The effectiveness of physiotherapy for patients with isolated cervical dystonia: an updated systematic review and meta-analysis.

BACKGROUND: Cervical dystonia is a movement disorder typically characterized by a patterned and twisting movement of sustained or intermittent muscle contractions. Recently, new clinical trials are emerging, highlighting the potential benefit of physiotherapy (PT) on disease outcomes. Thus, the objective of this review is to update the effectiveness of PT on cervical dystonia disease outcomes and subsequently perform a meta-analysis. METHODS: Interventional studies published in English with adult patients with isolated cervical dystonia following a physiotherapy program were included. Relevant articles were searched in PubMed (MEDLINE), Web of Science, and Scopus. Cochrane and Joanna Briggs Institute risk of bias checklists were used for quality reporting. Meta-analysis was done using Review Manager 5.3 statistical software and a pooled mean difference for pain was presented. RESULTS: Fourteen articles were included in the review and two articles were included in the meta-analysis. The meta-analysis revealed that PT intervention had a significant effect on pain reduction scale (-5.00, 95% CI -6.26, -3.74) when used as an additional therapy with botulinum toxin (BoNT) injection. Additionally, findings indicate a possible positive effect of PT disease severity, disability, and quality of life. CONCLUSIONS: Physiotherapy in addition to BoNT is recommended to decrease pain. The findings suggest a reduction of disease severity, disability, and improvement in quality of life. The variety in the type and duration of PT interventions did not allow a clear recommendation of a specific type of PT.

Hyperacusis: demographic, audiological, and clinical characteristics of patients at the ENT department.

PURPOSE: To document whether patients with and without hyperacusis differ from each other on demographic, audiological, and clinical characteristics. METHODS: Based on the Hyperacusis Questionnaire's (HQ) cut-off (HQ > 28), a total of 2301 participants were divided into patients with and without hyperacusis. Demographic data, scores on self-reported questionnaires [Tinnitus Functional Index (TFI), Visual Analogue Scale of tinnitus loudness (VASloudness), Hospital Anxiety Depression Scale (HADS)], and audiological parameters were retrospectively analysed to determine differential factors between the two groups. RESULTS: In total, 10.9% of the patients was classified as hyperacusis patients (n = 251). They reported a significant, higher tinnitus severity (mean difference of 19 points on TFI) and mental distress (mean difference of 4 points on the HADS subscales) (p < 0.001) than patients without hyperacusis. Moreover, this group consisted of more women (45% % in hyperacusis group vs. 35% in non-hyperacusis group) and women scored significantly higher on the HQ (p < 0.001) and TFI (p < 0.01). CONCLUSION: Patients with hyperacusis have distinctive characteristics. The presence of hyperacusis in combination with tinnitus can indicate a higher need for psychoeducation. Patients that present themselves with hyperacusis without tinnitus complaints remain a minority, yet might be underdiagnosed. Hence, future studies should disentangle tinnitus from hyperacusis. In clinical practice, greater efforts are required to increase knowledge about hyperacusis as a primary or secondary complaint and to provide individualized treatment for these patients.

The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis.

BACKGROUND: In patients with frequent migraine, prophylactic treatments are used. Patients often request non-pharmacological alternatives. One treatment option can be aerobic exercise. The value of aerobic exercise as prophylactic treatment however needs to be determined. METHODS: A systematic review and meta-analysis was performed to investigate the result of aerobic exercise on the number of migraine days, duration and pain intensity in patients with migraine. After screening three online databases, PubMed, Cochrane library and Web of Science, using predefined in- and exclusion criteria, six studies were retained. Pooling of data was performed when possible. RESULTS: Significant reductions in the number of migraine days after aerobic exercise treatment were found with a mean reduction of 0.6 ± 0.3 migraine days/month. Other outcomes were too variable to pool due to heterogeneity of outcome measurements. Unpooled data revealed small to moderate reductions in attack duration (20-27%) and pain intensity (20-54%) after aerobic exercise intervention. Various exercise intensities are applied. CONCLUSION: There is moderate quality evidence that in patients with migraine aerobic exercise therapy can decrease the number of migraine days. No conclusion for pain intensity or duration of attacks can be drawn. Effect sizes are small due to a lack of uniformity. For future studies, we recommend standardized outcome measures and sufficiently intense training programs. TRIAL REGISTRATION: CRD42018091178 .

