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CX Headache Sharmann
CX Headache Sharmann
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A Case Report
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Mary Kate McDonnell, PT, DPT, OCS 1
Shirley A. Sahrmann, PT, PhD, FAPTA 2
Name _______________________________________________________________________________________________
Linda Van Dillen, PT, PhD 3
Address _____________________________________________________________________________________________
Address _____________________________________________________________________________________________
C
Study Design: Case report. ervicogenic headache
Phone _____________________________Fax____________________________Email
Objective: To describe an intervention approach consisting of a specific active-exercise program _____________________________
(CH) has been de-
CASE
and modification of postural alignment for an individual with cervicogenic headache. scribed as a syndrome
Would you like
Background: Thetopatient
receive
wasJOSPT email male
a 46-year-old updates
with aand renewal
7-year of cervicogenicheadache.
history notices? Yes No
that is ‘‘a final com-
He reported constant symptoms with an average intensity of 5/10 on a visual analogue scale mon pathway—not an
where 0 indicated no pain and 10 the worst pain imaginable. Average pain intensity in the week
entity.’’32 Thus, CH is a syndrome
REPORT
Payment
prior to the Information
initial evaluation was 3/10 secondary to trigger point injections. The patient’s
that can have many contributing
headache symptoms worsened with activities that involved use of his arms and prolonged sitting.
Methods
Check enclosed
and Measures: (madeThepayable to treated
patient was the JOSPT).
7 times over a 3-month period. Impairments of
factors. The World Cervicogenic
41
alignment, muscle function, and movement of the cervical, scapulothoracic, and lumbar regions Headache Society has defined
Credit Card (circle one) MasterCard VISA American Express
were identified. Outcome measurements included headache frequency, intensity, and the Neck CH as referred pain perceived in
Disability Index (NDI) questionnaire. Intervention included modification of alignment and any part of the head and caused
Card Numberduring
movement ___________________________________Expiration
active cervical and upper extremity movements. The patient Datealso
_________________________________________
received by a primary nociceptive source in
functional instructions focused on diminishing the effect of the weight of the upper extremities on the musculoskeletal tissues that are
Signature ______________________________________Date
the cervical spine. __________________________________________________
innervated by the cervical nerves.
Results: The patient reported a decrease in headache frequency and intensity (1 headache in 3 Pain associated with CH has been
weeks, intensity 1/10) and a decrease in his NDI score from 31 (severe disability) to 11 (mild attributed to physical impair-
To orderin call,
disability). The patient also demonstrated improvement fax, email
upper cervical or mail
joint mobility, to: ments42 of the joint, muscle, and
cervical
range of motion, scapular alignment, and scapulothoracic muscle strength. neural structures in the cervical
1111 North Fairfax Street, Suite 100, Alexandria, VA 22314-1436
Conclusion: Interventions that included modification of alignment in the cervical, scapulothoracic, region, and, in particular, the up-
and lumbar region, alongPhone 877-766-3450
with instruction • Fax 703-836-2210
in a specific • Email:
active-exercise program to subscriptions@jospt.org
address per cervical spine region.4,14,31
movement impairments in these 3 regions, appeared to have been successful in relieving The majority of rehabilitation-
headaches and improving function in this patient. JThank youPhysfor
Orthop Sports Thersubscribing!
2005;35:3-15. based clinical trials for treatment
Key Words: cervical spine, muscle impairments, posture, scapular alignment of CH have examined the effect of
manual therapy performed on
cervical joints to alleviate the
identified dysfunction.20-22,29,39,40
Manual therapy studies have dem-
onstrated positive effects at both
1
Instructor, Program in Physical Therapy, Washington University School of Medicine, St Louis, MO. the impairment (pain and muscle
2
Professor and Associate Director for Doctoral Studies, Program in Physical Therapy, Washington
University School of Medicine, St Louis, MO. function) and disability level, with
3
Assistant Professor, Program in Physical Therapy, Washington University School of Medicine, St Louis, most studies focusing on short-
MO. term outcomes.10,36 Overall, the
The protocol for this case report was approved by the Human Studies Committee of Washington impairment level effects have in-
University Medical Center.
