Clinical Edge - 121. Neck pain assessment, clinical reasoning & rehab. Physio Edge podcast with Prof Gwendolen Jull Clinical Edge - 121. Neck pain assessment, clinical reasoning & rehab. Physio Edge podcast with Prof Gwendolen Jull

121. Neck pain assessment, clinical reasoning & rehab. Physio Edge podcast with Prof Gwendolen Jull

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David: Hi Gwen, how are you?

Gwen: Good, David. Nice to meet you.

David: Nice to meet you too. Thanks for coming on the podcast.

Gwen: My pleasure.

David: Really Looking forward to talking to you all that neck pain today. It's a massive topic but so much that we can explore. We'll look at the same, how much we can dive in and share with people today.

Gwen: Good. Good.

David: Excellent. Tell us a little bit about you. Currently you're based up in Queensland and tell us about yourself.

Gwen: Yes. Well, I'm currently an Emeritus Professor of Physiotherapy at the University of Queensland. So in normal words, that means that I've now retired, but I still have an honorary position at the university. So, I still involve myself in some research with a PhD students. I've also got some international research going. As I've mentioned, one of the good things is that I now have the pleasure of being able to choose what I do, what I don't do in this time of retirement which I'm enjoying.

David: So, you got tons of experience. Obviously at the last 20, 30, 40 years, things have changed a lot in the physio profession. So, what are some of the things that you've noticed. How has your understanding, or assessment, or treatment of neck pain changed over that period?

Gwen: I mean, it really. That's one of the advantages of actually aging away because I've seen an awful lot of history. When I start to think of basically how I used to treat neck pains or would have been taught to treat neck pain when I graduated and what's happening now, I mean there is just a massive difference. Really, it is good to reflect on history because it's only been really since say the late '80s, early '90s that our concepts of the biopsychosocial model had been around.

There are concepts of neural tissue have been around. It's only in the 2000s plus that really we've developed our knowledge in neuromuscular function and sensory motor function. We're really so equipped now compared to 20, 30 years ago. It's quite fantastic.

David: Yes. So specifically, what have you seen changed and when you look at that you go, "We're definitely using more of the biopsychosocial model now"? Talk to us a little bit, say for instance when you started in your career. What would be common way that you might treat neck pain at that point?

Gwen: Well, I can tell you exactly. My first unit, and I was at the days when we were still only allowed to treat on referral. So, that the treatment of neck pain was shortwave diathermy and exercises three times a week for three weeks, or if you had some variation, it was heat and traction three times a week for three weeks.

I mean, the change has just been dramatic. It is one of the most important things that when we changed from being a first contact practitioner, we rescinded the ethic about only treating up by referral and that was in the mid-'70s. It is really from then that the whole physiotherapy profession has exploded because really at that time we had to then take the responsibility of developing our research base in our evidence base because when you were treating under referral, I mean, there was no need to think. There was no need to clinically reason. You had a script in front of you and you fill the script. That change in ethic in the mid-'70s was probably the biggest thing that has happened to the physiotherapy profession since its inception basically, because it has got us to really think, research, and that's what development is all about.

David: What sort of journey did you take after that? I mean, you look back and you go shortwave diathermy and exercises three times a week. When you've got a prescription straight in front of you, it's not an incredibly satisfying way to work or you're probably pretty limited in your results as well. We want to enjoy your work and got a little bit of freedom. Tell us a little bit, that sort of journey and the things you've gone through.

Gwen: Well, personally, you're quite right. It was absolutely non-satisfying work. In the early days of my career, I found musculoskeletal so frustrating. Well so unsatisfying is probably a better word, that I actually got more involved in neurology because it was much more problem-solving and you're having to work out what to do in neurology than there was in musculoskeletal.

It wasn't until I went to Canada, and I actually worked in a private practice in Calgary in Canada that had a very, very progressive, (Australian actually), Australian who had set up his practice and had good relations with the doctors. The doctors even then were allowing the physios to actually develop the treatments. She arranged for us to do course work that got my first flavor of manipulative therapy when I was there, and I could suddenly see the possibilities of what we could do.

So, I did spend about four years, a couple of years in Canada or a couple of years in UK and Europe. Then, I came back and did the courses with Geoff Maitland. So, I did my grad dips and that just changed my world. You could actually see. I mean, it was Geoff Maitland who really, his strengths were in clinical reasoning.

When you're trained on a prescription basis, you not trained to think very critically. To learn about clinical reasoning and learn all that thinking process was quite revolutionary. Also, I had now had tools that I could use to treat patients which was most important.

So, that was the big change. From then on, that was the time that the ethic changed. So, I then started working at UQ in the late '70s, and I was given the responsibility of developing curriculum, or further developing curriculum that would cope with or training physios in clinical reasoning diagnostics, so that they could act as first contact practitioners.

So, it was a pretty exciting evolutionary time through the '70s and '80s to equip the new clinicians with their ability so that they could act as first contact practitioners. Then, that's when also the research started to develop and that is probably the most satisfying thing is when you could have research informed treatments. You know what you're doing and you know why you're doing it rather than doing a recipe.

David: Definitely. Which like you're talking before is a much more satisfying way of work when you can…

Gwen: Oh, absolutely. Absolutely, yeah.

David: So right now, when you look at the physio profession and if you look at neck pain in particular, where do you think we're at and where do you think our strengths, and weaknesses, and areas that we can improve on that thing right now?

Gwen: I think the strength that we mustn't forget that we have is that we're rehabilitation specialists with the biopsychosocial model that's expanded our horizons for sure. We've also had an emphasis on pain and pain management. I think what we're losing if we don't think about it is rehabilitation. So for example, using neck pain is the example, but there is no big challenge in getting an episode of neck pain better.

At the moment, the medical model is that you treat that acute thing and once they're better, they're discharged and that's it. If you look at the broader picture, the broader picture is that neck pain is a recurrent disorder. I mean, 70 to 80% of people once they have their first episode of neck pain are going to get it again, and again, and again.

It's often over a lifetime. So, if we look at the real burden and cost of neck pain, they're not in the one episode. They are in the recurrence.

So again, I think sometimes we lose our perspective that one of the biggest things that we can offer a patient with neck pain is rehabilitation, not only to just decrease their current pain but to also prevent recurrent episodes of back pain. So in other words, we should be rehabilitating their movement, their sensory motor systems, their neuromuscular systems with that aim in mind.

David: When you're working through your treatment of that current episode, do you look at it as you're giving them the skills or the capacity to continue on and to decrease that recurrence or prevent that recurrence in the future or are you looking at it more like you're treating it in a two-stage process type of thing?

Gwen: I think you treat it all as one. You've got to be able to do whatever you choose to do to decrease their pain. Now, I might put in a plug for manual therapy here because it's been depopularised and depopularised unnecessarily. There's a lot of moves to say hands off and that sort of thing. There's no real evidence that, that stance is actually correct. In fact, the evidence for neck pain is that manual therapy is very good at pain relief, very, very good at pain relief.

