We referred pain evoked from several heads, shoulder and

We introduce an instance of Forward Head Posture (FHP) in a Tension-Type Headache (TTH), which is often a common issue associated with office workers within this quick developing inaG1 ctive behaviour. The use of computer systems has accelerated dramatically over the last decade in diverse workplaces, which furthermore contributes to individuals spending a rigours amount of time sitting at computers. Those speedy changes can be followed through the superiority of poor posture, resulting in FHP & furthermore, TTH (Nejati et al., 2014).

FHP and rounded shoulders are described as a protrusion of the head and shoulders within the sagittal plane (Yip, Chiu and Poon, 2008; Kang et al., 2012). The relationship between FHP, rounded shoulders and TTH continues to be arguable. Some researchers declare a considerable distinction in FHP, rounded shoulders and TTP among patients and pain-free individuals, the FHP has not constantly been related to neck pain in literature, while TTH has a rather strong correlation in FHP (Fernández-De-Las-Peñas et al., 2006; Fernández-De-Las-Peñas, Cuadrado and Pareja, 2007; Silva et al., 2009).

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Headache disorders are one of the most common issues seen in medical practice, with TTH the most frequent amongst adults. Populace-based research advocate prevalence rates of 38.3% for Episodic TTH (ETTH) and 2.2% for Chronic TTH (CTTH) (Schwartz et al., 1998; Crystal and Robbins, 2010).G2 

As TTH could come to be a persistent and disabling symptom, as TTH is caused by referred pain evoked from several heads, shoulder and neck musclesG3 ; discovering and enhancing the risk factors appears to be a reasonable prevention approach (Ferguson and Gerwin, 2005). As incorrect posture is a threat towards TTH, the design of a corrective postural primarily based program with the important underlying issue being applied with the manual therapy interventions for the patient. Furthermore, the purpose of this study was to quantify postural changes while implementing manual therapy techniques to alleviate TTH with a patient who’s occupation consist of them being sedentary for 8 hours in their day, whilst working at a computer.

With reference to APPENDIX… the patient presented with symptoms of a TTH due to FHP. Within the Subjective and Objective findings of the first session, it was clear upon reflection of these findings that the patient suffered from TTH due to the severity of their FHP. Upon palpation of the upper trapezius, sternocleidomastoids, and temporalis muscles, the findings were evaluated for Myofascial Trigger Points (G4 TrP’s). G5 

The etiology of TrP advancement is currently unknown, late studies have conjectured that the pathogenesis comes about because of the overloading and damage of muscle tissue, prompting automatic shortening of confined strands. The areas of stressed soft tissue receive fewer amounts of oxygen, glucose, and nutrient delivery, and in this manner, gather elevated amounts of metabolic waste items. The final product of this course of occasions is the creation of modified tissue status, pain, and the improvement of G6 G7 TrP’s. TrP’s have been related with hyperalgesia and constrained scope of movement and in this manner, clinically imperative to distinguish as these have the possibility to limit functional activities (Simons et al., 1999; Mense, Simons and Russell, 2001; Nagrale et al., 2010)G8 G9 

TrP diagnosis was accomplished following the diagnostic standards with the aid of Simons et al., 1999 & Gerwin et al., 1997: (1) presence of palpable taut band in a skeletal muscle; (2) presence of a hypersensitive tender area within the taut band; (3) local twitch response elicited through the snapping palpation of the taut band; and (4) replica of the standard referred pain pattern of the TrP in response to compression. A TrP was viewed active if the alluded pain evoked by its pressure replicated a similar subject head pain, while a TrP was viewed as idle if the evoked alluded pain did not repeat a usual or familiar pain (Simons et al., 1999; Harden et al., 2000).


Manual methodologies were embraced to treat dynamic TrP’s, including Muscle Energy Technique (MET’s), Neuromuscular Techniques (NMT’s) and myofascial release. MET’s have been recommended by chaitow (2001) and Niel-Asjer (2005) as methods for overseeing TrP’s. With the utilisation of MET’s regularly used for accomplishing the inhibition of a muscle prior to stretching. Within the third treatment, as seen in APPENDIX… As cervical flexors act as a stabiliser, Watson & Trott (1993) found isometric endurance as a key contribution towards postural correction. From this, the use of MET’s of cervical neck flexors was used as a means of manual therapy.G10 G11 

Client information

The client in which was chosen initially presented with posterior neck pain located on the left side, with referred pain presenting in the temporal area of their head. From the subjective and objective assessment which can be viewed in APPENDIX…  G12 G13 













The client in which was used as a case study was a 26-year-old male, pension advisor. He reported to play football at amateur level whilst training twice a week and a game once a week. As this G14 G15 present male’s occupation involved him to be sedentary at a computer for eight hours a day, he then at that point started to report an occurrence of neck pain following on from a new job in which he had to travel an hour and 30 minutes each way to his new office location. The patient explained the occurrence of his injury occurred a week prior to his first treatment. From the primary treatment session with the client, his principle objectives for the span of his treatment was to clear his neck pain and improve his posture in his surrounding cervical area.

