OMPT and Cervicogenic Headache Orthopedic Manual Therapy Techniques in the Diagnosis and Treatment of Cervicogenic Headaches: A Case Report A Case Report Presented to The Faculty of the Department of Physical Therapy Florida Gulf Coast University In Partial Fulfillment of the Requirement for the Degree of Doctorate of Physical Therapy By Hayley B. Rodgers May 2014
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OMPT and Cervicogenic Headache
Orthopedic Manual Therapy Techniques in the Diagnosis and Treatment of Cervicogenic
Headaches: A Case Report
A Case Report
Presented to
The Faculty of the Department of Physical Therapy
Florida Gulf Coast University
In Partial Fulfillment
of the Requirement for the Degree of
Doctorate of Physical Therapy
By
Hayley B. Rodgers
May 2014
OMPT and Cervicogenic Headache
APPROVAL SHEET
This case report is submitted in partial fulfillment of
the requirements for the degree of
Doctorate of Physical Therapy
_____________________________________
Hayley B. Rodgers
Approved: May 2014
_____________________________________
Arie J. van Duijn, EdD, PT, OCS
Committee Chair/Advisor
_____________________________________
Jacqueline van Duijn, DPT, OCS
Committee Member
The final copy of this case report has been examined by the signatories, and we find that both
the content and the form meet acceptable presentation standards of scholarly work in the
above mentioned discipline.
OMPT and Cervicogenic Headache 1
Table of Contents
Abstract 1 Introduction 2 Purpose 3 Literature Review 3
Anatomy of the Cervical Spine 3 Biomechanics of the Cervical Spine 5 History and Background of Cervicogenic Headaches (CGH) 6 Pathophysiology of CGH 7 The Relationship between TMD and CGH 8 Diagnosing CGH 10 Manual Therapy Techniques in Treating CGH 14
Case Description 18 Past Medical History 18 Subjective History 19
Neck Disability Index 20 Pain Assessment 21 Behavioral Aspects 22
Objective Findings 22 Posture 22 Range of Motion 22 Manual Muscle Testing 23 Manual Examination and Palpation 23 Neurological Testing 24 Impression 24
Seated mobilization with movement C7-T1 to improve right rotation, 4 minutes Grades 3-4
Upslides and downslides right C6/C7 facet joint, Grades 1-3 for 5 minutes
The patient was instructed to continue to perform home exercise program as instructed during prior sessions. She was also instructed to continue to avoid self-manipulations.
OMPT and Cervicogenic Headache 32
Table 1: Case Report Physical Therapy Interventions (Continued)
Date of
Visit Interventions Home Exercise Program
Additions 1/29/14 Therapeutic Exercise:
Latissimus dorsi pull-downs at cable, 3 sets of 15 with 4 plates
Seated incline scapular stabilization with resistance into scapular protraction, 2 sets of 15 repetitions at 0.5 kg
Shoulder flexion and abduction in standing, 2 sets of 10 repetitions with 2 lb. dumbbells
The following table provides information on the subjective and objective progress
the case patient made with each subsequent visit:
Table 2: Subjective and Objective Short-Term Outcomes
Date of Visit
Subjective Report Objective Report
11/20/13 The patient reported experiencing an increase in neck pain due to driving long distances twice in the past week. She was able to regularly performing home exercise program (HEP). Resting pain level: 5/10 on the NRS.
No formal objective testing performed at this visit. The patient responded well to manual therapy and exercises without pain.
11/22/13 The patient reported an overall decrease in neck pain. She also reported a localized spot of pain on the left posterior and superior portion of her shoulder blade.
The patient displayed improved passive mobility of lower cervical spine (2+/6).
12/13/13 The patients states she had a 25% decrease in pain with activities such as performing work at the computer and picking her son up. Headaches were reported to be less intense in comparison to when she started physical therapy. The patient stated that she was able to perform her HEP regularly, but seldom uses the
Re-assessed with the following results:
AROM cervical spine rotation increased (75 degrees to the left and 55 degrees to the right, measured with goniometer). Improved from 70 degrees to left 54 degrees to right on first
OMPT and Cervicogenic Headache 33
Table 2: Subjective and Objective Short-Term Outcomes (Continued)
Date of Visit
Subjective Report Objective Report
12/13/13
(Continued)
Theraband for her scapular stability exercises. Her pain complaints during this visit were exacerbated due to straining her neck when she had to pick up several library books that had fallen to the ground while her toddler son began walking in the street at the same time. She reports that she will be having pelvic surgery on 12/18/13 to remove calcium deposits. Because of the need for this surgery, the physician did not feel comfortable proceeding with the planned in vitro fertilization until the tissue has healed. Self-reported pain range was reported from 3 at the lowest to 8 at the highest (slightly lower than first visit) based upon NRS.
visit, however, continues to report pain with both motions.
