Received: 21 March 2017 Revised: 6 October 2017 Accepted: 18 November 2017

DOI: 10.1002/pri.1700

RESEARCH ARTICLE

The effect of myofascial release and microwave diathermy

combined with acupuncture versus acupuncture therapy in
tension‐type headache patients: A pragmatic randomized
controlled trial
George Georgoudis1,2 | Bledjana Felah2,3 | Pantelis Nikolaidis4 | Dimitrios Damigos3

1
Musculoskeletal & Chest Physiotherapy
Research Laboratory, Department of Abstract
Physiotherapy, Athens University of Applied
Background and purpose: Nonpharmacological therapies for tension‐type headache (TTH)
Sciences, Greece
2
and cervicogenic cephalalgia are often a treatment choice, despite the weak to moderate evidence.
PhysioPain Group, Pain Management &
Physiotherapy, Athens, Greece
The aim of this study was to compare the effectiveness of an acupuncture/stretching protocol ver-
3
MSc in Pain Management, Department of sus acupuncture/stretching plus physiotherapy techniques, in patients with TTH cephalalgia.
Social Medicine & Psychological Health, Methods: A single‐blind, prospective, multicentre, randomized controlled trial was designed
University of Ioannina, Greece
4
considering the pragmatic situation of administering such protocols and treating the 44 headache
Exercise Physiology Laboratory, Nikaia,
patients participating in this study. The patients were randomly assigned in 2 treatment groups
Greece
Correspondence
(control group, n = 20, acupuncture/stretching; experimental group, n = 24, acupuncture/
Professor George Georgoudis, Department of stretching plus physiotherapy) and completed 10 treatment sessions within 4 weeks with measure-
Physiotherapy, Technological Educational ments taking place before treatment, after the fifth treatment and after the 10th treatment. The
Institution of Athens, 106 Antoniou Mpertou
mechanical pressure pain threshold (PPT) was considered as the main outcome measure, using a
Str., Amfiali, Pireas, Greece.
Email: gg@hol.gr mechanical algometer to measure 7 bilateral somatic points. Acupuncture in both groups included
17–20 acupuncture points, whereas stretching was initially taught and subsequently self‐adminis-
tered (self‐stretches), following a standardized set of movements of the cervical spine. Physiother-
apy consisted of microwave diathermy and myofascial release with hands‐on techniques.

Results/findings: An improvement was noted in both groups/treatments regarding the main

outcome measure PPT, all the way from the first to fifth and the 10th treatment, at all measuring
sites and at all measurements in both groups (p < .001). When comparing the 2 groups, differ-
ences were noted after the 10th treatment (p < .05).

Discussion: In conclusion, patients with TTH headache were benefited from acupuncture and
stretching but further PPT improvements were evidenced when physiotherapy hands‐on tech-
niques were added. In clinical terms, the combination of physiotherapy in the form of myofascial
release and microwave diathermy with acupuncture and stretching in order to improve the anal-
gesic effect (PPT) is strongly recommended.

KEY W ORDS

acupuncture, mechanical pain threshold, microwave diathermy, myofascial release, physiotherapy,

stretching, tension‐type headache

1 | I N T RO D U CT I O N infrequently and there is no need for further treatment although in

some patients, TTH occurs on several days per month or even daily.
Tension‐type headache (TTH) is the most common type of primary Physical therapy and acupuncture are known to be used for the
headaches. The disability attributable to TTH is larger worldwide than treatment of TTH. Despite the reports that acupuncture has been
that of migraine (Stovner et al., 2007). In most patients, TTH occurs found to be clinically beneficial for patients with chronic headaches,

