Cranial Made Clinical: Headache Symposium Part 2: Muscle ......– Migraine Cephalgia – Post...
Transcript of Cranial Made Clinical: Headache Symposium Part 2: Muscle ......– Migraine Cephalgia – Post...
3/11/2019
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Cranial Made Clinical:Headache Symposium
Part 2: Muscle Tension Headache
Kate Worden, DO, MS
Clinical Professor OMM
MWU AZCOM
AOMA Spring Convention
13 April 20191
Disclosure
• I have no financial or other disclosures to make regarding this presentation
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Learning Objectives:
• Be able to contrast the common clinical presentations of 4 distinct headache types:– Migraine Cephalgia
– Post Concussion Cephalgia
– Cervicogenic (Muscle Tension) Cephalgia
– Temporo-Mandibular Joint (TMJ) Dysfunction
• Using the Headache Algorithm identify the appropriate diagnostic work up & Tx for: – Cervicogenic/Muscle Tension Cephalgia
– Migraine Cephalgia
– Post Concussion Cephalgia3
Learning Objectives:
• Demonstrate a knowledge of the underlying mechanisms of these headache types.
• Identify which somatic dysfunctions are commonly found in each type of headache.
• Identify the Indications and Contraindications for Osteopathic Manipulative Treatment for the above headache types.
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Learning Objectives:Understand the importance of Restoring Autonomic Nervous System Balance in the Cervical & Thoraco-Lumbar Spine:
• SNS: • Trigeminal Nerve (CN5)-caudate nucleus to C1,C2, C3
• Sympathetic chain ganglia: – Cervical: upper, middle, lower
– Thoraco-Lumbar: T1-L2
• PNS: Vagus N (CN X) influence via :
– Compression of CN X at Upper C complex/Foramen magnum
– Entrapment of CN X within Occipital Mastoid Suture as it traverses the Jugular Foramen
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Learning Objectives (LAB):
Be able to perform the following techniques:
• Strain Counterstrain (SCS) to tenderpoints:– Posterior C1
– Anterior C1
• Still Technique to OA Joint (C0-C1)
• V-spread to the Occipito-Mastoid (OM) suture
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Case Presentation:
• 26 y/o Asian Female, Osteopathic Medical Student
• C/o gradual onset of neck stiffness, sore shoulder muscles & now almost daily headaches for 3 mo.
• 2 types: Start at base of skull then curve forward to forehead and behind the Right eye (Ram’s horn) OR, bilateral temples and pressure at bridge of nose
• Better for a short time with yoga & massage, some temporary relief with Aleve ii bid. Worse with prolonged studying & computer usage
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What Does a Headache Look Like?
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BilateralTemples
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Vertex & Nose Bridge
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Whole Head
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Base of the Neck
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Forehead
Behind the Eye
Kids get Headaches Too!
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The eyes are the window to the soul…
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What Brings on a Headache?
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Headaches & Life Stressors
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Headaches and Emotions
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Work Stress, Computers & Headaches
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Headaches & Prolonged Studying
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Headaches and Sleep Position
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Headaches & Weather Changes:
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Headaches and Headgear
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Myofascial Trigger Points & Headaches
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SCMTRAPS
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Biomechanics of Posture
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Straightened or even reversed C curve esp from hypertonic Scalenes & SCM-Leads to head forward posture.
Headaches vs Low Back Pain
• Low Back Pain is the #1 reason patients seek medical help
• BUT
• Headache is the #1 reason people miss work !