Pressure pain thresholds over the cranio-cervical region in headache: a systematic review and meta-analysis.

BACKGROUND: Sensitivity of tissues can be measured by algometry. Decreased pressure pain thresholds over the cranio-cervical area are supposed to reflect signs of sensitization of the trigemino-cervical nucleus caudalis. A systematic review was conducted to assess the current scientific literature describing pressure pain threshold (PPT) values over the cranio-cervical region in patients with migraine, tension-type headache (TTH), and cervicogenic headache (CeH). A literature search was executed in three databases. The search strategy included the following keywords: migraine, TTH, CeH, PPT and algometry. A total of 624 papers was identified of which relevant papers were subsequently assessed for methodological quality. Twenty-two selected papers were assessed by two independent reviewers and the majority of studies scored low risk of bias on the selected items. Mean PPT values of several sites measured in the cranio-cervical region in patients with migraine, chronic TTH and CeH scored lower values compared to controls. The trapezius muscle (midpoint between vertebrae C7 and acromion) was the most frequently targeted site and showed significantly lower PPT values in adults with migraine (pooled standardized mean difference kPa: 1.26 [95%CI -1.71, -0.81]) and chronic TTH (pooled standardized mean difference kPa: -2.00 [95%CI -2.93, -1.08]). Most studies found no association between PPT values and headache characteristics such as frequency, duration or intensity. Further standardization of PPT measurement in the cranio-cervical region is recommended.

Inter- and Intrarater Reliability of Clinical Tests Associated With Functional Lumbar Segmental Instability and Motor Control Impairment in Patients With Low Back Pain: A Systematic Review.

OBJECTIVES: To provide a comprehensive overview of clinical tests associated with functional lumbar segmental instability and motor control impairment in patients with low back pain (LBP), and to investigate their intrarater reliability, interrater reliability, or both. DATA SOURCES: A systematic computerized search was conducted on December 1, 2015, in 4 different databases (starting search year is indicated in parentheses, with articles included from that year until December 1, 2015): PubMed (1972-), Web of Science (1955-), Embase (1947-), and MEDLINE (1946-). STUDY SELECTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed during design, search, and reporting stages of this review. The included population comprised patients with primary LBP. DATA EXTRACTION: Data were extracted as follows: (1) description and scoring of the clinical tests; (2) population characteristics; (3) inclusion and exclusion criteria; (4) description of the used procedures; (5) results for both intra- and interrater reliability; and eventually (6) notification on used statistical method. The risk of bias of the included articles was assessed with the use of the COnsensus-based Standards for the selection of health Measurement INstruments checklist. DATA SYNTHESIS: A total of 16 records were eligible, and 30 clinical tests were identified. All included studies investigated interrater reliability, and 3 studies investigated intrarater reliability. The identified interrater reliability scores ranged from poor to very good (κ=-.09 to .89; intraclass correlation coefficient, .72-.96), and the intrarater reliability scores ranged from fair to very good (κ=.51-.86). CONCLUSIONS: Three clinical tests (aberrant movement pattern, prone instability test, Beighton Scale) could be identified as having an adequate interrater reliability. No conclusions could be made for intrarater reliability. However, further research should focus on better study designs, provide an overall agreement for uniformity and interpretation of clinical tests, and should implement research regarding validity.

Frequency-Following Responses in Sensorineural Hearing Loss: A Systematic Review.

