Does physical activity and inflammation mediate the job stress-headache relationship? A sequential mediation analysis in the ELSA-Brasil study

BACKGROUND

Evidence indicates that physical activity reduces stress and promote a myriad of health-enhancing effects through anti-inflammatory mechanisms. However, it is unknown whether these mechanisms interfere in the association between psychosocial job stress and headache disorders.

OBJECTIVE

To test whether physical activity and its interplay with the systemic inflammation biomarkers high-sensitivity C-reactive protein (hs-CRP) and acute phase glycoproteins (GlycA) would mediate the associations between job stress and headache disorders.

METHODS

We cross-sectionally evaluated the baseline data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) regarding job stress (higher demand and lower control and support subscales), migraine and tension-type headache (ICHD-2 criteria), self-reported leisure-time physical activity, and plasma hs-CRP and GlycA levels. Conditional process analyses with a sequential mediation approach were employed to compute path coefficients and 95 % confidence intervals (CI) around the indirect effects of physical activity and biomarkers on the job stress-headache relationship. Separate models were adjusted for sex, age, and depression and anxiety. Further adjustments added BMI smoking status, and socioeconomic factors.

RESULTS

In total, 7,644 people were included in the study. The 1-year prevalence of migraine and tension-type headache were 13.1 % and 49.4 %, respectively. In models adjusted for sex, age, anxiety, and depression, the association between job stress (lower job control) and migraine was mediated by physical activity [effect = -0.039 (95 %CI: -0.074, -0.010)] but not hs-CRP or GlycA. TTH was associated with higher job control and lower job demand, which was mediated by the inverse associations between physical activity and GlycA [Job Control: effect = 0.0005 (95 %CI: 0.0001, 0.0010); Job Demand: effect = 0.0003 (95 %CI: 0.0001, 0.0007]. Only the mediating effect of physical activity in the job stress-migraine link remained after further adjustments including socioeconomic factors, BMI, smoking, and the exclusion of major chronic diseases.

CONCLUSION

In the ELSA-Brasil study, physical activity reversed the link between job stress and migraine independently of systemic inflammation, while the LTPA-mediated downregulation of GlycA was associated with lower job stress-related TTH.

Resistance Exercise Minimal Dose Strategies for Increasing Muscle Strength in the General Population: an Overview

Many individuals do not participate in resistance exercise, with perceived lack of time being a key barrier. Minimal dose strategies, which generally reduce weekly exercise volumes to less than recommended guidelines, might improve muscle strength with minimal time investment. However, minimal dose strategies and their effects on muscle strength are still unclear. Here our aims are to define and characterize minimal dose resistance exercise strategies and summarize their effects on muscle strength in individuals who are not currently engaged in resistance exercise. The minimal dose strategies overviewed were: "Weekend Warrior," single-set resistance exercise, resistance exercise "snacking," practicing the strength test, and eccentric minimal doses. "Weekend Warrior," which minimizes training frequency, is resistance exercise performed in one weekly session. Single-set resistance exercise, which minimizes set number and session duration, is one set of multiple exercises performed multiple times per week. "Snacks," which minimize exercise number and session duration, are brief bouts (few minutes) of resistance exercise performed once or more daily. Practicing the strength test, which minimizes repetition number and session duration, is one maximal repetition performed in one or more sets, multiple days per week. Eccentric minimal doses, which eliminate or minimize concentric phase muscle actions, are low weekly volumes of submaximal or maximal eccentric-only repetitions. All approaches increase muscle strength, and some approaches improve other outcomes of health and fitness. "Weekend Warrior" and single-set resistance exercise are the approaches most strongly supported by current research, while snacking and eccentric minimal doses are emerging concepts with promising results. Public health programs can promote small volumes of resistance exercise as being better for muscle strength than no resistance exercise at all.

Inter-rater reliability, discriminatory and predictive validity of neck movement control tests in office workers with headache and/or neck pain

BACKGROUND

Movement control tests (MCTs) are clinical tests to evaluate impairment of movement and associated neuromuscular control and are commonly used to evaluate people with neck pain or headache conditions. The aim of this study was to establish inter-rater reliability as well as discriminatory and predictive validity for seven MCTs of the upper (UCS) and lower cervical spine (LCS) in office workers with headache or neck pain.

