cervicogenic headache

[linbin]

hi all
lets discuss the physiotherapy management of cervicogenic headache
my way of approach
posture correction
stretching of suboccipital muscles
deep neck flexor strengthening
suboccipital myofascial release
ergonomic advice

[CenteredHealth]

I feel that cervicogenic headaches, can be caused by anything from faulty biomechanics of the cervicals to poor crainal circulation to increased strain on the optic nerve to poor mobility through the sacum and lumbopelvic complex. We need to look at the whole body, expecially when headaches are involved.

I think I will begin by talking about biomechanics of the upper cervical spine. Typically one will find a complete disruption of mechanics throughout the c-spine but especailly C0-C3. Always there is some type of compression through the OA joints either one sided or bilateral. C1 will typically shear forward and C2 will appear relatively posterior and C3 will typically be relatively anterior to C2. The rest of the c-spine will do its best to compensate and right the head over the body in order to maintain balance and an appropriate field of vision.

Please do not forget about the importance of the cranial base and its relation to vital blood supply and nerve tissue. You had mentioned working the suboccipital muscles which will do wonders not only in aleviating protective muscle spasm in that region but also in decompressing the craninal base to allow improved blood flow especially through the circle of willis and decreased tension through the cerebellum and brain stem (all cranial nerves leave the brainstem!).

Also, please do not foget the improtance of the dural system and its attachment to the cranium and spine which can (and often does) contribute to increased spinal tension, faulty biomechanics and protective muscle spams.

The sacrum is of utmost importance in the treatment of headaches, as the dural tube inserts on S2. Any dysfucntion of the the sacrum will create a drag on the dural system contributing to a myriad of symptoms including compression of the cranial base and headaches.

Of course an appropriate program consisting of stretching and strengthening and neuromuscluar re-educaiton is critical to integrating the work done above. Address postural faults and muscular weakness. But please remember that each patient is different and unique and needs to be treated that way. Just because two people have identical symptoms does not mean that two identical treatment approaches are going to prove the same effectiveness. The therapy we pracice should not a cookbook that states do A, B, and C for X problem. Each patient needs to be evaluated objectively without bias in order to diagnosis the root cause and provide the most effective needs for that situation. (sorry about the rant)

[linbin]

hi
thanks centeredhealth for this wonderful post.it is really informative.i will be looking up for studies related to this

[jesspt]

linbin,

Good luck finding a high quality study related to the sacrum playing a role in cervico-genic headache.

Certainly there is research that implicates the cerivical/sub-occipital muscles in these headaches, and I would agree with both you and Centered that these should be addressed when treating a patient with Cervicogenic HA.

Centered,

I've asked for references from you in another post. I think it would be nice if you can support your craniosacral approach with some decent research. In keeping with full disclosure, I don't think you're going to be able to provide much.

[CenteredHealth]

Originally Posted by jesspt

linbin,

Good luck finding a high quality study related to the sacrum playing a role in cervico-genic headache.

Certainly there is research that implicates the cerivical/sub-occipital muscles in these headaches, and I would agree with both you and Centered that these should be addressed when treating a patient with Cervicogenic HA.

Centered,

I've asked for references from you in another post. I think it would be nice if you can support your craniosacral approach with some decent research. In keeping with full disclosure, I don't think you're going to be able to provide much.

Hello again Jess. Again thank you for challenging my posts, I am enjoying it. Unfortunately, I do not rely as heavily as you do on research studies, and the explanation is simple. I have learned over the years, in both performing research and studying research articles, that for every research article that proves one thing there are typically at least one other article that disproves the same thing. And before you discredit that statement, I ask you to please do a peer review of all ultrasound research articles. You will find that there are more research articles that debunk the effectiveness of ultrasound than there are that support its use. (I have done this in the past and was quite surprised at what I found, it quite literally shook my understanding of PhysioTherapy and turned it upside-down) And despite this PTs all over the world rely heavily on ultrasound as an effective modality, and I believe rightfully so.

Again, I am not going to supply you with the numerous research studies supporting CranioSacral, because you and anyone else for that matter can name at least hundreds of others that discredit the CranioSacral model. If you are interested in learning I can recommend reading anything by John Upledger, Leon Chaitow, Rollin Becker, Viola Fryman, etc.

In regards to the sacrum contributing to headaches, I simply say how can it not? Once you expand your box and begin to see that a craniosacral model is an appropriate model to explain motility of the nervous system, the explanation is in front of you. Very simply, the direct link between the cranium and the sacrum is the dural tube.

I believe that this post is a wonderful opportunity for the world community of PhysioTherapists to interact with each other and share their thoughts, comments and concerns regarding a wide spectrum of topics. I also understand that people abide to different philosophies, whether it be treatment approaches, diagnostic approaches or even general life beliefs such as spiritual philosophies. I simply ask people to be open minded.

"There are many paths to the top of the mountain, but the view is always the same."

