Neck Pain and Headaches – How can PT help?

by Margaret Blount, SPT

Introduction to Neck Pain and Cervicogenic Headache

Neck pain is a complex and multifaceted issue. A collection of leading physical therapists gathered in 2017 to better define the diagnostic criteria and best treatments for neck pain, published in 2017 as a Clinical Practice Guideline for Neck Pain: Revision 2017. This article will summarize the suggestions of the CPG¹, which defined 4 types of neck pain:

  • with mobility deficits
  • with movement coordination impairments (including whiplash-associated disorder)
  • with radiating pain (radicular)
  • with headaches (cervicogenic headaches).

This review will focus on the definition, diagnosis, and treatment recommendations of neck pain with headache, or cervicogenic headache. Cervicogenic headaches commonly include symptoms of non-continuous, one-sided neck pain with associated headache. Also, the headache is preceded or aggravated by neck movement or sustained postures. Further, symptoms can be defined by time since onset with classifications of acute, sub-acute, or chronic. Knowing when the injury happened and how irritable the tissues are can help the PT determine which treatment strategies are appropriate.

Physical Therapy Evaluation of Cervicogenic Headache

To evaluate if you have cervicogenic headache, a physical therapist will look at various issues relating to your head and neck movement and strength, and possibly some special tests. First, you may fill out a few questionnaires that investigate your pain levels, your ability to function, and/or your thoughts about pain (NDI, TSK/PCS, DHI). Next a therapist will take your medical history, so come prepared to describe the onset, quality, distribution, and intensity of your neck pain and headaches. Then, a PT will take a variety of measures of your neck and head movement, both with you actively and then the PT passively moving your head and neck. The PT may also apply pressure through the muscles and vertebrae in your neck to gauge the degree of muscular tension and quality of motion available at the joints in the neck. One special test the PT may perform is called the Cervical Flexion-Rotation Test which is used to determine the patient’s pain free ROM, with cut off scores of less than 32 degrees or a 10 degree reduction to either side². They will also measure the strength and endurance of various muscles in the neck, upper back, and arms.

According to the CPG¹, cervicogenic headache will present with a cluster of similar findings from these examinations.

  • Cervical Flexion test positive for decreased pain free range of motion.
  • Decrease in overall active range of motion of the neck.
  • Headache reproduced with palpation of the bony segments of the upper cervical spine.
  • Limited mobility of the cervical vertebral segments, meaning that there will be decreased motion between the segments compared to what is normally expected.
  • Deficits in the strength, endurance, and coordination of the neck muscles.

Treatment of Cervicogenic Headache

With the findings of the evaluation and the time frame of the injury in mind, the PT can begin treatment. The 2017 CPG outlines various exercises that are confirmed by high level evidence to be effective for neck pain with headache, depending on the chronicity of the injury¹. For acute cervicogenic headache, they recommend the C1-C2 self-SNAG, which stands for self-sustained natural apophyseal glide, and supervised instruction in active mobility exercises. For subacute patients, the CPG recommends more active exercises as the irritability of the local tissues has decreased. These activities should include cervical manipulation and mobilizations (in the absence of any contraindications) and can also be followed by a self-SNAG exercise. For patients with chronic neck pain with headache, PTs can provide cervical or cervicothoracic manipulations based on clinical judgement. These manipulations should be performed in conjunction with shoulder girdle and neck strengthening, stretching, and endurance exercises.

How Physical Therapy First Can Help You

The Physical Therapists at Physical Therapy First are experts in the diagnosis and treatment of cervicogenic headaches as proposed by the CPG. They can help to put together the puzzle pieces of your symptoms and create a plan for your treatment. Here at PT First you receive an hour one on one with a physical therapist to address your specific needs. We at PT First look forward to working together with you to decrease your pain and increase your quality of life.


  1. Blanpied P R et al. 2017. Neck Pain Revision 2017. J Orthop Sports Phys Ther. 47(7):A1-A83. doi:10.2519/jospt.2017.0302

Rubio-Ochoa J, Benítez-Martínez J, Lluch E, Santacruz-Zaragozá S, Gómez-Contreras P, Cook CE. Physical examination tests for screening and diagnosis of cervicogenic headache: A systematic review. Man Ther. 2016;21:35-40.

