Effect of PNF and Suboccipital relaxation on pain & disability in one side head ache & pain
- Conditions
- Other specified disorders of muscle,
- Registration Number
- CTRI/2023/12/060620
- Lead Sponsor
- Jayasudha A
- Brief Summary
EFFICACY OF PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION TECHNIQUE VERSUS SUBOCCIPITAL RELAXATION EXERCISE ON PAIN AND DISABILITY AMONG PATIENTS WITH CERVICOGENIC HEADACHE.
Under the guidance:
Dr. Rajendra kachhwaha (Principal and Professor)
Narayana Hrudayalaya Institute of Physiotherapy
Investigator:
Jayasudha A
MPT, Narayana Hrudayalaya Institute of Physiotherapy
PROJECT SUMMARY
The study aims to find whether proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on cervicogenic headache. With between-groups experimental design and random patient allocation to proprioceptive neuromuscular facilitation group versus suboccipital relaxation exercise group, the study aims to explore the effects of proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on pain and disability among cervicogenic headache. The study holds its grounds on strong evidence of reduction in the pain, disability and anticipates significant functional outcomes NDI and NPRS. The
Hypotheses and objectives of the study can be outlined as:
Hypothesis:
Null Hypothesis (H0):There is no significant difference between proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on pain among patients with cervicogenic headache.
-There is no significant difference between of proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on neck disability among patients with cervicogenic headache.
Alternate Hypothesis (H1): There is a significant difference between of proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on pain in patients with cervicogenic headache.
-There is a significant difference between of proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on neck disability among patients with cervicogenic headache.Objectives of the study: To compare the efficacy of proprioceptive neuromuscular facilitation vs suboccipital relaxation exercise on pain and disability among cervicogenic headache.
INTRODUCTION & BACKGROUND
In all headache patients, 15-20% have cervicogenic headaches, which share symptoms with migraine and tension headaches but are distinct from other headaches because they are caused by musculoskeletal issues in the region of the head that corresponds to the side where the headache first appeared. The discomfort from a cervicogenic headache, which is not a primary headache and which radiates from the back of the neck to the front of the head and the ipsilateral eye, can last anywhere between a few hours and days.
Primary headaches and secondary headaches are the two main categories for the international classification of headache disorders issued by HIS. Primary headaches are those with an identifiable etiology, such as vascular or muscle abnormalities. Migraine headaches, tension headaches, and other types of primary headaches are among them. Headaches that are secondary in origin refer to those that have another cause, such as a head or neck injury, a degenerative condition, inflammation, etc.
Cervicogenic headaches are regarded as “secondary headaches†in accordance with this classification.
The characteristics of the CGH set it apart from other types of headaches are side locking discomfort and pain that gets worse when you apply pressure.It is primarily unilateral and felt in the occipito-temporo-frontal areas when this type of headache occurs. The neck muscles and head movement also exhibit a variety of clinical symptoms.
When compared to the general population (4%), the frequency of CGH in the survey of health professional students is 17.76%.6 Females are four times more likely to be affected than men, and it is estimated that 0.4-2.5% of the general population is affected. Long-term neck flexion, poor static postures, and a history of trauma could all be contributing factors.
The trigeminal and superior cervical spinal nerves’ afferent branches may have come together in the trigeminal-cervical caudal nucleus, which is thought to be the source of this headache. This convergence might help to explain why individuals with CH frequently have headaches that correlate to the dermatomes in the trigeminal and cervical regions. As a result, experiencing a concussion or whiplash injury along with neck pain and movement restrictions might result in the development of CGH.
The C1-2 and C2-3 joints are considered as the predominant motion segment, with the C2 proposed as the most frequent cervical level for CGH origin. The third occipital nerve, which is located at C2-3, has been implicated as the source of pain in many CGH patients, according to diagnostic blocks, and has been the most frequent source of CGH symptoms in the C2-3 motion segment.
The primary clinical signs are a mild, dull headache with occipital pressure and tightening feelings. Neck pain, restricted cervical range of motion, a high Neck Disability Index score, and a diagnosis of cervical spondylotic myeloradiculopathy were all potential risk factors .In the differential diagnosis, other unilateral and side-locked headaches such cluster headache, CPH (chronic paroxysmal hemicrania) and HC must be considered. Cluster headaches and chronic generalized headaches (CGH) differs in their pain features, such as intensity, temporal pattern, and the presence of distinct autonomic symptoms and indications.
