From: Man Ther. 2009 Oct;14(5):475-9

The cranio-cervical flexion test tests the coordination of the deep and superficial cervical flexor muscles during a cranio-cervical flexion task. The test has revealed impairments in muscle function in younger/middle aged patients with various neck pain disorders. Neck pain and headache are common in elders but it is unknown if age alone affects performance in the cranio-cervical flexion test. This study compared performance in the cranio-cervical flexion test between healthy asymptomatic elderly and younger subjects. Electromyographic (EMG) amplitude in the sternocleidomastoid, angle of cranio-cervical flexion and ability to target the pressure levels of each test stage were examined in 44 elderly and 39 young participants.

The results indicated that the elderly group had higher measures of normalized EMG signal amplitude in the sternocleidomastoid during the test, greater shortfalls from the target pressures of all stages of the test, except for the 22 mm Hg stage, and larger variability of the cranio-cervical flexion range of motion for the five successive stages of the test (particularly at 26, 28 and 30 mm Hg stages) compared to young subjects. Clinicians must be aware of this occurrence when assessing performance in the cranio-cervical flexion test in elders with neck pain.

Tags: Cranio-cervical, flexion, test,, elderl,, neck, pain

From: Cephalalgia. 2009 Jun 8. [Epub ahead of print]

Spatial changes in pressure pain hypersensitivity are present throughout the cephalic region (temporalis muscle) in both chronic tension type headache and unilateral migraine. The aim of this study was to assess pressure pain sensitivity topographical maps on the trapezius muscle in 20 patients with chronic tension type headache and 20 with unilateral migraine in comparison with 20 healthy controls in a blind design. For this purpose, a pressure algometer was used to assess pressure pain thresholds over 11 points of the trapezius muscle: four points in the upper part of the muscle, two over the levator scapulae muscle, two in the middle part, and the remaining three points in the lower part of the muscle. Pressure pain sensitivity maps of both sides were depicted for patients and controls.

Chronic tension type headache patients showed generalized lower pressure pain thresholds levels compared with both migraine patients and controls. The migraine group had also lower pressure pain thresholds than healthy controls. The most sensitive location for the assessment of pressure pain thresholds was the neck portion of the upper trapezius muscle in both patient groups and healthy controls. Pressure pain thresholds was negatively related to some clinical pain features in both chronic tension type headache and unilateral migraine patients. Side-to-side differences were found in strictly unilateral migraine, but not in those subjects with bilateral pain, i.e. chronic tension type headache. These data support the influence of muscle hyperalgesia in both chronic tension type headache and unilateral migraine patients and point towards a general pressure pain hyperalgesia of neck and shoulder muscles in headache patients, particularly in chronic tension type headache.

From: Curr Opin Neurol. 2009 Mar 18. [Epub ahead of print]

This review discusses current data on nosological boundaries related to diagnosis, pathophysiology and therapeutic strategies in chronic tension type headache. Diagnostic criteria of chronic tension type headache should be adapted to improve its sensitivity against migraine. It seems that mechanical pain sensitivity is a consequence and not a causative factor of chronic tension type headache. Recent evidence is modifying previous knowledge about relationships between muscle tissues and chronic tension type headache, suggesting a potential role of muscle trigger points in the genesis of pain. An updated pain model suggests that headache perception can be explained by referred pain from trigger points in the craniocervical neck muscles, mediated through the spinal cord and the trigeminal nucleus caudalis rather than only tenderness of the neck muscles themselves.

Different therapeutic strategies for chronic tension type headache; pharmacological, physical therapy, psychological and acupuncture, are generally used. The therapeutic efficacy of nonsteroidal anti-inflammatory drugs remains incomplete. The tricyclic antidepressants are the most used first-line therapeutic agents for chronic tension type headache. Surprisingly, few controlled studies have been performed and not all of them have found an efficacy superior to placebo. Further, there is insufficient evidence to support or refute the efficacy of physical therapy in chronic tension type headache. Although there is an increasing scientific interest in chronic tension type headache, future studies incorporating subgroups of patients who will likely to benefit from a specific treatment (clinical prediction rules) should be conducted.

In Eur J Pain. 2007 May;11(4):475-82, it was noted that referred pain from trapezius muscle trigger points shares similar characteristics with chronic tension type headache. The results showed that manual exploration of trigger points in the upper trapezius muscle elicited referred pain patterns in both chronic tension type headache patients and healthy subjects. In chronic tension type headache patients, the evoked referred pain and its sensory characteristics shared similar patterns as their habitual headache pain, consistent with active trigger points.

