By Shirley Vanderbilt
Originally published in Massage & Bodywork magazine, June/July 2005.
When a headache strikes, many of us head for the medicine cabinet. Whether it’s an over-the-counter remedy or the stronger drugs prescribed for chronic sufferers, the “magic pill” seems a simple solution. But according to the authors of a recent study on the Trager Approach as a treatment for chronic headache, “Medication overuse and rebound can even be a cause for headache in patients suffering from migraine, tension-type headache, or combined headache.” In fact, the study’s subject population seems to bear out the suggestion that medication alone can be insufficient treatment or even a contributor to an ongoing problem. “Even though all participants had a history and current usage of medication, they were still having frequent headaches on entry to the study,” researchers write.1
The Trager study follows in the footsteps of a handful of alternative therapy trials showing mixed results in headache treatment. Among these, manipulative therapy and relaxation techniques appear to be of benefit and, the team notes, “Studies have found increased effectiveness through combined therapies.”2 Trager work is, in essence, a combination of both movement education through soft manipulation and a reinforcing of relaxation through the client’s heightened awareness of body-mind connection. Thus, it would seem to have potential as an effective treatment.
Working with the research team of Foster et al. was Jack Liskin, a Trager practitioner and physician’s assistant. After experiencing Trager’s benefits firsthand, he pursued training as a practitioner and subsequently offered his skills to patients at the family medicine clinic at Keck School of Medicine, University of Southern California, where he served as assistant professor. It was Liskin’s advocacy for Trager work that inspired this clinical trial.
“It struck me that it could and should have a place in medical practice, and I was able to bring it into our department,” he says. Although the clinic was not specifically geared toward alternative therapies, response to Liskin’s Trager work was positive. Having helped many clients who came in complaining of headaches, he was interested in scientifically testing his success. “I already had a sense the outcome would be good. In other Trager practices, therapists may see people who have headaches,” he says, but at the Keck clinic he was continually referred clients with specific chronic problems. “I didn’t do anything different,” he says of the treatment protocol. It was just a matter of putting a perceived benefit under the microscope of the scientific “gold standard” — the randomized controlled trial.
Trager to the Test
Eliminating participants who had prior exposure to Trager work, any whose condition contraindicated manipulation, and those whose headache etiology was potentially life-threatening, researchers narrowed their potential 49 respondents to an eligible subject group of 33 individuals, primarily female (86 percent). Attrition took its toll and, in the end, resulted in an imbalance of distribution among treatment and control groups. According to Liskin, this occurred after randomization, with some subjects lost prior to implementation of the protocol. Participants were designated to three groups: Trager treatment with medication (n=11), attention control group with medication (n=6), and medication only with no additional treatment (n=12).3 The inclusion of the second attention control group in this study design contributed to an interesting outcome, to be addressed later.
The team sought to evaluate the effects of each approach on headache frequency, intensity, and duration; medication usage; and impact on quality of life scores.4 It was the actual physical act of taking medication, not an evaluation of the particular drug involved, that was the focus in medication usage.5 Ranging in age from early 20s to 60s (average 29.9), participants averaged 17.4 years in length of headache chronicity, with a headache intensity score of 59.7 on a visual analog scale (scale 0 to 100). Also, there were no significant differences across the groups in baseline characteristics and headache history, such as headache length, intensity, location, or type; history of injury; caffeine use; association with light sensitivity or prevalence of nausea; and attitude toward complementary and alternative therapies. However, a greater proportion of attention control subjects reported experiencing occasional auras.6
For the beginning baseline data, established prior to randomization, participants completed a two-week Headache Diary (frequency, duration, intensity, and medication usage) and the Headache Quality of Life (HQOL) questionnaire. Throughout the six-week study period, subjects were asked to continue daily diary entries and submit their recordings weekly. The HQOL was administered again at the completion of the study.7
Trager treatment consisted of weekly, hour-long sessions in which areas of tension and restricted motion were addressed “in affected areas such as, but not limited to, the head, neck, upper back, and shoulders, in order to encourage site-specific, as well as general, relaxation.”8 As is typical in Trager work, participants were also taught simple movements to be practiced between sessions in order to maintain somatic awareness of the results. No-treatment control subjects did not visit a healthcare provider during the study period, and medication was not discussed with these or the Trager participants during that time. In the attention control group, subjects were seen weekly by a physician for a brief session (15 to 20 minutes) to discuss the previous week’s headache history and medication intake and to address any questions or concerns. Physicians also administered a head and neck exam each week, commenting on any findings or changes.9
Several positive results emerged for the Trager group, including a mean decrease in headache duration as compared to control group and 44 percent decrease in medication use. Researchers also note an apparent greater reduction in headache frequency for Trager subjects, 27.5 percent as compared to 3.7 percent for attention controls, while frequency increased by 13.5 percent in the no-treatment group. In addition, Trager subjects scored statistically significant improvements on the HQOL.10
While not as impressive as the results for Trager treatment, findings of improvement in HQOL and a decrease in medication use (19 percent) for the attention control group11 led to some interesting comments from the team. “That there were improvements in the attention group implies the close attention and education probably had positive effects on the patient,” the authors write.12 In contrast, the team found a statistically significant increase in headache duration and intensity in the no-treatment control group, along with a decline in HQOL and a 25 percent increase in medication use.13
The lowering of medication use in the Trager group was an unexpected outcome, Liskin says, as treatment protocol did not include addressing this issue with participants. Nonetheless, a spontaneous reduction did occur. “Even though physicians were talking about medications and altering them, the medication (attention control) group also reduced their medications,” he says. “I thought that was an important potential as well.”
