Physical Therapy and Headaches

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Clinical and radiographic findings of a 17
year-old female with cervicogenic headache A
case study

• Kristin Stockham, SPT
• Regis University

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Objectives

• The learner will be able
• To state the criteria necessary for a diagnosis
  of cerviogenic headache
• To provide information assessed in the
  examination and evaluation for cervicogenic
  headache
• To apply current evidence in development of an
  intervention for cervicogenic headache.

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• This 17 year old female was referred with the
  following information
• Dx Neck pain HA
• Rx Evaluate Treat
• S 2 year hx of R sided headaches that can be
  brought on by too much reading.

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What We Know

• Diagnostic Criteria
• International Headache Society1
• Pain localized in the neck and occiput, which can
  spread to other areas in the head, such as
  forehead, orbital region, temples, or ears,
  usually unilateral.
• Pain is precipitated or aggravated by specific
  neck movements or sustained posture.
• 3. At least one of the following
• Resistance to or limitation of passive neck
  movements.
• Changes in neck muscle contour, texture, tone, or
  response to active and passive stretching and
  contraction.
• Abnormal tenderness of neck musculature.
• 4. Radiological examination reveals at least one
  of the following
• Movement abnormalities in flexion/extension.
• Abnormal posture.
• Fractures, congenital abnormalities, bone tumors,
  RA, or other distinct pathology (not spondylosis
  or osteochondrosis).

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Cervicogenic Headache Facts

• Incidence (up to 20 of all headaches)2
• Structural Causes3
• Gross cervical ROM vs. C0-1 C1-2 ROM 4,5,6

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Anatomy
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Kinesiology Biomechanics

• C0-1-Convex-concave articulations
• Atlas moves in direction of skull motion7
• C1-2 Convex-convex articulations

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History

• Heather is a 17 year old female about to begin
  her senior year of high school. She started
  experiencing intermittent neck pain and headaches
  about 2 years ago. She reports no known MOI, but
  notes the pain has steadily increased. She
  inconsistently tried chiropractic treatments
  about 6-7 months ago, but found no relief. She
  said her headaches are usually right-sided and
  can be brought on with extended periods of
  reading. She also notes that sometimes she
  experiences numbness in her R arm with certain
  arm movements. She reports taking 2 extra
  strength Tylenol 4x/d.

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Initial Examination
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Radiograph
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Evaluation

• PIP I am unable to complete all my homework on
  time, because too much reading makes my headaches
  and neck pain worse.
• Pt presents with signs and symptoms consistent
  with cervicogenic headache as is seen by
• movement abnormalities of the upper cervical
  spine (C0-3) in flexion on radiographic imaging,
• decreased cervical lordosis in neutral on
  radiographic imaging,
• limitation of passive neck movements at C0-3,
• abnormal tenderness of neck musculature, and
• unilateral headaches and neck pain is aggravated
  by prolonged flexion.

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Diagnosis/Prognosis

• Preferred Practice Pattern B- Impaired Posture
• ICD-9 Codes
• 723.1- Cervicalgia
• 784.0- Headache
• Prognosis
• Based on the following prognostic factors, this
  patient has a good prognosis for restoration of
  upper cervical spine ROM and decreased HA
  frequency with physical therapy interventions.
• Positive Factors young age, active, unremarkable
  PMH, family support, motivated.
• Negative Factors chronic headache duration.

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Goals

• Within 2 weeks patient will
• Achieve at least 10º of R/L C1-2 rotation.
• Be able to read for 15 continuous minutes without
  increasing neck pain and exacerbating headaches.
• Within 4-6 weeks patient will
• Achieve 20º of R/L C1-2 rotation.
• Be able to read for 30 continuous minutes without
  experiencing neck pain (0/10) or headaches.
• Decrease headache frequency to no more than
  2x/wk.

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Plan of Care

• Physical therapy 2x/wk for 4-6 weeks including
• Manual therapy treatment utilizing the following
  joint mobilization/manipulation techniques to
  limited joints and soft tissue techniques
  including soft tissue mobilization to restore
  muscle motion and normal tone.
• Exercise program for neck specific ROM and
  nodding of the upper cervical spine.
• NO STRETCHES. This patient has increased
  mid-cervical spine joint motion.

