I thought you might find it interesting to know how we specifically look at headache management for your patients. Synergy is known for treating patients with complex cervicocephalic issues, and you might not know that. These are the main areas we look at: history of falls, trauma/injuries throughout the whole body, nutrition (food sensitivities), sleep, sleep postures, birth history, positional and occupational habits and recreational and hobby postures.
When treating headaches that are not cranial-trauma induced, it is necessary to take into account posture when sitting, standing and in supine. A person’s posture is developed from habit, occupational and recreational repetitive activities, emotional strain, and injuries. So determining the history of falls, especially hard falls on the coccyx, sacrum or ischial tuberosities is very important. The reason why this information is useful is the nature of the pelvis, vertebral column, dural attachments in the suboccipital region, anterior and posterior longitudinal ligaments and nuchal ligament. Any kind of trauma to the bone can lead to an intraosseous or interosseous lesion of the bone(s) in question. Falls can lead to pubic bone, sacroiliac, and lumbosacral joint dysfunction. These falls can cause a direct biomechanical problem or a more subtle change to the periosteum and then the attachment of tendons. The tendinous insertion dysfunction can result in asymmetries that then lead to imbalanced muscle firing. This imbalance in muscular firing can wreak havoc throughout the spine.
Imagine it happening with the small Rectus Capitis posterior minor/major muscles as they attach to the occiput, C1, and through a myodural bridge directly to the cervical dura. Hyperflexion extension injuries activate Rectus Capitus major /minor and Obliquus Capitus superior/inferior muscles and convey forces through the attachment to the cervical dura. Studies show that links between the suboccipital musculature, fascia, and cervical dura mater have involvement in cervicocephalic pain syndromes, sensorimotor activity, and postural regulation. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4025088/
Imagine it happening to the tiny multifidi muscles up through the spine. These muscles have the capacity to shift and change over and over throughout the day and night. Studies show that they fire before any motion actually happens in preparation to protect the spine, however if a few of them are in the contracted short or elongated position, other muscles will have to accommodate for them. This is generally not a problem, but what if they can’t accommodate anymore? Such as in permanent arthritic changes, surgery, disc damage, or a high velocity injury.
It then becomes imperative to give the body as much accommodation as possible in the available structures. Dysfunction low down on the kinetic chain can contribute to cervicocephalic headaches and pain syndromes along with myriad other complaints.
Aggressive treatment of the dural tube, the intraosseous and interosseous lesions in the sacrum, ilium, ischium and the pelvic floor to give as much ability to move in the pelvis, will invariably give the vertebral column room to move. More motion provides more motion. Give a little bit of motion in a lot of places translates to a lot of motion overall, versus focusing on the one area which doesn’t move. This is very common with new practitioners. The suboccipital region is tight and patients say that their headaches come from that spot. Practitioners do everything in that area, ice, heat, estim, vertebral mobilization, massage. Patients get some relief, but it often comes back eventually because the therapist didn’t find the source of the dysfunction. Finding the source that is driving that dysfunction is a much more global approach, it may take longer, but it also can be more permanent. Often times, headaches are as a result of lack of mobility in a certain area of the spine or pelvis.
So how we treat is not as important as why we treat the way we do. What is the rationale for the process that we use?
1. Removing edema and improving venous drainage through lymphatic drainage therapy, manual lymphatic massage, strain counterstrain venous/lymphatic techniques, or total body balancing (old Osteopathic global body treatment) is generally the first approach. We have many techniques to improve fluidic flow through the thoracic inlet.
2. Osseous and ligamentous restrictions need to be addressed (clavicular mobilization sternoclavicular and costoclavicular mobilization, including first rib and C7-T1 junction) and all of the associated ligaments. We also check for spring in the rib cage. If that entire area is rigid and fixed, it can lead to all sorts of mischief.
3. Next, we look at muscular and fascial restriction. Whatever cervical musculature is in spasm can be relieved through lymphatic techniques, myofascial release or strain counterstrain.
