Clinical Edge - 130. Neck pain objective assessment & treatment part 2 with Prof. Gwendolen Jull Clinical Edge - 130. Neck pain objective assessment & treatment part 2 with Prof. Gwendolen Jull

130. Neck pain objective assessment & treatment part 2 with Prof. Gwendolen Jull

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David: Last time, we were having a chat about objective examination. What do you think are some of the most important aspects? We talked last time about identifying red flags and making sure that we identify those in the subjective and doing any sort of red flag testing. What do you think are the most important aspects within the objective examination when you're looking at someone with neck pain?

Gwen: I think, that you've probably got to do a basic examination of all systems particularly posture, your movement system, and the neuromuscular system. And then if indicated from what you've found in the history taking and presentation of the patients. If they're complaining of activities that make you suspect that there is neural tissue involvement, I would then add that. If they are complaining of pain down their arm, I would add a neurological examination. If they're complaining of dizziness, unsteadiness, et cetera, I'd be looking at adding sensory motor testing. So, I suppose, the fundamental parts are your postural and movement analysis, and then testing of neuromuscular function. And, I think, they are fundamental to every neck pain patient. And then the other things come in almost as indicated.

David: We talked a bit last time about posture, and we're going to explore a bit more about finding out how that's relevant. Do you tend to look at that early in the initial phases? Or would you look at your movement analysis first in general? What would you tend to go with first?

Gwen: That's part of the communication with the patient, normally I'd start by asking the patient to show me their provocative activity or posture or whatever it is that is aggravating their neck pain.

And so, then I'll do analysis of that first. It's more of that functional analysis to understand and try to observe why they may be getting pain. Or why that may be aggravating their condition. And then once I have analysed that, I'll also try some corrective maneuvers to see if correcting the way that they are moving, for example. Or the way that they're sitting would in fact, change their neck pain.

So, you can sort of start to get an idea of the direct relationship between their movement, or posture and their neck pain. And also start to get an idea of, well, what have you got to change? And what's the patient got to change to actually stop aggravating their neck pain? And then once I've got that, I then go on to a more formal examination of their posture and their movements. And then their neuromuscular system at the minimum.

David: And when you're looking at that sort of provocative activity, can you give us an example of someone that you might start… What's a provocative activity that you've identified within the history or from what the patient said that you then start with?

Gwen: Well, an easy one could be a painter. And he's complaining that his neck really is hurting when he's trying to paint high areas, whether it's spray painting or doing it by hand. And so, you might observe then that he's got his head in extreme extension. So, he's got a lot of say craniocervical extension. And the reason he's got so much craniocervical extension you may see, is that he is very, very hypermobile in his cervicothoracic or low cervical area. And so, you can get an idea of the provocation is in the end range extension. And then the reason for the provocation could be that he can't extend in other areas of his cervical region well enough. And so, I've got those directives for treatment. Because for example, the functional cervical spine goes from C0-C1 down to about T4, T4-5. So that we're wanting to see that the motion can occur in all those areas.

The other simple one is, if patients are getting it at screen time. And then look at the way they sit and function in front of a screen.

The only thing that's of interest there, there was a lovely study that came out of Hong Kong, where they took a photo of static posture of people with neck pain who are office workers versus people without neck pain who were office workers. And what they actually found was that, at the beginning, both of their postures looked very, very similar.

But what happened over time was that the people who didn't get neck pain maintained that basic upright, neutral posture. Whereas, the people who got neck pain tended to actually drift into that slumped increased thoracic flexion and that forward head posture. So, they had that functional forward head posture, which you could postulate was one of the things aggravating their neck while they worked. So, that was a study by Grace Szeto several years ago, and then we replicated it actually and found similar results.

David: And do you think it's that they're sustaining it? Or do you think with patients, for instance, if they're in office work and they've got that pain that starts to come on after a while. And you've noticed that they start off okay when you look at them, “Show me how you'd sit at your desk,” or whatever. Do you think that then it's a matter of saying, “Well, you need to maintain this”? Or that you need to just take them out of those positions frequently throughout the day? What are we looking to achieve there?

Gwen: The latter. Well, you don't want them to be in a bolt, upright, stiff posture their whole life anyway. And so, what I'd be talking to them about is again, having good office ergonomics because their chair can support them in a reasonably good posture. And then, the important thing is to get themselves out of that posture at regular intervals. And, I think, we might have talked about it last time that we've actually shown that if they reverse their posture… and I use that analogy about squatting, you stay down there too long, it starts to get painful. And you relieve it by standing up. I usually ask patients to say reverse their posture every 15 odd minutes. But we know if they reverse it at least a couple of times in their working hour, that that can actually hit their muscle function. And it also, again, can help relieve their pain.

