A Massage Therapists Guide to Treating Headaches and Neck Pain E-Book
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I work with a lot of headache issues. I learned some new things about headaches, that I didn't know. I have had migraines since I was 16 years old, so I will be trying some of these new techniques. What is a secondary headache? A category of headache which is not due to an underlying case B. A category of headache which is caused by tension C. A category of headache which is due to an underlying cause D.
A category of headache which has no structural etiology.
Verbal rating scale B. Debate over the veracity of PCS or WAD symptomology has persisted; however, there is no single explanation for the etiology of these disorders, especially since the onset and duration of symptoms can vary greatly among individuals. Many of the symptoms of PCS and WAD tend to increase over time, especially when those affected are engaged in physical or cognitive activity. Chronic neck pain is often described as a long-term result of both concussion and whiplash, indicating that the most likely structures to become injured during these traumas are the capsular ligaments of the cervical facet joints.
In light of this, we propose that the best scientific anatomical explanation is cervical instability in the upper cervical spine, resulting from ligament injury laxity. The occipito-atlanto-axial complex has a unique anatomical relationship with the vertebral arteries. In the lower cervical spine, the vertebral arteries lie in a relatively straight-forward course as they travel through the transverse foramina from C3-C6.
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However, in the upper cervical spine the arteries assume a more serpentine-like course. The vertebral artery emerges from the transverse process of C2 and sweeps laterally to pass through the transverse foramen of C1 atlas. From there it passes around the posterior border of the lateral mass of C1, at which point it is farthest from the midline plane at the level of C1 [ , ].
This pathway creates extra space which allows for normal head rotation without compromising vertebral artery blood flow. Considering the position of the vertebral arteries in the canals of the transverse processes in the cervical vertebrae, it is possible to see how head positioning can alter vertebral arterial flow. Studies have shown that contralateral neck rotation is associated with vertebral artery blood flow changes, primarily between the atlas and axis; such changes can also occur when osteophytes are present in the cervical spine [ , ].
Proper blood flow in the vertebral arteries is crucial because these arteries travel up to form the basilar artery at the brainstem and provide circulation to the posterior half of the brain.
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VBI usually occurs in the presence of atherosclerosis or cervical spondylosis, but symptoms can also arise when there is intermittent vertebral artery occlusion induced by extreme rotation or extension of the head [ , ]. This mechanical compression of the vertebral arteries can occur along with other anomalies, including cervical osteophytes, fibrous bands, and osseous prominences [ , ] These anomalies were seen in about half of the cases of vertebral artery injury after cervical manipulation, as reported in a recent review [ ].
Whiplash injury itself has been shown to reduce vertebral artery blood flow and elicit symptoms of VBI [ , ]. In one study, the authors concluded that patients with persistent vertigo or dizziness after whiplash injury are likely to have VBI if the injury was traumatic enough to cause a circulation disorder in the vertebrobasilar arterial system [ ].
Other researchers have surmised that excessive cervical instability, especially of the upper cervical spine, can cause obstruction of the vertebral artery during neck rotation, thus compromising blood flow and triggering symptoms [ - ]. Symptoms include neck pain, headaches, dizziness, vertigo, visual and auditory disturbances, memory and cognitive impairment, and migraines.
It has been surmised that cervical arthritis or injury provokes an irritation of both the vertebral and sympathetic nerves. As a result, current treatment now centers on resolution of cervical instability and its effects on the posterior sympathetic nerves [ ]. There is considerable overlap in symptoms amongst these conditions, possibly because they all appear to be due to cervical instability.
Cervical Spine. Orthopedic Physical Assessment. Rehabilitation of concussion and post-concussion syndrome. Sports Health.
Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury. J Neuropsychiatry Clin Neurosci. Upper cervical instability: fact or fiction. J Manip Physiol Ther. Tamura T. Cranial symptoms after cervical injury. J Bone Joint Surg Br. Biomechanics of whiplash injury.
Cervical vertigo and dizziness after whiplash injury. Various tensile forces place strains with differing deformations on a variety of viscoelastic spinal structures, including the ligaments, the annulus and nucleus of the intervertebral disc, and the spinal cord.
