Chiropractic spinal manipulative therapy for migraine: a study protocol of a single-blinded placebo-controlled randomised clinical trial

The effects of upper cervical spine manual therapy on central sensitization and brainstem auditory evoked potentials in subjects with migraine and neck pain

BACKGROUND

Migraine is an important disease due to its impact on global health. Due to association of neck pain with migraine, manual therapy (MT) often used in management. The aim of this study was to evaluate the effects of upper cervical spine MT on specific mechanisms including central sensitization (CS) and brainstem auditory evoked potentials (BAEPs) in subjects with migraine and neck pain.

METHODS

30 subjects with migraine and neck pain (30 female, mean age 43.10 ± 8.13) were randomly assigned to a medication plus MT (MedMT) group, a medication plus sham manual therapy (sham MT) group, and a medication alone (Med) group. CS was evaluated using the Central Sensitization Inventory (CSI) and BAEP determined electrophysiologically in all subjects pre and post intervention. Subjects in MedMT and sham MT groups received either 4 sessions of MT or sham MT. All subjects received medication.

RESULTS

Subjects in MedMT group had a significant reduction in CSI score (P < 0.05) compare to the other 2 groups. For BAEPs, MedMT and sham MT groups had significantly decreased wave V latency on the right side (P < 0.05) compared to Med group.

DISCUSSION

Manual therapy plus medication may have beneficial effects in people with migraine and neck pain by normalizing central sensitization levels. Additionally, upper cervical manual therapy or sham manual therapy have demonstrable neurophysiological effects reflected by changes in the auditory transmission pathways in the brainstem. Further research is required to investigate the mechanisms of action of MT in migraine.

Can upper cervical manual therapy affect the blink reflex in subjects with migraine and neck pain?

BACKGROUND

Neck pain is a common complaint among migraineurs possibly due to the anatomic connections between cervical and trigeminal afferents in the trigeminocervical complex (TCC). Manual therapy (MT) is used in the management of headache disorders, with demonstrable neurophysiological effects. The blink reflex (BR) is one method of analyzing neurophysiological effects in headache patients. The purpose of this study was to investigate the effect of upper cervical spine MT on BR in subjects with migraine and neck pain.

METHODS & MATERIALS

Twenty subjects were assigned to a medication plus MT (MedMT) group (n = 10) and medication plus sham MT (sham MT) group (n = 10). After random assignment, all patients underwent testing for the BR (R1, R2, R2c responses). Then, subjects in group MedMT and group sham MT received either 4 sessions of MT or sham MT to the upper cervical spine. After completion of the intervention, BR testing was repeated.

RESULTS

There were no significant differences in both side R1 latency between group MT and group sham MT (P > 0.050). For both sides, R2 latencies were significantly prolonged in MedMT group compared with sham MT group (P < 0.050). Subjects in MedMT group showed significant prolongation in right and left R2c latency compared with sham MT group (P < 0.050).

DISCUSSION

The present study demonstrated that upper cervical MT affected trigeminal nociceptive neurotransmission in subjects with migraine and neck pain as reflected by changes in the BR. The increase in BR late response latencies of BR indicates an inhibitory effect of upper cervical spine MT on the TCC in these subjects. Trial Registration: The trial design was registered at the Iranian Registry of Clinical Trials (IRCT ID: IRCT20160621028567N2, url: https://www.irct.ir/) before the first patient was enrolled.

Chiropractic spinal manipulative therapy for acute neck pain: A 4-arm clinical placebo randomized controlled trial. A prospective study protocol

INTRODUCTION

Neck pain poses enormous individual and societal costs worldwide. Spinal manipulative therapy and Non-Steroidal Anti-Inflammatory Drug treatment are frequently used despite a lack of compelling efficacy data. This protocol describes a multicentre 4-arm, clinical placebo randomized controlled trial (RCT), investigating the efficacy of chiropractic spinal manipulative therapy (CSMT) versus sham CSMT, ibuprofen, and placebo medicine for acute neck pain. This superiority study will employ parallel groups, featuring a 1:1:1:1 allocation ratio.

