Cervical Spine Manipulation Versus Sub-Occipital Muscle Release Technique in the Treatment of Tension Type Headaches

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How to cite this thesis

Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/ M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved from: https://ujcontent.uj.ac.za/vital/access/manager/Index?site_name=Research%20Output (Accessed: Date). Cervical Spine Manipulation versus Sub-Occipital Muscle Release Technique in the Treatment of Tension Type Headaches

A dissertation submitted to the Faculty of Health Sciences, University of Johannesburg, as partial fulfilment for the Master’s Degree in Technology, Chiropractic by

Craig Ross Orr (Student Number: 201201444)

Supervisor: ______Date: ______Dr C.J. Hay

DECLARATION

I, Craig Ross Orr, declare that this dissertation is my own, unaided work. It is being submitted as partial fulfilment for the Master’s Degree in Technology, in the program of Chiropractic, at the University of Johannesburg. It has not been submitted before for any degree or examination in any other University or Technikon.

______Craig Ross Orr

On this day the ______of the month of ______2018

DEDICATION

I would like to dedicate this to my Mother Jennifer Orr, without you this would not have been possible. Thank you for providing a solid foundation for me to grow and learn, for loving, supporting, encouraging and believing in me. You have always been my rock, through the tough times. Throughout this long journey, whenever I felt like giving up, you have given me the strength to keep going. You are the dream role model and mother that any child can ask for. Words cannot express how grateful I am for everything. I love you.

To Katherine Valkenburg, over the past two years you have supported me along my journey proving me with motivation to carry on. Your love and motivation has helped dearly throughout this time. Thank you.

To my special friends, Todd Page, Candice Bowes, Mathew Penny, Sebastian Moreli, Keegan and Tristan Shcut, words cannot express how grateful I am to you for everything. You are more than friends to me, you are my Family. Thank you for the unforgettable years, all the laughter, tears, good times and bad times. I love you.

ACKNOWLEDGEMENTS

To my supervisor, Dr Caroline Hay, thank you for all the guidance, effort and patience you have given through this process. Thank you.

To Juliana Van Staden from Statkon, thank you so much for your assistance. I truly appreciate it. Lastly, to the thirty participants, without you this would not have been possible. Thank you.

ABSTRACT

Objective: The aim of the study was to determine the efficacy of cervical spine chiropractic manipulation and muscle tension release technique of the sub occipital muscles in relieving tension-type headaches. This study was also used to determine which treatment protocol would be most effective in relieving tension-type headaches, cervical spine chiropractic manipulation, and muscle tension release technique of the sub occipital muscles or a combination of both treatment protocols.

Study design: A randomized clinical study was used in this research study.

Setting: University of Johannesburg, Chiropractic Day Clinic, Johannesburg, South Africa.

Subjects: A total of thirty participants were used, male and female, between the ages of 18-50 years. The participants were divided into three groups, with each group consisting of ten participants. Group A received cervical spine manipulations; Group B received muscle tension release technique of the sub occipital muscles and Group C a combination of cervical spine manipulation and muscle tension release technique of the sub occipital muscles . Methods: Prior to becoming a participant, each individual was assessed according to inclusion and exclusion criteria. Thereafter participants had to read and sign relevant information and consent forms. A full case history, physical examination and cervical spine regional examination was then completed.

Procedure: Subjective data was collected from the participants using the Numerical Pain Rating Scale, Headache Impact Questionnaire and the Neck Disability Index. Objective data was collected from the participants by using the Pressure Algometer. Objective and subjective data was collected prior to the 1st and 3rd treatment consultations and at the 5th final consultation. Each participant was treated four times, over a two week period. An additional 5th consultation was done to obtain objective and subjective data only.

Results: Statistically significant improvements regarding the Headache Impact Questionnaire, Numerical Pain Rating Scale, Neck Disability Index and Pressure Algometer occurred in all three groups. However in terms of intergroup analysis regarding the Headache Impact Questionnaire, Numerical Pain Rating Scale, Neck Disability Index and Pressure Algometer, no statistically significant improvements occurred, meaning that no group proved to be more superior to the others.

Conclusion: Based on the results obtained, it is suggested that cervical spine chiropractic manipulation, muscle tension release technique of the sub occipital muscles and a combination of the two treatments were effective treatment methods in relieving tension-type headaches. However, neither the cervical spine chiropractic manipulation, muscle tension release technique of the sub occipital muscles nor a combination of the two treatments was more effective in relieving tension-type headaches. Definitive conclusions could not be made in terms of intergroup analysis and therefore further research should be performed to yield more results on the comparison of all three treatment methods.

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TABLE OF CONTENTS DECLARATION...... ii AFFIDAVIT ……………………………………………………………………………………………….…….....iii DEDICATION...... ……….iv ACKNOWLEDGEMENTS...... v ABSTRACT...... vi TABLE OF CONTENTS...... viii LIST OF FIGURES...... xii LIST OF TABLES...... xiii LIST OF APPENDICES...... xiv

CHAPTER ONE - INTRODUCTION 1.1 Problem statement...... 1 1.2 Aim of study...... 2 1.3 Benefits of study...... 2

CHAPTER TWO - LITERATURE REVIEW 2.1 General overview of headaches...... 3 2.2 The cervical spine...... 3 2.2.1 Anatomy of the cervical spine...... 3 2.2.2 Intervertebral disc...... 6 2.2.3 Uncovertebral joints...... 7 2.2.4 Facet joints…………...... 7 2.2.5 Blood supply to the cervical spine ...... 8 2.2.6 Innervation of the cervical spine...... 9 2.3 Skeletal muscle...... 10 2.3.1 Anatomy of skeletal muscle...... 10 2.3.2 The muscle spindle...... 11 2.3.3 The Golgi tendon organ...... 12 2.3.4 Physiology of muscle contraction...... 13 2.4 The sub occipital muscles...... 14 2.4.1 Anatomy of the sub occipital muscles...... 14 2.4.2 Muscle attachments, innervation and function...... 15 2.4.3 The sub occipital triangle...... 15

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2.5 Myofascial trigger points...... 16 2.5.1 Definition of a myofascial trigger point...... 16 2.5.2 Classification of myofascial trigger points...... 16 2.5.3 Pathophysiology of myofascial trigger points...... 17 2.5.4 Myofascial trigger points in the sub occipital muscles...... 18 2.6 Tension-type headaches...... 19 2.6.1 Definition...... 19 2.6.2 Demographics of tension-type headaches...... 20 2.6.3 Pathophysiology of tension-type headaches...... 20 2.6.4 Myofascial trigger points as a primary cause of tension-type headaches…………..……….… 23 2.6.5 The relation of active sub occipital trigger points to tension-type headaches….………… 23 2.7 The vertebral subluxation complex…………………………………………………………….…..….. . 24 2.8 Chiropractic manipulation...... 27 2.8.1 Definition...... 27 2.8.2 The clinical effects of chiropractic manipulation...... 28 2.8.3 The neurophysiological effects of chiropractic manipulation...... 29 2.8.4 The effect of cervical spine manipulation on tension-type headaches...... 29 2.9 Muscle tension release technique...... 30 2.9.1 Definition...... 30 2.9.2 Physiological mechanisms of muscle tension release technique...... 30 2.9.3 Muscle tension release technique and active myofascial trigger points...... 32

CHAPTER THREE - METHODOLOGY 3.1 Introduction...... 33 3.2 Study design...... 33 3.2.1 Participant recruitment...... 33 3.2.2 Sample selection and size...... 33 3.2.3 Inclusion criteria...... 34 3.2.4 Exclusion criteria...... 34 3.2.5 Random group allocation...... 36 3.3 Treatment approach...... 36 3.3.1 Initial consultation...... 36 3.3.2 Method of treatment...... 37 3.3.3 Follow up Consultation…………………...... 38

3.4 Subjective and objective measurements...... 38 3.4.1 Subjective measurements...... 38 3.4.2 Objective measurements...... 39 3.5 Data analysis...... 40 3.6 Ethical considerations...... 41

CHAPTER FOUR – RESULTS 4.1 Introduction...... 42 4.2 Demographic data analysis...... 43 4.3 Subjective data analysis...... 44 4.3.1 Numerical Pain Rating Scale...... 44 4.3.2 Neck disability index...... 45 4.3.3 Headache Impact Questionnaire……………………………..……………….………………...... 47 4.4 Objective data analysis...... 49 4.4.1 Pressure Algometer...... 49

CHAPTER FIVE - DISCUSSION 5.1 Introduction...... 51 5.2 Demographic data...... 51 5.2.1 Gender distribution...... 51 5.2.2 Age distribution...... 52 5.3 Subjective data...... 52 5.3.1 Numerical Pain Rating Scale...... 52 5.3.2 Neck disability index...... 53 5.3.3 Headache Impact Questionnaire …………..…………………………………………………………54 5.4 Objective data...... 56 5.4.1 Pressure Algometer ……………...... 56

CHAPTER SIX - CONCLUSION 6.1 Conclusion...... 58 6.2 Recommendations...... 59

Referances...... 60

LIST OF FIGURES

Figure 2.1: Location of the cervical spine...... 4 Figure 2.2: Typical cervical vertebrae...... 4 Figure 2.3: Superior views of the Atlas C1 and Axis,C2…...... 5 Figure 2.4: The intervertebral disc and its components...... 6 Figure 2.5: Uncovertebral joints...... 7 Figure 2.6: Facet Joint Capsule...... 8 Figure 2.7: Anatomy of skeletal muscle...... 10 Figure 2.8: Muscle proteins...... 11 Figure 2.9: Muscle spindle and Golgi tendon organ...... 12 Figure 2.10: Cross bridge...... 13 Figure 2.11: Anatomy of the sub occipital muscles...... 14 Figure 2.12: Sub occipital triangle...... 15 Figure 2.13: Energy crisis hypothesis...... 17 Figure 2.14: Trigger points and pain referral pattern in the sub occipital muscle……………………...... 18 Figure 2.15: Flow diagram of the model for the pathogenesis of tension-type headaches……….……. 22 Figure 2.16: Sandoz’s model for joint range of motion...... 27 Figure 2.17: Neurophysiological mechanisms during post-isometric relaxation...... 31 Figure 2.18: Neurophysiological mechanism during reciprocal inhibition...... 32

Figure 3.1: Pressure Algometer...... 40

Figure 4.1: Line Graph representing the mean values of the NPRS for all three groups at the 1st, 3rd and 5th visits...... 44 Figure 4.2: Line Graph representing the mean values of the NDI for all three groups at the 1st, 3rd and 5th visits...... 45 Figure 4.3: Box and Whisper Graph representing the mean values of the HIT for all three groups at the 1st, 3rd and 5th visits...... 47 Figure 4.4: Line Graph representing the mean values of the pressure algometer for the sub occipital muscles in kg/cm2 for all three groups at the 1st, 4th and 7th visits...... 49

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LIST OF TABLES Table 2.1: Depicting muscle attachments, innervation and function...... 15

Table 3.1: Depicting pathologic headache warning signs...... 35

Table 4.1: Depicting the number, percentage and gender of the participants per group which participated in the study...... 43

Table 4.2: Depicting the age of participants whom participated in this study with regards to mean, minimum and maximum age per group...... 43

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LIST OF APPENDICES APPENDIX A: Advertisement APPENDIX B: Information form APPENDIX C: Consent form APPENDIX D: International Headache Society diagnostic criteria APPENDIX E: Contra-indications for Chiropractic manipulation APPENDIX F: Case history form APPENDIX G: Physical examination APPENDIX H: Cervical spine regional examination APPENDIX I: SOAP note form APPENDIX J: Numerical Pain Rating Scale APPENDIX K: Headache Impact Questionnaire APPENDIX L: Neck Disability Index APPENDIX M: Pressure algometer readings APPENDIX N: Ethics approval document APPENDIX O: Turnitin report

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CHAPTER ONE - INTRODUCTION

1.1 Problem Statement

Tension-type headaches are the most common type of headaches, having a lifetime occurrence of between 30% and 78% (Kaniecki, 2015), tension-type headaches are often associated with disruptions to daily activities, quality of life and work conditions (Chai, Rosenburg and Peterlin, 2012). Tension-type headaches are described as a bilateral tightening quality pain with a mild to moderate pain intensity (International Headache Society, 2004).

The pain experienced by the tension-type headaches may result in patients being incapable of performing daily duties or attending certain activities. Apart from the pain tension-type headache suffers may experience irritability, fatigue and muscle aching (Holroyd, Stensland, Michael, Lipchik, Hill, O’Donnell and Cordingley, 2000). Although tension-type headaches are the most common form of headaches, the causes of are not well understood, providing it to be quite difficult to treat tension-type headaches. It has been noted that sub occipital myofascial tissue is seen to be tender in patients with tension-type headaches, which is in direct relation to both the frequency and intensity of these headaches (Ashina, Bendsten and Ashina, 2012). Myofascial trigger points in the sub occipital muscles may be a cause or be associated with aggravating tension-type headaches however research is still required to validate this (Fernández-de-las-Peñas, Alonso-Blanco, Luz Cuadrado and Pareja, 2006).

Chiropractic manipulation has been shown to assist in increasing cervical spine mobility and decrease muscle dysfunction which is associated with pain and muscle spasms. Cervical spine manipulation specifically, has been noted to have an outcome that can be compared to first line prophylactic medications that are used for treatment in chronic tension-type headaches. Evidence suggests that chiropractic manipulation improves the symptoms of tension-type headaches, but more data is required to form a conclusion of the effect (Posadzki and Ernst, 2012).

The other type of treatment used within this study was myofascial tension release technique, which involves the neuromuscular inhibition, ischemic compression and positional release of a myofascial trigger point. This technique has been tested and shown as an effective technique in management of myofascial trigger points (Chaitow, 2006).

Neither cervical spine manipulation nor myofascial tension release technique have been tested in the treatment of trigger points, specifically the sub occipital trigger points, with regards to tension-type headaches.

