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The Neurotransmitters: Clinical Neurology Education
Healing Headaches: A Physical Therapy Approach with Dr. Sam Kelokates
Join us in yet another headache podcast but this time with a doctor of physical therapy, Dr. Sam Kelokates!
In this episode, we discuss the role of physical therapy in treating different headache disorders. We talk about the importance of posture, exercise, manual therapy, neuromodulation, lifestyle management, and the need for trial and error to achieve optimal results. Tune in now!
Dr. Kelokates has a private practice located in Philadelphia, PA. You can find him on his website https://www.kelosphysicaltherapy.com/ or on Twitter/X at @TheHeadachePT
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Hello and welcome back to the Neurotransmitters. Thank you for joining us today. So not our first episode on headache but I think, a very interesting spin on headache. I'm very happy to be joined by Dr Sam Kelokates, a doctor of physical therapy, and thank you so much for joining us today.
Dr. Sam Kelokates:Yeah, thank you, Michael, for inviting me on today to talk a little bit about headache with physical therapy.
Dr. Michael Kentris:So you know, as a, as a, you know, so I'm a, a DO by training, so I have. I have a little bit of musculoskeletal knowledge, just enough.
Dr. Michael Kentris:I'm a few years away from it at this point, working in my specialty, but I kind of came from like a family of chiropractors and that was always kind of near and dear to my heart, my father or my sister, some cousins so and I was initially thinking of going into like physical medicine and rehab, and so I was fortunate enough as a as a student, to spend some time with physical therapists who, some of them, had some unique emphases in their practice, and that's essentially what you do. You have a very unique emphasis in your practice, focusing on on headaches. So just tell us a little bit about your, your journey into that particular niche within physical therapy.
Dr. Sam Kelokates:Yeah, so I started my own private practice about three years ago in 2021.
Dr. Sam Kelokates:And I just was kind of doing that on the side, on top of my full-time job, just to make a little extra income.
Dr. Sam Kelokates:And so I was going to see some family friends and, just like other people, that kind of like came and fell into being seen for, I guess, general orthopedic issues, and I started seeing some friends that had headache, complaining of headache, and at that time I was thinking like oh, neck pain headache, it's cervical genetic headache. But I was like I really wanted to feel familiar, familiar with my, familiarize myself with, like, how treatments go for that. I really started to find out like neck pain doesn't mean cervical genetic headache. And I got down this whole rabbit hole of, like migraine and tension headache and what the path of physiology was that and how we kind of there's at least in the United States, there's not a really big robust physical therapy program to treat people with headache disorders and really manage them appropriately. So that's where I started really niching down and following that as like where my practice is going to really focus on treating those with headache disorders.
Dr. Michael Kentris:Interesting. Now, as you said, right, everyone thinks so physical therapy, musculoskeletal, but you're also talking about kind of these more primary headache disorders like migraine and things like that. So it's very easy for many of us in medicine to kind of fall into this algorithmic approach to different problems. But how do you find that you're able to tailor your approach to these different types of headache?
Dr. Sam Kelokates:Yeah.
Dr. Sam Kelokates:So with the exam I'm really looking for impairments that are associated with certain types of headaches.
Dr. Sam Kelokates:So for migraine, there might be certain types of mobility restrictions or pain pressure sensitivity, so like how much pressure they can take in the upper cervical spine or the face that would indicate maybe they have a lower pain threshold, Because there's different interventions we can do that are more long term management, like exercise, helps improve pain pressure thresholds.
Dr. Sam Kelokates:So looking at that, identifying range of motion deficits that might be contributing to their mig, at least for migraine, their migraine trigger, so that their upper cervical spine or their head and face might be contributing as a musculoskeletal trigger for those people. So we're trying to manage that trigger as much as possible and hopefully end the end. At the end goal is decrease the frequency and the intensity of those headaches related to that specific musculoskeletal trigger. And then it goes into the treatment for lifestyle management. How do we appropriately prescribe exercise for people with migraine so they might have a sensitivity to that increased physical stress or that increased blood pressure or heart rate? Then we really think about okay, well, exercise causes acute dehydration as well as use of blood sugar, so they might become like acutely hypoglycemic even though they're not having any symptoms of that, their body might respond to that and be more sensitive to an attack at that time.
