Management of the Cervicogenic Patient · 3 Scope of the problem Headaches affect 66% of the...
Transcript of Management of the Cervicogenic Patient · 3 Scope of the problem Headaches affect 66% of the...
1
Management of the
Patient with Cervicogenic
Headaches
By: Julie McGee, PT, DTP, CEAS
Provider Disclaimer
• Allied Health Education and the presenter of this
webinar do not have any financial or other
associations with the manufacturers of any products or suppliers of commercial services that may be
discussed or displayed in this presentation.
• There was no commercial support for this
presentation.• The views expressed in this presentation are the
views and opinions of the presenter.
• Participants must use discretion when using the
information contained in this presentation.
Welcome Introduction
Incidence of Cervicogenic Headaches
Patient presentation
Differential Diagnosis
What does the Research Say?
Patient Evaluation and Treatment
Conclusion
2
Introduction Have worked in a variety of settings: Acute Rehab,
Worker’s Comp, Outpatient Orthopedics, Home Health.
B.S. from University of Massachusetts, Amherst.
MSPT & DPT from UCSF/SFSU Graduate program in
physical Therapy.
Performed ergonomic evaluations.
Worked at an onsite health clinic for a large tech
company.
Why Cervicogenic
Headaches?
Clinical work
Personal experience with cervicogenic headaches
Treating patients with head pain can be scary
Treating patients with had pain can be confusing
Neck pain
Shoulder pain
Objectives To understand the impact that cervicogenic headaches
(CGHA’s) have: number of population affected
impacts on quality of life
To be able to identify patients suffering from CGHA
To be able to provide effective treatment to those with
CGHA
3
Scope of the problem Headaches affect 66% of the world’s population (NIH)
2.5%-4.1% are due to cervicogenic causes
20% of headache patients being seen in pain clinics had a
headache from cervicogenic causes. (Haldeman et. al.)
Those with cervicogenic headaches (CGHA) report a lower
quality of life compared to controls. The quality of life is
similar to those with migraines and tension type headaches.
Those with CGHA had the greatest loss of physical function
when compared to those suffering from other types of
headaches.
What is a cervicogenic
headache?
“Cervicogenic Headache is referred pain…perceived in the head from a source in the neck.” (American MigraneFoundation)
What is a cervicogenic
headache? “The trigeminal nucleus is a region of the upper cervical
spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve (trigeminal nucleus caudalis) are believed to interact with sensory nerve fibers from the upper cervical roots. This functional convergence of upper cervical and trigeminal sensory pathways allows the bidirectional referral of painful sensations between the neck and trigeminal sensory receptive fields of the face and head. A functional convergence of sensorimotor fibers in the spinal accessory nerve (CN XI) and upper cervical nerve roots ultimately converge with the descending tract of the trigeminal nerve and might also be responsible for the referral of cervical pain to the head.” (Biondi)
4
Cervical Plexus
What is a cervicogenic
headache?
Often times upper cervical spine is implicated:
Head and neck extensors
Infrahyoid muscles (C1-3)
Rectus Capitus anterior and lateral (C1, C2)
Longus Capitus (C1-3 (C4))
Longus Colli (C2-6 (C7))
Levator Scapulae (C3-5)
5
Dermatomes
6
Typical Presentation:
Headache pattern
Often: Pain pattern that is supraorbital, or going over the top of the head
Typical Presentation:
Headache pattern
Typical Presentation Women affected more than men
Report a deep ache that can pulse or throb
May have crepitus
Limited cervical ROM, especially into flexion and extension
Posture: Forward head posture, or upper cervical spine extension
Dizziness that is instantaneous, not long lasting, not related to movement or head position
7
Dizziness and CGHA CGHA
Quick onset and resolution
Not related to head or neck position
Benign paroxysmal positional
vertigo (BPPV):
dizziness lasting 30 seconds-
1 minute
related to changes in head position
Neurogenic dizziness:
lasting >1 minute
not related to changes in head position
Typical Presentation: Posture
Typical Presentation: Aggravating and Easing Factors
Aggravating factors:
Prolonged neck postures (i.e. driving, computer use)
Neck movements
Pressure on the back of the head
Easing factors:
Lying down
Change in neck position
Ice or analgesics
Sometimes can’t identify aggs and eases
8
Red Flags
Sudden onset of a new, severe headache
Worsening of a pre-existing headache without obvious predisposing factors
Headache associated with fever, neck stiffness
Skin rash, especially with a history of cancer,
HIV, or other systemic illness
Red Flags continued Headache associated with focal neurological signs
Dysarthria, vertigo, tinnitus, double vision, other visual
disturbances, ataxia, personality changes, decreased level of consciousness, distal parathesias, and weakness
Moderate or severe headache triggered by coughing,
or bearing down
When in doubt: Go with your gut!
