A Specific Exercise Program and

Modification of Postural Alignment for

Treatment of Cervicogenic Headache:
A Case Report
Mary Kate McDonnell, PT, DPT, OCS 1
Shirley A. Sahrmann, PT, PhD, FAPTA 2
Linda Van Dillen, PT, PhD 3
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C
Study Design: Case report. ervicogenic headache
Objective: To describe an intervention approach consisting of a specific active-exercise program (CH) has been de-

CASE
and modification of postural alignment for an individual with cervicogenic headache. scribed as a syndrome
Background: The patient was a 46-year-old male with a 7-year history of cervicogenic headache. that is ‘‘a final com-
He reported constant symptoms with an average intensity of 5/10 on a visual analogue scale mon pathway—not an
where 0 indicated no pain and 10 the worst pain imaginable. Average pain intensity in the week
entity.’’32 Thus, CH is a syndrome

REPORT
prior to the initial evaluation was 3/10 secondary to trigger point injections. The patient’s
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

that can have many contributing

headache symptoms worsened with activities that involved use of his arms and prolonged sitting.
Methods and Measures: The patient was treated 7 times over a 3-month period. Impairments of
factors. The World Cervicogenic
alignment, muscle function, and movement of the cervical, scapulothoracic, and lumbar regions Headache Society41 has defined
were identified. Outcome measurements included headache frequency, intensity, and the Neck CH as referred pain perceived in
Disability Index (NDI) questionnaire. Intervention included modification of alignment and any part of the head and caused
movement during active cervical and upper extremity movements. The patient also received by a primary nociceptive source in
functional instructions focused on diminishing the effect of the weight of the upper extremities on the musculoskeletal tissues that are
the cervical spine. innervated by the cervical nerves.
Results: The patient reported a decrease in headache frequency and intensity (1 headache in 3 Pain associated with CH has been
weeks, intensity 1/10) and a decrease in his NDI score from 31 (severe disability) to 11 (mild
Journal of Orthopaedic & Sports Physical Therapy®

attributed to physical impair-

disability). The patient also demonstrated improvement in upper cervical joint mobility, cervical ments42 of the joint, muscle, and
range of motion, scapular alignment, and scapulothoracic muscle strength. neural structures in the cervical
Conclusion: Interventions that included modification of alignment in the cervical, scapulothoracic, region, and, in particular, the up-
and lumbar region, along with instruction in a specific active-exercise program to address per cervical spine region.4,14,31
movement impairments in these 3 regions, appeared to have been successful in relieving The majority of rehabilitation-
headaches and improving function in this patient. J Orthop Sports Phys Ther 2005;35:3-15. based clinical trials for treatment
Key Words: cervical spine, muscle impairments, posture, scapular alignment of CH have examined the effect of
manual therapy performed on
cervical joints to alleviate the
identified dysfunction.20-22,29,39,40
Manual therapy studies have dem-
onstrated positive effects at both
1
Instructor, Program in Physical Therapy, Washington University School of Medicine, St Louis, MO. the impairment (pain and muscle
2
Professor and Associate Director for Doctoral Studies, Program in Physical Therapy, Washington
University School of Medicine, St Louis, MO. function) and disability level, with
3
Assistant Professor, Program in Physical Therapy, Washington University School of Medicine, St Louis, most studies focusing on short-
MO. term outcomes.10,36 Overall, the
The protocol for this case report was approved by the Human Studies Committee of Washington impairment level effects have in-
University Medical Center.
Send correspondence to Mary Kate McDonnell, Program in Physical Therapy, Washington University cluded a decrease in headache
School of Medicine, Campus Box 8502, St Louis, MO 63110. E-mail: mcdonnellm@wustl.edu frequency, intensity, and duration.

