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• Patient Profile 58 y.o. female, works full time as a teacher. Active with going to the gym, primarily likes using the eliptical and stairmaster, general weight training • Chief complaint: “ Constant tightness in my neck that leads to a headache about 3 days/week.

” • Self Report inventories – Numeric pain scale • Best in the last week: 0/10 • • Worst in the last week: 5/10 Average in the last week: 3/10 – Neck Disability Index: 34%

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History of Current Episode • • • • • Duration of symptoms: 20 year hx of neck pain and HA Mechanism of onset: insidious Progression of symptoms since onset: greatly improved over time. “ It used to get so bad I would have to go home and go straight to bed, and it was almost daily.

” Current status (improving, static, worsening): static Treatment and response: felt all prior rx was helpful to some degree and had a cumulative effect over time: – – chiropractic manipulation: for several years, several years ago PT (primarily massage and exercise): last round approx 3 years ago, cx massage, generic UE exercise – massage: full body, including cx approx 2-3x/year

• • • • Previous History Previous Episodes: severe HA requiring going to bed Contributing Factors: posture, work as teacher involving sitting for computer work, some bending to work with children. Resting posture promotes upper cx extension, bending promotes upper cx extension, and pt likely remains/sustains posture during computer work.

Previous Treatment: chiro, PT, massage Medical History/Co-morbidities: approx 2006 bilateral carpal tunnel sx, left ulnar nerve relocation, L5 spondy, osteoporosis

Area Aggravating/Easing Factors Aggravating Activity Time required /Pain Level reached Eases with/ Time to ease back to baseline P1 - neck “ tightness ” working as a teacher: standing, bending, sitting at computer. Accumulative effect, end of day syx, approx 4:00. 5/10 at worst “ relaxing, going home and lying down for 15 minutes ” , returns to baseline P2 - HA always follows an increase in neck syx P3- thoracic “ stiffness ” Eliptical 20 min same as above A few minutes after with general stretching Worst area: upper cx, rams-horn HA Best: Preferred Position of Rest: lying down in any position 24 hour behavior: best in am, worst by pm

Red & Yellow Flag Screen • • • • • • • General Health - good, all clear Age 50 with history of cancer -no Cord: Clumsiness in hands, disturbance of gait suggestive of spasticity: -no Cauda Equina: -no Steroids or anticoagulants: -no Numbness and tingling in the hands and feet: -no 5 D ’ s (dizziness, diploplia, dysphagia, dysarthria) -no • Yellow flags? FABQ/Depression -no

• • Working Hypotheses Hypothesis: upper cx dysfunction, rests in upper cx extension; “ high-low ” . Onset of upper cx, primarily C2 based on rams-horn distribution, HA at end of day after likely functioning in her preferred posture involving upper cx extension. Syx b/w shoulder blades likely thoracic in nature given the large area and behavior of syx, however, need to rule out Cloward ’ s sign/cx referral • Evidence supporting: observed posture, distribution and behavior of syx Evidence against: exhibits sharp lordotic curve with “ step ” at mid-cx. Possible that syx are also generated from this area.

Area Severity Irritability Nature Stage Stability Presentation P1 low low upper cx dysfunction, HA chronic currently static P2 low low chronic currently static

Objective Examination • • Observation – Affect: very happy, energetic – Fitness: general good m. tone, clearly healthy and active – Gait: normal, maintains fwd head posture Posture – – Habitual: fwd head, rounded shoulders Spinal contours: sharp cx lordotic curve – Signs of muscle imbalance: weak deep cx flexors, scap retractors

Neurological Examination • • • Reflex: normal Dermatome: decreased sensation bilateral thumb, left pinky (correlates to hx of carpal tunnel and ulnar nerve sx) Myotome: normal

Active Range of Motion Cervical Flexion** Extension Rotation left* Rotation right Upper cx flexion** Range 50 45 55 50 stiff Deviation none none none none none Upper cx extension moves easily none Retraction (dorsal glide through Tspine) stiff Symptoms Limit of Range “ my tightness none, “ won ’ ” t go ” R-sided syx with OP tightness, stretch with OP mid-cx listhesis, hypothetical stops none with OP “ my tightness ” none syx b/w scapulae, no thoracic syx with cues stops “ tight ”