According to recognized diagnostic criteria, these headaches originate in the neck or occipital area and are accompanied by discomfort in the cervical paraspinal tissues.
The cervical flexion-rotation test (CFRT) has the highest diagnostic accuracy and reliability for the diagnosis of CGH.Invasive therapies can be challenging to apply since they call for a high level of skill and understanding, and many medications used to treat headaches have undesirable side effects. For the management of CGH, particularly in mild to moderate intensity, non-pharmacological therapies are beneficial.
The best accessible treatment among these is physiotherapy. Suboccipital relaxation on cervicogenic headache patients was found to be effective in decrease of muscular fatigue of upper trapezius and Sternocleidomastoids, muscular tone of sternocleidomastoids, and headache intensity. Also, this technique helps to decrease the tightness and pain restricted fascia in cervicogenic headache. PNF technique helps to Improve cervical muscle strength and endurance in cervical defects .
also proved that PNF is more effective in reducing the pain and disability cervical osteoarthritis.No, the most studies were to identified the effect of PNF technique in cervicogenic headache. These techniques are rarely applied compared to other physiotherapy techniques and the number of studies done in the literature is very limited. The effects of these two approaches in the treatment of pain severity, disability, to improve the quality of life are not known in the patients with CGH.
REVIEW OF LITERATURE:
•Prevalence of cervicogenic headache
Hiral Jain et al (2022) conducted a cross-sectional study on the prevalence of cervicogenic headache in computer users. Where the 104 subjects are included between the age groups of 18 and 40 years. This study reported that there are 56.9% men and 43.1% women among computer users. 28% of users have CGH, as determined by the Biondi Checklist for CGH and the International Headache Society’s ICHD-3 criteria. Cervicogenic pain, which frequently affects computer users between the ages of 18 and 40, has been acknowledged.
Heidi Knackstedt et al (2010) conducted cross sectional study on cervicogenic headache in the
general population. In that they have reported that there were more women than men with CEH, which had a 0.17% frequency in the overall population. Overusing medications occurred in 50% of cases, and migraines in 42% of cases. The pericranial tenderness score was significantly higher other pain than non-pain side (p<.005). In comparison to non-pain cases, the pericranial muscle soreness score was considerably higher in the pain cases.
Nikolai Bogduk et al (2009) conducted study on assessment of the evidence on clinical diagnosis, invasive tests, treatment of cervicogenic headache. In this reported that when clinical criteria have been applied, the prevalence of cervicogenic headache has been estimated to be 1%, 25%,17, or 41%18 in the general population and as high as 175 % among patients with severe headaches.17 Patients with headaches following whiplash can experience a prevalence of up to 53%.
Scott Haldeman DC et al (2001) conducted a critical review on cervicogenic headache. In that they have reported that estimates of prevalence range from 0.4% to 2.5% of the general population to 15% to 20% of people who suffer from chronic headaches. Patients that suffer from CGH often have a mean age of 20 to 42, a 4:1 female predisposition, and a chronic nature.
•Review of Suboccipital relaxation exercise
Dae Jung Yang et al (2017) reported that this study compared and analyzed the effects headaches in terms of their cervical muscular exhaustion, tone, and headache intensity. 10 participants each group were chosen from among 30 patients with cervicogenic headache. Were randomized at random to the control, suboccipitalis relaxation, and cervical flexion exercise groups. For four weeks, each group received intervention five times each week. It was discovered that suboccipitalis relaxation on cervicogenic headache patients was beneficial in reducing headache intensity, upper trapezius and sternocleidomastoideus muscle exhaustion, a muscle tone.
Prasad Kharwandikar et al (2019) reported that interventional investigation on the effectiveness of cervical manipulation and sub-occipital relaxation on patients with cervicogenic headache. 30 participants were included in the study between the age group of 20-40 years and the intervention is given twice a week for 4weeks. The pre and post NPRS and PSQI recorded. In adults with cervicogenic headache, sub-occipital myofascial release and cervical manipulation were effective treatments. As a result, cervicogenic headache can frequently be treated with sub-occipital relaxation.
