Orthopedic Manual Therapy Techniques in the Diagnosis …27266... · OMPT and Cervicogenic Headache Orthopedic Manual Therapy Techniques in the Diagnosis and Treatment of Cervicogenic

OMPT and Cervicogenic Headache

Orthopedic Manual Therapy Techniques in the Diagnosis and Treatment of Cervicogenic

Headaches: A Case Report

A Case Report

Presented to

The Faculty of the Department of Physical Therapy

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctorate of Physical Therapy

By

Hayley B. Rodgers

May 2014

OMPT and Cervicogenic Headache

APPROVAL SHEET

This case report is submitted in partial fulfillment of

the requirements for the degree of

Doctorate of Physical Therapy

_____________________________________

Hayley B. Rodgers

Approved: May 2014

_____________________________________

Arie J. van Duijn, EdD, PT, OCS

Committee Chair/Advisor

_____________________________________

Jacqueline van Duijn, DPT, OCS

Committee Member

The final copy of this case report has been examined by the signatories, and we find that both

the content and the form meet acceptable presentation standards of scholarly work in the

above mentioned discipline.

OMPT and Cervicogenic Headache 1

Table of Contents

Abstract 1 Introduction 2 Purpose 3 Literature Review 3

Anatomy of the Cervical Spine 3 Biomechanics of the Cervical Spine 5 History and Background of Cervicogenic Headaches (CGH) 6 Pathophysiology of CGH 7 The Relationship between TMD and CGH 8 Diagnosing CGH 10 Manual Therapy Techniques in Treating CGH 14

Case Description 18 Past Medical History 18 Subjective History 19

Neck Disability Index 20 Pain Assessment 21 Behavioral Aspects 22

Objective Findings 22 Posture 22 Range of Motion 22 Manual Muscle Testing 23 Manual Examination and Palpation 23 Neurological Testing 24 Impression 24

Prognosis 25 Patient Goals 25 Intervention 26 Outcomes 33 Discussion 35

Conclusion 42 References 44


Abstract

The inclusion of orthopedic manual therapy in the diagnosis and treatment of

cervicogenic headaches (CGH) has resurfaced as a topic of interest within the field of

physical therapy. The use of manual therapy approaches in the evaluation and treatment

for CGH continues to evolve and grow as higher level pieces of research are published. The

underlying culprit of CGH is a mechanical dysfunction of the cervical spine (Becker, 2010).

Recent studies have provided results that support the use of manual therapy to the cervical

spine, as well as to the temporomandibular joint, thoracic spine, and first rib, in order to

relieve pain, increase range of motion (ROM) and improve overall quality of for patients

who suffer from this chronic disorder (Von Piekartz & Ludtke, 2011; Masaracchio, Cleland,

Hellman & Hagins, 2013). Manual examination skills have also shown to have high

sensitivity and specificity in diagnosing CGH (Jull, Amiri, Bullock-Saxton, Darnell, & Lander,

2007). For this reason, manual approaches for both diagnosing and treating the mechanical

dysfunction underlying CGH are investigated.

The case study involves a 35-year old woman who presented to orthopedic

outpatient physical therapy with signs and symptoms suggestive of cervicogenic headache.

The purpose of the case report is to reflect the reorganization and synthesis of extant

information of orthopedic manual physical therapy interventions for patients with

cervicogenic headaches that took place with completion of the investigator’s independent

study. In addition, the presentation of this case report provides the clinical reasoning

behind the orthopedic manual therapy examination and treatment of a patient with

cervicogenic headaches and discusses the outcomes of her plan of care.


Introduction

The inclusion of orthopedic manual therapy in the diagnosis and treatment of

cervicogenic headaches (CGH) has resurfaced as a topic of interest within the field of

physical therapy. The use of manual therapy approaches in the evaluation and treatment

for CGH continues to evolve and grow as higher level of evidence is published. The

underlying culprit of CGH is a mechanical dysfunction of the cervical spine (Becker, 2010).

Recent studies have provided results that support the use of manual therapy to the cervical

spine, as well as to the temporomandibular joint, thoracic spine, and first rib, in order to

relieve pain, increase range of motion (ROM) and improve overall quality of for patients

who suffer from this chronic disorder (Von Piekartz & Ludtke, 2011; Masaracchio, Cleland,

Hellman & Hagins, 2013). Manual examination skills have also shown to have high

sensitivity and specificity in diagnosing CGH (Jull, Amiri, Bullock-Saxton, Darnell, & Lander,

2007).

As a physical therapy student with a strong interest in manual therapy, this

investigator has found it both challenging and advantageous to explore the use of manual

therapy for treating CGH. With the recent increase in number of high quality research

demonstrating the advantages of utilizing manual therapy in the treatment of cervicogenic

headaches, beneficial insight will be gained into this role. This advancement of orthopedic

manual skills and increase in knowledge of the cervical spine beyond that of an entry-level

physical therapist will be particularly advantageous for the investigator in treating patients

with this condition.


Purpose

The following case report involves a 35-year old woman who presented to

orthopedic outpatient physical therapy with signs and symptoms suggestive of

cervicogenic headache. The purpose of this case report is to reflect the reorganization and

synthesis of extant information of orthopedic manual physical therapy interventions for

patients with cervicogenic headaches that took place with completion of the investigator’s

independent study. In addition, the presentation of this case report provides the clinical

reasoning behind the orthopedic manual therapy examination and treatment of a patient

with cervicogenic headaches and discusses the outcomes of her plan of care.

Literature Review

Anatomy of the Cervical Spine

The cervical spine is composed of seven vertebrae and is divided into upper and

lower regions. The upper cervical spine includes the occipital condyles and the first two

cervical vertebrae, and the lower cervical spine includes C3-C7. The two atlanto-occipital

joints consist of two concave superior facet joint of C1 articulating with the two convex

occipital condyles of the skull. The C1 vertebra is unique in that it is shaped like a ring and

lacks a body and spinous process. The three joints that make up the atlantoaxial joints

include the median atlantoaxial joint between the dens and the atlas (supported by the

transverse ligament) and the two lateral facet joints (Levangie & Norkin, 2011). The lateral

facet joints are oriented approximately 45 degrees from the frontal and horizontal planes,

but this may vary from person to person (Levangie & Norkin).

The joints of the cervical spine are weight bearing structures and can be easily

injured from the weight of the head along with the result of potential high velocity injuries


which occur today and for everyday activities which the neck was never designed for by

evolutionary forces (Becker, 2010). In addition, they are designed for mobility rather than

stability, thereby increasing its chance of injury and trauma (Becker, 2010). Many

potentially painful structures exist in the cervical spine that has a rich nociceptive

innervation. These structures include the zygopophyseal joints, the intervertebral discs, the

ligaments and muscles, and the skin. Of these, the zygopophyseal joints appear to be the

most important pain generators (Becker).

There are four ligaments that are continuous with the longitudinal tract system and

four ligaments that are specific to the cervical spine which provide support to the neck

(Levangie & Norkin, 2011). The posterior atlanto-occipital and antlantoaxial membranes

run continuous with the ligamentum flavum, which connect the each lamina to the next,

however in the cervical spine this structure is less elastic to allow for more range of

motion. The anterior antlanto-occipital and atlantoaxial membranes are continuous with

the anterior longitudinal ligament. The tectorial membrane is a strong and wide ligament

continuous with the posterior longitudinal ligament. The ligamentum nuchae is a thick,

sheetlike structure that runs continuous with the supraspinous ligament. The four

remaining ligaments are unique to the cervical spine and include: the transverse atlantal

ligament, atlantal cruciform ligament, alar ligaments, and apical ligament (Levangie &

Norkin).

The intervertebral discs in the cervical spine are different from the discs of the rest of

the spine. For one, the annulus is a discontinuous ring surrounding a fibrocartilaginous

core (Levangie & Norkin, 2011). Also, the annulus is not arranged in alternating lamellae, is

thick anteriorly, only thin posteriorly, and may be absent laterally.Fissures and clefting of


the disc by occurs typically by 9 years of age at which point these fissures become the

uncovertebral joints (Levangie & Norkin, 2011).

