Welcome back to the Healing Pain Podcast with Professor Matteo Castaldo, PhD

Our expert guest is Professor Matteo Castaldo. He graduated as a physiotherapist in 2007. After a few years of practice and many courses in Manual Therapy, he decided to pursue a research PhD where they focus on chronic neck pain, chronic headache, its mechanisms and central sensitization. He’s working as a post-Doctoral researcher exploring headaches and other chronic pain syndromes. He works part-time as a treating clinician specializing in headache and neck pain, as well as teaches post-graduate courses to a physical therapist and medical doctors. In this episode, you’ll know all about the role of biomechanics and neck-related structures and headache type pain, how to properly assess headache and neck pain. Why physical therapy is helpful for treating these conditions and the shared mechanisms between neck pain, headache, and central sensitization.

Before we begin it, don’t forget there’s still time to take advantage of our summer 2020 free book giveaway. All you have to do is visit our show on Apple Podcasts and leave us a review and then fill out the form by going to the URL, www.IntegrativePainScienceInstitute.com/giveaway. I’ll send you a free copy of my book, Heal Your Pain Now. Remember, there are only 50 copies available. Take advantage of this limited offer while it lasts. Let’s begin and let’s meet Professor Matteo Castaldo and learn about neck pain and chronic headaches.

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Neck Pain, Headache and Manual Therapy: Mechanisms And Efficacy With Professor Matteo Castaldo, PhD

Matteo, welcome to the show. It’s great to have you here.

Thank you, Joe. It’s a big pleasure to be here with you too. I was looking forward to this interview.

You reached out to me and you said, “I completed my PhD work and I have some interesting things to discuss with regards to headache pain, neck pain and central sensitization.” Those are all topics that we’ve covered on the show, but we haven’t gone deep into neck pain and headaches, some of the things you’re going to talk about. Tell us how you got started looking into some of these topics.

I graduated as a physical therapist in 2007 at my hometown, University of Parma in Italy. It took many different clinician works and I move part-time as I’m still a clinician to the research work in 2012. In 2013, I started and developed my PhD project at Aalborg University in Denmark. I have to say that in the last few years, I’ve been a part-time clinician treating mainly musculoskeletal dysfunction, particularly headache and still a researcher. When I completed my PhD and it was 2017, in that period I was moving from neck pain to headache work. I was always studying tension-type headache and in particular migraine and the central sensitization mechanism going on in the brain of those patients.

You’ve mentioned neck pain, central sensitization, headache pain, migraines and tension-type headaches. They were all related, but what did you start with first?

I started with neck pain. My PhD was mainly a comparison between central sensitization that was more prevalent and more predominant in whiplash patients as compared to mechanical neck pain patients. As we knew from the literature that if in whiplash patients, we had clear signs of central sensitization, even in the first stages after the car accident. In mechanical pain, the literature was a bit unclear about that. We wanted to assess for musculoskeletal dysfunction for the health situation of those two different neck pain populations and some sensitization mechanism to assess them, compare them and to see if there were two different populations or if the same mechanism was of the same prevalent between them.

From your research, do we know why, or do we have any idea why central sensitization tends to happen more in whiplash patients than those with mechanical neck pain?

It seems to be much more prevalent as you correctly say it in whiplash patients. Something strange is that in whiplash patients when it develops, it develops quite soon. We have some studies showing that people who still have neck pain or neck complaints from disability after one year, they already had some clear signs of sensitization after the first month from the accident. It is strange because with many other chronic pain and musculoskeletal and not only musculoskeletal conditions, we know that central sensitization is linked to the duration of the pain.

As much as you suffer from a specific condition, the more you become likely to develop sensitization, but in whiplash, it seems that it’s something that is linked to something also genetic. There are a lot of studies about the genetic work as there are some patients that are predisposed to that. It can develop central sensitization and even with as much trauma and fast. We know from some Australian research group that also the stress mechanisms are involved. There are some people that probably are more vulnerable to these mechanisms. Their stress reaction is in some way we can say bad and not as good as other people. Those patients can start developing psychological complaints, catastrophizing more pain, some hyperalgesia, and all this stuff that are linked to central sensitization development.

For clinicians reading, and they’re seeing people with whiplash-type diagnoses and injuries, how would that change their treatment approach when working with someone who has chronic pain?

