Clinical Edge - 106. Cervical radiculopathy, central sensitisation, achilles tendinopathy, hip & groin pain, and strength testing with Paula Peralta, Simon Olivotto, Nick Kendrick & David Toomey Clinical Edge - 106. Cervical radiculopathy, central sensitisation, achilles tendinopathy, hip & groin pain, and strength testing with Paula Peralta, Simon Olivotto, Nick Kendrick & David Toomey

106. Cervical radiculopathy, central sensitisation, achilles tendinopathy, hip & groin pain, and strength testing with Paula Peralta, Simon Olivotto, Nick Kendrick & David Toomey

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David Pope: Hey guys, how's it going?

David Toomey: Good.

Simon Olivotto: Good, Dave.

Nick Kendrick: Going well, mate.

Paula Peralta: Yup. Good. Thank you, Dave. David Pope: Excellent. Well, it's great to have you all here for a night of Q and A so, welcome. We've got Simon, Dave Toomey. We've got Paula Peralta and Nick Hendrick. So we've got the A-Team here to answer the questions that members have submitted. So, looking forward to having a chat to you all tonight. So we've got some good questions coming in, so we're going to dive straight into them. So we're going to kick off. Esther asked a question here about cervical radiculopathy patient. So she said if the patient has cervical spine Modic change type one at the same segment of stenosis, does it change our clinical management?

And is there any precaution to take for these patients? So she had a moderately irritable patient who had these Modic changes with that radiculopathy and they're not getting much relief from NSAIDS and Lyrica. So Nick, do you want to take it away with this one?

Nick Kendrick: Thanks, Esther for writing in, and it definitely sounds like a tricky patient. The thing I generally think about when I first see a question like this, or I see a patient come in with imaging, is I definitely want to look at that imaging, but I also want to make sure I'm taking into account the whole patient picture. And so, I would be having a really thorough subjective examination of this individual and making sure I do a thorough objective and really looking at all the things that might be contributing to this person's pain and not just the imaging that they come in with, so I don't make any firm decisions on how someone is going to present based on the imaging report that they come in with.

And so that'd be the first thing I'd say about this particular person. And then when I see Modic changes on someone's report, I think about what might be happening at that level. And we know that there might be some inflammatory changes happening in the bone or at the end plates of that level, but that's not going to mean that we need to take any major precautions with regards to range of motion or movement. Probably, with this particular person, if there's some stenosis, that might be causing a myelopathy or radiculopathy, they're the things we want to be a bit more cautious about rather than some bony inflammation or some edema in the bones of that level.

So, that'd be the first thing I'd say about this particular patient. The other thing you sort of mentioned there is that they're not having much relief from the NSAIDS or the Lyrica, and at least in Australia, medications are a bit beyond the scope of usual practice for physiotherapists, but maybe where you're from, you might be able to talk a bit more deeply about that with your patients. I typically get people to really have those discussions with their doctors, their treating team. And sometimes it can be really helpful just to organise a case conference so you can all talk about what's happening at the time. And so, you're discussing the patient's presentation with the patient and the doctor at the same time and highlighting to the doctor that these...

And Lyrica is quite a strong medication. These strong medications aren't having much effect, and they can come with their own set of side effects, that might mean that it's not worth continuing down path and we need a changeup of some sort. And, if there's a medical team involved, they might have a strong opinion about whether those Modic changes are really relevant and they want to try and target them with some other types of medicines, a bit stronger than the nonsteroidal anti-inflammatories.

David Pope: So you're looking at the really interested in their presentation and exploring that more than you are, whether they've got the particular Modic changes, and then looking at all their treatment options and their medications in conjunction.... The medications involving their GP or whoever their medical practitioner is.

Nick Kendrick: Yeah. I strongly believe that if you're just a bit unsure, it's best off asking the people prescribing the medications, and then it can be really powerful for the patient to have you and the treating medical team having a conversation with them about their treatment, so they feel like everyone's on the same page. And then that can be empowering for you, as the physio you can say, "This is what I can help you with. And this is what I want to help you with." And then the doctors are like, "Well, this is going to be our plan of action." And the patient sees that everyone's there for supporting them in their recovery.

David Pope: And what sort of treatments do you guys tend to find in cervical radiculopathy patients? Do you have any sort of commonly used types of approaches to cervical radiculopathy patients?

