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Physical Therapy, PLLC

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Feb 2018 Newsletter

Posted on February 13, 2018 at 1:50 PM

What is Central Sensitization?

Central sensitization syndrome (CSS) is a condition of the nervous system that is associated with the development and maintenance of chronic pain. When central sensitization occurs, the nervous system goes through a process called wind-up and gets regulated in a persistent state of high reactivity. This persistent, or regulated, state of reactivity lowers the threshold for what causes pain and subsequently comes to maintain pain even after the initial injury might have healed.


Central sensitization has two main characteristics. Although these are not essential to diagnose CSS, both involve a heightened sensitivity to pain and the sensation of touch. They are called allodynia and hyperalgesia. Allodynia occurs when a person experiences pain with things that are normally not painful. For example, chronic pain patients often experience pain even with things as simple as touch or massage. In such cases, nerves (called interneurons which are not normally turned on but are on high alert in patients with CSS) in the area that was touched sends signals through the nervous system to the brain. Because the nervous system is in a persistent state of heightened reactivity, the brain doesn't produce a mild sensation of touch as it should. Rather, the brain produces a sensation of pain and discomfort. Hyperalgesia occurs when a stimulus that is typically painful is perceived as more painful than it should. An example might be when a simple bump, which ordinarily might be mildly painful, sends the chronic pain patient through the roof with pain. Again, when the nervous system is in a persistent state of high reactivity, it produces pain that is amplified.



Mindful Breathing

This exercise can be done standing up or sitting down, and pretty much anywhere at any time. If you can sit down in the meditation (lotus) position, that's great, if not, no worries.

Either way, all you have to do is be still and focus on your breath for just one minute.

1 Start by breathing in and out slowly. One breath cycle should last for approximately 6 seconds.

2 Breathe in through your nose and out through your mouth, letting your breath flow effortlessly in and out of your body.

3 Let go of your thoughts. Let go of things you have to do later today or pending projects that need your attention. Simply let thoughts rise and fall of their own accord and be at one with your breath.

4 Purposefully watch your breath, focusing your sense of awareness on its pathway as it enters your body and fills you with life.

5 Then watch with your awareness as it works work its way up and out of your mouth and its energy dissipates into the world.


Throughout the month of February give your mindful breathing a try. Schedule yourself time or on the fly. It may be difficult at first to let go of wandering thoughts and focus on one thing your breath. Try not to get frustrated just relax and try again later or the next day. The more you practice the easier it will become.


CoQ10 and Migraines

Posted on January 31, 2018 at 9:10 AM

An article appearing on January 3, 2018 in Nutritional Neuroscience describes a randomized, double-blind, placebo-controlled trial that resulted in a reduction in migraine duration, frequency and severity, as well as a lower levels of calcitonin gene-related peptide (CGRP) and tumor necrosis factor-alpha (a marker of inflammation) among participants who received daily supplements of coenzyme Q10 (CoQ10)


The trial included 45 women aged 18 to 50 years diagnosed with episodic migraine. In addition to migraine prophylactic medication, 23 participants received 400 milligrams CoQ10 per day and 22 participants received a placebo for three months. Serum CoQ10, CGRP, tumor necrosis factor-alpha (TNF-a), and other factors were measured at the beginning and end of the study.


Migraine severity, duration, and frequency per month were lower at the end of the study among those who were given CoQ10 compared to the placebo. In addition to a rise in serum CoQ10 levels, women who received CoQ10 experienced a reduction in TNF-a and CGRP at the end of the treatment period. “There is a correlation between neurologic inflammation and CGRP release in migraine,” Monireh Dahri and colleagues explain. "Likewise, CGRP transcription can be stimulated by endogenous inflammatory molecules, such as TNF-a, which increases the CGRP promoter activity and actuates MAPK pathway. In our study, reduction of TNF-a in CoQ10 treated group was accompanied with CGRP decrease, which can be explained by the above-mentioned mechanism."


"As migraine patients have higher level of inflammation and have been reported to have CoQ10 deficiency, CoQ10 supplementation may be a beneficial complementary treatment in migraineurs," they suggest.

Headache Behind the Ear? Don't forget the SCM!

Posted on May 16, 2017 at 7:40 AM

What does a headache behind the ear mean? Signs, causes, and treatments


There are several causes of headaches behind the ear. With proper medical treatment, these headaches can be relieved.

A headache behind the ear refers to any pain that originates from that specific area of the head. Though headaches themselves are very common, headaches that occur exclusively behind the ear are fairly unusual.