In Pain Med. 2009 Jan;10(1):43-8, referred pain elicited by manual exploration of the lateral rectus muscle in chronic tension type headache. In some patients with chronic tension type headache, the manual examination of lateral rectus muscle trigger points elicits a referred pain that extends to the supraorbital region or the homolateral forehead. Nociceptive inputs from the extraocular muscles may sustain the activation of trigeminal neuron, thus sensitizing central pain pathways and exacerbating headache.

According to Headache. 2007 May;47(5):662-72, Active trigger points in the upper trapezius, sternocleidomastoid, and temporalis muscles were more common in tension headache subjects than in healthy controls, although trigger point activity was not related to any clinical variable concerning the intensity and the temporal profile of headache, tension headache patients showed greater forward head posture and lesser neck mobility than healthy controls, although both disorders were not correlated with headache parameters.

From: Cephalalgia. 2009 Feb;29(2):250-7

Headaches and neck pain are reported to be among the most prevalent musculoskeletal complaints in the general population. A significant body of research has reported a high prevalence of headaches and neck pain among adolescents. Sitting for lengthy periods in fixed postures such as at computer terminals may result in adolescent neck pain and headaches. The aim of this paper was to report the association between computer use (exposure) and headaches and neck pain (outcome) among adolescent school students in a developing country. A cross-sectional study was conducted and comprehensive description of the data collection instrument was used to collect the data from 1073 high-school students. Headaches were associated with high psychosocial scores and were more common among girls. This study found a concerning association between neck pain and high hours of computing for school students, and have confirmed the need to educate new computer users (school students) about appropriate ergonomics and postural health.

From: Man Ther. 2009 Feb 10. [Epub ahead of print]

There is an opinion that with increasing cervical degenerative joint disease with ageing, cervicogenic headaches become more frequent. This study aimed to determine if cervical musculoskeletal dysfunction was specific to headache classifiable as cervicogenic or was more generic to headache in elders. Subjects (n=118), aged 60-75 years with recurrent headache and 44 controls were recruited. Neck function measures included range of motion (ROM), cervical joint dysfunction, cranio-cervical flexor muscle function, joint position sense (JPS) and cervical muscle strength. A questionnaire documented the characteristics of headaches for classification. A cluster analysis based on three musculoskeletal variables aligned previously with cervicogenic headache, divided headache subjects into two groups; cluster 1 (n=57), cluster 2 (n=50). Dysfunctions were greater in cluster 1 than in 2 for extension range and C1-2 joint dysfunction. Most cervicogenic headaches were grouped in cluster 1, but musculoskeletal dysfunction was also found in headaches classifiable as migraine or tension type headache. Neck dysfunction is not uniquely confined to cervicogenic headache in elders. Further research such as headache responsiveness to management of the neck disorder is required to better understand about the neck’s causative or contributing role to elders’ headache.

From: J Man Manip Ther. 2007;15(2):82-92

Neck pain as well as headaches with a proposed neck related etiology or contribution are highly prevalent disorders. Doug lass and Bope reported a point-prevalence for neck pain in the general population of 9%. They further noted a 1 month, 6 month, and lifetime prevalence of 10%, 54%, and 66%, respectively. In a cross-sectional population survey, investigators found an 18% prevalence for chronic neck pain greater than months’ duration. Headache types associated with cervical spine dysfunction include tension type and cervicogenic headache, occipital neuralgia, and to a lesser extent migraine headaches. Tension type headache affects two-thirds of men and over 80% of women in developed countries. For the general population, the prevalence of cervicogenic headache varies between 0.4% and 2.5%; in those with chronic headaches, prevalence may be as high as 15% to 20%.

Neck pain and headache are not only highly prevalent but also frequent reasons for patients to seek medical or physical therapy care. In the United States, neck pain accounts for almost 1% of all primary care physician visits, and cervical spine diagnoses were the reason for referral in 16% of 1,258 outpatient physical therapy patients, second only to lumbar spine related diagnoses, which accounted for 19% of referrals. No data are available on the prevalence of headache as a cause for physical therapy management; however, an investigator reported headache as co-morbidity in 22% of 2,433 patients presenting for outpatient physical and occupational therapy, and headaches are reportedly the leading cause for visits to a neurologist.

