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Manual Physical Therapy and Exercise for Neck Pain and
Cervicogenic Headache: A Case Report
Jaclyn Christofilos, SPT
Governors State University - University Park, IL
ABSTRACT
Study Design: The design is a case report of a clinical physical therapy case.
Background: Neck pain is very common among the general population and is associated with increased disability,
poor self-perceived health, and high recurrence rates. Patients with neck pain may be experiencing an accompanying
cerviogenic headache. Neck pain and cervicogenic headache is often treated with manual therapy and therapeutic
exercise; however, limited research exists on the effectiveness of intervention variety.
Case Description: The patient was a 71-year-old male experiencing neck pain and cervicogenic headache
symptoms. Limitations included but were not limited to pain with ADLs, driving, cervical mobility and reduced
activity tolerance. Treatment focused on manual therapy consisting of cervical and thoracic thrust and nonthrust
mobilization/manipulation techniques and instrument assisted soft tissue massage. Therapeutic exercise was also
implemented into the treatment program for a combination approach.
Outcomes: The patient had reductions in disability evidenced by a lower score on the NDI and no pain according to
the NPRS at the end of treatment. Results also showed improvements in cervical AROM, deep cervical neck flexor
strength/endurance, and postural awareness. Patient reports indicated increased activity tolerance resulting in return
to prior level of function.
Conclusion: A multimodal approach combining manual therapy and therapeutic exercise to target cervical
musculoskeletal impairments resulted in beneficial outcomes. Further research can help determine the optimal
approach for certain patient subtypes as well as long-term effectiveness of treatment to help prevent recurrence.
Background Reports estimate that among those who
experience an episode of neck pain, 50%-
Neck pain is considered common in the 75% will have complaints of neck pain 1 to
1 3
general population. It is estimated that neck 5 years later. A systematic review
pain affects 30-50% of the general completed by Bone and Joint Decade 2000-
population annually.1 Among adults with 2010 analyzed prognostic indicators relative
neck pain, 7.5% to 14.5% report difficulty to neck pain in the general population.3
with activities and 2.5% experience Gender as a prognostic factor is ambiguous
cervicogenic headaches according to one and age has an inverse relationship on
1 recovery.3 Findings note regular physical
month prevalence rates. Consistent research
findings suggest that neck pain and other activity to prevent neck pain occurrence.3
health conditions often coexist, such as low Psychological health and strong support
back pain, headaches, and poor self-rated systems are predictive of improved
1 3
health. outcomes. It has been concluded that
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Manual Physical Therapy and Exercise for Neck Pain and Cervicogenic Headache
prognostic factors relating to poor outcomes diagnosing a cervicogenic headache.6
3
are consistent with neck pain risk factors. Examination often reveals upper cervical
Misailidou et al, Bogduk and McGuirk segmental restrictions and tenderness to
provide a regional description of cervical palpation.5 Several factors are considered
spinal pain (posterior pain from superior contributory to the present cervical
nuchal line to T1), to upper and lower musculoskeletal impairments, such as poor
cervical spinal pain by a transverse line posture and traumatic events.5
4
above or below C4. Upper cervical A systematic review exploring treatment of
segments typically refer pain to the head; patients with cervicogenic headache
pain in the scapular region, shoulder and concluded that cervical manipulation,
anterior chest wall may arise due to lower mobilization and therapeutic exercise had
cervical segments.4 Suboccipital pain is the greatest effect on reducing cervicogenic
located between the superior nuchal line and headache intensity and frequency.5 Only one
C2, a region that is associated with studied compared an exercise only group
cervicogenic headache.1 versus exercise combined with manual
5
According to Racicki et al, the International technique. Manipulative treatment for the
Headache Society classifies cervicogenic management of cervicogenic headache is
headache as a secondary headache supported in the literature, however, no
originating from a source in the neck that studies have compared manipulation versus
refers pain to one or more regions of the mobilization.5 A randomized clinical
5
head or face. Musculoskeletal impairments research study specifically investigated the
of the neck are implicated in headache effects of spinal manipulative therapy
development.6 Disturbances are typically (SMT) on neck pain in the elderly.8 Subjects
noted in the occipital, frontal, or retro-orbital were broken into groups of SMT with home
region.5 Suboccipital neck pain is frequently exercise, supervised exercise plus home
