Use of cervical spine manipulation under anesthesia for management of cervical disk herniation, cervical radiculopathy, and associated cervicogenic headache syndrome

OBJECTIVE: To demonstrate the benefits of cervical spine manipulation with the patient under anesthesia as an approach to treating a patient with chronic cervical disk herniation, associated cervical radiculopathy, and cervicogenic headache syndrome. CLINICAL FEATURES: The patient had neck pain with radiating paresthesia into the right upper extremity and incapacitating headaches and had no response to 6 months of conservative therapy. Treatment included spinal manipulative therapy, physical therapy, anti-inflammatory medication, and acupuncture. Magnetic resonance imaging, electromyography, and somatosensory evoked potential examination all revealed positive diagnostic findings. INTERVENTION AND OUTCOME: Treatment included 3 successive days of cervical spine manipulation with the patient under anesthesia. The patient had immediate relief after the first procedure. Her neck and arm pain were reported to be 50% better after the first trial, and her headaches were better by 80% after the third trial. Four months after the last procedure the patient reported a 95% improvement in her overall condition. CONCLUSION: Cervical spine manipulation with the patient under anesthesia has a place in the chiropractic arena. It is a useful tool for treating chronic discopathic disease complicated by cervical radiculopathy and cervicogenic headache syndrome. The beneficial results of this procedure are contingent on careful patient selection and proper training of qualified chiropractic physicians.     

Self-Referral and the Boutique Hospital Industry

Abstract

Six individuals suffering from chronic cervicogenic headache were the subjects of a series of case studies involving manual therapy, exercise, and a home-exercise program. Headache duration ranged from three months to twenty years. During the course of treatment, the subjects maintained a journal tracking duration, frequency, and intensity of their headaches as well as any relieving factors. The purpose of this series of studies was to describe the use of manual therapy and exercise in the treatment of chronic cervicogenic headaches. Subjects were treated using a custom home-exercise protocol; manual therapy involving soft tissue and non-thrust joint manipulation, aerobic conditioning, and resistance exercise. The Pain Disability Index (PDI) was used as the functional improvement scale. The PDI was administered pre-, post- and six months post-treatment. Five of the six subjects reported improvement. These five subjects were seen for an average of 5.9 sessions over an average of 3.8 weeks. The average improvement on the PDI was 29.5% at discharge and 28.8% at 6- month follow-up. The five subjects each reported the need to continue their home exercise program in order to control their headaches at 6-month follow-up. A voluntary decrease in medication intake was also reported by five of the six subjects at discharge. Six-month follow-up showed that these five patients were still taking less medication than reported at time of the intial examination. No follow-up data was available for the patient which reported no improvement. The results of these case studies seem to indicate that a treatment regimen of exercise and manual therapy can be beneficial in the treatment of chronic cervicogenic headaches.     

Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache

Persistent intermittent headache is a common disorder and is often accompanied by neck aching or stiffness, which could infer a cervical contribution to headache. However, the incidence of cervicogenic headache is estimated to be 14-18% of all chronic headaches, highlighting the need for clear criterion of cervical musculoskeletal impairment to identify cervicogenic headache sufferers who may benefit from treatments such as manual therapy. This study examined the presence of cervical musculoskeletal impairment in 77 subjects, 27 with cervicogenic headache, 25 with migraine with aura and 25 control subjects. Assessments included a photographic measure of posture, range of movement, cervical manual examination, pressure pain thresholds, muscle length, performance in the cranio-cervical flexion test and cervical kinaesthetic sense. The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension (P=0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.     

A novel way of functional retraining of cervical motor control in a water polo player with combined cervicogenic and tension type headaches

This case report introduces an innovative and novel way of functionally retraining the sport specific cervical function in a 13-year-old elite water polo player with a combined tension type headache and cervicogenic headache. After an evidence based assessment and manipulative physical therapy management regime, consisting of manual mobilization and exercise focused on retraining the deep cervical flexors and sub-occipital extensors, the patient was left with persistent residual complaints inhibiting competitive level sport participation. Re-assessment and subsequent retraining of a specific provocative functional task was facilitated by using the Cervical Trainer^?. Using a wireless sensor worn on the head, this device registers three-dimensional movement and displays this on a computer screen, providing direct feedback on movement performance. After a 6-week period of training sessions, the residual complaints subsided and her score on the Headache Impact Test-6 questionnaire improved from 51 to 36 signifying no impact of her headache on daily life activities.     