Biomechanics of the Cervical Spine

Levangie and Norkin (2011) outlines the function of the cervical spine as

demonstrating the most flexibility of any of the regions of the vertebral column. It is also

reported that the neck may move on average 600 times for every hour, whether awake or

sleeping. Regarding the cervical spine, most of the flexion-extension comes from the

atlanto-occipital joint and reportedly ranges from 10 degrees to 30 degrees (Levangie &

Norkin). By utilizing the roll and glide rule, one can determine that during flexion of the

antlanto-occipital joint the occipital condyles roll forward and slide backward, and the

reverse is true for extension. Approxiamtely 55-58% of the total rotation of the cervical

spine comes from the antlantoaxial joint, with the alar ligaments limiting rotation to some

degree (Levangie & Norkin)

Lateral flexion and rotation are coupled motions throughout the entire vertebral

column. For the upper cervical segments, lateral flexion is coupled with contralateral

rotation and rotation is coupled with contralateral side flexion (Levangie & Norkin, 2011).

The muscles of the sub-occipital region are responsible for smaller motions such as

nodding and attach from the transverse or posterior prominences of C1/C2 to the occiput

or C1 (Levangie & Norkin).

Discs are absent at the atlantooccipital or atlantoaxial joints, therefore required the

compressive load from the weight of the head to be transferred through the articular facets

(Levangie & Norkin, 2011). Compressive loads are comparatively lower during standing

and sitting postures versus during end range flexion and extension (Levangie & Norkin).


This may explain why muscle imbalances of the anterior and posterior neck muscles may

promote an increase in compressive loads by forcing the cervical spine into poor posture

(forward head and hyperextension), particularly at the upper cervical segments.

History and Background of CGH

From a global epidemiological perspective, it is estimated those with an active

headache disorder is 46% of the adult population (Vavrek, Haas, & Peterson, 2010).

Headache is the most common pain condition causing loss of productive time in the US

workforce, with an average loss of 3.5 h/wk (Vavrek, Haas, & Peterson). Studies estimate

that only 14-18% of chronic headaches occur from musculoskeletal dysfunction in the

cervical spine (Zito, Jull, & Story, 2003; Vavrek, Haas, & Peterson, 2010). Complementary

and alternative medicine practitioner visitation within the last 12 months of receiving

formal physical therapy treatment was 37.5% among those who reported neck problems

(Vavrek, Haas, & Peterson).

In order to genuinely appreciate the budding evolution of the treatment of

cervicogenic headaches, it is important to understand its history. The first medical

description of a headache linked to a dysfunction of the neck was published by

Schutzenberger, in 1853 (Antonaci et al., 2005). In a 1913 report by Holmes described

headaches could originate from the neck and may be associated with the existence of

painful nodules in the posterior muscles of the neck (Antonaci et al.). This description later

provided the basis for the subsequent definition of rheumatic headache (Antonaci et al.). In

1926, French Neurologist Jean Alexandre Barre described a headache with greater

intensity in the occipital region, associated with dizziness and with hearing and visual

disturbances, and called this picture “posterior cervical sympathetic syndrome”,


(Fernandez de-las-Penas et al., 2006). Shortly after Dr. Barre, important research studies by

Ray and Wolff demonstrated the stimulation of the sensory nerve endings above and/or

below the upper surface of the tentorium cerebelli could reproduce pain felt centrally or

frontally (Fernandez de-las-Penas et al.). As a result of these studies, the role of the afferent

nerves of the upper cervical region was investigated (Fernandez de-las-Penas et al.).

Prior to the early 1980’s, headache originating from the neck was nonexistent in the

International Headache Classification (Fernandez de-las-Penas et al., 2006). The term

“cervicogenic headache” was first introduced by Sjaastad in an article published in 1983

and was greeted with skepticism within the medical world (Fernandez de-las-Penas et al.).

Cervicogenic headache still remains a controversial topic nearly thirty years later for a

number of reasons. In a recent 2010 article, Becker explains that cervicogenic headaches

are relatively uncommon compared to other types of headaches such as migraine or

tension-type, have a complex clinical picture, and may require diagnostic testing that is

unavailable at many clinics either due to resources or specialization. All of these reasons

have created historical controversy surrounding the diagnosis of cervicogenic headaches.

With the advent of new research and developments in patient management of cervicogenic

headaches, more information exists to assist practitioners in making clinical decisions.

Pathophysiology of Cervicogenic Headaches

CGH is a sub-group of the classification of secondary headache arising from cervical

spine musculoskeletal dysfunction (Hall, Briffa, Hopper & Robinson, 2010). Becker (2010)

explains that the anatomical convergence of pain fibers from the trigeminal nerve including

the ophthalmic division of this nerve and from the upper cervical nerves is the basis for the

referral of pain from the upper cervical region to the head, including frontal head regions.


Likewise, stimulation of dural mater also leads to sensitization of the second order sensory

neurons so that they are now more easily activated by neck muscle and greater occipital

nerve stimulation (Becker, 2010). These anatomical and physiological findings logically

demonstrate the possibility for nociceptive afferents from the neck to cause headache, and

also for nociceptive inputs from the dura to potentiate neck pain (Becker). This information

was confirmed in another study by Hall et al. (2010).

Temporomandibular Dysfunction and Cervicogenic Headache

One topic commonly overlooked in the research literature is the close relationship

of temporomandibular dysfunction (TMD) and CGH. Temporomandibular dysfunction

(TMD) is associated with increased headache frequency via convergence of afferent input

at the trigeminal nuclei from trigeminal afferents and afferents from the upper cervical

spine (Fernandez de las Penas, 2006). It is important to consider the impact of TMD on

increasing the severity of CGH in order to provide more comprehensive treatment to the

patient with such comorbidities. Temporomandibular disorders (TMD) are rarely used in

the inclusion and exclusion criteria of randomized, controlled studies examining outcomes

from orthopedic manual therapy for the management of cervicogenic headaches (Von

Piekartz & Ludtke, 2011) even though the prevalence of TMD ranges from 8% to 15% in

women and from 3% to 10% in men and headache patients, the prevalence of TMD is

estimated to be much higher (51.6%) (Von Piekartz & Ludtke, 2011).

Some authors suggest that for patients diagnosed with CGH, the cervical spine is

often overvalued as the source of the symptoms and other contributing favors, such as

TMD, do not receive sufficient attention (Von Piekartz & Ludtke, 2011). The study by von

Piekartz & Ludtke identified the prevalence of TMD in a sample of patients diagnosed with


CGH, determined the tests that are clinically relevant to detect TMD in CGH patients, and

evaluated the effect of additional orofacial physical therapy after three and six months in

comparison with control group. The inclusion criteria for patients to receive orofacial care

for this experiment included a minimum of one of the four signs of TMD: joint sounds,

deviation during mouth opening, extraoral muscle pain at a minimum of two tender points

in the masseter or temporalis muscles and pain during passing mouth opening. The

researchers gathered pre and post measurements using the colored analog scale (CAS),

Neck Disability Index (NDI), Anamnestic Questionnaire CMD (Conti), Noise Registration at

the Mandibular Joint, Graded Chronic Pain Status (GCPS-NL), mandibular deviation, mouth

opening measurement, and pain threshold measurement of the masticatory muscles. The

manual therapy treatment techniques consisted of accessory movements of the

temporomandibular region and/or masticatory muscle techniques, such as tender-trigger

point treatment and muscle stretching. Results from this study provided data that CGH

patients showed a higher prevalence of TMD than the healthy population. This study also

helped to propose that clustering of tests such as mouth opening (range and pain), NDI, and

VAS of headaches, contributes to an improved diagnosis of TMD in chronic CGH patients.

The beneficial treatment effect in the experimental group that remains or is improved at six

months follow-up helps to indicate that TMD may be a contributing or etiological factor in

chronic CGH patients. Unfortunately, other research studies of this quality and

comprehensive nature were absent from the literature, therefore research studies on CGH

should include inclusion and exclusion criteria for TMD for their sample populations.


