Study protocol: Accommodative effects on the musculoskeletal system

Accommodation is a phenomenon of the eyeball, which consists of adapting to view objects at different distances. The main aim of this study is to evaluate the effect of accommodations on the musculoskeletal system in myopic and emmetropic subjects. To date, the effect of accommodative paralysis on the musculoskeletal system has not been studied. The research hypothesis based on the current research reports is that accommodation affects the musculoskeletal system in myopic and emmetropic subjects. A smaller aim of the study is to evaluate the effect of unilateral accommodative palsy on the musculoskeletal system in myopic and emmetropic subjects. According to the authors of the previous reports, unilateral accommodative palsy will affect increased musculoskeletal asymmetry in myopic and emmetropic subjects. The surface electromyography (sEMG) of the musculoskeletal system will be performed by using the Noraxon Ultium DTS 8-K MR 3 myo Muscle Master Edition. Cycloftyal (10 mg/ml, eye drops, solution) will be used to paralyze accommodation. After the paralysis of unilateral accommodation, the test will be repeated. Both-sided accommodation will be paralyzed next, and the test will be repeated. The study may provide insight into the effects of accommodation on the musculoskeletal system, and it may also help in understanding the connections between these systems.

Headache frequency and neck pain are associated with trapezius muscle T2 in tension-type headache among young adults

BACKGROUND

Tension-type headache (TTH) is the most prevalent primary headache disorder. Neck pain is commonly associated with primary headaches and the trigemino-cervical complex (TCC) refers to the convergence of trigeminal and cervical afferents onto neurons of the brainstem, thus conceptualizes the emergence of headache in relation to neck pain. However, no objective biomarkers exist for the myofascial involvement in primary headaches. This study aimed to investigate the involvement of the trapezius muscles in primary headache disorders by quantitative magnetic resonance imaging (MRI), and to explore associations between muscle T2 values and headache frequency and neck pain.

METHODS

This cohort study prospectively enrolled fifty participants (41 females, age range 20-31 years): 16 subjects with TTH only (TTH-), 12 with mixed-type TTH plus migraine (TTH+), and 22 healthy controls (HC). The participants completed fat-suppressed T2-prepared three-dimensional turbo spin-echo MRI, a headache diary (over 30 days prior to MRI), manual palpation (two weeks before MRI), and evaluation of neck pain (on the day of MRI). The bilateral trapezius muscles were manually segmented, followed by muscle T2 extraction. Associations between muscle T2 and the presence of neck pain as well as the number of days with headache (considering the 30 days prior to imaging using the headache calendar) were analyzed using regression models (adjusting for age, sex, and body mass index).

RESULTS

The TTH+ group demonstrated the highest muscle T2 values (right side: 31.4 ± 1.2 ms, left side: 31.4 ± 0.8 ms) as compared to the TTH- group or HC group (p < 0.001). Muscle T2 was significantly associated with the number of headache days (β-coefficient: 2.04, p = 0.04) and the presence of neck pain (odds ratio: 2.26, p = 0.04). With muscle T2 as the predictor, the area under the curve for differentiating between HC and the TTH+ group was 0.82.

CONCLUSIONS

Increased T2 of trapezius muscles may represent an objective imaging biomarker for myofascial involvement in primary headache disorders, which could help to improve patient phenotyping and therapy evaluation. Pathophysiologically, the increased muscle T2 values could be interpreted as a surrogate of neurogenic inflammation and peripheral sensitization within myofascial tissues.

Masseter muscle contraction and cervical muscle sensitization by nerve growth factor cause mechanical hyperalgesia in masticatory muscle with activation of the trigemino-lateral parabrachial nucleus system in female rats

OBJECTIVE

To establish a new rat model of craniofacial myalgia, and to clarify which central nervous system pathways are activated in the model.

BACKGROUND

Craniofacial myalgia, represented by myogenous temporomandibular disorder and tension-type headache with pericranial tenderness, is more common in female patients. The pain is thought to be a type of multifactorial disorder with several coexisting causes. To our knowledge, there are no models of craniofacial muscle hyperalgesia caused by multiple types of stimuli.

