Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review

Effects of cervical stabilization training in patients with headache: A single-blinded randomized controlled trial

BACKGROUND

This study aimed to investigate the effects of Cervical Stabilization Training (CST) on the headache, neck pain and cervical musculoskeletal system in patients with headache compared to the control group.

METHODS

A total of 90 female patients with migraine, tension-type headache and cervicogenic headache (CGH) participated in this study. The patients were divided into the cervical stabilization training group (CSTG) and the control group (CG). The CSTG performed the CST three times a week for 8 weeks while the CG continued their ongoing medical treatment. The pain intensity was assessed by Visual Analogue Scale, forward head posture by craniovertebral angle measurement, the endurance of deep cervical flexor muscles by craniocervical flexion test and the endurance of cervical muscles by flexor and extensor endurance tests before and after 8 weeks. In addition, disability levels, health-related quality of life, sleep quality and mood were assessed by the Migraine Disability Assessment questionnaire, Neck Disability Index (NDI), Short Form 36 Quality of Life Scale, the Pittsburgh Sleep Quality Index and Beck Depression Scale, respectively.

RESULTS

Headache frequency, duration and intensity, neck pain intensity and forward head posture reduced while activation and performance of deep cervical flexor muscles, the endurance of cervical flexor and extensor muscles increased in the CSTG (p < 0.05). Furthermore, the disability levels, quality of life, sleep quality and mood also improved in the CSTG (p < 0.05).

CONCLUSIONS

This study suggests that CST reduces headaches and neck pain by improving the cervical musculoskeletal system in patients with headache.

SIGNIFICANCE

The CST improved the headache frequency, duration and intensity, neck pain intensity, cervical posture, activation of deep cervical flexor muscles and endurance of cervical muscles in patients with headache. In addition, improvements in the cervical musculoskeletal system contributed to a reduction in the intensity of headaches and neck pain. Therefore, CST may be preferred in the treatment of headaches, especially with coexisting neck pain.

Reliability and measurement properties of upper cervical flexion-extension range of motion testing in people with cervicogenic headache and asymptomatic controls

OBJECTIVE

The objective was to determine reliability of sagittal plane range of motion (ROM) assessment in a healthy population and in people with cervicogenic headache (CGH).

METHODS

Upper cervical flexion/extension ROM was measured using an iPhone magnetometer sensor and retraction/protraction ROM measured by linear displacement. Two independent raters evaluated these movements in 33 subjects with CGH and 33 age and gender matched asymptomatic healthy controls on two occasions. Measurement procedures were standardized; and the order of testing randomized. Reliability, standard error of measurement (SEM) and minimum detectable change (MDC) were calculated.

RESULTS

Subjects comprised 30 females and 36 males. The iPhone method demonstrated high reliability (ICC >0.82) with SEM values ranging from 0.62 to 1.0 and MDC values ranging from 1.70 to 4.81 respectively. Evaluation of linear displacement demonstrated moderate reliability (ICC >64). with SEM values ranging from 0.38 to 1.91 and MDC values ranging from 1.05 to 1.63 respectively. Compared to healthy controls, upper cervical flexion, retraction and protraction ROM was significantly less in the CGH group with mean difference of 6.50°, 1.52 cm and 2.34 cm respectively.

DISCUSSION

Upper cervical spine sagittal plane ROM can be measured with moderate to high reliability and was found to be more restricted in people with CGH.

Cervicogenic headache - How to recognize and treat

Cervicogenic headache, described almost 100 years ago, only had its clinical awakening at the end of the century with the work of Professor Sjaastad. Its classic definition is the induction of trigeminal symptoms from cervical disorders, thanks to trigeminocervical convergence mechanisms. For this reason, it can manifest several features typical of migraine, leading to diagnostic errors. Classically, subjects complain of fixed unilateral headaches, with cervical onset and trigeminal irradiation, associated with reduced neck mobility and flexion strength. The headache is mild to moderate, described as pulsatile or compressive, accompanied by nausea, vomiting, photophobia, phonophobia, and may present autonomic symptoms and dizziness. The pain duration varies from one day to weeks, and its frequency is unpredictable. A history of whiplash injury is common. The differential diagnosis encompasses migraine and tension-type headache. Management includes physiotherapy rehabilitation, anesthetic blocks, and selectively surgical procedures. In this article, all these aspects were extensively covered.

Utilizing directional preference in the management of cervicogenic headache: a case series

BACKGROUND/PURPOSE

Headaches are among the most common complaints requiring medical care, and annual expenditures for this condition are estimated to be 14 billion US dollars. The International Headache Society (IHS) describes cervicogenic headache (CGH) as a secondary type of headache emanating from the cervical spine which may be referred to one or more regions of the head and/or face. Mechanical Diagnosis and Therapy (MDT) is an approach shown to be effective in the management of spinal musculoskeletal disorders; however, there is limited evidence as to its efficacy in the management of CGH. The purpose of this case series was to examine the MDT approach in the assessment, classification, and management of a sample of patients experiencing cervicogenic headache.

CASE DESCRIPTION

This study was a prospective case series. Following IRB approval, 15 patients meeting the study inclusion criteria were recruited from a hospital-based outpatient physical therapy clinic. All subjects received a physical therapy examination by a Diploma trained MDT clinician which included but was not limited to patient self-report forms and the testing of repeated end range movements. The Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Headache Disability Index (HDI), Yellow Flag Risk Form (YFRF), Cervical Flexion Rotation Test (CFRT), and the Craniocervical Flexion Test (CCFT) were administered at the initial visit, 5th visit, and 10th visit or discharge, whichever occurred first. The NPRS, NDI, and HDI were re-administered at a 3 month follow up. Following the initial examination, patients were classified into the MDT categories of derangement, dysfunction, postural, or 'other' and then received intervention based on directional preference.

OUTCOMES

Fifteen subjects (mean age, 45.9 years; F = 11, M = 4; symptom duration, 44.3 months; average visits, 8.8) received an examination and intervention and completed follow-up outcome measures. Based on MDT classification criteria, all 15 subjects in this case series were classified as derangements. A non-parametric Friedman test of Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation differences among repeated measures was conducted on all outcome measures revealing statistically significant improvements in NPRS (p < .01), NDI(p < .01), and HDI (p < .01) scores at visit 10 and 3 month follow up. The mean change scores exceeded the minimal clinical important difference (MCID) for NPRS (4.2), NDI (7.6), and HDI (28.5). CCFT scores improved significantly from the initial examination to visit 5 (p < .01) and YFRF scores improved significantly between visits 5 and 10 (p < .01).

DISCUSSION/CONCLUSION

The diagnosis of CGH is difficult to determine based on pathoanatomical assessment. This case series suggests that the patient's response to repeated end range movements may indicate a directional preference for manual procedures and exercises which may be used in management of musculoskeletal conditions such as CGH.

The cervical spine in tension type headache

INTRODUCTION

The concept that headaches may originate in the cervical spine has been discussed over decades and is still a matter of debate. The cervical spine has been traditionally linked to cervicogenic headache; however, current evidence supports the presence of cervical musculoskeletal dysfunctions also in tension-type headache.

PURPOSE

This position paper discusses the most updated clinical and evidence-based data about the cervical spine in tension-type headache.

