Sternocleidomastoid muscle imbalance in a patient with recurrent headache

Manual Therapy 11 (2006) 78 82 Case report Sternocleidomastoid muscle imbalance in a patient with recurrent headache Michael T. Cibulka Jefferson County Rehabilitation & Sports Clinic, 1330 YMCA Drive, Suite 1200, Festus, MO 63028, USA Received 21 April 2004; received in revised form 24 November 2004; accepted 5 January 2005 www.elsevier.com/locate/math Keywords: Headache; Physical therapy; Upper cervical spine 1. Introduction Headache is a common complaint seen by physical therapists. Headache that develops from the upper cervical spine has been called cervicogenic headache (Bogduk, 1992; Nilsson et al., 1997; Biondi, 2001). The three upper cervical spine joints (atlanto-occipital, atlanto-axial, and C2/3) are often associated with headache (Bogduk, 1992; Dvorak and Walchli, 1997; Jull, 1997; Bogduk, 2001). Besides problems of upper cervical joint mobility, problems related to the muscles of the cervical spine have also been linked to cervicogenic headache (Jull, 1997; Jull et al., 1999). Muscle impairment of the sternocleidomastoid (SCM), the anterior scalene (AS) and the deep cervical flexor muscles (longus capitus and colli and rectus capitus anterior) has also been found to be associated with neck pain and cervical osteoarthritis (Gogia and Sabbahi, 1994; Barton and Hayes, 1996; Jull et al., 2002; Falla et al., 2004). The author has noticed that patients with cervicogenic headache often have imbalances in muscle length and strength between the left and right SCM and AS muscles. This case report describes the evaluation and treatment of a patient with cervicogenic type headache who also showed left to right imbalance between the SCM muscles and restricted upper cervical spine motion. 2. Examination 2.1. History 2.1.1. General demographics The patient was a 38-year-old female with a 12-month history of recurrent headache. The headaches developed over the right supra-orbital region, along both temples (right worse than left) as well as in the left and right (right worse than left) sub-occipital region. The patient had a history of right-sided neck pain that developed after being rear ended in a moving vehicle accident 2 years previously. Since her car accident she had neck pain at least three times in between now and then but no report of headache until the last 12 months. The initial whiplash neck pain was treated by physical therapy, which included moist heat, cervical traction, mobilization, and exercises to reduce forward head posture (chin tuck exercises). After the physical therapy she reports that she had only minor neck pain. 2.1.2. Current conditions/chief complaints Her chief complaint was recurrent headaches, which would last usually until she had taken some medication (two capsules of 200 mg Motrin gelcaps). The pain usually started as stiffness in the sub-occipital region which later spread to the right temple and then to the right and later left supra-orbital region. No complaint of vertigo, jaw or dental pain was given. Tel.: +1 636 931 7600; fax: +1 636 931 8808. E-mail address: mcibulka@earthlink.net. 2.1.3. Functional status and activity level The headaches did not usually interfere with her job or activities of daily living but when she developed a 1356-689X/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2005.01.006

M.T. Cibulka / Manual Therapy 11 (2006) 78 82 79 headache she had to take her medicine right away or the headache would often intensify and the medicine would not work as well. Headaches often came on for no apparent reason. However, she did note that sitting longer that 2 or 3 h at a time could precipitate a headache. 2.2. Test and measures 2.2.1. Pain Current headache pain was rated as 1 out of 10 on a Likert like 0 10 scale where 0 is no pain and 10 is the worst pain possible. Worst pain on the VAS scale was rated as 7 out of 10 while the best was 0 of ten, when she did not have a headache. The neck pain questionnaire was also given because the patient had neck pain. The neck pain questionnaire is a self reported patient response outcome measure designed to determine patient response on 10 different items for pain and function (Vernon and Mior, 1991). The neck pain questionnaire score was 12%, with a 4 out of 5 on the headache subsection. The patient reported that she developed headaches about 17 days of the month. 2.2.2. Posture and alignment When standing in a comfortable upright stance with the feet placed shoulder s width apart no forward head posture or thoracic kyphosis was noted from a lateral view. From an anterior/posterior view the head was held in a position of 101 of left lateral flexion. However, no obvious torticollis was observed in the cervical spine. Examination in sitting showed that she did display some forward head posture. Examination of her jaw showed a normal angle class I occlusion with normal centric position of her teeth on full occlusion. She had no missing teeth except for her Wisdom teeth. 