METHODS

Seven MCTs of the UCS (3) and LCS (4) were performed at baseline on 140 office workers which were included in a cluster randomized controlled trial. The occurrences of headache and neck pain were established at baseline (discriminatory validity) and at a 15-month follow-up (predictive validity). Inter-rater-reliability was established in a separate cross-sectional study.

RESULTS

MCTs showed slight to almost perfect inter-rater reliability but limited discriminatory (baseline) and limited to small predictive validity (15-month follow up) for different subgroups of office workers with headache and/or neck pain. MCTs of the UCS showed limited discriminatory validity, especially for rotation in participants with headache and neck pain compared to those with headache only (Negative Likelihood-ratio: 0.82, 95% CI: 0.69-0.98). Participants with neck pain only and ≥1/4 positive MCTs for the sagittal plane had an increased risk for future neck pain (Relative risk: 3.33, 95% CI: 1.05-10.56).

DISCUSSION

MCTs of the UCS and LCS are reliable but have only limited to small validity to predict future headache events in office workers. Insufficient sagittal plane movement control may predict neck pain relapses in the future.

Manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education for patients with tension-type headache. A systematic review and meta-analysis

Background

Tension-type headache (TTH) has been ranked the second most prevalent health condition worldwide. Non-pharmacological treatments for TTH are widely used as a supplement or an alternative to medical treatment. However, the evidence for their effects are limited. Therefore, the aim of this study was to review the evidence for manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture and patient education as treatments for TTH on the effect of headache frequency and quality of life.

Methods

A systematic literature search was conducted from February to July 2020 for clinical guidelines, systematic reviews, and individual randomised controlled trials (RCT). The primary outcomes measured were days with headache and quality of life at the end of treatment along with a number of secondary outcomes. Meta-analyses were performed on eligible RCTs and pooled estimates of effects were calculated using the random-effect model. The overall certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach (GRADE). In addition, patient preferences were included in the evaluation.

Results

In all, 13 RCTs were included. Acupuncture might have positive effects on both primary outcomes. Supervised physical activity might have a positive effect on pain intensity at the end of treatment and headache frequency at follow-up. Manual joint mobilisation techniques might have a positive effect on headache frequency and quality of life at follow-up. Psychological treatment might have a positive effect on stress symptoms at the end of treatment. No relevant RCTs were identified for patient education. The overall certainty of evidence was downgraded to low and very low. No serious adverse events were reported. A consensus recommendation was made for patient education and weak recommendations for the other interventions.

Conclusion

Based on identified benefits, certainty of evidence, and patient preferences, manual joint mobilisation techniques, supervised physical activity, psychological treatment, acupuncture, and patient education can be considered as non-pharmacological treatment approaches for TTH. Some positive effects were shown on headache frequency, quality of life, pain intensity and stress symptoms. Few studies and low sample sizes posed a challenge in drawing solid conclusions. Therefore, high-quality RCTs are warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01298-4.

Effectiveness of Exercise and Manual Therapy as Treatment for Patients with Migraine, Tension-Type Headache or Cervicogenic Headache: An Umbrella and Mapping Review with Meta-Meta-Analysis

The aim of the study was to perform a mapping and umbrella review with meta-meta-analysis (MMA) to synthesise and critically evaluate the effectiveness of manual therapy (MT) and aerobic exercise (AE) in relation to pain intensity, frequency, disability and quality of life in patients with migraines, tension-type headaches (TTH) and cervicogenic headaches (CGH). A systematic search was conducted in PubMed, PEDro, Scielo and Google Scholar up to December 2020. A total of 18 articles met the inclusion criteria, and only 8 were included in the quantitative analysis. The MMA showed results in favour of the interventions in terms of pain intensity and quality of life in migraine, TTH and CCH. Data were also in favour of the intervention in terms of pain frequency in migraine and in terms of disability in TTH. However, there were no significant effects on pain frequency in TTH and CGH. The results showed moderate evidence to suggest that AE reduces pain intensity in patients with migraine. In addition, the evidence in favour of MT or a mixed intervention (including therapeutic exercise) was also moderate in terms of reducing pain intensity in patients with TTH.