IMPLICATIONS

Subjects with tension-type headache exhibit concomitant neck pain, cervical spine sensitivity, forward head posture, limited cervical range of motion, positive flexion-rotation test and also cervical motor control disturbances. In addition, the referred pain elicited by manual examination of the upper cervical joints and muscle trigger points reproduces the pain pattern in tension-type headache. Current data supports that the cervical spine can be also involved in tension-type headache, and not just in cervicogenic headache. Several physical therapies including upper cervical spine mobilization or manipulation, soft tissue interventions (including dry needling) and exercises targeting the cervical spine are proposed for managing tension-type headache; however, the effectiveness of these interventions depends on a proper clinical reasoning since not all will be equally effective for all individuals with tension-type headache. Based on current evidence, we propose to use the terms cervical "component" and cervical "source" when discussing about headache. In such a scenario, in cervicogenic headache the neck can be the cause (source) of the headache whereas in tension-type headache the neck will have a component on the pain pattern, but it will be not the cause since it is a primary headache.

Evaluation and management of temporomandibular disorders. Part 2: an orthopaedic physical therapy update on examination and clinical reasoning

Temporomandibular (TM) disorders afflict many people globally and, despite the presence of existing peer-reviewed material that assists conservative orthopedic providers, recent advances in knowledge indicate that updated resources are required for students, clinicians, and educators. This two-part series builds off previously published material to present newer supplementary information that can be useful during the evaluation and management processes. Content in Part 1 of this series includes a discussion about the factors that have been shown to contribute to TM disorders, an updated perspective of relevant pain science, a discussion of self-report outcome measures, and various different topics related to the examination of patients with TM disorders. Part 2 addresses information related to the temporomandibular joint disc, joint hypermobility, oral splints, and clinical reasoning. In combination with other available publications, this two-part series provides clinicians an opportunity to improve their delivery of effective and efficient clinical services for people diagnosed with TM disorders.

Headache and orofacial pain: A traffic-light prognosis-based management approach for the musculoskeletal practice

Introduction

Headache (HA) is one of the most prevalent disabling conditions worldwide and is classified as either primary or secondary. Orofacial pain (OFP) is a frequent pain perceived in the face and/or the oral cavity and is generally distinct from a headache, according to anatomical definitions. Based on the up-to-date classification of the International Headache Society, out of more than 300 specific types of HA only two are directly attributed to the musculoskeletal system: The cervicogenic HA and HA attributed to temporomandibular disorders. Because patients with HA and/or OFP frequently seek help in the musculoskeletal practice, a clear and tailored prognosis-based classification system is required to achieve better clinical outcomes.

Purpose

The aim of perspective article is to suggest a practical traffic-light prognosis-based classification system to improve the management of patients with HA and/or OFP in the musculoskeletal practice. This classification system is based on the best available scientific knowledge based on the unique set-up and clinical reasoning process of musculoskeletal practitioners.

Implications

Implementation of this traffic-light classification system will improve clinical outcomes by helping practitioners invest their time in treating patients with significant involvement of the musculoskeletal system in their clinical presentation and avoid treating patients that are not likely to respond to a musculoskeletal based intervention. Furthermore, this framework incorporates medical screening for dangerous medical conditions, and profiling the psychosocial aspects of each patient; thus follows the biopsychosocial rehabilitation paradigm.

A perspective on the use of the cervical flexion rotation test in the physical therapy management of cervicogenic headaches

BACKGROUND

The Cervical Flexion-Rotation Test (CFRT) is widely used in the assessment of upper cervical spine mobility impairments and in the diagnosis of cervicogenic headache (CGH) by physiotherapist. Many studies investigated its different properties, and the results show that the CFRT has good construct validity in the measurement of C1-C2 rotation as well as good to excellent reliability.

PURPOSE

In this theoretical paper, we explore the value and point out two methodological issues associated to the CFRT, one related to the procedures and another related to its diagnostic accuracy.

RESULTS

Our analysis indicate that there are many confounding factors that could affect the CFRT cut-off's accuracy, which are likely to overestimate the diagnosis properties of CFRT. Potential solutions are discussed. Moreover, the gold standard (manual examination) used to examine the validity of the CFRT for the diagnosis of CGH appears to be far from perfect - we could argue that the diagnostic properties of the CFRT for CGH might be biased and the likelihood ratios are likely to be overestimated. However, it could be relevant to explore if results of the CFRT could be considered as a treatment-effect modifier. Maybe the CFRT could be more valuable as a prognostic factor?

CONCLUSION

The quality of evidence supporting the validity of the CFRT is most likely biased. In the absence of a better gold standard, maybe the CFRT could be a more valuable test to establish the patient's prognosis and help the clinician to choose the most appropriate treatment options.

Flexion-rotation test and C0-C2 axial rotation test. Are they equally reliable for novice clinicians?

OBJECTIVE

To analyse the inter- and intra-examiner reliability for the neck flexion-rotation test and the C0-C2 axial rotation test when applied in asymptomatic subjects by two novice physiotherapists.

DESIGN

Repeated measures reliability study design. The study was approved by the Research Ethics Committee of [X], in compliance with the Declaration of Helsinki (CSEULS-PI: 004/2020).

METHODS

32 asymptomatic adults were included, recruited by convenience sampling. Two sessions were scheduled for each subject, with an intersession break of 30 min. Two inexperienced raters blinded to their own previous and peer results performed three movements to both sides using the flexion-rotation test and the C0-C2 axial rotation test in randomised order of rater, test and direction. A third researcher collected the data measured by inertial sensors and displayed to the Pro Motion Capture software.

RESULTS

Both raters showed good-excellent intra-examiner reliability (ICC_(2,3) ranging from 0.88 to 0.94) and moderate to good inter-examiner reliability (ICC_(2,3) ranging from 0.58 to 0.86) to measure the rotation ROM with the FRT. The C0-C2 axial rotation test resulted in poor to moderate intra-examiner reliability (ICC_(2,3) ranging from 0.33 to 0.74) and poor inter-examiner reliability using (ICC_(2,3) ranging from 0.16 to 0.37).

CONCLUSION

Although performed by novice raters, the FRT showed good to excellent intra and inter-examiner reliability. Results for the C0-C2 axial rotation test were less reliable. We suggest that novice physiotherapists use the FRT instead of the C0-C2 axial rotation test in order to determine C1-C2 dysfunction.

Reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization may help identify cervicogenic headaches: a case-control study

BACKGROUND

The relative value of clinical tests toward identifying cervicogenic headache (CGH) remains under investigated. Whilst certain physical examination findings have been associated with CGH, consensus on which findings provide the strongest association remains elusive.

OBJECTIVES

To determine which cervical musculoskeletal assessment procedures used in CGH are positively associated with CGH.

DESIGN

Single blind observational study.

METHODS

Four selected musculoskeletal assessment procedures of the cervical spine, craniocervical flexion test, cervical flexion-rotation test, cervical retraction range of motion and reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization, were applied to 20 headache and 20 controls. Inclusion criteria for the headache group met the International Headache Society criteria for CGH except positive diagnostic blocks.

RESULTS

Upper cervical spine sustained joint mobilization testing associated with reproduction and resolution of familiar head pain was strongly associated with CGH (Odds Ratio = 36, p < 0.01). This was 78% sensitive and 90% specific in identifying CGH. Other physical tests were not statistically associated with CGH.

CONCLUSIONS

Reproduction and resolution of familiar head pain with upper cervical spine sustained joint mobilization is effective in differentiating those with CGH from control participants. Other cervical measures did not clearly identify CGH in this study.

Effectiveness of sustained natural apophyseal glides in females with cervicogenic headache: A randomized controlled trial

BACKGROUND

Cervicogenic headache (CGH) is a common condition that results in significant disability. To treat this dysfunction, Mulligan described sustained natural apophyseal glides (SNAGs) as a manual therapy approach. However, only inconclusive short-term evidence exists for treating CGH with SNAGs.

