Posts in headaches
Significant Cervical Weakness Found Among Patients With Migraine

According to the Global Health Burden studies, Migraine is the 3rd most prevalent disorder (14.7% of global population: 1 in 7 people)  and 3rd most cause of disability in those under 50 years old. It is more prevalent than diabetes, epilepsy and asthma combined. Migraines occur with 17% of women and 6% of men.  Symptoms of migraine include: Headache on bilateral or unilateral sides around temporal region, with or without visual disturbances.

A recent study (JOSPT 2019) investigated the role of the musculature in the cervical spine in those with migraines. A lack in neck endurance strength of the neck musculature has been shown to be correlated with chronic migraines. The authors found a significant difference in neck extensor and flexor strength with those with and without migraines. The findings of the study suggest addressing the strength of the musculature of the neck to assist in management of headaches

Physical Therapy Headache Solutions

Headaches remain a significant source of pain and disability for patients in our country costing over $30 billion dollars each year. Symptoms can be driven by different types of headache including tension, migraine, and cervicogenic (driven from the neck). Cervicogenic headaches can be found in 4% of the general population, 20% of all patients with headaches, and up to 50% of patients with headaches after a whiplash mechanism of injury.

The upper neck vertebrae are most commonly associated with these symptoms with the 2nd and 3rd vertebral joint driving 70% of headaches. The clinical diagnosis can be made based on the following criteria

  1. Pain that originates in the neck and radiates to the frontal and temporal regions

  2. Unilateral symptoms (may be bilateral but never together)

  3. Radiates to ipsilateral shoulder and arm

  4. Provocation of symptoms with neck movement

  5. History of neck pain

Physical Therapy remains a first line treatment for cervicogenic headaches. Researchers advocate for a mulitimodal approach including spinal manipulation, neck and upper back strengthening (see videos). These interventions have received the highest grade (A) of evidence for treatment of this condition. Specifically, evidence supports the use of manual therapy and exercise over primary care management, manual therapy or exercise alone in patients with neck pain and headache. These benefits are sustained at 1 and 2 year follow up time periods. Finally, the number needed to treat (NNT) is 2 for patients with neck pain treated with manual physical therapy and exercise to achieve one additional successful outcome than would have occurred if patients received an alternative treatment.

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Concussion Rates at Altitude

Winter sports are in full spring in Colorado with many people taking their athletic pursuits outside.  Skiing and snowboarding continue to grow in popularity throughout our state among both children and adults.  Thankfully, ski helmets have become the norm at our state's ski areas.  These helmets are an essential piece of equipment to reduce the forces placed on the brain and skull during a fall.  Concussion is one of the most commonly diagnosed injuries to the head among athletes.  New research is examining the impact of altitude on concussion incidence and symptoms.   

Authors have previously reported fewer concussions are diagnosed in high school and professional athletes competing at higher altitudes (Myer et al. 2014, Smith et al. 2013).  This has led clinicians and researchers to believe high altitudes may have a protective effect on brain injuries like concussion.  These first two articles were only preliminary reports and the definition of injury and high altitudes was not clear.  A recent article in the Journal of Orthopedic and Sports Physical Therapy examined concussion rates at 21 NCAA division I football programs across the country (Lynall et al. 2016).  The article stated 169 concussions were reported by these programs medical staffs over 63 seasons (1-5 seasons for each team).  Surprisingly, these authors found higher altitudes may be associated with higher rates of concussions.  

Differences between this study and previously studies may be due to differences in research methodology including injury tracking and athlete selection.  For example, the college athletes in this study may not have enough time prior to competition for beneficial physiological adaptations to occur compared to their pro counterparts.  Usually adaptations are observed 48-72 hours after traveling to altitude.  Further research is needed to determine the impact of these physiological changes on brain health in athletes, but this research adds to existing research questioning the protective benefits of altitude competition on concussion rates. 

Jaw Pain and Physical Therapy Treatments

Temporomandibular Disorders (TMJ/TMD)


TMJ/TMD are a major cause of non dental jaw and facial pain.  Approximately 18 million word days are lost annually per 100 million full time working adults due to symptoms of TMD (2).  

Women have a 3:1 greater ratio of incidence compared to men between age 30 and 50 (1).

Disk Displacement and Arthritic symptoms peak at age 30 and 50, respectively (1).

