2 P H Y S I O T H E R A P Y JUNE, i 9 7 4 MIGRAINE AND OTHER CHRONIC HEADACHES Preliminary Report on Experimental Physical Treatment JO Y E D ELIN G * B.Sc. (Ptays.) R and, P rincipal P hysiotherapist, K im b erley H osp ital. In a p p ly in g M a itla n d m a n ip u la tiv e tre a tm e n t to h e a d ­ a ches o f su sp e c te d c erv ical o rig in , 1 e x p e rim e n ta lly a p ­ plied th ese m e th o d s to h e a d a c h e s o f o th e r d iag n o ses. T h e re su lts w ere so e n c o u ra g in g th a t I b e g a n to ig n o re acc ep te d c la ssifications o f h e a d a c h e s a n d fo u n d t h a t I w as tre a tin g , w ith success, b a d “ m ig ra in e s” . A sto n ish e d a t th e re sp o n se t h a t re p e a te d ly c am e fro m a ll k in d s o f h e a d a c h e s, I w as led to a c o m p le te , re th in k a b o u t th e p o ssib le u n d e rly in g p a th o lo g y o f c h ro n ic h e a d a c h e . Seeing t h a t I h a d a p p lie d th e sa m e tre a tm e n t, a n d o nly th a t, to th is g re a t v a rie ty o f c h ro n ic h e a d a c h e s w h ic h h a d b een re s is ta n t to as g re a t a v a rie ty o f tr e a t ­ m e n t a n d t h a t th e y a ll h a d re s p o n d e d to th is o n e t r e a t ­ m e n t, I w as o b lig e d to a c c e p t th e a p p a r e n t fa c t t h a t the p a in in a ll th ese cases m u s t a rise f r o m th e sa m e so u rc e. A s th e tre a tm e n t used w as m o b ilis a tio n o f th e a tla n to - o c c ip ita l a n d a tla n to -a x ia l jo in ts, a n d in a ll th e cases th ese jo in ts w ere re m a rk a b ly ir r ita b le a n d o fte n r e ­ s p o n d e d w ith e x a c e rb a tio n o f s y m p to m s b e fo re re lief, (ju s t as a n y o th e r irrita b le jo in t re sp o n d s to m o b ilis a ­ tio n ), I see n o a lte rn a tiv e b u t to th in k t h a t th e sy m p to m s a rise fro m a d e ra n g e m e n t o f th ese jo in ts a n d th a t th e p a in in th e h e a d is re fe rre d — ju s t as p a in in th e leg is re fe rre d fro m a lu m b a r-jo in t lesion. F o rtu n a te ly , M a itla n d m o b ilisin g tre a tm e n t re q u ire s re c o rd e d d e ta ile d e x a m in a tio n a n d a sse ssm e n t a t each tre a tm e n t session so th a t I h a v e, in m y h e a d a c h e series to d a te , su c h re c o rd s o f e a c h case t h a t in d ic a te p recise re a c tio n o f sy m p to m s to specific te c h n iq u e s. I a m c o m ­ p letin g th ese re c o rd s w ith fo llo w -u p a n d aim to b a se m y th e o ry o n 500 su c h cases. I sh a ll th e n r e p o rt o n these in th is J o u r n a l. A lth o u g h th e d ra m a tic re lie f o f p a in in re sp o n se to th is tr e a tm e n t w as g ra tify in g , it w as n o t s u rp risin g as th is is th e re sp o n se we h a v e c o m e to e x p e c t in m o b ilis­ ing v e rte b ra l jo in t le sio n s a t o th e r levels. B u t w h a t h a s ta k e n m e c o m p le te ly by s u rp rise , h a s b een th e c o m ­ p a ra b le re sp o n se o f sy m p to m s o th e r th a n p a in . W e a re a ll a w a re o f th e b e w ild e rin g a r ra y o f “ o th e r ” sy m p to m s a sso c ia te d w ith h e a d a c h e viz. v isu a l d istu rb a n c e s , d izziness b lo ck e d e ars n a u se a fe elin g s o f lo c a l p re ssu re b lo c k e d n a sa l p a ssa g es a ta x ia to n a m e so m e o f th e m o re c o m m o n ones. I h a v e re c o