Dolor Craneo Cervical (Ingles) PDF

CLINICAL PROCESSES CERVICAL SPINE AND HEAD Musculoskeletal Physiotherapy 2 Physiotherapy Department. ELBOW FME2 TEORÍA  Chronic medial epicondylalgia Clinical Chronic lateral epicondylalgia processes Radial tunnel syndrome...

CLINICAL PROCESSES CERVICAL SPINE AND HEAD Musculoskeletal Physiotherapy 2 Physiotherapy Department. ELBOW FME2 TEORÍA  Chronic medial epicondylalgia Clinical Chronic lateral epicondylalgia processes Radial tunnel syndrome Pronator teres syndrome Chronic medial epicondylalgia  Chronic medial epicondylalgia "Golfer's elbow", "Epitrochleitis". Tendon-periosteal involvement of radial and ulnar flexors, pronator teres and palmaris major. Collagen degeneration, degradation of the fundamental substance, fibrosis and neovascularisation proximal to the insertion. Non-inflammatory=> Tendinosis Chronic medial epicondylalgia Low and variable prevalence, 0.4 to 1.9%. Occupational pathology 90-95% 20-50% associated with ulnar neuritis Chronic medial epicondylalgia: Factors involved Women 40-60 yo. Repetitive flexion and pronation movements Dominant arm Muscle imbalance: Weakness, flexibility Sports Obesity Diabetes Smoking Chronic medial epicondylalgia: Body chart Throbbing pain at the inside of the elbow May radiate down the front of the forearm  Inability to carry weights. Pain when fist. Chronic medial epicondylalgia: Pain when moving arm or wrist. 24 h. behavior Complete ROM. Relief with ice and NSAIDs.  Chronic medial epicondylalgia: Current and past history 70% Progressive onset 30% Acute onset: Specific overuse Partial improvement with rest, ice and stretching Relapse on repetition of injury mechanism: Worse recovery=> Chronicity Worsens with overhead and downward strokes (tennis serve, javelin), also with wrist flexion (golf) Radiculopathy C6-C7 Chronic medial epicondylalgia: Special questions Ulnar neuropathy ("driver's elbow") Chronic lateral epicondylalgia Chronic lateral epicondylalgia "Tennis elbow", "Epicondylitis". Tendon-periosteal injury of the common tendon insertion of the extensor carpi radialis brevis and extensor digitorum commonis (95%) Non-inflammatory=> Degeneration=> Epicondylosis Preference dominant arm. Rarely bilateral. Chronic lateral epicondylalgia Worldwide incidence (40-50 years): 1 and 3%. 11%=> Occupational 20-60% office workers Tennis players 5-10% incidence Acute direct or indirect injury: 20%. Trauma or repetitive movements: 80%. Favourable natural evolution. Recurrence after two years high.  Degree of severity of epicondylalgia according to MRI findings Grade Description Severity rating Lenght Normal Homogeneous tendon 1 0-2 mm Moderate Moderately increased focal signal 2 5.5 mm Severe Generalised increased focal signal 3 6 mm  Nirschl and Ahman's classification of the stages of lateral epicondylalgia Stage Description of pain level in epicondylitis I Moderate post-exercise pain lasting less than 24 hours. II Pain after exercise that lasts more than 48 hours and resolves with physical means. III Pain with exercise, but not limiting IV Pain with exercise and is limiting V Pain with heavy activities of daily living VI Pain with light activities of daily living; intermittent pain at rest, but does not interfere with sleep. VII Constant pain at rest, interferes with sleep  Chronic lateral epicondylalgia: factors involved Over 30 y.o. ("Working age"). Same incidence in both sexes. Manual work and/or repetitive movements: Handling tools heavier than 1 kg, handling loads heavier than 20 kg at least 10 times/day and repetitive movements for more than 2 hours per day. Weakness of short and long radial extensor muscles. Overuse, training errors => Microscopic tearing Mechanical factors: Misalignments, flexibility problems, strength deficits or muscle imbalance. Ageing=> degenerative process. Poor circulation. Psychological factors. Chronic lateral epicondylalgia: Body chart Localised pain Numbness or tingling of the forearm and/or hand Chronic lateral epicondylalgia: 24 h. behaviour Inability to carry weights Pain when making a fist Pain when moving arm or wrist High reactivity to palpation Poor reaction to NSAIDs Chronic lateral epicondylalgia: Current and past history - Acute onset: Few hours after intense exercise - Direct trauma or repetitive finger and wrist extension movements. Chronic lateral epicondylalgia: Special questions Diferencial diagnosis: o Posterolateral rotational elbow instability=> painful clicking and locking, dislocation sensation. o Osteochondral defect o Synovial plica o Radial tunnel syndrome o Interosseus nerve syndrome o Growth plate disorder, CS o >35=> OA Radial tunnel syndrome  Radial tunnel syndrome Radial tunnel syndrome or "Posterior interosseous nerve syndrome". Dynamic/intermittent compression of the motor branch of the interosseous nerve (radial nerve branch) under the supinator brevis muscle. Heterogeneity Sx: Difficult Dx=> No sensory or motor deficit.  