PURPOSE: This systematic review aims to assess the impact of sensorineural hearing loss (SNHL) on various frequency-following response (FFR) parameters. METHODS: Following PRISMA guidelines, a systematic review was conducted using PubMed, Web of Science, and Scopus databases up to January 2023. Studies evaluating FFRs in patients with SNHL and normal hearing controls were included. RESULTS: Sixteen case-control studies were included, revealing variability in acquisition parameters. In the time domain, patients with SNHL exhibited prolonged latencies. The specific waves that were prolonged differed across studies. There was no consensus regarding wave amplitude in the time domain. In the frequency domain, focusing on studies that elicited FFRs with stimuli of 170 ms or longer, participants with SNHL displayed a significantly smaller fundamental frequency (F0). Results regarding changes in the temporal fine structure (TFS) were inconsistent. CONCLUSION: Patients with SNHL may require more time for processing (speech) stimuli, reflected in prolonged latencies. However, the exact timing of this delay remains unclear. Additionally, when presenting longer stimuli (≥ 170 ms), patients with SNHL show difficulties tracking the F0 of (speech) stimuli. No definite conclusions could be drawn on changes in wave amplitude in the time domain and the TFS in the frequency domain. Patient characteristics, acquisition parameters, and FFR outcome parameters differed greatly across studies. Future studies should be performed in larger and carefully matched subject groups, using longer stimuli presented at the same intensity in dB HL for both groups, or at a carefully determined maximum comfortable loudness level.

Headache associated with cough: a review.

Headache only triggered by coughing is a rather uncommon condition. The aim of the present review is to present an overview of the diagnosis, clinical characteristics, pathophysiology and treatment of both primary and symptomatic cough headache and discuss other relevant headache disorders affected by coughing. The diagnosis of primary cough headache is made when headache is brought on and occurs only in association with coughing, straining or a Valsalva manoeuvre and in the absence of any abnormalities on neuro-imaging. In case an underlying pathology is identified as a cause of the headache, the diagnosis of symptomatic cough headache is made. The vast majority of these patients present with a Chiari malformation type I. Other frequently reported causes include miscellaneous posterior fossa pathology, carotid or vertebrobasilar disease and cerebral aneurysms. Consequently, diagnostic neuroimaging is key in the diagnosis of cough-related headache and guides treatment. Besides primary and symptomatic cough headache, several other both primary and secondary headache disorders exist where coughing acts as a trigger or aggravator of headache symptomatology.

How do patients with chronic dizziness experience a web-based home rehabilitation programme for customised vestibular therapy ('WeBaVeR')? A qualitative study.

BACKGROUND: Vestibular rehabilitation therapy (VRT) is the first choice approach for chronic dizziness. However, current home treatment programmes often lack attention to the individual needs of the patient and the integration of visual desensitisation therapy. We therefore developed a customised web-based VRT programme containing visual desensitisation exercises. OBJECTIVE: To assess the user experience (usability, satisfaction, acceptability, and quality) of patients with chronic dizziness with the customised WEb-BAsed VEstibular Rehabilitation, further called 'WeBaVeR'. METHODS: Patients with chronic dizziness, attending the Department of Otorhinolaryngology of the Antwerp University Hospital (period September 2021 to May 2022), received a customised programme, i.e. exercises supported by our web application and booklet. The programme lasted 6 weeks, with weekly supervision by phone. Patients' user experience was examined with the System Usability Scale (SUS), Client Satisfaction Questionnaire (CSQ), Service User Technology Acceptability Questionnaire (SUTAQ), and the User version of the Mobile Application Rating Scale (uMARS). RESULTS: Twelve patients with chronic dizziness (mean age: 45.33 ± 13.26 years) participated. The overall rated level of perceived usability (mean SUS score: 78.75 ± 8.95 points), satisfaction (mean CSQ score: 33.08 ± 3.37 points), acceptability (mean SUTAQ score: 105.67 ± 13.40 points) and quality (mean uMARS score: 94.58 ± 10.69 points) was good. The main remarks concerned the user interface and the interactive capabilities of the web application, and that WeBaVeR does not increase health awareness, or accessibility to health care providers. CONCLUSION: Patients with chronic dizziness consider WeBaVeR as useful, acceptable, satisfactory and of good quality. To facilitate implementation in practice, further optimisation of WeBaVeR based on the feedback received, is useful.

