Journal of Bodywork & Movement Therapies (2011) 15, 538e541

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CLINICAL METHODS

A case study utilizing Vojta/Dynamic Neuromuscular

Stabilization therapy to control symptoms of
a chronic migraine sufferer
PREVENTION & REHABILITATION e CLINICAL METHODS

David D. Juehring, DC, DACRB*, Michelle R. Barber, BA, MSW, DC

Palmer Chiropractic Rehabilitation and Sports Injury Department, Palmer College of Chiropractic, 1000 Brady Street,
Davenport, IA 52803, United States
Received 10 November 2010; received in revised form 21 December 2010; accepted 14 January 2011

KEYWORDS
Migraine;
Chronic;
Treatment;
Vojta;
Dynamic Neuromuscular
Stabilization

Summary Introduction: Migraine is a complex disorder of the brain characterized by severe

headache, photophobia, phonophobia, and nausea. This case report demonstrated the reduction of a 49-year-old females chronic migraine symptoms after 12 weeks of Vojta/Dynamic
Neuromuscular Stabilization (DNS) therapy.
Methods: Vojta/DNS treatment occurred either in the office or at home over a 12-week period.
Symptoms were tracked via a patient diary, a VAS pain scale, and a Headache Disability Index
(HDI).
Results: The patients migraine symptoms were typically of 3 days duration, a frequency of
8e10 times per month, and an intensity of 10/10 on a VAS pain scale. After a 12-week trial
of Vojta/DNS care, subjective improvements were noted, with a reduction in frequency to
1e2 times per month, duration of 12 h at most, and decreased intensity to a 2/10 on a VAS pain
scale. HDI scores dropped from 48% to 34%.
Discussion: This therapy reduced the patient migraine sysmptoms in frequency, duration and
intensity. This therapy is not well-known in North America despite its use for over 40 years
in Europe.
Conclusion: This case demonstrated that Vojta/DNS treatment over a 12-week period helped
manage the patients migraines and could be a possible treatment option for future research.
2011 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: 1 563 884 5455; fax: 1 563 884 5865.
E-mail address: juehring_d@palmer.edu (D.D. Juehring).
1360-8592/$ - see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2011.01.019

Introduction
Migraine is a complex disorder of the brain which is typically
characterized by spontaneous attacks of unilateral, throbbing headaches which are often aggravated by movements
(Messlinger, 2009), along with non-headache symptoms
including photophobia, phonophobia, and nausea (Sprenger
and Goadsby, 2009). These characteristic symptoms are
found in all types of migraine, the most common types being
migraine without aura, fo0llowed by migraine with aura
(Messlinger, 2009). It has been found that nearly half the
worlds population has an active headache disorder and
according to the American Migraine Prevalence and
Prevention study of 2004 (Lipton et al., 2007), migraine in
particular has a prevalence of 12% in the general population,
18% in women, and 6% in men (Robbins and Lipton, 2010).
Migraine is reported to be among the top 20 causes of
disability worldwide, as more than half of those affected
have such severe symptoms that they cannot function normally in their routine daily activities, including work, school,
and social activities (Brandes, 2009). 48.2% of migraineurs
reported some level of impairment, 22.1% were severely
disabled, and more than half reported the need for bed rest
(Lipton et al., 2007). In addition, during the periods between
attacks, worry, stress, and expectation of future attacks may
also lead to functional impairment, a phenomenon known as
the interictal burden (Brandes, 2009).
It is commonly noted that migraine attacks may be
precipitated by a number of factors, which are often termed
migraine triggers. Approximately 76% of migraine sufferers
report identifiable triggers (Sauro and Becker, 2009).
Reported triggers are widely varied, including hormonal
changes in women e migraine headache is related to the
menstrual cycle in about 60% of female patients (Lambert
and Zagami, 2009) e certain foods, missing meals, weather
changes, alcohol, and sleep disturbances. Fatigue is the most
commonly reported trigger, with stress the second most
common (Sauro and Becker, 2009). Additional triggers can
include flickering lights, loud noises, strong smells, drugs
which deplete the brain of the neurotransmitter serotonin,
environmental changes e especially in temperature and
barometric pressure e and for many patients no external
trigger is apparent at all (Lambert and Zagami, 2009).
The variety of triggers and the individual nature of
triggers have led to the hypothesis that only some kind of
neural event can explain triggering. There is much evidence
in the literature at this time to support the notion that
migraine is more than a headache disorder, but instead is
a pathophysiologically complex disorder that arises from
a neurovascular disturbance in the brain itself, and involves
modulatory mechanisms in the brainstem, subcortical, and
cortical levels to process pain. These processing mechanisms may be abnormal in migraine, which uses otherwise
normal neural pathways for pain transmission (Purdy,
2010). As depression travels slowly across the cerebral
cortex (cortical spreading depression), trigeminal nerve
terminals surrounding the meningeal arteries are stimulated, eliciting a trigeminovascular reflex that explains
subsequent vascular changes and headache (Martins, 2009).
Migraine sufferers typically try a multitude of interventions in an effort to reduce the frequency and severity of