Association Between Trapezius Muscle Tenderness and Tension-Type Headache in Female Office Workers: A Cross-sectional Study

OBJECTIVE

The purpose of the study was to determine the association between trapezius muscle tenderness and tension-type headache among female office workers.

METHODS

Through a questionnaire survey, 256 female office workers with tension-type headaches reported the level of palpable tenderness ("no," "some," or "severe tenderness") in the trapezius muscle. The number of days with headache ("0-7," "8-14," or ">14"), intensity ("low," "moderate," or "high"), duration of headache ("<8 hours per day," ">8 hours per day," and "all day"), and use of analgesic medications were reported. Odds ratio (OR) for tenderness in the trapezius muscle ("no/some" vs "severe tenderness") as a function of days with headache, intensity of headache, duration of headache, and use of analgesic medications were calculated using a binary logistic regression controlling for age and body mass index.

RESULTS

After adjustments for confounders, a strong association was found between the level of trapezius muscle tenderness and intensity of headache (moderate intensity, OR 2.45; 95% confidence interval [CI] 1.08-5.54; high intensity, OR 7.51 [95% CI 2.65-21.29]) and days with headache (>14 days, OR 4.75 [95% CI 1.41-15.89]). No association was observed for duration of headache or use of analgesic medications.

CONCLUSIONS

For the participants studied, there was a strong association between trapezius muscle tenderness and the level of intensity and the number of days with a headache among female office workers. No association was seen for duration of headaches or use of analgesic medications.

Neck/shoulder function in tension-type headache patients and the effect of strength training

Introduction

Muscle pain has been associated with reduced maximal muscle strength, and reduced rate of force development (RFD). Strength training (ST) has shown an effect in not only normalizing muscle function but also reducing neck muscle pain.

Aim

The aims of this study were to compare muscle function in terms of strength, force steadiness in neck flexion, as well as extension, and rate of RFD of the shoulder in tension-type headache (TTH) patients and healthy controls and to examine the correlation to tenderness. Furthermore, the aim of the study was to examine the effect of ST on neck and shoulder functions in TTH patients.

Participants and methods

In all, 60 TTH patients and 30 sex- and age-matched healthy controls were included for a case–control comparison. The 60 patients with TTH were randomized into an ST and an ergonomic and posture correction (EP) control group. The ST group trained for 10 weeks with elastic bands.

Results

TTH patients had a lower extension force steadiness with a significant 15% higher coefficient of variation (CoV) compared to healthy controls (p=0.047). A significantly lower RFD (25%) was noted in the TTH group than in the healthy controls (p=0.031). A significant (p<0.01) and moderate correlation to muscle tenderness was found. In the intervention, 23 patients completed ST and 21 patients completed EP. No significant between-group effect was observed, but at 22 weeks follow-up, both groups had a significant within-group effect of improved extension force steadiness (ST: p=0.011 and EP: p<0.01).

Conclusion

TTH patients showed a deteriorated muscle function, indicated by a lower force steadiness and RFD, compared to the healthy controls. The effect of ST was not larger than EP as both groups of TTH patients showed some improvement in neck and shoulder functions during the 10 weeks intervention and at follow-up. Future interventions are needed to elucidate if normalization of muscle function can lead to a reduction in headache.

Effect of resistance training on headache symptoms in adults: Secondary analysis of a RCT

BACKGROUND

While strength training for the neck and shoulder muscles may be effective in reducing headache, the optimal combination of exercise frequency and duration is unknown. This study investigates the effect of different time-wise combinations of one weekly hour of strength training for the neck and shoulder muscles on headache frequency, intensity, and use of analgesics.

METHODS

A total of 573 office workers were randomly allocated at the cluster-level to five groups; 3 × 20 min a week of minimally supervised (3MS), 1 × 60 (1WS), 3 × 20 (3WS) or 9 × 7 (9WS) min a week of supervised high-intensity strength training for 20 weeks, or to a reference group without training (REF). Headache frequency, intensity, and use of analgesics in relation to headache were determined by questionnaire at baseline and follow-up.

