Conservative Management Of Cervical Tension Cephalalgia
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Conservative management of cervical tension cephalalgia Franklin Schoenoltz, DC, DABCO Arcadia, California Doctors of Chiropractic have long recognized the therapeutic value of manipulative therapy in the management of cervical tension cephalalgia. From a clinical standpoint, the role of manipulation in headache has been somewhat controversial. An attempt is made to present a clinical approach to a neuromusculoskeletal disorder which responds favorable to chiropractic manipulative procedures.
Introduction The causes of headache are legion. It is one of the most common and confusing symptoms faced in private practice. It is conceivable that as this entity is understood, the mechanisms that determine its various causes will be able to be classified. We will address ourselves to the most common headache, known by several terms such as tension headache, cervical tension cephalalgia, suboccipital cephalalgia, etc. We will exclude intracranial headaches or those which are secondary to generalized disease. Pathophysiology The functional importance of the musculoskeletal structure requires that particular attention be directed to the myofascial tissue as well as the articular components. In disorders of the myofascia, the pain and suboccipital muscle spasm must first be brought to terms. The nerves in this region lie in close proximity to the vertebral artery, at its point of angulation, prior to entering the skull
Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists, and maintains a private practice at 226-228 East Foothill Blvd, Arcadia, California 91006. He taught Diversified Technique and Undergraduate Orthopedics at the Los Angeles College of Chiropractic from 1964-1976. Presently, Dr Schoenholtz is the secretary-treasurer of the Board of Regents at LACC. He has authored numerous articles on the manipulative management of various musculoskeletal conditions. The most recent, “Conservative Management of Temporomandibular Joint Dysfunction,” appeared in the August 1978 issue of the ACA Journal.
through the foramen magnum. These nerves are vulnerable to irritation from the myofascial attachment of the cervical muscles to the base of the skull, muscles through which they transverse. Neural discharges or firings from extracranial tissues may result from abnormal psychological reactions mediated via muscular contraction. Because of the combination of the irritation of C-1 and C-2, which are primarily sensory, and suboccipital muscle spasm, patients may complain of pain at the upper neck region accompanied by tingling in the occipitoparietal region (Figure 1).
ACA Journal of Chiropractic /June 1979 Copyright The Journal of the American Chiropractic Association Copyright Dr Franklin Schoenholtz 2009
Symptoms and signs There is general agreement that stress may precipitate headache attacks and that the over-conscientious or perfectionistic individual is especially susceptible to develop this syndrome. Frequently, the patient complains of pain in the neck and suboccipital region, radiating up and over the whole of the posterior portion of the skull. Headaches and neckaches occur concurrently, are generally intermittent, and usually originate from the neck. The syndrome is not only influenced by position and activity, but can happen as a result of certain positions and activities. Localized signs in the neck may include stiffness and muscle tension. Many patients develop symptoms at the end of a stress-filled day. However, it is interesting to note that the syndrome has also occurred the morning after the patient held his head in an unsuitable position during sleep. Examination The patient’s complaints may be misleading because the area of complaint may be different from the actual site of the irritation. Therefore, the physical examination should include attempts to reproduce the pain by palpation of the myofascia or by passive stretching.
Palpation of the osseous structures of the cervical spine will usually reveal vertebral derangement. Localized tender points in the occipitocervical junction are revealed on palpatory examination. The atlantooccipitial joint may be remarkably fixed, and deep pressure palpation may reproduce occipitoparietal tingling. Investigation of this area should be conducted with the patient relaxed, in a sitting position, and with the head maintained in a forward flexed position. Palpation of the occipitocervical junction will often reveal the epicenter of the pain. Neurological examination will reveal no positive changes, but the deep tendon reflexes are frequently very active. The patient may appear tense and apprehensive; tachycardia and mild hypertension may be present. Even though a high proportion of cervical-occipital headaches have a mechanical basis, each patient must be examined individually. Other causes such as eye strain, sinusitis, digestive disturbance and neurological diseases must be excluded. Radiological examination Functional x-rays, such as the three lateral views taken of the patient sitting upright (the Davis Series), may assist the doctor in confirming his palpatory mobility tests. Range of motion is a function of the confining ligaments, but the range of motion is not only covered by the ligaments. Other factors include weight bearing an the tone of the muscles, which also influence the movements. When evaluating the lateral radiographs, evidence of hypomobility or fixation of the atlanto-occipital joint may be seen, thus confirming clinical findings. Treatment
Figure 1. The sensory distribution of the greater and lesser occipital nerves is in the posterior and lateral portion of the scalp. The shaded area represents hyperesthesia or anesthesia of the scalp which may occur from compressibility or irritation of these nerve roots.
