Helena Lagerlöf magisteruppsats

Transcription

AN INDIVIDUALLY TAILORED
BEHAVIOURAL MEDICINE
TREATMENT IN PHYSIOTHERAPY
FOR TENSION-TYPE HEADACHE
A single-case study of three patients
HELENA LAGERLÖF
Akademin för hälsa, vård och välfärd
Fysioterapi
Avancerad nivå
15 hp
Examensarbete
VSG009
Handledare: Anne Söderlund
Examinator: Maria Sandborgh
Datum: 2015-05-06
SAMMANFATTNING
Bakgrund och syfte: Huvudvärk av spänningstyp (HST) är vanligt förekommande. Det finns
oklarheter avseende både dess patofysiologi och olika behandlingars effekt. Syftet med denna
studie var att beskriva och utvärdera effekten av en individuellt anpassad beteendemedicinsk
behandling i fysioterapi för patienter med HST.
Metod: En single-case studie med A1-A2-B-A3-design av tre patienter med HST
genomfördes. Utfallsvariabler var huvudvärksfrekvens (antal dagar med huvudvärk),
huvudvärksindex (medelintensitet), konsumtion av smärtlindrande medicin, tro på sin
förmåga avseende kontroll av huvudvärken, samt upplevd påverkan av huvudvärken på
funktion i vardagsaktiviteter och på glädje i aktiviteter med familj och vänner.
Resultat: Tro på sin förmåga avseende kontroll av huvudvärken ökade markant för 2 av 3
patienter. Huvudvärksfrekvens och huvudvärksindex minskade markant för en av
patienterna. En av patienterna svarade först inte alls på behandlingen, men blev mycket
bättre inför den sista uppföljningen avseende huvudvärksindex och funktion och glädje i
aktiviteter.
Diskussion och konklusion: Ett beteendemedicinskt förhållningssätt i behandling som
grundar sig på funktionell beteendeanalys kan vara ett sätt att som fysioterapeut hantera
patienter med HST. HST är en vid diagnosgrupp och det verkar då logiskt att behandlingen
bör anpassas individuellt för att få bästa effekt.
Nyckelord: Huvudvärk av spänningstyp, Primärvård, Self-efficacy, Fysioterapi,
Beteendemedicin.
ABSTRACT
Background and aim: Tension-type headache (TTH) is common. There are uncertainties
regarding both the pathophysiology and the effect of treatments. The aim of this study was to
describe and evaluate the effect of an individually tailored behavioural medicine treatment in
physiotherapy, based on a functional behavioural analysis.
Method: A single-case study with A1-A2-B-A3-design of three patients with TTH was
performed. Outcome variables were headache frequency (days with headache), headache
index (mean intensity), consumption of analgesics, headache management self-efficacy
(HMSE), disability and feelings of loss of happiness in activities with family and friends.
Results: HMSE increased markedly for 2 of 3 patients. Headache frequency and headache
index decreased for one of the patients. One of the tree patients did not first respond to
treatment but was much better before the last follow-up regarding headache index, disability
and loss of happiness.
Discussion and conclusion: A behavioural medicine treatment in physiotherapy based on a
functional behavioural analysis can be a way for physiotherapists to handle patients with
TTH. Since the diagnosis TTH is heterogenic it seems logical that the treatment should be
individually tailored.
Keywords: Tension-type headache, Primary health care, Self efficacy, Physical therapy
modalities, Behavioural medicine.
TABLE OF CONTENTS
1
INTRODUCTION .............................................................................................................1
1.1 Epidemiology ........................................................................................................... 1
1.2 Classification ........................................................................................................... 1
1.3 Pathophysiology...................................................................................................... 2
1.4 Treatments for tension-type headache .................................................................. 3
1.5 Behavioural medicine in physiotherapy ................................................................ 3
1.6 The rationale of this study ...................................................................................... 4
2
AIM ..................................................................................................................................5
3
METHOD .........................................................................................................................5
3.1 Design and content of the phases.......................................................................... 5
3.2 Patients and setting ................................................................................................ 5
3.3 Behavioural medicine intervention in physiotherapy for TTH .............................. 6
3.4 Data collection ......................................................................................................... 7
3.5 Data analyses .......................................................................................................... 8
3.6 Ethical consideration .............................................................................................. 8
4
RESULTS ........................................................................................................................9
4.1 Patient 1 ................................................................................................................... 9
4.1.1
Functional behavioural analysis ....................................................................... 9
4.1.2
Individually tailored treatment..........................................................................10
4.1.3
Outcome .........................................................................................................10
4.2 Patient 2 ..................................................................................................................13
4.2.1
Functional behavioural analysis ......................................................................13
4.2.2
4.2.3
Outcome .........................................................................................................14
4.3 Patient 3 ..................................................................................................................17
4.3.1
Functional behavioural analysis ......................................................................17
4.3.2
4.3.3
5
Outcome .........................................................................................................18
DISCUSSION.................................................................................................................21
5.1 Results ....................................................................................................................21
5.2 Methodological considerations .............................................................................24
6
CONCLUSIONS ............................................................................................................26
7
REFERENCES ..............................................................................................................26
SUPPLEMENT A: DIAGNOSTIC HEADACHE DIARY (IN SWEDISH)
SUPPLEMENT B: HEADACHE DIARY (IN SWEDISH)
SUPPLEMENT C: ACTIVITY DIARY (IN SWEDISH)
SUPPLEMENT D: HEADACHE MANAGEMENT SELF-EFFICACY SCALE (IN SWEDISH)
1
INTRODUCTION
1.1 Epidemiology
Headache disorders are common and one of the most frequent diagnoses is tension-type
headache (TTH) (R. Jensen & Symon, 2006). The prevalence varies widely between different
studies, mostly due to methodological differences since the classification of TTH has been
modified (International Headache Society [IHS], 1988, 2004). In a recent study (Schwaiger
et al., 2009) of Italian men and women aged 55-94 years the one-year-prevalence was 36%
for all sorts of headaches, 16% for frequent TTH and 2% for chronic TTH. In earlier extensive
studies (Lyngberg, Rasmussen, Jorgensen, & Jensen, 2005; Rasmussen, Jensen, Schroll, &
Olesen, 1991) of Danish adults the prevalence of frequent TTH was 29% in 1989 and 37% in
2001 in the same population. Chronic TTH increased from 2 to 5% during the same period of
time in the same population.
1.2 Classification
According to the second edition of International Classification of Headache Disorders
(ICHD-2) (and also the beta version of ICHD-3 that was published after the onset of this
study) TTH has to meet two of the following four criteria: Headache with a) a bilateral
localization, b) by pressing or tightening quality, c) of mild to moderate intensity, d) which is
not aggravated by routine physical activity such as walking and climbing stairs (IHS, 2004,
2013). It is required that the person has had at least 10 episodes for at least 30 minutes.
There are three subcategories depending on the frequency. Episodic infrequent TTH is
apparent for less than 12 days a year whereas episodic frequent TTH is apparent more often.
Chronic TTH occurs at least 15 days per month. Episodic TTH should not be associated with
nausea or vomiting, nor in combination with more than one of photophobia (light sensitivity)
or phonophobia (sound sensitivity). In chronic TTH one of the symptoms of photophobia,
phonophobia or mild nausea may occur.
Differential diagnoses to consider are migraine, secondary headache forms and new daily
persistent headache (NDPH). If the headache meets the criteria for TTH, but was presented
for the first time in close connection with an incident such as a whiplash injury, the headache
should be categorized as secondary TTH. NDPH is a primary headache diagnosis that could
be very much alike TTH, with the exception that it is daily from the onset. A person can meet
the criteria of multiple forms of headache, and for example have both diagnoses TTH and
migraine (IHS, 2004).
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1.3 Pathophysiology
The term "tension-type headache" was first introduced in 1988 by IHS and then replaced
several earlier terms such as "muscle contraction headache", "tension headache" and "stress
headache". These former terms indicated a pathophysiological explanation for the headache
that had not been possible to confirm in studies. Despite extensive research since 1988, the
causal relationships between TTH and muscle tension is still vague and the term TTH is still
being used (Silberstein et al., 2005).