Diagnosing Cervicogenic Headache

The International Headache Society (IHS) released the first criteria for cervicogenic

headaches in 1998, which included: pain localized in the neck and occipital region, may

project to forehead, orbital region, temples, vertex, or ears, pain precipitated or aggravated

by particular neck movements or posture, either resistance/limitation of passive beck

motion, palpatory changes in neck musculature or altered response to

stretching/contraction, or abnormal neck muscle tenderness (Vavrek, Haas, & Peterson,

2010). Cervicogenic headache has been validated by the International Headache Society

(IHS) and its updated diagnostic criteria are shown in Figure 1 (Antonaci et al., 2005).

Figure 1:

IHS Cervicogenic Headache Diagnostic Criteria (Sjaastag, Fredriksen, & Pfaffenrath, 1998)

The Cervicogenic Headache International Study Group (CHISG) diagnostic criteria

includes: unilaterality of pain (although it is recognized that bilateral cervicogenic

headache may occur) , restriction of ROM in the neck, provocation of usual head pain by

neck movement or sustained awkward neck positions, provocation of usual head pain with


external pressure over the upper cervical or occipital region on the symptomatic side,

ipsilateral neck, shoulder, or arm pain, usually of a vague nonradicular nature, occasionally

radicular (Becker, 2010). The IHS diagnostic criterion does not list unilaterality of

headache as a conclusive factor as the CHISG classification outlines. The IHS’s diagnostic

criterion, albeit extensive, is far more comprehensive in nature and includes further

criterion factors as critical for diagnosis such as “imaging and nerve block positive results”,

and “resolution of pain within 3 months after successful treatment of the causative

disorder or lesion”. The notes outlined by the IHS diagnostic criteria also provide the

practitioner with important pieces of information to consider when making a decision

about the patient’s diagnosis. In the second note, it addresses the importance of coding the

patient under tension-type headache when myofascial tender points are the causative

factor for the headache symptoms. There is considerate symptomatic overlap and it is very

possible for the patient to have a combination of tension-type and cervicogenic headaches

congruently, which may lead to a more complicated diagnosis (Jull, 1998).

Determining which objective measures are indicative of CGH pain is important for

clinical research as well as for the medical provider (Vavrek, Haas, & Peterson, 2010).

Cervical ROM and ROM-elicited pain measures have been found to be predictive of

subjective CGH experience at baseline (Vavrek, Haas, & Peterson, 2010). Restriction of

cervical active extension ROM may be typical for this population and is a possible focus for

treatment assessment (Vavrek, Haas, & Peterson, 2010).

One of the common diagnostic obstacles in headache evaluation is to distinguish

CGH from migraine. Studies have shown that an incorrect headache diagnosis may occur in

more than 50% of cases (Hall et. al., 2010). It is very important to correctly classify the


headache disorder so that treatment can be directed appropriately (Hall et. al., 2010).

Because the pathophysiology underlying CGH is musculoskeletal dysfunction in the upper

three segments, physical examination of the upper cervical spine is particularly important.

Dysfunction may involve any of the upper three cervical segments and can be

measured by manual examination. Manual examination is a means of determining from

which spinal segment pain arises, and consists of tests of unilateral passive accessory

intervertebral motion (PAIM) and passive physiological intervertebral motion (PPIM)

(Hall, Briffa, Hopper & Robinson, 2010). Manual therapy has high sensitivity (100%) and

specificity (94%) to detect the presence or absence of cervical joint dysfunction from

migraine in neck pain and headache patients (Hall, Briffa, Hopper & Robinson). However,

these tests involve a high degree of skill on the part of the therapist, and their reliability has

been questioned (Hall, Briffa, Hopper & Robinson). C1/2 was the most dominant

symptomatic segment at approximately 63% of positive cases (Hall, Briffa, Hopper &

Robinson). Differences in anatomical morphology of the C1/2 articulation may be a

contributing factor. A study by Hall and Robinson (2004) found the C1/C2 segment to be

the most symptomatic cervical motion segment in 80% of a sample of 28 subjects with

CGH.

A recent study by Jull from 2007 has shown that the combination of three tests of

cervical spine musculoskeletal function can identify subjects with CGH, from other

headache forms, with 100% sensitivity and 94% specificity. These tests include cervical

range of motion, manual examination of the upper cervical spine, and cervical motor

control evaluated by the craniocervical flexion test (Jull et. a., 2007). The cervical flexion-

rotation test is gaining credibility as a useful aid in the classification of CGH (Smith, Hall, &


Robinson, 2008; Hall, Briffa, Hopper & Robinson, 2010). The FRT consists of pre-

positioning the cervical spine in maximal end range flexion followed by passive rotation of

the head to the left and the right, with the subject relaxed in supine (Hall, Briffa, Hopper &

Robinson). End of range in each direction is determined either by firm resistance or pain,

and compared between left and right. The call for substantiation of efficacy of manual

therapy emphasizes the need for accurate diagnosis to distinguish cervicogenic headache

from other causes of chronic headache so that the appropriate patients receive manual

therapy treatment (Zito, Jull, & Story, 2003). The historical research study conducted by

Zito et al. (2003) determined that the presence of upper cervical joint dysfunction most

clearly differentiated the cervicogenic headache sufferers from those with migraine with

aura and control subjects. The patient with CGH also presented with restriction in cervical

motion, a higher frequency of muscle tightness, and a poorer muscular performance and

strength with cranio-cervical flexion testing. Such musculoskeletal dysfunction was not

apparent in the group with migraine with aura who did not differ from the control group.

These musculoskeletal criteria are in accordance with, but better define those listed by the

HIS diagnostic criteria. Identification of these physical impairments in the musculoskeletal

system linked to clinical features will contribute to the justification and selection of

treatment for CGH. Further work is necessary to address issues of generalizability and

reliability of these results (Zito, Jull, & Story, 2003).

Also, manual examination should be used in conjunction with other physical tests to

improve overall accuracy in identifying CGH (Hall, Briffa, Hopper & Robinson, 2010). In the

most recent version of these diagnostic criteria, confirmatory local anesthetic blocks in the

cervical region are also considered necessary to make a firm diagnosis of cervicogenic


headache (Becker, 2010; Goodman & Fuller 2009). With regard to examination and

treatment for patients with cervicogenic headache, the general recommendation exists to

use less invasive assessment procedures and treatment interventions first (Becker, 2010).

By using a conservative approach for this population, invasive testing and treatments such

as suboccipital nerve blocks and surgery should only be considered when prior

conservative assessment and intervention was unsuccessful (Becker, 2010).

Manual Therapy Techniques in Treating CGH

A study by Hoving, et al., demonstrated that directly referring patients with neck

complaints to a physical therapist specializing in manual therapy is more effective and

cost-saving than guidance from a first-line medical professional (Hoving et al., 2003; Von

Piekartz & Ludtke, 2011). The most common and accepted assumption of spinal

manipulation and mobilization is that it results in an increase in either passive and/or

active range of motion (Whittingham & Nilsson, 2001). Spinal manipulation is the

application of force of varying velocity and frequency ranges on one or more vertebrae

(e.g. sustained, oscillatory, or high-velocity thrust) that may be manually applied as a

passive treatment or combined with active movements of the spine (Fernandez de-las-

Penas et al., 2006).

Numerous pieces of historical research suggest that the afferent input produced by

manipulative therapy procedures may stimulate neural inhibitory systems at various levels

in the spinal cord helping to reduce nociceptive levels perceived by the patient (Christian,

Stanton, & Sissions, 1988; Allen, Terrett, & Vernon, 1984). Spinal manipulative therapy may

also activate descending inhibitory pathways from, for example, the lateral periaqueductal

gray area of the midbrain (Wright, 1995). The lateral periaqueductal gray (PAG) area of


the midbrain has been shown to have an integral role in the behavioral responses to pain,

stress, and other stimuli in maintaining internal homeostasis, which (Fernandez de-las-

Penas et al., 2006). It is able to achieve this through coordination of responses of various

systems throughout the body including the nociceptive system, autonomic nervous system,

and motor system (Depaulis & Bandler, 1991).

