The child with tension-type headache. Physical factors and interactive interventions

Abstract

Tension-type headache (TTH) in children and especially girls is a prevalent problem worldwide, and means there is a risk of school absenteeism, medication overuse and persistent headache. Knowledge about the associated physical factors is limited, as is knowledge on evidence based interventions.

The overall aim of this thesis was to examine the associations of physical factors with frequent or chronic TTH in children. Furthermore to examine aspects of interactive interventions as empowering patient education studying where and how to direct interdisciplinary headache services for the child and parents from the perspective of a physiotherapist.

The first study piloted computer-animated relaxation therapy with children 7-13 years of age and investigated how so young the children experienced the therapy. Furthermore it piloted enrolment procedures, the compliance of the child and parents and to gauge whether a large-scale controlled trial was warranted. The second study aimed at determining the test-retest repeatability of neck-shoulder muscle strength in healthy children 9-18 years of age. The second study also

determined the test-retest repeatability of the Total Tenderness Score (TTS) and of a sub-maximal cycle ergometer test predicting maximal oxygen uptake. The third study was a case-control study aiming at examining the combined measurements of muscle strength in the neck-shoulder region, aerobic power, and pericranial tenderness in girls 9 to 18 years of age, and the measurements associations with frequent episodic or chronic TTH compared to healthy controls. The fourth study

based on a randomized controlled trial examined the outcomes of specific strength training of shoulder muscles compared with counselling with nurse and physiotherapist in short defined patient education programmes for girls 9-18 years with TTH.

Results from study I indicated that a nine session computer-animated

relaxation therapy seemed a significantly effective learning strategy

presenting a mean improvement percent of 45% of headache frequency. The

children expressed a growing understanding of body reactions and an acquired ability to deactivate and regulate these reactions. The study also elucidated the enrolment procedures and capacity of the clinic for the planning of the larger study. The results from study II found acceptable test-retest repeatability,providing a stable basis for the research in study III and IV. The main findings in study III were that girls with TTH had significantly higher pericranial tenderness than controls in correlation with headache frequency (r=0.66, p<0.001). Results indicated a significant association between reduced shoulder and neck strength and headache. There was likewise a significant association between reduced predicted VO2max and headache. From study IV the girls self-reported health related quality of life indicated experienced difficulties in physical health, emotional health and school functioning. The results showed a significant effect on headache frequency and duration from both strength training and counselling with no significant between group differences. During 22 weeks 33% of the girls had a headache reduction ≥ 30% and 26% reached a reduction of ≥ 50%. Both groups also seemed to benefit from exercising or body awareness with a significant reduction in neck extension/flexion ratio. Strength training showed a potential to increase strength and oxygen uptake. Perceived lack of time and/ or motivation constrained inclusion and dropouts.As a conclusion the results highlight that physiotherapy plays a central role in headache services in educating the children in strategies to enhance health-related physical factors and body-awareness, reduce headache and thus improve their quality of life. Strength training or relaxation therapy in combination with interdisciplinary counselling will provide positive outcomes. As both relaxation therapy and strength training presented significant outcomes the use of these interventions should be decided by the physiotherapist, the child and parents an evaluation of the child’s individual needs. Interpreting the results within an empowering patient education we can summarize that the interventions and materials used in the studies were relevant and suitable for children 7-18 years of age. It is recommended to consider the relationship between weekly exercise intensity and exercise variation in order to keep a stable weekly exercise volume.

Motivation for change and the barriers the contemporary family, children and parents may experience in order to integrate learning and change habitual physical behaviours need to be examined. The organization of patient education is recommended to be considered innovatively in order to further reach the needs of the contemporary family. This thesis presents the dimensions of empowerment that are essential in relation to the child with TTH and their parents.

Abstract (Swedish)

Popular Abstract in Danish

Børn og især piger med spændingshovedpine (på engelsk tension-type headache,TTH) har en høj forekomst på verdensplan og betyder for børnene en risiko for skolefravær, medicin over forbrug og vedvarende hovedpine. Den viden, der findes om fysiske faktorers sammenhæng med hovedpine, er begrænset, ligesom viden og dokumentation for interventioner er det.

Det overordnede mål med denne tese var at undersøge de fysiske faktorer,

som har en sammenhæng med hyppig eller kronisk spændingshovedpine hos børn. Endvidere at undersøge aspekter af interaktive interventioner som empowerment i patient uddannelse, for at undersøge hvad og hvordan vi bør planlægge den interdisciplinære hovedpine service for barnet og forældrene set fra et fysioterapeutisk perspektiv.

Det første studie undersøgte i et pilotstudie computeranimeret afspændingsterapi med børn 7-13 år og hvordan så unge børn oplevede terapien. Endvidere undersøgte det inklusions procedurer, barnet and forældrenes compliance samt estimerede om et større controlleret studie kunne lade sig gøre. Det andet studie havde til formål at bestemme test-retest repeterbarheden af muskel styrke variabler for nakke og skulder hos raske børn 9-18 år. Endvidere at bestemme test-repeterbarheden af Total Tenderness Score (TTS) og af en sub maksimal cykel ergometer test som estimerede maksimal oxygen optag. Det tredje studie var et case-control studie, som havde til formål at undersøge kombinerede målinger af

muskelstyrke i nakke-skulder region, aerobic power, and perikraniel ømhed hos piger 9 til 18 år og sammenhængen med hyppig eller kronisk spændingshovedpine sammenlignet med raske kontroller. Det fjerde studie var et RCT studie, som undersøgte resultaterne af specifik styrketræning af skulderens muskler til sammenligning med samtaler og vejledning med fysioterapeut og sygeplejerske i korte definerede patient uddannelses forløb for piger 9-18 år med TTH.