Physiother Res Int. 2018;23:e1700. wileyonlinelibrary.com/journal/pri Copyright © 2017 John Wiley & Sons, Ltd. 1 of 8
https://doi.org/10.1002/pri.1700
2 of 8
migraines (Vickers et al., 2004), and TTH (Linde et al., 2016) and that
acupuncture is used in many countries for TTH prophylaxis (to reduce
the frequency and intensity of TTH; Burke, Upchurch, Dye, & Chyu,
2006), there is still a lack of evidence regarding the efficacy of acupunc-
ture compared to or adjacent to a physiotherapy regime. The combina-
tion of acupuncture and stretching in cervical myofascial pain syndrome
produces higher increases in PPT and analgesia compared to acupunc-
ture alone or placebo (Wilke et al., 2014), at least for the short term.
Also in TTH, stretching (Beltran‐Alacreu, Jimenez‐Sanz, Fernandez
Carnero, & La Touche, 2015) and acupuncture (Linde et al., 2016) were
shown to increase PPT and produce analgesia, but their combination,
which seems to be a favourable clinical approach, has not been exam-
ined extensively (France et al., 2014; Wilke et al., 2014).
On the other hand, physiotherapy care has also demonstrated
evidence to manage adults with headaches, either by hands‐on
techniques such as manual therapy/myofascial release techniques
(Bryans et al., 2011), stretching or more passive electrotherapy
modalities (Tella, Unubum, & Danesi, 2008). Serrano, Andrés, and
Sánchez‐Palomo (2007) showed that pericranial muscle contracture
has an enhanced role in headache's physiopathology, which justifies
the presence of pericranial pain hypersensitivity and decreased pain
threshold in TTH patients. This finding has also recently been
supported by Soee, Skov, Kreiner, Tornoe, and Thomsen (2013) who
showed the central pain‐processing mechanism of TTH and how this
is estimated using PPT measurements.
In this study, the term physiotherapy refers only to the myofascial
release techniques employed and the microwave diathermy application.
Myofascial release techniques aim to treat the sensitized myofascial
trigger points and fascia and the referred pain patterns they produce,
providing a direct connection with TTH clinical image and patient's
subjective pain experience (Alonso‐Blanco, de‐la‐Llave‐Rincon, &
Fernandez‐de‐las‐Penas, 2012). It is also evidenced that interventions
aiming at the fascia (Chatchawan, Eungpinichpong, Sooktho, Tiamkao,
& Yamauchi, 2014) and myofascial trigger points manage to reduce
the local headache pain intensity, the extent of referred pain fields,
and the pressure pain sensitivity (Toro‐Velasco, Arroyo‐Morales,
Fernandez‐de‐Las‐Penas, Cleland, & Barrero‐Hernandez, 2009).
In pragmatic situations, more and more therapists tend to combine
therapeutic techniques in order to enhance the analgesic efficacy of
their patients' headaches (France et al., 2014; Ohlsen, 2012). However,
the literature is lacking of studies that combine physiotherapy,
needling, and stretching techniques. In order to investigate the
pragmatic conditions of implementation of the above techniques, this
study was designed to examine the analgesic efficacy of a treatment
protocol of acupuncture and stretching with a protocol of
acupuncture, stretching, and myofascial release technique with
microwave diathermy on patients with TTH.
2 | METHODS
2.1 | Study design
A multicentre randomized controlled trial was designed with the
most important component to be the pragmatic character of the
GEORGOUDIS ET AL.
therapeutic protocols employed. A single‐blind design (examiner
blinded) was employed. It was thought not applicable to include
“pseudophysiotherapy” in the protocol, because the “hands‐on”
character of physiotherapy and pseudophysiotherapy would compli-
cate rather than assist the conclusions of the study.
2.2 | Subjects
Fifty‐seven subjects with TTH were initially screened, and 44 were
eventually allocated and received treatment. All subjects were
recruited from three physiotherapy practices and a rehabilitation clinic.
Initial diagnosis and appropriateness of the patient to participate in the
study were assessed by two medical doctors (neurologist or orthopae-
dic surgeon) according to the diagnostic definitions for TTH as pro-
vided by the IASP sub committee (Headache Subcommittee, 2004).
In total, 13 patients were excluded according to the inclusion/exclu-
sion criteria (Table 1). Eleven patients failed to fulfil the criteria, and
two reported phobia in needles. The appropriate candidates (n = 44)
were randomly allocated to either group of treatment and signed the
study's informed consent. No dropouts or lost patients were noted
(Figure 1).
In order to produce a bias‐free randomization procedure, with
equal chances to include any patient in either group, the selection was
based on the number of letters that formed the patients' last name. If
it was an odd number, a specific treatment group was selected, whereas
if it was an even number, the other treatment option was chosen.
The characteristics of the subjects of the study are depicted in
Table 2. The study was conducted according to the principles of the
Declaration of Helsinki and the Guidelines on the Practice of Ethics
Committees in Medical Research Involving Human Subjects. Primary
outcome measure was considered the pressure algometry readings.
Secondary measurements were all other measurements (question-
naires and visual analogue scales).
2.3 | Clinicians
Every patient in the study was treated by a specific clinician who
applied the acupuncture and instructed self‐stretch, without knowing
the treatment group of the patient. The physiotherapy treatment of
TABLE 1 Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria
1. Unilateral or bilateral headache 1. Major pathology or surgery at the
with mild or medium intensity neck or the head
and “tension‐type” qualitative
characteristics
2. Headache with no worsening 2. Migraine or other officially
due to usual daily activities diagnosed headache type
3. Headache‐related photophobia 3. Recent injury or road accident
or phonophobia, but not their injury at the head or the cervical
combination, or/and dizziness spine
or nausea
4. Headache that can worsen due 4. Cancer pain
to myofascial causes 5. Rheumatologic or immune‐
related diseases
6. Pregnancy
7. Inability to read, understand, and
write Greek
GEORGOUDIS ET AL. 3 of 8