Journal of Orthopaedic & Sports Physical Therapy 3

 The disability effects have been evidenced through
improvements in performance of ever yday
activities.20-22,29,39,40
Impairments involving muscle, specifically the deep
neck flexors, also have been identified in patients
with CH.2,13,23,24,24,38 Placzek et al24 demonstrated
that patients with CH had significantly less strength
and endurance of the deep neck flexors compared to
age-matched controls. Jull et al13 also identified a
decrease in strength of the deep neck flexors in
patients with CH, when compared to able-bodied
individuals. In a recent clinical trial involving patients
with CH, Jull et al15 compared the effects of specific
active exercises directed at improving the strength
and endurance of the deep neck flexors to manual
therapy treatment of the cervical joints. Patients who
received active exercise, manual therapy, or a combi-
nation of active exercise and manual therapy, dis-
played better outcomes than a control group who
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received no treatment. In particular, the groups who
received active exercise improved in both pain behav-
ior and strength of the deep neck flexors. Although
there was no difference in outcomes among the
different treatment groups, this study suggests the
potential importance of impairments of the deep
neck flexors as a contributing factor to CH.
Based on these studies, treatment of joint and
muscle impairments in the cervical region appear to
be beneficial with regard to pain behavior for pa-
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tients with CH. Muscle function, when specifically
addressed, also appears to improve in these patients.
While previous studies have demonstrated positive
effects by focusing their intervention on joint and
muscle impairments in the cervical region, we have
noted additional impairments that could be impor-
tant contributing factors in the development and
continuation of CH.28 The additional impairments
are present not only in the cervical region, but also
Journal of Orthopaedic & Sports Physical Therapy®
in the scapulothoracic and lumbar regions. Impair-
ments outside of the cervical region are of particular
interest because some investigators have described
how changes in alignment or movement in other
regions have the potential to alter the biomechanics
of the cervical spine.7,35 Alterations in the biome-
chanics of the cervical region can contribute to local
concentrations of high stress in cervical spine struc-
tures.1 Such stress has the potential to cause cumula-
tive microtrauma to tissue and, over time, potential
tissue failure and development of CH symptoms.
A forward head position with increased extension
of the upper cervical region is commonly observed.16
This extended alignment is of particular importance
because some investigators have described how cervi-
cal extension may contribute to increased stress on
the cervical facet joints as a result of approximation
of the facet joint surfaces.16,26 We also have observed
that patients with CH frequently extend their neck
when they perform unilateral or bilateral shoulder
4 J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005
flexion. The active neck extension induced by shoul-
der motion is often associated with an initial forward
head position. Repetition of such neck movements
with shoulder movements, particularly when per-
formed from an initial position of increased upper
cervical extension, could also be a contributing factor
to extension stresses on posterior cervical spine
structures.
In the scapulothoracic region, we have noted that
patients with CH often display an alignment of
scapular abduction and depression, indicating length-
ened levator scapulae and trapezius muscles. Addi-
tionally, we observe that this scapular alignment is
often associated with concomitant weakness of some
or all portions of the trapezius as well as the
rhomboids and levator scapulae. The potential result
of these impairments is compressive loading of the
cervical spine, resulting from a transfer of the weight
of the upper extremities to the cervical region
through the cervicoscapular muscle attachments. The
role of these impairments on the patient’s clinical
presentation may be assessed by first testing cervical
motion and symptoms while the patient is sitting in
his/her preferred alignment. The assessment is then
repeated while the examiner modifies the patient’s
postural impairments by manually lifting and adduct-
ing the scapulae. If the scapulothoracic impairments
are contributing to the patient’s symptoms, a de-
crease or elimination of symptoms is reported along
with an increase in cervical region motion.
Finally, we have in the past observed that modifying
impairments of the lumbar region appears to have a
positive effect on outcomes of patients with CH.
Lumbar region impairments have the potential to
affect the biomechanics in the cervical region.3 For
example, an increased lumbar lordosis is often associ-
ated with an increased thoracic kyphosis and cervical
extension.26 Patients with CH appear to actively
extend the lumbar region and lift their rib cage when
they flex their shoulders, which may ultimately rein-
force the active cervical extension previously de-
scribed.
Because impairments in the cervical, scapulo-
thoracic, and lumbar regions may alter the biome-
chanics of the cervical spine, it would be reasonable
that, when present, such impairments may be contrib-
uting factors to the clinical presentation of the
patient with CH. The purposes of this case report are
to describe the findings from an examination of a
patient with CH that includes assessment of impair-
ments in the cervical, scapulothoracic, and lumbar
regions, and to describe an intervention that includes
active exercise and modification of functional activi-
ties to minimize the impact of impairments in these 3
regions. The primary focus of the intervention is on
(1) modification of static alignment in all 3 regions,
(2) modification of the patient’s scapular position
prior to movement of the neck or shoulders, as well
 as modification of scapular movement during shoul-
