Neck Solutions

Efficacy of physiotherapy including a cranio cervical neck exercise training programme for tension type headache

From: Cephalalgia, 2006, 26, 983–991

Tension type headache is the most prevalent headache type. Almost 80% of the total population will experience a tension type headache at some time. Headache is one of the 10 major complaints of patients seen in primary care practices and 47% of all headaches are tension type headaches. ‘Tension-type’ labels a headache classification developed in 1988 by the International Headache Society. It can be divided into an episodic and a chronic version and is commonly more experienced by women (female:male ratio 5 : 4). Because of its high prevalence—1-year prevalence in women 86% and in men 63% and its wide spectrum of disability, tension type headache has a greater socioeconomic impact than any other headache type. In spite of this, only 15% of people with tension type headache seek medical attention and 60% of those reporting severe headaches use only over-the-counter medication, standing a chance of analgesic rebound. Instead of self-management, a therapeutic approach, incorporating both non-pharmacological and pharmacological intervention, shows a success rate of greater than 90% in patients with tension headaches.

Physiotherapy consisted of a threefold approach: conventional Western massage techniques, oscillation techniques and instruction on postural correction. Conventional massage techniques included the following modes: ‘effleurage’ (stroking), ‘petrissage’ (kneading) and ‘friction’ (deep pressure). Mode and intensity were determined by the physiotherapist in accordance with the diagnosis and the patient’s condition as a clinical routine. Oscillation techniques included the use of low-velocity, passive cervical joint mobilization, in which the cervical segments are rhythmically moved following a regimen described by Maitland. The two approaches described above are intended to reduce pain and musculotendinous tension.

Instruction on postural correction originates with the worst postural position of cranio cervical neck exercise extension (anteversion) of the head, cervicothoracic flexion, protraction of the shoulders and increased thoracic kyphosis and flattened lumbar lordosis while sitting. The physiotherapist instructs patients to correct these postural abnormalities through cranio cervical neck exercise flexion (retroversion) and cervicothoracic extension, retraction of the shoulders, extension of the thoracic spine and normalization of lumbar lordosis.

The cranio cervical neck exercise training programme was a new developed programme using low-load endurance exercises in order to train and/or to regain muscle control of the cervicoscapular and cranio cervical neck exercise regions. To address the impairment in neck flexor synergy found in cervicogenic headache and other neck pain disorders, cranio cervical neck exercise flexion exercises were performed, using a latex band resistive exercise system, blue colour-coded level of progressive resistance. The 150-cm latex band was used as a circular band, with one side positioned at the cranio cervical neck exercise region of the patient’s neck and the other side fixed somewhat above the horizontal. The resistance of the band was used in such a way that it facilitated the longus colli muscles. Exercises were performed in a sitting position with a natural lumbar lordosis, under slight scapular retraction and adduction and slightly elongating the cervical spine. Participants were instructed to perform a slow and controlled cranio cervical neck exercise flexion over various ranges of motion, resulting in various resistances, with various speeds using isometric contractions in various positions.

This cranio cervical neck exercise low-load training regimen was also incorporated in postural correction exercises. The duration of the cranio cervical neck exercise training programme part of the treatment session did not exceed 15 min. During the intervention period, the participants were instructed to practice this cranio cervical neck exercise training programme at home twice a day for 10 min per session. Using a daily diary, changes in headache frequency, intensity, duration and medication intake were monitored and compliance was controlled. After the treatment period the participants were instructed to continue the cranio cervical neck exercise training at home with a frequency according to their complaints, but at least twice a week. Preceding the start of the trial, 20 experienced senior physiotherapists in the seven participating treatment centres were explicitly trained to execute the protocolled treatments.

This trial supported evidence that physiotherapy combined with a specific therapeutic exercise regimen was effective for tension type headache. Although there was no significant difference between the two treatment groups immediately after treatment (end-point), at follow-up a significant and clinically relevant effect was shown in the cranio cervical neck exercise training programme group.

As various research suggests, afferent input produced by joint mobilization stimulates inhibitory systems at various levels in the spinal cord and modulates pain perception. It is most likely that the mechanisms of the treatment effect in this trial are to be found in the afferent input attributed to the mobilization and oscillation techniques of physiotherapy and to treatment by cranio cervical neck exercise exercises. This specific cranio cervical neck exercise training programme emphasized motor control rather than muscle strength and was carried out daily to twice a week in the post-treatment period. In this way, afferent input was continued in the cranio cervical neck exercise training group after end-point measurement. Possibly, this post-treatment period had a consolidating effect.

The group performing the cranio cervical neck exercises showed a decrease in medication intake of 60%, which is more than 50% compared with the control group. The episodic tension type headache assessed in this study is synonymous with the frequent episodic tension type headache according to the ICHD-II classification. Participants suffering from infrequent episodic tension type headache were not included. Within the cranio cervical neck exercise training programme group, a higher reduction of medication intake was shown in the chronic tension type headache group compared with the episodic tension type headache group.

The calculated effect size showed a large effect for all headache symptoms. A 50% reduction in headache frequency is regarded as clinically relevant by the IHS. In this study 85% of the participants in the cranio cervical neck exercise training programme group showed a 50% reduction in headache frequency at follow-up, with 48% reporting 80. 100% reduction at that time, indicating substantial clinical relevance. In contrast to what might be expected, the Headache Locus of Control was not influenced by the treatment effect and consequently could not be regarded as a predictive factor for any outcome measure.

Since patients with tension type headache very often use self-administered pain-relieving manoeuvres with only scant efficacy, the cranio cervical neck exercise training in this trial caters for this target group since the exercises are easy to perform, take little time and are effective. Considering the fact that reduction of headache frequency, intensity and duration continues after 6 months, a follow-up study including a longer time frame should be conducted to determine the efficacy of cranio cervical neck exercise exercises as a potential stand-alone treatment over a longer period of time.

A substantially longer follow-up will also emphasize the aspect of self-management of cranio cervical neck exercise training and might eventually detect a change in the Headache Locus of Control. The question arises whether the underlying mechanisms of cranio cervical neck exercise training reflect modulation of pain perception through increased afferent input, or the effect on cranio cervical neck exercise posture resulting in reduction of cervicoscapular muscle tone. In other words: is it the action, or is it the posture? No answer can be provided from this trial, but the results underline the necessity for researching multimechanisms to explain pain reduction by this physiotherapeutic treatment. Trials of non-invasive physical therapies for tension type headache have been criticized for poor methodological quality. Reviewers’ recommendations suggest the necessity of further research, using rigorous scientific methods. We tried to fulfil this condition by following the guidelines for randomized clinical trials; subject selection was based on validated criteria for tensiontype headache, randomization was computerized and evaluation was performed through blinded data assessment. The statistical power was adequate to detect the hypothetical effects and loss to follow-up evaluation was low (3.7%). The nature of the intervention precluded the necessity for any blind condition on participants or therapists (open label trial).

In conclusion, this trial has shown that physiotherapy including a cranio cervical neck exercise training programme is effective in the management of chronic and episodic tension type headache over a prolonged time frame.