Differential Diagnosis Cranial tumors/space occupying lesions
Meningitis
Sub-arachnoid hemorrage
Migraine/vascular headache
Carotid or Vertebral artery dissection
Trigeminal neuralgia
9
Differential Diagnosis
continued
May ask about onset of HA, fever, past neurological dx, history of cancer, history
of trauma
Differential Diagnosis
continued
Other non-cevicogenic causes of HA
Migraines: Those with CGHA often have more limitations
in cervical flexion and extension, as well as noticeable differences in cervical muscles tightness as compared to
those with Migraines.
(Clinical tests CGHA Zito, 2006)
Patient gets referred to your
clinic
10
Subjective Questionnaires:
Neck Disability Index (NDI) (Vernon, 1991)
Headache Disability Inventory (Jacobsen, 1994)
Ask about onset
when/ how long going on
what
24 hour pattern
Subjective Aggravating factors: if patient is not able to identify
aggs, may ask about specific movements
Eases: If patient is not able to identify, may ask about specifics
Ask about medical history: History of cancer, history of
stroke/TBI, Car accidents, migraines, neck injuries
Can ask about stress levels and stress management
Ask about occupation and leisure activities
Examination Posture
ROM:
Cervical spine
upper and lower cervical ROM
may look at prolonged hold
Thoracic spine
Shoulder flexion and abduction ROM
Observe neck position
11
Examination: Special Tests Upper cervical ligament stability
Sharp-Purser test: Assess the integrity of the cruciform or
transverse ligament of C1-2
Tectorial membrane test: Assess integrity of tectorial
membrane
Alar ligament stress test: Assess the integrity of the alar
ligament
Upper cervical ligament
stability When to perform:
history of trauma
rheumatoid arthritis
ankylosing spondylitis
focal neuro signs
before manipulation/ high grade mobilization
Positive findings:
increased laxity
focal neuro signs
Sharp-Purser Test
12
Tectorial Membrane Test
Alar ligament stress test
Examination: Special Tests Vertebro-Basilar Insufficiency (VBI) / Cervical Arterial
Dysfunction (CAD)
Hold endrange AROM extension, right rotation and left rotation each for 10 seconds with 10 seconds rest in between positions
Monitor for dizziness, diploplia, dysarthria, nausea, level of alertness, parasthesias
Patient supine with head off of mat: hold PROM extension, right rotation and left rotation each for 10 seconds with 10 seconds rest in between positions
Monitor for dizziness, diploplia, dysarthria, nausea, level of alertness, parasthesias
13
VBI/ CAD Testing: PROM
extension
VBI/ CAD Testing: AROM
rotation
VBI/ CAD Testing: AROM
extension and rotation
14
VBI/ CAD Testing: PROM
extension
VBI/ CAD Testing: PROM
rotation
VBI/ CAD Testing: PROM
extension and rotation
15
CAD/ VBI testing
When to perform:
before manipulation/ high grade mobilization
focal neuro signs
Positive findings:
focal neuro signs
Refer back to MD
Examination
Manual Examination:
Low evidence, but can be helpful in diagnosis
(Howard, 2015)
Cervical-Flexion rotation test
(Hall, 2008)
16
TreatmentWhat does the research suggest?
Raciki et.al., 2013 Systematic review looking at conservative physical therapy
management of CGHA.
Searched CINAHL, ProQuest, PubMed, MEDLINE and SportDiscus
Inclusion criteria: RCT
Dx of CGHA using International Headache Society Classification
At least one:
baseline measurement
outcomes measure
an assessment of a conservative technique
Raciki et.al., 2013 Search yielded 6 RCT’s
Interventions:
Therapist-driven cervical manipulation and mobilization
self applied cervical mobilization
cervico-scapular strengthening
therapist driven thoracic manipulation
17
Raciki et.al., 2013 5 of the 6 RCT’s suggested a reduction in pain and
disability, and improved function.
Conclusion: Mix of manual therapy ( manipulation,
STM) and exercise can be effective in treating patients with CGHA
Malo-Urries et. al., 2017 Purpose: evaluate immediate effects of upper cervical
translatoric spinal mobilization on cervical mobility and
pressure pain threshold
82 Volunteers randomly divided into treatment and
control groups
Treatment group received mobilization
Control group rested in the same position
No treatment
Malo-Urries et. al., 2017 Outcomes measured: Cervical mobility, pressure pain
thresholds, current headache intensity (VAS)
Treatment group showed significant increases in
cervical mobility and significant decrease in headache intensity
No significant difference in pressure pain thresholds
18
Bodes-Pardo et. al., 2013 Pilot study
Measured the effects of manual therapy on active
trigger points on the sternocleidomastoid in the
treatment of CGHA
20 patients:
Treatment: manual pressure to trigger points and
stretching.
