Craniofacial Pain Neuromusculoskeletal Assessment Treatment and Management

Therapeutic communication during management of craniofacial pain 85 When such reactions are found in patients, this People act from their own personal view- means that the therapist cannot assume that point (individual reality), irrespective of actual the patient is able to realistically judge the reality. Understanding someone therefore success of therapy. The patient’s expectations means meeting them in their reality. are either unrealistically high or extremely low – ‘nobody can help me anyway’. In either case, Each type of behaviour has a positive inten- the patient will not recognize successful treat- tion for the person concerned. Each person ment, particularly if the effect is small. Suc- does the best they can do at the time in each cessful treatment outcomes lag far behind situation. This also means that a negative or those achieved with patients with a realistic inappropriate type of behaviour will only be understanding of their treatment. As this is a abandoned when a better form of behaviour is well-known situation, Keeser and Bullinger available. (‘A wrong passion is not removed by (1990) suggest questioning two typical medical quashing it but by driving it out with a real assumptions when dealing with chronic pain passion’ – Bernhard of Clairvaux, co-founder patients: of the Cistercian Order 1090–1153.) ● Firstly that the patient really (i.e. consciously The speaker (transmitter) is responsible for and subconsciously) wants to be cured communication: ‘It is not what I say, but what is understood that counts.’ The importance of ● As a result of the above, such a cure can be communication lies in the result it achieves. effected with the appropriate means and (‘Because you were angry and corrected him methods available. with more candour than was your right, you did not improve him, but only angered him; in Under favourable conditions of communica- future pay attention not only to the truth of tion it is possible to structure contact with what you say, but also whether he to whom these patients, who are mainly described as you speak can bear the truth’ – Seneca, Roman ‘difficult’, in such a way that the chances of philosopher ca. 0–65.) successful therapy are substantially increased. To this end, a certain communicative attitude Resistance is the result of a lack of flexibility based on the following assumptions has been in the speaker (in particular with regard to found to be helpful. structuring contact, preparation of the message and timing of the communication). As a rule, ASSUMPTIONS FOR FAVOURABLE more time is used in dealing with resistance COMMUNICATION CONDITIONS after the fact than in correct preparation of mes- sages; thus avoid resistance as far as possible. These assumptions are creations of thought which are neither true nor false. They have In communication there are no mistakes, been found useful for communication with only new information. If you receive the infor- patients because numerous treatment options mation that a counselling technique has not arise from the resultant therapeutic disposi- functioned as you had hoped, then try some- tion, allowing considerable therapeutic flexi- thing else. Do not, however, repeat the first bility. These prerequisites promote therapeutic technique – and certainly not without suffi- communication within the framework of an cient further preparation. One reason for this existing treatment agreement. is that you have already encountered a reaction of resistance and this resistance would only These communication basics are, of course, increase. not new, and for this reason historical notes have been added in certain places. These come Behaviour and thinking are guided by the either from philosophers or from monks, the direction of the attention given. The questioner great orators of the past. steers attention and in so doing guides the con- versation in the direction required. The person who orientates the conversation toward goals and resources (e.g. exceptions in the course of the illness) gives the patient the possibility of

86 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT dealing with their problems in a new way. For Patterns of behaviour are mirrored, which potentially curable illnesses one can even say means that the conversation partners have: that each human being already has what they need to achieve their goals. ● A similar tempo in movement and speech ● A similar style of language (number of Behind every complaint there is a wish. Those who understand this wish and refer to foreign words, length and complexity of it meets the patient in their world and the sentences, emotionality, etc.). patient feels understood. Dealing with wishes is also far more pleasant than dealing with Very often, spontaneous adaptation of breath- complaints and ‘moaning’. ing patterns then results. The above assumptions result in an involved, If good professional contact is to be interested questioning attitude on the part of established with the patient it is necessary to the therapist. Protracted lecturing of the patient accompany the person until rapport has been should be the exception, not the rule. The recognizably established. Good conversational patient is listened to and experiences under- contact can be recognized by the following standing and goodwill from the therapist. This indications: the patient begins to slightly nod enables an open conversation in which a patient his head in agreement, body language becomes will divulge far more information than in a more open, when the therapist smiles the ‘normal’ consultation. patient smiles back, if the therapist moves soon after the patient will also move, eye C O N TAC T contact increases. At the point where good con- versational contact has been established it is A prerequisite for such communication is advised to move from accompanying the that contact with the patient is built up in an patient to leading the conversation. Unpleasant appropriate manner. A basic rule is that, in or difficult topics can now be dealt with. Should communication, people react far more strongly rapport diminish during the conversation, to how something is said rather than to what is return immediately to pacing. said. For therapeutic counselling there is usually Good communicative contact is often an implicit treatment agreement. As a rule there described as rapport. When people have a are two conditions for such an agreement: rapport with one another you can see this from a distance. Their behaviour patterns resemble ● The patient really wants to get better and is each other. Use can be made of observable pat- prepared to do everything necessary to terns of behaviour by consciously adapting to achieve this. The patient will therefore the patient. This ‘virtual mirroring’ is also keep to the agreements (shows high referred to as pacing. With pacing, adaptation compliance). of behaviour occurs in the following areas. ● The therapist has ways and means to allevi- The therapist adapts their attitude – at least ate the symptoms and, if possible, to cure in certain areas – to that of the patient. Where the illness. there is good contact this happens spontane- ously (as seen with couples or business part- This relatively simple model usually functions ners negotiating in a restaurant). What this extremely well with many acute treatments means in practice is that the conversation part- such as therapy for acute inflammation. For ners, as far as possible: this reason it is often generalized and applied to chronic conditions. Here, however, various ● Meet at the same eye level special points should be noted. ● Adapt to one another’s hand, foot and head PAIN-INFLUENCING FACTORS movements. The sensation of pain (in particular chronic pain) consists of several components (Fig. 4.1).

Therapeutic communication during management of craniofacial pain 87 Ritual Mood What does this pain mean to my family? Pain /in my culture? Receptor Gain Electrical Is there a secondary gain to the illness? potential Meaning What does this pain mean to me? Motivation Motivation to become pain-free Emotions Suffering, willingness to suffer Behaviour How is the pain expressed? Environment Search for external triggers Prostaglandin and others Fig. 4.1 Factors influencing pain. Stimuli in the wider sense are responsible for ● Emotions: The amount the patient is pre- the basis of the sensation of pain, be they pared to suffer and the intensity of suffering mechanical, chemical, caused by temperature, varies greatly between patients. The more inflammatory or similar. Different patients intensively the patient concentrates their react very differently to stimuli of comparable emotions on the pain, the greater will be the intensity. Here, among other things, the fol- sensation of pain. lowing psychologically influenced factors play a part: ● Motivation: The will to cope as best as pos- sible with the pain and the illness varies ● Mood: Patients with negative mood (e.g. greatly. Sensation of pain is reduced with depressive patients) have a low tolerance of increasing motivation to cope with the pain pain (Flor 1990) (see Case study 4.1). For this and more realistic expectations of thera- reason some clinics are starting to employ peutic outcomes. The more realistically the clowns to improve the mood of seriously ill patient views their being cured and the cancer patients and so reduce the use of higher the motivation to cope with the pain, analgesic drugs (in addition to stimulating the lower the sensation of pain. the immune system). ● Meaning: The sensation of pain varies with ● Attitude to pain: Many patients tend to the meaning that is attached to the pain adopt extreme, partly cramped postures or (Müller-Busch 1990). When an injury during work methods which actually increase pain. a competition is regarded as unimportant Ergonomic training, relaxation and breath- compared with the chance of victory, the ing techniques and behavioural therapy real extent of the injury will only be realized approaches can effect positive changes. after achieving the goal. If, on the other hand, a mild pain means the growth of a

88 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT tumour, then this pain, when it occurs, will of a patient. In this way, for instance, a be felt much more strongly. migraine patient will receive special atten- ● Gain: People always live in relationships tion during a migraine attack (e.g. not having and systems. These systems react to the pain to carry out their duties). When the migraine Case study 4.1 followed by about 5 days of subjective freedom from pain. Although the patient Not all factors are always of equal relevance continues rinsing his mouth at home, the for an episode of pain. A 75-year-old patient symptoms reappear in another place after who has been widowed for 4 months (a about 5 days. pensioner, former metal-worker) goes to the surgery of a young colleague again and again The treatment which led to freedom from because of painful tender spots following his pain in three sittings consisted of changing receiving new dentures (the new dentures the pattern of treatment. Every 3 days the had been absolutely necessary). They know patient was given an appointment at 7.45 that the patient does not want morning a.m. before the start of morning surgery for appointments. Over a course of several weeks ‘systematic oral treatment’ with a mild, dilute the patient comes to afternoon surgery with camomile solution. Treatment was the same the same subjective complaints. He has no as before, except it was carried out by an appointment and puts up with long waiting older, resolute dental assistant. The dentist times. only briefly checked the result of treatment and then sent the patient home. After three The tender spots cannot be seen on sittings there was subjective freedom from examination of the mouth, although according pain. The patient cancelled the fourth to the patient the dentures have been worn appointment and only returned 6 months continuously. The dentures are in a hygienic later for the agreed check-up. condition. An allergy test carried out by the man’s general practitioner after some The patient’s reactionary depressive basic appointments shows no indication of allergic mood led to reduced tolerance of pain. reaction. As the dentures sit perfectly, Normal adjustment procedures when fitting treatment consists of two components: the dentures are subjectively experienced as placing the dentures in an ultrasound bath acute pain. Because of his grief, the patient (this apparatus lies in another room, cannot at present experiences great willingness to be seen by the patient but heard) and suffer. The gain resulting from this pain treatment of the mouth with a mild diluted situation is quite high. The patient regulates camomile solution. The dentures are not his need for contact and his need for altered because there are no obvious tender conversation via the dentures. Minimizing the spots and the dentures sit as they should. illness gain then also leads to a reduction of the symptoms. The unwillingness to go to his During the treatment the patient seems to GP for talks is a result of the purely dental want to talk a lot and complains about his treatment agreement. In order to successfully present situation in life. When the dentures suggest such treatment, a preparatory again start to press, he cannot eat properly conversation about the possibilities of a and also not speak properly. Not speaking psychological component in the illness would wasn’t so bad, he had no-one to talk to have been necessary. It seemed a good idea anyway, but not eating was a problem. On to minimize the illness gain by achieving being advised to go to his GP because of his freedom from the symptoms in order to difficult situation, he brusquely rejects this prevent a chronic situation in the sense of advice and blames the apparently functional habitual incompatibility with the dentures. pains on his dentures. Each treatment is

Therapeutic communication during management of craniofacial pain 89 is over, the so-called illness gain is also lost. embarrassed. The patient either resists or For this reason some psychosomatic clinics breaks off treatment. wait to see if the patient’s request to retire ● The patient desires (due to personal factors, will be granted (where medically possible) e.g. illness gain) that success of treatment be before they admit the patient. limited. For inexplicable reasons a difficult ● Ritual: In various ethnic groups and also and limited process of healing results. within families there are rituals regarding illnesses and pain (Müller-Busch 1990). In In order to avoid these obvious difficulties it is this way a family tendency to ‘keep a stiff important to ensure that there is always a clear upper lip – no complaining’ can lead to treatment agreement before these methods are serious delays in the diagnostic measures applied. necessary. At the other end of the scale the presumption that ‘a boy who is not brought ! In personal relationships there are no forth in pain will become a weakling’ can lead to an enhanced subjective sensation of treatment agreements. Here all such pain during childbirth despite an effective intervention using professional epidural. communication techniques are to be absolutely avoided! When one considers all these pain-influencing factors, it is easy to understand that the above- TREATMENT AGREEMENT mentioned implicit treatment agreement is not always enough for treating chronic pain Within the framework of the treatment agree- patients. An explicit treatment agreement clar- ment a clear definition of aims is compiled ifies the conditions of treatment and the inten- with the patient. Following this the exact tions of patient and therapist. framework of the course of treatment is agreed. In doing this the patient receives security, the Efficient methods of communication are relationship with the therapist is intensified very effective. When these methods are openly and compliance increased. When determining applied in the medical context within the the aim of treatment the following aspects are framework of the existing treatment agree- considered: ment they serve to achieve the predetermined aim of treatment in the fastest way possible. ● What exactly do you want to achieve/have? This procedure, if an open one, is acknow- (the aim must be positively formulated): ledged and respected by the patient. Where Only a positive description allows an exact there is no such treatment agreement the fol- idea of the state required such that one can lowing risks arise: exactly and clearly imagine an idea of the desired goal. In goal definition, therefore, ● The therapist intervenes in order to pursue there can be no negation and no compari- their own personal (legitimate) interests son. A negation firstly produces an image of (e.g. tries to achieve success in treatment by the problem and then the accompanying a certain method). The patient feels that this negation of the aim. A goal which contains procedure is manipulative and reacts with comparisons produces two ideas of goal: resistance. one positive and desired, and another that reflects the undesired problem. Both nega- ● The therapist intervenes in order to use tions and comparisons lead to failure. secret ‘areas’ of the patient for treatment purposes (e.g. asks personal questions about possible psychological causes of illness without first clarifying the framework of treatment and the treatment agreement). The patient senses the intrusion and feels

90 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ● The patient is encouraged to describe the of the treatment agreement, the part which goal concretely with his senses: This is a the patient themselves must play is precisely pattern of speech from the area of hypnosis. defined. In doing so it is important to check The patient is requested to give an exact whether the demands made on each patient lie goal description using his senses (what will within the area of their subjective possibilities. you see, hear, feel and smell when you have reached this goal?) In doing this the aim of ● Cost–benefit analysis – examining the treatment will become even more real for greater framework of the aim: What are the the patient. The more exact the description, consequences which arise from achieving the more exact the picture. The more exact this goal? How does one’s life change in the picture, the more attractive the goal and achieving this goal? the greater the compliance! Failure to consider the impact of a patient ! The desired goal attitude must lie within reaching their goal on the other people in the patient’s life can have disastrous consequences. the patient’s reach. Several small, successful The questions used to examine the greater and successive treatment agreements are framework are unusual. Therefore, it is often more effective than one that is too necessary to first explain the advantages of ambitious. an exact cost–benefit analysis to the patient (Table 4.2). Patients often want something to happen pas- sively to them (e.g. massages) which leads to ● How does the patient know that he has recovery without their own active participa- reached his goal? This question sounds tion. Within the framework of goal definition strange, but it is very helpful when the patient knows exactly how to recognize that a particular stage of treatment was successful. Table 4.2 Cost–benefit analysis The problem remains, the The problem is solved – the What do you gain when . . . goal is not achieved? goal is reached? What do you lose when . . . What is the good side of the What is good about the goal? problem? What can you do when you What is good about the have reached your goal? current situation? What is the disadvantage of the What is the worst thing that can goal? happen if the problem remains? What do you lose when you have reached your goal? What is the good in this? What do you have to do in What do other people gain when . . . Who profits when you do not order to achieve your goal? What do other people lose when . . . reach your goal? What do you have to do when you have reached your goal? Who else loses something when you do not reach your goal? Who else profits when you do reach your goal? Who else loses something when you do reach your goal?