 

This type of headache pain can have several causes. The cause of the headache behind the ear will determine symptoms and treatment.

 

This article explores the signs and symptoms of headaches behind the ear and details what causes them. It also discusses how they can be treated to relieve pain and the associated symptoms.


Causes

There are several possible causes of a headache behind the ear. These include the following:

 

Occipital neuralgia[woman with a headache behind her ears]

Occipital neuralgia can cause pain behind the ears.

One of the most common causes of a headache behind the ear is a condition called occipital neuralgia.

 

Occipital neuralgia occurs when the occipital nerves, or the nerves that run from the top of the spinal cord up through the scalp, are injured or inflamed.

 

People often mistake sharp pain behind the ear to be the result of a migraine or similar types of headaches, as symptoms can be similar.

 

People who suffer with occipital neuralgia describe the chronic pain as piercing and throbbing. They also describe it as similar to the feeling of receiving an electric shock in the following places:

 

upper neck

back of the head

behind the ears

Occipital neuralgia happens as a result of pressure or irritation to the occipital nerves. It typically only appears on one side of the head.

 

In some cases, the pressure or irritation maybe because of inflammation, overly tight muscles, or an injury. Often, doctors cannot find a cause for occipital neuralgia.

 



Mastoiditis

Mastoiditis is an infection of the mastoid bone, which is the bone directly behind the ear.

 

This infection is much more common in children than adults and generally responds to treatment with no complications.

 

Mastoiditis causes a headache behind the ear as well as fever, discharge from the ear, tiredness, and hearing loss in the affected ear.

 



TMJ

The temporomandibular joints (TMJ) are the ball and socket joints of the jaw. These joints can become inflamed and painful.

 

[pointing out the symptoms of tmj on a model skull]

TMJ can cause aching behind the ear and it usually accompanied by jaw pain.

While most people with TMJ inflammation feel the pain in the jaw and behind the ear, others may just experience a headache behind the ear.

 

TMJ can be caused by:

 

stress

teeth grinding

arthritis

injury

jaw alignment

Symptoms

Symptoms of headaches behind the ear can vary based on the causes.

 

Occipital neuralgia may cause intense pain to the back of the head and/or upper neck. Often, it can start in the neck and work its way up to the back of the head. The episodic pain is like an electric shock to the back of the head and/or neck.

 

Signs of an infection, such as fever or tiredness, often accompany mastoiditis.

 

People experiencing TMJ may sense jaw tightness and pain in addition to a headache behind the ear.

 

Additional symptoms that people who suffer from headaches behind the ear may experience include:

 

pain on one or both sides of the head

sensitivity to light

aching, burning, and throbbing pain

pain behind the eyes

tender scalp

pain with neck movement



Diagnosis

The main causes of headache behind the ear often overlap. It is crucial to get a proper diagnosis so the condition can be treated appropriately.

 

For diagnosis, a doctor will ask a person questions about medical history. Information about any recent head, neck, or spine injuries should be included.

 

After asking questions, a doctor will probably do a physical examination. For this, the doctor will press firmly around the back of the head and base of the skull in an attempt to reproduce the pain through touch. This examination checks for occipital neuralgia, as this condition is sensitive to the touch in most cases.

 

Some additional steps in diagnosis may include a shot to numb the nerve. If a person experiences relief then occipital neuralgia is likely to be the cause of the pain.

 

In more atypical cases, a doctor may order an MRI or blood test to further confirm or rule out other causes of the pain.

 

If occipital neuralgia is ruled out as a possible cause of pain in the initial visit, the doctor will probably check for signs of mastoiditis, including fever and discharge from the ear.

 

For further diagnosis, a doctor may examine the jaw or recommend a visit to a dentist to check for TMJ.

 

Home treatments

Treating the pain is the primary method of dealing with a headache behind the ear, unless a root cause can be determined.

 

There are some at home treatment options for people to try before or in addition to a doctor's care.

 

[woman in yellow sweater sleeping on the couch]

A common way to manage headaches at home is to rest or nap in a quiet room.

Some at home treatments include:

 

rest in a quiet room

over-the-counter anti-inflammatory drugs, such as ibuprofen

massage of neck muscles

apply heat to back of neck

reduce stress

stop teeth grinding

As with any treatment options, a doctor should be consulted before adding medications.

 



Treatment of headaches behind the ear

When under a doctor's care, someone will have a treatment plan for headaches behind the ear that will include managing the pain and treating underlying causes of the pain.

