Cervicogenic headache

Transcription

1 A Specific Exercise Program and Modification of Postural Alignment for Treatment of Cervicogenic Headache: A Case Report Mary Kate McDonnell, PT, DPT, OCS 1 Shirley A. Sahrmann, PT, PhD, FAPTA 2 Linda Van Dillen, PT, PhD 3 Journal of Orthopaedic & Sports Physical Therapy Study Design: Case report. Objective: To describe an intervention approach consisting of a specific active-exercise program and modification of postural alignment for an individual with cervicogenic headache. Background: The patient was a 46-year-old male with a 7-year history of cervicogenic headache. He reported constant symptoms with an average intensity of 5/10 on a visual analogue scale where 0 indicated no pain and 10 the worst pain imaginable. Average pain intensity in the week prior to the initial evaluation was 3/10 secondary to trigger point injections. The patient s headache symptoms worsened with activities that involved use of his arms and prolonged sitting. Methods and Measures: The patient was treated 7 times over a 3-month period. Impairments of alignment, muscle function, and movement of the cervical, scapulothoracic, and lumbar regions were identified. Outcome measurements included headache frequency, intensity, and the Neck Disability Index (NDI) questionnaire. Intervention included modification of alignment and movement during active cervical and upper extremity movements. The patient also received functional instructions focused on diminishing the effect of the weight of the upper extremities on the cervical spine. Results: The patient reported a decrease in headache frequency and intensity (1 headache in 3 weeks, intensity 1/10) and a decrease in his NDI score from 31 (severe disability) to 11 (mild disability). The patient also demonstrated improvement in upper cervical joint mobility, cervical range of motion, scapular alignment, and scapulothoracic muscle strength. Conclusion: Interventions that included modification of alignment in the cervical, scapulothoracic, and lumbar region, along with instruction in a specific active-exercise program to address movement impairments in these 3 regions, appeared to have been successful in relieving headaches and improving function in this patient. J Orthop Sports Phys Ther 2005;35:3-15. Key Words: cervical spine, muscle impairments, posture, scapular alignment 1 Instructor, Program in Physical Therapy, Washington University School of Medicine, St Louis, MO. 2 Professor and Associate Director for Doctoral Studies, Program in Physical Therapy, Washington University School of Medicine, St Louis, MO. 3 Assistant Professor, Program in Physical Therapy, Washington University School of Medicine, St Louis, MO. The protocol for this case report was approved by the Human Studies Committee of Washington University Medical Center. Send correspondence to Mary Kate McDonnell, Program in Physical Therapy, Washington University School of Medicine, Campus Box 8502, St Louis, MO mcdonnellm@wustl.edu Cervicogenic headache (CH) has been described as a syndrome that is a final common pathway not an entity. 32 Thus, CH is a syndrome that can have many contributing factors. The World Cervicogenic Headache Society 41 has defined CH as referred pain perceived in any part of the head and caused by a primary nociceptive source in the musculoskeletal tissues that are innervated by the cervical nerves. Pain associated with CH has been attributed to physical impairments 42 of the joint, muscle, and neural structures in the cervical region, and, in particular, the upper cervical spine region. 4,14,31 The majority of rehabilitationbased clinical trials for treatment of CH have examined the effect of manual therapy performed on cervical joints to alleviate the identified dysfunction ,29,39,40 Manual therapy studies have demonstrated positive effects at both the impairment (pain and muscle function) and disability level, with most studies focusing on shortterm outcomes. 10,36 Overall, the impairment level effects have included a decrease in headache frequency, intensity, and duration. Journal of Orthopaedic & Sports Physical Therapy 3

2 The disability effects have been evidenced through improvements in performance of everyday activities ,29,39,40 Impairments involving muscle, specifically the deep neck flexors, also have been identified in patients with CH. 2,13,23,24,24,38 Placzek et al 24 demonstrated that patients with CH had significantly less strength and endurance of the deep neck flexors compared to age-matched controls. Jull et al 13 also identified a decrease in strength of the deep neck flexors in patients with CH, when compared to able-bodied individuals. In a recent clinical trial involving patients with CH, Jull et al 15 compared the effects of specific active exercises directed at improving the strength and endurance of the deep neck flexors to manual therapy treatment of the cervical joints. Patients who received active exercise, manual therapy, or a combination of active exercise and manual therapy, displayed better outcomes than a control group who received no treatment. In particular, the groups who received active exercise improved in both pain behavior and strength of the deep neck flexors. Although there was no difference in outcomes among the different treatment groups, this study suggests the potential importance of impairments of the deep neck flexors as a contributing factor to CH. Based on these studies, treatment of joint and muscle impairments in the cervical region appear to be beneficial with regard to pain behavior for patients with CH. Muscle function, when specifically addressed, also appears to improve in these patients. While previous studies have demonstrated positive effects by focusing their intervention on joint and muscle impairments in the cervical region, we have noted additional impairments that could be important contributing factors in the development and continuation of CH. 28 The additional impairments are present not only in the cervical region, but also in the scapulothoracic and lumbar regions. Impairments outside of the cervical region are of particular interest because some investigators have described how changes in alignment or movement in other regions have the potential to alter the biomechanics of the cervical spine. 