And patients by the way, and this is totally anecdotal and clinical, but I've had so many patients that if they really get themselves into that routine of reversing their postures. And you explain to them, you only want them to reverse it for that 10 odd seconds. It's not as though they've got to sit bolt upright. But if they do get into that routine regularly and you get them to not only lengthen the back of their neck, like we talked about last time but also activate their axioscapular muscles, and they just hold it for about 10 seconds. But if you can get people into that very, very simple regime that doesn't stop them working, doesn't interrupt their working life. That they actually, that one self-help maneuver can make quite a significant difference to the good old office worker type neck pain.

David: So, you've looked at their posture, you've looked at their functional activity. And then you're trying to identify what you can change within their functional activity. You came up with hypothesis by the sounds of it, as they go through that to identify. Say, they're that painter they're looking up. You've identified, they're getting most of their movement happening at their upper cervical spine. And you're hypothesising that maybe their low cervical spine and upper thoracic spine might be hypermobile or hypomobile, I should say. And so you're then going through your objective to see, is there something that you can change then to change it? And you're looking at symptoms in particular at this point in time while they're performing that functional activity?

Gwen: Yeah. You do relate it to their symptoms all of the time. But you could try to change them and try to encourage the patient to then extend, trying to use their mid-cervical area and see if that in fact changes their pain. That painter, for example, was probably complaining about upper cervical pain and headaches. So, you could see if he could distribute it.

And a lot of them, you will make a change. But then you've got some patients who are so hypermobile that you'll have to then treat that and keep reassessing. If you're treating that hypermobility, is it changing the way that they can move in their cervical spine?

So, you hopefully will get some immediate change in symptoms. But again, if they're too stiff, it may take you a couple of treatments to be able to find that out. But it is important to do that test retest, I think, in those sorts of situations to really guide you in your hypothesis making and also your decision-making.

David: And in that test retest situation, what are your main indicators that you're looking... What tells you that you're on the right track there?

Gwen: Usually a change of pain and a better distribution of movement, for example. David: Okay. What would you consider a change in pain? What's you sort of minimum clinically significant change there?

Gwen: I'll do it with the patient in a patient's language. Has it been slight or moderate amount or helped significantly? I would like at the minimum, a slight to moderate amount. If you're really down at that really, really slight level, half the time patients always like to please and that sort of thing. And so that, I don't regard a really, really slight change in pain as probably being clinically significant. So, anything from a slight to moderate above is what, I think, tells me that I'm on the right track in this sort of analysis that I'm doing and where I'm taking it.

David: When you're looking at their analysis of their functional movements and activities, what are some examples that you might change to try and change their pain?

Gwen: Well, again, it will be multiple. So, I may use both active and passive mobilisation to start addressing their hypermobility. And in tandem with that, try to teach them the sort of movement pattern that I'd like them to have.

For the painter, for example, I'd get them to focus on their mid lower cervical extension as they look upwards. That's what they'd focus on in that whole re-education. Rather than telling them they can't do this. And they can't do that. I think, it's always better to focus on what they should be trying to do.

David: Are you cuing them with like a MWM? Or are you placing your fingers there? Or are you trying to cue them? How are you giving them ideas of how to move at their mid and low cervical spine?

Gwen: Any of those. You can facilitate it with your hand. You might do mobilisation with movement. I probably would most use guided movement. So, I would hold them and take them through the pattern. And then change that from a semi-passive to an assisted active, to an active type movement so that they can understand. A lot of it is proprioceptive deficits. People don't know where they're moving. And so, it's a sort of get them knowledgeable about what parts should be moving and where to feel it, et cetera.

David: And how do you identify if they're doing it from a more protective reason? Like they've had some sort of pain down in their low cervical spine. Or they're doing it for a reason to protect that area rather than that it's a…

Gwen: Habitual thing.

David: Yeah, that's right.

Gwen: Hopefully, I'd pick that up in my examination of the movements. So that if, for example, he wouldn't extend in the lower part of his cervical spine because of pain. Hopefully, when I do my more formal assessment of cervical movement, I would clearly have picked that up. Because if I could see that he couldn't move at that area, I would actually in an assisted active way, try to get him to focus there. And then I'd find out if pain was his major limitation. And in that case, you've got to try to overcome that pain because they won't move there if it is painful.