OBJECTIVE

The present study aims to investigate the effect of SNAGs in the treatment of CGH.

METHODS

Fourty female patients ranging from 20 to 40 years with CGH were randomly assigned to two groups: 20 in a treatment group and 20 in a control group. SNAGs were applied to the treatment group while the control group received placebo treatment. Both groups received their respective treatment for 20 minutes, alternately three times per week, for a total of 12 times in four weeks. The outcome measures were the Neck Disability Index (NDI) and the Visual Analogue Scale (VAS). Participants were assessed at baseline and at the end of each week. The data was analyzed using SPSS version 20. Independent t-testing was used to reveal changes between groups. One-way ANOVA was used to determine changes within groups. The level of significance was P< 0.05.

RESULTS

Twenty participants (100%) in the treatment group and 17 (85%) in the control group had a history of headache aggravation with active movements or passive head positioning. There was no significant difference at baseline (p> 0.05), indicating that both groups were homogeneous at the time of recruitment. The p value (p< 0.05) showed a significant difference in pain and level of disability at three and four weeks (p< 0.05) in patients treated with SNAGs. However, the cervical range of motion (ROM) showed a statistically significant improvement in flexion and extension in the treatment group (p< 0.05) while there was no significant improvement in side flexion and rotation ROM in both groups (p> 0.05).

CONCLUSION

This study found that SNAGs were effective in reducing pain and neck disability and improved ROM in females with CGH.

Efficacy of Physiotherapy Interventions for The Management of Adults With Cervicogenic Headache: A Systematic Review and Meta-Analyses of Randomized Controlled Trials

OBJECTIVE

To update and appraise the efficacy of physiotherapy for adults with cervicogenic headache.

LITERATURE SURVEY

Bibliographic searches were conducted up to September 2021 for randomized controlled trials, assessing the efficacy of physiotherapy interventions for adults with cervicogenic headache, in five databases: CINAHL, PEDro, PubMed, Sage Journals and Wiley Online Library.

METHODS

Data extraction of included trials was conducted by two reviewers according to a standardized extraction form. The PEDro tool and the GRADE approach were used for grading evidence. Results from trials with similar interventions and with similar outcome measures were pooled into separate meta-analyses. A qualitative synthesis was performed for studies that were not pooled into meta-analyses.

SYNTHESIS

Fourteen trials were included. Moderate-certainty evidence indicates that manual therapy significantly reduces headache frequency (MD: -0.93 episodes/week; 95%CI: -1.40 to -0.46; 2 RCTs; n=265) compared to sham manual therapy, and headache frequency (MD: -1.23 episodes/week; 95%CI: -1.55 to -0.91; 3 RCTs; n=126) and intensity (MD: -1.63/10; 95%CI: -2.15 to -1.10; 4 RCTs; n=208) compared to no treatment in the short term. At 12-month follow-up, moderate-certainty evidence indicates that manual therapy did not lead to greater reduction in headache intensity (MD VAS 0-10: -0.12; 95%CI: -0.49 to 0.26; 2 RCTs; n=265) nor frequency (MD: -0.32 episodes/week; 95%CI: -0.91 to 0.28; 2 RCTs; n=265) when compared to a sham manual therapy. In the long-term, in one high quality trial, neck exercise significantly reduces headache intensity compared to no treatment (MD: -1.51/10; 95%CI: -2.52 to -0.50; n=100) or to aerobic exercises in another trial of moderate quality (MD: -1.15/10; 95%CI: -2.1 to -0.20; n=180).

CONCLUSIONS

Manual therapy in the short term and neck exercise in the long term may be efficacious to treat adults with cervicogenic headache. More high quality evidence is needed and future results may change the current conclusions. This article is protected by copyright. All rights reserved.

Physiotherapeutic Methods in the Treatment of Cervical Discopathy and Degenerative Cervical Myelopathy: A Prospective Study

Spinal dysfunctions are very common in the population. However, there is still a lack of information on how to diagnose and treat them properly. The common causes of spinal dysfunctions are cervical discopathy and degenerative cervical myelopathy. The aims of the study are to examine whether a combination of manual therapy and stabilometer platform exercises can be effective in treating cervical discopathy and degenerative cervical myelopathy, and the possibility of observing the differences between patients suffering from the above diseases. The study involved 40 patients referred for rehabilitation, who formed two groups of 20 people. The first group consisted of patients suffering from cervical discopathy, the second group consisted of patients affected by degenerative cervical myelopathy. During therapy, manual therapy techniques and a stabilometric platform were used. The Neck Disability Index and Pain Numeric Rating Scale were used for clinical evaluation. The correlation between the existing diseases and the results obtained in the Neck Disability Index and Pain Numeric Rating Scale was examined. The distribution of patient responses in questions of the Neck Disability Index was also checked. Clinical evaluation was performed twice, before the start of therapy and after a two-week rehabilitation treatment. The study showed a significant difference between the patients’ results before the start of therapy and after the end of the rehabilitation stay in both used questionnaires (p = 0.00). A difference in the distribution of responses between the two groups after therapy was also found in the Neck Disability Index (p = 0.018) and in the Pain Numeric Rating Scale (p = 0.043). The study shows that manual therapy and exercises using the stabilometric platform are effective methods of treating both patients with cervical discopathy and patients with degenerative cervical myelopathy. It was also noted that, when comparing groups of patients, patients with degenerative cervical myelopathy tend to have greater disturbances in concentration-related activities, such as reading, focusing, driving, sleeping, and resting.

Pain Symptoms in Optic Neuritis

Signs and symptoms of optic neuritis (ON), an autoimmune disorder of the central nervous system (CNS), differ between patients. Pain, which is commonly reported by ON patients, may be the major reason for some patients to visit the clinic. This article reviews the presence of pain related to ON with respect to underlying disorders, including multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD), and myelin oligodendrocyte glycoprotein associated disease (MOGAD). The aim of this review is to provide an overview of pain symptoms in accordance with the context of various pathophysiological explanations, assist in differential diagnosis of ON patients, especially at the onset of disease, and make recommendations to aid physicians make decisions for follow up diagnostic examinations.

Clinical Assessment of Concussion and Persistent Post-Concussive Symptoms for Neurologists

PURPOSE OF REVIEW

Concussion produces a variety of signs and symptoms. Most patients recover within 2-4 weeks, but a significant minority experiences persistent post-concussive symptoms (PPCS), some of which may be from associated cervical or persistent neurologic sub-system (e.g., vestibular) dysfunction. This review provides evidence-based information for a pertinent history and physical examination of patients with concussion.

RECENT FINDINGS

The differential diagnosis of PPCS is based on the mechanism of injury, a thorough medical history and concussion-pertinent neurological and cervical physical examinations. The concussion physical examination focuses on elements of autonomic function, oculomotor and vestibular function, and the cervical spine. Abnormalities identified on physical examination can inform specific forms of rehabilitation to help speed recovery. Emerging data show that there are specific symptom generators after concussion that can be identified by a thorough history, a pertinent physical examination, and adjunct tests when indicated.

The Effect of Adding Dry Needling to Physical Therapy in the Treatment of Cervicogenic Headache: A Randomized Controlled Trial

OBJECTIVE

To compare the long-term effect of adding real or sham dry needling with conventional physiotherapy in cervicogenic headache.

DESIGN

A randomized controlled trial.

SETTING

Physiotherapy Clinic, Rouhani Hospital of Babol University of Medical Sciences, Iran.

SUBJECTS

Sixty-nine patients with cervicogenic headache.