Manual therapy and exercise for neck pain: A systematic review

Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:?1.69,?0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:?0.76,?0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made.     

Diagnosis and Management of Cervicogenic Headache and Local Cervical Syndrome with Multiple Pain Generators

Abstract

Numerous pain generators can be responsible for cervicogenic headache and pain in both the cervical and thoracic regions. A 45-year-old female presented in the clinic with a 20-year history of cervicogenic and migraine headaches, accompanied by a prolonged history of local cervical and interscapular pain. The cervicogenic symptoms were attributed to secondary discrelated changes in the cervical spine, as evidenced by specific provocation behaviors and segmental limitation patterns. The patient was educated regarding the presenting problems, and ergonomic changes were initiated. The limitations were addressed with joint-specific mobilization techniques, accompanied by specific home exercises. The patient demonstrated initial rapid improvements that were characterized by reduced symptoms and increased motion, followed by gradual full motion recovery and resolution of cervicogenic symptoms. This recovery pattern suggests the efficacy of manual techniques in the management of cervicogenic headaches and local cervical syndrome, even in the context of rather prolonged symptoms.     

Physical Therapy Diagnosis and Management of a Patient with Chronic Daily Headache: A Case Report

Abstract

Chronic headaches are a significant health problem for patients and often a clinical enigma for the medical professionals who treat such patients. The purpose of this case report is to describe the physical therapy diagnosis and management of a patient with chronic daily headache. The patient was a 48-year-old woman with a medical diagnosis of combined common migraine headache and chronic tension-type headache. An exacerbation of these long-standing headache complaints had resulted in a chronic daily headache for the preceding eight months. Symptoms included bilateral headache, neck pain, left facial pain, and tinnitus. Outcome measures used included the Henry Ford Hospital Headache Disability Inventory (HDI) and the Neck Disability Index (NDI). Examination revealed myofascial, articular, postural, and neuromuscular impairments of the head and neck region. Treatment incorporated myofascial trigger point dry needling, orthopaedic manual physical therapy, exercise therapy, and patient education. On the final visit, the patient reported no headaches during the preceding month. There was a 31% improvement in the HDI emotional score, a 42% improvement in the functional score, and a 36% improvement in the total score for the HDI, the latter exceeding the minimal detectable change for the total score on this measure. The NDI at discharge showed an 18% improvement with a maximal improvement during the course of treatment of 26%. Both improvements exceeded the minimal clinically important difference for the NDI. This case report indicates that physical therapy diagnosis and management as described may be indicated for the conservative care of patients with chronic headaches.     

The Use of Upper Thoracic Manipulation in a Patient With Headache

Abstract

This case study describes how thrust manipulation in the upper thoracic spine was effective in reducing symptoms in a patient with complaint of headache; it discusses potential theories and interrelationships. The study describes a 29-year-old female with onset of occipital headaches who noted no change in symptoms after five treatments over a period of three weeks. Treatment included soft tissue mobilization, passive stretching, postural instruction/exercise and nonthrust manipulation to occipito-atlantal (O/A), atlanto axial (A/A) and cervical facet joints. The patient's sixth visit, that occurred 5 days after the fifth treatment session, included a thrust manipulation to the upper thoracic spine (T1/2) after which she noted a significant reduction in symptoms. The patient was then seen for two additional visits which included nonthrust manipulation techniques. Two days after her final visit, the patient noted full resolution of symptoms. The patient continued to note full resolution of symptoms for six weeks. The patient then returned to physical therapy with similar complaints but at approximately 50% of the earlier intensity. Two treatments, over a period of one week, utilizing nonthrust manipulation techniques yielded no relief in symptoms. One week later, the patient received a thrust manipulation at T2/3 after which she noted full resolution of symptoms. At follow up, seven weeks later, the patient remained symptom free.     

