This study aimed to evaluate the effectiveness of the court-type traditional Thai massage (CTTM) to treat patients with chronic tension-type headaches (CTTHs) comparing with amitriptyline taking. A randomized controlled trial was conducted. Sixty patients diagnosed with CTTH were equally divided into a treatment and a control group. The treatment group received a 45-minute course of CTTM twice per week lasting 4 weeks while the control group was prescribed 25 mg of amitriptyline once a day before bedtime lasting 4 weeks. Outcome measures were evaluated in week 2, week 4 and followed up in week 6 consisting of visual analog scale (VAS), tissue hardness, pressure pain threshold (PPT), and heart rate variability (HRV). The results demonstrated a significant decrease in VAS pain intensity for the CTTM group at different assessment time points while a significant difference occurred in within-group and between-group comparison (
Tension-type headache (TTH) is the most common type of headache that patients always suffer from mild to severe pain that reduces their ability to perform daily activities [
The treatment of TTH is carried out following both pharmacological and nonpharmacological approaches. As for pharmacological approaches, patients are often prescribed acetaminophen, or aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) [
Among the nonpharmacological approaches, traditional Thai massage (TTM) is an alternative treatment that has been widely practiced to reduce musculoskeletal illnesses in Thailand [
A pilot study was carried out on ten subjects who were recruited using the inclusion criteria developed by the International Headache Society (IHS). They received two 45-minute massage sessions over a one-week period. Therapeutic effectiveness was evaluated before and after each treatment. The results revealed that there was a significant reduction in CTTH symptoms after the treatment at
The study design was randomized controlled trial conducted at the Department of Traditional Thai Medicine, Bamnet Narong Hospital, Amphur Bamnet Narong, Chaiyaphum Province, Thailand.
The study was approved by the 1st Ethics Review Committee for Research Involving Human Subjects, Health Science Group, Chulalongkorn University (COA number 052/2557).
The patients aged 18–65 years at Bamnet Narong Hospital diagnosed with CTTH according to the criteria of IHS [
The main inclusion criterion was CTTH diagnosed by criteria of IHS [
Patients were excluded for any of the following: other types of headache not classified as CTTH and history of the following illnesses or disorders: (a) cervical disorders, such as cervical spondylosis, or herniated disc, (b) neurological disorders, such as hemiplegia or paresis, and (c) skin diseases, such as chickenpox or herpes zoster, no communicative ability or inability to follow instructions, and a fever of 38.5°C.
Outcome measures including the VAS, tissue hardness meter and algometer, and the HRV were assessed before the first treatment; assessment was conducted again in weeks 2 and 4 and follow-up in week 6. The assessor was a licensed physical therapist who was blinded on group allocation of the patients.
The researchers used measurement instruments as follows.
The VAS is an instrument for measuring perception of current pain, rated from 0 (no pain) to 10 (most severe pain ever experienced). In this study, the VAS was assessed before the first treatment as well as before and after the treatment at week 2 and week 4 and followed up in week 6. Tissue hardness and pressure pain threshold (PPT) were measured using a tissue hardness meter and algometer (OE-220, ITO/JAPAN). Tissue hardness measurement involved pushing the force sensor of the device on the skin over the trapezius muscle until the beep sound was noted and then stopping pushing and reading the recorded number giving the percentage of tissue hardness. PPT was measured using the algometer mode of the device. The 1-cm2 sensor knob was gradually pushed down on the skin over the muscle until the patient feels a little discomfort without pain. At this time, the patient was informed to push the hand-held switch with a beep sound to stop the procedure and read the recorded force for PPT. The reliability of measurement was tested at the beginning of the study and found high for tissue hardness (ICC = 0.97) and PPT (ICC = 0.92). The tissue hardness and the PPT were assessed before the first treatment as well as after the treatment at week 2 and week 4 and followed up in week 6.
