HA/Migraine Lecture Flashcards
1
Q
what are the sx of a tension HA?
A
mild to moderate aching pressure in the entire head or in a band around the head
short lived
relieved with OTC analgesic
2
Q
what other dx does tension HA resemble?
A
meningitis
common cold
dehydration
tumor
stroke
3
Q
what are some known causes of HA/migraine?
A
chocolate
coffee
caffeine
numerous foods
hormones
vascular
tension/stress
psychological
4
Q
what are some treatment approaches to HAs?
A
diet changes
drugs
hormones
nerve blocks
steroid injections
manipulation
biofeedback
counseling
immitrex injections
5
Q
why is SO (suboccipital) tightness such a big factor in HAs?
A
bc of it superficial nerves, multiple lig attachments, small/delicate/highly innervated structure, with a short lever arm
6
Q
why does the short lever arm of the SO tissue put pts at risk for HAs?
A
bc it doesn’t take much flexion to stretch them and pull on the dura mater
7
Q
what CNs are involved in the trigeminocervical nucleus (TCN)?
A
facial
glossopharyngeal
vagus
8
Q
what does irritation of the 1st division (ophthalmic division) of the trigeminal nerve cause?
A
facial pain
retro-orbital pain
9
Q
what does irritation of the 2nd division (maxillary division) of the trigeminal nerve cause?
A
pain along the zygomatic arch
10
Q
what does irritation of the 3rd division (mandibular division) of the trigeminal nerve cause?
A
pain near the ear/mandible
mimics TMD
11
Q
how does the motor branch of the trigeminal nerve affect HA/TMJ sx?
A
it can create jaw tightness that brings the disc fwd and creates clicking
12
Q
what are bite splints used for?
A
to protect the teeth
13
Q
do bite splint help correct the problem?
A
no, they do nothing for jaw tension
14
Q
t/f: if we can shut off jaw tightness, we can solve TMJ issues
A
true
15
Q
what C spine nerve roots influence the TCN?
A
C1-3
16
Q
what does the vagus nerve innervate?
A
sensory fibers to the ear and tongue, spinal meninges and cervical nerves
parasympathetic to thoracic and abdominal viscera
17
Q
what allows for upper cervical pain to be referred to regions of the head?
A
cervical afferents
18
Q
t/f: the further up the cervical spine problem is, the more fwd in the head the sx can be
A
true
19
Q
what joints are the most common source of cervicogenic HA?
A
C2-3 zygopophysial joints
20
Q
t/f: many HAs are cervicogenic in nature
A
true
21
Q
what does DiMaggio believe is the cause of the vast majority of HAs?
A
cervicogenic
upper cervical and SO soft tissue tightness from trauma, scarring, and/or adaptive shortening
22
Q
what does DiMaggio believe is the cause of the vast majority of TMJ pain?
A
cervicogenic
upper cervical and SO soft tissue tightness resulting from trauma, scarring, and/or adaptive shortening
23
Q
what are the reasons SO tissues “get no respect”?
A
multiple small structures
highly innervated tissues
numerous cervical and CNs (TCN)
vagus nerve
dura
c-spine is the least protected and most vulnerable
posterior SO region is in a continued shortened position via poor postural habits
adaptively shortened tissues don’t show up on x-ray, CT, MRI
medicine’s general lack of appreciation for these above points
failure to appreciate sensitivity, vulnerability of SO tissues, extensiveness of sx production
24
Q
what are some causes of SO tightness?
A
poor posture
trauma
immobilization post trauma
FOOSH
25
what trauma can cause a shortening of SO tissues?
whiplash causing crush/tear injury to the posterior occiput
26
how can FOOSH cause SO tightness?
bc the neck may get whiplash injury from transmission for axial load through the hand-->clavicle-->neck
27
what are some mechanical irritants of the SO tissues?
prolonged cervical flexion
prolonged cervical rotation
excessive movt in any direction
vibration (car, plane, bike, walking, running, etc)
physical pressure (hand rubbing, lying upper neck on something, STM)
chemicals (alc, hormones)
occipital bone compressing SO tissue (too much upper cervical ext)
28
what are two ways that SO tissues shorten?
disuse-->adaptive shortening
trauma-->scarring
29
how do shortened SO tissues reduce fxn?
