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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 16
| Issue : 1 | Page : 23-27 |
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Effectiveness of neck flexors and extensors muscle strengthening exercises on pain and function in migraine patients
S Priya, PV Abhilash, M Gopika Sivasankaran
Physiotherapy, Laxmi Memorial College of Physiotherapy, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka, India
| Date of Submission | 12-Nov-2021 |
| Date of Decision | 20-May-2022 |
| Date of Acceptance | 21-May-2022 |
| Date of Web Publication | 22-Jul-2022 |
Correspondence Address:
Dr. M Gopika Sivasankaran
Sivasankaran,
Laxmi Memorial College of Physiotherapy, Rajiv Gandhi University of Health Sciences, Bengaluru, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/pjiap.pjiap_34_21
CONTEXT: Migraine is a primary episodic headache disorder, characterized by combinations of neurological, gastrointestinal, and autonomic changes in the body. Migraine patients are more likely to self-report neck pain, to have more cervical trigger points and tenderness over cervical muscles. Neck flexor and extensor muscles have shown decreased strength in migraine patients.
AIMS: To determine the effectiveness of neck flexors and extensors muscles strengthening exercises on pain and function in migraine patients.
SETTING AND DESIGN: A case–control study was conducted among 14 individuals of ages 20–30 years with Migraine in a Tertiary Care Hospital, India.
SUBJECTS AND METHODS: Fourteen migraine patients were selected for the study and neck flexor and extensor strengthening exercises were administered for 4 weeks. The pain, cervical range of motion, and disability were measured using visual analog scale (VAS), universal goniometer, migraine disability assessment score (MIDAS) before and after the intervention.
STATISTICAL ANALYSIS USED: Data were analyzed using SPSS v. 26.0. Values are expressed in terms of mean and standard deviation (X̄ ± SD). Statistical analysis to compare pre and post group was done using paired t-test.
RESULTS: Paired t-test was used to compare the interventions within the group. Statistical analysis showed significant improvement in pain and function on migraine patients after 4 weeks of treatment. VAS (t = 6.358, P < 0.05), MIDAS (t = 3.798, P < 0.05), ROM (t = 5.014, 2.851, P < 0.05).
CONCLUSION: The present study concluded that strengthening exercises of both neck flexors and extensors muscles reduced pain and improved function in migraine patients.
Keywords: Migraine disorder, neck pain, strength
How to cite this article:
Priya S, Abhilash P V, Sivasankaran M G. Effectiveness of neck flexors and extensors muscle strengthening exercises on pain and function in migraine patients. Physiother - J Indian Assoc Physiother 2022;16:23-7 |
How to cite this URL:
Priya S, Abhilash P V, Sivasankaran M G. Effectiveness of neck flexors and extensors muscle strengthening exercises on pain and function in migraine patients. Physiother - J Indian Assoc Physiother [serial online] 2022 [cited 2023 Jun 5];16:23-7. Available from: https://www.pjiap.org/text.asp?2022/16/1/23/351862 |
| Introduction | |  |
Migraine is a primary episodic headache disorder characterized by neurological, gastrointestinal, and autonomic changes in the body. The word migraine was derived from a Greek word hemicrania.[1]
Migraine affects approximately 12% of the world's adult population.[2] As a part of migraine pathophysiology, certain neuronal groups sensitization that is in the brainstem leads to muscle sensitivity and allodynia causing muscle dysfunctions in craniocervical area, will trigger migraine and increase their frequency. The pathophysiology of migraine is not completely understood.[3] Migraines are a complex neurovascular brain disorder that affects cortical, subcortical, and brainstem areas. During a migraine attack, carotid vessels are dilated and vasoconstricting drugs are effective treatments.
The prevalence of neck pain is 30%–50% in the general population.[4] People with migraine are more likely to self-report neck pain, have more trigger points (TrPs), and tenderness over the cervical muscles.
Reports suggest that patients with neck pain will have weakness and fatigability. Among other factors that affect neck muscles performance, the pain has been considered important.[5]
Hence, if there is an improvement in neck muscle strength there will be a reduction of neck pain intensity and disability.