METHODS

We injected nerve growth factor into the trapezius muscle of female and male rats and repeatedly stimulated the masseter muscle (MM) electrically for 10 days. We determined the mechanical head-withdrawal threshold of MM and extent of phosphorylated extracellular signal-related kinase 1/2 (pERK) immunoreactivity in various regions of the lower brainstem. We conducted retrograde tract-tracing to determine the projection of mechanosensitive MM-innervating secondary neurons to the lateral parabrachial nucleus. Finally, we administered morphine in rats to determine whether increases of pERK immunoreactivity were dependent on noxious inputs.

RESULTS

In female rats, but not male rats, the mechanical head-withdrawal threshold was decreased significantly from days 9 to 12. The number of pERK-immunoreactive neurons in the brainstem was increased significantly in female rats in the group with both stimuli compared to rats in other groups with a single stimulus. Mechanosensitive MM-innervating neurons in the brainstem projected to the parabrachial nucleus. Morphine administration blocked the increase in the number of pERK-immunoreactive neurons in both the brainstem and parabrachial nucleus.

CONCLUSIONS

We established a model of craniofacial myalgia by combining trapezius and MM stimuli in female rats. We found mechanical hyperalgesia of the MM and activation of the pain pathway from the brainstem to parabrachial nucleus. The model reflects the characteristics of patients with craniofacial myalgia and might be helpful to clarify the pathogenic mechanisms underlying these disorders.

The Role of the Autonomic Nervous System in Headache: Biomarkers and Treatment

Purpose of Review

In this review, the role of the autonomic nervous system in tension-type headache and migraine is reviewed.

Recent Findings

A pathophysiological model for tension-type headache is proposed that is compatible with most physiological and behavioral literature.

Summary

A treatment protocol is described that follows from this model. For migraine, incorporating autonomic factors into the pathophysiology offers rationales for behavioral interventions that have been shown to be useful in migraine treatment and a biofeedback protocol is proposed.

Ultrasound-guided 5-in-1 trigger point injection for treating tension-type headache: A case report

RATIONALE

Tension-type headache (TTH) is the most common type of primary headache, and trigger point injection (TPI) is frequently used for controlling pain originating from TTHs. In the current report, we introduce a TPI technique involving 4 neck muscles (upper trapezius, splenius capitis, semispinalis capitis, and inferior oblique capitis) and a greater occipital nerve (GON) block within the same sonographic view for the treatment of TTHs.

PATIENT CONCERNS

A 44-year-old woman complained with pressing and tightening, nonpulsating, recurrent headaches, mainly in the bilateral occipital area, lasting for approximately 6 months (numeric rating scale: 5). The patient had no nausea, vomiting, photophobia, or phonophobia.

DIAGNOSES

The patient was diagnosed as having a TTH.

INTERVENTIONS

Under ultrasound (US) guidance, a mixed solution of 2 mL of 2% lidocaine and 5 mL of normal saline was injected layer-by-layer into the 4 target muscles of the neck (upper trapezius, splenius capitis, semispinalis capitis, and inferior oblique capitis) and near the right GON within the same sonographic view bilaterally.

OUTCOMES

Two- and 4-week follow-ups after administration of the injections revealed no headache. Our US-guided 5-in-1 TPI technique is viable for treating patients with TTH.

LESSONS

We believe that it can aid in reducing the procedure time and associated pain.

Localization of the Center of the Intramuscular Nerve Dense Region of the Suboccipital Muscles: An Anatomical Study

Purpose

This study aimed to determine the body surface puncture position and depth of the center of the intramuscular nerve dense region in the suboccipital muscle to provide morphological guidance for accurate botulinum toxin A injection to treat headaches caused by increased suboccipital muscle tension.

