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A 34-year-old woman presented to the clinic
for moderate bilateral headaches (at least 4-5 days a week), deep burning
sensation and neck pain that she was experiencing for more than 11 months.
Although the symptoms were not worsened with rigorous activity, she had
experienced increased sensitivity to light. She had consumed over-the-counter
pain relievers, but there was no relief. The patient weighed 60 kg that was
appropriate for her height (BMI <23; indicating normal height-weight
balance). Around three years ago, she was treated with methocarbamol plus
acetylsalicylic acid and NSAIDs, had no improvement in the symptoms. Moreover,
her symptoms were slightly relieved after manual therapy, but had the short
term effects.
The most likely
diagnosis of this presentation is
Tension type headache (TTH) is the most
common headache; affecting 0.5 to 4.8 % of the
worldwide population. It shares quite similar clinical features of
common manifestations of muscle referred pain. The severity of TTH may vary
from episodic/ moderate to chronic. Episodic TTH exhibits
higher levels of peripheral excitability whereas chronic TTH clearly shows
central sensitization manifestations. Although the
corresponding mechanism remains unclear, increased peripheral levels of
pro-inflammatory cytokines may act as mediators of several chronic pain
disorders. Moreover, Domingues RB, et al found that interleukin-8 was increased
and monocyte chemoattractant protein-1 was higher in patients with TTH,
suggesting that pro-inflammatory mechanisms may participate
in TTH pathophysiology. Understanding
the possible triggers in TTH, muscle hyperalgesia, and widespread pain
sensitization, may help to develop better management regimes and possibly
prevent TTH from developing into more chronic conditions. Cumulative evidences
suggest a combination of manual therapy (MT) and therapeutic exercise as an
effective measure in reducing the medication intake and minimizing the
frequency and intensity of headaches.
Multimodal physical rehabilitation therapy combining therapeutic patient education, manual therapy and motor control therapeutic exercises provided significant symptomatic relief in the patient presented with CTTH.
A general physical examination revealed a forward
head posture and pain during cervical extension and lateral bending and the
ranges of cervical motion were normal. In addition, stiffness and limited
cervical accessory mobility were observed and manual palpation indicated the
presence of myofascial trigger points in the neck muscles. The assessment of
neck flexor endurance (isometrically and against gravity) using the neck flexor
muscle endurance test showed moderate reliability with a time endurance of
24.1±12.8 seconds for neck pain.
The treatment
aimed to regain and maintain mobility to the cervical vertebrae and to relax
the neck muscles. To achieve the treatment goals, a multimodal physical
rehabilitation approach, including manualf therapy, motor control therapeutic
exercise (MCTE) and therapeutic patient education was undertaken. The first two
weeks of treatment involved total four sessions, two sessions a week, followed
by one session of 45 minutes a week.
Therapeutic patient education involved five interactive sessions lasting
for 15 minutes each. These sessions included talks supported by the
presentations conveying the importance of good ergonomics, self-treatment
approaches (including stretching, auto-traction, diaphragmatic breathing and
relaxation techniques), the neurophysiological bases of pain and the importance
of the patient’s involvement in the treatment. The MCTE was taught in the
clinic and advised to practice at home. The MCTE approach included,
craniocervical flexors exercise, co-contraction of the flexors and extensors
and a synergy exercise to retain the strength of the superficial and deep
flexor. Total eleven sessions of
treatment including manual therapy, motor control therapeutic exercise (MCTE)
and therapeutic patient education (TPE) were applied in 72 days.
Therapeutic
management of TTH should involve a multimodal approach including pharmacological
and non-pharmacological interventions to reduce the symptoms. The ideal
treatment approach aims to reduce the number of TTH attacks, and prevent or
delay the progression. In
recent years, non-pharmacological treatment approaches have been preferred over
pharmacological treatments, as effective alternative interventions.
The present case
was successfully evaluated and treated with multimodal therapy based on a
biobehavioral approach. Pain catastrophizing refers to a cognitive factor that
implies an exaggeration of the perceived threat of either a real or anticipated
pain experience. This psychological construct is linked to motor disturbances,
such as reduced function, impaired quality of life, impaired of exercise
capacity, increased recovery time, disability and higher drug intake. Evidences
have proved the importance of increased neck flexor endurance in patients with
CTTH.
Espí-López GV and colleagues revealed
that although individual manual therapy treatments impose a positive
change in headache features, measures of photophobia, photophobia and
pericranial tenderness can only be improved by combining the treatments
suggesting that combined treatment is the most appropriate for symptomatic
relief of TTH.
In the present
case, a multimodal physical approach based on a biobehavioral approach,
combining manual therapy, TPE and MCTE, resulted in a substantial reduction in
pain severity, pain catastrophizing, disability and improved overall quality of
life.
A multimodal physical approach based on a biobehavioral
approach, combining manual therapy, TPE and MCTE, can lead to a substantial
reduction in pain severity, pain catastrophizing, disability and improve
overall quality of life.
Anesth Pain Med. 2015 Dec; 5(6): e32697.
Multimodal Physiotherapy Based on a Biobehavioral Approach as a Treatment for Chronic Tension-Type Headache: A Case Report
Hector Beltran-Alacreu et al.
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