Dr. Michael Kentris:Got you, yeah, this very kind of whole body approach, a whole person approach, if you will. So that's always a good thing to think about and I know certainly we always forget. Right, migraine is not just headache. There's all these things in between, like the fatigue or the kind of the prodromal symptoms where, like these hypersensitivity things creep in. And how do you find you mentioned kind of these sensitivities in different parts of the head and neck and all those sorts of things? How does that like, say, you do have someone with migraines, with these hypersensitive areas? How does that factor into kind of your treatment approach or your selection of different treatment modalities?
Dr. Sam Kelokates:The treatments I'm usually addressing with people are ones that tend to help those specific impairments that we find musculoskeletal wise, but then we really need to tailor down to how does that person respond to that particular treatment. So it's a little bit of trial and error but also patient preference. If they've gone to like a power pack before another physical therapist and they were having manipulations done and they always had an migraine attack or they felt worse or better afterwards, that might be an indicator that that's a treatment path that I want to go down or avoid and come or come back to later, depending on how that person was responding at that time. Really, knowing how do they respond after each treatment session, talking about did they have a headache attack, did they feel better, did they feel worse, was something better but something else was worse and trying to figure out what that means in relationship to their specific, unique presentation.
Dr. Michael Kentris:Gotcha Now I know before we started recording you also said there's not a lot of training programs in the physical therapy world specifically for this. So how did you integrate kind of the training you did receive in your traditional path pathway? And then what kind of education did you seek out or how did you kind of develop some of your approaches to these patients?
Dr. Sam Kelokates:So, like I said earlier, I really just went down to Rabbit Hall so I was reading a lot of research studies about like physical therapy for headache management, which there wasn't a whole lot. There's growing body. That means it's getting more and more in the last few years with more professionals really doing that kind of research. But that's where I started and then I would reach out to some people, some of those authors, about more information and they would send along some articles or book recommendations.
Dr. Sam Kelokates:There was one course in the US that came out, but it's a self-directed course so you just kind of go through and read the content. But at that, prior to that, I read most of the articles that they had cited for that CEU course. So I kind of felt like I was already where I should be after that course. But that's really where I'm at now. Is that to really stay on top of managing people with headache, is that I need to keep reading literature, talking to neurologists, finding other sources of education, because for physical therapists we just don't really get a big robust education in headache medicine or headache treatments or even the diagnosis about them and how to recognize them. In PT school I remember looking back at one of like the biggest textbooks I have and it was just called. I think it was just called physical rehabilitation. Then there's just like one section that's like a paragraph that talks about what migraine is and it really didn't even get into the classification on how you actually diagnose that appropriately.
Dr. Michael Kentris:Oh wow. So in your experience, what kind of modalities do you tend to utilize most often in your practice? I know there's no one size fits all, but just curious.
Dr. Sam Kelokates:I don't really use modalities too often in practice.
Dr. Sam Kelokates:I do talk with patients about it, like hot, using heat versus cold and what I kind of think about that and how ice can help with some people during the acute phase of an attack.
Dr. Sam Kelokates:The one modality that I do use would be neuromodulation, so like a TENS unit, think like how like there's the migraine specific devices now, like cephalia and the rivio, but what I would use in practice because I can't prescribe those, because I don't, that's not something that we do in the US is a TENS unit. We can recommend them and train people on how to use them for home management uses. Another reason I like TENS units is because they can be applied anywhere in the body, so the head, the face, the neck, the lower back, the mid-backs if they're having pain elsewhere and they're trying to avoid using other medications for pain management. Because I know for a lot of people with chronic migraine there is concerns for medication overuse. So if I can train them on how to use a TENS for their headache condition but as well as their other, maybe less of a skeletal conditions, then that's a really good way to help them manage long term.
Dr. Michael Kentris:Got you, and what kind of exercises do you typically end up using? Or like actual physical therapies, I should say.