Radial tunnel syndrome Second most common upper limb neuropathy EMG and MRI very insensitive Areas of compression: o Middle and distal arm o Localised area of tunnel at elbow o Proximal to wrist, between brachialis muscle and extensor carpi longus. Differential diagnosis Radial tunnel syndrome: Factors involved 30-60 yo Dominant arm 30% Bilateral Space occupying lesions Diabetes Smoking Alcohol Rheumatoid arthritis Hypothyroidism Radial tunnel syndrome: Body chart Main pain on dorsum of forearm, 5-7 cm distal to epicondyle Radial tunnel syndrome: 24 hours behavior Cutting, piercing or stabbing pain affecting the upper forearm, the back of the hand and the side of the elbow. Pain of fluctuating intensity: mild persistent discomfort that occasionally increases to become very intense and irritating. Pain on extension of the wrist and fingers. Heaviness. Worsening when sleeping. Antalgic posture: Radial deviation when supporting the arm. Radial tunnel syndrome: Current and past history Humerus fracture Repetitive pronosupination with elbow 0-45º flex Lateral epicondylalgia=> Posterior interosseus nerve=> Origin of the radial wrist extensor and supinator muscles Radial tunnel syndrome: Special questions Differential diagnosis: Tennis elbow! Night pain, not numbness. Pronator teres syndrome Pronator teres syndrome Compression of the median nerve between the two heads of the pronator teres muscle or below the proximal border of the flexor digitorum superficialis arch. Prevalence lower than carpal tunnel=> 1 PS case per 201 CTS cases. Anatomical determinants Pronator teres syndrome: Factors involved Women 40 yo Associated with CTS Trauma Haematoma, ossicular deformity Muscular and fascial hypertrophy Mass (lipoma) Pronator teres syndrome: Body chart Paresthesias/numbness in palm of hand and 1st, 2nd, 3rd and half of fourth fingers Pain at the front of the forearm  Pronator teres syndrome: 24 hours behavior Paresthesias in the palm of the hand, thumb, index, middle and radial half of the fourth finger. Anterior forearm pain Tenar eminence atrophy or weakness Absence of nocturnal symptoms Pronator teres syndrome: Current and past history Occasional origin: Sporting or occupational Inability to pronate without pain Decreased IR shoulder Pronator teres syndrome: Special questions Differential diagnosis: Carpal syndrom=> Absence of nocturnal symptoms Ankle-Foot FME2 Teoría Ankle: clinical processes Osteoarthritis Chronic ankle instability Achilles tendinopathy Fasciopathies Morton´s Neuroma Tarsal tunnel syndrome C/O- Clinical records Ankle Osteoarthritis Ankle Osteoarthritis Joint degenerative condition => progressive loss of articular cartilage => marginal bone hypertrophy (osteophytes) => changes in the synovial membrane Genetic and proteomic pattern of inflammatory characteristics.​ IRREVERSIBLE​ Prevalence lower than knee or hip, but higher if post-traumatic (65-80%) Ankle OA: Factors involved Age​ Overweight Anatomical malformations Mortise fracture Recurrent sprains High performance physical activity Ankle OA: Body chart Pain, swelling and stiffness, localised onset at the rearfoot and evolution towards the forefoot  Stiffness Crepitation Inflammation Ankle OA: 24 Pain hour behavior Decrease of physical activity Daily activities limitations Relieves NSAIDs and rest  Post-traumatic: o Tibial fractures Ankle OA: o Malleolus fractures o Talus fractures Current and past history Anatomical:​ ▪ Joint alignment ▪ Joint damage ▪ Chronic instability Ankle OA : Special questions Osteonecrosis o Freiberg disease Müller-Weiss disease Orthopedic soles Cronic ankle instability  Cronic ankle instability Differentiate: Mechanical instability=> Laxity caused by ligament injury => Evidence by examination. Functional instability=> proprioception and neuromuscular deficits caused by ankle sprain => Sx Congruency: Astragalar dome and TPA mortise. Very stable joint (max D flex+eversion). Main cause: Sprain PAAL is the weakest=> 60% sprains with rupture Sprain Lateral sprains: Forced plantar flex + inversion + slight RI 85% affects ELL=> APAL 44% sequelae. 