Again, it could be a mobilisation with movement, a passive, some sort of manual therapy approach.

David: So, you find if they've got like more of a protective thing and you try to encourage them to move their symptoms might be a bit worse if they move that way. Or just it's not really improving their functional ability.

Gwen: Patients don't deliberately want to hurt themselves. So, you've got to help them to start moving there with lesser and lesser pain. Or give them a maneuver that helps them lessen the pain as they try to move there. Well, it's unnatural. You don't normally try to hurt yourself repeatedly unless it's in a very disciplined and the approach has been explained greatly. I, on principle, don't like causing a lot of pain. Because pain will inhibit the musculature if they're in a lot of pain. So, you tend to get into this cycle where you wonder how much good or how effective you're being really.

David: So, you've had a look at their functional activity and identified if there's any potential changes in the way that they're moving, that might be impacting their current pain or causing symptoms. You've then made some changes to see if you can address or change their pain. And then you've had a look at their posture, and we've had a bit of a chat about posture. So tell us a little bit about the next part of your assessment. Where would you go to next, Gwen?

Gwen: Well, if it's in a relatively straightforward patient, the next thing I'd go to would be looking at their spine from a segmental level. So that would be my manual examination so that I can try to confirm what I've actually seen and observed in their different movements. So, say with the painter, for example, I would expect to find symptomatic upper cervical joints. I'd expect to find that their low cervical and their cervicothoracic area were hypermobile.

And one of my favourite expressions really is to make the pattern fit. Because if, for example, I've made all those hypotheses based on my observation of movement.

And then suddenly, when I do the manual examination and find that his upper cervical spine has no pain and he's moving quite well in his mid to low cervical spine, the pattern certainly doesn't fit. And that will send me back to square one to say, “Well, what have I not observed? What's gone wrong here?” So, all the time I'm trying to make the pattern fit.

So, I'll next do my manual examination to see if my findings there fitted the pattern that I had predicted or I had observed, and then predicted from the active movement examination. As I said, pain is a powerful inhibitor and pathology is a powerful inhibitor of the muscle system. And our research or lot of people's research has shown that. So from there, I would go on to testing the muscle system. And again, the extent of that examination is also governed by their current pain. And also what I've maybe observed in the observation of posture say, for their axioscapular region.

David: And so when you're going through your manual palpation, what's your favorite position to assess people in? Do you tend to vary it a bit depending on what's their most comfortable position? How do you decide?

Gwen: I think, everybody starts to do things in the way that they feel most comfortable and competent. So again, there are many ways that you can do a manual examination. For me personally, usually I lie people down and I might have had a look at neural or whatever. So that, I'll do the passive physiological intervertebral movements while I've got the patient supine. And then I will do, I hate the word passive accessory intervertebral movements, because in a way we're not doing passive accessory intervertebral movements. The amplitude is so small and we actually almost do either a slide into extension with a PA or intermittent compression with a PA. So it's much better as a provocative test in the examination sense. And it's also, PAs for example, are also very, very good at modulating input. So that we can modulate input into the central nervous system to decrease their pain as a treatment technique.

But as an examination technique, I like to think of it as a very, very controlled loading or provocation of each segment. And then with that provocation, a symptomatic segment will react. Usually, by some sort of subtle muscle spasm and pain.

So that, I'll get my motion, my ideas of motion from my PPIVM. And my ideas of which is the most symptomatic segment through my posterior-anterior glide or my PA glide examination. And that should extend, by the way. You should do a quick screen from occiput down to the mid-thoracic area, and then focus in on which are the most symptomatic areas.

David: So, you've started off with your PPIVMs in this manual examination to identify any sort of hypomobile areas. And seeing if that fits with that pattern that you picked up, that you were expecting from their movements before in that functional task that was painful. Then you're checking to say, “Does it fit that pattern or doesn't it?” And if it doesn't, then you're re-thinking maybe I missed something in there in my observation?

Gwen: Exactly.

David: How far down are you working with your PPIVMs to identify any hypomobile areas?

Gwen: In supine, I go down to around about C5-C6 or maybe C6-C7 if I'm lucky, I usually examine the cervicothoracic area. So ,from say C7 down to T4 with a technique that it's not a mobilisation with movement, really but I do this in sitting. And if you get the patient to turn their head, and then you put your hand on the side of the spinous process of C7. And then as they turn their head, you can apply a little of a lateral glide. But if you do that, that patient just gently, repeatedly rotates their head and you palpate down C7, T1, T2, T3, T4 is enough. It doesn't go much lower than that with head movement, but you can quite easily feel which segments move and which segments don't move. And it's not a pure PPIVM. It's very much a clinical adaptation of a principle of a PPIVM, but I've turned it into an assisted active movement because it's easier to do, it's easier to feel.