7,35 Alterations in the biomechanics of the cervical region can contribute to local concentrations of high stress in cervical spine structures. 1 Such stress has the potential to cause cumulative microtrauma to tissue and, over time, potential tissue failure and development of CH symptoms. A forward head position with increased extension of the upper cervical region is commonly observed. 16 This extended alignment is of particular importance because some investigators have described how cervical extension may contribute to increased stress on the cervical facet joints as a result of approximation of the facet joint surfaces. 16,26 We also have observed that patients with CH frequently extend their neck when they perform unilateral or bilateral shoulder flexion. The active neck extension induced by shoulder motion is often associated with an initial forward head position. Repetition of such neck movements with shoulder movements, particularly when performed from an initial position of increased upper cervical extension, could also be a contributing factor to extension stresses on posterior cervical spine structures. In the scapulothoracic region, we have noted that patients with CH often display an alignment of scapular abduction and depression, indicating lengthened levator scapulae and trapezius muscles. Additionally, we observe that this scapular alignment is often associated with concomitant weakness of some or all portions of the trapezius as well as the rhomboids and levator scapulae. The potential result of these impairments is compressive loading of the cervical spine, resulting from a transfer of the weight of the upper extremities to the cervical region through the cervicoscapular muscle attachments. The role of these impairments on the patient s clinical presentation may be assessed by first testing cervical motion and symptoms while the patient is sitting in his/her preferred alignment. The assessment is then repeated while the examiner modifies the patient s postural impairments by manually lifting and adducting the scapulae. If the scapulothoracic impairments are contributing to the patient s symptoms, a decrease or elimination of symptoms is reported along with an increase in cervical region motion. Finally, we have in the past observed that modifying impairments of the lumbar region appears to have a positive effect on outcomes of patients with CH. Lumbar region impairments have the potential to affect the biomechanics in the cervical region. 3 For example, an increased lumbar lordosis is often associated with an increased thoracic kyphosis and cervical extension. 26 Patients with CH appear to actively extend the lumbar region and lift their rib cage when they flex their shoulders, which may ultimately reinforce the active cervical extension previously described. Because impairments in the cervical, scapulothoracic, and lumbar regions may alter the biomechanics of the cervical spine, it would be reasonable that, when present, such impairments may be contributing factors to the clinical presentation of the patient with CH. The purposes of this case report are to describe the findings from an examination of a patient with CH that includes assessment of impairments in the cervical, scapulothoracic, and lumbar regions, and to describe an intervention that includes active exercise and modification of functional activities to minimize the impact of impairments in these 3 regions. The primary focus of the intervention is on (1) modification of static alignment in all 3 regions, (2) modification of the patient s scapular position prior to movement of the neck or shoulders, as well 4 J Orthop Sports Phys Ther Volume 35 Number 1 January 2005

3 as modification of scapular movement during shoulder movements, and (3) restriction of compensatory movement in the cervical, thoracic, and lumbar regions with shoulder movements. CASE DESCRIPTION The patient was a 46-year-old male referred to physical therapy with a medical diagnosis of CH. Informed consent was obtained and the rights of the subject were protected. Chief Complaint The patient reported a 7-year history of headaches that limited his ability to concentrate and sleep. The patient reported constant headache-related pain located in the posterior cranium, neck, and upper trapezius region bilaterally. His average pain on a visual analogue scale (VAS) was reported to be 5/10 and his worst pain was reported to be 10/10, 6 with 0 indicating no pain and 10 indicating the worst pain he could imagine. Other aspects of the patient s medical history were unremarkable. Aggravating Factors The patient reported that his headache pain increased with most activities that involved the use of his arms. Specifically, he had difficulty working with his horses and sitting at his computer greater than 30 minutes. The patient also reported difficulty with sleep, awakening every 2 to 3 hours because of headache-related pain. He usually was able to return to sleep quickly if he changed his position, but sometimes he required pain medication to return to sleep. Previous Intervention One week prior to his initial physical therapy visit the patient s doctor performed 1% lidocaine trigger point injections. The patient reported that there were multiple injections administered in the posterior cervical and upper trapezius region bilaterally, and that he had a complete reduction in his headache pain for 24 to 48 hours afterwards. Since the injections, the patient reported that the intensity of his average headache pain had decreased to 3/10, but the pain was still constant. Functional Disability Functional disability was assessed with the Neck Disability Index (NDI) questionnaire. The NDI is used to assess functional limitations and disability. Studies of the NDI have demonstrated that the measure has adequate reliability and validity characteristics, and has been shown to be sensitive to different levels of severity and to changes in severity over time. NDI scores range from 0 to 50, with 0 indicating no disability and 50 indicating complete disability. The patient s pretreatment NDI score was 31, indicating severe disability. Physical Examination Visual Appraisal Visual examination revealed (1) a forward head posture with increased extension in the upper cervical spine, (2) excessive scapular abduction and depression, (3) a kyphotic thoracic curve, and (4) a prominent abdomen. A tape measure was used to quantify the position of the scapula. The vertebral borders of both scapula were found to be 17.8 cm lateral to the vertebral column, which would be considered to be excessive scapular abduction bilaterally. 