B. Restriction of the range of motion in the neck. C. Ipsilateral neck, shoulder, or arm pain of a rather vague, nonradicular nature, or, occasionally, arm pain of a radicular nature. II. Confirmatory evidence by diagnostic anesthetic blockades. III. Unilaterality of the head pain, without side shift. 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 pattern of painful upper cervical joint dysfunction associated with restricted extension range of motion. The American Physical Therapy Association (APTA) has also developed a list of diagnostic criteria for cervicogenic headaches. The APTA criteria emphasize the specific examination using manual techniques (Dale et al., 2020). In Neck Pain: Clinical Practice Guidelines , which was published by the APTA, the following criteria 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 presence of upper cervical joint dysfunction as determined via manual 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 identify involved segments. Manual examination also involves several special tests that are listed below. Evidence-based practice: There are several assessment 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–rotation 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–anterior pressure to the facet joints with the goal of determining (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.
A. Precipitation of head pain, similar to the usually occurring headache: i. By neck movement and/or sustained awkward head positioning, and/or ii. By external pressure over the upper cervical or occipital region on the symptomatic side. Differentiating migraine and cervicogenic headaches Anarte-Lazo et al. (2021) conducted a systematic review and meta-analysis to determine if physical examination findings could effectively differentiate migraine from cervicogenic headache. Compared with patients with migraine, patients with cervicogenic headache demonstrate a reduction in range of rotation during the flexion–rotation test (FRT) as well as decreased neck flexion strength as measured by the craniocervical flexion test (CCFT). Compared with tension-type headaches, neck movements do not typically aggravate tension- type headaches but often do aggravate cervicogenic headaches (physiopedia.com). Also, compared to patients with migraine headaches and control groups, patients with cervicogenic headaches tend to have increased tightness and trigger points in the upper trapezius, levator scapulae, scalene, and suboccipital extensor muscles (physiopedia.com). Serious pathologies that can present with symptoms similar to cervicogenic headache include vascular pathologies of the neck, intracranial pathology, cervical instability, cervical myelopathy, and occipital neuralgia (physiopedia.com). Flexion–rotation test Since facet joints at the occiput/C1, C1/C2, and C2/C3 have been found to refer symptoms to the occipital and suboccipital regions, testing of these joints for dysfunction is typically part of confirming a cervical source of headache pain (Bravo Peterson et al., 2015). The flexion–rotation test (FRT) is used to test movement at the C1/C2 facet joints. To complete the flexion– rotation test, the therapist passively positions the patient’s neck in full flexion to pretension the structures of the middle and lower cervical spine. Next, the patient’s head is passively rotated in both directions while the flexed position is maintained. Since 40%–60% of total cervical rotation comes from C1/C2, this test is meant to isolate motion at that segment. Criteria for a positive test include (1) ROM restriction with firm resistance and (2) a 10-degree difference in motion between painful and nonpainful sides, and pain provocation (Bravo Peterson et al., 2015). 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. 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 craniocervical 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). c. C1/C2; cervicogenic. d. C2/C3; cervicogenic. Craniocervical flexion test
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