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

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:

FROM:   J Manipulative Physiol Ther. 2009 (Sep); 32 (7): 527–535 ~ FULL TEXT

Cristina Toro-Velasco, PT, Manuel Arroyo-Morales, MD, PT, PhD,
César Fernández-de-las-Peñas, PT, PhD, Joshua A. Cleland, PT, PhD,
Francisco J. Barrero-Hernández, MD

Department of Physical Therapy,
Health Sciences School,
Universidad Granada, Spain

OBJECTIVE:   The purpose of this study was to investigate the immediate effects of head-neck massage on heart rate variability (HRV), mood states, and pressure pain thresholds (PPTs) in patients with chronic tension-type headache (CTTH).

METHODS:   Eleven patients (8 females), between 20 and 68 years old, with CTTH participated in this crossover study. Patients received either the experimental treatment (massage protocol) or a placebo intervention (detuned ultrasound). Holter electrocardiogram recordings (standard deviation of the normal-to-normal interval, square root of mean squared differences of successive NN intervals, index HRV, low-frequency component, and high-frequency component), PPT over both temporalis muscles, and Profile of Mood States questionnaire (tension-anxiety, depression-dejection, anger-hostility, vigor, fatigue, confusion) were obtained preintervention, immediately after intervention, and 24 hours postintervention. Self-reported head pain was also collected preintervention and 24 hours postintervention. Separate analyses of covariance (ANCOVAs) were performed with each dependent variable. The hypothesis of interest was group x time interaction.

RESULTS:   The ANCOVA showed a significant group x time interaction for index HRV (F = 4.5, P = .04), but not for standard deviation of the normal-to-normal interval (F = 1.1, P = .3), square root of mean squared differences of successive NN intervals (F = 0.9, P = .3), low-frequency component (F = 0.03, P = .8), or high-frequency component (F = 0.4, P = .5) domains. Pairwise comparisons found that after the manual therapy intervention, patients showed an increase in the index HRV (P = .01) domain, whereas no changes were found after the placebo intervention (P = .7). The ANCOVA also found a significant group x time interaction for tension-anxiety (F = 5.3, P = .03) and anger-hostility (F = 4.6, P = .04) subscales. Pairwise comparisons found that after the manual therapy intervention, patients showed a decrease in tension-anxiety (P = .002) and anger-hostility (P = .04) subscales, whereas no changes were found after the placebo intervention (P > .5 both subscales). No significant changes were found in PPT levels (right F = 0.3, P = .6, left F = 0.4, P = .5). A significant group x time interaction for pain (F = 4.8, P = .04) was identified. No influence of sex was found (F = 1.5, P = .3). Pairwise comparisons showed that head pain (numerical pain rating scale) decreased 24 hours after manual therapy (P < .05) but not after the placebo intervention (P = .9).

CONCLUSIONS:   The application of a single session of manual therapy program produces an immediate increase of index HRV and a decrease in tension, anger status, and perceived pain in patients with CTTH.

Key Indexing Terms:   Tension-Type Headache, Heart Rate, Manual Therapy

From the FULL TEXT Article:


Tension-type headache is common in the general population with a reported 1–year prevalence rate of 38.3% for the episodic form and 2.2% for the chronic type. [1] In addition, the prevalence of this particular headache disorder has recently been increasing. [2] Tension-type headache may cause substantial levels of disability for the patient. [3]

Although there has recently been an increasing interest in the pathogenic mechanisms of tension-type headache, the true pathoanatomical mechanism remains unclear. [4] However, it seems that hyperexcitability of nociceptive pathways may play an important role in tension-type headache. [5] This sensitization process typically results in increased muscle tenderness [6, 7] and decreased pressure pain thresholds (PPTs), particularly in patients with chronic tension-type headache (CTTH). [8, 9] In addition, it has been postulated that CTTH could be the manifestation of referred pain from muscle trigger points (TrPs) located in head, neck, and shoulder musculature. [10–12] It has been shown that sympathetic facilitation of mechanical sensitization and facilitation of the local and referred pain reactions in muscle TrPs exists, confirming sympathetic responses elicited by muscle TrPs. [13] It therefore seems sensible that impairments in the autonomic nervous system (ANS) could be associated with tension-type headaches.

