Physical Therapy Rehabilitation Protocol: Cervicogenic Headache (Cervical Spine)

Cervicogenic headache (CGH) is a secondary headache arising from a disorder of the cervical spine and its component bony, disc, and/or soft tissue elements. This protocol outlines a comprehensive physical therapy approach to manage CGH, progressing through phases focused on pain management, restoring cervical range of motion and strength, and returning to functional activities.

Pathophysiology

The pain in CGH originates from the cervical spine and is referred to the head. The trigeminocervical nucleus, located in the upper cervical spinal cord, receives sensory input from the upper three cervical spinal nerves (C1-C3) and the trigeminal nerve (CN V). This convergence allows for referral of pain from the cervical spine to the head. Common impairments include:

• Upper cervical joint dysfunction (hypomobility, hypermobility, or aberrant movement)
• Forward head posture
• Muscle imbalances (tightness in upper trapezius, levator scapulae, pectorals; weakness in deep neck flexors)
• Altered proprioception

Common Special Tests

• Cervical Flexion Rotation Test (FRT): Assesses upper cervical mobility. Positive test involves limited cervical rotation in full flexion.
• Joint Play Assessment: Palpation and assessment of movement at the occipitoatlantal (OA), atlantoaxial (AA), and lower cervical joints.
• Spurling's Test (Cervical Compression Test): Provocative test for cervical radiculopathy but can sometimes reproduce headache symptoms if cervical nerve roots are involved.
• Upper Limb Tension Test (ULTT): Assesses neural tension in the upper limb, which can be related to cervical dysfunction.
• Deep Neck Flexor Endurance Test: Measures the ability to maintain a chin tuck position, indicating deep neck flexor strength.

Phase I: Protection (Acute Phase)

Goals:

• Reduce pain and muscle spasm
• Restore basic cervical range of motion (ROM) within pain-free limits
• Improve postural awareness

Interventions:

• Patient Education: Explanation of CGH, posture correction, ergonomics, activity modification, stress management techniques.
• Modalities for Pain Relief:
  • Heat or ice (patient preference)
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • Ultrasound
  • Gentle massage to upper trapezius and suboccipital muscles
• Manual Therapy (Gentle):
  • Soft tissue mobilization to address muscle spasm
  • Gentle joint mobilization to upper cervical spine (OA, AA) targeting pain relief and improved mobility - Grade I and II mobilizations.
  • Muscle energy techniques for cervical muscles.
• Therapeutic Exercises:
  • Cervical isometrics (flexion, extension, lateral flexion, rotation) performed with minimal effort and pain-free. Focus on endurance over strength.
  • Chin tucks: Emphasize proper form, holding for 5-10 seconds, repeated 10-15 times.
  • Scapular retractions: To improve posture and strengthen middle trapezius and rhomboids.
  • Diaphragmatic breathing exercises: To promote relaxation and reduce muscle tension.

Phase II: Loading (Subacute Phase)

Goals:

• Increase cervical ROM and flexibility
• Improve muscle strength and endurance
• Normalize cervical joint mechanics
• Improve proprioception and balance

Interventions:

• Manual Therapy (Progressive):
  • Progress joint mobilizations to Grade III and IV as tolerated to address joint restrictions.
  • Muscle energy techniques to address specific muscle imbalances.
  • Trigger point release for myofascial pain.
• Therapeutic Exercises (Progressive):
  • Cervical ROM exercises (flexion, extension, lateral flexion, rotation) with emphasis on full, pain-free ROM.
  • Strengthening exercises with resistance bands or light weights: Deep neck flexor strengthening (progression of chin tucks), cervical extensor strengthening, scapular stabilization exercises.
  • Postural exercises: Wall slides, rows, reverse flyes.
  • Proprioceptive exercises: Balance board exercises, eye-head coordination exercises, cervical joint position error testing and training.
  • Start dynamic stabilization exercises.
• Ergonomic Assessment and Modification: Review workstation setup and make recommendations for optimal posture and biomechanics.

Phase III: Return to Function (Chronic Phase)

Goals:

• Maintain optimal cervical ROM, strength, and endurance
• Improve functional activities and prevent recurrence
• Return to sport/work-related activities

Interventions:

• Advanced Strengthening Exercises:
  • Progress resistance for strengthening exercises.
  • Incorporate functional exercises that mimic work or sport-related activities.
  • Plyometric exercises for cervical stabilizers (performed with caution and proper technique).
• Endurance Training:
  • Prolonged postural control exercises.
  • Low-impact aerobic exercises (walking, cycling) to improve overall fitness and reduce stress.
• Activity-Specific Training:
  • Simulate work or sport-related tasks to improve performance and reduce risk of injury.
  • Address any remaining functional limitations.
• Self-Management Strategies:
  • Home exercise program
  • Posture awareness and correction techniques
  • Stress management techniques
  • Ergonomic principles
• Discharge Planning: Establish a plan for long-term management, including periodic check-ups and self-care strategies.