Nick Kendrick: For me, it depends on, again, how they present and what's particularly aggravating. And is this a foraminal stenosis or a canal stenosis? Obviously, we want to be certain they're what's going on. And, are they able to get any positions of ease? And like, sometimes you can pick your cervical radiculopathy patient, because they're sitting in the waiting room like this, and that's going to be a pretty sure indicator that you want to try and offload that nervous system a little bit, take some mechanical sort of strain and tension out of it. And I typically would maybe try and manually support their shoulder girdle, and see if that changes their symptoms at all. And, if it does, I might be looking at providing some support with tape initially, on top of maybe some manual therapy that might mimic similar stuff.

So, even just moving their shoulder girdle passively with them or active assistedly, you might want to go into looking directly at the segmental level and see if you can make a change there.

I typically like to treat in supine for radiculopathy. I don't particularly think people love lying face down with their head in the hole and they've got a raging cervical radiculopathy, and there's some really nice techniques you can go towards with your manual therapy skills in that supine position. Simon Olivotto: I pretty much do very similar treatment, Nick. Sometimes, I also think whether there could be a compressive component to it and might consider, like Nick said, some of the manual therapy techniques where we might be looking at opening that intervertebral foramen, or increasing the size of that intervertebral foramen. And so, there's potential, in the clinic, to try things like some manual traction or potentially a lateral flexion away from the side of symptoms, if you want to open that up. And that can be useful to give the patients something to go home with as well as, some positioning. But, often there is that component, too, where there's that nervous system sensitivity, or there's that tension-type component to it. And, like Nick said, elevating that scapular girdle, or lots of positioning where you're limiting the amount of tension on the nervous system, just allow it to settle in the short term, and not being too aggressive with jumping in with neural sliders or gliders too early.

David Toomey: Yeah, for sure. I think with the neural gliders and sliders, it's something to definitely err on the side of caution as well, and be very clear with your reps and sets and stuff like that, because, otherwise, patients, particularly if the irritability is high or if there's indeed a little bit of latency, they might have to pay the pied piper a little bit later on, when you're not around. So, maybe using some of your assessment techniques and just using a slight little variation on that, where they haven't been aggravated and continuing that on to your treatment.

Nick Kendrick: Yeah. I think that's a good point, Dave, and speaks to this particular case where Esther said that her patient was a little bit irritable, and so erring on the side of caution is probably the best way forward there, in session. Sometimes, with these Modic changes, it can be reassuring to tell patients, not that it's a particularly fun time for them, but reassuring to say that it's not going to just be fixed in one week. These things take a little bit of time and we need that bony edema to settle down, and that sort of bony remodeling is going to take some time. And so, you're setting them up with the right expectations pretty early on, but you definitely still going to take into account the whole picture, and they might not be relevant at all, they might just be an incidental finding. But, if they're there, you can say, "Well, this might be a reason why you're having a little bit of persistence with your symptoms and it's not just fixed in one or two sessions of manual therapy."

David Pope: And we've got another question come in from Jason, and he's asking about ice. So, he said, in several presentations and podcasts, there's been mentioned of using cold and ice as an indicator for central sensitisation. And he thought it was in the Upper Extremity Diagnosis series. In the podcast, Dr. Cook talked about manual therapy. Can you elaborate or refer to some journal articles discussing this topic? So Dave, I know you're a big fan of ice baths. Let's hear from you all about ice mate.

David Toomey: Well, I'm cool as a cucumber, as you know. So, definitely happy to answer this for Jason. It's a good question. The way that I like to think of it as maybe divided into two parts. So you're thinking a little bit about central sensitisation first, and then also what cold or ice might do, rather than giving you a simple yes or no answer. So, I guess with respect to central sensitisation, its features and often how it manifests clinically is pain, hypersensitivity, allodynia, hyperalgesia, these types of things often enhance that temporal summation and that can often present as a result of prolonged nociception or prolonged nociceptor input, which can make everything just a little bit excitable and increase a lot of the synaptic activity there.

So, one of the things that happens is that we have a heightened response, or almost some of those secondary hyperalgesia-type signs, whereby usually there's an abnormal response, potentially to a non-noxious stimulus. So, if cold is starting to excite the system in a way that we wouldn't necessarily expect, that's may be an indicator that central sensitisation could be present. Now, not to put all our eggs in that basket, it's certainly not a diagnosis, definitively, or even proof of that kind of classification. But it can just start to maybe tip the scales, that weight of evidence, and increase your index of suspicion.

