Systemic tx class 1 (headaches)

Question 1

systems approach to care

Answer 1

Bio-psycho-social (BPS)

Think systems, as in physiology, not just anatomy

Patient centred care

Therapeutic relationship

Question 2

“more lifelike approach”

Answer 2

The enemy of individualized care is protocol and routine…

Each case is context dependent

There are multiple answers, so can you justify and defend your position?

Question 3

case management steps

Answer 3

Rule out red flags.

Modify.

Treatment goals-what can you do to increase the quality of life of your patient.

Indications for your treatment choices

Case management

Question 4

Rule out red flags.

Modify.

Answer 4

1) Rule out red flags-red flags require further investigation (we first need to know what they are)

Can we treat safely today?
*if no, when do we refer out
(is it a medical emergency)

*if yes, what modifications are needed for safety

What can we modify?

HOPNMRS is one tool to rule out and treat safely

(This class will emphasize history questions!)

Question 5

Treatment goals-what can you do to increase the quality of life of your patient.

Indications for your treatment choices

Answer 5

2) Treatment focus-treat effectively

Goals

 -consider the client’s goals, short and long term (this is where our goals come from)

-look at ‘contributing factors’ rather than cause. Often we don’t fully know the cause, and can be multifactorial.

-management of chronic conditions=complex

Question 6

treatment focus

Answer 6

Treatment focus

 -think systemically, engagement, interaction, and what can you affect?

 -treatments include assessment-reassassment/homecare/education, not just hands on. 

 -goal to increase the quality of life for our patients

WE ARE NOT FIXING OUR CLIENTS CONDITIONS

Question 7

Case Management

Answer 7

History questions to rule out red flags, determine health status, establish goals and expectations

Assess-Special tests to confirm, and direct treatment

Goals-based on client’s story

Techniques-determine what is indicated based on goals/symptoms

Homecare/hydro-relevant to patient goals/symptoms

Question 8

primary vs secondary headache

Answer 8

Primary –is the condition

Secondary-underlying condition

Question 9

three types of (primary) headaches

Answer 9

Tension

Migraine

Cluster

Question 10

E.g. of underlying conditions in secondary headaches

Answer 10

Organic -Exertion -Withdrawal/Rebound
Rebound -Allergy -Meningitis
TMJD -Cervicogenic -Cold/Flu
Exertion -TMJD -Organic (tumour)
Allergy -Trauma -Sinus

Question 11

note about severity of pain (similar to OA & other orthopedic conditions)

Answer 11

in headache as well

Severity of pain is not an accurate indicator of severity of condition

Question 12

about tension HA

Answer 12

Bilat px
Diffuse px
Band like px around head
Dull or vice like
Onset later in day
Last 30 min to weeks
Mm stiffness, hypertoned mm, tinnitus

These HA begin in adulthood

Affect both men and women

Primary HA-cause unclear
Contributing factors:
Stress, poor ergonomics or posture,
Family hx, trigger points in neck or head, cold, hypoglycemia, fatigue
Cervicogenic possible co-relationship

Question 13

about Migraine HA

Answer 13

Unilateral

Px starts as dull ache then becomes intense and pounding, has 3 phases, and triggers
Last 4-72 hours

May have aura or visual disturbances
Nausea, vomiting, photophobia, phonophobia,

Question 14

migraine demographics

Answer 14

Family hx 70%

Women more than men

Starts around first menses
May start again near perimenopause

Question 15

primary migraine HA

Answer 15

Primary HA-cause unclear, vascular/neuro?

Question 16

primary migraine HA – TRIGGERS

Answer 16

Triggers: hunger, stress, allergies, meds, weather, visual/auditory/ olfactory stimuli, sleep, hormones.

Question 17

CLUSTER HA

Answer 17

Unilat px

Intense severe px

Intermittent px
(daily, repeating for weeks/months)

Often nocturnal (waking up with HA)

Question 18

cluster HA demogrpahics

Answer 18

Affect only 0.1% of people
Men 5x more likely

Question 19

cluster headache contributing factors

Answer 19

Smoking is a risk factor

Association with abnormal hypothalamic function

Question 20

primary cluster HA?

