J Manipulative Physiol Ther. 2009 (Sep); 32 (7): 527–535 ~ FULL TEXT
Cristina Toro-Velasco, PT, Manuel Arroyo-Morales, MD, PT, PhD,
César Fernández-de-las-Peñas, PT, PhD, Joshua A. Cleland, PT, PhD,
Francisco J. Barrero-Hernández, MD
Department of Physical Therapy,
Health Sciences School,
Universidad Granada, Spain
OBJECTIVE: The purpose of this study was to investigate the immediate effects of head-neck massage on heart rate variability (HRV), mood states, and pressure pain thresholds (PPTs) in patients with chronic tension-type headache (CTTH).
METHODS: Eleven patients (8 females), between 20 and 68 years old, with CTTH participated in this crossover study. Patients received either the experimental treatment (massage protocol) or a placebo intervention (detuned ultrasound). Holter electrocardiogram recordings (standard deviation of the normal-to-normal interval, square root of mean squared differences of successive NN intervals, index HRV, low-frequency component, and high-frequency component), PPT over both temporalis muscles, and Profile of Mood States questionnaire (tension-anxiety, depression-dejection, anger-hostility, vigor, fatigue, confusion) were obtained preintervention, immediately after intervention, and 24 hours postintervention. Self-reported head pain was also collected preintervention and 24 hours postintervention. Separate analyses of covariance (ANCOVAs) were performed with each dependent variable. The hypothesis of interest was group x time interaction.
RESULTS: The ANCOVA showed a significant group x time interaction for index HRV (F = 4.5, P = .04), but not for standard deviation of the normal-to-normal interval (F = 1.1, P = .3), square root of mean squared differences of successive NN intervals (F = 0.9, P = .3), low-frequency component (F = 0.03, P = .8), or high-frequency component (F = 0.4, P = .5) domains. Pairwise comparisons found that after the manual therapy intervention, patients showed an increase in the index HRV (P = .01) domain, whereas no changes were found after the placebo intervention (P = .7). The ANCOVA also found a significant group x time interaction for tension-anxiety (F = 5.3, P = .03) and anger-hostility (F = 4.6, P = .04) subscales. Pairwise comparisons found that after the manual therapy intervention, patients showed a decrease in tension-anxiety (P = .002) and anger-hostility (P = .04) subscales, whereas no changes were found after the placebo intervention (P > .5 both subscales). No significant changes were found in PPT levels (right F = 0.3, P = .6, left F = 0.4, P = .5). A significant group x time interaction for pain (F = 4.8, P = .04) was identified. No influence of sex was found (F = 1.5, P = .3). Pairwise comparisons showed that head pain (numerical pain rating scale) decreased 24 hours after manual therapy (P < .05) but not after the placebo intervention (P = .9).
CONCLUSIONS: The application of a single session of manual therapy program produces an immediate increase of index HRV and a decrease in tension, anger status, and perceived pain in patients with CTTH.
Key Indexing Terms: Tension-Type Headache, Heart Rate, Manual Therapy
From the FULL TEXT Article:
Tension-type headache is common in the general population with a reported 1-year prevalence rate of 38.3% for the episodic form and 2.2% for the chronic type.  In addition, the prevalence of this particular headache disorder has recently been increasing.  Tension-type headache may cause substantial levels of disability for the patient. 
Although there has recently been an increasing interest in the pathogenic mechanisms of tension-type headache, the true pathoanatomical mechanism remains unclear.  However, it seems that hyperexcitability of nociceptive pathways may play an important role in tension-type headache.  This sensitization process typically results in increased muscle tenderness [6, 7] and decreased pressure pain thresholds (PPTs), particularly in patients with chronic tension-type headache (CTTH). [8, 9] In addition, it has been postulated that CTTH could be the manifestation of referred pain from muscle trigger points (TrPs) located in head, neck, and shoulder musculature. [10-12] It has been shown that sympathetic facilitation of mechanical sensitization and facilitation of the local and referred pain reactions in muscle TrPs exists, confirming sympathetic responses elicited by muscle TrPs.  It therefore seems sensible that impairments in the autonomic nervous system (ANS) could be associated with tension-type headaches.
In migraines, autonomic involvement has been identified. [14, 15] However, previous studies of tension-type headache have rarely investigated the contribution of the ANS function and have primarily focused on involvement of the sympathetic system. [16, 17] Numerous techniques exist to assess ANS function; nevertheless, techniques for evaluating parasympathetic activity have not been well established. Heart rate variability (HRV) has become the conventionally accepted term to describe variations of both instantaneous heart rate and rate recovery intervals.  Heart rate variability reflects the influence of the ANS on heart rate. Some studies found that manual therapy can influence HRV parameters in both healthy subjects  and patients with myofascial pain.  A recent study found that myofascial release therapy restored the HRV index and maintained high-frequency component (HF) domain of HRV during recovery after high intensity exercise.  It would be plausible to suggest that manual therapy aimed at inactivating muscle TrPs may have some impact on the ANS in patients with CTTH.