Methods

Twenty-four cadavers aged 66.5 ± 5.3 years were studied. The curve line connecting occipital eminence or mastoid process and spinous process of the 7th cervical vertebrae was considered the longitudinal reference line (L) and horizontal reference line (H), respectively. Sihler's staining, barium sulfate labeling, and CT were employed. The body surface projection point of the center of the intramuscular nerve dense region was designated as P. The projection of the center of the intramuscular nerve dense region was in the opposite direction across the transverse plane and was recorded as P'. The intersections of the vertical line through point P and lines L and H were designated as P_L and P_H. The percentage position of the P_H and P_L points on the H and L lines and the depths of the center of intramuscular nerve dense regions were identified.

Results

Sihler's staining showed one intramuscular nerve-dense region in each suboccipital muscle. The P_H of the center of the intramuscular nerve dense region was located at 51.40, 45.55, 20.55, and 43.50%. The P_L was located at 31.38, 30.08, 16.91, and 52.94%. The depth of the center of the intramuscular nerve dense region was at 22.26, 22.54, 13.14, and 27.30%. These percentage values are all the means.

Conclusion

Accurately defining the body surface position and depth of the center of intramuscular nerve dense region in suboccipital muscles will help to improve botulinum toxin A to target localization efficiency for treating tension-type headache.

The Effect of Hamstring Relaxation Program on Headache, Pressure Pain Threshold, and Range of Motion in Patients with Tension Headache: A Randomized Controlled Trial

The purpose of this study was to determine if the severity of headache is reduced by decreasing hamstring tension in patients with tension headache. Thirty patients participated in this study. The participants were randomly allocated to two groups: hamstring relaxation program (HR) group (n = 15) and control group (n = 15). The participants in the HR group participated in a HR program for 25 min per day, three times per week, for a period of 4 weeks, and the control group participated in an electrotherapy for 25 min per day, three times per week, for a period of 4 weeks. Both groups participated in a self-myofacial release for 5 min per day, three times per week, for a period of 4 weeks. Headache was evaluated using the headache impact test (HIT-6) and visual analog scale (VAS). The pain pressure threshold (PPT) was evaluated using a digital pressure algometer. The range of motion (ROM) was evaluated using a goniometer and two special tests: straight leg raise test (SLRT) and popliteal angle test (PAT). The two groups showed no significant differences in terms of age, sex, height, and weight. The VAS and HIT-6 scores (p < 0.05) and neck and hamstring PPT showed significant improvements (p < 0.05). Neck flexion ROM and SLRT and PAT scores showed significant improvements (p < 0.05) in both groups, and the HR group showed significantly more improvements than the control group. This study confirmed that the HR program has positive effects on tension headache and is a good intervention for alleviating headaches in patients with tension headache.

A pilot study on non-invasive treatment of migraine: The self-myofascial release

The aims of this paper was to determine the effect of self-myofascial release (SMFR) on postural stability and to analyze if it can influence migraine condition. Twenty-five subjects (age 49.7± 12.5) affected by migraine were enrolled. Assessments included a stabilometric analysis in order to evaluate balance and plantar support, with eyes open (OE) and closed (CE); cervical ROM measurement; evaluation of upper limb strength through handgrip. All the analysis were carried out before and after the administration of a single SMFR protocol, using medium density small balls laid in the three most painful trigger points in migraine patients: trapezius, sternocleidomastoids and suboccipital muscles. Performing a T test for paired samples, there was a significant increase in two ranges of the stabilometric analysis: ellipse surface, both with open and closed eyes (p value EO = 0.05; p value EC = 0.04) and length of the sway path, but just with closed eyes (p value = 0.05). SMFR might have a positive impact on postural stability in subjects with migraine. Further investigation should be conducted to confirm the hypothesis.