So, you may be using your manual therapy to help pain relief but you also got to understand that getting rid of pain doesn't rehabilitate the neuromuscular system. It doesn't rehabilitate the sensory motor system, and there are studies showing that despite the relief of pain, the impairments in these systems continue.

And there hasn't been a lot of studies on recurrence rates but you would think logically that if we rehabilitate those systems that, that would be the best thing that we could offer towards decreasing the recurrence rate. So, I think you've got to think about it holistically of the current episode of pain and then the major aim which is to prevent recurrences.

Certainly, you've got to train your patients, and it's the importance of a simple maintenance program because we've also got evidence that you can rehabilitate the impairment. So, you can get them up to the normal level of function for that task. So, the example on the one that we researched was their performance in the craniocervical flexion test.

So, we could show that after rehabilitation, their performance in the craniocervical flexion test improved dramatically. Then when we looked at them six months later, you could still see that they started to regress. So, the importance of that initial rehabilitation and then a maintenance program, it's got to be simple.

I often use the analogy of cleaning your teeth. You can clean them and have them very nice once, but if you don't do it repeatedly, they will decline. It's the same thing I think with some of the impairments in our neuromuscular and central nervous systems.

David: Which makes sense if you do it. If you train yourself to get strong and you're still training yourself whether…

Gwen: Exactly.

David: ... it's weightlifting or whether it's whatever it might be. If you stop, you're not getting, maintain that fitness, or the strength, or whatever, for whatever let's say.

Gwen: I think it's our education of the patients. Our education of the patients is very important that they understand about recurrence. I think most neck pain people do because maybe if it's their first ever episode of neck pain, they're not receptive, but you'll get patients and this is their second, or this is their third, or their neck pain is becoming more continuous with speaking to them, educating to them. I think they're quite receptive as long we keep those maintenance programs relatively simple for them to do.

Also, teach them a relapse prevention program so if they can feel their neck pain coming on, they know precisely which self-mobilising strategies they should recommence.

I think what we've got to do is keep thinking of the bigger picture not just that helping that first acute episode of pain.

David: Great. There's a few things within that I like to explore with you. So the first thing is, when you're looking at say their normal activities, you've rehabilitated and you've improved those impairments that they had, will their normal activities then continue to maintain at that level of whether reduced strength, or control, or any of those factors you've addressed. So their normal activities, do we just maintain that or do we need some sort of specific exercise?

Gwen: I do think you need some specific exercises because in the study that we did, those people did go back to their normal activities, et cetera. I suppose I'm a bit of a believer in sub-clinical pathology. I once went to a lecture by an orthopedic surgeon actually in Denmark. He was at sports conference. He got up there and kept showing these horrendous sporting injuries of knees in soccer players, et cetera.

That every time he showed these horrendous videos, he would say, "Osteoarthritis has just begun." Then, he showed the next video and then say, "Osteoarthritis has just begun. So, to emphasise the point that pathology is there and you might not feel pain all the time, but you've got some sub-clinical pathology that is probably going on.

I mean, there have been studies that showed the people even in their periods after a neck pain period, so they're not really complaining of pain, but they're still showing signs of some muscle inhibition, et cetera. So, I think it's like cleaning your teeth. You've just got to keep them pristine and that's what I think with the muscle system.

Once you've done the rehab and particularly in motor control, it doesn't necessarily take that much to just keep them pristine. So, you would hope that you get patients into a habit, and I use the analogy of cleaning your teeth. That is a preventative habit that we've adopted. Now, we've just go to adopt a few simple preventative habits as far as their neck is concerned.

David: Great, and we'll explore some of those with you later too. You mentioned there about recurrence and preventing recurrence. Has there been any evidence that we can decrease the recurrence or prevent it?

Gwen: No, no, no. See, most clinical trials had all focused basically on that acute episode or the one episode. So, a lot they look for long term follow up of pain relief but there haven't been a lot that had been absolutely dedicated to seeing if we can influence recurrences. I think that's one of the most important areas to move into.

It's difficult research by the way because you've got to then do follow ups over five to 10 years to really know if there's been any major impact, and it's difficult research which is probably why people aren't grabbing it. It's certainly the direction we have to go in.

David: From a practical level as well with patients. We know how hard it is often to get them to do exercises when they're coming to see you every week or every month, or whatever it might be for a little while. So they drop off, you'd imagine afterwards could be a bit of a hindrance…

Gwen: Yeah. As I said, I found with treating patients that once it was their second, third, fourth, or fifth episode of neck pain, they were more receptive into learning self-management and maintenance preventative strategies. I think it's in your education of the patients I think is one of the most important things and to make it simple. Don't make it hard.

David: So, what are some tips if people are thinking about incorporating that to get that patient buy-in? How would you describe it so someone?

Gwen: To continue with maintenance program?

David: Yeah.

Gwen: Well, I would talk to them about the recurrence rate. I would tell them about the natural progression of neck pain and that the aim is to limit it. As I said before, I think the most important thing to do is to make sure the maintenance program is very, very simple and doable, and I'm a very strong advocate of research informed exercises. I've got no research evidence.

Often with neck pain, a simple postural correction is a simple basic exercise that they can do repeatedly during the day. We have done research that actually shows that if patients assumed an upright posture and starting at the lumbar pelvic region, and then assume an upright posture and then do the action, they don't think about anything about head position. They just think about lengthening the back of their neck. That actually activate some of your deep stabilising muscles. We've been able to show that just by doing that exercise that people can say improve their performance, and I get fixated on the craniocervical flexion test but it is a measurable outcome which is easy to use in research. They could improve their performance in that test or keep their deep neck flexors going just by doing that exercise.

The exercise also has the advantage of, that you put your joints into a neutral position. So, you're relieving end of range strains on them except to say your changing your position activating your muscle system which is all necessary for a healthy neck in a way. So, that often my maintenance program with patients is that I teach them that postural correction. Well, this study, we asked them ideally to do it three or four times now, to do it every waking hour of their life. In the diaries, what we found was that they got their improvements when they did it twice now for eight hours a day. They're working. They did day and night. They achieved their results. So, then I'll teach that.

I'll also teach what I call an archery exercise. So, it's almost like they… imagine that they've got a target in front of them, and they literally hold a bow and arrow and try to shoot an imaginary target. That gives you a very, very, good rotation mobilisation, really from your mid-thoracic up until your occiput. Rotation is a very good way to ensure some muscle relaxation if we go back to the old neurological philosophies, and it's also as I said, maintains that range of motion very, very effectively.

So, you will and can add other things for individual patients but in my clinical experiences, if patients continue with those two relatively simple things, they can go a long way in self-maintenance, self-management.

David: Posture is obviously a hotly debated topic, and we're going to dive into this later on when we get down to the objectives of evaluation but this might not be a bad time to have to chat about it. Obviously, you're a big fan of clinical reasoning and they're just strong in everything that you do. So, tell us a little bit about posture and about the debate that goes on about whether there is a correct posture or an ideal posture or not? Then, how you incorporate your understanding and assessment of that in your clinical examination?