The muscular imbalance between the cervical extensors and flexors can be negatively correlated with the stabilization of this region.[6] A feasible and practical measure to verify this imbalance in the ratio between the cervical muscles can be calculated based on the strength and activity. It has shown a lower strength ratio between neck extensor and flexor muscles.
According to international guidelines, the most effective treatment for migraine patients is pharmacological.[7] However, it is associated with various side effects, like weight gain and adverse events such as cardiovascular disease. Therefore, the need of this study is to reduce medication intake using nonpharmacological interventions like physiotherapy.
A study conducted by Luedtke et al., efficacy of interventions used by physiotherapists for patients with headache and migraine, showed a significant reduction in pain intensity, duration, and frequency in migraine after physiotherapy interventions.[8]
Thus this study aims to determine the effectiveness of neck flexor and extensor muscle-strengthening exercise to reduce the intensity of pain, improve range of motion (ROM), and function in migraine patients.
| Subjects and Methods | | |
Study design and recruitment of patients
A case–control study was conducted in a tertiary care hospital, India. The study was approved by the “International Ethical Committee” (EC/NEW/INST/2020/741). Moreover, this trial is registered under the clinical trial registry in India; members of the ethical committee include clinician, basic medical scientists, member/statistician, and legal expert. Dr. Priya S (Associate professor) and Dr. Abhilash PV (Associate professor) were involved in the diagnosis of migraine patients using migraine criteria established by the International headache society, patients must have at least 5 headache attacks that lasted 4–72 h (untreated or unsuccessfully treated) and headache must have at least 2 of the following characteristics:
- Unilateral location
- Throbbing/pulsating
- Worsening by movement
- Moderate to severe intensity.
And any of the following:
- Nausea and vomiting
- Photophobia/phonophobia.
We identify two measures to differentiate between cervicogenic headache and migraine, there is reduced range of rotation during Flexion– rotation test and neck flexion strength in patients with cervicogenic headache compared to those with migraine.[9]
Fourteen patients with migraine were included in the study and the sample size was calculated to expect a mean difference of 8.8 in the migraine disability assessment score (MIDAS) before and after treatment with a standard deviation (SD) of 5.9 assuming a 95% confidence interval (CI), 90% power and 5% allowable error and was estimated for the study is 14. From October 1, 2021, to October 3, 2021 convenience sampling technique was used to recruit the sample based on inclusion and exclusion criteria. From October 04, 2021 patients were asked to do neck flexor and extensor muscle strengthening exercises for 4 weeks. On November 2, 2021, follow-up were done to measure the improvement in the outcome measures. Patients with ages between 20 and 30, fulfilling migraine criteria those who have episodic type of migraine, were selected for the study, and people suffering from tumors, underwent head- and neck-related surgeries were excluded from the study based on the exclusion criteria. Patients relying on medication only during severe pain are included in this study thus by doing the regular neck flexor and extensor muscle strengthening exercises will help them to reduce the severity and number of attacks thereby decreasing the medication intake and their side effects.
Other factors influencing biomechanical variations such as occupation, posture, time spend on mobile/computer, and number of pillow used while sleeping were recorded but posture, time spend on mobile/computer, and number of pillows used while sleeping cannot be recorded accurately as they vary each time depending on the convenience. All participants were explained the intervention procedure briefly and included in the study after written consent.
Outcome measures
Patients with migraines were selected and cervical flexion, extension ROM was measured using a goniometer, the pain was measured using a visual analog scale (VAS), and disability was measured using MIDAS. All these outcome measures are valid and reliable.[10],[11],[12] Outcome measures are noted before and after the intervention.
Exercise intervention
Neck flexor and extensor strengthening exercises are done for 4 weeks. The strengthening exercises include supine chin tuck, supine chin tuck with head elevation, prone head lift, forward isometric strengthening, backward isometric strengthening, neck extension in quadruped. Each exercise should be done with three sets, 15 repetitions.