Heart rate variability (HRV) refers to the beat-to-beat alterations in heart rate. This can be analysed as either time-domain or frequency-domain. Time-domain analysis is a continuous measurement of intervals of variability of the QRS complex, resulting from the sinus node depolarization of the ventricle, during an electromyography (ECG). The analysis of duration can be exhibited in the forms of mean normal-to-normal (NNI) intervals and the standard deviation of NNI (SDNN). The greater the SDNN, the higher the variability of the heart rates transmitted through the parasympathetic nerve. Frequency-domain analysis generates power spectral density (PSD) results, using precise mathematical calculation to determine the variability of signals in each frequency. The calculation is done nonparametrically and parametrically. The nonparametric analysis is superior in terms of the application of the fast Fourier transformation (FFT). On the other hand, the parametric one produces smoother frequency components, making it easier to distinguish frequency ranges as well as identify a mean frequency number. Additionally, an estimation of the PSD value from a small sample is still precise. Despite its advantages, the parametric analysis is complex and involves confirmation of the suitability of the sample. This HRV is the best indirect method for measuring cardiac autonomic control, including both the sympathetic and the parasympathetic systems [
Sixty patients aged 18–65 years who were diagnosed with CTTH according to the criteria of the International Headache Society (IHS) participated. They were randomly allocated into a treatment group and control group. After the preliminary diagnosis, the randomization, and signing of the consent form, the patients were given a 4-week treatment according to the group to which they belonged and a 2-week follow-up. The details are as follows.
The 30 patients who were randomly allocated in the treatment group received the CCTM. The CCTM was done by two licensed applied Thai traditional medical practitioners who have had experience with CCTM more than three years. Lasting 45 minutes for each session, the treatment was conducted twice per week for 4 weeks. A follow-up was done during week 6. The CCTM involved using thumb pressure along the massage meridian lines and points of CCTM (Figures
The massage points 1–5 on the back of the head of CTTH patient.
The massage points 1–5 on the forehead of CTTH patient.
In detail, the method for alleviating TTH using CCTM comprised seven steps lasting 45 minutes, starting from the shoulders (15 minutes), both sides of the upper back (5 minutes), the area connecting the neck and the shoulders (10 minutes), the tips of the shoulders (3 minutes), the back of the head (5 minutes) (Figure
The therapist stood behind the patient, performing one of the following three types of pressure of massage according to the pressure pain threshold of each patient: low-pressure massage, medium-pressure massage, and high-pressure massage. Basically, the thumb pressure must never exceed the pressure threshold of each patient as the therapist has estimated at the beginning of each treatment. The therapist stood with the feet placed slightly apart. For the medium-impact massage, the therapist moved one leg one step behind and bends the other leg slightly. For the high-impact massage, the therapist was in the same posture as for the medium-impact one but increased the bending angle of the trunk and lifted one heel so that she could transfer the body weight more to the thumb pressure. After that, the therapist starts by pressing the thumbs above the shoulder blades, two inches from the medial part of the shoulder tips, and then moving the press along the upper trapezius muscle to the side of C-7 spinous process. In sitting position, pressure from both thumbs is applied started from shoulder to neck and neck to shoulder for two rounds (upper trapezius muscle). Each press lasted 10 seconds (Figure
Shoulder massage.
The therapist stood behind the patient, pressing the thumb on the upper trapezius muscle near cervical vertebrae C-7 for 30 seconds (Figure
Back massage.
The therapist sat with his knees on the floor behind the patient; pressure from thumb was applied at side of the neck while the other hand of the therapist touched (as counter force) the subject’s forehead. Neck massage was started from C-7 (upper trapezius and splenius muscle) to the occipital area. After that, right side of the neck was also massaged with each press for 10 seconds (Figure
Basic massage of the neck.
The therapist sat with his knees on the floor beside the patient, holding the wrist of the patient with the hand on the same side of the patient’s shoulder. The therapist applied thumb pressure using the thumb of the other hand to press on the trapezius and supraspinatus muscles on the suprascapular fossa and maintained each press for 30 seconds (Figure
Shoulder tip massage.
The therapist sits with his knees on the floor behind the patient, pressing the thumbs on signals 1–5 of the back of the head and maintaining each press for 30 seconds (Figures
Massage on the back of the head.
The therapist stood behind the patient and pressed on the skull using the thumbs along midline of the head. The therapist held each press for 30 seconds (Figure
Massage on the middle of the head.
The therapist sat with his knees on the floor in front of the patient, using one thumb to press on each of the five points on the face, and maintained each press for 30 seconds (Figures
Face massage.
To minimize bruises, the intensity of a massage was adjusted to suit each individual patient’s pressure pain threshold and age, drawing on information from therapist observation and inquiries made to the patient regarding his/her feelings. In addition, the patients were requested to inform the therapist immediately if they experienced pain caused by excessive massage intensity. During each CTTH therapy session, the subjects suffering from bruises were treated with topical herbal press. If bruises broke out later, the participants could telephone those in the research team anytime.