1.2 Aim of this Study

The aim of the study was to determine the efficacy of cervical spine chiropractic manipulation and muscle release technique of the sub occipital muscles in relieving tension-type headaches. This study will also determine which treatment protocol would be most effective in relieving tension-type headaches, cervical spine chiropractic manipulation, and muscle release technique of the sub occipital muscles or a combination of both treatment protocols.

1.3 Benefits of this Study

The benefits of this study could determine which of the cervical spine manipulation or myofascial tension release technique or both would have the most beneficial outcome regarding tension-type headaches with specific reference to, intensity, and/or frequency of tension-type headaches. The researcher looked at three methods to determine which method. This study could also benefit patients by providing alternative treatment options instead of analgesics that are commonly used in tension-type headache treatments. This research study may positively contribute to establishing an effective treatment protocol for tension-type headaches. The muscle release technique as soft tissue therapy and may prove to be a safe and an alternate treatment for tension-type headaches when patients who suffer from tension-type headaches have contraindications to cervical spine manipulation.

CHAPTER TWO – LITERATURE REVIEW

2.1 General overview of headaches

A headache is defined as the feeling of pain in the region of the head and/or upper neck. The International Headache Society (2004) classified headaches into three categories: primary headaches, secondary headaches, and other headaches. Primary headaches are the most common type of headaches benign, recurrent headaches which are not caused by any disease or structural pathology. Primary headaches are further classified into:

• Tension-type headaches; • Migraines; • Cluster headaches; • Cervicogenic headaches.

Secondary headaches occur due to underlying causes. Other headaches are headaches occurring usually due to inflammation of nerves fibres, namely causing neuralgias (International Headache Society, 2004).

2.2 The cervical spine

It is of most importance to understand the anatomy and the neurology of the cervical spine so that the pathophysiology of tension-type headaches could be understood. With a good understanding of the tension-type headache pathophysiology, improved treatments could be formulated.

2.2.1 Anatomy of the cervical spine

The cervical spine (figure 2.1) is located between the skull and the thoracic vertebrae, and is composed of seven vertebrae. It may be separated into two different regions, namely the upper cervical spine and the lower cervical spine. The upper cervical spine consists of the articulation of the occipital condyles and the atlas (C1) and the articulation of the atlas and axis (C2).The lower cervical spine is composed of vertebrae C3 to C7 (Levangie and Norkin, 2011).

Figure 2.1: Location of the cervical spine (Barnes, 2017)

The vertebrae of the cervical spine have distinct features and are grouped into typical and atypical cervical vertebrae. Typical cervical vertebrae (figure 2.2) include C3, C4, C5 and C6. The vertebral bodies of typical cervical vertebrae are smaller and longer in the transverse diameter then the anteroposterior diameter. They have spinous processes that are bifid and short in nature. The transverse processes have transverse foramina for the transmission of neurovascular vessels (Moore, Dalley and Agur, 2010).

Figure 2.2: Typical cervical vertebrae (Fitzgordan, 2015)

The atypical cervical vertebrae are C1, C2 and C7 (figure 2.3). C1/Atlas: Can be described as ring shaped with two lateral masses attached to the anterior and posterior arches. The atlas has no spinous process or body. The atlas has transverse foramina which transmit the vertebral vessels, similar to the typical cervical vertebrae. Axis: The axis has one distinguishing feature that is a superior projection from the body known as the dens or odontoid process (Moore et al. 2010).

Figure 2.3: Superior views of the Atlas, C1 and Axis, C2 (Sharp, 2015)

C7: Has a larger transverse process and a longer spinous process than the typical cervical vertebrae. The transverse foramina of C7 are smaller than the typical cervical vertebrae (Moore et al. 2010).

2.2.2 Intervertebral discs

The intervertebral discs (figure 2.4) are fibrocartilaginous joints that connect the above vertebrae to the below vertebrae in the cervical spine from C2 to C7. Intervertebral discs consist of three parts: the annulus fibrosis, the nucleus pulposus and the vertebral end plate (Moore et al. 2010). The annulus fibrosis is the outer portion of the intervertebral disc, it is a fibrous ring made up of concentric lamellae. The lamella provides a strong connection between consecutive vertebrae. The annulus fibrosis is important in regulating tension within the intervertebral disc (Moore et al. 2010; Kapanji, 2008.). The nucleus pulposus is made up of a gelatinous substance that is in the central portion of the disc. It gives the resilience and flexibility to the intervertebral disc as well as the vertebral column (Kapanji, 2008; Moore and Dalley, 2006). The vertebral end plate is a cartilaginous structure situated at the superior and inferior portions of the vertebral bodies, which guides the annulus fibrosis and nucleus pulposus movements within their boundaries (Marieb, 2012).

Figure 2.4: The intervertebral disc and its components (Sharp, 2015)

2.2.3 Uncovertebral joints

The uncovertebral joints (figure 2.5) are found from C3 to C7, between the uncinate processes and the vertebral bodies above them. They enable some cervical spine flexion and extension, whilst restrict cervical spine lateral flexion (Lowe, 2014).

Uncovertebral joint

Figure 2.5: Uncovertebral joints (Lowe, 2014)

2.2.4 Facet joints

The cervical facet joints (figure 2.6) are diathroidal synovial joints, articulating between the superior articular facets of the vertebrae below and the inferior articular facets of the vertebrae above. The superior articular facets are orientated posteriorly, superiorly and medially whilst the inferior articular facets oppose the superior articular facets and are orientated anteriorly, inferiorly and laterally. Thus cervical spine flexion and extension could be achieved via the cervical spine vertebrae, whilst limiting rotation and lateral flexion at individual segments (Moore et al. 2010; Magee, 2008). Each facet joint is covered by a joint capsule, the joint capsule has characteristics that allow stability and laxity of the facet joints so that full movement in the cervical spine can be achieved. The cervical joint capsule is divided into three layers, which contain three types of receptors that are responsible for pain sensation, postural sensation and kinaesthetic sensations (Wyke, 1985):

Type I

• Are static and dynamic mechanoreceptors, • Are located in the outer layers of the cervical joint capsule, • Respond to small changes in the tension of the cervical joint capsule, • Are active at rest and during movement.

Type II

• Are dynamic mechanoreceptors. • Are located within deep layers of the joint capsule. • Respond only at the beginning of changes in the tension of the cervical joint capsule by emitting rapid, brief impulses. • Are rapidly adapting mechanoreceptors. • Are inactive in immobile joints.

Type IV

• Are nociceptors. • Are situated within the complete length of the joint capsule. • Respond to abnormal mechanical or chemical changes in the joint such as inflammation or an abnormally increased amount of tension of the cervical joint capsule.

Figure 2.6 facet joint capsule (Naick, 2014)

2.2.5 Blood supply to the cervical spine

Majority of blood supply to the cervical spine is supplied by the vertebral artery as it is the largest branch of the subclavian arteries. The vertebral artery runs upwards through the transverse foramina of C6 to C1, where it conjoins on either side to form the artery that supplies the brain, known as the basilar artery. It also branches into numerous segmental branches which supply bone, muscles, neural elements and joints (Borenstein, Wiesel and Boden, 1996).

2.2.6 Innervation of the cervical spine

Innervation of the cervical spine comes from the eight cervical spine nerve roots, which leave from the intervertebral foramina of each vertebra. The cervical spine nerve root is a mixed nerve, containing motor fibres, preganglionic fibres from the autonomic nervous system and sensory nervous system (Borenstein et al. 1996). Each cervical spine nerve divides into three main branches. a) Primary posterior rami

The primary posterior rami, also known as dorsal rami, supply the synovial joints of the vertebral column, intrinsic muscles and the overlying skin. The rami then bifurcate into a medial and lateral branch. b) Ventral rami

The ventral rami, innervate the following (Bogduk and McGuirk, 2006):

• The anterior portion of vertebral bodies, • The anterior portion of intervertebral discs, • The anterior longitudinal ligament, • The muscles of the neck including: trapezius, rectus capitus anterior, rectus capitus lateralis, longus capitus, longus coli, and sternocleidomastoid muscles. c) The recurrent nerve

The recurrent meningeal nerve is formed via fibres from the primary anterior ramus and sympathetic nerves. It contains sensory and sympathetic fibres and supplies the following (Magee, 2008; Levin, 2002):

• The posterior aspect of the vertebral bodies. • The posterior aspect of the intervertebral disc. • Posterior longitudinal ligament. • Anterior spinal dura mater. • Uncovertebral joints.

2.3 The skeletal muscle

2.3.1 The anatomy of the skeletal muscle

Muscles are specialised tissues that create movement of the body (Coetzee, Loots and Meiring, 2003). Skeletal muscle is composed of numerous cells, termed ‘muscle fibres’. The number of muscle fibres varies depending on size and area of the muscle. Muscles are covered by three connective tissue layers: the epismysium, perimysium and the endomysium. The epimysium is the outer most covering of the muscle and is a thick layer of connective tissue that separates the muscle from surrounding tissue and organs. It is also continuous with the connective tissue that surrounds tendons, bones, nerves and vessels. The perimysium divides muscle fibres into bundles, referred to as a ‘fascicle’. The perimysium has numerous nerves and blood vessels to innervate and provide blood flow to the muscle. The endomysium is a thin layer composed of connective tissue that surrounds each individual muscle fibre. Because of numerous capillary networks with in the endomysium .which supply blood to each muscle fibre and nerve fibre to control the muscle (Martini and Nath, 2009).

Figure 2.7: Anatomy of skeletal muscle (Hart, 2013)

Each muscle fibre has a cell membrane that is referred to as a ‘sarcolemma’, which surrounds the cytoplasms of a muscle fibre known as sarcoplasm. The sarcolemma has a transmembrane potential which is responsible for muscle contraction. Signals are transmitted in a muscle via transverse tubules, otherwise known as T tubules which are continuous with the sarcolemma. Each muscle fibre consists of hundreds to thousands of myofibrils which are cylindrical structures encircled by T-tubules. Myofibrils are

10 in turn composed of protein filaments, namely myofilaments. Myofilaments can be broken down into, thick filaments and thin filaments. The thick filaments consist of myosin and the thin filaments consist of actin. Actin and myosin are contractile proteins, the most important proteins in muscle. Tropomyosin is a regulatory protein that covers the actin. It regulates another protein called troponin, which covers the binding site for actin and myosin (Martini and Nath, 2009).

Figure 2.8: Muscle proteins (Tobias, 2016)

2.3.2 The muscle spindle

Muscle Spindles are located within the muscle belly with a primary function of passing information concerning muscle length and the rate of which muscle length changes to the central nervous system. The central portion of each muscle spindle has a small amount of actin and myosin filaments, thus functioning as a sensory receptor. Muscle spindles can also assist in regulating muscle contraction by activating motor neurons to resist muscle stretching via the stretch reflex (Coetzee et al. 2003; Guyton and Hall, 1997; Martini, 2004; Gatterman, 2005).

2.3.3 The Golgi tendon organ

The Golgi tendon organ shown in figure 2.9 is sensory propioreceptive receptor, located at the musculo- tendinous junction of a muscle. The Golgi organ transmits information regarding the degree of tension in the tendon. A few muscle fibre spindles pass through the Golgi tendon organ, where tension develops will, in turn, stimulate the organ. The Golgi tendon organ also aids in gauging external muscle tension and the rate of change of muscle contraction. Its function is facilitate muscle relaxation and to inhibit the muscle spindle, thus protecting muscles and tendons from injury (Martini, 2004; Guyton and Hall, 1997).

Figure 2.9: The muscle spindle and Golgi tendon organ (Guyton and Hall, 2000)

2.3.4 The physiology of muscle contraction

The sliding filament theory is process of muscle contraction. A nerve impulse arrives at the neuromuscular junction this stimulates the release of a chemical ‘Acetylcholine’ (Ach). Ach causes motor end plate depolarization passing through the muscle length, via the T-tubules, this causes calcium ions to be released from the sarcoplasmic reticulum. Elevated calcium ions concentration causes more calcium to bind to a protein called ‘troponin’, converting its shape so that tropomysosin exposes the active site. This allows the myosin filaments to connect to actin filaments, causing sliding to occur between actin and myosin filaments, this is known as a cross bridge. Adenosine tripshosphate (ATP), a high-energy molecule, binds to the myosin head, this allows myosin to pull the actin filaments inwards, thus creating muscle shortening. The process of muscle contraction lasts as long as calcium ion and ATP stores are adequate. As soon as the impulse ends, calcium ions are pulled back into the sarcoplasmic reticulum. Actin then goes back to its normal resting position and the muscle is once again lengthened and relaxed (Martini and Nath, 2009).

Figure 2.10: Cross bridge (Martini and Nath, 2009)

2.4 The sub occipital muscles

2.4.1 Anatomy of the sub occipital muscles

The sub occipital muscles (figure 2.11) are a group of muscles located close to the cervical vertebrae on the posterior aspect. There are four muscles that make up the sub occipital muscle group: rectus capitus posterior major and minor and obliquus capitis superior and inferior (Moore et al. 2010).

Figure 2.11: Anatomical location of the sub occipital muscles (Allegra, 2013)

2.4.2 Sub occipital muscle attachments, innervation and function

Table 2.1: Depicting muscle attachments, innervation and function (Vizniak, 2011)

This table indicates the common attachment and final insertion points of each of the sub occipital muscles as well as their associated action.

2.4.3 The sub occipital triangle

A triangle is formed in the posterior cervical region by the sub occipital muscles, called the

‘Sub occipital triangle’.

Figure 2.12: Sub occipital triangle (Dalton, 2011)

The boundaries of this triangle are (Moore et al. 2010):

• Superolateral boundary-obliquus capitis superior; • Superomedial boundary-rectus capitis posterior major; • Inferolateral boundary-obliquus capitis inferior; • Roof-semispinalis muscle; • Floor-posterior atlanto-occipital membrane and posterior arch of C1.

The contents of the triangle are (Moore et al. 2010):

• The vertebral artery; • The suboccipital nerve.