15-25% of all musculoskeletal system injuries: 1 sprain/day per 10000 inhabitants. 20-30% sports injuries. 80% resolve without sequelae.  Alignment Laxity Cronic ankle Intrinsic factors Muscle strength Neuromuscular control instability: Proprioception Factors Extrinsic factors Footwear Field involved Physical Activity …. Mechanical and functional insufficiency Cronic ankle in stability: Body chart Cronic ankle instability: 24 hours behavior Persistent and dull pain at lateral surface. Instability in inversion Insecurity Mechanical disturbances: blockages, clicking sounds Acute episodes Hypersensitivity with swelling Cronic ankle instability: Current and past history 20% acute sprains=> Instability Recurrent sprains=> shoe dependence Deformities: Varus-valgus, astragalar dome and TPA mortise. Tibiotalar, subtalar and midfoot mobility. Cronic ankle instability: Special questions Ankle osteoarthrosis Sports practice Injury mechanism Sx duration Biomechanical evaluation Pathologies that affect laxity Achilles tendinopathy Achilles tendinopathy Achilles tendon overload injury. Poor vascularization=> Increased predisposition. Tendinopathy= Inflammation and degeneration. Mechanical factors Metabolic factors Differentiate: o Non-insertional tendinopathy o Insertional tendinopathy=>"Enthesopathy or enthesitis". Achilles tendinopathy: Incidence 24% in athletes=> Marathon runners 7.4%. Running-related: between 11% and 85% => between 2.5 and 59 injuries per 1000 hours of running. Tendinopathy=> Tendinosis=> Rupture 2.1 per 100,000 individuals/year, with a ratio of 3.5 to 1 male / female. Achilles tendinopathy: Factors involved Age Men Flat foot, varus or valgus. Overpronation. Obesity Muscle stiffness or weakness Impact sports Footwear in poor condition, type of footwear Training terrain Diseases Medication: Fluoroquinolones "Weekend-sports people". Achilles tendinopathy: Body chart Localized pain in tendon insertion in calcaneus Pain in tendon pathway Achilles tendinopathy: 24 hours behavior Heel pain and walking pain. Footwear. Tiptoes. Localized deformity. Improved with ice, NSAIDs and rest. Achilles tendinopathy: Special questions Knee valgus Orthopedic insoles Sport activity Fasciopathologies Fasciopathologies "Plantar fasciosis/calcaneal entesopathy/Calcaneal spur syndrome": Retraction of plantar aponeurosis=> thickening >5mm Fasciopathologies: Thikening. Differenciate: o Fasciitis: Acute, inflammation o Fasciosis=> Chronic, degenerative  Fasciopathologies Most frequent heel pain: >13% reasons for podiatric consultation Calcaneal Spur=> 89% Most frequent in military personnel and sports ( Runners)= One in three cases is bilateral Fasciopathologie + calcaneal spur Calcaneal spur = osteophite o Older people o Women: 16.3, men 6.5% o Plantar fat ratio o Asymptomatic  Fasciopathology: Factors involved Women, 40-60 yo. Mechanical causes Overweight Overload Intoxication Employment Spur Achilles tendom (83% => shortening posterior chain) Fasciopathology: body chart Localised calcaneal pain Referred plantar arch and Achilles tendon pain Fasciopathology: 24 hours behaviour Pain, flushing, heat and tumour. Pain in mid-heel area, radiating to Achilles tendon=> passive dorsal flexion. Worse in the morning or after inactivity. Improves with NSAIDs, stretching and ice (80%). Worsens according to footwear and with long walks.  Acute onset: Improves with rest, ice and NSAIDs. Fascipathology: Clinical records: Current and past history o Lower limb Cx o Immobilisation/Orhtesis (Walker..) o Calcaneus (Stress) Fx o Posterior chain muscular problems  Fasciopathology: Special questions Subcalcaneal bursitis Arthritis False fasciitis Fascia tear Plantar fat atrophy Soleus or Anterior Tibial TP Radiculopathy L5-S1 Insertional Achilles tendinopathy Morton´s neuroma Morton´s neuroma Plantar interdigital nerve neuralgia at the third metatarsal space. Histological changes=> Thickening of endoneurium and epineurium. Hyalinisation of endoneural vessels Demyelination and degeneration of nerve fibres. o Inflammatory aetiology: Bursas=> Compression o Anatomical aetiology: Nerve confluences o Mechanical aetiology: Mobility of the radii Morton´s neuroma Morton´s neuroma Unilateral, less than 20% bilat Dx with ultrasound more accurate than with MRI (88% and 68%) Most common neuroma of the foot=> 75%. Sometimes