MMT: 3/5 for left and right middle and lower trapezius muscles, 3+/5 bilateral longus colli muscles (improved from 3/5 on first visit).
Tenderness to palpation of bilateral suboccipitals, left and right transverse processes of C1, and R transverse processes of C5 and C7.
NDI: 34% (improved from 40% on first visit).
Progress was documented within the daily note to be hastened due to medical comorbidities and poor consistency with HEP.
1/2/14 The patient stated during this visit that her neck had been feeling better overall. The night prior to this visit, she reported her right TMJ locked up. She was able to find some relief and help relax these muscles by using her hot tub at home. She reported she had not been able to perform her home exercise program due to tonsillitis. Pain level at rest was reported to be a 3/10.
The patient was found to have significant hypomobility with right rotation, particularly at the T1-T2 segment (1+/6). Following the mobilization treatment to this area, the patient displayed a significant increase in mobility at this level (2+/6 post treatment).
1/3/14 The patient reported her pain level at rest to be a 3/10 (left unchanged from previous visits). The patient also stated she has cancelled her future appointment on 1/8/14 for planned uterine surgery.
The patient demonstrated early fatigue with DICE exercises particularly of the deep neck flexors.
1/29/14 The patient reported her resting pain level to be a 2/10 today (1 point less than her typical report for the past 6 visits). The patient reported that she was able to participate in 80 minutes of yoga and had a headache immediately following the class
The patient displayed an increase in right cervical rotation following this treatment session (75 degrees to the left, and 60 degrees to the right). Decreased muscle tone was also noted within the bilateral upper
OMPT and Cervicogenic Headache 34
Table 2: Subjective and Objective Short-Term Outcomes (Continued)
Date of Visit
Subjective Report Objective Report
1/29/14
(Continued)
until the evening. She has only had two headaches during the past week and states they have been less intense overall. The patient also reports not self-manipulating her neck for the past six days.
trapezius and scalene musculature. She continued to demonstrate moderate fatigue with DICE exercises with repetition involving shoulder flexion and abduction.
Outcomes
Because of the nature of the course of physical therapy treatment, it is difficult to
make fully accurate inferences into the outcomes of care for this case patient. The patient
was seen for only seven visits over the course of three months, and attendance was
inconsistent throughout the plan of care. During the one month follow up visit, positive
progress was demonstrated by an improved NDI score from 40% to 34% (6%
improvement in functional level). Active range of motion of cervical spine rotation also
improved (75 degrees to the left and 55 degrees to the right, measured with goniometer).
This was a small improvement from 70 degrees left rotation and 54 degrees right rotation
on first visit. The patient however did report overall less pain with both motions. Muscular
strength of the bilateral longus colli muscles improved to 3+/5 (was recorded at 3/5 on
first visit).
As discussed before, the case patient was not seen for a formal discharge
appointment during which time more formal and objective measurements could have been
recorded. The study by Standford et al (1991) suggests that a change of 5 points or 10% on
the NDI demonstrates a clinically important change. The case patient could be postulated to
have been able to reach this minimal detectable change within the three months of
OMPT and Cervicogenic Headache 35
treatment; however this outcomes measure was only reassessed at her four-week follow
up appointment. It can also be postulated that significant improvements may have been
achieved regarding cervical spine range of motion, decrease in pain sensitivity with
palpation of original tender points, and muscular strength of bilateral deep neck flexors
and scapular stabilizers.
It is also clinically important to note that the patient reported improved mobility of
the lower cervical spine facet joints (2+/6) compared to initial measures of 1+/6
hypomobility during post-manual therapy testing on her fourth visit. Following the
interventions provided during her last visit, the patient displayed an increase in active
cervical rotation (75 degrees to the left, and 60 degrees to the right; originally 70 degrees
left rotation and 54 degrees right rotation during her first visit). Decreased muscle tone
was also noted within the bilateral upper trapezius and scalene musculature during this
visit.