2.5 Myofascial trigger points

2.5.1 Definition of a myofascial trigger point

A myofascial trigger point can be defined as a band of hyperirritability within a muscle that is generally painful on stretching, compression, and contraction. It causes specific pain referral pattern, depending on the muscle involved, and generally result in alteration of muscle function (Dommerholt and Fernández- de-las-Peñas, 2013).

2.5.2 Classification of myofascial trigger points

Trigger points could be separated into ‘active’ or ‘latent’ trigger points. So too, could be further grouped into being primary, secondary or satellite trigger points. Active trigger points cause pain spontaneously without applying pressure to the muscle whilst latent trigger points cause no pain, but are tender to palpation or compression. Primary trigger points develop first within a muscle, usually due to acute or chronic strain and/or overloading of the muscle. Secondary trigger points are formed in antagonist muscles when a protective contraction has happened. Satellite trigger points form in a muscle that is in a pain referral area of other myofascial trigger points (Travell and Simons, 1999).

2.5.3 Pathophysiology of myofascial trigger points

Formation of a trigger point is thought to be due to ‘energy crises’ (figure 2.13) within muscle group. Overloading, or excessive stretching or contracting of a muscle can result in microtrauma. Microtrauma damages the sarcolemma of the muscle, resulting in the release of calcium ions around the site of microtrauma. The calcium ion release is constant and causes myofilament activity, which results in sustained contraction of the muscle without any action potential transmission. Sustained muscle contraction causes increased metabolic demands in the muscle even though vasoconstriction is present, this causes the area to become ischemic and accumulate metabolic waste, forming an energy crises. Due to the damage of sarcoplasmic reticulum, the excess calcium floats freely without being removed, this creates an on-going cycle. This results in the production of inflammatory chemicals such as histamine, prostaglandin and bradykinin, causing pain due to nociception activation. Damage is only repairable when the cycle lasts a short period of time, as the healing process removes all the excess calcium (Travell and Simons, 1999).

Figure 2.13: Energy crisis hypothesis (Travell and Simons, 1999)

2.5.4 Myofascial trigger points in the sub occipital muscles

Location and pain referral pattern

Trigger points are most commonly found in the obliquus capitis inferior muscle bilaterally. They are a common source of headache type pain penetrating deep into the skull extending from the occiput to behind the eyes. Their pain referral pattern is difficult to localize (Travell and Simons, 1999).

Figure 2.14: Trigger points and pain referral pattern in the sub occipital muscles (Travell and Simons, 1999)

Symptoms of active sub occipital trigger points

Active sub occipital trigger points commonly cause complaints of a band like headache. The pain experienced is deep and lateral, and patients often identify the most aggravating point by compressing the sub occipital region with their fingers (Travell and Simons, 1999).

Activation and perpetuation of sub occipital trigger points

Sub occipital muscle trigger points can be activated by:

• Looking to one side for prolonged periods of time. • Lateral neck bending such as holding a phone to your ear without the use of your hands the phone for extended periods of time. • Extreme extension-hyperextension movements of the head and neck such as, painting overhead. • Forward head posture. • Whiplash injuries. • Emotional stress (Corna, Williams, Tilley and Ellison, 2015; Travell and Simons, 1999).

2.6 Tension-type headaches

2.6.1 Definition

Tension type headaches can be defined as a bilateral, non-throbbing, band like pain felt in the head, forehead, neck and occipital region having a mild to moderate intensity. Tension type headaches differ from other primary headaches, due to the lack of autonomic symptoms like nausea and vomiting. However, tension type headaches may be associated with phonophobia or photophobia, but never both at the same time (International Headache Society, 2004). The International Headache Society (IHS) distinguishes four types of tension type headaches.

1) Frequent episodic tension type headaches: patient experiences no less than ten episodes of headaches lasting for more than 24 hours, over a period of 15 days in a month.

2) Chronic tension type headaches: where patients have episodes that exceed fifteen days a month for approximately three months.

3) Probable tension-type headaches: is an atypical tension type headache, regards to having most of the diagnostic symptoms criteria for tension type headaches but not all of them.

4) Probable chronic tension-type headaches are commonly associated with medication overuse.

2.6.2 Demographics of tension-type headaches

a) Prevalence b) Gender and age distribution

2.6.3 Pathophysiology of tension-type headaches

There has yet to be definite causes found for tension type headaches, rather that tension type headaches have a cervicogenic origin, thus many factors contribute to the cause of tension type headaches (Vizniak, 2011).

These factors include:

• Cervical spine dysfunction/pathology. • Increased muscle tension/stress resulting in myofascial trigger points. • Poor posture. • Temporomandibular joint dysfuction. • Lack of sleep or rest. • Stress, anxiety and depression have also been linked to tension type headaches.

Since the tension type headache pathophysiology is not very well understood, their pathogenesis has numerous factors that hint to the pathophysiology of tension type headaches (Fumal and Schoenen, 2008). These pathogenesis factors are: a) Myofascial tissue

Myofascial tissue has more of a role in infrequent episodic tension type headaches. Cervical spine musculature indicted on a electromyography that activity of cervical spine muscle tension is much higher in tension headaches sufferers than in non-tension headaches sufferers, and increased hardness or tenderness with myofascial palpation of the sub occipital musculature was evident in tension headache suffers (Schoenberg, Gerard, De Pasquale and Sianard-Gainko, 1991; Jensen, Bendsten and Olesen, 1998; Bendsten). Studies revealed that active trigger points in the posterior neck and head regions contribute to headache pain patterns similar of that of a tension headache (Fernández-de-las-Peñas, Cuadrado, Arendt- Nielsen, Simons and Pareja, 2007).

20 b) Central sensitization

Central sensitization is the sensitization of neurons of the spinal cord and/or the trigeminal nucleus; this is brought on by permanent nociceptive firing from myofascial tissue (Bendsten, 2000). Sensitization of the nociceptive input further activates nitric oxide synthase (NOS).It is known that NOS inhibitor, reduces muscle tenderness and hardness, thus NOS synthase would do the opposite (Ashina, 2004; Ashina, Bendsten and Jensen, 1999; Ashina, Lassen and Bensten, 1999).

c) Structural brain changes

A study on tissue mass in the brain and medication overuse headaches, revealed a decrease in tissue mass in several brain areas in chronic tension-type headache sufferers. In contrast, patients whose headaches resulted from medication overuse had normal tissue mass (Schmidt-Wilcke, Leinisch and Straube, 2005).

d) Psychological and environmental factors

Many emotional disturbances have been implicated in tension type headaches, the most common being stress and mental tension (Spiering, Ranke and Honkoop, 2001; Rasmussen, 1993). There is evidence that, with chronic tension-type headaches; there is an association with more ‘daily hassles’ (De Benedittis and Lorenzetti, 1992). In a study on physical factors in adolescent patients suffering from migraines and tension-type headaches; tension-type headache patients demonstrated more instances of divorced parents and less peer relations when compared to migraine sufferers (Karwautz, Wöber, Lang, Böck, Wagner-Ennsgraber, Vesely, Kienbacher and Wöber-Bingöl, 1999). Several other investigations also revealed patients scoring higher on depression scales. However, it’s still uncertain whether depression is the primary or secondary cause of these headaches (Yucel, Kora, Ozyalcin, Alcalar, Ozdemir and Yucel, 2002).

e) Genetic factors

There is a correlation between genetics and specifically chronic tension-type headaches. Genetic epidemiological studies on the general population reported an increased risk of offspring becoming headache sufferers. It revealed that first degree relatives had a threefold risk of chronic tension-type headaches, while spouses showed no risk (Ostergaard, Russell, Bendtsen and Olesen 1997).

f) A model for the pathogenesis of tension-type headaches

Tension-type headaches arise from various pathophysiological abnormalities. This involves the complex interaction between changes in the brainstem and peripheral changes. Emotional factors can amplify muscle tension via the limbic system of the brain. With long-standing tension-type headaches, central mechanisms play more of a role, due to prolonged and increased sensitization of nociceptive neurons, gradually resulting in a chronic tension-type headache. Genetic components can also promote psychological and central changes that lead to tension-type headaches (Ashina et al. 2012; Fumal and Schoenen, 2008).

Figure 2.15: Flow diagram of the model for the pathogenesis of tension-type headaches (Vizniak, 2011).

2.6.4 Myofascial trigger points being a cause of tension-type headaches

Tension headache suffers have been seen to experience large amounts of muscle tenderness in the posterior neck and head region, with associated increase of muscle tension in these areas (Ingraham, 2012). Chronic tension type headaches patients have considerably larger number of myofascial trigger points, whether they were active and/or latent trigger points than in healthy patients (Fernández-de-las- Peñas, Alonso-Blanco, LuzCuadrado, Gerwin and Pareja, 2006a). A study on local and referred pain caused by active myofascial trigger points, revealed that reproduction of tension type headaches symptoms, is linked to active myofascial trigger points within the sub occipital muscles, superior oblique muscle, upper trapezius muscle and masseter muscle (Fernández-de-las Peñas, Ge, Alonso-Blanco, González-Iglesias and Arendt-Nielsen, 2009). Several studies have indicated that with higher concentrations of myofascial trigger points within the sub occipital muscles contribute to, or prolong, tension type headaches (Fernández-de-las-Peñas, Alonso-Blanco, Luz Cuadrado, and Pareja, 2006). The above suggests that myofascial trigger points can be linked to tension type headaches and their severity and/or longevity (Fernández-de-las-Peñas, Arendt-Nielsen and Gerwin, 2010).

2.6.5 The relation of active sub occipital trigger points to tension-type headaches

Patients, who suffer with tension-type headaches, have shown that active sub occipital trigger points were of highest prevalence when compared to other cervical muscles (Fernández-de-las-Peñas, Ge et al. 2009). In a study on chronic tension type headaches, it was noted that active sub occipital trigger points where linked to greater headache intensity and frequency (Fernández-de-las-Peñas, Alonso- Blanco, Cuadrado, Gerwin and Pareja, 2006b). Another study demonstrated that all patients showed trigger points in the sub occipital muscles; which of 60% had active sub occipital trigger points and the remainder 40% had latent trigger points (Fernández-de-las-Peñas et al. 2006). This can be explained by that the repeated and prolonged nociceptive input from myofascial tissue, in the suboccipital muscles, generates continuous afferent innovation to the trigeminocervical nucleus, resulting in headache pain (Bendsten, 2000). Rectus capitis posterior minor (RCPM) is one the most important muscles, due to its anatomy and connection to other underlying anatomical structures. The RCPM muscle has a intertwined connection to the underlying dura mater of the spinal cord via the originating fibres on the posterior atlanto-occipital membrane. Thus RCPM can have a biomechanical influences on the dura mater of the spinal cord. A hypertonic RCPM can transmit tension to a pain sensitive duramater, resulting in the

23 production of a constant and intense headache. In addition RCPM may irritate the C1 nerve; this may result in hyperexcitable sympathetic nerve fibres, causing a chronic headache. Furthermore, irritation to RCPM can even cause reflexive activity surrounding other cervical and jaw muscles, thereby resulting in other structures causing pain (McPartland and Bordeur, 1999).

It has been seen that in treatment and management of sub occipital muscle trigger points there was a significant reduction of pain in patients suffering with tension type headaches (Fernández-de-las-Peñas, Alonso-Blanco, Cuadrado, Pareja, Barriga and Miangolarra, 2004).

Active sub occipital muscle trigger points have been noted to reduce with number of treatments, including cervical spine manipulation, dry myofascial needling and the myofascial muscle release technique (McPartland and Bordeur, 1999).

2.7 The Vertebral Subluxation Complex

The vertebral subluxation complex (VSC) is a theoretical model, created to explain the dysfunction of a spinal motion segment. A spinal motion segment is two adjacent vertebrae and the associated connective tissue that integrates them. The interaction of pathological changes in this segment is explained by this model (Vernon and Mrozek, 2005). Chiropractic manipulation is utilized for influencing the neurophysiological function and restore normal joint and muscle function, thereby restoring physiological function (Gatterman, 2005).

Components of the VSC include (Gatterman, 2005):

• Kinesiopathology. • Neuropathology. • Connective tissue pathology. • Myopathology. • Vascular abnormalities. • Inflammatory response.

24 a) Kinesiopathology

The spine is considered to be the link of all synchronous movement in the body. Any limitations of motion of the spine can result in compensatory adjustments on any other level in the spine. Thus, each spinal motion segment cannot exist without it affecting other spinal motion segments. Immobilization of the spine has been seen to increase the risk of degeneration of the spine. The lack of movement results in pain and stiffness; this is followed by degeneration and finally ankylosis, abnormal stiffening and immobility of a joint due to fusion of the bones between two joint segments. Chiropractic manipulation restores normal range of motion of a joint that was previously immobilized, thus restoring normal joint function (Gatterman, 2005).

b) Neuropathology

The nervous system has major potential to become compressed and injured thus assisting in neurological dysfunction; these structures that are associated with neurological dysfunction are the spinal cord, spinal nerve roots and segmental nerves (Moore and Dalley, 2006). The dorsal root ganglion (DRG) is a structure inside the vertebral complex that contains cell bodies of all sensory neurons apart from those of cranial nerves. It is situated within the intervertebral canal, close to the articular capsule. This location exposes the DRG to causing spinal subluxation and dysfunction. The DRG displays a very high level of sensitivity to mechanical stimulation. Thus over stimulation results in inflammation of the DRG, this is caused by the hyperexcitability, result in impetuous discharges and episodes of continuous firing that outlasts the initial stimulus. Therefore, the pain is felt even after the removal. The DRG is greatly vascularized without a blood nerve barrier, making it highly susceptible to infection by viruses, bacteria and/or chemical irritants, biological or exogenous (Gatterman, 2005). As discussed earlier, spinal joint receptors are divided into four components: three mechanoreceptors and one nociceptor (Wyke, 1985). Articular mechanoreceptors produce afferent discharges as they enter the spinal cord, causing a threefold effect: reflexogenic effects, pain suppressive effects and perceptual effects. Articular nociceptors are sensitized during joint inflammation thus fire during rest and when they should not (Dvorak and Gilliar, 2011). A second theory can also assist in the neurologic component of the VSC, the pain gate control theory, suggests that the conduction of pain is reliant on the nerve conduction of large A beta fibres and small A delta and C fibres on the gate. When certain spinal cord neurons are evoked, the awareness of pain may be controlled (Gatterman, 2005).