 

Depending on the exact cause of headaches behind the ear, a doctor may prescribe medications, including:

 

prescription muscle relaxants

nerve blocks and steroid shots

physical therapy

antidepressants

antiseizure drugs, such as carbamazepine and gabapentin

antibiotics if mastoiditis is suspected

a night-guard for TMJ

Nerve blocks and steroid shots are often temporary and necessitate repeat visits to the doctor to be reinjected. Furthermore, it may be necessary to administer several shots before the pain is manageable.

 

In rare cases, an operation may be required. Typically, operations are used if pain does not get better with other treatments or keeps recurring.

 


Operations may include:

 

Microvascular decompression: This procedure involves the doctor finding and repositioning the blood vessels that are compressing the nerves.

Occipital nerve stimulation: A neurostimulator delivers several electrical pulses to the occipital nerves. In this case, the electric pulses may help block pain messages to the brain.

No matter the treatments decided upon, it is important to relay to a doctor whether or not they are effective.

 

In some cases, continued pain may indicate that it is the result of another condition, which needs to be treated differently.

 



Outlook

Generally, headaches behind the ear are not the result of a life-threatening condition.

 

In many cases, people experience pain relief when resting and taking medication as prescribed or directed.

 

In most cases, people with a headache behind the ear should see full or nearly full symptom relief with proper diagnosis and treatment.

Upper Traps role in headaches

Posted on May 15, 2016 at 7:20 PM







Upper trapezius and its referral sources

The trapezius commonly contains trigger points, and referred pain from these trigger points bring patients to the office more often than for any other problem. As you can see from the picture, the trapezius is a large kite-shaped muscle, covering much of the back and posterior neck.

There are three main parts to the muscle: the Upper, middle, and lower trapezius, and each part has its own actions and common symptoms.

Common Symptoms

 

Upper Trapezius

headaches on the temples / "tension" headaches

facial, temple, or jaw pain

pain behind the eye

dizziness or vertigo (in conjunction with the sternocleidomastoid muscle)

severe neck pain

a stiff neck

limited range-of-motion

intolerance to weight on your shoulders

Middle Trapezius

mid-back pain

headaches at the base of your skull

TrP5 refers superficial burning pain close to the spine

TrP6 refers aching pain to the top of the shoulder near the joint

Lower trapezius

mid-back, neck, and/or upper shoulder region pain

possibly referral on the back of the shoulder blade, down the inside of the arm, and into the ring and little fingers (TrP7), very similar to a serratus posterior superior referral pattern

headaches at the base of the skull 5

TrP3 can refer a deep ache and diffuse tenderness over the top of the shoulder 6

 

Causes and Perpetuation of Trigger Points

one leg shorter than the other

a hemipelvis that is smaller on one side (the part of the pelvis you sit on)

short upper arms (which causes you to lean to one side to use the armrests)

large breasts

fatigue

tensing your shoulders

cradling a phone between your ear and shoulder

a chair without armrests, or the armrests are too high

typing with a keyboard too high

sewing on your lap with your arms unsupported

jogging

sleeping on your front or back with your head rotated to the side for a long period

playing a violin

sports activities with sudden one-sided movements

sitting without a firm back support (sitting slumped)

backpacking

bike-riding

kayaking

any profession or activity that requires you to bend over for extended periods (i.e.. dentists/hygienists, architects/draftsmen, and secretaries/computer users)

bra straps that are too tight (either the shoulder straps or the torso strap)

a purse or daypack that is too heavy

a mis-fitting, heavy coat

carrying a day pack or purse over one shoulder -- even if you think you are not hiking up one shoulder, you are, no matter how light the item

whiplash (a car accident, falling on your head, or any sudden jerk of the head) 10

head-forward posture

walking with a cane that is too long

turning your head to one side for long periods to have a conversation

tight pectoralis major muscles

 

Often times, we can address these trigger points in 1-2 sessions and by eliminating these, patients see a drastic redution in neck, and headache pain as well as an immediate increase in AROM. Contact us today to set up an evaluation!!! 502-771-1774

 

 

 

Is your computer causing you headaches?

Posted on January 22, 2016 at 12:50 AM

A hidden cause of neck pain, headaches and tension

 

 

Your computer or workstation can cause you pain.

 

Do you have headaches, stress or tension? Do these symptoms occur especially while at work or at the end of the day?

Your workstation, desk or computer environment may be the cause, or a major contributor factor to your pain and discomfort. Some of the problems your sitting posture can contribute to are headaches, neck pain, eye pain, shoulder knots & tension, back pain, wrist pain, carpal tunnel syndrome and fatigue. If you maintain a sustained posture throughout the day it can create patterns of myofascial and muscle tightens that can contribute to pain elsewhere in your body.