Active Range of Motion Thoracic Symptoms Range Flexion Extension Rotation left Rotation right Lateral flexion left Lateral flexion right reversal of kyphotic curve Deviation “ stiff in that area ” Limit of Range

Other tests • Deep cx flexor strength: weak, unable to hold without compensation

Palpation Findings: PPIVMS Palpation Findings: Occiput C1 C1C2 C2C3 C3C4 C4C5 C5C6 C6C7 C7T1 Range R SB and rot

Occiput C1 C1C2 C2C3 C3C4 C4C5 Palpation Findings: PAIVMS Range R stiff vs L UPA End Feel gunky Symptoms comparable pain R stiff vs L UPA R stiff vs L UPA relatively mobile CPA/UPA relatively mobile CPA/UPA gunky stiff *comparable pain **comparable pain tender tender Reason for stop R1=P1 R1=P1 R1=P1 none C5C6 C6C7 C7T1 mid-Tspine relatively stiff CPA/UPA stiff relatively stiff CPA/UPA stiff relatively stiff CPA/UPA stiff stiff stiff none none comparable stiffness

Assessment Following the Objective: Review and re-rank your hypotheses • Hypothesis - upper cx extension dysfunction, upper cx HA • Evidence supporting - comparable cx pain with palpation suboccipitals/upper cx exam. No reproduction of thoracic syx with cx PAIVMs.

• Evidence against

Select Subjective and Objective Asterisks Subjective /Functional Asterisks End of day increase in cx syx Subsequent HA Objective Asterisks *L rot with OP **flexion **upper cx flexion *C1, C2 palpation -end-feel and comparable pain *suboccipital palpation -HA prodrome

Treatment Day 1 Technique/Intervention: sub-o pump stretch into upper-cx flexion progressing to active, mid-thoracic central gr IV PA ’ s Intention of Technique: restore upper-cx mobility into flexion, normalize tissue. Restore thoracic mobility.

Patient /tissue response during performance of technique: “ that ’ s going to give me a HA ” (cervical), “ that ’ s like the spot I feel on the eliptical ” (thoracic) Reassess Subjective /Functional Asterisks: Reassess Objective Asterisks: “ I feel so much looser, tightness is gone ” Flexion- 60 “ less tight ” (was 50) L rotation with OP- 60 less resistance (was 55) Upper-cx flexion “ less tight ” Dorsal glide -syx free after thoracic ex Exercise to support intervention: deep cx flexor strengthening, self-thoracic mob Trial of exercise: effort for strengthening, no HA. Thoracic mob to comparable area. Result: no syx provocation, maintained results following rx Patient Education/Instruction: postural awareness throughout day, esp with bending, sitting at computer. Posture/form while on eliptical and stairmaster.

Assessment Following Treatment • • • • • Working hypothesis: upper cx dysfunction, HA, true thoracic syx Initial hypothesis confirmed Classification: Cervical dysfunction with HA clinical syndrome apparent: upper cx related HA, “ high-low ” Assessment of Presentation remained

Visit # 2 Assessment

Subjective: No return of HA or “ tightness ” . When cx syx started to increase at end of day, could fend it off with postural correction. Syx have localized to R upper cx secondary to carrying heavy object this am.

Time from start of care: next day Time from last visit: next day Reassess Subjective /Functional Asterisks: Reassess Objective Asterisks: end of day syx improved flexion 60, syx-free, less resistance retained gain L rotation 60 OP less resistance with syx retained gain upper cx flexion, less resistance thoracic syx this am relived with thoracic ex dorsal glide without syx

