374 BrJP. São Paulo, 2021 oct-dec;4(4):374-8 ABSTRACT BACKGROUND AND OBJECTIVES: Headaches are the most common neurological symptom and the most frequent me- dical complaint, with tension-type pain being one of the most re- ported forms, being considered a public health problem. Among the manual therapies indicated for the treatment of tension type headaches (TTH) is myofascial release (MRL), which consists of releasing muscle and fascia tension, through techniques that deactivate trigger points (TP). Thus, the objective of this integra- tive review is to determine the effectiveness of physical therapy using MRL in the treatment of TP-induced TTH. CONTENTS: The guiding question of the study was: “What is the effect of manual therapy using myofascial release as a treat- ment in patients with tension-type headaches”? Searches were performed in LILACS and Pubmed/Medline databases until Au- gust 2021. Sixteen studies published between 2003 and 2021 were included in this integrative review, including case reports and clinical trials, presenting a total of 481 patients. CONCLUSION: It was possible to conclude that the MRL te- chnique showed positive results as a treatment for TTH through the reduction of pain, intensity and frequency. Keywords: Musculoskeletal manipulations, Tension-type heada- che, Trigger points. Efficiency of myofascial release in patients with tension-type headaches: integrative review Eficácia da liberação miofascial em pacientes com cefaleias do tipo tensional: revisão integrativa Marcela Galdina Silva1, Victor Augusto Alves Bento2, Daisilene Baena Castillo3 Marcela Galdina Silva – https://orcid.org/0000-0002-9422-4165; Victor Augusto Alves Bento – https://orcid.org/0000-0003-0558-4239; Daisilene Baena Castillo – https://orcid.org/0000-0003-4261-7503. 1. Anhanguera de Campo Grande University Center, Unit II, Physical Therapy, Campo Grande, MS, Brazil. 2. Júlio de Mesquita Filho São Paulo State University, School of Dentistry, Dentistry Materi- als and Prostheses Department, Araçatuba, SP, Brazil. 3. Federal University of Matro Grosso do Sul, School of Dentistry, Dentistry Prostheses Department, Campo Grande, MS, Brazil. Submitted on May 02, 2021. Accepted for publication on September 22, 2021. Conflict of interests: none – Sponsoring sources: none. Correspondence to: Departamento de Materiais Odontológicos e Prótese Faculdade de Odontologia de Araçatuba Universidade Estadual Paulista Júlio de Mesquita Filho Rua José Bonifácio, 1193 16015-050 Araçatuba, SP, Brasil. E-mail: vtrbento97@gmail.com © Sociedade Brasileira para o Estudo da Dor RESUMO JUSTIFICATIVA E OBJETIVOS: As cefaleias se constituem no sintoma neurológico mais comum e de queixa médica mais fre- quente, sendo a dor de tipo tensional uma das formas mais rela- tadas e um problema público de saúde. Entre as terapias manuais indicadas ao tratamento da cefaleia de tipo tensional (CTT), está a liberação miofascial (LM), que consiste na liberação da tensão do músculo e da fáscia por meio de técnicas para desativação de pontos-gatilhos (PG). O objetivo deste estudo foi determinar a eficácia da fisioterapia utilizando a LM no tratamento das CTT induzidas por PG. CONTEÚDO: A questão norteadora do estudo foi: “Qual o efeito da terapia manual utilizando a liberação miofascial como tratamento em pacientes com cefaleias do tipo tensional”?  As buscas foram realizadas nas bases de dados LILACS e Pubmed/ Medline até agosto de 2021. Foram incluídos nessa revisão 16 estudos publicados entre 2003 e 2021, sendo relatos de caso e ensaios clínicos, com um total de 481 pacientes. CONCLUSÃO: A técnica de LM apresentou resultados positi- vos como tratamento para CTT, pela diminuição intensidade e frequência da dor. Descritores: Cefaleia do tipo tensional, Manipulações muscu- loesqueléticas, Pontos-gatilho. INTRODUCTION Headaches are neurological symptoms common in doctors’ offi- ces and may present different characteristics. The most reported headaches are tension-type, cervicogenic and migraines1. These are associated with a high burden of suffering and considerable socioeconomic costs2 because they are debilitating disorders whi- ch make routine actions impossible and are considered a public health problem3. According to the World Health Organization (WHO)4, heada- ches will be experienced at some point by most people around the world. The belief is that about 80% of the population suffers from this disease every year, and only in 10 to 20% of the cases a doctor is consulted5,6. The low consultation rate can be explained by insufficient information about the effectiveness of treatments or by negative health