Sitting down all day shortens your hip flexors, pecs and suboccipital muscles and sticks your head forward, allowing these muscles to tighten over time and cause or contribute to pain and restrictions in your body.

A few things you can do to address these issues and prevent problems:

 

1) Take frequent stretch breaks from your work area.

• Put your hands behind your head and stretch backwards over the edge of your chair to open up your chest, front of your neck and to extend your spine backwards.  

• Cross your legs, pull the top leg into your chest for a hip stretch.  Then twist, towards the same side as your top leg, to look behind you.  This should feel good.  Repeat on the other side.

• Put your hands on your desk and arch your back like a “cat.”  Then round your back the other way, stomach forward, like a “cow.” viola… desk yoga. (wink wink)

2) Get up and walk around the office at least once an hour.  Take wellness break and go outside and get a breath of fresh air, go to the water fountain for a sip of water or “take a lap” around your office to get your blood flowing again and muscles moving.

3) Sit with your keyboard, mouse and computer monitor in front of you. You should sit with both feet on the floor, your hips slightly above your knees, your back supported, elbows at your side and hands comfortably on the keyboard. The top edge of your monitor should be the same level as your eyebrows and it should be about 18″ away from you

 

 

 

 

 

4) If you wear bifocals and need to use the lower lens at your computer, it may cause you to extend your neck too far back. To reduce this, invest in a dedicated pair of glasses for when you sit at your computer.

 

5) If you talk or use the phone for your job holding a telephone between your head and shoulder is asking for neck and shoulder pain. Invest in or ask your employer for a “hands free” headset. This will give you the freedom to sit with good posture at your desk and easier use of both hands.





 

 

DID YOU KNOW?

Posted on December 5, 2015 at 11:35 AM

CFS article Quite intriguing.

Posted on March 3, 2015 at 7:50 PM

IOM committee calls for new criteria, name for chronic fatigue syndrome

 

Chronic fatigue syndrome is a serious, real disease, one that deserves a more accurate name — systemic exertion intolerance disease — and a new code in the International Classification of Diseases, 10th Edition, according to the Institute of Medicine.

 

“Many ME/CFS patients believe that the term ‘chronic fatigue syndrome’ perpetuates misunderstanding of the illness and dismissive attitudes from healthcare providers and the public,” the committee wrote in the report brief.

 

ME/CFS, which causes profound fatigue, sleep abnormalities, cognitive dysfunction, pain, autonomic manifestations and other symptoms that worsen with exertion, can severely impair patients’ ability to lead normal lives. Between 836,000 and 2.5 million Americans suffer from this disease, according to the report. However, the authors wrote, many wait years for a diagnosis, partly because many clinicians misunderstand the disease or lack information to diagnose or treat it.

 

“Many healthcare providers are skeptical about the seriousness of ME/CFS, mistake it for a mental health condition, or consider it a figment of the patient’s imagination,” the authors wrote in the report. “Misconceptions or dismissive attitudes on the part of healthcare providers make the path to diagnosis long and frustrating for many patients. The committee stresses that healthcare providers should acknowledge ME/CFS as a serious illness that requires timely diagnosis and appropriate care.”

 

To develop the new diagnostic criteria, the committee completed a comprehensive review of available evidence and also considered input from patients, advocates and researchers.

 

For a patient to be diagnosed with ME/CFS, all three of the following symptoms must be present:

 

A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social or personal activities accompanied by fatigue

Worsening of symptoms after physical, cognitive or emotional activity

Unrefreshing sleep

At least one of the following two symptoms also must be present:

 

Cognitive impairment

Orthostatic intolerance

To distinguish ME/CFS from other diseases, these symptoms must have persisted for at least six months, and the patient must be moderately, substantially or severely affected by them at least half of the time.

 

The committee wrote that clinicians should diagnose ME/CFS if the new criteria are met after a patient history, physical exam and medical work-up.

 

Recommendations in the report also call on the U.S. Department of Health and Human Services to develop a toolkit for evaluating and diagnosing patients in clinical settings including primary care offices, PT and OT clinics, EDs, behavioral and mental health clinics, and some specialty settings.

 

Included in the report is a table listing examples of patient descriptions, potential questions for taking medical histories or in-office questionnaires.

 

The authors call for more research, especially focusing on patients diagnosed using the new criteria. They also propose another review of the evidence after no more than five years.