Treatment Visit 2 Technique/Intervention: focus therex b/c of next day visit. Active thoracic dorsal glide-prone with wedge. Ball postural ex. Intention of Technique: active mobilization, postural strengthening Patient /tissue response during performance of technique: decrease in thoracic resistance, and increased in range during wedge ex Reassess Subjective /Functional Asterisks: Reassess Objective Asterisks: elimination of resting syx after therex L rotation 65, no syx with OP (was 60) flexion 65, no resistance OP (was 60) upper cx flexion, no resistance dorsal glide without syx Exercise to support intervention: added same ball ex to HEP Trial of exercise/result: elimination of syx after therex Patient Education/Instruction: reviewed postural cues, basic concept of current therex applying to all ex and daily function, also considering lumbar spine

• • •

Visit 3: 5 days later

S: No return of HA. Cx syx 50-60% improved, primarily R-sided. Worse with computer work while sitting >20 min (this is her new baseline). Quickly ease with postural correction/chin tuck. O: AROM: *R-sided syx at end-range R & L upper cx rotation, less range with L, approx 35deg. PAIVMs: *C2 UPA (prone) in R rotation, gunky 29

• • • •

Visit 3 Rx

gr IV R U PA C2 in R rotation – decreasing resistance and syx during rx – AROM: 60% decrease in cx syx with R & L upper cx rotation, improvement in quality and quantity of range, L upper-cx rotation range < R, approx 40deg supine gr IV L rotation/upglide C2 – decreasing resistance and syx during rx – upper-cx AROM: near elimination of syx upper cx pump stretch central and with bias to R side - passive and with active upper cx flexion: equal R and L upper cx rotation, elimination of syx Therex: same: deep cx flexor strengthening, upper thoracic dorsal glide/self-mob, prone over ball postural endurance 29

Visit 4: 2 days later

• • • S: no return of HA or cx syx for approx 24 hrs following last visit. Awoke with HA this a.m., went away during workout at gym, but slowly returned at a lower intensity. Noted “ bulged ” muscle on R side (middle scalene) of neck accompanied HA. Pt could relieve HA with rubbing of this muscle while moving neck. No relief with upper cx flexion ex. O: *upper cx ext -> high R “ muscle ” pain at end range, *R upper cx rotation less than L -> high R “ joint ” pain at end range, less range than previous visit, approx 35deg Palpation: spasm, tenderness along R side neck/scalene

Visit 4 Rx

• • • STM/muscle bending R scalene/R lateral neck with contract/relax into L rotation (actively rotating R, relaxing to L) – softening and decreasing tenderness during rx – elimination of resting syx after rx. Cx syx with R upper-cx rotation. L side-lying R scalene STM down to 1st rib with active scap depression. Gr IV caudal glide 1st rib because of attachment of scalene.

– no resting syx, no syx with R upper cx rotation, full range Therex: self stretch/STM to R cx spine with L SB/scap depression

Visit 5: 5 days later

• • • S: Rx soreness after last visit, but no return of HA. Mild and infrequent return of cx syx, quickly relieved with postural correction and self-STM to R cx spine. “ Tennis balls really help the thoracic area ” . O: *R-sided syx with L upper cx rotation, less range than R Rx: – supine gr IV L rotation/upglide C2 - added contract/relax • decreasing resistance and syx during rx • AROM: near elimination of syx – R OA gapping, targeting soft tissues (gap with L SB) significant improvement in range and syx, 45deg – upper cx pump stretch with R bias ->elimination of syx – Therex: reviewed HEP

• • •

Visit 6: 2 days later

S: Rx soreness remainder of day after last visit. “ I can go lots of hours without even noticing my neck now ” . Around 5:00 begins to notice need to stretch to fend off syx while doing mostly seated work. O: R and L upper cx rotation clear of syx, L limited in range vs R with “ stretch ” with OP into L rotation Rx: – Gr IV C1-C2 L rotation • improvement in L upper-cx rotation quality – R OA gapping • significant improvement of L upper-cx rotation, 45 deg active and with OP, and at rest “ I feel so much looser!

” – Therex: self-OA traction/gapping w/ strap or hand, upper cx active stretch. Reviewed all other HEP.

Assessment Functional Asterisks and Impairments At initial evaluation NDI: 34% 5/10 pain at worst, requiring lying down Current Status. NDI: 10% 1/10 at worst, managed with HEP/tools