As a preliminary pilot with small sample size, this study does have its limitations, including the lack of homogeneity in medication type used by subjects. In considering a larger, multi-site trial, researchers suggest the “ideal situation” would include having participants who are all on the same specific drug, where clear measurement could be defined for increase or decrease of use of that particular medication. Addi-tionally, they note, “A larger study is needed to evaluate the types of medications taken and examine this component more carefully while addressing drug-induced headache and the troubles of withdrawal.”14
It appears that attention, both in the form of Trager work and as provided in the physician-subject interaction for the control, played a role in improvement of the status quo for these headache sufferers. Researchers note that measurement of headache duration and intensity is subjective and conditional, while that of frequency is objective and unconditional. Though neither treatment group experienced statistically significant decrease in duration and intensity, the gains in less frequent episodes would have a positive impact translating “into fewer days or hours lost from work, regardless of the duration or intensity.” Likewise, a reduction in medication use would be of “substantial economic and clinical value” in the treatment process.15 Overall, these factors contribute to hope for a better quality of life for the patient.
Although authors emphasize the implied greater benefits of Trager’s focused attention along with manual therapy, they say the attention group findings suggest that even within the healthcare provider-patient relationship there lies potential for increasing patient awareness and subsequent improvement.16 And as evidenced, those subjects in the no-treatment group who spent the six-week study period without healthcare contact declined in all parameters measured.
Of the headache types documented in study participants — migraine, migraine with tension, tension, and cluster-migraine with tension was most often reported, with five Trager subjects taking migraine-specific medication. Researchers indicate that whether or not diagnostic classification is important or necessary is debatable, with some studies supporting a “spectrum” or “continuum” concept ranging from tension at the beginning to migraine at the severe end. In Liskin’s experience, “Patients diagnosed with migraine and those diagnosed with tension headache have similar muscle tension patterns, particularly in the neck and upper back, and both kinds of patient respond similarly to treatment.”17
The ability of the Trager approach to recalibrate the body is likely the physiological mechanism contributing to effectiveness in pain reduction, Liskin says. In this process, a lengthening of muscle tissue is communicated to the brain, resulting in a reduction of tone. “There is a resetting of the tone so that spindle fibers in the muscle are able to actually lengthen and reset themselves in a more relaxed state,” he says. “Within the relaxation, and especially because Trager attends to muscle tone, we may be moving various parts of the body and at the same time feeling and influencing muscle in the part of the body that’s being moved. That kind of resetting, we think, can have a lasting effect.”
But that’s not the whole of it. There’s also Trager’s emphasis on the client’s awareness of this relaxed state and the continued work outside the session where one is encouraged to practice movements that maintain and reinforce those therapeutic changes. The team notes supportive studies that show improvement is more likely in those patients who have a better understanding of their headaches, as well as the influencing factor of mind-body integration.18 In fact, they offer that not only is Trager a promising treatment for chronic headache, but also that it “has the potential to be efficacious when applied to other conditions in which tension may be ameliorated through self-awareness and relaxation.”19
Speaking to the current state of affairs in research, Liskin says, “How highly unusual it is to have a scientific study of any alternative medicine.” He likens Trager to “other modalities that therapists know are valuable but haven’t really been proven in a way acceptable to the scientific community. Because I was in that domain, it was important to show that. Finally, there’s a very clean and scientifically-controlled study that shows definite benefits for a certain group of people.” Now retired, he says this is
the legacy he wanted to leave behind.