Electromyographic Patterns of Masticatory Muscles in Relation to Active Myofascial Trigger Points of the Upper Trapezius and Temporomandibular Disorders

The presented study aimed to analyze and compare the electromyographic patterns of masticatory muscles in subjects with active myofascial trigger points (MTrPs) within upper trapezius, patients with temporomandibular disorders (TMDs) and healthy adults. Based on the diagnostic criteria of MTrPs according to Travell & Simons and the Research Diagnostic Criteria for Temporomandibular Disorders, 167 people were qualified for the study. Subjects were divided into 3 groups: with active MTrPs in the upper trapezius, with diagnosed temporomandibular disorders (TMDs) and healthy adults. Measurements of the bioelectric activity of the temporalis anterior (TA) and masseter muscle (MM) were carried out using the BioEMG III ™. Based on statistical analysis, significantly lower values of TA resting activity were observed among controls in comparison to MTrPs (1.49 μV vs. 2.81 μV, p = 0.00) and TMDs (1.49 μV vs. 2.97 μV, p = 0.01). The POC index values at rest differed significantly between MTrPs and TMDs (86.61% vs. 105%, p = 0.04). Controls presented different electromyographic patterns within AcI in comparison to both MTrPs (4.90 vs. −15.51, p = 0.00) and TMDs (4.90 vs. −16.49, p = 0.00). During clenching, the difference between MTrPs and TMDs was observed within MVC TA (91.82% vs. 116.98%, p = 0.02). TMDs showed differences within AcI in comparison to both MTrPs group (−42.52 vs. 20.42, p = 0.01) and controls (−42.52 vs. 3.07, p = 0.00). During maximum mouth opening, differences between MTrPs and TMDs were observed within the bioelectric activity of masseter muscle (16.45 μV vs. 10.73 μV, p = 0.01), AsI MM (0.67 vs. 11.12, p = 0.04) and AcI (13.04 vs. −3.89, p = 0.01). Both the presence of MTrPs in the upper trapezius and TMDs are related to changes in electromyographic patterns of masticatory muscles.

Integrative East-West Medicine Intervention for Chronic Daily Headache: A Case Report and Care Perspective

Chronic daily headache is a group of headache syndromes including most commonly chronic migraine and chronic tension-type headache, which often overlap, are complicated by medication overuse and are disabling, costly, and variable responsive to western pharmacotherapeutic interventions. There is growing research and awareness of integrative health approaches and therapies to address patients with chronic headache, yet limited examples of how to deliver this approach. This article reviews a commonly seen challenging case of a patient with overlapping chronic migraine and chronic tension-type headache complicated by medication overuse managed with an integrative east-west medicine intervention. This included person-centered biopsychosocial history taking, traditional Chinese medicine informed acupuncture, trigger point injections, and contributing factors modifications. A narrative review of the literature is presented to demonstrate an evidence-informed rationale for incorporating nonpharmacologic approaches to effectively help reduce the symptom burden of this patient population.

Remedial Massage Therapy Interventions Including and Excluding Sternocleidomastoid, Scalene, Temporalis, and Masseter Muscles for Chronic Tension Type Headaches: a Case Series

BACKGROUND

Tension-type headache (TTH) is the most prevalent primary headache type world-wide. Chronic TTH (CTTH) of >15 headache-affected days per month for > 3 months can cause considerable pain and disability.

PURPOSE

This case series aimed to investigate whether massage therapy interventions were more effective when muscles of the anterior neck, jaw, and cranium were included.

DESIGN

Four female clients suffering CTTH received six pre-determined massage therapy interventions, 45 minutes each, over three weeks. Case A and B (exclusion cases) received interventions addressing shoulder, posterior neck, and occiput muscles; Case C and D (inclusions cases) received interventions addressing the same areas as well as the sternocleidomastoid, scalene, temporalis, and masseter muscles.

INTERVENTION

Treatment included myofascial trigger point release, neuromuscular therapy, and consideration of central sensitization mechanisms present in CTTH.

OUTCOME MEASURES

Headache frequency (primary), intensity, and duration (secondary) were recorded via headache diaries for baseline measures (one week), interventions (three weeks), and a runout period (two weeks). Secondary measures also included a headache disability inventory (HDI) at baseline, intervention conclusion, and final measures. After final measures, clients received stretching education and four weeks later, a follow-up phone conversation to note subjective headache reports.