Therapeutic communication during management of craniofacial pain 91 When checking success, there are two different VERBAL METHODS OF situations. For the interim steps, brief feedback INTERVENTION is important (feedback curve), i.e. when the patient notices success immediately after the Patients with chronic pain frequently have treatment step, this motivates the patient to indications for more general psychotherapeu- take the next step. When the final treatment tic treatment (e.g. of concomitant depression). goal has been reached it is necessary to note In such cases treatment by a psychotherapist this in order to adjust behaviour to the may also be necessary. However, there is a state achieved (e.g. resuming normal fitness whole spectrum of specific communication training). techniques to influence pain conditions that can be used by any trained doctor. To what Example 1 extent the therapist themselves can and wish to apply these techniques depends on their Diets often fail because, while people know particular qualifications. This spectrum ranges how to lose weight, when they have reached from classic relaxation methods (Jacobson their ideal weight they do not know how to training, autogenic training, self-hypnosis) via recognize that they are full. hypnotic guidance of speech during general treatment to psychotherapeutic intervention. If treatment aims, treatment steps, the criteria by which the patient can recognize Hypnosis, in particular self-hypnosis, as a their progress and any conditions under which relaxation method has a similarly wide range the treatment agreement must be altered are as, for instance, the self-hypnosis of autogenic included in the treatment agreement, it is training. It can be used as a supportive form of possible to use communication techniques to therapy in the whole area of psychosomatics influence conditions of pain. If such methods and to stimulate learning and creativity. Here are to be employed they must be expressly it is important to pay careful attention to posi- agreed within the framework of the treatment tive expression of the often unspecific sug- agreement. gestions. The transition to hypnotherapy is flexible. Example 2 Trance experiences are routinely used in For years a patient has had recurring chronic many societies for healing, reflection or in nocturnal grinding of teeth. When during goal order to deepen experiences. In Western definition the question arose as to what he Europe, however, the expression ‘trance’ would lose if he lost this symptom he burst belongs mainly to the area of hypnotherapy. In out: ‘Then I could no longer grit my teeth our everyday life we are expected to be fully when my wife starts yelling. Then I don’t oriented and conscious. Day-dreaming, for know how I would react!’ In this way he instance, is strictly forbidden to schoolchil- recognizes that grinding his teeth allows him dren, whereby this is nothing more than a to tolerate a difficult marital situation with (good) daily trance. Trance experiences are an extremely jealous wife. As a result he completely normal; they are practised by every decides to undergo psychotherapy (indicated healthy person daily. According to Rossi for several reasons) as advised, something he (Schors & Ahrens 2002), one’s day is composed has rejected up to now. of so-called ultradianous 90-minute rhythms. Following a phase of activity of 90 minutes a roughly 10-minute rest phase – a light trance phase – is inserted. In jobs requiring high con- centration one can observe this in an increased number of mistakes. These phases of day- dreams which help one to recover are helpful in influencing pain conditions.

92 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Therapeutic communication makes use of subconscious in such a way that various these trance conditions. They are partly applied parts take on different duties. When one within the framework of imagination tech- part is impeded in its work it starts to send niques, partly within the framework of formal signals. If one fails to hear the quiet signals, hypnosis. Hypnosis in the treatment of acute then loud signals are sent – the symptoms. pain conditions has been particularly success- Imaginative images are then developed ful and for this reason use has begun in as to what the part sending the symptom many dental practices. Hypnosis is also might look like. Following this, questions becoming more important in midwifery and are asked about this 'part': What would it anaesthetics. like to say? What is its true function? Why is it sending out a signal? This results in the Imaginative approaches lead to considerable development of a metaphoric insight into improvement in eating problems, smoking and the illness. alcohol abuse. They are also being applied ● Shifting of modalities: we receive all our more and more to treat cancers. Here the aim perceptions via our sensory channels – is to reduce the side effects of chemotherapy, one refers to sensory modalities (e.g. visual to strengthen the immune system, reduce pain, – seeing). These perceptions are again increase life expectancy and improve the divisible into smaller subunits (e.g. with quality of life. sight, considering the colour, the size of the image, picture or film, etc.). These subu- The following types of intervention are espe- nits are called submodalities. When one cially suitable for influencing pain conditions. alters a submodality, the sensation of pain changes. IMAGINATIVE IMAGES LEAD, THROUGH INTENSIVE ‘DAY-DREAMS’ TO Other techniques SPONTANEOUS TRANCE CONDITIONS ● Finding and acknowledging exceptions: It Metaphoric patterns and imagination is especially important that chronic pain patients take note of even small improve- With the help of metaphors and stories it is ments and value these. It is, therefore, criti- often possible to achieve considerable changes cal to ensure that all exceptions to the in conditions of pain. Professional usage of experience of chronic pain are acknow- such stories produces spontaneous trance con- ledged. It is then essential to find out exactly ditions. With these methods one also speaks of what led to this exception and how this state indirect hypnotic intervention. As one works can again be reached. When patients realize with images a (light) trance spontaneously their own potential to influence the situa- develops. tion, this stabilizes their self-confidence. ● The patient is asked to imagine a control ● Activating all resources: Many patients desk to regulate undesired symptoms and have the tendency to ‘root around’ in nega- to adjust the values accordingly. tive memories. In doing so their general mood worsens and their pain threshold is ● The patient imagines the pain as a symbol, lowered. If, on the other hand, one trains the following which the symbol is altered or a patient to independently and regularly different symbol chosen. relive positive memories and situations (resources) within the framework of relaxa- ● Images are developed by inner helpers. tion exercises, their mood stabilizes and the These inner helpers give the patient sugges- pain threshold is increased. tions as to how the pain can be changed. Religious patients often encounter their ● Reinterpretation (reframing of context and guardian angels in such images. meaning): When pain occurs, a catastrophic ● Images of ritual healing ceremonies can be used, e.g. bathing in a healing spring. ● A concept is explained to the patient in which one can imagine the work of the

Therapeutic communication during management of craniofacial pain 93 meaning is frequently ascribed to it (e.g. ‘It’s The situation described in Case study 4.2 is a got to be cancer’). In such cases it can be classic case of reinterpretation of meaning. The very helpful to assign a different meaning patient’s behaviour at having left his father in to the pain. Fear is then reduced and the the hospital is no longer seen by him as not pain threshold increased (Case study 4.2). having carried out his father’s last wishes but as having behaved responsibly with respect to Case study 4.2 his father’s health. A 45-year-old male teacher, married with two FORMAL HYPNOSIS: USEFUL IN children, had great tension in his masticator CERTAIN CIRCUMSTANCES muscles. On noting his medical history it was found that this tension and pain had arisen Direct suggestions are often used as ‘gut feel- suddenly. Following this a connection was ings’. They are not usually particularly effec- sought to his present situation in life and it tive without proper hypnosis; however, when turned out that the tension had arisen at the a patient is already in a trance they can be very time of his father’s death. helpful. On further questioning the following ● Direct address: The pain is, for instance, additional connections were revealed. The linked to another bodily function. ‘The patient’s father had always expressed a wish unpleasant feeling decreases with each to die at home. Due to a serious illness he had been admitted to hospital. His condition breath.’ continued to worsen and he had asked his son to take him home. The doctors had, ● Changing the signalling system: ‘Pay however, strongly advised the son against attention to another signal rather than the this because they expected his condition to improve with treatment. The son had pain.’ therefore persuaded his father to remain in hospital where the father then died following ● Altering area and intensity: ‘Perceive the a sudden deterioration in his condition. pain in a lower intensity over a larger Shortly before his death the father had area.’ complained that his last wish, to die at home, had not been granted. Since then the son Shifting the pain had suffered from feelings of guilt and extreme nocturnal grinding of teeth. On In these procedures replacement ideas instead being asked what would have actually of the pain are offered. Such images are so happened if the son had taken his father effective in hypnotic trances that they are home and he had then died there, although used to carry out operations under hypno- the doctors had assumed that his father’s anaesthesia. condition would improve within a few days, the son’s face brightened at once and he ● Glove anaesthesia: A glove is suggested replied: ‘Then I would have actually been which causes the patient not to feel the pain. partly responsible for my father’s death.’ This numbness is then applied to other areas of the body (Schmierer 1997). When questioned about how he now viewed the situation, he replied: ‘In the ● Analgesics: Feeling the pain differently is particular circumstances my behaviour would suggested to the patient (e.g. as numbness, seem to have been right.’ In a check-up 2 cold, etc.). weeks later it was found that the muscle pains had disappeared and the patient could ● Paradoxical intervention: ‘This is pain and not recall grinding his teeth in the meantime. it does not hurt you.’ (This pattern matches physiological discoveries in the brain regard- ing fighting pain with hypnosis. The pain is transmitted to the brain but is not felt as pain.)

94 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ● Disorientation: Pains can also be shifted Contraindications whereby the pain is directed to a different part of the body. Trance conditions work with images. At best, these images were once real but are not, ! This procedure can lead to shifting of however, real at the present time. As a rule psychotic people have great difficulty in recog- symptoms, especially when the patient nizing hallucinations for what they are and forgets the shifting of pain (amnesia). differentiating them from images. For this reason one must proceed very carefully with Distraction techniques all imagination techniques, as well as autogenic training. This also applies to all symptoms By focusing attention on other activities or where the relationship between patient and ideas the sensation of pain can be greatly therapist is not clearly stable and good. Most reduced. personality disorders, in particular borderline disturbance, are included in this category. ● Focusing attention (disassociation): The Aggressive patients should not be placed in a attention of the patient is concentrated on trance: in lowering the inhibition threshold a different emotionally intensive situation they could become more aggressive. (e.g. imagining playing sport intensively just at this moment). PATTERN OF ADJUSTMENT FOR PAIN CONDITIONS ● Disorientation – out-of-body experience: The patient is asked to leave his body behind Finally, a procedure will be described which and at the same time to be in another place very often leads to a swift reduction of symp- (e.g. his favourite place). toms in both acute and chronic pain. A pre- requisite for employing this procedure is that Time gaps the cause of the pain has been physiologic- ally completely determined. (Altering unclear, Through the use of imagination the patient is not fully diagnosed pain is regarded as ‘sent’ into a pain-free time or is trained to medical malpractice, as an important diag- experience some periods of time as longer and nostic criterion would be missing.) others as shorter. The aim of this procedure is to change the ● Time without pain: Going into the past or pain sensation with features of the patient’s future experience (submodalities) (Handrock 1999). ● Distortion of time: The way one experi- First of all it is necessary to create the condi- ences time is changed, e.g.: tions which apply to every therapeutic com- ❍ Fast time – time goes faster – in a contrac- munication intervention: tion during labour ❍ Slow time – time goes slower – in the ● Establish good contact with the patient and break between contractions. maintain this. Amnesia suggestions ● Extend the treatment agreement in such a way that the patient is prepared to work One can directly or indirectly (e.g. using pic- with visual images. tures of drifting snow covering everything) request a patient to consciously not remember ● Carry out a cost–benefit analysis (see Table certain things (e.g. unpleasant and painful 4.2). interventions). The patient is then asked to describe the pain precisely. As a support measure one can, for instance, use the question system outlined in Table 4.3, which can be extended at will. In