And that's a very important area with so many of our patients that, that whole cervicothoracic area does get quite hypomobile.

David: Okay. In this case, they're sitting and you're checking their movements in sitting?

Gwen: Yeah. So, I would have done that before I lay them down. I do that immediately after the active movement examination actually.

David: Okay. And then you palpating their spinous processes to see the relative movement as they perform say a rotation or an extension or whatever.

Gwen: Yeah. Because remember that the cervicothoracic area rotates for us to get full head turn, we must have about a 10 degree contribution from the cervicothoracic area. So, to get our head all the way around, you've got to have at least 10 degrees rotation provided by those segments. This is skipping all over the place, but you won't get full rotation of the head restored unless they can move at that cervicothoracic area. It's an important area not to forget. Particularly, in our mechanical neck pain, which is often posturally induced et cetera, they do get very, very stiff in those areas.

David: You're palpating there through that low cervical and upper thoracic area on those spinous processes. And then if you find areas where they're particularly not moving, you might provide a bit of a manual assistance to that like a MWM or a snap to those spinous processes to help.

Gwen: Yes, this is popping now to treatment, but you've got to be thinking treatment the whole time you're examining. It's the natural thing to do because your treatment should be directed by what you're finding. If I do find that area, I'll use a mobilisation with movement. Or if people are uncertain about that you can just use a mobilisation, invent your own mobilisation with movement in a way. So that, as the patient actively rotates their head, you can do a transverse glide. So, you are mobilising while the patient's moving. It's just not the strict technique that Mulligan would advocate, but very effective.

And then as, I think, I mentioned last time you won't get maintenance, or I don't believe you get maintenance unless immediately you start getting the patient to actively use that range. Part of it is that, they get an understanding of how to move there if they haven't moved there for ages. So that, I'll immediately get them to do an active movement. And, I think, I mentioned this last time, the exercise I like, is that they simulate archery. And they really focus on getting that stretch across their cervicothoracic area.

And sometimes, and we're getting heavily into treatment here, sometimes when people do it and asked if they'll have most of their rotation literally occurring in their mid-upper cervical area. And then they'll jump down to, say their mid-thoracic area. And you can still see that that area is stiff. So, in those patients to actually teach them the sensation of where you want them to move, it's often good to make them deliberately slump. So, in other words, they put their lumbar spine and mid-low thoracic areas in flexion. So, they won't move there as well. And just, they practice then really focusing on that cervicothoracic, that upper one third of their thoracic area to get the feel of what it's like there. And then once they've got that, they can just be in their normal posture to do the exercise. But it is important that you teach it well.

It's a very stable area of the spine. So, it's a difficult area for them to mobilise. But, clinically I found that that's quite an effective exercise to do. They are doing range of movement, literally from occiput down to T4-T5 type of area.

David: Excellent. And so, that was that archer exercise. And so, just to recap, if people haven't heard that one from the last one. Just walk us through that exercise, Gwen.

Gwen: Well, even though probably 90% of our society have never held a bow and arrow in their life, they actually understand what archery is. And so, you get them to look at a target straight ahead of them. And their eyes should not come off that target. And then they hold the bow in one hand, and they pull back the string with the other hand, which will induce the cervical and thoracic rotation. And then, they keep their head steady. So, they're moving their thoracic spine and their cervical spine on their head. And then they come back and then they swap hands. They hold the bow with the other hand and the string with the other hand, so that they rotate in the opposite direction.

The two main things you've got to watch is, number one, they keep looking at the target. So, that gives them a stable base on which to rotate in a way. And number two, as I just mentioned that the movement is happening in their cervicothoracic area that they're not suddenly doing all the rotation in their mid-lower thoracic area. And if you find that, as I mentioned before, just put them into slump until they get the idea of the movement occurring in the upper third of their thoracic area. So, they may practice in a slump for a day or two, you really get the feeling right. But once they have got the feeling right, then let them just sit in their normal upright posture.

David: And so, just coming back to a couple of those aspects, because there's lots of hot debate about the role of manual therapy and that sort of thing within it. And we'll cover that a little bit, but looking at this exercise in particular, do you think that we can achieve the same results just by using the exercise? Or do we need the manual therapy that goes along with it that leads into the exercise?