539

their attacks as well as to improve function and reduce

disability (Brandes, 2009). There are numerous pharmacological interventions, including beta-blockers, antidepressants, anticonvulsants, calcium channel blockers and
serotonin antagonists, but side effects and contraindications because of co-morbidities can complicate treatment
(Sprenger and Goadsby, 2009). Over half of the diagnosed
migraineurs in the US use OTC analgesics, which are
effective in up to 60% of cases (Whyte et al., 2010). Many
migraine patients try manual therapies; primary choices are
physical therapy, massage, and spinal manipulative therapy
(Biondi, 2005). Recent reviews have shown physical therapy
is most effective in combination with other therapies such
as biofeedback, relaxation training, and exercise (Biondi,
2005). Massage therapy was shown to be beneficial in
reducing frequency of migraine attacks, as well as
improving perceived stress and coping efficacy (Lawler and
Cameron, 2006). There is also some evidence indicating
that spinal manipulation has effectiveness similar to a firstline prophylactic prescription medication (amitriptyline)
for the prophylactic treatment of migraine (Bronfort et al.,
2010). In addition, migraine patients also frequently use
complementary and alternative medicine (CAM), with
relaxation therapies and chiropractic care being the most
common CAM therapies employed (Astin and Ernst, 2002).
Additional alternative treatments include: vitamins and
minerals such as riboflavin, niacin, and magnesium;
supplements such as feverfew, butterbur, and coenzymeQ10; mind-body therapies such as biofeedback, cognitive behavioral therapy, guided imagery, headache
school, self-hypnosis, meditation, and relaxation training;
physical treatments such as acupuncture, massage therapy,
physical therapy, and spinal manipulation; and lifestyle
modifications such as food and alcohol elimination, aerobic
exercise, and sleep hygiene (DynaMed, 1995).
Vojta/Dynamic Neuromuscular Stabilization (DNS) is
a therapy used predominantly in Europe to manage neurological and musculoskeletal conditions (Laufens et al., 1999;
Niethard, 1987; Bo
hme and Futschik, 1995; Bauer et al.,
1992; Vojta and Peters, 2007). Vojta therapy was developed from 1955 to 1969 by a Czech pediatric neurologist
Vaclav Vojta (Bauer et al., 1992; Vojta and Peters, 2007). His
treatment approach in the broadest of terms involved
utilizing digital pressure on specific points of the body to
provide afferent stimulation to evoke genetically predetermined CNS motor programs to address various neurological-based conditions (Vojta and Peters, 2007). Since the
mid-nineties, these treatment principles and approaches
have since been modified by Pavel Kola
r, a physiotherapist
from the Czech Republic. His modified approach was eventually named Dynamic Neuromuscular Stabilization (Bokarius
and Bokarius, 2008). The purpose of this case report is to
demonstrate how the Vojta/DNS treatment approach greatly
reduced diagnosed migraine symptoms over a 12-week
period for a 49-year-old female who had consistently experienced intense frequent symptoms over her last 40 years.