Therapeutic communication during management of craniofacial pain 95 Table 4.3 Scheme of questions for pain conditions Area of perception Appropriate type of question Bodily feeling How large is the area that hurts? Where are the borders? How would you describe this sensation (e.g. stabbing, dragging, pressing)? When is the pain stronger – when does it lessen somewhat? How bad is the pain now on a scale of 1 to 10? If you concentrate totally on the pain can you then intensify it? (This is a so-called ‘convincing question’ because if the patient can increase the pain it means that they can alter the pain!) If you were to touch the area in your imagination would it tend to be hard or soft, rough or smooth, warm or cool? Visual imagination If the pain had a colour, what colour would this be? Are there colour variations in this area? Where is it lighter or darker? Is it matt or glossy? What do the contours look like – do they tend to be sharp or blurred with no clear border? Aural imagination If the pain had a tone how would it sound? Would it tend to be loud or quiet? Is the sound continual or does it rise and fall, rhythmic or non- rhythmic? order to answer these questions the patient of the unpleasant area and to try to reach the must be prepared to use their imagination. submodalities of the ‘normal condition’ in the (Should the patient directly resist and say they visual and auditory areas as precisely as pos- cannot imagine all this, it is not a good idea to sible. The area of kinetics is not involved at this work against their feelings, and other interven- point. tion techniques can be applied.) The patient must be carefully observed after When the painful area is described in this each suggestion of change. Only pleasant way the patient is instructed to describe the changes are retained – otherwise the change is surrounding healthy area with the same inten- immediately reversed. sity and detail. The question system can again be used for this. When the colour and tone characteristics of the painful area have been adjusted as One now builds a further framework for far as possible to those of the healthy area, change by asking the patient what would one first talks for a few minutes about a happen if the colour or the tone was slightly neutral subject (so that the change can stabi- altered (e.g. from red to pale red). Which would lize). The patient is then asked about how they be better? It may be helpful to ask the patient feel in general (and not specifically about the to imagine a control desk or a remote control pain). with which all suggested changes can be directed (or, if necessary, be reversed). As the Within the framework of a text like this it patient has by this point already experienced is only possible to give brief consideration to some inner pictures it is usually quite easy for the use of the techniques described and to them to imagine such a thing. demonstrate these with examples (Case study 4.3). However, the use of these methods broad- Following this the patient is instructed to ens the rather somatic-oriented procedure effect change in the individual submodalities considerably.

96 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Case study 4.3 described how the noise of the ‘swarm of bees’ calmed down. A 52-year-old female patient with bilateral disc inflammation and a background of At the same time the redness of the rheumatoid arthritis was taught to use this inflamed areas substantially decreased. This procedure in a form of self-hypnosis when resulted in a considerable reduction of pain she noticed that her daily maximum dose of which lasted between 1 and 3 hours on each pain killers is inadequate. She needed occasion. approximately 20 minutes each time for this procedure. She described the painful SUMMARY temporal areas in her imagination as being taut, thick, hot, smooth, shiny, hard, red with ᭿ The use of verbal therapeutic methods to orange patches in the middle surrounded by influence pain (and in this particular a clear border. The tone was felt to be a high instance craniofacial pain) clearly widens buzzing, like a swarm of bees. the range of available treatment options. She described the surrounding healthy ᭿ Verbal support is particularly helpful for area in her imagination as smooth, soft, dull, patients with chronic pain. green, like a meadow with many flowers on it. ᭿ Due to a change in the subjective experience of pain a clear improvement The patient was then asked to watch how in the general situation of the patient the red colour became very slightly paler. She can often be observed, even when the experienced this as very pleasant. She was somatic conditions have not changed or then asked to note at the same time how the have even worsened. meadow very slowly grew in from the sides into this paling area. She then spontaneously References Müller-Busch H C 1990 Kulturgeschichtliche Bedeutung des Schmerzes. In: Basler H-D et al Adler R 1996 Schmerz. In: von Uexküll T et al (eds) (eds) Psychologische Schmerztherapie. Springer, Psychosomatische Medizin, 5th edn. Urban and Berlin Schwarzenberg, Munich Rehfisch H P, Basler H D 1990 Entspannung und Basler H-D et al (eds) 1990 Psychologische Imagination. In: Basler H-D et al (eds) Schmerztherapie. Springer, Berlin Psychologische Schmerztherapie. Springer, Berlin Flor H 1990 Verhaltensmedizinische Grundlagen Schmierer A 1997 Einführung in die zahnärztliche chronischer Schmerzen. In: Basler H-D et al (eds) Hypnose, 2nd edn. Quintessenz, Berlin Psychologische Schmerztherapie. Springer, Berlin Schors R, Ahrens S 2002 Schmerzsyndrome. In: Ahrens S, Schneider W (eds) Lehrbuch der Handrock A 1999 Sprache und Verständlichkeit. Psychotherapie und der Psychosomatischen Quintessenz, Berlin Medizin, 2nd edn. Schattauer, Stuttgart Keeser W, Bullinger M 1990 Psychologische Sternbach R A 1968 Pain: a psychophysiological Verfahren bei der Behandlung von Schmerzen. In: analysis. Academic Press, New York Pongratz W (ed.) Therapie chronischer Schmerzzustände. Springer, Berlin

97 Chapter 5 Reciprocal connection between the craniocervical and the craniomandibular region: a hypothetical model Harry von Piekartz CHAPTER CONTENTS INTRODUCTION Introduction 97 Most clinicians and researchers regard the Neuroanatomy 98 reciprocal connection between the craniocervi- Biomechanics 100 cal and the craniomandibular region as poorly Neurodynamics 101 understood (Kraus 1994). One of the first Clinical/functional 103 publications on the topic is from 1926 and Whiplash-associated disorders and their was extremely advanced for that time. The Austrian dentist Martin Schwarz concluded influence on the craniomandibular from his observations that the mandibular region 105 resting position is not fixed but depends on the Influence of the craniomandibular region position of the head. He emphasized the impor- on the cervical spine 109 tance of a vertical mid-position of the head to A question of completeness 113 achieve a mandibular resting position when assessing occlusion (Schwarz 1926). This chapter will discuss the various ideas and studies regarding a connection of two regions which is of great importance for the therapeutic decision-making process. Finally, some recommendations for research and man- agement are presented. Studies may be grouped into two categories: those which investigate the influence of the craniocervical region on the craniomandibular region and vice versa. Aetiological studies outline four major explanatory models:

98 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Interaction Explanatory model cranium, allowing for all physiological mandibular movements (Kazis & Kazis 1956, Craniocervical • Neuroanatomical, Preiskel 1965). The ideal mandibular resting influence on physiological position is mandatory for an optimum occlusal craniomandibular – symptoms relationship and an optimum muscle balance region – posture of the masticatory muscles (Murphy 1967, Kraus 1994). A number of studies showed that Craniomandibular • Biomechanical different positions of the head strongly influ- influence on • Neurodynamic ence the mandibular resting position (Preiskel craniocervical region 1965, Makofsky 1989, Gonzalis 1996, Miralles et al 2001). Sometimes the term ‘upright postural Fig. 5.1 The craniocervical region interacts with position of the mandible (UPPM)’ is used. One the craniomandibular region. should also look out for the functional influ- ences of head, neck and hyoid (Rugh & Drago ● Neuroanatomical/physiological model, based 1981), since an ideal head position alone does upon pain and posture not automatically guarantee an ideal mandibu- lar position (Michelotti et al 2000). Sometimes ● Biomechanical the correction of head and neck position may ● Neurodynamic result in an increase of masticatory muscle ● Clinical/functional. tone (EMG activity) (Kawamura & Fujimoto 1957, Wessberg et al 1983). Classic experimen- As some overlap occurs naturally between tal studies showed an increase of EMG activity those groups, this is not an absolute classifi- of the temporal muscle, the masseter and the cation. digastricus anterior with cervical extension followed by a slight retrusion of the mandible, Figure 5.1 gives an overview. Examples of therefore influencing occlusion (Funakoshi the explanatory models are described in the et al 1976, Forsberg et al 1985, Kraus 1994). following sections. Increased activity of the digastricus anterior and the masseter muscle increased cervical NEUROANATOMY extension which then reduced the EMG activ- ity of these muscles (Funakoshi & Amano Pain 1973). Nociceptive input from craniocervical tissue is Experimental studies on healthy volunteers sent to the trigeminocervical nucleus, which is using different head positions confirmed also the receptor for input from the trigeminal that the position of the head influences nerve. The trigeminal nucleus consists of neu- the movement and therefore the function rones responsible for the transmission of affer- of mandibular closing. Positions evaluated ent information to the cortex where pain is were: natural position (NP), anteroposition perceived. As the synapses of the trigeminal (forward head posture, FHP), maximal antero- neurones and the neurones of the brainstem position (maximal forward head posture, are in close proximity and influence each other, MFHP) and military position (MP). Each pain may be referred into the facial, head or position is associated with different muscle jaw region (Kerr 1961a,b, 1963, Bogduk 1986a, activity patterns and different occlusion types Okeson 1995). (Goldstein et al 1984). The craniomandibular muscles are also influenced by neurological As a result of secondary hyperalgesia reflex systems such as the tonic neck reflex (caused by the craniocervical region), tests for (TNR) (Bratzlavsky & van der Eecken 1977). the craniomandibular region may show false- Cervical afferent information enters the positive results (Fig. 5.2). subnucleus caudalis via the dorsal horn and Mandibular position The mandibular resting position is the ideal position of the mandible in relationship to the

Reciprocal connection between the craniocervical and the craniomandibular region 99 CNV Mandibular CN VII structures CN IX CN X C1 C2 C3 C4 C5 Skin Vessels Muscles Fig. 5.2 Schematic overview of the afferent input from muscles, joints, and blood vessels from the craniocervical junction (primary afferent neurone = 1st neurone). These end in synaptic junctions to the 2nd neurone in the trigeminocervical nucleus, where the afferent craniomandibular neurones may also interfere (2nd neurone). Afferent information is passed on via the spinothalamic tract to the thalamus. The 3rd neurone projects the information to the somatosensory cortex (modified from Okeson 1995). triggers neck reflexes by stimulating the paraspinal muscles not only increased the trigeminocervical nucleus which stimulates activity of the superficial and deep neck the motor neurones of the masticatory muscles muscles but also those of the masticatory (Funakoshi & Amano 1973, Sumino et al 1981). system. This may explain the clinical observa- Hu et al (1993) observed that prolonged tions of facial pain and of parafunctions after nociceptive (inflammatory) stimuli from the whiplash injury.

100 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT BIOMECHANICS Following whiplash-associated disorders (WAD), clinical and radiological cervical Cephalometric measurements show a clear kyphosis is diagnosed frequently (Deltoff reciprocal influence of the craniocervical 2001). This is also true for adolescents with region, the mandibular position and the a history of craniocervical birth trauma, for hyoid. Rocabado (1983) made the following example kinematic imbalance due to sub- statements: occipital strain (KISS) (Fig. 5.3c). ● The angle between the two cephalometric AA OP lines MGP (McGregor's plane) and OP (odontoid plane) is 96° in normal cervical lor- OA M’ dosis. The vertical hyoid position is below MGP H RGN the C3 line and the outermost inferopost- erior part of the mandible (retrognathion, C1 RGN). There is a triangle between the C3 C3 line, RGN and hyoid (Fig. 5.3a). a ● A flat cervical spine (loss of physiological lor- dosis) shows an MGP–OP angle of less than 96° and the hyoid lies on the C3–RGN line. ● Kyphotic cervical spines show a MGP–OP angle that is either normal or less than 96°. The hyoid is above the C3–RGN line with a negative triangle between C3, RGN and hyoid (Fig. 5.3b). Fig. 5.3 b a Cephalometric picture of a healthy volunteer. AA, c atlas anterior; H, hyoid; MGP, McGregor’s plane (a line that connects the base of the occiput with the side of the nose); RGN, retrognation (the part of the hyoid bone that lies the most superior and anterior). The MGP–OP angle is 101° on average The distance between occiput and atlas (OA) is between 4 and 9 mm on average The hyoid is positioned underneath the C3–RGN line. b Cephalometric picture of a patient with a craniocervical kyphosis. Note the differences from the healthy volunteer: MGP–OP angle is greater than 96° OA distance is greater than 9 mm Hyoid is above the C3–RGN line and the RGN–H– C3 triangle is smaller. c Comparison with a person in craniocervical extension. Note that: MGP–OP angle is less than 96° OA distance is less than 4 mm Hyoid is on the RGN–C3 line and RGN–H–C3 triangle is smaller compared to the healthy volunteer. The C3–RGN line becomes longer.