RESULTS

The intention-to-treat analysis showed reduced headache frequency and intensity of approximately 50% in all training groups compared with REF at 20-week follow-up (P < 0.001). Use of analgesics was lower in the supervised training groups (1WS, 3WS and 9WS), but not in the group with minimal training supervision (3MS), compared with REF at follow-up.

CONCLUSION

One hour of specific strength training - regardless of the distribution during the week - effectively reduced both headache frequency and intensity in office workers. Thus, a large time-wise flexibility exists when implementing specific strength training at the workplace. However, only supervised training led to a reduction in use of analgesics for headache.

Efficacy of strength training on tension-type headache: A randomised controlled study

Background Strength training has shown effects in reducing neck pain. As neck pain is highly prevalent in tension-type headache (TTH), it is relevant to examine the effect of strength training of the shoulder muscles on TTH patients. Aim To examine the effect of strength training of the shoulder/neck muscles on TTH frequency and duration. Methods Sixty patients with TTH were randomised into strength training or a control group. The strength training group trained ten weeks with elastic resistance bands. The control group performed ergonomic and posture correction. Efficacy was evaluated at follow-up after 19-22 weeks. Results Twenty-three patients completed strength training and 21 completed ergonomic and posture correction (per-protocol). No between-group effect was detected, but within groups numerical reductions were noted in both groups from baseline to follow-up. Frequency of TTH in the strength training group decreased by 11% ( P = 0.041) and duration decreased by10% ( P = 0.036), while the ergonomic and posture correction group showed a significant reduction in frequency of 24% ( P = 0.0033) and a decrease in duration of 27% ( P = 0.041). Conclusion No significant difference between the groups was found and the within-group effects did not reach clinical significance. Combining all the elements into a multifaceted intervention could prove more useful and should be further explored in future studies. Clinical trials registration number NCT02984826.

Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain

Background

The prevalence of migraine with co-existing tension-type headache and neck pain is high in the general population. However, there is very little literature on the characteristics of these combined conditions. The aim of this study was to investigate a) the prevalence of migraine with co-existing tension-type headache and neck pain in a clinic-based sample, b) the level of physical activity, psychological well-being, perceived stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain compared to healthy controls, c) the perceived ability of persons with migraine and co-existing tension-type headache and neck pain to perform physical activity, and d) which among the three conditions (migraine, tension-type headache or neck pain) is rated as the most burdensome condition.

Methods

The study was conducted at a tertiary referral specialised headache centre where questionnaires on physical activity, psychological well-being, perceived stress and self-rated health were completed by 148 persons with migraine and 100 healthy controls matched by sex and average age. Semi-structured interviews were conducted to assess characteristics of migraine, tension-type headache and neck pain.

Results

Out of 148 persons with migraine, 100 (67%) suffered from co-existing tension-type headache and neck pain. Only 11% suffered from migraine only. Persons with migraine and co-existing tension-type headache and neck pain had lower level of physical activity and psychological well-being, higher level of perceived stress and poorer self-rated health compared to healthy controls. They reported reduced ability to perform physical activity owing to migraine (high degree), tension-type headache (moderate degree) and neck pain (low degree). The most burdensome condition was migraine, followed by tension-type headache and neck pain.

Conclusions

Migraine with co-existing tension-type headache and neck pain was highly prevalent in a clinic-based sample. Persons with migraine and co-existing tension-type headache and neck pain may require more individually tailored interventions to increase the level of physical activity, and to improve psychological well-being, perceived stress and self-rated health.

Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015

BACKGROUND

Conventional management for concussion involves prescribed rest and progressive return to activity. Recent evidence challenges this notion and suggests that active approaches may be effective for some patients. Previous concussion consensus statements provide limited guidance regarding active treatment.

OBJECTIVE

To describe the current landscape of treatment for concussion and to provide summary agreements related to treatment to assist clinicians in the treatment of concussion.

METHODS

On October 14 to 16, 2015, the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion meeting was convened in Pittsburgh, Pennsylvania. Thirty-seven concussion experts from neuropsychology, neurology, neurosurgery, sports medicine, physical medicine and rehabilitation, physical therapy, athletic training, and research and 12 individuals representing sport, military, and public health organizations attended the meeting. The 37 experts indicated their agreement on a series of statements using an audience response system clicker device.