2.2.3. Palpation Palpation of the muscles of the cervical spine showed tenderness only in the right SCM muscle when compared to the left. Also, the right SCM muscle appeared to be smaller in circumference than the left SCM muscle when palpating with the thumb and index finger. 2.2.4. Range of motion Active cervical range of motion was measured with the cervical range of motion (CROM) goniometer. The reliability of the CROM has shown to be high (Youdas et al., 1992). Left and right active shoulder range of motion was full, with 1751 of abduction and flexion, 90 of external rotation and 601 of left internal rotation and 551 of right internal rotation (Norkin and White, 1995). Muscle length tests of the pectoralis major and latissimus dorsi, as described by Kendall et al., were symmetrical and normal in length (Kendall et al., 1952). Testing the antero-lateral neck flexors (SCM and AS) by side-bending the head as far as possible and then rotating to the opposite side showed reduced length of the left when compared to the right side. This test showed the left SCM and AS were shorter in length than the right side. 2.2.5. Joint mobility Specific joint mobility of the cervical spine was tested, although the inter-tester reliability of testing specific joint mobility has been shown to be fair to moderate (Kappa coefficients 0.28 0.43) (Smedmark et al., 2000). In a study of patients with headache Jull et al. (1997) found high intra-tester reliability in finding cervical dysfunction. The atlanto-occipital joint was assessed using the method described by Bourdillon and Day (1987). On passive motion testing the author noticed that right side bending motion appeared less than left side bending at the atlanto-occipital joint. Assessment of the atlanto-axial joint was performed using a method described by Bourdillon and Day (1987). Assessment of the atlanto-axial joints showed less right rotation than left rotation observed visually by 201. After the upper cervical joints were tested the lower cervical joints were testing using a side gliding technique. Movement of right side gliding was found diminished at C2/3 but not with left side gliding. Movement appeared symmetrical for segments from C3/4 to C6/7. Also, no pain was created nor did the end feels appear different from side to side. 2.2.6. Muscle performance Manual muscle testing was performed according to the method of Kendall et al. (1993). Testing the left and right shoulders of the right abductor, right shoulder flexor, and right external rotator muscles, all displayed Normal muscle grades. Manual muscle testing of the SCM and AS muscles showed weakness on the right, a Good Minus muscle grade (Kendall et al., 1993). Testing the anterior head and neck flexor muscles (longus capitus and colli and rectus capitus anterior aided by the SCM, AS, and hyoid muscles) was performed supine as described by Kendall et al. (1993). Resistance was applied to the chin and resistance was placed in the direction of head. Backward bending was attempted to test the ability of the anterior neck flexor muscles (longus capitus and colli and rectus capitus anterior) to maintain the head in chin tucked or flexed position. No weakness of the anterior neck flexors was noted suggesting a Normal muscle grade. Although some studies suggest that manual muscle testing scores have questionable reliability, (Frese et al., 1987; Wadsworth et al., 1987) others suggest that they can be used for detecting substantial weakness. Florence et al. found the manual muscle testing intrarater reliability for individual muscles range from kw ¼.80 to.99 (Cohen s

80 ARTICLE IN PRESS M.T. Cibulka / Manual Therapy 11 (2006) 78 82 weighted Kappa) in patients with neuromuscular impairments (Florence et al., 1992). Bohannon (1999) found that manual muscle tests grades correlated well with hand held dynamometry scores in 50 patients suggesting that they measure the same variable-strength. 2.2.7. Special tests A Sharp-Purser test was performed as well as the extension-rotation test to assess the possibility of atlanto-axial ligamentous laxity or vertebral artery occlusion. Uitvlugt and Gndenbaum (1988) showed that the Sharp-Purser test is a useful clinical examination to diagnose atlanto-axial instability (sensitivity 88%; specificity 96%). The extension-rotation test, like other vertebral artery tests, has been shown to have excellent specificity but poor sensitivity (Cote et al., 1996). Both tests were negative. 3. Diagnosis and prognosis The diagnosis of this patient was cervicogenic headache with limited upper cervical mobility (decreased right side bending at the atlanto-occipital and C2/3 joint and decreased left rotation at the atlanto-axial joint) and SCM/AS neck flexor muscle imbalance (weakness of the right SCM and diminished length of the left SCM). The prognosis was only Fair due to the fact that she had had little success with previous treatments and that the headache was a recurrent problem. 