Send correspondence to Mary Kate McDonnell, Program in Physical Therapy, Washington University cluded a decrease in headache
School of Medicine, Campus Box 8502, St Louis, MO 63110. E-mail: mcdonnellm@wustl.edu frequency, intensity, and duration.
CASE
laxed sitting.27,43 Each cervical motion was performed
Aggravating Factors 3 times. The average of the 3 trials was recorded. The
The patient reported that his headache pain in- patient was asked to report changes in headache pain
creased with most activities that involved the use of with performance of each motion. The patient dis-
REPORT
his arms. Specifically, he had difficulty working with played limitations in cervical motion in rotation and
his horses and sitting at his computer greater than 30 extension, and reported an increase in headache
minutes. The patient also reported difficulty with pain with both rotations as well as with extension
sleep, awakening every 2 to 3 hours because of (Table 1).
headache-related pain. He usually was able to return Cervical rotation measurements were repeated
to sleep quickly if he changed his position, but while modifying the position of the patient’s scapula.
sometimes he required pain medication to return to The examiner passively elevated and adducted the
sleep. scapula while supporting the weight of the patient’s
arms (Figure 1). The test with manual correction of
the position of the scapula was designated as the
Previous Intervention
passive correction of scapular position test (PCSPT)
One week prior to his initial physical therapy visit (Table 1). The patient repeated cervical rotation to
the patient’s doctor performed 1% lidocaine trigger the left and right and reported his symptoms with the
point injections. The patient reported that there were PCSPT relative to his symptoms without support. The
multiple injections administered in the posterior patient displayed a 10° increase in cervical rotation in
cervical and upper trapezius region bilaterally, and both directions and a decrease in his headache pain.
that he had a complete reduction in his headache Shoulder AROM and Pain Behavior Shoulder motion
pain for 24 to 48 hours afterwards. Since the injec- and symptoms with motion were measured with the
tions, the patient reported that the intensity of his patient in sitting. The patient achieved 130° of
average headache pain had decreased to 3/10, but shoulder flexion with each extremity and reported an
the pain was still constant. increase in pain in the upper trapezius region with
both shoulder movements. During shoulder flexion,
Functional Disability the scapula appeared to move into excessive abduc-
tion with minimal upward rotation or elevation.11,28
Functional disability was assessed with the Neck In addition, the angle of scapular upward rotation
Disability Index (NDI) questionnaire. The NDI is was estimated to be approximately 35°, indicating
used to assess functional limitations and disability. limited upward rotation.11,25 Subsequently, the exam-
Studies of the NDI have demonstrated that the iner manually assisted rotation and elevation of the
measure has adequate reliability and validity charac- scapula during shoulder flexion and the patient
teristics, and has been shown to be sensitive to reported a decrease in the upper trapezius pain.
The humerus was observed to move into excessive according to the methods described by Maitland18 for
medial rotation and the lumbar spine into extension the amount of passive motion, joint end feel, and
during shoulder flexion. Such a movement strategy symptoms. The occipital atlanto joint displayed sig-
suggests a limitation in the length of the latissimus nificant limitation of motion in the direction of
dorsi muscle.16 Additionally, the patient’s lower cervi- flexion, with a stiff end feel. The axial atlanto joint
cal spine translated forward and his upper cervical displayed significant limitation of motion and a stiff
spine moved into extension. When movement occurs end feel with both right and left rotation. The
in a segment other than the segment where the movement and end feel of segments in the lower
primary movement is intended to occur, the authors cervical region18 were considered normal and were
consider this movement to be compensatory and, in asymptomatic with testing.
most cases, undesirable because it often occurs in the Muscle Strength, Length, and Stiffness Lower abdomi-
region associated with the patient’s pain prob- nal muscle strength was assessed using the procedures
lem.16,17,28 Potentially, in this patient, every time he described by Sahrmann.28 The patient’s lower ab-
flexed his shoulders he translated and extended his dominal muscles were graded as 0.5/5 on a scale of
cervical spine. 0.1 to 5.0 (Table 2). When the patient attempted to
Passive Mobility Assessment of the Cervical Region The contract the lower abdominals, as instructed, he
occipital atlanto and axial atlanto joints were assessed elevated his rib cage, extended his spine, and ab-
CASE
extending knees, then, with both knees ex-
tended, lower both lower extremities to sup- Strength of the scapulothoracic muscles was tested
porting surface in prone.16 There was decreased strength of the
rhomboids and middle and lower trapezius with the
greater loss of strength noted in the trapezius
REPORT
(Table 1).