RESULTS

A total of 16 statements of agreement were supported covering (1) Summary of the Current Approach to Treating Concussion, (2) Heterogeneity and Evolving Clinical Profiles of Concussion, (3) TEAM Approach to Concussion Treatment: Specific Strategies, and (4) Future Directions: A Call to Research. Support (ie, response of agree or somewhat agree) for the statements ranged from to 97% to 100%.

CONCLUSION

Concussions are characterized by diverse symptoms and impairments and evolving clinical profiles; recovery varies on the basis of modifying factors, injury severity, and treatments. Active and targeted treatments may enhance recovery after concussion. Research is needed on concussion clinical profiles, biomarkers, and the effectiveness and timing of treatments.

ABBREVIATIONS

ARS, audience response systemCDC, Centers for Disease Control and PreventionDoD, Department of DefensemTBI, mild traumatic brain injuryNCAA, National Collegiate Athletic AssociationNFL, National Football LeagueNIH, National Institutes of HealthRCT, randomized controlled trialRTP, return to playSRC, sport- and recreation-related concussionTBI, traumatic brain injuryTEAM, Targeted Evaluation and Active Management.

Effectiveness of preventive and treatment interventions for primary headaches in the workplace: A systematic review of the literature

Aim The purpose of this systematic literature review is to assess the benefits of workplace-based occupational therapies and interventions, including acute and preventive medication, on headache intensity and frequency, related disability as well as work-related outcomes. Methods A search of the literature was conducted in PubMed, MEDLINE, Cochrane library, CINAHL and Embase using terms related to headache, workplace and occupational health. The Cochrane Collaboration's risk of bias assessment tool was used on individual studies to assess internal validity and the Grading of Recommendations Assessment, Development, and Evaluation system was applied to studies by clinical outcome and used to rate quality of evidence. Results Fifteen articles were included in the systematic review. None of them were classified as low risk of bias according to the Cochrane Collaboration's tool for assessing risk of bias. This systematic review found preliminary low-quality evidence suggesting that exercise and acupuncture can reduce workers' headache pain intensity, frequency and related disability. Conclusion Although this systematic review provided preliminary low evidence in favour of work-based intervention, studies with more rigorous designs and methodologies are needed to provide further evidence of the effectiveness of workplace-based headache management strategies.

Specific strength training compared with interdisciplinary counseling for girls with tension-type headache: a randomized controlled trial

BACKGROUND

Childhood tension-type headache (TTH) is a prevalent and debilitating condition for the child and family. Low-cost nonpharmacological treatments are usually the first choice of professionals and parents. This study examined the outcomes of specific strength training for girls with TTH.

METHODS

Forty-nine girls aged 9-18 years with TTH were randomized to patient education programs with 10 weeks of strength training and compared with those who were counseled by a nurse and physical therapist. Primary outcomes were headache frequency, intensity, and duration; secondary outcomes were neck-shoulder muscle strength, aerobic power, and pericranial tenderness, measured at baseline, after 10 weeks intervention, and at 12 weeks follow-up. Health-related quality of life (HRQOL) questionnaires were assessed at baseline and after 24 months.

RESULTS

For both groups, headache frequency decreased significantly, P=0.001, as did duration, P=0.022, with no significant between-group differences. The odds of having headache on a random day decreased over the 22 weeks by 0.65 (0.50-0.84) (odds ratio [95% confidence interval]). For both groups, neck extension strength decreased significantly with a decrease in cervicothoracic extension/flexion ratio to 1.7, indicating a positive change in muscle balance. In the training group, shoulder strength increased $10% in 5/20 girls and predicted [Formula: see text] increased $15% for 4/20 girls. In the training group, 50% of girls with a headache reduction of $30% had an increase in [Formula: see text] >5%. For the counseling group, this was the case for 29%. A 24-month follow-up on HRQOL for the pooled sample revealed statistically significant improvements. Fifty-five percent of the girls reported little to none disability.

CONCLUSION

The results indicate that both physical health and HRQOL can be influenced significantly by physical exercise and nurse counseling. More research is needed to examine the relationship between physical exercise, [Formula: see text], and TTH in girls. Thus, empowering patient education to promote maximum possible outcomes for all children needs more attention.