der movements, and (3) restriction of compensatory
movement in the cervical, thoracic, and lumbar
regions with shoulder movements.
CASE DESCRIPTION
The patient was a 46-year-old male referred to
physical therapy with a medical diagnosis of CH.
Informed consent was obtained and the rights of the
subject were protected.
Chief Complaint
The patient reported a 7-year history of headaches
that limited his ability to concentrate and sleep. The
patient reported constant headache-related pain lo-
cated in the posterior cranium, neck, and upper
trapezius region bilaterally. His average pain on a
visual analogue scale (VAS) was reported to be 5/10
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and his worst pain was reported to be 10/10,6 with 0
indicating no pain and 10 indicating the worst pain
he could imagine. Other aspects of the patient’s
medical history were unremarkable.
Aggravating Factors
The patient reported that his headache pain in-
creased with most activities that involved the use of
his arms. Specifically, he had difficulty working with
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
his horses and sitting at his computer greater than 30
minutes. The patient also reported difficulty with
sleep, awakening every 2 to 3 hours because of
headache-related pain. He usually was able to return
to sleep quickly if he changed his position, but
sometimes he required pain medication to return to
sleep.
Previous Intervention
Journal of Orthopaedic & Sports Physical Therapy®
One week prior to his initial physical therapy visit
the patient’s doctor performed 1% lidocaine trigger
point injections. The patient reported that there were
multiple injections administered in the posterior
cervical and upper trapezius region bilaterally, and
that he had a complete reduction in his headache
pain for 24 to 48 hours afterwards. Since the injec-
tions, the patient reported that the intensity of his
average headache pain had decreased to 3/10, but
the pain was still constant.
Functional Disability
Functional disability was assessed with the Neck
Disability Index (NDI) questionnaire. The NDI is
used to assess functional limitations and disability.
Studies of the NDI have demonstrated that the
measure has adequate reliability and validity charac-
teristics, and has been shown to be sensitive to
J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005
different levels of severity and to changes in severity
over time. NDI scores range from 0 to 50, with 0
indicating no disability and 50 indicating complete
disability. The patient’s pretreatment NDI score was
31, indicating severe disability.
Physical Examination
Visual Appraisal Visual examination revealed (1) a
forward head posture with increased extension in the
upper cervical spine, (2) excessive scapular abduction
and depression, (3) a kyphotic thoracic curve, and
(4) a prominent abdomen. A tape measure was used
to quantify the position of the scapula. The vertebral
borders of both scapula were found to be 17.8 cm
lateral to the vertebral column, which would be
considered to be excessive scapular abduction bilater-
ally.33 The humeri were positioned in excessive me-
dial rotation and the infrasternal angle was increased,
with a measurement of greater than 90°.44
Cervical Active Range of Motion and Pain Behavior
Cervical spine motion was assessed with a cervical
range of motion instrument (CROM Deluxe; Perfor-
mance Attainment Associates, St Paul, MN) in re-
CASE
laxed sitting.27,43 Each cervical motion was performed
3 times. The average of the 3 trials was recorded. The
patient was asked to report changes in headache pain
with performance of each motion. The patient dis-
REPORT
played limitations in cervical motion in rotation and
extension, and reported an increase in headache
pain with both rotations as well as with extension
(Table 1).
Cervical rotation measurements were repeated
while modifying the position of the patient’s scapula.
The examiner passively elevated and adducted the
scapula while supporting the weight of the patient’s
arms (Figure 1). The test with manual correction of
the position of the scapula was designated as the
passive correction of scapular position test (PCSPT)
(Table 1). The patient repeated cervical rotation to
the left and right and reported his symptoms with the
PCSPT relative to his symptoms without support. The
patient displayed a 10° increase in cervical rotation in
both directions and a decrease in his headache pain.
Shoulder AROM and Pain Behavior Shoulder motion
and symptoms with motion were measured with the
patient in sitting. The patient achieved 130° of
shoulder flexion with each extremity and reported an
increase in pain in the upper trapezius region with
both shoulder movements. During shoulder flexion,
the scapula appeared to move into excessive abduc-
tion with minimal upward rotation or elevation.11,28
In addition, the angle of scapular upward rotation
was estimated to be approximately 35°, indicating
limited upward rotation.11,25 Subsequently, the exam-
iner manually assisted rotation and elevation of the
scapula during shoulder flexion and the patient
reported a decrease in the upper trapezius pain.
5
 TABLE 1. Outcome measures.
Follow-up
Visit 4 Visit 5 Visit 6 Visit 7 Phone
Visit 2 Visit 3 (31⁄2 wk (51⁄2 wk (81⁄2 wk (31⁄2 mo Call
(4 d After (1 wk After After After After After (5 mo After
Outcome Measurement Visit 1 Visit 1) Visit 1) Visit 1) Visit 1) Visit 1) Visit 1) Discharge)
Headache behavior Constant; Intermit- Frequency Several Several Able to Headache Headache
average, tent; de- and in- days days perform fre- frequency,
5/10; creased tensity without without functional quency, 1 episode
worst, intensity; decreas- headache headache activities 1/wk; during
10/10 no head- ing without headache 3-wk pe-
ache for increase intensity, riod
3h in head- 1/10
ache pain
Neck disability index
score37* 31/50 14/50 14/50 14/50 11/50
Scapular position† 17.8 cm 15.2 cm 11.4 cm
Range of motion
Cervical rotation Right, 39° Right, 30° Right, 50° Right, 50°
P; left, NP; left, NP; left, NP, left,
40° P 50° NP 50° NP 50° NP
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Cervical rotation PCSPT Right, 50°