4. Intervention The goals of the intervention included diminishing/ eliminating headache, restoring mobility to the upper cervical spine joints, and restoring muscle balance (muscle length and strength) to the cervical spine SCM and AS muscles. The treatment on day one included manual therapy of the cervical spine using a technique (Nicholas, 1974) to increase motion between the second and third cervical vertebrae (C2/3) in side-bending right. Before the manipulative technique was performed moist heat was applied to her cervical spine for twenty minutes to relax the patient. The manipulative technique was then performed. Briefly, the patient lies supine; the therapist holds the patient s occiput with the left hand and with the right hand using the radial aspect of the MCP joint of the index finger engages the right articular pillar of C3. The patient s neck is side bent right by pushing with the right hand medially into C3 and then rotated left until all the motion is taken up. Once the slack is taken up a sudden medial movement on C3 pillar was given. A resultant audible pop was heard. After the treatment to the patients C2/3 segment she reported no increase or decrease in headache pain or did she have any other symptom. Nothing in the history or physical examination suggested any contra-indications to using this technique. On the second visit the patient reported some relief in headache intensity on the next day (worst pain was only a 5 out of 10 compared to 7 out of 10 previously) and was again assessed for upper cervical mobility. Again the C2/3 joint range was found diminished when compared to the left side. Treatment again was with a manipulative technique to the C2/3 joint and she was taught a home stretching exercise of the left SCM. Briefly she was asked to stretch 3 4 times daily by lying supine with her head in neutral. By grasping her head with her right hand over her head she pulled her head into right side bending until a gentle stretch was felt in the left SCM. Stretch was held for 30 s or until the sensation of stretch in the left SCM disappeared. Four stretch repetitions were performed each time. On the third visit (one week) she again completed the Likert pain scale and Neck Pain Questionnaire scores before therapy. Her worst pain score was 3 out of 10 while her Neck Pain score was 6%. On the third visit low load exercises were started to increase the strength and endurance of the right SCM and AS muscles. The patient was instructed to lie supine with shoulders flexed and elbows bent to 901. The patient was then instructed to lift the left ear toward her chest (sternum) in the same way Kendall describes the SCM muscle tests (Kendall et al., 1993). Each time she lifted her head she held the head up for two counts and then slowly lowered the head down. The patient was instructed to exercise the right SCM muscle until she felt fatigue in the right SCM muscle but not pain or an increase in headache. The onset of fatigue was the stopping point of the exercise. The patient started with two sets of 8 and built up to two sets of 25 by her last day, two weeks from the initial evaluation (6th visit). After two weeks the Likert pain score for the worst pain possible was 2 out of 10 and her Neck Pain Questionnaire score was 2%. No limitations in mobility were noted in her upper cervical spine with Normal right SCM/AS muscle grades. Muscle length of the left and right SCM were symmetrical. Physical therapy was discontinued. A month later the patient came by for a re-evaluation and reported no complaint of recurrent headache. Muscle grades and muscle length of the SCM were normal as was the mobility in the upper cervical spine. 5. Discussion The treatment of cervicogenic headache has been described by many clinicians (Dreyfuss et al., 1994; Hurwitz et al., 1996; Jull, 1997; Pollmann et al., 1997; Bove and Nilsson, 1998; Biondi, 2000, 2001; Bronfort

M.T. Cibulka / Manual Therapy 11 (2006) 78 82 81 et al., 2001; Gross et al., 2002). Many of the treatments include joint mobilization/manipulation, based on studies that suggest that limited mobility of the upper cervical joints can create headache (Hurwitz et al., 1996; Nilsson et al., 1997; Jull et al., 2002). Another treatment approach for patients with headache is strengthening the muscles of the cervical spine (Jull, 1997; Jull et al., 2002). Although only a few randomized controlled trials have been performed, studies suggest that strengthening the deep anterior cervical muscles of the cervical spine is effective in helping patients with cervicogenic headache (Gross et al., 2002; Jull et al., 2002; Stanton and Jull, 2003). So far no studies have described the treatment of SCM weakness in patients with unilateral neck pain and headache. Studies have shown the relationship between the SCM and unilateral neck pain and headache. Barton and Hayes (1996) found SCM muscle weakness in patients with unilateral neck pain and headache. Falla et al. (2004) found neck flexor (SCM and AS) fatigue