The Role of Manual Therapies in the Treatment of Headache Disorders

PURPOSE OF REVIEW

A comprehensive headache treatment plan typically requires both medication and non-medication treatment strategies. Manual therapies offer another therapeutic approach to headache treatment. This article reviews the evidence for manual therapies in the treatment of headache disorders.

RECENT FINDINGS

Current evidence shows potential benefit from myofascial trigger point injections, myofascial release, and massage for the treatment of various headache types. There is also evidence for strain counterstrain technique, ischemic compression, and spinal manipulative therapies for cervicogenic headache. Although larger randomized clinical trials are necessary for many of these modalities, recent findings show that manual therapies could be an important tool for the treatment of some headache disorders.

Eagle's syndrome, elongated styloid process and new evidence for pre-manipulative precautions for potential cervical arterial dysfunction

INTRODUCTION

Safety with upper cervical interventions is a frequently discussed and updated concern for physical therapists, chiropractors and osteopaths. IFOMPT developed the framework for safety assessment of the cervical spine, and this topic has been discussed in-depth with past masterclasses characterizing carotid artery dissection and cervical arterial dysfunction. Our masterclass will expand on this information with knowledge of specific anatomical anomalies found to produce Eagle's syndrome, and cause carotid artery dissection, stroke and even death. Eagle's syndrome is an underdiagnosed, multi-mechanism symptom assortment produced by provocation of the sensitive carotid space structures by styloid process anomalies. As the styloid traverses between the internal and external carotid arteries, provocation of the vessels and periarterial sympathetic nerve fibers can lead to various neural, vascular and autonomic symptoms. Eagle's syndrome commonly presents as neck, facial and jaw pain, headache and arm paresthesias; problems physical therapists frequently evaluate and treat.

PURPOSE

This masterclass aims to outline the safety concerns, assessment and management of patients with Eagle's syndrome and styloid anomalies. By providing evidence of this common anomaly found in almost one-third of the population, hypothesis generation and clinical reasoning with patients presenting with head and neck symptoms can improve.

IMPLICATIONS

Including styloid anomalies as potential hypotheses for patients with head and neck complaints can assist therapists in safe practice and expedite referral. The authors recommend updating the IFOMPT framework to incorporate Eagle's syndrome, a comprehensive autonomic assessment, and palpation of the stylohyoid complex to avoid potentially serious complications from conceivably hazardous interventions.

The risk associated with spinal manipulation: an overview of reviews

BACKGROUND

Spinal manipulative therapy (SMT) is a widely used manual treatment, but many reviews exist with conflicting conclusions about the safety of SMT. We performed an overview of reviews to elucidate and quantify the risk of serious adverse events (SAEs) associated with SMT.

METHODS

We searched five electronic databases from inception to December 8, 2015. We included reviews on any type of studies, patients, and SMT technique. Our primary outcome was SAEs. Quality of the included reviews was assessed using a measurement tool to assess systematic reviews (AMSTAR). Since there were insufficient data for calculating incidence rates of SAEs, we used an alternative approach; the conclusions regarding safety of SMT were extracted for each review, and the communicated opinion were judged by two reviewers independently as safe, harmful, or neutral/unclear. Risk ratios (RRs) of a review communicating that SMT is safe and meeting the requirements for each AMSTAR item, were calculated.

RESULTS

We identified 283 eligible reviews, but only 118 provided data for synthesis. The most frequently described adverse events (AEs) were stroke, headache, and vertebral artery dissection. Fifty-four reviews (46%) expressed that SMT is safe, 15 (13%) expressed that SMT is harmful, and 49 reviews (42%) were neutral or unclear. Thirteen reviews reported incidence estimates for SAEs, roughly ranging from 1 in 20,000 to 1 in 250,000,000 manipulations. Low methodological quality was present, with a median of 4 of 11 AMSTAR items met (interquartile range, 3 to 6). Reviews meeting the requirements for each of the AMSTAR items (i.e. good internal validity) had a higher chance of expressing that SMT is safe.

CONCLUSIONS

It is currently not possible to provide an overall conclusion about the safety of SMT; however, the types of SAEs reported can indeed be significant, sustaining that some risk is present. High quality research and consistent reporting of AEs and SAEs are needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015030068 .

Beliefs and practice patterns in spinal manipulation and spinal motion palpation reported by canadian manipulative physiotherapists

PURPOSE

This practice survey describes how Fellows of the Canadian Academy of Manipulative Physiotherapy (FCAMPT) use spinal manipulation and mobilization and how they perceive their competence in performing spinal assessment; it also quantifies relationships between clinical experience and use of spinal manipulation.

METHODS

A cross-sectional survey was designed based on input from experts and the literature was administered to a random sample of the FCAMPT mailing list. Descriptive (including frequencies) and inferential statistical analyses (including linear regression) were performed.