Psychological stress is the most common trigger for TTH (P. R. Martin, Milech, & Nathan,
1993; Nash & Thebarge, 2006). Nash and Thebarge (2006) concluded that psychological
stress and headache are interrelated in a multifaceted way, physiologically as well as
psychosocially. The relationship is mutual, since stress might predispose, trigger and
exacerbate headache but headache might as well aggravate stress. However, the earlier
hypothesis that stress causes increased muscular tension which causes headache has not
been confirmed in studies (Bendtsen & Fernandez-de-la-Penas, 2011). Numerous studies (R.
Jensen, Rasmussen, Pedersen, & Olesen, 1993; Lipchik, Holroyd, Talbot, & Greer, 1997;
Metsahonkala et al., 2006) have shown that people with TTH, both children and adults, have
an increased tenderness to palpation in pericranial muscles, but in terms of muscle activity
and electromyography (EMG), the results are conflicting (Wittrock, 1997). A theory that has
been investigated in recent years is that TTH might be referred pain from trigger points in
head and neck muscles (Bendtsen & Fernandez-de-la-Penas, 2011; Fernandez-de-Las-Penas,
Alonso-Blanco, Cuadrado, & Pareja, 2006; Fernandez-de-Las-Penas, Cuadrado, & Pareja,
2007). Joint dysfunctions in neck and jaw have been proposed as possible factors leading to
trigger points (Graff-Radford & Newman, 2002). Persons with TTH tend to have a more
forward head posture and restricted neck range of motion in comparison with controls, but
the causal relationships are still unclear (Fernandez-de-Las-Penas et al., 2007). Most
researchers seem to agree that the cause of TTH is multifactorial with both peripheral and
central mechanisms involved and that central sensitization is of importance particularly
when TTH evolves from episodic to chronic (IHS, 1988).
A contributing factor to the difficulty in understanding the pathophysiology and establishing
effective treatments might be that TTH is not a homogenous disorder (Fernandez-de-lasPenas et al., 2011; Sjaastad, 2011). Fernández-de-las-Peñas (2011) tried to identify prognostic
factors in the history and physical examination among women that were likely to benefit
from multimodal physiotherapy sessions including manual therapies to joints and muscles,
indicating that TTH should be divided into sub-groups and the treatments should not be the
same for all patients. Sjaastad (2011) described patients with remarkably different history,
from psychological problems to low grade intoxication and concluded that all of them could
have had the diagnosis TTH based on questionnaires frequently used in studies, but they
would most likely not benefit from the same treatments.
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1.4 Treatments for tension-type headache
Persons with TTH seeking public health care for their pain is a relatively small group
compared to for example those with migraine. Many people treat their headaches with over
the counter drugs for symptom relief (Rasmussen, Jensen, & Olesen, 1992). Antidepressants,
like Amitriptyline, have been used for prophylactic treatment of frequent and chronic TTH.
These drugs have demonstrated significant efficacy over placebo in several studies (Gobel et
al., 1994; Lampl, Marecek, May, & Bendtsen, 2006), but the clinical relevance has been
questioned since the improvement is often limited (Fumal & Schoenen, 2008), and a recent
systematic review (Verhagen, Damen, Berger, Passchier, & Koes, 2010) showed no evidence
or conflicting evidence for the effectiveness of prophylactic drugs on chronic TTH. (Gobel et
al., 1994; Lampl et al., 2006).
Conservative treatments used and evaluated in controlled studies include acupuncture,
physical exercise, relaxation, and cognitive/behavioural treatments. In a systematic literature
review (Linde et al., 2009) it was concluded that acupuncture could be a valuable tool in the
treatment of frequent and chronic TTH. Physical exercise, relaxation and acupuncture were
compared in a randomized controlled study of chronic TTH sufferers´ well-being. There were
some significant differences in favour of relaxation and physical exercise (Soderberg,
Carlsson, Stener-Victorin, & Dahlof, 2011). A craniocervical training program combined with
physiotherapy, mostly consisting of massage and postural correction, had better effect than
physiotherapy alone for TTH in one study (van Ettekoven & Lucas, 2006). Relaxation has in a
previous meta-analysis demonstrated efficacy (Bogaards & ter Kuile, 1994). However, in a
recent literature review (Verhagen, Damen, Berger, Passchier, & Koes, 2009) the conclusion
was drawn that there is no evidence that relaxation, biofeedback or cognitive/behavioural
therapy is better than no treatment, waiting list or placebo. Apparently there is no consensus
about the optimal treatment for TTH.
1.5 Behavioural medicine in physiotherapy
Behavioural medicine in physiotherapy is anchored in the biopsychosocial perspective
(Elven, Hochwalder, Dean, & Soderlund, 2014), which has become widely accepted for
explaining illness and pain. This perspective emphasizes a distinction between nociception
and pain, with nociception being a biological event, whereas pain is a subjective perception
that can only be understood if the interrelationships between biological changes,
psychological status, and the sociocultural context are considered (Gatchel, Peng, Peters,
Fuchs, & Turk, 2007). Behavioural medicine is a broad area applied by different professions
in different disciplines (McKegney & Schwartz, 1986).
Behavioural medicine in physiotherapy considers medical, physical, cognitive, and social
environmental factors in analysis and treatment of pain-related disability (Soderlund, 2011).
The behavioural medicine treatment in physiotherapy is individually tailored and based on
functional behavioural analysis (FBA) (Asenlof, Denison, & Lindberg, 2005a). The FBA has
the purpose of exploring and defining the variables that have an impact on a person’s
problem behaviours contributing to disability. With this analysis as a base the individual´s
3
skills that need improvement can be determined, whether these are physical skills, cognitive
or social skills (Haynes & O´Brien, 1990). Behavioural medicine in physiotherapy rests on
several theoretical models.
The FBA is highly based on the ideas of operant conditioning, described by Skinner (1988),
explaining how a behaviour is controlled by the consequences that the individual experience
from the behaviour. A behaviour that is followed by something that the person perceives as
positive will probably be repeated, whereas behaviours followed by something negative are
not as likely to be repeated. There are also behaviours that are learned through respondent
conditioning. These behaviours are automatic reactions, usually physiological or emotional,
elicited by a conditioned stimulus. The respondent conditioning occurs when a neutral
stimulus becomes conditioned because it is associated with an unconditioned stimulus that
would automatically elicit an unconditioned response (Linton, Melin, & Gotestam, 1984).
An important theory for behavioural medicine in physiotherapy is also the social cognitive
theory (SCT), described by Bandura (1986). SCT describes an interdependence between the
individual, the behaviour and the environment. Any of these three factors could be the target
of change, in order to reach a specific goal. Self-efficacy is a central concept in SCT, referring
to the strength of one´s belief in ability to complete tasks with a specific behaviour in order to
achieve specific goals (Bandura, 1997). Self-management refers to how a person deals with
the diversity of tasks related to their condition, such as taking medication or maintaining or
creating new meaningful behaviours or life roles. Self-management is accordingly dependent
on the person´s self-efficacy for these tasks (Lorig & Holman, 2003).
Another theory that has influenced behavioural medicine in physiotherapy is the
transactional theory of stress and coping, described by Lazarus (1993). This theory describes
how the response to a perceived threat, a stressor, is individual. The response, called coping,
is dependent on an individual’s evaluation of the stressor and the perceived possibilities of
handling with the stressor (Lazarus, 1993).
The biopsychosocial perspective requires evaluation of pain from a wider perspective. The
individual´s response to pain and the individual´s perception of impact from pain on one´s
life becomes central. Multidimensional pain inventory (MPI) is one example where the
physical, social and psychological impact of pain on one´s everyday life is rated (Kerns, Turk,
& Rudy, 1985).
1.6 The rationale of this study
There is a high prevalence of TTH in the adult population. Also, according to empirical
experience it is common for a physiotherapist in primary health care to meet patients with
TTH. Different treatments including over the counter drugs, antidepressants, physiotherapy
and cognitive behavioural therapy have been tried without a consensus of optimal treatment.
An individually tailored behavioural medicine treatment in physiotherapy, that target both
physical and psychosocial impairments, would seem appropriate due to the complex nature
and heterogeneity of TTH.
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2
AIM
The aim of this study was with an experimental single-case design, to describe and evaluate
the effect of an individually tailored behavioural medicine treatment in physiotherapy for
patients with tension-type headache.
