In March, Blue Cross Blue Shield (BCBS) eliminated thirteen procedures for cervicogenic headache and occipital neuralgia that physicians may have been depending on to offer relief to patients. But physical therapists say not to worry.
"We see these headache patients all the time. We have a high degree of success treating them. We resolve the symptoms and get the pain to where it's manageable and no longer requires medical intervention, including physical therapy," said Emmett Parker PT, ATC, with Accelerated Physical Therapy.
The BCBS policy still covers most physical therapy treatments for cervicogenic headache and occipital neuralgia, including manual therapy, mobilization techniques, joint mobilization techniques, TENS, and manipulation therapy. "Regarding headaches, there's not any silver bullet," Parker said. "It's the combination of procedures, like what's in the BCBS policy, that gets them better."
Physical therapy procedures focus on normalizing the soft tissue or mechanical dysfunction that causes headaches. "These are techniques that are fairly specific and highly skilled," Parker said, listing techniques such as mobilizing the C5-6 segment for a facet disorder, performing a suboccipital release technique, or mobilizing the first rib.
For headache sufferers where it's not contraindicated, such as with rheumatoid arthritis, physical therapists can do manual or mechanical traction procedures to provide decompression.
Even headache sufferers with spinal columns beginning to fuse, like those with ankylosing spondylitis, can be helped with physical therapy. If the spine has already fused, physical therapy's role is limited. But strengthening can get as much pressure off that area as possible, relieving pain. If the column is not yet fused, physical therapy helps the patient maintain mobility, strength and posture. And if the spinal column spontaneously fuses, physical therapy can help prevent it from fusing in a flexed posture.
Physical Therapists Search for Cause of Pain and Teach
Imagine you have back pain. You've been to a massage therapist, a chiropractor, both of whom brought you some relief, but the pain is chronic, never really ending. So your doctor refers you to a physical therapist. Will the PT do anything different?
Yes, according to Jane Pierluisi, BS, RPT, of Hanover Health. "Our goal," she says, "is to look for the root cause of the pain. While a massage therapist will try to alleviate the pain, we want to correct movement patterns that may be causing the pain. For example, maybe you come in with neck pain, and we see that you're tilting your head and tensing your shoulders. Or maybe there's pain on one side of your back, and we discover that you had chronic ankle injuries in high school, and have been favoring your ankle, so that your body is off balance."
After Pierluisi has worked with patients to improve their movements, she gives them a stretching protocol. "We're all so busy," she says. "People work all day long without taking a break to stretch. You should stretch whatever you're flexing, whether it's your hands with carpel tunnel or your neck from looking down at a computer screen, at least every two hours and as much as every 30 minutes, if you're in an acute stage.
Once the patient is comfortable with a series of stretches, Pierluisi with work with her on strengthening areas of imbalance. For example, if someone has been favoring one side of their body, the other side might be weaker.
Pierluisi believes that the thread that binds all phases of physical therapy together is teaching. "We're teachers first," she says. "Anyone can go to the bookstore and buy an exercise book, but we teach you to do the stretches and exercises right. We hope to make you more aware of your body and how you move. And we find that, if we educate you as to why the program will help you, you're much more likely to stick with it, and ultimately get better for good."
Not that physical therapy can treat all causes of cervicogenic headache and occipital neuralgia. "It has to be more musculo-skeletal or mechanical in nature, which a lot of this is," Parker said. Which is why Parker stressed the need for a medical workup first to eliminate any causes that require medical procedures first, such as tumors, vascular diseases, or infections. "And then they need to come see us," he added.
Pharmaceuticals also play a role in treatment, but physical therapy can enhance and prolong their pain-reducing effects. "Drugs are good. Patients need drugs to help kill the symptoms and give them some relief," Parker said. But drugs alone often don't resolve the headaches caused by mechanical or soft tissue dysfunction or postural causes. "If you do physical therapy in conjunction with drugs, you ensure a better chance of a good outcome over the long haul versus getting temporary relief."
Jane Pierluisi, BS, RPT, of Hanover Health and Rehab thinks doctors are now realizing that in many situations, like with headaches, it's not about the technology, but going back to some of the basics. "There are a lot of non-surgical techniques and good old-fashioned hands-on techniques that are highly beneficial, especially in the neck and back," she said.
Postural issues rate high with physical therapists dealing with headache sufferers. "People are in a flex posture all the time. They work on the computer, read, write, talk on the phone in this posture. And it overtaxes discs and other anatomical structures that can lead to headaches and other problems," Parker said. He stresses the necessity of education to permanently relieve postural causes. "Education is real, real important, and that's not in that policy. We can get you in a good place, but if you go back to the same paradigms, then the headaches are coming back."
"The very first time I see anyone with pain, I use some movement awareness, general stretching techniques, and deep tissue massage. I think it makes a huge difference," Pierluisi said. She advocates making people aware of their body placement and focusing on core strengths to alleviate the muscle abnormalities that can cause so many headaches.
Trying to resolve the cause of headaches or simply relieve the pain long-term leads to ongoing frustration for many doctors and patients, especially with fewer options now available. But Parker advocates giving physical therapy a chance. "For physicians who have not tried physical therapy with their cervicogenic headache and occipital neuralgia patients, they may be pleasantly surprised at how well this can work for them."