occurs between 2nd and 3rd space (17%)=> 2nd space Syndrome Morton´s neuroma: Factors involved Women (60-75%)=> 4:1 men Age 25-50 Footwear Deformities Sports Trauma or adjacent pathologies Morton´s neuroma: Body chart Electrical and hot shock with irradiation to the interdigital space. Located at the third intermetatarsal space Morton´s neuroma: 24 hours behaviour Electrical pain during toe off phase (toes in dorsal flex) 91% ptes=> Plantar location at the third intermetatarsal space Pain worsens with deambulation and relieves with rest and off-loading Pain improves with soft, wide toe box and low heeled shoes Pain improves with NSAIDs and ice Morton´s neuroma: Current and past history Use of narrow and stiff toe shoes Use of low heels=> Decompression of MTT heads=> hyperext MTT=> pain Use of insoles with subcapital off-loading  Morton´s neuroma: Special questions Rule out: - Synovitis of the metatarsal heads=> Pain at MTT heads. - Metatarsalgia, whether or not associated with psoriatic arthritis. - Inflammation of other structures - Second space syndrome (20% neuromas). Foot surgery Tarsal tunnel syndrome Tarsal tunnel syndrome Peripheral neuropathy Tunnel=> Flexor retinaculum=> Posterior tibial nerve External compression=> 17-43%. Internal compression Tarsal tunnel syndrome: Factors involved Under-described incidence: Women, 40-45 yo. Obesity Foot characteristics Space occupation Previous injuries Impact sports Tarsal tunnel syndrome: Body chart Pain-burning, accompanied by paraesthesia, hypoesthesia, dysesthesia or cramps May extend to the tibia  Inability to flex the toes, plantar flexion or inversion Weakness of toe extension Tarsal tunnel Worsens with activity and tight shoes syndrome: 24 hours Improves with rest and ice behaviour Improves with NSAIDs Night pain may intensify Tarsal tunnel syndrome: Current and past history Acute onset=> Marathons => NSAIDS, rest => Improvement Iatrogenic injuries Systemic diseases Tarsal tunnel syndrome: Special questions Study of the footprint Not to be confused with: - "Anterior tarsal tunnel syndrome"=> Peroneus profundus in extensor retinaculum - Plantar fasciitis Any questions?  GENERAL AND TYPICAL DISORDERS UPPER CERVICAL MIDDLE CERVICAL LOWER CERVICAL SPINE C0-C3 SPINE C3-C5 SPINE C5-C7 Head over neck Neck over neck Neck over trunk Headaches Facet syndrome Discogenic pain Radiculopathy Thoracic outlet syndrome HEADACHES OF CERVICAL ORIGIN 3  HEADACHES OF CERVICAL ORIGIN Syndrome originating from cervical nociceptive structures: facet joints, intervertebral discs, muscles and ligaments. Cervical structures may be related to Primary Headaches (Migraine and Tension-type Headache), Cervicogenic Headache, Occipital Neuralgia, Neck-Tongue Syndrome (hypoglossal with C2) and Glossopharyngeal neuralgia ( Styloid process & C1-C2). Innervated by segmental nerves C1-C3 Prevalence 1-4% (up to 53% after whiplash) Normal imaging tests.  MECHANISMS OF INJURY PREDISPOSING AND PAIN AGGRAVATING SOURCES FACTORS CEPHALEA JOINTS SYMPTOMS INVOLVED INJURY PROCESSES CLINICAL PROCESSES Cervicogenic Headache. Tension-Type Headache. Migraine Chronic cervical/neck pain. 6 Cervicogenic Headache 7  Cervicogenic Headache “Headache caused by disorders of the cervical spine and its bony, disc and/or soft tissue elements, usually but not always accompanied by neck pain..” (IHS 2018) It is the 3rd most frequent type of headache after tension and migraine headaches (20% of headaches, with a prevalence of 0.4% to 2.5% in the total population). 8  Cervicogenic Headache Diagnostic Criteria (IHS 2018): – 1. There is clinical and/or imaging evidence confirming a documented cervical spine or neck soft tissue disorder or injury as the cause of headache. – 2. Causality is demonstrated by at least two of the following characteristics: A. The onset of the headache is related in time to the onset of the cervical disorder or the presentation of the lesion. B. Headache has relieved or significantly subsided simultaneously with the improvement or remission of the cervical disorder or injury. C. Cervical range of motion is reduced and the headache is significantly worse with provocative manoeuvres. D. The headache resolves after diagnostic local (anesthetic) block of a cervical structure or its innervation. E. Not attributable to another diagnosis of ICHD-III3-5.  