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Cervicogenic Headache: DefinitionRecommended term vs Muscle Tension Headache
• Pain referred to head from musculoskeletal dysf of Cervical region & related areas– Etiology: Som Dysf w muscle spasm, decreased ROM,
tenderness, worse w movement, better w rest
– Assoc. w C muscle tendonitis, triggerpoints (TP), tenderpoints (tp), in head +/or neck, & C Jt. Inflam
– Pain relieved by successful Tx of SD once r/o systemic or local head region pathology as cause
• See Cervicogenic HA International Study Group for diagnostic criteria
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Cervicogenic Cephalgia: Sx
• Suboccip radiates to vertex or retro orbital
• Usu bilat, vice like tightness+/-photophobia & nausea, may be throbbing or pounding
• Trigeminally mediated pain-arises from a combo of spinal facilitation & referred pain patterns- typical Ram’s Horn distribution
• Rarely unilat & no prodrome/aura
(vs Migraine usu unilat & often have aura)28
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Dx Criteria from International HA Society:
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Cervicogenic HA: Natural Hx
• Lack regular pattern
• Quality of life affected-loss physical functioning
• Recurrent, episodic, last hrs to days
• Whiplash injury can lead to chronic Cervicogenic HA
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Inertial Injury
Diffuse Axonal Traction Injury:
Bone & Soft Tissue Injury
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Post Whiplash SyndromeInertial Injuries
*Head rotated at impact*
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Extends then Flexes*
Cervicogenic HA: Differential Dx (DDX)
• Migraine
• Occipital neuralgia
• Muscle Tension-type HA
• TMJ Dysfunction• Causes of Head Pain from other Cervical pathology:
– Trauma
– Herniated Disc
– Spondylosis (OsteoArthritis)
– RA34
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DDX cont.
• AV Malformations
• Cerebral Aneurysm
• Chiari Malformations
• Pseudotumor cerebri
• Vasculitis
• Vertebral Artery Dissection
• Glaucoma
• Meningitis
• Posterior Fossa Tumor
• Hemorrhage– Subdural
– Subarachnoid-Thunderclap HA
– Epidural
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HA Algorithm
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Functional Anatomy:
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All parts can generate pain
Autonomic(ANS) Influences of C spine
• Sympathetic(SNS): sup, middle & inf chain ganglia– C1-C4 Cervical Plexus-Cervico-Cranial Syndrome esp
via Trigeminal (CN V)– C5-T1 Brachial Plexus-Cervico-Brachial Syndrome– T1-T4 provide SNS to Head & Neck
• Parasympathetic(PNS):– CranioSacral System esp via Vagus (CN X)
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Key Muscles:
• Suboccipitals- level the occiput & temporals to horizon to ensure optimal fxn visual & vestibular systems
• Levator scapula-attaches T spine, UE, neck(not head)-causes “stiff neck”
• Trapezius - attaches T spine, UE, neck & HEAD-causes “Ram’s Horn” HA
• SCM: attaches sternum & med clavicle to mastoid pr of temporals-SB to & Rotate away from affected muscle-leads to head tilt to SideBent side
• Scalenes: attach R1 & R2 to neck-lead to forward head posture
• Semispinalis, Splenius capitis, Longissimus capitis-connect head & neck to T spine
• Anterior Cervical Flexors: Longus coli, Longus capitis-like psoas (hip flexor) in the neck 39
Suboccipital Muscles:Rectus capitis posterior
major
minor
Obliquus capitis
superior
inferior
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LEVATOR SCAPULA & SPLENIUS CERVICIS
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Neck mm attach as low as T4!
Trapezius
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SCM –2 Different Pain Patterns:
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Sternal Head (AC8) Clavicular head (AC7)
Scalenes and Longus coli & capitis
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Longus coli m of the ant neck-like the Psoas m of the ant hip!
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Fascial Triggers:
• Nuchal Ligament: can actually limit neck flexion
• Myo-dural Bridge: formed by suboccipital mm & their tendons & perivascular fascial sheaths– Muscles fuse directly w spinal dural from C1-C3!
– Forms the tender Atlanto-Occipital membrane (Ant & Post)
• C spinal dura:
– innervated by sensory n.