Symptoms can be broken down into 3 areas:

Muscle or myofascial pain (45%), Osteoarthritis (41%), and Osteoarthrosis

Physical Therapy Treatments

Review articles support a mulimodal approach for the management of TMD including: joint mobilization/manipulation, soft tissue mobilization, active exercise, proprioception training, and relaxation training (6,7,11).

boulder physical therapy treatments jaw pain face pain

Evidence for Physical Therapy Interventions 

Shiffman et al. found rehabilitation was as effective as arthroscopic surgery or arthroplasty (4).

Manual therapy has been shown to be more cost effective and less prone to side effects than dental treatments (5).

Dry needling of the facial muscles has shown positive results in recent trials (12).

Neuromuscular re education and behavioral changes are more effective than splinting (6).

Nicolakis et al. demonstrated >85% of patients with TMD treated with PT report excellent functional improvement, reduce pain, and improved ROM.  76% of patients required no further care up to 3 years after treatment (8,9).

Furto et al. demonstrated improved short term outcomes following Physical Therapy treatments involving manual therapy and exercise (10).

Manual therapy interventions to the cervical and thoracic spines, as well as, dry needling has demonstrated further improvements in pain and disability (12). 

When to Refer to Physical Therapy

Patients with TMD often display signs and symptoms including: TMJ pain and myofascial pain in the face, jaw or neck, TMJ sounds, restrictions, deviations, or deflections of the jaw during jaw opening and closing.

The American Association for Dental Research reports

"Unless there are specific and justifiable indications to the contrary, treatment of patients with TMD initially should be based on the use of conservative, reversible, and evidence based therapeutic modalities."


1. Manfredini, D. et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Oct;112(4):453-62.

2. Okeson, J. et al. Temporomandibular disorders in medical practice. J Fam Pract. 1996. 43(4):347-56.

3. Truelove, E. The efficacy of traditional, low cost and non splint therapies for temporomandibular disorder. A randomized controlled trial. J Am Dent Assoc. 2006.

4. Schiffman et al. Randomized Effectiveness Study of Four Therapeutic Strategies for TMJ Closed Lock J Dent Res 1986(1):58-63, 2007

5. Kalamir A, Pollard H, Vitiello
myofascial therapy for chronic myogenous temporoman- dibular disorders: a randomized, controlled pilot study. J Man Manip Ther. 2010;18(3):139-146.

6. Medlicott, M. et al. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporo- mandibular disorders. Phys Ther. 2006;86:955-973.

7. Kalamir, A. et al. Manual therapy for temporomandibular disorders. A review of the literature. J Bodywork Movement Therapies. 2007.

8. Nicolakis, P et al. An investigation of the effectiveness of exercise and manual therapy in treating symptoms of TMJ osteoarthritis. Cranio. 2001. 19(1):26-32. 

9. Long term outcome after treatment of temporomandibular joint osteoarthritis with exercise and manual therapy. Cranio. 2002. 20(1):23-27.

10. Furto, E. et al. Manual physical therapy interventions and exdrcise for patients with temporomandibular disorders. Cranio. 2006. 24(4):283-91.

11. Shaffer, S. Temporomandibular disorders. Part 2: conservative management. JMMT. 2014.

12. Gonzalez-Iglesias, J. et al. Mobilization with movement, thoracic spine manipulation, cervical spine manipulation, and dry needling for the management of temporomandibu- lar disorder: A prospective case series. Phys Ther Theory and Prac. 2013.





Concussion and Risk of Future Injury

Concussion recognition and management has improved dramatically over the last decade.  Coaches and Physical Therapists are able to both recognize the signs and symptoms of concussion and direct the athlete to the appropriate health care treatment.  Without proper management concussions can have serious and deadly consequences for the nervous system and musculoskeletal system.  Lynall et al. reported concussed collegiate athletes were twice as likely to suffer an acute lower extremity injury compared to non concussed athletes (Med Sci Sp Ex. 2015).  This increased risk is due to changes in our nervous system's ability to communicate with the muscles and joints in our body.  In particular, we have identified lasting balance, coordination, and control changes after a concussion injury.  

