Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study

German translation, transcultural adaptation and test-retest reliability of the headache screening questionnaire

INTRODUCTION

Tension-type headache (TTH) and migraines are frequent headache types. For appropriate treatment, physiotherapists need to be able to recognize these two headache types. The Dutch Headache Screening Questionnaire (HSQ-DV) is the only screening questionnaire designed specifically for migraines and TTH, based on the latest International Classification of Headache Disorders and supporting evidence. The aim of this study is to translate the HSQ-DV into German and evaluate its test-retest reliability.

METHODS

A cross-sectional and prospective cohort study was conducted to answer the research questions. The HSQ-DV was translated according to the COMSIN checklist for patient-reported outcome measurement instruments. Test-retest reliability was assessed with a retest after two weeks. Weighted kappa values, intraclass-correlation coefficients (ICCs) and standard error of the measurements (SEMs) were calculated separately for migraines and THH, based on point scale ranging from 0 to 8.

RESULTS

The HSQ-DV was translated and culturally adapted into German. An introductory clarification was added to guide participants with multiple headaches, which headache type to consider. Sixty-one subjects were included in the reliability study. For migraine, the weighted kappa was 0.70 (95% Confidence Interval (CI) 0.52 to 0.87), the ICC was 0.84 (95% CI: 0.71 to 0.91), and the SEM was 0.39 points. For TTH, the weighted kappa was 0.73 (95% CI: 0.57 to 0.90), the ICC was 0.85 (95% CI: 0.74 to 0.92), and the SEM was 0.29 points.

CONCLUSION

The HSQ-GV is a reliable screening questionnaire for migraines and TTH in physiotherapy settings, demonstrating substantial to nearly perfect reliability.

Clinical features, risk factors, and a nomogram for predicting refractory cervicogenic headache: a retrospective multivariate analysis

Introduction

Given the intricate nature and varied symptoms of cervicogenic headache, its treatment can be challenging, potentially leading to refractory cervicogenic headache. We aimed to identify risk factors that could help predict the development of refractory cervicogenic headache in patients with cervicogenic headache.

Methods

This is a retrospective cohort study of patients diagnosed with cervicogenic headache between January 1, 2022 and March 1, 2024 who underwent greater occipital nerve block. Data were collected by reviewing patients' medical records and pain questionnaires. Covariates were selected using univariate and multivariate logistic regression analyses. A predictive nomogram model was developed to predict the unresponsiveness of the greater occipital nerves to anesthetic blockade.

Results

Of the 82 patients studied, 46 experienced relief from headache following greater occipital nerve blocks, whereas 36 did not. In a multivariate analysis of patients with refractory cervicogenic headache, factors such as C2-C3 sensory loss [odds ratio (OR) = 13.10, 95% confidence interval (CI): 1.45-118.54], bilateral headache (OR = 7.99, 95% CI: 1.36-47.07), having two or more types of pain sources (OR = 5.51, 95% CI: 1.01-30.16), and limited cervical range of motion (>1) (OR = 13.05, 95% CI: 2.28-74.59) were identified as major prognostic indicators of unresponsiveness to greater occipital nerve blocks in cases of large occipital and cervical spine-related factors.

Conclusion

Patients with severely limited cervical spine mobility, bilateral headaches, and C2-C3 sensory loss may not respond well to greater and lesser occipital nerve block therapy. Pain originating from multiple sources is typically associated with less favorable outcomes.

Expert Consensus on Dry Needling Practices for Headache: An International Delphi Study Protocol

Background: Dry needling is increasingly utilized by clinicians in the treatment of patients with headaches. Although current evidence supports the use of dry needling for reducing headache pain, needling approaches are inconsistent among published studies, and no guidelines on dry needling for headaches have been established. Methods: A study will be conducted using the Delphi method, consisting of three rounds of questionnaires sent to an expert panel of clinicians and researchers. Results: To guide the development of the initial survey, we completed a literature review of articles related to dry needling for headaches. A steering committee will assess the initial survey items synthesized from the literature search and provide recommendations for the first and subsequent rounds of the study. Percentage agreement will be the primary measure throughout all rounds of this study. We define consensus to have been reached when 75% agreement is achieved. Conclusions: We seek to develop clinical recommendations that will guide research and treatment practices regarding dry needling for headaches. Having consensus-driven recommendations on dry needling for headaches will assist researchers in the design of future studies on this condition. In addition, having guidelines that clinicians can reference prior to the delivery of dry needling for headaches would benefit patient care.