33 The humeri were positioned in excessive medial rotation and the infrasternal angle was increased, with a measurement of greater than Cervical Active Range of Motion and Pain Behavior Cervical spine motion was assessed with a cervical range of motion instrument (CROM Deluxe; Performance Attainment Associates, St Paul, MN) in relaxed sitting. 27,43 Each cervical motion was performed 3 times. The average of the 3 trials was recorded. The patient was asked to report changes in headache pain with performance of each motion. The patient displayed limitations in cervical motion in rotation and extension, and reported an increase in headache pain with both rotations as well as with extension (Table 1). Cervical rotation measurements were repeated while modifying the position of the patient s scapula. The examiner passively elevated and adducted the scapula while supporting the weight of the patient s arms (Figure 1). The test with manual correction of the position of the scapula was designated as the passive correction of scapular position test (PCSPT) (Table 1). The patient repeated cervical rotation to the left and right and reported his symptoms with the PCSPT relative to his symptoms without support. The patient displayed a 10 increase in cervical rotation in both directions and a decrease in his headache pain. Shoulder AROM and Pain Behavior Shoulder motion and symptoms with motion were measured with the patient in sitting. The patient achieved 130 of shoulder flexion with each extremity and reported an increase in pain in the upper trapezius region with both shoulder movements. During shoulder flexion, the scapula appeared to move into excessive abduction with minimal upward rotation or elevation. 11,28 In addition, the angle of scapular upward rotation was estimated to be approximately 35, indicating limited upward rotation. 11,25 Subsequently, the examiner manually assisted rotation and elevation of the scapula during shoulder flexion and the patient reported a decrease in the upper trapezius pain. J Orthop Sports Phys Ther Volume 35 Number 1 January

4 TABLE 1. Outcome measures. Journal of Orthopaedic & Sports Physical Therapy Outcome Measurement Visit 1 Headache behavior Constant; average, 5/10; worst, 10/10 Visit 2 (4 d After Visit 1) Intermittent; decreased intensity; no headache for 3h Visit 3 (1 wk After Visit 1) Frequency and intensity decreasing Visit 4 (3 1 2 wk After Visit 1) Several days without headache Visit 5 (5 1 2 wk After Visit 1) Several days without headache Visit 6 (8 1 2 wk After Visit 1) Able to perform functional activities without increase in headache pain Neck disability index score 37 * 31/50 14/50 14/50 14/50 11/50 Scapular position 17.8 cm 15.2 cm 11.4 cm Range of motion Cervical rotation Right, 39 P; left, 40 P Right, 30 NP; left, 50 NP Right, 50 NP; left, 50 NP Right, 50 NP, left, 50 NP Visit 7 (3 1 2 mo After Visit 1) Headache frequency, 1/wk; headache intensity, 1/10 Cervical rotation PCSPT Right, 50 DP; left, 50 DP Cervical flexion 40 P 40 NP 35 NP 31 NP Cervical extension 25 P 50 NP 40 NP 40 NP Shoulder flexion 130 P 150 NP Passive joint mobility Upper cervical joints Occipital atlanto 18 Limited Not limited Atlanto axis 18 Limited Not limited Muscle strength Lower abdominals /5 0.75/5 Lower trapezius /5 3.0/5 Middle trapezius /5 3.0/5 Rhomboid /5 4.0/5 Deep neck flexors 16 Muscle length 16 Pectoralis major Pectoralis minor Latissimus dorsi Cervical extensors Unable to test Short Short Short Short Abbreviations: P, painful; DP, decrease in pain; NP, nonpainful; PCSPT, passive correction of scapula position test. * Scores: 0-4, no disability; 5-14, mild disability; 15-24, moderate disability; 25-34, severe disability; 35, complete disability. Measured from the midpoint of the vertebral border of the scapula to the corresponding thoracic spinous process. The humerus was observed to move into excessive medial rotation and the lumbar spine into extension during shoulder flexion. Such a movement strategy suggests a limitation in the length of the latissimus dorsi muscle. 16 Additionally, the patient s lower cervical spine translated forward and his upper cervical spine moved into extension. When movement occurs in a segment other than the segment where the primary movement is intended to occur, the authors consider this movement to be compensatory and, in most cases, undesirable because it often occurs in the region associated with the patient s pain problem. 16,17,28 Potentially, in this patient, every time he flexed his shoulders he translated and extended his cervical spine. Passive Mobility Assessment of the Cervical Region The occipital atlanto and axial atlanto joints were assessed 2.0/5 Follow-up Phone Call (5 mo After Discharge) Headache frequency, 1 episode during 3-wk period according to the methods described by Maitland 18 for the amount of passive motion, joint end feel, and symptoms. The occipital atlanto joint displayed significant limitation of motion in the direction of flexion, with a stiff end feel. The axial atlanto joint displayed significant limitation of motion and a stiff end feel with both right and left rotation. The movement and end feel of segments in the lower cervical region 18 were considered normal and were asymptomatic with testing. Muscle Strength, Length, and Stiffness Lower abdominal muscle strength was assessed using the procedures described by Sahrmann. 28 The patient s lower abdominal muscles were graded as 0.5/5 on a scale of 0.1 to 5.0 (Table 2). When the patient attempted to contract the lower abdominals, as instructed, he elevated his rib cage, extended his spine, and ab- 6 J Orthop Sports Phys Ther Volume 35 Number 1 January 2005