So a nice little study has shown this, a clinical test of using ice can be pretty close to your quantitative sensory testing. And it's a really simple test, which is holding an ice cube on the patient's skin for five seconds. And you ask the patient, rather, to rate the pain on the numerical rating scale from zero to ten. And a cold pain rating scale of greater than five indicates that there's a 90% likelihood of cold hyperalgesia. So, if you take that, with maybe some subjective clues, like sensitivity to cold, not liking the cold or maybe finding that the cold weather is not so good for them, in conjunction with maybe a screening questionnaire, if your spidey sense is tingling for central sensitisation, then the central sensitisation inventory is your screening tool that you could use there.

And also, some of those subjective tips or clues, like constant high levels of pain, none dermatomal distribution, spontaneous pain, pins and needles, burning, numbness, all those types of things would really start to raise that index of suspicion. So, not a diagnosis, but will definitely add ways into potentially confirming a central sensitisation for you. David Pope: And how does that impact your choice of treatment or what you're going to do within your session, Dave?

David Toomey: I think that when we're looking at treatment modalities, if we know that there's abnormal processing, I guess is a nice way of putting it, it will often have an impact on both the modalities that we use, and also, maybe some of the narratives that go along with them. So, again, it might be that the grades of treatment that you use, you really need to pair back to see how those settle. It might mean that we are treating away from the injury site. So, if somebody, for example, has knee osteoarthritis, where you might have central sensitisation, you can get some nice analgesic effect by maybe doing an upper body session or doing some upper body weights, which can have the systemic effect on the body, but we're not poking the bear too much at the provocative knee. Or, you can alternate that if it's a shoulder issue.
You can get them on the bike for some systemic changes without getting into the nitty gritty of the area that they're coming to you with, I guess.

David Pope: I think that's a really nice response, you really thoroughly covered there Dave, and it's perfect. And just have a chat to you Simon, about some clinical examples. Have you got any recent patients that have had this type of thing?

Simon Olivotto: Some of the whiplash patients I've seen. I know that there's a lot of literature about the cold hyperalgesia that Dave's talking about, in terms of it being a prognostic indicator of a worse outcome. And people like Michelle Sterling and Trudy Rebbeck have had a look at this. When they apply the ice tests, exactly as Dave has described, so they apply it on the skin for the 10 seconds. When they applied over the upper traps or the area of the neck, they're seeing hyperalgesia, or increased cold sensitivity. Then, if they test it somewhere really remote, so, say in the tibialis anterior or somewhere, a distal site that's not related to the neck, and that's also an amplified response. And that tends to suggest is that, possibly that central nervous system changing processing that Dave was talking about. So, like you said, it's not definitive, but it shows that.

So, sometimes and the patients, like Dave said, I've had someone recently who said, "Oh, when I walk in the cold room, my pain's a whole lot worse." So I applied the ice cube over the area of her pain, which in this case was her thoracic spine. And she reported the pain as seven out of 10. Then I had a look and said, "That's really interesting. Let's see what it looks like when we apply it over your foot." And we did the same thing and it also was seven out of 10. So, that was useful as just a way to link into her story, that cold was sensitive for her. It also helped start opening a conversation that this was a problem of pain sensitivity, and it wasn't purely just the structure, that was a problem. There was lots of other things going on here as well. And it just helped frame that in a way that we could discuss it as a pain sensitivity thing, rather than just sort of telling her and giving her pain education. It was a way for her to experience it, and start seeing this in a different way.

Nick Kendrick: I'll just say that Simon's highlighted that it's been demonstrated in whiplash patients and Dave talked about knee OA, and it's not just in these isolated cases. I think it's even been demonstrated in lateral epicondylalgia by Leanne Bisset and Brooke Coombes. So the member who asked the question, Jason, wanted to look up some names. Simon mentioned Trudy Rebbeck and Michelle Sterling, Brooke Coombes, and Leanne Bisset for the elbow. I don't know if Dave has some ideas for knee OA, but a couple of the articles that Simon has flicked through to us recently: Zhu and colleagues in 2019 and Beales and colleagues in 2020, both talk about clinical sensory tests and how they might correlate with those more quantitative sensory tests that are typically reserved for our research papers. So, if Jason if you want to look those up, he could definitely go and find them.

Simon Olivotto: And we have to add: Nick Kendrick's presentation, that's coming up in the pain module is going to go into that. So that's going to be really awesome to look at, too. The one thing I just wanted to quickly mention is something that took myself a little while to get my head around, was just because they had cold hyperalgesia locally, didn't mean that that was indicative of central sensitisation. It could be, it could still be, but usually, it's if it's that widespread.
So, like I said, if they've got a problem in their neck, it's whiplash, if they're experiencing it in the foot as well, then that's when it's possibly central sensitisation. That's my understanding. Unless you think any different, Dave?