What is the Status Quo of Patient-Centred Physiotherapy Management of People with Headache within a Biopsychosocial Model? - A Narrative Review

PURPOSE OF REVIEW

Patient-centred care (PCC) is deemed essential in the rehabilitation of musculoskeletal pain. Integrating such care within a biopsychosocial framework, enables to address all facets of the individual pain experience, and to manage the individual instead of the condition. This narrative review describes the status quo of PCC physiotherapy management of people with headache within a biopsychosocial model. PubMed, EMBASE, Web of Science, Scopus were searched (update 07.05.2024). The search-query comprised terminology relating to "headache", "patient-centred", "biopsychosocial", "physiotherapy". Additional eligibility criteria were reviews, trials, cohort, case report, case-control studies in English, Dutch, French.

RECENT FINDINGS

Gaps are exposed in patient-centred physiotherapy management of migraine, tension-type headache, and cervicogenic headache. While a biopsychosocial approach is advised to manage migraine and tension-type headache, its use in clinical practice is not reflected by the literature. A biopsychosocial approach is not advised in cervicogenic headache. Psychosocial-lifestyle interventions are mainly delivered by health-care providers other than physiotherapists. Additionally, psychologically-informed practice is barely introduced in physiotherapy headache management. Though, managing the social context within a biopsychosocial framework is advised, the implementation by physiotherapists is unclear. Comparable conclusions apply to PCC. PCC is recommended for the physiotherapy management of primary and secondary headache. Such recommendation remains however theoretical, not reaching clinical implementation. Yet, a shift from the traditional disease-centred model of care towards PCC is ongoing and should be continued in physiotherapy management. With this implementation, clinical and economical studies are needed to evaluate its effectiveness.

Thoracic spinal postures and mobility in patients with cervicogenic headache versus asymptomatic healthy controls: A longitudinal study

INTRODUCTION

Studies analyzing postures and mobility of the thoracic spine in the context of cervicogenic headache are missing. Insight in these parameters is needed since the cervical and thoracic spine are biomechanically related.

OBJECTIVE

To compare self-perceived optimal and habitual postures, active-assisted maximal range of motion, and repositioning error of the upper-thoracic and lower-thoracic spine between a cervicogenic headache-group and matched healthy control-group before and after a 30 min-laptop-task.

METHODS

A non-randomized longitudinal design was used to compare thoracic postures and mobility between 18 participants with cervicogenic headache (29-51 years) and 18 matched healthy controls (26-52 years). Outcomes were: self-perceived optimal and habitual postures, active-assisted maximal range of motion, and repositioning error of the upper-thoracic and lower-thoracic spine evaluated in sitting with a 3D-Vicon motion analysis system.

RESULTS

Habitual upper-thoracic postures in the cervicogenic headache-group were significantly (p = .04) less located toward the maximal range of motion for flexion compared to the control-group, self-perceived optimal upper-thoracic posture was significantly (p = .004) more extended in the cervicogenic headache-group compared to the control-group, and self-perceived optimal lower-thoracic posture could not be reestablished in the cervicogenic headache-group after the laptop-task (p = .009).

CONCLUSION

Thoracic postures differ between a cervicogenic headache-group and control-group. These differences were detected by expressing the habitual thoracic posture relative to its maximal range of motion, and by analyzing the possibility of repositioning the thoracic spine after a headache provoking activity. Longitudinal studies are needed to determine the contribution of these musculoskeletal dysfunctions to the pathophysiology of cervicogenic headache.

Therapeutic Patient Education as Part of the Physiotherapy Management of Adults with Headache: A Scoping Review

PURPOSE OF REVIEW

Physiotherapy interventions for headache mostly include exercise and manual therapy. Yet, the complex nature of headache, sometimes characterized by symptoms of facilitated central pain mechanisms, demands an individualized approach in which therapeutic patient education could be supportive. This scoping review aimed to summarize the position of therapeutic patient education within the physiotherapy management of adults with headache. PubMed, EMBASE, Web of Science, and Scopus were searched. The search-query comprised terminology relating to "headache", "education", and "physiotherapy". Eligibility criteria were: adults with headache, interventions including education within the domain of physiotherapy, reviews, clinical trials, cohort, case report, case-control studies.