It’s different because if you are managing some patients with musculoskeletal dysfunction and if they don’t have signs of central sensitization, you can use your biopsychosocial approach, but you can mainly focus on the dysfunction on exercise, education, Manual Therapy, manipulation, or whatever. If you had a patient that you can clearly recognize from your baseline assessment that has strong signs of central sensitization, we have to change the way we approach the patient. As we know that Manual Therapy will not be probably sufficient as we have some literature showing that when the patient is high sensitized, they have a lower response to the Manual Therapy approach and to medication as well.

That’s something that is linked to the patient. For example, about the symptomatic medication like triptans, the patient can take to try to interrupt the headache when it’s starting that if the patient is sensitized, that triptans have less effective. This is something that has come up from two different studies. It’s interesting that when your brain is already too sensitized, even the efficacy and the effect of the symptomatic drugs are not the same as it was before. The same is happening with Manual Therapy and our approach.

Clinicians can start to piece these out into two different boxes almost, and I want to talk about signs of central sensitization. If someone seems like they’re sensitized and they have a whiplash-type injury, then less Manual Therapy and more toward the psychosocial aspects of pain coping for that patient.

That is something that you can decide in the first assessment. As you were saying, you can put the patient into different boxes. The one in which you decided that the patient naturally has no clear signs of sensitization. You work more on Manual Therapy, some exercise and then some education. When you have a patient that has strong signs of sensitization, the management needs to be more multidisciplinary, as you need more often a psychologist. When they are sensitized, quite often they have some catastrophizing coping strategies. They are depressed. They show signs of anxiety. They are not as motivated as the other one who is trying to improve their condition. They are not motivated at all. Sometimes we also think about motivation and finding the right people following the patient 360-degrees, otherwise you will be one in the list of those chronic pain patients. We’ve had a lot of failure with different osteopaths, chiropractors, physical therapies, drugs, and whatever.

 

When we look at central sensitization in that population of those with whiplash, are the signs and symptoms of central sensitization the same as chronic low back pain, or do they present differently?

Do you mean when the patient shows signs of central sensitization if they got the same features?

Yes.

They’re mainly the same. In your assessment, you can recognize if you’re a chronic musculoskeletal pain is sensitized or not from the interview. You have a question when you are adjusting, reviewing and talking with a patient. We’ve got some questionnaires. The most important is the CSI, the Central Sensitization Inventory, which is a good instrument. It has a cutoff of 40 points. If your patient is fulfilling more than 40 points, it’s considered highly sensitized. It is a useful item also to show the patient that there is a test saying that they need something more complex. The problem is not localized anymore, but it’s something that is spread more and needs to be treated differently.

We use, but that’s more for the research setting, the QCT, the Quantitative Central Testing. We have many of them to assess allodynia and hyperalgesia as one of the main clinical features, as we were saying in both whiplash and chronic low back pain if they are sensitized. They’ve got a widespread pain even in the healthy body part. Maybe the patient is coming to the clinic complaining of some neck pain or low back pain but if you test and assess other body parts, it should be healthy. They should not have hyperalgesia or allodynia. You will find some of that also in the healthy body parts.

How did you move on from whiplash into different types of headaches, the assessment and the treatment of headaches?

It happened when I was almost in my last year of my PhD. I was a bit confused. I was saying, “I’m almost getting my PhD, but what do I want to do later? Do I want to be a researcher, clinician and teacher? Do I want to do all of them and making my life crazy?” The idea was to keep on going with the research. I am still doing part-time research and part-time as a clinician as I didn’t want to stop with my patient. The most interesting question comes from patients. Everything that I studied in my research activity during the last few years has come from some specific questions that I had when I was treating and assessing my patients.

As I started to work with headache patients and I was mainly treating neck pain patients, whiplash or mechanical neck pain, and many of those complaints are of headache. I started to get interested in headaches and I started to study literature. I was looking at what was still lacking in the literature. I was involved in a big international project in which I was the leader of the responsible for the Italian part. We had also Denmark and Spain involved. It was a long longitudinal project that has lasted for two years. It was mainly on tension-type headache patients. After that, I moved into a migraine as it is much more interesting. Even if at that time I told that “As physical therapists, we will not be successful with migraine patients.” After a few years, I have to say that I was completely wrong because if you study the literature in the clinic if you treat a migraine patient, you will have huge and impressive results as well.