care experiences7. Authors8 reported that 82% of physicians who perform primary health care were not aware of the classification and diagnostic criteria for primary headache disorders. The types and characteristics of tension-type headaches (TTH) were included in the primary headaches category by DOI 10.5935/2595-0118.20210058 REVIEW ARTICLE 375 Efficiency of myofascial release in patients with tension-type headaches: integrative review BrJP. São Paulo, 2021 oct-dec;4(4):374-8 the International Headache Society (IHS) in 20049. The most common TTH are episodic tension-type headaches (ETTH), in which the frequency is less than 15 days per month, and chronic tension-type headaches (CTTH), in which the fre- quency is more than 15 days per month. CTTH is also cha- racterized by pain episodes that vary from 30 minutes to 7 days, and in most cases, impairment in work performance is reported10, generating a risk factor for excessive use of anal- gesic drugs11. Musculoskeletal system impairments play an important role in headaches12, such as myofascial trigger points (TP), bringing evi- dence of a potential association with TTH13. TP are defined as “hypersensitive nodules in the taut bands of the skeletal muscles that cause referred and autonomic pain, as well as motor symp- toms when stimulated”14. Studies have reported that the referred pain caused by TP active in the muscles of the head, neck, and shoulder mimic the pain pattern in individuals with ETTH13,15 and CTTH16,17. Neck and head TP in patients with TTH pre- sent greater pain in intensity and frequency compared to patients with TTH and no TP18. Several therapeutic approaches have been proposed for the treatment of headaches, such as drugs, physical therapy, and relaxation/cognition therapies19. The clinical guidelines on the treatment of TTH by the European Federation of Neurologi- cal Societies concluded that conservative management such as physical therapy and acupuncture should always be considered, although their scientific basis is still limited20. A study conducted in the USA revealed that manual therapies are the most reques- ted therapeutic strategies by patients with TTH21,22. Manual therapy is a type of non-surgical conservative treatment that is based on the treatment of neuromusculoskeletal dysfunc- tion through analytical muscle and joint manipulations, with the goal of assessing, diagnosing, and treating a variety of symptoms and conditions23. Manual therapy consists of a wide variety of te- chniques24, and all show positive results regarding the reduction of drug use and decrease in symptoms of pain25. Among manual therapies, a widely used technique is myofascial release (MRL), which consists of releasing muscle and fascia tension through TP deactivation techniques, thus increasing local circulation, which consequently decreases pain, spasms, and symptoms of TTH, besides bringing other benefits26. Therefore, the aim of the present study was to determine the effectiveness of physical therapy using MRL in the treatment of PG-induced TTH. CONTENTS An integrative literature review, characterized by the resear- cher’s interest in summarizing results of a set of studies on the same subject, allowing the link between research evidence and health practices, with the possibility of contributing to the care provided to users of health services27. The study will be developed in the following stages: identification of the sub- ject and elaboration of the guiding question; establishment of inclusion and exclusion criteria; search in the scientific literature; definition of the information to be collected and assessment of the studies selected for review; interpretation; and knowledge synthesis. The study’s guiding question was: “What is the effect of ma- nual therapy using myofascial release as treatment in patients with tension-type headaches”? Searches were performed in LILACS and Pubmed/Medline databases until August 2021. The descriptors used were: “Cefaleia do Tipo Tensional”, “Fi- sioterapia”, “Manipulações Musculoesqueléticas”, “Liberação Miofascial” e “Terapia Manual”, present in the Descriptors in Health Sciences (DeCS - Descritores em Ciências da Saúde) - and their correspondents in English: “Tension-Type Hea- dache”, “Physical Therapy Specialty”, “Musculoskeletal Ma- nipulations”, “Myofascial Release” and “Manual Therapy”, present in the Medical Subject Headings (MeSH). The des- criptors were associated with each other using the Boolean operator AND. Inclusion criteria were case reports or clinical trials using MRL therapy, published in Portuguese, English or Spanish, with full text available in