Construct validity of the Single Arm Military Press (SAMP) test for upper limb function in patients with neck pain.

BACKGROUND: Neck pain (NP) is often associated with upper limb disability (ULD). A clinically feasible measure to evaluate ULD in NP patients is necessary. The Single Arm Military Press (SAMP) is a ULD performance-based measure, specifically for NP patients. The validity of the SAMP in patients is still unknown. OBJECTIVE: To explore the construct validity (hypotheses testing) of the SAMP in NP patients. METHODS: A total of 210 NP patients and 81 controls were recruited. The SAMP; Disability of the Arm, Shoulder, and Hand (DASH); and Neck Disability Index (NDI) were completed at baseline and 4-7 days later. The Visual Analogue Scale (VAS) was used to measure NP and ULD severity pre-testing in both occasions. Patients were divided into 4-subgroups based on their NDI score. Convergent validity was examined using Pearson correlation. The t-test and analysis of variance (ANOVA) were used to evaluate discriminant and known groups' validity. To determine SAMP cut-off scores, the sensitivity and specificity were explored. RESULTS: A negative correlation between the SAMP and DASH/NDI scores was found in the patient group (r = -0.91 and -0.87, p < 0.01). The t-test revealed substantial differences (t = -23.96) in score between patients and controls. Also, ANOVA revealed substantial differences (f = 20.86) between the patients' subgroups. The area under the curve (AUC) for patients and controls exceeded 0.90 when sensitivity and specificity were at equal importance. CONCLUSION: The SAMP can distinguish between NP patients and controls, and between different NP disability levels. The responsiveness of the SAMP needs to be investigated.

The multiple hop test: a discriminative or evaluative instrument for chronic ankle instability?

OBJECTIVE: To determine whether the multiple hop test should be used as an evaluative or a discriminative instrument for chronic ankle instability (CAI). DESIGN: Blinded case-control study. SETTING: : University research laboratory. PARTICIPANTS: Twenty-nine healthy subjects (21 men, 8 women, mean age 21.8 years) and 29 patients with CAI (17 men, 12 women, mean age 24.9 years) were selected. INTERVENTIONS: Subjects performed a multiple hop test and hopped on 10 different tape markers while trying to avoid any postural correction. MAIN OUTCOME MEASURES: Minimal detectable changes (MDC) of the number of balance errors, the time value, and the visual analog scale (VAS) score (perceived difficulty) were calculated as evaluative measures. For the discriminative properties, a receiver operating characteristic curve was determined and the area under curve (AUC), the sensitivity, specificity, diagnostic accuracy (DA), and likelihood ratios (LR) were calculated whether 1, 2, or 3 outcomes were positive. RESULTS: Based on their MDC, outcomes should, respectively, change by more than 7 errors (41%), 6 seconds (15%), and 27 mm (55%, VAS score) before considering it as a real change. Area under curves were, respectively, 79% (errors), 77% (time value), and 65% (VAS score). The most optimal cutoff point was, respectively, 13.5 errors, 35 seconds, and 32.5 mm. When 2 of 3 outcomes were positive, the sensitivity was 86%, the specificity was 79%, the DA was 83%, the positive LR was 4.2, and the negative LR was 0.17. CONCLUSIONS: The multiple hop test seems to be more a discriminative instrument for CAI, and its responsiveness needs to be demonstrated.

Evidence-based treatment methods for the management of shoulder impingement syndrome among Dutch-speaking physiotherapists: an online, web-based survey.

