This patient was interesting given her 17 year history of headaches, having not been able to go more than 1-3 months in this period without headaches. The simplicity of Robin McKenzie’s MDT system of assessment & management is brilliant for these unresolved scenarios.
The patient is a lovely emergency nurse in her mid 30’s. She was active doing personal training and yoga a few times a week but had a debilitating headache history. She was referred by a friend who had a chronic problem that I was able to rapidly resolve using MDT, and so had come to see if there was any solution to her chronic headache problem.
She described headache symptoms (into the forehead) that had been ongoing for 17 years. She did not know why they started, and never had symptoms in the neck, although the frontal headache was often accompanied by a left upper trapezius/scapula ache. She never got this symptom without the headache.
She noted she was unsure what would bring on the headache but was very certain once it came on it would never resolve on its own, even with medication. The longest she had gone over the 17 years history without symptoms was 1-3 months.
Her impression was that the source of the headache must be her neck even though she did not experience pain in the neck. She based this on the fact that whenever she had the headache it never went on its own, and she was only able to get relief with treatment on her neck. Typically, she had some kind of manual therapy on her neck for a few sessions, and this would resolve the episode. She had tried and received similar relief (albeit short-term) from chiropractic, physiotherapy, osteopathy and myotherapy.
Yellow Flag Screening:
I ask all my patients to complete a Yellow Flag Risk Form in the waiting room prior to the consultation, as well as a regional form like the Neck Disability Index. It can help identify yellow flags and important non-mechanical factors. In a patient with chronic symptoms like this it can be particularly useful.
She scored 45/130.
Recommended YFRF cut off scores:
· Low risk of CNS characteristics – under 50 points
· Moderate risk of CNS characteristics – 50-65 points
· High risk of CNS characteristics – over 65 points
Despite the chronic timeframe of symptoms her score was in the low risk group.
She scored very low in the fear avoidance questions, and this fit with her physical exam where she did not demonstrate any fear to move her neck for the assessment.
She did score high in the emotion subsection questions, with a self-rated score of 9/10 for depression (where 10 is extremely depressed and 0 is not depressed at all). She scored high for anxiety with 7/10.
I asked her why she scored herself high in these emotion questions, and she noted that although she had in her opinion mild depression, she scored high based on dealing with these headache symptoms as a substantial backdrop to her life.
What about red flags? Headache symptoms could represent something non-mechanical.
Headaches, especially if severe, worsening and unrelenting can represent serious pathology. Apart from the persistent nature of the headaches, they were moderate in strength and never severe. She had no other history of cancer, weight loss, serious illness and had imaging of her brain (MRI) that was reported as normal. Her GP had seen her multiple times about this issue. I decided to assess her mechanically given there were no clear contraindications, and had a low index of suspicion for red flags given the above information.
Assessment with MDT to determine if the headaches were mechanical in nature and to attempt to classify/diagnose her problem.
At the end of her history I asked her about any resting symptoms. She had the headache (which always makes the assessment easier than seeing the patient when they are asymptomatic) and the left upper trapezius ache.
As is standard assessment using MDT, I first assessed the effect on posture.
Her sitting posture was already quite upright despite sitting and chatting to me for 15 mins by this stage. Further correction (slight increase in lumbar lordosis and retraction of the neck) had no effect. I asked her to slouch for a few mins, and again found no change to her resting headache symptoms.
In her natural quite upright sitting posture (without any correction given the lack of change in symptoms) I assessed her neck ROM (range of motion):
- Mild loss of left rotation
- Full right rotation
- Moderate loss of left lateral flexion (increasing the headache)
- Nil loss of right lateral flexion
- Full painless cervical flexion
- Full cervical protrusion (upper cervical segment extension)
- Mild-moderate cervical retraction (upper cervical flexion)- that made her “feel funny in the head”
- Mild-moderate loss of cervical extension (feeling of decreasing the headache)
My quick impressions at this point:
There is some definite movement loss of the neck (expected if indeed her problem is mechanical and not from postural syndrome). Some of the neck movements are affecting the headache symptom (increasing potential for the problem to be mechanical). There is some asymmetry in her range of movement, with less movement on the same side she gets the trapezius ache.
What MDT classifications are possible with the history and this movement loss information??
