Chronic Upper Thoracic Hyper-Flexion and Headaches
Friday, October 22, 2010 at 6:25AM Don Meyer, DC
Private Practice Huntington Beach, CA
President Circular Traction Supply
CBP Instructor
INTRODUCTION
It is sometimes difficult to differentiate between a simple forward head posture problem and an upper thoracic hyper-flexion subluxation problem. Their symptoms and appearance can be very similar, but their corrective treatment is quite different. In this article, I will present a case study that illustrates the differences between these two conditions.
Case Study
A 23 year old male presents with chronic severe headaches that he has suffered with (2-3 times per week) for the last 2-3 years. He rates the headaches as a 7-10 level on a 0-10 numeric pain scale. He also denotes having occasional left upper thoracic/neck pain that he rates as a 4-7 level.
The patient’s initial cervical ROM exam demonstrates a restriction of flexion, rotation and lateral flexion (3% whole person impairment). His postural exam shows a general forward head carriage on lateral inspection. His AP head/thoracic posture is relatively normal. His initial lateral cervical x-ray analyses was preformed with the Posture Ray™ digitizing program and denoted 28.3 mm C2-C7 anterior translation and a 33.1% loss of normal lordosis (see x-ray #1). He has a positive foraminal compression test bilaterally in the upper cervical region indicating a chronic upper cervical facet joint inflammation.
The patient was started on a rehabilitative treatment program to strengthen the deep anterior neck flexors and reduce the Forward Head Posture (FHP). This consisted of posture corrective head weighting and ambulatory use of the Cervical Remodeling Collar™ (10-15 minutes each). Diversified spinal manipulation was also preformed. After 14 treatments the patient was re-evaluated.
The patient’s pain levels and frequency had now decreased. His new cervical ROM exam reveals grossly improved rotation and flexion, but only a mild improvement of lateral flexion. His new lateral x-ray showed only a mild improvement of the FHP to 27.4 mm and a moderate improvement of the lower cervical lordosis.
Because of the persistent FHP, the patient’s lateral cervico-thoracic posture was re-evaluated with the patient and on the new lateral x-ray. On closer inspection, it was determined that this patient’s upper thoracic spine was fixated in a state of hyper-flexion. To confirm this on the radiograph, lines are drawn on the back of the body of C7 and vertically up from the posterior inferior body corner of C7. The angle these two lines create should be approximately 22-24° in the normal upper thoracic spine. A much larger angle is indicative of an upper thoracic hyperkyphosis and a much lower angle indicates a straightened upper thoracic spine. This patient’s C7 to vertical angle was increased to 37°, confirming the upper thoracic hyperkyphosis.
The CRCollar™ and head weighting was discontinued and the patient was started on motorized axial extension traction as shown in
Figure 1. This traction targets the lower cervical/upper thoracic spinal regions and provides passive intermittent extension traction at a rate of 13 times per minute
.
The patient performed 10 more treatments of this new traction (10-12 minutes) and continued manual manipulation of the thoracic and cervical regions. The patient’s symptoms continued to decrease in frequency and severity throughout this last phase of his treatment. On his final re-evaluation not only did this patient’s lateral flexion ROM notably improved, but his FHP was reduced to only 11.6 mm and his cervical lordosis was completely restored (see x-ray #2).
CONCLUSION
The typical patient with moderate FHP will usually have an extension fixation of the upper cervical spine (restricted flexion). Performing posterior head translation traction (CRCollar™) will induce flexion into the upper cervical spine and along with muscle rebalancing (head weighting) will nicely correct this aberrant condition. But as this case demonstrates, it is possible that the FHP can be secondary to an upper thoracic flexion fixation which usually shows itself as restricted cervical lateral flexion. Upper thoracic extension traction must be performed to correct the FHP in these patients.