Clinical reasoning for manual therapy management of tension type and cervicogenic headache

In recent years, there has been an increasing knowledge in the pathogenesis and better management of chronic headaches. Current scientific evidence supports the role of manual therapies in the management of tension type and cervicogenic headache, but the results are still conflicting. These inconsistent results can be related to the fact that maybe not all manual therapies are appropriate for all types of headaches; or maybe not all patients with headache will benefit from manual therapies. There are preliminary data suggesting that patients with a lower degree of sensitization will benefit to a greater extent from manual therapies, although more studies are needed. In fact, there is evidence demonstrating the presence of peripheral and central sensitization in chronic headaches, particularly in tension type. Clinical management of patients with headache needs to extend beyond local tissue-based pathology, to incorporate strategies directed at normalizing central nervous system sensitivity. In such a scenario, this paper exposes some examples of manual therapies for tension type and cervicogenic headache, based on a nociceptive pain rationale, for modulating central nervous system hypersensitivity: trigger point therapy, joint mobilization, joint manipulation, exercise, and cognitive pain approaches.     

Neurofibromatosis type I: clinical and imaging features of Von Recklinghausen's disease

OBJECTIVE: To discuss the case of a 45-year-old woman, with a prior diagnosis of neurofibromatosis type 1 (NF-1), complaining of low back and cervical spine pain with bilateral upper extremity paresthesias. CLINICAL FEATURES: The patient had a dull, achy, constant low-back pain of 4 months' duration, with mild headaches and upper extremity paresthesias. Multiple skin lesions and spinopelvic postural imbalances were present. Diagnostic radiography, along with advanced imaging, demonstrated multilevel dysplastic osseous changes, with dural ectasia, scoliosis, and tumor extension. In addition to the previous diagnosis of NF-1, our clinical diagnosis included segmental dysfunction with resultant cervicalgia, lumbalgia, and myospasm. INTERVENTION AND OUTCOME: Treatment consisted of a course of spinal manipulation of the lumbopelvic region, with adjunctive therapy consisting of interferential therapy, heat, and rehabilitative exercise. Marked reduction in pain and paresthesia with improved function were achieved. CONCLUSIONS: NF-1 is a multisystem disease with neoplasia of the skin and nervous system. Patients experience a lifetime of morbidity and increased risk of mortality, depending on the extent of the disease. A multitude of therapeutic regimens may be engaged to improve NF-1-associated symptomatology and morbidity. Chiropractic spinal manipulation may have a positive effect in pain reduction and improved function in patients who have NF-1 without spinal instability.     

Spinal manipulation and headaches of cervical origin

The role of the cervical spine in headache remains controversial. Often confused as tension or common migraine headache, headaches arising from the neck pose a diagnostic and therapeutic challenge. Practitioners of spinal manipulation have reported very satisfactory results, although the only published randomized controlled trial did not demonstrate that manipulation was significantly helpful. This article reviews the published clinical studies of manipulation in the treatment of tension and migraine headaches. The topic of cervical headaches in general is reviewed and the current model of cervicogenic headache is critiqued. A representative case history is used to illustrate the thesis that the current model of cervicogenic headache may be too restrictive. The role of spinal manipulation as a trial of therapy in individual patients is also discussed. a retrospective diagnosis of cervical headache can often be confirmed by a successful outcome.     

Are "cervicogenic" headaches due to myofascial pain and cervical spine dysfunction?

The purpose of this investigation was to evaluate whether the pain of cervicogenic headache could be due to referred symptoms from myofascial trigger points. The presence or absence of cervical spine dysfunction was also of interest. Eleven patients with cervicogenic headaches were systematically examined for myofascial trigger points and cervical spine dysfunction. All patients had at least three myofascial trigger points on the symptomatic side. In eight of these patients, trigger point palpation clearly reproduced their headache. There were 70 myofascial trigger points (35 "very tender", 35 "tender") and 17 non-myofascial tender points on the symptomatic side, compared to 22 myofascial trigger points (one "very tender", 21 "tender") and 19 non-myofascial tender points on the asymptomatic side. These differences were statistically significant [chi-square (2df) = 22.04, p less than 0.0001]. All patients had some evidence of cervical dysfunction. Ten patients (91%) had specific segmental dysfunction of occiput on atlas and/or atlas on axis. Five patients were entered into a non-invasive, interdisciplinary pain management program designed to treat cervical spine dysfunction and myofascial pain. Treated patients reported a significant decrease in the frequency and intensity of their headaches during a median two-year follow-up. It is concluded that myofascial trigger points may be an important pain producing mechanism in cervicogenic headache and that segmental cervical dysfunction is a common feature in such patients. Conservative, non-surgical treatment appears to be effective in reducing the frequency and intensity of cervicogenic headache. These data suggest that surgical approaches should be reserved only for those patients who fail conservative therapy.     