5 TABLE 2. Grading criteria for lower abdominal strength assessment. 28 The primary criterion for correct performance of all tests is to keep the lumbar spine in contact with the examiner s fingertips as the examiner palpates the lumbar spinous processes during the lower extremity movements. The patient s abdomen also should remain flat. All tests are performed with the patient positioned in supine, with hips and knees bent and feet flat on the support surface. The patient is instructed to contract his abdominals by exhaling and pulling the abdomen in, so that the umbilicus is moving toward the spine. Test Grade Slide heel to extend lower extremity 0.10/5 Lift one foot, flexing hip 0.25/5 Lift one foot, hold knee to chest with hand, lift 0.50/5 other foot Lift one foot flexing hip to 115, lift other foot 0.75/5 Lift one foot flexing hip to 90, lift other foot 1.00/5 Lift one foot flexing hip to 90, flex the other hip 2.00/5 and slide the foot on the supporting surface, extend the hip/knee Lift one foot flexing hip to 90, flex the other hip 3.00/5 and, while holding foot off the supporting surface, extend the hip/knee Lift both feet to flex hips, slide both feet along 4.00/5 the supporting surface so that both hips and knees extend Lift both feet to flex hips, keep hips flexed while 5.00/5 extending knees, then, with both knees extended, lower both lower extremities to supporting surface FIGURE 1. Sitting passive correction of scapula position test. ducted his scapulae. These movements were considered compensations for the patient s lack of abdominal muscle strength and control. Upper quarter muscle length and stiffness were assessed according to the procedures described by Kendall. 16 Passive length of the pectoralis minor and pectoralis major was decreased bilaterally. Moderate stiffness was noted during muscle length assessment of each of the pectoralis minor, but no symptoms were reproduced. Stiffness in this context is defined as resistance of tissue to passive lengthening. 28 Length of the posterior cervical extensor muscles was assessed by passively moving the head and neck into cervical flexion while the patient was supine. Limited motion and moderate resistance to lengthening was noted, indicating decreased length and stiffness of the posterior cervical muscles. The patient also complained of pain in the upper cervical and occipital region with the test. An attempt was made to test the strength of the deep neck flexor muscles (longus colli, longus capitis, and rectus capitis) as described by Kendall. 16 An accurate muscle test of the neck flexors, however, was not possible because the patient was unable to achieve the appropriate test position. Strength of the scapulothoracic muscles was tested in prone. 16 There was decreased strength of the rhomboids and middle and lower trapezius with the greater loss of strength noted in the trapezius (Table 1). Diagnosis The patient s movement system impairment diagnosis was cervical extension with scapular abduction and depression (Table 3). Impairments of muscle function, postural alignment, and movement were considered to have contributed to stress on the tissues in the cervical region, resulting in the patient s pain complaints. The goal of the intervention was to address the identified impairments in the cervical, scapulothoracic, and lumbar regions in an attempt to reduce the stress on cervical structures, and to assist the patient in achieving his primary goal of decreasing the intensity and frequency of his headache pain. INTERVENTION Following the examination, the patient was instructed in exercises that addressed the identified impairments. The focus of the home exercise program was to (1) increase the strength and control of the abdominals, (2) increase the length of the anterior thorax muscles, (3) increase the length of the posterior cervical extensor muscles, (4) improve the strength and decrease the length of the posterior scapulothoracic muscles, and (5) increase shoulder J Orthop Sports Phys Ther Volume 35 Number 1 January

6 TABLE 3. Patient s movement impairment diagnoses: key impairments. Scapular Abduction Scapular position of excessive abduction 2. Scapular movement into abduction more than upward rotation during shoulder flexion 3. Modification of scapular position in the direction of elevation and adduction resulting in an increase in active cervical rotation and decreased pain with rotation 4. Weak and increased length of the trapezius and rhomboids 5. Short and stiff pectoral muscles Scapular Depression Scapular position of depression 2. Modification of scapular position in the direction of elevation during shoulder flexion, resulting in decreased upper trapezius pain 3. Modification of scapular position in the direction of elevation and adduction, resulting in increased active cervical rotation and decreased pain with rotation 4. Weak and increase length of the trapezius muscle 5. Short latissimus dorsi muscle Cervical Extension Forward head posture with increase extension at the lower cervical and upper cervical spine 2. Pain with active cervical extension 3. Compensatory movement of cervical extension during movements of the upper extremity 4. Short cervical extensor muscles 5. Weak deep neck flexor muscles joint and cervical spine motion. Instructions emphasized the need to minimize the compensatory movements of the cervical and lumbar region during the exercise performance. Modification of functional activities included instruction in strategies to support the weight of the upper extremities, thus minimizing the downward pull of the cervicoscapular muscles on the cervical spine. Exercises Lower Abdominals The exercise was performed from a hooklying position (Table 4 and Figure 2). 