In migraines, autonomic involvement has been identified. [14, 15] However, previous studies of tension-type headache have rarely investigated the contribution of the ANS function and have primarily focused on involvement of the sympathetic system. [16, 17] Numerous techniques exist to assess ANS function; nevertheless, techniques for evaluating parasympathetic activity have not been well established. Heart rate variability (HRV) has become the conventionally accepted term to describe variations of both instantaneous heart rate and rate recovery intervals. [18] Heart rate variability reflects the influence of the ANS on heart rate. Some studies found that manual therapy can influence HRV parameters in both healthy subjects [19] and patients with myofascial pain. [20] A recent study found that myofascial release therapy restored the HRV index and maintained high-frequency component (HF) domain of HRV during recovery after high intensity exercise. [21] It would be plausible to suggest that manual therapy aimed at inactivating muscle TrPs may have some impact on the ANS in patients with CTTH.

Population-based studies and clinical investigations found high comorbidity between headache and mood-anxiety disorders. [22] Furthermore, psychologic states (anxiety or depression) may influence quality of life and other clinical parameters in patients with CTTH. [23] Perozzo and Fondazione [24] found that patients with tension-type headache exhibited a significantly higher level of angry temperament, angry reaction anxiety, depression, or emotional liability. To the best of our knowledge, no study has investigated the effects of manual therapy on HRV parameters, psychologic disorders, PPT, and pain intensity in CTTH. Therefore, the purpose of this study was to investigate the immediate effects of head-neck massage on HRV, mood states, and PPT in patients with CTTH.


The results of our study showed that a single session of a manual therapy protocol aimed to inactivate muscle TrPs decreases the emotional tension and increases HRV, immediately after treatment, as compared with detuned ultrasound, in patients with CTTH. Nevertheless, we only found a transient effect of the treatment, which may have a limited clinical significance.

It has previously been identified that manual therapy associated with active aerobic recovery can restore balance to the ANS of an individual after exercise. [21] Our study found that a single 40–minute session of manual therapy is a simple method to increase HRV values as evidenced by HRV index at short-term. Our results are consistent with previous studies, which have investigated the parasympathetic effects of manual therapy, despite the older age and different characteristics of the patients used in other studies. [34–36] In addition, our study is the first to analyze changes in parasympathetic system in patients with CTTH who had not undergone surgical intervention as in other studies. [37, 38]

A number of studies have used sympathetic nervous system activity in an attempt to quantify the physiologic effects of other manual therapies (mobilization and manipulation). [39–43] Many of these studies showed that spinal manipulative therapy produces a significant sympathoexcitatory response when compared with a placebo or control group. [40, 42, 43] A number of these studies also showed that a hypoalgesic effect accompanied the spinal mobilizations to a magnitude that was also statistically significant when compared with placebo and control groups. [39, 41, 42] Vicenzino et al in a double-blind, placebo-controlled, repeated-measures study investigated the effects of cervical mobilizations (Maitland, grade 3 lateral glides) on PPTs and skin conductance in the limbs of subjects with lateral epicondylalgia. [42] The results showed not only a statistically significant increase in sympathoexcitatory response and hypoalgesia but also a strong correlation (r = 0.82, P = .05) between the hypoalgesic effect and sympathoexcitatory response produced with spinal mobilization. [42] It is also possible that this may have also occurred with the manual therapy techniques used in the current study.

In addition, it is possible that the physiologic mechanism by which the intervention works may be associated with stimulation of central control mechanisms (periaqueductal gray area). [44, 45] This may result in a reflex stimulation of descending inhibitory mechanisms. [42, 46–48] Nevertheless, it seems that more than one mechanism explains the effects of manual therapy, [49] and there is insufficient evidence to claim a major role for either peripheral or central mechanisms. Future research is necessary to determine whether manual therapy exerts its effects either through mechanical or neurophysiologic mechanisms or through both.

Following the same hypotheses as other authors on the psychologic effects of massage, [34, 50] this study confirms that manual therapy does not induce changes in mood state. However, the short-term effects after the massage session were associated with a decrease in tension-anxiety and lower anger-hostility levels, which differed from the placebo condition. These changes may be related to the ability of manual therapy to produce a parasympathetic vegetative response associated with massage-induced improvements in HRV, blood pressure, [21] and immune function [51] Chronic tension-type headache is associated with an increase in anxiety, depression, and an impairment of anger control. [23, 24] In the current study, the manual techniques apparently influenced the patients' mood state by decreasing the emotional tension and anger, although only at short-term.