FIGURE 1 CONSORT flow diagram

TABLE 2 Descriptive statistics for the participating subjects at 2.5 | Algometry

baseline
The PPT measured in this study is the minimum pressure required to
Control group (n = 20) Experimental group (n = 24)
produce the first sensation of pain. All PPTs were measured with the
Age (years) 43.0 ± 6.5 34–54 54.8 ± 14.7 29–78 COMPACT SIMPLICITY (Wagner Instruments®) algometer, a
Height (m) 1.71 ± 0.10 1.60–1.92 1.63 ± 0.06 1.54–1.80 mechanical algometer, calibrated in kg/cm2, with a rubber disc of
Weight (kg) 69.5 ± 15.0 49–94 64.3 ± 11.6 53–95 1 cm2 and a range of 10 kg in divisions of 100 g (Fischer, 1988). The
VASaverage 6.5 ± 2.5 3–9.6 7.8 ± 1.8 4–10 instrument has been shown to be reliable and gives reproducible
VASmax 7.2 ± 2.8 3–10 8.2 ± 1.8 5–10 results (Fischer, 1987).
VASmin 4.9 ± 2.5 2–9.5 6.6 ± 1.7 4–8.5 The measurement sites were marked on the subjects (Figure 2). The
Note. Control group = acupuncture and stretching exercise; experimental algometer was then calibrated according to the procedure described by
group = acupuncture, stretching exercise, and physiotherapy. VAS = Visual the manufacturer, and practice measurements were attempted until the
Analogue Scale.
subject and the examiner were familiar with the technique. All PPT
recordings were collectively repeated 3 times with a 5‐min interval
the experimental group was provided by another independent physio- between each (Delaney & McKee, 1993) and were taken bilaterally fol-
therapist. All acupuncture clinicians had at least 200 hr of acupuncture lowing a random order. The mean average of the last two measures was
training and practiced acupuncture for 2–15 years. A 1‐day training taken as the best estimate of the PPT (Pöntinen, 1998). Standardized
session emphasizing the acupuncture points, the physiotherapy modal- instructions were given before each measurement on all occasions. All
ities, and treatment protocol, together with the procedures of the procedures were completed within 10–15 min minimizing the effect
study, was organized. of fatigue and loss of concentration (Hagander, Midani, Kuskowski, &
Parry, 2000). Subjects, acupuncturists, physiotherapists, and the exam-
iners were kept uninformed of the PPT scores throughout the study to
2.4 | Procedures prevent previous scores from influencing the results (Delaney & McKee,
During the first visit and before the first treatment (t1), initial baseline 1993). All measurements took place in the same clinic by the same blind
pressure algometry measurements were taken (see Section 2.5). Simi- examiner between 16:00 and 20:00 hr (Koltyn, Focht, Ancker, & Pasley,
larly, algometry measurements and questionnaires were completed 1999). The temperature, draughts, cold, and dampness were kept as
after the fifth treatment session (t2) and the last treatment (10th), for steady as possible throughout the study (Hildebrandt, Bongers, van
both groups. Dijk, Kemper, & Dul, 2002). Bilateral measurements were taken at the
The algometer operator was blinded to the patient's treatment suboccipital (at the insertion of trapezius), the midway of the upper
group and the previous pressure pain threshold (PPT) readings of the trapezius, bilaterally the C7 spinous process, the insertion of the levator
same subject. scapulae at the scapula, the rhomboid (midway at T8 level), the
4 of 8
FIGURE 2 Measurement sites of pain pressure threshold
infraspinatus (in the middle), and the deltoid (midway from the acromion
to insertion). These muscles were chosen as they appear to be the most
common in TTH and are appropriate to be measured in terms of validity
and reliability with a pressure algometer (Fischer, 1988).
The Visual Analogue Scale (VAS) was used to measure the average
intensity of pain (Ferreira‐Valente, Pais‐Ribeiro, & Jensen, 2011).
2.6 | Treatment options
2.6.1 | Acupuncture
According to STRICTA 2010 (MacPherson et al., 2010), all acupuncture
trials should include information on all six suggested fields: the rational
of acupuncture, the details of needling, the treatment regimen,
practitioner background, control interventions, and other components
of treatment.
In this study, biomedical acupuncture was the main therapeutic
selection combined with some Traditional Chinese Medicine (TCM)
points, because both techniques are equally effective to manage TTHs
(Larner, 2005). A number of approximately 20 stainless steel needles
(25 × 0.25 mm) were used in every treatment session. The 15–17 nee-
dling points were predefined myofascial trigger points, whereas 3–5