RECENT FINDINGS

Eleven publications were included from the 281 retrieved publications. These publications were clinical trials (n = 4), reviews (n = 4), case-reports (n = 2), and a guideline (n = 1). Type of headaches studied were migraine (n = 3), post-traumatic headache (n = 2), tension-type headache (n = 2), cervicogenic headache (n = 1), primary headaches (n = 1), chronic daily headache (n = 1), and mixed migraine-cervicogenic headache (n = 1). Education seems an umbrella-term for postural education, lifestyle advice, and pain education. Three themes emerged across the publications: handling headache triggers (migraine, post-traumatic headache), promoting active lifestyle (post-traumatic headache, chronic daily headache, migraine), evaluating posture (post-traumatic headache, chronic daily headache, tension-type headache, cervicogenic headache). All publications recommended education in the management of headache. Only one (of the 11 included) publication described the educational program and determined its efficacy. Based on this scoping review, therapeutic patient education seems supported within physiotherapy management of headache. However, it is unclear how such education is tailored to the specific needs of the individual, the headache subtype, or when it should be added to physiotherapy management of headache.

Differences in musculoskeletal dysfunctions and in postural alterations between chronic migraine and chronic tension type headache: A cross-sectional study

OBJECTIVE

The aim of present study is to assess postural alterations and musculoskeletal dysfunctions over all spine in patients with chronic migraine and chronic tension type headache, moreover to highlight the differences between these two forms of primary headache.

METHODS

A Cross sectional study was adopted to evaluate the musculoskeletal profile in patients with chronic migraine and with chronic tension type headache. The Bio photogrammetric evaluation was performed using the postural assessment software PAS/SAPO, while unilateral passive accessory intervertebral motion (PAIMs) were applied for manual examinations of spine segments from C0 to L5 vertebra. The One-way Analysis of Variance (ANOVA) test was used to compare the three groups with the software GraphPad InStat 3.06.

RESULTS

A total of 60 patients were recruited, 20 for chronic tension type group, 20 for chronic migraine group and 20 healthy controls. The most interesting findings was that patients with chronic primary headaches presented postural alterations in all parameters (cranio-vertebral angle and lumbar-pelvic angle) and musculoskeletal dysfunctions in all spine with respect to healthy controls. Finally, the most clinically relevant finding was that no differences were found between chronic migraine and chronic tension type headache concerning the postural alterations nor the musculoskeletal dysfunctions.

CONCLUSION

The sensitization acts as a substrate or consequence of these musculoskeletal dysfunctions in chronic primary headache. Therefore, non-pharmacological treatments targeted in the musculoskeletal system may be a good option in the management of chronic primary headache, especially when these therapies integrate various techniques that involve all spine.

Proposal for a physiotherapy assessment form for the evaluation of women patients with uro-gynecological disorders: A Delphi study

BACKGROUND

The correct selection of treatment techniques and methods in physiotherapy depends directly on a well-structured anamnesis, examination and assessment. Within urogynecological and obstetric physiotherapy there is no standardized and protocolized assessment that allows to follow established steps. For all this, the main objective of this study was to identify the assessment items that should be included in the a physiotherapeutic uro-gynecological assessment.

METHODS

Delphi study through a group of experts. Prior to this, a systematic search was carried out, accompanied by a review of grey literature, to obtain the possible items to be included in the forms. Subsequently, a Delphi study with two consecutive rounds of questionnaires was developed. A total of 6 expert physiotherapists participated in the study.

RESULTS

The initial questionnaire had 97 items and after two rounds one item was eliminated to obtain a total of 96 items in the final questionnaire.

CONCLUSIONS

The experts agreed on most of the choices and finally obtained a standardized and protocolized assessment in uro-gynecological physiotherapy. Furthermore, this proposal should be considered by other professionals involved in the process of evaluation and treatment of pelvi-perineal alterations.

Inter-individual variability in mechanical pain sensation in patients with cervicogenic headache: an explorative study