Evidence-Based Approach to the Physical Therapy Diagnosis and Management of Neck and Upper Extremity Pain using Cervical and Thoracic Spine Thrust Manipulation: A Case Report

Abstract

Neck and upper extremity pain are common medical diagnoses for patients seeking physical therapy care. The purpose of this case report is to describe an evidence-based approach to the physical therapy diagnosis and management of a 46-year-old female reporting insidious onset neck pain and bilateral upper extremity paraesthesiae of two years duration. Evaluation of examination data, based on research data with regard to diagnostic accuracy of the tests and measures used, indicated a diagnosis of cervical radiculopathy. Management was based on a treatment-based classification approach and focused on restoring mobility by way of thrust manipulations directed at the thoracic and cervical spine. At the completion of the physical therapy plan of care (8 visits), the patient rated her perceived improvement on the Global Rating of Change Scale as "a very great deal better." The Numerical Pain Rating Score improved from 6/10 to 0/10. Patient-perceived disability, as measured by the Neck Disability Index, improved from 26% to 0%, and the patient's score on the modified Oswestry Disability Index improved from 30% to 0%. Bilateral upper extremity paraesthesiae also had completely resolved. These clinically meaningful improvements in pain and perceived disability were maintained six weeks after discharge. While a cause-and-effect relationship cannot be inferred from a case report, it is plausible that an orthopaedic manual physical therapy approach in the management of patients with both neck and upper extremity pain may result in decreased pain and improved function. Further clinical trials are needed to test this hypothesis.     

A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial

OBJECTIVE: To evaluate a new 3-point bending type of cervical traction. DESIGN: Nonrandomized controlled trial of prospective, consecutive patients compared with control subjects. Follow-up patient data were obtained at 3 and 15(1/2) months, and 8 1/10 months for controls. SETTING: Data were collected at a spine clinic in Nevada. PATIENTS: Volunteer subjects consisted of 30 patients and 24 controls. Subjects had cervicogenic pain (neck pain, headaches, arm pain, and/or numbness). Subjects were included if their Ruth Jackson radiographic stress lines measured less than 25 degrees but were excluded if they had suspected disk herniation or canal stenosis. All subjects completed the first follow-up examinations, and 25 of 30 patients completed the long-term follow-up examination. INTERVENTIONS: Spinal manipulation for pain and a new form of 3-point bending cervical traction to improve lordosis. Cervical manipulation was provided for the first 3 to 4 weeks of treatment. Traction treatment consisted of 3 to 5 sessions per week for 9 +/- 1 weeks. MAIN OUTCOMES MEASURES: Besides pain visual analog scale (VAS) ratings, pre- and posttreatment lateral cervical radiographs were analyzed. RESULTS: Control subjects reported no change in the pain VAS ratings and had no statistically significant change in segmental or global radiographic alignment. For the traction group, VAS ratings were 4.3 pretreatment and 1.6 posttreatment. Traction group radiographic measurements showed statistically significant improvements (P <.008 in all instances of statistical significance), including anterior head weight bearing (improved 6.2mm), Cobb angle at C2-7 (improved 12.1 degrees ), and angle between posterior tangents at C2-7 (improved 14.2 degrees ). For the treatment group, at 15(1/2)-month follow-up, only minimal loss of C2-7 lordosis (3.5 degrees ) was observed. CONCLUSIONS: Sagittal cervical traction with transverse load at midneck (2-way cervical traction) combined with cervical manipulation can improve cervical lordosis in 8 to 10 weeks as indicated by increases in segmental and global cervical alignment. Magnitude of lordosis at C2-7 remained stable at long-term follow-up.     