– responsive to stretch
– potential mechanism for pain in post occipital area after a strain or prolonged contraction
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Contributory Nerves:
• CNS:– Tectospinal tract coordinates eye & neck
movements• Oculo-cephalic reflex-can use eye muscles to
move small neck muscles for Muscle Energy
– Vestibular fxn (balance & equilibrium)-• linked to neck motion
– Neck motion-• linked w Shoulder & Upper Back motion
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Contributory Nerves: Cranial Nerves
– Trigeminal (CN V)• Som dysf of C spine refers
pain to head & face via CN V
• innervates cranial & facial structures, incl. cerebral blood vessels, dura mater
– Trigeminal Nucleus Caudalis (TNC)
• descends as low as C4-contiguous w the grey matter in the spinal cord dorsal horn
• converge w Sensory n’s from Upper C (C1-C3) -
Thus: pain signals from neck can be referred to head & face
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Contributory Nerves:
• Lower C (C5-C7): nociceptors can refer pain to head & face via TNC because info can ascend 1-3 levels before entering dorsal horn
• Bottom Line: nociceptors from Cervical structures can be perceived as head pain in regions where Trigeminal (CN V) innervates: occipital, temporal, frontal, facial areas*
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Contributory Nerves:
• Vagus (CN X): – ganglia lie below the foramen magnum
Mixed nerve w motor, sensory & PNS
– Nociceptors & inflam stimuli from the larynx, pharynx, thoracic & abdominal viscera are transmitted by Vagus to Upper Cervical afferents
– this can lead to efferent discharge of C spinal motor n,
– accounts for palpable incr in myofascial tissue tension in Upper C spine (ie, viscerosomatic reflex)
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Contributory Nerves:
• Primary sensory axons from sup. vagal gangli terminate in TNC carrying sensation from EAM (ear canal), ext TM (eardrum), and skin of the ear to the TNC
• Myofascial Restriction of the Jugular foramen thru Occip-Mastoid Suture (OM) affects CN IX, X, XI
• Spinal Acces N (CN XI): – sends motor to SCM & Trapezius
– some afferents to TNC to produce pain
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Vagus (PNS) & Trigeminal(SNS) lie adjacent at upper C complex:
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Note:
1. How far inferiorthe nuclei of CNs V & X go below Foramen magnum
2. How close they are together!
Contributory Nerves:
• SNS:– SNS fibers dense in dura mater at Occipital base
– SNS afferents from skin (vaso-, sudo- & pilo-motor)
– C SNS ganglia (sup, mid, inf)-Sup C ganglion, ANT to C articular pillar of C2 vert. -innervate vasculature & mucous membrane of head
– T1-T4 spinal n send SNS preganglionic fibers to head
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Contributory Nerves: Peripheral Nerves:
• C1-C3: form Greater & Lesser Occip Ns -innervate post scalp-entrapment can lead to Occipital Neuralgia– C1 n innervates OA Jt. -can refer pain from SD to the Occipital region
– C2 n-innervate AA Jt & C2 & C3Jts. SD refers deep dull pain from occip to parietal, temporal, frontal & periorbital, w paroxsysmal sharp pain superimposed (C2 Neuralgia)
– C3 n -innervates C2 & C3 Jts. SD often in whiplash injury transmits referred pain to fronto-temp and periorbital regions
– C4 n-innervates midscapular & shawl of shoulder areas
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Cervical Nerves to the Head:
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Upper Cervical Nerve Patterns:
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Inflammatory Markers:
• Pro-Inflammatory cytokines are higher in Pt w Cervicogenic HA than Pt. with migraine– Interleukin (IL-1)
– Tumor Necrosis Factor (TNF)
– Nitrous Oxide (NO)
• Calcitonin Gene Related Peptide (CGRP) is present in Pt. with Migraine HA but not in Pt. with Cervicogenic HA
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Key to tell Cervicogenic from Migraine HA:
