Neck Solutions

A specific exercise program and modification of postural alignment for treatment of cervicogenic headache: a case report.

From: J Orthop Sports Phys Ther. 2005 Jan;35(1):3-15

An intervention approach consisting of a specific active exercise program and modification of postural alignment for an individual with cervicogenic headache. 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.

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 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.

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.

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.

Cervicogenic headache has been described as a syndrome that is ‘‘a final common pathway—not an entity.’ Thus, neck related cervicogenic headache is a syndrome that can have many contributing factors. The World Cervicogenic Headache Society has defined cervicogenic headache 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 neck related cervicogenic headache has been attributed to physical impairments of the joint, muscle, and neural structures in the cervical region, and, in particular, the upper cervical spine region.

The majority of rehabilitation based clinical trials for treatment of neck related headaches have examined the effect of manual therapy performed on cervical joints to alleviate the identified dysfunction. 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. Overall, the impairment level effects have included a decrease in headache frequency, intensity, and duration. The disability effects have been evidenced through improvements in performance of everyday activities.

Impairments involving muscle, specifically the deep neck flexors, also have been identified in patients with neck related cervicogenic headache. Placzek et al demonstrated that patients with neck related cervicogenic headache had significantly less strength and endurance of the deep neck flexors compared to age matched controls. Jull et al also identified a decrease in strength of the deep neck flexors in patients with neck related cervicogenic headache, when compared to able-bodied individuals. In a recent clinical trial involving patients with neck related cervicogenic headache, Jull et al 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 neck related cervicogenic headache.

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 neck related cervicogenic headache. 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 neck related cervicogenic headache. 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. Alterations in the biomechanics of the cervical region can contribute to local concentrations of high stress in cervical spine structures. Such stress has the potential to cause cumulative microtrauma to tissue and, over time, potential tissue failure and development of neck related cervicogenic headache symptoms.

A forward head position with increased extension of the upper cervical region is commonly observed. 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. We also have observed
that patients with neck related cervicogenic headache 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 neck related cervicogenic headache 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 neck related cervicogenic headache. Lumbar region impairments have the potential to affect the biomechanics in the cervical region. For example, an increased lumbar lordosis is often associated with an increased thoracic kyphosis and cervical extension. Patients with neck related cervicogenic headache 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 neck related cervicogenic headache. The purposes of this case report are to describe the findings from an examination of a patient with neck related cervicogenic headache 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 as modification of scapular movement during shoulder movements, and (3) restriction of compensatory movement in the cervical, thoracic, and lumbar regions with shoulder movements.

In the past, the focus of physical therapy intervention for neck related cervicogenic headache 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 neck related cervicogenic headache.