The How and Why of Patients’ Sleep Disorders After A Total Knee Arthroplasty (TKA)

by Bridget Collier, PT, DPT

Many individuals suffer from impaired quality of sleep after undergoing a TKA. There have been multiple studies done in the past that confirm poor sleep quality effects the outcomes of a patient’s rehabilitation including a reduced pain threshold, decline in performance, increased fatigue and emotional dysregulation. There are 8 categories of sleep disorders with 81 major disorders according to the Diagnostic Classification of Sleep and Arousal Disorders. Insomnia is the category that occurs most frequently post TKA, therefore, that will be the focus going forward.

Insomnia Definitions and Classifications

  • Insomnia
    • Individuals with a primary complaint of difficulty falling asleep, difficulty staying asleep, waking up too early, or low-quality of sleep. Individuals must have this complaint despite having acceptable circumstances and opportunity to achieve a good night’s sleep.
  • Primary Insomnia
    • Adjustment sleep disorder (acute insomnia)
      • Insomnia that lasts less than 3 months.
      • Brought on by an identifiable stressor such as an environmental change, depression, anxiety and/or pain after surgery
      • Typically resolves once the stressor is removed from the individual’s life
    • Insomnia due to mental disorder
      • Occurs when individual who has been previously diagnosed with anxiety or depression have an increased worry about things. Some common items that cause the mental disorder to heighten may be the act of surgery, costs of medical bills, recovery process, etc.
    • Inadequate sleep hygiene
      • Occurs when individuals partake in activities that directly affect their sleep
      • Activities may include taking too many naps, consuming caffeine close to bed time, and going to sleep/waking up at different times every day.
    • Psychophysiological insomnia
      • Occurs when individuals are overly worried about sleeping, causing them to have sleep disruptions
    • Idiopathic Insomnia
      • Insomnia that occurs since childhood with no known cause
      • Typically, chronic and relentless in nature
    • Secondary Insomnia
      • Insomnia due to medical condition
        • Individuals may develop insomnia due to medical conditions that arise such as heart failure and asthma
      • Insomnia due to drug or substance
        • Occurs when individuals are withdrawing from drugs such as analgesics and sedatives.
      • Physiological (organic) insomnia
        • Occurs when insomnia does not fit into any of the categories listed above or there isn’t enough information to classify an individual into a specific category

In the article titled: Analysis of patients’ sleep disorder after a total knee arthroplasty- A retrospective study; the authors looked at the reasons for insomnia in patients who have received a TKA. The authors analyzed data from 965 patient cases using their medical records.

The authors found that ~3/4 of the patients were classified into primary insomnias, with adjustment sleep disorder being the most common. The sleep disorders with higher prevalence are as follows: adjustment sleep disorder (43.7%), insomnia due to a mental disorder (24.1%), insomnia due to a medical condition (19.2%), inadequate sleep hygiene (6.3%). All other sleep disorders had 5% or less of patients in the classification.

The study also looked at the causes of insomnia in the patient’s following a TKA. The top 4 causes found were as follows: pain (40.1%), mental elements such as depression and anxiety (31.3%), other medical conditions such as heart failure (15%), and noise (4.4%).

Overall, individuals who described their insomnia complaint as difficulty staying asleep or low-quality of sleep had worse pain and longer stays in the hospital. These patients also had more rehabilitative deficits such as decreased active range of motion. This was compared to the individuals who described their insomnia complaint as difficulty falling asleep or waking up too early.

The physical therapists at Physical Therapy First will provide you with the highest quality of care following surgery for a total knee arthroplasty. During each session, you will be provided 1-on-1 care with your physical therapist for a full 60-minutes. Give us a call or visit the website to schedule an appointment!


Long G, Suqin S, Hu Z, Yan Z, Huixin Y, Tianwang L, Yang Y, Zhenhu W. Analysis of patients’ sleep disorder after total knee arthroplasty-A retrospective study. J Orthop Sci. 2019 Jan;24(1):116-120. doi: 10.1016/j.jos.2018.07.019. Epub 2018 Aug 23. PMID: 30146382.

Effect of NSAIDs on Bone Healing Rates: A Meta-analysis

by Bridget Collier PT, DPT


Up to 100,000 fractures do not heal properly each year; either through nonunion, delayed union, or symptomatic pseudarthrosis. These instances may cause complications such as additional surgeries, pain, prolonged immobilization, increased physician visits which can all be time consuming and expensive. There are multiple risk factors that have been identified as possibly affecting the rate of bone healing. Older age, female sex, fracture characteristics, fracture location, and patient co-morbidities are nonmodifiable risk factors. Some of the many modifiable risk factors are alcohol and tobacco consumption, nutritional status, and medications. Nonsteroidal Anti-inflammatory drugs (NSAIDs) are one of the medications thought to effect bone healing, but past research has been controversial.

