Is It Useful To Assess In Headache?
In a recent international survey, 17 internationally recognised physiotherapy headache experts was conducted to identify which physical examination tests are considered most clinically useful.1
In addition, the international experts were asked to specify for which types of headache i.e. Cervicogenic Headache (CH), Tension-type headache (TTH) and Migraine (M) or in which clinical situation the tests would be useful.1
The results showed that, in TTH less than 25%, approximately 15% in M, and 75% in CH, of the experts considered active cervical range of movement (ACROM) ‘extremely useful’, with
25 % not considering ACROM in CH at all i.e. 25% of the experts do not assess ACROM in CH and even less in TTH and M presentations.1 Does this mean at the very least 25% of international physiotherapy headache experts are incompetent?
Furthermore, the reported prevalence of CH is estimated to be 4.1% in the general population;2 patients attending dedicated headache clinics present with variable (TTH, M and other) presentations. Further, it is widely recognised amongst expert diagnosticians, that diagnosing headache is fraught with difficulty.3-5 Headache of cervical origin and M often shows similar clinical presentations;4 one of the confusing phenomena about CH is that its symptoms can present as M, TTH or even Cluster Headaches;3 assessment of ACROM was perceived by the experts to be even less informative in other (than CH) presentations.1
Ultimately, whilst ACROM, muscle tests of the shoulder girdle, and screening of the thoracic spine were considered clinically useful,1 they were considered less important than others.1
Finally, the authors recognise that this ‘consensus study’,1 only reflects the opinion of experts and that the results should stimulate future discussion and as well as scientific evaluation i.e. currently there is no agreed protocol on the most important physical examination techniques when assessing headache patients.1
Altered ACROM does not infer causality, only association.
In a recent, large cohort study3 no correlation was demonstrated between neck pain and ACROM. The authors concluded that ‘cervical range of movement (CROM)… should not be used as indicator(s) to measure the progress of chronic neck pain in physiotherapy…’.3 It is not unreasonable to extrapolate this to a headache population, further diluting the possibility of gaining meaningful information from ACROM.
Further it is recognised that the complex structure of the cervical spine, makes it difficult for any clinician to obtain reliable and valid results from ACROM.4 This recognition perhaps underpins the ambivalence of international physiotherapy headache experts towards ACROM when assessing headache patients.1
A stronger relationship and case for assessing ACROM is where patients report that typical head pain is triggered by cervical movements. Whilst this feature is considered a diagnostic criterion for CH, headache triggered by neck movement is rare. This is supported by a survey5 which demonstrated reproduction of headache by neck movement in only six of 410 headache patients. This finding demonstrates that headache triggered by head movement is not a sensitive or specific diagnostic criterion for cervical involvement in headache,5 and whilst should be assessed in patients who report reproduction of headache with neck movements, suggests that assessing ACROM is not a high priority.
In the light of the current literature, to conclude that not assessing ACROM in headache patients amounts to clinical incompetence, is indeterminate, and questions the expertise of the 17 internationally recognised physiotherapy headache experts.
- Luedtke K, W. Boissonnault W, Caspersen N, Castien R, Chaibi D, Falla D, Fernandez-de-las-Pen~as C, Hall T, Hirsvang JR, Horre T, Hurley D, Jull G, Krøll LS, Madsen BK, Mallwitz J, Miller C, Schafer B, Schottker-Koniger T, Starke W, von Piekartz H, D. Watson D, Westerhuis P, May A. International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Manual Therapy 23 (2016) 17-24
- Sjaastad O, Bakketeig LS. Prevalence of cervicogenic headache: vågå study of headache epidemiology. Acta Neurol Scand 2008 Mar 1;117(3):173-80.
- Rothbart P. The cervicogenic headache: A pain in the neck. Can J Diagnos 1996; 13: 64–71.
- Goadsby PJ, Bartsch T. Anatomy and physiology of pain referral patterns in primary and cervicogenic headache disorders. Headache Currents 2005;10:42-48.
- Gallagher R, Cervicogenic Headache; A special report. Expert Rev. Neurotherapeutics 2007;7(10) 1279-83
- Kauther MD, Piotrowski M, Hussmann B, Lendemans S, Wedemeyer C. Cervical range of motion and strength in 4,293 young male adults with chronic neck pain. Eur Spine J 2012;21:1522-7.
- Strimpakos N. The assessment of the cervical spine. Part 1: Range of motion and proprioception. Journal of Bodywork & Movement Therapies (2011) 15, 114-124
- Massimo L, Domenico D, Licia G, Angelo A; Gennar B. Cervicogenic headache: a critical review of the current diagnostic criteria. Pain 1998 78(1):1–5