Gwen: Well, there's a textbook ideal posture, which is to have the spine in a neutral position because then you get adequate load sharing between the elements of the vertebral column. It's that neutral posture that has minimal muscle activities, so there's minimal loading. So from the biomechanical point of view, there is that ideal posture.

If we translate that to the human, I think it's a range. I mean, we don't want people sitting absolutely bolt upright, but there is a range of postures that they can have within that neutral. So, I would advocate that a good position is a neutral posture. I mean, that doesn't say that it has to be strictly upright or that sort of thing.

I think in people with office work, et cetera, the ergonomics is quite important because they can be sitting in a good chair and be supported in a basically neutral upright posture. I mean, how much posture plays in a pain syndrome is probably a different question, and their posture doesn't necessarily play a role in their pain syndrome. If we think about the research, there are many papers showing that a forward-head posture is associated with neck pain as there are papers saying it's not associated with neck pain. So, I think the static measurements aren't necessarily indicative of what's going on.

In the clinical situation, I am very much for that you've got to prove the associations of different factors. So for example, if you've got neck pain and if I can look at your level of pain, look at your movement and a common movement I use is rotation, I'll then experiment of putting you into neutral postures or other postures. The most important thing is to understand whether it does change your pain or change your range of motion.

If you get dramatic relief of pain and dramatic increase as in range of motion by putting them in a neutral posture compared to their normal sitting posture, that would give you some indication that poor posture is one of their drivers to neck pain. But, I mean if you're getting no change, it's a waste of time spending hours getting them to correct postures, et cetera, for the purpose of decreasing their pain.

So it's very, very individual, and I suppose that's the other message that every patient is an individual, that you have really got to assess what they're presenting with, what modifies their pain. That can also help you in what you're going to do treatment-wise and also what you're going to advise them on.

David: So, if you're looking at changing someone's posture, you're looking for that strong support within your objective to say we've got improvements in their pain and their range of movement significant improvements or minimum clinically significant improvements?

Gwen: I would put a lot of emphasis on posture if I was getting dramatic changes in their pain, et cetera. Even in patients who obtain no real relief by correcting their postures, I must say that I would still advise them on working postures, and sitting postures, and to go into an upright position every so often to relieve things as a preventative thing, but it wouldn't be one of my major emphasis of treatment as compared to the patient who gets dramatic relief. Because you know that patient, that if they don't do something about their posture, well, they're just going to get their pain back anyway.

David: So, talk to us a little bit about then, we know patients can occasionally get fearful of moving. For instance if they got low back pain, they can get a bit fearful of bending and that type of thing. If we look at your neck pain and we're looking at postures that we're recommending to people, how do we avoid fear in patients from moving out or staying outside normal correct postures if we put those…?

Gwen: It's in the way you educate them. To get them into this upright neutral posture which I like them to do as a maintenance program, it's for a 10-second period. So, then they can relax into their normal posture. Say for an office worker for example, I would talk to them about having good office set ups, this is where research can backfire a little bit. I think if you look at the systematic reviews on ergonomics, they don't come out with flying colors like most systematic reviews. That is intuitive sense that if you're going to sit completely scrunch up and bent over, it's not a healthy position to be in for your spine or even be on lungs and heart really, but I wouldn't ask the patients to go into their ideal postures for more than 10 seconds every couple of hours. So otherwise, they rest really in a good, supported chair, et cetera.

I mean, you get accused of being hypervigilant and all of that sort of stuff. You certainly don't want that in your patients. But I think it's in the way you teach it to them that if you detect any fearful behaviors or everything, it's your assurance about what's going on and what your expectation is that I think is the most important.

It's communication skills and cannot be overemphasised. We talk a lot about fear of movement, and anxiety, and all that thing, but we've got to make sure that it's not iatrogenic or in other words, it's not clinician-induced fear. I think the way we communicate with patients is just extraordinarily important. Patients want to be believed. They like a bit of empathy, and I think believing them, showing some empathy and understanding goes a long way to start to build up your communication with your patient.

David: Do you have some tips for people that are describing this to their patients that they want to improve? They want to take the patients into postures forward. You mentioned there 2 lots of 10 seconds every hour. So if you're doing that with patients, how do you describe to them to say they don't get vigilant and that don't induce that iatrogenic issues?

Gwen: I do the analogy of cleaning their teeth. They’re cleaning their teeth at least twice a day, that hasn't made them mentally or psychology disturbed. So, doing this twice now shouldn't either. Cleaning your teeth is a very, very good analogy because it's something that has not harmed them over their life. It's harmful if they don't do it.

People aren't suddenly hypervigilant about their teeth and getting anxious about their teeth just because they clean them twice a day. I think we've got to talk to the patients about these exercises in that sort of framework. Staying on that track, once they feel the benefit of doing it, the compliance is no issue. It doesn't become a big issue.

I use analogies such as squatting. I say that a patient's okay if I get you to squat. What's going to happen after I've left you down there for two, or three, or four, or five or half an hour? They can visualise that if they have to squat for half an hour, their knees would be crying. So, I say to them, "What are you going to do?" They'll say to you, "I'll stand up." So, you say, "Well, it’s exactly the same with your neck. Rather than leave your joints and ligaments on that stretch the whole time, just relieve them."

So, just downplay. Make the explanation simple and use as many analogies as you can I think is the best way.

David: I think that gives lots of easy understandable of ways that patients can associate with relieving pain, and with normal day-to-day activities, and how that works and fits in with them. So, I want to take a few steps back to how to think about neck pain and how we might go back classifying neck pain. There's lots of different ways we can think about it on patho-anatomical lines, time, making this in one sit. That type of thing with neck pain, how do you tend to think about it or categorise neck pain?

Gwen: When you have so many different ways of categorising neck pain, you understand that well, we don't know how to categorise it really well. Once you know something is fact, there is one way sort of thing. I still categorise neck pain as idiopathic or mechanical neck pain, as trauma-induced neck pain such as whiplash, then getting into our cervical radiculopathies, et cetera.

We have got clear evidence of differences between whiplash associated neck disorders and idiopathic neck pain. So, I think those three broad classifications are still very, very appropriate. After that, your sub-categories of neck pain are often treatment-based. So for example, the McKenzie Method is treatment-based. If you look at the American classification that John Childs did, it's very much treatment-based on totally different criteria than McKenzie one. So a lot of them become treatment-based, and I think some of those classifications probably are helpful on a second tier really of directing treatment.

I must admit I'm not a huge one on classification systems. I'd rather approach the patient as an individual, do a thorough assessment and let the assessment guide how I'm going to manage them. So intuitively, I'll have those classifications or all those treatment-directed classifications in the back of my head, but I won't use them directly. I'd rather just look at the individual patient and examine each system and see where we're going with them.

