Effect of Different Physical Therapy Approaches in Management of Migraine Headache

Transcription

1 Med. J. Cairo Univ., Vol. 83, No. 1, December: , Effect of Different Physical Therapy Approaches in Management of Migraine Headache MOSHIRA H. DARWISH, Ph.D.*; MOHAMED S. EL-TAMAWY, Ph.D.**; HALA R. EL-HAPASHI, Ph.D.*** and AYSHA S. EL-HOMRAN, M.Sc.* The Departments of Physical Therapy for Neuromuscular Disorder & its Surgery, Faculty of Physical Therapy*, Neurology**, Faculty of Medicine** and Neurophysiology, Faculty of Medicine***, Cairo University Abstract Introduction: Migraine is a very common primary headache disorder with no underlying identifiable pathological cause. Migraine affects 11% of the total adult population creating a significant socio-economic burden on society. Transcranial Magnetic Stimulation (TMS) is a non-invasive tool alter the excitability of the cerebral cortex, and intracortical inhibitory circuits. It is a therapeutic modality that is being developed as both an acute and preventive treatment for migraine. Manipulative therapy is program of soft tissue manipulation, balancing the body's central nervous system with the musculoskeletal system. It is based on neurological laws that explain how the central nervous system initiates and maintains pain. Purpose: This study aimed to determine and to investigate effect of different physical therapy approaches in the management of migraine headache. Methods: Thirty migraine patients participated in the study, their aged from 2-5, assigned into three equal groups (G1, G2 & G3). Treatment consisted of daily twelve low frequency (1Hz) rtms sessions, delivered to the group one and three over occipital lope. Sham rtms was used for the group two that is treated with manual therapy. Manual therapy also was delivered to G3. Pain intensity was measured with visual analogue scale before and after treatment. Results: Within each group: The G1 showed a statistical significant decrease in the mean value of VAS (p-value=.5). Also in G2, the mean value of VAS was significantly decreased at post-treatment (p-value=.5). The same findings were also recorded in G3, the mean value of VAS was decreased significantly (p-value=.4). The percentage of improvement in VAS was nearly similar in groups 1, 2 and 3 (68.54%, 65.96% and 71.58% respectively). Conclusion: In light of the findings yielded from this study, we can conclude that low-frequency rtms over occipital cortex is effective in improving migraine headache. But provided no additional benefit when compared to manipulative therapy alone, in the treatment of migraine headaches in adults. 115

2 116 Effect of Different Physical Therapy Approaches in Management of MH but can be proposed. Most of them, alone or in supplement to medicinal treatment, are particularly adapted to elderly patients and limit the need for drugs. The side effects and interactions of which may have severe consequences in fragile patients and those suffering from multiple diseases [5]. Among the medical devices with potential therapeutic use in migraine, Transcranial Magnetic Stimulation (TMS) offers substantial promise. Transcranial magnetic stimulation was first developed in 1985, and has been studied significantly since Strong evidence suggests that singlepulse TMS (stms) is an effective acute treatment for migraine with aura. Emerging evidence suggests that repetitive TMS (rtms) may have promise as a preventive treatment for migraine. Transcranial magnetic stimulation also has been examined as a diagnostic tool and as a treatment for an array of other neurological and psychiatric disorders. The clinical applications of TMS exploit the fact that a fluctuating magnetic field applied to the surface of the scalp noninvasively generates electrical changes in the underlying cerebral cortex [6]. The aim of the study was to determine and to investigate the effects of different physical therapy approaches in the management of migraine headache. Patients and Methods Patients: Thirty patients from both sexes diagnosed as having migraine headache. All the patients were selected from out-patient clinic of Neurology Department of Cairo University (Kasr El-Aini) Hospital from June 214 to June 215. Their ages ranged from 2 to 5 years. The patients were assigned into three equal groups: Group one (G1): Treated by rtms. Group two (G2): Treated by manual therapy program which consist of trigger point compression, and myofascial release and Placebo rtms. Group three (G3): Trea-ted by rtms in addition to manual therapy program which consist of, trigger point compression and myofascial release. Participants met the following inclusion criteria: 1- Patients with migraine headache without aura. 2- Age of patients ranges from 2 to 5 years. 3- Duration of headache pain is more than three months. 4- The patients were referred from neurologist. 5- Computed tomography Scan (CTS) or MRI were done to exclude secondary causes of migraine. 6- Migraine is diagnosed clinically when the patient meet at least five headache attacks that lasted 4-72 hours (untreated or unsuccessfully treated) and that the headache must have had at least two of the following characteristics: Unilateral location, pulsating quality, moderate or severe pain intensity and aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs). During the headache the patient must have had at least one of the following: Nausea and/or vomiting, photophobia and phonophobia, these features must not have been attributable to another disorder. The patients were excluded if they had one of the following conditions or diseases: 1- Patients with neurological diseases. 2- Epileptic patients or family history of epilepsy. 3- Patients with infections. 4- Patients with neoplasm. 5- Patients who had pacemaker. 6- Patients with intracranial metal objects. 7- Pregnant women. 8- Patients with other causes of headache. 9- Patients with abnormal CT or MRI. Instruments: A- Assessment instruments: Neurocare Centre Pain Management Headache Assessment: Was used as general clinical evaluation sheet. Visual Analogue Scale (VAS): Was used to assess the severity of pain. It consists of a line, usually 1cm long, whose ends are labeled as the extremes of pain. Radiological assessment: Computed Tomography (CT) and/or Magnetic Resonance Image (MRI) of the brain were done to exclude secondary causes of headache and so supporting the clinical diagnosis of migraine headache. B- Treatment instruments: Transcranial Magnetic Stimulation (TMS) is a device for gently stimulating the brain. It utilizes a specialized electromagnet placed on the patient's scalp that generates short magnetic pulses, roughly the strength of an MRI scanner's magnetic field but much more focused. The magnetic pulses pass easily through the skull just like the MRI scanner fields do, but because they are short

