Craniofacial Pain Neuromusculoskeletal Assessment Treatment and Management

Assessment and treatment of cranial nervous tissue 535 bc e Fig. 17.76—cont’d b Anteroposition of the head. c Reduced mandibular asymmetry. d Reduction of anteroposition. d e Long sitting slump (LSS).

536 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT and the trigeminal, facial, accessory and vagus SUMMARY tests. ᭿ In the third part of this chapter physical Maitland et al (2001) described how to test examination and different clinical abnormal intervertebral movements manually. patterns of the third category (specific The most common hypomobilities and immo- cranial tissue) were discussed. bilities (32 out of 48 cases) were observed at occiput–C1, normally on the side where the ᭿ In particular, cranial nerves with a occipital bone was prominent. specific function are discussed in this chapter, which also react with a typical It should be mentioned that the collection of clinical pattern in disease. these data, which is relatively straightforward in practice, is not a basis for more standardized ᭿ Abnormal signs found during research but to enable new clinical patterns to cranioneurodynamics can easily be be recognized. The unproven correlations integrated during passive and active between these data which give the therapist rehabilitation programmes. clues for new investigation and management strategies are interesting (Case study 8). ᭿ When it is felt that the clinical pattern is unclear and the results are not what was expected, treatment must be stopped and the patient referred to a specialist for further diagnosis. References Armon C, Daube J 1989 Electrophysiological signs of arterio-venous malformation of the spinal cord. Abel M D, Levine R A 2004 Muscle contractions and Journal of Neurology, Neurosurgery and auditory perception in tinnitus patients and Psychiatry 52:1176–1181 nonclinical subjects. Cranio 22(3):181–191 Arzouman M, Otis L, Kipnis V, Levine D 1993 Adams R, Victor M 1985 Principles of neurology, 3rd Observation of the anterior loop of the inferior edn. McGraw-Hill, Berkshire alveolar canal. International Journal of Oral and Maxillofacial Implants 8:295 Agerberg G, Carlsson G 1972 Functional disorder of the masticatory system. I. Distribution of Ash C, Pinto O 1991 The TMJ and the middle ear: symptoms according to age and sex judged from structural and functional correlates for aural investigation by questionnaire. Acta Odontologica symptoms associated with temporomandibular Scandinavica 30:597 joint dysfunction. International Journal of Prosthodontics 4:51–57 Aizawa S, Tsukiyama Y, Koyano K, Clark G T 2002 Reperfusion response changes induced by Aspinall W 1989 Clinical testing for cervical repeated, sustained contractions in normal human mechanical disorders which produce ischemic masseter muscle. Archives of Oral Biology vertigo. Journal of Orthopaedic and Sports 47(7):537–543 Physical Therapy 11:176 Alcantara J, Plaugher G, Klemp D, Salem C 2002 Atkinson W 1949 The anterior inferior cerebellar Chiropractic care of a patient with artery. Its variations, pontine distribution, and temporomandibular disorder and atlas significance in the surgery of cerebello-pontine subluxation. Journal of Manipulative and angle tumours. Journal of Neurology, Physiological Therapeutics 25:63 Neurosurgery and Psychiatry 12:137–151 Amyes E, Anderson F 1956 Fractures of the odontoid Aurbach G, Ullrich D, Mihm B 1991 Chirurgische process. Archives of Surgery 72:377 Anatomie des Nervus opticus und der Arteria carotis interna in der lateralen Anderson R 1975 Shoulder disability and neck Keilbeinhöhlenwand. Eine anatomische Studie am dissection. In: Anderson R, Hoopes J (eds) Schädel–Basis–Präparat. HNO 39:467 Symposium on malignancies of the head and neck. Mosby, St Louis Badia L, Parikh A, Brookes G 1994 Management of middle ear myoclonus. Journal of Laryngology Aramideh M, Ongerboer de Visser B 2002 Brainstem and Otology 108:380 reflexes: electrodiagnostic techniques, physiology, normative data, and clinical applications. Muscle and Nerve 26:14

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551 Chapter 18 Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system Harry von Piekartz CHAPTER CONTENTS INTEGRATING CRANIODYNAMIC MOBILIZATION INTO THE Integrating craniodynamic mobilization into OVERALL MANAGEMENT the overall management 551 Butler emphasizes: ‘Neurodynamics is not an Case studies 563 isolated treatment approach but should be embedded into the overall management’ (Butler 1991, Butler & Moseley 2003). This prin- ciple may be applied at different stages of the treatment and may influence movement in various ways. Neurodynamics is often misunderstood as a ‘neural stretching technique’. This is not quite correct; rather the emphasis should be on nerve movement and on influencing its physi- ology. The techniques aim to restore the most important quality of the nerve, i.e. its ability to move (Nathan & Keniston 1993, Butler 2000). Neurodynamics has also been integrated into the assessment and treatment within pain management approaches (Gifford 1998, Butler 2000), which additionally broadens the thera- peutic horizon. During the late 1980s and early 1990s neurodynamics was primarily viewed as a mechanical model for the evaluation of periph- eral nociceptive clinical patterns. Today the results of neurodynamic tests are interpreted by applying knowledge from recent pain

552 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT research. Hence neurodynamics is integrated ● Indicator of pain mechanisms: Combining into pain management approaches and may be the results of the subjective examination an important component of explanatory pain with the findings from a passive movement models. Neurodynamics is a big topic. gives us some idea about the dominant pathobiological mechanisms. For the purpose of this chapter we will focus on the neurodynamics of the craniofacial ● Explanations: Understanding pain mecha- region, although the odd excursion into the nisms and the possible sources of the field of pain management might be necessary. symptoms may be of major importance for adequate problem management. For There are four options for cranial neuro- example, a patient with unspecific otalgia mobilization: (toothache without any visible reason) might have an increase of symptoms on upper cer- ● Passive influence vical flexion and laterotrusion of the man- ● Active influence dible. The hypothesis points towards a ● Indirectly influencing the neural container neuropathic component. This technique ● Direct influence, neurodynamic movement and the patient’s reaction to it provide valu- able information towards an explanation and palpation. of the underlying pain mechanisms (Table 18.1). DIFFERENT TYPES OF CRANIAL N EU R O M O B I L I Z AT I O N Active influence Passive influence There are fewer variations for active influence than for passive influence, but active influence Passive influencing techniques include: has other advantages. ● Physiological movements: neurodynamic CONTINUOUS PHYSIOLOGICAL INFLUENCE tests or components of neurodynamic tests Because the patient can perform the techniques ● Palpation: mentioned later in this chapter as themselves and as often as they like, they are a ‘directly influencing technique’. given the chance to continuously influence the physiology of the nervous system, especially Neurodynamic tests have very specific fea- axonal transport, the vascular system and tures and the effects are different when the the connective tissue of the cranial nervous tests are performed passively rather than system. Studies have shown that early mobili- actively. The most important features are listed zation results in positive outcomes for the below: (neuro)physiology (Rosenfeld et al 2000). ● Optimum evaluation of movement para- Target tissue rehabilitation meters: Passive testing and mobilization allow for the assessment of pain, resistance Target tissue exercises may be integrated into and muscle spasm (Maitland et al 2000). the regime of active neuromobilization and These components will guide the clinical neurodynamic positioning. Due to the active decision making process by indicating the afferent–reafferent impact, the somatosensory intensity, range and direction of the appropri- cortex receives information about the affected ate mobilization technique. An example is structures (Ramachandran & Blakesee 1998). shown as a movement diagram in Figure 18.1. Since the orofacial area is largely projected This shows mandibular lateral movement onto the somatosensory cortex, active target before and after a mobilization technique. tissue exercises may be integrated into the overall management at an early stage. Some ● Reassessment tool: Since three parameters examples are as follows: (pain, resistance and spasm) are included, the passive movement is a valuable tool to assess behaviour pre- and post-test (Maitland et al 2000).

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 553 C R2 D Fig. 18.1 Movement diagram showing resistance (R) and pain (P) on laterotrusion to the left with a A R1 P1 P' B 2 cm of mouth opening in craniocervical flexion + C 23mm lateroflexion to the left (test for the right mandibular L nerve). 15mm D a Before the ‘slider’: Average laterotrusion (AB line R2 is 23 mm; von Piekartz 2001). The resistance increases steadily and limits the movement at roughly 15 mm (R1–R2, L = limit = 15 mm); pain (P1–P′) is not dominant and shows a score of 7 on the visual analogue scale (VAS). b Immediately after the ‘slider’: The onset of resistance (R1) and the onset of pain (P1) have moved further to the right of the diagram. The range of movement has increased: L has moved to the right in the diagram (20 mm), while P′ on the VAS is now 4. c Assessment during the second session: The onset of R1 and P1 is earlier again. The limit is 18 mm and the pain intensity is described as 5 on the VAS. P' b R1 P2 L B A 20 mm C R2 D P' cA R1 P1 L B 18mm 23mm ● Patients with Bell’s palsy may perform active irritation of the hypoglossal nerve (XII), neurodynamic movements of the head and and therefore neurodynamic movements also receive muscular facilitation in or out may be effective, accompanied by functional of neurodynamic tension. target tissue exercises (for the tongue). The therapist may challenge somato- ● Patients with neck–tongue syndrome sensory input by repeating the same (Bogduk 1981) may experience mild dys- exercise in various neurodynamic phagia and paraesthesia of the tongue. It positions. can be hypothesized that this is due to an

554 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Table 18.1 Overview of clinical interpretations of patient responses based on pain mechanisms: this example shows passive shoulder depression on accessory nerve testing Input dominant Processing dominant Output dominant Stimulus response predictable Stimulus response unpredictable Stimulus response generally cumulative Behaviour of pain and Behaviour of pain and resistance Behaviour of pain and resistance consistent inconsistent resistance variable Resistance usually increases Pain may increase without an Prolonged spasms and gradually towards the end of increase of resistance autonomic changes (e.g. range sweating, temperature changes) Anticipation pattern during Pain with accumulating and latent Increasing vegetative test is known characteristics; coping, anxiety, reactions (e.g. sweating, modification of concentration and temperature changes) and distraction modify the response affective influences largely determine the responses ● After whiplash injuries some patients might Sequence of movements and experience blurred vision and/or diplopia. trick movements Impaired accommodation of the eyes and diplopia may be symptoms of a dysfunction Example of the sequence of movements of the oculomotor nerve. In this case active and passive mobilization, combined with During a neurodynamic test the mandibular functional activities of the eyes, may be nerve becomes irritated on mouth opening helpful. with pain and trismus of the masticatory muscles. It is sensible here to assess mouth Variations of active movements opening first followed by cranial flexion and lateroflexion. If the mouth can clearly be There are many options for the integration of opened wider, it is sensible to first improve active craniodynamics into patient manage- cranioneurodynamic movements with mouth ment and day-to-day activities. activity. Butler (2000) stated that the ‘sequence of Trick movements are closely connected to movements’ and ‘trick movements’ may chal- the sequence of movement components. lenge the mechanical influence on the nervous They provide us with information about a system. If the homunculus receives a sufficient movement and about the environment which number of afferences, movement may no longer is often used to challenge it. be interpreted as pain. This principle works whenever a pain has become chronic, i.e. when the central nervous system is sensitized, and may be useful for the management approach.