rd e d te s tim o n y o f im m e d ia te re lie f o f such s y m p to m s d irec tly a fte r m o b ilisa tio n . T h e p a tie n t w o uld sit u p f o r re a ss e s sm e n t a n d say “ t h a t b u rs tin g fe elin g is g o n e ” o r “I d o n ’t feel n a u se o u s a n y m o r e ” w ith a n e x ­ p re ssio n o f in c re d u lity th a t only, in th e b e g in n in g , e q u a lle d m y o w n. She h a d n o t b e en a sk e d w h e th e r she w as still n a u se o u s, n e ith e r h a d th e re b een a n y sugges­ tio n th a t th e tre a tm e n t m ig h t affect it. In fa c t, th e t r e a t­ m e n t is so m in im al th a t in th e b e g in n in g th e y d o n ’t even k n o w t h a t t h a t w as su p p o s e d to be “tr e a tm e n t” a n d th in k t h a t w e a re ju s t “ p o k in g a r o u n d ” . T h is is n o t an iso la te d e x a m p le . M y re c o rd s a b o u n d w ith re sp o n se s w h e re t h a t re m a rk m a y b e — “ M y e a r h a s o p e n e d u p — I can h e a r y o u b e tte r ” “ t h a t th ic k fe elin g in m y th r o a t h a s g o n e ” , “ I c a n fo c u s p ro p e rly n o w ” , “ th e w h irrin g in m y e a rs is g o n e ” , “th e th ro b b in g h a s s to p p e d ” . E v e n b e fo re th e y r e p o r t t h a t th e p a in h a s e ith e r les se n e d o r s h ifte d o r g o n e — a n d o c c a sio n ­ a lly , t h a t i t is w orse. T h e o nly d is a p p o in tin g re sp o n se is w h e n th e y s it u p a n d n o th in g h a s c h an g e d — a n d as m y e x p e rie n c e in cre ases I find t h a t u su a lly m e a n s th a t I h a v e fa ile d to lo ca lise th e so u rc e o f sym ptom s th e n by tr ia l a n d e r ro r I find the specific jo in t and th d ire c tio n a n d g ra d e o f m o b ilis a tio n to w hich it r sp o n d s — a g ain as in th e tre a tm e n t o f a n y o th e r pa ;e' f u lly re stric te d jo in t w h ic h is th ro w in g o u t symptoms'1 I d o n o t p re su m e to u n d e rs ta n d th e m ec h an ism s in volved in su c h re a c tio n s , b u t in a ll h o n e sty , 1 also d n o t u n d e rs ta n d th e m e c h a n ism by w hich “ m ig ra in e ” n° o th e r v a sc u la r h e a d a c h e s p ro d u c e p a in . Is vase F c o n s tric tio n o r d ila ta tio n a p a in fu l p ro c ess? 0 O n th e o th e r h a n d we d o u n d e rsta n d th e p a in mechan ism o f d ista l re fe rre d p a in in o th e r p a rts o f th e bod" W h e re p a in fu l irrita tio n o f a p a in -sen sitiv e s tru c tu r e * , felt, b y m is ta k e n c o rtic a l re fe re n c e , a t a p o in t distanr to th e so u rc e b u t w ith in th e sa m e d e v e lo p m e n t segm en t A nd w e d o a c c e p t t h a t w h e re this so u rc e o f p a in is a m e c h a n ic a l d e ra n g e m e n t, p h a rm a c o lo g ic a l tre a tm e n t is n o t effective a n d t h a t th e o n ly tre a tm e n t is to p h y sica lly re s to re th e d y sfu n c tio n . A s fo r th e o th e r s y m p to m s — d o th e y re a lly provide e v idence th a t th e p ro b le m is a v a s c u la r o n e ? Mobilisa­ tio n o f a jo in t c a n h a v e n o v a s o m o to r effect. T h e fact t h a t th e s e sy m p to m s su b sid e d a fte r m o b ilisin g th e appro­ p r ia te jo in t m ea n s to m e t h a t th e y w ere in fa c t symp­ to m s w h ic h a ro se as a re s u lt o f a n a u to n o m ic reaction to a p a in fu l jo in t. O n im p ro