encountered in patients with cervicogenic exercise, and home exercise alone.8 Results
headache.5 Manifestation revolves around indicated treatment effect on pain was the
structures innervated by the C1-C3 spinal greatest in the SMT with home exercise
8
nerves, including muscle and synovial group. Within the past decade, a body of
joints. Sensory input to the deep somatic research regarding neck pain has emerged
tissues of the suboccipital region is approving the use of manual therapy
controlled by the C1 spinal nerve.7 Through directed at the thoracic spine as a treatment
the cervical plexus, C2 ventrally innervates method.9 A randomized clinical trial
the sternocleidomastoid, trapezius, and revealed immediate relief of neck pain
dorsally innervates the splenius capitis and symptoms compared to a placebo group in
semispinalis capitis.7 The various patients receiving thoracic spine
10
innervations of the C3 spinal nerve include manipulation. Another study by Cleland et
the splenius capitis and cervicis, longissimus al, found thrust mobilization/manipulation
capitis, semispinalis cervicis, multifidus, and of the thoracic spine affected neck pain
semispinalis capitis.7 The joints affected by more optimally than nonthrust technique.9
these nerves are the atlanto-occipital, The purpose of this case report was to
atlantoaxial, and C2-3 zygapophyseal and supplement the current body of literature
7
disc. Cervicogenic headache is theorized to with data concerning physical therapy
arise from dysfunction at C3 and above, management for patients with neck pain and
although this matter remains controversial.5 accompanying cervicogenic headache. The
Literature points to the C2-3 and C3-4 approach was multimodal focusing primarily
zygapophyseal joints as potential sources as on manual therapy intervention.
well.5 A thorough physical exam must be
completed to attain the necessary criteria in
JOURNAL OF STUDENT PHYSICAL THERAPY RESEARCH | 2011 ⏐VOLUME 9, NUMBER 2, ARTICLE 2
Manual Physical Therapy and Exercise for Neck Pain and Cervicogenic Headache
Case Description unremarkable. The subject’s
musculoskeletal system was impaired
Patient History demonstrated by pain, limitations in range of
The subject, KK, was a 71-year-old motion, and strength. Bilateral shoulder
Caucasian male with neck pain that was AROM was within functional limits and
insidious onset, occurring 4-5 weeks prior to without symptom provocation. See table 1
initial physical therapy examination. The for test and measure data.
patient was retired; his hobbies included
gardening, yard work, golf, disc jockeying ROM
and exercise at a local gym. KK had no prior Cervical spine AROM was measured with a
history of neck pain, headaches, or trauma to universal goniometer (UG) with the subject
his cervical spinal region. The pain was dull, in a seated position. Youdas et al., measured
intermittent and localized to the posterior the reliability of testing cervical spine
neck region that occasionally began to AROM with a UG in patients referred
11
radiate up the base and posterior aspects of mostly for cervical muscle pain. Intraclass
the occiput after several days. The pain was correlation coefficient (ICC) values showed
11
worse with cervical end range motion in all good reliability ranging from 0.83 to 0.90.
planes and increased levels of activity
(lifting, yardwork). The neck pain and Deep Neck Flexor Endurance
headache appeared to be related occurring The deep cervical neck flexors include the
with similar onsets. KK reported the longus colli, longus capitis, rectus capitis
headache pain was exhausting, decreasing anterior, and rectus capitis lateralis.
his activity tolerance. He reported the Activation of these muscles is vital during
headache to occur both unilaterally and movement due to the stability provided to
bilaterally, decreasing following termination the cervical spine. Patients with neck pain
of irritating stimuli. He attributed the often have reduced activation of the deep
headache onset to sustained neck cervical flexors with more pronounced
positioning. KK received a cortisone shot in muscle activity of the sternocleidomastoid
his neck prior to initial examination, and anterior scalenes causing muscle
relieving symptoms for six days. KK imbalance.12 Without the action of the
reported limitations in mobility, driving, and longus colli, an increased lordosis of the
activity tolerance. KK had a positive attitude cervical spine would occur during flexion.13
toward physical therapy due to previous The longus capitis primarily performs
14
outcomes at the outpatient facility for a craniocervical flexion. To test deep
different diagnosis. KK’s goals were to be cervical flexor endurance, the patient was
pain free with mobility and usual activities. supine and instructed to perform
The patient’s medical history included craniocervical flexion followed by a one
controlled hypertension and skin cancer inch head lift off the table to attain cervical
during the previous year; he was cleared for flexion. The examiner observed the
red flags indicated for cancer. maintenance of the chin tuck, level of head
elevation, and any aberrant movement.