Statistical analysis
Data were analyzed using SPSS version. 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp). values are expressed in terms of mean and SD. Statistical analysis to compare pre and post group was done using paired t-test. The test was applied 95% CI and a P < 0.05 is considered statistically significant.
| Results | | |
Fourteen patients were selected for the study and treatment was administered for 4 weeks. The table represents baseline and postinterventional data. The result shows significant improvement in pain, function, and ROM in people with migraines after 4 weeks of treatment [Table 1]. | Table 1: Effect in range of motion, visual analog scale and migraine disability assessment score before and after neck flexor and extensor muscle strengthening exercises
Click here to view |
| Discussion | | |
The study intended to determine the effectiveness of neck flexors and extensors strengthening exercise on pain and function in migraine patients. Various physiotherapy interventions such as aerobic exercises, manual therapy, and ultrasound therapy showed a reduction in migraine frequency and intensity. Studies also show that there is an imbalance in muscle strength over neck and shoulder region but no studies succeeded in proving that neck flexors and extensors muscle strengthening exercises would reduce the frequency and intensity of pain and improve in Rom and functions in migraine patients. Most of the migraine patients suffer more neck-related problems due to the same, thus this study proves that strengthening of neck muscles especially flexors and extensors is effective in reducing frequency and intensity of pain, and improves ROM and functions in migraine patients.
The research hypothesis states that neck flexor and extensor muscle strengthening exercises will reduce frequency, intensity of pain and improve ROM and function in migraine patients.
Thus this study will help the migraine patients to reduce migraine and neck-related issues at home itself without spending much time and money and also helps them to reduce medications intake and their side effects. The people of the age group between 20 and 30 years are most commonly affected among them females are most commonly affected, hence this study was targeted on people between 20 and 30 years and people suffering with episodic type of migraine. The neck flexor and extensor muscle strength of migraine patients are reduced compared to the people without migraines. This raised the research question and the need to conduct the study to determine the effectiveness of the neck flexor and extensor muscles strengthening exercise on pain and function in migraine patients. Most of the migraine patients complained of self-reported neck pain due to reduced muscle strength and also reduced cervical ROM thus this study needs to find whether there is an increase in cervical ROM, reduced pain intensity, and improved function after the neck muscle-strengthening exercise are administered. Fourteen participants included in the study had completed 4 weeks of neck flexors and extensors muscle strengthening exercises under supervision without fail.
We also record the factors such as occupation, time spend in mobile/computer, posture, and number of pillow used while sleeping but posture, time spend on mobile/computer, and number of pillows used while sleeping cannot be recorded accurately as they vary each time depending upon the convenience of the patients. The participant was asked to alter the possible biomechanical factors such as the time spend in mobile/computer, maintaining a proper posture, and reducing the number of pillows used while sleeping, but there is no proper evidence that biomechanical factors would influence the migraine patients.
The outcome measures like the pain were measured using a VAS, cervical ROM was measured using a goniometer, and disability was measured using MIDAS.
The study showed that the neck flexors and extensors muscle strengthening exercises administered for 4 weeks was effective in reducing pain intensity, improving cervical ROM and function in migraine patients.
A study done by Benatto et al. on neck-specific strengthening exercise compared with sham ultrasound when added to home stretching exercise in patients with migraine concluded that a neck-specific exercise program may be effective in reducing the frequency and intensity of migraine attacks.[13]
A study was done by Luedtke et al. on neck treatment compared to aerobic exercise in migraine.[6] The study concluded that both groups showed small reductions in headache frequency. Patients with pain referred to the head responded best to physiotherapy intervention.
A study was done by Luedtke and Gabler on the Effectiveness of physiotherapy on intensity, duration, frequency, and quality of life on migraine and concluded that Physiotherapeutic modalities such as different manipulative/mobilization techniques, TrP therapy, lymphatic drainage, traditional massage, and stretching/strengthening techniques included in this review seemed to be beneficial for investigated outcomes for migraineurs.[14] Physiotherapeutic treatment could enhance the effects of medical treatment and may result in lowering the economic burden of migraine.