Bo-Been Kim et al (2016) reported that an interventional study was done on patients who had a forward head posture to see how suboccipital relaxation with craniocervical flexion exercise affected their alignment and extrinsic cervical muscle activity. Using G-power software, 19 subjects (7 males and 12 females) with forward head posture were chosen for the investigation. For patients with forward head position, suboccipital release combined with craniocervical flexion exercise produced superior results to craniocervical flexion exercise alone. Therefore, the study demonstrated that forward head posture in cervicogenic headache is affected by suboccipital relaxation exercise.
•Review of proprioceptive neuromuscular facilitation
Dong Gun Oha et al (2016) reported that the aim of this study was to investigate the effects of cervical alignment, discomfort, and physical characteristics when proprioceptive neuromuscular facilitation (PNF) techniques were used on individuals with forward head posture. The 24 white-collar workers who participated in this study exhibited cervical pain and FHP of greater than 15mm. They were divided randomly into two group, 12 subjects for each PNF and control group. Given for 6times a week for 4weeks. According to the study’s findings, PNF intervention employing scapular and upper extremity patterns is beneficial for FHP.
Tomasz Maick et al (2017) reported that this study’s objective was to assess the efficacy of manual therapy and PNF techniques in the treatment of patients with cervical spine osteoarthritis. The study comprised 80 randomly chosen females between the ages of 45 and 65. They were split into two groups of 40 people each at random. Manual therapy was administered to one group while PNF treatment was given to the other. Given for 5weeks, each group received twice a week. The PNF group lessened pain more than the MAN.T group did. When compared to the MAN.T group, the PNF group shown a better improvement in carrying out daily activities like sleeping, caring for oneself, travelling, working, playing, lifting, walking, and standing. The study so demonstrated that PNF is successful in reducing pain in cervical diseases.
•Review of outcome measure
Liang YangA (2022) reported that cohort research was done on anterior cervical decompression and fusion for cervicogenic headache. Where NPRS scale used as primary outcome measure. The outcome demonstrated that the surgical group’s NPRS during follow-up was statistically significantly lower. Between-group differences demonstrated that the NPRS in the surgery group had significantly improved after one month. According to the study, NPRS can accurately assess the frequency and severity of pain in cervicogenic headache patients
Amy W McDevitt et al (2022) reported that randomized clinical trial on thoracic spine thrust manipulation for patients with cervicogenic headache. 48 people were the subject of a randomized controlled crossover trial and treatment given for 4weeks. Outcome were collected at 4, 8, 12weeks and included the Headache Disability Inventory (HDI), neck Disability Index (NDI), and the global rating of change (GRC) were among the outcomes that were gathered at 4, 8, and 12 weeks. Comparing hold to active treatment, HDI were not significantly different between groups (mean difference = 7.39, 95 CI: −4.39 to 19.18; P = 0.214) at any timepoint; the NDI was significant (mean difference = 6.90, 95 CI: 0.05 to 13.75; P = 0.048) at 4 weeks. The study shown that the NDI is a reliable indicator of pain and functional impairment in cervicogenic headache sufferers.
Ian A Young (2019) reported that secondary analysis of a 110-person, randomized clinical trial (n = 110) comparing the effectiveness of spinal manipulative treatment and exercise in treating cervicogenic headaches. The Neck Disability Index has values for responsiveness, thresholds for least detectable change, construct validity, responsiveness, and clinically significant difference values. The Neck Disability Index showed excellent reliability. At the 1-week and 4-week follow-ups, the NDI demonstrated favorable reliability and significant construct validity.
James R. Dunning (2016) reported that the study compared the effects of manipulation, mobilization, and exercise on people with CH in order to determine which had the best results. (n = 110) CH patients were randomized to either mobilization and exercise (n = 52) or cervical and thoracic manipulation (n = 58). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Additionally, the Neck Disability Index (NDI) was used to assess disability and secondary outcomes such as headache frequency and duration. NDI’s outstanding test-retest reliability, strong construct validity, great internal consistency, and good responsiveness in measuring impairment were all mentioned in the study.