28 The purpose of the exercise was to improve the strength and control of the abdominal muscles, which is required to stabilize the trunk during movements of the extremities. During the performance of the exercise the patient was instructed to recruit the rhomboids and the trapezius to reduce the scapular position of excessive abduction. Additionally, the patient was provided with cues that encouraged modification of his preferred alignment of cervical extension. Specifically, he was instructed to keep his chin down towards his Adam s apple. The patient was not able to lift his second knee toward his chest without lumbar extension. He also was unable to maintain the upper quarter alignment as instructed. The exercise was modified so that the FIGURE 2. Lower abdominal exercise. FIGURE 3. Upper cervical flexion in supine. FIGURE 4. Shoulder flexion in supine. patient held one knee toward his chest with the ipsilateral arm and then lifted the opposite leg (Figure 2). This modification was used to reduce the force the abdominal muscles needed to generate 8 J Orthop Sports Phys Ther Volume 35 Number 1 January 2005

7 when performing the exercise. 28 The patient was able to perform the modified exercise with the correct alignment of the upper quarter. Upper Cervical Flexion The purpose of the exercise was to increase the length of the posterior cervical muscles and perform active contraction of the deep neck flexors while maintaining the thoracic and lumbar spine in the correct alignment. The patient was instructed to move his chin towards his Adam s apple without lifting the head off the supporting Journal of Orthopaedic & Sports Physical Therapy TABLE 4. Patient-specific cues for exercises and functional activity modification. General guidelines: 1. Perform exercises at least 1 time a day for 15 to 20 minutes, and perform 5 to 10 repetitions of each exercise 2. Stop performance of an exercise if pain increases 3. Emphasize performing each exercise slowly and without movements of the spine or rib cage Patient-Specific Cues Initial patient position The patient lies supine with his hips and knees bent and the feet flat on the support surface. Exercise 1: lower abdominal exercise (Figure 2) Exercise 2: upper cervical flexion in supine (Figure 3) Exercise 3: shoulder flexion in supine (Figure 4) Exercise 4: shoulder abduction and lateral rotation in supine (Figure 5) Exercise 11: supine upper cervical flexion with head lift (Figure 9) Initial patient position Exercise 5: sitting against the wall, upper cervical flexion (Figure 6) Exercise 6: sitting against the wall, cervical rotation Exercise 7: sitting against the wall, shoulder flexion (Figure 7) Exercise 8: sitting against the wall, shoulder abduction lateral rotation Initial patient position Exercise 9: facing the wall, arm slide and scapula adduction (Figure 8) Exercise 10: facing the wall, arm slide and cervical rotation Raise the shoulder blades up and together and keep the chin down, keeping your shoulder blades squeezed together and your chin tipped towards your Adam s apple when performing leg movements. Tighten the abdominal muscles by pulling your navel in towards the table. Lift one knee to the chest, then lift the second knee to the chest. Slowly return 1 leg at a time to the initial position. Tighten your abdominal muscles by pulling your navel in, raise your shoulder blades up and together. Move your chin down towards your Adam s apple. Avoid lifting your head off the support surface. Hold this final position for a count of 5 and then relax. You should feel a stretch down the back of your neck without reproduction of your headache or neck pain. Tighten your abdominal muscles by pulling your navel in, raise your shoulder blades up and together, and keep your chin down. Flex your arms overhead leading with your thumbs. Maintain the shoulder blade position during the arm movement. Do not let your rib cage or chin lift up during the arm movements. Tighten your abdominal muscles by pulling your navel in. Raise your shoulder blades up and together, and keep your chin down. Bring your arms out to the side and slide your arms overhead. Do not let your rib cage or chin lift up during the arm movements. Bring your chin down to your Adam s apple, and then, with help of your hands, lift your head off the table maintaining your chin position. Slowly lower your head back to the starting position. The patient is sitting with his back to the wall and his arms supported on pillows. Exercises begin with tightening the abdominal muscles by pulling the navel in and raising the shoulder blades up and together. Move your neck by bringing your chin down to your Adam s apple while keeping your head close to the wall. You should feel a stretch down the back of your neck but not a reproduction of your headache or neck pain. Perform exercise 5, then rotate your neck to the right for 5 repetitions, and then repeat to the left. Imagine that you are rotating your neck about an axis. Try not to side bend your neck. The movement should be performed in a pain-free range. Raise your arms overhead with your palms turned toward the wall. Do not let your low back come away from the wall and keep your chin down. Bring your arms out to the side and slide your arms overhead. Keep your arms close to the wall, do not let your low back move away from the wall. Keep your chin down. The patient is facing the wall, placing hands on the wall and sliding arms overhead, up the wall. Squeeze your shoulder blades together and lift your arms off the wall. Keep your abdominal muscles tight and keep your chin down. Return your arms to the wall. Rest your arms on the wall and rotate your neck. Imagine that you are rotating your neck about an axis. Try not to side bend your neck. The movement should be performed in a pain-free range. Initial patient position Facelying, arms overhead. Exercise 12: prone, arms overhead with scapula adduction position. Squeeze your shoulder blades together and then lift your arms off the table. Return arms to the initial (Figure 10) Functional instructions During the day support the weight of your arms as frequently as possible. For example, when working at your computer, make sure your forearms are supported on the desk or when standing place your hands in your pockets. J Orthop Sports Phys Ther Volume 35 Number 1 January