25 c) Connective tissue pathology

Joint immobilization can also have quite a significant effect on connective tissue components of the VSC. Each connective tissue component individually can be affected differently by immobilization. Synovial fluid undergoes fibro-fatty change, which increases the adherence characteristic of the fibrous tissue. This results in the initiation of deposition of bone salts in the matrix. This change in the matrix causes shrinking of articular cartilage due to the loss of vital proteaglycans. Eventually softening of the articular cartilage develops with associated ulcerations of the subchrondral bone, increasing the risk of the articular cartilage getting damage. Joint immobilization can cause the formation of adhesions between connective tissue structures, nerves and ligaments. Therefore, when movement occurs, these adhesions can break, causing an inflammatory response, which elicits pain. Ligaments at the end stages undergo a condition called ‘ligament laxity’ where they become more pliable due to joint immobilization. Ligament laxity can then result in joint instability (Gatterman, 2005).

d) Myopathology

The main function of muscle is to create movement by moving bones around joints, which act as levers. When a joint mobility is compromised, the muscle surrounding that joint undergoes disuse atrophy, due to the lack of full function use, essentially a degenerative change occurs to the muscle fibres. These changes to the muscle spindles include: shortening, thickening, loss of cross striations and swelling. This causes a physiological change, such as an elevated resting rate of discharge and increased sensitivity to stretching, resulting in the formation of muscle spasms and painful trigger points. Prolonged immobilization of joints may result in contributing to joint degeneration such as osteoarthritis (Gatterman, 2005).

e) Vascular component

Segmental arteries supply each spinal motion segment. Radicular arteries supply nerve roots of the spine. Spinal arteries anastomose (connect) with these arteries, contributing to the blood supply within the spinal cord (Martini and Nath, 2009). Arteries are also prone to mechanical stress just as there associated nerve root counterparts. Therefore can be damaged in the same way such as being impinged (Gatterman, 2005). Venous drainage is achieved via the plexus of Batson which is a broad network of segmental veins, which drain blood from the vertebrae into this plexus (Martini and Nath, 2009). Due to venous anatomy, there is possibility of retrograde flow, which will allow inflammatory products and toxins to transfer from one spinal segment to the next. Joint immobilization results in blood stasis (stagnated

26 blood), which causes an accumulation of toxins and inflammatory products, initiating major nociceptive activity and accelerating joint degeneration. This may be resolved by restoring of motion to the joint segments (Gatterman, 2005).

f) Inflammatory component

Joint immobilization may result in an inflammatory process which may lead to ossification in severe cases. The inflammatory process can extend into surrounding tissues, such as nerve tissue causing irritation, a term called ‘chemical radiculitis’. The clinical manifestation of this inflammation is pain. Nerves that are inflamed develop irregular behaviour and become hyper-excitable. (Gatterman, 2005).

2.8 Chiropractic manipulation

2.8.1 Definition

Chiropractic manipulation can be defined as: “a manual, therapeutic procedure that involves a controlled force, velocity, amplitude, leverage and direction aimed at specific joints to enhance joint movement and neurophysiologic function” (Haldeman, 1992). Sandoz (1976) proposed a mechanism of how spinal manipulation affects a joint depicted by figure 2.16 below:

Figure 2.16: Sandoz’s model for joint range of motion (Esposito and Phillipson, 2005)

Illustrated in figure 2.16, motion within a diathroidal joint can be divided into four phases:

• Active motion. • Passive motion. • Paraphysiologic space motion. • Motion that exceeds the paraphysiologic phase.

Active and passive motion, are termed together: the zone of normal physiologic movement. These zones are where mobilizations of the spine as well as a low force or no force manipulations can be performed. The paraphysiologic zone is the zone of joint play, in which high velocity manual thrust manipulations separate the joint articular surfaces by overcoming the elastic barrier of resistance of connective tissue. When this occurs, an audible crack sound is heard, and there is the emergence of a radiolucent cavity inside the joint space. The third zone is the pathological zone if this zone is reached, it means that the joint has passed the anatomical barrier of integrity, and therefore a sprain or medical subluxation can occur (Esposito and Philipson, 2005).

2.9.2 The clinical effects of chiropractic manipulation

Chiropractic manipulation has numerous clinical effects according to Esposito and Phillipson (2005):

• Increased active and passive range of motion via normal axis of rotation. • Reduction in pain. • Increased skin pain tolerance level. • Increased paraspinal muscles pressure pain tolerance. • Reliable and consistent reflex responses from muscles in the limbs and spine. • Reduction in muscle tension and electrical activity. • Releasing an entrapped meniscoid, synovial folds or hyperplastic synovial tissue. • Breaking of contractile tissue and collagen adhesions in local soft tissues and supporting structures. • Effects upon the intervertebral disc -either in form of intradiscal block or generalized effects on the process of disc protrusion. • Various autonomic responses -including vasomotor changes, sudomotor activity and changes in visceral regulation control, namely.

1. Blood flow and distal skin temperature changes. 2. Blood pressure. 3. Blood chemistry changes control of papillary diameter.

2.8.3 The neurophysiological effects of chiropractic manipulation

As mentioned earlier, many mechanoreceptors are found within the joint capsule. It is the changes of activity within these mechanoreceptors that results in neurophysiological effects. When manipulative procedures are applied to joints in the spine, changes in joint tension occur, thereby causing the stimulation of mechanoreceptors. The afferent discharges from these mechanoreceptors enter the central nervous system, producing a threefold effect of reflexogenic effects, perceptual effects and pain suppressive effects. Reflexogenic effects involve changes in muscle tone, both facilitation or inhibition, by influencing the activity of gamma motor neurons found in the ventral horn of the spinal cord. Perceptual effects encompass the awareness of postural sensation. When mechanoreceptors are stimulated, they can result in presynaptic inhibition of nociceptive activity, thereby causing pain suppressive effects (Wyke, 1985).

2.8.4 The effect of cervical spine manipulation on tension type headaches

Manipulations delivered to the occiput, atlas and axis are effective in reducing the frequency, intensity and functional disability of tension type headaches. It’s also efficient in increasing cervical spine range of motion, specifically flexion and extension (Espí-López, Gómez-Conesa, Gomez, Martínez, Pascual-Vaca and Blanco, 2014). A randomized study, comparing chiropractic manipulation and medical prophylactic treatment, revealed a statistically significant improvement with cervical spine manipulation (Vernon, Jansz, Goldsmith and McDermaid, 2009). Most research on chiropractic cervical spine manipulation in relieving tension type headaches is encouraging (Posadzki and Ernst, 2012). Thus, cervical spine manipulation is clinically effective in relieving tension type headaches.

2.9 Muscle tension release technique

2.9.1 Definition

Muscle tension release technique (MTRT) is a manual procedure which is used for the treatment of dysfunctional myofascial tissues, thus aiding in treatment of spinal joint dysfunctions and peripheral joint dysfunctions (de Sousa and Lima de Matos, 2014). MTRT has been proven to have effective clinical uses for the following (Mitchell, 1979; Bourdillon, 1992; Mitchell and Mitchell, 1995; Goodridge and Kuchera, 1997, Chaitow, 2008; Greenman, 1996 and Fryer, 2011):

• Lengthening a shortened, contracted or spastic muscle. • Strengthening a weakened muscle. • Deactivating active myofascial trigger points. • Mobilizing a restricted joint. • Reducing oedema and congestion.

Methods used in MTRT involves the practitioner applying ischemic compression to the specific muscle trigger point, as well as passively moving the joint associated with the muscle in its full range of motion (Chaitow, 2008).

2.9.2 Physiological mechanisms of muscle energy technique

According to Chaitow (2006), two physiological mechanisms are utilized to reduce muscle tone:

• Post-isometric relaxation; • Reciprocal inhibition.

30 a) Post-isometric relaxation

Post-ischemic relaxation (figure 2.17) occurs when a muscle has reduced muscle tone after an ischemic compression. During this refractory period, passive stretching of that muscle can be accomplished. Golgi tendon organ proprioceptors experience an increase in tension due to muscle compression and an ischemic reaction, which, in turn, activates a neurological reflex loop, causing the post-ischemic relaxation effect in that muscle (Chaitow, 2006). The goal of post-ischemic relaxation is to facilitate muscle relaxation (Ward, 2003).

Figure 2.17: Neurophysiological mechanisms during post-isometric relaxation

(Chaitow, 2006)

b) Reciprocal inhibition

Reciprocal inhibition (figure 2.18) involves decreasing muscle tone or lengthening a muscle by compressing the muscle and moving the joint in the joint’s full range of motion. This initiates a neurological reflex (Chaitow, 2006). The goal of reciprocal inhibition is to lengthen a muscle that is shortened due to acute or chronic spasm (Ward, 2003).

Figure 2.18: Neurophysiological mechanisms during reciprocal inhibition (Chaitow, 2006)

2.9.3 Muscle tension release technique and active myofascial trigger points

Muscle tension release technique (MTRT) has been shown to be an easy, safe and effective technique in reducing active myofascial trigger points. MTRT focuses on restoring normal muscle length, so that active myofascial trigger points do not re-activate, providing a long term treatment. The passive stretching and ischemic compression utilized in MTRT, alters the circulatory imbalance within the taut bands in active myofascial trigger points which, in turn, assists in deactivating them (Chaitow,2006). Post-ischemic relaxation is also a key factor in releasing active myofascial trigger points. Research on MTRT applied to cervical spine musculature is greatly limited. Some studies have demonstrated that MTRT can be used as a treatment for myofascial sub occipital trigger points amongst other treatments (Fernández-de-las- Peñas, Cleland, Palomeque-del-Cerro, Caminero, Guillem-Mesado and Jiménez-Garcia, 2011; Hamilton, Boswell and Fryer, 2007; McPartland and Bordeur, 1999).

CHAPTER THREE - METHODOLOGY

3.1 Introduction

This chapter outlines a detailed description of the purpose of this study, participant recruitment and the treatment protocol followed.

3.2 Study Design

This study design is a comparative study, utilizing convenient sampling and random group allocation, to determine the effects of two different treatments and a combination of those treatments on participants suffering from tension type headaches.

3.2.1 Participant recruitment

Participants were recruited through advertisements (appendix A) placed at the University of Johannesburg, the Chiropractic Day Clinic, Doorfontein and through word of mouth.

3.2.2 Sample selection and size

A selection of thirty participants were recruited for this study. They were made up of males and females between the ages of 18 and 50 years old. Participants were accepted for the study according to the inclusion and exclusion criteria.

3.2.3 Inclusion criteria

To be included in the study, the participants must have complied with the following criteria:

• Both male and female, between the ages of 18 and 50 years old were allowed to participate in the study. Tension type headaches may transpire at various ages, however it usually commences during teenage years or young adulthood. This is generally more prevalent in individuals aged between 20-50 years (Singh, 2014). • Meet the requirements of The International Headache Society diagnostic criteria for tension- type headaches (appendix D). • At least one restriction in the upper cervical spine (C1-C3) confirmed by cervical spine motion palpation. A restriction is a limited or absent joint motion, altering the functionality of the joint, resulting in dysfunction thus causing pain (Kalikar, 2013). • Present with at least one active myofascial trigger point in the sub occipital muscles, confirmed by myofascial palpation. An active myofascial trigger is a hyper-irritable spot in a taut band of muscle which causes a specific pain referral pattern distant from the site of the origin, spontaneously as well as on compression, stretching and contraction (Dommerholt and Fernández-de-las-Peñas, 2013).

3.2.4 Exclusion criteria

Potential participants were excluded from the study if they had any of the following:

• Contra-indications to cervical spine manipulation (appendix E); • Signs and symptoms of the headache being secondary due to an underlying pathology, seen in table3.1.

Table 3.1: Depicting pathological headache warning signs (Vizniak, 2011):

• Participants who were not eligible for this study are those who had,had any other kind of treatment that could have interfered with the results of this study. This included: other chiropractic treatment, physiotherapy, and medication, such as anti-inflammatory drugs or muscle relaxants.

3.2.5 Random group allocation

Participants who met the inclusion criteria were randomly allocated to one of three groups by drawing a coloured block from a bag. Each block colour represents an appropriate group and the groups were addressed as group 1, group 2 and group 3. Group 1 received cervical spine manipulations; group 2 received muscle tension release technique of the sub occipital muscles; and group 3, a combination of cervical spine manipulation and muscle release technique of the sub occipital muscles.

3.3 Treatment approach

3.3.1 Initial consultation

An explanation was provided on how the research would be carried out upon arrival.

The initial consultation consisted of the following:

• Signing of the information and consent forms (appendices B and C)

• Taking of a thorough case history (appendix F)

• Completion of a full physical examination (appendix G)

• Assessment of the cervical spine by means of a cervical spine regional (appendix H)

• Palpation of the sub occipital muscles to examine for active trigger points was performed to determine further appropriateness for the study. All participants were subjected to protocols in the same in the same manner; patients were placed in the supine position with the doctor standing at the head of the table, gently supporting the patients head. Trigger points were then located via deep palpation by feeling for areas of muscle tension or tenderness within the sub occipital region (Travell and Simons, 1999).

• Completing the numeric pain rating scale (NPRS) (appendix J)

• Answering the Vernon and Mior neck disability index (NDI) (appendix L)

• The Headache Impact Test (HIT-6) is completed (appendix K)

• Establishing pressure tenderness of the sub-occipitals via the use of a hand held pressure algometer (appendix M). • The participant receives the assigned treatment method. • All findings were recorded on the treatment SOAP note (appendix I)

3.3.2 Methods of treatment:

Chiropractic cervical spine manipulation

Motion palpation of the cervical spine (C0-C4) was first performed to identify the restricted segments. This technique was performed by the researcher in order to locate limitation and restriction of motion in the upper cervical spine. The cervical spine manipulations were delivered to the most restricted segments of the upper cervical spine. Standard diversified techniques were used, depending on the restriction found and the comfort of the researcher and patient, according to Peterson and Bergmann (2002).