3 Moshira H. Darwish, et al. 117 pulses and not a static field, they can stimulate the underlying cerebral cortex (brain). Low frequency (once per second) TMS has been shown to induce reductions in brain activation while stimulation at higher frequencies (>5 pulses per second) has been shown to increase brain activation. It has also been shown that these changes can last for periods of time after stimulation is stopped. The system comprises: Magstim Air cooled Double 7mm Stimulating Coil (164-), Coil Stand (1261-), Vacuum Unit (1618-). Procedure: A- Assessment procedure: Visual Analog Scale: Pain intensity of each patient was assessed by VAS before starting treatment (first session) and at the end of all sessions after twelve sessions. The VAS consists of a line, usually ten cm long, whose ends are labeled as the extremes of pain (e.g., no pain to unbearable pain) [7]. Fig. (1). Each patient was asked to place a mark at the point on the line which best represent their experience of pain between "no pains" to "worst pain No pain Maximum pain Fig. (1): Visual analogue scale. B- Treatment procedure: The protocol application of rtms: A low-frequency rtms with magstim rapid magnetic stimulator (Magstim Company, Whitland, Wales, UK), connected with a figure-of-eight coil with a diameter of 7mm in diameter. The patients were seated in a chair that allowed them to keep their arms and hands relaxed. Determination of motor threshold: The motor threshold was determined in all patients before first session, using single-pulse stimulation over the primary motor cortex at the hot point of first dorsal interosseus muscle. The motor threshold was defined as lowest intensity required to elicit a motor evoked potential in 5%of successive trials or to produce a visible movement of the thumb, wrist or fingers in at least half of 1 stimulations in a fully relaxed muscle [8]. Patients of the study group received twelve sessions of low frequency rtms, delivered daily,

4 118 Effect of Different Physical Therapy Approaches in Management of MH Results Demographic of the patients in the studied groups: The age of G1 ranged from 2 to 5 years with a mean age (±SD) of 32.6±8.86. The age of G2 ranged from 25 to 5 years with a mean age (±SD) of 33.4±7.99. The age of G3 ranged from 2 to 47 years with a mean age (±SD) of 32.1±7.92 [(Table 1) & Fig. (2)]. They were 23 females (76.7%) and 7 males (23.3%) with male to female ratio of 1: 3.2. [(Table 1) & Fig. (3)]. Table (1): Demographic features of the three studied groups. Items Group one (G1) Group two (G2) Group three (G3) F- value p - value Age (years): Min.-max (NS) Mean ± SD 32.6± ± ± Gender:.29* Female 5 (5%) 1 (1%) 8 (8%) 2= X Male 5 (5%) (%) 2 (2%) 7.81 Data are expressed as mean ± SD or number (%). X 2 : Chi square test. Age (yrs.) Fig. (2): Mean values of age in the three studied groups. Percentage of pain intensity % Female Male Fig. (3): Gender distribution in the three studied groups. The mean values of VAS pre-and post-treatment in the three studied groups (G1, G2 & G3). Pre-treatment, there was no statistical significant difference between mean value of VAS in G1 (8.9±1.2), G2 and (9.4±1.8) G3 (9.5±.97) with Chi square value=2.262 and p-value=.322. Also at post-treatment, there was no statistical significant difference between mean value of VAS in G1 (2.8 ±1.81), G2 (3.2±1.75) and G3 (2.7 ±1.57) with Chi square value=.474 and p-value =.789 [(Table 2) & Fig. (4)]. Table (2): The mean value of VAS pre-and post-treatment treatment in the three studied groups (G1, G2 & G3). Items Group one (G1) Group two (G2) Group three (G3) x 2 value p-value Pre-treatment 8.9± ± ± (NS) Post-treatment 2.8± ± ± (NS) NS: p>.5 = Not Significant. χ 2 : Kruskal Wallis test.