Gwen: I don't think you know how to do the exercise unless you've examined them manually. Exercise is critical. I have absolutely no qualms about that, it's utterly critical. With the manual examination, the skills that you must have are your diagnostic skills of being able to actually segmentally examine the spine. So, whether or not you decide that you want to augment your exercise with some manual therapy in the first place, that can be a decision. My decision is, I like to do a multimodal treatment. So, I will augment my active exercise with manual therapy. But if you decide you don't want to, that is fine.

But I don't think you can make very, very good diagnostic or exercise decisions unless you actually know what's happening segmentally.

David: So, you're using your manual palpation to guide what's going on even within your exercise, whether you're actually carrying on your manual therapy or not?

Gwen: Yes. I've got to know whether I want to do mobilisation with movement at C4-C5. I want to know whether I should be doing a segmental exercise wherever. If I want to mobilise the upper cervical spine, how hypomobile is it? Am I just doing it by routine? Or are there specific indications? Furthermore, if you have an idea that you want to use active exercise to say mobilise the cervicothoracic area, you can't assess the effect of your exercise unless you go back and reassess your baseline segmental motion. I'm very strong advocate of your manual examination skills. What you use in treatment can vary and that's fine as long as you've got those basic examination skills. And then, you can constantly assess the effect of your treatment.

Because there's no use doing fantastically tremendous exercises, if they're doing nothing for the patient. And you'll only know if they're doing anything for the patient, if you've got your baseline examination of your articular system, your muscle system, your nervous system, whichever one you're trying to exercise. You've got to have that very, very strong examination skills to evaluate if what you're doing is having any effect. We talked a little bit about recurrences. Remember anything will get rid of pain. So, just because the pain decreases doesn't indicate whether you've really rehabilitated that patient. They can take painkillers and it'll get rid of their pain. But that doesn't mean that they have restored their movement, that they've restored their muscle control, that they've restored their sensory motor control or whatever. So, the examination, our manual skills and whether it is feeling joints move, whether it is facilitating muscles or whatever, are crucial.

David: When you look at your manual palpation and we’re looking at practical tips that people can have when they're going through performing that manual examination. You got any tips that you can share with people with that?

Gwen: I think, the first thing that they've got to do in manual examination is that they've got to get themselves to a level where their actual contact pressure is comfortable for the patient. So, in other words, if you're pushing into a patient, you can hurt yourself by just jamming your thumb anywhere. And so, if you're actual manual handling, your hands and the way you do the technique, it causes pain in itself, you risk an awful lot of false positive results. And your treatment and your examination results becomes very, very inexact.

PPIVMs normally aren't uncomfortable. What can be uncomfortable are your PAs. And, I think, people have got to make sure that the way that you don't hurt is to make sure that the movement is induced not by thumb pressure but is actually induced by elbow movement with your thumbs just being the transmitter of the movement and the force. And the way to do that is, that if you grasp the patient's neck from the side and gently place your thumbs on, and then really make sure that you grip with your whole hand and fingers, you grip the patient's neck, and then you can actually just move your elbows to induce the movement. The minute your thumbs are the producer of the force, they're going to be painful.

So, we've got to make sure that they are the point of contact through which the force is transmitted. And the force comes literally from your elbows in doing a PA. So, what they should keep practicing is to just keep saying to the patient, “Are my thumbs comfortable?” And to reduce those false positive things that the patient's got pain everywhere. And the other thing that, I think helps your palpation is that, you just say to the patient, when they're prone, “I just want to have a feel of your neck first. And then we'll talk about what I'm finding.” And then to just feel, up and down the lamina because so often the painful joint is protected by very, very subtle multifidus muscle spasm.

So, if you just run your fingers gently up and down the lamina, you'll often feel where it's hard. And that hardness is multifidus muscle spasm.

And so, even without doing the PAs you can often identify the level just from feeling at what level the muscle spasm is. So, if we've got the patient prone, go out lateral to the muscle bulk of the extensors, and then come in underneath the extensors. So, you push them medially and come in so that you can rub your thumbs up and down the lamina. And you feel for that hardness, which is the muscle spasm. And often, that will start to tell you where the painful joint is. We have very sensitive hands. A human's ability to feel for differences in tissue compliance is very good. And so, that's all you're feeling for is a difference in tissue compliance when you do that.

And in fact, what you're doing in your manual examination is feeling how that tissue is changing when you induce some movement. What we're feeling for on the whole, is that muscle reaction that makes it feel as though it's hypomobile.

David: So, it sounds like you'll have often a gentle screen first when you're feeling for any multifidus spasm. Is that right?