RESULTS

All cases had headache frequency and HDI score reductions, while intensity and duration measures fluctuated. At final measures, exclusion Case A and both inclusion cases (C and D) had headache frequency reductions to below CTTH diagnostic criteria, clinically meaningful (> 16%) HDI score reductions, and subjectively reported continued improvements after study completion. Inclusion cases overall had greater decreases in headache frequency and HDI measures.

CONCLUSION

Comparative results suggest there may be additional benefit in reducing headache frequency and disability with inclusion of anterior neck, jaw, and cranial muscles in treatment strategies of CTTH. However, limited sample size makes it difficult to rule out outliers or individual variables. Further investigation is recommended.

The effect of physiotherapy and acupuncture on psychocognitive, somatic, quality of life, and disability characteristics in TTH patients

Introduction

Nonpharmacological therapies have been widely used to treat tension-type headache (TTH); however, limited evidence exists with regards to their effectiveness. Therefore, the aim of the present study was to examine the combined effect of acupuncture, stretching, and physiotherapy (myofascial release techniques and microwave diathermy) on psychocognitive, somatic, quality of life, and disability characteristics in such patients.

Subjects and methods

Patients with TTH (n=44) performed either acupuncture or stretching (control group, n=20) or acupuncture, stretching, and physiotherapy (experimental group, n=24) during a 4-week intervention period including 10 treatment sessions. They were tested for the Greek version of the Short-Form McGill Pain Questionnaire, the Greek version of the Migraine Disability Assessment Questionnaire, the Greek version of the Hospital Anxiety and Depression Scale, Short Form Health Survey 12 9 (SF-12), and Pain Catastrophizing Scale at baseline after the fifth and tenth sessions.

Results

All measures were improved throughout the first to tenth session (P<0.05), though no significant differences were observed between the two groups (P>0.05).

Conclusion

In summary, a significant beneficial role of acupuncture, stretching, and physiotherapy on cognitive, psychosomatic pain measures, disability index, quality of life, and catastrophizing in patients with TTH was observed.

The effect of myofascial release and microwave diathermy combined with acupuncture versus acupuncture therapy in tension-type headache patients: A pragmatic randomized controlled trial

BACKGROUND AND PURPOSE

Nonpharmacological therapies for tension-type headache (TTH) and cervicogenic cephalalgia are often a treatment choice, despite the weak to moderate evidence. The aim of this study was to compare the effectiveness of an acupuncture/stretching protocol versus acupuncture/stretching plus physiotherapy techniques, in patients with TTH cephalalgia.

METHODS

A single-blind, prospective, multicentre, randomized controlled trial was designed considering the pragmatic situation of administering such protocols and treating the 44 headache patients participating in this study. The patients were randomly assigned in 2 treatment groups (control group, n = 20, acupuncture/stretching; experimental group, n = 24, acupuncture/stretching plus physiotherapy) and completed 10 treatment sessions within 4 weeks with measurements taking place before treatment, after the fifth treatment and after the 10th treatment. The mechanical pressure pain threshold (PPT) was considered as the main outcome measure, using a mechanical algometer to measure 7 bilateral somatic points. Acupuncture in both groups included 17-20 acupuncture points, whereas stretching was initially taught and subsequently self-administered (self-stretches), following a standardized set of movements of the cervical spine. Physiotherapy consisted of microwave diathermy and myofascial release with hands-on techniques.

RESULTS/FINDINGS

An improvement was noted in both groups/treatments regarding the main outcome measure PPT, all the way from the first to fifth and the 10th treatment, at all measuring sites and at all measurements in both groups (p < .001). When comparing the 2 groups, differences were noted after the 10th treatment (p < .05).

DISCUSSION

In conclusion, patients with TTH headache were benefited from acupuncture and stretching but further PPT improvements were evidenced when physiotherapy hands-on techniques were added. In clinical terms, the combination of physiotherapy in the form of myofascial release and microwave diathermy with acupuncture and stretching in order to improve the analgesic effect (PPT) is strongly recommended.