Tests and Measures Olson et al found good reliability of this test
The patient presented with a forward head with ICC values for 3 testers: inter-rater=
and shoulder posture, which increased upper 0.83, 0.85, 0.88 and intra-rater for tests 1
cervical extension. KK’s cardiopulmonary and 2 ICC=0.78, 0.85.12
and integumentary systems were remarkable
only for a history of controlled hypertension Segmental Mobility
and skin cancer in the previous year and The patient’s cervical segmental mobility
KK’s neuromuscular system was was examined in supine assessing the
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Manual Physical Therapy and Exercise for Neck Pain and Cervicogenic Headache
16 20
passive downglide of C2-C7 as in Olson. items each scored 0 to 5. Scores can be
20
Bakhtadze et al., established kappa values documented as a percentage. The NDI was
on the right and left as k=0.77 and k=0.72 completed at the first and ninth visit. Young
when researching the reproducibility of the et al. displayed moderate test-retest
17 20
side bending spring test at C2-3. reliability with an ICC of 0.64.
Interventions to address deficits in thoracic
spine mobility in patients with neck pain Cervical Flexion Rotation Test (AA
have proved to be significant, indicating the rotation test)
potential correlation among thoracic spine The cervical flexion rotation test was used to
dysfunction and symptomatic neck pain.9 analyze atlantoaxial rotation with the subject
The subject’s thoracic spine segmental in supine to isolate rotation of the C1-2
mobility was measured in prone applying a segments. Cervical joint dysfunction,
central posterior to anterior (PA) force as in especially the upper segments, is a strong
16
Olson. Heiderscheit and Boissonnault identifier of patients with cervicogenic
21
found central thoracic PAs to have intra- headaches. Rotation of less than 45
rater reliability of slight to fair (k=0.17, degrees was considered positive. Hall et al,
k=0.26) according to strict agreement found the Sensitivity and specificity were
18
calculation. When expanding the definition 90% and 88% for the experienced group
of agreement, intra-rater reliability was good with 92% agreement; the inexperienced
(k=0.75, k=0.61) and inter-rater reliability examiners recorded greater mobility during
18
was moderate (k=0.59). Thoracic spine the test but the psychometric values were
21
mobility was not tested at the final visit due within clinically acceptable ranges. The
to basal cell removal in this area reported by ICC value for inter-tester reliability in the
the patient on the seventh visit. experienced group was 0.93 and in the
21
inexperienced group were 0.84 and 0.76.
Numeric Pain Rating Scale (NPRS) See Table 1 for test and measure data.
KK attributed much of his functional Clinical Impression
limitations to pain onset. The NPRS was The patient’s deficits appeared to be
used to quantify pain level. A rating of 0 musculoskeletal in nature. The patient was
correlated to no pain and 10 was the most likely experiencing cervicogenic headaches
extreme pain warranting a visit to the as a referral pattern from upper cervical
emergency room. A study conducted on dysfunction: segmental restriction, increased
patients with mechanical neck pain found muscular tension, and tenderness to
the NPRS demonstrated adequate palpation in this region. The posterior neck
responsiveness and moderate test-retest pain that KK reported seemed to be related
reliability with an ICC of 0.76.19 Also, this to postural deficiency, cervical/thoracic
tool exhibited construct validity during segmental hypomobility, and deep neck
follow-up examination with scores reflecting flexor muscle weakness. Examination ruled
19
decreases in disability. The minimum in cervicogenic headache versus a migraine
detectable change (MDC) and minimal headache. Manual exam can differentiate
clinically important difference (MCID) were between the two headaches with 80%
19 16
2 points and 1.3 points respectively. sensitivity. Patients with cervicogenic
headaches have reduced cervical range of
Neck Disability Index motion and higher incidence of C1-C3
16
The Neck Disability Index (NDI) is the most dysfunction. The headache develops in
well researched and accepted outcome relation to the onset of a cervical disorder,
20
measure for neck pain. It evaluates both has posterior to anterior pain radiation, and
subjective symptoms and activities of daily is provoked by pressure on neck
20 22
living (ADLs). The NDI consists of 10 musculature as in this case. Migraine
JOURNAL OF STUDENT PHYSICAL THERAPY RESEARCH | 2011 ⏐VOLUME 9, NUMBER 2, ARTICLE 2
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