How are NSAIDs thought to effect bone healing?

Prostaglandins are believed to play a part in bone healing and metabolism because the concentration of Prostaglandin E2 (PGE2) is thought to control osteoblast behavior through the relative expression of the receptor activator of nuclear factor kappa-B ligand and osteoprotegerin. These are regulated through the enzymes cyclooxygenase (COX)-1 and (COX)-2 which are inhibited by NSAIDs. This inhibition causes a decreased in PGE2 which is thought to cause the delayed bone healing.

In the article titles: Effect of NSAIDs on Bone Healing Rates: A Meta-analysis; the authors analyzed 16 research articles to determine the whether the use of NSAIDs increased the risk of delayed union or nonunion after a fracture, osteotomy, or fusion surgery.

The articles were all analyzed together as well as in subgroups. The following conclusions were made by the authors:

  • Analyzing all studies together; without subgroups
    • NSAIDs increased the risk of delayed union or nonunion healing.
  • Subgroup: only studies including pediatric studies
    • NSAIDs did not result in an increased risk of delayed union or nonunion healing.
    • Limitations: Small study pool (4 studies)
  • Subgroup: only studies including adult studies
    • NSAIDs increased the risk of delated union or nonunion healing
  • Subgroup: adult only with long bone involvement
    • NSAIDs increased the risk of delated union or nonunion healing
  • Subgroup: adult only with spine involvement
    • NSAIDs increased the risk of delated union, nonunion healing, or pseudarthrosis
    • Limitations: Small study pool (5 studies)
  • Subgroup: low dose NSAIDs or short duration of NSAID use
    • Low dose was defined as <125 mg/d of diclofenac, 150 mg/d of indomethacin, or 120 mg/d of ketorolac.
    • Short duration was defined as <2 weeks of NSAID use.
    • NSAIDs did not result in an increased risk of delayed union or nonunion healing.
    • Limitations: Small study pool (4 studies) and inconsistent findings between studies (2 found an increased risk while the other 2 found no effect).
    • Author thoughts:
      • For lower dose NSAIDs, the authors believed that there may be less potency and/or less prosoglandin suppression which may allow fracture healing to continue at a slower rate
      • For short duration, the authors believed the bone healing is able to continue as usual after withdrawal of NSAIDs.


  • As mentioned earlier, there are multiple factors that contribute to bone healing, with age being one of them. In the study, the authors found the effect of NSAIDs on delayed union or nonunion was directly related to patient age. Therefore, it is difficult to determine if the age of study participants also played a role in the results. The authors stated age was difficult to analyze as a continuous variable due to there being a large age gap between the ages of 18 to 35 years throughout the studies and the mean age of adult studies being on the higher end.
  • Limited availability of randomized control trials
  • Heterogeneity (diversity of subjects) of analyzed studies made them difficult to compare

For more information regarding this topic or the research presented, please see the article referenced below. Here at physical therapy first, we understand how unique everyone’s rehabilitation is. When starting care here, you will begin with an initial evaluation in order to determine an individualized rehabilitative program for you. Give us a call or visit the website to schedule an appointment!


Wheatley BM, Nappo KE, Christensen DL, Holman AM, Brooks DI, Potter BK. Effect of NSAIDs on Bone Healing Rates: A Meta-analysis. J Am Acad Orthop Surg. 2019 Apr 1;27(7):e330-e336. doi: 10.5435/JAAOS-D-17-00727. PMID: 30260913.

The Efficacy of Mirror Therapy in Patients with Adhesive Capsulitis: A Randomized, Prospective, Controlled Study

by Logan Swisher, PT, DPT


Adhesive Capsulitis also known as “frozen shoulder” is a painful condition characterized by gradual limitation of active and passive joint movements as a result of progressive fibrosis and excessive contracture of the glenohumeral joint capsule. Most commonly, patients will notice limitations in shoulder external rotation and abduction range of motion. This pathology affects about 2-5% of the population and frequently occurs in females between the ages of 40-60 years. Adhesive capsulitis is more common among patients with diabetes mellitus, thyroid dysfunction, Dupuytren’s contracture, myocardial infarction and those who have been treated for breast cancer. Typically, treatment for this pathology includes stretching, therapeutic exercises and use of modalities like heat to help loosen the soft tissue restrictions.

