Aim We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH). Methods We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality. Results Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH (p < 0.0001; mean reduction −1.11 on a 0–10 visual analog scale (VAS); 95% CI −1.64 to −0.57) and CGH (p = 0.0002; mean reduction −2.52 on a 0–10 VAS; 95% CI −3.86 to −1.19) pain intensity, CGH frequency (p < 0.00001; mean reduction −1.34 days per month; 95% CI −1.40 to −1.28), and migraine (p = 0.0001; mean reduction −22.39 hours without relief; 95% CI −33.90 to −10.88) and CGH (p < 0.00001; mean reduction −1.68 hours per day; 95% CI −2.09 to −1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity (p < 0.00001; mean reduction −1.94 on a 0–10 VAS; 95% CI −2.61 to −1.27) and frequency (p < 0.00001; mean reduction −9.07 days per month; 95% CI −9.52 to −8.62). Discussion Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

Objective: The aim of this project was to evaluate the prevalence and pattern of musculoskeletal dysfunctions in migraine patients using a rigorous methodological approach and validating an international consensus cluster of headache assessment tests. Methods: A physiotherapist, blinded towards the diagnosis, examined 138 migraine patients (frequent episodic and chronic), recruited at a specialised headache clinic, and 73 age and gender matched healthy controls following a standardised protocol. Eleven tests, previously identified in an international consensus procedure, were used to evaluate cervical and thoracic musculoskeletal dysfunctions. Results: Primary analyses indicated statistically significant differences across groups for the total number of trigger points, flexion-rotation test, thoracic screening, manual joint testing of the upper cervical spine, cranio-cervical flexion test, and reproduction and resolution. Ninety three percent of the assessed patients had at least three musculoskeletal dysfunctions. Post-hoc tests showed significant differences between episodic or chronic migraine patients and healthy controls, but not between migraine groups. Conclusions: A standardised set of six physical examination tests showed a high prevalence of musculoskeletal dysfunctions in migraine patients. These dysfunctions support a reciprocal interaction between the trigeminal and the cervical systems as a trait symptom in migraine.

Objective To evaluate the effectiveness of transcranial direct current stimulation alone and in combination with cognitive behavioural management in patients with non-specific chronic low back pain. Design Double blind parallel group randomised controlled trial with six months’ follow-up conducted May 2011-March 2013. Participants, physiotherapists, assessors, and analyses were blinded to group allocation. Setting Interdisciplinary chronic pain centre. Participants 135 participants with non-specific chronic low back pain >12 weeks were recruited from 225 patients assessed for eligibility. Intervention Participants were randomised to receive anodal (20 minutes to motor cortex at 2 mA) or sham transcranial direct current stimulation (identical electrode position, stimulator switched off after 30 seconds) for five consecutive days immediately before cognitive behavioural management (four week multidisciplinary programme of 80 hours). Main outcomes measures Two primary outcome measures of pain intensity (0-100 visual analogue scale) and disability (Oswestry disability index) were evaluated at two primary endpoints after stimulation and after cognitive behavioural management. Results Analyses of covariance with baseline values (pain or disability) as covariates showed that transcranial direct current stimulation was ineffective for the reduction of pain (difference between groups on visual analogue scale 1 mm (99% confidence interval −8.69 mm to 6.3 mm; P=0.68)) and disability (difference between groups 1 point (−1.73 to 1.98; P=0.86)) and did not influence the outcome of cognitive behavioural management (difference between group 3 mm (−10.32 mm to 6.73 mm); P=0.58; difference between groups on Oswestry disability index 0 point (−2.45 to 2.62); P=0.92). The stimulation was well tolerated with minimal transitory side effects. Conclusions This results of this trial on the effectiveness of transcranial direct current stimulation for the reduction of pain and disability do not support its clinical use for managing non-specific chronic low back pain. Trial registration Current controlled trials ISRCTN89874874.

To evaluate the effectiveness of transcranial direct current stimulation on clinical and experimental pain, and to identify the most beneficial stimulation parameters. Predefined search using key terms of information sources including: MEDLINE, EMBASE, CAB Abstracts, and PsychINFO, Cochrane Register of Controlled Trials, CINAHL, and PeDRO databases; reference lists of retrieved articles, journal contents, and conference proceedings. Two reviewers independently searched and evaluated publications. English and non-English controlled trials that applied direct current stimulation to the brain published before September 30, 2010 were included. Studies using magnetic stimulation or pulsed currents were excluded. Trials investigating experimental pain in healthy participants (n=6) used a wide variety of stimulation and outcome parameters that did not allow a synthesis across outcome parameters. Trials investigating chronic pain (n=8) used anodal motor cortex stimulation of 1 or 2 mA intensity, either as a single dose or on a maximum of 10 consecutive days. Four trials on chronic pain were excluded due to a high risk of bias. A meta-analysis of 4 trials on chronic pain found a pooled effect size of −2.29 with a 95% confidence interval of −3.5 to −1.08. This effect does just reach minimal clinically important difference recommendations. The level of evidence for the efficacy of transcranial direct current stimulation in experimental and chronic pain reduction is low. Evidence from high quality randomized controlled trials is required before this treatment should be recommended.