Manual Treatment for Cervicogenic Headache and Active Trigger Point in the Sternocleidomastoid Muscle: A Pilot Randomized Clinical Trial

Objective

The purpose of this preliminary study was to determine feasibility of a clinical trial to measure the effects of manual therapy on sternocleidomastoid active trigger points (TrPs) in patients with cervicogenic headache (CeH).

Methods

Twenty patients, 7 males and 13 females (mean ± SD age, 39 ± 13 years), with a clinical diagnosis of CeH and active TrPs in the sternocleidomastoid muscle were randomly divided into 2 groups. One group received TrP therapy (manual pressure applied to taut bands and passive stretching), and the other group received simulated TrP therapy (after TrP localization no additional pressure was added, and inclusion of longitudinal stroking but no additional stretching). The primary outcome was headache intensity (numeric pain scale) based on the headaches experienced in the preceding week. Secondary outcomes included neck pain intensity, cervical range of motion (CROM), pressure pain thresholds (PPT) over the upper cervical spine joints and deep cervical flexors motor performance. Outcomes were captured at baseline and 1 week after the treatment.

Results

Patients receiving TrP therapy showed greater reduction in headache and neck pain intensity than those receiving the simulation (P < .001). Patients receiving the TrP therapy experienced greater improvements in motor performance of the deep cervical flexors, active CROM, and PPT (all, P < .001) than those receiving the simulation. Between-groups effect sizes were large (all, standardized mean difference, > 0.84).

Conclusion

This study provides preliminary evidence that a trial of this nature is feasible. The preliminary findings show that manual therapy targeted to active TrPs in the sternocleidomastoid muscle may be effective for reducing headache and neck pain intensity and increasing motor performance of the deep cervical flexors, PPT, and active CROM in individuals with CeH showing active TrPs in this muscle. Studies including greater sample sizes and examining long-term effects are needed.     

Die Kopfgelenke und ihre besondere Bedeutung beim Kopfschmerz

The so-called head joints consist of the segments occiput/C1, C1/C2, C2/C3. The existence of cervicogenic headaches is not fully accepted by the different medical schools. Morphological alterations in the upper cervical spine are seldom causes of complaints, similar to X-ray diagnosed anomalies of the position of the joints in the upper spine. The vertebrogenic headaches (upper cervical syndrome, cervicocephalic syndrome, cervicocranial syndrome) are discussed as to anamnesis, the topic of pain, and the functional findings. According to Gutmann a distinction is made between the headache caused by blockages, the headache caused by hypermobility, and the headache caused by tensed muscles. It has been criticized that headache specialists diagnose tension headaches based to a large extent on the anamnesis and not the clinical examination. The hope for medical high technology should not put a damper on clinicians’ professional skills.     

Abstracts of Current Literature

Abstract

The objective of our study was to determine the effectiveness of manual therapy for balancing C1 and a home exercise program, including active neck retraction exercises performed in a series of progressions, in the treatment of cervicogenic headache. The subjects included a 42-year-old male (Subject 1) and a 25-year-old female (Subject 2), both with a primary complaint of right-side suboccipital headache. Subject 1 was functionally limited in reading, sleeping, and playing basketball. Subject 2 reported problems with working, sleeping, and running on a treadmill. Both subjects met the criteria for cervicogenic headache as adapted from the International Headache Society. On Day 1, each subject completed three self-report measures: a numeric pain scale for both worst and average headache pain as well as the Patient Specific Functional Scale. Each subject was treated on Days 1, 3, and 5. Intervention included using a muscle energy technique for balancing C1 and a home program consisting of a progression of McKenzie's retraction/extension/rotation exercises. Each subject was told he/she may continue the home program on his/her own accord every 2 hours or as a headache occurred. On days 12 and 26, each subject completed the previous three self-report measures as well as the Global Rating Scale during blinded follow-up phone visits. The subjects demonstrated an increase in functional activities, a decrease in average and worst headache pain, and an overall improvement in their perception of change in the headache. Manual therapy in addition to a home program of active neck retraction exercises in a series of progressions was successful in relieving cervicogenic headache and improving function in two subjects. Patients with cervicogenic headaches could be empowered to alleviate their own symptoms with decreased physical therapy visits and decreased cost by having a manual therapy technique performed on them followed by a home exercise program.     

Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A discriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.