Regarding subjective outcomes, the patient reported her resting pain level to be a
2/10 during her last visit (1 point less than her average report for the past 6 visits). The
patient reported only having two headaches within the past week which was a significant
improvement from initial reporting of 5 headaches per week on average. The patient
reported the overall intensity of the headache was noticeably less than when she first
began therapy. The patient also reported during the last visit not self-manipulating her
neck for the past six days. Overall, small improvements were achieved using both
subjective and objective measures in lieu of inconsistent attendance of physical therapy
sessions and medical complications.
OMPT and Cervicogenic Headache 36
Discussion
This case report describes the physical therapy diagnosis, management,
interventions including therapeutic exercise and orthopedic manual therapy, outcomes,
and other considerations of a patient with cervicogenic headache. The patient was a 35-
year old female referred by her primary care physician with complaints of chronic neck
pain. The patient presented at her initial evaluation with decreased range of motion of
cervical spine , tenderness to palpation of bilateral upper trapezius, sternocleidomastoid,
and suboccipital muscles, left transverse process at C2, and right transverse process at C7,
headaches into right frontal (supraorbital) region several times/month, multi-level cervical
and upper thoracic segmental mobility dysfunction, muscular weakness of scapular
stabilizers (middle/lower trapezius) and deep neck flexors, and postural impairments. The
Neck Disability Index (NDI) and Numerical Rating Scale (NRS) was a validated and reliable
outcomes measure tool used to determine progress over the course of treatment. Her
initial score was a 40%, moderate severity of functional impact of impairments. Patient
management of her condition consisted of various non-thrust manipulations, soft tissue
mobilizations, postural re-education, progressive therapeutic exercise, and patient
education for improved self-prevention of neck pain to address her impairments.
Although the patient made some minor improvements as indicated above within the
outcomes portion of this report, the overall progress was clinically insignificant most likely
due to poor compliance with home program, numerous medical comorbidities, and her
inability to regularly attend physical therapy. The patient’s improvement on the NDI and
NRS did not meet clinically important differences and minimal detectable change, however
did show minor improvement. Although outcomes for this case patient were not significant,
OMPT and Cervicogenic Headache 37
the progress indicated as supported by current evidence, suggest that a multi-modal
physical therapy treatment program approach using orthopedic manual physical therapy
interventions in addition to soft tissue manipulation, patient education, and therapeutic
exercise may be effective in the management of a patient diagnosed with cervicogenic
headache.
The mobilization techniques utilized for the case patient to improve overall cervical
spine mobility and decrease pain are based upon the manual therapy approaches
popularized by Stanley Paris of the University of Saint Augustine. These techniques include
upslides and downslides that utilize posterior-anterior mobilization combined with cranial
or caudal (respectively) glides to promote motion at restricted zygopophyseal joints.
A recent study examined the short-term biomechanical effects of non-thrust
(Maitland, Grade III techniques) PA manipulation techniques on the cervical spine (Lee et
al, 2005). Although this manual therapy technique is relatively common in the evaluation
and treatment of neck pain, little is known about the actual biomechanical effects. Much of
the research has historically been focused on the benefits within lumbar spine for patients
with low back pain. Within this study, the cervical spines of nineteen healthy subjects were
scanned using an open interventional magnetic resonance imaging scanner.
Posteroanterior (PA) mobilization forces were applied to the fifth cervical vertebra in the
prone position. It was shown from sagittal images obtained before and during the
mobilization that PA mobilization of the cervical spine generally produced extension of the
upper motion segments and flexion of the lower segments when forces were applied at the
5th cervical vertebrae. The cervical lordosis was found to increase with repeated PA loading
cycles, which is particularly important to know when clinically providing interventions to
OMPT and Cervicogenic Headache 38
restore cervical lordosis that may be significantly reduced with a resting forward head
posture. It was also found that forces applied at one spinous process produced not only
movements at the target vertebra, but also movements throughout the entire cervical spine
helping to restore cervical lordosis and overall mobility. The most interesting
interpretation from this research study was that mobilizations to this area should be
interpreted as three-point bending of the entire cervical spine, rather than simple gliding of
one vertebra upon another. Several of the mobilizations provided to the case patient were
applied to the fifth cervical vertebrae which may explain her improvements in overall
range of motion even after just seven visits.