Research questions:
What effect does an individually tailored behavioural medicine treatment in physiotherapy
have on a TTH patient´s
a)
b)
c)
d)
e)
f)
3
headache frequency (days with headache per week)?
headache index (mean of headache intensity scores on NRS 0-10 over a week)?
behaviour of consumption of analgesics?
disability?
feelings of loss of happiness?
self-efficacy for headache management?
METHOD
3.1 Design and content of the phases
A single-case A1-A2-B-A3 design with non-concurrent multiple baselines across subjects was
used (Morgan & Morgan, 2009). During A1, the first baseline phase, the subjects were not
exposed to any part of the intervention. Baseline data for headache parameters were collected
for approximately one week during this phase. Phase A2, the second baseline phase, was
started with discussing behavioural factors - feelings, thoughts and doings - of the patient´s
everyday life that might have effect on the headache. The patient then filled in an individually
tailored diary with focus on behaviours possibly influencing the headache, as well as scores
regarding the influence of daily life by the headache. Continued baseline data collection of
headache parameters was also proceeded. Phase B started with the functional behavioural
analysis. During this phase also the intervention steps were started: basic skills acquisition,
applied skills acquisition and generalization of skills. During phase A3 the intervention was
withdrawn except for two follow-up visits.
3.2
Patients and setting
Three patients were recruited (by the author) among ordinary patients seeking
physiotherapist care in primary health care. The patients might have been seeking care
directly or been referred from other physiotherapists or general practitioners. The criteria of
5
inclusion followed the criteria established in the guidelines for behavioural treatments of
TTH (Penzien et al., 2005). Although, in contrast with these guidelines it was in this study
permitted for the patient to have other forms of headache in addition to TTH without being
able to discriminate them. Thus, adult persons 18-65 years old with frequent or chronic TTH
according to ICHD-2 were included (IHS, 2004). The patients filled in a previously used
Diagnostic headache diary (Russell et al., 1992) (Suppl A), translated to Swedish, during
phase A1 and A2 and the final inclusion was made after these two baseline phases to ensure
that the headache was actually classified as TTH. The first three patients that fulfilled all
phases are reported. There were four other patients that were first included but were
withdrawn because they did not show up on visits or did not fill in the requested forms.
3.3 Behavioural medicine intervention in physiotherapy for TTH
The intervention consisted of an application of the model for analysis and behavioural
medicine treatment in physiotherapy described by Åsenlöf, Denison & Lindberg (2005b) (see
bullet points below). A modification was made since the connection between headache and
activities are not usually as apparent as for other musculoskeletal pain, and when tried it
showed to be difficult to start by choosing target activities as the model suggests.
1. Identifying problematic situations and activities.
The patient was asked to list activities or situations when the headache was
problematic or in some other way connected to the headache. The patient then was
asked to describe his/her thoughts and feelings that were usually associated with
these activities or situations.
2. Self-monitoring with a diary.
In this stage the patient would at the end of each day summarize and write down
notes of activities during the day as well as feelings and thoughts during the day. This
was done with a diary specifically made for this purpose.
3. Individual functional behavioural analysis (FBA) and goal setting.
From the information from earlier stages a hypothesis was drawn, of causal
relationships leading to and maintaining the patient´s behaviour that was supposed
to affect the headache. Antecedents, responses and consequences were identified, the
components that seemed possible to change were discussed, and goals were
determined regarding target behaviours. The hypothesis was subject to recurrent reevaluation during the forthcoming stages.
6
4. Basic skills acquisition.
The components identified in the former stages were targeted with preferably home
exercises and occasional manual treatments to increase the physical, psychological
and social capabilities to reach the goals. Examples of physical skills being targeted
were joint mobility in neck and jaw, muscular endurance and mobility, posture and
relaxation. Examples of cognitive skills that were targeted were adopting alternative
coping strategies, learning to recognize and replace negative thoughts, and seeking
social support. Home exercises were used for acquisition of physical, cognitive and
social skills. The physiotherapist used different techniques to support the subject’s
behavioural change, such as self-monitoring, pacing, shaping and fading. It was an
essential part of the treatment to strengthen the patient´s self-efficacy in behavioural
change through reinforcement of steps taken by the patient according to plan for
behavioural change.
5. Applied skills acquisition.
During this stage the exercises were more complex and several basic skills were
combined in one exercise. The exercises were also to be performed in daily situations
and activities.
6. Generalization.
When the first goal was met regarding the first target behaviour, the procedure was
repeated with other target behaviours listed at the first stage. The FBA was
complemented and additional basic skills as well as applied skills were rehearsed.
7. Maintenance and relapse prevention.
This stage included two follow-up sessions to prevent relapse, at approximately 1
month and 3 months after the treatment. These sessions were to coach the patients in
maintenance of the new behaviour and to prevent relapse.
3.4 Data collection
Headache frequency, headache index and behaviour of consumption of analgesics were
measured with the Headache diary (Suppl B) through A1, A2, B and one week before each
follow-up session in A3. In the Headache diary the patient was to score the headache
intensity on an 11-point (0-10) numerical rating scale (NRS) and the consumption of
analgesics four times a day. Headache frequency is a recommended outcome variable in
studies of behavioural treatments for TTH (Penzien et al., 2005). Headache index is an
outcome variable that take frequency, duration and intensity into account, and therefore
sometimes can reflect the overall level of suffering better than headache frequency (Lake &
Saper, 2002). There is no consensus about how to define headache index (Penzien et al.,
7
2005). Headache index was in this study defined as means of intensity scores NRS (0-10) per
week, i. e. the sum of all 28 scores for one week divided by 28.
Disability and feelings of loss of happiness were measured with the Activity diary (Suppl C)
through A2, B and one week before each follow-up session in A3. The Activity diary consisted
of a modified version of MPI-S, part 1, questions nr 8-10 (Bergstrom et al., 1998). The patient
scored on NRS (0-10) at the end of every day how much impact the headache had had on the
ability to participate in daily activities (disability), and the feelings of loss of happiness from
headache in doing activities with family and friends. The purpose of measuring disability and
loss of happiness, was to continuously evaluate pain from a wider perspective. Although the
biopsychosocial perspective is well accepted for understanding pain, all three components are
not always well-represented in the outcome measures (Froud et al., 2014). Disability and
feelings of loss of happiness represent the psychosocial aspects of pain, and measure how
much impact headache has on the individual’s everyday life.
Self-efficacy for headache management was measured with Headache Management Selfefficacy Scale (HMSE) (French et al., 2000) (Suppl D). It was filled in before A1, before B,
immediately after B and at the two follow-up sessions of A3. HMSE is a scale with 25 items
rated on a 7-point scale that ranges from 1 = strongly disagree to 7=strongly agree. The
statements provide information about the patient´s confidence in their ability to prevent
headache episodes and manage headache-related pain and disability. It is a brief self-efficacy
measure with a simplified item and scoring format constructed in order to make it easily
used, and it has proved to have a high level of internal consistency as well as construct
validity (French et al., 2000). This scale was translated to Swedish.
3.5 Data analyses
Self-rated scores of headache frequency, headache index, consumption of analgesics,
disability, and loss of happiness are presented with graphs, each point representing scores for
one week. Headache frequency are presented as number of days per week. Headache index,
disability and loss of happiness are presented as means per week. Behaviour of consumption
of analgesics are presented as number of units taken per week (one unit representing
prescribed adult dose of over the counter analgesics). The graphs were analysed only visually
(not by statistical methods) for observed level, trend and variability within and between
phases. The visual inspection is a subjective mode of analysis and offers no formal criteria for
evaluation (Morgan & Morgan, 2009).
Results of HMSE are presented with descriptive data.
3.6 Ethical consideration
Participation in the study was voluntary, and the conditions were clarified before the patient
approved to be a part of the study. Patients seeking care for their headache had to wait for
8
the actual treatment to start for between two to four weeks. The patients were informed
about the possibility to get treatment directly, if the patient choose to not participate in the
study. But then the treatment could not be as tailored as if he or she had agreed to be a part
of the study. Data was collected and presented with respect to confidentiality so that the
patients would not risk to be identified by the reader.
4
RESULTS
The data for the FBA were collected through physiotherapy clinical history and physical
examination and through Activity diary used from baseline phase A2 and trough out the
study. The individually tailored treatment was based on the FBA. These steps are described
shortly for each patient prior to results of headache frequency and headache index, behaviour
of consumption of analgesics, disability, feelings of loss of happiness and HMSE score.