Combined therapy in this type of syndrome includes the use of manipulation, soft tissue technique, traction and psychological support. The design of therapy should include combinations of modalities, to be used to reinforce each other in alleviating the symptoms. Manipulative therapy is well suited to the patient’s needs as one of the essential modalities for managing the musculoskeletal component of cervical tension cephalalgia. Musculoskeletal structure and function are governed by recognized mechanical principles in which weight
he pushes down on the forehead; the right hand remains immobile in order to exercise counterpressure (Figure 3). The doctor then cups his left hand against the table and slowly raises his elbow (and to some lesser degree, his wrist), bending the patient’s head to one side in combined extension and lateral flexion. Maintain this position for a moment, and then release. The procedure should be repeated several times, since it often reduces pain by stretching and relaxing rigid muscles. Invariably, the source of the muscle irritation can be traced to the articulation connected with the muscle. It then becomes necessary to correct the cause of the articular lesions. Manipulative technique
Figure 2. Intermittent motorized head halter traction should be arranged so that the pull will be in a 30° forward-flexed position with a cold pack placed under the patient’s neck. bearing forces and factors of stress and strain have a most important role. To achieve the maximum benefit from any form of therapy, the doctor should use discretionary latitude in choice of treatment. Variations in treatment must be made in response to the patient’s reaction, which may change from visit to visit.
Manipulation, well-selected and correctly performed, often constitutes and appropriate therapeutic solution. It should be very specific. The effort should be directed toward the articular derangement at the site of muscle contracture. The doctor stands at the patient’s head while the patient is supine; with his left hand, the doctor supports the head of the patient placed in left rotation (reverse technique for the opposite side). The lateral edge of the axis should make contact with the radial border of the right index finger. Rotate and extend the cervical spine to its maximum,
Intermittent motorized traction When the muscle spasm is primarily in the posterior cervical region, head-halter cervical traction may be helpful. The traction should be arranged so that the pull will be in a 30° forward-flexion position, allowing the posterior joints to open. Intermittent motorized traction gently stretches the posterior cervical musculature, thus improving mobility. It has been this author’s experience that a coldpack placed under the patient’s neck while traction is being applied is of great benefit because of its decongestive physiological action and anesthetic effect (Figure 2). Manual traction maneuver As a precursor to manipulation, a manual traction maneuver may be employed which stretches the posterior cervical spasm and mobilizes the upper cervical spinal joints. Te doctor stands at the left of the patient while the patient is in a supine position. The doctor places his left forearm under the cervical spine, his hand flat on the table and, using his right hand,
Figure 3. Movement of the cervical spine becomes combined extension and lateral flexion as the head is bent to one side.
taking up all the slack; by exercising a quick, firm, forwardand-left thrust of the right index finger, the corrective adjustment will be made in the direction of the movement. It should be emphasized that only the left hand supports the head of the patient (Figure 4). Muscle spasm is usually secondary to mechanical disturbances, but may outlast them, thus maintaining a pain-generating cycle. Effective manipulation stretches the involved structures producing a sudden limited traction of contracted muscles and other elements of the joints. This stimulates the corresponding proprioceptors and induces a reflex action. The technique attempts to interrupt the pain cycle, correct the articular lesion and alleviate the symptoms.
personality, individuality and weakness. The doctor can be of considerable aid to the patient in developing new patterns of daily living that will provide a healthy control of the pathopsychologic state. Psychologic factors are often significant in the management of altered musculoskeletal function. To achieve optimum treatment results, the responsibility of management may have to be shared. When sympathetic attitudes and demonstrated reassurance fail to help the patient, it may be time to seek specialized consultation for the patient with either a psychologist or psychiatrist.