A cross-sectional study was done by Florencio et al., on neck pain and disability on the frequency of migraine attacks and concluded that neck pain significantly adds to the overall disability of individuals with episodic and chronic migraines.[4]
Limitations of the study
This research, however, is subjected to limitations like manual resistance given to each varied, elastic resistance such as therabands can be a better option than manual resistance which has not been administered.
| Conclusion | | |
The present study concluded that strengthening exercise of both neck flexors and extensors muscles reduced pain intensity, improved cervical flexion and extension ROM, and increased function in migraine patients. As the intensity of migraine decreases the people depending on medication during severe pain also decreases hence reducing medication intake. The significance of the study was to decrease the use of medication intake in migraine patients.
Acknowledgment
The authors acknowledge Dr. Manjula Suvarna, Assistant professor/statistician for her contribution toward sample size calculation, data analysis, and interpretation. I would like to extend my thanks to my parents and all those who have provided immense help and guidance for the completion of this work.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Silberstein SD. Migraine. Lancet 2004;363:381-91.  |
| 2. | Bevilaqua-Grossi D, Gonçalves MC, Carvalho GF, Florencio LL, Dach F, Speciali JG, et al. Additional effects of a physical therapy protocol on headache frequency, pressure pain threshold, and improvement perception in patients with migraine and associated neck pain: A randomized controlled trial. Arch Phys Med Rehabil 2016;97:866-74. |
| 3. | Deneris A, Rosati Allen P, Hart Hayes E, Latendresse G. Migraines in women: Current evidence for management of episodic and chronic migraines. J Midwifery Womens Health 2017;62:270-85. |
| 4. | Florencio LL, Chaves TC, Carvalho GF, Gonçalves MC, Casimiro EC, Dach F, et al. Neck pain disability is related to the frequency of migraine attacks: A cross-sectional study. Headache 2014;54:1203-10. |
| 5. | Tolentino GA, Bevilaqua-Grossi D, Carvalho GF, Carnevalli AP, Dach F, Florencio LL. Relationship between headaches and neck pain characteristics with neck muscle strength. J Manipulative Physiol Ther 2018;41:650-7. |
| 6. | Luedtke K, Starke W, Korn K von, Szikszay TM, Schwarz A, May A. Neck treatment compared to aerobic exercise in migraine: A preference-based clinical trial. Cephalalgia Rep 2020;3:1-9. |
| 7. | Benatto MT, Florencio LL, Bragatto MM, Lodovichi SS, Dach F, Bevilaqua-Grossi D. Extensor/flexor ratio of neck muscle strength and electromyographic activity of individuals with migraine: A cross-sectional study. Eur Spine J 2019;28:2311-8. |
| 8. | Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis. Cephalalgia 2016;36:474-92. |
| 9. | Anarte-Lazo E, Carvalho GF, Schwarz A, Luedtke K, Falla D. Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: A systematic review and meta-analysis. BMC Musculoskelet Disord 2021;22:755. |
| 10. | Stewart WF, Lipton RB, Kolodner K, Liberman J, Sawyer J. Reliability of the migraine disability assessment score in a population-based sample of headache sufferers. Cephalalgia 1999;19:107-14. |
| 11. | Audette I, Dumas JP, Côté JN, De Serres SJ. Validity and between-day reliability of the cervical range of motion (CROM) device. J Orthop Sports Phys Ther 2010;40:318-23. |
| 12. | Begum R, Hossain MA. Validity and reliability of visual analogue scale(VAS) for pain measurement. J Med Case Rep Rev 2019;16:87-101. |
| 13. | Benatto MT, Florencio LL, Bragatto MM, Dach F, Fernández-de-Las-Peñas C, Bevilaqua-Grossi D. Neck-specific strengthening exercise compared with sham ultrasound when added to home-stretching exercise in patients with migraine: Study protocol of a two-armed, parallel-groups randomized controlled trial. Chiropr Man Therap 2020;28:22. |
| 14. | Gabler T, Lüdtke K. Effectiveness of physiotherapy on intensity, duration, frequency and quality of life on migraine–systematic review.Res Gate 2020;47:1-29. |
[Table 1]
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