headaches

[vinniek21]

Hi
i am a new grad so any help will will be appreciated!
I have a 75+ old pt who on reports has C4-5 spondylosis and has neural foraminal degen changes at C4,5,6 levels. however, there is no nerve encrouchment.
She complains of severe pain post neck (L>R) and post head, on top of head and front of face (L>R) worsening past 2weeks. she has no radiating arm/hand changes
She is very irritable so i didnt push her much.
On Cx movements, had about 1/4 normal L and R rotation, LF, Ext and flex. These were her comfortable ROM, but she was uncomfortable at EoR.
Sx and Ox she didnt complain of Dizziness etc
SHe had very tense para musculature of SCM, traps, LS etc. Has FHP and IR shoulders.
I had 1 session with her in which i gave her a heat pack and the a soft tissue msg to the cervical musculature which she found helped relax her a lot, also taught Cx retraction ex.
i was wondering whether in this case, would it be safe for me to perhaps trial gentle PA mobs, or at least gentle PPIVMs on rotation...im suspecting the joints to be stiff, so maybe some gentle PPIVMs may loosen her up as well? Do you think these could be indicated given her irritability?
Looking forward to your ideas!!
Thanks
V

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[alophysio]

Hi Vinnie,

Sounds like you have things under control.

Try this:

> Start at C1 TPs bilaterally with the patient supine and you at the head of the bed with your fingers under to palpate.
> Determine which one feels closer to the bed - this is the side that the segment is rotated to. eg: R C1 TP close to bed at C1/2= C1 rotated right on C2.
> Determine how much movement there is via PPIVM rot and PPIVM LF. Do this in neutral, extension and flexion. I usually hold both the C1 and C2 to feel the C1/2 segmental motion.
> If the TPs level up in one direction, then treat in the other. eg: in extension (most commonly), the TPs level out therefore continue below with C/S flexion...
> Find the limit of rotation to the other side. eg: segmental limit of L rot of C1 on C2.
> Hold this position. eg: in flexion and rotation L
> In the position above, now find limit of LF L (it will be very small. The reason why is because in the C/S, rotation is coupled with ipsilateral LF.
> Now ask the patient to "move the head to the right" - some will rotate, others will LF. It doesn't matter since they couple to the same side.
> Hold for 6-8 seconds.
> Reassess.
> Repeat x2 more times
> Work you way down the neck.

You have just done MET 101 for the C/S!

[MrPhysio+]

Hi Vinnie and Alophysio,
Good advice. Muscle energy techniques can help, without further irritating the lady, whilst building trust. Check out the patients osteoporosis status prior to manual techniques, and be very vigilant regarding dizziness during treatments in the elderly.

Most patients respond well to soft tisue techniques, even when the cervical spine can be fairly stiff and degenerate. Determine how much function the patient requires for average daily activities - if they aren't normally very active, there is no need to aim for function levels at a high level.
MrPhysio

[vinniek21]

THanks a lot for your reply guys.
I have been following your suggestions.
As of now i have been using a heat pack along with gentle STM, and have also been doing gentle rotational PPIVMs with her in supine at around the C1-C5 levels
WHile we are achieving slight improvements in ROM, her headaches remain the same.
I am now thinking about perhaps trialing TENS on her neck for pain relief?
Am i jumping the gun?
Thanks
Vinnie

[alophysio]

Why TENS? A paracetamol tablet will do the same.

This is what my post about relying on electro was about! Electro is not going to solve any problems. My advice is...DON'T COP OUT!!!!!

Firstly, forget the heatpack, you have better things to do with your tie and it is obviously not helping anyway. I find that it can alter the patient's perception of symptoms during rx and then they crash later and blame me. If they want, they can buy one and put it on at home...

Secondly, you haven't hit the problem on the head (no pun intended!). If you aren't getting results, you aren't doing the right thing. It's that simple. When you get it right, they will feel immediate relief and they will know it (and so will you).

Ok, some questions...
1. Do the headaches alternate?
2. Where exactly are the headaches. Please be specific - e.g. pain behind the eyes, pain in the eyebrow, pain above the eyebrows, pain in the central top of head, pain obliquely on head etc.
3. You say she responds to relaxing. Is she overactive in her posture (e.g. loss of T/S kyphosis)? Is her FHP from poor T/S and L/S positioning or tight/overactive SCM?
4. Did you try the muscle energy stuff in my last post?

Some more opinions... the older people get, the less migraines usually so this would be unusual. Also, the lower C/S stuff on XR/CT is not a great concern if there are no corresponding clinical signs.

Try fixing her C3 and posteriorly gliding her C2 over the C3 *carefully* and sustain it. It might provoke her symptoms.

To get rid of headaches, i bring them on then sustain the pressure and hold until it goes. Works well...

Let us know what is going on!