Sep 16, 2013

Case of The Week: Persistant Postural Headache

Today's case is hot off the press. Hot as in I just saw and treated this patient today.

History: This was a 22 year old collegiate softball player this plays catcher. She has a previous history of occasional headaches that weren't associated with general medical illness. Four days prior to seeing my this patient began suffering from an unusually strong headache. The pain was focal behind her eyebrows and began while she was busy studying and reading in the evening. The patient took ibuprofen but found no relief from it.

Day 2: The patient awoke the next morning with the headache again. This lingered throughout the day and ibuprofen still provided no relief. The headache was severe enough to cause nausea and dizziness as a result. The patient then tried Excedrin which provided minor relief enough to allow her to fall asleep that night.

Day 3: The patient awoke with the same searing headache and once again took Excedrin. This time it only provided minor relief for an hour or two at most. As the day went on the pain increased and induced nausea once again. This night the patient was unable to find sleep at all.

Day 4: A repeat of the previous day began with daybreak and this student-athlete had a lot of reading and studying to do for school. These activities only exacerbated her symptoms even more. Over-the-counter medications now provided no relief and her symptoms continued into the next day when she consulted with me.

Observation: On day 5 of this the patient presented me with her history and symptoms. Upon inspection she had a forward head posture, Bilaterally elevated and protracted shoulders, and an excessively forward slouching posture. I like Jay Dicharry's acronym for this postural presentation "F.A.T.S." aka female adolescent texting syndrome.

Treatment:  I began her treatment much like I do most of my treatments and that was with some light instrument assisted soft tissue mobilization (IASTM). I did IASTM along a cervical pattern and a little bit of her upper traps as well.

Next, I had her do some foam rolling rolling of her thoracic spine to help with increasing thoracic extension and to promote better posture. After this, I had the patient lie supine on the treatment table and had her perform 15-20 cervical retractions into the table. While she would hold the retraction into the table I would apply a light bilateral - posterior to anterior force with the pads of my index fingers just lateral to her C2 spinous process.

The next technique I applied was passive cervical retraction using my right shoulder to her forehead with manual traction/distraction by gripping the occiput with my right hand. I held this for about 20 seconds and did a few repeated retractions as well.

I then instructed the patient on how to perform repeated cervical retractions to cervical extension with manual overpressure. I had her do this for a set of twenty and instructed her that this would be her home exercise program to repeat. Here is a quick video on how these look.

After completion of this I asked the patient how she felt. She told me that her headache was completely abolished and that she an indescribable sensation of clarity. She felt as if she could see further and think more clearly...Funny how pain can cloud our judgement sometimes?

I educated the patient on proper posture and ergonomics for reading and studying. I also lectured her on the necessity to repeat her HEP because of the transient benefits from my treatment.  I told her that she should be able to self-medicate without medication and all that she needed was some quality movement.

I feel that this case highlights a few important things, some are repeat themes to my blog so far:
  • Pain can be debilitating even if it from seemingly common and minor issues such as headaches or migraines.
  • A rapid onset of pain can usually be rapidly reduced
  • Sometimes the best medicine is movement
    • This patient wasn't ill and her body wasn't short on OTC meds like ibuprofen or acetaminophen. These drugs aren't helping to fix your pain, just mask it.
  • Posture can be paramount but it is not as simple just remembering to sit up straight.
  • Patient education and empowerment 
    • Patients shouldn't have to rely on my hands or treatments. We should teach them how to carry on the benefits that we provide them and how to treat themselves in the future.

*Case Update*
I just consulted with the patient again and it is the day after my treatment session with her. Her headache did not return later that evening even after heavy exertion at softball practice.  She still feels great and not even a slight migraine to complain about.


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