Effects of combining manual therapy, neck muscle exercises, and therapeutic education pain neuroscience in patients with migraine: a 3-armed randomized clinical trial

Author(s)

Gabriella de Almeida Tolentino

• Document type: Doctoral Thesis
• Press: Ribeirão Preto.
• Institution: Universidade de São Paulo (USP). Faculdade de Medicina de Ribeirão Preto (PCARP/BC)
• Defense date: 2024-11-18

Examining board members

Debora Bevilaqua Grossi; Marisa de Cássia Registro Fonseca; Daniella Araújo de Oliveira

• Advisor: Debora Bevilaqua Grossi; Lidiane Lima Florencio

Abstract

Physical therapy represents a non-pharmacological approach for the management of migraine, with the potential to improve clinical outcomes in patients. However, the comparative efficacy of a multimodal approach-combining manual therapy, specific cervical exercises, and therapeutic education in pain neuroscience-versus the isolated use of these techniques has not yet been established. Objective: This randomized clinical trial aims to evaluate the efficacy of a multimodal protocol in comparison to the isolated use of manual therapy or pain neuroscience education in patients with migraine. Methods: A three-arm, parallel, single-blind, randomized clinical trial was conducted, with a 12-week treatment protocol. Participants were evaluated at three time points: at the baseline, during treatment (at weeks 4, 8, and 12), and after treatment (at follow-up assessments conducted at 1-, 2-, and 4-months post-treatment). Participants were randomized into three groups: Pain Neuroscience Education Group (TEG, n=25); Manual Therapy Group (MTG, n=25); and Multimodal Group (MUG, n=25). The primary outcome was the Headache Impact Test (HIT-6&trade;). Secondary outcomes included headache frequency, intensity, and duration; neck pain frequency, intensity, and duration; Neck Disability Index (NDI); 12-item Allodynia Symptom Checklist (ASC-12); Tampa Scale for Kinesiophobia (TSK); Pain Catastrophizing Scale (PCS); European Quality of Life Five Dimension with Five Levels (EQ-5D-5L); Dizziness Handicap Inventory (DHI); Patient Global Impression of Change Scale (PGIC); neck joint palpation; cervical pressure pain threshold (PPT); cervical range of motion (ROM); cervical muscle strength; Flexion Rotation Test (FRT); and Craniocervical Flexion Test (CCFT). Mixed models were used in SPSS to analyze group effects, time effects, and group-time interactions, with a significance level of 0.05. Results: Significant improvements in HIT-6 scores were observed in all groups over time (p<0.001). The MUG demonstrated greater improvement in headache impact compared to the MTG at follow-up. Similarly, the TEG showed greater improvement compared to the MTG at the end of treatment. Significant grouptime interactions, indicating favorable outcomes for the multimodal treatment, were noted for headache frequency and intensity, neck pain frequency, ASC-12, NDI, EQ-5D-5L, and FRT (group-time interaction; p < 0.01). Clinically relevant changes were observed in NDI, PCS, and EQ-5D-5L in all groups, in ASC-12 in the MUG and MTG groups, and in TSK only in the TEG. Conclusion: The multimodal treatment demonstrated superior results in reducing the impact of headaches in patients with migraine. Although all groups showed improvement in headache impact over time, the multimodal approach proved more effective in reducing migraine frequency and intensity, allodynia, cervical disability, catastrophizing, and in improving quality of life and upper cervical mobility. (AU)

• FAPESP's process: 20/10091-7 - Effect of manual therapy associated with neck muscle exercise program and pain education in patients with migraine: a 3-armed randomized clinical trial
• Grantee: Gabriella de Almeida Tolentino
• Support Opportunities: Scholarships in Brazil - Doctorate (Direct)