Cervical Dysfunction Research Articles

Cervicogenic Headache Caused by Myofascial Trigger Points in the Sternocleidomastoid: A Case Report

Disturbances in the integrity of the upper cervical spine are now well known to be associated with head pain and can give rise to chronic daily headaches (1–3). Head pain that derives from cervical dysfunctions or disease is now contained under the category of cervicogenic headaches (4), which describes a heterogeneous group of disorders that commonly refer pain from structures in the cervical spine region (e.g. joints, muscle, nerve) to various regions in the head. The mechanisms that underlie head pain referred from the neck are not entirely understood. There is general consensus that the trigeminocervical complex, which is located in the lower brainstem and upper three cervical spinal segments and receives multiple afferent inputs from both the trigeminal nerve and cervical peripheral afferents, serves as the centre of convergence for the projection of perceived pain in the head that originates from cervical pain generators (1). However, this model may not explain all forms of cervicogenic pain, in particular myogenic referred head pain that derives from myofascial trigger points (MTrPs) of the cervical and upper back musculature (5, 6). An accurate diagnosis of the aetiology of cervicogenic headache can be challenging for the clinician due, in part, to the overlap of pain and associated symptoms between cervicogenic headache and primary headache (3, 7, 8) and the multiple abnormalities of the cervical spine and musculature that can be a primary source of head pain (9–12). Several authors have emphasized the role of anaesthetic nerve blockade, particularly directed to the occipital nerve and C2 spinal level, as the primary criterion for the diagnosis of cervicogenic headache (1, 3, 13). The increasing attention to anaesthetic blockade as a diagnostic tool has paralleled the expansion of the use of interventional procedures for the treatment of chronic cervicogenic headache (14–16). Interventional diagnostic measures tend to follow from abnormal radiographic findings, such as spondylosis, disk disease or facet arthropathy (1,9), and rely on patient report of diminished pain to anaesthetic challenge as a guide to diagnosis. Increasing reliance on nerve blockade as a diagnostic tool may encourage de-emphasis on the clinical examination of the musculature. Reliance on an interventional approach to the diagnosis of cervicogenic headache that targets joint arthropathies or possible nerve involvement tend to ignore the potential contribution of MTrPs or intersegmental motion restrictions as primary causes of cervicogenic headache (10, 17–19). Identification of the musculoskeletal dysfunctions requires a careful and informed clinical examination. Lack of familiarity with the characteristic myofascial referred pain patterns frequently leads to misdiagnosis and ineffectual headache interventions (10). We report a case of a male with a 25-year history of chronic headaches despite an extensive course of medical evaluations and treatment. After a recent hospitalization and further interventional procedures to identify a cause of his pain, a careful physical examination of the cervical musculature identified MTrPs in the sternocleidomastoid (SCM) muscle as a primary source of his head pain. Physical therapy that focused on reducing the myofascial dysfunction and addressing perpetuating factors felt to be maintaining his MTrP activity brought about dramatic reduction in his pain within 6 weeks, which was maintained at 6 months.