Dr. Sam Kelokates:So I would break down treatments into like manual therapies and then into exercise, and exercise would be further broken down into generalized exercise, so that would be like aerobic training or just generalized strength training. It could even be yoga, swimming, walking, gardening, just being physically active, because that is really helpful for a lot of reasons with overall brain health and wellness. And then we can break it down even further into more headache specific exercise, and those exercises are going to be more tailored to that person's individual impairments. The most common impairments I typically see in the clinic are weakness of the deep cervical flexors, tightness of the self-excipitals, the upper traps, the levator scap and some joint restrictions. So then we're doing exercises that would help facilitate mobility and stability, so usually exercises of the neck and the upper shoulders.
Dr. Michael Kentris:So it sounds like a lot of computer desk neck type stuff, probably a component to that as well.
Dr. Sam Kelokates:It could be. Sometimes I feel like posture is a little bit of a red hang for people, and it's not that being in a bad posture is. I don't think that's bad. I think being in one posture for a prolonged period of time is what's bad. Really, our bodies want to get up and they want to move, and when we start getting an achiness for that tightness, it's our body telling us that we're getting fatigued and we need to start moving.
Dr. Sam Kelokates:So one of the aspects of therapy that I do is actually educating people like we need to have maybe more movement snacks involved in the day, especially for people that are like work from home or on the computer or at a desk job. Every hour you should be getting up, whether it's to go for a walk, to get water or doing neck specific exercise or doing some like chair yoga. You should be doing some of the breaks up that monotony of sitting in one position, even if it's that forward head posture or a perfect sitting up posture. If I'm sitting in that posture for one, two, three hours, I'm going to start getting kind of achy and not feeling as comfortable. It's just our body's way of saying we need to start moving. That makes sense.
Dr. Michael Kentris:Now you mentioned manual therapy earlier, so for those who may not be overly familiar, what's involved in that?
Dr. Sam Kelokates:Manual therapy is just the application of hands-on techniques. I would break down manual therapies then into two segments into soft tissue and then into joint-based interventions. So joint-based interventions might be the mobilizations and manipulations of the upper cervical spine, the lower cervical spine or the upper thoracic areas. Soft tissues would be involved more like the muscles and tendons and ligaments.
Dr. Michael Kentris:Okay, and is that, if you would care to, for those again who might be listening differentiating the way, because I know there's differences in application but also in philosophy, between the way that physical therapists versus osteopathic physicians, versus chiropractors versus massive therapists I know that might be a little too into the weeds, but just broad strokes how do you think that the way that a physical therapist applies manual therapy kind of differs from these other practitioners?
Dr. Sam Kelokates:I can't really speak broadly because there's a few schools of thought for it. But the way I go about looking at manual therapy application is will it help and has it been? Is there evidence to support its application for a specific impairment that I'm trying to treat? So the one of the most common ones I'm using right now is called a manual pressure technique. That specifically is a manual pressure that's applied to the upper cervical spine. That's kind of acting as a mechanical trigger for your familiar headache. So the way that would, the theory for that working, is that I'm applying a manual pressure to the upper cervical spine. Those upper cervical apharons are sending neural information back to the trigeminal cervical nucleus and because of convergence theory we know that they. We think that there's a referral pattern from the trigeminal cervical nucleus out through the trigeminal nerve and that's where people are getting that head and face pain through migraine and tension headache. So if I'm able to stimulate mechanically the upper cervical spine and then mimic or have them feel or elicit their familiar headache, that there might be an application for addressing the upper cervical spine in their headache disorder.
Dr. Sam Kelokates:Other ways to look at it is if I know that there's patterns for cervical genic headache based on some other research. If I'm doing certain joint mobilizations to help facilitate that, if I know that there's like imaging that would suggest a cervical pathology that would be related to headache, then we could address that through manual therapy as well. But I usually take what the physical exam shows and apply manual therapies as I think that would help those impairments, but also based on what the patient preference is, because some patients don't want to be touched or they're very apprehensive about it. So that might be something where we get into later and we see how it goes or we do a trial of it. So it's kind of a mixed bag sometimes with some people.
Dr. Michael Kentris:No, that makes complete sense. So obviously most of these people are kind of dealing with these chronic headaches, chronic neck pain. I always talk to people and I say, like this isn't a problem that started overnight. We're probably not going to be seen in overnight cure. How do you counsel people and how do you gauge whether your interventions are having a noticeable benefit?