The other 30 patients who were randomly allocated into the control group were given amitriptyline by a licensed medical practitioner. They were prescribed 25 mg once daily before bedtime for 4 weeks, and a follow-up was carried out in week 6. Each of them was informed that the medication could cause drowsiness and recommended that strict adherence to the prescribed time of consumption was required.
The patients meeting the inclusion criteria were assigned to either the treatment group (receiving CTTM) or the control group (taking amitriptyline) using the simple random sampling technique. The randomization was performed using a lottery by the researcher assistant.
The data was analyzed in terms of mean and standard deviation (SD) for continuous variables and percentage for categorical variables. The study aimed to analyze each session of treatment separately at different time points: before the first treatment, after week 2, after week 4, and after week 6 (during the follow-up). All the analysis was performed on the basis of intention to treat.
An analysis of Repeated Measures ANOVA was used to compare the means of within-group data, and analysis of covariance (ANCOVA) was also conducted to compare the differences between the two groups as well as estimate the adjusted difference between the two groups at 95% confidence level. Post hoc tests using Fisher’s Least Significant Difference (LSD) were applied for multiple comparisons.
A total of ninety-two subjects responded to the recruitment advertisements and were screened for eligibility for the study. After screening by medical doctor, thirty-two subjects dropped out because of low frequency (
Flow chart of entry and discontinuation by participants during the study.
Details of demographic data were presented in Table
Demographic data.
Characteristics | CTTM | Control |
|
---|---|---|---|
|
| ||
Gender | |||
Female | 26 (86.70) | 29 (96.70) | <0.05 |
Male | 4 (13.30) | 1 (3.30) | |
Aged (year) | |||
23–36 years | 6 (20.00) | 1 (3.30) | 0.350 |
37–50 years | 13 (43.30) | 13 (43.30) | |
51–64 years | 11 (36.70) | 16 (53.30) | |
|
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|
|||
Occupation | |||
Agriculture | 9 (30.00) | 10 (33.30) | 0.939 |
Self-employed/business | 4 (13.30) | 3 (10.00) | |
Government officer/government employer | 8 (26.70) | 7 (23.30) | |
Work as employee | 9 (30.00) | 10 (33.30) | |
Underlying diseases | |||
None | 25 (83.30) | 26 (86.70) | 0.690 |
Yes (allergy) | 2 (6.70) | 1 (3.30) | |
Yes (diabetes mellitus) | 1 (3.30) | 2 (6.70) | |
Yes (hypertension) | 2 (6.70) | 1 (3.30) | |
History of headache in the lifetime (time) | |||
Headache frequency of life (time) ≥ 50 times | 30 (100.00) | 30 (100.00) | 1.000 |
Duration time in each headache attack | |||
<30 minutes | 1 (3.30) | 1 (3.30) | 1.000 |
30 minutes to 1 hour | 18 (60.00) | 18 (60.00) | |
1 hour to 2 hours | 6 (20.00) | 6 (20.00) | |
> a day <7 days | 5 (16.70) | 5 (16.70) | |
Working affected by headache | |||
None | 1 (3.30) | 4 (13.30) | 0.926 |
Can work but less than normal | 18 (60.00) | 16 (53.30) | |
Can work if it is necessary | 6 (20.00) | 6 (20.00) | |
Cannot work (stop working) | 5 (16.70) | 4 (13.30) | |
Previous treatments of headache | |||
Rest | 9 (30.00) | 5 (16.70) | 0.935 |
Drug | 11 (36.70) | 12 (40.00) | |
Medical doctor | 10 (33.30) | 13 (43.30) | |
Baseline of clinical outcome measure | |||
Visual analog scale (VAS 0–10 cm); mean ± SD | 6.30 ± 1.20 | 6.06 ± 0.94 | 0.105 |
Tissue hardness (%); mean ± SD | 59.89 ± 11.04 | 57.16 ± 8.50 | 0.159 |
Pressure pain threshold (kg/cm2); mean ± SD | 3.17 ± 0.69 | 2.85 ± 0.79 | 0.264 |
Heart rate variability (HRV); mean ± SD | |||
Standard deviation from the mean RR value; SDNN (Ms) | 35.57 ± 13.38 | 35.93 ± 24.46 | 0.119 |
Root mean square of the standard deviation; RMS-SD (Ms) | 30.89 ± 15.40 | 33.18 ± 30.01 | 0.162 |
Low frequency power; LF (ms2) | 95.97 ± 72.94 | 80.87 ± 76.01 | 0.724 |
High frequency power; HF (ms2) | 83.43 ± 75.74 | 73.47 ± 74.60 | 0.654 |
Low frequency to high frequency ratio; LF/HF (ms2) | 1.79 ± 1.52 | 1.82 ± 1.51 | 0.933 |
Patient-rated outcome repeated measures at all assessment time points during the baseline, week 2, and week 4 of treatment and at week 6 follow-up after final treatment (Repeated Measures ANOVA).