METHODS

Patients were randomly assigned into a control group (n = 23) receiving conventional physical therapy; a dry needling group (n = 23) receiving conventional physical therapy and dry needling on the cervical muscles; placebo needling group (n = 23) receiving conventional physical therapy and superficial dry needling at a point away from the trigger point. The primary outcome was the headache intensity and frequency. Neck disability, deep cervical flexor performance and range of motion were secondary outcomes. Outcomes were assessed immediately after treatment and one, three and six months later.

RESULTS

Sixty-five patients were finally included in the analysis. Headache intensity and neck disability decreased significantly more in the dry needling compared to sham and control groups after treatment and during all follow-ups. The frequency of headaches also reduced more in the dry needling than in control and sham groups, but it did not reach statistical significance. Higher cervical range of motion and enhancement of deep cervical flexors performance was also observed in the dry needling compared to sham and control groups.

CONCLUSION

Dry needling has a positive effect on pain and disability reduction, cervical range of motion and deep cervical flexor muscles performance in patients with cervicogenic headache and active trigger points, although the clinical relevance of the results was small.

Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis

BACKGROUND

Migraine and cervicogenic headache (CGH) are common headache disorders, although the large overlap of symptoms between them makes differential diagnosis challenging. To strengthen differential diagnosis, physical testing has been used to examine for the presence of musculoskeletal impairments in both conditions. This review aimed to systematically evaluate differences in physical examination findings between people with migraine, CGH and asymptomatic individuals.

METHODS

The databases MEDLINE, PubMed, CINAHL, Web of Science, Scopus, EMBASE were searched from inception until January 2020. Risk of bias was assessed with the Downs and Black Scale for non-randomized controlled trials, and with the Quality Assessment of Diagnostic Accuracy Studies tool for diagnostic accuracy studies. When possible, meta-analyses with random effect models was performed.

RESULTS

From 19,682 articles, 62 studies were included in this review and 41 were included in the meta-analyses. The results revealed: a) decreased range of motion [°] (ROM) on the flexion-rotation test (FRT) (17.67, 95%CI:13.69,21.65) and reduced neck flexion strength [N] (23.81, 95%CI:8.78,38.85) in CGH compared to migraine; b) compared to controls, migraineurs exhibit reduced flexion ROM [°] (- 2.85, 95%CI:-5.12,-0.58), lateral flexion ROM [°] (- 2.17, 95% CI:-3.75,-0.59) and FRT [°] (- 8.96, 95%CI:-13.22,-4.69), reduced cervical lordosis angle [°] (- 0.89, 95%CI:-1.72,-0.07), reduced pressure pain thresholds over the cranio-cervical region [kg/cm²], reduced neck extension strength [N] (- 11.13, 95%CI:-16.66,-5.6) and increased activity [%] of the trapezius (6.18, 95%CI:2.65,9.71) and anterior scalene muscles (2.87, 95%CI:0.81,4.94) during performance of the cranio-cervical flexion test; c) compared to controls, CGH patients exhibit decreased neck flexion (- 33.70, 95%CI:-47.23,-20.16) and extension (- 55.78, 95%CI:-77.56,-34.00) strength [N].

CONCLUSION

The FRT and neck flexion strength could support the differential diagnosis of CGH from migraine. Several physical tests were found to differentiate both headache types from asymptomatic individuals. Nevertheless, additional high-quality studies are required to corroborate these findings.

STUDY REGISTRATION

Following indications of Prisma-P guidelines, this protocol was registered in PROSPERO on 21/05/2019 with the number CRD42019135269 . All amendments performed during the review were registered in PROSPERO, indicating the date and what and why was changed.

Application of Physical Examination Data on Health Analysis and Intelligent Diagnosis

Analysis and diagnosis according to the collected physical data are an important part in the physical examination. Through the data analysis of the physical examination results and expert diagnoses, the physical condition of a specific physical examination unit can be achieved which may guide individual health development. However, in general, the application of physical examination data is insufficient in most of the current physical examination organizations. Therefore, in the present study, statistical analysis and intelligent diagnosis were applied to maximize the utilization of physical examination data. The physical examination data collected from different departments of Dalian University of Technology were statistically analyzed and then synthesized for stimulating the thinking mode and knowledge framework of medical experts by a learning model on machine, resulting in the construction of an intelligent physical examination diagnosis method with 93.4% accuracy confirmed by experts. In conclusion, a potential artificial intelligence model of psychical examination data on health analysis and intelligent diagnosis was established, which may become more and more accurate with data accumulation in the near future.

[The Second Short Form of the McGill Pain Questionnaire as the useful additional tool for differential diagnostics of migraine and cervicogenic headache]

OBJECTIVE

To study the effectiveness of the Second Short Form of the McGill Pain Questionnaire (SF-MPQ-2) as an instrument for assessment and comparison of quantitative characteristics of pain in patients with chronic musculoskeletal impairment of the cervical spine and nonspecific neck pain accompanied by chronic migraine or cervicogenic headache (CeH).

MATERIAL AND METHODS

Forty-nine patients, aged from 19 to 60 years (mean age 42.8±10.4), were divided into 2 comparable by age and gender groups with migraine (n=18) and CeH (n=31). Neck pain and headache intensity was measured by the 11-points Numerical Rating Scale (NRS). Quality of pain and related symptoms were measured by SF-MPQ-2. Multidisciplinary and multimodal approaches were applied for treatment, including several modalities of manual therapy.

RESULTS

Headache intensity was higher in the migraine group in comparison with the CeH group (7.8±1.7 vs 6.0±1.5, respectively; p<0.05). No significant differences in neck pain intensity were found (6.2±1.8 vs 5.3±1.7; p=0.08). Patients with migraine usually chose more descriptors than patients with CeH (14 vs 4, respectively) and higher range of their intensity (p<0.001). By the end of treatment session, the number of descriptors and their intensity decreased significantly on all SF=MPQ-2 scales (p<0.001) in both groups. Most patients of migraine and CeH group were satisfied with treatment (83% and 97%, respectively) and marked «much improved» and «very much improved» on the 7-point Patient Global Impression of Change scale.

CONCLUSION

SF-MPQ-2 is a useful tool for differential diagnosis of migraine and CeH, as it contains the sufficient number of descriptors and the scale for measuring their intensity.

The association between specific temporomandibular disorders and cervicogenic headache

BACKGROUND AND AIMS

Upper neck signs, symptoms and hypomobility have been shown to present with a higher prevalence in patients with temporomandibular disorders (TMDs). However, there is currently no evidence of an association between specific TMDs and cervicogenic headache (CGH). Therefore, the aim of this study was to evaluate the odds ratio and the relative risk of CGH in patients with specific TMDs.

METHOD

116 participants, including 74 patients with TMD (pain-related/intraarticular/mixed TMD) and 42 healthy controls took part in this study. The TMD diagnosis was made by senior faculty members of the Dental School according to the Diagnostic Criteria for TMD, while the cervical diagnosis was made by a qualified senior physical therapist. The analysis comprised the evaluation of the odds ratio of CGH among patients with TMD and the relative risk (RR) for CGH during 14-24 months of follow-up.

RESULTS

Significantly higher odds ratios of cervicogenic headache were found among pain-related and mixed TMD (12.17 and 10.76, respectively) versus healthy controls. During the 14-24 months of follow-up, there was no significant difference of relative risk for CGH among patients with TMD versus healthy controls.

SUMMARY AND CONCLUSIONS

The results support a clear clinical association between painful TMD (pain-related and mixed TMD) and cervicogenic headache.

Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study

BACKGROUND

Though a large amount of research on the management of headache has been conducted, the clinical effectiveness of these treatments remains unclear.