DP; left,
50° DP
Cervical flexion 40° P 40° NP 35° NP 31° NP
Cervical extension 25° P 50° NP 40° NP 40° NP
Shoulder flexion 130° P 150° NP
Passive joint mobility
Upper cervical joints
• Occipital atlanto18 Limited Not limited
• Atlanto axis18 Limited Not limited
Muscle strength
Lower abdominals28 0.5/5 0.75/5
Lower trapezius16 2.0/5 3.0/5
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Middle trapezius16 2.0/5 3.0/5

Rhomboid16 3.0/5 4.0/5
Deep neck flexors16 Unable to 2.0/5
test
Muscle length16
Pectoralis major Short
Pectoralis minor Short
Latissimus dorsi Short
Cervical extensors Short
Abbreviations: P, painful; DP, decrease in pain; NP, nonpainful; PCSPT, passive correction of scapula position test.
Journal of Orthopaedic & Sports Physical Therapy®

* Scores: 0-4, no disability; 5-14, mild disability; 15-24, moderate disability; 25-34, severe disability; ⬎ 35, complete disability.
†
Measured from the midpoint of the vertebral border of the scapula to the corresponding thoracic spinous process.

The humerus was observed to move into excessive
medial rotation and the lumbar spine into extension
during shoulder flexion. Such a movement strategy
suggests a limitation in the length of the latissimus
dorsi muscle.16 Additionally, the patient’s lower cervi-
cal spine translated forward and his upper cervical
spine moved into extension. When movement occurs
in a segment other than the segment where the
primary movement is intended to occur, the authors
consider this movement to be compensatory and, in
most cases, undesirable because it often occurs in the
region associated with the patient’s pain prob-
lem.16,17,28 Potentially, in this patient, every time he
flexed his shoulders he translated and extended his
cervical spine.
Passive Mobility Assessment of the Cervical Region The
occipital atlanto and axial atlanto joints were assessed
according to the methods described by Maitland18 for
the amount of passive motion, joint end feel, and
symptoms. The occipital atlanto joint displayed sig-
nificant limitation of motion in the direction of
flexion, with a stiff end feel. The axial atlanto joint
displayed significant limitation of motion and a stiff
end feel with both right and left rotation. The
movement and end feel of segments in the lower
cervical region18 were considered normal and were
asymptomatic with testing.
Muscle Strength, Length, and Stiffness Lower abdomi-
nal muscle strength was assessed using the procedures
described by Sahrmann.28 The patient’s lower ab-
dominal muscles were graded as 0.5/5 on a scale of
0.1 to 5.0 (Table 2). When the patient attempted to
contract the lower abdominals, as instructed, he
elevated his rib cage, extended his spine, and ab-

6 J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005


TABLE 2. Grading criteria for lower abdominal strength assess-
ment.28 The primary criterion for correct performance of all
tests is to keep the lumbar spine in contact with the examiner’s
fingertips as the examiner palpates the lumbar spinous pro-
cesses during the lower extremity movements. The patient’s ab-
domen also should remain flat. All tests are performed with the
patient positioned in supine, with hips and knees bent and feet
flat on the support surface. The patient is instructed to contract
his abdominals by exhaling and pulling the abdomen in, so that
the umbilicus is moving toward the spine.
Test Grade
Slide heel to extend lower extremity 0.10/5
Lift one foot, flexing hip 0.25/5
Lift one foot, hold knee to chest with hand, lift 0.50/5
other foot
Lift one foot flexing hip to 115°, lift other foot 0.75/5
Lift one foot flexing hip to 90°, lift other foot 1.00/5
Lift one foot flexing hip to 90°, flex the other hip 2.00/5
and slide the foot on the supporting surface,
extend the hip/knee
Lift one foot flexing hip to 90°, flex the other hip 3.00/5
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and, while holding foot off the supporting sur-
face, extend the hip/knee
Lift both feet to flex hips, slide both feet along 4.00/5
the supporting surface so that both hips and
knees extend
Lift both feet to flex hips, keep hips flexed while 5.00/5
extending knees, then, with both knees ex-
tended, lower both lower extremities to sup-
porting surface
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®
FIGURE 1. Sitting passive correction of scapula position test.
J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005
ducted his scapulae. These movements were consid-
ered compensations for the patient’s lack of abdomi-
nal muscle strength and control.
Upper quarter muscle length and stiffness were
assessed according to the procedures described by
Kendall.16 Passive length of the pectoralis minor and
pectoralis major was decreased bilaterally. Moderate
stiffness was noted during muscle length assessment
of each of the pectoralis minor, but no symptoms
were reproduced. Stiffness in this context is defined
as resistance of tissue to passive lengthening.28
Length of the posterior cervical extensor muscles
was assessed by passively moving the head and neck
into cervical flexion while the patient was supine.
Limited motion and moderate resistance to lengthen-
ing was noted, indicating decreased length and stiff-
ness of the posterior cervical muscles. The patient
also complained of pain in the upper cervical and
occipital region with the test.
An attempt was made to test the strength of the
deep neck flexor muscles (longus colli, longus capitis,
and rectus capitis) as described by Kendall.16 An
accurate muscle test of the neck flexors, however, was
not possible because the patient was unable to
achieve the appropriate test position.
CASE
Strength of the scapulothoracic muscles was tested
in prone.16 There was decreased strength of the
rhomboids and middle and lower trapezius with the
greater loss of strength noted in the trapezius
REPORT
(Table 1).
Diagnosis
The patient’s movement system impairment diag-
nosis was cervical extension with scapular abduction
and depression (Table 3). Impairments of muscle
function, postural alignment, and movement were
considered to have contributed to stress on the
tissues in the cervical region, resulting in the pa-
tient’s pain complaints. The goal of the intervention
was to address the identified impairments in the
cervical, scapulothoracic, and lumbar regions in an
attempt to reduce the stress on cervical structures,
and to assist the patient in achieving his primary goal
of decreasing the intensity and frequency of his
headache pain.
INTERVENTION
Following the examination, the patient was in-
structed in exercises that addressed the identified
impairments. The focus of the home exercise pro-
gram was to (1) increase the strength and control of
the abdominals, (2) increase the length of the
anterior thorax muscles, (3) increase the length of
the posterior cervical extensor muscles, (4) improve
the strength and decrease the length of the posterior
scapulothoracic muscles, and (5) increase shoulder
7
 TABLE 3. Patient’s movement impairment diagnoses: key im-
pairments.
Scapular Abduction28
1. Scapular position of excessive abduction
2. Scapular movement into abduction more than upward rota-
tion during shoulder flexion
3. Modification of scapular position in the direction of eleva-
tion and adduction resulting in an increase in active cervi-
cal rotation and decreased pain with rotation
4. Weak and increased length of the trapezius and rhomboids
5. Short and stiff pectoral muscles
Scapular Depression28
1. Scapular position of depression
2. Modification of scapular position in the direction of eleva-
tion during shoulder flexion, resulting in decreased upper
trapezius pain
3. Modification of scapular position in the direction of eleva- FIGURE 2. Lower abdominal exercise.
tion and adduction, resulting in increased active cervical
rotation and decreased pain with rotation
4. Weak and increase length of the trapezius muscle
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5. Short latissimus dorsi muscle