Answer 20

cause unclear

Question 21

trauma headache

Answer 21

Pain in the head or neck from injury

As a result of trauma – anyone

Question 22

trauma headache etiology

Answer 22

Trauma to the head, neck or spine. Falls on tailbone may create headache due to dural tube and meninges tension

Question 23

sinus HA

Answer 23

Pain in face- forehead, maxilla, btw eyes

Nasal drip or congestion

Pain increases in different positions

Facial tenderness

Question 24

sinus HA – demographics

Answer 24

Anyone experiencing upper respiratory issues

Question 25

sinus HA -- etiology

Answer 25

Viral, bacterial infections, allergies, hx of facial trauma, abcesses in molars

Question 26

withdrawal headache

Answer 26

Begin in early am when blood levels of drug are lower Throbbing px Bilateral px

Question 27

withdrawal HA -- demographics

Answer 27

Anyone experiencing medication/drug withdrawal

Question 28

withdrawal HA -- etiology

Answer 28

Removal of caffeine, drugs or medications

Question 29

migraines

Answer 29

Most commonly no aura (visual disturbance) Migraines may have 3 phases

Question 30

THREE PHASES OF MIGRAINE

Answer 30

PRODROMAL -mood changes, cravings, cold (may have aura-visual, confusion, slurred speech) ATTACK -unilateral, throbbing, sensitive to light and noise, nausea, vomiting POSTDROMAL -tired, sluggish, flaring pain during quick movement

Question 31

FOUR CONDITIONS w/ HA when pt must be referred out

Answer 31

*Temporal arteritis -rare condition affecting elderly. Inflammation of the temporal artery. Throbbing at temple, may appear red and swollen. Refer to doctor within 24 hours. *Preeclampsia-HA in pregnancy-especially if severe. Immediate doctor referral. *Aneurism-sudden, severe, explosive(like lightning) –Immediate referral to doctor *Meningitis-fever, stiff neck (+Koernig’s) Immediate referral to doctor

Question 32

Koernig's sign test

Answer 32

Kernig's sign is a physical exam used to assess for meningitis, an inflammation of the membranes around the brain and spinal cord: The patient lies on their back with their hips and knees bent at a 90-degree angle. The examiner then slowly extends one knee at a time. A positive Kernig's sign is indicated by pain, resistance, or an inability to extend the knee. "Extension of the leg while performing Kernig's sign stretches the hamstring, which pulls on the surrounding tissue near the inflamed spinal canal and meninges."

Question 33

RED FLAGS FOR HEADACHES ---> INCORPORATE INTO Hx Q

Answer 33

Severe pain that comes on suddenly Head pain accompanied by fever Headache with nausea, and/or vomiting Head pain that worsens over time, especially if it follows a head injury (also- recent head injury) Accompanied by mental confusion, seizures, mood swings, or other neurological symptoms (memory loss, double vision, loss of motor control/coordination,/strength, affects special senses) HA that occurs after physical activity, straining or coughing New headache after the age of 55 (---> or in early childhood) HA’s accompanied by numbness on one side of the face/head (pins/needles in case study) HA’s accompanied by clear fluid or blood coming out of ears HA’s that do not fit a recognizable, usual pattern of s&s to the person –unusual presentation New HA in a person with a history of cancer or heart disease CURRENT HA WILL NEED TREATMENT MODIFICATIONS

Question 34

TREATMENT MODIFICATIONS FOR ACTIVE HA

Answer 34

Less physical assessment during active HA (more time on history to rule out red flags) Modify position-supine or sidelying, check if client can tolerate prone (level of HA on scale) Techniques-during active HA, ask if ok to touch/work directly on head Limit strokes toward head (BLOODFLOW TOWARDS THROBBING/PAINFUL ACUTE AREA) Less TPR and pressure during active HA (RATTRAY ALSO SAYS NOT TOO DEEP W/ PRESSURE) Aware of triggers in room-lights/noise

Question 35

E.g. of longterm vs shortterm goals for HA

Answer 35

reduce current discomfort = short-term reduce frequency of HA = long term --> E.g. via change in habits, or reducing/removing stressful triggers

Question 36

TREATMENT IN BETWEEN HA

Answer 36

Decrease TPs (where is usual pain?) ---> E.g. SCM Decrease stress response/feedback loop (SNS) Consider habitual postures ie. Head forward ---> HOMECARE for posture Consider areas with lack of movement (TENSION)

Question 37

Education-patient self management tools

Answer 37

----> Diaphragmatic breathing, movement, stretch, hydro ALSO CONSIDER ISOMETRICS FOR NECK (see Rattray)

Question 38

finding ways to decrease "fid" of HA

Answer 38

removing/reducing triggers changing habits (including sleep, exercise) etc.