v in g th e c o n d itio n of the jo in t, th e a u to n o m i c 1 re a c tio n , as w ell as th e pain, subsides. P e rh a p s th e p re v a le n c e o f h e a d a c h e s has, as the p re v a le n c e o f b a c k a c h e c e rta in ly h a s, its ro o ts in the e v o lu tio n a ry d e v e lo p m e n t o f th e u p rig h t p o stu re . Most p e o p le a re te n d e r a t th e fa c e t jo in ts b e tw ee n th e occiput a n d the a tla s. B ut th e n m o s t p e o p le h a v e a n occasional h e a d a c h e in th e p re sen c e o f a n y o n e o f th e m any well- k n o w n p re c ip ita tin g fa c to rs o f h e a d a c h e e.g. febrile c o n d itio n s, fa tig u e , e m o tio n , lu m b a r p u n c tu re , dialysis, m en ses, sin u sitis a n d m a n y m o re . I t is o n ly w hen some­ th in g h a p p e n s to a g g ra v a te th is jo in t — it m ay be an in ju ry o r lo c a l p a th o lo g y — t h a t it b eco m es more irrita b le a n d th ro w s o u t sy m p to m s a t in cre asin g ly less p ro v o c a tio n . T h is e x p la in s th e “w o rs e n in g ” p a tte rn ^ cases o f lo n g sta n d in g re s is ta n t c h ro n ic h e a d a c h e — W reflects a d e te rio ra tio n o f th e c o n d itio n o f the joint M o b ilis a tio n im p ro v e s to s u b -s y m p to m a tic level, the c o n d itio n o f th e jo in t. T h in k in g a lo n g th e s e lines, I a rriv e d a t th e following p o ss ib le e x p la n a tio n : H Y P O T H E S I S T h a t th e u n d e rly in g c a u s e o f c h ro n ic h e ad a ch e s is a m e c h a n ic a l d e ra n g e m e n t o f th e a tla n to -o c c ip ita l and/or th e a tla n to -a x ia l jo in t w h ic h gives rise to a tru e referred p a in w ith in th is d e v e lo p m e n ta l se g m en t (cf. projected p a in ). F u r t h e r th a t th e re is lo ca l irrita tio n o f the b ra n c h e s o f th e e x te rn a l a n d i n te r n a l ' c a ro tid arteries w h ic h lie in close a n a to m ic a l re la tio n s h ip w ith these jo in ts. T h is re su lts in v a so -c o n s tric tio n fo llo w ed by re­ flex v a s o d ila ta tio n o f th e c ra n ia l b lo o d vessels. In addi­ tio n t h a t th e a u to n o m ic n e tw o rk in th is re g io n becom es in v o lv e d giving rise to a m is c e lla n y o f sy m p to m s other th a n p a in . O n th is basis I q u e stio n th e a c c e p te d classification of h e a d a c h e s w h ic h a re sy m p to m a tic a lly classified. I think th a t e a c h “ g ro u p ” is sim p ly a n o th e r a g g ra v a tin g o r pi®" c ip ita tin g c o n d itio n w h ic h flares u p th e p h e n o m e n o n 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) j UNIE 1974 F I S I O T E R A P I E 3 be a b o v e. A n y o n e o f th e s e c o n d itio n s d o n o t give descrj he ad a ch e s in su b je c ts w h o h a v e n o p rim a ry rise . ]esion, o r w h o se lesio n is s u b -s y m p to m a tic . c erVthink th a t th e v a so -c o n s tric tio n a n d v a s o d ila ta tio n anial b lo o d vessels d e m o n s tra te d d u rin g a tta c k s of of m igraine” a re h o t c h e m ic a lly in d u c e d , b u t re s u lt trUe m e c h a n i c a l irrita tio n , a lte rn a tiv e ly a re a u to n o m ic fr0™nses to a lesion. 