Therapeutic Exercise Parameters, Considerations, and Recommendations for Migraine Treatment: An International Delphi Study.

OBJECTIVE: The goal of this study was to reach consensus about the best exercise prescription parameters, the most relevant considerations, and other recommendations that could be useful for prescribing exercise to patients with migraine. METHODS: This was an international study conducted between April 9, 2022 and June 30, 2022. An expert panel of health care and exercise professionals was assembled, and a 3-round Delphi survey was performed. Consensus was reached for each item if an Aiken V Validity Index ≥ 0.7 was obtained. RESULTS: The study included 14 experts who reached consensus on 42 items by the third round. The most approved prescription parameters were 30 to 60 minutes of exercise per session, 3 days per week of moderate-intensity continuous aerobic exercise, and relaxation and breathing exercises for 5 to 20 minutes every day. When considering an exercise prescription, initial exercise supervision should progress to patient self-regulation; catastrophizing, fear-avoidance beliefs, headache-related disability, anxiety, depression, physical activity baseline level, and self-efficacy could influence the patients' exercise participation and efficacy; and gradual exposure to exercise could help improve these psychological variables and increase exercise efficacy. Yoga and concurrent exercise were also included as recommended interventions. CONCLUSION: From the experts in the study, exercise prescriptions should be adapted to patients with migraine considering different exercise modalities, such as moderate-intensity aerobic exercise, relaxation, yoga, and concurrent exercise, based on the patients' preferences and psychological considerations, level of physical activity, and possible adverse effects. IMPACT: The consensus reached by the experts can help prescribe exercise accurately to patients with migraine. Offering various exercise modalities can improve exercise participation in this population. The evaluation of the patients' psychological and physical status can also facilitate the adaptation of the exercise prescription to their abilities and diminish the risk of adverse events.

Prescription of therapeutic exercise in migraine, an evidence-based clinical practice guideline.

The main objective of this clinical practice guideline is to provide a series of recommendations for healthcare and exercise professionals, such as neurologists, physical therapists, and exercise physiologists, regarding exercise prescription for patients with migraine.This guideline was developed following the methodology and procedures recommended in the Appraisal of Guidelines for Research and Evaluation (AGREE). The quality of evidence and strength of recommendations were evaluated with the Scottish Intercollegiate Guidelines Network (SIGN). A systematic literature review was performed and an established appraisal process was employed to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development, and Evaluation methodology).The evaluation of the current evidence, the elaboration of the grades of recommendation, and their validation show a B grade of recommendation for aerobic exercise, moderate-continuous aerobic exercise, yoga, and exercise and lifestyle recommendations for the improvement of symptoms, disability, and quality of life in patients with migraine. Relaxation techniques, high-intensity interval training, low-intensity continuous aerobic exercise, exercise and relaxation techniques, Tai Chi, and resistance exercise obtained a C grade of recommendation for the improvement of migraine symptoms and disability.

Manual therapy and exercise in temporomandibular joint disc displacement without reduction. A systematic review.

OBJECTIVE: The aim of this systematic review was to analyze the effectiveness of exercise and manual therapy interventions in patients with disc displacement without reduction. METHOD: The authors performed a systematic review of Medline, EMBASE, PEDro, CINAHL, and Google Scholar databases. Two independent reviewers conducted the eligibility and quality assessment of studies. Interventions based on exercise and manual therapy regarding pain intensity and maximum mouth opening as primary outcomes were examined. RESULTS: Ten articles were included, according to the inclusion criteria. Most of the interventions showed statistically significant improvements in the primary outcomes. CONCLUSION: Results show that interventions based on therapeutic exercise or manual therapy may be beneficial and play a role in the treatment of disc displacement without reduction. Limited evidence suggests that exercise significantly improves mouth opening in comparison to splints. Due to the heterogeneity of the included studies, these results should be interpreted with caution.