David Toomey: No, I think that's spot on. It's a sign, potentially of an altered endogenous modulatory system, but not necessarily purely central sensitisation. There can be a couple of players in the game, there for sure.

David Pope: Right. Our third question was from Jan, she's asking about calf and Achilles strength work. So, the question is, "When's the best to do calf raises and not drop the heel lower than the forefoot? Is it only for insertional Achilles issues?" So, why don't we go to you, Paula? Let's get your input on this one.

Paula Peralta: So, that's a good question. And, I guess, the context of the patient and the goal of the patient, is probably important to understand. How we do strength work for a calf problem as a calf muscle injury might be different, or will be quite different, to how we do it for an Achilles.

So, firstly, you're absolutely correct. We don't want to work and insertional Achilles tendinopathy into that end-range dorsiflexion, particularly if it's reactive. And, hopefully, we've got our impression of where it sits on the tendon continuum from our subjective. So, we've identified the abusive load or the changing training or changing load that has occurred for the patient that's seen us. Whether it's a changing shoes, whether it's increased running, whether it's a lot more uphill work, for example, because they're going to be not more end-range dorsiflexion. So, hopefully we've identified if it's a tendon problem, what that abusive load is. And that's something that we were obviously addressing that early phase with that reactive tendon.

It is important though, I guess, as we would for any other muscle group, we would work some inner-range strength potentially before we'd work outer range. So, I tend to do a lot of my calf work initially from the floor. For a lot of the athletes that we see, if they do high cutting or running agility sport, they do get into those end-range, dorsiflexion positions in that change of direction in that competitive environment. So it is something that we do need to move to and work towards. If it's Achilles tendon, what we'd be looking at if we're progressing along a program, so we'd have a strength component. I like Cook and Purdam’s isometrics when relevant. Slow concentric, eccentric. I know some of the literature talks about heavy, slow resistance, and then the energy storage and release.

And every time that we're, even just throughout tendon rehab, what we'd normally do is look at a tendon monitoring test. So, for Achilles, we'd look at either calf raise or hop depending on how irritable patient is. And that's gonna give us some indication about how the patient is coping or how the tendon is tolerating the current load. So, if they're tolerating it really quite well, then that's where we're going to progress along in our program. So that may be addition of energy storage and release, so jumping or skipping-type activities. So, if we think about double leg skipping as in jump rope, there's really not much eccentric load in that.

But if we actually then progressed to skipping those slow, and so we actually land and coming to dorsiflexion, there's a lot more energy storage and release. It's actually a harder activity. So, thinking about how we progress along there with our program, with our tendon monitoring tests to determine is the patient coping the current load? Now, depending on what the needs are for that particular patient is when we're going to start to work into dorsiflexion, so we need to make sure: One, the tendon is coping with the currently doing. And two is, is it relevant with these patients who are working to end-range dorsiflexion, as I mentioned for most athletes, yes.

If they're somebody who does lots of walking and they live in the Blue Mountains or somewhere really hilly, then absolutely. They do need to work into end-range dorsiflexion. Little things like, are they, if they're telling you they're more comfortable walking shoes rather than barefoot? That's going to give you an indication that they're not quite comfortable in that end-range dorsiflexion position. So, that's going to give you some indication there, and there's still plenty of ways to put load on a calf that's not in end-of-range dorsiflexion. So, you can manipulate, obviously, calf raise with more weight. Time under tension, so you can get them to do it slower. And then, as I said, you can manipulate the energy storage and release component as well.

So, I think, hopefully, that ends or answers the tendon component. And then the only other thing that I'd add on calf is that Craig Purdam talks a lot about for calf rehab, doing a lot more between calf raise and return to run. And he talks about that we don't do enough in this preparation to run phase. So, he'll talk about doing some of that fast skipping we talked about, and then skipping with slow lands. But also doing things like stairs. So, walking upstairs where it's a bit more, you have to generate a bit more force, and then actually doing that a little bit faster. He talks about the difference in rapid loading in terms of the calf, and how different it is for slow controlled exercise, like calf raise and running. And so, you're actually really coming up with a number of exercises in between that, that really prepare you and sets the patient up to have a lot more success when they return to run.

And the only other thing I would add on that if we jump back to tendon, is that when rehabbing a tendon, just remember that we need to consider offline, or curved running. So, a lot of the time that everything we do is straight line and we're probably conscious around hills and flat ground for our runners, but we need to really make sure that for our athletes, that play multi-directional sports, that we actually implement some curve running and offline change of direction throughout their rehab, so that we're loading the Achilles under some rotational force.