Cervicogenic Headache Diagnostic local (anesthetic) block : C1-C2: Lateral intra-articular block (currently not recommended, only PRF- pulse radio-frecuency). C2-C3: 3rd occipital nerve block (70% of cases!!!). C3-C4: Dorsal branch block C3 and C4.  Cervicogenic Headache Therefore any structure innervated by the C1-C3 spinal nerves can be a cause of cervicogenic headache. Convergence is not exclusively between the cervical and trigeminal nerve, but between the nerves that innervate the head and the cervical spine => any nociceptive element present in the cervical spine, especially in the upper cervical spine, may cause this disorder.  Cervicogenic Headache ** Headache incidentally associated with myofascial pain in the cervical region (myofascial trigger points) may, if it meets other criteria, be associated with a subtype of tension-type headache.… (IHS 2018)  Cervicogenic Headache - Factors involved : - Female sex. - History of cervical trauma (including whisplash), increases its incidence. - Clinical or imaging evidence of cervical spine disorder/pathology (degenerative arthritic signs in the cervical spine) => not a differential element. - Ageing (> 40 years). - Prolonged sitting (work) => muscle inhibition. - Lack of support due to weakness of the cervical stabilising muscles. 13  Cervicogenic Headache BODY CHART - Unilateral pain on the affected side (no change of side) of moderate-severe intensity. - Cervical onset pain extending to oculo-fronto-temporal level. - The highest intensity is perceived at the occipital level. - If cervico-occipital pain is increased head pain. 14  Cervicogenic Headache 24 H BEHAVIOUR Constant (monotonous) pain of a deep and heavy character during the day. May be accompanied by nausea/vomiting or photo-audiophobia, although vegetative symptoms are rare and if present are of low intensity. Headache is increased by movements or postures of the CS (sustained cervical hyperextension) or by direct manipulation of the CS (external pressure on the symptomatic side) There is limitation of CS ROM usually with movement to the symptomatic side. Some relief with oral NSAIDs and amitriptyline if in episodic pattern. Improved in decubitus, if the CS is not in extension. 15  Cervicogenic Headache PAST AND PRESENT HISTORY Onset symptoms: - It initially presents with a remitting (episodic) pattern, associated with CS postures. - Headache episodes are less than 15 days/month. Progression: - They evolve into a chronic pain pattern (with fluctuations) and less dependent on cervical mobility. - More than 15 days/month of headache. No response to treatment with indomethacin and sumatriptan (effective in migraines and cluster headaches) Frequent onset of the clinical process in middle-aged women (40-50 years). There may be previous predisposing factors: cervical trauma,... 16  Cervicogenic Headache SPECIAL QUESTIONS - Observation of dystonic postures in face and neck (focal dystonia). - Horner's syndrome (miosis, palpebral ptsosis and unilateral anhidrosis) => carotid dissection. - Tongue paresthesia (neck-tongue syndrome) - Assess headache that does not vary throughout the day, that is not too intense, and that even improves with exercise,... 17  Cervicogenic Headache 1. CURRENT SYMPTOMS 9. PHYSIOLOGICAL MOVEMENTS 2. OBSERVATION 10. PALPATION 3. FUNCTIONAL DEMONSTRATION 11. ACCESSORY MOVEMENTS 4. RE-EVALUATION 12. SCREENING TEST 5. ACTIVE MOVEMENTS 13. INITIAL TREATMENT 6. OVERPRESSURE TEST AND 14. RE-EVALUATION OTHERS. 7. ASSESSMENT OF OTHER 15. PATIENT INSTRUCTIONS STRUCTURES (MUSCULAR, NERVOUS SYSTEM, VASCULAR)*. 8. NEURODYNAMIC ASSESSMENT 18 Tension-Type Headache 19  Tension-Type Headache “Pain or discomfort in the head, scalp or neck that is often associated with tightness of the muscles in these areas.” It is the most common type of headache, with a lifetime prevalence in the general population ranging from 30% to 78%. It has a very high socio- economic impact. It is usually divided into 2 groups: - Episodic. - Chronic. 20  Tension-Type Headache Classification (IHS 2018): – 1. Infrequent episodic tension-type headache. 10 episodes of headache (12 days year). – 2. Frequent episodic tension-type headache. 10 episodes of headache (1-14 days/month for >3 months (≥12 and 3 months (≥180 days/year) – 4. Probable tension-type headache (infrequent, frequent or chronic). one of the characteristics required to meet the criteria for one of the subtypes of tension-type headache is missing. * The first 3 types differentiate 2 subgroups, depending on whether the headache is accompanied by cranial hypersensitivity or not (on palpation).  