Results from a recent systematic review support the use of combined mobilization,

manipulation, and exercise for short-term pain reduction, global perceived effect and

patient satisfaction in acute and chronic neck pain with or without cervicogenic headache

(Miller et. al, 2010). The use of manipulation and mobilization alone provides short-term

pain relief. Exercise appears to improve pain and function over the long-term. The

combination of manual therapy and exercise, however, seems to produce greater short-

term pain reduction than exercise alone and longer-term changes across multiple outcomes

in comparison to manual therapy alone (Miller et. al, 2010).

A Cochrane review has demonstrated the positive effect of specific cervicoscapular

resisted exercises, C1/C2 self-SNAG exercises, craniocervical endurance exercise and low

load endurance exercise, and upper extremity stretching and strengthening exercise , but

the optimal exercises to combine with manual therapy remain unknown (Miller et. al,

2010). Spinal manipulative therapy (SMT) is defined as controlled directional, high-

velocity, low-amplitude thrust. The primary objectives of SMT in the treatment of headache

and neck pain are the alleviation of pain, muscle spasm, and functional impairment

(Vavrek, Haas, & Peterson, 2010).

Another research study looked at the single toggle-recoil thrust (a short-level, high-

velocity technique) technique as one approach to spinal manipulative therapy


(Whittingham & Nilsson, 2001). The study found a consistent and statistically significant

increase in active range of motion in the cervical spine after manipulation; however,

improper sample and examiner blinding techniques may have been a major limitation of

the study (Whittingham & Nilsson, 2001). Moderate quality evidence from one recent

systematic review showed both cervical manipulation and mobilization produced similar

effects on pain, function and patient satisfaction at intermediate-term follow-up. Optimal

technique and dose still needs to be determined by future research studies (Gross, et. al.,

2010).

One mobilization technique may be superior to another, but the findings within the

research are inconclusive and preliminary in nature (Gross, et. al., 2010). A multitude of

approaches to manual therapy for the cervical spine are utilized to treat cervicogenic

headache, including myofascial release, distraction of the upper cervical segments, spinal

mobilization, spinal manipulation using thrust techniques, soft tissue mobilization, and

trigger point release. All of these topics that fall into the category of manual therapy will be

investigated throughout the course of this independent study.

A significant amount of evidence exists for the benefits of cervical manual therapy

techniques in treating cervicogenic headache. A 2001 study by Sterling, Jull, and Wright,

reported significant increases in pressure pain thresholds and a decrease in visual analog

scores when using spinal manipulation interventions compared to control placebo groups.

Spinal manipulation was also found to alter motor responses and facilitate muscle function

that was previously inhibited because of pain or impairment. These crucial findings help to

support the basis for the orthopedic manual therapy interventions utilized to reduce pain

and improve range of motion in cervical spine with the case patient discussed within this


paper. The case report that follows discusses orthopedic manual therapy and therapeutic

exercise interventions that were used in combination to improve pain intensity, headache

frequency, range of motion of the cervical spine, and gain in overall functional capabilities.

A randomized-controlled trial study looking at the effects of manipulative and exercise

interventions found no statistical advantage for short term outcomes when used in

combination (Jull et.al, 2002). It can be inferred from the data, however, that manipulative

therapy supplemented with therapeutic exercise progressions produce a higher optimal

effect across all outcomes over the long term. Therefore, it is clear that manual therapy is a

critical component of producing optimal outcomes for patients with cervicogenic

headaches, particularly when used with an appropriate therapeutic exercise prescription.


Case Description

The patient was referred to an orthopedic outpatient physical therapy clinic by her

primary care physician with the medical diagnosis of “cervicalgia”. Exactly one month

passed between the referral from her physician to the time of initial physical therapy

evaluation. The physical therapist who provided the plan of care for this patient is a Doctor

of Physical Therapy with a certification in Manual Physical Therapy through the University

of Saint Augustine for Health Sciences. He is also recognized as a Board Certified Clinical

Specialist in Orthopedics by the American Board of Physical Therapy Specialties with 14

years of experience of clinical experience. The details of his initial evaluation of the case

patient are an adaptation of the spinal evaluation outlined by University of Saint

Augustine’s founder Stanley Paris and Loubert (1999) and included the following areas.

Past Medical History

The case patient is a 35-year old female audiologist who sought physical therapy

treatment for neck pain. She was seen by the same physical therapist in July of 2012 to

treat similar problems of the neck, with left shoulder involvement. During this prior

episode of care, the neck pain was more symptomatic on the left side and the headaches

she experienced went to the left frontal cranium. Prior to the plan of care she had received

one cortisone injection in her left shoulder which brought some relief. Physical therapy

interventions consisting of a combination of manual therapy and therapeutic exercises was

a success during her past plan of care. The Shoulder Pain and Disability Index, which

examines the overall functional level of the involved shoulder (Roach, 1991), was reduced

from a 26% to a 5.4% over the course of one month. A reliability study published by Roach

et al. in 1991, found that the test-retest reliability of the SPADI total and subscale scores


ranged from 0.63 to 0.65 and internal consistency ranged from 0.86 to 0.95. The scores

were found to be highly negatively correlated with shoulder range of motion measures,

which suggests good criterion validity of the tool. This tool may be an important outcomes

measure when used in addition to the Neck Disabilities Index to measure progress of

patients with cervicogenic headaches and decreased upper extremity function undergoing

physical therapy treatment.

The patient also has a history of TMJ dysfunction on the left TMJ. She has

consistently worn a night guard for this condition since her teenage years. The patient

states that her “jaw frequently pops” and that she is currently on a modified soft diet. The

overall prevalence of TMD ranges from 8% to 15% in women and from 3% to 10% in men

(Von Piekartz & Ludtke, 2011). In headache patients, the prevalence of TMD is estimated

to be much higher (51.6%).

The patient also reports using a gluten-free diet in addition to her modified soft diet.

She has reportedly been using a gluten-free diet since early 2010. She has personally noted

a decrease in pain intensity and a reduction of gastrointestinal irritation as a result of this

diet. The patient had endometriosis (stage 4) which was medically treated with surgery

and ablation therapy after having her first child, who is now 22-months old. She is

currently seeking medical treatment for in-vitro impregnation to have her second child.

Subjective History

The patient stated during the initial evaluation that her current status included

“constant neck pain, decreased neck motion especially when driving, headaches going from

the back of the neck to the right forehead (average of 5 headaches per week), increased

stiffness, and painful jaw function”. Pain was self-reported to be an exacerbation of a


chronic condition she has experienced for over 15 years. Her prior level of function was

self-reported as independent with all ADL’s. Decreases in her current level of function

included having difficulty driving longer distances, using the computer for work, and caring

for her 20-month old son (23 pounds). The patient is an audiologist for the local County

Education Department, which requires her to travel in her car for several hours throughout

the workday.

The patient’s symptoms of neck pain had been persistent and worsening during the

year leading up to her first physical therapy appointment for this specific plan of care.

During that time she had been to see a chiropractor several times without success. She also

has regular massages every two weeks over the past two years with some relief.

The patient reports having frequent headaches (1-2 occurrences per week) that

radiate into the right frontal region of the head. The patient denies having any neurological

symptoms such as numbness or tingling that radiates into the upper extremities, and

denies pain that awakes her at night.