Effect of Manual Therapy and Therapeutic Exercise Applied to the Cervical Region on Pain and Pressure Pain Sensitivity in Patients with Temporomandibular Disorders: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the effectiveness of cervical manual therapy (MT) on patients with temporomandibular disorders (TMDs) and to compare cervico-craniomandibular MT vs cervical MT. DESIGN: Systematic review and meta-analysis (MA). METHODS: A search in PubMed, EMBASE, PEDro, and Google Scholar was conducted with an end date of February 2019. Two independent reviewers performed the data analysis, assessing the relevance of the randomized clinical trials regarding the studies' objectives. The qualitative analysis was based on classifying the results into levels of evidence according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE). RESULTS: Regarding cervical MT, MA included three studies and showed statistically significant differences in pain intensity reduction and an increase in masseter pressure pain thresholds (PPTs), with a large clinical effect. In addition, the results showed an increase in temporalis PPT, with a moderate clinical effect. MA included two studies on cervical MT vs cervico-craniomandibular MT interventions and showed statistically significant differences in pain intensity reduction and pain-free maximal mouth opening, with a large clinical effect. CONCLUSIONS: Cervical MT treatment is more effective in decreasing pain intensity than placebo MT or minimal intervention, with moderate evidence. Cervico-craniomandibular interventions achieved greater short-term reductions in pain intensity and increased pain-free MMO over cervical intervention alone in TMD and headache, with low evidence.

Effect of brain training through visual mirror feedback, action observation and motor imagery on orofacial sensorimotor variables: A single-blind randomized controlled trial.

OBJECTIVES: The main objective was to evaluate the effects of action observation (AO), visual mirror feedback (VMF) and motor imagery (MI), combined with an oro-facial exercise programme, on sensorimotor variables in asymptomatic participants. METHODS: We designed a randomised, single-blind, controlled trial that included 52 asymptomatic participants who were randomly assigned to 4 groups, 13 to each of the VMF, MI and AO groups and 13 to the control group (CG), which only performed the exercise programme. The primary outcomes were pain pressure sensitivity and tongue muscle strength. The secondary outcomes were maximum mouth opening, tongue length and the ability to generate mental motor images. Each group underwent a 3-session intervention using their respective exercise. Measurements were performed before starting the intervention and after each of the 3 sessions (pre, mid1, mid2 and post). RESULTS: ANOVA revealed significant changes in PPTs in the masseter muscle region in the MI and AO groups in the pre-post and mid1-post changes. ANOVA revealed significant differences in tongue muscle strength in the anterior direction only in the AO group in the pre-mid2 and pre-post changes. CONCLUSIONS: AO and MI, in conjunction with exercise, could induce changes in PPTs for the masseter muscle. In addition, only AO produced changes in tongue muscle strength. More research is needed to determine the role of brain representation techniques in the oro-facial region and transferring this exercise to the rehabilitation setting.

Effects of mental and physical orofacial training on pressure pain sensitivity and tongue strength: A single-blind randomized controlled trial.

OBJECTIVES: The main objective of this study was to analyze differences on pain pressure thresholds, tongue strength and perceived effort between various orofacial motor exercise training dosages of mental representation training through motor imagery (MI) and action observation (AO), first in isolation and then in combination with real exercise performance. METHODS: A single-blind randomized controlled trial was designed. 48 asymptomatic individuals were randomized into two groups: Intensive training group (IG) and Moderate training group (MG). Both groups performed a first session of MI and AO of orofacial exercises training and a second session of actual orofacial exercises combined with mental representation training, but with different dosage in terms of series and repetitions. Pain pressure thresholds (PPTs) in the masseter and temporal muscles and tongue muscle strength were the main variables. RESULTS: Regarding the PPT, ANOVA revealed significant between-group differences, where MG showed a significantly higher PPT than IG at post-day2, with a medium effect size. Both groups showed with-in group differences between pre and post intervention measures in the first session, but only the IG showed differences in the second. Regarding tongue muscle strength, ANOVA revealed significant within-group differences only in MG between the pre-day and post-day first intervention. CONCLUSION: The results of the present study suggest that movement representation training performed in isolation may have a positive effect on PPTs and tongue muscle strength. In addition, the combination with the actual execution of the exercises could be considered effective, but it is necessary to take into account the training dosage to avoid fatigue responses.