Cervical Extension19
1. Forward head posture with increase extension at the lower
cervical and upper cervical spine
2. Pain with active cervical extension
3. Compensatory movement of cervical extension during
movements of the upper extremity
4. Short cervical extensor muscles
5. Weak deep neck flexor muscles
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

joint and cervical spine motion. Instructions empha-

sized the need to minimize the compensatory move-
ments of the cervical and lumbar region during the
exercise performance. Modification of functional ac-
tivities included instruction in strategies to support FIGURE 3. Upper cervical flexion in supine.
the weight of the upper extremities, thus minimizing
the downward pull of the cervicoscapular muscles on
the cervical spine.
Journal of Orthopaedic & Sports Physical Therapy®

Exercises
Lower Abdominals The exercise was performed from
a hooklying position (Table 4 and Figure 2).28 The
purpose of the exercise was to improve the strength
and control of the abdominal muscles, which is
required to stabilize the trunk during movements of
the extremities. During the performance of the
exercise the patient was instructed to recruit the
rhomboids and the trapezius to reduce the scapular
position of excessive abduction. Additionally, the
patient was provided with cues that encouraged
modification of his preferred alignment of cervical
FIGURE 4. Shoulder flexion in supine.
extension. Specifically, he was instructed to ‘‘keep his
chin down towards his Adam’s apple.’’
The patient was not able to lift his second knee patient held one knee toward his chest with the
toward his chest without lumbar extension. He also ipsilateral arm and then lifted the opposite leg
was unable to maintain the upper quarter alignment (Figure 2). This modification was used to reduce the
as instructed. The exercise was modified so that the force the abdominal muscles needed to generate

8 J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005

 when performing the exercise.28 The patient was able
to perform the modified exercise with the correct
alignment of the upper quarter.
Upper Cervical Flexion The purpose of the exercise
was to increase the length of the posterior cervical
muscles and perform active contraction of the deep
neck flexors while maintaining the thoracic and
lumbar spine in the correct alignment. The patient
was instructed to move his chin towards his Adam’s
apple without lifting the head off the supporting

TABLE 4. Patient-specific cues for exercises and functional activity modification.

General guidelines:
1. Perform exercises at least 1 time a day for 15 to 20 minutes, and perform 5 to 10 repetitions of each exercise
2. Stop performance of an exercise if pain increases
3. Emphasize performing each exercise slowly and without movements of the spine or rib cage
Patient-Specific Cues
Initial patient position The patient lies supine with his hips and knees bent and the feet flat on the support surface.
Exercise 1: lower abdominal Raise the shoulder blades up and together and keep the chin down, keeping your shoulder blades
exercise (Figure 2) squeezed together and your chin tipped towards your Adam’s apple when performing leg move-
ments. Tighten the abdominal muscles by pulling your navel in towards the table. Lift one knee to
the chest, then lift the second knee to the chest. Slowly return 1 leg at a time to the initial position.
Exercise 2: upper cervical flex- Tighten your abdominal muscles by pulling your navel in, raise your shoulder blades up and together.
ion in supine (Figure 3) Move your chin down towards your Adam’s apple. Avoid lifting your head off the support surface.
Hold this final position for a count of 5 and then relax. You should feel a stretch down the back of
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your neck without reproduction of your headache or neck pain.

Exercise 3: shoulder flexion in Tighten your abdominal muscles by pulling your navel in, raise your shoulder blades up and together,
supine (Figure 4) and keep your chin down. Flex your arms overhead leading with your thumbs. Maintain the shoul-
der blade position during the arm movement. Do not let your rib cage or chin lift up during the arm
movements.

Exercise 4: shoulder abduction
and lateral rotation in supine
(Figure 5)
Exercise 11: supine upper
cervical flexion with head lift
CASE
Tighten your abdominal muscles by pulling your navel in. Raise your shoulder blades up and together,
and keep your chin down. Bring your arms out to the side and slide your arms overhead. Do not let
your rib cage or chin lift up during the arm movements.
Bring your chin down to your Adam’s apple, and then, with help of your hands, lift your head off the
table maintaining your chin position. Slowly lower your head back to the starting position.

REPORT
(Figure 9)
The patient is sitting with his back to the wall and his arms supported on pillows. Exercises begin with
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

tightening the abdominal muscles by pulling the navel in and raising the shoulder blades up and to-
Initial patient position gether.
Exercise 5: sitting against the Move your neck by bringing your chin down to your Adam’s apple while keeping your head close to
wall, upper cervical flexion the wall. You should feel a stretch down the back of your neck but not a reproduction of your head-
(Figure 6) ache or neck pain.
Exercise 6: sitting against the Perform exercise 5, then rotate your neck to the right for 5 repetitions, and then repeat to the left.
wall, cervical rotation Imagine that you are rotating your neck about an axis. Try not to side bend your neck. The move-
ment should be performed in a pain-free range.
Exercise 7: sitting against the Raise your arms overhead with your palms turned toward the wall. Do not let your low back come
wall, shoulder flexion (Figure away from the wall and keep your chin down.
Journal of Orthopaedic & Sports Physical Therapy®