I’m glad you brought that up because I have read that myself that physical therapy works poorly for migraine-type headaches. A good place to start is, can you explain to us and articulate the difference between a tension-type headache and a migraine-type headache as far as a clinical presentation?

The clinical presentation is different. Usually, even if the patient hasn’t got a medical diagnosis, you can strongly divide into two big categories your headache patients. Mainly the two most important characteristics as migraine patients are that the pain is located unilaterally, on one side of the face. Sometimes it could shift, but not together at the same time. The pain is usually around the eye and is a pulsating pain. When we moved to tension-type headache, the pain is bilateral and the pain is dull. The patient feels like they have pressure around their head.

Some other characteristics are that usually, migraine led to much more disability. That’s something that makes a bit of unclear in the classification. If you see the epidemiology, we know from the literature that there are many more patients suffering from tension-type headaches. Those suffering from migraine, they have a stronger disability as migraine for the Global Burden of Disease Study as the term the most disabling medical condition worldwide. It’s ranking number three. It’s quite high and that’s not happening the same for tension-type headache.

What’s happening is that the patient with a diagnosis of tension-type headaches, mostly they are not searching for medical diagnosis, but they will try to manage themselves with some basic medication, lifestyle, or sometimes some exercise. The migraine patient has a strong and disabling pain, which could last also for three consecutive days as the international criteria say that a migraine attack will be up to 72 hours without rest and any second without pain. To complete another big difference is that during the migraine attack, the patient has some nausea and sometimes photophobia.

Phonophobia is a generalized hypersensitivity that makes you understand and that’s when we move about the pathogenesis. There is something in the brain that is hyperactive, hyper-sensitive and makes these patients too sensitive both to every different stimulation from outside and even from inside. We can say that migraine is much more complex than a tension-type headache, even if the tension-type headache is much more diffused around the world. The prevalence is for sure, much higher in tension-type headache, but the disability is much higher in migraines.

I want to talk about the causes of each of those, but weaving this into what you mentioned with regard to central sensitization. Does central sensitization occur both in migraine as well as tension-type or was it more primarily in the migraine type-headache?

 

It could be present in both as there are many studies showing that central sensitization is the main feature of primary headache and both the headache form that we are talking about are primary headaches. We have good studies since the early 2000 years. We got good scientific evidence explaining and reporting that in both tension-type headache and migraine, central sensitization could be present and sometimes could be the predominant part of the problem. Even if we know that the migraine brain has much more studies on that. It has been studied much more as it’s more interesting because who pays for scientific research? Companies and they are much more interested in finding specific drugs, which is going to target the migraine brain as compared to the tension-type headache which they take a painkiller to manage it from themselves. If we talk from the literature, we got good evidence that central sensitization could be present in both forms of both migraine and tension-type headache as well.

I’ve seen some of the functional MRI studies on migraine. They’re interesting from a clinical perspective that the wave of depolarization that happens over the entire cortex is interesting to clinicians but both of them can be disabling conditions for patients. Can you talk about the causes of each, if they’re distinct tension-type and migraine type headache with regards biomechanical, psychosocial and then some of the lifestyle factors?

As we were saying, there are more studies on migraine but we have good evidence also for tension-type headache. Something that is interesting and often we are forgetting is that there are good evidence studies since the ’80s trying to link them together and seeing that probably they are two parts of the same trouble. It’s a model that is called the Continuum Model in which their idea of these different outlets, but many different outlets have the same idea and believing that they are a continuum in which the tension-type headache is the one with less disability. In some specific population with a genetic predisposition, they can evolve towards the most disabling forms of migraine.

From our viewpoint and that’s the magic that physical therapists are important to know. When we have a patient and we don’t know which kind of headache they have, we could even say that we are not interested in the fact that it’s a migraine or tension-type. For sure in the interview, we will have some information that we will have our idea of what’s the type of headache that the patient is presenting with. The most important for us is finding some kind of musculoskeletal dysfunction, which is related and linked to the headache of the patients.