Visual motor imagery predominance in professional Spanish dancers.

Purpose: The main objectives of the study were to analyse the predominant motor imagery modality used by professional Spanish dancers and to compare Spanish dancers' ability to perform mental motor imagery with that of non-dancers, and to analyse differences between male and female dancers. As a secondary aim, to compare the motor imagery ability between two styles of Spanish dance: classical Spanish dancers and Flamenco dancers. Methods: A total of 74 participants were classified into two groups: professional Spanish dancers (n = 37) and sedentary participants (n = 37). The professional Spanish dancer group was composed of two dance disciplines: flamenco dancers (n = 17), and classical dancers (n = 20). Results: Professional Spanish dancers used predominantly visual imagery modalities over kinesthetics to generate motor imagery, with a moderate effect size (p < .01, d = 0.68). Regarding the ability to generate motor imagery, significant intergroup differences between professional Spanish dancers and sedentary participants were observed in all variables, with a large effect size (p < .05, d > 0.80). Differences were obtained between men and women among non-dancers group (t = -3.34; p = .03; d = 0.5). No differences between Flamenco and classical dancers were observed. Conclusion: Visual motor imagery modality was easier than the kinaesthetic modality in the generation of motor imagery for professional Spanish dancers regardless of the dance style. Spanish dancers had a greater ability to perform motor imagery compared with non-dancer individuals, needing less time to perform these mental tasks. Men non-dancers had a greater ability to generate motor imagery than women. Reinforcing the training of kinaesthetic motor imagery might be useful for professional Spanish dancers.

Familiarity and complexity of a movement influences motor imagery in dancers: A cross-sectional study.

The present study aimed to analyze the differences between ballet, contemporary, and flamenco dancers when generating mental motor kinesthetic and visual images of simple and complex movements. A cross-sectional study, including 45 professional dancers (15 flamenco dancers, 15 ballet dancers, and 15 contemporary dancers), was planned. We analyzed the ability to generate mental motor visual and kinesthetic images with the revised movement imagery questionnaire (MIQ-R) and mental chronometry (MC); the real movement execution (RME) chronometry was also measured, using arm and jump movement assessments. ANOVA revealed significant differences between groups regarding the jump movement assessments for the kinesthetic MIQ-R item (F = 5.29, P = 0.009), for the RME chronometry (F = 13.19, P = <0.001), and for the kinesthetic MC (F = 9.28, P < 0.001). The post-hoc analysis revealed significant differences between flamenco dancers compared with contemporary and ballet dancers for all the variables regarding the jump movement. Flamenco dancers used significantly greater visual than kinesthetic imagery modalities to generate mental motor imagery in the jump movement (P = 0.024, d = 0.63). No differences were found in the arm movement assessment between groups. Results reveal differences in the ability to generate motor images, specifically the kinesthetic ones, between flamenco dancers and ballet and contemporary dancers. When performing a non-familiar complex movement, dancers predominantly use a visual motor imagery modality, which leads to a longer execution time as well as a longer time for kinesthetic mental motor imagery.

Diminished Kinesthetic and Visual Motor Imagery Ability in Adults With Chronic Low Back Pain.