ERP makes pts avoid end range creating more opportunity for further shortening
dec ROM
dec fxn (fwd head position)
30
what is involved in the upper cervical hx?
no lower cervical, thoracic, or UE sx
SO and upper cervical sx only
onset could be any time
31
what is involved in the lower cervical hx?
lower cervical, thoracic, or UE sx
HA sx alternate sides frequently
HA onset around the same time as lower cervical onset
32
what is involved in the upper cervical exam?
multiple reps of retraction produce or worsen HA
upper cervical position changes DO effect HA with slightest of adjustments
33
what is involved in the lower cervical exam?
multiple reps of retraction do not produce or worsen HA
upper cervical position changes DO NO affect HA with slight adjustments
retraction and extension can centralize HA as they can centralize lower cervical sx
34
HAs are often seen in pts referred for what?
c spine pain
35
what are red flags we may find in our eval?
sudden onset of HA at night with no previous hx
worsening pattern of HA (worse than i've ever had b4)
HA with systemic illness, fever, neck stiffness, rash
HTN with HA
HA with focal neuro signs
HA triggered by cough, exertion, Valsalva
HA during pregnancy or post partum
new HA type pain on pt with hx of CA
HIV
36
what would sudden onset of HA at night with no previous hx indicate?
subarachnoid bleed, mass, AVM
37
what would worsening pattern of HA (worse than i've ever had b4) indicate?
subdural hematoma
med overuse
38
what would HA with systemic illness, fever, neck stiffness, rash indicate?
meningitis
encephalitis
Lyme
arteritis
39
what would HA with focal neuro signs (facial droop, tongue deviation) indicate?
CVA
40
what would a HA triggered by cough, exertion, valsalva indicate?
subarachnoid bleed
41
what would new HA type pain in pts with hx of CA indicate?
possible metastasis
42
what causes chemical activation of nociception in HAs?
sufficient concentration of noxious chemicals
43
what causes mechanical activation of nociception in HAs?
application of sufficient mechanical force
44
what are the types of chemical nociception?
infectious process
inflammatory disease
trauma
45
if treated correctly, inflammation and swelling due to trauma start to subside form the ___ post-traumatic day
5th
46
if chemical nociception is due to trauma, what can disrupt the healing process? what can promote the healing process?
improper movt/positioning of the injured tissues can disrupt the healing process
proper movt/positioning of the injured tissues can promote the healing process
47
what are the types of mechanical activation?
force producing stress (sudden)
force producing creep (sustained)
force occurs at end ROM
sx may increase, decrease, or abolish with movts or positions
lying often offer relief but not always
sx are often intermittent but may also be constant
48
which is more reliable to establish clinical guidelines to treatment: pt sx or imaging/a-asymmetry/feel/mobility?
pt sx!!!!
49
what are the types of cervical and cervical referred pain to the cervical, thoracic, and UE?
sharp, stabbing
achy, dull ache, sore, throbbing, pulsing
brunindg, tingling, numb, cold, warm, heavy
tight, stiff
"feels different"
50
what are the types of SO, head and face pain and sx referred from the cervical spine?
sharp, stabbing, boring, piercing
achy, dull ache, sore, throbbing, pulsing
burning, tingling, electric-shock like
tight, vise-like, band-like pressure, sinus pressure
jaw pain/tightness, popping, clicking, bruxism
ear fullness, tinnitus, dizziness, nausea
visual disturbances, floaters, photophobia, dryness, blurred vision, tearing, blind spots, tunnel vision
51
what is one of our most powerful tools to know if our treatment is moving the pt in the right direction?
centralization
52
what is centralization?
a dec or abolishment of the most distal sx as a result of particular position or movt of the spine
53
what is peripheralization?
the opposite of centralization
an inc in distal sx or production of a more distal sx as a result of a particular position or movt of the spine
54
what is the correct direction of force in treatment?