Diagnosis
The patient’s movement system impairment diag-
nosis was cervical extension with scapular abduction
and depression (Table 3). Impairments of muscle
function, postural alignment, and movement were
considered to have contributed to stress on the
tissues in the cervical region, resulting in the pa-
tient’s pain complaints. The goal of the intervention
was to address the identified impairments in the
cervical, scapulothoracic, and lumbar regions in an
attempt to reduce the stress on cervical structures,
and to assist the patient in achieving his primary goal
of decreasing the intensity and frequency of his
headache pain.
INTERVENTION
Following the examination, the patient was in-
structed in exercises that addressed the identified
impairments. The focus of the home exercise pro-
gram was to (1) increase the strength and control of
the abdominals, (2) increase the length of the
anterior thorax muscles, (3) increase the length of
the posterior cervical extensor muscles, (4) improve
the strength and decrease the length of the posterior
FIGURE 1. Sitting passive correction of scapula position test. scapulothoracic muscles, and (5) increase shoulder
Exercises
Lower Abdominals The exercise was performed from
a hooklying position (Table 4 and Figure 2).28 The
purpose of the exercise was to improve the strength
and control of the abdominal muscles, which is
required to stabilize the trunk during movements of
the extremities. During the performance of the
exercise the patient was instructed to recruit the
rhomboids and the trapezius to reduce the scapular
position of excessive abduction. Additionally, the
patient was provided with cues that encouraged
modification of his preferred alignment of cervical
FIGURE 4. Shoulder flexion in supine.
extension. Specifically, he was instructed to ‘‘keep his
chin down towards his Adam’s apple.’’
The patient was not able to lift his second knee patient held one knee toward his chest with the
toward his chest without lumbar extension. He also ipsilateral arm and then lifted the opposite leg
was unable to maintain the upper quarter alignment (Figure 2). This modification was used to reduce the
as instructed. The exercise was modified so that the force the abdominal muscles needed to generate
CASE
Exercise 4: shoulder abduction Tighten your abdominal muscles by pulling your navel in. Raise your shoulder blades up and together,
and lateral rotation in supine and keep your chin down. Bring your arms out to the side and slide your arms overhead. Do not let
(Figure 5) your rib cage or chin lift up during the arm movements.
Exercise 11: supine upper Bring your chin down to your Adam’s apple, and then, with help of your hands, lift your head off the
cervical flexion with head lift table maintaining your chin position. Slowly lower your head back to the starting position.
REPORT
(Figure 9)
The patient is sitting with his back to the wall and his arms supported on pillows. Exercises begin with
tightening the abdominal muscles by pulling the navel in and raising the shoulder blades up and to-
Initial patient position gether.
Exercise 5: sitting against the Move your neck by bringing your chin down to your Adam’s apple while keeping your head close to
wall, upper cervical flexion the wall. You should feel a stretch down the back of your neck but not a reproduction of your head-
(Figure 6) ache or neck pain.
Exercise 6: sitting against the Perform exercise 5, then rotate your neck to the right for 5 repetitions, and then repeat to the left.
wall, cervical rotation Imagine that you are rotating your neck about an axis. Try not to side bend your neck. The move-
ment should be performed in a pain-free range.
Exercise 7: sitting against the Raise your arms overhead with your palms turned toward the wall. Do not let your low back come
wall, shoulder flexion (Figure away from the wall and keep your chin down.
7)
Exercise 8: sitting against the Bring your arms out to the side and slide your arms overhead. Keep your arms close to the wall, do
wall, shoulder abduction lat- not let your low back move away from the wall. Keep your chin down.
eral rotation
Initial patient position The patient is facing the wall, placing hands on the wall and sliding arms overhead, up the wall.