There are a few limitations to consider in this study. Only one therapist performed all the manual techniques, which may limit the generalizability of results. However, these techniques are commonly used in clinical practice and require minimal training. Hence, we expect that other clinicians may be able to provide similar treatments with similar results. We also used a small sample size with a 24–hour follow-up only. In fact, we only found a transient effect of the treatment, which may have limited clinical significance. It is possible that subsequent sessions may have a greater and longer lasting effect on clinical outcomes. Future studies using larger sample sizes with long-term follow-up periods are needed to elucidate the clinical relevance of the current findings. We also cannot exclude the placebo effects associated with hands-on technique, which in itself is capable of eliciting a sympathoexcitatory response. [43] However, it has been shown that manual techniques result in an increased sympathetic response when compared with a placebo technique, which consisted of solely manual contact. [43] Future studies should compare the manual techniques used in the current study to a placebo technique, which includes manual contact with the patient. Finally, we should recognize that blinding of patients may not be effective because the placebo intervention differed from the treatment physically. Therefore, the placebo effect associated with hands-on technique should not be ignored. Future randomized controlled trials should include a hands-on placebo intervention to further elucidate the real effects of the treatment protocol applied in the current pilot study.


The application of a single session of manual therapy program produces an immediate increase of index HRV and a decrease in tension, anger status, and perceived pain in patients with CTTH. Nevertheless, we only have found a transient effect of the treatment, which may have limited clinical significance. Future studies investigating the effects of numerous treatment sessions are needed to elucidate the clinical relevance of the current findings.

Practical Applications

  • The application of a session of head-neck massage produces an immediate increase
    of the index HRV in patients with CTTH.

  • The application of a session of head-neck massage produces an immediate decrease
    in tension, anger status, and perceived pain in patients with CTTH.


  1. Schwartz, BS, Stewart, WF, Simon, D, and Lipton, RB.
    Epidemiology of tension type headache.
    JAMA. 1998; 279: 381–383

  2. Bendtsen, L and Jensen, R.
    Tension type headache: the most common, but also the most neglected headache disorder.
    Curr Opin Neurol. 2006; 19: 305–309

  3. Stovner, L, Hagen, K, Jensen, R et al.
    The global burden of headache: a documentation of headache prevalence and disability worldwide.
    Cephalalgia. 2007; 27: 193–210

  4. Fumal, A and Schoenen, J.
    Tension-type headache: current research and clinical management.
    Lancet Neurol. 2008; 7: 70–83

  5. Bendtsen, L.
    Central sensitization in tension-type headache: possible patho-physiological mechanisms.
    Cephalalgia. 2000; 29: 486–508

  6. Metsahonkala, L, Anttila, P, Laimi, K et al.
    Extra-cephalic tenderness and pressure pain threshold in children with headache.
    Eur J Pain. 2006; 10: 581–585

  7. Fernández-de-las-Peñas, C, Cuadrado, ML, Ge, HY et al.
    Increased peri-cranial tenderness, decreased pressure pain threshold, and headache clinical parameters in chronic tension type headache patients.
    Clin J Pain. 2007; 23: 346–352

  8. Bendtsen, L, Jensen, R, and Olesen, J.
    Decreased pain detection and tolerance thresholds in chronic tension type headache.
    Arch Neurol. 1996; 53: 373–376

  9. Ashina, S, Babenko, L, Jensen, R, Ashina, M, Magerl, W, and Bendtsen, L.
    Increased muscular and cutaneous pain sensitivity in cephalic region in patients with chronic tension-type headache.
    Eur J Neurol. 2005; 12: 543–549

  10. Fernández-de-las-Peñas, C, Ge, HY, Arendt-Nielsen, L, Cuadrado, ML, and Pareja, JA.
    Referred pain from trapezius muscle trigger point shares similar characteristics with chronic tension type headache.
    Eur J Pain. 2007; 11: 475–482

  11. Fernández-de-las-Peñas, C, Cuadrado, ML, Arendt-Nielsen, L, Simons, DG, and Pareja, JA.
    Myofascial trigger points and sensitisation: an updated pain model for tension type headache.
    Cephalalgia. 2007; 27: 383–393