Within the three treatments, the main aim of each session was to reduce the G16 client’sG17  neck pain firstly and then correct their posture in order to reduce a re-occurrence of this incidence. Each treatment session was provided objective measurements to ensure adequate progression, or, an indicator of regression within the treatments. Each treatment session can be viewed in APPENDIX… along with objective measurements. G18 G19 G20 

A key measurement of which was used throughout this case study was the FHP angle. G21 FHP was assessed from a lateral view of each session after manual therapy treatment while capturing the client’s shoulder, neck and head position. From previous studies undertaken by G22 Fernández-De-Las-Peñas, Cuadrado and Pareja, (2007), the assessment criteria were used to assess craniovertebral angle: the angle between the horizontal line passing through C7 and a line extending from the tragus of the ear to C7 (FIG… Appendix). A smaller craniovertebral angle is associated with a greater FHP. A previous piece of literature clearly supported the high reliability of the stated procedure (ICC = 0.88) G23 (Raine and Twomey, 1997). FHP was assessed as an indicator of progressive manual therapy and biomechanical advances within the patient. Details of this protocol can be found in Appendix…G24 G25 G26 G27 

TrP’s were located by physical examination and palpation upon the initial treatment. The determination of a TrP is proficient upon physical examination, who must take into consideration the physical signs (Simons et al., 1999). Within the primary treatment, the principal regions of concern were to releaG28 G29 se hypersensitive areas and TrP’s, situated in the client’s posterior cervical region, such as Upper Trapezius, Levator Scapulae, Scalene and Sternocleidomastoid.G30 G31 G32 G33 G34 

Within the first treatment, massage techniques used were effleurage and petrissage for the relaxation of muscle fibres, reduction of muscle spasms and to increase local circulation to prepare the muscle for other manual therapy techniques. From this, deep transverse friction was applied to the affected areas of pain. Throughout the procedure, a pain scale from 0-10 was used throughout for the therapist to judge the amount of pressure applied to each area. The patient lay on the massage plint in prone throughout the first treatment session. TrP release was then used as a means of releasing G35 G36 active TrP’s through ischemic compression. VAS was used as a pain scale throughout with the aim of the treatment to avoid pain levels greater than 8 and prolonged pressure as it can then act as a defensive tissue response and Exacerbation of inflammation. REF!!G37 G38 G39 G40 G41 

Once the TrP’s were distinguished, treatment at that point began. With ischemic pressure, expanding levels of pressure applied to the point in which the tissue resistance was distinguished and the G42 pressure was then maintained until a release of the tissue. The pressure was then applied again until the point in which a release of tissue was felt. The procedure was rehashed to the point when delicacy was unidentified or 90 seconds had passed. All active TrP’s were treated G43 G44 (Nagrale et al., 2010).G45 G46 G47 G48 G49 G50 

Finally, the client obtained MET which was applied to the left upper trapezius. From Nagrale et al., (2010) study, MET treatment was guided by this investigation and furthermore, with aid of Sharkey (2008). Each isometric contraction was held for 10 seconds and was trailed by a further contralateral side-bending, flexion, and ipsilateral rotation to maintain soft tissue stretch. Each stretch was maintained for 30 seconds and was repeated three times per treatment session.


The client was treated in a total of three times over a two week period, with each treatment session G51 recording FHP, VAS & severity of TTH, after each manual therapy treatment (See Appendix…). The client demonstrated an improvement in FHP, VAS & severity of TTH subsequent to each treatment.

Causes of soft tissue dysfunction

Within the causes of soft tissue dysfunction, three areas are considered of importance to distinguish a specific underlying factor. Within this case study, two were of relevance; Biomechanical: Postural, Trigger Point & Psychosocial: Stress. These cases were identified from the first session with the client, and information regarding these causes of soft tissue dysfunction can be found in APPENDIX….G52 G53 

The aim of manual therapy treatment is to reduce the pain of the area, restore normal function and limit the amount of FHP. Most manual therapy treatments Myofascial Pain Syndrome (MPS)  are targeted through deactivation of TrP’s. Within this case study, two categories of physical therapy techniques are viewed; Manual Therapy techniques (MET’s, NMT’s, DtF) & Ultrasound TherapyG54 

The principle conclusion of the review of the literature is that no detailed treatment had been more strong G55 G56 thanG57  that of a control intervention. A portion of the trials that were evaluated in this review, affirmed that TrP treatment is effective in the lessening of pressure pain threshold and visual analogue scale (VAS) ) (Hanten et al., 1997; Carnero and Carlos Miangolarra Page, 2005). From this, a portion of the trials examined affirmed that treatment of TrP’s is viable in decreasing weight torment affectability. As enhancements happened in a few gatherings which TrP’s were dealt with utilising distinctive manual treatments (soft tissue massage, ischemic compression & deep pressure)G58 . G59 G60 G61 G62 


Isometric performance of upper cervical flexors

A FHP and weakness of the upper cervical flexors have been observed thG63 roughout the patient’s treatment. From a past report attempted G64 by Watson & Trott (1993) found that isometric endurance, as opposed to isometric strength, assumes an indispensable part of the support of normal head posture. This is not astonishing as the upper cervical flexors have a prevalently stabilising role to provide a holding mechanism to maintain stability and balance for the head. Within this study, it features the need to screen for cervical cause in patients who are suspect to suffering from TTH. Furthermore, clinicians ought to know about the correlation between a TTH and poor craniocervical posture. As within each treatment, a supplementary postural correction and re-education, ought to be a fundamental segment of the administration of patients with TTH G65 G66 G67 (Watson and Trott, 1993).G68 G69 G70