MATERIAL AND METHODS

We will randomize 320 participants equally into four groups: CSMT, sham CSMT, ibuprofen, or placebo medicine. CSMT groups are single-blinded, while the medicine groups are double-blinded. Data will be collected at baseline (Day 0), during treatment and post-treatment. The primary endpoint will assess the difference in mean pain intensity from Day 0 to Day 14 on a numeric rating scale 0-10; the CSMT group is compared to sham CSMT, ibuprofen, and placebo medicine groups, respectively. Secondary endpoints will assess mean pain intensity and mean duration at different time points, and adverse events, blinding success, and treatment satisfaction, including comparison between ibuprofen and placebo medicine. Power calculation is based on a mean neck pain rating of 5 at Day 0, with standard deviation of 1 in all groups. Mean pain reduction at Day 14 is expected to be 60% in the CSMT group, 40% in sham CSMT and ibuprofen groups, and 20% in the placebo medicine group. A linear mixed model will compare the mean values for groups with corresponding 95% confidence intervals. P values below 0.017 will be considered statistically significant. All analyses will be conducted blinded from group allocation.

DISCUSSION

This RCT aims towards the highest research standards possible for manual-therapy RCTs owing to its two placebo arms. If CSMT and/or ibuprofen proves to be effective, it will provide evidence-based support for CSMT and/or ibuprofen for acute neck pain.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT05374057. EU Clinical Trials Register: EudraCT number: 2021-005483-21.

Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases

BACKGROUND

Pain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery.

METHODS

In our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases.

RESULTS AND CONCLUSION

In this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

Adverse events in a chiropractic spinal manipulative therapy single-blinded, placebo, randomized controlled trial for migraineurs

BACKGROUND

Unlike pharmacological randomized controlled trials (RCTs), manual-therapy RCTs do not always report adverse events (AEs). The few manual-therapy RCTs that provide information on AEs are frequently without details, such as the type and-, severity of the AE and reason for withdrawal.

OBJECTIVE

To prospectively report all AEs in a chiropractic spinal manipulative therapy (CSMT) RCT.

DESIGN

A prospective 3-armed, single-blinded, placebo, RCT.

METHODS

Seventy migraineurs were randomized to the CSMT or a placebo, with 12 intervention sessions over three months. The recommendations by CONSORT and the International Headache Society's Task Force on AEs in migraine RCTs were followed. A standardized reporting scheme designed for pharmacological RCTs was used, and the AEs were described as frequencies and percentages within each group. The 95% confidence intervals (CIs) for the percentages (absolute risk) of AEs in each group were calculated when possible. Attributable risk (%) and relative risk were calculated with the corresponding 95% CIs.

RESULTS

AEs were assessed in 703 sessions, with 355 in the CSMT group and 348 in the placebo group. Local tenderness was the most common AE, reported by 11.3% and 6.9% of the CSMT group and the placebo group, respectively, and tiredness on the intervention day was reported by 8.5% and 1.4% of CSMT group and the placebo group, respectively. The highest attributable risk was for tiredness on the treatment day, 7.0% (CI 3.9-10.2%) which presented a relative risk of 5.9 (CI 2.3-15.0).

CONCLUSIONS

AEs were mild and transient, and severe or serious AEs were not observed.

Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial

Background and purpose

To investigate the efficacy of chiropractic spinal manipulative therapy (CSMT) for migraineurs.

Methods

This was a prospective three‐armed, single‐blinded, placebo, randomized controlled trial (RCT) of 17 months duration including 104 migraineurs with at least one migraine attack per month. The RCT was conducted at Akershus University Hospital, Oslo, Norway. Active treatment consisted of CSMT, whereas placebo was a sham push manoeuvre of the lateral edge of the scapula and/or the gluteal region. The control group continued their usual pharmacological management. The RCT consisted of a 1‐month run‐in, 3 months intervention and outcome measures at the end of the intervention and at 3, 6 and 12 months follow‐up. The primary end‐point was the number of migraine days per month, whereas secondary end‐points were migraine duration, migraine intensity and headache index, and medicine consumption.

Results

Migraine days were significantly reduced within all three groups from baseline to post‐treatment (P < 0.001). The effect continued in the CSMT and placebo group at all follow‐up time points, whereas the control group returned to baseline. The reduction in migraine days was not significantly different between the groups (P > 0.025 for interaction). Migraine duration and headache index were reduced significantly more in the CSMT than the control group towards the end of follow‐up (P = 0.02 and P = 0.04 for interaction, respectively). Adverse events were few, mild and transient. Blinding was strongly sustained throughout the RCT.

Conclusions

It is possible to conduct a manual‐therapy RCT with concealed placebo. The effect of CSMT observed in our study is probably due to a placebo response.