OBJECTIVES

To reach consensus among international musculoskeletal experts on what the most appropriate management is in patients that suffer from headache.

DESIGN

Expert group and Delphi-study.

METHODS

A total of 11 experts participated in the expert panel groups, where the role of physiotherapy in the management of headache was discussed. Afterwards, 14 of the initial 25 participants in the field of headache completed the whole Delphi study, which was conducted over 4 rounds. The first round aimed to identify clinical indicators and treatments that are useful in patients with headache. These questions were then categorized and ranked during the second, third, and fourth rounds. Consensual agreement was set at ≥ 80%.

RESULTS

After the final round, 9 interventions were rated as useful by the participants. In the final extra round, 14 clinical indicators were retrieved as important to decide whether or not to start one of the consensual treatments. The top 3 management strategies were (1) upper cervical spine mobilisations in cervivogenic headache, (2) active mobilisation exercises of the cervical spine in cervivogenic headache, and (3) lifestyle advice in tension-type headache and migraine.

CONCLUSION

International experts agreed that most scientifically established effective treatments are useful in cervicogenic headache. Consensual agreement on treatments for migraine and tension-type headache were only reached for specific treatments. Their recommendations provide a framework for further research and the clinical management of headache.

Are there gender differences in neck pain and musculoskeletal disorders of the cervical spine associated with migraine?

OBJECTIVE

To evaluate gender differences in clinical characteristics of migraine by examining presence and severity of cutaneous allodynia, migraine-related disability, neck pain and its associated disability, passive mobility of the upper cervical spine, and performance of the deep neck flexor muscles.

DESIGN

cross-sectional study.

SUBJECTS

30 men and 30 women with migraine.

METHODS

Participants responded to the questionnaires Migraine Disability Assessment questionnaire, 12-item Allodynia Symptom Checklist and Neck Disability Index. The mobility of the upper cervical spine was assessed by using the Flexion-Rotation Test. Performance of the deep neck flexor muscles was evaluated by applying the Craniocervical Flexion Test. Comparison of the groups was carried out by using the Student's t-test or the chi-square test. The prevalence ratio was also calculated.

RESULTS

Women showed a higher prevalence of cutaneous allodynia (p = 0.001) and a 4 times greater risk of having severe cutaneous allodynia than to men (p = 0.007). No gender differences were observed in migraine-related disability (p = 0.08). Women showed higher prevalence of self-reported neck pain (p = 0.03) and increased risk of having this symptom in comparison to men (Prevalence Ratio=1.69; p = 0.025). However, there were no gender differences in neck pain-related disability (p = 0.25), mobility of the upper cervical spine (p = 0.92), or performance of the deep neck flexor muscles (p = 0.52).

CONCLUSION

Women with migraine had a higher frequency of self-reported neck pain and higher prevalence and severity of cutaneous allodynia when compared to men. However, the two groups did not differ regarding neck pain-related disability and performance in the physical tests.

Physical therapist attitude and opinion about cervical spine examination: A national Spanish survey

OBJECTIVE

A correct examination is essential during a differential diagnosis of neck pain patients. Therefore, the objective of this study was to provide an update on the properties considered most important by physical therapists (PTs) when conducting accessory and physiological movement tests during the cervical spine physical examination.

METHODS

A total of 84 private physiotherapy centres participated in this online cross-sectional survey including 415 active physiotherapists and members of one autonomous Spanish Physiotherapists School. This survey included information about the characteristics of the respondents (eg, weekly patient care, highest qualification and specific training in osteopathy and manual therapy), their opinion about the accuracy and reliability of accessory and physiological movement tests, the frequency and importance of mobility and pain responses, and the most commonly reference used to make a judgement.

RESULTS

Pain responses are most frequently used by physiotherapists at a rate of 79.8% and also rated as important by 42.65% respondents mobility aspects such as quality of end-feel (17.3%), quantity of translation (16.4%) and quality of resistance (13.3%) during passive accessory intervertebral movement tests. During passive and active physiological movement tests, the most frequent properties assessed were the quality of motion path (80.5% and 84.3%, respectively) and quantity of angle bending (81.7% and 77.6%, respectively). Pain responses are used as reference by 54.7% to make a clinical judgement during passive accessory intervertebral movement tests.

CONCLUSION

Physical therapists face validity in relation to passive accessory intervertebral movement test for assessing spinal segmental motion aspects has been decreasing with more attention devoted to pain responses. The current scepticism regarding the motion properties assessed with these tests is associated with utility aspects such as validity, sensitivity, accuracy and specificity.

The C0-C2 axial rotation test - Reliability and correlation with the flexion rotation test in people with cervicogenic headache and migraine

OBJECTIVES

The C0-C2 axial rotation test is a measure of upper cervical range of motion (UCROM), reported to be reliable in a headache free population. The objective was to determine the intra- and inter-rater reliability of the C0-C2 axial rotation test in people with a diagnosis of cervicogenic headache (CGH) or episodic migraine.

METHODS

Two therapists independently evaluated UCROM during the C0-C2 axial rotation test and flexion-rotation test (FRT) with an iPhone in 70 subjects (mean age 37.7 SD 11.6 years) with a diagnosis of CGH (35 subjects) or episodic migraine (35 subjects) on two occasions. Measurement procedures were standardized; and the order of testing randomized.

RESULTS

Reliability of the C0-C2 axial rotation test was moderate to high (ICC > 0.70). The standard error of measurement and minimum detectable change for this test were at most 2°. In subjects with CGH mean UCROM to the most restricted side was 9.3° (1.9) and 8.8° (2.1) for rater 1 and 2 respectively. While in patients with episodic migraine mean UCROM to the restricted side was 13.7° (1.6) and 13.6° (2.0) for rater 1 and 2 respectively.

DISCUSSION

The C0-C2 axial rotation test has at least moderate levels of reliability and correlates well with mobility determined by the FRT.

An investigation of 3D spinal alignment in cervicogenic headache

BACKGROUND

There is a growing interest in the impact of body posture influences on outcome measures of cervicogenic headache (CGH).

OBJECTIVE

To evaluate differences in the 3D spinal alignment in cases suffering from chronic CGH compared to a group of strictly matched control participants without CGH.

DESIGN

A single-blinded, comparative cohort design.

METHODS

100 participants suffering from frequent headaches for at least 3 months who fulfilled the CHISG criteria for CGH were match by age and sex to 100 asymptomatic control group participants. A 4D Formetric device was used to assess participants' posture variables of: 1) thoracic kyphosis max (ICT-ITL in degrees); 2) trunk lateral imbalance (VP-DM in mm); 3) Trunk anterior inclination (VP-DM in mm); 4) lumbar lordotic angle (ITL-ILS max in degrees); 5) Vertebral rotation (rms) in degrees. A matched-pairs binary logistic regression was used to determine whether measurements of posture demonstrated an association with the likelihood of the presence of CGH.

RESULTS

There were statistically significant differences between the CGH and control group for all posture variables indicating larger posture displacements in the CGH group: ICT-ITL (p < .001), Lateral VP-DM (p < .001), Sagittal VP-DM (p < .001), ITL-ILS (p < .001), RMS (p < .001). Logistic regression revealed that as posture displacement increased, a statistically significant increased likelihood of having CGH occurred: (ICT-ITL (max) (p < .001); Trunk imbalance VP-DM (p < .004); Trunk inclination VP-DM (p < .001); and vertebral rotation (RMS) (p = .007). No such relationship was found for Lumbar Lordosis ITL-ILS max.