7)
Exercise 8: sitting against the Bring your arms out to the side and slide your arms overhead. Keep your arms close to the wall, do
wall, shoulder abduction lat- not let your low back move away from the wall. Keep your chin down.
eral rotation
Initial patient position The patient is facing the wall, placing hands on the wall and sliding arms overhead, up the wall.
Exercise 9: facing the wall, ‘‘Squeeze’’ your shoulder blades together and lift your arms off the wall. Keep your abdominal muscles
arm slide and scapula ad- tight and keep your chin down. Return your arms to the wall.
duction (Figure 8)
Exercise 10: facing the wall, Rest your arms on the wall and rotate your neck. Imagine that you are rotating your neck about an
arm slide and cervical rota- axis. Try not to side bend your neck. The movement should be performed in a pain-free range.
tion
Initial patient position Facelying, arms overhead.
Exercise 12: prone, arms over- Squeeze your shoulder blades together and then lift your arms off the table. Return arms to the initial
head with scapula adduction position.
(Figure 10)
During the day support the weight of your arms as frequently as possible. For example, when working
at your computer, make sure your forearms are supported on the desk or when standing place your
Functional instructions hands in your pockets.

J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005 9

 strategy the patient adopted was to put his hands in
his pockets or hook his thumb on his belt loop to
support the arms during standing.

OUTCOMES ACROSS INTERVENTION PERIOD

Figure 5. Shoulder abduction and lateral rotation in supine.
surface and maintaining the scapulae in an adducted
position (Figure 3 and Table 4).
Shoulder Flexion The purpose of the exercise was to
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Visit 2
Four days after the initial visit, the patient reported
that his headache pain was now intermittent rather
than constant and the intensity had diminished. He
attributed his improvements in headache pain to the
exercises he was prescribed, reporting that he could
remain symptom free for 2 to 3 hours after an
exercise session. The patient also reported that he
was performing his exercises twice a day, 50 repeti-
tions of each exercise per session. He chose to
perform the exercises more frequently because of the
positive effect on his headache pain.
The patient continued to display some difficulty
controlling the compensations in the cervical,

increase the length of the latissimus dorsi muscles
and increase shoulder flexion without cervical and
lumbar extension. The patient was instructed to flex
the arms overhead, avoiding rib cage elevation or
neck extension (Figure 4 and Table 4).28
Shoulder Abduction and Lateral Rotation The purpose
of the exercise was to increase the length of the
pectoral muscles without compensatory movements in
the cervical, thoracic, and lumbar regions (Figure
5).28 The patient was instructed to adduct his scapu-
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
scapulothoracic, and lumbar regions with some exer-
cises. He was instructed in 2 modifications to assist
him: to hold his knee closer to his chest during the
lower abdominal exercise and to increase the amount
of shoulder lateral rotation when performing the
shoulder flexion exercise.
Visit 3
Seven days following the initial visit, the patient

lae as he performed shoulder abduction, while keep-
ing the cer vical and lumbar spine regions
appropriately aligned.
Prescription Guidelines The patient was advised to
perform 5 to 10 repetitions of each exercise once a
day. The exercises were to be performed slowly,
avoiding compensatory movements, and without an
increase in pain. Emphasis was placed on correct
performance rather than on the number of repeti-
Journal of Orthopaedic & Sports Physical Therapy®
reported a continued decrease in the frequency and
intensity of his headache pain. His NDI score was 14,
indicating mild disability and a significant improve-
ment compared to his initial NDI score of 31. The
patient displayed only minimal compensatory move-
ments during his exercises.

tions. The patient was told that the exercises were

expected to decrease and not increase his pain. He
also was instructed to contact the therapist if there
was an increase in any of his primary pain complaints
during or after the performance of the exercises. He
was advised that the exercises were designed to
decrease the stress on the painful tissues and, over
time, should help decrease his headache pain.

Modification of Functional Activities

The primary emphasis of modifications to func-
tional activities was on developing activity-specific
strategies to diminish the effect of the pull of the
cervicoscapular muscles on the cervical spine. The
patient was educated in the potential effect the
weight of his arms had on his neck and the need to
identify the activities he performed across his day in
which his arms were unsupported.30 For example, a FIGURE 6. Sitting against the wall, upper cervical flexion.