Reciprocal connection between the craniocervical and the craniomandibular region 101 On the basis of these biomechanical effects BNL C2 HOR it is easy to see how the activity of the cervical C1 OPT muscles and of the infra- and suprahyoid muscles influence each other as well as the a VER position of the tongue and the mandible. b The examples described all refer to postural correlations. Winnberg et al (1988) showed Fig. 5.4 Relation between the range of how differences in head position may not only craniocervical extension and the expected influence range and quality of movement prognathic mandibular growth. regarding hyoid and mandible but also change a The craniocervical position and the relevant EMG activity of the masseter and suprahyoid muscles. Clinical observations as well as cephalometric lines and angles according to cephalometric measurements demonstrated Huggare and Cooke (1994). that maximum mouth opening moves the BNL = bridge of the nose line hyoid downwards and causes an upper cervi- HOR = horizontal line cal extension of the occiput in relationship to OPT = orthodontal process tangential line (line the atlas (Muto & Kanazawa 1994). between the dens and the vertebral body of C2) VER = vertical line. If the head is held in permanent extension, b The relation between BNL and the line through the atlas morphology will influence the direc- retrognation (RGN) and the junction of the BNL– tion of growth and the size of the mandible. OPT lines (see Fig.5.4a). Huggare and Cooke (1994) showed in The smaller the BNL–OPT angle, the more likely is several studies how the mandible tends the mandible to develop prognathically. to grow anteriorly towards a prognathic position in such cases. This will also have stem gets longer and the load on the inner and an effect on dental occlusion (McClean et al outer layers of the dura increases (Breig et al 1973, Rocabado et al 1983, Chapman et al 1991, 1966, Doursounian et al 1989). The load on the Urbanowicz 1991, Kraus 1994, Makofsky & cranial nerves is particularly high near the criti- Sexton 1994, Salonen et al 1994). Makofsky cal zones, for example the cerebellopontine found that the initial occlusal pattern (IOCP) angle (CPA), the sinus cavernosus (SC) and the was significantly changed in forward head posture (FHP), and that there were individual differences but no age dependency (Makofsky 2000) (Fig. 5.4). NEURODYNAMICS A number of studies emphasize the connection between the craniocervical and the cranio- mandibular nervous systems. Some examples are mentioned here. Cervical movement Cervical movements influence brain structures and cranial nerves because the nervous system is an anatomic continuum (Lang 1995). When the head is moved from flexion into extension, the spinomedullary angle increases, the brain-

102 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT foramina (Profitt 1993, Smirniotopoulos et al neurodynamic function significantly (Butler 1993, Schick et al 1996). The most important 2000). In the author’s opinion, this knowledge cranial nerve for the craniomandibular region is not applied sufficiently for the recognition is the trigeminal nerve. It innervates the cranio- of typical patterns that commonly indicate mandibular region, divides into branches cranioneural dysfunctions. Examples are: there and is (co-)responsible for facial pain (Zakrzewska 1995, Zakrzewska & Hamlyn 1999). ● Antalgic head position, typically upper cer- The nerve originates from the dorsolateral part vical extension and lateroflexion away from of the brainstem and runs within the cerebello- the painful side pontine angle (CPA; runs through the sinus cavernosus). The maxillary and mandibular ● Active and/or passive craniocervical flexion branches run through the foramina of the sphe- and lateroflexion towards the painful side, noid bone towards maxilla and mandible. The frequently leading to brief motor output CPA, SC, foramina and tissues – including reactions of the facial, masticatory and swal- muscle, fascia and the mandible – are critical lowing muscles. Sensory reactions such as zones (parts of the body that demand the most facial pain are also commonly observed. adaptation to movement) and may restrict For more about other aspects of nervous system testing, see Chapters 16 and 17 (Fig. 5.5). ab Fig. 5.5 a The classic posture of a patient with pathodynamic changes of the craniocervical and facial regions. Note the head forward position, the increased midcervical lordosis and the flat upper thoracic spine. b Even in flexion the upper cervical extension is maintained and active cervical flexion is restricted. Reactions and restriction of flexion are commonly enhanced by a neurodynamic sensitizing manoeuvre of the legs (e.g. knee extension).

Reciprocal connection between the craniocervical and the craniomandibular region 103 Neurophysiology CLINICAL/FUNCTIONAL It has only recently been recognized that the Maitland (1991) observed that accessory move- craniocervical and cranial dura itself has a ments of the atlas and the axis led to reactions large number of nociceptors and plays an in the facial region and to pain or reflex muscle important role in the pathogenesis of vascular contractions of the masticatory and facial headaches (Moskowitz 1984, Andres et al 1987, muscles in healthy subjects as well as in neck Kumar 1995 (in Kumar et al 1996)). Hu et al pain patients. Within the patient group the (1995) found in experimental animal studies pain was regularly perceived as more severe that irritation of dural vascular tissue in rats and the resistance during accessory move- with mustard oil caused an irreversible activa- ments clearly changed whenever the mandibu- tion of the masticatory and neck muscles. This lar position was shifted (Fig. 5.6). may be an explanation for the clinical observa- tion of hypertonic muscles, trigger points, In 1994 both Kraus and Mohl independently bruxism and teeth clenching in patients with observed a change in mandibular movement cervical symptoms. quality with different neck positions. With C R2 D Strength and irritability P' (Headache) bA R' P' B C R2 D a cA Strength and irritability P' B (Headache) Fig. 5.6 a The patient lies prone. Both thumbs are in R' P' contact with the right lamina of the axis (C2). Both index and middle fingers hold the mandible to prevent mandibular movement. The position also allows variation of the mouth opening angle during the test procedure. b Unilateral posterior–anterior movement on the C2 lamina without mouth opening. The movement is slightly restricted with resistance being the limiting factor. The patient perceives a slight dorsal sensitivity to pressure. c Unilateral posterior–anterior movement on the C2 lamina with mouth opening. Note that the movement is restricted by 50% and limited by resistance (R1–R2) and that the patient’s headache symptoms are clearly reproduced (P). In this case the mandibular position changes the quality of movement and the patient’s reaction to the posterior–anterior C2 movement.

104 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT extension, a significant retrusive movement component (von Piekartz 2005). Inclusion cri- was noted whereas in upper cervical flexion teria were: the tendency was towards a protrusive man- ● More than 3 months of physiotherapy or dibular shift. The mandibular resting position was changed as well as habitual occlusion pat- manual therapy without any notable result terns (Kraus 1994, Mohl 1994). ● No dental treatment or craniomandibular In a study on 230 participants, Wright (2000) physiotherapy during these 3 months. showed that pressure on cervical trigger points (trapezius, splenus capitis and sternocleidomas- The measurement tool was the Conti Anam- toid muscles) led to referred pain into the head nestic Questionnaire that is validated in the and face, more so than trigger points of the mas- Dutch language (Box 5.1). Based on the Helkimo ticatory muscles were referred into the neck. Index, this questionnaire showed a reliable detection rate of craniomandibular dysfunc- Visscher et al (2000) demonstrated that there tion (Conti et al 1996) (Fig. 5.7). The investiga- is a great variability of posture and curvature tion showed that 78% had a moderate to severe among healthy subjects without headaches, facial or neck pain. The same applies for Box 5.1 Conti Anamnestic Questionnaire patients with craniocervical and craniofacial symptoms. This observation led to the conclu- ᭿ Do you find it difficult to open your sion that posture is an unlikely cause or risk mouth? factor for craniomandibular and cervical dys- function and pain. ᭿ Do you find it difficult to move your jaw? ᭿ Are your jaw muscles sensitive? In a study that included 111 cervical patients ᭿ Do you have muscular pain when chewing? and 103 craniomandibular patients, de Wijer ᭿ Do you have headaches? and Steenks (1995) showed, based upon an ᭿ Do you have neck or shoulder pain? anamnestic self-administered questionnaire ᭿ Do you have pain in or around the ear? and active/passive orthopaedic physical tests, ᭿ Do you notice noises in your that: temporomandibular joints? ● Patients with craniocervical dysfunction do ᭿ Do you feel that your bite is normal? not show a greater prevalence of cranio- ᭿ Do you only use one side of your mouth mandibular problems than others. when chewing? ● The active and passive assessment of the ᭿ Do you have facial pain in the morning? neck and the shoulder showed no sig- nificant patterns that differentiated be- Reproduced with permission from Conti (1996). tween craniocervical and craniomandibular patients. 38 n = 100 32 De Wijer concluded that signs and symptoms in the craniomandibular region do not neces- 14 16 sarily derive from craniocervical structures. He also stated that mouth opening and retru- b None Minimal Moderate Severe sion of the mandible was significantly restricted in the craniomandibular group compared to Fig. 5.7 The results of the Conti Anamnestic the craniocervical group. He recommended Questionnaire (AQ) of patients diagnosed as ‘cervical the inclusion of the craniomandibular region syndrome’ sufferers who did not or only slightly in assessment of craniocervical patients and improved after 3 months of physiotherapy. The score vice versa. is expressed as a percentage. An unpublished randomized pilot study investigated 100 participants diagnosed with cervical complaints for a craniomandibular

Reciprocal connection between the craniocervical and the craniomandibular region 105 craniomandibular component. This is 20% ● Muscular dysfunction higher than the estimated average prevalence ● Mental distress and culture of craniomandibular dysfunction in the ● Clinical. Western world (Dao et al 1994). Therefore it seems that the prevalence increases in a patient Neurophysiological/histological sample with persistent unspecific craniocervi- cal pain and no firm diagnosis. Obviously no Studies have showed significant neurophysio- conclusions can be made as to whether the logical changes after neck injury, for example: craniomandibular component is responsible for the persistence of the craniocervical com- ● The inhibitory reflex of the temporal muscles plaints. Further studies are needed to show an was affected without any neurological or influence of craniomandibular dysfunction on arthrogenic injuries of the cervical spine prolonged cervical symptoms. (Keidel et al 1994). This may influence the muscle tone regulation of the masticatory As the reader may have realized, the von system (Dao et al 1994). Piekartz (2005) study does not offer any par- ticular clarity. The therapist should still depend ● Nociceptive neurogenic convergence occurs on the clinical presentation of the individual after whiplash injury; 50% of all nociceptive patient. Possibly some interesting aspects are facial afferent neurones of the cervical spine gained by studying cervical trauma such as converge and may cause pain to project into WAD for influences on the craniomandibular the deeper layers of the craniofacial tissues region. Here are some postulates. (Radanov et al 1993). WHIPLASH-ASSOCIATED DISORDERS ● Dysfunction of the trigeminovascular system, AND THEIR INFLUENCE ON THE the site of the cranial autonomic nervous CRANIOMANDIBULAR REGION system. The result is a dysfunction of cere- bral vascularization and an increase of the In daily practice with patients who suffer from intercranial cerebrospinal fluid pressure whiplash injuries and associated disorders, it (Lindvall et al 1978, Mathew et al 1996). is frequently observed that facial and neck This imbalance of output mechanisms in pain may be provoked by manual cranioman- the sympathetic and the neuroendocrine dibular tests. When treating craniomandibular systems may increase symptoms in the dysfunction in subacute or chronic WAD head, face or neck (Pillemer et al 1997). patients, the reactions to conservative ap- proaches such as physiotherapy or manual ● After whiplash injuries with indirect vascu- therapy are often unpredictable. Sometimes lar trauma to the brainstem and the trigemi- improvements may be impressive; at other nal nerve, fewer neurotransmitter substances times nothing is gained. The question is such as 5-HT (serotonin) are produced. The whether results may simply be due to chance immediate result may be emotional imbal- or whether there is a clear connection. The lit- ance and impaired pain reduction (in the erature does not provide any answers. Within craniomandibular region among others) the different disciplines there are some contra- (Westerhuis 2001, Kasch et al 2002). dictory models and theories about the connec- tion between cervical whiplash injuries and Anatomical/biomechanical craniomandibular disorders. Some arguments that support or contradict the hypotheses are Anatomical and biomechanical explanations discussed below. They are categorized as: arise from the acceleration–deceleration model for the mandible and the cervical structures ● Neurophysiological/histological (Fig. 5.8a). The temporomandibular joint is a ● Anatomical/biomechanical synovial joint, therefore symptoms in the ● Articular dysfunction craniomandibular region may occur due to overstretching of the ligaments, capsule, muscles, nervous tissue and other soft tissues (Bogduk 1986b). Some hypotheses about

106 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT a Bogduk (1986b) emphasizes that radiological and surgical findings frequently confirm V1 V3 destruction of the temporomandibular joint V2 and the disc capsule with retrodiscal tears. Moreover, various structures of the cervical spine may be pathological (discs, zygapophy- seal joints, muscles), so that it is suggested that multiple structures may be responsible for the patient’s symptoms in the craniomandibular region and elsewhere (Frankel 1972). Several case studies warn of the effect of airbags on the craniomandibular region. Garcia and Arrington (1996) reported a 20-year-old motorist who suffered from muscle spasm and restricted mouth opening after airbag deploy- ment. MRI of his temporomandibular joints showed bilateral inflammation and disc dis- placement with reduction. Craniomandibular trauma seems more complex after airbag deployment than after blunt mandibular injury (Levy et al 1998). According to Levy, three forces interact resulting in a very large force on the TMJ: ● Vector 1: anterior movement of the mandible during the impact ● Vector 2: the cranial force that is loading the airbag ● Vector 3: the posterior movement of the airbag during the impact (Fig. 5.8b). b Knowing that airbags can cause bone fractures in the cervical and thoracic spine, as well as Fig. 5.8 cardiac trauma (Lancaster et al 1993), helps a The mandible-whiplash model. (Is the us to understand the enormous force that loads the mandible during such accidents. anatomical–biomechanical model a realistic On the other hand, some authors state that expression of what really happens? Opinions craniomandibular dysfunction after whiplash regarding anatomical, clinical and epidemiological injuries is overdiagnosed. Clark et al (1993) results vary widely.) stated that only 3–5% of the population b Diagram of influencing forces of an airbag with signs and symptoms really require treat- deployment. The velocity forces of the head (V1) ment and that includes the whiplash patients. are enhanced by the velocity of the airbag and Ferrari and Leonard (1998) and Ferrari et al the compression (V2, V3) (reproduced with (1999) take the hypothesis one step further and permission from Levy et al 1998). say that anatomical changes of the temporo- mandibular joints are not significant compared which structures are injured during which to a control group and that the complaints are phase of the impact were also investigated due to psychological profiles and cultural (Mannheimer et al 1989, O’Shaughnessy 1994). influences. In a literature review about the anatomy and pathophysiology of whiplash injuries,