CONCLUSIONS

Participants with CGH exhibited increased magnitudes of thoracolumbar posture displacements which corresponded to an increased odds of suffering from CGH compared to matched control participants.

Effects of the Manual Therapy Approach of Segments C0-1 and C2-3 in the Flexion-Rotation Test in Patients with Chronic Neck Pain: A Randomized Controlled Trial

Background: Flexion-rotation test predominantly measures rotation in C1-2 segment. Restriction in flexion-rotation may be due to direct limitation in C1-2, but also to a premature tightening of the alar ligament as a result of lack of movement in C0-1 or C2-3. The aim of this study was to compare the effect of a 20-min single cervical exercise session, with or without manual therapy of C0-1 and C2-3 segment in flexion-rotation test, in patients with chronic neck pain and positive flexion-rotation test. Methods: Randomized controlled clinical trial in 48 subjects (24 manual therapy+exercise/24 exercise). Range of motion and pain during flexion-rotation test, neck pain intensity and active cervical range of motion were measured before and after the intervention. Results: Significant differences were found in favour of the manual therapy group in the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); pain during the flexion-rotation test: right (p < 0.001) and left rotation (p < 0.001); neck pain intensity: (p < 0.001); cervical flexion (p < 0.038), extension (p < 0.010), right side-bending (p < 0.035), left side-bending (p < 0.002), right rotation (p < 0.001), and left rotation (p < 0.006). Conclusions: Addition of one C0-C1 and C2-C3 manual therapy session to cervical exercise can immediately improve flexion-rotation test and cervical range of motion and reduce pain intensity.

A sonographic comparison of the effect of dry needling and ischemic compression on the active trigger point of the sternocleidomastoid muscle associated with cervicogenic headache: A randomized trial

BACKGROUND

Cervicogenic headache (CeH) is among the common types of headache which has an undesirable influence on the quality of life. The myofascial trigger point (MTrP) within the sternocleidomastoid (SCM) muscle is one of the most important causes of CeH.

OBJECTIVE

The purpose of this study was to compare the effect of dry needling (DN) and ischemic compression (IC) on the headache symptoms as well as MTrP-related features in subjects with CeH originating from MTrPs of the SCM muscle using a sonographic method.

METHODS

A total of 29 female subjects aged 35.34 ± 12.19 on average with a clinical diagnosis of CeH originating from MTrP in the SCM muscle were randomly divided into the DN, IC, and control groups. Both DN and IC groups received 4 treatment sessions. Headache intensity, duration, frequency, MTrP elastic modulus, MTrP area, and pressure pain threshold (PPT) were assessed 2 weeks before and after treatments.

RESULTS

In both DN and IC groups, a significant improvement was found in the headache intensity, duration, frequency, PPT, and MTrP area (P< 0.05). No significant differences were observed between DN and IC (P> 0.05). Pearson correlation revealed a significant correlation between headache intensity and the MTrP elastic modulus (P< 0.05).

CONCLUSIONS

Both interventions could reduce headache symptoms, PPT, and MTrP area. Neither intervention was found to be superior to the other in short-term follow-up. IC may be preferred since it has fewer unwanted side effects compared to DN. Based on the data, it may be concluded that some MTrP biomechanical features such as stiffness may influence the produced headache symptoms.

Rehabilitation of Sport-Related Concussion

This article provides a summary of clinical assessment methods and nonpharmacologic rehabilitation techniques used for concussed patients. It describes concussion-relevant physical examination methods to identify underlying symptom generators. This approach allows practitioners to prescribe targeted rehabilitation therapies to treat postconcussion symptoms. Evidence-based rehabilitation approaches include cervical rehabilitation, vestibulo-ocular rehabilitation, and sub-symptom threshold aerobic exercise.

Physician Medical Assessment in a Multidisciplinary Concussion Clinic

Concussive brain injury (CBI) is encountered by clinicians in sports medicine, pediatrics, neurosurgery, neurology, physiatry, and primary care. There is no gold standard diagnostic test for CBI, nor is there consensus on what neuromusculoskeletal physical examination tests should be performed on patients who have sustained CBI. This article presents an approach to the history and physical examination of the patient who has sustained a CBI that is based on a review of the literature evidence and the authors' extensive experience with this patient population. Suggested components include an elemental neurological examination that emphasizes the oculomotor/ophthalmologic and vestibular systems, as well as appropriate musculoskeletal assessment of the craniocervical and upper shoulder girdle complex. The use of supplementary tests for CBI, including assessment of exercise tolerance using the Buffalo Concussion Treadmill Test and tests of neurocognitive function, can aid in the differential diagnosis of CBI. The proposed protocol is envisioned for initial and follow-up assessments in the clinic after CBI, as well as for those with more protracted signs or symptoms. If symptoms persist beyond 2 weeks in adults or 4 weeks in adolescents, then referral to a multidisciplinary center that focuses on CBI is recommended.

Concurrent validity and reliability of measuring range of motion during the cervical flexion rotation test with a novel digital goniometer

BACKGROUND

Headache is a common and costly health problem. Although the pathogenesis of headache is heterogeneous, reported contributing factors are dysfunctions of the upper cervical spine. The flexion rotation test (FRT) is a commonly used diagnostic test to detect upper cervical movement impairment. A digital goniometer may support precise measurement of movement impairment in the upper cervical spine. However, its reliability and validity is not assessed, yet. The aim of this study was to investigate the reliability and validity of the digital goniometer compared to an ultrasound-based movement analysis system.

METHODS

Two separate cross-sectional studies were conducted using the digital goniometer EasyAngle (Meloq AB, Stockholm, Sweden) for a) investigating the concurrent validity of upper cervical range of motion (ROM) during the FRT and b) determining the inter- and intra-rater reliability in the target population of patients with head and neck pain. Sixty-two participants, 39 with and 23 without head and neck pain, were recruited for the concurrent validity study. For the reliability study, a total of 50 participants were recruited. Intraclass correlation coefficients (ICC) and Bland Altmann plots were used to assess validity and ICC values, Bland Altmann plots as well as Kappa coefficients were used for estimating intra-rater and inter-rater reliability.

RESULTS

Concurrent validity was strong with an ICC (2,1) of 0.97 for ROM to either side (95%CI = 0.95-0.98). Bland Altman Plots revealed a mean difference between measurement systems of 0.5° for the left and 0.11° for the right side. The inter-rater ICC (2,1) was 0.66 (95%CI 0.47-0.79, p <  0.001, SEM 6.6°), indicating good reliability. The limits of agreement were between 10.25° and - 11.89°, the mean difference between both raters was - 0.82°. Intra-rater reliability for the measurement of ROM during the FRT was between 0.96 (ICC 3,1) for rater 1 and 0.94 (ICC 3,1) for rater 2.

CONCLUSIONS

The digital goniometer demonstrated strong concurrent validity and good to strong reliability and can be used in clinical practice to accurately determine movement impairment in the upper cervical spine.

TRIAL REGISTRATION

German Registry of Clinical Trials DRKS00013051 .

Can physical testing be used to distinguish between migraine and cervicogenic headache sufferers? A protocol for a systematic review

INTRODUCTION

Differential diagnosis of migraine and cervicogenic headache (CGH) can be challenging given the large overlap of symptoms, commonly leading to misdiagnosis and ineffective treatment. In order to strengthen the differential diagnosis of headache, previous studies have evaluated the utility of physical tests to examine for musculoskeletal impairment, mainly in the cervical spine, which could be provoking or triggering headache. However, no systematic review has attempted to evaluate whether physical tests can differentiate CGH from migraine or both conditions from asymptomatic subjects.