points were selected according to the patient's symptoms. A number
of specific acupuncture points served as the selection pool for bilateral
needling on every patient. These were GB20, GB21, B10, B38, UB2,
GB8, SI14, SI11, ST9, LI4, GV20, and GV24 (YinTang). The depth of
the needling was decided upon the provocation of symptoms, upon
production of local twitch response, or upon the suggestions according
to TCM. The needles stayed in place for 20 min with manual stimula-
tion every 5 min. The stretching protocol followed the acupuncture
(see Section 2.6.2).
2.6.2 | Stretching
A stretching protocol, consisted of muscle stretches and head move-
ments, was taught to all patients. Specifically, the muscles trapezius,
levator scapulae, rhomboids, infraspinatus, and sternocleidomastoid
were passively self‐stretched for 30 s, for three consecutive repeti-
tions. Also, left and right rotation and protraction and retraction head
movements were taught. All exercises were given on a leaflet, and the
GEORGOUDIS ET AL.
patients were encouraged to reproduce them 2–3 times daily. According
to their self‐report, the compliance rate of the exercises was ~80%.
2.6.3 | Physiotherapy
The physiotherapy in this study consisted of microwave diathermy and
myofascial release techniques. The microwave diathermy was chosen
as a deep thermotherapy means, with a pulsed wavelength (1:2) and
an intensity of 75 W, for 10 min with a distance of 10–15 cm from
the seventh cervical vertebra, in order to produce a light warm
sensation to the subject. Following the diathermy, the patients
received a 15‐min myofascial release protocol comprising of soft tissue
and trigger point release techniques, on the muscles/fascia reproduc-
ing the patient's symptoms, such as the occipitalis, suboccipitalis,
temporalis, sternocleidomastoid, masseter, and frontalis. Various
myofascial techniques were employed in this protocol such as
effleurage, deep friction, and muscle energy techniques.
Two licensed, state‐registered physiotherapists with >7‐year
experience in myofascial pain delivered the myofascial component of
the treatment. The therapists worked as a team for more than 6 years
at the PhysioPain Group®; therefore, no further education session was
considered necessary. Every patient was assigned to a single therapist
to complete all treatment sessions.
2.7 | Statistical analysis
Because PPT measurements are considered continuous response vari-
ables, the use of parametric statistics was formally chosen. A between‐
and within‐subjects analysis of variance examined the main effects of
treatment group and time, and the group * time interaction on PPT.
Bonferroni test was used for post hoc comparisons. The effect size
was evaluated using eta square (η2). Significance was set at p < .05. SPSS
v.23.0 (SPSS, Chicago, USA) and GraphPad Prism v.7.0 (GraphPad
Software, San Diego, USA) were employed in all statistical analyses.
3 | RESULTS
A large main effect of time on trapezius (p < .001, η2 = 0.644),
suboccipital (p < .001, η2 = 0.604), C7 (p < .001, η2 = 0.585), levator
GEORGOUDIS ET AL.
(p < .001, η2 = 0.746), rhomboid (p < .001, η2 = 0.664), infraspinatus
(p < .001, η = 0.711), and deltoid (p < .001, η = 0.595) was observed
2 2
with score in t3 being larger than t2, and both were larger than t1
(Figure 3). No time * treatment interaction on trapezius (p = .486,
η2 = 0.016), suboccipital (p = .156, η2 = 0.044), C7 (p = .096,
η = 0.055), levator (p = .127, η = 0.096), rhomboid (p = .153,
2 2
η2 = 0.044), and deltoid (p = .368, η2 = 0.023) was shown. A moderate
time * treatment interaction on infraspinatus was found (p = .034,
FIGURE 3 Effect of treatments on pain pressure threshold. * different from t1; § different from t1 and t2; ‡ time * treatment interaction. Error bars
represent standard deviations
5 of 8
η2 = 0.084), where the experimental group increased less the score
in t2 and t3 compared to control group.
A large main effect of time on VASaverage (p < .001, η2 = 0.712),
VASmax (p < .001, η2 = 0.566), VAStoday (p < .001, η2 = 0.773), and
pain intensity (p < .001, η2 = 0.573) was observed with score in t3
being smaller than t2, and both were smaller than t1 (Figure 4). No
time * treatment interaction on VASaverage (p = .107, η2 = 0.055),
VASmax (p = .206, η2 = 0.038), and pain intensity (p = .279,
6 of 8
FIGURE 4 Effect of treatment on Visual Analogue Scale (VAS). * different from t1; § different from t1 and t2; ‡ time * treatment interaction. Error
bars represent standard error of measurement
η2 = 0.030) was shown. A large time * treatment interaction on