10 J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005


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FIGURE 7. Sitting against the wall, shoulder flexion.
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®
FIGURE 8. Facing the wall, arm slide and scapula adduction.
Treatment during the third visit focused on review
and revision of his exercises and modification of
functional activities. The emphasis of the revisions
was on correcting excessive rib cage elevation,
scapular abduction, and cervical extension during the
performance of the shoulder exercises. He was re-
minded to continue all of the strategies he had
learned to minimize the downward pull of the
shoulder girdle muscles on his neck. He also was
advised to begin a walking program to increase his
endurance and fitness level.
The upper cervical flexion exercise was progressed
by having the patient perform the exercise movement
while sitting against a wall (Figure 6 and Table 4,
J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005
exercise 5). This position requires greater trunk
strength and control to maintain proper trunk align-
ment while moving the neck.
Visit 4
Twenty-five days after his initial visit, the patient
reported a continued decrease in the frequency and
intensity of his headache pain, and stated he could
be pain free for several days. The patient noted,
however, that when his symptoms were present, per-
forming his exercises did not relieve them as they
had been in the past. He reported that he finally
realized he had not been performing the exercises as
carefully as in the past, and when he resumed the
exercises with the appropriate modifications his symp-
toms were once again relieved. The patient also
reported that he initiated his walking program of 2.5
km/d without any effect on his symptoms.
Measures of cervical motion were repeated (Table
1). The patient displayed increased pain-free motion
in cervical extension and left rotation. Specifically,
the patient displayed a 25° increase in extension and
a 10° increase in left rotation. Rotation to the right
decreased 9°, but the motion was no longer painful.
CASE
The patient’s NDI score was 14, indicating no change
since his previous visit.
Revision to his program during visit 4 emphasized
restoring cervical rotation to the right and making
REPORT
his shoulder exercises more challenging. The cervical
rotation exercise required the patient to sit with his
back against the wall, his arms supported, and per-
form rotation without cervical extension or side
bending (Table 4, exercise 6). When the patient
performed the exercise correctly, the rotation motion
was limited but pain free. Shoulder flexion and
abduction exercises were progressed by having the
patient perform the motions while sitting with his
back to the wall (Figure 7 and Table 4, exercises 7
and 8). Emphasis was placed on avoiding compensa-
tory motions in the cervical, scapulothoracic, and
lumbar regions.
Visit 5
Thirty-nine days after the initial visit, cervical range
of motion measurements revealed an increase in
right rotation, but a slight decrease in flexion and
extension. The patient’s NDI score remained at 14,
indicating mild disability. Passive mobility testing of
axial atlanto rotation and occipital atlanto flexion
revealed increased range of motion and decreased
stiffness, and both rotation and flexion were now
pain free.
Visit 6
Sixty days after the initial visit, the patient reported
that his headache pain was better. He could do more
11
 at work and home without producing headache pain.
He also reported that he was able to perform horse
care activities without reproduction of his symptoms.
In addition, the patient reported walking approxi-
mately 40 min/d.
The patient’s exercises were reviewed. No revisions
were recommended at this time. He was advised to
continue with his exercises, functional modifications,
and walking.

Visit 7
Three and a half months following the initial visit,
the patient reported that his headache pain occurred
only once a week and he rated his symptoms at 1/10
when present. The patient also reported that when
his symptoms started, performance of his exercises FIGURE 9. Supine upper cervical flexion with head lift.
would abolish his headache pain within an hour. He
reported that, on average, he performed his exercises
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2 times a day.
The patient’s exercises were reviewed. He was
instructed in 4 additional exercises. While facing a
wall, the first exercise was to slide his arms up the
wall and then adduct his scapulae (Figure 8 and
Table 4, exercise 9). The purpose of this exercise was
to increase the strength of the trapezius muscle. In
the end range position of the arm-sliding exercise,
the second exercise was to perform cervical rotation
without cervical side bending. The purpose of this
exercise was to improve cervical rotation with the
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

upper extremities supported (Table 4, exercise 10).

The third exercise was performed in supine (Figure 9
and Table 4, exercise 11). The patient performed
cervical flexion using his hand to assist in lifting his
head. The purpose of this exercise was to increase FIGURE 10. Prone arms overhead with scapula adduction.
the strength of the deep neck flexors and continue to extremity weight-lifting activities with free weights and
increase the length of the neck extensors. Finally, in resistive-exercise equipment without an exacerbation
prone with his arms positioned overhead, the patient of his symptoms.
was to perform scapular adduction (Figure 10 and
Journal of Orthopaedic & Sports Physical Therapy®

The patient acknowledged that he had made sig-

Table 4, exercise 12). The purpose of this exercise
was to progress the strengthening of the lower and
middle trapezius.
Five-Month Follow-up
nificant improvement in his ability to perform func-
tional activities. He was now able to sleep through the
night without pain or use of medications and to
perform all horse care activities without an exacerba-
tion of his symptoms.

The patient was contacted by telephone 5 months DISCUSSION

after discharge. He reported occasional symptoms
(approximately every 2 to 3 weeks) that, when
present, could last up to half a day. The patient
reported that the onset of his headache pain typically
occurred when he had to sit at work for prolonged
periods of time and was unable to take a break to
perform his exercises. He stated that in most in-
stances he was able to work at his computer without
headache pain if he attended to his posture.
He continued to perform his program every other
day, performing 20 to 30 repetitions of each exercise.
He also reported that he was performing upper
Currently, the specific factors contributing to CH
syndrome are not fully understood. The current case
report suggests that impairments, not only in the
cervical region, but also in the scapulothoracic and
lumbar regions, may be important to consider in the
treatment of CH. Treatment of impairments in all 3
regions resulted in important short- and long-term
improvement in a patient with a 7-year history of CH.
Exercises focused on (1) improving alignment in
each region, (2) improving strength of the cervical,
scapulothoracic, and abdominal muscles, and (3)