RESULTS

The response rate was 82% (278/338 eligible FCAMPTs). Most (99%) used spinal manipulation. Two-thirds (62%) used clinical presentation as a factor when deciding to mobilize or manipulate. The least frequently manipulated spinal region was the cervical spine (2% of patients); 60% felt that cervical manipulation generated more adverse events. Increased experience was associated with increased use of upper cervical manipulation among male respondents (14% more often for every 10 years after certification; β, 95% CI=1.37, 0.89-1.85, p<0.001) but not among female respondents. Confidence in palpation accuracy decreased in lower regions of the spine.

CONCLUSION

The use of spinal manipulation/mobilization is prevalent among FCAMPTs, but is less commonly used in the neck because of a perceived association with adverse events.

Complementary medicine and safety: a systematic investigation of design and reporting of systematic reviews

OBJECTIVES

The objective of this study was to examine the methods used in systematic reviews of safety across a range of complementary therapies to assess the variation in approach and the potential for developing guidance on conduct and reporting.

DESIGN

Systematic reviews focusing on safety were retrieved from NHS Evidence and searches of major databases. A pre-prepared template was used for data extraction. Information extracted included details of search strategies, sources, participants, interventions, reported adverse event/effect(s) and causality assessment. Data extraction was carried out by one researcher and a check for accuracy by a second researcher. Methods were assessed against criteria based on guidance provided by the Cochrane Adverse Effects Methods Group.

RESULTS

A total of 2563 citations were screened and 88 systematic reviews were selected for inclusion. The majority focused on the safety of herbs and nutritional supplements. Approximately half the reviews covered all aspects of safety; other reviews addressed specific adverse effects or interactions. Types of data included in the reviews did not always reflect the focus of the review. Search strategies, sources used, quality assessment and assessment of causality also varied.

CONCLUSIONS

Detailed examination and comparison of the methods has highlighted several areas in which there is potential for development of guidelines and consensus on standards. These include search strategies, sources of information, data extraction and assessment of causality. The value of systematic reviews in relation to large outcome studies requires further consideration.

Defining adverse events in manual therapy: an exploratory qualitative analysis of the patient perspective

Rare, serious, and common, benign adverse events (AE) are associated with MT techniques. A proposed standard for defining AE in manual therapy (MT) practise has been published but it did not include the patient perspective. Research comparing clinician and patient reporting of AE demonstrates that several differences exist; for example, the reporting of objective versus subjective events. The objective of this study was to describe how patients define AE associated with MT techniques. A descriptive qualitative design was employed. Semi-structured interviews were used with a purposive sample of patients (n = 13) receiving MT, from physiotherapy, chiropractic and osteopathic practises in Ontario, Canada. The interview guide was informed by existing evidence and consultation with content and methodological experts. Interviews were audiotaped and transcribed verbatim. Date were analysed by two independent team members using thematic content analysis. A key finding was that patients defined mild, moderate and major AE by pain/symptom severity, functional impact, duration and by ruling out of alternative causes. An overarching theme identified multiple factors that influence how the AE is perceived. These concepts differ from the previously proposed framework for defining AE that did not include the patient perspective. Future processes to create standard definitions or measures should include the patient viewpoint to provide a broader, client-centred foundation.

Deaths after chiropractic: a review of published cases

OBJECTIVE

The aim of this study was to summarise all cases in which chiropractic spinal manipulation was followed by death.

DESIGN

This study is a systematic review of case reports.

METHODS

Literature searches in four electronic databases with no restrictions of time or language.

MAIN OUTCOME MEASURE

Death.

RESULTS

Twenty six fatalities were published in the medical literature and many more might have remained unpublished. The alleged pathology usually was a vascular accident involving the dissection of a vertebral artery.

CONCLUSION

Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit.

Manual therapy and cervical arterial dysfunction, directions for the future: a clinical perspective

This paper offers a contemporary, evidence-based perspective on the issue of adverse neurovascular events related to cervical spine manual therapy. The purpose of this perspective is to challenge traditional thought and practice and to recognize areas where practice and research should develop. By considering the themes presented in this paper, the clinician can broaden his or her approach to neurovascular assessment in line with contemporary evidence and thought. We present information based on clinically relevant questions. The nature of vertebrobasilar insufficiency and the utility of pre-treatment testing are examined in light of contemporary evidence. In addition, we report on internal carotid artery pathology, and the significance of appreciating atherosclerosis in clinical decision-making. These later two areas are not commonly recognized within manual therapy literature, and we suggest that their importance to differential diagnosis of head and neck pain, as well as estimating treatment related risk, is paramount. We propose that the term cervical arterial dysfunction is more appropriate than classically used nomenclature. This term refers more accurately and completely to the range of pathologies at different anatomical sites that manual therapists treating patients with head and neck pain are likely to encounter. Finally, we present a brief review of the medico-legal status pertaining to this area. Although this is English law-related, the themes derived from this section are of interest to all manual therapists.