Tension-Type Headache Diagnostic criteria (IHS 2018): Al At least two of the following four characteristics: 1. Bilateral localisation. 2. Tight or oppressive quality (non-pulsatile). 3. Mild to moderate intensity. 4. No worsening with usual physical activity, such as walking or climbing stairs. * The following two characteristics: a. Episodic: No nausea or vomiting. May be associated with photophobia or phonophobia (not both). b. In chronic: May be associated with either photophobia, phonophobia or mild nausea (no more than one). Neither moderate or intense nausea nor vomiting.  Tension-Type Headache Its pathogenesis is currently considered to be multifactorial and the mechanisms involved in the origin of pain may be dynamic and variable from one individual to another and within the same individual during the evolution of the disease. Peripheral (myofascial) and central mechanisms have been implicated in the pathophysiology of pain, the first ones predominating in episodic tension-type headache (frequent and infrequent) and the second ones in chronic tension-type headache.. (SEN 2020)  Tension-Type Headache ** Headache incidentally associated with myofascial pain in the cervical region (myofascial trigger points) may, if it meets other criteria, be associated with a subtype of tension-type headache… (IHS 2018)  Tension-Type Headache - Factors involved : - Female sex. - First-degree family history and in twins (polygenic inheritance). - Psychological factors (stress, mental tension) are triggers of the headache without being the cause of the headache itself. - Sleep disturbances => chronification of the headache. - Poorly corrected visual acuity disorders (presbyopia, myopia, etc.). - Excessive use of screens or situations that require prolonged visual effort. 25  Tension-Type Headache BODY CHART - Bilateral, non-pulsating, mild- moderate pain. - Pain perceived as compressive or constricting ("helmet" or "tight band"). - The greatest intensity is perceived at occipital level, although it extends to the neck, scapular and frontal region - May be perceived as more intense on one side than on the other side. 26  Tension-Type Headache 24 H BEHAVIOUR Headache onset while the patient is awake and worsens over the course of the day. The duration of episodes is variable, but usually lasts more than four hours. It is not associated with significant vegetative symptoms (nausea/vomiting or photo-audiophobia) It does not cause cervical ROM restriction or cervical triggers (although the patient often feels pain also in the neck and shoulders). It does not usually impede activities of daily living, although it does make them difficult. Relief with oral NSAIDs (especially ibuprofen) in pain crises. 27  Tension-Type Headache PAST AND PRESENT HISTORY Onset symptoms: - Initially it presents with an episodic pattern, associated with activities that generate distress or lack of rest. Self-limited and disappear with rest - Episodes of headaches are less than 14 days/month. Progression: - They evolve into a pattern of chronic pain normally associated with the existence of some chronifying factor (insomnia, anxiety, visual fatigue, etc.). - More than 15 days/month of headache for more than 3 months. They may be medicated with tricyclic (Amitriptyline) or tetracyclic antidepressants, with good preventive results in the appearance of crises. Frequent occurrence of the clinical process in young women. 28  Tension-Type Headache SPECIAL QUESTIONS - Observation of dystonic postures in face and neck (focal dystonia). - Horner's syndrome (miosis, palpebral ptsosis and unilateral anhidrosis) => carotid dissection. - Tongue paresthesia (neck-tongue syndrome) - Assess headache that does not vary throughout the day, that is not too intense, and that even improves with exercise,... 29  Tension-Type Headache 1. CURRENT SYMPTOMS 9. PHYSIOLOGICAL MOVEMENTS 2. OBSERVATION 10. PALPATION 3. FUNCTIONAL DEMONSTRATION 11. ACCESSORY MOVEMENTS 4. RE-EVALUATION 12. SCREENING TEST 5. ACTIVE MOVEMENTS 13. INITIAL TREATMENT 6. OVERPRESSURE TEST AND 14. RE-EVALUATION OTHERS. 7. ASSESSMENT OF OTHER 15. PATIENT INSTRUCTIONS STRUCTURES (MUSCULAR, NERVOUS SYSTEM, VASCULAR)*. 