Muscle Tension release technique

Muscle tension release technique is a manual treatment, whereby patients’ muscles are compressed and passively stretched via very specific directions and positions, by the researcher (Chaitow, 2006). There are many of different variations of the muscle release technique. The technique utilized in this research trial was a combination of ischemic compression and active myofascial release (Chaitow, 2006) this technique encompasses:

• The location of active trigger points in the suboccipital muscles via palpation. • Placing the participant in the supine position with a pillow supporting their head and neck. • The researcher standing or sitting on a chair at the head of the table, facing the foot of the table. • Ischemic compression then being applied to the sub occipital muscles until the participant stated a change in pain or a release of the pain. • Performing passive flexion, extension, lateral flexion and rotation of the cervical spine whilst maintaining the sub occipital pressure of the muscles containing the trigger points. This is repeated 7 times.

3.3.3 Follow up consultations

Participants continued to receive their treatment as per allocated group during follow up visits. All groups attended four follow up consultations that consisted of two treatments a week for a two week period. Subjective and objective measurements were retaken at the beginning (before treatment) of the fourth visit and during the fifth visit. No treatment was administered, during the fifth treatment, only readings of subjective and objective data were taken. Also, advice on alterations of daily activities was given to prevent or reduce tension type headaches in future.

3.4 Subjective and Objective Measurements

3.4.1 Subjective measurements

a) Numeric Pain Rating Scale

The NPRS (appendix J), was completed by each participant on the first, third and fifth visits. It uses a numbered scale to measure the intensity of pain that the participant had. The scale ranges from 0 to 10, with 0 being no pain and 10 being the most severe pain felt. The test is designed to identify the patient’s own perception of their condition as the research study progresses (Ritter, Gonzalez, Laurent and Lorig, 2006). The NPRS can help to determine the severity of the pain, which can then identify a level of disability of the participant. The NPRS has sensitivity, reliability as well as validity when compared to the frequently used pain rating scales, namely the Visual Analogue Scale and Verbal Rating Scale (Hoggart and Williamson, 2005). Also, when compared to other pain rating scales, the NPRS is the most responsive test, and it can help to distinguish pain intensity differences between sex’s (Ferreira-Valente, Pais-Ribeiro and Jensen, 2011).

38 c) Neck Disability Index

The NDI (appendix L) is a simple ten item questionnaire used to assess patients with neck pain. The NDI measures the functional ability, wellbeing and the overall health of patients. It is used as a gold standard in health economics to assess the health utility, gain and economic impact of medical interventions (McCarthy, Grevitt, Silcocks and Hobbs, 2007). c) Headache Impact Test

The HIT-6 (appendix K) is a questionnaire constituted of six questions that are designed to represent the effect of a headache on an individual’s everyday life. Whilst having the ability to monitor the change of the headache impact over the course of the treatment. This questionnaire is designed specifically for tension type headaches and migraines and is intended for adults who are eighteen years of age and older. It consists of five columns with different points increasing numerically from the first column. The points are totalled up in each column and a final score is calculated. The HIT-6 questionnaire was completed by each participant on the first, third and fifth visits. According to the HIT-6 questionnaire structure, a higher final score represents an increased severity of the headache, thus affecting the participant’s functionality at work, school and in social situations. After all the data has been collected, a decrease in approximately eight points indicates that there is a clinically relevant improvement in the participant’s tension type headaches (Castien, Blankenstein, van der Windt and Dekker, 2012). It has been found that HIT-6 is a reliable and valid questionnaire for the evaluation of tension type headaches (Zandifar, Banihashemi, Haghdoost, Masjedi, Manouchehri, Asgari, Najafi, Ghorbani, Zandifar, Saadatnia, Mohammad and White, 2013).

3.4.2 Objective measurements

Pressure Algometer

The pressure algometer (figure 3.1) is an instrument that can be utilized to measure the pressure and/or force eliciting pain in myofascial trigger points. In this study, a hand held Pressure algometer was used gauge at what pressure/force pain was elicited in the active sub occipital muscles’ trigger points. Studies have demonstrated a comparable connection between active sub occipital trigger points and tension type headaches (Fernández-de-las-Peñas, Arendt-Nielsen and Gerwin, 2010).

Figure 3.1: Pressure Algometer (Ingber, Kostopoulos, Larkin and Nelson, 2008)

The pressure algometer was placed perpendicular to the identified trigger point. Pressure was then applied at constant and slow rate of 1kg per second (Ingber, Kostopoulos, Larkin and Nelson, 2008). The pressure algometer gauge measures the amount of pressure/force the participant can withstand until pain is felt. The participants relayed the moment that pain was experienced, and, at that point, the pressure was released and a reading was taken. The measurements were taken for each participant: to aid in validity. All measurements were recorded on a sheet (appendix L) and readings were recorded on the first, third and fifth visits. The pressure algometer has high reliability and validity as compared to readings from a force plate (Kinser, Sands and Stones, 2009). Also, when compared to a digital algometer; the manual pressure algometer has excellent reliability and validity (Thongbuang, Chatchawan, Eungpinichpong and Manimmanakorn, 2014).

3.5 Data analysis

All data; subjective and objective, was collected and consolidated by the researcher during the research trial. A statistician at STATKON (located at the University of Johannesburg, Kingsway Campus) then analysed all the captured data. A cross tabulation was performed to look at the distribution of group, gender and age. Parametric tests were used as tests of comparison. These included the one-way ANOVA (analysis of variance) test, which was then repeated. Inter group analysis, which will include either parametric or non-parametric analysis of data needed for conclusions to be made, Kruskal-Wallis tests will help define further analysis.

3.6 Ethical considerations

All participants who partook in this particular study have read the information form (appendix B) and signed the consent form (appendix C), which is specific to this study. This research study was approved by the ethics committee of the University of Johannesburg (appendix N). According to the University of Johannesburg’s strict plagiarism guide, this study was submitted to Turnitin in order to generate an originality report (appendix O).

The information and consent forms outlined the names of the researcher, purpose of the study and benefits of partaking in the study, participant assessment and treatment procedure. Any risks, benefits and discomforts pertaining to the treatments involved will also be explained and they will be assured that all precautions will be taken to ensure their safety. The information and consent forms also explained that the participant’s privacy will be protected as only the doctor, participant and clinician will be in the treatment room and that anonymity will be ensured as the participant information will be converted into data and therefore cannot be traced back to the individual. The form also stated that standard confidentiality will be adhered to at all times when compiling the research dissertation.

The participants’ files are stored in a safe and secure room in an enclosed cabinet at the University of Johannesburg Chiropractic Day Clinic. The participants were informed that their participation is on a voluntary basis and that they were free to withdraw from the study at any phase without penalty.

CHAPTER FOUR - RESULTS 4.1 Introduction

This chapter contains the results of this research study. The sample group of this study was made up of three groups of ten participants each. Group one received cervical spine manipulation, group two received muscle tension release technique of the sub occipital muscles, and group three received a combination of cervical spine manipulation and muscle tension release technique of the sub occipital muscles. As this study is comprised of a small group of participants, no conclusions could be made regarding the general population. Due to the group sizes being less than fifteen participants per group, the Shapiro-Wilk test was used to test normality within the groups. Parametric tests were used as assumptions of normality and equal variances proved true. The two parametric tests used were the one- way ANOVA test repeated for intragroup analysis and the one-way ANOVA test for intergroup analysis. The p-value, value of significance, was set at 0.05 for all tests. Therefore a p-value less than or equal to 0.05 was statistically significant (p ≤ 0.05).

The analysis included:

1. Demographic data namely gender and age.

2. Subjective measurements- The NPRS, the NDI and the HIT-6.

3. Objective measurements, namely the pressure algometer.

4.2 Demographic data analysis

This study’s demographic data of gender and age is depicted in table 4.1 and 4.2 respectively.

Table 4.1: Demographic data regarding gender

Frequency Percentage

Male 15 50.0 Female 15 50.0 Total 30 100.0

Out of the total 30 participants 15 females and 15 males participated the study.

Table 4.2: Demographic data regarding age

Statistic

Group 3 Mean 22.30 0.943

Median 21.50

Minimum 19.00

Maximum 28.00

Range 9.00

Group 2 Mean 31.40 3.874

Median 26.00

Minimum 19.00

Maximum 52.00

Range 33.00

Group 1 Mean 31.30 4.709

Median 24.00

Minimum 21.00

Maximum 61.00

Range 40.00 43

Table 4.2 demonstrates that the combination treatment group had a mean age of 22.3 years, a maximum age of 28 years, and a minimum age of 19 years. The muscle tension release technique group had a mean age of 31.4 years, a maximum age of 52 years, and a minimum age of 19 years. The cervical spine manipulation group had a mean age of 31.3 years, a maximum age of 61 years, and a minimum age of 21 years.

4.3 Subjective data analysis

4.3.1 NPRS

Figure 4.1: Line Graph representing the mean values of the NPRS for all three groups at the 1st, 3rd and 5th visits

Figure 4.1 illustrates the NPRS mean values obtained on the 1st, 3rd and 5th visits. At the 1st visit, the combination treatment group obtained a mean value of 6, the muscle tension release group had a value of 6.9 and the cervical spine manipulation group had a value of 5.5. At visit 3, the combination treatment group resulted in a mean value of 4, the muscle tension release group a value of 4.1 and the cervical spine manipulation group a value of 4.1. At visit 5, the combination treatment group had a mean value of 1.5, the muscle tension release group a value of 2.5 and the cervical spine manipulation group a value of 3.

44 a) Intragroup analysis

The Wilks’ Lambda test was chosen to establish if a change was found over the two week period, between the 1st, 3rd and 5th visit in all three groups. The p-value was 0.00, indicating that there was a significant change in the NPRS between the 1st, 3rd and 5th visits in all three groups. Due to a statistically significant difference found on the NPRS over the three visits (p ≤ 0.05).

b) Intergroup analysis

To reiterate, the Levene test was first used to determine if the all the variables were homogenous. With regards to the NPRS, the p value for visit one was 0.653, the p value for visit three was 0.429, and the p value for visit five was 0.332. Due to all the p-values being greater then 0.05, the variances for Groups 1, 2 and 3 were homogenous. Thereafter, an ANOVA test was used to determine if differences occurred between the three groups with regards to the 1st, 3rd and 5th visits. The p-value for visit 1 was 0.136, for visit 3, 0.860 and visit 5, 0.117.

Due to all p-values still being more than 0.05, no statistically significant differences for the NPRS between groups were noted (p>0.05).

4.3.2 NDI

Figure 4.2: Line graph representing the mean values of the NDI for all three groups at the 1st, 3rd and 5th visits

Figure 4.2 illustrates the NDI mean values obtained on the 1st, 3rd and 5th visits. At the 1st visit, the combination treatment group obtained a mean value of 23, the muscle tension release group had a value of 42 and the cervical spine manipulation group had a value of 28. At visit 3, the combination treatment group resulted in a mean value of 25, the muscle tension release group a value of 29 and the cervical spine manipulation group a value of 19. At visit 5, the combination treatment group had a mean value of 5, the muscle tension release group a value of 29 and the cervical spine manipulation group a value of 18.

a) Intragroup analysis

The Wilks’ Lambda test was chosen to establish if a change was found over the two week period, between the 1st, 3rd and 5th visit in all three groups. The p-value was 0.85, indicating that there was a significant change in the NDI between the 1st, 3rd and 5th visits in all three groups. Due to a statistically significant difference found on the NDI over the three visits (p ≤ 0.05).

b) Intergroup analysis

To reiterate, the Levene test was first used to determine if the all the variables were homogenous. With regards to the NDI, the p-value for visit one was 0.062, the p value for visit three was 0.336, and the p value for visit five was 0213. Due to all the p values being greater then 0.05, the variances for Groups 1, 2 and 3 were homogenous. Thereafter, an ANOVA test was used to determine if differences occurred between the three groups with regards to the 1st, 3rd and 5th visits. The p-value for visit 1 was 0.003, for visit 3, 0.062 and visit 5, 0.171. Due to all p-values still being more than 0.05 except for the visit 1, no statistically significant differences for the NPRS between groups were noted (p>0.05).

4.3.3 HIT-6

Points

Combination Treatment MTRT Manipulation Groups Figure 4.3: Box and whisker graph representing the mean values of the HIT for all three groups at the 1st, 3rd and 5th visits

Figure 4.3 illustrates the HIT mean values gathered on the 1st, 3rd and 5th visits. At the 1st visit, the combination treatment group had a mean value of 61, the muscle tension release technique group had a value of 62, and the cervical spine manipulation group had a value of 60.30. At visit 3, the combination treatment group had a mean value of 52.40, the muscle tension release technique group had a value of 53.30, and the cervical spine manipulation group had a value of 52.10. At visit 5, the combination treatment group had a mean value of 46.60, the muscle tension release technique group a value of 47.20, and the cervical spine manipulation group a value of 43.1.

47 a) Intragroup analysis

The Wilks’ Lambda test was used to determine if a change was found over the two week period, between the 1st, 3rd and 5th visit in all three groups. The p-value was 0.00, indicating a significant change in the HIT between the 1st, 3rd and 5th visits in all three groups. Due to a statistically significant difference found on the HIT over the three visits (p ≤ 0.05), the effect size of the result was also determined. The partial eta squared value was used to determine this and the value was 0.74. Using the guidelines suggested by Cohen (1988), a value of 0.01 is small; a value of 0.06 is moderate; and a value of 0.14 is large. This indicates that the result is a large result.

b) Intergroup analysis

The intergroup analysis was performed to look for differences between the groups during the 1st, 3rd and 5th visits. The Levene test was first used to determine if the all the variables were homogenous. The p values were as follows for visit one was 0.3, for visit three was 0.33, and for visit five was 0.065. Due to all the p values being greater then 0.05, the variances for Groups were homogenous. Thereafter, an ANOVA test was used to determine if differences occurred between the three groups with reference to the 1st, 3rd and 5th visits, with regards to the specific time intervals. The p values were for visit 1 – 0.75, visit 3 – 0.77, and for visit 5 - 0.61. Due to all the p-values being greater than 0.05, no statistical significant differences between groups was noted (p>0.05).