David: So, you're using all the aspects you gather in the subjective and objective to help you guide you about what's needed for that individual in front of you?

Gwen: Yup.

David: So, let's talk a little bit about that then. So, when we're looking at the subjective, we're looking to develop some hypothesis and to gather all relevant information. What do you think is some of the key questions that are going to help us in the subjective history. I mean, there's so much that we can dive into here, but some of the key aspects there, when someone would say ongoing neck pain?

Gwen: I think it's best to keep the questions as open as possible. I think one of the best things is that a clinician is relaxed enough about what they need to get out of the history taking to just listen to the patient's story. Patients on the whole are relatively good historians. So, I think this aspect of listening and actually hearing what they say is one of the most important things.

So ideally, I would try to ask as minimal questions as possible in a subjective but certainly what you have got to understand is the origin of their neck pain. I think asking them about their history and length of history first sets the scene quite well. I know historically we were often taught to ask their area of pain and all of that thing.

Really, I do think that it's better to get the historical perspective of their neck pain. Is this their first episode or is this their 10th episode and have they had it for 10 years? That gets the perspective right. Then, once you've got them into perspective of where they are, to then find out certainly where the neck pain is, et cetera, but also find its association with their activities, and their function, and their work because other things that I'm thinking of preventative strategy, they've got to have good work practices in that because I'm trying to think all the time of not just fixing this particular pain but how am I going to prevent it coming on. What are the strategies the patients have got to learn or adopt, to try to stop it coming back again?

So, understanding their occupations or their physical drivers of their pain is very, very important. So, that's an important thing that I need to elicit from my subjective examination. Then also, I want to be assured that it is a musculoskeletal disorder. So, our normal stuff of looking at whether it is increased with activity and relieved basically by rest is not a bad formula that you want to hear coming through the patient's story that they can tell you that sort of thing. Then understanding their pain, their pain type, their sleep, et cetera, is also important. The other thing, our responsibility as first contact practitioners is to be able to identify any so-called red flags, et cetera. So, I think it's this ability to just listen to them and see if they're describing a straightforward musculoskeletal pattern or are we starting to get some of the things that are just not making sense.

I suppose in thinking about neck pain, one of the catastrophic red flags for neck pain is the arterial dissection. I mean, if a patient comes in and are talking to you about this recent onset headache that is rapidly progressing, et cetera, that is just not the history of a cervicogenic headache. Cervicogenic headaches usually start gradually, and they have a slow onset over weeks, months, years, et cetera. So, the story is just very different. So, it's this thing of not getting fixated that I've got to ask this question and that question. It's listening to them. Listening to their story and see if their story fits a musculoskeletal pattern or if their story doesn't fit a musculoskeletal pattern and then let your questions come out of that to go deeper into why for example it's not a typical musculoskeletal story.

David: When you look at those red flags, are there any other particular things that you look, "Oh, you mention there," whether it's looking like it's mechanical and it's increasing with activities and decreasing with rest? Then, you're looking for any sudden onsets of severe headaches. Any other red flags that people should really be aware of and keeping an eye at for?

Gwen: Intense aching and neck pain are the things that you've got to look out for. It is possible to have tumors and metastasis, et cetera, in the cervical spine, but they're not really common. It is to keep an eye open to that. The way rheumatoid is handled these days is so much better than it used to be but inflammatory arthritis such as rheumatoid, ankylosing spondylitis, they still exist. So, it's looking for that undue inflammatory type story. Disturbed sleep at night have a lot of different causes, but I think understanding their sleep and why it is disturbed is very, very important as well.

David: You mentioned their functional activities in work. So, can you give us an example of how you might ask someone about that to get a relationship with their neck pain and would be a good place to start?

Gwen: I'll probably ask them to demonstrate. Action’s worth a thousand words. So that getting them to actually demonstrate and show you what hurts them and what they can't do, or what positions they're in when they get their pain, et cetera, is probably the most helpful and most direct in a way.

David: Any other key questions that you'd like that people can use within their subjectives to get that key information?

Gwen: I think they've always got to ask what we used to call special questions, inquiring about the patient's general health and past surgeries, medications, X-rays. We had dizziness before has been one of our key questions. I think that's quite acceptable. I think it's quite necessary, although people should realise that if neck pain patients are complaining a bit of lightheadedness or unsteadiness, it's probably more likely to be a sensory motor disturbance than probably vertebral arteries we were taught about before. It can still be vertebral artery, but that's usually their other comorbidities it will be associated with that, the older person, peripheral vascular disease, et cetera.

So, those questions to make sure that we have got a good knowledge of any background medical information is important.

I think before, listening to their story and just asking for clarification of some points all the way through is probably my style rather than having a list of definitive questions. I've certainly used to ask a lot of definitive questions, and I think that's part of an experience process that the more experience you get, the more confident you get. The more knowledge you get about the neck pain, the more relaxed you can be in the history taking and let the patient tell their story because that is the clearest way to get the information.

David: That's really nice, create your subjective rather than having a strict format that you're following that patient's story. You're allowing them to express it while getting the information that you need.

Gwen: When you do that, you can also were aware of also understanding any psychological things, but you can also get an idea then if they are fearful. You get an idea of their self-efficacy. You can get an indication of their low mood, et cetera. Within neck pain patients, I think the most common one is fear of movement. I think what we've all got to understand is that's normal. You are psychologically disturbed if you thoroughly enjoy hurting yourself by doing something to your neck. That's when you got serious psychological problems.

It's pretty normal to be fearful if you know when you turn your head to the left, it's going to give you this sudden jab of pain. So, I think you got to also look at these emotions, and it's the same thing with anxiety. If a person doesn't know what's happening or if they're worried about it being a tumor. Certainly, when you treat pain with headaches, they are always worried that it's going to be a tumor, et cetera. When they have no understanding of what's going on, that increases their anxiety, again which is normal. We can quite easily deal with that with assurance and education, et cetera. I supposed there's been a few papers coming out saying that don't over read some of the psychological things. That they are normal reactions, not necessary psychopathology with the patient. I think we've ought to be careful of that.

David: We want to take that information from your subjective and use it to guide your objective. So, you mentioned there are really nice way when the patient was discussing their function or their activities that were causing pain. And how you like to get them to demonstrate that to you. I think that's a beautiful way. I'll get you to talk a little bit more about that in a second. So, are there any other key aspects you find within the subjective that are gonna help to guide you within that objective examination?

Gwen: Well, I think demonstrating what they do. We can talk about that. An office work is an easy example. If you've understood that they have sat for hours in a computer, let's say not in a particularly good posture, you know that you need to look at their work situation. You probably do know that you're going to look at their posture.

Also in that situation, you want to look at their endurance capacity, their muscles, thinking of the longer term rehabilitation if they are in the static postures for hour on hour. Also, you get directives from their area of pain, et cetera on what levels are likely to be symptomatic.

David: What do you generally consider about your goals with your objective examination? What are you going to achieve with it?

