PPIVMs for Cervicogenic Headache (PPIVMs)

May 29, 2026 updated by: Saddam Kanaan, Jordan University of Science and Technology

The Effectiveness of Passive Physiological Intervertebral Movements in Patients With Cervicogenic Headache: A Randomized Clinical Trial

Cervicogenic headache is a type of headache that originates from problems in the neck, particularly the upper cervical spine. It may cause headache pain, neck pain, reduced neck movement, disability, emotional distress, and reduced quality of life. Physiotherapy management commonly includes therapeutic exercise and manual therapy techniques.

This randomized clinical trial examined whether adding Passive Physiological Intervertebral Movements to a structured therapeutic exercise program was more effective than therapeutic exercise alone in patients with cervicogenic headache. Participants diagnosed with cervicogenic headache were randomly assigned to one of two groups. The intervention group received Passive Physiological Intervertebral Movements targeting the upper cervical joints, in addition to therapeutic exercises. The control group received the same therapeutic exercise program without Passive Physiological Intervertebral Movements.

Both groups received eight supervised treatment sessions over four weeks, with each session lasting approximately 15 to 20 minutes. The exercise program included cervical flexion exercises, scapular retraction, stretching exercises, and active neck mobility exercises. Participants were also encouraged to perform the exercises at home.

The study was conducted between May 2022 and August 2025 at the outpatient physiotherapy departments of Jordan University of Science and Technology and King Abdullah University Hospital. Outcomes were assessed at baseline, immediately after the four-week intervention, and at three-month follow-up. The outcomes included headache pain intensity, headache frequency, neck pain intensity, neck disability, depression, anxiety, stress, and quality of life. These were measured using validated tools, including the Numeric Pain Rating Scale, Neck Disability Index, Depression Anxiety Stress Scale-21, and Short Form-12 quality of life questionnaire.

The study aimed to determine whether adding Passive Physiological Intervertebral Movements to exercise provides additional benefits for patients with cervicogenic headache compared with exercise alone. The trial included 64 participants.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

This study was designed as a parallel-group randomized clinical trial to evaluate the added effect of Passive Physiological Intervertebral Movements when combined with therapeutic exercise for individuals with cervicogenic headache. The trial compared a combined manual therapy and exercise approach with the same exercise program delivered without Passive Physiological Intervertebral Movements.

Participants were screened using a standardized clinical diagnostic process for cervicogenic headache. The diagnostic process included clinical history, physical examination, assessment of upper cervical dysfunction, and exclusion of headache presentations more consistent with primary headache disorders or other cervical conditions not suitable for mobilization. Screening and baseline assessment procedures were performed using standardized methods to support consistency across participants.

After eligibility confirmation and baseline assessment, participants were randomly allocated to one of two treatment groups. Randomization was performed using a computer-generated random sequence. Allocation concealment was maintained using sequentially numbered, opaque, sealed envelopes prepared before recruitment. Group assignment was managed by an independent researcher who was not involved in treatment delivery or outcome assessment.

The experimental intervention consisted of Passive Physiological Intervertebral Movements applied to the upper cervical region in addition to a structured therapeutic exercise program. The manual therapy component was individualized according to the participant's clinical presentation and focused on restoring mobility of the upper cervical segments, particularly the atlanto-occipital, atlantoaxial, and C2-C3 regions. Manual therapy was delivered by a qualified physiotherapist with experience in spinal mobilization.

The comparator intervention consisted of the same structured therapeutic exercise program without Passive Physiological Intervertebral Movements. The exercise program included deep cervical flexor activation, scapular control exercises, cervical stretching, and active cervical mobility exercises. Exercise delivery was standardized through training of the treating students/therapists and use of a consistent intervention protocol. Participants were also encouraged to continue the prescribed exercises at home.

Both groups received eight supervised treatment sessions over four weeks. Treatment sessions were delivered twice weekly and lasted approximately 15 to 20 minutes. The intervention period was followed by post-treatment assessment and longer-term follow-up assessment.

To reduce bias, outcome assessments were conducted by an assessor who was not involved in treatment delivery and was blinded to group allocation. The treating clinicians were not involved in outcome assessment. Baseline demographic and clinical characteristics were collected to describe the sample and examine comparability between groups before treatment.

Data analysis was planned to compare between-group differences across the assessment time points. Baseline characteristics were summarized using descriptive statistics. Continuous variables were described using means and standard deviations, and categorical variables were described using frequencies and percentages. Baseline group comparability was examined using appropriate statistical tests. Multivariate analysis was used to examine between-group differences in clinical outcomes at follow-up time points, followed by individual between-group comparisons where appropriate. Statistical analyses were conducted using IBM SPSS.

The study was approved by the Institutional Review Board at Jordan University of Science and Technology. Written informed consent was obtained from all participants before enrolment. Data were handled confidentially and stored securely according to institutional procedures.

Study Type

Interventional

Enrollment (Actual)

64

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Jordan
      • Irbid, Jordan, 22110
        • Jordan University of Science and Technology

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • Were diagnosed with cervicogenic headache using a standardized clinical diagnostic protocol based on history and physical examination.

Had a positive Cervical Flexion-Rotation Test, defined as reduced cervical rotation by ≥10° on the symptomatic side compared with the asymptomatic side, or total rotation <32°.