8 Figure 5. Shoulder abduction and lateral rotation in supine. surface and maintaining the scapulae in an adducted position (Figure 3 and Table 4). Shoulder Flexion The purpose of the exercise was to increase the length of the latissimus dorsi muscles and increase shoulder flexion without cervical and lumbar extension. The patient was instructed to flex the arms overhead, avoiding rib cage elevation or neck extension (Figure 4 and Table 4). 28 Shoulder Abduction and Lateral Rotation The purpose of the exercise was to increase the length of the pectoral muscles without compensatory movements in the cervical, thoracic, and lumbar regions (Figure 5). 28 The patient was instructed to adduct his scapulae as he performed shoulder abduction, while keeping the cervical and lumbar spine regions appropriately aligned. Prescription Guidelines The patient was advised to perform 5 to 10 repetitions of each exercise once a day. The exercises were to be performed slowly, avoiding compensatory movements, and without an increase in pain. Emphasis was placed on correct performance rather than on the number of repetitions. The patient was told that the exercises were expected to decrease and not increase his pain. He also was instructed to contact the therapist if there was an increase in any of his primary pain complaints during or after the performance of the exercises. He was advised that the exercises were designed to decrease the stress on the painful tissues and, over time, should help decrease his headache pain. Modification of Functional Activities The primary emphasis of modifications to functional activities was on developing activity-specific strategies to diminish the effect of the pull of the cervicoscapular muscles on the cervical spine. The patient was educated in the potential effect the weight of his arms had on his neck and the need to identify the activities he performed across his day in which his arms were unsupported. 30 For example, a strategy the patient adopted was to put his hands in his pockets or hook his thumb on his belt loop to support the arms during standing. OUTCOMES ACROSS INTERVENTION PERIOD Visit 2 Four days after the initial visit, the patient reported that his headache pain was now intermittent rather than constant and the intensity had diminished. He attributed his improvements in headache pain to the exercises he was prescribed, reporting that he could remain symptom free for 2 to 3 hours after an exercise session. The patient also reported that he was performing his exercises twice a day, 50 repetitions of each exercise per session. He chose to perform the exercises more frequently because of the positive effect on his headache pain. The patient continued to display some difficulty controlling the compensations in the cervical, scapulothoracic, and lumbar regions with some exercises. He was instructed in 2 modifications to assist him: to hold his knee closer to his chest during the lower abdominal exercise and to increase the amount of shoulder lateral rotation when performing the shoulder flexion exercise. Visit 3 Seven days following the initial visit, the patient reported a continued decrease in the frequency and intensity of his headache pain. His NDI score was 14, indicating mild disability and a significant improvement compared to his initial NDI score of 31. The patient displayed only minimal compensatory movements during his exercises. FIGURE 6. Sitting against the wall, upper cervical flexion. 10 J Orthop Sports Phys Ther Volume 35 Number 1 January 2005

9 exercise 5). This position requires greater trunk strength and control to maintain proper trunk alignment while moving the neck. Visit 4 Journal of Orthopaedic & Sports Physical Therapy FIGURE 7. Sitting against the wall, shoulder flexion. FIGURE 8. Facing the wall, arm slide and scapula adduction. Treatment during the third visit focused on review and revision of his exercises and modification of functional activities. The emphasis of the revisions was on correcting excessive rib cage elevation, scapular abduction, and cervical extension during the performance of the shoulder exercises. He was reminded to continue all of the strategies he had learned to minimize the downward pull of the shoulder girdle muscles on his neck. He also was advised to begin a walking program to increase his endurance and fitness level. The upper cervical flexion exercise was progressed by having the patient perform the exercise movement while sitting against a wall (Figure 6 and Table 4, Twenty-five days after his initial visit, the patient reported a continued decrease in the frequency and intensity of his headache pain, and stated he could be pain free for several days. The patient noted, however, that when his symptoms were present, performing his exercises did not relieve them as they had been in the past. He reported that he finally realized he had not been performing the exercises as carefully as in the past, and when he resumed the exercises with the appropriate modifications his symptoms were once again relieved. The patient also reported that he initiated his walking program of 2.5 km/d without any effect on his symptoms. Measures of cervical motion were repeated (Table 1). The patient displayed increased pain-free motion in cervical extension and left rotation. Specifically, the patient displayed a 25 increase in extension and a 10 increase in left rotation. Rotation to the right decreased 9, but the motion was no longer painful. The patient s NDI score was 14, indicating no change since his previous visit. Revision to his program during visit 4 emphasized restoring cervical rotation to the right and making his shoulder exercises more challenging. The cervical rotation exercise required the patient to sit with his back against the wall, his arms supported, and perform rotation without cervical extension or side bending (Table 4, exercise 6). When the patient performed the exercise correctly, the rotation motion was limited but pain free. Shoulder flexion and abduction exercises were progressed by having the patient perform the motions while sitting with his back to the wall (Figure 7 and Table 4, exercises 7 and 8). Emphasis was placed on avoiding compensatory motions in the cervical, scapulothoracic, and lumbar regions. Visit 5 Thirty-nine days after the initial visit, cervical range of motion measurements revealed an increase in right rotation, but a slight decrease in flexion and extension. The patient s NDI score remained at 14, indicating mild disability. Passive mobility testing of axial atlanto rotation and occipital atlanto flexion revealed increased range of motion and decreased stiffness, and both rotation and flexion were now pain free. Visit 6 Sixty days after the initial visit, the patient reported that his headache pain was better. He could do more J Orthop Sports Phys Ther Volume 35 Number 1 January