Psychologic Factors The various psychologic mechanisms at work in creating this syndrome may vary greatly and should always be considered when the symptoms do not fit into a known clinical pattern. It is important that the doctor inform the patient of the nature of the disorder as accurately as possible. Sometimes, the basic problem may be unalterable and the doctor’s advisory role becomes paramount. A major responsibility may lie in easing the anxieties of the patient. The clinician has to understand the patient’s character,
Bibliography 1.Bourdillon, Spinal Manipulation, 1975. 2.Cailliet, Soft Tissue Pain and Disability, 1977. 3.Cyriax, Textbook of Orthopedic Medicine, 1975 4.Cyriax, Treatment of Pain by Manipulation, 1976. 5.Finnerson, Diagnosis and Management of Pain Syndromes, 1963. 6.Hart, The Treatment of Chronic Pain, 1974. 7.Hoag, Osteopathic Medicine, 1969. 8.Hoppenfield, Physical Examination of the Spine and Extremities, 1976. 9.Jackson, Cervical Syndrome, 1971. 10.Maigne, Orthopedic Medicine, 1976 11.Stoddard, Manual of Osteopathic Practice, 1969 12.Stoddard, Manual of Osteopathic Technique, 1974. 13.Tobis, Approaches to the Validation of Manipulation, 1977. 14.Zohn-Mennell, Musucloskeletal Pain, 1976.
Figure 4. Contact is made on the lateral edge of the axis with the radial border of the right index finger. The thrust is made with the index finger forward and to the left in the direction of the movement for the corrective adjustment to be made. The left hand only supports the head of the patient.
Conservative management of cervical tension cephalalgia Franklin Schoenoltz, DC, DABCO Arcadia, California Doctors of Chiropractic have long recognized the therapeutic value of manipulative therapy in the management of cervical tension cephalalgia. From a clinical standpoint, the role of manipulation in headache has been somewhat controversial. An attempt is made to present a clinical approach to a neuromusculoskeletal disorder which responds favorable to chiropractic manipulative procedures.
Introduction The causes of headache are legion. It is one of the most common and confusing symptoms faced in private practice. It is conceivable that as this entity is understood, the mechanisms that determine its various causes will be able to be classified. We will address ourselves to the most common headache, known by several terms such as tension headache, cervical tension cephalalgia, suboccipital cephalalgia, etc. We will exclude intracranial headaches or those which are secondary to generalized disease. Pathophysiology The functional importance of the musculoskeletal structure requires that particular attention be directed to the myofascial tissue as well as the articular components. In disorders of the myofascia, the pain and suboccipital muscle spasm must first be brought to terms. The nerves in this region lie in close proximity to the vertebral artery, at its point of angulation, prior to entering the skull
Dr Franklin Schoenholtz is a diplomate of the American Board of Chiropractic Orthopedists, and maintains a private practice at 226-228 East Foothill Blvd, Arcadia, California 91006. He taught Diversified Technique and Undergraduate Orthopedics at the Los Angeles College of Chiropractic from 1964-1976. Presently, Dr Schoenholtz is the secretary-treasurer of the Board of Regents at LACC. He has authored numerous articles on the manipulative management of various musculoskeletal conditions. The most recent, “Conservative Management of Temporomandibular Joint Dysfunction,” appeared in the August 1978 issue of the ACA Journal.
through the foramen magnum. These nerves are vulnerable to irritation from the myofascial attachment of the cervical muscles to the base of the skull, muscles through which they transverse. Neural discharges or firings from extracranial tissues may result from abnormal psychological reactions mediated via muscular contraction. Because of the combination of the irritation of C-1 and C-2, which are primarily sensory, and suboccipital muscle spasm, patients may complain of pain at the upper neck region accompanied by tingling in the occipitoparietal region (Figure 1).