This is regardless of the medical diagnosis. The medical diagnosis for sure is much important about the medication, exclusion criteria, and some red flags, which need to be investigated when we deal with headache pain. Especially if you’ve got a headache that is changing in characteristic in a person, which is not that young as when the headache started, as headaches start at a young age. Otherwise, when we have our patients, we have to assess the musculoskeletal dysfunction, which is relevant for those patients.

We have good studies saying that those dysfunctions are prevalent in both tension-type headache and migraine. Whatever is the diagnosis, when we are the patient, the most important thing to do as physical therapists in order to be able to say, “I can take you as my patient that I’m going to try to help you with your disability, frequency and headache intensity, and with your symptoms. I need to find the link between your neck or temporomandibular joint and your headache. Otherwise, I will not be a professional who can help you.”

There’s a connection you’re saying between the structure and function of the cervical spine and someone’s headache pain, whether it’s tension-type or migraine?

Yes. The idea is it comes from neurophysiology as we have in MRI which is called the trigeminocervical nucleus, which is receiving afferent information from both the trigeminal nerve, especially from the ophthalmic branch and the first three cervical spine nerves. This creates an effect, which is called a convergence effect in which all the afferent information goes on the same station. They are projected upwards towards cortex, thalamus, hypothalamus, and many different areas that are involved in pain modulation and pain processing.

Because of that, it’s common that regardless of the medical diagnosis you can find in headache patients when you go to stimulate some specific neck area, it could be joint muscle or with some specific test and movement, you can reproduce the head pain that is felt in the patient during the attack. That’s strong because if you think how does it work with a neurologist interview with an assessment with a patient. They’re asking stuff. they’re having a neurological assessment. For sure that is highly important, but they’re not trying to reproduce the head pain that the patient is experiencing. We could be the only professional that can directly show to the patient that we can interact with their head pain.

As we can move something in the neck that they don’t know what’s going on, that can reproduce their head it’s strong for the patient as the patient say, “He understood something about my headache as he’s able by pushing or moving something to reproduce my head pain.” This is effective especially when we have a patient that has a lot of failure in his history for his headache. He has tried many different medications and healthcare professionals. Maybe it’s coming to us because we were treating the sister, colleague, or parent and he’s not motivated. After that, if you can show that you can have a dialogue with their head pain, that’s strong for the patient. It’s impressive for them.

As professionals, sometimes we forget that a thorough physical evaluation because we do it every day over and over again, but it can be validating for a patient when you’re doing something that reproduces their symptoms, that no one’s been able to see anything on an X-ray or an MRI. As you mentioned before, a basic evaluation may have missed that, but they come to your office and you place your hands on them and their pain is reproduced. If you could, you know alleviate the pain somewhat, then that’s the best-case scenario. Talking about Manual Therapy, specifically, Manual Therapy is a big term. There are lots of different techniques and approaches. What does the evidence say with regard to Manual Therapy for the treatment of headaches?

Regarding Manual Therapy, we have different important information. First of all, we know that neck pain is highly prevalent in all headache pain. It’s ranging between 75% and 90%, depending on the diagnosis. We have a comorbidity of neck pain as well, not just headaches. Most important is that quite often neck pain is considered something that could start even earlier before the head pain attack and could last until the end and even for 1 or 2 days after the attack. It’s not considering in the diagnostic criteria, even if nausea, which is less predominant is considered as part of the diagnostic criteria. It sounds quite strange that the neck pain is not considered, even if it’s prevalent. It’s important in headache patients.

Second, what is important and allow us to treat with Manual Therapy those patients is that there is a battery of tests that have been studied a lot in both migraine and tension-type headache. From my colleague, a German physical therapist, she studied all the different Manual Therapy tests that we can use for our patients from the Manual Therapy approach. She found that there are six different tests, which you can assess the patient in 25, 30 minutes and finding positive tests you can say that you can treat the patient.

When you move to the literature, we have some systematic review and meta-analysis saying that Manual Therapy could be affected as much as the drugs, especially in the short-term. Even in the long-term, after six months that you stopped with a Manual Therapy approach. You don’t have any negative effects on Manual Therapy as compared with drugs for sure. It’s something that is not considered as we have some specific American guidelines, neurologist guidelines saying that physical therapy and Manual Therapy should be used as a treatment for tension-type headaches. How often does it truly happen that the neurologist is sending to a specialized musculoskeletal physical therapist and headache patients? I don’t know the situation in your country, but at least in Italy, it is naturally happening often. Even if in the guidelines, even the European guidelines have seen the same that we should treat muscle and joints of our patients, headache patients as this could lead to an improvement of symptoms, but this is usually not considered.