10 at work and home without producing headache pain. He also reported that he was able to perform horse care activities without reproduction of his symptoms. In addition, the patient reported walking approximately 40 min/d. The patient s exercises were reviewed. No revisions were recommended at this time. He was advised to continue with his exercises, functional modifications, and walking. Journal of Orthopaedic & Sports Physical Therapy Visit 7 Three and a half months following the initial visit, the patient reported that his headache pain occurred only once a week and he rated his symptoms at 1/10 when present. The patient also reported that when his symptoms started, performance of his exercises would abolish his headache pain within an hour. He reported that, on average, he performed his exercises 2 times a day. The patient s exercises were reviewed. He was instructed in 4 additional exercises. While facing a wall, the first exercise was to slide his arms up the wall and then adduct his scapulae (Figure 8 and Table 4, exercise 9). The purpose of this exercise was to increase the strength of the trapezius muscle. In the end range position of the arm-sliding exercise, the second exercise was to perform cervical rotation without cervical side bending. The purpose of this exercise was to improve cervical rotation with the upper extremities supported (Table 4, exercise 10). The third exercise was performed in supine (Figure 9 and Table 4, exercise 11). The patient performed cervical flexion using his hand to assist in lifting his head. The purpose of this exercise was to increase the strength of the deep neck flexors and continue to increase the length of the neck extensors. Finally, in prone with his arms positioned overhead, the patient was to perform scapular adduction (Figure 10 and Table 4, exercise 12). The purpose of this exercise was to progress the strengthening of the lower and middle trapezius. Five-Month Follow-up The patient was contacted by telephone 5 months after discharge. He reported occasional symptoms (approximately every 2 to 3 weeks) that, when present, could last up to half a day. The patient reported that the onset of his headache pain typically occurred when he had to sit at work for prolonged periods of time and was unable to take a break to perform his exercises. He stated that in most instances he was able to work at his computer without headache pain if he attended to his posture. He continued to perform his program every other day, performing 20 to 30 repetitions of each exercise. He also reported that he was performing upper FIGURE 9. Supine upper cervical flexion with head lift. FIGURE 10. Prone arms overhead with scapula adduction. extremity weight-lifting activities with free weights and resistive-exercise equipment without an exacerbation of his symptoms. The patient acknowledged that he had made significant improvement in his ability to perform functional activities. He was now able to sleep through the night without pain or use of medications and to perform all horse care activities without an exacerbation of his symptoms. DISCUSSION Currently, the specific factors contributing to CH syndrome are not fully understood. The current case report suggests that impairments, not only in the cervical region, but also in the scapulothoracic and lumbar regions, may be important to consider in the treatment of CH. Treatment of impairments in all 3 regions resulted in important short- and long-term improvement in a patient with a 7-year history of CH. Exercises focused on (1) improving alignment in each region, (2) improving strength of the cervical, scapulothoracic, and abdominal muscles, and (3) 12 J Orthop Sports Phys Ther Volume 35 Number 1 January 2005

11 eliminating compensatory movements of the cervical and lumbar spine regions during upper extremity movement. Functional training emphasized patientspecific methods to decrease prolonged loading on the cervical spine tissues across the day. Taken together, these components provided the patient with a program that allowed him to manage his CH symptoms independently. In the cervical region the patient s preferred alignment was increased extension in the upper cervical spine and a forward head. Consequently, the primary factor considered to contribute to the patient s symptoms was excessive compressive loading on tissues in the cervical region, in particular, the vertebral arch and facets joints. 4,5 Modifying the patient s posture, performing active upper cervical flexion exercises, and reducing compensatory movements may have resulted in reducing loads to pain-sensitive structures. In the scapulothoracic region, the patient s excessive scapular abduction and depression was considered to contribute to prolonged compressive loading of the posterior cervical structures by way of transfer of the weight of the upper extremities to the cervical region through the attachments of the cervicoscapular muscles (levator scapulae and upper trapezius). 30,34 Johnson et al 12 have noted that the majority of the upper half of the trapezius muscle travels a transverse course from the lower half of the ligamentous nuchae to the acromion and spine of the scapula. The function of the transverse orientation of the trapezius fibers is to relieve the cervical spine of compressive loads by transferring the weight of the upper extremity to the sternoclavicular joint. 