Migraine HA:
• Nausea + Vomiting
• Too severe to sleep
• +/- Aura
• IL-1, TNF (low)
• NO (low)
• CGRP (+)
Cervicogenic HA:
• Nausea but NO Vomiting
• Able to sleep
• No aura
• IL-1, TNF (high)
• NO (high)
• CGRP (-)
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Levels of Medical Evidence:
A = Highest– Randomized Controlled
Trials
– Meta-Analyses
– Systematic Reviews-well designed
B = Medium– Case Controlled or Cohort
Studies
– Retrospective Studies
– Uncontrolled Studies
C = Least – Consensus Statement
– Expert Guidelines
– Usual Practice
– Opinion
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Level A Evidence for C manipulation:INDICATIONS for OMT: in Acute, Subacute & Chronic
Neck Pain and Headache
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Benefits of OMT for Cervicogenic HA:
• Decreased Pain -frequency, intensity & duration
(Level A Evidence)
• Improved functionality -in Activities of Daily Living (ADL) & work productivity
• Decreased reliance on analgesic & other medications-can have side effects & complications
• Less need for more invasive procedures- (Triggerpointor Botox injections, Nerve blocks, Steroid epidural injections, Radiofrequency Ablation or Surgery)
(Level A Evidence: randomized controlled trials, meta-analyses & systemic reviews)62
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Contraindications to OMT:
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Cervicogenic CephalgiaWhere to focus your OMT:
• Jt: OA, AA, C2, C4-C5, C7, T1, T4
• Muscles: – Traps, SCM, scalenes, suboccipitals
– Reflex to M. of Mastication-clenching, bruxism
– SCS tenderpoints
• Fascia: Cervical & Upper Thoracic
• Cranial: compression of: SBS, Occ condyles, Occipital-Mastoid suture
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Typical Sequence for Tx Cervicogenic HA:
• Seated– Necklace technique (MFR) to Thoracic outlet & C-T fascia (LYMPH)
– ME or Still to TLJ & T4-T1
– Still to R1, R2, Sternoclavicular Jt. using UE
• Supine– MFR to Cervicals: bowstring +/-squeeze toothpaste tx for (LYMPH)
– Indirect Rib raising from above: to T1-T4 (SNS)
– SCS: to key muscles (Traps + SCM, Lscap, Scalenes, ant & post Cs)
– ME or Still: to remaining Cervical Jt dysfunctions
– Suboccipital Release, BLT, ME, Still or HVLA: to OA (SNS & PNS)
• Cranial– Venous Sinus Drainage with Occ condylar decompression
– CV4 & V-spread the Occipito-Mastoid suture 65
Other Structures above are: Facilitated Structures
Case Presentation: CC:
• 26 y/o Asian Female, Osteopathic Medical Student
• CC: neck stiffness, sore shoulder muscles & now almost daily headaches
• 2 types: – Start at base of skull then curve forward to forehead and
behind the Right eye (Ram’s horn) OR, – Bilateral temples and pressure at bridge of nose
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Case Presentation: Hx
• Occasional nausea, but no aura or neuro symptoms
• Intensity: pain range: 0-8/10, 4-5 bad days/week
• Soc Hx: Lots of pressure from family to succeed, Diet: Lots of sugar & caffeine to make up for lack of sleep, No TOB or ETOH.
Denies depression but often worried re failure
• Previous Injuries: As a kid ran into glass door, hit nose & R forehead, stitches but no LOC or Fx(significance-predict what cranial findings?)
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Case Presentation: PE
Vitals: 110/65, 85, 14, 5’4”, 140#, 98.2 F
– Gen: mild distress w pain facies, holding R forehead
– Mental Status: A & O x 3, Affect blunted (signif?)
– Neuro: CN I-XII intact, Sensation Intact (LT), Strength (5/5), DTR (+2/4 sym)
– HEENT: decr ROM but no rigidity, no discharge
– CV: HRR w/ occ ectopy (why?)
– Lungs: clear to auscultation
– GI: BS x 4 w/o mass, tender or HSM (hepatosplenomegaly)68
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Case Presentation: PE
• Screening Osteo/MSK Exam:– C: increased lordosis w/ marked decr Flexion & SB Left,
Rot Bilat. (which mm’s tight?)
– T: upper & lower incr kyphosis, mid-flattened (signif?)