12 J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005

 eliminating compensatory movements of the cervical
and lumbar spine regions during upper extremity
movement. Functional training emphasized patient-
specific methods to decrease prolonged loading on
the cervical spine tissues across the day. Taken
together, these components provided the patient with
a program that allowed him to manage his CH
symptoms independently.
In the cervical region the patient’s preferred align-
ment was increased extension in the upper cervical
spine and a forward head. Consequently, the primary
factor considered to contribute to the patient’s symp-
toms was excessive compressive loading on tissues in
the cervical region, in particular, the vertebral arch
and facets joints.4,5 Modifying the patient’s posture,
performing active upper cervical flexion exercises,
and reducing compensatory movements may have
resulted in reducing loads to pain-sensitive structures.
In the scapulothoracic region, the patient’s exces-
sive scapular abduction and depression was consid-
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ered to contribute to prolonged compressive loading
of the posterior cervical structures by way of transfer
of the weight of the upper extremities to the cervical
region through the attachments of the cervico-
scapular muscles (levator scapulae and upper
trapezius).30,34 Johnson et al12 have noted that the
majority of the upper half of the trapezius muscle
travels a transverse course from the lower half of the
ligamentous nuchae to the acromion and spine of the
scapula. The function of the transverse orientation of
Copyright © 2005 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
the trapezius fibers is to relieve the cervical spine of
compressive loads by transferring the weight of the
upper extremity to the sternoclavicular joint.12 Be-
cause of the impairments of the upper trapezius
(decreased strength and increased length) noted on
examination, we assumed that the trapezius was not
effectively transferring the upper extremity loads to
the sternoclavicular joints. As a result, the posterior
cervical spine structures were bearing the weight of
Journal of Orthopaedic & Sports Physical Therapy®
the upper extremities throughout the day. Such load
bearing was considered to contribute to an increase
in the patient’s cervical extension position, altered
cervical movements, increased tissue stress in the
posterior cervical region, and CH symptoms. The
findings from the PCSPT test provides some support
for the proposed mechanism of upper extremity
weight transfer to the cervical region. Elevating and
adducting the patient’s scapulae and supporting the
weight of the limbs resulted in increased cervical
motion and a decrease in symptoms. Decreasing the
prolonged effect of the weight of the upper extremi-
ties on the cervical spine was treated (1) through
exercise to address the strength and length of the
cervicoscapular and scapulothoracic muscles, and (2)
by frequently supporting the upper extremities
throughout the day.
Finally, in the lumbar region, the patient’s pre-
ferred extension alignment was also considered to be
J Orthop Sports Phys Ther • Volume 35 • Number 1 • January 2005
a potential factor contributing to the patient’s pro-
longed cervical extension alignment. An increase in
lumbar extension can be associated with a compensa-
tor y thoracic kyphosis and extended cer vical
spine.3,9,16,26 The 2 factors, in particular, that were
addressed to modify the patient’s lumbar extension
included latissimus dorsi length and abdominal con-
trol and strength. Decreased length of the latissimus
dorsi muscle has been proposed to contribute to
increased lumbar extension,16 while abdominal
muscle strength and length has been proposed to be
important in maintaining a neutral lumbar spine
alignment.16 Thus, the goal of instructing the patient
to regularly correct his lumbar spine alignment in
sitting and standing was one method of minimizing
the thoracic and cervical region compensatory align-
ments and thus indirectly decrease the prolonged
loading into extension in the cervical region.3,9
The second factor considered to contribute to the
excessive loading in the posterior cervical region was
repeated cervical extension movements. The primary
means by which cervical extension was repeated was
through compensatory cervical extension movements
with shoulder movements. It is our view that every
CASE
time our patient lifted his arms he potentially was
extending his cervical spine.8,17 In this patient, fre-
quent cervical extension in an already extended
upper cervical spine was considered to be a factor
REPORT
that could accelerate the accumulation of tissue stress
in the posterior cervical region. Prescription of exer-
cises to allow full shoulder movement without com-
pensatory cervical spine movement was important,
because it addressed a factor that potentially was
contributing to not only the development but also
the persistence of his CH symptoms.
Manual therapy techniques have been reported
to provide short-term benefit to patients with
CH.10,20-22,29,39,40 The patient described in the cur-
rent report did not receive manual therapy even
though movement of upper cervical region was found
to be very limited. Interestingly, significant changes at
the impairment and functional limitation level were
obtained with treatment based solely on active exer-
cise and positioning performed by the patient. Of
particular note was the improvement in joint mobility
of the upper cervical region. The proposed mecha-
nism for these changes is related to how changes in
alignments and movements in the cervical, scapulo-
thoracic, and lumbar regions may have affected the
alignment and loading in the cervical spine region.
The goal of treatment was to decrease tissue loading
by changing his preferred cervical extension align-
ment and frequent movements into end range exten-
sion. We propose that addressing the factors that
appeared to contribute to maintaining an extended
cervical spine alignment decreased the patient’s pain
level and allowed him to achieve a more neutral
cervical spine position with less facet joint approxima-
13
 tion. The more neutral spine position then allowed
cervical joint range of motion, eventually restoring
much of his cervical mobility without passive treat-
ment. Considering the positive effects of manual
therapy reported, however, it is possible that a com-
bined treatment of manual therapy, exercise and
positioning, as we have described, might result in
even more rapid and long-lasting recovery than our
patient attained.
CONCLUSION
In the past, the focus of physical therapy interven-
tion for CH has included manual therapy to address
cervical joint impairments and, more recently, exer-
cise to address cervical muscle impairments. This case
report suggests that impairments not only in the
cervical region, but also in the scapulothoracic and
lumbar regions, may be important to consider when
treating a patient with CH.
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CASE
REPORT
15