LACUNAE IN LITERATURE
evident from the above literature review, currently, there is a lack of research regarding effects of proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on pain and disability among cervicogenic headache. Although PNF technique shows improved effect on cervical osteoarthritis is yet to be established for cervicogenic headache. Thus, further high quality studies like RCTs need to be performed. Realizing this need, the current study has been proposed. 5
RESEARCH QUESTIONS :
-Does proprioceptive neuromuscular facilitation and suboccipital relaxation exercise are effective on pain and disability among cervicogenic headache?
-What is the most significant effect of proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on cervicogenic headache?
-What factors affect the outcome of treatment in cervicogenic headache?
AIMS AND OBJECTIVE
Aim: To determine the effect of proprioceptive neuromuscular facilitation versus suboccipital relaxation on pain and neck disability among the patients cervicogenic headache.
Objectives:
-To compare the efficacy of proprioceptive neuromuscular facilitation technique and suboccipital relaxation exercise on pain and neck disability among cervicogenic headache.
MATERIALS AND METHODS :
Study area: Narayana hrudayalaya foundation
Study population: subject with cervicogenic headache between the age group of 22-45years
Sample size: 52 subjects
-Study design: Randomized controlled study design.
-Randomization: A simple random method will be followed based on computer generated randomization. Patients will be randomly divided into group A and group B and the treatment will be assigned using the scaled envelop technique.
-Blinding: No blinding technique are used since the procedures of the two treatment intervention are different and the principal investigator only will do the intervention and asses the outcome.
-Type of study: Experimental study
-Duration of study: study will be commenced after ethical committee approval.
- Method of measurement of outcome measures: Neck disability index is most commonly used outcome measure to assess the neck disability basis of pre and post treatment to know the improvement of the patient in neck disability and NPRS is another outcome measure mainly asses the pain levels basis of pre and post treatment to know the improvement of the patients on pain level.
Intervention performed by: principal of investigator.
-Assessment of outcome measure is performed by: principal of investigator.
- Study intervention: The subjects who fulfill the inclusion criteria and are willing to participate in the study will be assigned to one of two groups after obtaining written informed consent.
Inclusion criteria:
Age group between 20-45years
Both males and females
Unilateral headache
Subjects with frequency of headache for at least twice a week
Positive cervical flexion rotation test ï‚· 41- 60% Scoring of NDI scale.
Exclusion criteria:
Cluster headache
Features of migraine type headache
Degenerative cervical pathologiesProtocol,
Headache attributed to trauma, cervical/cranial vascular disorder, infection psychiatric disorder
Previous cervical surgery.
The subject who fulfills the inclusion criteria and are willing to participate in the study will be assigned to one of two groups after obtaining written informed consent
METHODOLOGY:
We will be recruiting the subjects according to eligibility criteria and are willing to participate in the study. ï‚· We will be randomizing the subject by simple random sampling using computer generated tables the subjects will be allocated in to 2 groups. ï‚· This study would be registered in CTRI. ï‚· Technique applied in the study will be of standard of care.
Study Design
GROUP A: 26 subjects :
-This group will undergo current standard care of following exercise like Proprioceptive neuromuscular facilitation technique includes the PNF stretching of tighten group of muscles and for weaker muscles slow reversal, repetitive contraction techniques.
- The hold relax method of PNF stretching used for tighten group muscles. -Hold relax includes putting a muscle in stretched positions & holding for few seconds followed by isometric contraction for 6-10sec relaxing the stretch & again stretching while exhaling.
-Slow reversal is applying maximal resistance to allow patients move through entire range in normal speed.
-PNF will be given as 5 repetitions/set, 3sets/session, 4session /week for 4weeks duration for cervical flexors, extensor, lateral flexors.
GROUP B: 26 subjects :
-This group will undergo current standard care of following exercise like suboccipital relaxation exercise, therapist positioned him/herself over head of the subjects, placed fingertip just suboccipital region of subjects supported occiput of the subjects with his/her palm.
-Suboccipital region was protracted with fingertip so that it would make an axis.
-Then the head was lightly supported with palm so that the neck wouldn’t be fully extended for 20 min, releasing the suboccipitalis.  Subject will be applied for 20min 4session /week for 4weeks of duration.
- Total time of treatment will be 60min for both groups.
-Treatment will be given for 4 days a week for both groups.
-Total duration of the study will be 4weeks.
-Pre and post assessment done for both groups by using NDI and NPRS.
