Self-Assessment Quiz Question #20 The flexion–rotation test is used to assess motion at the joints. Dysfunction of these joints may be involved in ___________ headaches: a. Occiput/C1; migraine. b. C1/C2; migraine.
Evidence-based practice: There are several assess - ment strategies for assessing upper cervical spine function. These include posture analysis (with special attention paid to a forward head posture that places the upper cervical spine in extension), the flexion–rota- tion test to assess upper cervical spine rotation, and the craniocervical flexion test to assess the strength of the deep cervical flexion muscles. However, according to Hall et al. (2008), the most effective assessment may be one of the most basic—the application of posterior–an- terior pressure to the facet joints with the goal of deter- mining (1) if there is a restriction in motion and (2) if the pressure elicits pain. This simple test has been shown to have both high sensitivity and high specificity. In terms of muscle involvement, Hall et al. (2008) state that muscle dysfunction (weakness, decreased endurance, decreased exten- sibility) is an important feature of cervicogenic headaches. A de- crease in deep neck flexor muscle strength appears to be one of the defining characteristics of this type of headache, a finding that is not present in migraine or tension-type headaches. Muscle tightness and trigger points have also been associated with cer- vicogenic headaches. The muscles implicated include the upper trapezius, sternocleidomastoid, scalenes, levator scapulae, pec- toralis minor and major, and short suboccipital extensors (Hall et al., 2008). Finally, examination for sensorimotor dysfunction is relevant for di- agnosis of cervicogenic headaches. Cervical joint position sense, postural stability, and oculomotor control have been described as relevant (Hall et al., 2008). Evidence-based practice: Different types of head - aches can have cervical spine involvement. Migraine, tension-type, and cervicogenic headaches all have been shown to sometimes have accompanying cervical spine dysfunction. One way to differentiate headache type in this situation is to assess deep neck flexor mus- cle strength. According to Hall et al. (2008), weakness in the deep neck flexor muscles is a defining character- istic of cervicogenic headaches and it is not found in migraine or tension-type headaches. Getsoian et al. (2020) designed a study to validate a pattern of cervical musculoskeletal signs to identify when a cervical source of head and neck pain is indicated and a cervicogenic headache is present. They used the “gold standard” of controlled diagnostic cervical nerve blocks to validate their findings. They found that when the following four criteria are present, accurate diagnosis of cervicogenic headache improves substantially: ● Reduced cervical extension motion. ● Symptomatic upper cervical joint dysfunction as defined by moderate to severe restriction of motion/tissue compliance of each facet joint from C0/C1 to C3/C4 as rated by the exam- iner (therapist), as well as a rating of 2/10 on the pain scale of perceived pain at each joint by the participant (patient); this dysfunction/pain could be present at any level. ● Impaired muscle function as measured by the craniocervical flexion test (CCFT). ● No impairment in C1/C2 as measured with the flexion–rota- tion test (FRT), where rotation of the head is measured with the neck prepositioned in full flexion.
c. C1/C2; cervicogenic. d. C2/C3; cervicogenic. Craniocervical flexion test
The deep cervical flexor muscles, longus colli and capitis, provide cervical segmental support and stability. The craniocervical flexion test is used to test for dysfunction in these muscles. The craniocer - vical flexion test involves controlled upper cervical flexion motion during craniocervical range of motion. To complete the test, an air-filled pressure sensor—most typically a blood pressure cuff is used in the clinic—is placed under the neck of the patient, who is lying supine. This sensor is used to provide and monitor feedback as the client engages the deep flexor muscles by flattening the cervical lordosis via contraction of the longus colli muscle. The client should be able to achieve and maintain pressure on the sensor via isometric contraction without compensatory movement or excess use of the superficial cervical flexors (Perez-Fernandez et al., 2020). In addition to positive findings with the flexion–rotation test and craniocervical flexion test, according to Anarte-Lazo et al. (2021), subjects with cervicogenic headaches were found to have a pat- tern of painful upper cervical joint dysfunction associated with re- stricted extension range of motion. The American Physical Therapy Association (APTA) has also de - veloped a list of diagnostic criteria for cervicogenic headaches. The APTA criteria emphasize the specific examination using man- ual techniques (Dale et al., 2020). In Neck Pain: Clinical Practice Guidelines , which was published by the APTA, the following crite- ria were established for neck pain with headache. Common symptoms (Dale et al., 2020): A. Noncontinuous, unilateral neck pain with associated (referred) headache. B. Headache precipitated or aggravated by neck movements or sustained positions/postures. Expected exam findings: A. Positive cervical flexion–rotation test. B. Headache reproduced with provocation of the involved upper cervical segments. C. Limited cervical ROM. D. Restricted upper cervical segmental mobility. E. Strength, endurance, and coordination deficits of the neck muscles. (Cavallaro Goodman et al., 2018) Manual examination According to Hall et al. (2008), manual examination has high sensitivity and specificity to detect the presence or absence of cervical joint dysfunction in headache patients. In fact, the pres- ence of upper cervical joint dysfunction as determined via man- ual examination more clearly identifies a cervicogenic source of headache pain than does posture, cervical range of motion, cervical kinesthesia, and craniovertebral muscle function (Hall et al., 2008). Manual examination of the upper cervical segments should include assessment of accessory intervertebral motion via posteroanterior pressure. A pain response can be used to iden- tify involved segments. Manual examination also involves several special tests that are listed below.
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