1 Question th e e x iste n ce o f a “ p sy c h o g e n ic ” h e a d a c h e until I am satisfied th a t it is n o t o f c erv ica l o rig in . T R E A T M E N T . I th in k t h a t su c c essfu l tre a tm e n t o f , nic h e ad a ch e s is p h y sic al a n d n o t p h a rm a c o lo g ic a l. 1 fm c u rre n tly tre a tin g a n y h e a d a c h e th a t p re sen ts, a n d i t h e sam e tim e a n a ly sin g th o se tre a te d a n d fo llo w in g Hi m up. I w o u ld b e g ra te fu l to a n y o n e c o n c u rre n tly w o r k in g o n h e a d a c h e s fo r c o m p a ra tiv e re su lts. 1 By m edical tre a tm e n t. 7 By p h ysical tre a tm e n t o th e r th a n m o b ilisin g e.g. ’ m an ip u latio n o r tre a tm e n t o f m u sc le spasm . 3 By a ny p h y s io th e ra p is t w h o w o u ld lik e to try a —' group u n d e r m y d irec tio n . E sp e c ia lly b y a n y o n e w h o m a y b e w o r k i n g a l o n g th e sa m e lin e s a n d is f o r m i n g s im i l a r o r d iv e r g e n t o p in io n s. B r e a k d o w n o f R e s u lts to d a te Of 105 re c o rd e d cases tre a te d by o u r staff o f th e p a st two years: 95 re sp o n d ed p ro m p tly w ith re lie f o f p a in a n d o th e r sy m p to m s; 10 did n o t re sp o n d fa v o u ra b ly o r a t all. Some of these w ere very ir r ita b le jo in ts a n d re sp o n d e d with increased p a in w h ic h se ttle d to its p re v io u s level. On F ollow -up o f 6-12 m o n th s la ter 37 have rep lied to d a te . O f th e s e :— 8 R e p o rt no im p ro v e m e n t; 17 re p o rt im p ro v e m e n t o f m o re th a n 6 0 % ; 12 no re c u rre n c e a t all. M y re su lts a re o p e n to in sp e c tio n a n d disc u ssio n . N o d o u b t th e r e is f a u lt to b e fo u n d w ith m y a sse ssm e n t a n d e v a lu a tio n o f re su lts — I a m a novice a t c o m p ilin g sta tistic s a n d w o u ld g re a tly v a lu e a d v ic e a n d /o r c o rre c ­ tio n — a n d h e lp . A b o v e reflects m y b e s t e ffo rt a t p re s e n tin g m y e x p e rie n c e in figures. A D V A N T A G E S O F P H Y S I C A L T R E A T M E N T 1. M o re effective th a n m edical tre a tm e n t. 2. I t is a g e n tle tre a tm e n t w ith n o c o n tra -in d ic a tio n s y e t c o m e a cro ss. 3. R e q u ire s n o h o s p ita lis a tio n . 4. N o d ru g s e m p lo y e d . 5. R e su lts in tre m e n d o u s re d u c tio n in d ru g -ta k in g — to m y m in d , th e m o s t sig n ific a n t a s p e c t— in sp ite o f th e fa c t t h a t I n e v e r suggest to th e p a tie n t t h a t th e y re d u c e th e ir se lf-m e d ic a tio n . 6 . N o b ra in w a s h in g o f p a tie n t. 7. N o “ e n v iro n m e n ta l m a n ip u la tio n ” . 8 . N o c o -o p e ra tio n ne ce ssa ry . 9. E a s ily ta u g h t te c h n iq u e . 10. C o s t — in sig n ific an t c o m p a re d to t h a t o f c o m ­ p lic a te d d ru g re g im es. 11. T h e p a tie n ts ’ in e v ita b le a n x ie tie s a b o u t m o re s in iste r c au se f o r u n su c c e ss fu lly tre a te d h e a d a c h e s a lla y e d . 12. N e u ro se s, w h ic h re s u lt fro m p ro lo n g e d u n a lle v ia te d p a in , re so lv e a n d p a tie n t g ra te fu lly re su m e s n o rm a l w o rk o r d o m e stic d u tie s a n d p e rs o n a l re la tio n s h ip s . A c k n o w le d g e m e n t. T h e a u th o r w o u ld lik e to th a n k th e M e d ic a l S u p e rin te n d e n t, K im b e rle y H o s p ita l f o r his h e lp a n d e n c o u ra g e m e n t in th e in v e s tig a tio n s a n d p r e ­ p a r a tio n o f th is a rtic le . A SHORT REAPPRAISAL OF THE PRINCIPLES OF TREATMENT IN CEREBRAL PALSY S. Irw in -C a rru th e rs , N a t. D ip . P h y sio . (P ta .), T e a c h in g D ip . P h y s io . (P ta .)