MDT is first and foremost a classification system, rather than a type of treatment. Experienced MDT clinicians are taught to take the information presented and continually think of which classifications they can first rule out, to clarify the potential remaining classification options.
With this in mind:
- I could exclude posture syndrome (apologies this post does assume some knowledge of the MDT system and how it works, but hopefully even without it the reasoning still makes sense to those without MDT training) given the resting symptoms that were not affected by posture correction, and there was movement loss.
- I could exclude an upper cervical dysfunction as the cause of the headache, as in this scenario the headache would not be present at rest and would only be produced with end-range movement.
- OTHER- Serious pathology seemed unlikely given the information in the red flags section with an otherwise healthy young woman.
- Cervical derangement (likely upper cervical spine given the symptom location) was still possible but needed to be tested.
- While less likely, thoracic and lumbar derangement can produce neck tension symptoms and present at headache (I personally have a lumbar derangement that used to frequently present as headaches before I figured it out and resolved it)
- OTHER- Chronic Pain was certainly a possibility, although the lower YFRF score decreased but not removed this potential in my thinking.
- OTHER- Mechanically Inconclusive was still a possibility, but this classification is one of exclusion after all other options have been eliminated.
- Other non-mechanical sources of headache was still possible, but again a mechanical evaluation should always be performed before arriving at this conclusion, unless the history suggests a mechanical evaluation is inappropriate.
MDT- The part of the assessment that tends to reveal the true nature of the complaint- Time for repeated movement testing!
The history did not reveal any obvious direction preference. So, it was decided to test repeated movements of the upper cervical spine first (given symptom location) and in no particular order, but simply to gather information about how the symptoms behaved.
My phrasing to the patient was that her headaches had clearly shown over many years that specific treatment on her neck does relieve her headaches, and that I wanted to test her neck to see if we could find a movement/loading strategy that moved her neck in a way that would provide relief. In effect I told her we were looking to see if we could find something she could do to switch of her own headache, rather than having something done to her.
Just prior to testing repeated movements, resting symptoms were assessed and reported as:
Left mild upper trapezius ache, and frontal headache 4/10 self-reported intensity.
- Repeated retraction (upper cervical flexion) was tested first in sitting with the following response- There was no effect on the symptoms, and no change in ROM afterwards.
- Given the lack of information gained (no change in pain or ROM after 10-12 reps) retraction with patient over-pressure (light pressure applied with the fingers on the chin at end-range retraction) was assessed- There was an increase in headache, which did not remain worse and no change in neck ROM.
- Repeated protrusion was tested next in sitting x 12 reps- decrease of symptoms on the right side of the forehead was perceived with production of right eye symptoms, and there was a definite increase in left rotation and left lateral flexion.
- Further testing with more repetitions (around 30-40 in total) of repeated protrusion were performed given the clear mechanical improvement, and yet pain decreased but did not remain better afterwards (in MDT noted as a decrease, no better response or yellow light response).
My impression at this point:
We are having a decrease in pain that is not remaining better. Sounds like we may be moving in the correct direction (for those familiar with the MDT traffic light guide to interpreting pain, it sounds like a yellow light that wants to go green). There is clear ROM improvement with the left lateral signs, which increases the likelihood we are on the right track and also decreases the potential to require lateral forces (given sagittal plane loading is improving the lateral movement loss).
Should we stop testing at this point?
The history tells us that headache symptoms do not ever resolve on their own, and manual work on the neck always sorts it out. We have a suggestion of a directional preference with the testing, the problem appears stable and we have no red flags of concern.
I decided to test repeated protrusion/extension to emphasis the upper cervical extension direction loading, asking her to poke the head forward fully, and then look up.
We did x 15 reps. The symptoms reduced by 50% in her estimation, and she noted in her view “the headache was clearly better”.
To increase the plausibility that we had truly found an upper neck derangement, (which by definition will have a direction where repeated movements in the directional preference will reduce symptoms and improve the ROM), we retested repeated retraction (the opposite direction to our supposed directional preference) and the headache worsened and we re-obstructed the left rotation and left side-bending. This was expected if our suspicion of a headache caused by upper cervical derangement was our MDT classification. Movements in the direction opposite to the directional preference should worsen symptoms and movement.