VAStoday (p = .002, η2 = 0.139) was found, where the experimental
group decreased more the score in t3 compared to control group.
4 | DISCUSSION
This study aimed to examine the analgesic effect of two pragmatic
treatment protocols for TTH: acupuncture and stretching versus
physiotherapy, acupuncture, and stretching. Primary outcome measure
was considered the PPT. The main findings were that (a) the PPT
showed improvements (increase) in TTH patients for both treatment
protocols, when compared within groups, and (b) differences were also
observed between the two treatment protocols and between groups,
with physiotherapy providing an additional increase on PPT.
5 | PPT MEASUREMENTS
The major finding in this study was that there were main effects of
time and treatment and an interaction among them on PPT. The
increase in PPT values after following a treatment protocol with
physiotherapy or acupuncture in TTH was in agreement with the
existing literature (Endres et al., 2007; Espi‐Lopez, Arnal‐Gomez,
Arbos‐Berenguer, Gonzalez, & Vicente‐Herrero, 2014; Espi‐Lopez,
Rodriguez‐Blanco, Oliva‐Pascual‐Vaca, Molina‐Martinez, & Falla,
2016; France et al., 2014; Karakurum et al., 2001; Karst et al., 2001;
Moraska et al., 2015; Sun‐Edelstein & Mauskop, 2012; Torelli, Jensen,
& Olesen, 2004). Likewise, in this study, research studies in TTH
patients, where acupuncture has been employed as the main treatment
GEORGOUDIS ET AL.
option, have shown significant improvement for acupuncture when
compared with superficial (Karakurum et al., 2001) or sham acupunc-
ture (Endres et al., 2007). Recent meta‐analyses confirmed the positive
results (France et al., 2014; Sun‐Edelstein & Mauskop, 2012), despite
the fact that initial reviews were showing ambiguous results (Davis,
Kononowech, Rolin, & Spierings, 2008).
The increase in PPT values was supported by the administered
clinical self‐report pain measures such as the VAS and Present Pain
Index (a numerical rating scale [PPI]). The patients were asked to report
the subjective levels of their pain experience at all measurement times
pre‐ and post‐treatment. The VAS and PPI pain reports were in accor-
dance with the PPT increased values, indicating that the clinical mea-
sures and central sensitization measures were analogous in this
study. This is a usual phenomenon in the literature (Bevilaqua‐Grossi
et al., 2016) without however occurring at all times, especially when
it refers to headache frequency (Palacios‐Cena et al., 2016).
The current study aimed to assess pragmatic treatment protocols
by combining acupuncture and stretching despite the fact that in the
literature, acupuncture has usually been examined as a monotherapy.
Recent studies have provided the evidence for a combined approach
of acupuncture and stretching, and it was fundamental for the
approach selected in this study (Wilke et al., 2014). Physiotherapy
and hands‐on techniques have also showed promising results in TTH,
as earlier and recent research (Bevilaqua‐Grossi et al., 2016; Bodes‐
Pardo et al., 2013; Chatchawan et al., 2014; Moraska et al., 2015)
has shown. Either as monotherapies or as combinations, positive ther-
apeutic results have been described in the review by Espi‐Lopez et al.
(2016). This study also supports the analgesic effect of protocols
where hands‐on techniques are implicated in TTH as seen in the
GEORGOUDIS ET AL.
literature (Aaseth et al., 2011; Alonso‐Blanco et al., 2012; Fernandez‐
de‐Las‐Penas, Alonso‐Blanco, Cuadrado, Gerwin, & Pareja, 2006).
However, the literature cannot conclude if myofascial release tech-
niques alone or in combinations can produce any additional therapeu-
tic effects on top of acupuncture/+stretching.
We confirmed that the addition of physiotherapy in the treatment
protocol rendered higher PPT values (reduced pain) not only at the
myofascial trigger point measuring sites but also at the control points
where PPT was measured. This result indicates that physiotherapy
manages more central mechanisms and additively reduces central sen-
sitization. Moreover, this effect was seen in both treatment groups
confirming that TTH management implicates central mechanisms, as
already mentioned in Section 1. Interestingly, the statistically signifi-
cant differences (increases) at all PPT measuring sites after the 10th
treatment session, between treatment groups, stretch the enhanced
role of the hands‐on techniques/diathermy both in local and more cen-
tral sensitivity. This assertion is not strange in the literature and has