4.1 Patient 1
4.1.1 Functional behavioural analysis
The first patient (P1) was a 68-year old female, retired from work. She was living with her
husband and had grown up children that had moved out long time ago. A few years ago she
had problems with her right jaw when chewing. Ever since then she had felt that her jaw was
tense. At some point she started to feel light headaches every now and then and the last year
she had experienced headaches almost every day. The headache was usually present already
when she woke up in the morning. It seemed to get somewhat worse during days when she
was stressed. She perceived her jaw muscles as tense and tender. She had low intensity
headaches most of the days (figure 1 and 2), with no perceived disability but affecting feelings
of happiness in activities with family and friends (figure 4). Her self-efficacy for managing
headache (HMSE) was low (table 1). She used analgesics but not that much that it would be
primary problem behaviour (figure 3).
From the anamnestic information, headache diary, and the clinical investigation it was in the
FBA hypothesized that the behaviour that would have most effect on her headaches was her
continuous contracting of jaws. This behaviour probably increased headache intensity and
use of analgesics, influenced negatively her self-efficacy for managing headache and
perceived feeling of happiness in activities. Therefore, the behaviour of contracting the jaw
muscles was analysed in order to understand the function of the behaviour. The behaviour
seemed to be going on almost all the time, even during nights, and in that way it had become
more or less automatic. The antecedents and consequences of this behaviour were therefore
hard to identify. However, it could be concluded that the behaviour was intensified in
9
situations with psychological stress, as for example worry for family members being ill.
Contracting her jaw was clearly a behavioural excess, and being relaxed was a behavioural
deficit. She was motivated and seemed to be in a good position for changing her behaviour.
The long-term goal was set to no headache more than twice a week. It was concluded that the
primary purpose of the treatment would be to find a way for her to increase the control of
tension of the jaw during the daytime activities. It was hypothesized that the jaw muscles
would continue to be relaxed during the nights if they were relaxed during the days.
4.1.2 Individually tailored treatment
The treatment consisted of eight visits with home exercises in between, including two followup visits.
Basic skills targeted were: to know and feel what is a neutral relaxed position of the jaw, to be
able to control the muscular tension, and to do her exercises regularly. Applied skills targeted
were to recognize when her jaw gets tens in activities and to do the exercises when necessary
to decrease tension. Generalization of the skills was not needed.
The behaviour change was guided by the physiotherapist. The behaviour change techniques
self-monitoring, feedback, shaping and fading were used and the physiotherapist aimed to
strengthen the patient´s self-efficacy for behavioural change through reinforcement of every
progress during all treatment stages.
4.1.3 Outcome
All outcomes were considered as proxy measures for increased control of the tension of jaw
muscles.
The goal of no headache more than twice a week was met.
Headache frequency and headache index are presented in figure 1 and figure 2. During
baseline she had headaches at 6 out of 7 days and during the two follow-up visits these
figures were 1 and 2 out of 7 days respectively.
The behaviour of consumption of analgesics is presented in figure 3 and was reduced to zero
at the follow-ups.
Disability and feelings of loss of happiness. She reported no disability in activities during any
of the phases. Loss of happiness was reduced to zero after treatment and was stable through
follow-up (figure 4).
HMSE score increased considerably from baseline to directly after treatment and was stable
through follow-up (table 1).
10
Headache frequency
number of days with headache
7
A
1
A
2
B
A
3
6
5
4
3
2
1
0
1
4
7
10
13
16
19
22
Week
Figure 1: Patient 1. Headache frequency in self-reported days with headache per week.
10
Headache index
self-rated scores on NRS 0-10
9
A
1
A
2
B
A
3
8
7
6
5
4
3
2
1
0
1
4
7
10
13
16
19
22
Week
Figure 2: Patient 1. Headache index in means per week of self-reported intensity on NRS-scale 0-10 at
4 times a day.
11
10
Medication units per week
9
A
1
A
2
A
3
B
8
7
6
5
4
3
2
1
0
1
4
7
10
13
16
19
22
Week
Figure 3: Patient 1. Self-reported consumption of analgesics in units per week (1 unit = 500 mg
paracetamol or 400 mg ibuprofen).
Self-rated scores on NRS 0-10
10
9
8
A A
1 2
A
3
B
7
6
5
4
3
2
1
0
1
4
7
10
13
16
19
22
Week
Disability
Loss of happiness
Figure 4: Patient 1. Self-rated disability and loss of happiness on NRS-scale 0-10 in means per week.
12
Table 1: Patient 1. HMSE (Headache Management Self-Efficacy) scale 0-176 point, higher point
indicating higher self-efficacy (French et al., 2000).
Week
1 (before A1)
3 (before B)
9 (after B)
14 (follow-up 1)
26 (follow-up 2)
HMSE
131
125
170
161
169
4.2 Patient 2
The second patient (P2) was a 28-year old woman, with office work, living with her
boyfriend. She had experienced daily headaches for approximately six months. She had
started on a new work eight months ago and after that the headache had got worse. She could
not understand why since she felt that the new work was less stressful than the former one.
According to her diary she had headaches continuously varying in intensity between 2 and 6
on a NRS-scale (figure 5 and 6), and often worse in the afternoon than in the mornings. Her
analgesics use behaviour showed that she seldom used them (figure 7). Analgesics seemed to
not help. She reported both dysfunction (avoidance of activities due to headache) and
feelings of loss of happiness, but loss of happiness was generally higher than dysfunction
(figure 8). The physical examination showed that she had a minor cervical dysfunction of C2
with a slight tenderness on the right facet joint and, a slightly restricted range of motion in
neck rotation to the right, and tender muscles on the right side of neck and shoulder. Thus,
behaviour of slightly excessive contracting of shoulder and neck muscles seemed to be
present. She was also slightly tender in the muscles of the jaw by having a contracting
behaviour of jaw muscles. She had an occlusal splint that she used during the nights since
long time ago. She had a very low HMSE-score indicating low self-efficacy for controlling her
headache (table 2).
It could be concluded in the FBA that the headache intensity was rather stable with no
scorings of less than 2. It was not possible to see a pattern from the diary that would explain
the variation of headache in behavioural terms otherwise than the excessive contracting
behaviour of jaw, neck and shoulder muscles, and feelings of being stressed. This made it
difficult to choose behaviour to do a proper FBA. The patient and physiotherapist agreed to
try to target all possible dysfunctions that could contribute to TTH i.e. tension of muscles of
neck, shoulders, jaw as well as stressful feelings. During the treatment the diary would still be
filled in and supposedly new hypothesis of behavioural causes to the maintenance of
headache would come up.
13
The treatment consisted of nine visits with home exercise in between, including baseline
visits. There were no follow-up visits, but the requested forms for follow-up (Activity diary)
was sent by mail.
Basic skills that were targeted were increased endurance and circulation of muscles that
supposedly might cause TTH, and to recognize muscle tension and when she felt
psychologically stressed. Applied skills targeted were to recognize muscle tension and then
decrease the tension in activities. Psychological stress after all did not seem to be a problem
and was not further targeted.
The behavioural change was supported by the physiotherapist through techniques of selfmonitoring, feedback, shaping, pacing and fading. To strengthen the patient´s self-efficacy
for success in the behavioural change was central.
When treatment seemed to have no effect, manual manipulation of C2 was performed three
times as a complement to the behavioural treatment. The neck range of motion increased but
with momentary or no effect on the headache.
4.2.3 Outcome
There was no recognized change of the headache during the treatment. Thus, the patient and
the physiotherapist agreed to stop the treatment after nine visits during three months. The
patient was in contact with her doctor, which resulted in further investigation with no
findings. At the last follow-up five months after treatment the headache was much better,
with still no explanation why.
Headache frequency and headache index are presented in figure 5 and figure 6. The patient
had headaches all days through all the phases. The intensity was rather stable through all
phases until the last follow-up period when it was approximately half of the means through
the other phases.
The behaviour of consumption of analgesics is presented in figure 7 and was negligible
through all phases.
Disability and feelings of loss of happiness seemed to get progressively slightly higher
through treatment and then lower at the last follow-up. See figure 8.
HMSE score increased from baseline to directly after treatment but was not stable through
follow-up (table 2).