Neck disability index. Upon the initial evaluation, the patient scored a 40% (within

moderate disability range) on the Neck Disability Index (NDI, Appendix 1). The NDI was

developed as a modification to the Oswestry Low Back Pain Disability Index and is a

patient-completed, condition-specific functional status questionnaire (Macdermid et al.,

2009). There are 10 items total, including questions on pain intensity, personal care, lifting,

reading, headaches, concentration, work, driving, sleeping, and recreation. The NDI is

indicated for the following patient populations: chronic neck pain, musculoskeletal or

mechanical neck pain, cervicogenic headaches, whiplash injuries or whiplash associated

injuries, and cervical radiculopathy. One study found that in using the NDI for patient


clinical decision making, a clinically important change was calculated as 5 points, with a

sensitivity of 0.78 and a specificity of 0.80 (Stratford et al, 1999). The NDI has a fair to

moderate test-retest reliability in patients with mechanical neck pain, although intra class

correlations range between 0.50 and 0.98 (Cleland, Childs, & Whitman, 2008). The NDI has

good construct validity in comparison to other outcomes measurement tools including the

Visual Analog Scale, the Northwick Park Neck Pain Questionnaire, the Patient-Specific

Functional Scale, and The Disability Rating Index (Vernon & Mior, 1991; Hoving et al.,

2003).

Pain assessment. The patient was provided a numerical rating scale (NRS), which

is a patient, self-reported numerical rating of pain. The NRS allows the patient to select a

number from zero to ten with zero being “no pain” and ten being “worst pain imaginable”.

The NRS is a very common tool within the outpatient physical therapy setting, is easy to

reproduce, and has been validated by multiple patient populations (Goodman and Fuller,

2007). It is also important to note that in a recent study conducted on the mechanical neck

pain population, it was found that a point difference of greater than or equal to 1.3 is

suggestive of a minimum clinical important difference (Cleland & Fritz, 2006).

Jensen et al (1999) proposes that using a composite scoring system of current, best,

and worst levels of pain over the last 24 hours was effective at maximizing overall

reliability of this tool. Upon initial visit the patient reported her perceived pain level of the

cervical spine to be 7/10 at rest, 3/10 at its lowest, and 9/10 at its highest within the past

24 hours. The pain is located in bilateral upper trapezius muscles with the pain on the

right side being greater than on the left, in addition to the medial scapular region

bilaterally. The patient described this pain as being constant, dull, and worsens over the


course of the day. The patient also reported using ice, over-the-counter NSAIDs, soaks in

her Jacuzzi, and rest for relief from neck pain.

Behavioral aspects. The patient stated during her first visit that she felt as though

her neck was “out of place”. Because of this feeling, she reports regularly performing

intentional “cracks” of her neck. She states having some pain relief from this, but the

effects are short-lived. When there is hypermobility of the mid-cervical spine and

hypomobility demonstrated above and below these levels, it is possible that such frequent

intentional self-manipulations can have a negative impact on the relative mobility of the

cervical spine in regards to overstretching already relatively loose ligamentous structures.

The hypermobile mid-cervical articulations generally become even more hypermobile

overtime, which as a result predisposes the patient to having an increase of hypomobility

above and below the mid-cervical segments.

Objective Findings

Posture. The patient was found upon postural evaluation to have a resting forward

head position of the head on the cervical spine with hyper-extension of the upper cervical

segments. The resting position of the cervical spine was shown to be slightly bent to the

right. Both scapulae were found to be mildly abducted and demonstrated mild winging at

rest and increased with overhead movement, bilaterally.

Range of motion. Active range of motion of bilateral upper extremities was

screened and was found to be in normal, functional limits and pain-free. Cervical spine

active range of motion was measured using a standard goniometer to be 55 degrees for

forward flexion, 50 degrees for extension, 70 degrees for left rotation, and 54 degrees for

right rotation. Active movements into cervical spine extension, bilateral rotation, and


bilateral side-bending all were reported to be painful for the patient. Passive range of

motion was found to be restricted to only 20 degrees at the atlanto-axial joint (C1-C2) with

right rotation.

Manual muscle testing. Manual muscle testing was performed using the protocol

as outlined by Kendall, McCreary & Provance (2005). All muscles were found to be 5/5,

except for deep neck flexors (longus colli), middle trapezius, and lower trapezius which

were all found to be 3/5, or able to achieve full range of motion against gravity, but unable

to take any manual resistance.

Manual examination and palpation. The cervical spine passive intervertebral

motion examination revealed painful hypomobility (1+/6) with right rotation at the

atlanto-axial (C1-C2) joint. Hypomobility was also noted with passive downslide of the

right C6-C7 facet joint and with inferior glide of the right first rib. Hypermobility was noted

bilaterally with passive downslide of the mid-cervical spine.

Upon manual palpation of the neck region, the patient reported moderate

tenderness at the following anatomical landmarks: left transverse process of C2, right

transverse process of C7, bilateral sternocleidomastoid throughout the muscle bellies,

bilateral suboccipitals. Pressure over the right suboccipital muscle bellies were reported to

increase radicular symptoms into the side of the head. Cervical distraction testing resulted

in a patient-reported decrease of pain symptoms. Right-sided cervical compression (side-

bending with caudal overpressure) resulted in a patient-reported increase of pain

symptoms without radiculopathy. Alar and transverse ligament testing was found to be

negative.


Neurological testing. All dermatome testing resulted in normal findings, except for

the right C3 dermatome which was reported to be slightly diminished compared to the left

side. C5-C6 and C6-C7 reflex testing was found to be normal and symmetrical (2+).

Impression. It can be deduced from the examination findings that the case patient

has the signs and symptoms consistent with cervicogenic headaches. By using the IHS

diagnostic criterion for cervicogenic headaches (Figure 1), the case patient is found to

satisfy criteria A-C1. The case patient also satisfies the CHISG diagnostic criteria on all of

the following accounts: unilaterality of pain and headache, restricted neck ROM,

provocation of usual head pain by neck movement or sustained poor posture, and

provocation of usual head pain with external pressure over the upper cervical or occipital

region on the symptomatic side. It is also clear that this dysfunction is chronic in nature

based on her past history and amount of time that has passed since the beginning of her

symptoms. The major impairments that were gathered upon initial evaluation include:

1. Decreased range of motion of cervical spine

2. Tenderness to palpation of bilateral upper trapezius, sternocleidomastoid, and

suboccipital muscles, left transverse process at C2, and right transverse process

at C7.

3. Headaches into right frontal (supraorbital) region several times/month

4. Multi-level cervical and upper thoracic segmental mobility dysfunction

including: subcranial and lower cervical spine hypomobility and mid-cervical

spine hypermobility.

5. Muscular weakness of scapular stabilizers (middle/lower trapezius) and deep

neck flexors


6. Postural impairment: forward head, subcranial fault resting position of head

(side bent right), hyperextension of upper cervical spine, and abducted and

mildly winged scapula.

7. NDI Score of 40% - moderate severity of functional impact of impairments.

Prognosis

The chronic nature of the patient’s dysfunction complicates the rehabilitation

process and indicates a poorer prognosis overall. One study investigated the prognostic

factors that are associated with chronic neck pain. The patient was able to establish

significant self-reported and clinical progress in the past with physical therapy for similar

conditions in her prior plan of care from 2012. During this time, her SPADI score 26% to a

5.4% over the course of one month (9 visits total) which demonstrates a positive and

successful outcome to physical therapy.

Patient Goals

The original plan of care established included 4 weeks of formal physical therapy, two

times per week for a total of 8 visits. The following short term goals were established for

the patient to be met within 2 weeks:

1. Independence with home exercise program.

2. Patient to take an active role in rehabilitation program.

The following long term goals were established for the plan of care to be met within 4

weeks:

1. Reduced NDI from 40% to 18%.

2. Ability to look over either shoulder to see oncoming traffic while driving.


3. Improved strength (4/5 or above) for deep neck flexors, and scapular stabilizers.

4. 75%-100% reduced in frequency and intensity of headaches.

5. Ability to perform computer activities for work and pick up son with 75% decrease

of pain complaints.

Intervention

The patient was seen for a total of seven outpatient physical therapy visits with one

visit constituting the initial evaluation and the other six as follow-up visits. The patient was

not seen for a formal final visit and was discharged from the clinic at the end of February

due to her inability to attend physical therapy secondary to conflicts of schedule, both from

work and from prioritizing her efforts of in vitro fertilization in hopes of having her second

child.