Gwen: My goals are try to understand their origin of pain. Again, neck can be averagely challenging although is not as challenging as I think it's made out to be some time. So, I want to look at their source of pain, and then I do want to look at what are the contributing factors to that pain. So, what are the things that are going to perpetuate it, whether it would be work postures or the way a person does a technique or something like that.

I also am thinking about their recurrence in that I want to do a screen of their articular, neural, muscle, sensory motor systems, so that I can have a comprehensive rehab program. So, I'm having a look at their immediate sources of pain, how pain pathology or whatever has affected all of the other systems so that I know what I need to normalise and rehab. I know we've gone into this era of non-specific everything, non-specific neck pain, non-specific low back pain. I detest the word, “non-specific” because in most patients, you can find a very specific cause of their neck pain. I can't necessarily tell you the exact pathology, but in the neck, I can definitely tell you if it's coming from a zygapophyseal joint or that part of it is coming from some nociception from a zygapophyseal joint or some nociception from C1-2, et cetera.

We've got proven tests that are being tested against anaesthetic blocks that show us that we're quite capable of doing that. So, I might not be able to tell you the exact pathology that is going on C2-3 zygapophyseal joint. At least tell you that that is the source of nociception in this patient. So, pain has profound effects on your muscle sensory motor systems, et cetera, so that we've got to look at what's happening in those systems as a result of that pain that I need to know for rehabilitation.

The spine is often made mysterious, when in fact it's not. If you think of the patient that comes in, and they've had a medial ligament strain of their knee, you're automatically going to look at function. You're going to look at gait. You're going to look at all those things. You will routinely look at their range of movement, stress to see how stable their ligament is. You'll be looking at their muscle system. You'll be looking at their proprioceptive system because that's all in part of your rehab. Really, it's just no different to the spine. I think the spine is just being made, because we don't see it as well as we see an ankle or a knee. It's suddenly become all mysterious. I don't think there's any mystery there at all.

David: Oftentimes, you can identify sources of nociception and then identify some of those impairments that are going on within the neck or around that area that are contributing to it.

Gwen: We've got the tools to do that. There's no debate about that. We have got the tools. You look at the work of Toby Hall, just as a couple of examples of Toby Hall who's validated the flexion rotation test for identifying C1-2 dysfunction. You've got the work of Geoff Schneider from Canada who's validated that if you use the combination of extension-rotation test which is two thirds of a quadrant, plus your manual examination, you are highly sensitive and specific to identify a zygapophyseal joint dysfunction.

So, his was against diagnostic anaesthetic blocks. So, we know that we can do that. Physio should be confident that with decent handling skills that they can do it. It's nonsense to say we can't, because we can. We have got tests that show changes in neuromuscular control and they are quite valid tests. We have got tests that showed that there are problems in sensory motor control, so we can these days with the improvement that there's been in our diagnostics over the last 20 odd years, we can very confidently examine a patient's neck and be able to describe what are the physical manifestations of this patient's presentation, without a doubt. Think of that within the biopsychosocial model as well because you have got the other psychological influences, and you have got social influences works, the easiest social influence to think about. I'm not trying to make out that it's a straight biological problem but in the biopsychosocial model, we went from a strict biological viewpoint, we then flip an absolute 180 to be a totally psychosocial model where suddenly, biology was a dirty word.

Thank goodness, it's now starting to come back. That middle ground which should always be that it is a biopsychosocial model so that understanding their work process is understanding their thoughts and altitudes, and all of that sort of stuff is tremendously important and equally as important is the biological information. That's what we've got to be able to do is just integrate the information in that model and not suddenly go to one side of the other.

That pendulum has a nasty habit of swinging and that's really got to stay in the middle which allows you to look at all aspects of the problem.

David: So you've identified with the patient that they might have, so let's just say C5-C6 zygapophyseal joint that's irritated. We know it's overlying that results for some of the psychosocial factors as well. That's what you're saying there that's impacting their pain experience?

Gwen: Yup, and muscle factors. Anxiety will increase their pain. It's just almost a straightforward as well. That's making it simplistic, but yes, they will amplify pain. That's why the practice within a biopsychosocial framework is good practice. There's no doubt about that, but it's that you can't treat one, two, and ignore the other aspects.

So treating their anxiety will not make it, and it's proved that it will decrease their anxiety but won't decrease their zygapophyseal joint pain. Treating their zygapophyseal joint pain in fact may decrease the anxiety because often a lot of those psychological fear factors for sure, fear factors decrease as the pain decreases. It is treating the whole person I think is very, very important.

David: So, we've got a lot of tests within our objective that we could do. Where do you like to start your objective then?

Gwen: I usually start by getting the patient as I mentioned before to demonstrate their aggravating function or whatever movement function so that I can analyse that. You often get quite a lot of information where you can see them either getting into very loaded positions for their joints or you start to see that they're putting excess strain.

The other important thing to do if you can is to try to modify what they're doing and see if you can change pain because that then gives you big treatment hints, and it also is very powerful for the patient to be able to see that they can change their pain.

That's part of the story about getting compliance if you can keep showing that what you're doing is influencing their pain. It gives them incentive. It's a powerful incentive for them to change either behaviors or to do their simple exercises if they can see a fix immediately. That also shows you that whether or not changing that is likely have a change on pain. So, I think doing that functional assessment first is best and then I'll go into almost routine I suppose. I will look at their posture in a more routine way in standing but with neck pain, I tend to look at it more in sitting and it's a matter of looking at spinal. Then, what is so important for a lot of people is axioscapular postures.

If I'm seeing either an abnormal spinal posture or what I think is an abnormal anterior tilting or downward rotating of the scapula, to make sure that I correct those postures and then see if it does affect their pain or range of movement because that informs me if it makes no difference whatsoever, there is a lot of variation in the so-called normal so that makes no change. There's no use spending hours and hours with your treatment time trying to change it. So, I'll look at that and look at how we can change posture.

Then, I'll look at a movement examination. So, it's looking at both their range and their pain, looking at their control, looking at their velocity because in fact, it’s been shown likely that lack of velocity of movement is probably more a greater functional impairment than lacking a little bit of range. You're looking at the quality of movement as well as just range.

What I'm thinking of, and this is the thing. Your mind's got to think when you're clinically reasoning. You're clinically reasoning on two or three different levels. So one of my clinical reasoning hats is, well, what's happening with this patient? What's the matter with them? So, the diagnostic. Then the other clinical reasoning side of me while I'm going through this test is saying, "Well, this is something that needs to be included in rehabilitation program," so whether it be posture. You can see their reluctance, or their lack of control, or their lack of smoothness of movement, so that you may be starting to think, "Well, I need to get them to improve their movement control, not just their range of motion." So, I'll look at, do my movement analysis. Then as I'm doing the knee, I will do an examination of their articular system. So, the good old PPIVM’s and accessory movements. The accessory movements really are a very good diagnostic tests for pain provocation really.