Reciprocal connection between the craniocervical and the craniomandibular region 107 Various publications show that after whip- Muscular dysfunction lash injuries there are indeed neurological dys- functions that include injuries of the brainstem A number of studies confirmed the increase and the cranial nerves (Hohl 1974, Balla 1980, of masticatory muscle tone and a lowered Deans et al 1987, Maimaris et al 1988, Barry pain threshold after cervical whiplash injury 1992). Sturzenegger et al (1994) showed in a (Deans 1980 (in Deans et al 1987), Kasch cohort study on 137 whiplash patients that 33% et al 2002). Various authors do not accept the (45 patients) showed symptoms due to pathol- theory that the increased muscle tone after ogy of the brainstem and the cranial nerves. whiplash injury is due to an acceleration– The incidence of cervical nerve root and cervi- deceleration injury to the mandible (Mohl cal spinal cord injury was significantly lower 1974, Kraus 1994). This may be because there at 10% (14 patients) and 4% (5 patients), is sufficient clinical evidence that muscle- respectively. related craniomandibular complaints such as bruxism, teeth clenching and muscle ache Articular dysfunction can be reduced by neuromuscular braces that ‘deprogramme’ muscle activity arising Various MRI studies confirmed the frequent from occlusal irregularities (Nielsen et al occurrence of articular dysfunction such as 1990, Naeije & Hansson 1991, Wilkinson et al disc displacement, joint inflammation and 1992, Losert-Bruggner 1998). These authors are oedema in the retrodiscal space. The incidence convinced that muscular pain after whiplash of articular disc-related problems is around injury is a reaction to the cervical pain. It 80–97% (Kirkos et al 1987, Shellock et al 1990, was also shown that the jaw opening reflex Pressmann et al 1992, Garcia & Arrington in whiplash patients is significantly reduced 1996). The most common dysfunction is disc similar to the clinical presentation of migraine displacement with reduction. Garcia states that or tension headache patients. This phenome- the prevalence is about 72% (Garcia & Arrington non might be explained by a dysfunction 1996). These authors are convinced that whip- in the reflex chain at the brainstem level lash-related disorders such as headaches, facial that regulates the opening reflex (Keidel et al pain, neck pain, earache, tinnitus and swal- 1994, Christensen & McKay 1997). The loss lowing problems may be maintained by man- of this reflex may increase the activity of dibular dysfunction. the mandibular elevator muscles followed by local trophic changes within the muscles Bergman et al (1998) conclude from a and pain (Boismare et al 1985, Bottin et al prospective MRI study that there is no increase 1989). In a similar study by Christensen of disc dysfunction, joint effusion or other and McKay (1997), no significant change craniomandibular trauma after cervical whip- of jaw opening reflex could be shown in lash injury. They criticize previous investiga- whiplash patients, and the diagnosis of man- tions and claim that subjects were selected dibular acceleration–deceleration trauma was from those who already suffered from cranio- dismissed. mandibular dysfunction. It is common for cervical trauma patients to It is clear that the authors are attempting to show a change in neck muscle EMG activity establish whether articular dysfunction shows followed by a change of head position (Lader an unambiguous positive correlation with the 1983, Sterling et al 2001). Therefore the neck patients’ signs and symptoms. muscles need to adapt to a new situation. This may influence occlusion, the position of the It should be added that it still remains temporomandibular joint and the hyoid (Boyd uncertain whether MRI is the gold standard et al 1987). A useful working model based for the assessment of articular dysfunc- upon the current literature was suggested by tion (Chen et al 2002) and not every cranio- Rocabado (1981) (Fig. 5.9). mandibular articular dysfunction causes symptoms.

108 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Series of results from cervical TMJ trauma Mental distress and culture (temporomandibular joint) Neuropsychological studies show that whip- Trauma of the cervical muscles (whiplash injury) lash-related craniomandibular disorder patients show a significantly greater incidence of ob- Spasm of the posterior cervical muscles sessions, somatization, depression and rage (Goldberg et al 1996). There is also a greater Posterior movement of the head (extension) chance for symptoms to spread to the head, neck and shoulders within the group of whip- Afferent input to CNS from mechanoreceptors and lash patients (Burgess 1991, Braun et al 1992, proprioceptors in the cervical muscles Krogstad et al 1998). In a comparison of treat- (longus colli muscle) ment efficacy for whiplash patients and patients with idiopathic temporomandibular dysfunc- Reflectory adaptation to an anterior head position tion, Krogstad et al (1998) showed that the whiplash injury patients obtained only a Increased tension of the infrahyoid and minimal decrease in the proportion of tender suprahyoid muscles muscles on standard palpation following treat- ment. The incidence and the visual analogue Inferior and posterior mandibular movement scale (VAS) values for intensity of headache changes in tongue position remained unchanged, unlike in the idiopathic group. It has been known for some time that Changed occlusional contact (tight occlusion cervical whiplash injury may influence emo- in the posterior molar region) tional and cognitive functions and lead to per- CNS input sonality changes, depression and non-specific Muscle stiffness physical symptoms (Sternbach et al 1980, Balla 1982, Drottning et al 1995). Patients who suffer Mouth and masticatory muscle spasm from prolonged whiplash symptoms (symp- Load changes in the TMJ toms for more than 6 months post-injury) apparently show secondary hyperalgesia in TMJ dysfunction and pain the head and face regions. The therapist will therefore frequently have to consider false- Fig. 5.9 Predominantly muscular dysfunction positive results when assessing the cranioman- model of the craniomandibular region due to dibular region and should be aware of cognitive craniocervical trauma (modified from Rocabado and behavioural aspects. 1981). Ferrari and Leonard caused great turmoil in the late 1990s when they stated that there was no convincing proof for mandibular accelera- tion–deceleration trauma. Their epidemiologi- cal observations and meta-analyses concluded that craniomandibular symptoms in late whiplash injury patients were not caused by the injury itself but by psychological distress (Ferrari & Leonard 1998). They added that the quality and duration of the symptoms were strongly influenced by the cultural background of the individual patient. They investigated the symptoms of 165 Lithuanian whiplash patients in a controlled cohort study 14–27 months post-injury for craniomandibular dysfunction.

Reciprocal connection between the craniocervical and the craniomandibular region 109 The signs and symptoms included were click- ular region in the patient’s symptoms. ing noises on jaw movements, pain in and Routine investigation and treatment of the around the ear, mouth opening deficits, cranio- craniomandibular region of whiplash pa- facial pain and tinnitus. The results showed tients was strongly recommended. that only 2.4% of patients (4 out of 165) had ● Intensity of craniofacial pain determined by such symptoms for a day or more. A healthy algometry and sensomotor function in terms Lithuanian control group showed an incidence of mouth opening after whiplash injury of 3.3% (6 out of 180). The result was that these does not significantly differ from the state numbers do not bear any resemblance to the after an ankle injury. This was the result of prevalence in the rest of the Western world. a prospective study by Kasch et al (2002). This varies between 34 and 82%, depending on They did not find any significant changes 4 the study (Ferrari et al 1999). weeks and 6 months post-injury in 19 whip- lash patients compared with 19 ankle trauma Clinical patients, and concluded that cervical trauma is not a clear risk factor for the development The site of the symptoms, the quality of the of craniomandibular symptoms. symptoms and the clinical tests regarding quality and range of movement as well as Conclusions and state of the art clinical palpation of the masticatory muscles may reasoning strategies in WAD patients indicate, retrospectively, whether the cranio- and craniomandibular dysfunctions mandibular region was affected by a whiplash injury. To gain some insight, the following is a Scientific and clinical opinions on the develop- summary of the literature: ment and occurrence of craniomandibular dysfunction and pain due to whiplash associ- ● Braun et al (1992) showed that whiplash ated disorders vary between disciplines. This patients referred for physiotherapy had a implies that the therapist needs to carefully higher incidence of craniomandibular dys- consider craniomandibular symptoms in WAD function and pain (between 2 days and 10 patients. The therapist should always investi- weeks). Compared with a group of volun- gate the quality of the symptoms and include teers, pain was rated higher, mouth opening special tests such as muscle palpation, the was restricted and intracapsular cranioman- mouth opening test and passive assessment of dibular dysfunctions were detected. These the craniomandibular region. A detected dys- authors postulated that assessment and, if function should be treated initially on a trial required, treatment of the craniomandibu- basis; subjective symptoms and physical signs lar region should be mandatory for effective from the craniocervical and craniomandibular management of post-traumatic cervical regions should be continuously evaluated patients. during treatment sessions. Whether a cranio- mandibular dysfunction is relevant for the ● Kronn (1993) compared a group of whiplash individual complaints can only be shown patients (n = 40) with a control group of retrospectively when signs and symptoms idiopathic craniomandibular dysfunction change after an appropriate technique. patients (n = 40). He investigated mouth opening, shift, palpation of the masticatory INFLUENCE OF THE muscles and clicking on jaw movements. The CRANIOMANDIBULAR REGION ON two groups were found to differ only with THE CERVICAL SPINE respect to mouth opening and sensitivity of the masticatory muscles. Kronn concluded For unknown reasons, the influence of the that the combination of relatively authorita- craniomandibular region on the cervical spine tive clinical tests such as the ones mentioned has not been investigated as thoroughly as the above cannot provide sufficient information about the involvement of the craniomandib-

110 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT opposite influence described in the section can have a strong influence on the biomechani- above. Nevertheless, some important studies cal function of the upper cervical spine in and ideas relating to this complex but interest- patients with multiple craniocervical dysfunc- ing field can be cited. tions such as dizziness, migraine, acute locked neck and pain. The craniomandibular region Neurophysiology was treated with muscle and joint techniques. After the intervention the symptoms were PAIN PROJECTION reduced significantly. After 30 days both patients’ radiological investigation showed a The somatosensory projections of cranioman- normal cervical lordosis. dibular structures project mainly on second- ary trigeminal neurones in the trigeminal In a similar study on 16 young volunteers nucleus of the brainstem. Here, synaptic con- with craniomandibular dysfunction, Huggare nections with neurones of other cranial nerves and Raustia (1992) found similar effects. They and the cervical spine may occur (Hu et al assessed the craniocervical region radiologi- 1992, Yu et al 1995, Hu 1999). Hence, pain pro- cally and observed significantly increased cer- jection from the craniofacial on the cranio- vical extension compared with an age-matched cervical region is theoretically possible (Hu control group. They also found that the patient 2001). group showed a narrower atlas, the base of the cranium was flatter and the posterior–anterior Clinical studies showed that the pain pro- relationship of the facial height was reduced. jection from the craniomandibular region to Treatment consisted of braces as well as active the neck is more diffuse and less severe and passive muscle exercises. The post-treat- than the pain projection from the cervical ment x-rays showed that 13 out of the 16 patients spine to the face. now had a normal cervical lordosis. Huggare concluded that the masticatory muscles directly POSTURE influence the stabilizing cervical muscles. He further hypothesized that dysfunctions of both The muscle tone of the craniocervical region regions may change craniofacial morphology may change in reaction to nociceptive input (Huggare 1991, Huggare & Raustia 1992). from the craniomandibular region. This may also influence the positioning of the head. Neurodynamics Noxious craniofacial stimulation of the deeper tissues (e.g. bone, capsule, ligaments and disc) Little is known about the influence of neuro- triggers the output system. Autonomic re- dynamic changes in the cranial nervous system actions such as changes in blood pressure and on the craniofacial region. Responsible for the breathing and also an increase in muscle activ- innervation of the region are the trigeminal ity within the craniomandibular region and and the facial nerves which are embedded in the neck may be the result (Cairns et al 1998). the craniofacial tissues. Like most of the cranial nerves they are connected to the brainstem Biomechanics which in turn has a close connection to the craniocervical region (von Piekartz et al Chinapi and Getzoff (1994) postulated that the 2001). reduction of radiographically measured cervi- cal lordosis may be the result of a unilateral It is known that the mandibular nerve is craniomandibular dysfunction. Cranialization 8 mm longer on mouth opening than in the of the hyoid may be another indicator and pos- resting position (Segter et al 1993). Hypotheti- sibly correlates directly with the compensatory cally, due to the continuity of the nervous changes in cervical lordosis. Moreover, EMG system, this may influence (dural) nervous measurements of the supra- and infrahyoid structures such as the brainstem, CPA and muscles showed an increase in activity. dura mater. This again may change the arthro- Knutson and Jacob (1999) showed in two case studies that the craniomandibular region

Reciprocal connection between the craniocervical and the craniomandibular region 111 kinematics of the craniocervical junction that (Fig. 5.11). For further information, see is closely connected to dural tissue (Breig et al Chapters 17 and 18. 1966, Lang 1995). Clinically this is observed frequently as shown in the two examples that Clinical/functional follow. In a descriptive study on 13 healthy volunteers, ● A patient experiences peripheral neurogenic Daly et al (1982) observed that an experimental pain whenever she bends her neck with brace (8 mm) increased neck extension by maximum mouth opening. Commonly 2.9°. An hour after removal of the brace, head upper cervical flexion is impossible but extension was back to normal. The same obser- flexion occurs in the mid- and lower cervical vation was made by Vig et al (1980). A poten- spine (Fig. 5.10). tial explanation is that, since the eyes are moved into the horizontal plane by the oculo- ● When stimulating activity of the mimic motor reflex for balance reasons, the head muscles in patients with facial paresis one adapts to the position of the eyes (Kraus 1994) may observe compensatory upper cervical (Fig. 5.12). extension and ipsilateral lateroflexion. On correction of the head position the patient According to Kraus, two types of adaptation complains of a ‘pulling’ or ‘tearing’ sensa- may occur: an axial head–neck position with tion and the contraction of the mimic the head being moved into extension, or an muscles becomes more difficult to perform anteriorly directed caudal adaptation that ab Fig. 5.10 a Patient suffering from a minimal neurodynamic dysfunction of the right mandibular nerve. Flexion without mouth opening. b Flexion with mouth opening of 40 mm and slight laterotrusion to the left. The patient perceives a severe pulling sensation in the left mandibular region. Note the quality of movement in the craniocervical region.