 

Considering how many people struggle with headaches, it’s almost like chronic low back pain. Almost everyone has a headache, migraine, or a tension-type headache when you start asking them at one point in their life. The referrals to practitioners like you and I are as physical therapists are probably quite low. As you mentioned, people will go and pick up Tylenol, Advil and Aleve and potentially things that are either strong. I’ve even had people on Neurontin for migraine pain that had little effect on an outcome at all. Getting back to that Manual Therapy, if we look at let’s say massage therapy, joint mobilization and joint manipulation, like a high thrust grade five manipulation, are any of those more effective, or are they all treating a similar mechanism?

When we speak about Manual Therapy, there is always this debate going on between, “Is it better to mobilize the spine of the patient, or we need this specific spinal manipulation in order to achieve a better improvement?” There are good papers showing this matter manipulation and other ones showing that it’s better mobilization. Some others saying that the results are almost the same. If you figure out how many different Manual Therapy approach do we have worldwide that has developed in the last years between the USA, Europe and Australia. To me, that means that there is nothing better than the other one. Otherwise, we will all study the same Manual Therapy techniques. If there are many teachers, many courses, it doesn’t matter what you do.

You need to find a specific and the right approach for that specific patient, which is not always the same as we know that. For example, also what the patients want to have as a therapy. If they want to be manipulated, they will be better responders if you manipulate them. If they want to have a massage and you’re going to say no, you have to do a specific therapeutic exercise. Even if we know that probably the literature that saved that for low back pain is better to exercise instead of massage or manipulation. You will have less improvement as the patients were expecting something else. The expectation also needs to be matched.

We don’t have any technique, any approach that is correct worldwide and is the one that is the right one for every single headache patient. The most important is to rely on our musculoskeletal assessment. If you find that there are some joints, muscles, or movements that are painful or producing and alleviating the symptom, you need to work on that. That is naturally important with specific techniques you use, but coming back to manipulation and mobilization are two different ways of reaching the same goal. Sometimes it’s working better on one of the two. Sometimes it’s working better than the other one, but it’s something that you can decide pre or to assess your patient, dialogue and speak with him and assess what they want to have and what you think that is going to be better for them.

Along that same theme with regard to exercise, there are exercises that we can get people that are specific for their neck and head or there’s a more general exercise like aerobic conditioning or strengthening. Is there a certain approach with therapeutic exercise that has proven to be more effective for these types of patients?

Yes, especially migraine patients can have a good improvement. With aerobic exercise, it’s still a bit unclear how often and what is the optimal dosage for those patients of aerobic exercise, but it’s important. Something that we didn’t say before about this that is prevalent in our migraine tension-type headache is that they are quite lazy. They’re not moving at all. They experienced and the pain was going worse with some running or biking so they stopped. The neurologist said that you don’t have to train otherwise you will have some strong symptoms, but that’s true during the attack. If we think about prophylaxis made by aerobic exercise, we have some papers showing that those patients can have a good improvement at the same with therapeutic exercise.

With therapeutic exercise targeting the neck flexor or some mobility exercise. Everything could be useful for those patients. For Manual Therapy, even here, we don’t have something better than the other, but most often this patient needs to have some Manual Therapy approach, especially in the first stage of our treatment. Some therapeutic exercises, some changing the lifestyle to be more active, to eat well, and all the things that could help to improve their symptoms. There are many studies going on right now and we know that it’s important to take into account all these different aspects. From the therapeutic exercise to aerobic exercise, there is no one approach that is better than the other.

We talk about food and nutrition a lot on this show. In your research, I know there’s some information with regard to certain foods being triggers for people with migraines and other types of headaches. Has that come up in the PT literature much or is that still tucked away a little bit more in the nutrition dietetic and world?