Control: longitudinal stroking of trigger points and
stretching
Bodes-Pardo et. al., 2013 Outcomes: headache intensity (VAS), neck pain
intensity, cervical range of motion, pressure pain
thresholds, deep cervical flexors motor performance
Measured at baseline and 1 week post treatment
Subjects in the treatment group:
Greater reduction of headache and neck pain
Improvements in motor control of the deep cervical
flexors, cervical active ROM and pressure pain thresholds
Dunning et. al., 2017 110 subjects with CGHA randomized into 2 groups:
Cervical and thoracic manipulation, mobilization and
exercise
Subjects completed 6-8 treatment sessions over 4 weeks
Outcome: Headache intensity (NPRS), headache
frequency, headache duration, disability (NDI),
medication intake
Measured at baseline, 1 week, 4 weeks, and 3 months
19
Dunning et. al., 2017 Analyzed with a 2 way mixed model ANOVA
Those receiving manipulation
Reported significant reductions in headache intensity and disability at 3 months follow up
At each follow up reported shorter duration and less
frequent headaches
Had significantly greater percieved improvement at 1
week and 4 week follow up
Ylinen et. al. 2010 180 female office workers with chronic neck pain
Randomly assigned to one of three groups:
Strength group
Isometric, dynamic and stretching
Endurance Group
Dynamic muscle and stretching
Control group
Stretching only
Subjects performed a 12 month training program
Ylinen et. al. 2010
Pain assessed using VAS at baseline and a 12
months
At 12 months headache decreased
Strength group: 69%
Endurance group: 58%
Control group: 37%
20
Jull et. al. 2002 RCT studying manipulative therapy and exercise in the
treatment of CGHA when used alone, in combination
and compared to a control group.
200 participants who met diagnostic criteria:
manipulative therapy
exercise therapy
combined therapy
control group
Jull et. al. 2002
Treatment period: 6 weeks
Follow up: post treatment, 3,6 and 12 months
Outcomes: change in HA frequency
HA intensity
HA duration
Jull et. al. 2002
Results: Exercise and Manipulative therapy group had significantly less HA
frequency and intensity
21
Pharmacological
management?
May be helpful for some patients
Warning that patients with CGHA that only rely on pharmacological agents are at an increased
risk of dependency (Biondi, 2005)
What does this all mean?
Manual Therapy: Gr V or manipulation
Mobilizations
Contract/relax stretching
Soft tissue mobilization
What does this all mean?
Exercises: training postural stabilizers
self mobilization
stretching
22
What does this all mean?
Ergonomics: getting the patient out of their position of discomfort
Treatment: Manual Therapy Soft tissue mobilization: suboccipitals, upper trapezius,
levator scapulae
Joint mobilization: P/A of C1 articluar pillar, A/P of occiput with C1 stabilized
Grade V, high velocity low amplitude/ manipulation
Contract/ relax stretching
STM to paraspinals and
suboccipitals
23
STM to paraspinals and
suboccipitals
STM to upper trapezius
STM to upper trapezius
24
STM to levator scapulae
STM to levator scapulae
Manual Therapy: Joint
Mobilization P/A of C1
25
Manual Therapy: Joint
Mobilization A/P of Occiput
Manual Therapy: Contract/
Relax stretching
Manual Therapy: Contract/
Relax stretching
26
Therapeutic Exercises Chin tucks
Scapular strengthening
Postural training
Pectoral stretching
Self mobilization
Core strengthening
Aerobic exercise
Therapeutic exercises:
chin tucks
Chin tucks with pneumatic
pressure feedback device
27
Therapeutic exercise:
chin tucks
Therapeutic exercises:
diaphragmatic breathing
Therapeutic exercises:
Scapular strengthening
28
Therapeutic exercises:
Scapular strengthening
Therapeutic exercises:
serratus anterior
Therapeutic Exercises: pelvic
tilts
29
Therapeutic Exercises:
Postural Training
Therapeutic Exercises: prone on
exercise ball
Therapeutic Exercises:
quadriped progression
30
Therapeutic Exercises:
Pectoral Stretching
Therapeutic Exercises:
Pectoral Stretching
Therapeutic Exercises:
Pectoral Stretching
31
Therapeutic Exercises: Self
Mobilization
Therapeutic Exercises: Self
Mobilization
Therapeutic Exercises:
Aerobic Exercise
32
Ergonomics Ergonomic evaluation
Refer to an ergonomic specialist
Advising patient on proper workplace setup
Ergonomics
Ergonomics
33
In Conclusion CGHA can be treated by a physical therapist
Subjective and objective can help to identify patients
with CGHA
Mix of manual therapy and exercises can beneficial
Do not forget about ergonomics
Questions?