Further to this, cadaver experiments have shown that the spinal cord and the intervertebral disc components carry considerably lower tensile forces than the spinal ligament column [ , ]. Encapsulated mechanoreceptors and free nerve endings have been identified in the periarticular tissues of all major joints of the body including those in the spine, and in every articular tissue except cartilage [ ]. Any innervated structure that has been injured by trauma is a potential chronic pain generator; this includes the intervertebral discs, facet joints, spinal muscles, tendons and ligaments [ - ].
The posterior ligamentous structures of the human spine are innervated by four types of nerve endings: pacinian corpuscles, golgi tendon organs, and ruffini and free nerve endings [ 40 ]. These receptors monitor joint excursion and capsular tension, and may initiate protective muscular reflexes that prevent joint degeneration and instability, especially when ligaments, such as the anterior and posterior longitudinal, ligamentum flavum, capsular, interspinous and supraspinous, are under too much tension [ , ].
Collectively, the cervical region of the spinal column is at risk to sustain deformations at all levels and in all components, and when the threshold crosses a particular level at a particular component, injury is imminent owing to the relative increased flexibility or joint laxity. As described earlier, the nucleus pulposus is designed to sustain compression loads and the annulus fibrosus that surrounds it, to resist tension, shear and torsion.
The stress in the annulus fibers is approximately times the applied stress in the nucleus [ , ]. Pressure within the nucleus is approximately 1. As such, the nucleus is relatively incompressible, which causes the intervertebral disc to be susceptible to injury in that it bulges under loads - approximately 1 mm per physiological load [ ]. As the disc degenerates on bulging herniates , it looses elasticity, further compromising its ability to compress.
Shock absorption is no longer spread or absorbed evenly by the surrounding annulus, leading to greater shearing, rotation, and traction stress on the disc and adjacent vertebrae. The severity of disc herniation can range from protrusion and bulging of the disc without rupture of the annulus fibrosus to disc extrusion, in which case, the annulus is perforated, leading to tearing of the structure.
There are a number of treatment modalities for the management of chronic neck pain and cervical instability, including injection therapy, nerve blocks, mobilization, manipulation, alternative medicine, behavioral therapy, fusion, and pharmacologic agents such as NSAIDS and opiates.
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However, these treatments do not address stabilizing the cervical spine or healing ligament injuries, and thus, do not offer long-term curative options. In fact, cortisone injections are known to inhibit, rather than promote healing. As mentioned earlier in this paper, most treatments have shown limited evidence in their efficacy or are inconsistent in their results.
In a systematic review of the literature from January to July on physical modalities for acute to chronic neck pain, acupuncture, laser therapy, and intermittent traction were found to provide moderate benefits [ 5 ]. The literature contains many reports on injection therapy for the treatment of chronic neck pain. Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and function for patients with cervical disc herniation and radiculitis [ ]. However, many other studies have had more nebulous results. In a systematic review of therapeutic cervical facet joint interventions, the evidence for both cervical radiofrequency neurotomy and cervical medial branch blocks is fair, and for cervical intra-articular injections with local anesthetic and steroids, the evidence is limited [ ].
In another systematic review evaluating cervical interlaminar epidural injections, the evidence indicated that the injection therapy showed significant effects in relieving chronic intractable pain of cervical origin; specific to long-term relief the indicated level of evidence was Level II-1 [ ]. In the case of manipulative therapy, the results of a randomized trial disputed the hypothesis that supervised home exercises, combined or not with manual therapy, can be of benefit in treating non-specific chronic neck pain, as compared to no treatment [ 7 ].
The study found that there were no differences in primary or secondary outcomes among the three groups and that no significant change in health-related quality of life was associated with the preventive phase. Participants in the combined intervention group did not have less pain or disability and fared no better functionally than participants from the two other groups during the preventive phase of the trial.
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Another randomized clinical trial comparing the effects of applying joint mobilization at symptomatic and asymptomatic cervical levels in patients with chronic nonspecific neck pain was inconclusive in that there was no significant difference in pain intensity immediately after treatment between groups during resting position, painful active movement, or vertebral palpation [ 8 ]. Massage therapy had similar inconclusive results.