The crowned dens syndrome. Evaluation with CT imaging

The purpose of this study was to verify the value of computed tomography (CT) in the diagnosis of the "crowned dens" syndrome, not only in crystal deposition diseases, but also in other rheumatic or nonrheumatic conditions. Thirty-eight patients (15 men and 23 women; mean age 55 years; age range 35-79) with neck pain were examined and divided into two groups: (1) patients already identified as rheumatic and referred for further investigation of the atlantoaxial region; (2) patients with symptoms confined to the cervical spine, with inconclusive radiographic findings. Unenhanced CT of the cervical spine (Tomoscan SR 7000 Philips, Eindhoven, Netherlands) was performed in all patients. There were 11 cases of rheumatoid arthritis (ten women and one man), two calcium pyrophosphate dihydrate crystal deposition disease (both women), one of systemic sclerosis (a woman), one of osteoarthritis (a man), one of seronegative arthritis (a man), four of neoplasm (one woman and three men) with suspected cervical involvement, one (a man) of haematological disease (lymphoma), one (a woman) of menopausal osteoporosis, ten (five men and five women) of recent or previous trauma with suspected involvement of the skull base and first cervical vertebrae and six of unknown painful cervical dysfunction (three men and three women). CT demonstrated calcific deposits around the dens in 12 patients (three men and nine women), in the transverse and alar ligaments, and in the anterior atlantooccipital membrane. CT revealed horseshoe- or crown-like calcification surrounding the odontoid process. In our series, other rheumatic diseases, especially rheumatoid arthritis, showed similar irregular calcifications of the atlantoaxial joint. Discussion. In calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, the spine may be the only site of involvement, generally asymptomatic. Crystals located in the transverse ligament of the atlas give rise to the crowned dens syndrome, usually in patients affected by severe degenerative lesions of the atlantoaxial joint and peripheral chondrocalcinosis. Symptoms may be absent, or a neurological compressive syndrome may develop. Symptoms tend to worsen with age. The diagnosis is not always easy, as the symptoms are similar to those of other diseases, such as meningitis, cervicobrachial pain, occipitotemporal headache, calcific tendinitis of the longus colli muscle, spondylodiscitis and retropharyngeal abscess. CT is the gold standard in identifying crowned dens syndrome, as it is able to depict the shape and site of calcification and any bone erosions. Radiography of other joints (wrist, knee, pubic symphysis) may help to ascertain whether the disease is due to calcium pyrophosphate dihydrate or hydroxyapatite crystals, and is therefore recommended for routine patient management. Magnetic resonance imaging (MRI) is indicated for the study of neurological complications.

Cutaneous silent periods in the evaluation of cord compression in cervical spondylosis

The clinical diagnosis of cervical spondylotic myelopathy (CSM) may be challenging in patients with cervical spondylosis (CS). Routine nerve conduction studies (NCS) may not evaluate cord compression adequately. We obtained cutaneous silent periods (CSP) in 26 consecutive patients presenting with clinical features of CS, in comparison with 30 normal controls. The results were also compared with transcranial magnetic stimulation (TMS) findings, and magnetic resonance imaging of the cervical cord as the gold standard. CSP findings showed similarly high sensitivity of up to 96% with TMS in evaluating cervical cord dysfunction. In specific clinical settings, CSP is of value for the diagnosis of CSM in CS. CSP measurement is advocated as a simple and rapid diagnostic adjunct to NCS in evaluating CS patients with possible cord compromise.

Cervical spine alignment and hyoid bone positioning with temporomandibular disorders

The relationships between temporomandibular joint (TMJ) disorders and cervical structure dysfunctions have already been demonstrated. The aim of the present study was to investigate functional and structural alterations of the head and neck of 17 individuals with TMJ disorders (TMD group), compared with a control group of 17 asymptomatic subjects in a cross-sectional design. The outcome variables included pain on palpation of the sternocleidomastoideus, superior trapezius and subocciptal muscles, as well as radiographic measures of alignment of the cervical spine and positioning of the hyoid bone. Cervical alignment, determined by measures of the cervical curvature angle, was investigated by the Cobb method. Independent Student t-tests were used to investigate differences between groups for all outcome variables (alpha < 0.05). The results demonstrated that individuals with TMJ disorders, when compared with asymptomatic subjects, presented higher levels of perception of pain in all cervical muscles (P < 0.0001). No significant differences were found between groups for the cervical alignment measures. In the TMD group, the position of the hyoid bone in relation to the cervical spine did not appear to be different from the control group.