Then as in the knee, I would like at their muscle system. So, I'd look at their flexors, their extensors, and axioscapular muscles. I look at them from the perspective first of control and then a secondary thing of strength. The strength measurement I may leave to a little bit later because if the patients got a fair bit of pain, the sensory motor test of all low load, so you can do those immediately and start rehabilitating that immediately. If they're in a fair bit of pain, you can get incorrect interpretation to some of your strength measures if there's pain inhibition. So, that just depends on the patients and levels of pain where I bring in those assessments. If the patient is complaining of dizziness and lightheadedness, which commonly happens with the whiplash and probably happens in about 30% of our idiopathic neck pains, well, that would save me. It's probably a good idea to look at their sensory motor control whether it's joint position sense, movement sense, balance. You can do those sorts of tests again to be the foundation for your rehab program.

So, the other system I've left out completely is the nervous system. Again, if patients are complaining of tingling and numbness, I'm going to do a neurological examination. If I've got a patient who comes in with localised neck pain and little else, I'm not going to prioritise a neurological examination. Again, as far as testing for neural tissue dynamics or mechanosensitivity, again you can be directed to that through your subjective examination and your observation. For example, if patients are saying to you that they can feel their neck and arm pain when they're reaching across. They're literally putting their limb in an upper limb tension test position, that makes you think neuro. If in the sitting and observing them, you see the elevated scapular, I don't think of overactive upper trapezius as my first priority. I think of protection for neural tissue mechanosensitivity is my first priority.

So, if I'm getting those indications, I'll do a full screen of the neural system as well. I need that screen to get a baseline, and it's my baseline for rehabilitation. I'm thinking about what's happening to the pain? What's the immediate manifestations of that? What have I got to treat to get rid of that pain, but at the same time thinking about how's this condition affected their movement system sensory motor, neuromuscular system? So, what's the foundation of my rehab program?

David: That's quite comprehensive. You're looking at all the different aspects within that. You mentioned the nervous system, the articular, their movement control, and their velocity and range of movements. There's a lot within that, that you mentioned there. What tests do you use that to identify into those aspects and how do you fit it all into a treatment session?

Gwen: I did clinical practice my whole life, and you can do a very comprehensive examination of the neck in 40, 45 minutes. I genuinely did that with every patient because I don't know where to start treatment unless I have this sort of baseline understanding of the patient. Again, it's familiarity speeds you up. So, when you're very familiar with the tests.

So examining the neck extensors, I can probably do within a minute because I'm very familiar with the signs and away you go. You can get that baseline assessment. So, it is a matter of familiarity I suppose. It's the simplest way to put it. I mean, if you can't manage at all in one assessment, I mean, leave the less important things to the second time you see the patient.

I firmly believe, again, you just put a peripheral joint disorder, put a knee disorder and what you're going to do with that knee disorder into the neck and you should be doing the same sort of examination.

Nobody in the world would have a person who injured their knee come in and look at range of movement, and gait, and all that sort of stuff and do no muscle testing. Physios have a compulsion to want to look at how the quadriceps functions in the knee. They've got to have that same fanaticism for how the muscle system functions in the spine as well. That's what I think we sometimes miss out on, or we go to the other extreme.

The other extreme is you just test strength and endurance without having a really good understanding of what's going on in the articular and movement system. You need to be comprehensive. It's an interrelated musculoskeletal system.

David: Can you talk some of the tests that you use when it comes to identifying their strength and control? You mentioned neck extensors, neck flexors, or shoulder girdle. Can you talk us through some of the tests you will use there?

Gwen: The initial assessment is an out of function testing. So, that we use for the neck flexors, I use the craniocervical flexion test for their actual control. To the neck extensors, we can either do it in prone lying, four-point kneeling, et cetera. Where basically, you look at their ability to be able to move the craniocervical area into an extension and flexion. So in other words, you don't want them moving from C2 down type of thing. You just want them to focus on the head movement, the head movement in rotation. Rotation is very important because remember, your sub-occipital muscles have got massive, massive number of muscle spindles for proprioception. So many of your neck pain patients and the headache patients, they really lose their ability to control those muscles.

So for example, when I'm looking at C1-C2 rotation, and it takes two seconds to do. One of the things that patients can't do is dissociate C1-C2 movement from the rest of the cervical spine, so that you simply just stabilise C2 and ask them to turn their head. You'll often find that they can't do it. Then, if you just give them a little bit of facilitation, suddenly they can do it. So you know that maybe that's not a joint problem, that's more a motor control problem or sensory motor problem.

We haven't got a discrete test for deep versus superficial extensors as we have for the flexors. If you ask the patient to actually extend their neck while keeping their craniocervical area in a neutral position, that will definitely bias your deeper muscles. Then, the easiest way to do that is that I'll have the patient for example in four-point kneeling, or prone on elbows and you tell them to pretend that they've got a book between their wrists. If they keep their eyes on their book as they extend, they're keeping their eyes down, keeps the craniocervical flexion, not retraction, flexion.

David: You can see if you’re doing..

Gwen: Yes. Again, it's a real arching type movement, but that just keep their craniocervical area neutral and through their facilitation with their eyes. So, I'll do those two. With the scapular muscles, I'll literally do a low load holding test. It's almost the equivalent to a grade three traditional muscle test for the lower trap, middle trap, upper trap, et cetera, because when you're looking at motor control, the minute you add load, all different muscles come in to resist the load. So, if you were wanting to look at specific muscles are they acting well like, "Is your lower trapezius working well?" Then, you've got to decrease that load so you can focus it.

The traditional muscles test, there's nothing novel or mystical about them, if you use your traditional muscle tests. Some of the stuff that convinced me so much when we started researching this area or the value of low load test and looking at muscle control was that you could have these quite strong individuals come in.

But when you break it down and you're asking them to actually activate and hold particular muscles, they couldn't do it or they were very, very weak, and there's a huge advantage in looking at those control aspects. That's what I concentrate on first in rehab, is getting their control. Then once I've got control, we then address their strength and endurance issues.

David: There was a lot there within that. So, that was fantastic guidance of people. Coming back to one second there, you mentioned disassociation of C1-C2 rotation as supposed to rotating below. You mentioned there stabilising at the C2 and then ask them to rotate. Then, facilitating them to see if they actually can't do it or the facilitation helps. How do you actually facilitate that movement? What sort of guidance do you give them?

Gwen: I'll do a pincer grip around C2 to hold it. Then, I literally hold the crown of their head or hold their head, and then manually twist their head for them and get them to help. You know if it's a proprioceptive problem if suddenly you start getting with that extra facilitation and guidance, you start getting a whole lot more movement. Then, you know that you've got a bit of proprioceptive problem.

Just to put this in context, this is probably going all over the place. For example, if you've got a patient with C1-2 dysfunction and you treat it with manual therapy alone. On the spot, you'll decrease the pain. If the patient hasn't got a clue how to move their C1-C2 or comes back and gets stiff by next time, this is where I'm a strong advocate of manual therapy for pain relief, but you've also got to understand the limitations of manual therapy.