14
Headahce frequency
7
6
5
B
A A
1 2
A
3
4
3
2
1
0
1
4
7
10
13
16
19
22
25
28
31
Week
Headache index
10
B
9 A A
8 1 2
A
3
7
6
5
4
3
2
1
0
1
4
7
10
13
16
19
22
25
28
31
Week
Figure 6: Patient 2. Headache index in means per week of self-reported intensity on NRS-scale 0-10 at
4 times a day.
15
10
9
8
B
A A
1 2
A
3
7
6
5
4
3
2
1
0
1
4
7
10
13
16
19
22
25
28
31
Week
Figure 7: Patient 2. Self-reported consumption of analgesics in units per week (1 unit = 500 mg
paracetamol or 400 mg ibuprofen).
10
9
8
B
A A
1 2
A
3
7
6
5
4
3
2
1
0
1
4
7
10
13
16
19
22
25
28
31
Week
Disability
Loss of happiness
indicating higher self-efficacy.
Week
1 (before A1)
3 (before B)
16 (after B)
20 (follow-up 1)
34 (follow-up 2)
HMSE
50
59
79
59
68
16
4.3 Patient 3
The third patient (P3) was a 30-year old female with migraine and/or tension-type headache
several days a week. She was working as a psychologist in the primary care, living with her
boyfriend. She had experienced headaches since she was a little girl and migraine since she
was fifteen years old. She had tried lots of medication and had at last found one medicine that
had at least some effect - if taken early it could stop an oncoming migraine attack.
According to the baseline data she had headaches every other day with intensity varying from
low to very high (figure 9 and 10) and sometimes she could not tell if it was migraine, TTH or
something else. Both physical and psychological factors contributing to headache were found.
She had marks around her tongue indicating that she had behaviour of pressing her tongue
against the teeth. She used an occlusal splint during nights. She had negative thoughts about
the headache and got stressed from having headache since she could not control it and she
did not know if she would be able to work in the future. She did not exercise regularly
although she thought she should. This made her feel unsatisfied with herself. She was taking
her migraine medicine several times a week (figure 11), more often than she thought was
healthy. One reason for this was that she often could not tell if it was migraine or other
headache and she thought she could not risk getting a real migraine attack, especially not if
she had to be at work. Her perception of disability and feelings of loss of happiness was
highly varying depending on how much headache she had (figure 12). She had a low HMSEscore and thus had a low confidence for controlling her headaches (table 3).
There were several behaviours that were supposed to contribute to her headaches, which led
to several intertwined FBAs. Contracting her muscles of shoulders, neck and jaw was a
behavioural response primarily in situations when she felt psychological stress. This physical
reaction is a natural unconditioned response in situations that are perceived as stressful. But
in this case the reaction was also thought to be a conditioned response to situations that
resembled earlier stressful situations, and thereby occurred more frequently. She felt the
stress in situations when she was feeling not in control, often either not in control of
headache or not in control of work-related tasks. Automatic negative thoughts were also
common in these situations. The consequence she felt was tension and headache and even
more stress of not being in control, which positively reinforced her automatic negative
thoughts. Her feeling of anxiety for getting headache was also a behaviour in close connection
with psychological stress. This behaviour had the antecedent of knowing that it would not be
a good time for having headache, e. g. when she knew that she had important things to do
that would be difficult to call off. Her low self-efficacy for controlling her headache was
thought to be an important psychological factor for maintaining the behaviour of physical
tension, automatic negative thoughts and feelings of anxiety.
Sometimes her headache or fear of headache made her take migraine medicine. This operant
response had the short term positive reinforcing consequence of her feeling that she had
done something to prevent the worst scenario of migraine headache. At the same time it
17
made her in the long run feel even less in control of her headache, and it made her worried
that the medicine would not be healthy and that she would get even more headache from
taking them.
Another behaviour targeted was her physical activity level. Her headaches made her tired and
she felt not able to be physically active as much as she would like to. She had tried to go to
classes at the gym. If she had headache when she started the consequence would often be
worse headache afterwards, a positive punishment that made it difficult for her to plan the
activities. In the long run her low physical activity might lead to more physical and
psychological stress, and more headache.
In summary, the interrelationship of stress and headache was obvious, and her feeling of not
being in control was important for maintaining her behaviours. The short-term goals were
that she would feel that she had tools to brake behavioural chains earlier and for example
start to do her exercises instead of getting tens when she felt worried. The long-term goal was
set to a maximum of headache two days per week.
The treatment consisted of 14 visits with home exercises in between, including baseline and
follow-up visits.
Basic physical skills that were targeted were to learn to activate the deep forward muscles of
the neck and to increase the endurance and blood circulation of neck and shoulder muscles in
order to be able to control muscle tension. Cognitive basic skills that were targeted were: to
recognize negative thoughts, get conscious about reasons that she takes her medication and
to use support from her boyfriend to keep up physical activity. Applied skills were better
posture in everyday activities, to recognize and replace negative thoughts in activities,
questioning medication intake, and to be physically active on a regular basis.
First focus was set on physical skills (i. e. muscular endurance and posture), then cognitive
skills (i. e. negative thoughts), after that medication overuse, and lastly physical activity.
Through all of the treatment stages the physiotherapist used techniques to support the
patient´s behavioural change, with self-monitoring, feedback, shaping, pacing and fading. To
strengthen the patient´s self-efficacy of ability to influence the headache and to succeed in
the behavioural change was important.
4.3.3 Outcome
All outcomes were considered as proxy measures for increased control over muscular
tension, psychological stress and medication overuse.
She did not reach the goal of headache a maximum of 2 days a week.
Since the variability of the outcome in diaries through the baseline and treatment phases
proved to be high, it was decided that the patient would fill in the diary continuously through
18
the follow-up period (A3) and not only at one week before the follow-up visits. Otherwise it
was considered that the results might be skewed. Although, the diary for week 39 and 40 was
unfortunately lost by the patient.
Headache frequency and headache index are presented in figure 9 and figure 10. The
variability is high and it is difficult to draw conclusions, although the trend is that both mean
frequency and index reduced slightly from baseline, through intervention, to follow-up.
The behaviour of consumption of migraine medicine reduced considerably when this was
targeted in treatment, and was stable on a lower level through follow-up, although the
variability was high (figure 11).
The behaviour of consumption of over the counter analgesics varied through the phases with
no certain difference from baseline through treatment to follow-up (figure 11).
Disability and feelings of loss of happiness. The variability is high and no trends can be
observed (figure 12).
HMSE increased considerably, from baseline to after treatment and through follow-up,
indicating that her self-efficacy for managing headache did increase during the treatment
(table 3).
Headache frequency
7
A
1
6
A
2
B
A
3
5
4
3
2
1
0
1
4
7
10
13
16
19
22
25
28
31
34
37
40
Week
19
43
46
Headache index
10
A
1
9
B
A
2
A
3
8
7
6
5
4
3
2
1
0
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
Week
Figure 10: Patient 3. Headache index in means per week of self-reported intensity on NRS-scale 0-10
at 4 times a day.
10
9
8
7
6
5
4
3
2
1
0
A
1
1
B
A
2
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
Week
over the counter analgesics
migraine medicin
Figure 11: Patient 3. Self-reported consumption of migraine medicine and analgesics in units per week
(1 unit = 500 mg paracetamol or 400 mg ibuprofen).
20
10
9
8
7
6
5
4
3
2
1
0
A
1
1
A
2
4
B
7
10
13
16
19
A
3
22
25
28
31
34
37
40
43
46
Week
Disability
Loss of happiness
indicating higher self-efficacy.
Week
1 (before A1)
5 (before B)
35 (after B)
39 (follow-up 1)
47 (follow-up 2)
5
HMSE
132
127
148
147
153
DISCUSSION
5.1 Results
This study presents a possible way for management of patients with TTH in the
physiotherapy field. To conduct an FBA can be a starting point for an individually tailored
behavioural medicine treatment based on hypotheses related not only to the patient´s
diagnosis but also to physical, psychological and social factors that are specific for that
particular patient. All three patients in this study were categorized as having TTH according
to the IHS classification, however, the FBAs led to different conclusions regarding the
individualized behavioural medicine treatment.