the spinal position or movt which centralizes sx
55
t/f: when sx can be centralized, spinal movts or positions which cause peripheralization are contraindicated
true
56
what is rapid centralization?
centralization that occurs within seconds or minutes helping to confirm the preferred direction of force
57
what is gradual centralization?
centralization that occurs over days and weeks helping to provide objective data to confirm progress
58
t/f: proximal sx may abolish when working on distal sx
true
59
what are the associated characteristics of centralization?
proximal sx may inc in frequency/intensity
sx may cross the midline and be produced on the opposite side
cervical/thoracic/head and face centralization analysis is trickier that lumbar
60
what is the order of centralization in the cervical/thoracic/UE?
fingers/hand
wrist/forearm
arm
lower thoracic, mid thoracic, scapula
distal (bra strap), mid, proximal UT
cervical spine
61
will a regular upper quarter screen be enough for pts with spotty cervical distribution of sx to the t spine, scap, shoulder, elbow, wrist, head/face?
nope
62
what is the pattern of centralization for the SO, head and face?
mouth/teeth
nose/cheeks
eyes
frontal
parietal
temple
TMJ
ear
occiput
upper cervical
63
what pt info is included in the ABPC pt eval form?
pain drawing
VAS
hx
sx frequency
fxnal comparison
physical exam
static/dynamic force application
64
if someone has a lower cervical problem, what is the first step of the SO 2 algorithm we should try?
loaded retraction in reps of 10 in a small range
65
if someone has a lower cervical problem, after doing loaded retraction, what is the next step of the SO 2 algorithm we should try?
loaded extension for a 30-60 sec hold
66
if sx are no longer getting better or worse with something in the SO2 algorithm, what should we do?
increased the range or move to the next step
67
what does manually unloaded mean in the SO2 algorithm?
distraction
68
what is the position to perform manually unloaded retraction and extension in the SO2 algorithm?
supine
69
in manually unloaded position, what should we start with in the SO2 algorthim?
retraction in reps of 10 then extension for 30-60 sec holds
70
what is the order of exercises to go through with asymmetrical force in the SO2 algorithm?
lateral flexion
rotation
loaded lateral flexion
loaded rotation
71
if a pt has an upper cervical problem, what is the first thing we want to do in the SO3 algorithm?
loaded protrusion
72
after doing loaded protrusion in the SO3 algorithm, what do we move on to trying?
loaded upper cervical extension
73
after doing upper cervical extension in the SO3 algorithm, what do we move on to trying?
loaded retraction
74
after doing loaded retraction in the SO3 algorithm, what do we move on to trying if lower cervical is suspected?
loaded extension
75
after going through the loaded exercises in the SO3 algorithm, what do we move on to?
unloaded exercises in supine
76
what is the first unloaded exercise to try in the SO3 algorithm for upper cervical problems?
supine protrusion/retraction
77
after trying the unloaded protrusion/retraction in the SO3 algorithm for upper cervical problems, what do we try?
unloaded cervical extension
78
if we try unloaded exercises in the SO3 algorithm for upper cervical problems in supine but they aren't working what should we move to try?
try them in SL (protrusion/retrusion first, then upper cervical extension)
79
after trying the symmetrical exercise for upper cervical problem in the SO3 algorithm, what should we try?
asymmetrical force into rotation and lateral flexion
80
with an upper cervical problem in the SO3 algorithm for asymmetrical force into rotation then lateral flexion, which direction do we go into first?
the most restricted direction
81
in the SO3 algorithm for upper cervical problems, do we do rotation or lateral flexion first?
rotation
82
what should be included in the cervical/head pt home program?
PREP
cervical alignment
ADL modification
pt self-monitor
83
what is the most effective intervention strategy for pts with neck pain?
manual therapy and specific exercises with education addressing self-efficacy
84
what is the goal of treatment?
for the pts to become independent of the medical system in managing their disorder
85
what are some dependent conservative treatments for the cervical spine?
modalities
traction
high tech equipment
mobilization
manipulation
86
what are some independent conservative treatments for the cervical spine?