 

“The primary message of this report is that ME/CFS is a serious, chronic, complex, multisystem disease that frequently and dramatically limits the activities of affected patients,” the authors wrote. “It is ‘real.’ It is not appropriate to dismiss these patients by saying, ‘I am chronically fatigued, too.’”

 

The study was sponsored by HHS, the CDC, the National Institutes of Health, the Agency for Healthcare Research and Quality, the Food and Drug Administration and the Social Security Administration.

 

To read the full 282-page report, visit http://books.nap.edu/openbook.php?record_id=19012&page=1.

 

Report brief: www.iom.edu/~/media/Files/Report%20Files/2015/MECFS/MECFS_ReportBrief.pdf

 

 

Vertebral Artery Test...Good Article.

Posted on February 16, 2015 at 3:45 PM

Pre-Manipulative Testing Prior to Cervical Manipulation: Time to Abandon the VBI Test?

 

Considerable attention has been given to the potential risks associated with high-velocity, low-amplitude (HVLA) thrust manipulation procedures in the cervical region.1-5 The most recent and robust evidence for the risk of vertebrobasilar (VBA) stroke and cervical HVLA thrust manipulation comes from the case control study (n=818) by Cassidy et al.3 Contrary to traditionally held views,6,7 Cassidy et al3 found no evidence of excess risk of VBA stroke associated with cervical HVLA thrust manipulation compared to primary medical physician care. Moreover, after quantifying the strains and forces sustained by the vertebral artery in situ during manipulation, Symons et al8 concluded cervical HVLA thrust manipulation is “very unlikely to mechanically disrupt the vertebral artery.” Similarly, Austin et al9 found 1,000 repeat strain cycles mimicking cervical HVLA thrust manipulation did not cause histologically identifiable microdamage in arterial tissue. Additionally, using piezoelectric ultrasound crystals to measure strains and instantaneous lengths of vertebral artery segments within the transverse foramina, Wuest et al10 found the vertebral artery strains experienced during cervical HVLA thrust manipulation were substantially less than the strain in the C1-6 vertebral artery segments experienced during normal neck rotation or pre-manipulative vertebrobasilar insufficiency testing (i.e. sustained cervical extension plus rotation). Moreover, after a review of the literature,8-11 Herzog et al12 concluded, “cervical spinal manipulative therapy performed by trained clinicians does not appear to place undue strain on the vertebral artery, and thus does not seem to be a factor in vertebrobasilar injuries.”

 

Using magnetic resonance angiography to examine the effects of selected manual therapy interventions on blood flow in the craniocervical arteries and blood supply to the brain, Thomas et al13 concluded total blood supply to the brain was not compromised by C1-2 rotation, end-range rotation, or rotation and distraction positions commonly used in manual therapy. Likewise, using phase-contrast magnetic resonance imaging, Quesnele et al14 found no significant changes in blood flow or velocity in the vertebral arteries after various head positions and upper cervical HVLA thrust manipulations.

 

Physical therapists that still insist on using variations of the “VBI” test before manual therapy to the cervical spine—often due to claiming “it is standard practice” or “it provides legal protection”—should remember that the most recent literature suggests pre-manipulative cervical artery testing is unable to identify those individuals at risk of vascular complications from cervical HVLA thrust manipulation,2,15,16 and any symptoms detected during pre-manipulative testing are likely unrelated to changes in blood flow in the vertebral artery,13,14 so that a negative test neither predicts the absence of arterial pathology nor the propensity of the artery to be injured during cervical HVLA thrust manipulation, with testing neither sensitive or specific.2,5,15-18 Moreover, in a recent systematic review to evaluate the diagnostic accuracy of premanipulative tests, Hutting et al16 reported the sensitivity of the VBI tests was low (0% to 57%) and is considered not sufficient for clinical use in premanipulative screening procedures. In short, a large body of literature does not support continued use of the “VBI” test or what is now commonly referred to as pre-manipulative functional screening for Cervical Artery Dysfunction (CAD).

 

In another recent literature review, Murphy19 concluded “the current evidence indicates vertebral artery dissection syndrome is not a complication to cervical manipulation.” Similarly, in a 2014 systematic review, Chung et al20 found no epidemiologic studies to support the hypothesis that cervical spine manipulation is associated with an increased risk of internal carotid artery dissection in patients with neck pain or headaches. Moreover, another recent systematic review4 concluded there is no strong evidence linking the occurrence of serious adverse events with the use of cervical manipulation or mobilization in adults with neck pain.

