August 17, 2011

Role of posture in the manifestation of Occipital pain/neuralgia & its management with Marma chikitsa:-

                                 Dr.Bhat.A.Rangaprasad -Sarve janah Sukhino Bhavanthu || Sarve santhu Niramayah ||

This clinical case is about evaluation of the effect of incorrect posture causing certain distress in the neck & head region, portraying the features of Migraine Head ache and there by arising a suspicion in the mind of a clinician as a clinical migraine..

The following phenomenon of neck pain associated with radiation of the same to the occipital; vertex & temporal or pre-auricular area has been observed in quite a number of clients of mine, especially in people who are prone to sleep in prone posture ( Upside down posture of sleeping ).

I am here by discussing a recent & interesting case dealt with recently.

Name of the patient:- Mrs.Xyz

Age:- 36 yrs

Occupation: - House wife

Nature of jobs done in a day: - House hold activities by herself (no house maid); teaching her child by sitting in floor (where in her neck will always be in flexion)

Sitting pattern: - She most of the time uses a sofa to watch television. She used to lie over the sofa in left lateral position with her head resting either over the raised hand rest portion of the sofa or by giving support to her head with her arm underneath her head(of course over the hand rest of the sofa ).

Sleeping pattern:- Never sleeps on supine posture, but always either on left lateral posture with either raised pillow or left arm underneath the head... or upside down (Prone position).The next day morning, after sleep, she used to feel a gnawing head ache starting from the nape of the neck which radiates upwards reaching the vertex of head; the temples; the area in front of the ear associated with giddiness.

Aggravating factors: - Sudden movements of the neck like flexion/ extension/ lateral rotation of the neck soon after rising from lying posture. Closing the eyes causes fear of getting giddy..

Relieving factors:- Mild movement of neck in the form of stretching exercise; hot water bath; fomentation; application of any liniments or medicated oils.

History of other illness: - Nothing significant. She is an Adiabetic; Non hypertensive; with regular history of Menstrual cycle. Her hematological reports are NAD. The MRI of Brain shows Normal study. X-Ray of the cervical spine- NAD.

History of present Illness: - The subject under discussion had been suffering from this problem, since the birth of her lone child, some 12 years ago. The entire clinical symptoms would come on & off. She observes that whenever she is stressed with strenuous activities, the pain start in the occipital region and spreads upwards to reach the vertex and the temples; pre-auricular region. Whenever she tries to turn her head she used to feel or hear some cracking sounds (crepitations..?) at the base of her head (actually refers to the Atlanto-Occipital junction). As and when time advances she would feel the pain to be lancinating, like that of an electric shock, and worst of all when the pain increases will get nausea..

She had consulted with many super specialists, who found no obvious reason for her symptoms, since none of the diagnostic measures done, paved a way for a proper diagnosis. Hence, she had been prescribed analgesics & anti spasmodic & muscle relaxants. For almost until this period she had been taking Vasograin regularly...

On the day of consultation with us, she had severe spasmodic pain radiating to her jaw, which was a new feature in her history of the disease. She had actually misunderstood the condition to be a “Lock Jaw”, since, she felt severe spasm and pain at the area of Tempero-mandibular joint causing distress while chewing. Hence, requested for an emergency appointment with us, to get it rectified with Marma chikitsa…

Clinical examination:-

On the day of her personal sitting, we were astonished to see no features of lock jaw, but only signs of stiffness of the Platysma; Strenocliedo mastoid, Semispinalis capitis; splenius capitis(image).

Tenderness at the various level s of cervical region & other areas of pain…

C1 to C3 – 2+
C4 to C7 – 1+
Mastoid process – Right –3+  Left—2+
Supra clavicular – 3+
Pre-auricular – 2+
Temporal – 2+
Vertex – 3+
She was able to move her mandible freely and that there were negative signs of dislocation of the T.M joint.

Provisional Diagnosis –

1.     Inflammation of Cervical plexus (Cervical plexalgia…) &
2.  Vertebro-basilar insufficiency

The concept of posture & Anatomical considerations w.r.t to the above provisional diagnosis…:-


(A) Involvement of Cervical plexus:- 

The tenderness and pain in the region of the sternocliedo mastoid (which helps in nodding and turning of head); Splenius capitis(which helps in extension and turning of head) and painful mandible movement were suggestive of involvement of stretching/inflammation of the cervical plexus & the the cervical nerves..  vide:-
The sensory branches of spinal nerves include: lesser occipital, C-2, great auricular, (C-2 and C-3); transverse cervical, C-2 and C-3; and Supraclavicular, C-3 and C-4. These nerve groups transmit afferent (sensory) information from the Scalp,Neck & Shoulders to the brain. Vide:-

(B) Involvement of the vertebro basilar artery :- 

The vertebral arteries are major arteries of the neck. They branch from the subclavian arteries and merge to form the single midline basilar artery in a complex called the vertebrobasilar system, which supplies blood to the posterior part of the circle of Willis and thus significant portions of the brain.

At the C1 level the vertebral arteries travel across the posterior arch of the atlas through the suboccipital triangle before entering the foramen magnum.

Inside the skull, the two vertebral arteries join up to form the basilar artery at the base of the medulla oblongata. 

The vertebral artery may be divided into four parts. of which the third part of the part of the artery is covered by the Semispinalis capitis and is contained in the suboccipital triangle—a triangular space bounded by the Rectus capitis posterior major, the Obliquus superior, and the Obliquus inferior.

The first cervical or suboccipital nerve lies between the artery and the posterior arch of the atlas.