Exercise 9: facing the wall, ‘‘Squeeze’’ your shoulder blades together and lift your arms off the wall. Keep your abdominal muscles
arm slide and scapula ad- tight and keep your chin down. Return your arms to the wall.
duction (Figure 8)
Exercise 10: facing the wall, Rest your arms on the wall and rotate your neck. Imagine that you are rotating your neck about an
arm slide and cervical rota- axis. Try not to side bend your neck. The movement should be performed in a pain-free range.
tion
Initial patient position Facelying, arms overhead.
Exercise 12: prone, arms over- Squeeze your shoulder blades together and then lift your arms off the table. Return arms to the initial
head with scapula adduction position.
(Figure 10)
During the day support the weight of your arms as frequently as possible. For example, when working
at your computer, make sure your forearms are supported on the desk or when standing place your
Functional instructions hands in your pockets.
Visit 4
Twenty-five days after his initial visit, the patient
reported a continued decrease in the frequency and
intensity of his headache pain, and stated he could
be pain free for several days. The patient noted,
however, that when his symptoms were present, per-
forming his exercises did not relieve them as they
had been in the past. He reported that he finally
realized he had not been performing the exercises as
carefully as in the past, and when he resumed the
exercises with the appropriate modifications his symp-
toms were once again relieved. The patient also
reported that he initiated his walking program of 2.5
km/d without any effect on his symptoms.
Measures of cervical motion were repeated (Table
1). The patient displayed increased pain-free motion
FIGURE 7. Sitting against the wall, shoulder flexion.
in cervical extension and left rotation. Specifically,
the patient displayed a 25° increase in extension and
a 10° increase in left rotation. Rotation to the right
decreased 9°, but the motion was no longer painful.
CASE
The patient’s NDI score was 14, indicating no change
since his previous visit.
Revision to his program during visit 4 emphasized
restoring cervical rotation to the right and making
REPORT
his shoulder exercises more challenging. The cervical
rotation exercise required the patient to sit with his
back against the wall, his arms supported, and per-
form rotation without cervical extension or side
bending (Table 4, exercise 6). When the patient
performed the exercise correctly, the rotation motion
was limited but pain free. Shoulder flexion and
abduction exercises were progressed by having the
patient perform the motions while sitting with his
back to the wall (Figure 7 and Table 4, exercises 7
and 8). Emphasis was placed on avoiding compensa-
tory motions in the cervical, scapulothoracic, and
lumbar regions.
FIGURE 8. Facing the wall, arm slide and scapula adduction. Visit 5
Treatment during the third visit focused on review Thirty-nine days after the initial visit, cervical range
and revision of his exercises and modification of of motion measurements revealed an increase in
functional activities. The emphasis of the revisions right rotation, but a slight decrease in flexion and
was on correcting excessive rib cage elevation, extension. The patient’s NDI score remained at 14,
scapular abduction, and cervical extension during the indicating mild disability. Passive mobility testing of
performance of the shoulder exercises. He was re- axial atlanto rotation and occipital atlanto flexion
minded to continue all of the strategies he had revealed increased range of motion and decreased
learned to minimize the downward pull of the stiffness, and both rotation and flexion were now
shoulder girdle muscles on his neck. He also was pain free.
advised to begin a walking program to increase his
endurance and fitness level.
Visit 6
The upper cervical flexion exercise was progressed
by having the patient perform the exercise movement Sixty days after the initial visit, the patient reported
while sitting against a wall (Figure 6 and Table 4, that his headache pain was better. He could do more
Visit 7
Three and a half months following the initial visit,
the patient reported that his headache pain occurred
only once a week and he rated his symptoms at 1/10
when present. The patient also reported that when
his symptoms started, performance of his exercises FIGURE 9. Supine upper cervical flexion with head lift.
would abolish his headache pain within an hour. He
reported that, on average, he performed his exercises
2 times a day.