Had referred pain originating from the cervical spine, confirmed by mechanical provocation such as manual palpation or pressure over the C1-C3 zygapophysial joints reproducing typical headache symptoms.

Had pain behavior consistent with cervicogenic headache, such as symptoms worsened by sustained neck posture or specific neck movements.

Had other primary headache disorders excluded based on clinical history and symptom characteristics.

Exclusion Criteria:

  • Diagnosed with disc herniation and stenosis of the spinal canal.
  • Clinically diagnosed as a case of cervical radiculopathy or myelopathy.
  • Subjects with conditions or diseases that are contraindicated for mobilization treatment: rheumatoid arthritis, ankylosing spondylitis, spondylolistheses, cervical fractures, osteoporosis, osteomyelitis, malignancy, and pregnancy
  • Have received manual therapy or exercise by a physical therapist in the last six months.
  • Patients diagnosed with cognitive dysfunction, psychological disorder, or communication/cognitive deficits.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Double

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Passive Physiological Intervertebral Movements plus Therapeutic Exercise
Participants received Passive Physiological Intervertebral Movements targeting the upper cervical joints in addition to a structured therapeutic exercise program.
Procedure: Passive Physiological Intervertebral Movements
Manual therapy technique applied to the upper cervical spine, targeting C0-C1, C1-C2, and C2-C3 mobility.
Procedure: Therapeutic Exercise
Structured exercise program including cervical flexion/chin tuck exercises, scapular retraction, stretching, and active neck mobility exercises.
Active Comparator: Therapeutic Exercise Alone
Participants received the same structured therapeutic exercise program without Passive Physiological Intervertebral Movements.
Procedure: Therapeutic Exercise
Structured exercise program including cervical flexion/chin tuck exercises, scapular retraction, stretching, and active neck mobility exercises.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Headache Pain Intensity Measured by Numeric Pain Rating Scale
Time Frame: Baseline, 4 weeks, and 3 months
Headache pain intensity was assessed using the 11-point Numeric Pain Rating Scale. Scores range from 0 to 10, where 0 indicates no pain and 10 indicates the worst pain imaginable. Higher scores indicate greater headache pain intensity.
Baseline, 4 weeks, and 3 months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Headache Frequency Per Week
Time Frame: Baseline, 4 weeks, and 3 months
Headache frequency was assessed as the number of headache episodes reported per week. Higher values indicate more frequent headache symptoms.
Baseline, 4 weeks, and 3 months
Neck Pain Intensity Measured by Numeric Pain Rating Scale
Time Frame: Baseline, 4 weeks, and 3 months
Neck pain intensity was assessed using the 11-point Numeric Pain Rating Scale. Scores range from 0 to 10, where higher scores indicate greater neck pain intensity.
Baseline, 4 weeks, and 3 months
Neck Disability Measured by Neck Disability Index
Time Frame: Baseline, 4 weeks, and 3 months
Neck-related disability was assessed using the Neck Disability Index. The scale includes 10 items, each scored from 0 to 5, with a total score ranging from 0 to 50. Higher scores indicate greater neck-related disability.
Baseline, 4 weeks, and 3 months
Stress Symptoms Measured by Depression Anxiety Stress Scale-21
Time Frame: Baseline, 4 weeks, and 3 months
Stress symptoms were assessed using the stress subscale of the Depression Anxiety Stress Scale-21. The score ranges between 0 and 21. Higher scores indicate greater stress symptoms.
Baseline, 4 weeks, and 3 months
Anxiety Symptoms Measured by Depression Anxiety Stress Scale-21
Time Frame: Baseline, 4 weeks, and 3 months
Anxiety symptoms were assessed using the anxiety subscale of the Depression Anxiety Stress Scale-21. The score ranges between 0 and 21. Higher scores indicate greater anxiety symptoms.
Baseline, 4 weeks, and 3 months
Depression Symptoms Measured by Depression Anxiety Stress Scale-21
Time Frame: Baseline, 4 weeks, and 3 months
Depression symptoms were assessed using the depression subscale of the Depression Anxiety Stress Scale-21. The score ranges between 0 and 21. Higher scores indicate greater depressive symptoms.
Baseline, 4 weeks, and 3 months
Quality of Life Measured by Short Form-12
Time Frame: Baseline, 4 weeks, and 3 months
Quality of life was assessed using the Short Form-12 questionnaire. Higher scores indicate better health-related quality of life.
Baseline, 4 weeks, and 3 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Jordan University of Science and Technology

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

May 2, 2022

Primary Completion (Actual)

August 7, 2025

Study Completion (Actual)

August 7, 2025

Study Registration Dates

First Submitted

May 20, 2026

First Submitted That Met QC Criteria

May 29, 2026

First Posted (Actual)

June 1, 2026

Study Record Updates

Last Update Posted (Actual)

June 1, 2026

Last Update Submitted That Met QC Criteria

May 29, 2026

Last Verified

May 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 73/148/2022

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

IPD Plan Description

Individual participant data will not be shared because the participant consent and ethical approval covered confidential use of the data for the final research report and academic publications, not public sharing of individual-level data. In addition, the study sample was relatively small and included clinical and demographic information, which may increase the risk of participant re-identification. Aggregate results will be reported.

This is appropriate because the consent form states that participant information would be treated confidentially and used anonymously in reports/publications, and the thesis ethics section states that data were stored securely and confidentially.

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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