is side specific in patients with unilateral neck pain. Gogia and Sabbahi (1994) reported higher fatigue of the upper trapezius and SCM muscles in patients with osteoarthritis of the cervical spine. This case report describes the successful treatment of the SCM muscle imbalance in a patient with unilateral neck pain and headache. As a group the sternocleidomastoid muscles and the anterior scalene muscles flex the cervical spine. Individually the SCM and AS side-bend the cervical spine and head to the same side and rotate the head and cervical spine to the opposite side (Kendall et al., 1993). The finding of limited active right side-bending and limited left rotation is consistent in a patient with a weak right sternocleidomastoid muscle (Kendall et al., 1993). The patient also showed limited passive length of the left SCM. Often when a muscle is weak its antagonist will display diminished muscle length (Kendall et al., 1952). Mobility tests of the upper cervical spine were also consistent with the muscle length and strength findings of the SCM muscles. In this case limited right atlantooccipital and C2/3 right side bending and limited left atlanto-axial rotation correlate with finding a weak right SCM/AS and short left SCM/AS. Thus the agreement between finding limited mobility of the upper cervical spine in the same direction one would expect weakness of the right SCM give credibility in the evaluation of this patient. The reason why the right SCM muscle in this patient was weak is unknown. The patient gave a history of having a motor vehicle accident previously. In a motor vehicle accident the neck is often whip-lashed and the cervical muscles are often involved (Kumar et al., 2002; Kumar et al., 2004a, b). Macnab found that in flexionextension injuries from motor vehicle accidents, the SCM and longus colli muscles sustain extensive injury (Macnab, 1971). More recently Kumar et al. (2002, 2004) found that the SCM muscles are the most common muscles involved in a low velocity rear-end accident. The SCM is not only the longest muscle of the cervical spine but also the muscle furthest away from the neutral axis during bending. During normal bending the greatest tensile forces develop in those tissues that are furthest from the neutral axis on the convex side (Popov, 1976). Thus the cervical muscles located the furthest away from the neutral axis of bending appear most susceptible to injury. Although the accident happened a few years ago the possibility exists that the previous motor vehicle accident weakened her right SCM muscle is a credible notion. Future studies that specifically examine the effect a motor vehicle accident has on the SCM and AS muscles would be an interesting study. The episodic symptoms of headache create finding an appropriate outcome measure important. The outcome measure that was chosen to assess headache was not ideal. The patient s chief complaint was not neck pain but headache. The neck pain questionnaire is not well suited for headache. Of the 10 subsections of the neck pain questionnaire only three were filled out on the initial evaluation. The Headache subsection was rated 4 out of 5 (highest), Pain Intensity was rated 1 out of 5, while reading was rated 1 out of 5. All of the other subsections were rated 0 out of 6, including driving, sleeping, recreation, lifting, personal care, work, and concentration. The neck pain questionnaire score was initially only 12%, which appears low. A problem with any outcome questionnaire is capturing meaningful and useful data. When a patient exhibits a headache they are often incapacitated at that particular time. However, when they don t have a headache they are usually fine and are without symptoms. Therefore, unless the patient has a headache at the time they are filling out the neck pain questionnaire, the neck pain questionnaire may not be very useful or sensitive of an outcome measure. It has been suggested (Jull, 1997; Jull et al., 2002) that anterior neck flexor weakness is related to cervicogenic headache. Jull et al. (2002) suggest that poor activation levels and endurance capacity of the deep and postural supporting muscles of the neck may develop in patients with headache. The same authors have shown that manipulative therapy combined with endurance exercises for the anterior neck flexor muscles diminished cervicogenic headache (Jull et al., 2002). In this case report the deep anterior neck flexors were tested for isometric strength but not for endurance as described by Jull et al. (1999) because at the time this case was written the author did not know this method of testing. Examining the relationship between the anterior neck flexors and the SCM and AS in future studies would be interesting. The effectiveness of treating headache with this intervention cannot be proven in a case report. However, an essential role of a case report is to provide a framework for new concepts and ideas that may

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