112 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Fig. 5.11 A patient with peripheral facial nerve Fig. 5.12 Adaptation of the craniocervical region paresis on the right. The mimic muscles on the due to changes in the vertical dimension, e.g. after affected side are stimulated to contract. Note the intraoral orthodontic intervention. compensatory craniocervical extension and Dotted line: Axial adaptation of the head–neck ipsilateral lateroflexion that the patient performs to position. The cranium tilts posterior on the atlas to achieve a better muscle contraction. keep the eyes horizontal. Line: Adaptation of the cranium towards anterior and flexion to maintain the eye position on a horizontal line (modified from Kraus 1994). changes muscle activity and arthrokinematics tion between the neck, masticatory and hyoid of the upper cervical spine (Kraus 1994). muscles is normalized by the brace. To what extent craniocervical adaptive As mentioned by Hülse et al (2001) the posture changes morphology in adolescents, symptoms commonly occur as diffuse sensa- while the viscerocranium is not fully devel- tions that are difficult to diagnose and whose oped, remains unknown. Some high-quality sources are hard to detect. Sometimes it is not studies have been published in the past about clear whether they derive from the cranio- neck extension as a compensation for nasal cervical or the craniomandibular region. obstruction and mouth breathing and about Descriptive clinical studies show that: the developmental capacities of the facial bones (Rickets 1968, Solow & Tallgren 1976, 1977). ● These diffuse symptoms as well as shoul- der–arm pain may be caused by both regions Hülse et al (2001) described in various case and may overlap considerably (de Wijer studies that post-cervical trauma patients with 1995). diffuse and diagnostically challenging symp- toms such as vertigo, tinnitus and swallowing ● Muscular craniomandibular dysfunctions difficulties improved significantly when sup- are known to cause pain in the neck plied with neuromuscular braces. Retrospec- (Lobbezoo-Scholte 1993, de Wijer et al 1996). tively, the authors believe that upper cervical dysfunction may cause craniofacial symptoms ● Craniocervical dysfunctions do not project and vice versa. They explain that the connec- as strongly to the craniomandibular region as the other way round (de Wijer 1995).

Reciprocal connection between the craniocervical and the craniomandibular region 113 These findings frequently lead therapists to tion has not been discussed (Ganong 1978, believe that the neck can be excluded if the Kraus 1988). In addition, the influence of diagnosis is a craniomandibular dysfunction. craniofacial growth during posture changes of However, in the author’s experience, the cranio- the mandible and the craniocervical region mandibular region is too often neglected in deserves more attention (Oudhof 2000). Unfor- patients with longstanding neck pain. Possibly tunately more in-depth literature does not therapists are misguided by the location of the exist at present. pain, especially if the symptoms are localized dominantly in the neck and not in the face. For SUMMARY further information, read Chapter 3. ᭿ The craniocervical and the De Wijer et al (1996) therefore recommend: craniomandibular regions and their reciprocal influence have been discussed ● Assessing the craniomandibular region in in their various aspects. patients with longstanding neck pain and treating potential dysfunctions. ᭿ The result is that there is no definite conclusion although a number of authors ● Assessing the neck region orthopaedically are convinced of a direct connection. if, during a course of craniomandibular treatment, improvement of dysfunction and ᭿ Therapists should remember to examine symptoms is not satisfactory. If craniocervi- the craniomandibular region whenever cal dysfunction is found, the dentist should they are confronted with longstanding be informed and cervical dysfunction craniocervical symptoms; potential should be treated. dysfunctions need to be evaluated for their relevance to the problem. ● Using a standardized anamnestic screening list to evaluate the dominant region. This is ᭿ Probationary treatment of an important clinical instrument and may craniomandibular structures followed by assist the therapist in the clinical decision- a reassessment of the craniocervical and making process. craniomandibular regions constitutes clinical proof of the relevance of A QUESTION OF COMPLETENESS craniomandibular dysfunction. This implies that the problem is of a This text does not claim to be exhaustive. For dominantly nociceptive nature. example, the influence of peripheral control mechanisms such as the vestibular and oculo- motor systems on head and mandibular posi- References trauma: a prospective study using MR imaging. American Journal of Roentgenology 171:1237–1243 Andres K H, Düring von M, Muszynski K, Schmidt Bogduk N 1986a Cervical causes of headache and R F 1987 Nerve fibres and their terminals of the dizziness. In: Grieve G (ed.) Modern manual dura mater encephali of the rat. Anatomy and therapy. Churchill Livingstone, Edinburgh, p 289 Embryology 175:289–301 Bogduk N 1986b The anatomy and pathophysiology of whiplash. Clinical Biomechanics 1:92–101 Balla J I 1980 The late whiplash syndrome. Australian Boismare F, Boquet J, Moore N, Chretien P, Saligaut and New Zealand Journal of Surgery 50:610–614 C, Daoust M 1985 Hemodynamic behavioural and biochemical disturbances induced by Balla J I 1982 The late whiplash syndrome: a study of experimental craniocervical injury (whiplash) in an illness in Australia and Singapore. Culture, rats. Journal of the Autonomic Nervous System Medicine and Psychiatry 6:191–210 13:137–147 Barry M 1992 Whiplash injuries. British Journal of Rheumatology 31:579–581 Bergman H, Andersson F, Isberg A 1998 Incidence of temporomandibular joint changes after whiplash

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119 Chapter 6 Cervical instability Pieter Westerhuis CHAPTER CONTENTS INTRODUCTION AND DEFINITIONS Introduction and definitions 119 A variety of different aspects related to the Clinical presentation of cervical concept of cervical instability can be different- iated. Depending on the individual focus, clini- instability 121 cians have defined spinal instability in various Physical examination 125 ways (Adams 1999). Panjabi (1992a) divides Case report 141 the spinal stabilizing system into three sub- systems (Fig. 6.1): ● The passive subsystem (joints, capsule, liga- ments, etc.) ● The active subsystem (muscles, strength, endurance, etc.) ● The regulating or controlling subsystem (coordination, control, proprioception). THE PASSIVE SUBSYSTEM The stability of the passive subsystem is influ- enced by several factors, including orientation of the zygapophyseal joints, the integrity of the joint capsule and ligaments and the integrity of the discs. Damage of these structures poten- tially causes structural instability (Zhu et al 1999, Wilmink & Patijn 2001, Lomoschitz et al 2002). Regulating subsystem Passive Active subsystem subsystem Fig. 6.1 The stabilizing system of the spine.

120 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Some biomechanical aspects are particu- resistance when accessory movements are larly relevant. If one performs an instability examined (Maitland et al 2001). test on a peripheral joint (e.g. the anterior drawer test to examine the anterior cruciate All traditional segmental instability tests ligament of the knee) the examiner is evaluat- will primarily assess structural rather than ing the integrity of the passive subsystem. The functional instability (among others, Aspinall examiner seeks the following information: 1990, Pettman 1994). ● The available range of motion before any According to Sanchez Martin (1992) the resistance is felt (neutral zone, NZ) (Panjabi most common causes of structural instability 1992b) are: ● The behaviour of resistance once the move- ● Trauma: ment is continued into resistance. This is to ❍ Massive external forces, e.g. whiplash assess ‘stiffness’ within the ‘elastic zone’ injuries (EZ) (Pope & Panjabi 1985) ❍ Repetitive microtrauma ● The overall range of motion (ROM) ● Congenital, for example: ● Perceived pain ❍ Occipitalization of C1 ● Protective muscle spasm. ❍ Down syndrome From a biomechanical point of view the fol- ● Metastases lowing definitions can be made. ● Diseases such as: Definitions ❍ Rheumatoid arthritis A structural instability is an excessive range of ❍ Ehlers–Danlos syndrome motion of an accessory movement that shows ❍ Ankylosing spondylitis. an abnormal behaviour of resistance with an increased neutral zone and a loss of stiffness The greatest difficulty is that structural insta- (adapted from Panjabi et al 1994 and Maitland bility is not correlated with any specific symp- et al 2001). toms (Cattrysse et al 1997, Pitkanen et al 1997, Eisenstein 1999). Hypermobility: This is defined as above- average mobility in a physiological direction THE ACTIVE AND REGULATING with normal resistance (R1–R2) behaviour. SUBSYSTEM Hypermobility may also occur at one or more intervertebral joints, in which case these joints The stability of the active subsystem depends are excessively mobile with respect to on the capacity of the muscle units to develop neighbouring joints. A hypermobile joint is not force and to maintain it over a prolonged necessarily unstable. Instability refers to a period of time. Therefore the combination of joint with loose supporting ligaments, which force and endurance is relevant. allows the joint to move more than normal (see page 121). The regulating subsystem coordinates the timing and intensity of individual muscle According to Panjabi (1992b), changes in the contractions. It depends on sensory input neutral zone are more significantly correlated provided by the joints (McLain 1994), discs with the occurrence of instability than changes (Mendel et al 1992) and muscles (Heikkiläa & in range of motion. This was confirmed in Astrom 1996). The regulating system processes recent studies. all inputs to coordinate an adequate muscular reaction. On clinical examination evaluation of range of motion is sometimes difficult due to protec- Dysfunctions of the regulating subsystem tive muscle spasm. An important clue in the can affect either input (afference/proprio- assessment of instability is a delayed onset of ception) or output (efference/coordination). Panjabi proposed in 1992 that dysfunctions of one of the three subsystems can be compen- sated by the two other subsystems (Panjabi

Cervical instability 121 1992a). Kettler et al (2002) demonstrated that pezius and levator scapulae will show activity. mechanically stimulated muscle forces have Both muscles originate at the cervical spine the capacity to stabilize an unstable segment. and both muscles are neck extensors. The counterbalance of neck extension requires Studies on patients with lumbar spine insta- activity of deep cervical neck flexors (Mayoux- bility show that specific muscle rehabilitation Benhamou et al 1995). Dysfunction of those significantly relieves symptoms (O’Sullivan stabilizing muscles leads to excessive neck et al 1997). Hence therapists examining poten- extension on normal movements and may tial instability patients will need to evaluate cause symptoms. the function of each subsystem separately. CLINICAL/FUNCTIONAL INSTABILITY CLINICAL PRESENTATION OF CERVICAL INSTABILITY If the three subsystems fail to stabilize the spinal segment adequately, this results in clini- BODY CHART cal/functional instability. During the subjective examination, location of Definition the symptoms and type of symptoms are Clinical instability of the spine is defined as recorded on a body chart. Pettman (1994) the loss of the ability to maintain the pointed out the importance of so-called ‘cardi- orientation between vertebrae under nal symptoms’. These are symptoms indicative physiological loads in such a way that there is of obvious structural instability and therefore neither initial nor subsequent damage to the warning signs for a negative prognosis. Car- spinal cord and there is no development of dinal symptoms for structural instability in- incapacitating deformity or severe pain (White clude spinal cord signs and vertebrobasilar et al 1999). insufficiency. According to this definition, stability is SPINAL CORD SIGNS assessed functionally, in terms of the spine’s ability to control the orientation of individual Authors as early as Fielding et al (1974) have segments with respect to each other without shown that instability of C1–C2 negatively neurological problems, symptoms or deform- influences spinal cord integrity. Patients with ity arising. an atlantodental interval (Fig. 6.2) larger than 7 mm commonly show neurological signs and This implies that patients with structural symptoms. instabilities (e.g. whiplash) do not always become functionally unstable as long as they These might be (Wiesel & Rothman 1979, can still control the positioning of the verte- Delphini et al 1999): brae. From the opposite perspective, however, this also means that patients may exhibit func- ● Instability on walking tional instability in the absence of structural ● Stumbling instability. ● Ataxia ● Extrasegmental sensitivity dysfunctions ! A structural instability is not, by (arms/legs) definition, necessarily a functional ● Loss of bladder/bowel control instability. ● Hyperreflexia ● Pathological reflexes (e.g. Babinski, clonus) One test for functional instability includes ● Muscle spasms. the observation of cervical control on bilateral arm elevation. With this movement upper tra- Physiotherapists in private practice will rarely come across such patients since they are usually