the selected databases. The exclusion criteria were articles that did not use MRL therapy, dupli- cates, texts with incomplete text or unavailable in full, and those that did not fit the study’s subject and aim. To assess the data, a research instrument was developed struc- tured according to the guiding question, divided into 11 items in order to record information from the articles: num- bering, title, authors identification, authors titles, year of pu- blication, journal, study objective, methodology, study loca- tion, results, and conclusions. This instrument was filled out after reading the content of the articles, taking into account the guiding question. For data analysis and interpretation, a synoptic table was prepa- red to record the synthesis of the information obtained in the articles. These elements served as a basis for the analysis and discussion of the results and to answer the research problem. To analyze the data, an initial evaluation of the selected arti- cles took place, and they were compared to each other, aiming to create a dialogue with the similarities and to point out the differences. Then, the data obtained were registered in the form of a synoptic table, which enabled a more synthesized and comparative interpretation of the data found. RESULTS The database search selected 330 articles, including 99 studies in LILACS and 231 studies in Pubmed/Medline. All duplica- te references were excluded, and the inclusion/exclusion cri- teria were applied, resulting in 16 articles. The results found in the databases are shown in table 1. Table 1. Distribution of bibliographic references found and selected according to the databases and descriptors Databases Studies found Studies selected LILACS 99 3 Pubmed 231 13 Total 330 16 376 BrJP. São Paulo, 2021 oct-dec;4(4):374-8 Silva MG, Bento VA and Castillo DB A total of 16 studies28-43 published between 2003 and 2021 were included. Fifteen studies were clinical trials, while 3 were case reports. Nine studies used MRL therapy alone and 9 studies used MRL therapy associated with other manual therapies. This review included a total of 481 patients. The features of the inclu- ded studies are listed in table 2. DISCUSSION In all selected studies, participants were diagnosed with TTH by neurologists or physical therapists. According to study44, the diagnostic interview with a specialist is the gold standard, whe- reas questionnaires and interviews with laypersons are less accu- rate diagnostic tools regarding headache disorders. Table 2. Distribution of selected studies Authors n Type of study Treatments Conclusion Mignelli, Tollefson and Stefanowicz 28 1 Case report MRL of masseter and tem- poralis muscles Manual therapy in the form of cervical flexion-distraction with MRL was effective in reducing neck and chest pain and redu- cing headache frequency. Corum et al.29 15 RCT MRL and suboccipital inhi- bition Manipulative exercise was shown to be more effective than MRL. Pérez-Llanes et al.30 12 Clinical trial MRL and suboccipital inhi- bition MRL reduced disability and impact of headache on daily life by 4 weeks. Shields and Smith31 4 Clinical trial Release of myofascial TP in anterior neck, mandible and skull region, and neuromus- cular therapy Applied therapy reduced the frequency of headaches, and may be an effective method for treating TTH. Georgoudis et al.32 24 RCT MRL and stretching The combination of physical therapy in the form of MRL, acu- puncture and stretching to improve analgesic effect is stron- gly recommended Moraska et al.33 62 RCT MRL in trapezius and su- boccipital muscles The proposed therapy may show complete resolution of hea- dache after several treatment sessions. Antunes et al.34 20 Clinical trial MRL associated with pom- page Both massage therapy and pompage promoted an improve- ment in pain and quality of life, with massage therapy having a better result in the pain condition and pompage in quality of life. Ferragut-Garcías et al.35 97 Clinical trial MRL and neural mobiliza- tion MRL with neural mobilization techniques is more effective in the management of patients with chronic headache. Sousa et al.36 9 Clinical trial MRL Presented a significant result in the reduction of overall sub- jective pain intensity, relief of sensory and affective compo- nents and decrease in pain frequency in women. Bastos et al.37 1 Case report MRL and Stretching Manual therapy improved quality of life of patients with chro- nic tension headache. Rodríguez- Fernández et al.38 76 Clinical trial MRL Participants were classified as having achieved a successful outcome one week after the session based on