OBJECTIVE: The purpose of this study is to examine whether Dutch-speaking physiotherapists in Belgium report using evidence-based practice methods for the treatment for patients with shoulder impingement syndrome (SIS). METHODS: An online questionnaire, consisting of open-ended and multiple choice questions, was sent to Dutch-speaking members of the representative Belgian physiotherapists society that likely treated patients with shoulder pain. The electronic survey was sent to members of the Belgian Physiotherapists Society (AXXON) (n = 3877). Therapists were asked to report interventions that they used for the treatment for patients with SIS. Survey responses were interpreted using current literature that supports various active treatments for SIS, including supervised exercise, home exercise, and exercise therapy combined with manual therapy. RESULTS: A total of 119 (3%) of the AXXON members completed the online survey (68 men; mean age, 38 years). Sixty-one percent of the respondents were manual therapists, and 36% were sports physiotherapists. Exercise therapy was the most often reported therapeutic intervention (96.6%). Manual mobilization was most frequently reported for the treatment of SIS (94.1%), followed by postural training (85.7%) and stretching (76.5%). The remaining interventions were applied by less than 54% of the responders. CONCLUSIONS: The results suggest that exercise therapy and manual therapy were reportedly used by most physiotherapists responding to this survey. These practices are in line with current evidence for the treatment of SIS.

Comparison of Clinical Balance and Visual Dependence Tests in Patients With Chronic Dizziness With and Without Persistent Postural-Perceptual Dizziness: A Cross-Sectional Study.

Background: The diagnosis of persistent postural-perceptual dizziness (PPPD) is primarily based on medical history taking. Research on the value of clinical balance and visual dependence tests in identifying PPPD is scarce. Objectives: (1) to contrast clinical balance and visual dependence tests between PPPD patients, dizzy non-PPPD patients, and healthy persons; and (2) to evaluate whether these clinical tests can help to identify PPPD in patients with chronic dizziness. Methods: Consecutive patients with chronic dizziness (38 PPPD and 21 non-PPPD) and 69 healthy persons underwent Static Balance tests, the Timed Up and Go test, the Tandem Gait test, and the Functional Gait Assessment (FGA). Visual dependence tests included the Visual Vertigo Analog Scale (VVAS), the Rod-and-Disc test (RDT), and postural sway while facing rotating dots. Groups were compared using ANOVA with post-hoc Tukey, or independent samples t-tests. The value of the clinical tests for PPPD identification was evaluated through logistic regression and Partial Least Squares Discriminant (PLS-DA) analyses. Results: PPPD patients had significantly higher VVAS scores than dizzy non-PPPD patients (p = 0.006). Facing rotating dots, PPPD and dizzy non-PPPD patients had increased postural sway compared to healthy persons (PPPD vs. healthy: center of pressure (COP) velocity p < 0.001, and COP area p < 0.001; but non-PPPD vs. healthy: COP velocity p = 0.116 and COP area p = 0.207). PPPD patients had no significantly increased postural sway compared to dizzy non-PPPD patients. PPPD and dizzy non-PPPD patients also scored significantly worse on balance tests compared to healthy persons (PPPD vs. healthy: for all balance tests p < 0.001; non-PPPD vs. healthy: FGA p < 0.001, for all other tests p < 0.05). Differences were insignificant in balance scores between PPPD and dizzy non-PPPD patients, or in RDT scores between the three study groups. In patients with chronic dizziness, a higher VVAS score was most associated with PPPD [odds ratio 1.04; 95% CI (1.01; 1.07); p = 0.010]. The cross-validated (CV) PLS-DA model with all clinical tests included, had fair discriminative ability (CVerror = 47%). Conclusion: PPPD patients were more visually dependent, but did not have worse postural balance compared to dizzy non-PPPD patients. Elevated VVAS scores characterized PPPD most in patients with chronic dizziness.

Outcome for dizzy patients in a physiotherapy practice: an observational study.

