RSSHeadache, Orofacial Pain and Bruxism
December 16, 2009 by David Fitzgerald |
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Filed under Headache, Physiotherapy Blog
The International Headache Society originally classified 126 different types of headaches and orofacial pain. In primary care 3 sub-classifications of headaches allow useful patient categorisation.
Migraine
Tension type headache
Cervicogenic headache.
Orofacial pain and Bruxism often compound the diagnosis of headache as there maybe overlapping pathophysiology. Exclusion of “red flags” is critical.
Headache “Red Flags”
1) Instantaneous headache
2) Sub-acute headache in patients over 55
3) Neurological signs
4) Fever
5) Neck stiffness
6) Headache worse on wakening
7) Recent head trauma.
Having excluded the red flag categorisations you are then left with the three defining categories as above of migraine, tension type headache and cervicogenic headache.
Migraine
Symptoms …..
Fequently intense
more likely to be unilateral
Pounding
Nausea
Photophobia
Phonophobia
Helped by sleep.
Typically occurring episodes lasting between 4-72 hours.
True migraine can be managed by the use of pharmacological agents such as:
Ergotamine
Triptan
Simple analgesics
Antiemetic medications.
These are obviously issues for a prescribing physician or neurologist. The physiotherapist needs to be aware of these therapeutic modalities as often the patient will present with neck pain which is secondary to a primary vascular cause of migraine. Detailed history of the migraine pattern in terms of precipitating factors which maybe well known food substances e.g. chocolate, red wine, dairy products or less frequently dehydration, fatigue, exercise, physical loading, ergonomics and musculoskeletal factors. While these patients may have true vascular migraine, mechanical factors amenable to physiotherapy may also be relevant triggers and thus are legitimate targets for treatment.
Tension-Type Headache
Very often a chronic migraineur develops a pattern, persistent tension type headache as part of an ongoing symptom pattern punctuated by episodes of an acute vascular migraine. The ongoing tension headache is often more debilitating and functionally impairing and harder to manage with pharmacological strategies. Typically described as:
Dull pressure
Band like pain radiating from the forehead to the occiput
Often involving the neck muscles.
Pathogenesis is unclear at this point. In association with persistent muscle tension the obvious therapeutic strategies of optimising muscle control, improving deep neck flexor function and optimising scapula control are all part of the routine testing protocols which should be addresses if clinically demonstrated. For patients who do not display these deficits there maybe a role for general relaxation or specific biofeedback training. The commonest clinical challenge is to prioritise from a multitude of co-existing findings.
Cervicogenic Headache
This is frequently under recognised in primary care masquerading under a diagnosis of migraine. Typically these patients describe symptoms, which last longer than an acute migraine episode of 4-72 hours with symptoms often lasting days to weeks. Sleep does not usually influence symptoms and the pain intensity is usually of less severity that an acute migraine attack. There may be some associated sensations of aura mimicking a migraine. These can sometimes be reproduced by cervical provocation testing using manual techniques. Pain is usually localised on one side and frequently periorbital distribution but can also involve the maxillary and mandibular regions. Co-existing TMJ pathology may compound the diagnosis.
TMJ Related Headache
The pain referral pattern from the TMJ may involve the temporal and frontal regions and the myofascial referral zones involve the head, face and neck. The primary issue with TMJ related pain is to establish whether it is driven by Dental issues relating to occlusion and bite mechanics, which require specific intervention from those specialties.
Alternatively, Bruxism (habitual grinding) – both nocturnal and daily are often significant perpetuating factors in the symptom pattern. Treatments that target the TMJ involve specific joint mobilisation, improving general ranges of motion, post-isometric relaxation, general jaw mobilisation and specific myofascial trigger point therapy using either palpatory of dry needling techniques. Dental occlusion splints at night are also typically part of the management strategy.
From a physiotherapy perspective it is common to observe a temporary reduction in clinical signs by treating symptomatic articular / myofascial components but the effects of treatment are relatively short lived. In these situations the challenge is then to explore symptom drivers. The use of kinesio tape is beneficial for evaluating the role of postural alignment as often there is a dual ergonomic and stress / tension component related to occupational factors as part of the symptomatology. These are undoubtedly challenging patients to treat and certainly require multi disciplinary collaborative input in order to optimise management.
Enjoy the clinical challenge
David
Whiplash Treatment
November 27, 2009 by David Fitzgerald |
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Filed under Headache, Physiotherapy Blog
The spectrum of whiplash treatment is a reflection of the diversity of pathology which is encountered and may in turn lead to a variety of clinical manifestations now referred to as whiplash associated disorders (WAD).
The initial guidelines on WAD were formulated in 1996 by the Quebec task force.