8. NEURODYNAMIC ASSESSMENT 30 Migraine 31  Migraine “Neurological disease of genetic cause, which causes, among other symptoms, recurrent episodes of headache of moderate or severe intensity, very disabling due to its impact on the personal, family, social and occupational spheres.” De Boer et al., 2019 3rd most frequent neurological disease worldwide, and 2nd cause of disability (due to any disease). Prevalence of 14% of the world population, being more frequent in women (19%) than in men (10%). It is usually divided into 2 main groups: - Migraine without aura. - Migraine with aura. 32  Migraine - Aura: “Transient focal neurological symptoms that often precede or accompany the headache” * Visual aura (90% of patients): Zigzag patterns from left to right, leading to different degrees of scotoma. * Sensory disturbances: Tingling that moves from the origin to one side of the body, face and/or tongue. Numbness. * Language disorders: aphasia and/or dysarthria. Much less frequent.  Migraine without Aura Diagnostic criteria (IHS 2018): A. At least five crisis meeting criteria B-D.: B. Headache episodes of 4-72 hours duration (untreated or unsuccessfully treated) C. The headache has at least two of the following four features: 1. Unilateral localisation. 2. Pulsatile character. 3. Pain of moderate or severe intensity. 4. Worsens with or prevents usual physical activity (e.g. walking or climbing stairs)... D. At least one of the following symptoms during the headache: 1. Nausea and/or vomiting. 2. Photophobia and phonophobia.  Migraine with Aura Diagnostic criteria (IHS 2018): Apart from those described above… - A. At least five migraine crisis meeting criteria B and C. - B. One or more of the following fully reversible aura symptoms: - 1. Visual. 2. Sensory. 3. Speech or language. 4. Motor. 5. Troncoencephalic. 6. Retinal. - C. At least three of the following six characteristics: - 1. Gradual spread of at least one aura symptom over a period of ≥5 min. 2. Two or more aura symptoms occur in succession. 3. Each aura symptom has a duration of 5-60 min. 4. At least one of the aura symptoms is unilateral. 5. At least one of the aura symptoms is positive. 6. The aura is accompanied by or is followed within 60 minutes by a headache. 35  Migraine Phases of a “migraine attack” and characteristic symptoms of each phase. (Andreou y Edvinsson, 2019). 36  Migraine Etiopathogenic theories: - Vascular disturbance: Vasodilatation => prior vasoconstriction. - Extended cortical depression: extreme depolarisation of glial cell membranes and neuron membranes => ischaemia - Activation of trigemino vascular afferents (CGRPs) - Low grade inflammation (TNF α , IL-1β IL-6, CGRP): Peripheral - central sensitivity. - Oxidative status: increased level of oxidants and/or decreased antioxidant capacity.  Migraine - Factors involved : - Genetic: Family history. Different genes involved.. - Female sex - The rest of the factors increase the risk of suffering a crisis or increase its intensity: - Psychological factors (stress, anxiety, depression). - Dietary factors => alcohol, chocolate, caffeine, tobacco, glutamate.. - Hormonal disorders: menstruation, pregnancy,...,.. - Medication: excessive use. - Environmental: smells, loud noises, intense light, pressure changes,...,… 38  Migraine BODY CHART - Unilateral pain (usually), throbbing and of moderate or severe intensity. - Fronto-temporal pain, which some patients also perceive at facial level ("facial migraine"). - The greatest intensity is perceived at the fronto-temporal level (next to the eye). - In < 18 years (children and adolescents) it may be felt bilaterally. 39  Migraine 24 H BEHAVIOUR Recurrent headache that manifests with attacks lasting 4 to 72 hours. Prodromal/Premonitory symptoms start hours or ½ days before (tiredness, difficulty concentrating, cervical stiffness, sensitivity to light or noise, nausea, blurred vision, yawning or pallor). The pain worsens with (ambient) light, so that the patient often lies down in the "dark“ Associated with significant vegetative symptoms (nausea/vomiting or photo-audiophobia). It worsens with physical activity (walking, climbing stairs, running, etc.). No change in cervical mobility, but prevents many activities of daily living. Relief with ergotamine drugs and triptans (produce vasoconstriction) in pain crisis. 40  Migraine PAST AND PRESENT HISTORY Onset symptoms: - It initially presents with an episodic pattern, associated with physical and sporting activities, which usually subside more quickly than in chronic processes. - Headache episodes do not have a clear pattern, either in intensity or frequency. Progression: - They evolve into a chronic episodic pain pattern, characterised by a more or less stable pattern. - 1 or 2 migraine attacks per month. They may be medicated with prophylactic drugs (antiepileptic drugs, antidepressants, beta- blockers) and use triptans or ergotamines for migraine crisis. Frequent onset of the clinical process in middle-aged women (20-50 years). 