Question 39

cluster HA

Answer 39

"Extreme sharp or stabbing pain, usually in, behind or around one eye. The pain can spread to other areas of the face, head and neck. Pain on one side of the head in a single cluster. Pain can switch to the other side in another cluster." "The symptoms of a cluster headache include stabbing severe pain behind or above one eye or in the temple."

Question 40

THREE "levels" for Hx Qs

Answer 40

Level 1-safety/rule out/investigate red flags Level 2-Treatment and type of HA Level 3-Contributing factors

Question 41

Level 1-safety/rule out/investigate red flags

Answer 41

-HA now, neuro symptoms, intense pain with sudden onset, Dr, Meds, trauma, fever, underlying health, new H/A in young/old, unusual

Question 42

Level 2-Treatment and type of HA

Answer 42

-where is the pain, when, FIDs of HA, stress level, triggers, other tx (eyes, dentist, chiro)

Question 43

Level 3-Contributing factors

Answer 43

-lifestyle: sleep, work, family hx, activity level

Question 44

valuable special tests during Dx/Ax of HA

Answer 44

1) Cervical compression/distraction (tests for nerve root or facet joint irritation) ---> POSITIVE: radiating pain or other neurological signs in affected arm indicates compression of a cervical nerve root  POSITIVE: pain in the neck/shoulder indicates cervical facet joint irritation

Question 45

1)Cervical compression/distraction (tests for nerve root or facet joint irritation)

Answer 45

---> POSITIVE: radiating pain or other neurological signs in affected arm indicates compression of a cervical nerve root  POSITIVE: pain in the neck/shoulder indicates cervical facet joint irritation DISTRACTION: reduction of SSx = positive

Question 46

2) Spurling’s Test / “Quadrant” (tests for cervical nerve root, facet joint irritation)

Answer 46

 Unaffected side first!  Seated; extend, side bend & rotate  Carefully apply compression downward  POSITIVE: pain radiates down into the arm on that side  Repeat on other side

Question 47

3) Vertebral Artery Test (VAT) (Tests for circulation deficiency of the vertebral artery at the transverse foramen)

Answer 47

 Patient is supine; therapist seated by guest’s head  Patient has eyeglasses off (if applicable); asked to keep eyes open  Passively fully extend the head and neck, side flexion, then fully rotate to the same side, hold for 30 seconds  Repeat on other side  POSITIVE: vertigo, nausea, nystagmus – do not perform further testing if positive

Question 48

signs and symptoms which may indicate possible vertebral-basilar artery problems (from Magee)

Answer 48

o Malaise o Nausea o Vomiting o Dizziness/vertigo o Unsteadiness in walking, incoordination o Visual disturbances o Severe headache o Weakness in extremities o Sensory changes in face or body o Dysarthria (speech) o Dysphagia (swallowing) o Disorientation, light headedness o Hearing difficulties o Facial paralysis

Question 49

4) Kernig's sign test

Answer 49

noted in previous card

Question 50

5) Soto Hall test

Answer 50

 Patient is supine on the table  Ask the patient to place their hands behind their head and flex their chin to their chest  If the patient experiences a sharp pain down the posterior neck and spine this may indicate meningitis

Question 51

rebound headaches (withdrawal HA)

Answer 51

“Rebound headaches: also called analgesic or painkiller rebound, caffeine withdrawal, and holiday, weekend or travel headaches, (they) are classified as vascular headaches, but are much less intense than a migraine, cluster, and sensitivity headaches. Characterized by dull throbbing pain on both sides of the head, these headaches strike when you miss your daily medication or caffeine.” “… over-consumption of or withdrawal from narcotics or caffeine-containing substances (etc.)…constrict blood vessels, and the subsequent “rebound” dilation can trigger a headache. “…Rebound headaches are best treated by gradually removing the rebound-causing substance and by whole natural body detoxification.” (p. 59).