  12. Fernández-de-las-Peñas, C, Ge, HY, Arendt-Nielsen, L, Cuadrado, ML, and Pareja, JA.
    The local and referred pain from myofascial trigger points in the temporalis muscle contributes to pain profile in chronic tension type headache.
    Clin J Pain. 2007; 23: 786–792

  13. Ge, HY, Fernández-de-las-Peñas, C, and Arendt-Nielsen, L. Sympathetic facilitation of hyperalgesia evoked from myofascial tender and trigger points in patients with unilateral shoulder pain. Clin Neurophysiol. 2006; 117: 1545–1550

  14. Peroutka, SJ.
    Migraine: a chronic sympathetic nervous system disorder.
    Headache. 2004; 44: 53–64

  15. Yerdelen, D, Tayfun, A, Goksel, B, and Mehmet, K.
    Heart rate recovery in migraine and tension-type headache.
    Headache. 2008; 48: 221–225

  16. Mikamo, K, Takeshima, T, and Takahashi, K.
    Cardiovascular sympathetic hypofunction in muscle contraction headache and migraine.
    Headache. 1989; 29: 86–89

  17. Takeshima, T, Takao, Y, and Takahashi, K.
    Pupillary sympathetic hypofunction and asymmetry in muscle contraction headache and migraine.
    Cephalalgia. 1987; 7: 257–262

  18. Force, Task. Heart rate variability.
    Standards of measurement, physiological interpretation, and clinical use:
    Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology.
    Eur Heart J. 1996; 17: 354–381

  19. Sneed, NV, Olson, M, Bubolz, B, and Finch, N.
    Influences of a relaxation intervention on perceived stress and power spectral analysis of heart rate variability.
    Prog Cardiovasc Nurs. 2001; 16: 57–64

  20. Goodfellow, LM.
    The effects of therapeutic back massage on psychophysiologic variables and immune function in spouses of patients with cancer.
    Nurs Res. 2003; 52: 318–328

  21. Arroyo-Morales, M, Olea, N, Martínez, M, Moreno-Lorenzo, C, Díaz-Rodríguez, L, and Hidalgo-Lozano, A.
    Effects of myofascial release after high intensity exercise: a randomized clinical trial.
    J Manipulative Physiol Ther. 2008; 31: 217–223

  22. Baskin, SM, Lipchik, GL, and Smitherman, TA.
    Mood and anxiety disorders in chronic headache.
    Headache. 2006; 46: S76–S87

  23. Peñacoba-Puente, C, Fernández-de-las-Peñas, C, González-Gutiérrez, JL, Miangolarra-Page, JC, and Pareja, JA.
    Mediating or moderating effect of anxiety and depression in headache clinical parameters and quality of life in chronic tension type headache.
    Eur J Pain. 2008; 12: 886–894

  24. Perozzo, P and Fondazione, C.M.
    Anger and emotional distress in patients with migraine and tension-type headache.
    J Headaches Pain. 2005; 6: 392–399

  25. IHS: Headache Classification Subcommittee of the International Headache Society:
    The International Classification of Headache Disorders, 2nd edition.
    Cephalalgia. 2004; 24: 9–160

  26. Jensen, MP, Turbner, JA, Romano, JM, and Fisher, L.
    Comparative reliability and validity of chronic pain intensity measures.
    Pain. 1999; 83: 157–162

  27. Nyenhuis, DL, Yamamoto, C, Luchetta, T, Terrien, A, and Parmentier, A.
    Adult and geriatric normative data and validation of the profile of mood states.
    J Clin Psychol. 1999; 55: 79–86

  28. Lira, FT and Fagan, TJ.
    The profile of mood states: normative data on a delinquent population.
    Psychol Rep. 1978; 42: 640–642

  29. Hernández Mendo, A and Ramos Pollán.
    Herramienta 2: Información del Profile of Mood Status de MacNair, Lorr y Dropleman. in: A Hernández Mendo, R Ramos Pollán (Eds.) Introducción a la informática aplicada a la psicología del deporte.
    Ra-Ma, Madrid; 1996

  30. Vanderweeen, L, Oostendorp, RB, Vaes, P, and Duquet, W.
    Pressure algometry in manual therapy.
    Man Ther. 1996; 1: 258–265

  31. Chesterson, LS, Sim, J, Wright, CC, and Foster, NE.
    Inter-rater reliability of algometry in measuring pressure pain thresholds in healthy humans, using multiple raters.
    Clin J Pain. 2007; 23: 760–766