During her initial evaluation, the patient was provided with manual therapy and

therapeutic exercise services. Gentle kneading and soft tissue massage was performed

bilaterally to the posterior cervical paraspinal musculature for five minutes. Two

therapeutic exercises were instructed, performed, and established for her home exercise

program: supine chin tucks in hooklying (3 sets of 10 repetitions, twice per day), and

doorway stretches for corrective posture (3 30-second stretches, twice per day).

Subsequent visits consisted of progressive manual therapy including soft tissue

massage and joint mobilization to the cervical spine and progressive strengthening

exercises to improve the postural balance of the upper quarter and stabilization of the

cervical spine as outline by Jull. All intervention sessions were tolerated well by the patient

and no reports were ever provided that described any adverse reactions to the physical


therapy sessions. The interventions utilized during the six follow-up visits are outlined

within the following table in detail:

Table 1: Case Report Physical Therapy Interventions

Date of

Visit Interventions Home Exercise Program

Additions 11/20/13 Warm-Up:

Upper Body Ergometer, Level 3 for 5 minutes

Manual Therapy:

Supine suboccipital release, 4 minutes Supine manual upper cervical traction, 5

minutes Downslides right C6/C7 facet joint and

upslides right C3-C4, Grades 1-3 for 5 minutes

Gentle kneading bilateral upper trapezius muscles for 5 minutes

Gentle manual bilateral upper trapezius stretch, 4 minutes

Therapeutic Exercise:

Supine chin tucks, 2 sets of 10 repetitions Manual (therapist) isometric supine bilateral

side-bending and bilateral rotation, 2 sets of 5 repetitions

Manual (self) isometric seated bilateral side-bending with rotation, 1 set of 5 repetitions

Latissimus dorsi pull-downs at cable, 3 sets of 15 with 3 plates

Resisted scapular retraction at cable, 2 sets of 15 with 5 plates

Manual (self) isometric seated bilateral side-bending with rotation, 1 set of 5 repetitions once a day


Table 1: Case Report Physical Therapy Interventions (Continued)

Date of Visit

Interventions Home Exercise Program Additions

11/22/13 Warm-Up:

Upper Body Ergometer, Level 3 for 5 min

Manual Therapy:

Supine suboccipital release, 4 minutes Supine manual upper cervical traction, 5

minutes Downslides right C6/C7 facet joint and

upslides right C3-C4, Grades 1-3 for 5 minutes

Gentle kneading bilateral upper trapezius muscles and left levator scapula muscle origin at superior angle of scapula for 5 minutes

Gentle manual bilateral upper trapezius stretch, 4 minutes


Supine chin tucks, 2 sets of 10 repetitions Manual (therapist) isometric supine bilateral

side-bending and bilateral rotation, 2 sets of 5 repetitions

Supine resisted bilateral rotation, red theraband 1 set of 10 in each direction


Resisted scapular retraction with shoulder extension, green theraband 1 set of 15 repetitions

Resisted scapular retraction with shoulder extension with green theraband, 2 sets of 15 repetitions once a day.

12/13/14 Warm-Up:

Upper Body Ergometer, Level 3 for 5”

Manual Therapy:

Supine suboccipital release, 4 minutes Supine manual upper cervical traction, 5 min.



Date of


Additions 12/13/14

Upslides and downslides right C6/C7 and C4/C5, Grades 1-3 for 7 minutes

Gentle kneading bilateral upper trapezius muscles for 5 minutes

Supine occipito-atlantal right side-bending mobilization grade 3, 2 minutes


Supine chin tucks, 2 sets of 10 repetitions Manual (therapist) light resistance bilateral

rotation, 2 sets of 10 repetitions to each side within mid-range

Manual (self) isometric supine bilateral rotation, 2 sets of 10 repetitions to each side

No new additions to the patient’s home exercise program were provided at this visit.

1/2/14 Warm-Up:


Manual Therapy:

Manual upper cervical traction, 5 minutes Seated mobilization with movement T1-T2 to

improve right rotation, 4 minutes Grades 3-4 Upslides and downslides right C6/C7 facet

joint, Grades 1-3 for 5 minutes Gentle kneading bilateral upper trapezius

muscles for 5 minutes


Supine chin tucks, 2 sets of 10 repetitions Supine chin tuck with head lists, 2 sets of 5

repetitions Seated PNF UE D2 pattern, bilateral without

resistance, 2 sets of 10 repetitions Manual (self) isometric seated bilateral

rotation, 1 set of 10 repetitions to each side

No new additions to the patient’s home exercise program were provided at this visit.



Date of


Additions 1/3/14 Warm-Up:

Upper Body Ergometer, Level 3 for 5 minutes

Manual Therapy:

Supine manual upper cervical traction, 5 minutes

Seated mobilization with movement T1-T2 to improve right rotation, 4 minutes Grades 3-4

Upslides and downslides right C6/C7 facet joint, Grades 1-3 for 5 minutes


Supine chin tucks, 2 sets of 10 repetitions Supine chin tuck with head lists, 2 sets of 5

repetitions Seated PNF UE D2 pattern, bilateral without

resistance, 2 sets of 10 repetitions Resisted bilateral shoulder extension at

cable, 5 plates for 2 sets of 15 repetitions Multidirectional DICE exercises in standing,

2 sets of 15 repetitions

The patient was further encouraged to continue to perform her band resistance exercise on a home basis as instructed.

1/29/14 Warm-Up:


Manual Therapy:

Seated upper thoracic spine extension mobilization, 2 minutes

Supine manual upper cervical traction, 5 minutes

Seated mobilization with movement C7-T1 to improve right rotation, 4 minutes Grades 3-4

Upslides and downslides right C6/C7 facet joint, Grades 1-3 for 5 minutes

The patient was instructed to continue to perform home exercise program as instructed during prior sessions. She was also instructed to continue to avoid self-manipulations.



Date of


Additions 1/29/14 Therapeutic Exercise:


Seated incline scapular stabilization with resistance into scapular protraction, 2 sets of 15 repetitions at 0.5 kg

Shoulder flexion and abduction in standing, 2 sets of 10 repetitions with 2 lb. dumbbells

The following table provides information on the subjective and objective progress

the case patient made with each subsequent visit:

Table 2: Subjective and Objective Short-Term Outcomes

Date of Visit

Subjective Report Objective Report

11/20/13 The patient reported experiencing an increase in neck pain due to driving long distances twice in the past week. She was able to regularly performing home exercise program (HEP). Resting pain level: 5/10 on the NRS.

No formal objective testing performed at this visit. The patient responded well to manual therapy and exercises without pain.

11/22/13 The patient reported an overall decrease in neck pain. She also reported a localized spot of pain on the left posterior and superior portion of her shoulder blade.

The patient displayed improved passive mobility of lower cervical spine (2+/6).

12/13/13 The patients states she had a 25% decrease in pain with activities such as performing work at the computer and picking her son up. Headaches were reported to be less intense in comparison to when she started physical therapy. The patient stated that she was able to perform her HEP regularly, but seldom uses the

Re-assessed with the following results:

AROM cervical spine rotation increased (75 degrees to the left and 55 degrees to the right, measured with goniometer). Improved from 70 degrees to left 54 degrees to right on first


Table 2: Subjective and Objective Short-Term Outcomes (Continued)

Date of Visit


12/13/13

(Continued)

Theraband for her scapular stability exercises. Her pain complaints during this visit were exacerbated due to straining her neck when she had to pick up several library books that had fallen to the ground while her toddler son began walking in the street at the same time. She reports that she will be having pelvic surgery on 12/18/13 to remove calcium deposits. Because of the need for this surgery, the physician did not feel comfortable proceeding with the planned in vitro fertilization until the tissue has healed. Self-reported pain range was reported from 3 at the lowest to 8 at the highest (slightly lower than first visit) based upon NRS.

visit, however, continues to report pain with both motions.

MMT: 3/5 for left and right middle and lower trapezius muscles, 3+/5 bilateral longus colli muscles (improved from 3/5 on first visit).

Tenderness to palpation of bilateral suboccipitals, left and right transverse processes of C1, and R transverse processes of C5 and C7.