5 Moshira H. Darwish, et al. 119 Mean value of VAS Pre-treatment Post-treatment Fig. (4): The mean values of VAS pre-and post-treatment in the three studied groups (G1, G2 & G3). The mean values of VAS pre-and post-treatment in each study group: In G1, there was a statistical significant decrease in the mean value of VAS measured post-treatment (2.8±1.81) when compared with its corresponding level at pre-treatment (8.9±1.2) (Z-value= 2.82 and p-value=.5). Also in G2, the mean value of VAS was significantly decreased at post-treatment (3.2±1.75) when compared with its corresponding level at pre-treatment (9.4±1.8) (Zvalue= and p-value=.5) [(Table 3) & Fig. (5)]. The same findings were also recorded in G3, the mean value of VAS measured post-treatment (2.7±1.57) was significantly decreased when compared with its corresponding level at pretreatment (9.5±.97) (Z-value= and p- value=.4). The percentage of improvement in VAS was nearly similar in groups 1, 2 and 3 (68.54%, 65.96% and 71.58% respectively) [(Table 3) & Fig. (6)]. Table (3): The mean values of VAS in in each study group. Items Group one (G1) Group two (G2) Group three (G3) Pre-treatment 8.9± ± ±.97 Post-treatment 2.8± ± ±1.57 Difference % improvement Z-value p-value.5**.5**.4** NS : p>.5 = Not Significant. ** : p<.1 = Highly significant. Z-test: Wilcoxon Signed Ranks test. Mean value of VAS Pre-treatment Post-treatment Fig. (5): The mean values of VAS pre-and post-treatment in each study group. Percentage of improvement % Fig. (6): Percentage of improvement in VAS in the three studied groups (G1, G2 & G3). Discussion Migraine is usually managed by medication, but some patients do not tolerate acute and/or prophylactic medicine due to side effects, or contraindications due to co-morbidity of myocardial disorders or asthma among others. Some patients wish to avoid medication for other reasons. Nonpharmacological management such as massage, physiotherapy and chiropractic may be an alternative treatment option. Massage therapy in Western cultures uses classic massage, trigger points, myofascial release and other passive muscle stretching among other treatment techniques which are applied to abnormal muscle tissue [1]. The age of the patients in this study ranged from 2 to 5 years. This is consistent with the prevalence of migraine in the age range of years [11].

6 12 Effect of Different Physical Therapy Approaches in Management of MH The results of the study showed improvement in the three studied groups. In TMS Group (G1) there was a significant improvement. The theoretical mechanism of the improvement is based on decreasing the cortical hyper-excitability in the visual cortex as the hyper-excitability is the main cause of the migraine. A low phosphene threshold is considered expression of visual cortex hyperexcitability, so in the present study, 1HZ rtms applied on visual cortex to increase Phosphene Threshold (PT) and decrease visual cortex hyperexcitability. Repetitive transcranial magnetic stimulation gives the opportunity to modify the activity of cortical neurons locally and non-invasively. These findings are in agreements with the results of Clark et al., Young et al., and Mulleners et al., [12-14]. In agreement with the study, the using of 1Hz rtms over primary visual cortex not over vertex as in study for Teepker et al., [15] who concluded that the application of of1hz rtms over vertex not effective for migraine prophylaxis. High frequency rtms applied on the left Dorsolateral Prefrontal Cortex (DLPFC) was effective in improving migraine patients. Dorsolateral prefrontal cortex seems to exert an inhibitory effect on pain perception by playing a negative modulation of central supraspinal pain pathways [16,17]. This could seem in contrast with our results, as we used low frequency rtms that is known to have inhibitory effects on visual cortex hyper-excitability. In the manipulative Group (G2), there was significant improvement. The use of manual therapy as a treatment for headaches is predicated upon the impairment of Diffuse Noxious Inhibitory Controls (DNIC). This impairment is a contributing factor in the etiology of migraine headaches. So the aim of the manual therapy was activation of DNIC. Pain modulatory systems subserving diffuse noxious inhibitory controls is mediated by a loop established by the spino-bulbospinal circuit, producing a post-synaptic inhibitory system that acts directly on spinal and trigeminal wide-dynamicrange neurons. Diffuse noxious inhibitory controls can be activated by stimuli that are not painful, as in the present study with manual therapy. These finding are compatible with Piovesan et al., [18] who found that massage over different regions of the skin produce scarce results in a good or excellent pain control. The results are greatly consistent with that obtained by Lawler & Cameron, [19] and Dogniez et al., [2]. In addition, the improvement could be explained by an increase in the plasma beta-endorphin concentrations, which has been proposed in a study was done by Maigne et al. [21]. In G3 also there was significant improvement. The efficacy of manual therapy and TMS in the prevention of migraine was for the combination effects of the inhibitory control produced by DNIC acts specifically on spinal and trigeminal (WDR) neurons and decreasing of primary visual cortex hyperexitability of brain. Conclusion: In light of the findings yielded from this study, we can conclude that low-frequency rtms over occipital cortex is effective in improving migraine headache. But provided no additional benefit when compared to manipulative therapy alone, in the treatment of migraine headaches in adults. References 1- FARINELLI I. and DIONISI I.: Rehabilitating chronic migraine complicated by medication overuse headaches: How can we prevent migraine relapse. Intern. Emerg. Med., 6 (1): 23-8, MILHAUD D., BOGOUSSLAVSKY J., VAN MELLE G. and LIOT P.: Ischemic stroke and active migraine. 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