perceived re- covery. Data from 76 individuals were included in the analysis, of which 36 had a successful outcome (48%). Hoffmann et al.39 22 Clinical trial MRL Improvement in pain, discomfort and quality of life, but there are limitations due to the small number of patients treated. Macedo et al.40 37 Clinical trial MRL and Stretching Manual therapies with cranial and cervical maneuvers are ef- fective and should be used for the treatment of women with chronic headache. Morelli and Rebelatto41 6 Clinical trial MRL Regarding intensity, the treatment showed greater difficulty in improving symptoms in the group of individuals who don’t have vertebral alterations, but in relation to the threshold of pain by pressure, the individuals with associated vertebral al- terations showed marked improvement. Morelli and Rebelatto42 24 Clinical trial MRL Effectiveness in headache relief and increasing pain threshold was observed. Hoffmann and Teodoroski43 1 Case report MRL associated with pom- page The pompage technique on the posterior and lateral muscles of the cervical spine showed effectiveness in the treatment of TTH. MRL = myofascial release; RCT = randomized clinical trial; TP = trigger point; TTH = tension-type headache. 377 Efficiency of myofascial release in patients with tension-type headaches: integrative review BrJP. São Paulo, 2021 oct-dec;4(4):374-8 The studies34,36,39,40 evaluated only female patients, as this is the audience most susceptible to these types of ailments45. In the other studies, the delineation was between both sexes, however, a higher number of females was observed, with ages ranging from 18 to 65 years. By analyzing these studies, it was not possible to identify which age group suffers the most from TTH and which had the best results after treatment. All studies presented differences in their methodologies regar- ding the number of patients, physiotherapeutic techniques, and treatment time, which often prevents reaching what is conside- red the gold standard in clinical case studies46. However, the stu- dies39-43 followed a standard regarding treatment time, and the report is that a total of ten sessions is enough to achieve positi- ve results, although in the randomized study29 a period of three months with two weekly sessions was required for full effective- ness of MRL. The treatment effect regarding pain frequency and intensity was assessed using guided questionnaires, the visual analog scale (VAS), or a combination of both. The VAS was the most used instrument in the studies, for being an instrument that is easy- -to-apply and to be understood by the patient, and which can provide pain quantification, facilitating the search for positive or negative responses about the developed therapy. Another instru- ment used was the Headache Impact Test (HIT-6). Some review studies have shown that MRL combined with other physical therapy techniques, such as cervical relaxation, cervical mobilization and stretching, have greater efficacy in reducing the frequency, intensity and duration of pain in patients with TP, besides increasing range of motion37,40. However, few are the studies that implement specific physical therapy techniques ba- sed on manual therapies for the treatment of headache, probably due to the effectiveness in pain relief through pharmacological measures25. Study47 performed a systematic review of RCT to determine the effectiveness of physical therapy in patients with TTH. Eight RCT that used physical therapy in the treatment of TTH in adults were selected. These studies showed a variety of interven- tions, and only two were of high quality; however, they showed high clinical heterogeneity, making it impossible to draw valid conclusions. More evidence-based studies are needed to determine the effi- cacy of physical therapy in patients with TTH, and RCT di- vided into groups with MRL treatment or with an association of techniques, associated or not with the use of drugs, may better evaluate the impacts of manual therapies in the treat- ment of TTH. This review highlighted other physical therapy techniques that include manipulative manual therapy and the important evaluations in different spheres such as quality of life, disability, pain impact and pain perception. The main limi- tation of the present study is that the results did not take into consideration the risk of bias. CONCLUSION The MRL technique showed positive results as a treatment for TTH by decreasing pain intensity and frequency, as well as im- proving quality of life, pain impact, disability, and psychological aspects. 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