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