PREP
postural exercises
ADL modification
self-monitoring
87
what are the advantages of self-treatment?
gives the pt control
promotes self-reliance
PREP and postural exercises = prevention
immediate relief of recurrent sx (mechanics b4 meds)
88
what are some tx options for HAs/migraines?
appropriate exercise programs
individualized postural realignment
sleeping
unloading
manual therapy
prevention
89
what are good exercises in treating the cervical spine?
PREP
posture
neuromuscular re-ed
90
when there is an upper and lower cervical COMBINED problem, what do we always treat first?
the HA (upper cervical) first bc we will worsen their upper cervical problems with lower cervical tx
91
if a pt has an upper cervical problem, what do we do for treating it?
use extremely small position changes
loaded protrusion/upper cervical extension (escape position) (PREP)
unloaded protrusion/upper cervical extension (escape position) (PREP)
use escape positions to take tension off the upper cervical structures
92
why would we use SL in the upper cervical PREP?
bc supine position failed
relieves compression force for the pillow on the SO tissues
93
when would we want to reduce head elevation in supine in the upper cervical unloaded progression?
when retraction ROM improves
when the pt can lie supine with less hand support and no ERP
94
how do we stretch shortened tissues in the posterior upper cervical spine?
starting with retraction
95
when would we want to start to stretch the posterior upper cervical spine?
when there is dec tissue irritability/sensitivity
96
t/f: when stretching the shortened tissues in the posterior upper cervical spine, we should just barely be provoking sx and they must abolish/lessen/return to baseline when pressure is released
true
97
what does persistent pain following release of the stretch of shortened posterior upper cervical spine tissues indicate?
overstretching
98
what do the PREP exercise clinical guidelines say about progression from unloaded to loaded?
there should be clear, objective improvements
there should be consistent control of sx when in supine
the pt can be upright for longer periods control sx
the pt can frequently lessen/abolish sx when upright using postural realignment
clinical testing of retraction when upright produces ERP but doesn't worsen
99
how many reps/session of PREP should we start with?
5 reps
100
how many sessions/day of PREP should we start with?
3x/day (although lower cervical may do 30-60 to get rid of their sx)
101
what is the ideal reps and reps/day to complete of the PREP?
10 reps Q2hrs (8x/day)
102
how many factors of the PREP (reps, sessions, force) should we increase at a time?
just one
103
how many asymmetrical exercises should we be adding to the PREP at a time?
one at a time
104
what is involved in the PREP for a lower cervical problem?
retraction
extension
SB
rot
105
is upper or lower cervical treatment more repetitive and frequent?
lower cervical
106
when treating a lower cervical problem with upper cervical involvement, what should we do to put the SO tissues on slack?
lift the chin
107
t/f: unloaded retraction has the potential to cause more upper cervical flexion, so be careful when there is upper cervical involvement
true
108
with the head at 0 deg flexion, what is the weight on the neck?
10-12 lbs
109
with the head at 15 deg flexion, what is the weight on the neck?
27lbs
110
with the head at 30 deg flexion, what is the weight on the neck?
40 lbs
111
with the head at 45 deg flexion, what is the weight on the neck?
49 lbs
112
with the head at 60 deg flexion, what is the weight on the neck?
60 lbs
113
what is waking pain?
pain present as soon as you open your eyes in the am
114
if a pt presents with waking sx, what is an important thing to include in our session?
sleeping education
115
is there such a thing as PWB of the spine?
nope, not like the LE
116
t/f: the spine is either FWD or NWD
true
117
what is the correction cascade for strategic unloading of the spine?
correct posture
change loaded position
unload (lie down) in the escape position
begin PREP (if thsi relieves sx better than escape position)
118
what is the best manual therapy for an upper cervical problem?
HANDS OFF is best
119
what are the best manual therapy techniques for getting rid of difficulty upper cervical HAs?
suboccipital release
SO STM
120
what may we need to utilize with retraction/extension/rot/SB to centralize sx in a lower cervical problem?
manual unloading (traction)