4.4 Objective data analysis 4.4.1 Pressure algometer

2 Estimated Marginal Means kg/cm Means Marginal Estimated

Figure 4.4 Line Graph representing the mean values of the pressure algometer for the sub occipital muscles in kg/cm2 for all three groups at the 1st, 3rd and 5th visits

Figure 4.4 illustrates the mean values in kg/cm2 obtained on the 1st, 3rd and 5th visits. At the 1st visit, the combination treatment group the combination treatment group obtained a mean value of 5.1 kg/cm2, the muscle tension release group, a value of 6.4, and the cervical spine manipulation group, a value of 2.3 kg/cm2. At visit 3, the combination treatment group resulted in a mean value of 6.9 kg/cm2, the muscle tension release group, a value of 7.9 kg/cm2, and the cervical spine manipulation group, a value of 5.5 kg/cm2. At visit 5, the combination treatment group had a mean value of 9.2 kg/cm2, the muscle tension release group, a value of 9.2 kg/cm2, and the cervical spine manipulation group a value of 7.1 kg/cm2.

a) Intragroup analysis

The Wilks’ Lambda test was elected to decide if a change was found over the two week period, between the 1st, 3rd and 5th visits in all three groups. The p-value was 0.035, indicating that there was a considerable change in the Pressure algometer readings between 1st, 3rd and 5th visits in all three groups. Due to a statistically significant difference found on the Pressure algometer readings over the three visits (p ≤ 0.05).

49 b) Intergroup analysis The Levene test was first used to verify if the all the variables were homogenous. With regards to readings of the Pressure algometer: the p-value for visit one was 0.725; the p-value for visit three was 0.874; and the p-value for visit five was 0.762. Due to all the p-values being greater then 0.05, the variances for groups were homogenous. Thereafter, an ANOVA test was used to determine if differences occurred between the three groups in terms of the 1st, 3rd and 5th visit, which were the specific time intervals. The p-value for visit 1 was 0.119; for visit 3, 0.41; and visit 5, 0.088. An increase in all p-values between the specific time intervals was noted. Due to all p-values still being greater than 0.05, no statistically significant differences for Pressure algometer readings between groups was noted (p > 0.05).

CHAPTER 5 - DISCUSSION

5.1 Introduction

The aim of this research study was to determine if cervical spine manipulation combined with the muscle tension release technique of the sub occipital muscles, would have any effect on tension-type headache symptoms and severity. As well as, this study was used to explore whether cervical spine manipulation alone, the muscle energy technique of the sub occipital muscles used in isolation, or a combination of the two treatments, was most effective in relieving tension-type headache symptoms. This chapter contains the explanation and discussion of the results found during this study. References will be made to chapter two and chapter four when applicable. The statistical evaluation will be discussed in terms of intragroup and intergroup analysis with results obtained from the NPRS, NDI, HIT-6, and pressure algometer measurements.

5.2 Demographic data

5.2.1 Gender distribution

Of the total 30 participants in this study, 15 were female and 15 were male, having a female to male ratio of 1:1. Epidemiological studies have shown that females have a slightly higher prevalence of tension- type headaches, with a female to male ratio ranging from approximately 2:1 to 3:1 (Chai, Rosenberg and Peterlin, 2012). Which is not suggested in this study as the ratio of male to female participates is 1:1.

5.2.2 Age distribution

All participants had to be between the ages of 18 and 50 in this study, as per the inclusion criteria. This was to minimize the risk of other complications that could predispose one to tension-type headache or be seen as a differential to tension-type headaches, such as degenerative facet joint and disc changes that can occur with increasing age in the cervical spine (Regis and Haid, 2015). The mean age for all participants in all three groups was 28.3 years. The mean age for the combination treatment group was 22.3 years, the mean age for the muscle tension release group was 31.4 years and the mean age for the cervical spine manipulation group was 31.3 years. Each group mean fell within the age bracket suggested by epidemiological studies, that have also shown that the majority tension-type headaches are prevalent before the age of 35 (Chai, Rosenburg and Peterlin, 2012). In this study, the mean for all three groups, as well as each individual group, was less than 35 years of age, substantiating the appropriate age distribution in this study.

5.3 Subjective data

5.3.1 NPRS

a) Clinical analysis

The results for the NPRS showed improvement for all three groups over time. The combination treatment group an initial mean value of 5.5 and a final mean value of 1.3, indicating an improvement of 78.4%. The muscle tension release group had an initial mean value of 6.8 and a final mean value of 2.5 indicating an improvement of 63.3%. The cervical spine manipulation group had an initial mean value 5.5 and a final mean value of 3, revealing an improvement of 45.5%.

b) Intragroup analysis

The results from the NPRS displayed a statistically significant improvement in all three individual groups over the time period. A p-value 0.00 for each group states that all three treatment groups had a positive effects on their perceived their headache pain (p ≤ 0.05).

52 c) Intergroup analysis

The results obtained from the NPRS did not show statistically significant differences between the three treatment groups, due to all the p-values being greater than 0.05. Therefore, there were no statistically significant differences found between the three treatment methods (p>0.05). Although no statistically significant differences were found, it was apparent that the p-values decreased from visit 1 to visit 5, which could indicate that a research study with a longer time period and larger sample group could have proved to be statistically significant. A possible explanation of the poor statistical significance is that, as discussed above, is that all treatment methods were effective via different mechanisms in treating tension-type headaches. The NPRS is also a subjective test. Hence, the improvement could have been due to a physiological manifestation as the participants received medical attention for their headaches.

5.3.2 NDI

a) Clinical analysis

The results for the NDI showed improvement for all three groups over time. The combination treatment group an initial mean value of 23 and a final mean value of 8.4, indicating an improvement of 63.5%. The muscle tension release group had an initial mean value of 42.4 and a final mean value of 17.6 indicating an improvement of 58.5%. The cervical spine manipulation group had an initial mean value 32.8 and a final mean value of 16, revealing an improvement of 51.3%.

b) Intragroup analysis

The results from the NDI displayed a statistically significant improvement in all three individual groups over the time period. A p=value 0.00 for each group states that all three treatment groups had a positive effects on their perceived their headache pain (p ≤ 0.05).

53 c) Intergroup analysis

The results obtained from the NDI did not show statistically significant differences between the three treatment groups, due to all the p-values being greater than 0.05. Therefore, there were no statistically significant differences found between the three treatment methods (p > 0.05). Although no statistically significant differences were found, it was apparent that the p-values decreased from visit 1 to visit 5, which could indicate that a research study with a longer time period and larger sample group could have proved to be statistically significant. A possible explanation of the poor statistical significance is that, as discussed above, is that all treatment methods were effective via different mechanisms in treating tension-type headaches. The NDI is also a subjective test. Hence, the improvement could have been due to a physiological manifestation as the participants received medical attention for their headaches.

5.3.3 HIT-6

a) Clinical analysis

The HIT-6 showed improvement in all three groups over the time period of this study. A decrease in approximately 8 points between the first and last visits indicates that there is a clinically relevant improvement in the participants’ tension-type headaches (Castien, Blankenstein, van der Windt and Dekker, 2012). The combination treatment group had an initial mean value of 61.5 and a final mean value of 46.6, indicating a decrease of 14.9 points. This shows an improvement of 24.2%. The muscle tension release group had an initial mean value of 62 and a final mean value of 47.2, indicating a decrease of 14.8 points. This shows an improvement of 23.8%. The cervical spine manipulation group had an initial mean value 60.3 and a final mean value of 49.1, indicating a decrease of 11.2 points. This shows an improvement of 18.6%. b) Intragroup analysis

The results seen in the HIT-6 indicate a statistically significant improvement in all three individual groups over the time period of the research study. A p-value 0.00 for each group concludes that all three treatment groups had a positive outcome on how participants perceived their tension-type headaches in a way that it affected their lifestyles. Furthermore, the effect size of the result was also determined, and was ranked large, indicating that the improvement for each group was not only statistically significant.

54 c) Intergroup analysis

The results obtained from the HIT-6 did not show statistically significant differences between the treatment groups, due to all the p-values being greater than 0.05. Thus there are no statistically significant differences found between the three treatment protocols (p > 0.05). Although no statistically significant differences where seen, it was apparent that the p-values decreased over the specific time intervals, which could indicate that a research study with a longer time period and more participants could have proved to be statistically significant.

From the clinical analysis, all three groups’ demonstrated improvement over time, with the combination treatment group demonstrating the largest percentage improvement (23.8%), yet no statistical significant difference was found between them. A possible cause of this significance is that all three treatment methods were effective by use of different mechanisms that aid in treating tension-type headaches. Both joint dysfunction and muscle hypertonicity are involved in the cause and/or continuity of tension-type headaches. On-going activation of myofascial trigger points and muscle hypertonicity has been linked to aid in restricted joint movement. Myofascial conditions are triggered by many causes such as trauma, emotional distress, exposure to cold, visceral conditions and postural stress. Sustained muscle contraction can develop into a source of pain and joint dysfunction. These results in a cycle of pain and muscle hypertonicity called the ‘Myofascial cycle’. Chiropractic manipulation has been proven to have an effect on both pain and muscle hypertonicity (Peterson and Bergmann, 2002). As mentioned in Chapter two, this occurs by stimulating receptors that induce reflex responses that reduce pain and cause reflex inhibition of hypertonic muscles (Wyke, 1985).

Numerous studies have indicated that cervical spine manipulation is clinically valuable in relieving tension-type headaches by reducing the duration, frequency, intensity and emotional and functional disability of these headaches (Espí-López et al. 2014; Posadzki and Ernst, 2012; Vernon et al. 2009). This is a possible explanation as to why the combination treatment group showed a statistically significant improvement in the perception of pain. Muscle Tension Release Technique (MTRT) has also been proven to effect pain and muscle hypertonicity (Mitchell, 1979; Bourdillon, 1992; Mitchell and Mitchell, 1995; Goodridge and Kutchera, 1997 and Chaitow, 2008; Greenman, 1996; Fryer, 2011).

As discussed in Chapter Two, MTRT focuses on restoring normal muscle length, thereby inactivating myofascial trigger points, thus reducing pain and muscle hypertonicity. MTRT also has effect on restricted joints by assisting in increasing soft tissue range of motion, thereby reducing pain and muscle spasm that

55 was caused by joint dysfunction (Chaitow, 2006). This is a possible explanation as to why, the muscle tension release group showed a statistically significant improvement in the perception of pain. A combination of cervical spine manipulation and muscle energy technique had a synergistic effect on one another. Both treatments, via different mechanisms, assisted in reducing muscle spasm and pain. This signifies the rationale as to why the cervical spine manipulation group showed a statistically significant improvement in the perception of pain.

It must also be taken into consideration that the HIT-6 is a subjective test: therefore, the improvement could have been due to a physiological manifestation as the participants received medical attention for their headaches. Placebo analgesia is well established and may contribute to afferent fibre inhibition, thereby decreasing the symptoms of tension-type headaches (Craggs, Price, Perlstein, Verne and Robinson, 2007).

5.4 Objective data

5.4.1 Pressure Algometer

a) Clinical analysis

The combination treatment group had an initial mean value of 5.09kg/cm2; and a final mean value of 9.39 kg/cm2, indicating an improvement of 46%. The muscle tension release group had an initial mean value of 6.38 kg/cm2, and a final mean value of 9.36 kg/cm2; showing an improvement of 32%. The cervical spine manipulation group had an initial mean value of 4.16 kg/cm2 and a final mean value of 7.21 kg/cm2, reflecting an improvement of 42%.

b) Intragroup analysis

The results from the Pressure algometer suggested a statistically significant improvement in all three individual groups over the research study. A p-value of 0.00 for each group concludes that all three treatment groups showed an improvement in trigger point severity (p ≤ 0.05).

56 c) Intergroup analysis

The results obtained from the Pressure algometer throughout the study revealed no statistical difference between all three groups at each individual visit due to all the p-values being greater than 0.05 (p > 0.05). Although no statistically significant difference was found, it was found that. From the clinical analysis, all three groups demonstrated improvement, with the combination treatment group demonstrating the largest percentage improvement of 46%.

The Muscle Tension Release technique (MTRT) reduces pain sensitivity levels of cervical spine musculature. The exact mechanism through which this is applied is still uncertain, however, both mechanical and neurophysiological factors play a role. The techniques of contraction and stretching utilized in MTRT can produce viscoelastic changes in the connective tissue of a muscle. ‘Viscoelasticity’ is a term used to describe an object or substance that exhibits both viscous and elastic properties. If temporary stress is applied to the object or substance, it will deform, but return to its normal state soon after the stress has subsided. However, if the stress is maintained, the deformation can be permanent.

MTRT can produce greater viscoelastic change than other techniques, such as passive stretching alone. This occurs by altering the fluid content of the muscles connective tissue, thereby influencing the length and stiffness of a muscle. This essentially increases the elasticity of a muscle. MTRT can realign poorly formed connective tissue and break poorly aligned linkages of connective tissue which is known as scar tissue with the muscle fibres. Another technique utilized in MTRT, post-isometric relaxation, this is important in the process of de-activating, active myofascial trigger points.

Post-isometric relaxation is when a muscle or a group of muscles has reduced muscle tone following an isometric contraction. As mentioned earlier, application of MTRT can decrease pain perception by stimulating mechanoreceptors and causing inhibition of pain at the dorsal horn of the spinal cord, implied by the pain gate theory (Chaitow, 2006). A reduction in pain can result in active myofascial trigger point deactivation, thus increasing the pain pressure thresholds of the patient (Hong, 2004).