Physical therapists place a diagnostic emphasis on identifying impairments that may be amenable to management with interventions within their scope of practice. In this context, impairments are defined as any loss or abnormality of body structure or of a physiological or psychological function. Studies have shown a strong correlation between neck pain and restricted cervical flexion-extension mobility, and limited motion may be the most relevant impairment associated with neck pain and headache of a proposed cervical etiology. An investigator attributed cervical hypomobility to either a voluntary or reflexogenic muscular restraint caused by pain or a purely mechanical restraint caused by degeneration of the joint surfaces and ligaments. Corresponding to said degenerative process, investigators described a fibrotic process in connective tissue, whereby it shrinks progressively, caused by arthrokinematic dysfunction, poor posture, overuse, habit patterns, or structural or movement imbalances. They further suggested that in many cases the surrounding musculature maintains a hypertonic recruitment pattern long after the inducing injury has healed, potentially immobilizing joints by the surrounding muscle hypertonicity.

Myofascial trigger points in the cervical muscles constitute another potentially relevant muscle dysfunction leading to limited cervical spine mobility. These are defined as hyperirritable spots in skeletal muscle with a potential to give rise to characteristic referred pain, motor dysfunction, and autonomic phenomena. Motor aspects of myofascial trigger points may include disturbed motor function, muscle weakness as a result of motor inhibition, and most importantly in the context of this study—muscle stiffness and restricted range of motion. Trigger points in the head and neck region have been implicated in the reported headache and central sensitization in patients with tension type headache. Their referral patterns correspond to the pain characteristics and distribution reported by patients with cervicogenic headache, occipital neuralgia, and migraine headache. Studies have reported significantly greater numbers of active myofascial trigger points in the suboccipital muscles of patients with tension type headache and in patients with migraine headache when compared to asymptomatic controls. Motor effects of these suboccipital myofascial trigger points in the sense of muscle shortening may explain the increased forward head posture and decreased cervical active range of motion reported in patients with chronic tension type headache or migraine headache as compared to asymptomatic controls.

Relevant to the management of patients with neck pain and headache, Paris has described a technique called inhibitive
distraction in which the therapist uses the fingertips of both hands to exert a sustained ventrocranial force on the occiput just caudal to the superior nuchal line. He proposed that this technique might inhibit the muscles inserting into the nuchal line and that it could be used to apply a distraction to the cervical spine structures. Paris did not claim this technique as his own, instead ascribing its origin to cranial osteopathy. Indeed, this technique has been described within various manual medicine disciplines under various names such as cranial base release, suboccipital release, and trigger point pressure release. The proposed effects are mainly neurophysiological, perhaps circulatory, and mildly mechanical.

Within the context of this study, the relevant suggested effects of inhibitive distraction on the cervical spine involve inhibition of local and general posterior muscle tone, inactivation of suboccipital muscle trigger points, and gentle joint mobilization. These effects are all hypothesized to result in an increase in cervical flexion active range of motion. Therefore, the purpose of this pilot study was to examine the immediate effects of inhibitive distraction on active range of motion into cervical flexion in patients with neck pain with or without concomitant headache. The main objective was to show whether, when used alone in a single treatment session, this intervention would signifi cantly increase cervical flexion active range of motion. A secondary objective of this study was to see whether patient subgroups could be identified that might benefit more from inhibitive distraction by studying variables such as age, pain intensity, presence
of headache, or pre-intervention active range of motion and by looking at patients’ ability to identify pre to post intervention changes in their ability to actively move through a range of motion.

For both the experimental and the placebo intervention, the patient was asked to rest supine on the treatment table. The experimental inhibitive distraction intervention had the therapist place the fingertips onto the suboccipital musculotendinous structures just caudal to the superior nuchal line and induce a sustained force in a ventrocranial direction, thus exerting compressive forces as well as a distraction to the cervical and suboccipital structures. The pressure applied to achieve muscle inhibition during treatment was applied slowly, maintained, and then released slowly; it was applied perpendicular to the longitudinal axis of the muscles and tendons involved. The amount of applied pressure was adjusted to just less than that which would excite the muscle further, and as the therapist maintained the pressure and the patient’s muscles relaxed, ideally the pressure was applied at an increasingly deeper level. Good palpatory awareness is important for correct execution of inhibitive distraction, as excessive pressure will have the opposite effect by causing irritation and an undesired increase in muscle tone. In other words, the amount of pressure applied was individualized according to therapist perception of the patient’s tolerance as reflected by muscle response. This muscle response was constantly monitored and thus, the amount of pressure could change during the administration of this intervention. Thus, the force applied varied anywhere from light pressure and no distraction forces applied with the weight of the subject’s head partially supported by the therapist’s thenar eminences, to the full weight of the subject’s head resting on the therapist’s fingertips and distraction applied. The inhibitive distraction intervention was applied for 3 to 3.5 minutes.

