SPINEPASS: SPINE Self-Management Techniques for Persistent Headache After Concussion - Physical Therapy Targeting Autonomic and Dura Mater Function

Background

Persistent post-traumatic headache (PPTH) is a significant problem for the US military affecting up to 33% of service members with a history of mTBI and treatment is often ineffective. PPTH is commonly migraine-like and associated with visual complaints, and transient neurological abnormalities that can be classified as autonomic nervous system (ANS) in nature.

Due to the forces involved during concussion, injury to the brain and neck likely co-occur. Our recent research suggests that upper cervical hypermobility may trigger an ANS response and be related to these headaches, due to close anatomical connections to the ANS and dura. Specifically, the dura has unique upper cervical myodural connections to help protect the spinal cord during head movements and attachments throughout the entire spine. It is innervated by the ANS, is pain-sensitive and can cause headaches.

SPINEPASS development

We have developed a rehabilitation program (SPINEPASS) directed towards dysfunction of the upper cervical region, myodural connections and changes throughout the entire spine affecting the dura. The program is individualized to patients’ impairments and includes tailored manual therapy and specific exercises.

The patients perform a core set of daily maintenance exercises and due to day-to-day functional demands placed on the patient’s spine, they are also taught to monitor for and alleviate symptoms and signs daily by selecting specific exercises to self-manage and prevent relapse of headaches. This also helps patients to manage other body pains along with bothersome and often concerning symptoms relating to ANS function such transient visual disturbances, dizziness and neurological symptoms.

In a recent record review this treatment approach demonstrated improvement in headache frequency, duration and intensity and a decrease in severity of ANS symptoms, with large effect size.

Project aims

This RCT, with a community-based participatory research approach, will explore the efficacy of the SPINEPASS approach on headache disability and self-confidence to manage headache without abortive medication compared to to standard physical therapy (PT) for persistent symptoms post mTBI. Standard PT will specifically address the neck and the vestibular and oculomotor systems as well as prescribing graded exercise and or relaxation training for management of ANS dysfunction. It does not address the dura mater and does not consider the precise restoration of balance of the upper cervical muscles, or consider the role of the dura mater.

We will also explore patient experiences and acceptability and feasibility of the program. We hypothesise that overall, patients will have unique insights and will rate SPINEPASS more appropriate, acceptable, and feasible.

By systematically evaluating this non-pharmacological intervention this effort adds to treatments for PPTH. It also has potential to reduce ongoing pain, disability, and burden of TBI, reduce dependence on pharmaceutical management and its associated side effects, enabling military personnel to effectively self-manage and prevent relapse of PPTH, and substantially change the way it is managed.