The patient also reported a decrease in pain overall within the neck region and
decreases in headache intensity and frequency which may very well be related to the
nociceptive inhibitory effect spinal manipulation therapy is able to produce. As stated
before, spinal manipulative therapy has been shown to help activate descending inhibitory
pathways from, the lateral periaqueductal gray area of the midbrain (Wright, 1995). The
lateral periaqueductal gray (PAG) is closely related to the behavioral responses to pain,
stress, and other stimuli in maintaining internal homeostasis, which (Fernandez de-las-
Penas et al., 2006). Although the overall patient outcomes were minimal due to poor
consistency and adherence to a regular physical therapy program, positive gains were
made regarding cervical spine range of motion, pain level, and headache intensity and
frequency. From this information, it can be inferred that spinal manipulative therapy
utilizing PA forces for the cervical spine may help to improve clinical outcomes for patients
with cervicogenic headaches.
OMPT and Cervicogenic Headache 39
Because the case patient had been experiencing headaches and neck pain for many
months and had entered a chronic stage of her condition, evidence for the use of thoracic
spine manipulation to improve neck pain may not have been indicated as outlined by a
recent clinical prediction rule by Childs et al (2007). When 5-6 of the clinical prediction
rule factors (symptoms <30 days, no symptoms distal to the shoulder, looking up does not
aggravate symptoms, Fear Avoidance Beliefs Questionnaire Physical Activity (FABQPA
<12), diminished upper thoracic spine kyphosis based on visual estimate, and cervical
extension ROM <30 degrees) are satisfied a positive likelihood ratio of greater than 12 is
indicated for positive outcomes in reducing neck pain from thoracic spine manipulation. In
a later validation study of this clinical prediction rule, patients with mechanical neck pain
who received thoracic spine manipulation and exercise exhibited significantly greater
improvements in disability and pain at both the short- and long-term follow-up periods
compared with patients who received exercise only. The benefits of targeting manipulation
to patients who were positive on the CPR were marginal and were evident only at the
short-term follow-ups visits. From this information, it may be inferred that the even though
the case patient may not have met the clinical prediction rule, she may have still benefitted
from thoracic spine manipulations during each treatment session to help decrease overall
disability and pain.
To consider patient management for chronic-type conditions of cervicogenic
headaches it is important to consider the benefits of utilizing a combined approach of
manipulative therapy with therapeutic exercise. A recent study investigated the effects of
low load cranio-cervical flexion verses neck flexor strengthening exercises on deep cervical
benefit of exercise (Jull et al, 2009). In this study forty-six subjects with chronic neck pain
were randomly assigned to one of following two groups for a 6-week training program:
o Low Load training: 10 reps of 10 seconds at progressively higher
biofeedback pressure unit levels (20mmHg – 30mmHg)
o Higher load strength training:
Stage one: 12-15 reps at a load that could initially be only lifted 12
times
Stage two: 3 sets of 10 reps using 50% 10 repetition max load, then
75% RM, then 100% RM.
Based upon electromyographic activity data of the neck musculature before and after
exercise intervention, the low load-training group had increases in EMG activity of the deep
cervical flexors, with decreases in EMG amplitude for the sternocleidomastoid and anterior
scalene muscles across all stages of the cranio-cervical flexion test. The cranio-cervical
flexion low load training has been study extensively by Jull and colleagues, and have been
shown to be an effective intervention for patients with chronic mechanical neck pain (Jull
et al., 2002; Jull et all., 2008).
Canegie et al (2007) also found similar results previously by examining functional
MRI results to evaluate cervical flexor activity during different cervical flexion exercises.
The results from this study demonstrated that combined cranio-cervical flexion and
cervical flexion (chin tuck with head lift) produced the highest increase between rest and
post exercise, demonstrating that all synergists were active and that this exercise is useful
for strengthening the sternocleidomastoid (SCM), longus capitis, and longus colli. During
OMPT and Cervicogenic Headache 41
cervical flexion (head lift), it was found that the longus colli is more active than longus
capitis and SCM, although the differences were found to be statistically insignificant.
The therapeutic exercises used for this case patient both within the clinical setting
and for her home exercise program are consistent with the recommendations made based
on these studies and involved low load, high repetitions at progressively higher demands
over time. In addition, the therapeutic exercises were gradually progressed in order to
allow the patient to develop proper recruitment of deep neck flexors in order to prevent
further neck strain and overuse of superficial anterior neck muscles, as commonly seen
with this population. By also including exercises which required the recruitment of deep
neck flexors immediately prior to active upper extremity resisted movements (DICE
exercises), the patient was able theoretically able to facilitate coordination with functional
overhead and lifting activities. Unfortunately, the final two physical therapy sessions were
the only sessions that included these exercises; continued sessions with such interventions
may have provided more significant outcomes.