Those in the control group rested their heads in the palms of the clinician for the same duration to mimic the treatment position as much as possible. In this way, these subjects received the effects of touch, warmth, and rest, without the actual proposed mechanical effects of the experimental inhibitive distraction intervention.

Although equally affecting both groups, an important issue that needs to be addressed concerns the observed variability of change in active range of motion. In this study, the amount of change in active cervical flexion over all varied greatly, regardless of whether the patient received the pressure treatment or the placebo treatment, and ranged from a decrease of 10° to an increase of 16°. A large variability in cervical active range of motion has been reported for both asymptomatic and symptomatic subjects, measured with an electro-goniometer and an electromagnetic tracking system. Alteration in proprioceptive sensibility is a dysfunction recognized in patients with cervical pain, and Rheault et al suggested that a “guarding” effect at the end of active range of motion may be a characteristic of patients with neck dysfunction. Both proprioceptive dysfunction and end-range guarding may have led to the great degree of variability between measurements observed in the symptomatic subjects participating in this study, in spite of our efforts to minimize measurement errors. It is possible that the observed variability “washed out” the small pre to post intervention changes observed in this study, and we have to consider that active range of motion measurements may not be an appropriate outcome measure to study the effects of inhibitive distraction and other manual interventions. Alternatively, variability could possibly be decreased by selection criteria that result in a more homogenous patient population.

As noted above, we were not able to identify subgroups more likely to benefit from inhibitive distraction however, a trend for the greatest post-intervention changes was found in those subjects in the experimental group, who complained of headaches, indicated lower levels of pain, had less pre-intervention active range of motion, and had suffered discomfort for greater than 6 months. These subjects may have had symptoms that were more likely to respond to a muscle inhibitory treatment or they may have tolerated the treatment better due to a more chronic state and lower levels of pain, or both. In this study, a number of the patients in the experimental group did not tolerate the full application of inhibitive distraction and received only gentle pressure not dissimilar from the placebo intervention. Consequently, a sufficient mechanical and/or neurophysiological effect was probably not obtained and statistical significance of between group differences was likely affected. Future studies and possibly clinical application of this technique should likely limit selection criteria to reflect the trend for greater improvement in chronic patients with headaches, lower pain levels, and less active range of motion.

The results of the present study suggest that applying sustained pressure to the sub-occipital region does not result in improved cervical flexion active range of motion. The results do not, however, exclude the occurrence of potential short-lived neurophysiological inhibitory effects, as these were not directly measured. Studies on the effects of tendon pressure on muscle activity have found that although excitability of the motor neurons supplying the muscles decreased, this effect lasted only as long as the stimulus was present. If immediate short-lived inhibitory effects are, in fact, achieved, sustained pressure treatment may be suitable as a preparatory treatment for soft-tissue or joint manipulation, which should take place immediately after the application of the inhibitory pressure. This may have implications for future study with inhibitory distraction as part of a pragmatic physical therapy intervention and for its use in clinical practice. Our results, however, show no indication that any effects due to the sustained pressure alone are maintained long enough to be beneficial to the patient, e.g., for self-stretching or range of motion exercises after the pressure is released.

A final consideration is that the inhibitory distraction technique may have a local rather than the proposed regional effect, i.e., that its effect is limited to the suboccipital muscles. If this is the case, the expected changes in active range of motion may be limited to cranio-cervical motion and might not be captured with a general cervical flexion active range of motion measurement.

This pilot study researched the immediate effects of inhibitive distraction on cervical flexion active range of motion in patients with neck pain with or without associated headache. It also attempted to identify potential subgroups more amenable to this technique based on subject age, pain intensity, presence of headache, or preintervention active range of motion. The results did not show a statistically significant advantage of inhibitive distraction over the placebo treatment. We were also unable to identify potential subgroups more likely to respond to inhibitive distraction, although a trend emerged for greater improvement in chronic patients with headaches, lower pain levels, and less active range of motion.