Gwen: Absolutely. That's got to be totally non-painful. If you start digging in people will react. So, that's where you get your false positives, because they're just reacting to the pain that you're inducing rather than reacting to their own painful joint being provoked.

David: And so then, after you've done that, and you've started to get an idea about if there's any hardness or muscle spasm over any particular levels, then do you go out and then continue to perform your PA assessment through centrally and unilaterally?

Gwen: Yes. I like to do a full screen, literally, two to three, four oscillations on each level. So, I'll go down there centrally, do that unilaterally. That will take a minute and then I'll focus in. That gives me the idea of where I've got to start focusing in with my manual examination.

David: They were really nice tips. You've got any other tips when it comes to that?

Gwen: The other area, and this is just from teaching an awful lot of students over many, many years, is the other area that people find difficult is the upper cervical area. They frequently miss C0-C1. So, a couple of just surface anatomy landmarks, actually, you've got a very, very big bite of spinous process of C2. If you feel the superior part of that process and come straight out laterally, you are literally right over C1-C2. And if you find the more distal part or caudad part of the spinous process of C2, you're over C2-C3. I use those as a landmark, always to adjust myself, to get myself on C1-C2 and C2-C3.

Now, with 0-1, the old adage about you've got to direct your pressure up towards the eye is true because you'll push on C1. If you push straight down, you bias the force to C1-C2 because you're right in line with the facet then. And what many people can't do is bias the force up towards the eye to actually bias that more to C0-C1. And so, even though I used to be a purist at the beginning, I gave that up really. And it's the one time that I don't mind people coming around, so that they're backers now towards the foot of the patient. So, if you can think of the normal PAs, they just turn themselves around. And then with their thumbs, come off the occiput and then really get their thumbs up and under that occiput. And if they do that, they'll automatically have them in the right direction. And then if they gently spring that occiput, they're more likely to bias 0-1.

It’s just with a whole lot of headache, I'll have people saying, “No, there's no joint signs there.” But when you look at them, their 0-1s are just awful, but they've missed them completely. And, I suppose, my fanaticism, and it is fanaticism with making sure that your hands don't create soreness was, I've had a long time interest in headache. And headache, there's central sensitisation of that trigeminocervical nucleus, basically in every sort of headache form.

So, so many of your headaches, regardless of what their cause is, they have neck tenderness. Neck tenderness doesn't mean joint signs. They get the neck tenderness because they are so centrally sensitised. And so, if you start hurting them with your hands on an already sensitive neck, you're going to get massive, false positive results. I found that really in a differential diagnosis of headache. And if there was cervical musculoskeletal dysfunction there, you had to make sure that you could literally spring those joints without causing any local soreness. To get an idea really of what was happening underneath that generalised sensitivity of the neck. So, if you can keep your hands pain-free, you get a much more accurate impression of what's going on in the neck.

David: So, you're using that gentle pressure to identify what the movements like and then the quality at each of those levels.

Gwen: Yes. It's not gentle pressure I can still move the neck quite well. Because I'm not using my thumbs to create the movement I'm not causing any local tenderness. So, it is “gentle” that I try to make sure my hands are non-provocative. But you can still move the neck quite enthusiastically, is always a subtle way to put it. You can still move their neck. You just got to make sure that your thumbs aren't creating local tenderness.

David: You've palpated for any of that hardness or muscle spasm. You've then gone out to assess the movement through each of those joints with your thumbs. Making sure that your thumbs are not creating the movement, but your elbow is. And it is just transmitting that through to the thumb.

And so, at this point, you're looking at the movement of those joints, rather than your symptom reproduction or identifying them at the most painful level, is that right?

Gwen: No, all of that happens at once.

David: Okay.

Gwen: Even if I've got good handling skills, once I'm over the patient's symptomatic area that will be uncomfortable for them. So, I'm using my manual examination to find the most comparable and symptomatic level. Again, the pattern is fitting that, that is relating to the type of pain and the type of provocative activities that the patient is referring to. Going back to that painter, I would expect his painful levels to be somewhere up in… Well, it could be any of 0-1, 1-2 or maybe 2-3. And then I'd expect him not necessarily to have any pain in his lower cervical upper thoracic region. But my prediction would be, my manual examination would be to confirm that it's hypomobile.

And if I didn't find that pattern, then I've have to rethink. So, again, it's all in the clinical reasoning to make the pattern fit. So, I got two things going on in my head is my diagnostic side. And then what's the implications of the examination for management? What am I going to do for this person? So, I think, those two constantly.