BACKGROUND: Low back pain (LBP) is the most prevalent musculoskeletal problem among adults. It has been observed that patients with chronic pain have maladaptive neuroplastic changes and difficulty in imagination processes. OBJECTIVE: To assess the ability of patients with chronic LBP (CLBP) to generate kinesthetic and visual motor images and the time they spent on this mental task compared with asymptomatic participants. DESIGN: A prospective, cross-sectional study. SETTING: Primary health care center in Madrid, Spain. PARTICIPANTS: A total of 200 participants were classified into 2 groups: asymptomatic participants (n = 100) and patients with CLBP (n = 100). METHODS: After consenting to participate, all recruited participants received a sociodemographic questionnaire, a set of self-report measures and completed the Revised Movement Imagery Questionnaire. MAIN OUTCOMES MEASUREMENTS: Visual and Kinesthetic Motor Imagery Ability using the Revised Movement Imagery Questionnaire. A mental chronometry using a stopwatch and psychosocial variables using self-reported questionnaires. RESULTS: Our results indicated that patients with CLBP had difficulty generating kinesthetic and visual motor images and also took a longer time to imagine them. A regression analysis indicated that in the CLBP group, the predictor variable for fear of activity and coping symptom self-efficacy was visual motor imagery (explaining 16.2% of the variance); however, the predictor variable for LBP disability and pain management self-efficacy was kinesthetic motor imagery (explaining 17.8% of the variance). CONCLUSIONS: It appears that patients with CLBP have greater difficulty generating visual and kinesthetic motor images compared with asymptomatic participants, and they also need more time to perform these mental tasks. LEVEL OF EVIDENCE: II.

Combining motor imagery with action observation training does not lead to a greater autonomic nervous system response than motor imagery alone during simple and functional movements: a randomized controlled trial.

Both motor imagery (MI) and action observation (AO) trigger the activation of the neurocognitive mechanisms that underlie the planning and execution of voluntary movements in a manner that resembles how the action is performed in a real way. The main objective of the present study was to compare the autonomic nervous system (ANS) response in an isolated MI group compared to a combined MI + AO group. The mental tasks were based on two simple movements that are recorded in the revised movement imagery questionnaire in third-person perspective. The secondary objective of the study was to test if there was any relationship between the ANS variables and the ability to generate mental motor imagery, the mental chronometry and the level of physical activity. The main outcomes that were measured were heart rate, respiratory rate and electrodermal activity. A Biopac MP150 system, a measurement device of autonomic changes, was used for the quantification and evaluation of autonomic variables. Forty five asymptomatic subjects were selected and randomized in three groups: isolated MI, MI + AO and control group (CG). In regards to the activation of the sympathetic nervous system (SNS), no differences were observed between MI and MI + AO groups (p > .05), although some differences were found between both groups when compared to the CG (p < .05). Additionally, even though no associations were reported between the ANS variables and the ability to generate mental motor imagery, moderate-strong positive associations were found in mental chronometry and the level of physical activity. Our results suggest that MI and MI + AO, lead to an activation of the SNS, although there are no significant differences between the two groups. Based on results obtained, we suggest that tasks of low complexity, providing a visual input through the AO does not facilitates their subsequent motor imagination. A higher level of physical activity as well as a longer time to perform mental task, seem to be associated with a greater increase in the ANS response.

Multimodal physiotherapy treatment based on a biobehavioral approach for patients with chronic cervico-craniofacial pain: a prospective case series.

The purpose of this prospective case series was to observe and describe changes in patients with chronic cervico-craniofacial pain of muscular origin treated with multimodal physiotherapy based on a biobehavioral approach. Nine patients diagnosed with chronic myofascial temporomandibular disorder and neck pain were treated with 6 sessions over the course of 2 weeks including: (1) orthopedic manual physiotherapy (joint mobilizations, neurodynamic mobilization, and dynamic soft tissue mobilizations); (2) therapeutic exercises (motor control and muscular endurance exercises); and (3) patient education. The outcome measures of craniofacial (CF-PDI) and neck disability (NDI), kinesiophobia (TSK-11) and catastrophizing (PCS), and range of cervical and mandibular motion (ROM) and posture were collected at baseline, and at 2 and 14 weeks post-baseline. Compared to baseline, statistically significant (p < 0.01) and clinically meaningful improvements that surpassed the minimal detectable change were observed at 14 weeks in CF-PDI (mean change, 8.11 points; 95% confidence interval (CI): 2.55 to 13.69; d = 1.38), in NDI (mean change, 5 cm; 95% CI: 1.74-8.25; d = 0.98), and in the TSK-11 (mean change, 6.55 cm; 95% CI: 2.79-10.32; d = 1.44). Clinically meaningful improvements in self-reported disability, psychological factors, ROM, and craniocervical posture were observed following a multimodal physiotherapy treatment based on a biobehavioral approach.