been shown in some cases (Jensen, 1999; Majlesi & Unalan, 2004).
The clinical implication of this finding underlines the role of the
hands‐on/diathermy techniques in treating specifically TTH patients.
5.1 | Limitations and strength
The methodological approach of the present study might be criticized
because it did not compare the treatment to be examined against a pla-
cebo or pseudotreatment, but against another full treatment protocol.
Previous studies (Bryans et al., 2011; Linde et al., 2016) have shown
the beneficial effect of acupuncture, stretching, and physiotherapy,
when applied separately or compared to a placebo, in headache
patients. The selection of two pragmatic treatment protocols to
compare might be considered a methodological flaw, but the purpose
of this study was exactly that, to compare two often used treatment
protocols for TTH.
Another point to criticize was that the physiotherapy group was
treated for more time with an extra hands‐on technique, compared
to the nonphysiotherapy one. Because some patients might feel more
positive with a lengthier treatment protocol and a hands‐on technique,
it remains unknown if the results of this study would differentiate if a
pseudophysiotherapy approach was implemented in the acupuncture–
stretching group.
Another limitation of this study was the inability to differentiate
the role of myofascial release technique from the microwave
diathermy on PPT and clinical pain measures (VAS and PPI). The prag-
matic nature of the study and the methodology implemented can only
produce meaningful results for the combination of myofascial release
and diathermy protocol rather than separately for each approach.
On the other hand, the most significant strength of this study was
actually its pragmatic nature, where daily treatment protocols can be
examined for their efficacy. Therefore, these findings seem to produce
interesting implications for physiotherapists in order to develop
optimal therapies for their TTH patients.
5.2 | Implications on physiotherapy practice
In conclusion, patients with TTH were benefited from acupuncture and
stretching, but further PPT improvements were evidenced when
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hands‐on techniques and diathermy were added. The additive role of
myofascial release and diathermy was further shown on PPT both at
the treating and the control sites identifying the central pain mecha-
nisms of TTH. In clinical terms, it is strongly suggested a combination
of myofascial release techniques/diathermy with acupuncture and
stretching in order to further improve the analgesic effect (both for
PPT and clinical pain measures).
ACKNOWLEDGEMENTS
We would like to acknowledge the assistance of Mr. Aggourakis
Manolis and the personnel in the PHYSIOPAIN group practices in data
collection. Also, it is highly appreciated the effort of the editor/
reviewers to improve the initial manuscript.
ORCID
Pantelis Nikolaidis http://orcid.org/0000-0001-8030-7122
RE FE RE NC ES
Aaseth, K., Grande, R. B., Leiknes, K. A., Benth, J. S., Lundqvist, C., & Russell,
M. B. (2011). Personality traits and psychological distress in persons
with chronic tension‐type headache. The Akershus study of chronic
headache. Acta Neurologica Scandinavica, 124(6), 375–382.
Alonso‐Blanco, C., de‐la‐Llave‐Rincon, A. I., & Fernandez‐de‐las‐Penas, C.
(2012). Muscle trigger point therapy in tension‐type headache. Expert
Review of Neurotherapeutics, 12(3), 315–322.
Beltran‐Alacreu, H., Jimenez‐Sanz, L., Fernandez Carnero, J., & La Touche,
R. (2015). Comparison of hypoalgesic effects of neural stretching vs
neural gliding: A randomized controlled trial. Journal of Manipulative
and Physiological Therapeutics, 38(9), 644–652. https://doi.org/10.1016/
j.jmpt.2015.09.002.
Bevilaqua‐Grossi, D., Goncalves, M. C., Carvalho, G. F., Florencio, L. L.,
Dach, F., Speciali, J. G., … Chaves, T. C. (2016). Additional effects of a
physical therapy protocol on headache frequency, pressure pain thresh-
old, and improvement perception in patients with migraine and
associated neck pain: A randomized controlled trial. Archives of Physical
Medicine and Rehabilitation, 97(6), 866–874.
Bodes‐Pardo, G., Pecos‐Martin, D., Gallego‐Izquierdo, T., Salom‐Moreno, J.,
Fernandez‐de‐Las‐Penas, C., & Ortega‐Santiago, R. (2013). Manual
treatment for cervicogenic headache and active trigger point in the
sternocleidomastoid muscle: A pilot randomized clinical trial. Journal
of Manipulative and Physiological Therapeutics, 36(7), 403–411.