NDI: 34% (improved from 40% on first visit).

Progress was documented within the daily note to be hastened due to medical comorbidities and poor consistency with HEP.

1/2/14 The patient stated during this visit that her neck had been feeling better overall. The night prior to this visit, she reported her right TMJ locked up. She was able to find some relief and help relax these muscles by using her hot tub at home. She reported she had not been able to perform her home exercise program due to tonsillitis. Pain level at rest was reported to be a 3/10.

The patient was found to have significant hypomobility with right rotation, particularly at the T1-T2 segment (1+/6). Following the mobilization treatment to this area, the patient displayed a significant increase in mobility at this level (2+/6 post treatment).

1/3/14 The patient reported her pain level at rest to be a 3/10 (left unchanged from previous visits). The patient also stated she has cancelled her future appointment on 1/8/14 for planned uterine surgery.

The patient demonstrated early fatigue with DICE exercises particularly of the deep neck flexors.

1/29/14 The patient reported her resting pain level to be a 2/10 today (1 point less than her typical report for the past 6 visits). The patient reported that she was able to participate in 80 minutes of yoga and had a headache immediately following the class

The patient displayed an increase in right cervical rotation following this treatment session (75 degrees to the left, and 60 degrees to the right). Decreased muscle tone was also noted within the bilateral upper


Table 2: Subjective and Objective Short-Term Outcomes (Continued)

Date of Visit


1/29/14

(Continued)

until the evening. She has only had two headaches during the past week and states they have been less intense overall. The patient also reports not self-manipulating her neck for the past six days.

trapezius and scalene musculature. She continued to demonstrate moderate fatigue with DICE exercises with repetition involving shoulder flexion and abduction.

Outcomes

Because of the nature of the course of physical therapy treatment, it is difficult to

make fully accurate inferences into the outcomes of care for this case patient. The patient

was seen for only seven visits over the course of three months, and attendance was

inconsistent throughout the plan of care. During the one month follow up visit, positive

progress was demonstrated by an improved NDI score from 40% to 34% (6%

improvement in functional level). Active range of motion of cervical spine rotation also

improved (75 degrees to the left and 55 degrees to the right, measured with goniometer).

This was a small improvement from 70 degrees left rotation and 54 degrees right rotation

on first visit. The patient however did report overall less pain with both motions. Muscular

strength of the bilateral longus colli muscles improved to 3+/5 (was recorded at 3/5 on

first visit).

As discussed before, the case patient was not seen for a formal discharge

appointment during which time more formal and objective measurements could have been

recorded. The study by Standford et al (1991) suggests that a change of 5 points or 10% on

the NDI demonstrates a clinically important change. The case patient could be postulated to

have been able to reach this minimal detectable change within the three months of


treatment; however this outcomes measure was only reassessed at her four-week follow

up appointment. It can also be postulated that significant improvements may have been

achieved regarding cervical spine range of motion, decrease in pain sensitivity with

palpation of original tender points, and muscular strength of bilateral deep neck flexors

and scapular stabilizers.

It is also clinically important to note that the patient reported improved mobility of

the lower cervical spine facet joints (2+/6) compared to initial measures of 1+/6

hypomobility during post-manual therapy testing on her fourth visit. Following the

interventions provided during her last visit, the patient displayed an increase in active

cervical rotation (75 degrees to the left, and 60 degrees to the right; originally 70 degrees

left rotation and 54 degrees right rotation during her first visit). Decreased muscle tone

was also noted within the bilateral upper trapezius and scalene musculature during this

visit.

Regarding subjective outcomes, the patient reported her resting pain level to be a

2/10 during her last visit (1 point less than her average report for the past 6 visits). The

patient reported only having two headaches within the past week which was a significant

improvement from initial reporting of 5 headaches per week on average. The patient

reported the overall intensity of the headache was noticeably less than when she first

began therapy. The patient also reported during the last visit not self-manipulating her

neck for the past six days. Overall, small improvements were achieved using both

subjective and objective measures in lieu of inconsistent attendance of physical therapy

sessions and medical complications.


Discussion

This case report describes the physical therapy diagnosis, management,

interventions including therapeutic exercise and orthopedic manual therapy, outcomes,

and other considerations of a patient with cervicogenic headache. The patient was a 35-

year old female referred by her primary care physician with complaints of chronic neck

pain. The patient presented at her initial evaluation with decreased range of motion of

cervical spine , tenderness to palpation of bilateral upper trapezius, sternocleidomastoid,

and suboccipital muscles, left transverse process at C2, and right transverse process at C7,

headaches into right frontal (supraorbital) region several times/month, multi-level cervical

and upper thoracic segmental mobility dysfunction, muscular weakness of scapular

stabilizers (middle/lower trapezius) and deep neck flexors, and postural impairments. The

Neck Disability Index (NDI) and Numerical Rating Scale (NRS) was a validated and reliable

outcomes measure tool used to determine progress over the course of treatment. Her

initial score was a 40%, moderate severity of functional impact of impairments. Patient

management of her condition consisted of various non-thrust manipulations, soft tissue

mobilizations, postural re-education, progressive therapeutic exercise, and patient

education for improved self-prevention of neck pain to address her impairments.

Although the patient made some minor improvements as indicated above within the

outcomes portion of this report, the overall progress was clinically insignificant most likely

due to poor compliance with home program, numerous medical comorbidities, and her

inability to regularly attend physical therapy. The patient’s improvement on the NDI and

NRS did not meet clinically important differences and minimal detectable change, however

did show minor improvement. Although outcomes for this case patient were not significant,


the progress indicated as supported by current evidence, suggest that a multi-modal

physical therapy treatment program approach using orthopedic manual physical therapy

interventions in addition to soft tissue manipulation, patient education, and therapeutic

exercise may be effective in the management of a patient diagnosed with cervicogenic

headache.

The mobilization techniques utilized for the case patient to improve overall cervical

spine mobility and decrease pain are based upon the manual therapy approaches

popularized by Stanley Paris of the University of Saint Augustine. These techniques include

upslides and downslides that utilize posterior-anterior mobilization combined with cranial

or caudal (respectively) glides to promote motion at restricted zygopophyseal joints.

A recent study examined the short-term biomechanical effects of non-thrust

(Maitland, Grade III techniques) PA manipulation techniques on the cervical spine (Lee et

al, 2005). Although this manual therapy technique is relatively common in the evaluation

and treatment of neck pain, little is known about the actual biomechanical effects. Much of

the research has historically been focused on the benefits within lumbar spine for patients

with low back pain. Within this study, the cervical spines of nineteen healthy subjects were

scanned using an open interventional magnetic resonance imaging scanner.

Posteroanterior (PA) mobilization forces were applied to the fifth cervical vertebra in the

prone position. It was shown from sagittal images obtained before and during the

mobilization that PA mobilization of the cervical spine generally produced extension of the

upper motion segments and flexion of the lower segments when forces were applied at the

5th cervical vertebrae. The cervical lordosis was found to increase with repeated PA loading

cycles, which is particularly important to know when clinically providing interventions to


restore cervical lordosis that may be significantly reduced with a resting forward head

posture. It was also found that forces applied at one spinous process produced not only

movements at the target vertebra, but also movements throughout the entire cervical spine

helping to restore cervical lordosis and overall mobility. The most interesting

interpretation from this research study was that mobilizations to this area should be

interpreted as three-point bending of the entire cervical spine, rather than simple gliding of

one vertebra upon another. Several of the mobilizations provided to the case patient were

applied to the fifth cervical vertebrae which may explain her improvements in overall

range of motion even after just seven visits.

The patient also reported a decrease in pain overall within the neck region and

decreases in headache intensity and frequency which may very well be related to the

nociceptive inhibitory effect spinal manipulation therapy is able to produce. As stated

before, spinal manipulative therapy has been shown to help activate descending inhibitory

pathways from, the lateral periaqueductal gray area of the midbrain (Wright, 1995). The

lateral periaqueductal gray (PAG) is closely related to the behavioral responses to pain,

stress, and other stimuli in maintaining internal homeostasis, which (Fernandez de-las-

Penas et al., 2006). Although the overall patient outcomes were minimal due to poor

consistency and adherence to a regular physical therapy program, positive gains were

made regarding cervical spine range of motion, pain level, and headache intensity and

frequency. From this information, it can be inferred that spinal manipulative therapy

utilizing PA forces for the cervical spine may help to improve clinical outcomes for patients

with cervicogenic headaches.