– L: lower incr lordosis Sacrum: rigid w L/S compression
– Pelvis: L post innom rotation
– Rib: R1-2 inhaled Right (which m tight?)
– Abd/Visc: breath shallow, Celiac & Sup Mes ganglia + (signif?)
– UE: hunched rounded shoulders, tense R forearm mm– LE: SLR (-) w/ tight hamstrings, psoas & weak abds
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Case Presentation: PE
• Cranial: CRI: Rate 10, Amplitude low, Flexion, R torsion, R Temporal IR w/ R occ-mastoid suture compression, Venous sinus congestion, Frontal compression, jaw deviates R with opening click (signif?)
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Case Presentation: Clinical Reasoning
• Where does this HA fit on the HA Algorithm?
• What clues are found in the Hx & PE?
• Where is the Area of Greatest Restriction (AGR)?
• How will I sequence the OMT Tx for this patient (Where do I start & where do I go next & why)?
• How might remote dysfunctions play a role in maintaining this headache pattern?
• What Exercises can I teach this patient to begin to change her postural imbalance?
• What lifestyle counseling does she need? 71
Case Presentation: ASSESSMENT & PLAN
ASSESSMENT:
• Headache:– Cervicogenic (ICD10: G43.909)
– Consider TMJ, Migraine
• Atypical Facial Pain (650.1)
• Anxiety, situational
• Somatic Dysfunction:– H, C, T, R, UE
PLAN:
• OMT to 5 areas– Regions: H, C, T, R, UE
– Using: ME, MFR, SCS, Cranial
– Response to OMT?
• Rx?
• Diagnostic Testing?– Labs or Imaging
• Teach Home Exercise
• Lifestyle Counseling
• Recheck72
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LAB
SCS to C1-posterior (PC1Reg) and anterior (A1C)
Still technique to OA
V-spread the Occipito-Mastoid Suture
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Headache Lab: Cervicogenic Headache > TREATMENT SEQUENCING
Palpate for Muscle Tension
Suboccipital area:• Rectus capitis posterior major & minor (PC1R)• Obliquus capitis • Occipital Condyle • Occipital Mastoid Suture
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Principles of Strain Counterstrain (SCS):
• Find a tenderpoint with testing pressure
• Put the associated muscle, fascia, etc. in its most relaxed position, wrapping around the opp. side and hold for 90 sec
• 3 phases of release:– Nerve phase: pain diminishes- then use monitoring pressure (less)
– Circulatory phase: as fascia relaxes, the relatively ischemic area allows fresh blood to enter-feel a pulse
– Lymphatic phase: as fluid passes through the capillary, the lymphatics drain-feel a softening
• Slowly, passively return body to a neutral position
• Retest. Goal is 70+% improvement
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Cervical
SCS of suboccipital muscles: Posterior C 1 Regular (P1C):
Anatomic Correlation: Rectus capitis posterior major/minor, Obliquus capitis superior & Post Occipto‐Atlantal membrane
Clinical Correlations: Headache on the ipsilateral side of the head
Location: On the occiput lateral to the main posterior cervical muscle mass 1 ½ inches from midline. Pressure is applied posterior to anterior directing the force slightly cephalad.
Technique:Patient: SupinePhysician: Seated at head of table1. Extension at level of C1: Hyperflex the cervicals to then allow
marked extension of C1 on the occiput. 2. Sidebend away slightly, and Rotate away slightly from side of TP.
Technique 1
P1C Regular SCS treatment position
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Technique 2
Cervical
SCS of suboccipital muscles: Cervical ANTERIOR C1 (A1C):
Anatomic Correlation: Rectus capitis anterior & fascia of the anterior Occipito‐Atlantal membrane
Clinical Correlations: Mimics TMJ pain, frontal headache, neck pain.
Location: The Posterior surface of ascending ramus of mandible ½ ‐ ¾ inch above angle of the mandible. Pressure is applied posterior to anterior on ramus of the mandible.