Methods
The initial treatments consisted of Vojta/DNS therapy for
10e15 min in a supine position with the patients palms

PREVENTION & REHABILITATION e CLINICAL METHODS

A case study utilizing Vojta/Dynamic Neuromuscular Stabilization therapy

PREVENTION & REHABILITATION e CLINICAL METHODS

540
placed down on the treatment table. The patient was
positioned supine due the ease of maintaining cervical
spine neutral posture. On general patient visual observation
of the cervical spine on both standing and supine the
patient had a slight left lateral shearing and rotation along
with anterior head carriage. It was theorized that this
postural aberration may have been the possible cause for
the patients chronic symptoms. To neutralize this postural
issue in the cervical spine, mild long-axis digital pressure
was applied at the occiput to help hold the cervical spine in
the neutral position while minimizing upper cervical
hyperextension. This positioning maximized cervical spinal
joint centration, ultimately relaxing overactive cervical
muscles and establishing a neutral cervical spine posture.
Along with this positioning, firm digital pressure was
applied between ribs seven and eight at the mid-clavicular
line directed towards the fourth thoracic vertebral body to
provide proprioceptive afferent input as part of the treatment approach. Clinical judgment determined daily treatment times based upon a reduction of cervical tension to
enhance neutral cervical posture; treatment times were
longer in the initial stages of care as compared to the end
stages of daily treatment times. Care was taken to apply
firm pressure without causing a painful stimulus to the
patient and that digital pressure did not cause any lateral
bending, rotation, or shear in the thoracic spine to maintain
a neutral spine. The above treatment procedure was performed on one side of the body for half the treatment time,
then switched to the contralateral side based upon the
patients cervical asymmetries (Kola
r, 2007).
During the course of treatment, the patients initial
Vojta/DNS treatments started at 2e3 days of treatments
each week for the first three weeks, then tapered to one
treatment every 2e3 weeks until the last month of care
when the patient was only seen once. At three weeks of
care it was apparent that positive outcomes were obvious
by patient report, at which time the patients spouse was
trained to provide basic care at home on non-office days to
help progress the continual drop in the patients frequency,
duration and intensity of symptoms. For home care, it was
recommended that the care be performed daily at the same
duration and position used in the office. It was also recommended to perform the care on a firm surface such as
the floor similar to the hardness of the office treatment
tables. The patients symptoms pertaining to these
parameters were monitored per patient visit and via a daily
diary kept by the patient. A Headache Disability Index and
VAS pain scale was utilized on the initial visit and only again
at week 12 comparison without intermediate assessments.

Results
Prior to treatment, the patient reported symptoms of
intense headaches, light sensitivity, vision disturbances,
vomiting, and fatigue which occurred 8e10 times per
month and lasted consistently for three days. After a 12week clinical trial, subjective improvements were noted,
with a reduction of symptom frequency of one to two times
a month, lasting at most 12 h in duration and with an eightpoint reduction on a ten-point VAS pain scale. Headache
Disability Index scores dropped from 48% to 34%. At one

D.D. Juehring, M.R. Barber

time during therapy, the patient was without migraines for
a three-week period, which she recalled had never
happened before.