Exercises for mechanical neck disorders: A Cochrane review update

BACKGROUND

Neck pain (NP) is disabling and costly.

OBJECTIVES

To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality of life (QoL) and global perceived effect (GPE) in adults with NP.

METHODS

We searched computerised databases up to May 2014 for randomized controlled trials (RCTs) comparing exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radiculopathy. Two reviewers independently conducted selection, data abstraction and assessed risk of bias. Meta-analyses were performed to establish pooled standardised mean differences (SMDp). The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body of evidence.

MAIN RESULTS

The following exercises (27 trials) were supported by 'Moderate GRADE' evidence: For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp -0.45 [95%CI: -0.72 to -0.18]) and function improvement; 4) cervico-scapulothoracic strengthening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp -14.90 [95%CI: -22.40 to -7.39]). 5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST). For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure biofeedback for small/moderate improvement of pain, function and GPE (IP/LT).

AUTHORS' CONCLUSIONS

Specific strengthening exercises of the neck, scapulothoracic and shoulder for chronic NP and chronic CGH are beneficial. Future research should explore optimal dosage.

Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

PURPOSE

To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches).

METHODS

We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles.

RESULTS

We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful.

CONCLUSIONS

The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy.

Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis

AIM

We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH).

METHODS

We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality.

RESULTS

Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH ( ITALIC! p < 0.0001; mean reduction -1.11 on a 0-10 visual analog scale (VAS); 95% CI -1.64 to -0.57) and CGH ( ITALIC! p = 0.0002; mean reduction -2.52 on a 0-10 VAS; 95% CI -3.86 to -1.19) pain intensity, CGH frequency ( ITALIC! p < 0.00001; mean reduction -1.34 days per month; 95% CI -1.40 to -1.28), and migraine ( ITALIC! p = 0.0001; mean reduction -22.39 hours without relief; 95% CI -33.90 to -10.88) and CGH ( ITALIC! p < 0.00001; mean reduction -1.68 hours per day; 95% CI -2.09 to -1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity ( ITALIC! p < 0.00001; mean reduction -1.94 on a 0-10 VAS; 95% CI -2.61 to -1.27) and frequency ( ITALIC! p < 0.00001; mean reduction -9.07 days per month; 95% CI -9.52 to -8.62).

DISCUSSION

Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

Headache in sports

Sports- and exercise-related headaches are not unusual. Despite their frequent occurrence in this context, there are little epidemiologic data concerning sports-related headache. The recent attention of concussive injuries and associated post-traumatic headache has renewed interest in the study of those headaches occurring after head trauma; however, any primary headache type can also occur in the setting of contact and/or collision sports. The nonspecific nature of headaches provides unique challenges to clinicians encountering this complaint. It is, therefore, imperative that physicians treating athletes are able to distinguish the various headache types and presentations often seen in this population.

Exercises for mechanical neck disorders

BACKGROUND

Neck pain is common, disabling and costly. Exercise is one treatment approach.

OBJECTIVES

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

MAIN RESULTS

Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

AUTHORS' CONCLUSIONS

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

Ask the Experts: Chronic neck pain: risk factors, consequences and solutions

Lars L Andersen, MSc PhD, is Professor of Musculoskeletal Disorders at National Research Centre for the Working Environment in Copenhagen (Denmark). With a background in exercise physiology, he has a special interest in the effect of strength training on health, performance and disease. Currently, he performs epidemiological and interventional research primarily in the field of musculoskeletal disorders, but also in psychosocial work environment, behavioral psychology, stroke, early aging, physical activity and workplace health promotion. He has led several research projects and published more than 90 original articles with peer-review in international journals. He is an editorial board member of BMC Musculoskeletal Disorders, Journal of Aging and Health and ISRN Pain. His research on treatment of musculoskeletal disorders using strength training and kettlebell training has been highlighted in the media, for example, by USA Today, the New York Times and Reuters.