The patient’s exercises were reviewed. He was
instructed in 4 additional exercises. While facing a
wall, the first exercise was to slide his arms up the
wall and then adduct his scapulae (Figure 8 and
Table 4, exercise 9). The purpose of this exercise was
to increase the strength of the trapezius muscle. In
the end range position of the arm-sliding exercise,
the second exercise was to perform cervical rotation
without cervical side bending. The purpose of this
exercise was to improve cervical rotation with the
upper extremities supported (Table 4, exercise 10).
The third exercise was performed in supine (Figure 9
and Table 4, exercise 11). The patient performed
cervical flexion using his hand to assist in lifting his
head. The purpose of this exercise was to increase FIGURE 10. Prone arms overhead with scapula adduction.
the strength of the deep neck flexors and continue to extremity weight-lifting activities with free weights and
increase the length of the neck extensors. Finally, in resistive-exercise equipment without an exacerbation
prone with his arms positioned overhead, the patient of his symptoms.
was to perform scapular adduction (Figure 10 and The patient acknowledged that he had made sig-
Table 4, exercise 12). The purpose of this exercise nificant improvement in his ability to perform func-
was to progress the strengthening of the lower and tional activities. He was now able to sleep through the
middle trapezius. night without pain or use of medications and to
perform all horse care activities without an exacerba-
Five-Month Follow-up tion of his symptoms.
CASE
scapular muscles (levator scapulae and upper time our patient lifted his arms he potentially was
trapezius).30,34 Johnson et al12 have noted that the extending his cervical spine.8,17 In this patient, fre-
majority of the upper half of the trapezius muscle quent cervical extension in an already extended
travels a transverse course from the lower half of the upper cervical spine was considered to be a factor
REPORT
ligamentous nuchae to the acromion and spine of the that could accelerate the accumulation of tissue stress
scapula. The function of the transverse orientation of in the posterior cervical region. Prescription of exer-
the trapezius fibers is to relieve the cervical spine of cises to allow full shoulder movement without com-
compressive loads by transferring the weight of the pensatory cervical spine movement was important,
upper extremity to the sternoclavicular joint.12 Be- because it addressed a factor that potentially was
cause of the impairments of the upper trapezius contributing to not only the development but also
(decreased strength and increased length) noted on the persistence of his CH symptoms.
examination, we assumed that the trapezius was not Manual therapy techniques have been reported
effectively transferring the upper extremity loads to to provide short-term benefit to patients with
the sternoclavicular joints. As a result, the posterior CH.10,20-22,29,39,40 The patient described in the cur-
cervical spine structures were bearing the weight of rent report did not receive manual therapy even
the upper extremities throughout the day. Such load though movement of upper cervical region was found
bearing was considered to contribute to an increase to be very limited. Interestingly, significant changes at
in the patient’s cervical extension position, altered the impairment and functional limitation level were
cervical movements, increased tissue stress in the obtained with treatment based solely on active exer-
posterior cervical region, and CH symptoms. The cise and positioning performed by the patient. Of
findings from the PCSPT test provides some support particular note was the improvement in joint mobility
for the proposed mechanism of upper extremity of the upper cervical region. The proposed mecha-
weight transfer to the cervical region. Elevating and nism for these changes is related to how changes in
adducting the patient’s scapulae and supporting the alignments and movements in the cervical, scapulo-
weight of the limbs resulted in increased cervical thoracic, and lumbar regions may have affected the
motion and a decrease in symptoms. Decreasing the alignment and loading in the cervical spine region.
prolonged effect of the weight of the upper extremi- The goal of treatment was to decrease tissue loading
ties on the cervical spine was treated (1) through by changing his preferred cervical extension align-
exercise to address the strength and length of the ment and frequent movements into end range exten-
cervicoscapular and scapulothoracic muscles, and (2) sion. We propose that addressing the factors that
by frequently supporting the upper extremities appeared to contribute to maintaining an extended
throughout the day. cervical spine alignment decreased the patient’s pain
Finally, in the lumbar region, the patient’s pre- level and allowed him to achieve a more neutral
ferred extension alignment was also considered to be cervical spine position with less facet joint approxima-
CASE
REPORT