4. We can determine specific arteries, veins, or nerves that are causing dysfunction and free them up.
For example, if someone has a Sternocleidomastoid chronic hypertonicity, we are going to evaluate the sternal, clavicular and mastoid attachments and see if there is rigidity, edema, heat or fibrosity. All of those symptoms reveal some sort of causality. We need to get fluid to flow to reduce hypertonicity. Jugulodigastric, anterior cervical and supraclavicular lymph needs to flow really well for ultimate healing to occur. Ligamentous hydration is addressed through oscillatory techniques. Fascial and muscular mobilization and stretching may be indicated, however we now know that compression of a structure is much more effective to provide long term change. Taking a region into ease is much less stimulating to the nervous system which promotes parasympathetic tone. Overall healing only happens in heightened parasympathetic tone.
Motion is first priority, then alignment through structural mobilization and then finally strengthening with the body in a balanced position.
We want to increase vitality in all of the structures treated. What is vitality? It is the inherent health of the tissues. Tissues on a 60-year-old smoker is much different than an organic eating 30-year-old athlete. Restoring vitality to the bones, increasing their hydration and capacity for hydration, changes the nature of the periosteum, thereby changing the tendinous attachments, thereby changing the ability, and perhaps even make up, of the muscle fibers from static to more dynamic.
It is very necessary to ensure that dura is moving as well as it can, especially in the upper cervical region. Direct mobilization is necessary with prolonged gentle force to make a change, because it is one tough mother, if you will.
Anterior longitudinal ligament and nuchal ligament mobilization in the cervical spine will improve cervical lordosis. As we age and have trauma and falls, the curves in our spine can change leading to a more flattened curve in the lumbar, thoracic and cervical region thus
displacing the forces of gravity and shifting them into a less energy conservative manner. As energy is expended to keep the head in neutral position and the eyes level with the horizon, muscles can splint into place and shorten posteriorly and lengthen anteriorly, especially in the neck. The contracted nuchal ligament can lead to degenerative changes in the spine. If the curves are maintained throughout life, the less chance of degenerative changes, especially at C5-6 and L4-L5,L5-S1, the most common areas for the discs to wear out. Optimal organ function and fluidic exchange is also tied to maintaining the curves.
Once the pelvis, thoracic and cervical spine influences to the cranium have been reduced, I will utilize craniosacral therapy techniques to specifically mobilize local structures that continue to be drivers of the pain/symptoms. These techniques are best suited to patients with post concussive syndrome, traumatic brain injury, vertigo, trigeminal neuralgia, Bell’s palsy, vision and auditory problems, (structurally based) birth trauma including colic, torticollis (jugular foramen compression) and myriad other specific cranial issues.
On the first or second visit I start to implement an exercise routine to give patients control over their own care and build body awareness. The one that I’ve most recently fallen in love with is called Total Motion Release. Otherwise known as TMR in our clinic. It’s a balancing technique, not a strengthening one because I’ve learned over time that pain is a result of imbalance. Perhaps in a joint, throughout the spine, various offending musculature regions, or intraosseous driven. It really doesn’t matter. Total Motion Release directs the patient to treat the good side, and by some weird neurological quirk, it fixes an imbalance in the body.
Try it. This is the participation part of the article- I know you didn’t expect this, bare with me, no one is watching you, well maybe they are, but be a rebel. Put your feet squarely on the floor, sit forward on the edge of the chair. Put your hands on your stomach, Twist to the right and look over your shoulder, then twist to the left and look over that shoulder. Test and see which way goes further, has greater ease, and no pain. Then twist that way (the good way) for 20 seconds, two times and then reevaluate (make sure you make it count, don’t be whimpy- push it). Your twists should be more symmetrical when you check right versus left. You might need to do it two, three or four times to get them even but eventually they will be, unless you have some sort of structural issue that needs treatment from someone like me. Balance leads to less pain.
Lastly, I utilize progressive relaxation techniques to teach patients how to let go of muscle tension that they might not be aware of and review postures that might be contributing to maintaining dysfunctional patterns.
Vitality, mobility and position are the tenants of the clinic. Hope you enjoyed the leisurely walk through my thinking process. Sometimes a headache isn’t just a headache.
Shauna Burchett OTR/L owner