Inhibitory effect of high-frequency greater occipital nerve electrical stimulation on trigeminovascular nociceptive processing in rats

Electrical stimulation of the greater occipital nerve (GON) has recently shown promise as an effective non-pharmacological prophylactic therapy for drug-resistant chronic primary headaches, but the neurobiological mechanisms underlying its anticephalgic action are not elucidated. Considering that the spinal trigeminal nucleus (STN) is a key segmental structure playing a prominent role in pathophysiology of headaches, in the present study we evaluated the effects of GON electrical stimulation on ongoing and evoked firing of the dura-sensitive STN neurons. The experiments were carried out on urethane/chloralose-anesthetized, paralyzed and artificially ventilated male Wistar rats. Extracellular recordings were made from 11 neurons within the caudal part of the STN that received convergent input from the ipsilateral facial cutaneous receptive fields, dura mater and GON. In each experiment, five various combinations of the GON stimulation frequency (50, 75, 100 Hz) and intensity (1, 3, 6 V) were tested successively in 10 min interval. At all parameter sets, preconditioning GON stimulation (250 ms train of pulses applied before each recording) produced suppression of both the ongoing activity of the STN neurons and their responses to electrical stimulation of the dura mater. The inhibitory effect depended mostly on the GON stimulation intensity, being maximally pronounced when a stimulus of 6 V was applied. Thus, the GON stimulation-induced inhibition of trigeminovascular nociceptive processing at the level of STN has been demonstrated for the first time. The data obtained can contribute to a deeper understanding of neurophysiological mechanisms underlying the therapeutic efficacy of GON stimulation in primary headaches.

Physical therapy for headaches

Background Headache is the medical problem most commonly observed by neurologists. Non-pharmacological treatments are commonly demanded by individuals with headaches, but their evidence of effectiveness is conflicting. Aim The current review provides an updated discussion on what is supported by current scientific evidence about physical therapies for tension-type headache (TTH), migraine, and cervicogenic headache (CeH), and which gaps there still may be in our understanding of the interventions. Methods PubMed, MEDLINE, EMBASE, AMED, CINAHL, EBSCO, Cochrane Database of Systematic Reviews, Cochrane Collaboration Trials Register, PEDro, and SCOPUS were searched from their inception through March 2015. Results/Discussion Several physical therapies including spinal joint manipulation/mobilization, soft tissue interventions, therapeutic exercises and needling therapies are proposed to be effective for the management of headaches. Current evidence has shown that the effectiveness of these interventions will depend on proper clinical reasoning since not all interventions are equally effective for all headache pain conditions. For instance, evidence of physical therapy in migraine is more controversial than in TTH, since migraine pathogenesis involves activation of sub-cortical structures and the trigemino-vascular system, whereas pathogenesis of TTH is more associated with musculoskeletal disorders, e.g. muscle pain. It seems that multimodal approaches including different interventions are more effective for patients with TTH, migraine and CeH.

A novel way of functional retraining of cervical motor control in a water polo player with combined cervicogenic and tension type headaches

This case report introduces an innovative and novel way of functionally retraining the sport specific cervical function in a 13-year-old elite water polo player with a combined tension type headache and cervicogenic headache. After an evidence based assessment and manipulative physical therapy management regime, consisting of manual mobilization and exercise focused on retraining the deep cervical flexors and sub-occipital extensors, the patient was left with persistent residual complaints inhibiting competitive level sport participation. Re-assessment and subsequent retraining of a specific provocative functional task was facilitated by using the Cervical Trainer(™). Using a wireless sensor worn on the head, this device registers three-dimensional movement and displays this on a computer screen, providing direct feedback on movement performance. After a 6-week period of training sessions, the residual complaints subsided and her score on the Headache Impact Test-6 questionnaire improved from 51 to 36 signifying no impact of her headache on daily life activities.