A large variability in active range of motion and intervention response contributed to the low power observed in the present study. Future studies should use selection criteria that are likely to produce a more homogenous study population by including only patients with symptoms of greater than 6 months’ duration, headaches, lower pain levels, and more restricted preintervention active range of motion. To allow for inferences with regard to the predictive validity of subject age with regard to outcome, older subjects will need to be recruited. Future studies may compare the effects of inhibitive distraction on patients with cervicogenic versus tension type headache, or as part of a pragmatic program to be directly followed by other manual interventions. If active range of motion measurements are selected as outcome measures, perhaps cranio-cervical rather than general cervical flexion measurements should be considered.

The limitations in this pilot study do not allow us to make inferences either way; inhibitive distraction may or may not have an immediate effect on cervical flexion active range of motion. The trend for greater effect noted in chronic patients with headaches, lower pain levels, and less active range of motion, in their opinion, warrant further study into this technique and continued—albeit more discerning—use of this technique in clinical practice.

From: Nig Q J Hosp Med. 2008 Jan-Mar;18(1):25-9.

Headache is one of the most frequent causes of consultation in both general medical practice and neurological clinics. It is the most common of all medical conditions causing pain and disability. Headache is experienced by 90% of the general population at some point in life, as a consequence of febrile illness. However, primary headache occur in some people on chronic basis such as tension headache, and require long-term relief.

This study was aimed at investigating the efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) on Pain, Functional Disability and Cervical Range of Motion in patients with Chronic Tension Type Headache.

Eight subjects aged 20-50 years with diagnosis of Chronic Tension Type Headache participated in the study. The subjects were treated thrice weekly for ten weeks with a TENS unit, at a pulse rate of 4Hz and pulse width of 200micros. Pain level, Functional Disability and Cervical Range of Motion were determined using the Visual Analogue Scale, Headache Disability Index and Universal Goniometer respectively. Data was analyzed using the Wilcoxon Signed Ranks Test for pain and functional disability while unpaired t-test was used to analyze cervical range of motion.

The result showed a significant reduction in pain and functional disability with a significant improvement of cervical range of motion within the studied subjects. Based on the findings of this study, it was therefore concluded that a TENS unit application should be considered in the long-term management of patients with chronic tension type headache.

From: Cranio. 2008 Apr;26(2):104-17

The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

From: Neurol Sci. 2008 Sep;29(4):285-7. Epub 2008 Sep 20

A 3 month open label trial of melatonin prophylaxis in children with primary headache. After a one month baseline period without receiving preventive drugs, all children received a 3-month course of melatonin, 3 mg, administered orally, at bedtime. A total of 22 children were enrolled (10 boys, mean age 12.2+/-2.6 years, age range 6-16 years), 13 had recurrent migraine without aura, 1 with aura and 8 had chronic tension type headache. When the trial ended, 14 of the 21 subjects reported that the headache attacks had decreased by more than 50% in respect to baseline and 4 of them reported having no headache attacks. After receiving melatonin for one month one subject dropped out because of excessive daytime sleepiness. Our promising results warrant randomized placebo controlled trials in children to assess the real effectiveness of melatonin in preventing primary headache.

From: Pol Merkur Lekarski. 2008 Jun;24(144):549-51 Article in Polish

In 2004 cervicogenic headache (neck related headache) was introduced into ICD-10 classification.The reasons of cervicogenic headache are changes within bones, soft tissue and nervous structures of cervical spine section. The pain may spread to the neck, occipital area of skull, area of jaw and eyeballs, and arms. There are many theories trying to explain spreading of the pain outside the area innervated by C1, C2 and C3 cervical roots. Their common denominator is communication between fibres running in those roots and neurons of trigeminal nerve. Many authors describe a possibility of such connection through the jelly-like nucleus of the trigeminal nerve located in the back funiculi of spinal cord. In this mechanism, the pain conducted via occipital nerves may affect activity of neurons of the trigeminal nerve and influence areas innervated by the trigeminal nerve. In general case history and physical examination are sufficient to make a diagnosis. Additional radiological and imaging examinations support this diagnosis. According to some authors, the necessary condition to make a diagnosis of cervicogenic headache is finding the changes of spondylosis nature of the cervical spine section (neck arthritis or degenerative disc disease) in additional examinations. In doubtful cases, diagnostic blockade of greater occipital nerve, resulting in headache relief, supports finally a diagnosis. Any treatment includes pharmacotherapy, rehabilitation, psychotherapy and surgical methods. The purpose of the study is to view literature on cervicogenic headache which causes many diagnostic problems and hence makes it difficult to choose effective treatment.