Population-based studies and clinical investigations found high comorbidity between headache and mood-anxiety disorders.22 Furthermore, psychologic states (anxiety or depression) may influence quality of life and other clinical parameters in patients with CTTH.  Perozzo and Fondazione  found that patients with tension-type headache exhibited a significantly higher level of angry temperament, angry reaction anxiety, depression, or emotional liability. To the best of our knowledge, no study has investigated the effects of manual therapy on HRV parameters, psychologic disorders, PPT, and pain intensity in CTTH. Therefore, the purpose of this study was to investigate the immediate effects of head-neck massage on HRV, mood states, and PPT in patients with CTTH.
The results of our study showed that a single session of a manual therapy protocol aimed to inactivate muscle TrPs decreases the emotional tension and increases HRV, immediately after treatment, as compared with detuned ultrasound, in patients with CTTH. Nevertheless, we only found a transient effect of the treatment, which may have a limited clinical significance.
It has previously been identified that manual therapy associated with active aerobic recovery can restore balance to the ANS of an individual after exercise.  Our study found that a single 40-minute session of manual therapy is a simple method to increase HRV values as evidenced by HRV index at short-term. Our results are consistent with previous studies, which have investigated the parasympathetic effects of manual therapy, despite the older age and different characteristics of the patients used in other studies. [34-36] In addition, our study is the first to analyze changes in parasympathetic system in patients with CTTH who had not undergone surgical intervention as in other studies. [37, 38]
A number of studies have used sympathetic nervous system activity in an attempt to quantify the physiologic effects of other manual therapies (mobilization and manipulation). [39-43] Many of these studies showed that spinal manipulative therapy produces a significant sympathoexcitatory response when compared with a placebo or control group. [40, 42, 43] A number of these studies also showed that a hypoalgesic effect accompanied the spinal mobilizations to a magnitude that was also statistically significant when compared with placebo and control groups. [39, 41, 42] Vicenzino et al in a double-blind, placebo-controlled, repeated-measures study investigated the effects of cervical mobilizations (Maitland, grade 3 lateral glides) on PPTs and skin conductance in the limbs of subjects with lateral epicondylalgia.  The results showed not only a statistically significant increase in sympathoexcitatory response and hypoalgesia but also a strong correlation (r = 0.82, P = .05) between the hypoalgesic effect and sympathoexcitatory response produced with spinal mobilization.  It is also possible that this may have also occurred with the manual therapy techniques used in the current study.
In addition, it is possible that the physiologic mechanism by which the intervention works may be associated with stimulation of central control mechanisms (periaqueductal gray area). [44, 45] This may result in a reflex stimulation of descending inhibitory mechanisms. [42, 46-48] Nevertheless, it seems that more than one mechanism explains the effects of manual therapy,  and there is insufficient evidence to claim a major role for either peripheral or central mechanisms. Future research is necessary to determine whether manual therapy exerts its effects either through mechanical or neurophysiologic mechanisms or through both.
Following the same hypotheses as other authors on the psychologic effects of massage, [34, 50] this study confirms that manual therapy does not induce changes in mood state. However, the short-term effects after the massage session were associated with a decrease in tension-anxiety and lower anger-hostility levels, which differed from the placebo condition. These changes may be related to the ability of manual therapy to produce a parasympathetic vegetative response associated with massage-induced improvements in HRV, blood pressure,  and immune function  Chronic tension-type headache is associated with an increase in anxiety, depression, and an impairment of anger control. [23, 24] In the current study, the manual techniques apparently influenced the patients' mood state by decreasing the emotional tension and anger, although only at short-term.
There are a few limitations to consider in this study. Only one therapist performed all the manual techniques, which may limit the generalizability of results. However, these techniques are commonly used in clinical practice and require minimal training. Hence, we expect that other clinicians may be able to provide similar treatments with similar results. We also used a small sample size with a 24-hour follow-up only. In fact, we only found a transient effect of the treatment, which may have limited clinical significance. It is possible that subsequent sessions may have a greater and longer lasting effect on clinical outcomes. Future studies using larger sample sizes with long-term follow-up periods are needed to elucidate the clinical relevance of the current findings. We also cannot exclude the placebo effects associated with hands-on technique, which in itself is capable of eliciting a sympathoexcitatory response.  However, it has been shown that manual techniques result in an increased sympathetic response when compared with a placebo technique, which consisted of solely manual contact.  Future studies should compare the manual techniques used in the current study to a placebo technique, which includes manual contact with the patient. Finally, we should recognize that blinding of patients may not be effective because the placebo intervention differed from the treatment physically. Therefore, the placebo effect associated with hands-on technique should not be ignored. Future randomized controlled trials should include a hands-on placebo intervention to further elucidate the real effects of the treatment protocol applied in the current pilot study.
The application of a single session of manual therapy program produces an immediate increase of index HRV and a decrease in tension, anger status, and perceived pain in patients with CTTH. Nevertheless, we only have found a transient effect of the treatment, which may have limited clinical significance. Future studies investigating the effects of numerous treatment sessions are needed to elucidate the clinical relevance of the current findings.
The application of a session of head-neck massage produces an immediate increase
of the index HRV in patients with CTTH.
The application of a session of head-neck massage produces an immediate decrease
in tension, anger status, and perceived pain in patients with CTTH.
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