Why Assessing the Upper Neck is so important with Headaches and Migraines

Why Assessing the Upper Neck is so important with Headaches and Migraines

We hear stories from patients all the time about failed techniques and strategies to try to deal with headache and migraine.  Things like trigger avoidance, drinking more water and taking stronger and stronger medication may not work, especially when there is a hidden cause that hasn’t been assessed.

When having headache and migraine assessed, it is vitally important that the upper cervical spine is assessed, and assessed properly.  It is now common knowledge that there is a common pathway that links the sensory nerves for your upper neck, jaw, face, and the blood vessels in your brain.  This is extremely important, and very often forgotten, when medical professionals are assessing how headaches and migraines are beginning.

Treating headache and migraine without assessing the neck is like treating chest pain without a stethoscope – the symptoms are all there, you can predict what it may be, but you’re not assessing it fully.  Without a full assessment, you cannot have the best diagnosis, and therefore not the most accurate and specific treatment plan. 

But that’s not all – the assessment of the neck must be carried out by someone who is acutely aware of how the neck moves, and how much movement a person can tolerate without making things worse.  It is commonly reported to us that patients have had their neck assessed and treated – “but it made things worse”.  The reason why things get worse, is usually because either the assessment was too much for the person’s system to handle (ie they have been pushed too hard), or that the assessment was carried out in the wrong direction (ie. They are pushing on the left rather than pushing on the right). 

The biggest mistake that health professionals make when considering headache and migraine is to neglect the upper neck in the assessment process – and the best way to assess the neck is to do things carefully and specifically.  The approach that our clinic uses is called the Watson Headache Approach, developed by South Australian Dr Dean Watson.  It is a systemised process which determines which joint is affected, and in which direction.  When this is carried out correctly, then diagnosing which joint is affected becomes quite straightforward.

All of the staff at The Headache and Pain Management Centre treat headache and migraine every single day, and have seen literally thousands of cases between them – including:

  • Migraine with Aura
  • Migraine without Aura
  • Tension Headache
  • Cluster Headache
  • Hormonal Headache
  • Trigeminal Neuralgia
  • Vestibular Headache/Migraine….

And many other rarer conditions.

The Watson Headache Approach, and the other assessment methods that we employ, give a very strong chance of diagnosing if the neck is involved or not.  If the neck is involved, then treatment begins immediately, with every step of the process explained in clear language on Day One, should you go ahead with treatment.

By Chris Fawcett - Director, The Headache and Pain Management Centre

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Back Surgery? Read this first.

Had Back Surgery?  Considering Back Surgery?  You need to see this.

Low Back Pain has a huge number of different reasons for starting, and a big number of effects on people that suffer with it.  One thing that the evidence is showing consistently over the last 15 years, is that the deepest muscle in your lower back – Multifidus – becomes fatty, and much less strong, in the presence of back pain.  In addition to some other findings on MRI, such as disc degeneration, herniations, or compression of the nerves, this can cause people to seek a surgical opinion to get relief from their pain.

Ironically, if a person has back surgery, the multifidus muscles mentioned earlier, are the main muscles that are disrupted (read: cut into) so the surgeon can access the nerves and discs underneath.  This means that post-surgery, these muscles are even weaker and inhibited than before.

The problem with this is obvious – if there is not really good pre-operative strength work done for these muscles, or if there is no program to get Multifidus strong and healthy again after the surgery, a weak, sore back can persist post-op – at times causing pain that is just as bad, if not worse, than before.  (Don’t believe me?  Google “Failed Back Syndrome” to see some horror stories)

When people have surgery on their back, and the pain persists, it often misleads them into thinking the surgery was “unsuccessful”.  The reality is that most surgeons are extremely good at removing and repairing tissues – but it may not have been what was needed for the pain.  A lot of the time, it was just more specific conservative rehabilitation was needed.  It may have even avoided surgery in the first place.

The best way to get Multifidus working again is by using the MedX Lumbar Extension Machine.  It is a safe way to isolate Multifidus and your other back muscles that keep you upright.  Load can be gradually added over time to facilitate strengthening, and studies have shown it can restore the muscle back to a healthy state, and have great outcomes in regards to pain.  Patients using the MedX machine after discectomy surgery have decreased post-operative pain and most return to work sooner (reference: Choi et al, 2005).  After most other types of surgery, the goal is to restore activation of the muscles that have been cut through and yet astonishingly, this is not routinely done after lumbar spine surgery in most cases.