Cervical arterial dysfunction assessment and manual therapy

In this paper, we present a clinical overview of cervical arterial dysfunction (CAD) for manual therapists who treat patients presenting with cervical pain and headache syndromes. An overview of vertebrobasilar arterial insufficiency (VBI) is given, with reference to assessment procedures recommended by commonly used guidelines. We suggest that the evidence supporting contemporary practice is limited and present a more holistic, evidence-based approach to considering CAD. This approach considers typical pain patterns and clinical progressions of both vertebrobasilar, and internal carotid arterial pathologies. Attention to the risk factors and pathomechanics of arterial dysfunction is also given. We suggest that consideration of the information provided in this Masterclass will enhance the manual therapist's clinical reasoning with regard to differential diagnosis of cervical pain syndromes, and prediction of serious adverse reactions to treatment.

Pain characteristics of temporomandibular disorder: a pilot study in patients with cervical spine dysfunction

Objective:The purpose of the present pilot study was to describe pain complaints of TMD patients and cervical spine dysfunction.Methods:Fourteen women with myogenous TMD, cervical motion limitation and rotation of at least one of the three first cervical vertebrae evidenced by radiographic examination participated in this study. The multidimensional pain evaluation was accomplished by a Brazilian version of the McGill Pain Questionnaire.Results:The results showed that the most painful body site mentioned was cervical spine, followed by scapular region and temporomandibular joint. More than half of the volunteers reported temporal pain pattern as rhythmic, periodic and, or still, intermittent. The majority of the patients classified the pain intensity assessed at the moment of the evaluation as mild to discomforting. Absolute agreement was not observed among volunteers regarding word dimensions used to describe their pain, although a great number of patients chose the descriptor related to tension as the better expression to describe their painful complaint.Conclusion:Pain characteristics of TMD patients with cervical spine dysfunction showed cervical spine as a common painful region reported and words related to affective and emotional dimensions of pain perception can be used by these patients to qualify their pain complain.

Lateral epicondylalgia: an overview

Lateral epicondylalgia is a complex condition affecting both athletes and sedentary people. Many patients do not respond to physiotherapy and the condition has a high recurrence rate. Lateral epicondylalgia may be more complex than a simple lesion at the common extensor tendon. Clinical trials in this area have failed to find conclusive evidence to support the conservative treatment of lateral epicondylalgia. Common confounding variables in such clinical trials include wide ranges of duration of symptoms within a sample, and subjects with different modes of onset. In some trials, the co-existence of cervical spine dysfunction and altered neurodynamics is noted, but not treated; this may represent a reason for the poor results reported from clinical trials. It has been suggested that lateral epicondylalgia is a multistructural pathology, but this is not quantified or controlled for in any of the clinical trials; this also has implications for therapy. If lateral epicondylalgia is a multistructural pathology, then it is essential to have a standard method of assessing and quantifying the extent to which other structures are involved. This would allow for better standardisation of the samples included in clinical trials, which would then potentially lead to a better understanding of appropriate therapy.

Repeated Measures of Recent Headache, Neck and Upper Back Pain in Australian Adolescents

The epidemiological and clinical literature identifies strong associations between adult headache, cervical and thoracic spine dysfunction and spinal posture. This paper reports on the prevalence and incidence of headache, neck and upper back pain which occurred in the previous week, in urban Australians aged 13-17 years. Commencing in 1999, we followed a cohort of South Australian students through 5 years of secondary schooling. Of our commencing cohort of students, 132 (30%) provided data on bodily pain every year. For both girls and boys, there was a significantly decreasing prevalence of headache over the study period, while neck pain and upper back pain increased. There was a significantly increasing trend over time for boys with upper back pain. Twenty percent of girls and boys consistently reported headache, neck pain or upper back pain over 5 years. The progression of early adolescent headaches to mid-adolescent neck and upper back pain potentially reflects the adolescents' biomechanical responses to intrinsic and extrinsic imposts. This requires further investigation to understand the causes of adolescent headache, neck and upper thoracic pain.