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 555 Example of trick movements Indirectly influencing the neural container This applies to gravity. If cervical flexion is more easily performed in side lying than in ‘Neural container’ stands for any tissue sur- supine (fewer symptoms), it makes sense to rounding and potentially influencing the incorporate side lying cervical flexion into the nervous system (Gifford 1998, Butler 2000). management of this patient. It is essential for Depending on the location, these may be the success of this exercise that the patient various types of tissue – blood vessels, bone, is conscious of these differences and fascia, and, intracranially, other types of neural understands what they mean. tissue (von Piekartz 2001, Austermann 2002). For example: Maximal mouth opening was 32 mm. Furthermore, unilateral increase in tone of the ● The posterior cerebral artery within the masseter muscle was noted. Admittedly, cerebellopontine angle (CPA) that touches mouth opening is more than 32 mm when the trigeminal nerve (Lang 1995) yawning or singing. The therapist now has the option to integrate functional activities such ● The cranial foramina, e.g. the foramen jugu- as singing or yawning, with or without lare with the vagus (X), glossopharyngeal neurodynamic positions, into therapy. (IX) and accessory (XII) nerves Part of pain management ● The lateral and medial pterygoid muscles contact the lingual nerve, a branch of the The principle of distraction (physical and/or mandibular nerve psychological distraction from the pain experi- ence of a patient) can be easily integrated into ● The major occipital nerve within the super- the treatment by including neurodynamic ficial dorsal cranial fascia. exercises. If a patient suffers from atypical facial pain and fears to increase headache If the therapist becomes aware of a dysfunction symptoms by moving the head, it might be in tissues surrounding the nerve during physi- useful to initiate the neurodynamic techniques cal examination, a local technique should be in the long sitting slump position. The patient attempted, followed by reassessment of the may move their legs or thoracic spine and keep neurodynamic test that showed abnormal the head static, while still achieving neuro- responses. In many cases an adequate answer dynamic movement. will be found. Cranioneurodynamic movements may Direct influence: neurodynamic also be applied as a pacing exercise. If, for movement example, craniocervical flexion triggers facial pain, the patient may be assessed and reas- Here the therapist performs specific manoeu- sessed by a quota system with the onset of pain vres designed to challenge nerve movement. being the indicator for improvement (Harding The techniques are based on knowledge of 1997). the anatomy of peripheral nerves. The most common manoeuvre is the straight leg raise A disadvantage may be that neurodynamic (SLR). Here dorsiflexion of the foot is the key movements are sometimes difficult to control. movement to detect a neuropathic problem in It is therefore sensible to wait for the effects the leg or the lumbosacral region. For treat- of the passive techniques before starting on ment the therapist usually applies components neurodynamic activities. of a neurodynamic test; sometimes the com- plete testing manoeuvre is used. The same principles apply for cranial nerves. Sugges- tions for neurodynamic testing of the cranial nerves based on the anatomical position are described in Chapter 17.

556 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT During the past 25 years various treatment the peripheral arm nerves, these might be strategies based on empirical data have been depression and elevation of the shoulder or suggested. The following section gives an midcervical sideglides (Elvey 1997). For the overview of the treatment choices: lower quadrant, proximal techniques are flexion + adduction of the hip. For the cranial ● Distal techniques nervous system craniocervical flexion and ● Proximal techniques lateroflexion are proximal techniques biased ● Sliders and tensioners towards the brainstem and the nerve exits ● Neural palpation. at this region (Breig 1978). These proximal components are also part of the suggested DISTAL TECHNIQUES cranioneurodynamic tests. The proximal com- ponents generally show a large range of move- These techniques approach a problem from a ment and are therefore easily observed and remote site. For example, if the pathomechanic controlled by the therapist. Clinically they not site of the accessory nerve is hypothesized to only influence peripheral processes but also be near the jugular foramen, depression or the responses due to the close connection to retraction of the shoulder would be a distal the neuraxis, for example neural mobilization technique. after acoustic neuroma surgery. The patient suffers from neck pain and stiffness on cervi- The advantage of distal techniques is that cal flexion (proximal sign) and also frequently they will not produce maximum stress and experiences fasciculations of the masseter that painful sites do not have to be touched or muscle and toothache (distal sign). An appro- moved (distraction). priate treatment technique may be a proximal approach with craniocervical flexion/exten- One disadvantage is that the therapist will sion in combination with lateroflexion. need thorough information about the neural container along the nerve. If a distal technique Furthermore, proximal techniques show is applied, although dysfunctions along the fewer irritable reactions than distal techniques. neural container of the nerve exist, this may Elvey (1986) observed this difference in reac- cause abnormal reactions at the dysfunctional tions while testing the neurodynamics of the site and possibly lead to pathodynamic changes upper extremity. Because of the irritability of (Breig 1978, Butler 2000). An example is scar many shoulder problems he preferred shoul- tissue behind the ear after salivary gland der movements rather than elbow or hand surgery that might contribute to peripheral movements. If the pain behaviour varies in its neuropathy. In this case the neural container duration and intensity it also makes sense to (scar tissue) needs to be treated before begin with a proximal technique. For example, approaching the facial nerve (VII). Afterwards if a patient complains of pain in the mandibu- the distal technique to influence the neurody- lar region, the problem is most likely irritable. namics of the facial nerve could be a movement If the therapist detects a clear mandibular dys- of the mandible that influences primarily the function, treatment should begin with proxi- distal mandibular ramus of the facial nerve. mal mobilization techniques. Craniocervical mobilization should precede mandibular These days, distal techniques can no longer mobilization. be viewed as purely mechanical influences on the nervous system; rather the effects may be Viewed clinically, distal techniques show viewed at the level of central processing mech- more disadvantages than proximal techniques. anisms. Central neurones are stimulated at the It should also be borne in mind that same site of the brain that usually represents neurodynamic techniques not only approach the previously experienced pain (Kaas et al neural tissue but also influence all other 1999, Butler 2000). proximal structures. Systematic reassessment of neurocranial structures and surrounding PROXIMAL TECHNIQUES These techniques apply movement near the neuraxis and therefore also near the trunk. For

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 557 muscles and joints is therefore essential after treatment. SLIDERS a The concept of ‘sliders/tensioners’ was intro- b duced in the mid 1990s by Butler et al (1994). The idea is to focus on the macroscopic func- Fig. 18.2 Slider concept applied to the mandibular tion of the nervous system: on ‘movement’. The nerve. choice of movement is directed by the anatomi- a The mandible is moved into laterotrusion in cal position of the nerve and by knowledge from macroscopic movement studies (Breig craniocervical extension with the mouth open 1978). In principle, the proximal end of the approximately 2 cm. nervous system is relaxed while the distal end b The mandible is returned to the mid-position in is put under tension and vice versa: the proxi- upper cervical flexion. mal component is under tension and therefore challenged while the distal component is slight amount of resistance. Sliders are good relaxed. This procedure emphasizes the move- tools for pain management and may be used ment of these particular nervous structures. as ‘distraction’ and ‘pacing’ exercises. Further- more, the therapist should make sure that the Some examples for basic techniques for the neural container does not cause any unneces- cranial nervous system include: sary stress and hence needs to be assessed prior to the slider techniques. ● Mandibular nerve: During craniocervical extension the mandible is moved into latero- When does it make sense to work with trusion with the mouth 2 cm opened. During sliders? Clinically there are some rules to the following craniocervical flexion the support the clinician in the hypothesis- mandible is moved back to midline position generating process which may point towards (Fig. 18.2). sliders as an effective treatment tool: ● Treating the neural container no longer ● Facial nerve: During craniocervical exten- sion and lateroflexion towards the same influences neurodynamics. side, the oral mimic muscles are activated. During the following craniocervical flexion and lateroflexion to the opposite side the facial muscles are relaxed. ● Hypoglossal nerve: During craniocervical flexion and lateroflexion to the contralateral side, the tongue is relaxed. During the fol- lowing craniocervical extension and latero- flexion to the other side, the tongue is moved into laterotrusion to the contralateral side (a spatula may be used). ● Abducens nerve: During craniocervical extension the eye is moved towards medial. During the following craniocervical flexion the eye is moved back to the mid-position. The great advantage of slider techniques is that they do not produce major stress for the periph- eral nervous system and are therefore easily performed actively. The techniques should not hurt and generally are performed within a