  32. Cowan, MJ.
    Measurement of heart rate variability.
    West J Nurs Res. 1995; 17: 32–48

  33. Van Ravenswaaij-Arts, CM, Kollee, LA, Hopman, JC, Stoelinga, GB, and van Geijn, HP.
    Heart rate variability.
    Ann Intern Med. 1993; 118: 436–447

  34. Moyer, CA, Rounds, J, and Hannum, JW.
    A meta-analysis of massage therapy research.
    Psychol Bull. 2004; 130: 3–18

  35. Labyak, SE and Metzger, BL.
    The effects of eflleurage backrub on the physiological components of relaxation: a meta-analysis.
    Nurs Res. 1997; 46: 59–62

  36. Corley, MC, Ferriter, J, Zeh, J, and Gifford, C.
    Physiological and psychological effects of back rubs.
    Appl Nurs Res. 1995; 8: 39–42

  37. Hulme, J, Waterman, H, and Hilier, VF.
    The effect of foot massage on patients' perception of care following laparoscopic sterilization as day case patients.
    J Adv Nurs. 1999; 30: 460–468

  38. Okvat, HA, Oz, MC, Ting, W, and Namerow, PB.
    Massage therapy for patients undergoing cardiac catheterization.
    Altern Ther Health Med. 2002; 8: 68–75

  39. Sterling, M, Jull, G, and Wright, A.
    Cervical mobilisation: concurrent effects on pain, sympathetic nervous system activity and motor activity.
    Man Ther. 2001; 6: 72–81

  40. Cleland, J, Durall, C, and Scott, S.
    Effects of slump long sitting on peripheral sudomotor and vasomotor function: a pilot study.
    J Man Manip Ther. 2002; 10: 67–75

  41. McLean, S, Naish, R, Reed, L et al.
    A pilot study of the manual force levels required to produce manipulation induced hypoalgesia.
    Clin Biomech. 2002; 17: 304–308

  42. Vicenzino, B, Collins, D, Benson, H et al.
    An investigation of the interrelationship between manipulative therapy-induced hypoalgesia and sympathoexcitation.
    J Manipulative Physiol Ther. 1998; 21: 448–453

  43. McGuiness, J, Vicenzino, B, and Wright, A.
    Influence of a cervical mobilization technique on respiratory and cardiovascular function.
    Man Ther. 1997; 2: 216–220

  44. Wall, PD.
    The dorsal horn.
    in: PD Wall, R Melzack (Eds.)
    Textbook of pain. 2nd ed.
    Churchill Livinsgtone, Edinburgh; 2006: 125

  45. Wright, A.
    Hypoalgesia post-manipulative therapy: a review of a potential neuro-physiological mechanism.
    Man Ther. 1995; 1: 11–16

  46. Vicenzino, B, Cartwright, T, Collins, D et al.
    An investigation of stress and pain perception during manual therapy in asymptomatic subjects.
    Eur J Pain. 1999; 3: 13–18

  47. Skyba, DA, Radhakrishnan, R, and Sluka, KA.
    Characterization of a method for measuring primary hyperalgesia of deep somatic tissue.
    J Pain. 2005; 6: 41–47

  48. Skyba DA, Radhakrishnan R, Rohlwing JJ, Wright A, Sluka KA.
    Joint Manipulation Reduces Hyperalgesia By Activation of Monoamine Receptors
    But Not Opioid or GABA Receptors in the Spinal Cord

    Pain. 2003 (Nov); 106 (1-2): 159–168

  49. Pickar, JG.
    Neurophysiological Effects of Spinal Manipulation
    Spine J (N American Spine Society) 2002 (Sep); 2 (5): 357–371

  50. Hilbert, J.E., Sforzo, G.A., and Swensen, T.
    The effects of massage on delayed onset muscle soreness.
    Br J Sports Med. 2003; 7: 72–75

  51. Arroyo-Morales, M, Olea, N, Ruíz, C, Luna del Castillo, JD, Martínez, M, Lorenzo, C.
    Massage after exercise. Responses of immunologic and endocrine markers:
    a randomized single-blind placebo-controlled study.
    J Strength Cond Res. 2009; 23: 638–644


Since 5–22–2017

                  © 1995–2024 ~ The Chiropractic Resource Organization ~ All Rights Reserved