Technique:Patient: SupinePhysician: Seated at head of table1. Side bend away from the TP slightly, and rotate away
markedly from the side of the TP. No flexion or extension.
SCS A1C treatment position
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Principles of Still Technique
• Make a Dx, eg C2 FRS R
• Indirect: Take the dysfunction to its most relaxed position eg flexed, rotated and sidebent right.
• Activate: Add slow steady compression (or distraction) until the dysfunction softens
• Direct: Take the dysfunction toward the barrier in all 3 planes, eg sidebend right, rotate right then extend.
• Recheck. May repeat 2-3x if needed
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Technique 3
Cervical:
Supine Still Technique of the OA:
Diagnosis: OA FSRRL
Technique: Patient: Lying SupinePhysician: At head w/ both hands on occiput in neutral.1. Flex & add SB (to R) by transla on (from R→ L).2. Add ROT to point of ease (L)3. Compress using both hands –just enough to hold position of
localization.4. Maintaining compression, slowly
take head toward barrier in each plane:• SB to (L)• ROT to (R)• Extend
5. Can repeat as needed6. RECHECK!
Figure 1a‐b. Hand position for Still OA Supine
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Tx 4: V-Spread Technique
• Fluid Technique-– We will use to release a fluid/fascial restriction of the
Occipito-Mastoid (OM) Suture
• Find the longest diagonal in the head from the restricted suture and send a fluid impulse until it softens.
• Activating force = The Potency of the Primary Respiratory Mechanism (PRM)/Cranial tide via a fluid wave
• Can use anywhere in the body on any restricted suture, quadrant of the head, SI joint, or element.
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Dx Occipito-Mastoid (OM) Suture Compression
Compression of Cranial Nerves IX, X, XI as they exit the Jugular foramen in the OM suture
• Gently palpate the OM suture
• Using your index or middle fingers on each side
• Assess for: – Edema (fluid in the ditch) or
– Joint restriction (woody, decreased ability to spring)
Tx: V-Spread OM Suture• Place one sensing hand gently over
the restricted suture (or joint) with index & middle finger lying side-by-side abducting to form a small V.
• Find the longest diagonal in the head from this restricted suture.
• With the tips of your finger of the other hand, send a gentle fluid pulse toward the restriction barrier
• After a brief pause, you will sense the wave under the V of your sensing hand. Be aware of the fluid bouncing back.
• Slowly repeat until a softening is felt in the area of the restriction and an impulse no longer sends a fluid wave.
• Recheck over OM suture for less edema (empty ditch) & resiliency of springing.
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V-Spread OM suture
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References:
• Chila, A, Foundations of Osteopathic Medicine, 3rd ed by Lippincott, Williams & Wilkins, 2011, Ch.37: Head and Suboccipital Region by Heinking, KP, Kappler, RE and Ramey, KA, 503 (Pt. Eval), 507-8 (Tension), 508-510 (Migraine), Ch 38: Cervical Region by Heinking, KP, Kappler, RE, 513-527, Ch 60: Cervicogenic HA by R. Hruby, et al, 939-945.
• Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition (beta version), Cephalgia, 33 (9) 629–808
International Headache Society 2013. DOI: 10.1177/0333102413485658
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References:
• Meyers, HL, et al, Clinical Application of Counterstrain, TOMF Osteopathic Press, 2006, Ch 1: Treatment of Headache, Neck Pain, and TMJ Dysfunction with Counterstrain by R. Kusunose, 1-38
• Seffinger, M and Hruby, R, Evidence Based Manual Medicine, Saunders Elsevier, 2007,129-187 (Mechanical Neck Pain), 189-205 (Cervicogenic HA), 207-220 (TMJ).
• DiGiovanna, EL and Schiowitz, S, in An Osteopathic Approach to Diagnosis and Treatment, Lippincott Williams & Wilkins, 3rd ed, 2005, 606-607.
• Hruby, RJ, Exploring Osteopathy in the Cranial Field, 2013.
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