 

The two largest randomized controlled trials21,22 within the past 10 years that have directly compared the effectiveness of cervical HVLA thrust manipulation with cervical non-thrust mobilization, did not report the specific vertebral motion segment targeted with the cervical HVLA thrust manipulation procedure. That is, it is not known whether patients with acute or chronic neck pain received upper, middle or lower cervical HVLA thrust manipulation in these two trials.21,22 Nevertheless, there were no serious neurovascular adverse events reported by any participants in either of the trials,21,22 and both trials reported no statistically significant difference in the incidence of minor adverse events between the cervical HVLA thrust manipulation and cervical non-thrust mobilization groups. Therefore to date, and in contrast to what many of us were taught in physical therapy school, there is no strong empirical evidence to support the notion that upper cervical HVLA thrust manipulation carries any greater risk of injury than middle or lower cervical HVLA thrust manipulation, or that non-thrust mobilization to any region of the cervical spine carries any less risk than HVLA thrust manipulation to the same region.1-4

 

AUTHORS:

 

James Dunning, DPT, MSc (Manip Ther), MMACP (UK), FAAOMPT

Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy

President, Alabama Physical Therapy & Acupuncture

Montgomery, AL

 

Raymond Butts, PhD, DPT, MSc (NeuroSci), Cert. DN, Cert. SMT

Senior Instructor, Spinal Manipulation Institute & Dry Needling Institute

Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy

Atlanta, GA

 

Ulysses Juntilla, DPT, OCS, Cert. DN, Cert. SMT, Dip. Osteopractic

Senior Physical Therapist, WJB DORN VA Medical Center, Columbia, SC

Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy

Columbia, SC

 

REFERENCES

 

Haldeman S, Kohlbeck FJ, McGregor M. Unpredictability of cerebrovascular ischemia associated with cervical spine manipulation therapy: a review of sixty-four cases after cervical spine manipulation. Spine (Phila Pa 1976). Jan 1 2002;27(1):49-55.

Kerry R, Taylor AJ, Mitchell J, McCarthy C, Brew J. Manual therapy and cervical arterial dysfunction, directions for the future: a clinical perspective. J Man Manip Ther. 2008;16(1):39-48.

Cassidy JD, Boyle E, Cote P, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine (Phila Pa 1976). Feb 15 2008;33(4 Suppl):S176-183.

Carlesso LC, Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Manual therapy. Oct 2010;15(5):434-444.

Kerry R, Taylor AJ. Cervical arterial dysfunction assessment and manual therapy. Manual therapy. Nov 2006;11(4):243-253.

Rothwell DM, Bondy SJ, Williams JI. Chiropractic manipulation and stroke: a population-based case-control study. Stroke. May 2001;32(5):1054-1060.

Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. May 13 2003;60(9):1424-1428.

Symons BP, Leonard T, Herzog W. Internal forces sustained by the vertebral artery during spinal manipulative therapy. J Manipulative Physiol Ther. Oct 2002;25(8):504-510.

Austin N, DiFrancesco LM, Herzog W. Microstructural damage in arterial tissue exposed to repeated tensile strains. J Manipulative Physiol Ther. Jan 2010;33(1):14-19.

Wuest S, Symons B, Leonard T, Herzog W. Preliminary report: biomechanics of vertebral artery segments C1-C6 during cervical spinal manipulation. J Manipulative Physiol Ther. May 2010;33(4):273-278.

Symons B, Wuest S, Leonard T, Herzog W. Biomechanical characterization of cervical spinal manipulation in living subjects and cadavers. J Electromyogr Kinesiol. Oct 2012;22(5):747-751.

Herzog W, Leonard TR, Symons B, Tang C, Wuest S. Vertebral artery strains during high-speed, low amplitude cervical spinal manipulation. J Electromyogr Kinesiol. Oct 2012;22(5):740-746.

Thomas LC, Rivett DA, Bateman G, Stanwell P, Levi CR. Effect of selected manual therapy interventions for mechanical neck pain on vertebral and internal carotid arterial blood flow and cerebral inflow. Phys Ther. Nov 2013;93(11):1563-1574.

Quesnele JJ, Triano JJ, Noseworthy MD, Wells GD. Changes in vertebral artery blood flow following various head positions and cervical spine manipulation. J Manipulative Physiol Ther. Jan 2014;37(1):22-31.

Taylor AJ, Kerry R. The ‘vertebral artery test’. Manual therapy. Nov 2005;10(4):297; author reply 298.