Using the MedX Lumbar Extension Machine at any time from 6 weeks post-op and even years after surgery, will ensure you have done everything possible to rehabilitate the “core” muscle of your spine.  Of course, there other exercises that you should complete for your hip muscles as well to ensure you can move smoothly too.  You will feel strong and confident to move – and in most cases any lingering pain should resolve.

If you’re considering spinal surgery, you can also undergo “prehab” – by strengthening Multifidus pre-surgery you can optimise your strength and function.  Many patients have resolved their pain and avoided spinal surgery by engaging in a MedX strengthening program.

Here’s the key takeaway, if you needed shoulder or knee surgery for a chronic condition, your physio or doctor would not allow you to have the surgery without completing several months of targeted rehab, so why should your back be any different?  The MedX is the key to successful spinal muscle rehabilitation.

All staff at The Headache and Pain Management Centre are trained to assess low backs using the MedX Machine – to book an appointment click on the link below, or visit the Contact Us page to find out if we can help you.

By Nikki Rathbone - APA Titled Sports Physiotherapist

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If you’ve been told you need a hip replacement – read this!

If you’ve been told you need a hip replacement – read this!

There is a wide misconception that any pain in the hip/groin region must come from inside the actual hip joint.  This can lead people to believe their hip joint is wearing out and eventually a joint replacement will be their only option.  The truth is, the hip is a very complex area and there are at least 4 other diagnoses which can result in pain in the hip region.  All of these diagnoses have the potential to respond well to physiotherapy if they are diagnosed and treated correctly.

The four diagnoses are:

  1. muscle related pain
  2. a labral injury
  3. an injury or wearing to a tendon, or
  4. a condition where the movement hip joint pinches the tissues surrounding the joint.

I will be doing another blog post explaining all of these at a later time – the important thing to know for the moment, is that hip replacements are quite often a drastic action to take, and possibly not even the correct one, to get the best outcome for your pain.

What we do differently is use a logical battery of clinical tests to isolate the contributing factors to the hip pain and firstly establish a correct diagnosis.  Getting the correct diagnosis is the most important thing when establishing what a treatment should be.  Often your scans can show a variety of different findings, but it doesn’t match up with the pain you’re experiencing.

True osteoarthritis of the hip will respond very differently during these clinical tests, as opposed to pain driven by the muscles, the tendons or a different joint altogether.

When the diagnosis is correct, you will feel confident you are on the right path to a successful outcome. Your symptoms will quickly improve, as the right areas will be targeted (and this will be different for each person).

Over 80% of the patients we see with hip pain have either osteoarthritis or degenerative changes on their scans… however this is, in almost all the cases, unrelated to their actual pain.  The pain is caused by a decrease in strength, or a decrease in movement.  Getting the movement confident and strong is key.  It’s important to not take imaging results at face value, and assume that because it’s on a scan then it must be the cause of the pain – it quite often isn’t.

When a person with hip pain visits, they are fully assessed to ensure they are given the correct diagnosis for their hip pain, and then prescribed the most effective treatment plan.

All staff at The Headache and Pain Management Centre are trained to assess hips – to book an appointment click on the link below, or visit the Contact Us page to find out if we can help you.

By Nikki Rathbone - APA Titled Sports Physiotherapist

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How could your upper neck cause pain in all of these nerves?

How could your upper neck cause pain in all these nerves?

The diagram above is a beautiful illustration of what are called the Trigeminal Nerves – they supply the head, face, jaw, forehead and temples. These are the nerves that can transmit information from those areas.

They are thought to be responsible for the pain that comes with Tension Headaches, Migraines, Trigeminal Neuralgia and Cluster Headaches. 

Problem is, that when these nerves are scanned on MRI in patients suffering from these conditions, it can all look normal.  They look as beautiful as the picture above on the scans, yet there is excruciating pain.

So what the heck is happening?!