BACKGROUND: Dizziness is a common reason for referral to physiotherapy. Additional information on clinical characteristics, treatment effect and prognostic indicators in physiotherapy practice are needed. METHODS: A retrospective observational study. Based on a standardised clinical evaluation patients were labelled as having Benign Paroxysmal Positioning Vertigo (BPPV) or not (no-BPPV). BPPV was treated with repositioning manoeuvres and exercises. In no-BPPV, treatment was based on additional clinical tests. Treatment was provided once per week and considered successful when the patient was free of symptoms confirmed by negative positional tests. RESULTS: From 148 referred patients, 88 were labelled as having BPPV, 60 as no-BPPV. The symptom of a short-lasting spinning sensation provoked by head movements was highly suggestive of BPPV. On average, in BPPV treatment was completed after 2.27 ± 1.68 treatments, in no-BPPV this was after 4.91 ± 3.46 treatments. The delayed outcome was related to higher 'age' and 'concomitant neck pain' in BPPV and with higher 'age' only in no-BPPV. Favourable outcome was related to the feature 'dizziness provoked by movements in the horizontal plane' in BPPV. CONCLUSIONS: Clinical evaluation and treatment in physiotherapy practice can be an effective and safe option for patients with dizziness. Several clinical variables with prognostic values were identified.Key messagesClinical evaluation and treatment in physiotherapy practice can be part of low threshold care for dizzy patients.Despite prior medical screening, one-third of patients without signs of BPPV were sent back for further evaluation, illustrating the need for interdisciplinary collaboration.Based on the description of the dizziness symptom (vertigo rather than light-headedness), provocation of the dizziness by movements, and a short duration of the dizziness attack, and positive clinical vestibular tests, BPPV treatment could be initiated.

Systematic review and meta-analysis of the therapeutic management of patients with cervicogenic dizziness.

BACKGROUND: Patients with cervicogenic dizziness (CGD) present with dizziness, cervical spine dysfunctions, and postural imbalance, symptoms that can significantly impact their daily functioning. OBJECTIVES: To provide evidence-based recommendations for the management of patients with CGD. METHODS: Three databases were searched for randomized controlled trials (RCTs) (last search 15 May 2021). Outcome measures included dizziness, cervical spine, and balance parameters. Cochrane standard methodological procedures were used and included the RoB 2.0 and GRADE. Where possible, RCTs were pooled for meta-analysis. RESULTS: Thirteen RCTs (n = 898 patients) of high (two RCTs), moderate (five RCTs), and low (six RCTs) methodological quality were analyzed. Six RCTs were included in the meta-analysis. Only three RCTs specified the cause of CGD. They showed inconsistent findings for the effectiveness of exercise therapy in patients with traumatic CGD. Manual therapy and manual therapy combined with exercise therapy may reduce CGD, cervical spine, and balance dysfunctions. CONCLUSION: There is moderate quality of evidence that manual therapy reduces CGD, cervical spine, and balance symptoms. When manual therapy is combined with exercise therapy, the positive effect on CGD, cervical spine, and balance symptoms is even stronger. However, the quality of the evidence here is very low.

Clinical characteristics and diagnostic aspects of cervicogenic dizziness in patients with chronic dizziness: A cross-sectional study.

BACKGROUND AND OBJECTIVES: Chronic dizziness can significantly affect quality of life, but identifying the underlying cause remains challenging. This study focuses on proprioceptive cervicogenic dizziness (CGD) and aims: (1) to compare clinical test results between patients with CGD, dizzy patients without CGD, and healthy controls; and (2) to evaluate the diagnostic value of the clinical tests for CGD in patients with chronic dizziness. METHODS: Sixty patients with chronic dizziness (18 with CGD and 42 without CGD), and 43 healthy controls underwent clinical tests evaluating neck function (mobility, proprioception, muscle function and disability), balance control, and the presence of visually induced dizziness. Data were analysed through one-way ANOVA, chi-square, independent samples t-test, and logistic regression analyses. RESULTS: Patients with CGD had significantly more neck pain-related disability (Neck Bournemouth questionnaire (NBQ), p = 0.006), but better static (Static Balance, p = 0.001) and dynamic balance (Tandem Gait, p = 0.049), compared to dizzy patients without CGD. Univariable analyses revealed that increased NBQ (OR 1.05 [1.01; 1.09], p = 0.017), Joint Position Error (JPE) after extension (OR 1.52 [1.00; 2.32], p = 0.050), and Tandem Gait scores (OR 1.09 [1.01; 1.18], p = 0.046) were individually associated with higher odds of having CGD. Their optimal cut-off level (based on the maximum Youden index) had high sensitivity but low specificity for CGD. The multivariable model, including NBQ and Tandem Gait, had fair discriminative ability (AUC = 0.74, 95% CI [0.61; 0.87]). CONCLUSION: The combined use of the NBQ and Tandem Gait tests had the highest discriminative ability to detect CGD in patients with chronic dizziness.