Upper quarter kinetic chain response to cervical manipulation: a case report

Objective The purpose of this single subject case study is to examine the relationship between cervical spine manipulation and tender points located in the upper quarter. Clinical Features A 45-year-old female presented with cervical spine pain and corresponding pain points in the upper quarter following a motor vehicle collision occurring 7 months prior to testing. Inclusion criteria were 22 of 22 clinically significant pain points as measured by pressure algometry. Intervention and Outcome High velocity/low amplitude manual manipulation was administered to areas of joint restriction in the cervical spine. Pre- and post-treatment computerized algometry readings were taken in areas of the cervical spine and upper extremities to assess change in pain over time. Algometry points were chosen based on published upper quarter tender points associated with cervical joint fixation/immobilization. Conclusion Following a series of 15 cervical chiropractic manipulations, the patient demonstrated a significant increase in pain tolerance related to upper quarter pain points and demonstrated by pressure algometry. These findings correlate well with the literature, indicating that cervical spine joint dysfunction should be considered globally as part of a dynamic kinetic chain involving the upper quarter. Dysfunction in one part of the kinetic chain should direct treatment to other areas of the chain.

The Tulip classification of perinatal mortality: introduction and multidisciplinary inter‐rater agreement

To introduce the pathophysiological Tulip classification system for underlying cause and mechanism of perinatal mortality based on clinical and pathological findings for the purpose of counselling and prevention. Descriptive. Tertiary referral teaching hospital. Perinatally related deaths. A classification consisting of groups of cause and mechanism of death was drawn up by a panel through the causal analysis of the events related to death. Individual classification of cause and mechanism was performed by assessors. Panel discussions were held for cases without consensus. Inter-rater agreement for cause and mechanism of death. The classification consists of six main causes with subclassifications: (1) congenital anomaly (chromosomal, syndrome and single- or multiple-organ system), (2) placenta (placental bed, placental pathology, umbilical cord complication and not otherwise specified [NOS]), (3) prematurity (preterm prelabour rupture of membranes, preterm labour, cervical dysfunction, iatrogenous and NOS), (4) infection (transplacental, ascending, neonatal and NOS), (5) other (fetal hydrops of unknown origin, maternal disease, trauma and out of the ordinary) and (6) unknown. Overall kappa coefficient for agreement for cause was 0.81 (95% CI 0.80-0.83). Six mechanisms were drawn up: cardio/circulatory insufficiency, multi-organ failure, respiratory insufficiency, cerebral insufficiency, placental insufficiency and unknown. Overall kappa for mechanism was 0.72 (95% CI 0.70-0.74). Classifying perinatal mortality to compare performance over time and between centres is useful and necessary. Interpretation of classifications demands consistency. The Tulip classification allows unambiguous classification of underlying cause and mechanism of perinatal mortality, gives a good inter-rater agreement, with a low percentage of unknown causes, and is easily applicable in a team of clinicians when guidelines are followed.

Head repositioning errors in normal student volunteers: a possible tool to assess the neck's neuromuscular system

BackgroundA challenge for practitioners using spinal manipulation is identifying when an intervention is required. It has been recognized that joint pain can interfere with the ability to position body parts accurately and that the recent history of muscle contraction can play a part in that interference. In this study, we tested whether repositioning errors could be induced in a normal population by contraction or shortening of the neck muscles.MethodsIn the experimental protocol, volunteers free of neck problems first found a comfortable neutral head posture with eyes closed. They deconditioned their cervical muscles by moving their heads 5 times in either flexion/extension or lateral flexion and then attempted to return to the same starting position. Two conditioning sequences were interspersed within the task: hold the head in an extended or laterally flexed position for 10 seconds; or hold a 70% maximum voluntary contraction in the same position for 10 seconds. A computer-interfaced electrogoniometer was used to measure head position while a force transducer coupled to an auditory alarm signaled the force of isometric contraction. The difference between the initial and final head orientation was calculated in 3 orthogonal planes. Analysis of variance (1-way ANOVA) with a blocking factor (participants) was used to detect differences in proprioceptive error among the conditioning sequences while controlling for variation between participants.ResultsForty-eight chiropractic students participated: 36 males and 12 females, aged 28.2 ± 4.8 yrs. During the neck extension test, actively contracting the posterior neck muscles evoked an undershoot of the target position by 2.1° (p <0.001). No differences in repositioning were found during the lateral flexion test.ConclusionThe results suggest that the recent history of cervical paraspinal muscle contraction can influence head repositioning in flexion/extension. To our knowledge this is the first time that muscle mechanical history has been shown to influence proprioceptive accuracy in the necks of humans. This finding may be used to elucidate the mechanism behind repositioning errors seen in people with neck pain and could guide development of a clinical test for involvement of paraspinal muscles in cervical pain and dysfunction.