Comparison of Dry Needling versus Orthopedic Manual Therapy in Patients with Myofascial Chronic Neck Pain: A Single-Blind, Randomized Pilot Study.

Objective. The aim of this study was to compare the efficacy of three interventions for the treatment of myofascial chronic neck pain. Methods. Thirty-six patients were randomly assigned to one of three intervention groups: orthopedic manual therapy (OMT), dry needling and stretching (DN-S), and soft tissue techniques (STT). All groups received two treatment sessions with a 48 h time interval. Outcome measures included neck pain intensity measured using a visual analogue scale, cervical range of motion (ROM), pressure pain threshold for measuring mechanical hyperalgesia, and two self-reported questionnaires (neck disability index and pain catastrophizing scale). Results. The ANOVA revealed significant differences for the group × time interaction for neck disability, neck pain intensity, and pain catastrophizing. The DN-S and OMT groups reduced neck disability. Only the OMT group showed decreases in mechanical hyperalgesia and pain catastrophizing. The cervical ROM increased in OMT (i.e., flexion, side-bending, and rotation) and DN-S (i.e., side-bending and rotation) groups. Conclusions. The three interventions are all effective in reducing pain intensity. Reduction in mechanical hyperalgesia and pain catastrophizing was only observed in the OMT group. Cervical ROM improved in the DN-S and OMT groups and also neck disability being only clinically relevant for OMT group.

Effectiveness of therapeutic patient education for adults with migraine. A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Our aim was to systematically review and meta-analyze the effectiveness of therapeutic patient education for migraine. METHODS: A literature search of multiple electronic databases (MEDLINE, EMBASE, PEDro, CINAHL, and PsychINFO) was conducted to identify randomized control trials (RCTs) published in the English and Spanish languages up to and including May 2013. Two reviewers independently selected the studies, conducted the quality assessment (Delphi list), and extracted the results. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was used throughout the systematic review and meta-analysis. Standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated for relevant outcome measures (headache frequency, headache disability, self-efficacy, depressive symptoms, and quality of life) and pooled in a meta-analysis using the random effects model. RESULTS: Fourteen RCTs were included in the systematic review. Only nine studies were included in the meta-analysis. The median quality score was 6.14 ± 1.29 (range: 5-9). There was strong-moderate evidence for intermediate-term effectiveness of therapeutic patient education on headache frequency (five studies: N = 940, SMD = -0.24, 95% CI of -0.48 to -0.01, P = 0.03), headache disability (four studies: N = 799, SMD = -1.02, 95% CI of -1.95 to -0.08, P = 0.03), and quality of life (three studies: N = 674, SMD = 0.36, 95% CI of 0.05-0.67, P = 0.02). There was no evidence for either short-term or intermediate-term effectiveness of therapeutic patient education on self-efficacy or depressive symptoms. CONCLUSION: This systematic review revealed strong-moderate evidence for intermediate-term effectiveness of therapeutic patient education for migraine. Further high-quality RCTs are required for conclusive determination of its effectiveness.

Does mobilization of the upper cervical spine affect pain sensitivity and autonomic nervous system function in patients with cervico-craniofacial pain?: A randomized-controlled trial.