For P1 the FBA was rather uncomplicated with one factor more important than others, her
behaviour of contracting the jaw muscles. When this was focused on, all self-rated scores
21
changed to the better and were stable through follow-up. Disability in activities was zero from
start and feelings of loss of happiness reduced to zero during treatment, meaning that the
headache had no longer impact on her feeling of happiness in activities after treatment. One
thing to consider is that P1´s headache perhaps should have been classified as secondary
TTH, since it seemed to have a connection with her earlier jaw problems. However, it did not
show up in close connection to an incident as stated in the classification (IHS, 2004).
For P2 the treatment seemed to have no effect, and the reason for this could only be
speculated on. One possible explanation could be that even though the criteria for TTH
according to the IHS classification were fulfilled, her headache should have been categorized
otherwise. An alternative diagnosis would be NDPH (IHS, 2004, 2013). This headache can be
very similar to chronic TTH with the exception that it is unremitting from the day of onset or
within the first three days after onset. NDPH is a primary headache diagnosis that can mimic
both TTH and migraine, and the pathogenesis is poorly understood (Rozen, 2014). There are
two sub forms of NDPH, of which one is self-limiting within several months and the other
one is refractory to treatment (IHS, 2004, 2013). Although P2 could not tell the exact day
when the headache started, which is often the case with sufferers of NDPH (Rozen, 2014), it
cannot be excluded that she had NDPH instead of TTH. In that case, this could explain why
she did not respond to treatment, and why it was suddenly better.
For P3 the FBA was multifaceted. She had migraine as a diagnosis aside of TTH and the
headaches had a major impact on her daily life. There seemed to be a slightly lowering trend
for the variables headache frequency and headache index through the treatment phase. But
the high variability through all phases makes it hard to draw conclusions. The consumption
of migraine medicine decreased in close temporal connection to when this target behaviour
was directed, with no demonstrable effect on headache frequency or headache index. The
HMSE score increased significantly from baseline to after treatment, which indicates that she
felt higher self-efficacy for controlling her headache after treatment. A higher self-efficacy for
being able to prevent headaches has been shown to be related to lower levels of depression
and anxiety, fewer somatic symptoms, and better adjustment to their headache-related
problems (N. J. Martin, Holroyd, & Rokicki, 1993). Higher management self-efficacy has
been associated with higher quality of life for patients with chronic conditions (Alok et al.,
2014; Cramm, Strating, Roebroeck, & Nieboer, 2013). Although, the causal relationships are
not clear, this suggests that even if the headache would not change at all from the treatment,
the treatment could still be justified if it leads to higher headache management self-efficacy.
For P1 and P2 both disability and feelings of loss of happiness decreased along with headache
frequency and index. Thus lower impact of pain is probably primarily an effect of less
headache for P1 and P2. For P3 disability and loss of happiness did not seem to decrease
during treatment whereas there seemed to be a slight decrease of headache frequency and
headache index. This is interesting since the HMSE score increased considerably from
baseline to after treatment. At the last follow-up this fact was discussed with the patient. Her
spontaneous explanation was that she had been trying to neglect her headaches and how she
felt, and tried to keep up with her work and activities until it was impossible. During
treatment she felt that she started to listen to her body, and sometimes that made her go
22
home from work or cancel activities. She felt that this was a progress, although she scored the
impact of pain higher these days.
It has been a question of discussion whether active coping strategies, that focus on
controlling pain or function despite pain rather than avoidance, is always advantageous for
headache sufferers. A common advice to headache sufferers has been to avoid triggers (P. R.
Martin, 2010). Passive coping strategies, which involve avoidance behaviour and
surrendering control over pain, have been associated with chronic pain in several studies
(Carroll, Ferrari, Cassidy, & Cote, 2014; Vlaeyen & Linton, 2000). But for migraine sufferers
it has been questioned if avoidance behaviour is as disadvantageous as it is for
musculoskeletal pain in general, since exposure to triggers might elicit migraine attacks that
could have been avoided (Wieser, Walliser, Womastek, & Kress, 2012). P. R. Martin (2010)
proposes that clinicians should start to think in terms of “coping with triggers” instead of
avoiding triggers. He summarizes evidence from several studies, including both persons with
TTH and migraine, showing that avoidance of triggers results in sensitization, and that
repeated prolonged exposure to triggers results in desensitization and less headache. His
reasoning is in line with other researchers (McLean, Coutts, & Becker, 2012) that have
proposed pacing as being most important both for migraine and tension-type headache
sufferers. The primary goal of pacing for headache patients is to avoid triggering of
headaches through self-regulation of physical exertion and psychological stress. Different
approaches to balance activity and rest are required, depending on the situation and how
many possible triggers that are present (McLean et al., 2012). This further underlines the
importance of individually tailoring the treatment to the patient.
To the authors´ knowledge, no earlier study has evaluated a behavioural medicine treatment
in physiotherapy for TTH with the intention to target physical, psychological and social
factors. Different kinds of physiotherapy treatments as well as behavioural treatments have
been evaluated though, but the evidence for these treatments cannot be summarized easily
since there are both unclear and conflicting results. One way of interpreting the rather
modest evidence of the effectiveness of these treatments for TTH is that the heterogeneity of
the patients with TTH might be too vast for the use of a more standardized treatment. It
might be that even though the patients can be categorized as having TTH, the factors and
behaviours that cause and contribute to maintain the headache are different between the
patients. In light of this reasoning, it is not that strange that group design studies that
evaluate the effect of one standardized treatment will not reach significant difference
between groups. If some of the patients have mostly physical impairments whereas others
have psychosocial impairments, they would most probably not benefit from the same
treatment. A refined classification with subcategories according to these possible causes, that
could guide the choice of treatment more, would be most helpful both for practitioners and
researchers. It seems logical that when diagnoses are wide and the classification is under
constant revision (IHS, 2013), it is even more important to individually tailor the treatment.
To apply individually tailored behavioural medicine treatment is like inventing a new
treatment for every patient, which is not exceptional or foreign to clinically working
physiotherapists, but in scientific literature it is still rather unusual. Methodologically strict
RCTs have been the golden standard for years, due to the growth of evidence based medicine
23
in the medicine field where that design has been most suitable for many research questions.
When it comes to psychosocial and other complex interventions, i.e. treatments that has
several interacting components, the rigid RCT has been questioned (Morgan & Morgan,
2009; Ruggeri, Lasalvia, & Bonetto, 2013). Ruggeri et al (2013) propose a new era with
pragmatic RCTs for evaluating psychosocial interventions. In short, their view is that it is
inherent in the psychosocial treatment that it needs to be individually tailored, which leads to
challenges regarding study design that would not be encountered in e. g. pharmacological
studies. If this difference is not considered and dealt with, the outcome of the complex
treatments might be undervalued in trials and the goal of finding the best treatment for each
patient cannot be reached (Ruggeri et al., 2013). This reasoning is also highly valid for a
behavioural medicine treatment in physiotherapy that is based on FBA.
5.2 Methodological considerations
The purpose of many clinical studies, be it a large scale randomized controlled study or an
experimental single-case study, is to isolate causal relationships between independent and
dependent variables. This task is always a question of probability, i. e. what the probability is
that the change in the dependent factor is due to the independent factor and not a result of
other possible factors. Depending on the study design there are different possibilities to rule
out these alternative explanations and secure the internal validity (Morgan & Morgan, 2009).
The experimental single-case design is dependent on replication and repeated
measurements. The withdrawal design is probably the most classic way of replicating in
experimental single-case design, but that is not possible when the treatment effect is
expected to last after cancellation of treatment. In those cases a multiple baseline design is a
possible way of replicating. It could be performed across either subjects, settings or
behaviours (Morgan & Morgan, 2009). The purpose of the present study was to use multiple
baselines across subjects. In an earlier study of individually tailored behavioural medicine
treatment targeting musculoskeletal pain, multiple baselines across situations have been
used with good results (Asenlof et al., 2005b). However, there are certain differences between
TTH and musculoskeletal pain in general, and the multiple baseline across situations design
seemed problematic in the current study, since it is usually problematic to pick situations
with apparent connection to TTH. Although most patients with TTH are aware of certain
behaviours that might elicit or enhance the headache, e. g. excessive contracting of muscles,
being stressed, sitting in certain positions, these activities or behaviours might elicit
headache one day and not the other day. Also, the headache often turns out afterwards and
not during the activity. Therefore, the decision was made not to concentrate on certain
activities but on certain behaviours in all kinds of activities that were supposed to affect the
headaches, and to try to replicate across subjects instead. The downside is that the more
general and diffuse the behaviours get, the harder it is to set well defined goals during
treatment, and the harder it is to isolate causal relationships.