Radiographic Analysis of Intervertebral Separation With a 0° and 30° Rope Angle Using the Saunders Cervical Traction Device

Radiographic analysis of cervical intervertebral separation, (IVS) while using the Saunders Cervical Traction Device (SCTD) (Chattanooga Corp., Chattanooga, TN) on a healthy population. To determine whether a rope angle of 0 degrees or 30 degrees achieves higher posterior and anterior IVS when using the SCTD. To our knowledge, research using a 0 degrees rope angle and the SCTD has not been documented. A convenience sample of 15 females and 5 males, with no history of cervical dysfunction, trauma, or pain, participated in the study. Static mechanical cervical traction, using the SCTD at a 0 degrees rope angle, was applied for 2 minutes using 11.34 kg (25 lb) of force. A cross-table lateral cervical spine radiograph was obtained before traction and again at 2 minutes of traction. Two weeks later, the subjects underwent the same procedure with the rope angle set at 30 degrees . A 0 degrees rope angle produced a significant mean difference in anterior IVS at all cervical segments as compared to a 30 degrees rope angle. Traction measurements comparing posterior IVS at 0 degrees and 30 degrees were not statistically significant. However, the posterior IVS increased significantly at a 0 degrees rope angle, with the exception of C2-C3. The research findings may have treatment implications when applying cervical traction with the SCTD. Further research using subjects with cervical nerve root compression will need to be conducted to substantiate clinical outcomes.

Reliability of a Measurement of Neck Flexor Muscle Endurance

Neck flexor muscle endurance has been negatively correlated with cervical pain and dysfunction. The purposes of this study were to determine rater reliability in subjects both with and without neck pain and to determine whether there was a difference in neck flexor muscle endurance between the 2 groups. Forty-one subjects with and without neck pain were enrolled in this repeated-measures reliability study. Two raters used an isometric neck retraction test to assess neck flexor muscle endurance for all subjects during an initial session, and subjects without neck pain returned for testing 1 week later. For the group without neck pain, intrarater reliability was good to excellent (intraclass correlation coefficient [ICC(3,1)]=.82-.91), and interrater reliability was moderate to good (ICC[2,1]=.67-.78). The associated standard error of measurement (SEM) ranged from 8.0 to 11.0 seconds and from 12.6 to 15.3 seconds, respectively. For the group with neck pain, interrater reliability was moderate (ICC[2,1]=.67, SEM=11.5). Neck flexor muscle endurance test results for the group without neck pain (mean=38.95 seconds, SD=26.4) and the group with neck pain (mean=24.1 seconds, SD=12.8) were significantly different. Reliability coefficients differed between the 2 groups and ranged from moderate to excellent and improved after the first test session. The interrater reliability of data obtained with the neck flexor muscle endurance test in people with neck pain must be improved in order for clinicians to distinguish a clinically meaningful change from measurement error. Neck flexor muscle endurance was both statistically and clinically greater for subjects without neck pain than for those with neck pain.

Autism: A chiropractic perspective

Chiropractors, as with other primary healthcare clinicians, are often faced with a child whom they suspect may have symptoms of autism, often previously undiagnosed. As such, it is important that there is familiarity with the symptoms, primary of which are difficulties in communicating or relating to other people. Although there is no known cause for autism, various potential aetiologies are under investigation. A number of abnormalities are found in multiple systems and functions in the autistic individual who presents a number of management challenges. Some researchers have discovered a laterality of the atlas in children with autism and there are various suggestions as to why removing upper cervical dysfunction may have a positive effect on the symptoms of autism. This paper offers a systematic review of the condition with emphasis on the elements pertinent to the manual therapist.