David: You mentioned before about, so you might find neck tenderness. So, how would you go about differentiating your neck tenderness versus your joint signs?

Gwen: Well, I would expect to see with the joint sign I want to see the three cardinal sort of things, which is a change of the tissue resistance or compliance when I move that. I want to feel, make an assessment of whether it is hypomobile. And also looking at, is it reproducing comparable, painful segment? So, those are the three things. So, if you're just getting tenderness, but really you're not feeling that the joint is the tissue resistance or what we're feeling with the joint is any difference. It's probably is a just tenderness of the area rather than the joint sign. So, the joint sign, you're wanting to feel that change in mobility in relation to your provocation. And again, the pattern between your PPIVMs and your examination with PAs should add up as well. But you'll often find that it's a bit more provocative when you're doing the PAs, because you're doing a direct stress on the joint. But that pattern should add up as well.

David: And so, if we come back to your PPIVM assessment just for a second. I know PPIVMs can be one of the more difficult skills, I think, to learn technically. But also, when we look at the reliability, how reliable are we with our PPIVMs? And how do you resonate into what you're doing?

Gwen: There's a whole lot of issues with those reliability studies to start with. Number one, is that if I examine that patient, I'm also mobilising the patient. And so, when examiner two comes along, I've changed the situation anyway.

So, that they either may be less hypomobile. Or because I've aggravated them, they're more hypomobile. So, you've got that thing. The second issue is that we were too ambitious. The common scales that a lot of those reliability studies were done on was if it was normal, slightly, moderately, or very hypomobile. In the earlier days, slightly, very, or moderately hypermobile. So, you had a seven point scale. And if you look at the amount of segmental movement, you might have had a total of five degrees. So, you're asking a person to make seven point scale decision over motion that is five degrees.

So, to say that we were ambitious is to put it mildly. We were crazy. I think, in the early days, and this is when a lot of those things were taking place, we took clinical theory and clinical measures and tried to immediately put it into a research measurement, which we can't. We've shown that about a million times that, to do those sort of experiments doesn't work. And we can't translate what we think we feel clinically into a measurable scale. So, if you look at the studies though, that have said, “Is there a painful hypomobile joint there?” Or for example, I've been involved in several studies, “Does this patient have cervicogenic headache based on your manual examination?” And so, you make these big decisions, then we're very good.

I think, last time we talked about the studies that have tested our manual examination against a controlled anaesthetic blocks. When we've just got to make a decision, “Yes, this is symptomatic. This is the one that will respond to the blocks,” when we do that we're quite good. We're very good, actually.

And so, the inter-therapist reliability for judging whether it's slightly, moderately, very hypomobile are not good. But, I think, that can be they're very difficult experiments to do because the person that you're doing on is changed. So, I think, they're hard. If you look at the studies that have used an artificial thing, and a couple of those came out of Sydney, I think, originally, where they had different strain gauges, and they got the physios to do their PAs on all these different strain gauges.

So, they set them up on a plunger type thing. And there were some out of South Australia as well from memory. So, when people were asked to do that, the physios were highly reliable in being able to determine which was more or less or very sort of stiff. When you had that constant compliance the inter-therapist reliability was very good. There's just so many problems when we try to do it in vivo. There are so many problems. I don't underestimate people's ability to feel differences in tissue compliance. And, I think, some of the earliest experiments were actually done with bakers. So, bakers had to feel the compliance of the dough to know if it was ready to put in the oven. So, their sensitivity to feel that change in tissue stiffness or texture was highly developed.

And again, the human ability to feel differences in tissue compliance, we can apply it to humans, not just bread dough. So, those things on reliability are difficult.

But, be encouraged by the studies that have looked at our ability to actually locate accurately a symptomatic segment. And we are very good at that.

David: And so, when you're looking at your PPIVMs and your PAs, then you're looking for more of the movement that's happening at those joints with your PPIVMs. If they differ, for instance, if you find actually that, in your PPIVMs that C3-C4 feels like it's not moving very well. And then you go to your PAs and you go, “Well, actually in a PA, it doesn't feel hypomobile at all.” Do you ever find that you're having differences between your PPIVMs or your PAIVMs?

Gwen: Yeah, you can. So, your PAIVMs or your PAs are a different test. They are provocative. They push to see if you get a painful reaction. So, for example, your C3-C4 maybe painlessly slightly hypomobile. In which case your PPIVM could show hypomobility. But your PAIVM, it's not painful, so that when you provoke it, we theoretically should feel that it's hypomobile. But it may not necessarily be painful. So, you can have those anomalies, I think, in your examination. You can see that a lot if you treat older people who have got the OA changes in their neck, as they get older.