Dr. Sam Kelokates:Yeah. So the first thing in Eval, actually sometimes even before the evaluation I talk about are they recording a headache Dior? If they are, please bring it in so we can review that. If not, we need to start even before you come in so we can see what the interventions are doing to you. Are they making you worse and they making you better? Are they making you worse right afterwards but then better in between sessions, so we can get a better gauge of what the relationship is between physical therapy and the headache disorder?
Dr. Sam Kelokates:And then usually for therapy, I'm doing anywhere from four to 10 sessions with people. It's very unlike. Usually I'm not doing less than four and I'm not doing that often more than 10. Because at that point I should be able to do the manual therapy or exercise. I need to and teach the person what they can do at home with what we're doing in the clinic, and then we do check-ins from there. From there on out on. Do you need to come back in because you're struggling to control things on your own? Are you continuing to make progress with your lifestyle and home exercise program? And we'll track it from there. Did that answer that question?
Dr. Michael Kentris:Yeah, yeah, no, that obviously does. I know I've had folks in the past and you always wonder, because they'll tell you like, oh, I went to physical therapy for my low back pain or my difficulty walking, for whatever reason, and it was like, oh, just made it worse. And you always wonder like well, was it worse, like you said, just after the treatment session, because certainly you know, exertion can worsen some of those symptoms transiently. Or was it a question of, like, the therapy plan not matching up with the patient specific needs?
Dr. Sam Kelokates:Yeah, you're asking how do I monitor that?
Dr. Michael Kentris:Yeah.
Dr. Sam Kelokates:Yeah, so we're going back, we're looking at what did I do in the last session. What do I expect the outcomes to be, especially early on if they're very sensitive. They have low pressure thresholds and I try to be mindful of not doing too much too soon with people so I avoid having headaches early on. But if we're doing some manual interventions there's always that risk that we're going to stimulate the trigeminal cervical nucleus and that could precipitate an attack. Now we also need to look at did we do the therapy session earlier in the day, late in the day? Did you get a good night's sleep afterwards as well? Because poor recovery might lead into an attack as well If you're not able to come back down and reduce your daily stressors and kind of like recharge that battery. But we kind of go through application. If something where I'm doing a therapy and you immediately start having an attack, I would probably link that much closer relationship to what we actually did. The further we get out from it, the less likely I would assume that it's due to the intervention.
Dr. Michael Kentris:Gotcha. Now that makes complete sense as far as common mistakes or let's just say missteps, if we want to be a little softer in our language that either either the person undergoing therapy or or the therapist may make when kind of approaching these patients. What are, what are, things that you commonly see like in your referral population?
Dr. Sam Kelokates:yeah, I think one of the common mistakes people make is associating neck pain during migraine is cervical genetic headache, where you really have to look at what are the other symptoms around that headache condition, where if it's just headache, you're probably more likely to be just cervical genetic and with those patients you can be a little bit more aggressive with the exercises and the manual therapy you're applying, just because of the pathophysiology.
Dr. Sam Kelokates:But if they're having neck pain and migraine we need to be more mindful of what's the pathophysiology about that, because they're more likely to be more sensitive to those interventions and not tolerate a very hands-on application of therapy to start therapy, to start a plan of care. So I think that's one of the big problems I see is misinterpreting what the relevance of neck pain is and what's causing that neck pain. Because for people with migraine, neck pain doesn't mean that they're having a neck problem, because migraine itself can refer pain to the neck and there'd be no dysfunction. There might be some dysfunctions but then and that could be also caused because of the migraine, because they're guarding, so we might see mobility restrictions. So we really need to evaluate people during their inner ictal phases, you know, between migraine attacks, to see do you actually have these neck impairments outside of attack ranges and then correlating them with how frequently they're having it is it related to their attack or not?
Dr. Michael Kentris:No, that makes a lot of sense actually, and that kind of makes me think of another scenario, if you will, that probably isn't unfamiliar to you. You know, someone maybe has a pre-existing diagnosis of migraine and then maybe they have like a fall or kind of a fender bender with a little whiplash, and then their migraines increase in frequency. And then you also have this superimposed new issue. Yeah, how do you tease that apart?