Validation of a Sham Manipulative Procedure for the Cervical Spine for Use in Clinical Trials

To develop a sham manipulation procedure for the cervical spine for use in randomized clinical trials of cervical disorders. A single-group, single-intervention study design was used. Adult neck pain subjects underwent a screening examination that included palpation for a site of cervical spine joint dysfunction. Eligible subjects underwent measurements of regional cervical ranges of motion as well as pressure algometry (tenderness) at the site of cervical joint dysfunction. Subjects were instructed that they would receive one of several types of manipulative procedures. A newly developed sham manipulation was delivered once. Subjects were then remeasured for ranges of motion and tenderness. They were asked if they had experienced any pain during the procedure, if they had experienced a "cavitation" sound, and if they thought that the procedure they received was a "real" manipulation. Finally, they were debriefed as to the deception involved in this study. A prior level of 65% was set for endorsement that the procedure was a real manipulation. Changes in pre-post measures of ranges of motion and tenderness were analyzed descriptively for clinically important differences. Twenty eligible subjects were included (12 males, 8 females) with an average age of 30.4 (2.8) years. Twelve of the subjects were not students, with 3 of these having no prior experience with chiropractic treatment; 8 were students. Of the total sample (N = 19), 8 (42.1%) indicated that the procedure was a "real adjustment"; of the 12 nonstudents, 8 (58.3%) indicated similarly. None of the procedures in the final sample resulted in a cavitation, and none of the subjects registered the procedure as painful. None of the measures for ranges of motion or tenderness showed clinically important changes. The sham cervical manipulation studied here appears to approximate the necessary features of a placebo maneuver in that it is perceived by a majority of nonstudent neck pain subjects to be a real manipulation, although it does not produce any important change in cervical status. The small sample size of nonstudent participants precludes a strong recommendation for this procedure at this time.

The Relationship Between Spinal Dysfunction and Reaction Time Measures

Objective The objective of this study was to investigate the relationship between the number of sites of spinal dysfunction and a range of measures of cognitive processing. Methods This double-blind, randomized, observational pilot study was performed at a chiropractic college clinical training facility. Thirty volunteers with clinical evidence of cervical spinal joint dysfunction participated. Subjects were classified into 2 groups depending on whether they exhibited signs of cervical spinal joint dysfunction at one or more sites. A range of computer-based tasks was used to determine simple reaction time (RT), choice RT, probe RT, and inhibition of a preplanned response. Results Multiple sites of cervical spinal joint dysfunction were related to impaired cortical processing as revealed by significantly higher loads on central capacity, significantly less accurate response selection, and a trend toward more variable performance of an anticipated response. Multiple sites of cervical spinal joint dysfunction do not appear to be related to the speed of response selection or the ability to inhibit a preplanned response. Conclusion This pilot study provides a context for the improvements in cortical processing observed after cervical spine adjustment. It shows that probe RT may be a useful tool in further studies examining the effects of cervical spine manipulation of joint dysfunction and the associated effect on cognitive function.

Effectiveness of cervical spine manipulation and prescribed exercise in reduction of cervicogenic headache pain and frequency: A single case study experimental design

