Physical Examination
The initial physical examination was performed by a physical therapist with 8 years of clinical experience. In addition, this clinician was also Certified in Dry Needling and a fellow-in-training within an APTA-accredited orthopaedic manual physical therapy fellowship program. The patient provided consent for treatment and for publication of the case details in a scholarly journal. Objective examination findings can be found in (Table 1) . Notably, the patient reported severe tenderness and specific reproduction of posterior neck and suboccipital pain with pincer grasp palpation to the distal levator scapulae muscle bilaterally (i.e., approximately one thumbwidth superior and medial to the superior angle of the scapula). Tenderness with referred pain was also reported during palpation over the muscle’s distal enthesis (i.e., the medial aspect of the superior angle of the scapula), bilaterally.
The patient demonstrated pronounced thoracic kyphosis and forward head posture while using a laptop computer. Correlations have been reported between forward head posture and increased incidence of neck and headache pain, with greater forward head posture demonstrated in patients with CTTH when compared to controls.55-58 A 3-D kinematics study of desk workers found increased head-neck flexion angles to be associated with increased upper trapezius muscle activity, a synergist of the levator scapulae.59 Additionally, significant weakness of the rhomboid and middle trapezius muscles have been reported in patients with neck pain when compared to controls, potentially increasing mechanical load to the scapular elevators.60,61 Among patients with work-related myofascial disorders, several prior studies have reported changes in muscle activity, stiffness and microcirculation during prolonged computer tasks, likely contributing to the onset and continuation of tension type headache.40,41,43,59,62