David Pope: Really nice, comprehensive answer, and giving them lots of good ideas. Is there any other pathologies, particularly when you round that area that you might be cautious with dorsiflexion as well?

Paula Peralta: If someone has anterior impingement of the ankle, you really don't want to load them into end-range dorsiflexion. So, if they've got an osteophytic talar crual joint, you really don't want to wind them up into that end range. Or, for some of those other patients that we see that are really just stiff bilaterally, so they're really just don't have much mobility in their ankle.

Don't be really jamming them up off the end of the step because, if they've always been like that and it's bilateral, you're probably not going to make much of a change and they probably have modified what they do, if they're an athlete anyway, that they just don't get into that same end of range. They just don't have it.

And, I guess the only other thing to say, is if it is a tendon, and there is no identifiable abusive load in terms of what's flared up the tendon, if it's insertional, it's an enthesopathy. Have the back of your mind that could it be a spinal arthropathy if there's no other identifiable cause for their presentation?

David Pope: All right, now. Our fourth question is from Shivani, and asking about the acetabular labrum. They've asked, "From the research, we know that the labrum has free nerve endings, which means that, technically, it can be a biological pain driver. And there's innovation of the human acetabular labrum and hip joint in an anatomical study. So given that there's a large percentage of asymptomatic labral tears in young and older individuals, does it stand to reason for us to consider the labrum as a pain driver for hip and groin pain in our subjective and objective assessment? As the labrum is a deep structure, so on to increase joint congruency and transfer load, should we be, instead, looking at other structures that might be driving pain? So, can you injure a deep structure without concomitant injury of superficial structures?" So, if we sum all that up, are we looking at the labrum or hip joint as drivers of pain or causes of pain? So, Simon, do you want to have a chat about this one? Simon Olivotto: Yeah, sure. So Shivani's, question's a great one, because I guess it's relevant to many different areas of the body where we see changes in pathology and imaging and not always is that symptomatic. I guess the subtlety with this one comes in when we're thinking about, without terminology with, is this a driver of symptoms or is it a source of symptoms?

So, the way I like to think about it, firstly, it's thinking about where the source of symptoms is coming from. One of the papers that we can use that helps with that is the Doha Agreement, 2015. So, particularly, when we're talking about the hip and groin, they’re divided into different types of groin pain. You've got your hip-related growing pain, which, as the acetabular labrum would fall into, you've got your adductor-related groin pain, iliopsoas-related groin pain. Inguinal-related, groin pain, and pubic-related growing pain, so there can be many different structures that can be affected. And that's what I would classify what I'm thinking about, sources of symptoms.

Nick's talked about this before with me. And we've talked about, even though that a structure's really deep, doesn't mean that it can't be the source of symptoms or injured on its own without other sources of symptoms are more superficial. So, it is possible, when we think about the loads and the things that are driving the symptoms. Thinking about impairments, and whether there's lack of range of movement or changes in load, which means you're getting more forces on that acetabular labrum, which.... You've got the sources of symptom being the labrum, and you've got some of the drivers of the symptoms being some of the impairments. So, I think that's the subtle difference and where we might be treating would be looking more at the impairments and addressing those things to see if we can make a change to the symptoms, overall. David Pope: Excellent. Nick, you got anything you want to add to that?

Nick Kendrick: Not particularly, just that distinction between what could be driving the problem versus the source of the symptoms, I think is a good distinction to make. The labrum could well be painful, but it's unlikely that it became painful of its own volition. As Simon said, there could be a range of motion problem. There could be a motor control problem. There could just be an abusive load problem. So, someone started a kicking sport and did too much too soon, too fast, and that labrum didn't get a chance to adapt, and so it becomes unhappy. We're going to look at modifying the load there, or helping change the motor control, or helping with range of motion, looking at the rest of kinetic chain. So, I think that's a really important point that Simon made to distinguish between what might be leading to the labrum becoming the unhappy source of the symptom.

So, absolutely you want to consider it in your subjective and objective, but you don't want to stop with identifying the painful bit, because most people come in and can pretty well point to where their pain is coming from. You want to then figure out why it became unhappy, and help them along that journey of making it happy again, basically.