METHODS/ANALYSIS

A systematic review protocol has been designed and is reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). A sensitive topic-based search strategy is planned which will include databases, hand searching of key journals and consultation of relevant leading authors in this field. Terms and keywords will be selected after discussion and agreement. Two independent reviewers will perform the search and select studies according to inclusion and exclusion criteria, including any cohort or observational studies evaluating the topic of this review; a third reviewer will confirm accuracy. A narrative synthesis will be developed for all included studies and, if possible, a meta-analysis will be conducted. The overall quality of the evidence will be assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) checklist for diagnostic accuracy studies and the Downs and Black scale for those studies where the QUADAS-2 checklist cannot be applied.

ETHICS AND DISSEMINATION

Ethical approval is not required since no patient information will be collected. The results will provide a deeper understanding about the possibility of using physical tests to differentiate cervicogenic headache from migraine and from asymptomatic subjects, which has direct relevance for clinicians managing people with headache. The results will be published in a peer-reviewed journal and presented at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42019135269.

Can the Neck Contribute to Persistent Symptoms Post Concussion? A Prospective Descriptive Case Series

BACKGROUND

Persistent symptoms post concussion can arise from a range of sources, including the neck. There is little description of neck assessment findings in people with persistent symptoms post concussion.

OBJECTIVES

To assess people with persistent symptoms following a concussion and determine whether the neck has also been injured, and to evaluate the potential of the neck to contribute to their symptoms.

METHODS

A consecutive series of participants (n = 20) referred for neck assessment were prospectively recruited by 2 providers of a multidisciplinary concussion service for people with persistent symptoms. Data were collected at initial assessment and on completion of neck treatment, which included standard questionnaires (Rivermead Post Concussion Symptoms Questionnaire, Neck Disability Index, Dizziness Handicap Inventory); patient-reported measures of headache, dizziness, and neck pain; physical examination findings; and details of comorbidities.

RESULTS

Participants were evaluated at a mean of 7.5 weeks post concussion (median, 5 weeks). On neck assessment, 90% were considered by the clinician to have a neck problem contributing to their current symptoms. Multiple findings were consistent with this view, including moderate-to-severe Neck Disability Index scores (mean ± SD, 33.4 ± 9.5 points), frequent neck pain (85%), frequent moderate-to-severe pain on occiput-C4 segmental assessment (85%), a positive flexion-rotation test (45%), and muscle tenderness (50%-55%).

CONCLUSION

Multiple findings were indicative of concurrent neck injury, particularly involving the upper cervical spine. These neck-related findings are important to recognize, as they have the potential to contribute to persistent symptoms post concussion and may respond to neck treatment. This study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001183471). J Orthop Sports Phys Ther 2019;49(11):845-854. Epub 1 Jun 2019. doi:10.2519/jospt.2019.8547.

Neck pain in South Africa: An overview of the prevalence, assessment and management for the contemporary clinician

BACKGROUND

Neck pain is a prevalent condition and is associated with high levels of disability and pain. The long-term prognosis can be poor, and therefore effective management in the acute stage is important.

OBJECTIVES

To provide an overview of the prevalence of neck pain and physiotherapy management and to provide evidence-informed recommendations for clinical practice within a South African context.

METHOD

The literature was reviewed considering prevalence, risk factors and examination. Management recommendations were derived from the highest levels of evidence of clinical practice guidelines, systematic reviews and randomised clinical trials.

RESULTS

Neck pain is classified into four grades, and three trajectories of recovery have been identified. Although the incidence of neck pain globally is high, in the South African context the majority of the population have limited access to physiotherapy management. Sound clinical reasoning is important in the assessment and decision-making process for management. Exercise, and mobilisation or manipulation are effective treatment options in the management of most types of neck pain. Other physical modalities such as needling, transcutaneous electrical nerve stimulation, laser and intermittent traction may be used as an adjunct to management.

CONCLUSION

The burden of neck pain globally is high; however, there is a lack of information on current practice, prevalence and burden of neck pain in the South African context. Sound evidence-informed clinical reasoning to inform a working diagnosis and to enable patient-centred management is important.

CLINICAL IMPLICATIONS

A thorough assessment is essential to gather information to formulate hypotheses regarding diagnosis and prognosis for neck pain. Exercise, and mobilisation or manipulation are effective management options.

Physical therapist clinical reasoning and classification inconsistencies in headache disorders: a United States survey

Objective: The purpose of this study was to investigate the decision-making processes of physical therapists relating to evaluation and categorization of patients with headaches, including consistency with criteria proposed by the International Headache Society (IHS).Methods: A national online survey was distributed in cooperation with the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Three hypothetical patient case vignettes featuring headache disorders were used as assessment instruments. Additionally, data on physical therapist education, clinical experience, manual therapy training, self-efficacy, and familiarity & consistency with IHS criteria were collected. Physical therapist identification and valuation of clinical features of headache disorders were also examined in the decision-making processes.Results: Among the 384 respondents, 32.3% classified the tension-type headache case consistent with IHS criteria. The cervicogenic and migraine headache cases were classified at 54.8% and 41.7% consistent with IHS categories, respectively. Experienced clinicians and those with formal manual training categorized patient presentations with greater consistency. Clinician familiarity with IHS classification criteria was low with 73.6% collectively somewhat and not familiar, while 26.4% of physical therapists were self-described as very or moderately familiar.Discussion: Clinicians' headache categorization was significantly affected by symptom misattribution and weighting of individual examination findings. Weighting by practitioners of clinical features varied markedly with greatest emphasis being placed on detailed manual examination procedures, including passive intervertebral movements. Inconsistencies in valuation of clinical features in headache categorization suggest a need for further formal education in physical therapy educational curricula and in post-graduate education, including of IHS criteria and classification.Level of Evidence: 2a.

Is the presence of neck pain associated with more severe clinical presentation in patients with migraine? A cross-sectional study

Objective

To investigate the association between the presence of self-reported neck pain in patients with migraine and clinical features, upper cervical mobility, and neck muscle performance.

Methods

A total of 142 patients with migraine were recruited and stratified by the presence (n = 99) or absence of self-reported neck pain (n = 43). The clinical examination included the Migraine Disability Assessment, the 12-item Allodynia Symptom Checklist, a flexion rotation test, and the Craniocervical Flexion Test.

Results

Migraine-related disability was reported by more than 80% in both groups ( p = 0.82). However, there was a greater prevalence and severity of cutaneous allodynia observed in the group with neck pain ( p < 0.001). Reduced upper cervical mobility was verified in 67% of the patients with neck pain and in 41% of those without neck pain ( p = 0.005). In addition, 67% of the patients with neck pain and 40% without neck pain were not able to maintain the third stage of the Craniocervical Flexion Test without compensation ( p = 0.003).

Conclusions

The presence of self-reported neck pain in patients with migraine was associated with a poor clinical presentation regarding cutaneous allodynia, neck mobility, and muscle function. However, there were no differences in migraine-related disability.

Intra-rater reliability of determining positions of cervical spinous processes and measuring their relative distances : An update to define rigid bodies of the cervical spine in a movement laboratory setting

Objectives

A reliable detection of bony landmarks of the spine is necessary in order to determine rigid bodies and to reduce the variability of marker placement in a movement laboratory setting. In a first study on the thoracic and lumbar spine, we demonstrated that placing markers on their relative positions between two major landmarks was superior to palpation of specific bony landmarks. The aims of this study were to examine the intra-rater reliability when palpating for spinous processes (SPs) of the second (C2) and seventh cervical vertebrae (C7), to determine the distances between C2 and C7 and the relative position of C7 along the length between C2 and the posterior superior iliac spine (PSIS) level.