It is important to discuss the issues of compliance and inconsistent attendance of
physical therapy for this case patient. The patient was seen for a total of seven visits over
the course of three months, which relative to the typical physical therapy plan of care, were
spread out over a long period of time. In addition, the patient had several medical
comorbidities during her plan of care and was dually seeking in vitro fertilization
treatment. As a result, she was unable to attend in a consistent manner as she had been
able to in her prior plan of care from 2012. During her prior plan of care, the patient was
able to regularly attend several times over the course of 5 weeks and made significant
progress in decreasing overall pain and improving functional use of her right upper
OMPT and Cervicogenic Headache 42
extremity. The Shoulder Pain and Disability Index, which examines the overall functional
level of the involved shoulder (Roach, 1991), was reduced from a 26% to a 5.4% over the
course of one month of her prior period of care during 2012. This was a clinically
significant and powerful reduction of overall disability which can be attributed, in part, to
her compliance with her home exercise program and ability to regularly attend physical
therapy during this time.
One recent study found strong evidence that poor treatment adherence was
associated with low levels of physical activity at baseline or in previous weeks, low in-
treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness,
poor social support/activity, greater perceived number of barriers to exercise and
increased pain levels during exercise (Jack, McLean, Moffett, & Gardiner, 2010). Although
this systematic review analyzed mostly prior studies that examined prognostic factors for
patients with chronic low back pain, these psychosocial aspects can also be applied to a
patient with chronic neck pain.
Another systematic review examined 70 articles on the course and prognostic
factors in neck pain and its associated disorders. It was found within the review that
younger age predicted better outcome. Psychosocial factors, including psychological health,
coping patterns, and need to socialize, were the strongest prognostic factors. It was also
found that factors including: higher initial pain intensity, longer duration, and increased
pain-related difficulties in performing activities, prior neck/shoulder symptoms, prior neck
injury, co-morbid low back pain, and self-perceived poor general health. Determining
prognosis for a patient with chronic neck pain can be difficult at times due to the complex
nature and combination effect of various demographic, socioeconomic, and psychosocial
OMPT and Cervicogenic Headache 43
factors. Future systematic reviews should continue to examine the major prognostic factors
for patients with chronic neck pain and headaches.
In summary, although the patient demonstrated inconsistencies in physical therapy
treatment attendance and poor compliance of her home exercise program, minor
improvements were made in regards to all initial impairments and particularly with overall
functional level as shown by the improved NDI score. It is likely that the patient had
multiple poor prognostic factors that also played a negative role in the degree of positive
outcomes that were made during this plan of care. A significant amount of evidence exists
to help support the basis for using orthopedic manual therapy interventions to reduce pain
and improve range of motion in cervical spine, and one can make the case that these
interventions combined with therapeutic exercises was able to create overall
improvements for this patient.
Conclusion
This case report demonstrates the physical therapy diagnosis, management,
interventions including therapeutic exercise and orthopedic manual therapy, and outcomes
of a patient with cervicogenic headache. The patient presentation corresponded with the
diagnostic criteria for cervicogenic headaches as outlined by the IHS and CHISG (Becker
2010; Antonaci et al., 2005). Comprehensive physical therapy treatment was provided to
this case patient for seven visits over a total of three months using orthopedic manual
therapy spinal mobilizations, soft tissue manipulation, patient education, and progressive
therapeutic exercises to improve strength of deep neck flexors and improve postural
impairments. Although outcomes for this case patient were not significant and all short
term and long term goals were not fully met, the progress indicated as supported by
OMPT and Cervicogenic Headache 44
current evidence, suggest that a multi-modal physical therapy treatment program
approach using orthopedic manual physical therapy interventions in addition to soft tissue
manipulation, patient education, and therapeutic exercise may be effective in the
management of a patient diagnosed with cervicogenic headache. This case report also
demonstrates the importance of considering prognostic factors and patient compliance in
providing treatment for patients with chronic neck pain and cervicogenic headaches. It can
OMPT and Cervicogenic Headache 45
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