Modulation of Central Nociceptive Transmission by Manual Pressure Techniques in Patients with Migraine: An Observational Study.

Background: Manual pressure in the upper cervical spine is used to provoke and reduce the familiar migraine headache. Information is scarce on the segmental levels, myofascial structure provocation, and reduction occurrences. The required dosage (amount of pressure, number of repetitions, and duration) has not been objectified yet. Methods: Prospective observational study. Thirty patients with migraine were examined interictally. Manual pressure was applied at four sites: the posterior arch of C1, the articular pillar of C2, the rectus capitis posterior major muscle, and the obliquus capitis inferior muscle, bilaterally. On sites where the familiar headache was provoked, the pressure was sustained to induce pain reduction (three repetitions). Provocation of familiar headache (yes/no), headache intensity (numerical pain rating scale), time to obtain a reduction of the headache (seconds), and applied pressure (g/cm2) were recorded. Results: Provocation of the familiar headache occurred at the posterior arches C1 in 92%, and at one of the articular pillars of C2 in 65.3% of cases. At one of the rectus capitis major muscles, the familiar headache was provoked in 84.6% of cases; at one of the oblique capitis inferior muscles, the familiar headache was provoked in 76.9% of cases. The applied mean pressure ranged from 0.82 to 1.2 kg/cm2. Maintaining the pressure reduced headache pain intensity significantly between the start and end of each of the three consecutive trials (p < 0.04). This reduction occurred faster in the third application than in the first application (p = 0.03). Conclusion: Manual pressure at upper cervical segments provokes familiar referred migraine headaches, with low manual pressure. Maintaining the pressure reduces the referred head pain significantly, indicating modulation of central nociceptive transmission.

Reduction of Somatic Tinnitus Severity is Mediated by Improvement of Temporomandibular Disorders.

BACKGROUND: Successful orofacial treatment can reduce tinnitus severity in patients with somatic tinnitus (ST). However, it is still unclear to what extent the degree of reduction in temporomandibular disorders (TMD) actually contributes to the decrease in tinnitus severity after orofacial treatment. Therefore, the aim of this study was to analyze the mediating effect of reduction in TMD pain on the improvement of tinnitus severity after multidisciplinary orofacial treatment. METHODS: A total of 80 patients with moderate to severe ST attributed to the temporomandibular region, were recruited from a tertiary tinnitus clinic. At baseline, patients were randomly assigned to the orofacial treatment group or to the control group. Both groups received a minimum of information and advice regarding their tinnitus complaints. The orofacial treatment group received orofacial physical therapy complemented with occlusal splints when needed, while the control group received no other treatment. A mediation analysis was performed according to the steps described by Baron and Kenny and the proportion of the mediating effect was calculated for the potential mediator: "change in TMD pain," measured by a one-point decrease in TMD pain screener score. RESULTS: Our analysis showed that 35% of the observed decrease in tinnitus severity can be attributed to a reduction in TMD pain. A significant total effect of orofacial treatment compared with control on the change in tinnitus functional index (TFI) score was found (B = 0.253 p = 0.025 Cl for B = 1.265-18.576). Orofacial treatment was also significantly related to the change in TMD pain (Exp (B) = 2.800, p = 0.034 Cl for Exp B 1.081-7.251). Additionally, the change in TMD pain screener score was significantly related to the change in TFI score (B = -0.273 p = 0.016 Cl for B = -19.875 to -2.119). CONCLUSION: Reduction of TMD pain is a mediating factor in the decrease of tinnitus severity after multidisciplinary orofacial treatment. PRACTICAL IMPLICATIONS: Orofacial treatment can be used to decrease tinnitus severity in patients with TMD related somatic tinnitus.