Results

The intra-rater reliability in determining the distance between C2 and C7 was found to be substantial, with an intra-rater reliability of 0.75 (95% confidence limits 0.55–0.99) and a standard error of the measurement of 0.34 cm. The relative distance of C7 along the total C2–PSIS length was estimated to be 11.5%. The determination of the relative positions of spinal landmarks through measurement is considered superior to their palpation, because it relies on a reproducible and comparable definition of rigid bodies.

The diagnostic accuracy of headache measurement instruments: A systematic review and meta-analysis focusing on headaches associated with musculoskeletal symptoms

AIM

To systematically review the available literature on the diagnostic accuracy of questionnaires and measurement instruments for headaches associated with musculoskeletal symptoms.

DESIGN

Articles were eligible for inclusion when the diagnostic accuracy (sensitivity/specificity) was established for measurement instruments for headaches associated with musculoskeletal symptoms in an adult population. The databases searched were PubMed (1966-2018), Cochrane (1898-2018) and Cinahl (1988-2018). Methodological quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2) and COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist for criterion validity. When possible, a meta-analysis was performed. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) recommendations were applied to establish the level of evidence per measurement instrument.

RESULTS

From 3450 articles identified, 31 articles were included in this review. Eleven measurement instruments for migraine were identified, of which the ID-Migraine is recommended with a moderate level of evidence and a pooled sensitivity of 0.87 (95% CI: 0.85-0.89) and specificity of 0.75 (95% CI: 0.72-0.78). Six measurement instruments examined both migraine and tension-type headache and only the Headache Screening Questionnaire - Dutch version has a moderate level of evidence with a sensitivity of 0.69 (95% CI 0.55-0.80) and specificity of 0.90 (95% CI 0.77-0.96) for migraine, and a sensitivity of 0.36 (95% CI 0.21-0.54) and specificity of 0.86 (95% CI 0.74-0.92) for tension-type headache. For cervicogenic headache, only the cervical flexion rotation test was identified and had a very low level of evidence with a pooled sensitivity of 0.83 (95% CI 0.72-0.94) and specificity of 0.82 (95% CI 0.73-0.91).

DISCUSSION

The current review is the first to establish an overview of the diagnostic accuracy of measurement instruments for headaches associated with musculoskeletal factors. However, as most measurement instruments were validated in one study, pooling was not always possible. Risk of bias was a serious problem for most studies, decreasing the level of evidence. More research is needed to enhance the level of evidence for existing measurement instruments for multiple headaches.

The Chinese Association for the Study of Pain (CASP): Expert Consensus on the Cervicogenic Headache

Cervicogenic headache is a relatively common but unique form of headache, and in China, as well as in several other countries, both diagnosis and a clear evidence-based treatment plan remain controversial. Therefore, the Chinese Association for the Study of Pain organized a meeting of pain management experts and created an expert consensus on the diagnosis and treatment of cervicogenic headache in China. This article summarizes the conclusions of the consensus group regarding the epidemiology, etiology, clinical features, diagnosis, differential diagnosis, treatment, and rehabilitation of cervicogenic headache in China.

Asymmetric Thickness of Oblique Capitis Inferior and Cervical Kinesthesia in Patients With Unilateral Cervicogenic Headache

OBJECTIVE

The purpose of this study was to compare the thickness of the oblique cervical inferior (OCI) and the error of the head reposition test between the painful and nonpainful sides of patients with cervicogenic headache (CeH) and between the patients and the asymptomatic group.

METHODS

Thirteen patients (24.5 ± 4.8 years) and 14 asymptomatic participants (23.9 ± 2.7 years) were included. The head reposition test was recorded by a 3-dimensional motion analysis system. The thickness of the OCI was recorded by ultrasonography. The measured outcomes were compared between the painful and nonpainful sides and with the asymptomatic participants.

RESULTS

The thickness of the OCI in the rest condition on the painful side (9.92 ± 2.31 mm) was smaller than that of the nonpainful side (10.56 ± 2.24 mm). The constant error of the head-to-target test toward the nonpainful side was smaller in the patients with CeH (-1.6 ± 4.3°) than in the asymptomatic group (3.3 ± 3.7°, P = 0.005).

CONCLUSION

Asymmetric OCI and cervical proprioception were demonstrated in patients with CeH.

The C0-C2 axial rotation test: normal values, intra- and inter-rater reliability and correlation with the flexion rotation test in normal subjects

OBJECTIVES

Impairment in upper cervical spine mobility is associated with cervicogenic headache severity and disability. Measures of such mobility include the flexion-rotation test (FRT), which requires full cervical flexion and may be influenced by lower cervical spine dysfunction. The C0-C2 axial rotation test also evaluates upper cervical mobility but normal values and reliability have not been reported. Our objective is to determine normal values, and intra-rater and inter-rater reliability of the C0-C2 axial rotation test.

METHODS

Two therapists independently evaluated the FRT and C0-C2 axial rotation test with an iPhone compass application on 32 asymptomatic subjects with mean age 40.53 (SD 11.64) years on two occasions. Measurement procedures were standardized; and order of testing randomized.

RESULTS

For the FRT and C0-C2 axial rotation test reliability was high (ICC > 0.88). For rater one, Mean range to the left during the FRT and C0-C2 axial rotation test was 45.0° (6.04) and 14.43° (2.94), respectively, while range to the right was 44.6° (6.57) and 15.44° (2.68). For the FRT and C0-C2 axial rotation test the standard error of measurement was at most 2°, while the minimum detectable change was at most 4°. A strong positive correlation exists between the FRT and C0-C2 axial rotation test (r = 0.84, P < 0.01).

DISCUSSION

The range recorded during the C0-C2 axial rotation test and FRT have high levels of reliability when evaluated using an iPhone. The strong correlation between the FRT and C0-C2 axial rotation test indicate that both may be measuring similar constructs, but each test needs to be referenced to normal values.

Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain - a diagnostic case-control study

Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions. Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38). Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004). Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON. Level of Evidence: 3b.

Development and psychometric validation of the headache screening questionnaire - Dutch Version

BACKGROUND

Headache is a common disorder which may lead to substantial socio-economic loss. Treatment options include self-management strategies, medication and physiotherapy. Physiotherapists need to be able to screen for the presence of migraine and tension-type headache (TTH), so they can adjust their treatment strategies to the type of headache. A quick screening questionnaire to recognize migraine and TTH in the physiotherapy practice is needed.

OBJECTIVE

The aim of this study was to create a headache screening questionnaire based on the ICHD-3 beta criteria for migraine and TTH, and to establish its content and criterion validity.

DESIGN

A cross-sectional design was used during the validation phase of the study.

METHODS

A screening questionnaire was developed for migraine and TTH. Content validity was checked by the research group and a headache research expert. For validation of this questionnaire, patients from the headache clinic of the Canisius Wilhelmina Hospital in Nijmegen were recruited. The outcome of the questionnaire was compared to the ICHD-3 beta diagnosis of the headache specialist. For criterion validity, sensitivity, specificity, likelihood ratios, and positive- and negative predictive values were calculated.

RESULTS

A 10-item questionnaire has been developed: the Headache Screening Questionnaire. For validation of the Dutch version (HSQ-DV), 105 patients were included in the study. The sensitivity and specificity were 0.89 and 0.54 respectively for probable migraine, and for probable TTH 0.92 and 0.48 respectively.

CONCLUSION

The HSQ-DV is a sensitive screening tool to detect patients with probable migraine and probable TTH.