Resultaterne fra studie I viste at et 9 sessioners kursus i computer-animeret afspændingsterapi er en signifikant effektfuld lærings strategi som viste en middel forbedringsprocent på 45% på hovedpinehyppighed og øget krops opmærksomhed. Børnene udtrykte en begyndende forståelse for kroppens mulige reaktioner og lærte sig at deaktivere og regulere disse reaktioner Studiet klargjorde også inklusions procedurer and klinikkens kapacitet med henblik på planlægning af det større studie. Resultaterne fra studie II viste acceptable analyser for repeterbarhed og var dermed et stabilt grundlag for studierne III og IV. De vigtigste fund i studie III var, at piger med TTH er signifikant mere ømme end raske kontroller og ømheden er korreleret med hovedpine frekvensen (r=0.66, p<0.001). Resultaterne viste også en signifikant association mellem reduceret nakke-skulder styrke og hovedpine. Endvidere sås en significant association mellem reduceret estimeret VO2max og hovedpine. I studie IV viste pigernes selv-rapporterede sundhedsrelaterede livskvalitet, at de oplevede vanskeligheder i fysisk sundhed, følelsesmæssig sundhed og skolefunktion. Resultaterne viste en signifikant reduktion af hovedpine-frekvens og varighed af både styrketræning og vejledning uden signifikante forskelle på de to interventioner. I løbet af 22 uger fik 33% af pigerne en hovedpine reduktion på ≥30% and 26% på ≥50%. Begge grupper opnåede efter øvelser og kropsbevidsthed en signifikant reduktion i nakke ekstensions/fleksions ratio. Styrke træningen viste potentiale til at øge både muskelstyrke og oxygen optag. En oplevelse af tidspres og manglende motivation begrænsede patient indtaget og var årsag til frafald.

Som konklusion peger resultaterne på, at fysioterapi har en central rolle i hovedpine service i at undervise børnene i strategier, der kan bedre sundhedsrelaterede fysiske faktorer og opmærksomhed på kroppen, reducere hovedpine og dermed også højne livskvalitet. Styrketræning eller afspændings terapi i kombination med interdisciplinær samtale og vejledning vil føre til positive resultater. Da både afspændingsterapi og styrketræning viste signifikante resultater bør brugen af disse interventioner afvejes i et samarbejde mellem fysioterapeut, barn og forældre og vurderes på basis af barnets individuelle behov. Når vi evaluerer resultaterne i forhold til en 'empowering patient education' teorimodel kan vi konkludere, at de interventioner og materialer, som blev anvendt, var relevante og tilpassede børn 7-18 år. Det anbefales at overveje forholdet mellem ugentlig øvelses intensitet og øvelses variation for at holde et stabilt ugentligt træningsvolumen. Motivation for forandring og de barrierer, som den nutidige familie måtte opleve i forhold til at integrere det lærte og ændre vaner for fysisk aktivitet i hverdagen bør undersøges nærmere. Det foreslås, at man med et innovativt sigte reviderer patient uddannelsen og dens organisering, således at den i højere grad er tilpasset den nutidige familie. Denne tese præsenterer de dimensioner af empowerment som er væsentlige i forhold til børn med TTH og deres forældre.

• author: Tornöe, Birte
• supervisor: Inger Hallström; Gunvor Gard; Liselotte Skov
• opponent: Prof Emerita Hall, Elisabeth, Aarhus University, Department of Public Health, Institute of Science in Nursing
• organization: Human Movement: health and rehabilitation (research group); Department of Health Sciences; Child and Family Health (research group)
• publishing date: 2014
• type: Thesis
• publication status: published
• subject: Health Sciences
• keywords: Empowering patient education, headache, child, health, neck and shoulder muscles, muscular fitness, cardiovascular fitness and physiotherapy
• categories: Higher Education
• in: Lund University Faculty of Medicine Doctoral Dissertation Series
• volume: 2014:89
• pages: 84 pages
• defense location: Health Science Centre, SSSH-salen
• defense date: 2014-09-05 13:00:00
• ISSN: 1652-8220
• ISBN: 978-91-7619-018-0
• language: English
• LU publication?: yes
• additional info: The information about affiliations in this record was updated in December 2015. The record was previously connected to the following departments: Department of Health Sciences (013220000), Division of Physiotherapy (Closed 2012) (013042000), Child, Family and Reproductive Health (013220003)
• id: 60259778-c52b-4afc-88e4-312bbff317f6 (old id 4584305)
• date added to LUP: 2016-04-01 14:06:16
• date last changed: 2020-01-24 09:43:09