122 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT A C According to Coman, these five D’s are indica- 4–5mm not <13mm tive for vertebral artery dysfunction (compare also Endo et al 2000). B PAIN Fig. 6.2 The distance between the dorsal margin Instability causes abnormal segmental move- of the anterior atlas arch and the anterior side of ment patterns. Joints and discs compensate the dens is called the atlantodental interval (ADI = abnormal mobility by bearing an increased B). The ADI should be <3 mm in adults (after White load and may respond with pain (Bogduk & Panjabi 1990). 2001). Additionally, nerves may also react due to abnormal compression and/or stretch, referred to surgery. However, they should keep leading to nerve impingement and pain an eye out for subtle spinal cord signs, since (Bogduk 1981, Rydevik & Olmarker 1999). they may indicate a definite worsening of the situation and will need adequate management Lance and Anthony (1980) describe the immediately. so-called ‘neck–tongue’ syndrome in which patients report unilateral occipital/suboccipi- VERTEBROBASILAR INSUFFICIENCY tal pain and paraesthesia of the tongue. Symp- toms are exacerbated by sudden movements of Abnormal translation in the midcervical seg- the head. These symptoms are viewed as indic- ments and/or excessive rotation in the upper ative for a segmental C1–C2 instability. Bogduk cervical spine may cause impaired blood flow (1981) mentions the following neuroanatom- in the vertebrobasilar system (McDermaid ical explanation: the hypoglossal nerve is 2001). One of the main symptoms is dizziness. responsible for motor innervation of the Coman (1986) states that dizziness may have a tongue. The ansa hypoglossi makes a connec- great variety of causes. If the dizziness is tion between the hypoglossal nerve and the caused by impaired blood flow in the vertebral cervical plexus (Fig. 6.3). Afferent fibres of the artery, other parts of the brain will also suffer hypoglossal nerve run parallel to the second a lack of blood flow. This may present as: spinal nerve. If the patient performs a sudden cervical movement this might irritate the C2 ● Dysphagia nerve and its dorsal root ganglion. As fibres of ● Diplopia the hypoglossal nerve would also be irritated, ● Dizziness tongue symptoms will be produced along with ● Dysarthria cervical symptoms. ● Drop attacks (the patient experiences sudden DIZZINESS loss of muscle control without losing con- sciousness, or falls on certain activities or Proprioceptive input of the upper cervical movements). spine has a great influence on the balance system. Consequently any changes of this input may cause dizziness (Karlberg et al 1996). Clinical features of cervical arthrogenic dizziness include the following: ● Patients rarely complain of true vertigo; rather they perceive their symptoms as modest instability on walking.

Cervical instability 123 C1 N. hypoglossus Nerve to M. rectus capitis lateralis Nerve to M. rectus capitis N. suboccipitalis anterior C2 Nerve to M. longus capitis Ganglion cervicale superior N. auricularis magnus Nerve to M. longus capitis Descensus hypoglossis C3 Nerves to Nerve to M. sterno- C4 Mm. intertransversarii cleidomastoideus C5 N. cervicalis cutaneus Nerves to Mm. longus N. accessorius capitis and colli Ansahypoglossis Nerves to Nerve to M. trapezius Mm. intertransversarii Nn. supraclaviculares Nerve to M. levator scapulae Nerve to M. longus colli Nerves to Mm. intertransversarii Nerve to M. scalenus medius Ganglion cervicale medius N. phrenicus N. dorsalis scapulae Fig. 6.3 The cervical plexus and its connections to the hypoglossal nerve (after Clemente 1985). ● Although associated symptoms are quite OTHER SYMPTOMS common, Coman’s five D’s do not occur. ● Movement limitations: It seems counterin- ● The dizziness can be clearly provoked by tuitive to hear patients with instability neck movements (clear on/off effect). problems complain of stiffness in the neck. A possible explanation is the occurrence ● Dizziness immediately follows a provoking of protective muscle spasm. movement (no latency). ● Locking: Patients frequently state that ● If a provoking position is held for any length certain movements cause their neck to lock. of time, dizziness usually decreases with Biomechanically, insufficient control of zyg- time. apophyseal joints due to lack of muscle control might cause an imbalance of rolling ● The history often indicates that the initial and gliding components in the joints. episode of dizziness is correlated with cer- vical trauma or cervical symptoms. ● Crepitation: Patients notice noises in their neck such as clicking or cracking on certain ● The physical examination of the cervical movements. spine will detect signs and symptoms (ROM limitations, instability, pain, etc.). ● Insufficient muscle control: Indicators for muscle deficits are statements such as: ‘I ● The hypothesis of cervical dizziness is con- firmed if treatment of the neck clearly influ- ences the symptoms.

124 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT have to hold my head with my hands’, ‘My slowing down, changing gear) in advance so head feels too heavy for my neck’, ‘My neck the muscles in the neck anticipate any changes gets very tired’, ‘My neck feels as if it’s made whereas the passenger needs to react. of glass and will break any minute’, ‘I can hardly hold my head up when I am Instability patients commonly feel better in shaving’. the morning than in the evening since the ● ‘Something feels stuck in my throat'/'I muscles were rested during the night. During have problems swallowing’: Besides neural the course of the day the symptoms usually causes for problems with swallowing (e.g. increase. vertebral artery dysfunction) a marked ante- rior glide of C1 in relation to C2, as is Some patients describe a painful arc on par- common in rheumatoid arthritis, can ticular movements. A lack of muscle control mechanically obstruct the oesophagus. within the neutral zone might be the explana- ● Associated symptoms, for example: tion here. ❍ Vomiting ❍ Tinnitus HISTORY ❍ Seeing spots in front of the eyes Again the dominant feature is inconsistency. (Wenngren et al 1998). Commonly patients have had their symptoms for a long time or have experienced recurrent BEHAVIOUR OF SYMPTOMS episodes of symptoms. Duration and intensity of painful episodes may vary greatly. Patients The dominant feature of symptom behaviour may report that they could hardly move their in cervical instability is the apparent inconsist- head 2 days ago whereas yesterday their range ency of the symptoms. Patients may be able to of movement was almost back to normal. perform physically exhausting tasks without any problems, but then complain of symptoms Triggering activities frequently do not cor- on some very light activities. Some patients relate with the intensity of the symptoms. It is can, for example, play volleyball quite easily quite possible that a patient cannot move their but suffer on sudden head movements during head for a whole week, suffering from great daily life. This seemingly contradictive pheno- pain, while the triggering movement was menon can be explained by muscle control merely a sudden turn of the head when revers- deficits. ing the car. Hogdes et al (1996) and Moseley et al (2002) It is important to ask for a previous history showed that primary stabilizing muscles of the of trauma. Studies have shown that whiplash lower back have a delayed reaction to sudden injuries may cause instabilities (Barnsley et al movements in patients with low back pain 1993, Spitzer et al 1995, Siegmund et al 2001). compared to pain-free controls. If the person is Even if the x-ray taken directly after the trau- involved in an activity like playing volleyball matic event is clear, instabilities may still be the stabilizing muscles are constantly active; present. Many x-rays are ‘false negatives’ however, if the person is relaxed the stabilizing (Jonsson et al 1991, Taylor & Twomey 1993). muscles are not activated. Sudden movements may now cause symptoms since the stabilizing Furthermore, authors like Foreman and muscles cannot control joint movement (Laurén Croft (1995) and Delphini et al (1999) point out et al 1997). the possibility of ‘delayed instability’ – defined as instabilities that become symptomatic 20 or Patients frequently state that they experi- more days after a trauma. Patients do not show ence symptoms when they are passengers in a any lesion on the initial x-rays (Herkowitz & car. This can be explained by hypothesizing Rothman 1984). that the driver knows his moves (acceleration, Taylor and Twomey (1993) demonstrated that whiplash injuries may cause so-called ‘rim lesions’. These are fine tears that run horizon- tally at the anterior side of the disc with the

Cervical instability 125 disc being torn off the deck plate. Rim lesions testing, the movement should not be contin- cannot be detected by ordinary x-ray but may ued to the end of range. It is contraindicated increase the degenerative process of the in this situation to assess for end-feel. For an segment. The mobile segment loses height and extensive description of the manual therapy hence causes ligament laxity (Twomey & Taylor examination of the cervical spine, see 1991). Maitland et al (2001). Consequently, clinicians will need to The following examination procedure focuses examine the segmental stability of any patient on the particular aspects of the assessment of who reports previous trauma. However, insta- unstable cervical segments. The individual bility is not always the result of severe trauma. results of one test alone do not confirm Seemingly light activities may trigger instabil- instability. Only if a number of tests are posi- ity symptoms. Examples are dental treatment tive can the presence of an instability be or a visit to the hairdresser. End of range posi- hypothesized. tions that had to be maintained over a stretch of time are commonly reported events to Each patient needs a thorough cervical spine trigger first episodes of neck pain. A combina- examination. The clinical pattern evolves from tion of muscle fatigue and creep effect lead to the overall impression gained throughout the malpositioning of the vertebrae. If this is fol- examination. To confirm or deny the diagnosis lowed by a relatively small impact like the of cervical instability, the following aspects fitting of a tooth crown, instability may occur. of the physical examination are particularly Patients who have previously suffered a whip- relevant: lash injury or other trauma, or who are gener- ally hypermobile, are especially at risk. ● Inspection ● Active movements The clinician should also ask about throat ● Passive physiological intervertebral move- infections just before the first onset of neck pain. Grisel described how bacteria might use ments (PPIVMs) the lymphatic system to reach C1–C2 and cause ● Linear movements including specific tests deficits of ligament integrity there (Aspinall 1990). for ligament integrity ● Passive accessory intervertebral movements PHYSICAL EXAMINATION (PAIVMs) INTRODUCTION ● Muscle control tests. If the results of the subjective examination INSPECTION point towards cervical instability, the follow- ing guidelines apply: Many patients, and particularly female patients, may have a relatively thin neck (‘swan neck’). ● Even if active movements do not produce Some patients seem to move their neck con- any pain one should refrain from adding stantly during the subjective examination overpressure since this might massively (‘patients talk with their necks’). worsen the situation. Another common feature is an increased ● Instability patients tend to react negatively kyphosis of the upper thoracic spine accompa- when structures are stressed at the end of a nied by a lordotic bend at C5–C6 with visible range of movement too frequently. If the creasing of the skin. These patients typically hypothesis is cervical instability, as little show instability on neck extension. testing as necessary should be performed. ACTIVE MOVEMENTS ● If the examiner feels an increased neutral zone and/or a loss of stiffness on passive One of the most important features that needs to be evaluated is the quality of movements.

126 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ● Which part of the cervical spine shows C R2 IV hypermobility and which part shows + hypomobility? Cervical ● Does the cervical spine show an even seg- rotation mental opening? to the right ● Is there a visible translation of one vertebra A R1 R2 B=L or is there any visible hinging in one a IV + segment? D C P ● Is there a painful arc? (This could point Cervical towards control deficits within the neutral rotation zone.) to the right ● Shaky muscle activity? A R1 P1 L B ● Protective muscle spasm? b ● Does the patient show apprehension? (This D R2 C IV + indicates fear of movement and is frequently found on cervical extension.) Cervical rotation When analysing a passive movement (see to the right Fig. 6.4), the behaviour of various factors can be depicted graphically in a movement diagram. A R1 B L The A–B line indicates the extent of the move- c ment, with B defined as the normal average limit of movement. L stands for the limit and C D P2/S2 indicates the limit of mobility for the individual patient. On a normal movement diagram, L Central and B are the same. The A–C line indicates the P/A C5 intensity of the individual factors. R stands for resistance (of the passive structures), P for pain, R IV – and S for spasm. C indicates the maximum intensity that the therapist is prepared to exert. A R1 P1 S1 L = I The shape of the resistance curve indicates d stiffness through the range of movement. Fig. 6.4 In this example of cervical rotation towards a Movement diagram of normal cervical rotation to the right, the normal range of movement is approximately 85°. The therapist notices the the right. onset of resistance at about 30°. Resistance b Movement diagram of hypomobile painful increases slowly at first, and then increases exponentially after 60°. There is pain without cervical rotation to the right. protective spasm. Figure 6.4a shows a normal c Movement diagram of hypermobile cervical movement diagram. rotation to the right. The movement diagram in Figure 6.4b indi- d Movement diagram of cervical instability. cates that right rotation is restricted by about 20°, the onset of resistance is observed at 15° and the onset of pain occurs at 45°. At the end of the movement this pain has an intensity of about 6 on a 10-point visual analogue scale (VAS). The movement diagram in Figure 6.4c shows an onset of resistance at 45°, i.e. the neutral