Self-report through diary four times a day is recommended for evaluating headache (Penzien
et al., 2005). The headache diary has proved to be socially valid, meaning that improvements
24
detected from headache diary are noticeable by a close relative (Blanchard, Andrasik, Neff,
Jurish, & O'Keefe, 1981). Measuring pain intensity concurrently with NRS has proved valid
and sensitive to changes (M. P. Jensen, Karoly, O'Riordan, Bland, & Burns, 1989). However,
the validity of measuring disability and feelings of loss of happiness with NRS retrospectively
for one day is uncertain since these outcome measures were made up for this study. It could
be questioned if it is possible for the patient to remember and “sum up” the total amount of
disability and loss of happiness throughout one day. Self-reporting of pain retrospectively has
proved to differ from concurrent self-reporting (Khoshnejad, Fortin, Rohani, Duncan, &
Rainville, 2014). The alternative to restrict disability and loss of happiness scorings to certain
activities was regarded difficult since the headaches could influence any activity through the
day.
The logic of the multiple baseline across subjects design is that the probability of alternative
explanations for the change of the dependent variable is lower if three subjects respond in the
same way. During this study it was concluded not to report the results of the three subjects in
the same graph as would be recommended according to the chosen design (Morgan &
Morgan, 2009). The reason for this was the heterogeneity of the results and the different
lengths for treatment that made it hard to form graphs over the three subjects that would be
easily visualized.
In order to be sure that the change of the dependent variable is a response to the independent
variable and not a confounder or maturation effect, it is necessary to have a stable baseline
(Morgan & Morgan, 2009). The more variability the longer baseline is needed. Longer
baseline and follow-up phases could for P3 possibly have elucidated differences on level
between the phases, and if the slight trend towards less days with headache and lower
headache intensity was random or a depicted reality. According to guidelines of behavioural
medicine treatments for headache, baselines of a minimum of 4 weeks and preferably 5
weeks to capture monthly hormonal changes, are recommended (Penzien et al., 2005).
However, longer baselines would also be a question of ethical consideration, since the
patients would have to wait for treatment even longer. In studies that include patients that
have been seeking care for their headache, as is the case in this study, longer baselines could
also mean that there probably would be less patients agreeing to participate. That would
mean a potential distortion of results. This is also a risk in studies that require much effort or
sacrifices from the patient. That might have been the case in this study where four patients
did not comply through all phases and were therefore excluded.
For the experimental single-case design to be strong in causality it is important to see that the
difference of the dependent variable appears in near temporal contact with the introduction
of treatment targeting the specific dependent variable (Morgan & Morgan, 2009). In this
study, this was only the case for P1 and for medication intake for P3. A delay of the treatment
effect makes it more difficult to isolate causal relationships with certainty. It is expected that
the treatment effect on headache would be delayed, since the headache is a result of several
behaviours in several activities, and also, that a central sensitization is often involved.
However, it would have been preferable, but decided not possible in this study, to evaluate
the behaviours that were targeted more directly. To, for example, measure tension of jaw
25
muscles with surface electromyography, or register negative thoughts continuously could
have been an option.
A limitation of the study is also that the analysis of data was performed solely through visual
inspection. Smaller changes could perhaps have been discovered if a quantitative analysis
had been used in addition to visual inspection. However, these changes would not have been
regarded clinically significant. It has been a common view that a clinically significant
treatment effect should be observable through visual inspection (Nugent, 2010).
To establish external validity might be an objective in experimental single-case research,
although never the foremost objective (Morgan & Morgan, 2009). In this study external
validity was not a goal and the results should not be generalized beyond the study. The
single-case study design has the advantage of not being dependent on homogenous study
groups. The risk of group design studies is that they are developed to be so strict that the
homogenous client profile is very far from the unique client characteristics that the
professionals encounter, and that would be a threat to the external validity. In many trials P3
would have been excluded (Penzien et al., 2005), since she could not always discriminate if
she was having migraine or TTH. It is important that patients with two headache diagnoses
are subject to research as well, and for that the experimental single-case design is most
suitable. To suffer from both TTH and migraine is common (Lyngberg et al., 2005), as it is
that the patient cannot always identify which type of headache that is present (Blumenfeld,
Schim, & Brower, 2010). An aim of this study was to reflect the reality that meets the
clinically working physiotherapist in primary health care.
6
CONCLUSIONS
FBA can be a tool for identifying potential factors with impact on a person´s TTH. An
individually tailored behavioural medicine treatment in physiotherapy targeting both
physical and psychological skills, and social/environmental factors, seems to have impact on
a person´s self-efficacy for managing their headaches. However, future controlled studies are
needed.
7
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Asenlof, P., Denison, E., & Lindberg, P. (2005a). Individually tailored treatment targeting
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controlled trial in patients with musculoskeletal pain. J Pain, 6(9), 588-603. doi:
10.1016/j.jpain.2005.03.008
Asenlof, P., Denison, E., & Lindberg, P. (2005b). Individually tailored treatment targeting
motor behavior, cognition, and disability: 2 experimental single-case studies of
patients with recurrent and persistent musculoskeletal pain in primary health care.
Phys Ther, 85(10), 1061-1077.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory:
Prentice-Hall, Inc, Englewood Cliffs, NJ.
Bandura, A. (1997). Self-efficacy: The Exercise of Control. New York: WH Freeman & Co.
Bendtsen, L., & Fernandez-de-la-Penas, C. (2011). The role of muscles in tension-type
headache. Curr Pain Headache Rep, 15(6), 451-458. doi: 10.1007/s11916-011-0216-0
Bergstrom, G., Jensen, I. B., Bodin, L., Linton, S. J., Nygren, A. L., & Carlsson, S. G. (1998).
Reliability and factor structure of the Multidimensional Pain Inventory--Swedish
Language Version (MPI-S). Pain, 75(1), 101-110.
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validation of the headache diary. Behav Ther, 12(5), 711-715. doi:
http://dx.doi.org/10.1016/S0005-7894(81)80142-6
Blumenfeld, A., Schim, J., & Brower, J. (2010). Pure tension-type headache versus tensiontype headache in the migraineur. Curr Pain Headache Rep, 14(6), 465-469. doi:
10.1007/s11916-010-0147-1
Bogaards, M. C., & ter Kuile, M. M. (1994). Treatment of recurrent tension headache: a metaanalytic review. Clin J Pain, 10(3), 174-190.
Carroll, L. J., Ferrari, R., Cassidy, J. D., & Cote, P. (2014). Coping and recovery in whiplashassociated disorders: early use of passive coping strategies is associated with slower
recovery of neck pain and pain-related disability. Clin J Pain, 30(1), 1-8. doi:
10.1097/AJP.0b013e3182869d50
Cramm, J. M., Strating, M. M., Roebroeck, M. E., & Nieboer, A. P. (2013). The Importance of
General Self-Efficacy for the Quality of Life of Adolescents with Chronic Conditions.
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Elven, M., Hochwalder, J., Dean, E., & Soderlund, A. (2014). A clinical reasoning model
focused on clients' behaviour change with reference to physiotherapists: its
multiphase development and validation. Physiother Theory Pract, 1-13. doi:
10.3109/09593985.2014.994250
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Myofascial trigger points in the suboccipital muscles in episodic tension-type
headache. Man Ther, 11(3), 225-230. doi: 10.1016/j.math.2006.07.003
Fernandez-de-las-Penas, C., Cleland, J. A., Palomeque-del-Cerro, L., Caminero, A. B.,
Guillem-Mesado, A., & Jimenez-Garcia, R. (2011). Development of a clinical
prediction rule for identifying women with tension-type headache who are likely to
achieve short-term success with joint mobilization and muscle trigger point therapy.
Headache, 51(2), 246-261. doi: 10.1111/j.1526-4610.2010.01789.x
Fernandez-de-Las-Penas, C., Cuadrado, M. L., & Pareja, J. A. (2007). Myofascial trigger
points, neck mobility, and forward head posture in episodic tension-type headache.
Headache, 47(5), 662-672. doi: 10.1111/j.1526-4610.2006.00632.x
French, D. J., Holroyd, K. A., Pinell, C., Malinoski, P. T., O'Donnell, F., & Hill, K. R. (2000).