So, manual therapy alone in that patient won't be the answer. It's the combination of manual therapy and active facilitation. So, then you teach the patient how to actually do C1-C2 rotation, and that can be, it's all depend on how the patient learns but sometimes the patients like to self-stabilise and then do C1-2 rotation.

Sometimes you can do it by having two dots on the wall that's only about 20 degrees toward the side and just with their eyes, they've got to go from side to side. That will get C1-C2 going. So, they'll never get permanent movement back in their C1-C2 until I can actively control it. There's combination of strategies that you need when you treat patients or treat dysfunctions.

David: You mentioned the craniocervical flexion. You're assessing that. Do you normally use a pressure biofeedback unit or is that your normal way of assessing?

Gwen: Yeah. We used to teach that you use the biofeedback in testing and training. We've actually changed over the years and use it mainly just for testing and teaching a person what they've got to do. I don't honestly think you have any idea of what the deep neck flexor performance is like, unless you test it formally. To just look at the person dropping their chin down to their throat, you can't tell. Everybody can do that, so you can't really tell what their activation and endurance capacity is like.

I do use the biofeedback for testing, but again you get very, very fast when you do it every day of your life. You get very fast in administering it. But for training, I'll train the person on the biofeedback in the rooms and let them practice in the rooms. So for example, say I wanted to train endurance capacity at the second level of the test. They will train that in the rooms with the feedback. What they're going to learn is what it feels like to do that with and then without the feedback because what we are finding, sending the pressure biofeedback home, even put your finger on the bag and the pressure goes up, or you can just push your head back in the bag and the pressure goes up.

So, we're finding that people got too fixated on the pressure and not on what they're actually trying to train. So, it's actually better that they can get the feedback on performance in the rooms, but at home they train without it, we found to be better.

David: What sort of cues do you give people as they're doing that exercise?

Gwen: Two main cues, that they feel that the back of their head slide up a bit, because what we don't want them to do is retraction. Retraction as a pain reliever in the McKenzie model is fine, but it's not fine for retraining the deep neck flexors. If you're using retraction as part of your pain management, your treatment of articular dysfunction, and you want to train the deep neck flexors, the patient learns two things and you keep them quite separate the whole time.

So I can do their retraction exercise, but then with the retraining is that they feel the back of their head slide up a bit because that will stop them retracting. They're not pushing into the bed. They're sliding up and that they've got to then have their eyes looking down, and they keep their eyes looking down. So, you've got the eye facilitation. You've got the movement, and then the eye facilitation that really gets that muscle activated.

The activation isn't as effective if they just close their eyes. It's better to facilitate with your eyes as well, and they do those two things. They try to target where they feel they went to in that practice session in the rooms, and then you'll test them the next time they' come in. Patients actually learn surprisingly quickly.

That would be the two most important things is feel the back of head, slide up the bed, and then you look down. You should nudge your chin, and you keep looking down. You keep looking down. You keep looking down for that 10 seconds, then relax. Now, usually get them to train formally at least once, ideally twice a day. They do their 10 by 10 second holds.

Then, the other important, because if you're doing any sort of skill learning, it's got to be repetitions. So, the other times during the day are in that postural correction where they'll activate their deep neck flexors during that postural activation. As I mentioned before, the important instruction in that exercise is to lengthen the back of your neck. So, that's the equivalent of sliding your head up the bed.

It's a much better instruction than say nod your chin, or pull your chin in, or pull your chin down. Just forget about the chin, patient should just focus on lengthening the back of their neck. That automatically bring the chin down anyway, but that's where the concentration should be to get a better contraction.

David: Really nice guides there, and ideas on how people can start to incorporate that. Do you introduce that into other activities or movements like rotation or any of those type of things, or do you keep them separate, or how do you tend to integrate that?

Gwen: You can do anything you like really. Just because I do it that way doesn't mean you have to do it that way. If you want to bring it into rotation and some people do have a bit of an imbalance left or right in their flexors. So, if you find that it's better to start practicing their in slide rotation, et cetera, by all means do it. Make sure it's patient specific.

Just two things. Don't make it too complex because if you make it too complex, patients will give up. The second thing is people can get quite creative and inventive with exercise, which is good. The only thing I'd ask for them is to regularly retest. So, if they've become very creative in a particular exercise, just retest to make sure in fact it is working. That's the main bit of advice is if you must have your test of the impairments in whatever you're doing, make sure that those tests were improving. That's the key message really.

David: Yeah, that makes sense. So, how does that compared to just a cervical flexion exercise?

Gwen: Like a head lift?

David: Yeah.

Gwen: Okay. So, head lift is an advance. So, the first one where you're training craniocervical flexion, we know from research that it becomes a bit of an imbalance between the deep and superficial flexors.

So, the training of motor control is to restore that balance between the deep and superficial flexors and that's low load and neck vein deep neck flexors.

So, once patients can do that and can start to do that, then when you introduce head lifts, et cetera, you're adding load. So now, what you're exercising is both the deep and the superficial muscles. It's a progression up of the exercise. The sternocleidomastoid and some of the other superficial flexors are very powerful, so they're happy to work.

What you've got to make sure is that you don't inhibit the deep neck flexors by having too much load. So, that's where you'll hear with everybody who does a head lift is you must watch the chin position, and the patient must be able to control their chin position. Once you start into head lifts, you are exercising both the deep and superficial muscles and strengthening both the deep and superficial. We do know it's important to do that because we know that people lose flexor and extensive strength with neck pain. So, that's part of the progress of the exercise.

David: So within your assessment there, when you're looking at that craniocervical flexion and you're using your pressure biofeedback to identify if there's any impairments in that. Is that generally how you use it to identify if this is the direction that you want to take their treatment or what sort of clues that they're giving you within the objective that might tell you that it should be a part of your treatment program?

Gwen: No, the test does. When people will vary on their tests, but the way I think of the deep muscles and we're talking a bit about flexors, but I'll also want to say extensors because we don't want to leave them out. They're equally as important. The reason why there's probably been more research done on the flexors is because it's easier to do. You've got two muscle groups that had different actions. So the actions of the deep neck flexors, so they're not your craniocervical region. The action of your flexors is to lift your whole cervical, raise, and lift your head.

The extensors are a bit more complex, so the harder to study. The studies that are being done at the moment are showing this tendency to and imbalance between the deep and superficial, the same as we find in the flexors. In talking a bit about the flexors, let's not think that they're the only muscles, the extensors are equally as important.

Now with the flexors, I will test them routinely like you would text quadriceps routinely in the knee. I'll test the deep neck flexors routinely and the extensors routinely in the knee and there will be variable responses. So, most people do have some impairment, but the impairment can be lesser or greater. So, what we found is that in normals, or people without neck pain, that their performance in the craniocervical flexion test, the lowest is usually around 26 but most of them can do 26, 28, and several of them could do 30.