Dr. Sam Kelokates:I would just go back more towards the physical exam and what the impairments are after. So I do see some patients actually right now that have kind of that similar presentation where they've had a history of migraine. It wasn't really frequent. They're probably averaging less than four a month, maybe even less, maybe one every few months, but then they had this post-traumatic injury, whether it's a headache or like a concussion or whiplash injury, and now their symptoms are coming up and they're becoming more episodic, even in the chronic. That would be an indicator to me that their upper cervical spine is involved in that at some level and we need to start working on desensitizing that area, improving possibly improving muscle skeletal endurance of the deep cervical flexors, working on proprioceptive control, seeing and, you know, really looking at what the symptoms are, correlating to that, what the impairment probably is, and then making a plan of care that addresses those impairments.
Dr. Michael Kentris:Excellent. Now I know something that frequently travels along with with chronic pain is there's sometimes some effective symptoms like depression and anxiety, things of that nature, like generalized fatigue. Do you find that you're often working with patients who have like some undiagnosed or untreated depression, and do you ever have to broach that in your practice, just out of curiosity?
Dr. Sam Kelokates:Sometimes it's, I think, for when I get to people they're already working with somebody for that and they're recognizing that's an issue for their condition.
Dr. Sam Kelokates:But when I do see people that are like, hey, I think that anxiety might be contributing to this or your depression or some other some other issue that is outside of my scope of practice, I'm being sure to want to at least educate on why I think that and then making a referral to a professional that I think would be best suited to them. The only area where I think I can help people with anxiety is if it's related around exercise so I want to get exercising. Or like I can't play with my kids and I get anxious about doing it because it's going to trigger an attack. Okay, well, let's build a rehab program around how do we become more physically active? So that's something I feel I can address in clinic and then it's appropriate. But if they're really having, like an anxiety disorder or depressive or depressive disorder, that I need to be making that referral to either a physician or another mental health specialist that can help them with that.
Dr. Michael Kentris:Excellent, yeah, yeah, there's so much that that goes along with headaches and migraines. What do you think you know in your like patients who are sent to you unmet needs in the community, in the migraine and headache community at large, where do you kind of see the the future of this particular sub-sub specialty going?
Dr. Sam Kelokates:Yeah, I think one thing that could benefit a lot of people with migraine and tension headache is having more professionals that are app that are able to properly apply and prescribe exercise.
Dr. Sam Kelokates:We know that exercise, as far as the long-term management tool is, really can be really helpful for a lot of people, especially if we get them. We get people before they become chronic. It tends to be more effective in the early, in the in the episodic stage. So getting them more physically active, teaching them how to properly exercise for their condition and and how to monitor and giving them a framework to work within where, if they are having having certain symptoms, is that something telling you not to exercise that day? Exercise a little bit? Is that a symptom where it's not going to be affecting your exercise program of physical activity levels? I think having a professional that knows how to look at each individual prescribed exercise to what we would know would be an appropriate level, but then making it very individualized and unique for that person to help them manage their condition is a need that I think would help a lot of people with with a headache disorder in the long run.
Dr. Michael Kentris:Excellent, and you know, I kind of thought of another question as you were talking. One of the things that, back to concussions and things like that that you mentioned is that we'll sometimes see kind of these vestibular disorders creeping in. How how much of vestibular therapy do you find yourself kind of working on alongside of kind of migraine specific treatments?
Dr. Sam Kelokates:Yeah, I've been more in the last three years. I practice very little vestibular dysfunction, it's just the patients that have come to me. I usually find finding something that has more significant vestibular dysfunction. Though I'm referring to a vestibular therapist. I just don't have enough training to deal with like very specific vestibular needs. Like for some people that do come in that have some types of dizziness, if it's mild and one of their lesser symptoms, that's usually something that determines that I'm going to work on. As far as neck specific exercise and manual therapy related to the neck and perpary sacrum exercise will help decrease those vestibular symptoms. But if I think they have another vestibular disorder on top of a headache disorder that I'm referring to another therapist.
Dr. Michael Kentris:Gotcha, that makes sense. Yeah, very those. I can only imagine how challenging those patients would be.