boulder physical therapy balance deficits

Authors estimate 1 player in the NFL sustains a concussion every 2 or 3 games (Casson et al. 2010).  These numbers are likely higher given the under reporting of concussions in collision sports.  Building off Lynall et al. report a recent article examined the impact of concussions on future injury in NFL players (Pietrosimone et al. Med Sci Sp Ex. 2015).  The authors mailed a survey to 3600 retired players and received 2,429 surveys in return.  60% of these athletes reported having at least 1 concussion during their NFL career.  When the authors compared injury rates among the concussed and non concussed athletes they found higher rates of injury in the players who sustained a concussion.  With each concussion athletes had a higher rate of musculoskeletal injury.  Players with >3 concussions had 165% greater odds of reporting injuries to their arms, legs, or spine during their careers.  This article provides further support on the link between concussion and injury.  Athletes should be both symptom free and use Physical Therapy to reduce the risk of future injury on the field.  

Neck Pain and Physical Therapy Treatments
neck pain, physical therapy, treatment

Neck Pain Background Information

Neck pain affects 10-15% of the population at any one time, with a lifetime incidence of 22-70% (1). Only 6% of patients with neck pain report resolution of symptoms at one year (2).

A recent systematic review demonstrated the prognosis from idiopathic neck pain is poor (3) and 50-75% of patients with neck pain will report symptoms at 1 and 5 year follow up (4).

Evidence suggests the utilization of manual therapy and exercise is a more cost effective intervention compared to primary care management alone or standard physical therapy (see graph). (5)

Our effectiveness in treating patients increases as we match interventions to a patient’s signs and symptoms. Evidence suggests outcomes are improved by correctly matching each Physical Therapy intervention to a specific patient category see below.(6)

Patients with mechanical neck pain, cervical radiculopathy, and cervicogenic headaches can benefit from Physical Therapy interventions including manual therapy and exercise to reduce pain and improve disability. 

neck pain costs, manual therapy, boulder physical therapy

Physical Therapy Interventions for Neck Pain

Exercise and Conditioning

Physical Therapy strengthening, neck pain

Patients within this category may display lower pain and disability levels and report a longer duration of symptoms.

Exercises will aim to improve muscle function within the deep cervical flexors and scapular muscles.

A recent systematic review provided Level 1 evidence on the benefits of exercise for patients with mechanical neck pain.(7)

Strong evidence supports the utilization of proprioception and strengthening exercises for patients with recurrent or chronic neck pain.(8)


A recent Cochrane review documented the improved effectiveness of manual therapy and exercise over manual therapy alone in patients with neck pain with or without headaches.(10)

Authors report the benefit of cervical manipulation on reducing head- ache intensity and frequency in patients with headache.(9)

The utilization of manual therapy and cervical strengthening has been show to reduce pain, disability, and headaches over both the short and long term (see graph) (11). 

headache, neck pain, boulder physical therapy treatments

Neck and Arm Pain/Cervical Radiculopathy


Patients within this category include those who have signs and symptoms of nerve root impingement or radicular symptoms.

Studies demonstrate 26% of patients with cervical radiculopathy who undergo surgery continue to experience high levels of pain at a 1-year follow-up.(12) Studies also suggest that patient outcomes may be superior with conservative management versus surgical interventions.(13, 14)

Physical therapy interventions consisting of manual therapy (17), cervical traction (15, 16), and cervical centralization exercises have been shown to decrease pain and improve function in this population.

Recently authors reported 91% of patients with cervical radiculopathy who underwent treatment of manual physical therapy, cervical traction and strengthening exercises showed significant functional improvement. (17). 

neck and arm pain, boulder physical therapy treatments, centralization

Pain Control

This subgroup comprises patients with acute or traumatic onset of neck pain, including whiplash injury, and those presenting with high levels of pain and disability.

Physical therapy interventions for this category aim to decrease pain and allow transition into other subgroups for treatment to reduce disability.

Evidence suggests utilization of thoracic spine manipulation18, cervical spine mobilizations19, neck active ROM exercises20, gentle soft tissue massage(21), and physical modalities such as TENS (22).

Interventions matched to patient’s signs and symptoms within the category demonstrate greater changes in pain and disability than unmatched interventions (6). 


neck pain, mobility, boulder physical therapy treatments

Patients within this group include those with symptoms proximal to the elbow, an acute onset (<30 days), and are younger than 60 years old.(6)

Evidence supports the utilization of both cervical and thoracic mobilization/manipulation, with exercise, to restore mobility, decrease pain, and improve function. (1, 22, 23)

Utilization of manual therapy can reduce long term management costs by as much as 2/3 in comparison with exercises or medical management alone. (24) 


Childs, J. Cleland, J. et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther 2008;38(9):A1-A34.