Outcome | Group | Baseline | 2-week follow-up | 4-week follow-up | 6-week follow-up |
|
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(Mean ± SD) | (Mean ± SD) | (Mean ± SD) | ||||
Visual analog scale (VAS 0–10 cm) | CTTM | 6.3 ± 1.20 | 3.73 ± 1.22 | 2.90 ± 0.95 | 2.60 ± 0.72 | <0.05 |
Control | 6.0 ± 0.94 | 4.40 ± 1.37 | 3.50 ± 1.27 | 2.90 ± 1.06 | <0.05 | |
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Tissue hardness (%) | CTTM | 59.89 ± 11.04 | 48.85 ± 11.29 | 46.20 ± 7.54 | 48.96 ± 8.01 | <0.05 |
Control | 57.16 ± 8.50 | 49.80 ± 10.45 | 49.51 ± 7.85 | 47.41 ± 8.62 | <0.05 | |
|
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Pressure pain threshold (kg/cm2) | CTTM | 3.17 ± 0.69 | 3.72 ± 0.60 | 4.01 ± 0.62 | 4.12 ± 0.55 | <0.05 |
Control | 2.85 ± 0.79 | 3.17 ± 0.65 | 3.48 ± 0.68 | 3.53 ± 0.73 | <0.05 |
The results showed a statistically significant increase in the outcome means for both the groups (
Comparison of the adjusted mean and 95% CI outcome measures (adjusted for baseline using ANCOVA) at each assessment time point.
Outcome | 2-week follow-up | 4-week follow-up | 6-week follow-up | |||
---|---|---|---|---|---|---|
(Mean ± SD) | (Mean ± SD) | (Mean ± SD) | ||||
CTTM | Control | CTTM | Control | CTTM | Control | |
(Mean ± SD) | (Mean ± SD) | (Mean ± SD) | (Mean ± SD) | (Mean ± SD) | (Mean ± SD) | |
Visual analog scale (VAS 0–10 cm) | 3.73 ± 1.22 | 4.4 ± 1.37 | 2.9 ± 0.95 | 3.5 ± 1.27 | 2.60 ± 0.72 | 2.9 ± 1.06 |
Difference (95% CI) | 0.90 (0.54 to 1.26) | 0.79 (0.42 to 1.5) | 0.44 (0.11 to 0.76) | |||
|
<0.05 | <0.05 | <0.05 | |||
Tissue hardness (%) | 48.85 ± 11.29 | 49.80 ± 10.45 | 46.20 ± 7.54 | 49.51 ± 7.85 | 48.96 ± 8.01 | 47.41 ± 8.62 |
Difference (95% CI) | −2.38 (−7.42 to 2.65) | 4.30 (0.70 to 7.89) | 0.97 (−3.27 to 5.22) | |||
|
0.347 | <0.05 | 0.647 | |||
Pressure pain threshold (kg/cm2) | 3.72 ± 0.60 | 3.17 ± 0.65 | 4.01 ± 0.62 | 3.4 ± 0.68 | 4.12 ± 0.55 | 3.53 ± 0.73 |
Difference (95% CI) | 0.35 (0.13 to 0.57) | 0.32 (0.09 to 0.55) | 0.38 (0.13 to 0.63) | |||
|
<0.05 | <0.05 | <0.05 |
Figures
Heart rate variability by SDNN.
Heart rate variability by RMS-SD.
Heart rate variability by LF.
Heart rate variability by HF.
Heart rate variability by LF/HF.
This study aimed to determine the effectiveness of the court-type traditional Thai massage (CTTM) in treating patients suffering from chronic tension-type headaches (CTTHs) in comparison with amitriptyline. Assessment was conducted at week 2, week 4, and week 6 follow-up for both the CTTM group and the control group. The outcome measures involved visual analog scale (VAS), tissue hardness, pressure pain threshold (PPT), and heart rate variability (HRV).