Dr. Sam Kelokates:Yeah, sometimes it. So. I do see sometimes some patients where they're seeing a vestibular therapist and they're seeing myself and it's just. It's not that I can't do vestibular rehab, I just don't have the education yet to be able to do advanced levels of of vestibular care and I'd rather give them a therapist that is better suited to them.
Dr. Michael Kentris:No, that makes complete sense. I often find myself referring to subspecialties in my own field as well, when it's just like. This is something a little strange. You probably need a second opinion, you know yeah, it's like I recognize.
Dr. Sam Kelokates:I recognize the problem here and it's just outside of my expertise and I want to get you that expert.
Dr. Michael Kentris:Absolutely so. Any final thoughts? What that you think like the general public should be looking into, even if they haven't seen a PT yet, or you know, obviously make sure touch and base with a Professional before starting any exercise. The regimens or your general recommendations be for the people out there.
Dr. Sam Kelokates:My general recommendation is be so. Even for people that I've seen a physical therapist and it didn't go very well, it's that don't not consider physical therapy again. There's so many therapists out there and we have different training from across the United States based on our manual therapy education, because there's so many different schools of training. Same thing with our application of exercise and our background with exercise that you know. Keep trying to find that right professional and ask maybe more specific questions when you're kind of doing your own interview for your health Professional that do they know what migraine is? Do they know how to make that diagnosis or at least the diagnosis criteria for that? Because if they don't, they probably don't know some of the nuances of the condition and how physical therapy will really affect them down the line.
Dr. Michael Kentris:And you know that that actually is a great point and that's the one that I think, even me as a Healthcare professional, right, when I'm referring people to physical therapy, I work in a healthcare system and it just goes into, you know, the ether, if you will right, it goes to the therapy department and you know, I know some of the therapists, but they're mostly the inpatient therapists that I work with on a regular basis, right? So they're working With gates and you know orthopedic injuries and things like that. Where is? If I'm referring to, like, say, a vestibular therapist or someone with headaches Specifically, yeah, I don't necessarily know who they're, who they're going to. Do you have any good recommendations? Or is this more a question of, like, you got to get out there and kind of beat the pavements and, you know, meet people, find out what their areas of expertise are?
Dr. Sam Kelokates:Yeah, that would probably be the best courses you know you can have to ask you probably better off with a manual, a therapist that understands manual therapy.
Dr. Sam Kelokates:Another good resource would be some of that does vestibular therapy.
Dr. Sam Kelokates:They're gonna at least have a good understanding from a vestibular migraine perspective on migraine disorder and be a little bit more Understanding of how exercise or manual therapy might affect it. Now they might not have the manual therapy skills and as a as a, because really most vestibular therapists tend to align more like the neurological side of physical therapy, so they're doing less manual type therapies, though there isn't, and there's people that the therapists that do manual therapies tend to be orthopedic in nature. So having some of that Understands either side of the the manual therapy side or the vestibular side could probably be a good therapist for you. I would just make sure that they understand that there's gonna be a lot of trial and error with how you respond to therapy interventions and we don't really want to make assumptions that you're gonna be too sensitive or you'll be fine. As you know, with this intervention we need to really tailor it to you, ask you what you've done before, what you're sensitive to now, and then work with you continuously throughout the plan of care.
Dr. Michael Kentris:No, that makes sense. Right, got a tailor to the individual, yeah. So thank you so much for coming on talking to us a little bit about physical therapy for headaches and migraines. If people want to find, I knew, but put out some good stuff online, where can they find you online?
Dr. Sam Kelokates:I tend to do a lot right now on Instagram and LinkedIn and Twitter, as well as my website. I try to post blogs pretty often to really know the. The blog is more patient-facing than it is clinician-facing, but on the other platforms I do a little bit mix of patient and provider facing information.
Dr. Michael Kentris:Excellent. And if people are looking for a physical therapist, what city are you located in?
Dr. Sam Kelokates:again, I'm located in Philadelphia PA.
Dr. Michael Kentris:Awesome, awesome, well, thank you so much. You can also find me online at Twitter, slash X, at dr Kentris, and our website, the neurotransmitterscom. Thank you everyone for tuning in and we'll see you all again next time you.
