Author Names
Mun ̃oz-Go ́mez, E. et al
Reviewer Name
Paige Dewalt
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Physiotherapy is used as a non-pharmacological treatment for migraine. However, controversy exists over whether articulatory manual techniques are effective in some aspects related to migraine. Objectives: To assess the effectiveness of a manual therapy protocol based on articulatory techniques in pain intensity, frequency of episodes, migraine disability, quality of life, medication intake, and self-reported perceived change after treatment in migraine patients. Design: Randomized controlled trial. Methods: Fifty individuals with migraine were randomized into the experimental group, which received manual therapy based on articulatory techniques (n = 25), or the placebo group (n = 25). The intervention lasted 4 weeks and included 4 sessions. Patients were assessed before (T1), after (T2) and at a one-month follow-up following the intervention (T3). The instruments used were the Migraine Disability Assessment (MIDAS) questionnaire, the Short Form-36 Health Survey (SF-36), the medication intake, and The Patients’ Global Impression of Change scale. Results: In comparison with placebo group, manual therapy patients reported significant effects on pain intensity at T2 (p < 0.001; d = 1.15) and at T3 (p < 0.001; d = 1.13), migraine disability at T3 (p < 0.05; d = 0.69), physical quality of life at T2 (p < 0.05; d = 0.72), overall quality of life at T2 (p < 0.05; d = 0.60), decrease in medication intake at T2 (p < 0.001; d = 1.11) and at T3 (p < 0.05; d = 0.77) and self-reported perceived change after treatment at T2 and T3 (p < 0.001). No serious adverse events were reported. Conclusions: The application of a manual therapy protocol based on articulatory techniques reduced pain intensity, migraine disability, and medication intake, while improving quality of life in patients with migraine.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Yes
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- Yes
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Cannot Determine, Not Reported, or Not Applicable
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
The present protocol based on articulatory techniques was effective in reducing pain intensity, migraine disability and medication intake, while improving physical QoL and self-reported perceived change after treatment; these changes were maintained after one month.
Key Finding #2
Significant differences were observed in terms of the frequency of episodes and mental QoL at T2 and T3 compared to the placebo intervention.
Key Finding #3
The decrease in pain intensity for the experimental group (AG) may be due to joint mobilization techniques, which target several regions of the spinal column, triggering systemic neurophysiological responses in the peripheral and central nervous system that lead to pain inhibition.
Please provide your summary of the paper
This study shows that a manual therapy protocol based on articulatory techniques reduces pain intensity, frequency of migraine, migraine disability, and medication intake, while improving QoL in patients with migraine. Low velocity and moderate to high amplitude movements were conducted on the neck and upper trunk joints and the SIJ joints to force their full ROM. The following techniques were applied bilaterally: occiput-atlas-axis articulatory manipulation, upper cervical spine (C0–C1) mobilization, middle cervical spine (C2–C7) mobilization in supine, middle cervical spine (C2–C7) mobilization in prone, cervicothoracic junction articulatory manipulation, upper thoracic spine (T2-T6) articulatory manipulation and global sacroiliac joint articulatory manipulation. Results from the short-term treatment provided in this study were maintained after one month, although longer interventions may be more effective in reducing frequency. The decrease seen in pain intensity for the AG group may be due to mobilization techniques triggering systemic neurophysiological responses in the PNS and CNS that lead to pain inhibition. The results from this study, along with additional research, suggest that combining cervicothoracic and lumbosacral techniques could be more effective in reducing medication intake. Primary headaches have a negative impact on QoL and manual therapy is considered an effective approach to improve QoL in patients with migraine, likely due to the decrease in pain intensity and frequency. However, the study does have limitations as most participants were women. Also given the variety of techniques used, improvement can’t be attributed to one technique alone.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study shows that low velocity and moderate to high amplitude articulatory techniques can be used on the neck/upper-trunk joints along with the SIJ to reduce pain intensity, frequency of migraine, migraine disability, and medication intake in individuals seen in the clinic for migraines. This is also a beneficial intervention for improving physical, mental, and overall QoL in this population. It’s important to review the clinical history and perform pre-manipulative testing of the cervical spine to rule out any possible cervical artery dissection before performing the intervention. Further research is needed to examine the appropriate dosage for each technique and whether or not multiple techniques are required in order to see improvements.