[linbin]

hi jesspt
thanks for the reply.i agree with your comments.

everyone should be research oriented.i would like to mention that high quality studies will always suport clinical practise.if centeredhealth couldn't come to a conclusion regarding the effectiveness of ultrasound ,doesn't mean we should turn back from research articles.there are many aspects-biopsychosocial- which will have an influence on the patient's condition.
critically analysing the articles are important."chew well before you swallow"
cheers

[CenteredHealth]

Thanks for your opinion Linbin.

I must add that I do not completely disregard research articles by any means. Obviously they are valuable tools. My point was to say that I put more credence in patients' response to my treatments than research articles. It may be 'wrong' according to scholastic standards, but I will do whatever necessary to help my patients even if it is against the grain. Thanks again.

[morwenna]

Originally Posted by CenteredHealth

Thanks for your opinion Linbin.

I must add that I do not completely disregard research articles by any means. Obviously they are valuable tools. My point was to say that I put more credence in patients' response to my treatments than research articles.

Quite. "Evidenced-based Practice" relies on various evidence, certainly not on research papers alone, but personal experience and even anecdotal evidence are all grist to the mill.

[jacinta]

hello,

thanks for all the informative posting.
how about a pt with problem mentioned above, who developed chronic fibromylagia over the years. Palaption reveals
- 'lumps' on right C2-C3,
- cord-like right upper trapz from C2 all the way to spine of right scapula.
- occasional numbness, right shd to right arm
generally Cx spine quality of movement is poor.
postural problem: poke-chin.

in 2/12, various sessions of manual therapy, stretching and strengthening ex ( continued as home ex prog) doesnt produce significant improvement.
pt c/o Upp Cx flx(retraction) ex as tough as ' fighting against my own neck'.

kindly share your idea. thanks.

[linbin]

hi
i suggest you to check the segmental mobility of spine seperately,i mean upper ,middle and lower.
try myofascial release-especially suboccipital release
ice and stretch to trapezius
ischaemic compression in trapezius
relaxation exercise
ergonomic advice

[jacinta]

Hi linbin,

thanks for ur reply.

Originally Posted by linbin

hi
i suggest you to check the segmental mobility of spine seperately,i mean upper ,middle and lower.
try myofascial release-especially suboccipital release
ice and stretch to trapezius
ischaemic compression in trapezius
relaxation exercise
ergonomic advice

well, we tried MFR and heat treatment, instead of ice.
Trapz stretch was done manually (maitland), and as self-strectching at home.
the mention areas do get soften aft treatment, however,
according to pt., effect last < 1/7.
the size and hardness of lump at upp. cx remained unchanged when
pt come back for treatment, twice weekly.

something to clarify,
is ischemic compression the same with acupressure point release?


thanks

[jesspt]

Sorry about my infrequent posts over the last few weeks - I was in a very rural part of South Dakota on vacation and had essentially no internet access.

I was just revisting this thread and and I was re-reading it, I saw a few things I must have missed earlier....the mind isn't what it once was, I'm afraid.

Unfortunately, I do not rely as heavily as you do on research studies, and the explanation is simple. Nothing unfortunate about it. Some therapists are strongly into correlating thier practice with research, others are not. It sounds as though you appraise the literature on occasion, at the very least.
I have learned over the years, in both performing research and studying research articles, that for every research article that proves one thing there are typically at least one other article that disproves the same thing. And before you discredit that statement, I ask you to please do a peer review of all ultrasound research articles.
I have.
You will find that there are more research articles that debunk the effectiveness of ultrasound than there are that support its use. (I have done this in the past and was quite surprised at what I found, it quite literally shook my understanding of PhysioTherapy and turned it upside-down) And despite this PTs all over the world rely heavily on ultrasound as an effective modality, and I believe rightfully so.
I respectfully disagree here. I think the modality has little, if any, clinical utility, and is widely overused by physiotherapists worldwide. The reasearch and my opinion are in absolute agreement on this. I haven't used an ultrasound for patient care in over a year, with no negative change in patient outcomes

In regards to the sacrum contributing to headaches, I simply say how can it not? Once you expand your box and begin to see that a craniosacral model is an appropriate model to explain motility of the nervous system, the explanation is in front of you. Very simply, the direct link between the cranium and the sacrum is the dural tube

My problem with craniosacral therapy is the theory behind its applciation. From what I can tell, the theory makes no sense. The body of research that flies in the face of the components of craniosacral therapy is large, and the body of evidence supporting it is very small.
Now, note that I am [i][i]not saying that craniosacral therapy does not result in some pain relief for some people, but I am saying that this pain relief is almost certainly not as a result of the normalisation of craniosacral rhthym or from mobilizing the cranial sutures. I also am unaware of any reliable assessment technique that would allow a clinician to ascertain which patients might receive benefit from craniosacral therapy - essetially, it's a shot in the dark, and should be used as such. In short, we should be using interventions such as craniosacral therapy (or ultrasound, for that matter) that have a mountain of evidence that show them to be ineffective, as a treatment of last resort. Our first therapeutic actions should be to use treatments that have been shown to have better efficacy in the patient population that we are treating.