Introduction Patients commonly present to osteopaths with a complaint of headache. There is a clear rationale for osteopathic manipulative treatment in management of headaches that involve cervical spine dysfunction such as cervicogenic headache. Recent evidence suggests that deficits in muscle performance of the deep neck flexor muscles may be linked to cervicogenic headache, and that specific exercise prescription may play an important treatment role. Evidence also suggests that combining both manipulative treatment and specific exercise may be an effective treatment approach. Methods A prospective case study utilising an A–B–C design was used to evaluate the effectiveness of osteopathic treatment and specific exercise of the deep cervical flexor muscles in reducing cervicogenic headache pain and frequency in a 26-year-old female, with a 16-year history of cervicogenic headache. The diagnosis of cervicogenic headache was based upon clinical examination, medical history and fulfilment of cervicogenic headache diagnostic criteria. The study consisted of a three-week baseline data collection phase, a three-week osteopathic manipulative treatment phase and a three-week home based exercise phase. Outcome measures included the quadruple visual analogue scale, a headache diary, and data recorded from a pressure biofeedback device. Osteopathic treatment involved high velocity low amplitude (HVLA) thrust techniques and a low load exercise programme targeting the deep cervical flexor musculature. Results Visual analysis of plotted outcome measure data indicated a reduction in both intensity of headache pain and frequency. Conclusions The findings of this single case study are limited in their generalisability, but are consistent with the results of other similar studies investigating cervicogenic headache using similar interventions.

The cranio-cervical flexion test using pressure biofeedback: A useful measure of cervical dysfunction in the clinical setting?

Aims The cranio-cervical flexion test (CCFT) was developed to indirectly measure the strength of the deep cervical flexor muscles. This pragmatic study was designed to analyse the reliability and discriminative validity of the test as used by osteopaths in the clinical setting. Methods Forty subjects were categorised into groups according to two different sets of criteria. Firstly they were divided into three groups who had either current neck pain, a history of neck pain but no current pain, or no history of neck pain. Secondly they were divided into three groups according to their level of neck disability, which was either no disability, mild disability, or moderate disability. The intra-rater and inter-rater reliability of the CCFT was calculated. Four practitioners performed the CCFT on each of the 40 subjects and CCFT scores were analysed in terms of pain intensity, pain history and neck disability. Results Intra-rater reliability (ICC) was 0.78 (95% CI 0.47, 0.92) for performance index (PI), and 0.78 (95% CI 0.47, 0.92) for activation score (AS). Inter-rater reliability (ICC) was 0.54 (95% CI 0.36, 0.70) for PI, and 0.57 (95% CI 0.37, 0.72) for AS. A significant correlation was found between the intensity of current pain and PI ( r = −0.37, P = 0.02), but not for AS ( r = −0.29, P = 0.16). No statistically significant difference in the CCFT score was found between groups for either pain history or neck disability. This result is in contrast to previous studies. Conclusion The practitioners in this study demonstrated ‘good’ inter-rater reliability and ‘excellent’ intra-rater reliability when using the CCFT. However, the discriminative validity of the CCFT was not demonstrated in this study as the CCFT failed to discriminate between those with current neck pain, those with a history of neck pain but no current pain, and those without neck pain.

Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache

Persistent intermittent headache is a common disorder and is often accompanied by neck aching or stiffness, which could infer a cervical contribution to headache. However, the incidence of cervicogenic headache is estimated to be 14–18% of all chronic headaches, highlighting the need for clear criterion of cervical musculoskeletal impairment to identify cervicogenic headache sufferers who may benefit from treatments such as manual therapy. This study examined the presence of cervical musculoskeletal impairment in 77 subjects, 27 with cervicogenic headache, 25 with migraine with aura and 25 control subjects. Assessments included a photographic measure of posture, range of movement, cervical manual examination, pressure pain thresholds, muscle length, performance in the cranio-cervical flexion test and cervical kinaesthetic sense. The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension ( P = 0.048 ) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P < 0.05 ) and muscle tightness ( P < 0.05 ). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.

Parry-Romberg syndrome with focal epilepsy, progressive cerebral MRI alterations and CSF findings of a chronic inflammatory CNS disorder

Objectives: The Parry-Romberg syndrome is characterized by a slowly progressive facial hemiatrophy primarily involving the subcutaneous and fatty tissue. Extrafacial manifestations are described. There may develop an additional atrophy of muscle, cartilage and bone tissue. In some patients a cerebral involvement with epilepsy has been reported. The etiology of the Parry-Romberg syndrome is unknown, suggested causes have included cerebral dysgenetic mechanisms, cervical sympathetic dysfunction, infectious agents and an autoimmunological process.