Cervical instability 127 zone is increased in size. This patient also until this movement is complete. Only then is shows above average right rotation, with the the head moved backwards. This abnormal limit of range of movement exceeding the B action will also increase shear forces in the value. The limit of movement is about 100°. midcervical spine. This is therefore not a case of instability, but rather of hypermobility. The basis for this is During the examination of active move- that, firstly the exponential resistance curve is ments the relative restriction of ranges of normal and there is no loss of stiffness, and motion should be evaluated. During flexion secondly the movement diagram is showing and extension, the head’s centre of gravity a physiological movement, not an accessory moves away from the perpendicular. These movement. movements are therefore more difficult than rotation and lateroflexion, and extension is The movement diagram in Figure 6.4d often much more restricted than rotation by shows a central posteroanterior movement on instability. C5, i.e. an accessory movement. Normally the A–B line is just 15 mm and the onset of resist- Example ance is rather early. However, in this case, the onset of resistance is delayed and the neutral A patient shows extension limited at 45° with zone is enlarged. Furthermore, resistance does unilateral symptoms on the left-hand side. If not increase exponentially, with the movement this restriction is caused by cervical instabil- showing loss of stiffness. Often these cases ity of a zygapophyseal joint on the left side, show limitation at the end of the range of rotation towards the left is usually relatively movement by a protective spasm or symptoms normal. If the restriction is due to a which the investigator is not able to resolve, hypomobile zygapophyseal joint, rotation to indicating that this is an example of structural the left will also usually be limited at about instability. 45°. It is also important to assess these aspects PASSIVE PHYSIOLOGICAL during return from end of range positions. For INTERVERTEBRAL MOVEMENTS example, a cranial to caudal movement should (PPIVMS) be initiated as a return movement from end of range extension (Hino et 1999). The deep cervi- PPIVMs examine the intersegmental range cal flexors are mainly responsible for segmen- of motion in a physiological direction. For tal control during this activity. With some a detailed description of these tests, see pathologies these muscles are inhibited (Jull Maitland et al (2001). 2000). This leads to an excessive activity of superficial muscles such as sternocleidomas- LINEAR MOVEMENTS AND SPECIFIC toid producing shear forces (Winters & Peles TESTS FOR LIGAMENT INTEGRITY 1990). Clinically these patients initiate return from extension by moving the midcervical seg- The so-called ‘linear stress’ tests consist of ments first while increasing upper cervical translational movements without any physio- extension. The neck moves with a protracted logical movement. The test results are negative chin until at the very end of the movement the if no distinct movement is possible. The end- head is repositioned to neutral alignment. Sim- feel should be hard–elastic. The reproduction ilarly inadequate muscle control has been of symptoms should also be evaluated. observed on return from end of range flexion. If the deep-lying stabilizing muscles (deep Pettman (1994) hypothesizes that linear tests neck flexors, multifidi and semispinalis) are might cause translational stress on the inhibited, the more superficial extensors such as the splenius capitis and the upper trapezius first pull the head in extension on the neck

128 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT vertebral artery and the nervous system in the angle, the more tension on the ligament on patients with cervical instability. upper cervical flexion due to the dorsal glide of the occiput (Penning 1998). Therefore stabil- Linear stress tests assess the passive subsys- ity testing should be performed in extension as tem as a whole for structural integrity. A well as in flexion (Willauschus et al 1995). positive result implies a possible segmental instability but does not point towards any The atlantal portion originates at the dens specific structural deficit. and inserts at the massa lateralis of C1. The alar ligaments limit rotatory movements of There are additional, more specific tests for the occiput–atlas–axis complex. According to the upper cervical spine (occiput–C2) that can Dvorak and Panjabi (1987) rotation towards the be used to selectively examine ligament integ- right loads the left alar ligament while the rity. The examiner evaluates the same aspects right alar ligament is relaxed (Fig. 6.6). as with PPIVM testing. The validity of these tests has not been researched in large scale Lateroflexion to the right loads the left occip- studies of trauma patients to date. ito-alar ligament, limiting the extent of move- ment. It also produces tension of the right Alar ligament atlanto-alar ligament. This produces rotation of C2 to the right. The spinous process of C2 The anatomy, biomechanics and pathology of moves to the left (Fig. 6.7). the alar ligament have been studied exten- sively by Dvorak and Panjabi (1987). The alar Lateroflexion to the right therefore causes a ligament usually consists of two portions: an relative left rotation of the C1–C2 segment occipital and an occasionally missing atlantal (lateroflexion to the right is coupled with left portion (Fig. 6.5). rotation of the C1–C2 segment). The occipital portion originates at the dens Dvorak and Panjabi (1987) described how and inserts at the occipital condyles. Depend- flexion combined with rotation causes maxi- ing on the size of the dens, its fibres run cranio- mum loading of the ligament. Clinically, pati- caudally, horizontally or caudocranially. In the ents with whiplash injury are often seen after transverse plane the left and the right occipital rear impact motor accidents. If the patient’s ligament form an angle of 150–180°: the smaller head was in a flexed position and turned to the right at the time of the impact (e.g. while waiting Fig. 6.5 Alar ligaments Membrana atlantooccipitalis Lig. apicis dentis and transverse ligament in anterior the horizontal plane Lig. allaria (pars atlantis) (reproduced with Dens axis Lig. allaria permission from Dvorak & Lig. apicis dentis Panjabi 1987) (pars occipitalis) Membrana Lig. transversum atlantooccipitalis atlantis posterior Lig. nuchae

Z Z’ Cervical instability 129 Z’ Z XXX ab c Fig. 6.6 Dorsal view onto the alar ligaments. On rotation to the right the left alar ligament and on rotation to the left, the right alar ligament are tensed (see text) (reproduced with permission from Dvorak & Panjabi 1987). Right Left the occiput. This is due to the wedge-shaped massa lateralis of C1. This atlas movement Fig. 6.7 On lateroflexion to the right the atlas additionally stresses the atlantal portion of the shifts to the right and the axis rotates to the right. alar ligament. This means that the spinous process of C2 moves to the left (after Penning 1998). Based on the knowledge of anatomy and biomechanics it is hypothesized that clinicians at traffic lights and opening the glove compart- will find the following test results in patients ment), the patient is at specific risk of having with left alar ligament insufficiency: injured the left alar ligament. ● Increased right rotation of occiput–C1 (rota- Besides the C1–C2 rotation, Penning (1998) tion PPIVM occiput–C1). has studied atlas translation on lateroflexion. He describes how lateroflexion to the right ● Increased lateroflexion of occiput–C1 with causes the atlas to move to the right relative to reduced glide of C1 towards the right com- pared to the left (lateroflexion PPIVM occiput–C1). Panjabi et al (1991a,b) demon- strated that not the overall range of motion but mainly the neutral zone increases in this case (see also Brodeur 2001). ● Increased right rotation of occiput–C2 (rota- tion PPIVM occiput–C2). ● Lack of movement of the C2 spinous process to the left on lateroflexion to the right (spe- cific alar ligament test). ● Fixation of the C2 spinous process allows lateroflexion of the occiput to the right (spe- cific alar ligament test). ● Increased translation to the right of occiput and C1 towards C2 on linear side force (spe- cific alar ligament test).

130 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Lateroflexion of occiput–C2 to the Interpretation right in sitting ● An intact left alar ligament will produce an This test evaluates the integrity of the left alar immediate rotation of C2. ligament (Fig. 6.8). ● The therapist should therefore feel an imme- Starting position diate rotation of the C2 spinous process. ● The patient is sitting, with the neck Lateroflexion of occiput–C2 to the relaxed. right in supine ● The neck is in a mid-position of cervical This test evaluates the integrity of the left alar flexion and extension. ligament (Fig. 6.9). Position of the examiner Starting position ● The therapist stands on the patient’s right. ● The patient is lying supine. ● The therapist holds the patient’s head with ● The patient’s head is positioned in the right the right hand. hand and is supported against the stomach ● The left thumb and index finger hold the of the therapist. ● This test is performed in upper cervical spinous process of C2. flexion, extension and neutral position. Fixation Position of the examiner ● There is no fixation. ● The therapist is sitting or standing behind the patient. Method Fixation ● The right hand of the therapist moves the head towards right lateroflexion. ● The left index finger holds the spinous process of C2 from the left side. ● It is important to avoid rotatory move- ments. b a Fig. 6.8 Alar ligament test in sitting (see text).

Cervical instability 131 a b Fig. 6.9 Alar ligament test in supine (see text). b Fig. 6.10 Rotationary stress to the right in sitting (occiput–C2) (see text). Note that the fixating hand at the spinous process of C2 is positioned flatter a and with more contact than in the previous test. ● The index finger should be positioned as far Rotatory stress to the right: dorsal as possible. occiput–C2 test in sitting Method This test evaluates the integrity of the left alar ligament (Fig. 6.10). ● The therapist attempts to perform an upper cervical lateroflexion to the right using the Starting position body and right hand. ● The patient is sitting with the neck relaxed. Interpretation Position of the examiner ● The therapist is standing on the patient's ● An intact alar ligament should not allow for any movement if the C2 spinous process is right. fixed.

132 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ● The therapist holds the patient’s head from Fixation cranial with the right hand. ● The radial side of the metacarpophalangeal Fixation joint of the therapist’s left index finger is positioned laterally against C2 transverse ● With the left thumb and index finger the process. lamina is held from dorsal. Method Method ● With the right hand the therapist attempts ● The right hand rotates the head towards the to shift the occiput and C1 to the left, relative right. to C2. Interpretation ● It is important to take up the soft tissue slack first to avoid false-positive results. ● An intact left alar ligament should limit rotation to the right at 30–35°. Interpretation ● The discrepancy between right and left ● Normally, no movement should be rotation should be no more than 8°. possible. Transverse stress test to the left: Transverse ligament occiput–C2 in supine The transverse ligament is the primary stabi- This test evaluates the integrity of the left alar lizer for C1–C2 flexion. It originates at the ligament (Fig. 6.11). massa lateralis of C1 on one side and inserts at the massa lateralis on the other. It runs post- Starting position erior to the dens and prevents ventral glide of C1 during flexion (or dorsal movement of ● The patient is lying supine. the dens which would impair the spinal medulla). Position of the examiner The following tests are designed to assess ● The therapist is sitting or standing behind the integrity of the transverse ligament: the patient. ● Sharp–Purser test (Sharp & Purser 1961, ● The patient’s head is positioned in the right Uitvlugt & Indenbaum 1988) hand and is supported against the stomach of the therapist. ● Anterior shear test (Aspinall 1990) ● Posterior–anterior movement of C2, with the ● The radial side of the metacarpophalangeal joint of the therapist’s right index finger is neck positioned in upper cervical flexion. positioned laterally against the C1 trans- verse process. a b Fig. 6.11 Transverse stress occiput–C2 to the left in supine.

Cervical instability 133 Sharp–Purser test (Fig. 6.12) flexion. In that case the examiner will find the following results: Starting position ❍ Dorsal movement of occiput and C1 ● Sitting. ❍ Possibly a palpable ‘click’ ● Head is relaxed. ❍ Reduced symptoms ● Neck in slight flexion (possibly move until ❍ A stable segment should not allow any onset of symptoms). movement and should show a hard– elastic end-feel. Position of the examiner ● Standing next to the patient. Anterior shear test (Fig. 6.13) ● Cradles the head of the patient with the left Starting position forearm and biceps. ● Supine with head on bench. Fixation Position of the examiner ● With the right hand (thumb and index ● Sitting or standing behind the patient with finger) the spinous process and both laminae both index fingers positioned on the atlas of C2 are held from dorsal. and fingers 3–5 against the occiput. Method Fixation ● The left hand attempts to move the head, ● Both thumbs fixate the C2 transverse pro- and therewith the occiput and C1 dorsally, cesses bilaterally from ventral. relative to C2. Method Interpretation ● The therapist attempts to move the atlas and ● An insufficient transverse ligament allows occiput ventrally against C2. C1 to translate ventrally on C2 on cervical a b Fig. 6.12 Sharp–Purser test.

134 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT a b Fig. 6.13 Anterior shear test. Interpretation In the case of a hypomobility dysfunction the therapist will find: ● Normally there should be no movement. ❍ No noticeable movement ❍ No ‘click’ Posterior–anterior relative to C2 in ❍ Possibly an increase of symptoms, since upper cervical flexion the occiput should perform a dorsal glide The posterior–anterior test on C2 is an adapta- on upper cervical flexion. tion of the Sharp–Purser test in supine. Tectorial membrane Starting position The tectorial membrane is an extension of the ● Supine. posterior longitudinal ligament. It is a large ● The head is positioned in upper cervical and strong ligament. It originates from the posterior vertebral body of C2, runs posterior flexion in the position of onset of symp- to the dens and inserts at the ventral foramen toms. magnum (Fig. 6.14) (Oda et al 1992, Harris et al 1993). Position of the examiner According to Pettman (1994), it is the ● The examiner is sitting or standing behind primary stabilizer for distraction of the head the patient. on the neck. Furthermore, it assists the trans- verse ligament to stabilize C1–C2 flexion (Oda Fixation et al 1992, Harris et al 1993). Harris et al (1993) dissected the tectorial membrane and found ● Both thenar eminences hold the head on instability on flexion but not extension. The either side. study did not assess behaviour on head distraction. Method Since the occiput moves ventrally on C1 ● Both middle fingers attempt to move C2 during extension, Pettman (1994) hypothesized ventrally, relative to C1. that the ligament is loaded in extension. There- fore the instability tests should be performed Interpretation in end of range flexion, extension and in mid-position. ● In the case of an instability, this test will reduce subluxation (analogous to the Sharp– Purser test). This leads to the following findings: ❍ Ventral movement ❍ Possibly a palpable ‘click’ ❍ Reduction of symptoms.