Myofascial trigger point-focused head and neck massage for recurrent tension-type headache: a randomized, placebo-controlled clinical trial

OBJECTIVE

Myofascial trigger points (MTrPs) are focal disruptions in the skeletal muscle that can refer pain to the head and reproduce the pain patterns of tension-type HA (TTH). The present study applied massage focused on MTrPs of patients with TTH in a placebo-controlled, clinical trial to assess efficacy on reducing headache (HA) pain.

METHODS

Fifty-six patients with TTH were randomized to receive 12 massage or placebo (detuned ultrasound) sessions over 6 weeks, or to wait-list. Trigger point release massage focused on MTrPs in cervical musculature. HA pain (frequency, intensity, and duration) was recorded in a daily HA diary. Additional outcome measures included self-report of perceived clinical change in HA pain and pressure-pain threshold at MTrPs in the upper trapezius and suboccipital muscles.

RESULTS

From diary recordings, group differences across time were detected in HA frequency (P=0.026), but not for intensity or duration. Post hoc analysis indicated that HA frequency decreased from baseline for both massage (P<0.0003) and placebo (P=0.013), but no difference was detected between massage and placebo. Patient report of perceived clinical change was greater reduction in HA pain for massage than placebo or wait-list groups (P=0.002). Pressure-pain threshold improved in all muscles tested for massage only (all P's<0.002).

DISCUSSION

Two findings from this study are apparent: (1) MTrPs are important components in the treatment of TTH, and (2) TTH, like other chronic conditions, is responsive to placebo. Clinical trials on HA that do not include a placebo group are at risk for overestimating the specific contribution from the active intervention.

Trigger point injections for headache disorders: expert consensus methodology and narrative review

OBJECTIVE/BACKGROUND

To review the existing literature and describe a standardized methodology by expert consensus for the performance of trigger point injections (TPIs) in the treatment of headache disorders. Despite their widespread use, the efficacy, safety, and methodology of TPIs have not been reviewed specifically for headache disorders by expert consensus.

METHODS

The Peripheral Nerve Blocks and Other Interventional Procedures Special Interest Section of the American Headache Society over a series of meetings reached a consensus for nomenclature, indications, contraindications, precautions, procedural details, outcomes, and adverse effects for the use of TPIs for headache disorders. A subcommittee of the Section also reviewed the literature.

RESULTS

Indications for TPIs may include many types of episodic and chronic primary and secondary headache disorders, with the presence of active trigger points (TPs) on physical examination. Contraindications may include infection, a local open skull defect, or an anesthetic allergy, and precautions are necessary in the setting of anticoagulant use, pregnancy, and obesity with unclear anatomical landmarks. The most common muscles selected for TPIs include the trapezius, sternocleidomastoid, and temporalis, with bupivacaine and lidocaine the agents used most frequently. Adverse effects are typically mild with careful patient and procedural selection, though pneumothorax and other serious adverse events have been infrequently reported.

CONCLUSIONS

When performed in the appropriate setting and with the proper expertise, TPIs seem to have a role in the adjunctive treatment of the most common headache disorders. We hope our effort to characterize the methodology of TPIs by expert opinion in the context of published data motivates the performance of evidence-based and standardized treatment protocols.

Efficacy of manual therapy in the treatment of tension-type headache. A systematic review from 2000-2013

OBJECTIVES

To study the efficacy of manual therapy in the treatment of tension-type headache (TTH) by assessing the quality of randomized control trials (RCTs) published from the year 2000 to April 2013.

METHODS

A search was performed in the following databases: MEDLINE, EBSCO, CINAHL, SCOPUS, PEDRO and OVID. An analysis was made of RCT including patients with TTH receiving any manual therapy, and assessing outcome measures including the intensity, and frequency or duration of the headache. Two independent referees reviewed the methodological quality of RCTs using the Jadad scale. Data from the studies were extracted by two different reviewers.

RESULTS

A total of fourteen RCTs were selected. Twelve studies showed acceptable quality (Jadad scale ≥3), and the remaining 2 had low quality (Jadad=2). The studies showed positive results, including reduction in headache intensity and/or frequency, reduction of medication consumption, and improvement in quality of life.