It’s something that has been studied with some diet and eliminating some elements that we know that can exacerbate the head pain of the patients. It’s not linked to our world. As a physical therapist, what I do with my patient, when I am assessing them, I investigate with some questions. If they have identified some food and elements that when they eat them, they get worse with our headache the day after. I have some suggestions for them trying to make some small changes in their diet to see if something changes. To assess if there is a change, you need to assess the patient for at least one month. Something that is important is the diary in which you can see and the patient can write every single triggering factor like, “I ate some chocolate or white wine.” If I understood that it needs to be approached in a different and more complex way, I send them to a professional, which is specialized in nutrition.

As you and I are talking, you’re a wealth of information on headache, which is great. As I think back to when I used to train more entry-level physical therapists, a lot of new physical therapists are a little fearful to treat headache patients. They’re scared to put their hands on them. Those types of patients can be very sensitized, which means they can be reactive to any type of treatment. Are we going deep enough in entry-level training with regard to migraine and tension-type headache for the newer practitioners?

Mostly they are afraid as we are not used to treating headache patients. What I usually say in my course is, “If you are here is because you never had some specific training into a headache.” When you go, for example, and you want to update yourself with a two-day course on low back pain or neck pain, probably you are used to treating these patients. You had already many courses on the management of neck pain, low back pain, or rehabilitation of a hip or knee. When you approach as a clinician, the headache field, it’s probably something completely new. You’re scared and afraid because you’re touching something that is sensitive because you’re not used to treating the head pain as compared to low-back pain in which you trust yourself, you trust all the patients that you treated with success.”

I have to say that also in my courses, I see that even the experienced Manual Therapists are afraid when they have to explore the upper cervical spine or some tissues in the frontal part of their neck. It’s important to find some specific areas in which can reproduce head pain as we are not trained in our basic background to manage the patients. It’s something that when you decide that you want to approach this patient, it’s something that is mainly new for our colleagues.

If there’s a newer practitioner, a newer physical therapist reading this, what would be a good first step for them? Maybe they didn’t learn a whole bunch about neck pain or migraine pain in school and they’re looking either for other than this show, reading to your resource, what’s a good place for them to start?

Sometimes I have some email in which there are students and the last year of university, writing to me and asking for information about courses on migraines and the management of headaches. They say, “Will I be able to follow the course immediately after that I graduate from university?” For sure they can, but I always suggest them to take some other, I would say easier, but it’s not the right word. Some other courses have something that they will treat more often in the clinic as they are not experienced.

 

My suggestion is always to start working in a clinic. See the patient that you are more interested in the pathology that you see more often in the clinic, and then take some specific courses about that. After a while, as you said, if you have some Manual Therapy background or some specific neck background, it’s going to be easier to approach the headache world. Otherwise, you can do that, but it’s going to be something that you lose the cost of 20%, 30% of something that is going to be explained as you need to go back at home and search for a lot of stuff. Maybe you never heard of the technique. You never heard this theory about the pathology and whatever. A general course of Manual Therapy and something specific about the management of neck pain or neck dysfunction is something that is going to be helpful before approaching the headache world.

What’s missing from our research and what new direction would you like to see the research go with headache and the physical therapy field?

Something huge is missing for that reason that medical doctors and neurologists, we’re not dialoguing with them a lot in having patients, receiving patients from them. They say, “I have some good evidence, scientific evidence and clinical improvement, as well as showing that you can be helpful for those patients, but you need to be able to prove why. What’s happening when you treat your patients? Why are they improving?” When you target a drug, you are targeting a receptor and it’s the molecular binding. You know exactly what’s going on when you give one pill, one drug for the patient, but we are not aware of what’s going on in the brain of our patient when you are applying a Manual Therapy technique. If it’s painful, not painful or an exercise, which mechanism we are modulating and activating.

For that, the next big project that we are writing I have to say that in the period of the quarantine which had to stop with the clinic and with patients, I had time to write and I’m completing the third one. It’s a big research project and one of that is about that. We want to show with a functional MRI study what’s going on in the migraine brain before and after our Manual Therapy techniques. If we are able to modulate, especially the periaqueductal gray and nucleus lentiform are and other brain areas that we know are involved in pain modulation to be able to show to the scientific world what’s going on with our techniques. Why we should be healthcare professionals that should assess and address those patients?