Lasting effects of workplace strength training for neck/shoulder/arm pain among laboratory technicians: natural experiment with 3-year follow-up

Objectives. This study investigated long-term effects and implementation processes of workplace strength training for musculoskeletal disorders. Methods. 333 and 140 laboratory technicians from private and public sector companies, respectively, replied to a 3-year follow-up questionnaire subsequent to a 1-year randomized controlled trial (RCT) with high-intensity strength training for prevention and treatment of neck, shoulder, and arm pain. Being a natural experiment, the two participating companies implemented and modified the initial training program in different ways during the subsequent 2 years after the RCT. Results. At 3-year follow-up the pain reduction in neck, shoulder, elbow, and wrist achieved during the first year was largely maintained at both companies. However, the private sector company was rated significantly better than the public sector company in (1) training adherence, (2) training culture, that is, relatively more employees trained at the workplace and with colleagues, (3) self-reported health changes, and (4) prevention of neck and wrist pain development among initially pain-free employees. Conclusions. This natural experiment shows that strength training can be implemented successfully at different companies during working hours on a long-term basis with lasting effects on pain in neck, shoulder, and arm.

Effect of training supervision on effectiveness of strength training for reducing neck/shoulder pain and headache in office workers: cluster randomized controlled trial

Objective. To investigate the effect of workplace neck/shoulder strength training with and without regular supervision on neck/shoulder pain and headache among office workers. Method. A 20-week cluster randomized controlled trial among 351 office workers was randomized into three groups: two training groups with the same total amount of planned exercises three times per week (1) with supervision (3WS) throughout the intervention period, (2) with minimal supervision (3MS) only initially, and (3) a reference group (REF). Main outcome is self-reported pain intensity in neck and shoulder (scale 0–9) and headache (scale 0–10). Results. Intention-to-treat analyses showed a significant decrease in neck pain intensity the last 7 days in 3MS compared with REF: −0.5 ± 0.2 (P < 0.02) and a tendency for 3WS versus REF: −0.4 ± 0.2 (P < 0.07). Intensity of headache the last month decreased in both training groups: 3WS versus REF: −1.1 ± 0.2 (P < 0.001) and 3MS versus REF: −1.1 ± 0.2 (P < 0.001). Additionally, days of headache decreased 1.0 ± 0.5 in 3WS and 1.3 ± 0.5 in 3MS versus REF. There were no differences between the two training groups for any of the variables. Conclusion. Neck/shoulder training at the workplace reduced neck pain and headache among office workers independently of the extent of supervision. This finding has important practical implications for future workplace interventions.

Implementation of specific strength training among industrial laboratory technicians: long-term effects on back, neck and upper extremity pain

BACKGROUND

Previous studies have shown positive effects of physical exercise at the workplace on musculoskeletal disorders. However, long-term adherence remains a challenge. The present study evaluates long-term adherence and effects of a workplace strength training intervention on back, neck and upper extremity pain among laboratory technicians.

METHODS

Cluster-randomized controlled trial involving 537 industrial laboratory technicians. Subjects were randomized at the cluster level to one of two groups: training group 1 (TG1, n = 282) performing supervised strength training from February to June 2009 (round one) or training group 2 (TG2, n = 255) performing supervised strength training from August to December 2009 (round two). The outcome measures were changes in self-reported pain intensity (0-9) in the back, neck and upper extremity as well as Disability of the Arm, Shoulder and Hand (DASH, 0-100).

RESULTS

Regular adherence, defined as at least one training session per week, was achieved by around 85% in both groups in the supervised training periods. In the intention-to-treat analyses there were significant group by time effects for pain in the neck, right shoulder, right hand and lower back and DASH-resulting in significant reductions in pain (mean 0.3 to 0.5) and DASH (mean 3.9) in the scheduled training group compared to the reference group. For TG1 there were no significant changes in pain in round two, i.e. they maintained the pain reduction achieved in round one. Subgroup analyses among those with severe pain (> = 3 on a scale of 0-9) showed a significant group by time effect for pain in the neck, right shoulder, upper back and lower back. For these subgroups the pain reduction in response to training ranged from 1.1 to 1.8.

CONCLUSIONS

Specific strength training at the workplace can lead to significant long-term reductions in spinal and upper extremity pain and DASH. The pain reductions achieved during the intensive training phase with supervision appears to be maintained a half year later.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear.

OBJECTIVES

To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

Computerized searches were conducted up to February 2012.

SELECTION CRITERIA

We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses.

MAIN RESULTS

Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.