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(2014). A systematic review and meta-synthesis of the impact of low back pain on
people's lives. BMC Musculoskelet Disord, 15, 50. doi: 10.1186/1471-2474-15-50
Fumal, A., & Schoenen, J. (2008). Tension-type headache: current research and clinical
management. Lancet Neurol, 7(1), 70-83. doi: 10.1016/s1474-4422(07)70325-3
Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The
biopsychosocial approach to chronic pain: scientific advances and future directions.
Psychol Bull, 133(4), 581-624. doi: 10.1037/0033-2909.133.4.581
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Gobel, H., Hamouz, V., Hansen, C., Heininger, K., Hirsch, S., Lindner, V., . . . Soyka, D.
(1994). Chronic tension-type headache: amitriptyline reduces clinical headacheduration and experimental pain sensitivity but does not alter pericranial muscle
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cervical dysfunction in tension-type headache. Curr Pain Headache Rep, 6(5), 387391.
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subjective experience of acute pain. An assessment of the utility of 10 indices. Clin J
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Jensen, R., Rasmussen, B. K., Pedersen, B., & Olesen, J. (1993). Muscle tenderness and
pressure pain thresholds in headache. A population study. Pain, 52(2), 193-199.
Jensen, R., & Symon, D. (2006). Epidemiology of tension-type headache. In J. Olesen (Ed.),
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strategies. Neurology, 59(5 Suppl 2), S8-13.
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study of the efficacy and tolerability of topiramate in the prophylaxis of chronic
tension-type headache. Cephalalgia, 26(10), 1203-1208. doi: 10.1111/j.14682982.2006.01193.x
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30
BILAGA A - Diagnostisk huvudvärksdagbok
Fyll i dagboken varje kväll om du haft huvudvärk någon gång under dagen. Sätt ett X
efter varje fråga i den ruta som stämmer bäst.
Datum:
/
När började
huvudvärken?
Indikera närmaste
timma:
Upplevde du några
syn:
störningar precis
känsel:
innan du fick
huvudvärk avseende
Var huvudvärken
annat:
högersidig:
vänstersidig:
på båda sidor:
Var huvudvärken
pulserande/dunkande:
pressande/tryckande:
Var huvudvärken
*) Se nedan
mild:
måttlig:
svår:
Förändrades
värre:
huvudvärken av
oförändrad:
fysisk aktivitet såsom bättre:
trappgång?
Var du illamående?
nej:
milt:
måttligt:
kraftigt:
Blev du störd av ljus? nej:
milt:
måttligt:
kraftigt:
Blev du störd av ljud? nej:
milt:
måttligt:
kraftigt:
1
/
/
/
/
/
När försvann
huvudvärken?
Indikera närmaste
timma:
Var det något som
provocerade fram
huvudvärken?
Specificera:
Tog du någon
medicin? Uppge varje
sort, hur mycket du
tog och när (närmaste
timme)
namn:
hur mycket:
tid:
namn:
hur mycket:
tid:
*Mild: Hämmar inte arbetsprestation eller andra aktiviteter
Måttlig: Hämmar men förhindrar inte arbetsprestation eller andra aktiviteter
Svår: Förhindrar arbete och andra aktiviteter
2
BILAGA B - Huvudvärksdagbok
Skatta huvudvärkens intensitet på skalan 0 – 10 enligt nedan.
0
1
2
3
4
5
6
7
8
9
10
Ingen
Värsta
huvudvärk
tänkbara
huvudvärk
Datum
kl 8
kl 12
kl 16
kl 20
Ev medicin
Ex.
2 Alvedon kl 8
1 Ipren kl 15
BILAGA C - Aktivitetsdagbok
A) Hur mycket har din huvudvärk påverkat dina möjligheter att delta i dagens aktiviteter?
0
1
Inte alls
2
3
4
5
6
7
8
9
10
Oerhört
mycket
B) Hur mycket har din huvudvärk försämrat det utbyte och den glädje du har av sådant du gjort
tillsammans med familj/vänner under dagen?
0
1
Inte alls
Datum
A (0 – 10)
B (0 – 10)
Lista dagens
aktiviteter
Ex.
- varit i skolan 8-15
- tränat fotboll 1tim
- passat
barnbarnen 2
timmar
- kört bil till S-holm,
shoppat 6 timmar
Tankar/känslor
kring dagen
Ex.
Stressig dag.
Känt oro över att…
Funkat bra idag.
Huvudvärken kom
efter att…
2
3
4
5
6
7
8
9
10
Oerhört
mycket
BILAGA D - Headache Management Self-Efficacy scale
Instruktioner: Nedan finner du ett antal påståenden relaterade till huvudvärk. Läs varje
påstående noggrant och markera hur mycket du är enig eller oenig genom att ringa in en siffra
efter påståendet. Använd följande skala:
Mycket
oenig
Något
oenig
Lite
oenig
Varken enig
eller oenig
Lite
enig
Något
enig
Mycket
enig
1
2
3
4
5
6
7
1. Jag kan hålla till och med en svår huvudvärk från
att förstöra min dag genom att förändra mitt sätt att
hantera smärtan.
1
2
3
4
5
6
7
2. När jag är i vissa situationer, finns det ingenting
som jag kan göra för att förhindra att jag får
huvudvärk.
1
2
3
4
5
6
7
3. Jag kan minska huvudvärkens intensitet genom
att slappna av.
1
2
3
4
5
6
7
4. Det finns saker som jag kan göra för att
minska huvudvärken.
1
2
3
4
5
6
7
5. Jag kan förhindra huvudvärk genom att känna
igen sådant som utlöser den.
1
2
3
4
5
6
7
6. När jag väl har huvudvärk finns det inget jag
kan göra för att kontrollera den.
1
2
3
4
5
6
7
7. När jag är spänd kan jag hindra huvudvärken
genom att kontrollera spänningen.
1
2
3
4
5
6
7
8. Inget jag gör minskar huvudvärken.
1
2
3
4
5
6
7
1
9. Om jag gör vissa saker varje dag, kan jag minska
antalet huvudvärksattacker.
1
2
3
4
5
6
7
10. Om jag kan upptäcka huvudvärken innan
den börjar kan jag ofta stoppa den.
1
2
3
4
5
6
7
11. Inget jag gör kan förhindra att en mild
huvudvärk blir en svår huvudvärk.
1
2
3
4
5
6
7
12. Jag kan förhindra huvudvärk genom att
ändra mitt sätt att hantera stress på.
1
2
3
4
5
6
7
13. Jag kan göra saker för att kontrollera hur
mycket huvudvärken påverkar mitt liv.
1
2
3
4
5
6
7
14. Jag kan inte kontrollera spänningen som orsakar
min huvudvärk.
1
2
3
4
5
6
7
15. Jag kan göra något som påverkar hur länge min
huvudvärk håller i sig.
1
2
3
4
5
6
7
16. Det finns inget av det jag gör som kan hindra att
en svår huvudvärk förstör min dag.
1
2
3
4
5
6
7
17. När jag inte är så stressad kan jag många gånger
förhindra huvudvärk.
1
2
3
4
5
6
7
18. När jag känner att huvudvärken är på gång finns
det inget jag kan göra för att förhindra den.
1
2
3
4
5
6
7
19. Jag kan förhindra att en mild huvudvärk förstör
min dag genom att ändra mitt sätt att hantera
smärtan.
1
2
3
4
5
6
7
20. Om jag är mycket stressad finns det inget jag kan
göra för att förhindra att jag får huvudvärk.
1
2
3
4
5
6
7
21. Jag kan göra saker som gör att huvudvärken
känns mindre illa.
1
2
3
4
5
6
7
2
22. Det finns saker jag kan göra för att hindra
huvudvärk.
1
2
3
4
5
6
7
23. Om jag är upprörd finns det inget jag kan göra
för att kontrollera huvudvärken.
1
2
3
4
5
6
7
24. Jag kan kontrollera huvudvärkens intensitet.
1
2
3
4
5
6
7
25. Jag kan göra saker för att hantera min
huvudvärk.
1
2
3
4
5
6
7
(Notera att poängen för följande punkter är inverterade: 2, 6, 8, 11, 14, 16, 18, 20, 23)
3
Box 883, 721 23 Västerås Tfn: 021-10 13 00
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Transcription

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