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When is someone with headaches not a candidate for PT?

There are conditions that may result in neck pain and/or headaches that are medical emergencies and not candidates for PT. These are cervical artery dissections (stroke), upper cervical instability and cervical myelopathy. The signs and symptoms we look for include: 

  • Cervical Artery Dissection (stroke): 
    • High blood pressure
    • Cardiovascular risk factors 
    • Changes in cranial nerves (cranial nerves include nerves responsible for smell, eye movement, taste, tongue movement, hearing and some muscles in the neck region. 
    • The “5 D’s” (dizziness, drop attacks (unexplained loss of consciousness, double vision, difficulty swallowing, difficulty speaking) 
    • The “3 N’s” (nausea, numbness, nystagmus (involuntary movements of the eyes))
    • Ataxia (lack of voluntary coordination of muscle movements resulting in gait abnormalities and/or speech changes
  • Upper Cervical Instability:
    • History of trauma
    • History of hypermobility disorders such as Ehler Danlos Syndrome (EDS), rheumatoid arthritis or down’s syndrome.
    • Changes in cranial nerves (cranial nerves include nerves responsible for smell, eye movement, taste, tongue movement, hearing and some muscles in the neck region. 
    • The “5 D’s” (dizziness, drop attacks (unexplained loss of consciousness), double vision, difficulty swallowing, difficulty speaking) 
    • The “3 N’s” (nausea, numbness, nystagmus (involuntary movements of the eyes))
    • Ataxia (lack of voluntary coordination of muscle movements resulting in gait abnormalities and/or speech changes
  • Cervical Myelopathy: 
    • Bilateral numbness and/or tingling in both hands and/or both feet
    • Disturbances in gait (walking)
    • Clumsiness in the hands (such as difficulty buttoning shirt) 
    • In severe cases, one may experience difficulty initiating urination, incontinence and inner-groin numbness 

Other concerns include spinal metastasis, infection and side-effects from medication. Symptoms we look for are fever, chills, night sweats, unexplained weight loss, recent infection and/or history of cancer. 

Medication-specific concerns include:

  • Steroids: risk of osteoporosis
  • Anti-coagulants: risk of bleeding
  • Immunosuppressants: risk of infections

References:

  1. “Neck Pain Guidelines: Revision 2017: Using The Evidence To Guide Physical Therapist Practice,” Vol 47, no. 7, 2017, pp. 511-512. Journal Of Orthopaedic & Sports Physical Therapy (JOSPT), https://doi.org/10.2519/jospt.2017.0507.

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