41  Migraine SPECIAL QUESTIONS - Observation of dystonic postures in face and neck (focal dystonia). - Horner's syndrome (miosis, palpebral ptsosis and unilateral anhidrosis) => carotid dissection. - Tongue paresthesia (neck-tongue syndrome) - Assess headache that does not vary throughout the day, that is not too intense, and that even improves with exercise,... 42  Migraine 1. CURRENT SYMPTOMS 9. PHYSIOLOGICAL MOVEMENTS 2. OBSERVATION 10. PALPATION 3. FUNCTIONAL DEMONSTRATION 11. ACCESSORY MOVEMENTS 4. RE-EVALUATION 12. SCREENING TEST 5. ACTIVE MOVEMENTS 13. INITIAL TREATMENT 6. OVERPRESSURE TEST AND OTHERS. 14. RE-EVALUATION 7. ASSESSMENT OF OTHER 15. PATIENT INSTRUCTIONS STRUCTURES (MUSCULAR, NERVOUS SYSTEM, VASCULAR)*. 8. NEURODYNAMIC ASSESSMENT 43  Headaches Differential diagnosis Disorder Pain Associated Intensity and Objective Examination Symptoms characteristics Cervicogenic headache Occipital pain and radiates to Nausea, vomiting and Ongoing pain Reduced cervical ROM the frontal region associated photophobia and/or Frequent disorder with movement phonophobia can occur but Moderate Challenge tests DO modify the much less intensity than headache + middle-aged women Uniltaral Episodic (minus 15 migraine days/month) or chronic Tension headache Bilateral occipital pain No Nausea or Vomiting Squeezing pain (pressure or Cervical mobility is not modified (although one side tightness) Headache + Frequent predominates) may radiate to Either photophobia or Challenge tests do NOT change the neck and shoulders phonophobia never both at Mild or moderate the headache + FREC Young and the same time middle-aged woman Episodic (minus 15 days/month) or chronic (plus 15 days/month) Not aggravated by exercise Migraine Frontal region pain Cause + Common of Unilateral Náuseas y/o vómitos Throbbing pain Cervical mobility is not modified Severe Recurrent Headaches Fotofobia y fonofobia Moderate to severe Challenge tests do NOT change the headache + middle-aged women Episodic (every 15 days) and chronic Worsening with Valsalva It is aggravated by exerciseio Arnold Neuralgia Occipital pain may radiate to Excessive scalp sensitivity Stabbing pain Pain when moving the neck parietal, frontal, temporal, or and eye discomfort Rare facial Severe Pain on palpation Arnold's point No Nausea or Vomiting Middle Age Unilaterally or bilaterally Photobobia and phonophobia Chronic cervical/neck pain 45  DISCOGENIC vs FACETY Differential Diagnosis Discogenic Facet + Frec middle age + Frec middle age Neck pain Localized neck pain Pain Deep, diffuse, and poorly localized Unilateral or billateral Unilateral or bilateral Cervical, shoulder, pectoral pain Associated Neck pain (but less than arm) Feeling fatigue or weakness in the hand Symptoms Possible scapular pain arm Intensity and Severe, hard-to-bear restlessness Variable from mild to severe characteristics Progressive pain. Several weeks Rapid onset, associated with motion Referral within 48 hours Objective Very sensitive overpressure test. Lack of painful response in provocation test. Pain on Examination Mechanical Rom Limitation (Extension, increasing IAP. Pain ROM Limitation (Protection) Rotation or Tilt) Radiculopathy vs TOS Differential Diagnosis TOS Radiculopathy + Often women between 20 and 50 years + frequent middle age old Neurological Symptoms to MMSS Neurologic pain at MMSS (unilateral) (Unilateral) Pain Paresthesias Paresthesias (neurogenic) Weakness Edema, cyanosis (venous) Cyanosis, claudication (arterial) Cervical, shoulder, pectoral pain Associated Neck pain (but less than arm) Feeling fatigue or weakness in the hand Symptoms Possible scapular pain arm Mild or moderate Intensity and Acute. Severe Intermittent & Transient characteristics Continuous & Deep Pain after prolonged postures and rapid remission after posture change Specific provocation test + Specific provocation test + Objective Sensory loss (hypoesthesia or anesthesia), motor loss (paresis Clinical aggravation with arm elevation Examination or atrophy), or impaired reflexes (hyporeflexia). Supraclavicular sensitivity in the plexus Limited or painful cervical rotation region