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Intervention and Evidence

• Van Duijn J, Van Duijn AJ, Nitsch W. Orthopaedic
  manual physical therapy including thrust
  manipulation and exercise in the management of a
  patient with cervicogenic headache A case
  report. J Manual Manipulative Ther.
  200715(1)10-24.9
• Case Study the use of manual therapy, including
  mobilization and manipulation to the upper neck,
  and exercise to treat a patient with cervicogenic
  headaches. Favorable response. ROM improved as
  well as subjective findings (I.e. NDI, pain).
• Hoving JA, Koes BW, de Vet HCW, et al. Manual
  therapy, physical therapy or continued care by a
  general practitioner for patients with neck pain.
  Ann Intern Med. 2002136713722.10
• Manual therapy is a favorable treatment option
  for patients with neck pain when compared with
  physical therapy or continued care by a general
  practitioner

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Interventions

• 97140 Manual therapy
• Soft tissue mobilization (STM) to posterior neck
  and upper thoracic spine (lamina release)
• Supine bilateral OA nodding
• Supine unilateral R/L OA nodding
• Supine unilateral R/L C1-2 rotation
• Sitting C1-2 rotation stretch
• Supine unilateral R/L C3-6 facet
  upglides/downglides
• Standing thoracic manipulation
• Prone thoracic PA mobilizations/manipulations.
• 97112 Neuro Re-Education
• Postural re-education
• Supine DNF exercises

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Re-Evaluation at visit 10
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Review

• Diagnostic Criteria for Cervicogenic Headache-
  IHS
• Clinical Tests Sitting C1-2 Rotation Test,
  Cervical Radiographs Flexion/Extension views,
  upper cervical joint mobility.
• Treatment Manual therapy to restore upper neck
  ROM, STM to decrease increased muscle tension,
  DNF training to increase muscle endurance.

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Check for Understanding

• T/F According to the International Headache
  Society an individual must present with bilateral
  pain in the neck and occiput to meet the
  diagnostic criteria for cervicogenic headache.
• Which test does the literature show is the most
  useful for the measurement of C1-2 rotation?
• Sitting C1-2 rotation
• Cervical flexion rotation
• General cervical AROM
• Which of the following is NOT an appropriate
  intervention strategy for a person with
  cervicogenic headaches presenting with
  mid-cervical spine hypermobility?
• Manual therapy to the cervical spine
• Cervical spine stretching
• DNF training

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References

• Headache classification subcommittee of the
  International Headache Society. The international
  classification of headache disorders 2nd
  edition. Cephaligia. 200424 Suppl 19-160.
• Hall T, Robinson K. The flexion-rotation test and
  active cervical mobility A comparative
  measurement study in cervicogenic headache.
  Manual Ther. 20049197-202.
• Zito G, Jull G, Story I. Clinical tests of
  musculoskeletal dysfunction in the diagnosis of
  cervicogenic headache. Manual Ther.
  200611118-129.
• Smedmark V, Wallin M, Arvidsson I. Inter-examiner
  reliability in assessing passive intervertebral
  motion of the cervical spine. Manual Ther.
  20005(2)97-101.
• Hoppenfeld S, Murthy VL. Treatment and
  rehabilitation of fractures. 1st ed.
  Philadelphia, PA Lippincott Williams Wilkins
  1999515.
• Aprill C, Axinn MJ, Bogduk N. Occipital headaches
  stemming from the lateral atlanto-axial (C1-2)
  joint. Cephaligia. 20022215-22.
• University of St. Augustine for Health Sciences.
  S3 Advanced evaluation manipulation of cranio
  facial, cervical upper thoracic spine. St.
  Augustine, FL.
• Gonnella C, Paris SV, Kutner. Reliability in
  evaluating passive intervertebral motion. Phys
  Ther. 198262(4)436-444.
• Van Duijn J, Van Duijn AJ, Nitsch W. Orthopaedic
  manual physical therapy including thrust
  manipulation and exercise in the management of a
  patient with cervicogenic headache A case
  report. J Manual Manipulative Ther.
  200715(1)10-24.
• Hoving JA, Koes BW, de Vet HCW, et al. Manual
  therapy, physical therapy or continued care by a
  general practitioner for patients with neck pain.
  Ann Intern Med. 2002136713722.

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Questions?