David Pope: Our last question's from Tina and she said, she's a physio in private practice in a country town, and she's looking for some help with a screening tool. She's got a 17-year-old motor cross rider. It's a pretty intense sport, motor cross. There's a lot that goes into it, a lot of high-speed stuff. But anyway, they've approached her for an initial assessment, an off-the-bike program, and they are really interested in having something measurable that he can apply after doing this program. Once enough, it's been effective when he's doing the program before and after measures.

So, "Are there any programs or NSWIS screening tools you know about?" And she said, when she's thinking about it, she's aware they require ankle strength, adductor and quad strength, hip mobility, core stability, shoulder, neck, and wrist strength, pretty much whole body. She's hit the nail on the head there, so it seems. I don't have any method of measuring shoulder or neck strength, and was hoping you might have some idea. So I think this might play to your strengths, Paula, can we get your input to help Tina out?

Paula Peralta: Thanks, Tina, for the question, I love this question because you're already thinking about how can you assess, do an intervention such as a program and then re-assess for change. So, I love your line of thinking there. There's multiple aspects to this question. So, I guess let's start with screening. Traditionally, there's always been a lot of screening in a late sport. And in more recent years, there's been some literature to suggest that we're wasting a lot of time on the screening. And then we had a couple of papers on don't throw the baby out with the bath water type thing. So, I think from a perspective of screening, a lot of elite sport now is moving towards what they call a periodic health evaluation. So, rather than a screening, that's generic for the whole sport or all the athletes in that sport, it's a bit more targeted. What I mean by that is we'd identify these particular athletes' previous injury history, and target our screening a little bit around that, and also the demands of the sport.

So as you mentioned in the question like motor cross, and to be honest, I don't know a lot about it, but it obviously is a highly demanding sport on multiple different areas of the body. So, I think ideally we'd want to pick a few key elements, because there's so many different components of it. We could be testing all day. So, firstly, I'd get the athletes input as well. What does he want to work on specifically? Because if he turns around and goes, "I don't really feel strong in my hips or I feel like when I land from this, my left ankle feels a bit weak because I rolled it two years ago." Or whatever, something like that.

Then you really want to be picking that as one of your key target measures. In terms of some ideas around measuring strength, and I think it's important that we consider strength and strength endurance because they're obviously two different things. And, depending on what you have access to in your clinic, there's multiple ways that we can measure this.

For strength, if you've got a handheld dynamometer, I think that's a really nice way to measure, particularly around hip joint. In terms of quad strength, for me personally, when I see really elite athletes, I can't always match them on a handheld dynos. So I'd prefer a six or an eight RM for knee extension. And I'd be really making sure that I'm hitting their max. I find that that's obviously a three range measure, and we can manipulate it a little bit better so that it's actually a max test.

You mentioned wrist strength, and I think grip strength for this athlete would be great. So if you've got a Jamar dynamometer, then I think a couple of... three repeated measures, or five, whatever you think is relevant for this athlete. I don't know how long motor cross goes for, in terms of how long the event is, et cetera. But, if it's something that goes for five or so minutes, then, like multiple grip strength measures would actually be relevant, so that you see if there is an effect of fatigue.

If you don't have access to say leg extension machine, or a handheld dynamometer, then I think you can still get some really good measures from a strength endurance perspective. For example, repetitions to fatigue. So whether that's body weight, so single leg bridge to fatigue, for example, we can also of course add a weight to that. Or, say for example, their endurance in that is quite good, so say they can do 30 single leg bridges, for example. You may actually ask for RPA, so standardised at 30 and do the left and the right do 30 reps, but ask them for their rate of perceived exertion on each side. So on that zero to 10 scale.

So that's a nice way to pick up a difference in effort and that's still a difference and it's still measurable and repeatable. So that's another option that you have in that regard. In terms of another option for reps to fatigue would be, I think you mentioned wrists. You could look at wrist extensor endurance, for example. So a standardised starting position, a standardised weight, and how many reps can you use a metronome to ensure repeatability in terms of timing? And you can do repetitions to fatigue. So I think there's quite a number of ways with lots of different accessibility to equipment that you can test and then be confident in your retest ability.

Other things to consider for this particular athlete, is that you could do handheld dyno for the shoulder, if you have access to it. Internal, external rotation.

But perhaps something functional, like a high plank to fatigue would work for this particular athlete as well. If that's quite easy for them with body weight, you could add a five or 10 kilo plate to their back and see time to fatigue, essentially, with that exercise. And I think the beauty about an exercise such as that, is that gives you some information around neck endurance as well. Looking at their net position, are they able to maintain that neck position? Do they drop into flexion as they get fatigued? It also gives you some information around scapular endurance. Do they wing, is there an element of fatigue there as well as their trunk position? So you can get lots of really great information. And if you did do that as a test, I'd be really strict on what you consider a failure. So if they’re head drops, you know, give them a warning, if they can't correct it, they're done and I'd record the time. And also where they're failed for want of a better expression.