Picavet HS, Schouten JS. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC(3)-study. Pain. 2003;102:167-178.

Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis. Arch Phys Med Rehabil 2011;92:824-9

Carroll L. Hogg-Johnson, S. et al. Course and Prognostic Factors for Neck Pain in the General Population. Spine. 2008;33(4):S75–S82.

Korthals-de Bos IB, Hoving JL, van Tulder MW, et al. Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial. BMJ. 2003.

Fritz JM, Brennan GP. Preliminary examination of a proposed treatment-based classification system for patients receiving physical therapy interventions for neck pain. Phys Ther. 2007;87:513–524.

Kay, T. Gross, A. et al. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews. 2005. CD004250.

Sarig-Bahat, H. Evidence for exercise therapy in mechanical neck disorders. Manual Therapy. 2003;8:10-20.

Nilsson, N. Christensen, J. et al. The effect of cervical manipulation on cervicogenic headache. J Manip Phys Ther. 1997;20:326-330.

10. Gross, A. Hoving, J. et al. A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Pain. Spine 2004;29:1541–1548

11. Jull, G. Trott, P. et al. A Randomized Controlled Trial of Exercise and Manipulative Therapy for Cervicogenic Headache. Spine. 2002;27(17):1835–1843

12. Heckmann JG, Lang CJ, Zobelein I, Laumer R, Druschky A, Neundorfer B. Herniated cervical intervertebral discs with radiculopa- thy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999;12:396-401.

13. Honet JC, Puri K. Cervical radiculitis: treatment and results in 82 patients. Arch Phys Med Rehabil. 1976;57:12-16.

14. Sampath P, Bendebba M, Davis JD, Ducker T. Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review. Spine. 1999;24:591-597.

15. Graham N, Gross AR, Goldsmith C. Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med. 2006;38:145-152.

16. Moeti P, Marchetti G. Clinical outcome from mechanical intermittent cervical traction for the treatment of cervical radiculopathy: a case series. J Orthop Sports Phys Ther. 2001;31:207-213.

17. Cleland, J; Whitman, J; Fritz, J; Palmer, J. Manual Physical Therapy, Cervical Traction and Strengthening Exercises in Patients with Cervical Radiculopathy: A Case Series. J Orthop Sports Phys Ther. 2005:35(12):802-809.

18. Gonzalez-Iglesias, J., Fernandez-de-las-Penas, C., Cleland, J., & Gutierrez-Vega, M. (2009). Thoracic spine manipulation for the

management of patients with neck pain: a randomized clinical trial. Journal of Orthopaedic & Sports Physical Therapy, 39(1), 20-27.

19. Conlin A, Bhogal S, Sequeira K, Teasell R. Treatment of whiplash- associated disorders, part I: non-invasive interventions. Pain Res Manag. 2005;10:21-32.

20. Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine. 2000;25:1782-1787.

21. Skyba D, Radhakrishnan R, Rohlwing J. Joint manipulation reduces hyperalgesia by activation of monoamine receptors but not opioid or GABA receptors in the spinal cord. Pain 2003;106:159e68.

22. Cassidy, J.D., Lopes, A.A., Young-Hing, K. The immediate effect of manipulation vs mobilization on pain and range of motion in the cervical spine: a randomized control trial. Journal of Manipulative and Physiological Therapeutics. 1992. 15:9.

23. Cleland, J.A., Mintken, P.E., Carpenter, K., Fritz, J.M., Glynn, P., Whitman, J., Childs, J. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a generally cervical range of motion exercise: multi-center randomized control trial. Physical Therapy. 2010. 90: 9.

24. Ingeborg, B.C., Korthals-de Bos, Hoving, J.L., Tulder, M.W., Rutten-van Molken, M., Ader, H.J., CW de Vet, H., Koes, B.W., Vondelling, K., Bouter, L.M. Cost effectiveness of physiotherapy, manual therapy, and general practicioner care for neck pain: economic evaluation alongside a randomized control trial. British Medical Journal. 2003. 326:911