Hutting N, Verhagen AP, Vijverman V, Keesenberg MD, Dixon G, Scholten-Peeters GG. Diagnostic accuracy of premanipulative vertebrobasilar insufficiency tests: a systematic review. Man Ther. Jun 2013;18(3):177-182.

Licht PB, Christensen HW, Hoilund-Carlsen PF. Is there a role for premanipulative testing before cervical manipulation? J Manipulative Physiol Ther. Mar-Apr 2000;23(3):175-179.

Magarey ME, Rebbeck T, Coughlan B, Grimmer K, Rivett DA, Refshauge K. Pre-manipulative testing of the cervical spine review, revision and new clinical guidelines. Manual therapy. May 2004;9(2):95-108.

Murphy DR. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropr Osteopat. 2010;18:22.

Chung CL, Cote P, Stern P, L’Esperance G. The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. J Manipulative Physiol Ther. Jan 3 2014.

Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A randomized trial of chiropractic manipulation and mobilization for patients with neck pain: clinical outcomes from the UCLA neck-pain study. Am J Public Health. Oct 2002;92(10):1634-1641.

Leaver AM, Maher CG, Herbert RD, et al. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain. Arch Phys Med Rehabil. Sep 2010;91(9):1313-1318.

 

 

SCM and its role in stubborn headache pain!

Posted on November 8, 2014 at 1:15 PM






 

Sternocleidomastoid



The sternocleidomastoid (SCM) is one of my favorite muscle groups to work with, mainly because the results can be simply extraordinary. Trigger point activity in this muscle can cause a bewilderingly set of symptoms, with many being confusingly similar to the symptoms associated with the common (no aura) migraine headache.

Make no mistake, these are the “go-to” trigger points when a client presents with any type of headache pain, but they can also produce such diverse symptoms as a dry cough, sore throat, sinus pain, excessive eye tearing, visual disturbances, fainting, and dizziness / vertigo.

 

Anatomical Highlights:

Each SCM group has two divisions that originate off the mastoid process behind the ear. The sternal division runs diagonally downward to attach to the sternum, while the clavicular division attaches right behind it on the medial clavicle.

Acting unilaterally, contraction of the SCM muscle turns the head towards the opposite side, while bilateral contraction flexes the neck and head forward.

The most important function of the SCM is to control and monitor the head’s position in space. Proprioceptive feedback from the SCM is essential to being able to maintain one’s balance, and is also important for interpreting visual information.

A secondary function of the SCM is to assist inhalation by lifting the rib cage.

Biomechanical Highlights:

The SCM muscles work synergistically with the trapezius and scalene muscles during lateral flexion of the neck, and with the scalene muscles during forced inhalation.

The trapezius muscle is antagonistic during forward neck flexion.

The Sternocleidomastoid Trigger Points

The SCM muscle group’s trigger point density is one of the highest in the body. Usually, both divisions have simultaneous trigger point activity, but on occasion, I’ll have a client with trigger points only in the sternal division. Trigger points typically develop in one SCM muscle group first, but quickly spread to the SCM on the opposite side of the neck.

 

 

 

 

Sternocleidomastoid Pain


Each SCM division has a separate and distinct referred pain pattern:

The sternal division’s referred pain is felt deep in the eye socket (behind the eye), above the eye, in the cheek region, around the temporomandibular joint (TMJ), in the upper chest, in the back of the head, and on the top of the head.

The clavicular division’s referred pain is felt in the forehead, deep in the ear, behind the ear, and in the molar teeth on the same side. The really strange thing about this pain presentation is that the forehead pain may extend across the midline of the forehead to the other side.

 

 

Sternocleidomastoid Symptoms & Disorders

The SCM trigger points are unique in that they can produce a copious amount of symptoms that appear to have nothing to do with the musculoskeletal system. Listed below are some of symptoms and disorders that can be produced by these trigger points:

Tension Headache: A common, but debilitating, headache that is typically attributed to perceived muscle tension in the neck and cranial muscles. The duration of these headaches can vary from 30 minutes to several days, and may occur daily in chronic cases.

Migraine Headache: The SCM trigger points can produce many of the symptoms associated with non-aura migraine headaches, such as visual disturbances, muscle tenderness, and unilateral (one-sided) headache pain.

Hangover Headache: The dehydration caused by excessive alcohol intake can activate trigger points in the SCM and trapezius muscles and produce the dreaded “hangover” headache.

Atypical Facial Neuralgia: Pain in the cheek, jaw, and temple regions.