For neck endurance, once again, you could go low plank, high plank, and look at fatigue or time to fatigue. I've added a bike helmet before for some athletes and some patients in private practice. You can train it with TheraBand, but, obviously that's harder to repeat, so I'd usually try and standardise bike helmet, cuff weight, improvise, something like that in terms of neck endurance in that particular position. And I think, for a motor cross athlete, taking, obviously, some weight through their upper body is completely relevant and looking at their neck position, so I think that's relatively functional for this particular athlete.

And then, I guess from a motor cross perspective, there's a strong element of balance and perturbation on landing from jumps, et cetera. So, a dynamic balance measure, such as star excursion, may be relevant, or maybe I look at some hop tests. I'm not sure that they're so relevant for this particular athlete, but a star excursion, or some measure of dynamic balance, I think, is really important for this particular athlete.

I guess, in terms of your intervention, I reckon it's such an awesome opportunity to write a really cool program and you can be as creative as you like. I think, even with the landing perturbation type aspect of it, using power bands with spores, kneeling on a Swiss ball, getting to upright, standing up, you see a lot of that in higher end elite athletes. I am aware that these athlete’s 17, and I don't know whether they've had previous exposure to this sort of programming before, but I think it's such a nice opportunity for you to identify a few key things that are relevant for this particular athlete, and put in place an intervention and remeasure it. And if you don't exactly make changing in a number of factors, that's okay, because, I think, it's a starting point and you know, you're trying to address a number of different factors potentially. But definitely get the patient's input or the athlete's input into what they think they need as well.

David Pope: I think that's given a lot to great stuff that she can work with, lots of tests, retests, things that she can use, and ideas for what to incorporate. Fantastic. That was great. I think she'll be stoked to get all that information and great that we can give her that support, being out in the sticks, out in the country, and not having people that she can work with to run stuff past and to be able to give her that support is fantastic.

And, the same with all these questions. It's been really great to get you guys all on, be able to share your expertise with all our members, and find out what challenges they're having in their clinic at the moment, and be able to get your input on all of that. So, thanks to all of you for coming on and sharing that and giving our members that support that they need. So, really appreciate it. It's been awesome.

Paula Peralta: Thanks, Dave.

Nick Kendrick: You're welcome.

David Pope: Fantastic. We've got some awesome stuff coming up in the pain module. That's coming up, Making Sense of Pain and, oh, there's tons of great stuff. Maybe you can share one thing from one of your upcoming presentations in the pain module that you're looking forward to presenting. I think Simon, you're kicking off the module. Do you want to tell us a little bit about, an interesting little tidbit that you are going to be covering?

Simon Olivotto: I'm going to be going through some of the sometimes complex pain science concepts that we might cover, but trying to make them really relevant and interesting. And so, how we can pick them up in clinical practice. So, understanding pain science in an easier way, just making sense of some of those pain features that we might see. David Pope: Beautiful. Yeah. Dave, tell us about something you're looking forward to talking about.

David Toomey: Well, as a little bit of a lead on from Simon, once you've ingested and digested that information... and I've got a lovely presentation, that's gonna help you relay this information with your patients, not just to your patients, but making sense of pain with them, and embarking on that journey together, as a team. So, really excited about that. David Pope: Great. And then, Paula, tell us a little bit about what you're going to be chatting about.

Paula Peralta: My presentation's around how we talk to our patients and how we question our patients and what sort of strategies we can employ with the way we ask our questions. So, particularly around patient fears or beliefs or their understandings, and how we can ask questions effectively that can help the patient take a different perspective, or see things from a different angle, if you like. Some great practical examples in there. And I think it's something that we probably don't always concentrate a lot on how we're sort of asking our questions and trying to educate our patient. Trying to get the patient to come to that realisation themselves around potentially adjusting their belief system.

David Pope: Awesome. And Nick, tell us a little bit about something you're talking about.

Nick Kendrick: My first presentation's basically looking at sources of pain, and then maybe applying those different sources to the different types of pain that someone might experience.