We need to be able to show what’s going on and why it can be helpful. That is the big missing link. Otherwise, you can have your clinical improvement and if you are good, you will always have a lot of patients, but if you want to have something good in general for the physical therapy world that we are must be able to prove what’s going on. We are designing this study, which should start in 2021, which is going to be interesting as it has never been done before. We have the idea of what’s going on. As we know, from other studies what’s going on with Manual Therapy techniques, that we are inhibitory effect and modulating of the pain system, but nothing specific about the migraine, which we know that these are more complex brain.

That’s useful for the profession because it takes it beyond, “This person lacks some range of motion, flexibility or strength from the biomechanical,” and it places it more in the neurophysiological level. We may be helping some with strength and range of motion, but there’s also more happening with regard to neurobiology.

The most important is we need to speak the same language as a medical doctor and neurologist. We can speak from the biomechanical model, as they are not aware of that. The neurologist doesn’t know anything about the rotation of C1 of C2 and of the access of C1 or whatever trigger point it is or not. As headache is their world, we need to be able to communicate with them to speak the same language at a good strategic level and to explain what we are doing, but not from a biomechanical viewpoint, as they are not interested.

I try to have many conversations with a good neurologist that was open to physical therapy, but all the time, there was the same question. They were interested that we were having an interesting conversation, but there was a point in which they said, “Can you prove what you’re saying? I know that if I send the patient to you, the patient will improve, but I need to know what’s going on before it becomes something that is the routine.” Before, it’s normal that every single headache patient is screened by a specialized physical therapist.

Keep us up-to-date on that study. I’d love to hear about it when it comes out and you’re welcome to come back. In the meantime, how can people follow you and continue to follow your work?

As a researcher, they can find information on a big network that they know that is ResearchGate, in which you can find all the information about the researcher and also all the published paper. If they’re interested in driving some courses into the headache field, I’m teaching to a medical doctor and physical therapist in many different courses. As I said before, the idea is that if they are already an experienced physical therapist that has some Manual Therapy background, it’s something that could be interesting and something that could give a lot of new possibilities. Headache is predominant worldwide. They are waiting for us. As something that we didn’t mention before that is highly important is that even if in the last twenty years, there have been a lot of studies on drugs and medications specific for migraine, we are far away from getting 100% of patients responding to medication.

They are still searching for something else, those patients, and they need to meet us. I’m not saying that we will resolve 100% of the problem as, to be honest, we have to explain to our patients that we can help them. We can improve some of the symptoms. We can decrease the use of medication, decrease disability, which is associated with headaches. To be honest, we have to say that they will still be headache patients, but this is the same that also in an honest neurologist will explain to the patient as we can try to manage the symptoms, but they will never fix it all a headache patient. That is something that we can be helpful to those patients. If they are interested, they can write also via email and I can give some good suggestions about what to read, where to start from or good colleagues that also work in that field. They can contact me and I can give you all the useful information that I had.

You also have a website too they can find you on. Is that right?

I have a website that is one of my clinics. I’m the owner of that clinic and they can take a look at it. I’m sorry that it’s Italian, unfortunately. The information is better on ResearchGate, as ResearchGate is in English. They will find out everything about me and also the email for contacting me otherwise, they could look at PoliambulatorioFisioCenter.com, which is the website of the clinic. They can find also there is some useful information.

I want to thank Matteo for joining us on the show. Make sure to share this episode out with your friends and colleagues on Facebook, Twitter, LinkedIn, or wherever people are hanging out, talking about headache, pain, persistent or chronic pain. We’ll see you. Be well.

Joe, thank you very much.

Important Links:

• Matteo Castaldo
• www.IntegrativePainScienceInstitute.com/giveaway
• Apple Podcast – The Healing Pain Podcast
• ResearchGate
• PoliambulatorioFisioCenter.com
• https://www.ResearchGate.net/profile/Matteo_Castaldo
• Matteo Castaldo Fisioterapista – Facebook

About Professor Matteo Castaldo, PhD

I graduated in physiotherapy at the University of Parma in 2007, then after many courses in manual therapy, i approached the research field. In 2017 i completed my PhD degree in Biomedical Sciences at the Aalborg University in Denmark, with a thesis on neck pain and central sensitization. To nowdays i work part-time as a postdoctoral researcher at Aalborg University (being involved in different headache projects, and part-time as a clinician, treating in my private clinic headache and neck pain patients. I also teach many postgraduate courses for PTs and MDs on the management of headache disorders.