As mentioned earlier, chiropractic cervical spine manipulation has numerous effects. Chiropractic cervical spine manipulation can affect capsular mechanoreceptors in a joint, which in turn, affects muscle tone by stretching the intrafusal muscle fibres and by stimulating the Golgi tendon organs inside skeletal muscle. Reduction in muscle spasm occurs as Golgi tendon organs inhibit muscle activity (Leach, 2004). This could possibly explain an increase in pain pressure threshold levels with chiropractic cervical spine manipulation.

CHAPTER SIX – CONCLUSION AND RECOMMENDATIONS

6.1 Conclusion

The aim of this research study was to determine the efficacy of chiropractic manipulation of the cervical spine and muscle tension release technique of the sub occipital muscles in relieving tension-type headaches. This research study was also used to establish which treatment protocol would be most effective in relieving tension-type headaches: chiropractic manipulation of the cervical spine; muscle energy tension release of the sub occipital muscles; or, a combination of both treatment protocols.

With reference to the subjective data of this study, chiropractic manipulation of the cervical spine, the muscle tension release technique of the sub occipital muscles, and a combination of both treatments, had clinical improvements over the two week period; this was statistically significant with regards to the HIT-6 and NPRS. However, when chiropractic manipulation of the cervical spine, the muscle tension release technique of the sub occipital muscles and a combination of both treatment protocols were compared to one another; no statistical difference was noted between all three groups over the two week period.

In terms of the objective data of this study, the chiropractic manipulation of the cervical spine, muscle tension release technique of the sub occipital muscles, and the combination of both treatment protocols; had clinical improvements over the two week period which was statistically significant with reference to the pressure algometer. However, when the chiropractic manipulation of the cervical spine, muscle tension release technique of the sub occipital muscles and the combination of both treatments were compared to one another; no statistical difference occurred over the two week period.

In conclusion, with reference to the results obtained, suggests that chiropractic manipulation of the cervical spine, the muscle tension release technique of the sub occipital muscles and a combination of the two treatments may be effective as treatment in relieving tension-type headaches. However, neither the chiropractic manipulation of the cervical spine, muscle tension release technique of the sub occipital muscles, or a combination of the two treatments; was more effective in relieving tension-type headaches, suggesting that both treatment and the combination of the two treatments would be ideal for treating tension-type headaches with in the chiropractic field.

Accurate conclusions could not be made in terms of intergroup analysis, and therefore further research should be performed to yield more results on the comparison of all three treatment protocols.

6.2 Recommendations

The following recommendations are suggested to further improve the results of this study:

1. A research study including a larger sample group should be performed to allow for a more precise representation of the general population. 2. A research study with an extended treatment period exceeding two weeks should be conducted to determine if a statistically significant difference does, in fact, occur between the three treatment groups. 3. Chiropractic manipulation should not only be limited to the cervical spine, but rather participants should receive full spinal treatment as other restricted joints may have an effect it may have on tension-type headaches. A study where joint restrictions were addressed in the thoracic and lumbar spine, demonstrated a 32% intensity diminishment and a 42% frequency reduction in tension-type headaches (Boline, Kassak, Bronfort, Nelson and Anderson, 1995). 4. To determine possible long-term benefits of the research study, a follow-up visit after one month should be included. 5. Replacing the manual algometer Device with the newer digital device may prove to provide more accurate results in pressure pain sensitivity. 6. The muscle tension release technique should be performed not only to the sub occipital muscles, but also to all the other musculature commonly associated with tension-type headaches to achieve better results. Other muscles such as the trapezius muscle, masseter muscle, sternocleidomastoid muscle and splenius capitus muscle that all, when have active myofascial trigger points may evoke symptoms similar to tension-type headaches (Fernández-de-las- Peñas et al, 2009).

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APPENDIX A - ADVERTISEMENT Research Do you suffer from tension HEADACHES? Please come be a part of this research study.

THE AIM OF THIS STUDY IS TO DETERMINE THE EFFECTS OF CERVICAL SPINE CHIROPRACTIC MANIPULATION, SUB OCCIPITAL MUSCLE TENSION RELEASE AND A COMBINATION OF BOTH IN TREATMENT OF TENSION HEADACHES.

This study will take place at the university of Johannesburg Chiropractic clinic in Doorfontein. To participate: You must be over the age of 18 and suffer from tension type headaches. To learn more, contact the principal investigator of the study, Craig Orr, on 0827210646 or [email protected]

Ethics Clearance Number REC-01-160-2017

APPENDIX B – INFORMATION FORM

Date: ______INFORMATION FORM

Dear Participant,

I, Craig Orr, am a student completing my Master’s Degree at the University of Johannesburg. I would like to invite you to consider participating in my research study entitled “A Comparison Study between Cervical Spine Manipulation and Sub-Occipital Muscle Release Technique in the Treatment of Tension Type Headaches”. Before agreeing to participate, there are a few points that I would like to bring to your attention:  This study is entirely voluntary and you are free to withdraw at any point without reason and without any consequences.  Your information will be kept confidential at all times and no data will be able to be traced back to you as your name will be converted to a file number on all documentation. The data from this study may however be used for publication purposes.

Some important details directly related to this study that I would like you to be aware of should you decide to participate:  You need to be over the age of 18 and suffer from tension type headache .You should not have any contraindications to chiropractic treatment or take any medications that may influence the results of this study, specifically any performance enhancing drugs. This criteria will be determined by the researcher and discussed in more detail with you at your consultation.

 You will have the motion restriction(s) manipulated by the researcher. Spinal manipulation is a standard procedure performed by Chiropractors on a regular basis. There are limited side effects, with a small chance of feeling some stiffness and mild discomfort after the treatment.

 You will need to notify me of any side effects that you may experience following treatment. Be aware that you may hear an audible clicking sound during treatment, this is completely normal.  The duration of the study will be 4 treatments every other day for a 2 week period. Each treatment will be a 30- 45 minutes duration,  If you have any questions at any time please contact me on 0827210646, or alternatively contact my supervisor, Dr C.J Hay on 011 559 6500 or [email protected]

Thank you for taking the time to read this form and consider participation in this study. Results will be available on request.

This study protocol has been approved by the University of Johannesburg’s Academic Ethics Committee and a written approval has been granted by that committee. The study has been structured in accordance with the Declaration of Helsinki of 2013, which deals with the recommendations guiding doctors in biomedical research involving human participants.

If you want any information regarding your rights as a research participant, you may contact the Chairperson of the University of Johannesburg’s Academic Committee. Dr C. Stein: [email protected] UJ Ethics Clearance number: REC-01-160-2017

APPENDIX C – CONSENT FORM

DEPARTMENT OF CHIROPRACTIC

Date: ______

CONSENT FORM

Dear participant

Before signing this consent form please take your time and read the information form.

Please indicate below, whether you want me to notify your personal doctor or your specialist of your participation in this study:  YES, I want you to inform my personal doctor/ specialist of my participation in this study Doctors Name ______Doctors Contact details ______ NO, I do not want you to inform my personal doctor/ specialist of my participation in this study  I do not have a personal doctor / specialist

Do you have any questions related to this study?

INFORMED CONSENT

 I hereby confirm that I have been informed by the researcher Craig Orr about the nature, conduct, benefits and risks of this study with the title “A Comparison Study between Cervical Spine Manipulation and Sub-Occipital Muscle Release Technique in the Treatment of Tension Type Headaches”.  I have also received, read and understood the written information (participant information leaflet) regarding this study  I am aware that the results of this study, including personal details regarding my sex, age, date of birth, and diagnosis will be anonymously processed into a study report  In view of the requirements of research, I agree that the data collected during this study can be processed  I may, at any phase, without prejudice, withdraw my consent and participation in this study  I have had sufficient opportunity to ask questions and (of my own free will) I declare myself prepared to participate in this study.

Signed Participant

Printed name Signature Date and time

Signed Researcher

Printed name Signature Date and time

For Completion by the Researcher Did the participant raise any questions? YES/NO If yes, what were they? ______

______

APPENDIX D – DIAGNOSTIC CRITERIA OF TENSION-TYPE HEADACHES

International Headache Society diagnostic criteria of tension-type (The International Classification of Headache Disorders 2004).

A. Suffering from at least 10 episodes of headaches per month for at least three months, and fulfilling criteria. B. Suffering headaches lasting from 30 minutes to 7 days. C. The headache has to have at least two of the following characteristics: 1. Bilateral location; 2. A pressing/tightening (non-pulsating) quality; 3. Mild or moderate intensity; 4. It is not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: 1. No nausea or vomiting (anorexia may occur) 2. No more than one of photophobia or phonophobia E. It must not be attributed to another disorder.

APPENDIX E - CONTRA-INDICATIONS FOR CHIROPRACTIC MANIPULATIONS

Contra-Indications for Chiropractic Manipulations (Gatterman, 1990) Vascular complications  Vertebral artery syndrome  Aneurysms Tumors  Primary to the bone  Secondary (metastasis to the bone) Bone infections  Tuberculosis of the spine  Osteomyelitis of the spine Traumatic injuries  Fractures  Instabilities  Dislocation  Unstable spondylolisthesis Arthritis  Ankylosing spondylitis  Rheumatoid arthritis  Psoriatic arthritis  Reiter’s syndrome  Osteoarthritis Psychological considerations  Malingering  Hysteria  Hypochondriasis  Pain intolerance  Dependent personality  Disability Syndromes Neurological complications  Cervical disc lesions and myelopathy  Nerve root damage

APPENDIX F – CASE HISTORY FORM

UNIVERSITY OF JOHANNESBURG CHIROPRACTIC DAY CLINIC

CASE HISTORY

Date: ______

Patient: ______File No: ______

Occupation: ______Age: ______Sex: ______

Student: ______Signature: ______

FOR CLINICIAN USE ONLY:

Initial visit clinician: ______Signature: ______:

Case History: ______

______

Examination: Previous: UJ Current: UJ Other Other

X-ray Studies: Previous: UJ Current: UJ Other Other

Clinical Path. Lab: Previous: UJ Current: UJ Other Other

Case status: PTT: Conditional: Signed off: Final sign out:

Recommendations:

Students case history:

1. Source of History: ______

2. Chief Complaint in patients own words:

______

3. PRESENT ILLNESS/PRIMARY COMPLAINT 4. PAST HISTORY

Location General Health Status

Childhood Illnesses Onset

Duration Adult Illnesses

Frequency Psychiatric Illnesses

Pain Character Accidents

Progression

Aggravating Factors Traumatic Injuries

Relieving Factors

Ass Signs & Symptoms Surgeries

Previous Occurrence Hospitalizations Past Tx and Outcomes

5. ANY OTHER COMPLAINTS

______

6. CURRENT HEALTH STATUS & LIFESTYLE 7. FAMILY HISTORY

Allergies Diabetes Mellitus

Immunizations Heart Disease

Screening Tests TB

Environmental Hazards HBP

Safety Measures Stroke

Progression Kidney Disease

Exercise and Leisure Cancer

Sleep Patterns Arthritis

Diet Anaemia

Current Mediation Headaches

Tobacco Thyroid Diseases

Alcohol Epilepsy

Social Drugs Mental Illness

Other Alcoholism

Drug Addiction

Other

8. PSYCHOSOCIAL HISTORY

Home Situation

Daily Life

Important Experiences

Religious Beliefs

Other

9. REVIEW OF SYSTEMS

General

Skin

Head

Eyes

Ears

Noses / Sinuses

Mouth / Throat

Neck

Breasts

Respiratory

Cardiac

Gastrointestinal

Urinary

Genital/Sexual Function

Vascular

Musculoskeletal

Neurological

Haematological

Endocrine

Psychiatric

Other

APPENDIX G – PHYSICAL EXAMINATION FORM

UNIVERSITY OF JOHANNESBURG CHIROPRACTIC DAY CLINIC

PHYSICAL EXAMINATION

Underline abnormal findings in RED Date: ______

Patient: ______File No: ______

Clinician : ______Signature: ______

Student: ______Signature: ______

STANDING EXAMINATION VITAL SIGNS

Minor’s Sign Height Skin Changes

Posture Weight  Erect

 Adams Temperature Romberg’s Sign

Pronator Drift Heart Rate Trendelenburg Sign Gait Pulse  Rhythm

 Balance Respiratory Rate  Pendulousness

 On toes

 On heels BLOOD PRESSURE  Tandem

Half Squat Left Right Scapular Winging Muscle Tone Arms Spasticity / Rigidity Chest measurement  Inspiration ______cm Legs  Expiration ______cm

Visual Acuity

Lumbar Spine ROM  Flexion (90º) General Appearance  Extension (50º)

 Lat. Flexion (30º) ______ Rotation (35º)

______

SEATED EXAMINATION Cont. SEATED EXAMINATION

Mouth & Pharynx Spinal Posture  Lips Head  Buccal Mucosa  Hair & Skin  Gums & Teeth  Scalp  Roof  Skull  Tongue  Face - Inspection Eyes - Movements  Observation - Taste - Conjunctiva - Palpation - Sclera  Pharynx – CN X - Eyebrows & Lids TMJ - Lacrimal Glands  Inspection - Nasolacrimal - ROM Duct - Deviation - Position  Palpation - Alignment - Crepitus - Cornea / Lens - Tenderness  Corneal Reflex Neck  Ocular Movements  Posture  Visual Fields  Size / Swellings  Accommodation  Scars  Ophthalmoscopy  Discolorations - Iris  Hairline - Pupils  Lymph Nodes - Red Reflex  Tracheal - Optic Disc Alignment - Macula  Thyroid & Carotids - Vitreous Cervical Spine ROM - Lens  Flexion (45º) Ears  Extension (55º)  Inspection  Lat. Flexion (40º) - Auricle  Rotation (70º) - Ear Canal

- Drum Peripheral Vascular

 Auditory Acuity  Inspection  Weber Test - Pigmentation,  Rinne Test Skin, Nailbeds, Nose Hairloss  External Inspection  Palpation  Internal Inspection - Pulses, Lymph