OBJECTIVES: The aims were to investigate the effects of anterior-posterior upper cervical mobilization (APUCM) on pain modulation in craniofacial and cervical regions and its influence on the sympathetic nervous system. METHODS: Thirty-two patients with cervico-craniofacial pain of myofascial origin were randomly allocated into experimental or placebo groups. Each patient received 3 treatments. Outcome measures included bilateral pressure pain thresholds assessed at craniofacial and cervical points preintervention, after the second intervention and after the final treatment. Pain intensity and sympathetic nervous system variables (skin conductance, breathing rate, heart rate, and skin temperature) were assessed before and immediately after each intervention. RESULTS: The pressure pain thresholds in the craniofacial and cervical regions significantly increased (P<0.001) and pain intensity significantly decreased (P<0.001) in the treatment group compared with placebo. APUCM also produced a sympathoexcitatory response demonstrated by a significant increase in skin conductance, breathing rate, and heart rate (P<0.001), but not in skin temperature (P=0.071), after application of the technique compared with placebo. DISCUSSION: This study provided preliminary evidence of a short-term hypoalgesic effect of APUCM on craniofacial and cervical regions of patients with cervico-craniofacial pain of myofascial origin, suggesting that APUCM may cause an immediate nociceptive modulation in the trigeminocervical complex. We also observed a sympathoexcitatory response, which could be related to the hypoalgesic effect induced by the technique, but this aspect should be confirmed in future studies.

Influence of different upper cervical positions on electromyography activity of the masticatory muscles.

OBJECTIVE: The aim of this study was to determine the activity of the masseter and anterior temporalis muscles in relation to different positions of the upper cervical spine during maximal voluntary isometric clenching by surface electromyography (EMG). METHODS: This was a cross-sectional study with a repeated-measures design performed using 25 asymptomatic subjects (13 female and 12 male; mean age, 31 years; SD, 8.51). The EMG activity of the masseter and anterior temporalis muscles was recorded bilaterally during maximal clenching at neutral position and during extension, flexion, ipsilateral lateral flexion, contralateral lateral flexion, and ipsilateral and contralateral rotations in maximal flexion. In addition, the upper cervical range of motion and mandibular excursions were assessed. The EMG activity data were analyzed using a 3-way analysis of variance in which the factors considered were upper cervical position, sex (male and female), and side (right and left), and the hypothesis of importance was the interaction side x position. RESULTS: The 3-way analysis of variance detected statistically significant differences between the several upper cervical positions (F = 13.724; P < .001) but found no significant differences for sex (F = 0.202; P = .658) or side (F = 0.86; P = .53) regarding EMG activity of the masseter muscle. Significant differences were likewise observed for interaction side x position for the masseter muscle (F = 12.726; P < .001). The analysis of the EMG activity of anterior temporalis muscle did not produce statistically significant differences (P > .05). CONCLUSION: This preliminary study suggests that the upper cervical movements influence the surface EMG activity of the masseter muscle. These findings support a model in which there are interaction between the craniocervical and the craniomandibular system.

Acupuncture in the treatment of pain in temporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: The aim of this study is to perform a qualitative and quantitative analysis of the scientific literature regarding the use of acupuncture in the treatment of pain associated with temporomandibular disorders (TMDs). METHODS: By using electronic databases, the goal was to search and evaluate all the randomized controlled trials (RCTs) in which acupuncture was used in the management of pain attributed to these clinical entities. For the meta-analysis, an adequate description of the results' statistical data was required along with a comparison of the treatment with a control group using a placebo or sham. Two independent reviewers evaluated the quality of the studies using the Jadad scale. RESULTS: A total of 8 RCTs were selected, and the quality of only 4 was considered acceptable. These 4 studies showed positive results such as reducing pain, improving masticatory function, and increasing maximum interincisal opening. By combining the studies (n=96) and analyzing the results, it was concluded that acupuncture is more effective than placebo in reducing pain intensity in TMD (standardized mean difference 0.83; 95% confidence interval, 0.41-1.25; P=0.00012). DISCUSSION: The results of this meta-analysis suggest that acupuncture is a reasonable adjunctive treatment for producing a short-term analgesic effect in patients with painful TMD symptoms. Although the results described are positive, the relevance of these results was limited by the fact that substantial bias was present. These findings must be confirmed by future RCTs that improve the methodologic deficiencies of the studies evaluated in this meta-analysis.