This patient group includes:
27% of subjects who still have pain 6 months post injury
15 – 20% of subjects develop persistent pain & disability
$29 Billion – The U.S. annual costs associated with WAD
Treatment
In general terms treatments involve a combination of:
● Manual Physical Therapy & Graded Exercise
● Deep Neck Flexor Endurance Exercise
● Patient Education on Staying Active
Evidence
Early referral to Physiotherapy results in superior short and long-term outcomes when compared to immobilization with a soft collar and advice to rest, even in patients with identified elevated psychological distress levels.
Associated mechanical thoracic spine impairments may be more prevalent in patients with WAD (69%) than in those with mechanical neck disorders (13%) and when treated with thoracic manipulation, patients with WAD demonstrate greater reductions in pain than patients with mechanical neck pain.
Retraining the deep cervical flexors in conjunction with manual therapy to the cervicothoracic spine can effectively decrease neck pain and headache with results being maintained at one-year follow-up.
Reassurance that there is no serious tissue damage, encouraging patients to stay active and maintain normal activities of daily living is effective in reducing delayed recovery.
Elevated psychological distress is a nearly uniform finding in patients suffering from acute WAD and is associated with several predictive factors
Prognostic Factors
≥26 pts on the Impact of Events Scale (IES) is indicative of patients with higher levels of post-traumatic stress reaction, adversely affected recovery, and more likely to benefit from specific treatment. In fact, an Neck Disability Index (NDI) score ≥30 combined with cold hyperalgesia results in a 10-fold increase in the odds of experiencing moderate to severe levels of posttraumatic stress.
Higher initial scores on the Neck Disability Index (NDI), older age, cold hyperalgesia and higher acute post-traumatic stress levels accurately are predictive of those who will experience moderate to severe symptoms at 6 months.
Management
Patients with Quebec Task Force WAD Grade I-III as early in the course of care as possible. This would include patients with headaches and non-progressive neurological symptoms
In particular, patients with the following factors should be referred in order to decrease the probability of developing chronic symptoms:
● IES score ≥26 pts
● NDI score ≥30 pts
● Older patients
● Cold Hyperalgesia
The key clinical issues are to determine if a patient has factors predictive of chronicity and the likelihood they would benefit from physiotherapy intervention.
Sterling’s Modified classification (2004)
| WAD 0 | No signs |
| WAD 1 | Complains of stiffness & tenderness
No physical signs |
| WAD 1A | Neck pain, Motor impairments, Reduced ROM, Local Hyperalgesia |
| WAD 1B | As 1A + Psychological distress |
| WAD 1C | As 1B + proprioceptive impairments, diffuse pain pattern, Post – traumatic stress |
| WAD 2 | As Quebec |
| WAD 3 | As Quebec |
| WAD 3 | As Quebec |
The suggested modifications are aimed at selecting sub-groups of patients where more specific whiplash treatment can be devised based on the spectrum of clinical signs and incorporating psychosocial factors and pain mechanisms.
Enjoy the clinical challenge.
David
Headache
July 1, 2009 by David Fitzgerald |
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Filed under Headache, Physiotherapy Blog
Differentiation of the pathogenesis of headaches is a complex clinical challenge. The International Headache Society have classified 126 types of headache on the basis of:
symptoms
behavioural characteristics
regional distribution
temporal characteristics
responsiveness to pharmacological intervention.
Many patients are diagnosed as Migraine sufferers but do not fit the classical ” migraine with aura” classification and are then classified as “atypical migraine without aura”.
While many of these patients can identify specific triggers (alcohol, dairy products, chemical irritants, ambient lighting, fatigue and dehydration many are unable to determine triggers.
Unfortunately, many chronic migrainuers develop “Tension type headache” or alternatively “chronic daily headache”
Physiotherapists dealing with this type of caseload commonly find a multitude of clinical signs in the cervical & thoracic spine together with TMJ dysfunction.
The clinical challenge is to determine the relevance of co-existing physical signs and the prioritisation of legitimate targets to treat.
The pain producing structures may be….
Articular
Myofascial
Neural
Common mechanisms may precipitate sensitisation of these structures
Such as
postural adaptation
occupational factors
ergonomics
previous musculoskeletal history
and the clinician must prioritise the primary target tissue.
Often this is influenced by clinician bias as to whether they utilise a manual therapy approach, a general exercise regime, a specific muscle imbalance protocol, myofascial techniques or dry needling.
The direction for future research into cervicogenic headaches needs to look at the testing and interpretation of musculoskeletal clinical signs which are frequently associated with headaches in order to establish clinical prediction rules and a clinical efficacy protocol for the management of these challenging patients.
Share your experiences with fellow clinicians by adding your comments below.
Enjoy the clinical challenge
David
