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12 Articles in Volume 9, Issue #1
Atypical Herpetic Reactivation and Chronic Pediatric Pain
Blending Prescription Pain Treatments with Alternative Medicine
Cervical Disc Disease with Referred Pain to TMJ
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1
In My Opinion
Laser Therapy: Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Pain Management in the Elderly
Personality Disorders in Migraineurs
Surgical Implants for Pain Management
Treating Shoulder Pain in Hemiplegic and Spinal Cord Injured Patients
Trigger Point Ablation and TMJ Syndrome
What a Decade of the Mind Affords the Decade of Pain Control and Research

Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 1

Myofascial stretching, self-mobilization, and muscle strengthening of the deep neck flexors may ameliorate forward head posture, cervicogenic headache, and tension-type headaches.
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Nearly fifty percent (50%) of the population is affected by cervical spine pain and/or headaches during their lives.1 Headache is not only one of the most common human ailments,2 but also accounts for the expenditures of billions of health care dollars annually and is a leading cause of lost time from work.3

Cervical dysfunction may be seen in up to seventy percent (70%) of the population suffering from any type of headache.4 This suggests that the cervical spine may be either a causative or contributing factor in the pathogenesis of many headaches.5

The pilot study by Placzek, Pagett, et al. demonstrated and supported the theory that headache may be influenced by cervical muscle strength, and that weakness of the cervical spine musculature may lead to abnormal stress on the upper cervical facets which are related to head and neck pain. It is further speculated that stability, and thus normal function and biomechanics, is dependent on a balance of anterior and posterior cervical muscle balance. Despite advances, the pathogenesis of tension-type headache is not clearly understood. However, cervical musculoskeletal abnormalities have been linked to multiple headache types.6-8

In the study published by Fernandez-De-Las-Penas, Perez-De-Heredia, Molero-Sanchez, and Miangolarra, the authors presented results similar to those previously reported:

1. impairment in deep neck flexor muscles in individuals with cervicogenic headaches, and
2. deficits in the performance of the cranio-cervical flexion test (ie., reduced endurance or holding capacity of the deep neck flexor muscles).

The authors concluded that patients with chronic tension-type headache showed reduced holding capacity of the deep neck flexors. Patients with chronic tension-type headache also exhibited greater forward head posture (FHP) in a standing position than healthy controls.

The dental profession has become increasingly aware of the postural relationships between the head and neck, especially with regard to the diagnosis and treatment of head and neck pain and temporomandibular disorders.10-12

Clinical observation suggests that FHP and weakness of the deep cervical flexor musculature are associated with, and co-exist in, the cervical headache patient.14,15 The study by Watson and Trott confirmed the clinical observation with respect to isometric endurance and isometric strength.16 The study also showed that cervical headache is commonly precipitated or aggravated by sustained neck posturing or neck movements.

Yip, Chiu, and Poon performed a cross-sectional correlation study to investigate the relationship between head posture with pain and disability in patients with neck pain.17 The study showed a significant difference in the Cranio-vertebral (CV) Angle between subjects with and without neck pain. There is a moderate negative correlation between CV Angle and neck disability. Patients with small CV Angle have a greater forward head posture and the greater the forward head posture, the greater the disability.17

Figure 1. PostureJac® exercise and posture-support device.

New Research

Preliminary data collected in the Department of Physical Therapy at the New York Institute of Technology (NYIT) in Old Westbury, New York, indicates that an exercise and posture-support device—such as the PostureJac® invented by one of the authors and illustrated in Figure 1—immediately increased the endurance capacity in the deep neck flexors by over forty percent (40%), whereas the control group showed only a six percent (6%) increase. This has implications for tension-type and cervicogenic headaches; where the endurance capacity of the deep neck flexors has been shown to be deficient.18,19 In addition, poor endurance of the deep neck flexor muscles (rectus capitus anterior, rectus capitus lateralis, longus capitus, and longus colli) may lead to forward head posture which has been linked to not only chronic headaches, but also to:


  • temporomandibular disorders,20

    Exercise and Posture Support Device

    Individuals can perform myofascial stretching, self-mobilization, and muscle strengthening utilizing an exercise and support device such as the PostureJac.

    While such a device works on a biomechanical basis to correct forward head/ rounded shoulders posture, perhaps its most profound effects on form and function operate on a neurological level through sensorimotor learning and improved kinesthetic awareness. Patients are trained to recognize abnormal postures and movement patterns and exchange them for static and dynamic alignment that is balanced, efficient, and in a vertical relationship with gravity.24 In addition to the therapeutic effects of posture correction, it serves as a tool for core strengthening of the local muscles of the lumbopelvic region (ie, transversus abdominis, pelvic floor, multifidi, and diaphragm) as well as the deep neck flexors (ie, rectus capitis anterior, rectus capitis lateralis, longus capitis, and longus colli)

    Two applications of the device—namely, posture correction exercises and deep neck flexor muscle training will be described below.

    Posture Correction Exercises

    The ‘Release.’ This introductory exercise involves the process of releasing excess tension in the upper half of the body. The upper trapezius and sternocleidomastoid muscles are known to generate excessive and unnecessary tension,25 the result being a tendency towards forward head/rounded shoulders posture. Most likely this tension is driven emotionally through the limbic system,26 but other postural influences certainly play a role.27 Ideally, the head-neck-shoulder region should remain relaxed and fluid. However, because of habitual tensing in these muscles, the head-neck may intermittently “freeze.” The goal of this release maneuver is to recognize when “freezing” occurs and to restore the head-neck region to its fluid and relaxed state. Following is a series of steps in accomplishing the desired result:

    Last updated on: November 1, 2012
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