Bryans, R., Descarreaux, M., Duranleau, M., Marcoux, H., Potter, B., Ruegg,
R., … White, E. (2011). Evidence‐based guidelines for the chiropractic
treatment of adults with headache. Journal of Manipulative and
Physiological Therapeutics, 34(5), 274–289. https://doi.org/10.1016/
j.jmpt.2011.04.008.
Burke, A., Upchurch, D. M., Dye, C., & Chyu, L. (2006). Acupuncture use in
the United States: Findings from the National Health Interview Survey.
Journal of Alternative and Complementary Medicine, 12(7), 639–648.
https://doi.org/10.1089/acm.2006.12.639.
Chatchawan, U., Eungpinichpong, W., Sooktho, S., Tiamkao, S., &
Yamauchi, J. (2014). Effects of Thai traditional massage on pressure
pain threshold and headache intensity in patients with chronic
tension‐type and migraine headaches. Journal of Alternative and Com-
plementary Medicine, 20(6), 486–492.
Davis, M. A., Kononowech, R. W., Rolin, S. A., & Spierings, E. L. (2008).
Acupuncture for tension‐type headache: A meta‐analysis of random-
ized, controlled trials. Journal of Pain, 9(8), 667–677.
Delaney, G. A., & McKee, A. C. (1993). Inter‐ and intra‐rater reliability of the
pressure threshold meter in measurement of myofascial trigger point
sensitivity. American Journal of Physical Medicine and Rehabilitation,
72(3), 136–139.
8 of 8
Endres, H. G., Bowing, G., Diener, H. C., Lange, S., Maier, C., Molsberger, A.,
… Tegenthoff, M. (2007). Acupuncture for tension‐type headache:
A multicentre, sham‐controlled, patient‐and observer‐blinded,
randomised trial. Journal of Headache and Pain, 8(5), 306–314. https://
doi.org/10.1007/s10194‐007‐0416‐5.
Espi‐Lopez, G. V., Arnal‐Gomez, A., Arbos‐Berenguer, T., Gonzalez, A. A., &
Vicente‐Herrero, T. (2014). Effectiveness of physical therapy in patients
with tension‐type headache: Literature review. Journal of the Japanese
Physical Therapy Association, 17(1), 31–38.
Espi‐Lopez, G. V., Rodriguez‐Blanco, C., Oliva‐Pascual‐Vaca, A., Molina‐
Martinez, F., & Falla, D. (2016). Do manual therapy techniques have a
positive effect on quality of life in people with tension‐type headache?
A randomized controlled trial. European Journal of Physical Rehabilitation
and Medicine, 52(4), 447–456.
Fernandez‐de‐Las‐Penas, C., Alonso‐Blanco, C., Cuadrado, M. L., Gerwin,
R. D., & Pareja, J. A. (2006). Myofascial trigger points and their relation-
ship to headache clinical parameters in chronic tension‐type headache.
Headache, 46(8), 1264–1272.
Ferreira‐Valente, M. A., Pais‐Ribeiro, J. L., & Jensen, M. P. (2011). Validity of
four pain intensity rating scales. Pain, 152(10), 2399–2404. https://doi.
org/10.1016/j.pain.2011.07.005.
Fischer, A. A. (1987). Pressure algometry over normal muscles. Standard
values, validity and reproducibility of pressure threshold. Pain, 30(1),
115–126.
Fischer, A. A. (1988). Documentation of myofascial trigger points. Archives
of Physical Medicine and Rehabilitation, 69(4), 286–291.
France, S., Bown, J., Nowosilskyj, M., Mott, M., Rand, S., & Walters, J.
(2014). Evidence for the use of dry needling and physiotherapy in the
management of cervicogenic or tension‐type headache: A systematic
review. Cephalalgia, 34(12), 994–1003.
Hagander, L. G., Midani, H. A., Kuskowski, M. A., & Parry, G. J. (2000).
Quantitative sensory testing: Effect of site and skin temperature on
thermal thresholds. Clinical Neurophysiology, 111(1), 17–22.
Headache Classification Subcommittee of the International Headache
Society (2004). The International Classification of Headache Disorders:
2nd edition. Cephalalgia, 24, S9–S160.
Hildebrandt, V. H., Bongers, P. M., van Dijk, F. J., Kemper, H. C., & Dul, J.
(2002). The influence of climatic factors on non‐specific back and
neck‐shoulder disease. Ergonomics, 45(1), 32–48. https://doi.org/
10.1080/00140130110110629.
Jensen, R. (1999). Pathophysiological mechanisms of tension‐type head-
ache: A review of epidemiological and experimental studies.
Cephalalgia, 19(6), 602–621.
Karakurum, B., Karaalin, O., Coskun, O., Dora, B., Ucler, S., & Inan, L. (2001).
The ‘dry‐needle technique’: Intramuscular stimulation in tension‐type
headache. Cephalalgia, 21(8), 813–817.
Karst, M., Reinhard, M., Thum, P., Wiese, B., Rollnik, J., & Fink, M. (2001).
Needle acupuncture in tension‐type headache: A randomized,
placebo‐controlled study. Cephalalgia, 21(6), 637–642.
Koltyn, K. F., Focht, B. C., Ancker, J. M., & Pasley, J. (1999). Experimentally
induced pain perception in men and women in the morning and
evening. International Journal of Neuroscience, 98(1–2), 1–11.
Larner, A. J. (2005). Guidelines for the management of headache in primary