Currently, evidence for effective physiotherapy interventions in patients with cervicogenic headache (CeH) is inconsistent. Although inter-individual variability in pain response is predictive for successful physiotherapy interventions, it was never explored in patients with CeH. Therefore the objective of the current study was to explore inter-individual variability in mechanical pain sensation, and its association with biopsychosocial-lifestyle (BPSL) characteristics in patients with CeH. A cross-sectional explorative analysis of inter-individual variability in mechanical pain sensation in 18 participants with CeH (29-51 years) was conducted. Inter-individual variability in mechanical pain sensation (standard deviations (SDs), F-statistics, Measurement System Analysis) was deducted from bilateral pressure pain thresholds of the suboccipitals, erector spine, tibialis anterior. BPSL-characteristics depression, anxiety, stress (Depression Anxiety Stress Scale-21), quality of life (Headache Impact Test-6), sleep-quality (Pittsburgh Sleep Quality Index), and sedentary time (hours/week) were questioned. Inter-individual variability in mechanical pain sensation explained 69.2% (suboccipital left), 86.8% (suboccipital right), 94.6% (erector spine left), 93.2% (erector spine right), 91.7% (tibialis anterior left), and 82% (tibialis anterior right) of the total variability in patients with CeH. The significant p-values and large F-statistic values indicate inter-individual differences in SDs. Significant associations between (1) lower quality of life and lower SDs of the suboccipital left PPT (p .005), and (2) longer sedentary time and higher SDs of the suboccipital left PPT (p .001) were observed. Results from our explorative study could suggest inter-individual variability in mechanical pain sensation at the left suboccipitals which associates with quality of life and sedentary time. These novel findings should be considered when phenotyping patients and 'individually' match interventions.

Translating the new International IFOMPT Cervical Framework into a framework flowchart for clinical practice and education

BACKGROUND

In 2020, a revised version of the International IFOMPT Cervical Framework was published. This framework provides both physical therapists and educators the necessary information to guide the assessment of the cervical spine region for potential vascular pathologies of the neck in advance of planned Orthopaedic Manual Therapy (OMT) interventions.

OBJECTIVE

The objective was to develop a framework flowchart which is useful in clinical practice and education to assist physical therapists to improve the safety of OMT, and apply this in a case report.

METHODS

The framework was developed in co-creation with manual therapy experts, researchers, educators in manual therapy, patients, medical specialists and the Manual Therapy Association in The Netherlands and Belgium. Manual therapists and patients tested the framework for intelligibility and usefulness.

RESULTS

A framework flowchart is developed and presented, that is easy to use in both clinical practice and education. It is a visual representation of the sequence of steps and decisions needed during the process. A case description of a patient with neck pain and headache is added to illustrate the clinical usefulness of the framework flowchart.

CONCLUSION

The framework flowchart helps physical therapists in their clinical reasoning to provide safe OMT interventions.

Effectiveness of spinal mobilization and postural correction exercises in the management of cervicogenic headache: A randomized controlled trial

OBJECTIVE

The study aims to assess the effect of spinal mobilization and postural correction exercises in patients suffering from cervicogenic headache.

METHODS

A randomized controlled trial was conducted with 72 patients. Patients were randomly allocated into three groups: spinal mobilization (n = 24), postural correction exercises (n = 24), and control group (n = 24). The primary outcome measure was headache impact test-6, and secondary outcomes were headache intensity, neck pain intensity, and neck pain-related disability measured at baseline, postintervention, and follow-up period.

RESULT

Comparison of baseline data (at 0 weeks) among groups showed a statistically nonsignificant difference. There was statistically significant improvement at postintervention (immediately after fourth week) in postural correction exercises group [headache disability: 14.95 ± 7.91 (p < .001); headache intensity: 2.58 ± 1.24 (p < .001); neck disability: 27.66 ± 18.71 (p < .001); neck pain: 1.91 ± 1.44 (p < .001)] and spinal mobilization group [headache disability: 13.83 ± 6.21 (p < .001); headache intensity: 2.29 ± 1.23 (p < .001); neck disability: 23.39 ± 19.51 (p < .001); neck pain: 1.72 ± 0.84 (p < .001)] as compared to the control group. The result of within-group analysis suggests that there was a statistically significant improvement in postintervention (immediately after fourth week) and follow-up (immediately after eighth week) scores as compared to baseline (at 0 weeks) scores for all outcomes in postural correction exercises [headache disability (p < .001), headache intensity (p < .001), neck disability (p < .001), neck pain (p < 0 .001)] as well as in spinal mobilization group [headache disability (p < .001), headache intensity (p < .001), neck disability (p < .001), neck pain (p < .001 for pre versus post; p = .001 for pre versus follow-up)]. There was a statistically nonsignificant difference between postintervention and follow-up scores of all the outcomes in the postural correction exercise and spinal mobilization group, which indicates that improvement in these groups was maintained during the follow-up period.

CONCLUSION

Spinal mobilization and postural correction exercises are effective in the management of cervicogenic headache.