* I I N T R O D U C T I O N In recent y e ars m u c h e m p h a sis rig h tly h as b e en placed on an a p p ro a c h to th e tr e a tm e n t o f c e re b ra l palsy based u p o n s o u n d n e u ro p h y s io lo g ic a l p rin cip les. Dr. and M rs. B o b a th h a v e c o n trib u te d th e m o s t fu lly developed a n d w ell d o c u m e n te d a p p r o a c h to th e tr e a t ­ ment of th e d is tu rb a n c e s o f m o to r f u n c tio n fo u n d in cerebral palsy a n d th e ir w o rk p ro v id e s a s o u n d a n d realistic o v e rall c o n c e p t o f tre a tm e n t. O th e r w o rk e rs in this field h a v e n o t a lw a y s fo llo w e d th e sa m e p r in ­ ciples, a lth o u g h so m e , su c h a s P r o fe s s o r R o o d , h a v e provided tec h n iq u es w h ic h in se lec te d in sta n c e s m a y b e of value in o b ta in in g specific re sp o n se s. W h ils t it is necessary to h a v e a k n o w le d g e o f th e v a rio u s a p ­ proaches to tre a tm e n t, th e d a n g e rs o f a n e le ctric a p ­ proach w hich u tiliz e s o p p o sin g p h ilo s o p h ie s o f tre a t- c an n o t t>e o v e r-stre sse d . W e a re d e a lin g w ith a Id w hose m o to r d e v e lo p m e n t, fo r a v a rie ty o f reasons, is going to b e a b n o r m a l — a n d th is a b n o rm a l Currently L e c tu re r in P h y s io th e ra p y , U n iv e rsity o f Stellenbosch. m o to r d e v e lo p m e n t is g o ing to ta k e p la c e a lo n g c e r­ ta in p r e d ic ta b le p a th w a y s . W e k n o w in a d v a n c e , to a g re a t e x te n t, w h a t a b n o r m a l p rim a ry a n d c o m p e n s a ­ to ry sy n e rg ies a re g o in g to a p p e a r a n d o u r tre a tm e n t is d ire c te d to w a rd s p re v e n tin g th e s e fro m th e m o m e n t o f th e c h ild ’s first asse ssm e n t. T o c h an g e fro m , say, B o b a th t o R o o d to p ro p rio c e p tiv e n e u ro m u s c u la r f a c ilita tio n to sp lin ta g e , a n d e v e n tu a lly su rg e ry d u rin g d iffe re n t sta g es o f a c h ild ’s d e v e lo p m e n t d isp lay s n o t o n ly a b re a k -d o w n in u n d e rs ta n d in g o f th e d isu rb a n c e s o f m o to r fu n c tio n in v o lv e d b u t a ls o a b re a k -d o w n in th e e x e c u tio n o f th e o rig in a l a p p r o a c h to tre a tm e n t. B e a rin g in m in d t h a t in S o u th A fric a w e u su a lly see th e s e c h ild re n w ith in th e first y e a r o f life w e a re in a p o s itio n to in fluence his m o to r d e v e lo p m e n t w h ilst s till a c k n o w le d g in g his lim its o f a tta in m e n t. T h e y o u n g c h ild d e v e lo p s his b o d y im a g e in th e first e ig h te e n m o n th s a n d his b a sic p o s tu r a l p a tte rn s d u rin g th e first th r e e y e a rs o f life, a n d by five y e a rs o f a g e h a s so p e rfe c te d h is m o v e m e n t p a tte rn s t h a t h e is re a d y fo r th e le a rn in g o f skills. F u r th e r p e rc e p tu a l d e v e lo p m e n t fo llo w s o n th e e sta b lis h m e n t o f b a sic s e n so ri-m o to r p a tte rn s — re q u irin g th e s e p a tte rn s fo r d e v e lo p m e n t R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )