An increasingly common presentation to musculoskeletal outpatient departments are cervicogenic headaches. During my four week musculo placement, I recall having three patients with this presentation. I found though, it is quite a difficult condition to treat. For example, when the patient presents to the clinic, they usually do not have the headache so it’s hard to fully determine the efficacy of you treatment.
Quite often there are associated problems, such as decreased ROM (due to tightness + pain), tight musculature (especially sub-occipitals, cervical erector spinae, upper traps), and hypomobile PAIVMS (+ pain reproduction) & PPIVMS. There is also usually poor postural awareness and poor deep neck flexor strength. Therefore, much of the treatment centres around postural education (inc. ergonomic advice) and postural re-education exercises, ROM ex’s, PAIVMS/PPIVMS and muscle length activities (e.g. STM, stretch, trigger point etc).
Despite treating these physical impairments, it is hard for the patient to judge their progress by your treatments, as cervicogenic headaches may not occur during the time of your clinical placement. Therefore, ensure the small improvements in physical signs are adequately explained, as if they are not, the patient may become despondent and not comply. Therefore, explain the gains you are making and ensure the patient monitors frequency, severity and duration of headaches to see if changes occur. Also, if the patient experiences a headache between the clinical visits, don’t be disappointed and feel as if you have failed. Rather look to see if there are any changes in duration and intensity of the headache, if they required as much medication, and if there was the same amount of time between the headaches as normal. By using these as clinical markers, I found I could be pleased with the progress that was being made, and these positive indicators could then be told to the patients.
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2 comments:
A very good point, Nicole. A family member of mine had chronic "migraines" that could well have been cervicogenic headaches. After years of crippling monthly episodes, she attended physiotherapy and pilates under physiotherapy instruction and two years later she realised that she was no longer suffering from these migraines. I say "migraines" because they ceased before I started physiotherapy and never got all the objective information to determine cervicogenic versus migraine. However it took a long time for recovery and management to be truly effective. Yet now she is completely self managing and free from the problem. Great! But a lot of patient hard work from both physiotherapists and herself. So realising the subtle achievements and effects is so important in persisting through the long haul of this kind of rehabilitation. But it can be done!
Did you try Mulligans technique at c2 for treatment. I have found this to be quite useful in reducing the frequency and intensity of headaches. Otherwise i think your management was spot on. If there headaches are that bad and frequent I think you will find compliance is generally high. Always difficult to treat when pain is not present during session.
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