● Impaired muscle function as measured by the craniocervical flexion test (CCFT). ● No impairment in C1/C2 as measured with the flexion– rotation test (FRT), where rotation of the head is measured with the neck prepositioned in full flexion. Self-Assessment Quiz Question #21 The craniocervical flexion test is used to measure:
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. In terms of muscle involvement, Hall et al. (2008) state that muscle dysfunction (weakness, decreased endurance, decreased extensibility) is an important feature of cervicogenic headaches. A decrease 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 cervicogenic headaches. The muscles implicated include the upper trapezius, sternocleidomastoid, scalenes, levator scapulae, pectoralis minor and major, and short suboccipital extensors (Hall et al., 2008). Finally, examination for sensorimotor dysfunction is relevant for diagnosis 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 headaches 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 muscle strength. According to Hall et al. (2008), weakness in the deep neck flexor muscles is a defining characteristic 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 examiner (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.
a. C1–C2 flexion range of motion. b. C2–C3 flexion range of motion. c. Deep cervical flexor muscle strength. d. Superficial cervical flexor muscle strength.
Self-Assessment Quiz Question #22 Which type of headache is accompanied by a sense of agitation or restlessness that often manifests itself in an inability to lie down? a. Migraine. b. Tension-type. c. Cluster. d. Cervicogenic. Case Study: Ms. Margaret Moore Ms. Margaret Moore is 35-year-old full-time office manager who presents to physical therapy with complaints of headache. She is 64 inches tall and weighs 127 pounds. Her headaches occur two to three times a week, almost always in the late afternoon when she is rushing to pick up her two children from daycare and make dinner. Her symptoms start on the left side of her neck and, with time, increase in intensity and spread to both the left and right temporal areas. Light and noise sensitivities are present and occasionally nausea. The headache is gone when she wakes up the next day. Her past medical history includes two Caesarean surgeries, seasonal allergies, and right anterior cruciate ligament repair. Examination reveals forward head posture with nearly full, symmetrical cervical range of motion. There is palpable tightness in bilateral scalene and levator scapulae muscles. Tenderness is present in bilateral suboccipital muscles. There is no palpable tenderness along the cervical spinous or facet joints. Rotation is symmetrical with the flexion– rotation test but limited approximately 10 degrees on each side. There is no weakness present in the deep cervical muscles as revealed via a normal craniocervical flexion test. Question What type of headache best explains this client’s symptoms? Discussion Although the client has headaches that start with neck pain, the clinician concluded that this was a migraine headache. Although there were some positive neck findings, the therapist thought the suboccipital muscle tenderness could be due to the patient’s forward head posture. The craniocervical test was negative and although the flexion– rotation test revealed decreased rotation at C1–C2, this is likely incident, as the preponderance of findings indicate migraine headaches. This includes the symptoms of light and sound sensitivity and nausea. The therapist completed postural education with the client and referred her to her primary care physician for further evaluation and possible pharmacological intervention.
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