Sore throat and Pain on Swallowing: The middle trigger point in the sternal division can produce pain at the base of the tongue that makes it difficult and/or painful to swallow.

Visual Disturbances: Trigger points in the sternal division commonly produce blurred vision, double vision, and a dimming of perceived light intensity.

Eye Problems such as a drooping eye-lid (ptosis), excessive eye tearing and/or reddening of one or both eyes.

Forehead Sweating: sweating on one side of the forehead, above the eye.

Dizziness & Vertigo: Dizziness when moving the head, such as lifting it to turn over in bed, or when tilting it backward to look at something above. Seasickness or car sickness are typically a problem, and quick movements of the head may cause fainting and/or nausea.

Hearing Impairment: Trigger points in the clavicular division may cause moderate deafness or “ringing” in one ear.

Sore Neck: While the SCM trigger points don’t refer pain to the neck, clients with these trigger points will often rub their necks to alleviate soreness in the region.

Upper Chest Pain: The lower trigger point in the sternal division may refer pain to the upper chest bone region.

What Causes Sternocleidomastoid Trigger Points?

In my clinical experience, trigger points in the SCM muscles are frequently caused by trigger point activity in the trapezius muscle, particularly if the trapezius trigger points are left untreated for an extended period. Both muscle groups can be overloaded by similar physical and behavioral stressors, which include:

Whiplash from a car accident can put extraordinary stress on the SCM muscles as they contract to control the violent backward movement of the head.

Working Overhead: Activities that require one to look upwardly for long periods of time, such as painting a ceiling, can overstretch the SCM muscles.

Forward-Head Posture: The all-too-common forward-head, slumped-shoulder postural distortion keeps the SCM muscles in an unnaturally shortened position, making them prone to developing trigger points.

Sleeping Position: Sleeping with the head flexed forward because the pillow is to big (or using two pillows), or with the head turned, can put strain on these muscles.

Chronic Cough: The SCM can be overloaded by repeatedly lifting the chest and ribcage during inhalation while coughing.

Tight Collar: Physical pressure from a tight neck-tie or collar may irritate SCM trigger points.

Limping: Limping on one leg for extended periods may overload the SCM as it tries to compensate for a leaning trunk and keep the eyes level.

 

 

Treatment of SCM Trigger Points

 

A trained clinician in trigger point release and or dry needling can reduce or completely remove trigger points in this muscle and alleviate many of the symptoms above.

 

For more information contact Bluegrass Doctors of Physical Therapy PLLC



**Images courtesy of Wikipedia

Welcome!

Posted on September 6, 2014 at 1:50 PM

Welcome to Bluegrass Doctors of Physical Therapy, PLLC Blog! In this blog we will review many common conditions and symptoms related to muskuloskeltal pain and dysfunction. Every few weeks will be a new topic!

Todays blog is about one of the many headache conditions we treat: Migraine Headaches.


 

Migraine headaches often begin in childhood, adolescence or early adulthood. Migraines may progress through four stages, including prodrome, aura, headache and postdrome, though you may not experience all the stages.

 

Prodrome

 

One or two days before a migraine, you may notice subtle changes that signify an oncoming migraine, including:

 

Constipation

Depression

Food cravings

Hyperactivity

Irritability

Neck stiffness

Uncontrollable yawning

Aura

 

Aura may occur before or during migraine headaches. Auras are nervous system symptoms that are usually visual disturbances, such as flashes of light. Sometimes auras can also be touching sensations (sensory), movement (motor) or speech (verbal) disturbances. Most people experience migraine headaches without aura. Each of these symptoms usually begins gradually, builds up over several minutes, and then commonly lasts for 20 to 60 minutes. Examples of aura include:

 

Visual phenomena, such as seeing various shapes, bright spots or flashes of light

Vision loss

Pins and needles sensations in an arm or leg

Speech or language problems (aphasia)

Less commonly, an aura may be associated with limb weakness (hemiplegic migraine).

 

Attack

 

When untreated, a migraine usually lasts from four to 72 hours, but the frequency with which headaches occur varies from person to person. You may have migraines several times a month or much less often. During a migraine, you may experience the following symptoms:

 

Pain on one side or both sides of your head

Pain that has a pulsating, throbbing quality

Sensitivity to light, sounds and sometimes smells

Nausea and vomiting

Blurred vision

Lightheadedness, sometimes followed by fainting

Postdrome

 

The final phase, known as postdrome, occurs after a migraine attack. During this time you may feel drained and washed out, though some people report feeling mildly euphoric.

- Mayo clinic website**