Whereas we find most neck pain patients can only do the first two levels of the test, 22, 24, but you do get some of them who can do 26. You do get some who may be able to even do 28. It's variable. So, you use that test response to then guide your treatment. So somebody who can do 26, I'll start the muscle and the deep neck flexors, but I know that within days that I'm going to convert the whole program to a strengthening program because I'll guide and facilitate them quite quickly when it's at that level.

Whereas, you've got some people who can't even do the action correctly and are just terrible. They will take longer to do. So again, all gets down to that individual patient assessment. I like to do that whole screening assessment, so that I know where I am with the patient in all the different domains.

David: So, you're using that impairment too for your guidance. That's the way that you believe that?

Gwen: Yes.

David: Okay. Do you often notice as well that after you've performed that exercise that there is a change in their range of movement or pain? Is that something that you reassess or is that you're more looking it, trying to change that over more of along the time period?

Gwen: No. You can get instant changes both in the axioscapular in testing axioscapular muscles and in testing the deep neck flexors. Because for example, if you do a manual examination during your PAs, it's a provocative test but it's usually tissue stiffness related to muscle spasm mainly. Multifidus muscle spasm, it's protecting the small tip of this muscle spasm, protecting that painful joint.

Now, when you do the deep neck flexors, you remember the old principles of reciprocal relaxation. So, I can track the flexors and I'll relax the extensors. The same thing can happen with the axioscapular muscles. So, if I test the scapular depressors, the scapular elevators, so upper trapezius, levator scap, et cetera, will relax. So, I'm taking the loads of those joints.

So one of the things that I'll frequently do with patients because again, this will increase compliance is that I'll do my manual examination, and I'll have this quite painful C3-C4 or whatever it is. Then, do the axioscapular muscle tests or do my deep neck flexor test, and you re-palpate when their muscles spasm has relaxed. Then suddenly, miraculously, their pain is decreased quite significantly.

When that happens, again you immediately come in and talk about the importance of them getting the muscles working correctly because it takes the load off their joints, and they can automatically feel that the pain is going down. So again, it's a good compliance trick really to do with your patients is to deliberately re-palpate after you've done the exercise to show them the immediately benefit of the exercise.

The patient's major thing is that they want their pain to go, so that when you can relate the exercises to the changing pain at their most painful joints, it's very compelling.

David: You mentioned there a little bit about the cervical extension test. Can you just recap how you'll assess the cervical extensors?

Gwen: If you can visualise, as I said you can do this in prone. You can do it prone on elbows, but let's just put the patient in four-point kneeling. I will put a pen or you can even put a book between their wrists on the bed. So as I mentioned before, the first thing that we want to look at is the sub-occipital extensors or the craniocervical extensors and rotators. So, that I would just hold C2 and just ask them to lift their chin up and down.

Again, you don't see too much but we do know from research that you get atrophy of your rectus capitis posterior major, minor, without the cervical joint problems. So, I almost automatically give that as an exercise of the patient because I know research has shown me that those muscles change.

Then, as I said before for the axioscapular rotators I’ll hold C2. See if the patient can voluntarily rotate at C2. If they can't, I'll hold it, and then I'll facilitate it by rotating the head myself so I can work out how much this joint stiffness, or how much is just proprioception, i.e. they just don't know how to do it. It could be a combination by the way of joint stiffness and proprioception, but it tells me what I've got to do in treatment to get it right.

Then for the cervical extensors, this is sort of C2 down. If you ask them to curl their head down, so that they're looking at their knees. So, you're starting flexion. Then, the instruction is that they've got to curl their head back but keep looking at the book. By getting into curl back with their eyes of facilitating the flexion, it keeps them in a craniocervical neutral position. So, what you expect them to be able to do is that they should be able to extend and they have got to keep looking down, and that's the instruction. Keep looking down as you arch your head backwards. They should be able to get to at least 20 degrees extension when you do that, and what you find with the neck pain patients is that often they can't get much past neutral or they'll be able to do it but they'll fatigue very quickly, because most people can do that forever. Your extensors are much stronger than your flexors.

It's not a highlight exercise. So they can't get much past 90, or they fatigued, or what you find is they just cannot for the life of them keep their craniocervical area in the neutral. They just can't control their chin. They're the most obvious signs that you see. The one that they just can't get to neutral is probably past neutral is probably the most common that you'll see. That will indicate that they have got some weakness there. So we then train that until I can get up to 20, then we'll add load to all of their neck extensors as a group, same as we did in the flexors. Make sure the interaction between the layers is right and then load the system.

David: That outlines it really nicely. Now, I know we've kept you in here quite a while because there's so many great areas that I’ve really been enjoying exploring with you. We haven't got into your treatment at all, and there's other aspects within the objective that are really going to explore, but I know now we're up to about an hour and half and you're busy and also we've covered a lot of great information.

So, would you be up to coming back on the podcast, Gwen, and having a chat on another episode about treatment and some of the other aspects within the objective as well that will help to guide your treatment?

Gwen: Yeah, I'd be happy to.

David: That's lovely. Well, really enjoyed it. I think what's really come through strongly is that you're looking for that clinical reasoning as you go through that assessment of your neck pain patient, and your treatment, you're looking to identify and not only any potential, nociceptive areas that are causing or contributing to their pain, but also to look at all the other impairments and looking to address those within your treatment. So, really fantastic to get you and be able to share all of that with our listeners.

Gwen: Okay. No worries.

David: Now, tell people about your textbook that you published. Tell us a little bit about that and where people can get hold of that one?

Gwen: Well, it's published by Elsevier. It's published last year by Elsevier. So, it's the work of our traditional research team. So it's me, it's Deborah Falla, but Deborah Falla is now the Professor of Physiotherapy over at the University of Birmingham in the UK. Julia Treleaven and Shaun O'Leary who we've all been in the cervical spine and whiplash research team here at UQ.

So, it's a book that is written for clinicians. It's very much a background into neck pain, but I mean half the book is the clinical aspect which basically talks about all the different assessment techniques, and then all the different treatment techniques that you can use. It would be available from Elsevier, or Amazon, or with those places I'm quite sure. As I said, it is meant to be a very helpful practical clinical guide. Importantly we put a (and it's in the title), a research-informed approach because it's very, very important that we understand what's happened in research. Research has told us so much about neck pain and how to manage it. So, it's very much a research-based dissertation per se.

David: It is and very easy to read. I purchased mine off the Kindle version on Amazon.

Gwen: Okay.

David: It's excellent. I really enjoyed reading through it, and there's lots of practical insights also. Lots of practical guides on how you can apply with your patients immediately. So definitely, while we're here ongoing, get a copy of that book. It's one of the easiest reading physio textbooks that I've come across. It's excellent. So, everyone go and get a copy of that. Gwen, it's been absolute pleasure to have you on the podcast, really enjoyed it. Really look forward to having you back on and being able to explore some more of those aspects with you.

Gwen: Okay, David. That's fine.

David: Thank you very much.

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