- Study duration: 2 weeks
Method of measurement of outcome:
For disability Neck disability Index and for pain assessed through NPRS scales are used. Method of assessing outcome measures:
Range of motion will be measured by using a goniometer on the day of assessment before intervention (pre-treatment) and in the 4th week after intervention (post-treatment).
Flexion rotation test will be assessed before intervention (pre-treatment) and in the 4th week after intervention (post-treatment).
The Numeric Pain Rating Scale (NPRS) (an outcome measure) that is a unidimensional measure of pain intensity. The NPRS can be administered verbally or graphically for self-completion. The 11-point numeric scale ranges from ‘0’ representing one pain extreme (e.g., “no painâ€) to ‘10’ representing the other pain extreme (e.g., “pain as bad as you can imagine†or “worst pain imaginableâ€). Pain level will be measured by using the NPRS scale on the day of assessment before intervention (pre-treatment) and in the 4th week after intervention.
The NDI is another outcome measure scale most commonly used self-report measure for neck pain. The NDI can be scored as a raw score or doubled and expressed as a percent Each section is scored on a 0 to 5 rating scale, in which zero means ‘No pain’ and 5 means ‘Worst imaginable pain’. Scoring classified as follow: 0-4points (0-8%) no disability,5-14points (10–28%) mild disability,15-24points (30-48%) moderate disability,25-34points (50- 64%) severe disability,35-50points (70-100%) complete disability. Disability will be measured by using the Neck disability index scale (NDI) scale on the day of assessment before intervention (pre-treatment) and in the 4th week after intervention (post-treatment).
NPRS and NDI these two outcome measures are free to access.
STATISTICAL METHODS:
Plan for analysis:
• Data will be analyzed using R software.
• Baseline patient characteristics will be described using mean and SD for continuous variables, frequency and percentage for categorical variables.
Outcome parameters between the two groups will be analysed using Paired T Test or Wilcoxon Signed Rank Test based on the Normality of the Data. Based on data collected after the time period of study, some of the additional statistical analysis will be performed. • P value less than 0.05 will be considered statistically significant.
ETHICAL CONSIDERATION:
Ethical clearance will be obtained before the commencement of the study from institution ethics committee. • Informed consent will be obtained from the patient before the onset of the study.
• There is no additional investigation required for my study. Privacy and confidentiality of the patient will be maintained. • Management of these patients will be along the standard guideline.
• The study involves the performance of physical activities as exercise so fatigue or tiredness are the primary effects. Apart from fatigue, no other risks and discomforts have been anticipated with such approaches.
The study benefit from the study with improved intensity and frequency of pain and neck disability, enabling you to carry out your work and maintaining a good posture.
- Detailed Description
Not available
Recruitment & Eligibility
- Status
- Closed to Recruitment of Participants
- Sex
- All
- Target Recruitment
- 52
Inclusion criteria: 1 Age group between 20-45years 2 Both males and females 3 Unilateral headache 4 Subjects with frequency of headache for at least twice a week 5 positive cervical flexion rotation test 6 30- 48% Scoring of HDI questionnaire.
Exclusion criteria: 1 Cluster headache 2 Features of migraine type headache 3 Degenerative cervical pathologies 4 Headache attributed to trauma, cervical/cranial vascular disorder, infection psychiatric disorder 5 Previous cervical surgery.
Study & Design
- Study Type
- Interventional
- Study Design
- Not specified
- Primary Outcome Measures
Name Time Method Pain - numerical pain rating scale (NPRS) The 11-point numeric scale ranges | from ‘0’ representing one pain extreme (e.g., “no painâ€) to ‘10’ representing | the other pain extreme (e.g., “pain as bad as you can imagine†or “worst pain | imaginableâ€). Pain level will be measured by using the NPRS scale on the day | of assessment before intervention (pre-treatment) and in the 4th week after | intervention.
- Secondary Outcome Measures
Name Time Method Disability -neck disability index (NDI) After 4 weeks
Trial Locations
- Locations (1)
Narayana Hrudayalaya Foundation
🇮🇳Bangalore, KARNATAKA, India
Narayana Hrudayalaya Foundation🇮🇳Bangalore, KARNATAKA, IndiaDr Jayasudha APrincipal investigator8884847300jaianjali82@gmail.com