- Septum nodes, Skin - Turbinates Temp - Olfaction  Manual Compression Sinuses  Retrograde Filling  Tenderness  Arterial Insufficiency  Transillumination  Allan’s Test

BREAST ABDOMINAL

Inspection Inspection  Skin  Skin  Size  Umbilicus  Contour  Contour  Nipples  Peristalsis  Arms Overhead  Pulsations

 Hands Against Hips  Hernias

 Leaning Forward Auscultation Palpation  Bowel Sounds  Axillary Lymph Nodes  Bruits  Breast Percussion  Breast tail  General

 Liver

THORAX – HEART AND LUNGS  Spleen Palpation Inspection  Superficial Reflex  Skin  Cough  Shape  Light  Respiratory Distrass  Rebound Tenderness

 Rhythm  Deep  Depth  Liver  Effort  Spleen  Intercostal Retraction  Kidneys Palpation  Aorta  Tenderness  Abdominal Masses

 Masses  Shifting Dullness  Respiratory  Fluid Wave Expansion Acute Abdomen  Tactile Fremitus  Where pain began?  JVP  Moved to where?  PMI  Cough

Percussion  Tenderness

 Lungs (posterior)  Guarding / Rigidity  Diaphgragmatic  Rebound Tenderness excursion Special Tests  Kidney Punch  Rovsing’s Sign Auscultation  Psoas Sign

 Breath Sounds  Obturator Sign

 Adventitious Sounds  Cutaneous  Voice Sounds Hyperaesthesia  Heart Auscultation  Murphy’s Sign  Heart Murmurs  Rectal Examination 

MUSCULOSKELETAL MENTAL STATUS

Shoulder Appearance & Behavior  Observation  LOC - Skin  Posture - Symmetry  Motor Behavior  ROM  Dress, Grooming - Glenohumeral  Facial Expression - Scapulo-thoracic  Affect - Acromioclavicular Speed & Language - Elbow  Quanity - Wrist  Rate Hip Left Right  Volume  Flexion (90° / 120°)  Fluency  Extension (15°)  Aphasia (pm)  Abduction (45°) Mood  Adduction (30°) Memory  Internal Rotation (40°)  Orientation  External Rotation (45°)  Remote Memory

Knee Left Right  Recent Memory  Flexion (30°)  New Learning Ability  Extension (0° / 15°) Higher Cognitive Function

Ankle Left Right  Information  Plantar Flexion (45°)  Vocabulary  Abstract Thinking  Dorsi Flexion (20°)

 Inversion (30°)

 Eversion (20°) Leg Length Left Right

 Apparent CRANIAL NERVES  Actual Left Right

CN I – Olfactory CN II – Optic CN III – Occulomotor CN IV - Trochlear CO-ORDINATION AND CEREBELLAR TESTING CN V – Trigeminal

 Motor Vertigo  Sensory Ataxic Gait CN VI – Abducents Nystagmus CN VII – Facial  Motor Intention Tremor Slurring/ Staccato Speech  Sensory Hypotension CN VIII - Vestibulocochlear CN IX – Glosopharyngeal Dysmetria (Point to point) Dysdiachokinesia CN X – Vagus Titubation CN XI – Spinal Accessory CN XII - Hypoglossal

NEUROLOGICAL ASSESSMENT NEUROLOGICAL ASSESSMENT

MYOTOMES DERMATOMES Level Left Right Lumbar Left Right Cervical Hip Flexion L1 / Cervical L2 Neck C1 / C2 Forward C2 Knee L2 / C3 Flexion Extension L3 / L4 C4 Neck C3 C5 Knee L5 / Lateral C6 Flexion Flexion S1

C7 Shoulder C4 Hip Internal L4 / C8 Elevation Rotation L5 Hip L5 / T1 Shoulder C5 T2 Abduction External S1 Rotation Elbow C5 Lumbar Flexion Hip L2 / Adduction L3 / T12 Elbow C7 L4 L1 Extension Hip L4 / L2 Elbow C6 Abduction L5 L3 Flexion Ankle L4 / L4 Forearm C6 Dorsiflexion L5 L5 Pronation Ankle S1 / S1 Forearm C6 Plantar S2 S2 Supination Flexion S3 Wrist C6 Hallux L5 REFLEXES Extension Extension Level Left Right Wrist C7 Eversion S1 Cervical Flexion Inversion L4 Biceprs C5 Finger C8 Hip L5 / Brachioradialis C6 Flexion Extension S1 Finger T1 Triceps C7 Abduction Lumbar Finger T1 Patella L3 / Adduction

L4 Medial Hamstring L5

Lateral Hamstring S1 Tibialis Posterior L4 / L5 Achilles S1 /

S2 Plantar Reflex

APPENDIX H – CERVICAL SPINE REGIONAL EXAMINATION

UNIVERSITY OF JOHANNESBURG CHIROPRACTIC DAY CLINIC

REGIONAL EXAMINATION CERVICAL SPINE

Date: ______

Patient: ______File No: ______

Clinician: ______Signature: ______

Student: ______Signature: ______

OBSERVATION Left Right Trigger points Posture: Skin Sternocleidomast Temporalis oid  Anterior (head tilt, head rotation) Masseter Scalene  Lateral (anterior head carriage, thoracic TMJ Trapezius and lumbosacral kyphosis, cervical and Lymph Nodes Levator scapulae lumbar lordosis) Trachea Posterior cervical  Posterior (scoliosis, antalgia, asymmetry) Thyroid Gland muscles General: Clavicle o Suboccipitals  Skin First rib  Hair and hairline Muscle tone  Muscle tone

 Muscle bulk

 Bony and soft tissue contours  Movement  Facial Expression

RANGE OF MOTION RANGE OF MOTION OF MOTION

Active

Flexion (+/- 45º (90º max)

Extension (+/- 55º (70º max)

Lateral Flexion (+/- 40º (20-45º) Rotation (+/- 70 - 90º)

Passive Resisted Isometrics

Flexion Left Right

Extension Flexion

Lateral Flexion Extension

Rotation Lateral

Flexion

Rotation

ORTHOPAEDIC EXAMINATION VASCULAR EXAMINATION

Left Right Left Right

Pulses

Compression Tests  Carotid Doorbells Sign  Subclavian Maximal Cervical  Brachial Compression Test  Radial

Axial Compression Test Blood Pressure (Spurling’s)

Foraminal Compression Jugular Venous

Tests Pressure and

 Rotate and Compress Pulses

 Lateral Flex and Compress (Jacksons) Heart Kemps Test  Inspection  Palpation

 Percussion Other Tests  Auscultation Cervical Distraction MOTION PALPATION

Shoulder Abduction Test Auscultate Left Right Shoulder Depression Test Carotid Arteries C0 C0/C1

Dizziness Rotation Test C1/C2 Auscultate Lhermittes Sign C2/C3 Subclavian C3/C4

 Brudzinskis Arteries C4/C5  Kernigs C5/C6 C6/C7 Allen's Test C7/T1 Brachial Plexus Tension T1/T2 Examination of T2/T3 Test Eyes and Ears T3/T4 T4/T5 T5/T6 Carpal Tunnel Syndrome T6/T7  Phalens Test

 Tinels Sign

Thoracic Outlet

Syndrome

 Adsons

 Halsteads

 Cervical Rib

 Pec Minor (Hyperabduction/ Wrights)  Costoclavicular

Co-ordination Cranial Nerves

Left Right Myotomes Left Right Rapid CN I alternating Left Right Smell movements C1/C2(neck CN II Point to point flexion) Visual acuity movements C3(lateral neck Optic fundi flexion) Visual fields by Stance C4(shoulder confrontation elevation) CN II and III Left Right C5 Pupils Romberg (shoulder Reactions to light Test for abduction) Near response pronator drift (elbow flexion) CN III, IV and IV Arm tapping C6 Extraocular movements (forearm Ptosis pronation) CN V Dermatomes (forearm Sensory supination) Motor Left Right C7 Corneal reflex C2 (elbow CN VII C3 extension) Muscles of face C4 (wrist flexion) CN VIII C5 C8 Auditory acuity C6 (finger flexion) Weber C7 T1 Rinne C8 (finger

CN IX and X T1 abduction)

Voice T2 (finger Movements of soft T3-T6 adduction) palate and pharynx

Gag reflex light touch Thumb CN XI pain and temperature  Flexion Shoulder elevation position and vibration (median)

Neck rotation  Extension (radial) CN XII Discriminitive sensations  Abduction

Asymmetry/deviation of (median)  Adduction tongue Left Right (ulnar) Fasciculation’s Stereognosis  Opposition (median Strength Graphesthesia and ulnar) Two point

discriminisation Reflexes Point Left Right localisation C5 (biceps) Extinction C6 (brachioradialis) C7 (triceps) 91

REFLEX GRADING

 4+ Very brisk, hyperactive. Perform ankle

clonus. APPENDIX I – SOAP NOTE FORM

UNIVERSITY OF JOHANNESBURG CHIROPRACTIC DAY CLINIC SOAP NOTE

Patient: Visit Number: File Number: Student: Date: Clinician: S: O:

A: Differential Diagnosis / ICD-10 Code P: Procedure Codes

Home Advice: Comments:

APPENDIX J – NPRS

Patient Instructions (adopted from (McCaffery, Beebe et al. 1989): “Please indicate the intensity of current, best, and worst pain levels over the past 24 hours on a scale of 0 (no pain) to 10 (worst pain imaginable)”

APPENDIX K – HIT-6

Headache Impact Questionnaire (Castien, R.F., Blankenstein, A.H., van der Windt, D. and Dekker, J. 2012). 1. When you have headaches, how often is the pain severe? Never Rarely Sometimes Very often Always

2. How often do headaches limit your ability to do usual daily activities including household Work, work, school, or social activities? Never Rarely Sometimes Very often Always

3. When you have a headache, how often do you wish you could lie down? Never Rarely Sometimes Very often Always

4. In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches? Never Rarely Sometimes Very often Always

5. In the past 4 weeks, how often have you felt fed up or irritated because of your headaches? Never Rarely Sometimes Very often Always

6. In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities? Never Rarely Sometimes Very often Always

COLUMN 1-6 points COLUMN 2- 8 points COLUMN 3-10 points COLUMN 4-11 points COLUMN 5-13 points

TOTAL 50 of higher-referral

APPENDIX L - NDI

Neck Disability Index This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only the one box that applies to you. We realise you may consider that two or more statements in any one section relate to you, but please just mark the box that most closely describes your problem. Section 1: Pain Intensity £ I have no pain at the moment £ The pain is very mild at the moment £ The pain is moderate at the moment £ The pain is fairly severe at the moment £ The pain is very severe at the moment £ The pain is the worst imaginable at the moment Section 2: Personal Care (Washing, Dressing, etc.) £ I can look after myself normally without causing extra pain £ I can look after myself normally but it causes extra pain £ It is painful to look after myself and I am slow and careful £ I need some help but can manage most of my personal care £ I need help every day in most aspects of self care £ I do not get dressed, I wash with difficulty and stay in bed Section 3: Lifting £ I can lift heavy weights without extra pain £ I can lift heavy weights but it gives extra pain £ Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table £ Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned £ I can only lift very light weights £ I cannot lift or carry anything Section 4: Reading £ I can read as much as I want to with no pain in my neck £ I can read as much as I want to with slight pain in my neck £ I can read as much as I want with moderate pain in my neck £ I can’t read as much as I want because of moderate pain in my neck £ I can hardly read at all because of severe pain in my neck £ I cannot read at all Section 5: Headaches £ I have no headaches at all £ I have slight headaches, which come infrequently £ I have moderate headaches, which come infrequently £ I have moderate headaches, which come frequently £ I have severe headaches, which come frequently £ I have headaches almost all the time

Section 6: Concentration £ I can concentrate fully when I want to with no difficulty £ I can concentrate fully when I want to with slight difficulty £ I have a fair degree of difficulty in concentrating when I want to £ I have a lot of difficulty in concentrating when I want to £ I have a great deal of difficulty in concentrating when I want to £ I cannot concentrate at all Section 7: Work £ I can do as much work as I want to £ I can only do my usual work, but no more £ I can do most of my usual work, but no more £ I cannot do my usual work £ I can hardly do any work at all £ I can’t do any work at all Section 8: Driving £ I can drive my car without any neck pain £ I can drive my car as long as I want with slight pain in my neck £ I can drive my car as long as I want with moderate pain in my neck £ I can’t drive my car as long as I want because of moderate pain in my neck £ I can hardly drive at all because of severe pain in my neck £ I can’t drive my car at all Section 9: Sleeping £ I have no trouble sleeping £ My sleep is slightly disturbed (less than 1 hr sleepless) £ My sleep is mildly disturbed (1-2 hrs sleepless) £ My sleep is moderately disturbed (2-3 hrs sleepless) £ My sleep is greatly disturbed (3-5 hrs sleepless) £ My sleep is completely disturbed (5-7 hrs sleepless) Section 10: Recreation £ I am able to engage in all my recreation activities with no neck pain at all £ I am able to engage in all my recreation activities, with some pain in my neck £ I am able to engage in most, but not all of my usual recreation activities because of pain in my neck £ I am able to engage in a few of my usual recreation activities because of pain in my neck £ I can hardly do any recreation activities because of pain in my neck £ I can’t do any recreation activities at all

Scoring: For each section the total possible score is 5: if the first statement is marked the section score = 0, if the last statement is marked it = 5. NDI developed by: Vernon, H. & Mior, S. (1991). The Neck Disability Index: A study of reliability and validity. Journal of Manipulative and Physiological Therapeutics. 14, 409-415

APPENDIX M - ALGOMETER READING SHEET

Algometer Readings Reading 1 Reading 2 Reading 3 Pre Trial Mid Trial Post-Trial

APPENDIX N – HIGHER DEGREES CLEARANCE LETTER

100

APPENDIX O – TURNITIN REPORT

101