ACA Journal of Chiropractic /June 1979 Copyright The Journal of the American Chiropractic Association Copyright Dr Franklin Schoenholtz 2009
Symptoms and signs There is general agreement that stress may precipitate headache attacks and that the over-conscientious or perfectionistic individual is especially susceptible to develop this syndrome. Frequently, the patient complains of pain in the neck and suboccipital region, radiating up and over the whole of the posterior portion of the skull. Headaches and neckaches occur concurrently, are generally intermittent, and usually originate from the neck. The syndrome is not only influenced by position and activity, but can happen as a result of certain positions and activities. Localized signs in the neck may include stiffness and muscle tension. Many patients develop symptoms at the end of a stress-filled day. However, it is interesting to note that the syndrome has also occurred the morning after the patient held his head in an unsuitable position during sleep. Examination The patient’s complaints may be misleading because the area of complaint may be different from the actual site of the irritation. Therefore, the physical examination should include attempts to reproduce the pain by palpation of the myofascia or by passive stretching.
Palpation of the osseous structures of the cervical spine will usually reveal vertebral derangement. Localized tender points in the occipitocervical junction are revealed on palpatory examination. The atlantooccipitial joint may be remarkably fixed, and deep pressure palpation may reproduce occipitoparietal tingling. Investigation of this area should be conducted with the patient relaxed, in a sitting position, and with the head maintained in a forward flexed position. Palpation of the occipitocervical junction will often reveal the epicenter of the pain. Neurological examination will reveal no positive changes, but the deep tendon reflexes are frequently very active. The patient may appear tense and apprehensive; tachycardia and mild hypertension may be present. Even though a high proportion of cervical-occipital headaches have a mechanical basis, each patient must be examined individually. Other causes such as eye strain, sinusitis, digestive disturbance and neurological diseases must be excluded. Radiological examination Functional x-rays, such as the three lateral views taken of the patient sitting upright (the Davis Series), may assist the doctor in confirming his palpatory mobility tests. Range of motion is a function of the confining ligaments, but the range of motion is not only covered by the ligaments. Other factors include weight bearing an the tone of the muscles, which also influence the movements. When evaluating the lateral radiographs, evidence of hypomobility or fixation of the atlanto-occipital joint may be seen, thus confirming clinical findings. Treatment
Figure 1. The sensory distribution of the greater and lesser occipital nerves is in the posterior and lateral portion of the scalp. The shaded area represents hyperesthesia or anesthesia of the scalp which may occur from compressibility or irritation of these nerve roots.
Combined therapy in this type of syndrome includes the use of manipulation, soft tissue technique, traction and psychological support. The design of therapy should include combinations of modalities, to be used to reinforce each other in alleviating the symptoms. Manipulative therapy is well suited to the patient’s needs as one of the essential modalities for managing the musculoskeletal component of cervical tension cephalalgia. Musculoskeletal structure and function are governed by recognized mechanical principles in which weight
he pushes down on the forehead; the right hand remains immobile in order to exercise counterpressure (Figure 3). The doctor then cups his left hand against the table and slowly raises his elbow (and to some lesser degree, his wrist), bending the patient’s head to one side in combined extension and lateral flexion. Maintain this position for a moment, and then release. The procedure should be repeated several times, since it often reduces pain by stretching and relaxing rigid muscles. Invariably, the source of the muscle irritation can be traced to the articulation connected with the muscle. It then becomes necessary to correct the cause of the articular lesions. Manipulative technique
Figure 2. Intermittent motorized head halter traction should be arranged so that the pull will be in a 30° forward-flexed position with a cold pack placed under the patient’s neck. bearing forces and factors of stress and strain have a most important role. To achieve the maximum benefit from any form of therapy, the doctor should use discretionary latitude in choice of treatment. Variations in treatment must be made in response to the patient’s reaction, which may change from visit to visit.