care: Are they being used? Journal of Headache and Pain, 6(5), 420–421.
https://doi.org/10.1007/s10194‐005‐0232‐8.
Linde, K., Allais, G., Brinkhaus, B., Fei, Y., Mehring, M., Shin, B. C., … White,
A. R. (2016). Acupuncture for the prevention of tension‐type headache.
Cochrane Database of Systematic Reviews, 4, CD007587. https://doi.
org/10.1002/14651858.CD007587.pub2.
MacPherson, H., Altman, D. G., Hammerschlag, R., Youping, L., Taixiang, W.,
White, A., & Moher, D. (2010). Revised STandards for Reporting
Interventions in Clinical Trials of Acupuncture (STRICTA): Extending
the CONSORT statement. Journal of Evidence‐Based Medicine, 3(3),
140–155. https://doi.org/10.1111/j.1756‐5391.2010.01086.x.
GEORGOUDIS ET AL.
Majlesi, J., & Unalan, H. (2004). High‐power pain threshold ultrasound
technique in the treatment of active myofascial trigger points: A
randomized, double‐blind, case‐control study. Archives of Physical Med-
icine and Rehabilitation, 85(5), 833–836.
Moraska, A. F., Stenerson, L., Butryn, N., Krutsch, J. P., Schmiege, S. J., &
Mann, J. D. (2015). Myofascial trigger point‐focused head and neck
massage for recurrent tension‐type headache: A randomized, placebo‐
controlled clinical trial. Clinical Journal of Pain, 31(2), 159–168.
Ohlsen, B. A. (2012). Combination of acupuncture and spinal manipulative
therapy: Management of a 32‐year‐old patient with chronic tension‐
type headache and migraine. Journal of Chiropractic Medicine, 11(3),
192–201. https://doi.org/10.1016/j.jcm.2012.02.003.
Palacios‐Cena, M., Wang, K., Castaldo, M., Guillem‐Mesado, A., Ordas‐
Bandera, C., Arendt‐Nielsen, L., & Fernandez‐de‐Las‐Penas, C. (2016).
Trigger points are associated with widespread pressure pain sensitivity
in people with tension‐type headache. Cephalalgia. https://doi.org/
10.1177/0333102416679965.
Pöntinen, P. J. (1998). Reliability, validity, reproducibility of algometry
in diagnosis of active and latent tender spots and trigger points.
Journal of Musculoskeletal Pain, 6(1), 61–71. https://doi.org/10.1300/
J094v06n01_05.
Serrano, C., Andrés, M. T., & Sánchez‐Palomo, M. J. (2007). Cefalea de
tensión. Medicine, 9(70), 4473–4479.
Soee, A. B., Skov, L., Kreiner, S., Tornoe, B., & Thomsen, L. L. (2013). Pain
sensitivity and pericranial tenderness in children with tension‐type
headache: A controlled study. Journal of Pain Research, 6, 425–434.
https://doi.org/10.2147/jpr.s42869.
Stovner, L., Hagen, K., Jensen, R., Katsarava, Z., Lipton, R., Scher, A., …
Zwart, J. A. (2007). The global burden of headache: A documentation
of headache prevalence and disability worldwide. Cephalalgia, 27(3),
193–210. https://doi.org/10.1111/j.1468‐2982.2007.01288.x.
Sun‐Edelstein, C., & Mauskop, A. (2012). Complementary and alternative
approaches to the treatment of tension‐type headache. Current Pain
and Headache Reports, 16(6), 539–544.
Tella, B. A., Unubum, E. V., & Danesi, M. A. (2008). The effect of TENS on
selected symptoms in the management of patients with chronic tension
type headache: A preliminary study. Nigerian Quarterly Journal of
Hospital Medicine, 18(1), 25–29.
Torelli, P., Jensen, R., & Olesen, J. (2004). Physiotherapy for tension‐type
headache: A controlled study. Cephalalgia, 24(1), 29–36.
Toro‐Velasco, C., Arroyo‐Morales, M., Fernandez‐de‐Las‐Penas, C.,
Cleland, J. A., & Barrero‐Hernandez, F. J. (2009). Short‐term effects of
manual therapy on heart rate variability, mood state, and pressure pain
sensitivity in patients with chronic tension‐type headache: A pilot
study. Journal of Manipulative and Physiological Therapeutics, 32(7),
527–535. https://doi.org/10.1016/j.jmpt.2009.08.011.
Vickers, A. J., Rees, R. W., Zollman, C. E., McCarney, R., Smith, C. M., Ellis,
N., … Grieve, R. (2004). Acupuncture of chronic headache disorders in
primary care: Randomised controlled trial and economic analysis. Health
Technology Assessment, 8(48), iii), 1–35.
Wilke, J., Vogt, L., Niederer, D., Hubscher, M., Rothmayr, J., Ivkovic, D., …
Banzer, W. (2014). Short‐term effects of acupuncture and stretching
on myofascial trigger point pain of the neck: A blinded, placebo‐
controlled RCT. Complementary Therapies in Medicine, 22(5), 835–841.
https://doi.org/10.1016/j.ctim.2014.09.001.
How to cite this article: Georgoudis G, Felah B, Nikolaidis P,
Damigos D. The effect of myofascial release and microwave
diathermy combined with acupuncture versus acupuncture
therapy in tension‐type headache patients: A pragmatic ran-
domized controlled trial. Physiother Res Int. 2018;23:e1700.
https://doi.org/10.1002/pri.1700