The Working Mechanism of Manual Therapy in Participants With Chronic Tension-Type Headache

Abstract

Chronic tension-type headache (CTTH) is associated with cervical spine impairments, including restricted range of motion (ROM) of the cervical spine, reduced neck flexor endurance, and greater forward head posture. 13,15,17,27,30 These associations have led to the development of a biomechanical model for CTTH. According to this conceptual model, cervical dysfunction elicits headache through peripheral or central pain mechanisms; therefore, improvement of cervical dysfunction by physical treatment should reduce headache. 5,18,19 Based on this model, we conducted a randomized clinical trial (RCT) to determine the effectiveness of multimodal manual therapy, including mobilization of the cervical spine, isometric training of neck flexors, and posture correction. A reduction in headache days of 50% or greater was the clinically relevant outcome.2 A significant difference of 87.5% versus 27.5% in outcome was found in favor of manual therapy, compared to usual care by the general practitioner, in participants with CTTH. 8The extent to which specific elements (mobilization, isometric training of neck flexors, or posture correction) contribute to the effectiveness of manual therapy is unknown, and information about the working mechanisms of manual therapy in participants with headache is urgently needed. 5,19 The biomechanical model mentioned above suggests that increased ROM of the cervical spine, increased neck flexor endurance, and a less pronounced forward head posture may offer potential explanations for the effect of manual therapy in reducing headache frequency. To explore the working mechanism of manual therapy, we investigated whether the above aspects of cervical spine function (cervical ROM, neck flexor endurance, and forward head posture) were mediators of the effect of manual therapy on headache frequency. METHODS Participants For the mediation analyses, we used the combined data obtained from 2 studies, a multicenter, prag-T T STUDY DESIGN: Prospective longitudinal study. T T OBJECTIVE:To explore the working mechanism of manual therapy, we investigated whether 3 cervical spine variables were mediators of the effect of manual therapy on headache frequency. T T BACKGROUND: Manual therapy has beenshown to reduce headache frequency in participants with chronic tension-type headache (CTTH). To what extent specific elements of treatment contribute to the effectiveness of manual therapy in CTTH is unknown. T T METHODS:One hundred eighty-two participants with CTTH participated in a prospective longitudinal study: 142 underwent manual therapy and 40 participants received usual care by their general practitioner. Regression analysis was performed according to the steps described by Baron and Kenny, and the proportion of mediated effect was estimated for 3 potential mediators: (1) cervical range of motion, (2) neck flexor endurance, and (3) forward head posture. Outcome was defined as a 50% or greater reduction in headache days.

Multimodal Physiotherapy Based on a Biobehavioral Approach as a Treatment for Chronic Tension-Type Headache: A Case Report

“…Finally, the time the patient maintained the craniocervical flexion position from T0 to T3 increased markedly (from 3 s to 32 s) to a value very close to those obtained from asymptomatic subjects (38.95 ± 26.4) ( 17 ). According to recent evidence, increased neck flexor endurance is crucial for improving patients with CTTH ( 38 ).…”

Clinical Reasoning Behind Non-Pharmacological Interventions for the Management of Headaches: A Narrative Literature Review

“…In fact, the application of strengthening exercises, ergonomic/posture correction programs and motor control exercise programs have demonstrated to be effective in TTH [64][65][66]. Interestingly, Castien et al found that neck flexor musculature endurance partially mediates the potential effects of manual therapy interventions in TTH [67]. Nevertheless, it should be noted that there are several studies also showing the presence of similar musculoskeletal disorders of the cervical musculature, e.g., decreased neck muscle endurance [68], increased activity of the superficial muscles during low-load isometric tasks [69], and altered muscle performance [70] in people suffering from migraine.…”

Are Pain-Related Fears Mediators for Reducing Disability and Pain in Patients with Complex Regional Pain Syndrome Type 1? An Explorative Analysis on Pain Exposure Physical Therapy

“… This model was used to analyse potential mediation between the independent variable (Pain Exposure Physical Therapy versus conventional treatment), the mediator variable (fear-avoidance beliefs or pain catastrophizing or kinesiophobia), and the dependent variable (pain-related disability or pain) [ 30 ]. PEPT = Pain Exposure Physical Therapy.…”

“…Only if both effects (between-group differences) were statistically significant, using alpha levels of up to 0.10 due to the exploratory nature of this study, we performed the third analysis, in which we regressed the dependent variables on both the mediators and the independent variable. For mediation to be present, the mediator had to be significantly related to the outcome (path b) and the direct effect of the independent variable on the outcome (arrow c 1 ) had to be smaller than the total effect (arrow c) [ 30 ]. On the basis of the standardised coefficients, we also planned to assess the proportion of mediated effect: (c—c 1 )/c x 100% [ 30 ].…”

“…For mediation to be present, the mediator had to be significantly related to the outcome (path b) and the direct effect of the independent variable on the outcome (arrow c 1 ) had to be smaller than the total effect (arrow c) [ 30 ]. On the basis of the standardised coefficients, we also planned to assess the proportion of mediated effect: (c—c 1 )/c x 100% [ 30 ].…”