes (2 points) and no (0 points). A total score of 10-28 is considered to indicate mild disability; 30-48 is moderate disability; 50-68 is severe disability; 72 or more is complete disability. Subjects will have to report their actual disability complaints at baseline, immediately after dry or sham needling + manual therapy and 1 week after the intervention.

Changes in Global Perceived Effect scores after dry needling, compared to sham needling, as assessed by the Global Perceived Effect Scale. This scale consists of 7 scores (ranging from 1 (very much better) to 7 (very much worser).
Subjects will have to report their global perceived effect at baseline, immediately after dry or sham needling + manual therapy and 1 week after the intervention.

Changes in headache impact after dry needling, compared to sham needling, as assessed by the Headache Impact Test (HIT-6) Subjects will have to report their headache impact at baseline, immediately after dry or sham needling + manual therapy and 1 week after the intervention.

Changes in global cervical mobility after dry needling or sham needling will be assessed at baseline, immediately after the intervention (needling + manual therapy) and 1 week after treatment. Measurements will be registered with the digital EasyAngle Goniometer (Meloq).
The change in global cervical mobility will be expressed in degrees.

Changes in PPTs after dry needling or sham needling will be assessed at baseline, immediately after the intervention (needling + manual therapy) and 1 week after treatment. Measurements will be registered with the digital hand-held pressure algometer (Wagner FPX 25 Force Gage). The change in PPTs will be expressed in Newton.
To standardize the pressure applied by the investigator, the same investigator always stabilized his wrist with his other hand. The PPT assessment was performed two times with a 30-second break between each application and the pressure was increased by 1N/s until the patient reported the pressure as unpleasant. This pressure was taken as PPT expressed in Newton (N); and the average will be taken of the three measurements on the spinous process of C2 and the Upper Trapezius Muscle.

Changes in joint position error after dry needling or sham needling will be assessed at baseline, immediately after the intervention (needling + manual therapy) and 1 week after treatment. Measurements will be registered with the digital Motion Guidance Laser.
The Cervical Joint Position Error (JPE) Test is a measurement tool used to clinically assess an individual's cervicocephalic proprioception ability. Cervicocephalic proprioception describes one's sense of position of their head and neck in space. The Cervical JPE Test measures the ability of a blindfolded patient to accurately relocate their head position back to a predetermined neutral point after cervical joint movement.

The Craniocervical flexion test (CCFT) is a clinical test of neuromotor control including the activation and endurance of the deep flexors of the cervical spine. This test involves the subject performing a "yes" like nod which is the anatomical action of the Deep Cervical flexors, against a pressure biofeedback.
Two subscores will be used: for performance and for endurance of the deep cervical flexors.

Psychosocial related parameters: Central Sensitization Index (CSI) + Pain Catastrophizing Scale (PCS) + Pain Coping Strategies (PCI) + Pain Related Fear: Tampa Scale of Kinesiophobia (TSK)

A single dry needling session will be performed with the subject lying in prone position. A trained physiotherapist will penetrate the needle into skin surface, fascia,into the muscle tissue at the MTrP location of the M. Obliquus Capitis Inferior, and will move the needle up and down to elicit local twitch responses.In case local twitch responses are elicited, this will be repeated until the local twitch responses are extinct. Afterwards, a rotational muscle energy technique will be applied to the atlanto-axial level.

A single sham needling session will be performed with the subject lying in prone position. A trained physiotherapist will penetrate the needle into the skin surface at the MTrP location. The fascia and muscle tissue will not be penetrated. Afterwards, a rotational muscle energy technique will be applied to the atlanto-axial level.

Dry Needling of the M. Obliquus Capitis Inferior on Rotational Mobility and Headache Related Outcome Measures in CH.

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