The Circle of Willis or the Circulus Arteriosus is the main arterial anastomatic trunk of the brain. According to Bhatnagar and Andy, 1995, anastomosis occurs when blood vessels bring blood to one spot from which it is then redistributed. The Circle of Willis is a point where the blood carried by the two internal carotids and the basilar system comes together and then is redistributed by the anterior, middle, and posterior cerebral arteries.
The anterior cerebral arteries of the two hemispheres are joined together by the anterior communicating artery. The middle cerebral arteries are linked to the posterior cerebral arteries by the posterior communicating arteries. This anastamosis or communication between arteries make collateral circulation which Love and Webb, 1995, define as "the flow of blood through an alternate route" (p. 40) possible. This is a safety mechanism, allowing brain areas to continue receiving adequate blood supply even when there is a blockage somewhere in an arterial system. The blood streams of the internal carotid system and the basilar system meet in the posterior communicating arteries. If there are no problems in either system, the pressure of the streams will be equal and they will not mix. However, if there is a blockage in one of them blood will flow from the intact artery to the damaged one, preventing a cerebral vascular accident. Vide:-

Cadaver studies have demonstrated that head rotation causes narrowing of the contra lateral vertebral artery at the C1-C2 level. The ipsilateral atlantoaxial articulation is fixed during rotation of the head, whereas the atlas moves both downward and forward in relation to the axis on the opposite side. It has been hypothesized that stretching of the vertebral artery associated with this movement at the atlantoaxial joint may produce narrowing or occlusion of the artery.


From the above anatomical considerations, in the above client of ours, who is habituated of sleeping in prone posture with her head fixed up in extreme lateral rotation on right side.., the Splenius capitis, sternocliedomastoid & supraclavicular muscles on the contra lateral side (i.e the left side) gets overstretched which in due turn causes exertion & stretching of the cervical nerves concerned with the respective innervating areas.

Due, to the continuous stretching of the cervical innervations of the above muscles, the resultant inflammation gets spread up and along the other courses of the Cervical plexus, there by involving the lesser occipital nerve (the tenderspot in scalp in the lateral area of the head the ear) & Greater occipital nerve (the tender spots of the following innervations of the greater occipital nerve in the subject /patient under discussion, is to be recollected over here viz., semispinalis capitis; trapezius ;posterior part of the scalp to the vertex & over the ear).

And thus the patient starts feeling the pain getting radiated from the middle of the cervical region to the occiput of head,simultaneously to the lateral portion of the head reaching up to the ears and to the vertex of head travelling vertically.

The giddiness occurs due to insufficient supply of blood, caused by temporary narrowing of the Vertebral artery, caused by the undue pressure exerted over the artery by the stiffened Splenius capitis & Semispinalis capitis muscles which are inserted to the occipital bone, at it’s nuchal line.

The best way to avoid the above agonizing pain, hence is, not to sleep in prone posture…


Soon after manipulating the krukatika marma the subject felt, sudden heat in the entire scalp region and inside the head, due to gushing of the erstwhile diminished supply of blood, due to the compression of the vertebral artery by the splenius capitis & Semispinalis capitis.

On manipulating the Adhipati, she felt immediate relief from the burning pain @ the vertex.
The careful manipulation of the Kakshadhara & supra clavicular areas which were most tenderful simultaneously in association with the manipulation of the Amsaphalaka relieved the pain in the regions of the right shoulder,right lateral portion of the neck and the one in the TM joint.

Mild massaging over the nuchal line & the shanka marma relieved the stress of the trapezius and temporalis muscle, thereby giving relief from the pain in the region of temple & posterior aspect of the scalp.

Manya after proper manipulation gave relief from the stiffness in the region of sternocliedomastoid & the pain in the angle of the mandible.

The patient got almost 80% of the relief in the first sitting. However she was adviced to come for next five consecutive sittings, in anticipation of certain new symptoms like pain in the region or precordium, which usually occurs in certain sensitive patients on manipulating the marmas. As anticipated she felt some stretching type of pain in the infra clavicular area extending along the borders of the Manubrium sterni,along with stiffness in the Pectoralis major muscle.

Hence on the second day of sitting additional manipulation of the brhati marma was done to ease the congestion of the pranic energy at the precordial region.

The medications which are anti vatic in property especially which has an upper hand in controlling the Oordhvajatrugata vata & kapha was selected and provided in the form of kashayam along with a vedanasthapaka yoga.

Since the patient got almost 90% of the relief on the 2nd day of sitting, the other remaining sittings were uneventful.

Post Marma session, the patient followed the advice of sleeping in supine posture only. She completely avoided sleeping over the sides or upside down…

When she came for her second level of consultation after 10 days of medications, she was totally asymptomatic.



Shan said...

good one.In some cases, where there is severe stiffness,when it is not possible for a manipulation,we do a greevadhara and abhyanga. It has given wonderful results.ksheerabala 101 caps intake and set of neck exercises prevent further occurence

drrangaprasadbhat said...

Thanks for the interest shown in the above topic w.r.t Marma chikitsa.
I do appreciate the worthy effect of the Greevadhara in nuchal stiffness.
But, ma'm it is possible to give relief from the stiffness even with out it's assistance but only with M/C.
Shall I reveal a secret.....?
Of course when published it may no longer be a secret....
Please do manipulate both the mastoid processes by simultaneously rotating the neck laterally on either sides; followed by diagonally flexing & extending the neck on either sides....
The rest, you will see for the good effect by yourself.
Hope, you will try this in your clients.
Warm regards.

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