What you can’t see on the diagram is where, on the inside of the brain, all of these nerves end up. They all end up merging together deep inside your brain.  But, not only do the nerves in the diagram end up merge together, but the nerves from the top three joints of your neck merge in with them as well.

It’s actually the SUM TOTAL of the signals from all the nerves in the diagram, and the neck nerves, that end up being sent to the big fleshy part of the brain for processing.  It’s like having the signals from the face, neck, jaw and head all packaged up into a box, and express delivered to the bigger part of the brain. 

All the brain receives is the box with the signals inside, but the brain doesn’t really have a good idea of where the signals are sent from. Is it the face, neck or somewhere else?

The brain then makes its best guess as to where the signals may have come from, and a lot of the time the brain gets it dead wrong.  Instead of having neck pain, you may have headaches or migraines… or you could have both neck and head pain at the same time.

The end result – you can have signals that come from your neck, that are misinterpreted by your brain, and then you end up with Migraines, Tension Headaches, Cluster Headaches or even Trigeminal Neuralgia.  As a matter of fact – more often than not, it’s the upper neck nerves that are the culprit, not the nerves in the picture above. 

That’s why we’ve created a booklet called A Sensitised Headache Hub – the real reason for your headaches and migraines

This booklet gives more information about how your neck could be causing your headaches and migraines, and if you read to the end, you will be eligible for our one-hour Initial Consultation for just $89 (a saving of $140).   

Click here for our free download (no email or personal details required!)

By Chris Fawcett - Director, The Headache and Pain Management Centre

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Hip Bursitis

Why your hip bursitis isn’t just a bursitis

When patients suffer with lateral hip pain, a really common diagnosis is something called Bursitis.  This is most commonly diagnosed after a patient visits their GP, and after looking at the results of an Ultrasound Scan.  

If you are diagnosed with an inflamed bursa, it would make sense to just get rid of the inflammation and things will be better, right?  It seems obvious but it’s not what it may seem.  We know now that treating just the bursa with medication or a cortisone injection is like dealing with the smoke without putting out the fire.  

This “medicine-only” approach has the potential to make you feel hopeless, like the problem will never get better, because a lot of the time, it can mask the symptoms for a while, but then they come right on back!.  It can seem like anytime you try some treatment for bursitis, you get only temporary relief, with no real long-term improvement.

Why is this happening?

Well the real underlying issue, when you have pan from a hip bursitis, is actually the tendons of the buttock muscles called your Gluteus Medius and Minimus.  Increased load on those tendons, creates thickening and degeneration of the tendons, and this can cause some really irritating pain – affecting walking, sleeping and feeling things feel hopeless.  These changes are commonly caused by a sudden change in activity, a weakening of muscles, and even some hormonal changes that are related to menopause.

It is actually that thickening and degeneration of the tendon that irritates the overlying bursa, causing pain and inflammation in the bursa itself.  If you are just injecting the bursa, it isn’t dealing with the tendons – which means the bursa will be good for a little while, but just come right on back again. 

The evidence now shows that the most effective treatment for lateral hip pain is two-fold – specific exercises to calm the tendon and bursa, and then to strengthen the surrounding muscles in a way that doesn’t cause extra pain.  Because of how painful it can get, it’s important to learn the correct exercises to do, to get the best result with only a minimal risk of flare-up.  

Modification of your current activity load is also a very important factor, as doing too little, too much or the wrong type of activity will hinder your progress.  Everyone is different, and there is no “one-size-fits-all” strategy.  A physiotherapist skilled in assessing the hip and lower back is crucial to getting the best outcome. 

When this is managed correctly, you will feel empowered and confident of a long-term solution, and get back to doing the things that you want to do.  In the short term, there will be a good reduction in pain levels, which means a steady improvement in your function and activities.  Over several months, you ability to do things will continue to increase, to the point where your activity level will return to where you would like them to be.

By Nikki Rathbone - APA Titled Sports Physiotherapist

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Rotator Cuff Tear or Rotator Cuff Wear

Is it a Rotator Cuff Tear, or Rotator Cuff Wear?

There is a wide misconception that if you have a rotator cuff tear you will need surgery to get relief from your symptoms. The truth is, that on ultrasound (which is how most rotator cuff tears are diagnosed) is that it is impossible to tell the difference between a tear, and what’s called a tendinopathy – which is just degenerative changes in the tendon… age-related wear and tear.  