Mirror therapy is an easy, inexpensive and patient centered treatment method used to provide immediate functional feedback to patients. It has been proposed that pain originates from an incoordination between the motor commands of the brain and the visual and proprioceptive feedback. The aim of the treatment is to have the patient view the unaffected shoulder in the mirror while the affected shoulder also performs the exercise to help the brain realize motor commands can be pain free. The study by Baskaya et al., investigated the effect of mirror therapy in conjunction with standard physical therapy on shoulder range of motion, pain and quality of life in patients with adhesive capsulitis.


30 total participants

-15 in the mirror group

-15 in the control group


All participants underwent a standard physical therapy program for 10 sessions consisting of transcutaneous electrical nerve stimulation (TENS), ultrasound, shoulder isometrics, range of motion exercises, stretching and home exercise program.  The mirror group performed the exercises with the reflective side of the mirror and the control group performed the exercise with the non-reflective side of the mirror. Pre-treatment and post-treatment assessments were taken of range of motion using a goniometer and pain using the visual analog scale.


The post treatment visual analog scale for pain was significantly lower in the mirror therapy group. The post treatment active/passive range of motion measurements were significantly higher in the mirror group compared to the control group.


The perception of pain is very complicated and varies greatly from person to person. Adhesive capsulitis is a diagnosis characterized with significant levels of pain and loss of active/passive range of motion which can last up to 2 years. The exact mechanism with which mirror therapy reduces pain is unclear but this study revealed that in the short term when mirror therapy is applied in conjunction with standard physical therapy methods for adhesive capsulitis it can reduce pain and improve joint range of motion, shoulder function and quality of life.


Baskaya MC, Ercalık C, Karatas Kır Ö, Ercalık T, Tuncer T. The efficacy of mirror therapy in patients with adhesive capsulitis: A randomized, prospective, controlled study. J Back Musculoskelet Rehabil. 2018;31(6):1177-1182. doi: 10.3233/BMR-171050. PMID: 30056414.

Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health-Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17,000 Patients

by Joe Holmes PT, DPT, CDN, FNCP


Diabetes has become one of the leading causes of disability and loss of function in the United States. The prevalence of diabetes mellitus (DM 2) is approximately 50% both diagnosed and un-diagnosed (1). Diabetes costs the US healthcare system $327 billion annually and is responsible for $1 in every $7 spent on healthcare (2). Diabetes can speed up the rate at which osteoarthritis progress, which worsens pain and all functional symptoms, and potentially worsens the outcomes of total knee arthroplasties (TKA), also known as a knee replacement (3). Previous studies have associated diabetes with a higher risk of surgical complications, however no meta-analysis has been performed on functional outcomes after a TKA until now.

Results & Discussion

Of the 2,132 studies identified as potentially meeting the inclusion criteria, only 21 met the eligibility criteria to be included. The results were broken down in to preoperative, early postoperative phase (0-12 months post op) and late postoperative phase (1-14 years post op). The overall early and late postoperative findings suggest that people with DM 2 are in worse physical function and have worse quality of life, worse early postoperative pain and strength, and worse late postoperative function, ROM, and QOL than those without DM 2 (3). Many inconsistencies in the studies that were analyzed presented either very low-quality evidence or inconsistent conclusions.


Patients with DM2 have overall increased pain and worse functional outcomes in respect to a TKA compared to patients without diabetes. The overall quality of evidence on this topic is poor and lacks consistent study design. None of the 21 studies included followed by the same rehabilitation protocol post-surgery, which also limits the consistency of the results. The overall message in this article show that overall metabolic health is an important factor in both the development of osteoarthritis and chronic joint pain, and also slows the process of recovery post-surgery.

Physical Therapy First Implications:

The Physical Therapists at Physical Therapy First will create an individualized care plan for you both pre- and post- surgery. All patients at Physical Therapy First receive a 1 hour 1-on-1 appointment at all PT appointments with a doctor of physical therapy. Call today or request an appointment online for any of our 4 locations in Greater Baltimore.


1: Centers for Disease Control and Prevention. Arthritis as a potential barrier to physical activ­ity among adults with diabetes—United States, 2005 and 2007. MMWR Morb Mortal Wkly Rep. 2008;57:486-489


3: Neumann J, Guimaraes JB, Heilmeier U, et al. Diabetics show accelerated progression of knee cartilage and meniscal lesions: data from the Osteoarthritis Initiative. Skeletal Radiol. 2019;48:919-930. s00256-018-3088-0

4: Na A, Opperman LM, Jupiter DC, Lindsey RW, Coronado RA.

Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health- Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17 000 Patients  J Orthop Sports Phys Ther 2021;51(6):269-280. Epub 19 Apr 2021. doi:10.2519/jospt.2021.9515

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