558 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ● After applying a technique the neurody- and rest there for a few seconds, for example namic test should have improved regarding during trismus of the masticatory muscles. range, resistance and symptoms. ● The conductive qualities of the nerve should not be affected negatively after any treat- ● At the beginning of the follow-up session ment technique but should be improved. the signs and symptoms should not be ● If sliders no longer have the desired effect, worse than at the end of the previous session. or whenever treating the neural container After the second treatment they should be does not improve the situation, tensioners clearly improved (see Fig. 18.1). may be attempted. ● Conductive qualities of the nerve should not Craniofacial examples include tensioners at the worsen after a technique. For example, if hypoglossal nerve after submandibular scar- after a slider technique the size of a par- ring due to surgery at the mouth or radiother- aesthestic area at the chin has increased, apy, and tensioners at the auriculotemporal the technique should be discontinued and nerve after interneural scarring due to the a neurology specialist should be contacted. pressure of glasses. TENSIONERS Direct influence: neural palpation Tensioners are the opposite of sliders; they INTRODUCTION produce an increase in tension in neural struc- tures. Here, both ends – proximal and distal – As mentioned above, nerve palpation may be are put under tension simultaneously. This viewed as a direct passive technique that influ- technique focuses on loading the connective ences the peripheral nervous system. This is tissues along a peripheral nerve (Kwan et al not a novelty. In medicine, especially among 1992). It relies on the natural viscoelasticity of orthopaedic surgeons, this was described very the nervous system and does not exceed the early. Previously, during or after an operation, elastic limit. If it is performed gently, with con- it was common practice to press, pull or move stant assessment of the responses and the a nerve to confirm the condition of the struc- resistance that is felt during the manoeuvre, ture. For example, before deciding on a trach- neural viscoelastic and physiological functions eotomy, the main branches of the pharyngeal will improve (Shacklock 2005). In this case nerve (derived from the vagus nerve) needed movement and the neural container are only of to be palpated (Gavilán & Gavilán 1986). secondary interest. With the new insights into the nervous Generally tensioners will not be a first choice system, palpation gained a new dimension. technique. The following thoughts may need Butler (2000) suggested palpation in order to to be considered: re-learn peripheral nerve anatomy, to decide upon a differential diagnosis and to detect ● The problem should not be irritable and has anomalies, as well as to treat the nerve tissue. not been so in the recent past. Hence, the Nowadays nerve palpation has to be viewed in patient has not experienced any major vari- a larger context. ations in intensity and location of the symp- toms during the past few weeks. ● Firstly, it is part of overall patient manage- ment and does not stand alone. Chronic ● For tensioners, the most positive results craniomandibular and craniofacial dysfunc- occur in situations that involve scar tissue tions generally involve many different struc- around or within the nervous structures, for tures. Mobilization of the cranial bones, example scarring behind the ear at the facial cranioneurodynamics and palpation in nerve or at the cranial dura after cranio- mildly neurodynamic positions are key cervical trauma. methods for the assessment and treatment of many head and facial complaints. ● During protective muscle spasm one might want to try to move the patient from a neuro- dynamic position into a tensioner position

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 559 ● Secondly, it may assist the therapist’s under- Butler 2000). When interpreting the clinical standing of the problem. Palpation of the pattern, certain pathophysiological knowledge lingual nerve may reproduce the patient’s needs to be applied, for example the vascular symptoms. If this is accompanied by a ‘neg- system, axoplasmatic flow, abnormal ‘pace- ative’ MRI, it will be easier for the therapist makers’ (abnormal impulse generating sites, to convince the patient that they are not suf- AIGS) and sensitization of the nervous fering from a malignant tumour, a very system. common fear among patients. Adhesions around the nerve (nerve is ● Thirdly, palpation can be considered within ‘glued together’ at one site) its wider context. For example, central sensitization and peripheral nerve tissue Stiff scar tissue affects the nerve, especially injuries in the past may change central mod- after injury, trauma or sustained abnormal ulation systems and cause unexpected reac- function of the neural container. Examples tions, including (secondary) hyperalgetic include a trapped lingual nerve due to the reactions. lateral pterygoid muscle after sustained devia- tion on mouth opening, sustained compres- It is strongly advised to integrate this know- sion of the hypoglossal and vagus nerves when ledge when interpreting neurodynamic test the neck is swollen due to salivary gland prob- results. The treatment of nervous tissue is not lems, and scar tissue caused by a haematoma a purely mechanical business (Butler et al in the orbit that produces pressure on the 1994). Clinical features regarding cranial lateral branches of the maxillary nerve. tissues and testing/treatment procedures are discussed in the following section. Adhesions of the nervous connective tissue (intraneural adhesions) PATHOBIOLOGICAL CHANGES IN PERIPHERAL CRANIAL NERVES The nerve demonstrates signs of intraneural connective tissue adhesions shown as swelling Dysfunctions as we know them from the trunk due to abnormal container movement or abnor- and the upper and lower extremities are also mal external pressure on gliding. Examples common in the craniofacial and craniocervical include the following: regions. It should be borne in mind that the nerve endings in the face are extremely sensi- ● A long styloid process will produce pres- tive, more than comparable nerve endings sure on the hypoglossal nerve on cervical of the upper and lower extremities. Motor flexion and ipsilateral lateroflexion. responses of the facial and masticatory muscles are not uncommon. The following local dys- ● The auriculotemporal nerve needs to glide functions are frequently seen in the cranial and extend excessively on mandibular nerves: subluxation when the mouth is opened. ● Adhesions around a nerve (a nerve might be ● Scarring and the development of an abnor- ‘glued together’ at one site) mal ‘pacemaker’ (AIGS) at the inferior alve- olar nerve of the mandible may occur after ● Adhesions of the nervous connective tissue tooth extraction. (intraneural adhesions) ● Wearing ill-fitting glasses may cause pres- ● A combination of morphological changes of sure on the maxillary nerve near the orbital the neural container and the connective foramen. tissue. Combination of morphological changes of Dysfunctions can be easily detected by the the neural container and the connective therapist and occur as swollen or hardened tissue tissue with a loss of transverse mobility and abnormal mechanosensitivity (Jabre 1994, This phenomenon is mainly seen when dys- functions have started very slowly, have a long

560 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Fig. 18.3 Example of scarring of the hypoglossal nerve palpation technique; 50% improved in and glossopharyngeal nerves at the ventral neck. their subjective and objective reassessment. Unfortunately there was no placebo or control history and show multistructural changes. group in this study (Jabre 1994). Okeson describes how reduced blood flow may risk the health of various structures in this It is difficult to decide which technique to region and emphasizes the effect on cranial choose in which clinical situation. Some neural connective tissue (Okeson 1995). Long- parameters such as mechanosensitivity, cen- term vasomotor changes in the cranium as tralized data documentation, level of treatment known in tension headaches and migraines and (meta-)cognition of the therapist play an may result in such multistructural changes. An important role in the clinical decision-making example is the development of trigger points process. Some basic techniques, modifications in the masticatory muscles. Trigger points are of the ‘twanging’ described by Butler, may defined by various clinicians and scientists as guide the therapist to find the appropriate the entrapments of peripheral nerve endings in intensity of stimulation. hypertonic muscles (see also Chapter 8). Other examples are multistructural changes follow- ● Starting position: The nerve is placed ‘in ing craniofacial surgery (e.g. after salivary tension’ or ‘out of tension’. This depends on gland surgery) when abnormal swelling the individual anatomy and the irritability around the ear occurs (mainly ventrocaudally) of the problem. accompanied by minimal trauma of the facial nerve (anastomosis of the buccal and mandib- ● Position of the thumb or finger: The tip of ular branches). In particular, cancer surgery at the finger or thumb should touch the nerve the neck in combination with radiotherapy laterally if the focus is on the nerve inter- leads to multistructural changes of the skin, face. If the emphasis is more on general local the muscles and the nerves (mainly the acces- tension, the fingertip may be placed directly sory nerve) (Lang 1995). onto the nerve. Assessment and treatment techniques ● Nerve movement: The palpatory movement may be performed in various directions. A number of assessment and treatment Nerve movement affects a large part of methods have been suggested. At present there the nerve and may be a preparation for the is still a lack of efficacy studies. Jabre (1994) following neurodynamic techniques. The presented an efficacy study on the topic of advantage of choosing a position ‘in neural ‘nerve rubbing’ in the cubital region. Twenty tension’ is that the head does not need to be therapy-resistant men diagnosed with ulnar moved, since headache, dizziness and tin- nerve neuropathy were treated with a certain nitus patients might prefer if their head remains in a position that they can control. The therapist’s finger or thumb can remain at the same spot during palpation. This way the nerve receives more stimulation. The basic principles for the progression of nerve stimuli and for the nerve’s surrounding structures may be combined. In the following text the general methods for treatment and assessment are discussed and applied to craniofacial dysfunctions. Figure 18.4 illus- trates a clinical example applied to the extrac- ranial part of the accessory nerve. ● Transverse movement of the relaxed nerve: For this first step of the twanging, gentle movement on the ophthalmic foramen

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 561 Fig. 18.4 An example for a manual palpation ● Transverse nerve movement combined technique on a cranial nerve (extracranial branch of with moving the whole nerve: Performed the accessory nerve). on the auriculotemporal nerve with jaw opening, this emphasizes the mobilization reproduces slight unilateral headache and of local adhesions within and around this punctiform pain at the front. The advantage nerve branch, for example in dysfunction of this technique is that local scar tissue and pain after prolonged wearing of glasses within and around those tiny nerve branches or a stethoscope. may be influenced. ● Transverse movement in optimal neuro- ● Mobilization of the neural container in dynamic relaxation: Assessment and treat- various neurodynamic positions: This ment of the buccal nerve (branch of the enables information about adhesions around facial nerve) above the zygomatic bone in a the nerve to be collected without directly position of upper cervical extension and pressing on the nerve. This can be helpful if lateroflexion away/rotation towards (opti- the treatment technique is supposed to mum relaxation of the facial nerve). The mainly influence the mechanical interface of transverse movement of the nerve can be the nerve. A good example is the accessory observed easily since the nerve runs super- nerve: the trapezius muscle pars descendens ficially over the zygomatic bone. Note also may have an abnormal mechanical influence how the movement continues over a long on the accessory nerve after long-term neck distance of the nerve. pain or ventral neck surgery. This may lead ● Transverse movement in increased neuro- to adhesions and movement deficits of the dynamic tension: If there is no hypersensi- nerve and the surrounding tissues. Palpat- tivity of the nervous system and the patient ing the nerve directly or placing it into is able to tolerate the position for a few neurodynamic tension might be painful. minutes, this might be an effective tech- Therefore it is suggested that the therapist nique. The local stimulus is quite intensive apply a little oil and influence the resistance and appropriate for local scar tissue. For of and around the nerve by applying vertical example, a patient who suffered from head- movements onto the nerve and the sur- aches, tinnitus and neck pain for 2 years fol- rounding structures. This technique may be lowing an episode of mastoiditis shows scar progressed by combining it with nerve tissue behind the ear on the mastoid process movement, influencing a larger range than and on some small branches of the vagus the palpation technique. nerve. The example shows a good position for examining and treating this patient. ● Pressure on the nerve during neurody- namic movement: The emphasis here is on the neurodynamics of the nerve itself, for example moving the hyoid bone caudally and laterally while holding the thumb on a branch of the suprahyoid hypoglossal nerve (that is slightly swollen when palpating the styloid process). A potential hypothesis to explain this technique is that intraneural transmitter substances such as cell fluids, blood with proteins and neurotransmitter might be mobilized. This may contribute to better health of the neural tissue and its sur- roundings. Within a context of information and education it may lead to positive results. A logical progression would be to combine transverse local techniques with neurody- namic movements.

562 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT SUMMARY tissue, and may use the assessment technique as the basic treatment technique. ᭿ Palpation of cranial nervous tissue However, these tests are not useful for all needs to be viewed as a regular part patients. of the assessment and management, combined with the results of subjective ᭿ A general overview of the pathobiologic data, conduction and neurodynamic mechanisms is necessary to interpret the tests of the cranium and the rest of relevance of differentiation tests, peripheral the body. sensitization and previous nerve injuries. This might contribute to additional care and ᭿ Based on the tests performed, the precautions (Table 18.2). therapist will gain information about the relevance and health of the nervous Table 18.2 General overview of advantages and disadvantages of various treatment approaches to influence the cranial nervous system Treatment Advantage Disadvantage approach Indirect Local technique Local (neural) stress might be Neural container Minimal neural stress intense Many variations in neurodynamic positions possible Direct Low load Little control over neural Neurodynamic Easy to integrate in pain container deficiencies management activities (e.g. Distal technique mental distraction) When performed in Low irritability neurodynamic positions it Proximal technique Influences neuraxis and the might produce large loads on peripheral system of the the nervous system Sliders extremities Neural container needs to be Low load to the nervous system clear Tensioners Easily performed actively Good integration into pain Sometimes difficult to identify Palpation management programmes the critical site Focus on tension in and around the nerve Do not perform when situation Neural containers experience less is irritable or central load than during sliders mechanisms dominate the Strong local influence of neural problem container and local nervous tissue

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 563 GUIDELINES FOR DETERMINING pathy (Case study 1); in the other the patient THE INITIAL TECHNIQUE suffers from prolonged chronic pain and neurological changes resulting in relevant If the therapist has decided to treat the patient physical dysfunctions (Case study 2). The with cranioneuromobilization techniques, the examples intentionally show peripheral following parameters may guide the decision neurogenic problems to demonstrate that for the initial technique: cranioneurodynamics may also contribute to improvement in this group of patients. These ● Starting position: The patient should be examples might be used as general guidelines positioned ‘out of neural tension’ or with for the treatment of the most common cranial only minimal stress on the cranial nervous neuropathies that are accompanied by physical system. dysfunctions. ● Direct or indirect influence: Usually an Case study 1 indirect technique is chosen (neural con- tainer). Once the neurodynamic tests have Previous history improved, direct cranioneural mobilization may be preferred. A 68-year-old male patient suffers from a facial paresis after salivary gland surgery to ● Location and order: Which cranioneurody- remove a benign tumour. Two weeks after namic test is first priority? Which is second surgery he realizes that some oral activities and which is third? Generally the primary such as speech and swallowing have become site of compression is chosen. This will also difficult to perform. The worst problem for help to decide whether the proximal or the him is that saliva flows out of his mouth in distal component should be moved first. public. His right eye feels dry and he cannot close it properly. After 4 weeks the situation ● Amplitude of movement: Large amplitudes remains unchanged and he worries that he are helpful whenever the nerve runs through may not improve. His surgeon reassures him a ‘tunnel’, when the trophic situation is that the symptoms will eventually disappear insufficient and to reduce fear of movement. but the patient is not convinced. After 6 Small amplitudes within the resistance zone weeks he is still the same and discusses the are used to improve stiffness of the neural problem with his GP who refers him to a tissue and to influence scar tissue and specialized physiotherapy and manual intraneural oedema (van den Berg 1999, therapy clinic (Fig. 18.5a). Abenhaim et al 2000). Following the subjective and physical ● Time and duration. examination a subacute peripheral ● Passive or active: As mentioned above, a neuropathy of the facial nerve is diagnosed. Additionally, the patient fears worsening of passive technique is preferred initially since the symptoms and does not appear well the dosage and impact are more easily con- informed. Therefore it was decided to use trolled by the therapist. mainly cranioneurodynamic techniques ● Target tissue test and/or rehabilitation: The accompanied with information and a therapist needs to control the function of thorough patient management with long the target tissue of the treated nerve and and short appointments. might need to include its functional rehabilitation. CASE STUDIES In this part of the chapter, two case studies are presented that show dysfunction of the cranial nervous system: one is of a patient with acute tissue injury and cranial neuro-

564 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ab Fig. 18.5 A 68-year-old patient with a subacute peripheral neuropathy of the facial nerve. a Stable condition during treatment. b Six weeks after treatment. Starting position action concept, see Chapter 1). In this case No matter which technique is used, a pain- the main dysfunctions were found on free ‘out of tension’ position is chosen. For rotation about the transverse axis of the this patient craniocervical extension, right temporal bone and some scar tissue in ipsilateral lateroflexion and relaxed facial front of the ear. These dysfunctions were muscles are suggested. treated by cranial mobilization of the temporal region and by stretching techniques Indirect passive techniques around the scar tissue. The most important neural containers that Direct techniques might be the potential source of facial nerve dysfunction are assessed. In this case the ● Proximal component: During the physical temporal and petrous bones, potential examination a minimal stiffness was found scarring and the facial muscles are included. on craniocervical flexion and lateroflexion Which technique is applied depends entirely to the right. Proximal techniques were on the signs and symptoms and the clinical therefore not the first choice. reasoning process of the therapist (wise

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 565 ● Sliders: ‘Distal’ sliders without discomfort neurodynamic mobilization of the facial or pain and lateroflexion to the right nerve, improved oral muscle activity in alternated with activation of the facial various neurodynamic positions. muscles might be a good technique for this patient if the neural container Target tissue re-education techniques reduce the physical signs and symptoms. In this case the technique The salivary glands can be exercised by proved to be very helpful. dripping lemon juice onto the tongue. The patient is asked to note the amount of saliva ● Order: Initially the facial muscles are production and to compare it before and activated without neural tension (upper after treatment with the non-affected side. cervical extension, lateroflexion to the The amount of lemon juice is increased with symptomatic side). During muscle time and the resting time between relaxation the therapist gently moves the stimulation is shortened. head into lateroflexion to the left. In particular, the orofacial muscles can be ● Dosage: In the subacute phase the facilitated in various neurodynamic positions. technique is initially performed ‘out of For example, craniocervical extension and resistance’ and without perceived ipsilateral lateroflexion helped this patient to discomfort. The duration is variable: it pull up the right side of his mouth. However, should not be performed for too long as endurance training was required, he (minutes) but also for no less than 10 exercised this activity in frequent repetitions. seconds. The position was chosen during Facilitation of the hypoglossal muscles and the neurodynamic testing procedure. If the the tongue may also contribute to facial treatment duration was too long, even muscle activity improvement. The patient was though it was performed pain-free, it may taught to gently press his tongue against the drastically change the symptoms roof of his mouth while practising, which immediately or cause neurogenic immediately improved the activity of the inflammation so that the symptoms will orofacial muscles. worsen over the following days. Only the optimum dosage of input will facilitate Home exercises improvement during the subacute state (Rosen 1981, van den Berg 1999, Stelnicki The described neurodynamic sliders and et al 2000). target tissue exercises were discussed and practised. The number of repetitions ● Other nerves: Directly related nerves depended on the phase of the treatment and such as the trigeminal nerve (pain and the effect of the exercises. facial muscles) and the vagus (X), glossopharyngeal (IX) and hypoglossal Results (XII) nerves should be assessed on both the affected and the unaffected side. The patient soon lost his feeling of Should they present any dysfunctions they hopelessness when he realized that after the may be integrated into the treatment. This first week his muscle function had clearly patient did not show any dysfunctions. improved due to the neurodynamic unloading of the facial nerve and the tongue facilitation Treatment by palpation technique. Progression of the treatment included an increase of repetitions for each Transverse movement of the auricular exercise: the neurodynamic mobilization and posterior nerve and the proximal portion the palpation mobilization. After the third of the buccal nerve in a position of slight treatment the neurodynamic tension was neurodynamic tension, plus slight pressure increased and target tissue exercises on the nerve while performing gentle enhanced.

566 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT The prognosis was good since this well- The spontaneous contractions of the motivated patient reduced his fear and his masticatory and facial muscles and the physical dysfunctions after only two headaches occurred with delay (Fig.18.6b). treatment sessions. After 6 weeks (two Neck flexion is limited by a protective muscle sessions per week) his situation was stable spasm. During the standard slump test the and he only retained some problems of same symptoms as when correcting the neck muscle activity around his mouth when he posture were provoked in an ‘on/off’ manner. felt tired (Fig. 18.5b). Based on these results the clinical pattern matches ‘tic douloureux’ (Breig 1978). In this Retrospectively it can be concluded that pathology the physical dysfunction of the neurodynamic treatment within a cranioneural tissue including the trigeminal biopsychosocial concept was what this nerve plays an important role. The situation patient needed for his pathology that usually is stable and not irritable. The behaviour of shows a high percentage of self-healing the symptoms shows an ‘input mechanism’. A (Honda et al 2002). suggested physiotherapy treatment focusing on neurodynamic techniques is described Case study 2 below. Previous history Starting position A 38-year-old car mechanic had surgery 4 If an indirect technique is chosen and the years ago to remove an acoustic neuroma signs do not change after the first session, in the cerebellopontine angle (CPA) that the techniques in the second session may be was detected because he suffered from performed in neurodynamic tension: headaches and toothache as well as craniocervical flexion and lateroflexion. hypertonic masticatory muscles, swallowing and balance dysfunctions and tinnitus. After Indirect technique the operation the symptoms were reduced significantly and he returned to work. Three The main neural containers – in this case the years later, for no obvious reason, he occipital bone, the craniocervical region experienced new symptoms such as diffuse (suboccipital scarring due to surgery), deep headaches, deep toothache near the sphenoid bone and the mandible (neural mandible and neck stiffness on flexion container of the trigeminal nerve) – need to activities (e.g. getting into his car, reading, be assessed for dysfunction and treated if putting on his shoes). Furthermore he necessary. showed an involuntary muscle contraction (‘tic’) when his head was placed in a certain Direct techniques position. Acupuncture every 2 weeks helped Sliders and tensioners initially but no longer has any effect, which is getting him worried. The neurologist claims In this case a combination of ‘sliders’ and that a second operation will not help and ‘tensioners’ is suggested, since intracranial that medication is his only choice. scarring of the dura and other connective tissue structures (e.g. falx cerebri and During the physical examination tentorium) is suspected. components of neurodynamic tests clearly provoked his symptoms. His head is Proximal components constantly held in craniocervical extension One might start immediately with the and lateroflexion towards the symptomatic proximal components which include side (Fig. 18.6a). Correction of this position depression/elevation of the shoulder, sets off his ‘tic’. sideglides (Elvey 1986) and/or mandibular depression/laterotrusion. If these techniques do not show the desired effect, cranial flexion and lateroflexion can be undertaken.

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 567 ab Fig. 18.6 A 38-year-old patient with physical dysfunction of the cranioneural tissue. a Head position of the patient prior to treatment. Elevated tension of the neck and facial musculature is noteworthy. b Correction of posture provokes tension and pain. Sequence of movements ● Mandibular laterotrusion, craniocervical Since the problem appears to include flexion, lateroflexion and LSS. cranioneurodynamic components, one should start with the proximal component, Dosage craniocervical flexion and lateroflexion. During the treatment the therapist has to be Combinations and order of sliders and prepared to move into resistance but to also tensioners that were applied in this case respect the patient’s symptoms. Therefore the study were: therapist needs to continuously communicate verbally or non-verbally with the patient to ● Craniocervical flexion, lateroflexion and confirm that the symptoms are bearable for lumbar/thoracic flexion in sitting the patient. Neurological signs such as paraesthesia, numbness, cramping or ● Craniocervical flexion, lateroflexion and fasciculations should not be provoked. shoulder depression in supine The frequency and duration depend on ● Craniocervical flexion, lateroflexion and the patient’s or the therapist’s capacities. long sitting slump (LSS) One would think in minutes rather than in

568 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT c d Fig. 18.6—cont’d (XII) nerves did not show any signs or c Passive neck flexion prior to treatment. symptoms. The intracranial tissue of the d Passive neck flexion 6 weeks after treatment. suboccipital region could obviously not be palpated. seconds, since a morphological change of a non-irritable situation is desired. Target tissue re-education Other nervous tissue Static and dynamic coordination of the Other cranial nerves that should be included masticatory muscles (trigeminal nerve) and are the facial nerve due to the patient’s the facial muscles are assessed before and mimic expressions and the similar intracranial after neurodynamic treatment. If quality and anatomical location with the trigeminal endurance of the activity improves, the nerve; also the vestibulocochlear and activity is automatically part of the home hypoglossal nerves because of the previous exercise regime. history with the acoustic neuroma and the experienced symptoms (tinnitus and balance Home exercises and swallowing dysfunctions). If a neurodynamic technique results in an Treatment technique: palpation improvement that persists until the following Palpation of the peripheral branches of the trigeminal (V), facial (VII) and hypoglossal

Treatment guidelines for neurodynamic techniques and palpation of the cranial nervous system 569 session this neurodynamic technique is looking forward to his return to work. Some adapted as a home exercise. For this patient sessions of acupuncture improved the ‘tic’ this included: and 8 weeks after the initial treatment the patient returned to work full time. ● Craniocervical flexion and lateroflexion in sitting; sliders alternated with tensioners SUMMARY ● Craniocervical flexion and knee flexion in ᭿ Various possibilities for LSS; sliders alternated with tensioners. cranioneurodynamic mobilizations are described and their advantages and Target tissue exercises as described above are disadvantages are discussed. also integrated into the patient’s home Furthermore, active versus passive activities. techniques and direct versus indirect techniques are presented. Results ᭿ There is no 'recipe' for treatment method After six sessions over 5 weeks the symptoms and dosage when treating were reduced dramatically. Headaches and cranioneurodynamic dysfunctions and toothache showed reduced intensity and pathologies. frequency after 3 weeks although the patient initially experienced exacerbated symptoms ᭿ Due to the lack of scientific data in this for 24 hours after the first two sessions. The relatively new field, the therapist needs perceived neck stiffness on flexion improved to rely on open models of thinking such at the same time. Objectively, a greater range as clinical reasoning skills. Some of movement was noted on craniocervical treatment choices are presented in two flexion (Fig. 18.6c,d). The ‘tic’ occurred less case studies. frequently but worsened in stressful situations. Nevertheless, the patient was References Butler D, Shacklock M, Slater H 1994 Treatment of altered nervous system mechanisms. In: Boyling J, Abenhaim L, Rossignol M, Valat J et al 2000 The role Palastanga M, Grieve S (eds) Modern manual of activity in the therapeutic management of back therapy, 2nd edn. Churchill Livingstone, pain. Spine 25:1 Edinburgh Austermann K 2002 Frakturen des Gesichtsschädels Elvey R 1986 Treatment of arm pain associated with (Mittelgesichtsfrakturen) In: Schwenzer N, abnormal brachial plexus tension. Australian Ehrenfeld M (eds) Spezielle Chirurgie, Zahn-, Journal of Physiotherapy 32:225 Mund-, Kiefer-, Heilkunde, Bd. 2. Thieme, Stuttgart, p 339 Elvey R 1997 Physical evaluation of the peripheral nervous system in disorders of Bogduk N 1981 An anatomical basis for the neck– pain and dysfunction. Journal of Hand Therapy tongue syndrome. Journal of Neurology, 10:122 Neurosurgery and Psychiatry 44(3):202 Gavilán J, Gavilán C 1986 Recurrent laryngeal nerve. Breig A 1978 Adverse mechanical tension in the Identification during thyroid and parathyroid central nervous system. Almqvist and Wiksell, surgery. Archives of Otolaryngology, Head and Stockholm Neck Surgery 112:1286 Butler D 1991 Mobilisation of the nervous system. Gifford L 1998 Neurodynamics. In: Pitt-Brooke J, Reid Churchill Livingstone, Melbourne H, Lockwood J, Kerr K (eds) Rehabilitation of movement: theoretical basis of clinical practice. Butler D 2000 The sensitive nervous system. NOI Saunders, London, p 159 Press, Adelaide Butler D, Moseley L 2003 Explain pain. Noigroup Publications, Adelaide

570 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Harding V 1997 Application of the cognitive- Okeson J 2005 Bell´s orofacial pains, 6th edn. behavioural approach. In: Pitt-Brooke J, Reid H, Quintessence, Chicago, p 435 Lockwood J, Kerr K (eds) Rehabilitation of movement: theoretical basis of clinical practice. Ramachandran V, Blakesee S 1998 Phantoms of the Saunders, London, p 540 brain. William Morrow, New York Honda N, Hato N, Takahashi H et al 2002 Rosen J M 1981 Concepts of peripheral nerve Pathophysiology of facial nerve paralysis induced repair. Annals of Plastic Surgery 7(2): by herpes simplex virus type 1 infection. Annals 165–171 of Otology, Rhinology and Laryngology 111:616 Rosenfeld M, Gunnarson R, Borenstein P 2000 Early Jabre J 1994 ‘Nerve rubbing’ in symptomatic intervention in whiplash-associated disorders. treatment of ulnar nerve paraesthesiae. Muscle Spine 25:1782 and Nerve 17:1237 Shacklock M 2005 Clinical neurodynamics. A new Kaas J, Florence S, Jain N 1999 Subcortical system of musculoskeletal treatment. Elsevier, contributions to massive cortical reorganisations. Edinburgh Neuron 22:657 Stelnicki E J, Doolabh V, Lee S et al 2000 Nerve Kwan M, Wall E, Massie J, Garfin S 1992 Strain, dependency in scarless fetal wound healing. stress and stretch of peripheral nerve. Rabbit Plastic and Reconstructive Surgery 105(1): experiments in vitro and in vivo. Acta 140–147 Orthopaedica Scandinavica 63:267 Van den Berg F 1999 Angewandte Physiologie: Lang J 1995 Skull base and related structures: atlas Das Bindegewebe des Bewegungsapparats of clinical anatomy. Schattauer, Stuttgart, p 31 verstehen und beeinflussen. Thieme, Stuttgart, p 215 Maitland G, Banks K, English K, Hengeveld E 2000 Vertebral manipulation, 6th edn. Butterworth- Von Piekartz H 2001 Neurodynamics of Heinemann, Oxford cranial nervous tissue (cranioneurodynamics). In: von Piekartz H, Bryden L (eds) Craniofacial Nathan P, Keniston R 1993 Carpal tunnel syndrome dysfunction and pain, manual therapy, and its relation to the general physical condition. assessment and management. Butterworth- Hand Clinics 9:253 Heinemann, Oxford, p 116

571 Chapter 19 Headaches in children: the state of the art Harry von Piekartz CHAPTER CONTENTS INTRODUCTION Introduction 571 Headaches are a growing problem in our society (Brna et al 2005). Therapists frequently The nature of the problem 571 find themselves stuck for an adequate answer to a seemingly simple syndrome such as juve- Pain: definitions and categories 572 nile headache. A detailed analysis has become necessary and frequent support from other The International Classification of Function medical disciplines is required. Some patients/ (ICF) 573 parents might turn to ‘therapy shopping’ as a consequence, which for many is a frustrating The child and its experiences with and unsatisfactory process (Überall 1999). This headaches 574 chapter aims to expand the knowledge of ther- apists about current research, epidemiological Some critical comments on the prevalence, pathophysiology and contributing International Headache Society (IHS) factors to headaches in children. In Chapter 20, classification 575 recommendations for the subjective and the physical examination as well as the manage- Primary and secondary headaches 577 ment of this problem are discussed. Hypothesis categories and recurrent juvenile headaches 579 THE NATURE OF THE PROBLEM Epidemiology The prevalence of headache in children has increased considerably during the past 30 years. Between 10 and 20% of preschool children complain of headaches (Pothmann et al 2001). Frankenberg et al (1992) examined 7000 German pupils with headaches: they classified 60% as tension headaches and approximately 12% as migraines; 30% of the headaches could not be clearly classified.

572 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Dutch researchers (Van Duin et al 2000) inter- non of pain itself. The International Associa- viewed 2691 children under the age of 18 as tion for the Study of Pain (IASP), a worldwide well as their parents and concluded that: organization of experts from various disci- plines, defined pain in 1994 as: ● 46% of 6–16 year old children had head- aches more than twice a year. However, ‘an unpleasant sensory and emotional these children did not perceive their head- experience associated with actual or potential aches as a serious problem. tissue damage or described in terms of such damage’ (Classification of chronic pain, task ● 9% had disabling headaches and children as force of taxonomy, IASP Press, 1994). well as parents agreed that the medical pro- fession was unable to give these children This definition underlines the importance of adequate attention. personal experience in the individual’s pain perception. The following dimensions of ● 10% had to discontinue sport or games; pain have been described (Melzack & Katz 2% took time off sport more than once a 1994): month. ● The sensory–discriminative dimension, e.g. ● By applying the diagnostic criteria of the area, intensity, behaviour of pain International Headache Society, 56% of these headaches could not be clearly classified ● The affective–motivational dimension, e.g. and belong to the category 'normal' or rage, anxiety, fear ‘unspecific’ headaches. ● The cognitive–evaluative dimension, e.g. Another Dutch study examining 2358 pupils thoughts and beliefs. between the ages of 10 and 17 years found that 21% of the boys and 26% of the girls in elemen- These dimensions vary from person to person tary schools and 14% of the boys and 28% of with regard to their individual interpretation the girls in secondary schools had headaches and proportion. They reflect dynamic patho- at least once a week. Comparing these findings biological processes. Children process their with a study from 1985, a 6% increase in the sensomotor inputs by applying the same weekly complaints of headaches can be found dimensions but in a more straightforward and (Bandell-Hoekstra et al 2001). simple way (Skoyles 2006). There is evidence that children with migraines demonstrate a Most studies note a higher prevalence in different affective–motivational dimension girls (Deubner 1977, Linet & Stewart 1987, Wang from children without migraines (McGrath & et al 2005). An average age for the onset of Hillier 2001). A summary of pain mechanism migraines remains unknown. Sillanpää (1983) and pain perception categories is represented claims, after assessing and reassessing 2291 in the diagram by Melzack and Katz (1994) children from age 0 to age 7, that 20% of (Fig. 19.1). migraine headaches begin between these ages. In most cases it is helpful for the therapist to find out how the child describes its pain. The occurrence of classic migraine is highest For example, children under the age of 5 at the ages of 7–13 years (McGrath & Hiller frequently identify their headaches as stomach 2001). Fifty per cent of juvenile migraine ache. patients will continue to have migraines in adulthood (Bille 1981). Emotions and cognition of the child are sometimes expressed in dramatic drawings PAIN: DEFINITIONS AND packed with expression. For example, Figure CATEGORIES 19.2a is a drawing made by an 8-year-old girl who describes her headaches as being like a Since we are discussing children with pain, the pony, which is tied firmly to a fence, that following are some thoughts on the phenome- stamps with its hoofs. Another example shows

Headaches in children: the state of the art 573 Associated with input PAIN Cognitive/ Nociceptive evaluative Peripheral neurogenic Sensory/ discriminative Associated with processing Associated Affective/ with output motivational Fig. 19.1 Overview of pain mechanisms and individual pain experience (reproduced with permission from Melzack and Katz 1994). how a 12-year-old boy perceives his headaches a as being as if a knife stabbed into his brain. He also shows an unusual fear of weapons which could be due to the experience of his brother threatening him with a knife (Fig. 19.2b). THE INTERNATIONAL CLASSIFICATION OF FUNCTION (ICF) The World Health Organization (WHO) has proposed a classification of functions (ICF). Therefore the clinical examination of the child should also include a multidimensional func- tional examination. The proposed model is based on the ICF and can easily be adapted for the examination of children with headaches. It is followed by an overview of the definitions found in the current literature (see also Chapter 1). Impairment (tissue damage) There is loss or deviation from the norm in the emotional, physiological or anatomical struc- ture or function, for example skull asymmetry or divergence of the eyes. Level of activity b This shows impairment of ability to perform a Fig. 19.2 Children’s depiction of headache. physical action, activity or task in a way that is a Picture by an 8-year-old girl who describes her efficient, typically expected or competent, for example lack of concentration and difficulties pain as a tethered pony stamping on the ground. studying (Fig. 19.3). b A 12-year-old boy experiences pain as a knife being stabbed through his head.

574 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Pain ? Healthy Headache Activity level Rheumatology Cancer 90 PedsQL 4.0 scores ? ? Impairment 80 Fig. 19.3 With juvenile headaches there is 70 frequently no direct relationship of pain, dysfunction/impairment and activity level. 60 Total Physical Emotional School score health functioning functioning Psychosocial Social health functioning a PedsQL 4.0 subscales Participation Healthy Headache Rheumatology Cancer Limitation of function within a certain social 90 context and/or physical environment, for PedsQL 4.0 scores example the child backs away from sport 80 activities and is happiest playing on its own. 70 The literature on chronic pain emphasizes that there is no proportional relation of pain, 60 Emotional School tissue damage and function in longstanding Total Physical neuromusculoskeletal pain disorders (Waddell 1998). It is concluded from a survey study score health functioning functioning (Pediatric Quality of Life Inventory – PedsQL 4.0) conducted on 572 children with primary Psychosocial Social headache aged 8–15 years that headaches sig- nificantly affected their health (quality of life, health functioning QOL) (Powers et al 2003; Fig. 19.4). The impact of headaches on QOL appears to be similar to b PedsQL 4.0 subscales that found in other chronic illness conditions such as rheumatoid diseases and cancer. Of Fig. 19.4 Pedsol 4.0 child self-report scores across all impairments at school and in emotional disease groups. functioning, headache is the most prominent a Data presented for healthy children, children with (Powers et al 2003). This is also true for long- standing headaches in children. The conse- headaches, and children with rheumatoid diseases quence is that it can sometimes be difficult for and cancer. The full range of the PedsQL 4.0 is the therapist to evaluate and to manage the 0–100. This figure uses a more limited range pain and behaviour of the child (McGrath presentation (reproduced with permission from 2001) (see Fig. 19.3). Powers et al 2003). b Pedsol 4.0 parent-report scores across disease THE CHILD AND ITS EXPERIENCES groups with the same parameter as used in WITH HEADACHES Figure 19.4a (reproduced with permission from Powers et al 2003). Forty per cent of children and adolescents describe headaches as the main reason for suf- medical disease (McGrath 2001). Disability can fering and disability in their day-to-day life, be quantified by days off school and the amount although the medical system classifies their of painkillers taken (Martin-Herz et al 1999). symptoms as a dysfunction and not as a Girls seem to suffer more than boys (Bille 1981, Frankenberg et al 1992). Adolescents frequently claim that their social peers misunderstand their headache problems and this makes them feel isolated (McGrath 2001). For a better com- prehension of the clinical features of juvenile headaches, the general characteristics of juve-

Headaches in children: the state of the art 575 nile headache will be briefly discussed in the ● Migraine and tension headaches are code following paragraphs. numbers 1 and 2 of the ICHD-II, indicating that they the highest in the hierarchy of General characteristics of juvenile headache types. headaches ● Migraine headache in childhood (code 1.3) The properties of headache, including accom- is a separate entity. panying symptoms, vary from child to child. The most common characteristics of juvenile ● Migraine headache is promoted to stage headache are described below. 3 instead of stage 5 in the ICHD-I (IHS 1988). PAIN PATTERN SOME CRITICAL COMMENTS ON THE INTERNATIONAL HEADACHE ● Time and intensity: Pain is usually experi- SOCIETY (IHS) CLASSIFICATION enced over several hours (1–6 hours). Inten- sity can be measured using a coloured The current literature criticizes the Interna- analogue scale (CAS) and has an average tional Classification of Headache Disorders value of 5.9 (McGrath & Koster 2001). (ICHD), published in 1988, as being outdated, claiming that the system does not account for ● Localization: Typical localization is frontal all types of juvenile headache. and temporal. Some facts: ● Quality: Mostly throbbing, dull pain; booming and pulsating in younger ● Maytal stated that 92.4% (high sensitivity) of children. children without migraine were classified correctly but that this was only the case for CONCOMITANT SYMPTOMS 27.3% of migraine patients (low specificity). He concluded that the IHS criteria do not Most children have typical concomitant symp- necessarily apply for children with head- toms such as nausea and vomiting, which are aches (Maytal et al 1997, Viswanathan et al a criterion for migraine; nausea is often not 1998). present during an attack. ● Wöber-Bingöl et al (1996) evaluated the DISABILITY validity of the IHS classification in 156 children and adolescents who had been The majority of children do not consider their diagnosed as tension headache patients. headache to be a significant day-to-day They came to a similar result, with the IHS problem. For this reason parents may also not classification showing a high sensitivity seek help for a first mild attack of headache in and a low specificity (Wöber-Bingöl et al their children. This can then become a contrib- 1996). uting factor for chronic headache (McGrath 2001). It can be construed that the IHS and other clas- sification systems do not give a clear indication Diagnostic classification of juvenile of the aetiology of primary headache in chil- headache dren. At present, Olesen’s (1997) modified rec- ommended classification is used clinically, for The classification of juvenile headache is based which the intensity and number of symptoms on the recommendations of the International present are adjusted (Table 19.2). Headache Society (IHS) (Soyka 1999). The majority of headaches belong to the two main In 2004, the second edition of the Interna- categories: migraine and tension headaches. tional Classification of Headache Disorders (ICHD-II) was released. These criteria pro- Table 19.1 provides an outline of the diag- vided improved recognition of childhood nostic classification of the IHS (International Classification of Headache Disorders-II [ICHD- II], IHS 2004). Note that:

576 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Table 19.1 ICHD-II classification code and WHO ICD-10 code ICHD-II Diagnosis WHO ICD-10 1 Migraine G43.9 1.1 Migraine without aura G43.0 1.2 Migraine with aura G43.1 1.2.1 Typical aura with migraine headache G43.10 1.2.2 Typical aura with non-migraine headache G43.10 1.2.3 Typical aura without headache G43.104 1.2.4 Familial hemiplegic migraine G43.105 1.2.5 Sporadic hemiplegic migraine G43.105 1.2.6 Basilar-type migraine G43.103 1.3 Childhood periodic syndromes that are commonly precursors of migraine G43.82 1.3.1 Cyclical vomiting G43.82 1.3.2 Abdominal migraine G43.820 1.3.3 Benign paroxysmal vertigo of childhood G43.821 1.4 Retinal migraine G43.81 1.5 Complications of migraine G43.3 1.5.1 Chronic migraine G43.3 1.5.2 Status migrainous G43.2 1.5.3 Persistent aura without infarction G43.3 1.5.4 Migrainous infarction G43.3 1.5.5 Migraine-triggered seizures G43.3 1.6 Probable migraine G43.83 1.6.1 Probable migraine without aura G43.83 1.6.2 Probable migraine with aura G43.83 1.6.5 Probable chronic migraine G43.83 2 Tension-type headache (TTH) G44.2 2.1 Infrequent episodic TTH G44.2 2.1.1 Infrequent episodic TTH associated with pericranial tenderness G44.20 2.1.2 Infrequent episodic TTH not associated with pericranial tenderness G44.21 2.2 Frequent episodic TTH G44.2 2.2.1 Frequent episodic TTH associated with pericranial tenderness G44.20 2.2.2 Frequent episodic TTH not associated with pericranial tenderness G44.21 2.3 Chronic TTH G44.2 2.3.1 Chronic TTH associated with pericranial tenderness G44.22 2.3.2 Chronic TTH not associated with pericranial tenderness G44.23 2.4 Probable TTH G44.28 2.4.1 Probable infrequent episodic TTH G44.28 2.4.2 Probable frequent episodic TTH G44.28 2.4.3 Probable chronic TTH G44.28 headache in the migraine (primary headache) ● Pain localization can be bifrontal or group. The important criteria are: bitemporal. Occipital pain requires further assessment. ● Expanded duration of attacks from 1 to 72 hours, but still possessing the features of a ● Migraine-associated symptoms include throbbing or pulsating headache of moder- nausea or vomiting (or both), or light and ate to severe intensity with exacerbation sound sensitivity. Additionally, the criteria with physical activity. allowed for parental inference of these asso- ciated symptoms.

Headaches in children: the state of the art 577 Table 19.2 International Headache Society diagnostic criteria for migraine in children younger than 15 years of age Migraine without aura Migraine with aura At least five attacks At least two attacks Duration 4–72 hours At least two of the following: At least three of the following: ● Unilateral ● At least one fully reversible aura ● Pulsating quality ● Symptoms indicating focal, cerebral, cortical ● Moderate to severe intensity ● Exacerbation by activity or brainstem dysfunction ● At least one aura symptom developing gradually At least one of the following: ● Nausea, vomiting or both for > 4 minutes or > 2 symptoms in succession ● Photophobia or phonophobia ● No aura > 60 minutes ● Headache begins before, simultaneously, or within 60 minutes of aura Adapted from Olesen (1997). Recent reliability studies of the ICHD-II the IHS definitions is more difficult than for suggest that, in idiopathic headache in child- primary headache (Überall 1999). ren under 6 years of age, the ICHD-II is too restrictive for migraine with aura and tension There is evidence that secondary headaches headache (Balottin et al 2005). The same con- might be caused by, for example, maxillary clusion is made in chronic headache in chil- sinusitis or impaired vision. Otitis media dren under 16 years of age (Wiendels et al (middle ear infection) or musculoskeletal dys- 2005). In addition, a recent study on the sensi- functions are possible causes for migraines tivity of ICHD-II in paediatric migraine sug- and tension headaches. Existing headache gests further revisions and modifications symptoms can be made worse by these impair- (Hershey et al 2005). ments (Pothmann et al 1994, 2001). PRIMARY AND SECONDARY A number of juvenile headache syndromes HEADACHES cannot be categorized by current classification systems. It has been observed clinically that A headache is called a primary headache if the many children with headaches also show mechanisms and the nature of the problem are accompanying symptoms such as motor, directly responsible for the symptoms. Exam- balance and psychosocial problems. Many of ples of primary headaches are migraines and these disorders are associated with the tension headaches (codes 1–4 of the ICHD-II). craniocervical region and with scoliosis and hip displacements (Biedermann 1999, 2004). Secondary headaches (code 5 of the ICHD-II – headache attributed to head and/or neck In summary it can be concluded that the trauma – and above) are headaches due to aetiology of juvenile headaches (primary, sec- indirect causes and mechanisms, suggesting ondary and mixed) is not fully understood and that the IHS consider this to be a less common there is to date no precise classification sys- category of headaches. It has also been shown tem. To fully comprehend children’s pain that classification of secondary headache using experience and the resulting pain behaviour, multicausal and integrative clinical reasoning of the treating therapist is required. The so called ‘onion-ring model’ by Loeser (1980) that

578 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Fig. 19.5 Biopsychosocial levels of pain experience for longer, her family doctor prescribed (according to Loeser 1980). antibiotics. Now, at 16 years of age, she still suffers from regular ear pain and headaches. is frequently used to explain complicated long- standing pain, as found in fibromyalgia and A year ago, the specialist undertook non-specific low back pain, can also be helpful several diagnostic procedures including x- for the assessment of juvenile headache suffer- rays, computed tomography and clinical ers (Fig. 19.5). examination, but did not find any residual inflammation (nociception). Nevertheless, The described headache dimensions can Elena claims that she suffers at least 10 also be applied to juvenile headache syn- acute episodes of head and ear pain each dromes. In order to completely understand year. Her behaviour when she gets the pain is and correctly assess an existing pain problem, similar to that of her parents: she believes the therapist needs to follow several hypo- the problem will get worse (cognition) and theses that represent the various aspects of feels anxious for that reason (emotion). She the pain problem. Case study 1 explains always wears warm jumpers during the this procedure. painful episodes, even in summer, and tells everyone not to come too close because they Case study 1 might catch her germs (behaviour, social contacts). She usually stays at home for a Elena is a 16-year-old girl who suffered from couple of days because she believes this is recurrent ear infections (nociception) essential to her recuperation. When at home, between the ages of 6 and 10 years. Her she stays up later than usual which she parents were told by the ENT doctor and by enjoys. When she does this, she knows that other parents to keep Elena away from water, the pain will be gone within 2 days, so she noise and cold wind. Whenever she started to does not need painkillers (cognition). complain of ear pain they wrapped her up warm, worrying that the symptoms might Clinical thoughts otherwise get worse. She was not allowed to go horse riding or join her usual gymnastics This example shows that Elena has learned class. Her parents made her stay at home from her parents’ behaviour and its positive whenever she was feeling ill. Usually the ear consequences (freedom from pain). The pain went away after a week and she did not positive effect is possibly that she continues need to take antibiotics. If the pain remained to apply the same coping strategies as when she was aged between 6 and 10 years. She does not know any other strategy than this, and it has always been successful. Why should she change anything when it eases her pain? She probably still believes that her symptoms are caused by inflammation, because the pain is the same. According to Loeser, the therapist will need to assess all levels of the pain experience. There is evidence that chronic ear infections at school age can cause morphological changes of the cranium leading to stress transducing dysfunctions. These are contributory factors for unilateral ear pain (Oudhof 2001, Spermon-Marijnen &

Headaches in children: the state of the art 579 Spermon 2001). The mucosa of ear and nose Contributing factors have been defined as: might also sensitize the nervous system without themselves being inflamed (Okeson ‘any predisposing factor involved in or 2005). A thorough manual therapy directly responsible for the development or assessment is certainly indicated but coping persistence of a patient problem’. This includes strategies and emotional factors (fear) should psychosocial, genetic, anthropometric and also be considered, and management ergonomic factors (Gifford 1998, Butler 2000). strategies for these applied if necessary. These might be found in various different HYPOTHESIS CATEGORIES AND fields, for example in biomechanics, the envi- RECURRENT JUVENILE HEADACHES ronment or psychology. These factors are also called ‘yellow flags’ (Gifford 1999, McGrath & As mentioned above, the aetiology of juvenile Koster 2001). headaches remains unknown (McGrath 2001). Multistructural and multicomponent influ- Some contributing factors have been ences are often difficult to identify. The logical described explicitly for juvenile headache consequence is that there is no commonly patients. The most important are listed below. accepted plan for the diagnostic procedure in Contributing factors are categorized as: children with headaches. The only option for the therapist is to work in collaboration with ● History the child and its parents, to include the parents’ ● Emotional and psychological influences views in the therapeutic decision-making ● Acquired factors process, to aim for mutual goals and to agree ● Daily life activities on management strategies. This procedure is ● Musculoskeletal factors called ‘collaborative clinical reasoning’ (Jones ● Growth factors. & von Piekartz 2001). The therapist’s role is one of a coach who guides the dynamic interaction HISTORY between parent and child. The task is to cate- gorize the information obtained, to consider ● Genetic: Prevalence rises by 64% if one clinical patterns and to evaluate its contents parent suffers from headaches and by 98% if according to hypotheses formulated (Jones & both parents suffer (Messinger et al 1991). von Piekartz 2001, Maitland et al 2001). This concept has been dealt with in greater detail in ● Bad general health, depression, malnutri- Chapter 1. tion and sleep disorders during childhood are predisposing factors for headaches later Contributing factors to recurrent in life (Aromaa et al 1998). headaches in children ● Children with a history of traumatic experi- One of the main topics in the literature about ences such as sexual, verbal, physical abuse, juvenile headaches is the role of contributing recurrent illnesses, death of a family member factors. To gain an insight into the aetiology or divorce of the parents, show a higher of the symptoms, to develop management prevalence of (chronic) facial pain syn- strategies and to be able to make prognostic dromes (Curran et al 1995, Goldberg et al decisions, the therapist needs to assess the con- 1999, Yucel et al 2002). tributing factors towards the individual head- ache syndrome. EMOTIONAL AND PSYCHOLOGICAL INFLUENCES ● Emotional factors such as anger caused by stressful situations at school and colds have an important role (Pothmann et al 1994). ● Daily hassles (Soyka 1999) and personality structures, such as hypersensitivity and anxious personalities, as well as depressive moods (Andrasik et al 1988).

580 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ● Neurovegetative instability, high ambitions nail biting) and children who talk a lot or and perfectionism have been shown to play a musical instrument might be at risk correlate with headaches (Vahlquist & of developing bruxism, clenching of the Hucknell 1949, Bille 1981). Children with jaws and headaches (Molina et al 2001). anxiety and depression have more frequent ● Atlanto-occipital dysfunctions in nursing headaches (principally migraine) than chil- children have been described as predispos- dren without these character traits; preva- ing factors for the development of headaches lence is higher among females than males later in life (KISS syndrome, Biedermann (Rhee 2005). 2001a). ● Posture (i.e. head forward posture) or irreg- ACQUIRED FACTORS ular breathing patterns combined with altered craniofacial morphology (Vig et al ● Influence of parental care on increase or 1981, Linder-Aronson & Woodside 2000) decrease of the symptoms. In the manage- have been put forward as ‘triggering factors’ ment of children with headaches the empha- for persistent headaches (see Chapter 21). sis often lies more on external influences such as air quality, nutrition, etc rather than GROWTH psycho-emotional factors like fear and aggression (Joffe et al 1983, Andrasik et al Juvenile headaches, especially migraines, can 1988). be accompanied by growth-dependent changes in the neurobiological processing of the brain. ● Model learning through copying the behav- This becomes apparent if the response to a iour of family members is contentious and repeated stimulus is too strong or lasts for too presumably not genetic (Überall 1999). long. Habituation is a protection from over- stimulation of the brain that sometimes does DAILY LIFE ACTIVITIES not act adequately and produces headache symptoms in some children (Kropp 2000). ● Sleeping habits can potentially influence headache symptoms. In particular, chronic SLEEP DISORDERS – ONE OF THE MAIN sleep deficits, irregular sleep, restless sleep CONTRIBUTING FACTORS or frequent short sleep periods throughout the day have been shown to contribute to There are different patters of interaction headache problems in adults and in chil- between headaches and sleep disorders: dren (Bruni et al 1997, Paiva et al 1997, Feikema 1999). ● Primary sleep disorder; headaches are usually secondary symptoms ● Bright sunlight and high temperatures are better, changes in air pressure, noise, crowds, ● Primary headaches which lead to sleep and excessive running during physical disorders activities are worse (McGrath & Koster 2001). ● Both problems are present but have separate pathological causes ● Greasy foods such as chocolate, eggs, nuts, cheese, as well as milk and wheat products, ● Headaches and sleep disorders with a strong affect the neurobiology of the juvenile interactive correlation. organism which might lead to headache symptoms (Dalton & Dalton 1979, Leviton A study by Paiva et al (1997) found that 55% of et al 1984). juvenile headache patients showed a signifi- cant sleep disorder. It was striking that head- ● Dehydration or caffeine intake in the ache children on average show shorter night evening (e.g. Coca-Cola, coffee) can poten- sleeping times and wake up more frequently tially influence headaches (Feikema 1999). than non-headache children. They also feel more tired in the mornings and do not settle ● Children with parafunctions of the temporo- to sleep as easily (Bruni et al 1997). Another mandibular joint or with chewing habits study describes a correlation of headaches (chewing gum, tongue biting, cheek biting,

Headaches in children: the state of the art 581 and sleep disorders with fear and depression Patricia McGrath, an American researcher (Kowal & Pritchard 1990, Passchier & Andrasik and psychologist, has investigated this special- 1993, Miller et al 2003). ized area for years and published a descriptive study, stating exactly which cognitive and Caffeine intake late in the day, dehydration, emotional factors can play a dominant role for long resting times during the daytime or recurrent headaches in children. watching television before going to bed might be directly responsible for sleep disorders A summary of the study with the following (Feikema 1999). Accompanying symptoms can topics is shown in Box 19.1: be (mainly for migraines): nightmares, sleep talking, restless sleep and bruxism (Bruni et al ● Cognitive factors 1997). ● Beliefs about pain control ● Emotional factors THE INFLUENCE OF COGNITIVE- ● Behavioural factors. EMOTIONAL-BEHAVIOURAL FACTORS Based on pain mechanism models a clear cor- In the literature it has been stated that emo- relation between input, output and processing tional and cognitive factors strongly influence factors becomes obvious. the behaviour of children with headaches. Box 19.1 Cognitive and affective factors that influence repetitive juvenile headaches Cognitive factors ᭿ Emotional suppression or denial of pressures ᭿ Beliefs about ethology ᭿ Fear of high achievement expectations ᭿ Patient and parents believe that the ᭿ Fear of a non-diagnosed condition ᭿ Fear of a life-threatening condition headaches have a certain cause ᭿ Fear of increasing symptoms and disability ᭿ Not understanding the primary and ᭿ Distress during a headache ᭿ Frustration that symptoms are unpredictable secondary causes ᭿ Frustration that activities are limited (child ᭿ Belief that the environment triggers the and family) symptoms ᭿ Not understanding why medicine cannot cure ᭿ Expectation that the headaches will be the headaches maintained in the future Behavioural features Lack of trust in pain control ᭿ Behaviour of child and parents during an ᭿ Little knowledge of possible medication ᭿ Little knowledge of alternative therapies attack ᭿ Belief that the child needs to rest or sleep ᭿ Inconsequent behaviour of the parents ᭿ Ineffective use of pain medication during an attack ᭿ Withdrawal from school, sports and social ᭿ Belief that no treatment will be successful ᭿ Beliefs about the influence of stress activities ᭿ Limited belief that stress might trigger the ᭿ Reduction of daily family activities ᭿ Reactions of the parents that promote illness symptoms ᭿ Limited knowledge of stress factors for the behaviour and stimulate limitations ᭿ Reactions of the parents to the recurrence of child ᭿ Little appreciation of high achievement headache symptoms ᭿ Primary confidence in medication expectations ᭿ Diagnostic assessment ᭿ Constant search for direct environmental Emotional (affective) factors ᭿ Specific stress situations (e.g. school, traffic, factors influencing the condition personal contacts)

582 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT A model of factors influencing ● Structured subjective assessment including recurrent juvenile headache pain measurements. The proposed model aims to represent the ● Assessment and treatment of physical current paradigms of the individual therapist dysfunction of the musculoskeletal system. and the physiotherapy profession in general, The changes seen in the reassessment are including knowledge and evidence from other also helpful parameters for parents as it disciplines. It is designed to support therapists, helps them to understand the treatment parents and patients in the process of analys- strategy. ing the dominant influences that have contrib- uted to the individual headache problem ● Proof that symptoms can be intentionally (Fig. 19.6). provoked and reproduced. Neuromusculoskeletal dysfunction and ● Development of a consistent ‘plan of action’ its relationship to juvenile headache for acute pain episodes. The neuromusculoskeletal system is a poten- ● Identify and desensitize stress increasing/ tial factor in headache which cannot be clearly inducing situations. diagnosed (around 30%) (Biedermann 2001b). Both clinical experience and the literature The therapist needs to gain an insight into the (Biedermann 1999, von Piekartz 2001) give multilayered components of the individual some key indications as to why the musculo- headache syndrome to ensure successful treat- skeletal system should be considered as an ment and management. important contributing factor to recurrent juvenile headache. In the author’s opinion SUMMARY neuromusculoskeletal impairment should also be considered in this model. ᭿ Although the prevalence of juvenile headache is increasing, its aetiology When following this model the therapist is remains unclear. The IHS does not guided towards the applicable assessment and appropriately classify juvenile headaches. management strategies: ᭿ Multifactorial influences such as posture, Cognitive Behaviour Affective stress, fear, daily routines and diurnal habits are potential contributing factors Neuro- Child Headaches for recurrent and ongoing headache musculo- • age syndromes. skeletal • sex dysfunction • cognitive level ᭿ A thorough insight into the • early pain pathobiological mechanisms as well as Situation the pain mechanisms, including experience emotional and cognitive factors of child • family learning and parents, are important for • culture assessment, treatment and management. Fig. 19.6 Work model for possible influences on ᭿ The neuromusculoskeletal system might juvenile headaches (modified from McGrath 2001). be a powerful contributing factor and should be incorporated into the clinical reasoning model.

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