Provisional classification and plan for the patient at the end of the initial assessment:
My explanation to the patient was simple. I asked her to perform x 15 reps of the exercise that reduced her headache by 50%, which was repeated protrusion/extension (upper cervical spine extension). I asked her to monitor both the symptoms and neck range of movement and gave her safety instructions about worsening or severe symptoms and my number to call if needed. I asked her how often she thought she should do the exercises, to which she replied “Why don’t I try them every 1-2 hours, and if they are working the symptoms will guide me as to how often I need them.”
Her response indicated she was not fearful, had good buy-in and she understood that the testing had identified an exercise that seemed likely to help. As she noted she had spent a great deal of money and time on treatment that was only providing short-term relief and she was wanting to try and see if we could identify a way for her to help herself long term.
I provisionally classified her with MDT as having an upper cervical derangement with a direction preference for extension. And as usual with MDT this needed to be confirmed or rejected with her trial of exercises every few hours at home for a 24-hour period. I did not give her any specific advice on posture given changing it in the exam did not affect her headaches. I did specifically mention to avoid/counter positions of upper cervical flexion given it appeared to be counter to our directional preference.
Follow up appointment 2 days later.
She arrived at her follow up appointment with a smile on her face. She had been very compliant with the exercises and was doing around 10-15 reps of protrusion/extension and noted the headache was virtually gone. This was particularly significant for her given her 17-year history of never being able to get relief until she had manual treatment to her neck, which usually involved a few sessions (typically 2-3) within a single week.
She noted the exercises gave her very definite relief, and her only complaint now was a pressure feeling behind both eyes, and a “funny feeling” that lingered for around 20 mins post exercise session (her specific directional exercises).
Examination in the rooms revealed full motion of the neck in all directions (at least visibly).
After watching her perform the exercises, we explored adding over-pressure to the protrusion/extension position. This abolished the remaining pressure symptoms behind her eyes.
Our provisional classification of upper cervical headache with a directional preference for extension was confirmed.
Our focus for the second session was education around continued application of the exercises to relieve the symptoms and prevent their recurrence. We also focused on regular daily self-monitoring of her left cervical rotation and side-bending. She was advised to check her range even in the absence of symptoms, and to perform the same exercises if she noticed she had lost range of motion (*mechanical evidence of the derangement returning).
What about the longer-term outcome? These headaches were ongoing for 17 years!
I saw the patient once more and she was doing great. The headaches had been completely resolved without the need for manual therapy. As the patient explained the time and cost on these treatments for many years was extensive and she was happy to be able to ease symptoms on her own.
I also followed her up with a text message months later, curious to see how she was going.
“I had a long time without them and then got another bad headache which made me realise I had forgotten to do the exercises. Will get to it. Thanks for checking in!”
Key messages to take from this case study:
- The MDT system is first and foremost a classification system, where information is gathered to form various hypotheses/classification options, and testing is done to further refine the classification.
- The MDT process quickly and inexpensively found a solution and differentiated between potential competing diagnoses/classifications through a simple yet rigorous assessment process
- The exercise/loading strategy that ultimately provided relief and proved to be the directional preference was uncovered by listening to the symptomatic/mechanical response. Interestingly I tried to find an image/video of repeated protrusion or protrusion/extension and could not find one on google images or You-tube. The web is littered with images of people performing retraction and exercises “to fix headaches”, and yet this patients solution was the opposite to a lot of the generic advice found online. Test every patient in front of you without bias.
- Red flags are always considered, as are Yellow flags and these can be very significant is some patients.
- A chronic time-frame of symptoms does not automatically place someone into the classification of OTHER- Chronic pain syndrome. Every patient should be mechanically assessed without bias to rule in/out other common classifications like derangement.
- Robin McKenzie was ahead of his time. He understood patient empowerment, self-management and involving the patient in their own care well before these concepts become embedded in the literature.
In this case despite her chronic timeframe of symptoms (17yrs!), this patient was able to learn to efficiently and effectively self-manage her headaches. She saved considerable time and cost, but more importantly, learned she could control her own symptoms. Everyone deserves a through MDT assessment, and should be taught how they can help themselves.
Written By Senior Physiotherapist & MDT Diplomat Joel Laing