Manipulation, well-selected and correctly performed, often constitutes and appropriate therapeutic solution. It should be very specific. The effort should be directed toward the articular derangement at the site of muscle contracture. The doctor stands at the patient’s head while the patient is supine; with his left hand, the doctor supports the head of the patient placed in left rotation (reverse technique for the opposite side). The lateral edge of the axis should make contact with the radial border of the right index finger. Rotate and extend the cervical spine to its maximum,
Intermittent motorized traction When the muscle spasm is primarily in the posterior cervical region, head-halter cervical traction may be helpful. The traction should be arranged so that the pull will be in a 30° forward-flexion position, allowing the posterior joints to open. Intermittent motorized traction gently stretches the posterior cervical musculature, thus improving mobility. It has been this author’s experience that a coldpack placed under the patient’s neck while traction is being applied is of great benefit because of its decongestive physiological action and anesthetic effect (Figure 2). Manual traction maneuver As a precursor to manipulation, a manual traction maneuver may be employed which stretches the posterior cervical spasm and mobilizes the upper cervical spinal joints. Te doctor stands at the left of the patient while the patient is in a supine position. The doctor places his left forearm under the cervical spine, his hand flat on the table and, using his right hand,
Figure 3. Movement of the cervical spine becomes combined extension and lateral flexion as the head is bent to one side.
taking up all the slack; by exercising a quick, firm, forwardand-left thrust of the right index finger, the corrective adjustment will be made in the direction of the movement. It should be emphasized that only the left hand supports the head of the patient (Figure 4). Muscle spasm is usually secondary to mechanical disturbances, but may outlast them, thus maintaining a pain-generating cycle. Effective manipulation stretches the involved structures producing a sudden limited traction of contracted muscles and other elements of the joints. This stimulates the corresponding proprioceptors and induces a reflex action. The technique attempts to interrupt the pain cycle, correct the articular lesion and alleviate the symptoms.
personality, individuality and weakness. The doctor can be of considerable aid to the patient in developing new patterns of daily living that will provide a healthy control of the pathopsychologic state. Psychologic factors are often significant in the management of altered musculoskeletal function. To achieve optimum treatment results, the responsibility of management may have to be shared. When sympathetic attitudes and demonstrated reassurance fail to help the patient, it may be time to seek specialized consultation for the patient with either a psychologist or psychiatrist.
Psychologic Factors The various psychologic mechanisms at work in creating this syndrome may vary greatly and should always be considered when the symptoms do not fit into a known clinical pattern. It is important that the doctor inform the patient of the nature of the disorder as accurately as possible. Sometimes, the basic problem may be unalterable and the doctor’s advisory role becomes paramount. A major responsibility may lie in easing the anxieties of the patient. The clinician has to understand the patient’s character,
Bibliography 1.Bourdillon, Spinal Manipulation, 1975. 2.Cailliet, Soft Tissue Pain and Disability, 1977. 3.Cyriax, Textbook of Orthopedic Medicine, 1975 4.Cyriax, Treatment of Pain by Manipulation, 1976. 5.Finnerson, Diagnosis and Management of Pain Syndromes, 1963. 6.Hart, The Treatment of Chronic Pain, 1974. 7.Hoag, Osteopathic Medicine, 1969. 8.Hoppenfield, Physical Examination of the Spine and Extremities, 1976. 9.Jackson, Cervical Syndrome, 1971. 10.Maigne, Orthopedic Medicine, 1976 11.Stoddard, Manual of Osteopathic Practice, 1969 12.Stoddard, Manual of Osteopathic Technique, 1974. 13.Tobis, Approaches to the Validation of Manipulation, 1977. 14.Zohn-Mennell, Musucloskeletal Pain, 1976.
Figure 4. Contact is made on the lateral edge of the axis with the radial border of the right index finger. The thrust is made with the index finger forward and to the left in the direction of the movement for the corrective adjustment to be made. The left hand only supports the head of the patient.
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