The problem with this is that when people hear they have a tear, they worry it will need an operation, and it makes them scared to use their arm for fear of making things worse. However, the reality is that if correct diagnosis can be made with a thorough physical exam, it can restore hope that a successful rehabilitation without the need for surgery can be achieved.

The best course of treatment involves a combination of soft tissue therapy to loosen up the tight and overactive parts of the shoulder, combined with specific exercise to improve the position of the shoulder blade and strength of the rotator cuff.  It is really important to have this combination of hands on treatment and exercise, as exercise alone takes much longer to show improvement in symptoms. 

When this process is done right, the prospect of needing surgery will be a distant memory. In the short term, the pain will be significantly less, especially at night and shoulder movement will be restored, and over 6-12 months shoulder function and strength should be close to normal.

Could you imagine having shoulder surgery, complete with a lengthy rehab period, which you may not have even needed! 

Correct diagnosis is the absolute key to getting a good outcome for shoulder pain involving the Rotator Cuff, as it allows a plan to be tailored for the specific problem, and really does increase the chances of getting back to normal.  

By Nikki Rathbone - APA Titled Sports Physiotherapist

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The two biggest things your health professional fails to consider when it comes to your lower back pain.

The two biggest things your health professional fails to consider when it comes to your lower back pain.

When patients come in to see us for lower back pain, and they have been elsewhere, inevitably they will tell us one of a number of things:

  • I’ve had this low back pain for years and it’s not getting any better
  • I am doing an exercise program but I’ve reached a plateau – and if I stop doing the exercises it goes back to square one
  • I’ve had all the scans and there isn’t anything major – but the pain just isn’t improving
  • I’ve done all of my “core” stability exercises and it isn’t helping.

…sometimes a combination, and sometimes more than that!

I guess where the advantage lies when treating patients in this condition is that they have normally seen pretty competent health professionals – which means by the time they get to us – we know what you have tried.  It means that we really don’t need to go over old ground, most of the time.

Usually, there are two main things that other health professionals don’t adequately consider when it comes to lower back pain – and I can summarise it in a very simple phrase:

“Tight at the front, weak at the back”

Fail No. 1 – Tight at the front

Most health professionals, when looking at back pain, fail to consider the key muscle which is the driver for most back pain.  It is a muscle that is actually deeper than your core abdominal muscles – it is called the Psoas.

Psoas attaches into the front of 5 vertebrae of your spine, crosses underneath your bowels and then attaches into the front of your hip.  It is the only muscle that crosses the centre of gravity, and is incredibly important acting as a mover and stabiliser of your back and pelvis.

If your psoas muscles are tight, it can cause:

  • Pain referral into your lower back
  • Back stiffness in the morning when you wake up
  • Other muscles up into your shoulders and down your hips and legs to compensate, causing pain in those areas as well.

It is extremely important not only to get this muscle assessed properly, but also to have it treated gently and properly, as there are many important vessels and organs that run around and through it.

Fail No. 2 – Weak at the back

It is a fact that when people have lower back pain, the deepest layer muscles in your lower back shrink.  These are called the multifidus muscles.

The reasons for this shrinking are a little complex (and I can address this in a later blog) – but the important thing is that those deep back muscles need to be strengthened in order for them to grow back to a size your body needs to support your weight, and offset the tightness of psoas.

If your deep back muscles are weak, it can cause:

  • Too much fatigue in your back – which means a “tight” feeling towards the end of the day and after things like housework or sport
  • Strength exercises for your glutes and “core” are ineffective, because you need the multifidus muscle working first before you can activate anything else
  • Ongoing low back pain because the muscles are forever in a protective mode, which doesn’t allow the movement you need to get things going again.

What is needed to correct these problems?

Simply two things:

  • A full assessment of the psoas muscles to see if they are contributing to your posture or pain picture
  • An accurate strength test for your multifidus muscles to specify exactly how strong your back is, and an exercise program to counter any deficits.

We have put together some more resources (here and here) on our website to explain this more… and treating backs in this very simple, logical way has helped people from elite athletes to people who are out of work and had failed back surgery.

By Chris Fawcett - Director HPM Centre

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