The headache pain intensity scores reduced from baseline at week 2, week 4, and week 6 follow-up for both the CTTM group and the control group. In terms of the VAS, a comparison between the two groups indicated statistically significant differences for all assessment time points. Such a decline in headache pain intensity may be explained in terms of physiological effects. Specifically, TTM involves stimulating blood and lymph circulation as well as the sympathetic nervous system through exerting pressure on the skin and muscles. As a result, the flow of nutrients to tissues is enhanced, and the discretion of toxins and residual substances inside the body improves, thereby reducing swelling and pain [
The results were consistent with Chatchawan and colleagues [
A comparison of the effectiveness in reducing tissue hardness within-group means for tissue hardness of the CTTM group and the control group at baseline, week 2, week 4, and week 6 follow-up indicated a significant decline for both the groups (
When the CTTM group and the control group were compared at each assessment time point, it was found that the two groups differed significantly at week 4 (
Similar findings are also reported elsewhere. Zheng et al. [
A comparison of the effectiveness in increasing pressure pain threshold within-group means of the CTTM group and the control group assessed at baseline, week 2, week 4, and week 6 follow-up indicated a significant increase in PPT at all assessment time points for both the groups (
The results are consistent with those of other researches carried out earlier. Kruapanich and colleagues [
On the other hand, the present findings do not resemble those reported in Toro-Velasco et al. [
The improvement in PPT reported in this study may be explained as follows. In CTTH patients, trigger points (TrPs) may be found around the head, temporal, occipital bone, shoulders, and eyes [
A comparison of the effectiveness in increasing heart rate variability within-group means of the CTTM group and the control group through a time-domain analysis of SDNN and RMS-SD as well as a frequency-domain analysis of LF, HF, and LF/HF at different assessment time points showed that the values of SDNN, RMS-SD, and HF for the CTTM group increased significantly (
When the CTTM group and the control group were compared, it was found that the LF value was statistically different at week 2 (
All the findings suggest that CTTM tends to be an effective therapy that can enhance the function of the parasympathetic nervous system, thereby reducing tension in CTTH patients.
Regarding side effects, we found some of the patients who had never received massage therapy before reported experiencing mild ache in the shoulders after the first treatment that subsided within one to two days. As for the control group, some of the patients reported morning drowsiness during the first few days of consumption of amitriptyline, so they were advised to have enough rest.
This research compares the effectiveness of CTTM and amitriptyline in treating CTTH patients. In terms of VAS the results showed a statistically significant decrease in headache pain intensity for the CTTM group at different assessment time points and a statistically significant difference between the CTTM group and the control group at each assessment time point. The superiority of CTTM over amitriptyline was also identified for other variables. As for tissue hardness, the value for the CTTM group was significantly lower than that of the control group at week 4, and the value for both the groups reduced at the other assessment time points, although not statistically significant. Additionally, the PPT of the CTTM group increased significantly and was significantly higher than that of the control group. Finally, the HRV of the CTTM group increased significantly in terms of SDNN, RMS-SD, and LF. It can therefore be concluded from the findings that CTTM seems to be an effective therapy for enhancing the function of the parasympathetic nervous system and other stress-related variables as well as reducing CTTHs.
Double blinded assessment was not applicable in this study since each of the patients knew the group they belonged to. However, blinded assessor was the only thing we could do apart from random allocation for compromising the internal validity of the study.
Based on the present findings, the CTTM could serve as an alternative therapy for the treatment of CTTH patients. This could be an appropriate therapy for the patients who suffer with adverse effects of medication. Further research should determine long term effects of these two types of treatment because some patients in the study were fully recovered within one month of treatment and two weeks of follow-up whereas the others were not. Effects of longer period of treatment and longer follow-up period are not known.
The authors declare that there is no conflict of interests regarding the publication of this paper.
This study (AS1148A-55, RES 560530243-AS) was supported by the Higher Education Research Promotion and National Research University Project of Thailand of the Office of the Higher Education Commission and the 90th Anniversary of Chulalongkorn University (Ratchadaphiseksomphot Endowment) Fund. This publication has been supported by the Ratchadaphiseksomphot Endowment Fund of Chulalongkorn University (RES560530243-AS) and this study was supported by the Thai Traditional Medical Knowledge Fund.