Because the case patient had been experiencing headaches and neck pain for many

months and had entered a chronic stage of her condition, evidence for the use of thoracic

spine manipulation to improve neck pain may not have been indicated as outlined by a

recent clinical prediction rule by Childs et al (2007). When 5-6 of the clinical prediction

rule factors (symptoms <30 days, no symptoms distal to the shoulder, looking up does not

aggravate symptoms, Fear Avoidance Beliefs Questionnaire Physical Activity (FABQPA

<12), diminished upper thoracic spine kyphosis based on visual estimate, and cervical

extension ROM <30 degrees) are satisfied a positive likelihood ratio of greater than 12 is

indicated for positive outcomes in reducing neck pain from thoracic spine manipulation. In

a later validation study of this clinical prediction rule, patients with mechanical neck pain

who received thoracic spine manipulation and exercise exhibited significantly greater

improvements in disability and pain at both the short- and long-term follow-up periods

compared with patients who received exercise only. The benefits of targeting manipulation

to patients who were positive on the CPR were marginal and were evident only at the

short-term follow-ups visits. From this information, it may be inferred that the even though

the case patient may not have met the clinical prediction rule, she may have still benefitted

from thoracic spine manipulations during each treatment session to help decrease overall

disability and pain.

To consider patient management for chronic-type conditions of cervicogenic

headaches it is important to consider the benefits of utilizing a combined approach of

manipulative therapy with therapeutic exercise. A recent study investigated the effects of

low load cranio-cervical flexion verses neck flexor strengthening exercises on deep cervical

flexor muscle activation, neck pain intensity score, neck disability index, and perceived


benefit of exercise (Jull et al, 2009). In this study forty-six subjects with chronic neck pain

were randomly assigned to one of following two groups for a 6-week training program:

o Low Load training: 10 reps of 10 seconds at progressively higher

biofeedback pressure unit levels (20mmHg – 30mmHg)

o Higher load strength training:

Stage one: 12-15 reps at a load that could initially be only lifted 12

times

Stage two: 3 sets of 10 reps using 50% 10 repetition max load, then

75% RM, then 100% RM.

Based upon electromyographic activity data of the neck musculature before and after

exercise intervention, the low load-training group had increases in EMG activity of the deep

cervical flexors, with decreases in EMG amplitude for the sternocleidomastoid and anterior

scalene muscles across all stages of the cranio-cervical flexion test. The cranio-cervical

flexion low load training has been study extensively by Jull and colleagues, and have been

shown to be an effective intervention for patients with chronic mechanical neck pain (Jull

et al., 2002; Jull et all., 2008).

Canegie et al (2007) also found similar results previously by examining functional

MRI results to evaluate cervical flexor activity during different cervical flexion exercises.

The results from this study demonstrated that combined cranio-cervical flexion and

cervical flexion (chin tuck with head lift) produced the highest increase between rest and

post exercise, demonstrating that all synergists were active and that this exercise is useful

for strengthening the sternocleidomastoid (SCM), longus capitis, and longus colli. During


cervical flexion (head lift), it was found that the longus colli is more active than longus

capitis and SCM, although the differences were found to be statistically insignificant.

The therapeutic exercises used for this case patient both within the clinical setting

and for her home exercise program are consistent with the recommendations made based

on these studies and involved low load, high repetitions at progressively higher demands

over time. In addition, the therapeutic exercises were gradually progressed in order to

allow the patient to develop proper recruitment of deep neck flexors in order to prevent

further neck strain and overuse of superficial anterior neck muscles, as commonly seen

with this population. By also including exercises which required the recruitment of deep

neck flexors immediately prior to active upper extremity resisted movements (DICE

exercises), the patient was able theoretically able to facilitate coordination with functional

overhead and lifting activities. Unfortunately, the final two physical therapy sessions were

the only sessions that included these exercises; continued sessions with such interventions

may have provided more significant outcomes.

It is important to discuss the issues of compliance and inconsistent attendance of

physical therapy for this case patient. The patient was seen for a total of seven visits over

the course of three months, which relative to the typical physical therapy plan of care, were

spread out over a long period of time. In addition, the patient had several medical

comorbidities during her plan of care and was dually seeking in vitro fertilization

treatment. As a result, she was unable to attend in a consistent manner as she had been

able to in her prior plan of care from 2012. During her prior plan of care, the patient was

able to regularly attend several times over the course of 5 weeks and made significant

progress in decreasing overall pain and improving functional use of her right upper


extremity. The Shoulder Pain and Disability Index, which examines the overall functional

level of the involved shoulder (Roach, 1991), was reduced from a 26% to a 5.4% over the

course of one month of her prior period of care during 2012. This was a clinically

significant and powerful reduction of overall disability which can be attributed, in part, to

her compliance with her home exercise program and ability to regularly attend physical

therapy during this time.

One recent study found strong evidence that poor treatment adherence was

associated with low levels of physical activity at baseline or in previous weeks, low in-

treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness,

poor social support/activity, greater perceived number of barriers to exercise and

increased pain levels during exercise (Jack, McLean, Moffett, & Gardiner, 2010). Although

this systematic review analyzed mostly prior studies that examined prognostic factors for

patients with chronic low back pain, these psychosocial aspects can also be applied to a

patient with chronic neck pain.

Another systematic review examined 70 articles on the course and prognostic

factors in neck pain and its associated disorders. It was found within the review that

younger age predicted better outcome. Psychosocial factors, including psychological health,

coping patterns, and need to socialize, were the strongest prognostic factors. It was also

found that factors including: higher initial pain intensity, longer duration, and increased

pain-related difficulties in performing activities, prior neck/shoulder symptoms, prior neck

injury, co-morbid low back pain, and self-perceived poor general health. Determining

prognosis for a patient with chronic neck pain can be difficult at times due to the complex

nature and combination effect of various demographic, socioeconomic, and psychosocial


factors. Future systematic reviews should continue to examine the major prognostic factors

for patients with chronic neck pain and headaches.

In summary, although the patient demonstrated inconsistencies in physical therapy

treatment attendance and poor compliance of her home exercise program, minor

improvements were made in regards to all initial impairments and particularly with overall

functional level as shown by the improved NDI score. It is likely that the patient had

multiple poor prognostic factors that also played a negative role in the degree of positive

outcomes that were made during this plan of care. A significant amount of evidence exists

to help support the basis for using orthopedic manual therapy interventions to reduce pain

and improve range of motion in cervical spine, and one can make the case that these

interventions combined with therapeutic exercises was able to create overall

improvements for this patient.

Conclusion

This case report demonstrates the physical therapy diagnosis, management,

interventions including therapeutic exercise and orthopedic manual therapy, and outcomes

of a patient with cervicogenic headache. The patient presentation corresponded with the

diagnostic criteria for cervicogenic headaches as outlined by the IHS and CHISG (Becker

2010; Antonaci et al., 2005). Comprehensive physical therapy treatment was provided to

this case patient for seven visits over a total of three months using orthopedic manual

therapy spinal mobilizations, soft tissue manipulation, patient education, and progressive

therapeutic exercises to improve strength of deep neck flexors and improve postural

impairments. Although outcomes for this case patient were not significant and all short

term and long term goals were not fully met, the progress indicated as supported by


current evidence, suggest that a multi-modal physical therapy treatment program

approach using orthopedic manual physical therapy interventions in addition to soft tissue

manipulation, patient education, and therapeutic exercise may be effective in the

management of a patient diagnosed with cervicogenic headache. This case report also

demonstrates the importance of considering prognostic factors and patient compliance in

providing treatment for patients with chronic neck pain and cervicogenic headaches. It can


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