Discussion
Vojta/Dynamic Neuromuscular Stabilization therapy has
been utilized in the management of neurological and
musculoskeletal conditions (Laufens et al., 1999; Niethard,
1987; Bo
hme and Futschik, 1995; Bauer et al., 1992; Vojta
and Peters, 2007) throughout Europe, though it is not well
known as a care option in North America. Vojta therapy has
been applied roughly from the 1950s to present and was
initially developed by the pediatric neurologist Vaclav Vojta
(Bauer et al., 1992; Vojta and Peters, 2007). Through his
clinical observation of the development of healthy infants,
he noted a natural progression that they underwent for
functional movements. He believed this was not a learned
behavior but a genetically predetermined program that was
expressed by the CNS as it developed (Vojta and Peters,
2007). Vojtas clinical approach to less-than-ideal development movement patterns was to manually stimulate specific
zones of the body to evoke genetically predetermined
efferent motor expressions of the CNS to regain ideal
movement patterns. This program was defined as reflex
locomotion (Vojta and Peters, 2007). This approach was
eventually applied to adults for numerous neuromusculoskeletal conditions. The principles and treatment
methods were later expanded upon by Pavel Kola
r, Director
of the Rehabilitation Department at University Hospital
Motol, in Prague, Czech Republic. Dr. Kola
r added active
components and loaded positioning to these methods to
address dysfunctions and coined the name Dynamic Neuromuscular Stabilization (DNS) (Bokarius and Bokarius, 2008).
In this case, the patient had been diagnosed with
migraines by two neurologists and three MRIs spanning
a twenty-year period. She tried many treatment approaches
with nominal results. She had tried upper cervical specific
chiropractic care for an approximately three-month period
of time with an occasional mild reduction of symptoms which
would quickly return within a week. Also she had tried soft
tissue release for two visits to address the hyperflexion of the
upper cervical spine which greatly intensified the frequency,
intensity and length of her migraine symptoms. The therapy
she most utilized was OTC pain and headache medicines with
only mild temporary results. She reported having debilitating migraines once to twice a year that would be relieved
by Imitrex (triptan) injections.
Unfortunately, there exists little published Vojta/DNS
literature on the concepts and treatment approaches, with
even less articles written in English. The Vojta/DNS
approach was considered in this case due to its proposed
speculative ability to address global neurological disturbances at a subcortical level, based upon the concepts and
treatment possibilities presented in printed materials
(Laufens et al., 1999; Niethard, 1987; Bo
hme and Futschik,
1995; Bauer et al., 1992; Vojta and Peters, 2007; Kola
r,
2007). With the theories of migraine as a pathophysiologically complex disorder that arises from a neurovascular
disturbance in the brain itself, and involves modulatory
mechanisms in the brainstem, subcortical and cortical

levels to process pain (Purdy, 2010), the authors postulated

that it would appear worthy of a clinical trial for this
patients particular condition utilizing Vojta/DNS therapy.
Vojta/DNS care was also considered as a possible method of
treatment due to her responses to other previous neuromuscular care. Although negative with the soft tissue
treatment and only slightly positive with the upper cervical
adjustive care the authors speculated that a treatment in
the cervical spine given the postural asymmetries could be
minimized or eliminated from the neuromuscular impacts
suggested in published articles (Bokarius and Bokarius,
2008; Laufens et al., 1999; Kola
r, 2007).
The supine position was utilized to help facilitate global
neutral positioning of the cervical spine to address left lateral
shear and rotation along with anterior head carriage to reduce
cervical postural asymmetries in hopes to impact symptoms.
The stimulation point and body posture utilized is considered
the most effective at facilitating sagittal stability (Vojta and
Peters, 2007). Other beneficial reasons for the choice of
this treatment position were its comfort for the patient and
the relative ease of educating the patients husband to
perform the appropriate positioning and treatment at home
for an effective therapeutic response by a lay person.

Conclusion
This case demonstrated that Vojta/DNS treatment over the
course of 12 weeks helped manage the patients migraines.
This treatment approach demonstrated an effect on this
patients condition by reducing the patients reported
frequency, duration and intensity of symptoms along with
reduced VAS pain scale and Headache Disability Index
scores. Migraine is a disorder of the brain characterized by
a complex sensory dysfunction, and as such, interventional
neuromodular approaches with neural targets are most
promising (Sprenger and Goadsby, 2009). Looking at
migraine from a neurobiological approach, it would seem
that any approaches which involve change or perturbation
of the abnormal processes could reduce migraine symptoms
(Purdy, 2010). The positive outcomes achieved in this case
using the Vojta/DNS approach to addressing neurological
disturbances have promising potential. Further research is
needed to evaluate this clinical approach and its success in
treating other patients with migraine disorders.

Conflict of interest
The authors declare that they have no conflict of interest.

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PREVENTION & REHABILITATION e CLINICAL METHODS

A case study utilizing Vojta/Dynamic Neuromuscular Stabilization therapy