CONCLUSIONS

The effectiveness of manual therapy for TTH cannot be completely assessed due to the heterogeneity in study design, outcome measures, and different treatments. Nevertheless, the results suggest patients with TTH receiving manual therapies showed better progress than those receiving conventional treatment or placebo. Further studies of high quality using manual therapy protocols, and also including standardized outcome measures, are now needed to clarify the efficacy of manual therapy in the management of TTH.

Myofascial trigger points and innervation zone locations in upper trapezius muscles

Background

Myofascial trigger points (MTrPs) are hyperirritable spots located in taut bands of muscle fibres. Electrophysiological studies indicate that abnormal electrical activity is detectable near MTrPs. This phenomenon has been described as endplate noise and it has been purported to be associated MTrP pathophysiology. Thus, it is suggested that MTrPs will be overlap the innervation zone (IZ). The purpose of this work was to describe the location of MTrPs and the IZ in the right upper trapezius.

Methods

We screened 71 individuals and eventually enrolled 24 subjects with neck pain and active MTrPs and 24 neck pain-free subjects with latent MTrPs. Surface electromyography (sEMG) signals were detected using an electrode matrix during isometric contraction of the upper trapezius. A physiotherapist subsequently examined the subject’s trapezius to confirm the presence of MTrPs and establish their location. IZ locations were identified by visual analysis of sEMG signals. IZ and MTrPs locations were described using an anatomical coordinate system (ACS), with the skin area covered by the matrix divided into four quadrants.

Results

No significant difference was observed between active and latent MTrPs locations (P = 0.6). Forty-five MTrPs were in the third quadrant of the ACS, and 3 were included in second quadrant. IZs were located approximately midway between the seventh cervical vertebrae and the acromial angle in a limited area in the second and third quadrants. The mean distance between MTrP and IZ was 10.4 ± 5.8 mm.

Conclusions

According to the acquired results, we conclude that IZ and MTrPs are located in well-defined areas in upper trapezius muscle. Moreover, MTrPs in upper trapezius are proximally located to the IZ but not overlapped.

Lidocaine injection of pericranial myofascial trigger points in the treatment of frequent episodic tension-type headache

Background

The present study aimed to evaluate the efficacy of local lidocaine injections into the myofascial trigger points (TPs) located at the pericranial muscles in patients with episodic tension-type headache (ETTH).

Methods

The study included 108 patients with frequent ETTH that were randomized into 4 groups. One injection of saline (NaCl 0.9%) was administered to group 1 (n = 27), 1 injection of lidocaine (0.5%) was administered to group 2 (n = 27), group 3 (n = 27) received 5 injections of saline (NaCl 0.9%), and group 4 (n = 27) received 5 injections of lidocaine (0.5%); on alternate days 2 mL for each muscle was injected into the frontal, temporal, masseter, sternocleidomastoid, semispinalis capitis, trapezius and splenius capitis muscles bilaterally. The frequency of painful days per month (FPD) and the patients’ visual analogue scales (VAS) were evaluated before treatment, and 2, 4 and 6 months after treatment.

Results

Mean age of the patients was 36.28 ± 9.41 years (range: 18–54 years). FPD scores improved significantly in group 2, 3 and 4 at 2 months posttreatment compared to pre- treatment (all P < 0.05), and also VAS scores improved significantly in group 2 and 4 at 2 months posttreatment (P < 0.05) but this improvement insisted at the 6 month only in group 4. Group 2 had better VAS and FPD than group 1 only at 2. and 4. months after treatment (for VAS P < 0.0121, P = 0.0232; for FPD P = 0.0003, P = 0.0004, respectively). Group 4 had better scores than group 3 at the 2., 4. and 6. months after treatment in both parameters (all P < 0.05). Group 2 had better scores than group 1 in FPD at the 2. and 4. months posttreatment (P = 0.0003, P = 0.0004, respectively), but not at the 6. month.

Conclusion

Local lidocaine injections into the myofascial TPs located in the pericranial muscles could be considered as an effective alternative treatment for ETTH.