12 Because of the impairments of the upper trapezius (decreased strength and increased length) noted on examination, we assumed that the trapezius was not effectively transferring the upper extremity loads to the sternoclavicular joints. As a result, the posterior cervical spine structures were bearing the weight of the upper extremities throughout the day. Such load bearing was considered to contribute to an increase in the patient s cervical extension position, altered cervical movements, increased tissue stress in the posterior cervical region, and CH symptoms. The findings from the PCSPT test provides some support for the proposed mechanism of upper extremity weight transfer to the cervical region. Elevating and adducting the patient s scapulae and supporting the weight of the limbs resulted in increased cervical motion and a decrease in symptoms. Decreasing the prolonged effect of the weight of the upper extremities on the cervical spine was treated (1) through exercise to address the strength and length of the cervicoscapular and scapulothoracic muscles, and (2) by frequently supporting the upper extremities throughout the day. Finally, in the lumbar region, the patient s preferred extension alignment was also considered to be a potential factor contributing to the patient s prolonged cervical extension alignment. An increase in lumbar extension can be associated with a compensatory thoracic kyphosis and extended cervical spine. 3,9,16,26 The 2 factors, in particular, that were addressed to modify the patient s lumbar extension included latissimus dorsi length and abdominal control and strength. Decreased length of the latissimus dorsi muscle has been proposed to contribute to increased lumbar extension, 16 while abdominal muscle strength and length has been proposed to be important in maintaining a neutral lumbar spine alignment. 16 Thus, the goal of instructing the patient to regularly correct his lumbar spine alignment in sitting and standing was one method of minimizing the thoracic and cervical region compensatory alignments and thus indirectly decrease the prolonged loading into extension in the cervical region. 3,9 The second factor considered to contribute to the excessive loading in the posterior cervical region was repeated cervical extension movements. The primary means by which cervical extension was repeated was through compensatory cervical extension movements with shoulder movements. It is our view that every time our patient lifted his arms he potentially was extending his cervical spine. 8,17 In this patient, frequent cervical extension in an already extended upper cervical spine was considered to be a factor that could accelerate the accumulation of tissue stress in the posterior cervical region. Prescription of exercises to allow full shoulder movement without compensatory cervical spine movement was important, because it addressed a factor that potentially was contributing to not only the development but also the persistence of his CH symptoms. Manual therapy techniques have been reported to provide short-term benefit to patients with The patient described in the current report did not receive manual therapy even though movement of upper cervical region was found to be very limited. Interestingly, significant changes at the impairment and functional limitation level were obtained with treatment based solely on active exercise and positioning performed by the patient. Of particular note was the improvement in joint mobility of the upper cervical region. The proposed mechanism for these changes is related to how changes in alignments and movements in the cervical, scapulothoracic, and lumbar regions may have affected the alignment and loading in the cervical spine region. The goal of treatment was to decrease tissue loading by changing his preferred cervical extension alignment and frequent movements into end range extension. We propose that addressing the factors that appeared to contribute to maintaining an extended cervical spine alignment decreased the patient s pain level and allowed him to achieve a more neutral cervical spine position with less facet joint approxima- CH. 10,20-22,29,39,40 J Orthop Sports Phys Ther Volume 35 Number 1 January

12 tion. The more neutral spine position then allowed cervical joint range of motion, eventually restoring much of his cervical mobility without passive treatment. Considering the positive effects of manual therapy reported, however, it is possible that a combined treatment of manual therapy, exercise and positioning, as we have described, might result in even more rapid and long-lasting recovery than our patient attained. CONCLUSION In the past, the focus of physical therapy intervention for CH has included manual therapy to address cervical joint impairments and, more recently, exercise to address cervical muscle impairments. This case report suggests that impairments not only in the cervical region, but also in the scapulothoracic and lumbar regions, may be important to consider when treating a patient with CH. REFERENCES 1. Adams MA, Bogduk N, Burton K, Dolan P. The Biomechanics of Back Pain. Edinburgh, UK: Churchill Livingstone; Beazell JR. 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The effect of mobilization on cervical headaches. J Orthop Sports Phys Ther. 1995;21: Schuldt K, Ekholm J, Harms-Ringdahl K, Nemeth G, Arborelius UP. Effects of arm support or suspension on neck and shoulder muscle activity during sedentary work. Scand J Rehabil Med. 1987;19: Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. The Cervicogenic Headache International Study Group. Headache. 1998;38: Sjaastad O, Fredriksen TA, Stolt-Nielsen A, et al. Cervicogenic headache: a clinical review with special emphasis on therapy. Funct Neurol. 1997;12: Sobush DC, Simoneau GG, Dietz KE, Levene JA, Grossman RE, Smith WB. The lennie test for measuring 14 J Orthop Sports Phys Ther Volume 35 Number 1 January 2005