So whether that's nociceptive or neuropathic or, or nociplastic, and then looking at some of the masqueraders of musculoskeletal pain that might present to us, and then finishing off with how we might tailor our treatments, depending on that pain type that a patient presents with. Your modality might cut across each one of those different pain types, but you want to apply it slightly differently. Like Dave mentioned earlier, with the cold hyperalgesia patient question. I'm also really looking forward to Simon Olivotto's quackery and other bullshit topic.

Simon Olivotto: Diving into some of the mechanisms of how some of the treatments we do work. And, even the most evidence based stuff that we do, sometimes we stack it up and compare it to some of the bullshit that's out there, and sometimes that stuff works too! We'll talk about some of the reasons of why that works. So, really interesting to understand those mechanisms, because I think we can get some better outcomes with our interventions when we can understand why they work.

David Pope: Perfect. Coming away from the module, what are you hoping that people are going to be, you know, getting out of it when it comes to understand your explaining pain? What's your goal with your presentations, do you feel like? So, maybe Simon, do want to tell us what do you want people to get out of it?

Simon Olivotto: I think just being able to understand pain a little bit better and put it into that clinical context that helps us make sense of (A), where the pain's coming from, understanding what our clinical tests mean when we apply them. And, like I said, with the mechanisms of how we manage and treat things, we can just get that as better outcomes when we understand what we're actually addressing with the targeted interventions that we apply, so, I think Making Sense of Pain's a great name for the module, because it's not all about just pain science, it's putting it into that clinical practice and there'll be heaps of clinical tips and strategies, which we can apply, and you don't always get them on pain courses. I think this is unique in that way and that will be really relevant to that clinical practice and that everyday clinical practice that we need.

David Pope: Yeah. Dave, what are you hoping that people get out of the module?

David Toomey: I think that, unfortunately a lot of clinicians in their undergrad don't get any exposure really to much pain than particularly the modern concepts of pain. So, it's a really tantalising opportunity for us as presenters, but also our members and the audience to upscale, and level up in that field. And there are some complex topics, but we've found a really nice way of sifting through that and having us present it in a way that's really easy to digest for members so that they've got skills that they can use on Monday with their patients.

David Pope: Definitely. Excellent. And Paula, tell us about your goals, what you'd like people to get out of the module or your presentations.

Paula Peralta: The key thing I think people will get out of this module from the whole team is that I think, our clinicians and our listeners are going to be a lot more confident in what they're doing with their patient, and I think that's from a better understanding of pain science.

It's from a better understanding of how to talk and approach, and what to do when it does work and what to do when it doesn't work, because we do go through all of that in this particular module. I just think, for me as we put this together, I just think the big thing for our listeners will be that they're going to be more confident in the approach. And lots of clinical examples, lots of clinical tips. And I think that they'll be listening to it going, "Oh, I can do that with Mary on Monday!" type things. For me, I think the big thing everyone's going to gain is confidence and know how to put things into practice straight away and improve their clinical skills in this space immediately.

David Pope: Awesome. And then Nick, tell us about some of the things that you're aiming to get people confident with your presos or with the module.

Nick Kendrick: I reckon Paula hit the nail on the head there with the confidence thing. And just thinking back to what Dave was saying there, about what people get in their undergraduate education around patients who present with pain. And how I was like in my first couple of years out, and you'd see the consent form and someone's written neck, shoulder, back, arm, leg ankle. And I just used to dread it, and think, "How quickly can I get this person off my list onto one of the senior clinicians' lists?" And I think people who are looking at this Master Clinician series are really keen and motivated to start tackling those complex patients, and I think what this module is going to bring to those people, there's a lot of confidence. That when they see that person come up on their list, that they're prepared to start helping them and helping them along their journey to recovery and getting back to all those things that they want to do in their lives, so it's a confidence piece. I reckon people are going to come out of this going, "I want that person on my list." They're not looking to handball them off.

David Pope: It's really great to be able to get you guys presenting within that module, sharing it and really making it the sort of thing that we would have loved to have throughout our careers and be able to get each of your unique inputs into it is awesome. Really looking forward to all those presentations and being able to share that with our members, so thanks, guys. Thanks for coming on, answering all those questions, providing your input, and for all the hard work you've put into the clinical reasoning module, and then the upcoming in Making Sense of Pain module. We've spent a lot of time planning it and figuring out how we can make it practical, how we can give everyone that's watching that confidence that you guys have talked about, and really, to make sense of pain. So, that's going to be fantastic. Thanks everyone. And we'll look forward to having you back on, and look forward your presentations.

Simon Olivotto: Thanks, Dave.

Paula Peralta: Cheers.

David Toomey: Cheers, Dave. Thanks a lot.

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