Their whole neck might be stiff, but not all segments are necessarily painful. Again, it will be trying to make this pattern fit. “Does it fit?” That should happen sort of thing is the clinical reasoning that should be going on.

David: Really, you feel like the PPIVMs are giving you more information about the movement quality there. Whereas your PAIVMs are giving you some information about the joint mobility, but they're also looking for that symptom reproduction as well.

Gwen: Yes. That's why they're sort of complimentary examination techniques.

David: Talking before about the next phase. You've gone through your manual examination there and you've identified with your PPIVMs and your PAIVMs some interesting levels. And whether you've got symptom reproduction as well, and the movement there, where do you tend to go to next?

Gwen: My screening examination of the neuromuscular system. So, that's where I'll go next. And at the beginning I will probably… first assessment concentrate more on the motor control. So, I'll be doing the deep neck flexor examination, which we talked about. I'll also look at the extensors, as we mentioned last time and also look at as relevant the axioscapular muscles. So, at the minimum, I will do that. If the patient's in a fair bit of pain, I will delay strength testing because I don't want to be provocative. If the pain is sort of quite minimal, and I find, for example, that they're reasonably good, say their tests or their extensors and they can extend up to 30 odd degrees or 20 to 30 degrees, I can, on that first day, introduce some strength testing. It really is patient dependent on how much I do.

My ultimate aim is that I'm going to test the interaction between their deep and superficial neck flexors, their deep and superficial neck extensors. I'm going to look at their axioscapular muscles. And particularly for control, the three parts of trapezius, serratus anterior, et cetera. And how fast I look at motor control and then strength really will depend on the patient.

So, it may not happen in patients with really poor motor control. It may not happen for two or three weeks. In patients with relatively good motor control, it can happen on the first treatment. It's very dependent on the patient presentation and their levels of pain. David: Great. And so when you're looking at those deep neck flexors and deep neck extensors relative to the superficial ones, is that where you're using your sphygmo…

Gwen: Well, just for the flexors not for the extensors. The sphygmo by the way, I should talk about that because this is where you need your skill in movement analysis. Because that's what it's all about. And even the deep neck flexors using the pressure by feedback, the feedback’s for the patient. It's basically telling them after I've stabilised the baseline at 20, it's basically giving the patient targets of where I want them to craniocervically flex to.

But the actual assessment is your observation of how the patient does it. So, you don't look at the pressure gauge, that's for the patient to look at. And what you've got to look at is that, a normal performance means that the patient can use craniocervical flexion. So, a real nodding movement to nod to 22, 24, 26, 28, 30. What you're looking at, is if patients can't do it, they'll then change their movement strategy to get themselves to that pressure level you've asked them to do. And the most common one is, that they start retracting. So, instead of actually, nodding to increase the pressure, because nodding facilitates longus colli, which flattens the cervical spine, which increases the pressure on the bag. If they can't do that action, then they just press back on the bag, which is retracting.

And so, you've got to actually look at them to make sure that you are getting an increase in range at each progressive stage of the test. Because what happens when they retract, you might see that they get so many degrees when they do 22. They get a couple more degrees correctly when they do 24. But then when they do 26, they're using the same amount of flexion. When they do 28 they're using the same amount of flexion. When they're doing 30, they're using the same amount. So, they are subtly starting to retract to get that pressure up.

So, you very carefully should just look. And once you're familiarised with it, it's quite easy to pick up. And then the other thing is, to observe how much activity they've got in their superficial flexors. Because they will have a little bit, but once you start retracting, you'll find that they'll start using their sternocleidomastoid, et cetera, to help them go back into retraction. David: And what do you find the easiest way to observe and check whether they are getting that ideal movement or not?

Gwen: Just stand at the side, watch their chin, watch their tragus. So, you want to see that angle with their chin, their tragus should basically stay where it is. And it shouldn't start heading towards the bed, which means that they're pushing their head backwards.

David: So, you're really only wanting them to take it to a level where they're not retracting? Where they're getting that head nodding, that flexion?

Gwen: Yeah. So, my assessment is, at what level can they activate? So, stage one, is your movement analysis to see can they do the movement correctly? And when doing the correct movement, what stage of the test they get up to? You've got some patients who don't really get past they can't do it at all. And if they can't do the test at all, then you just stop the testing. And that tells me my immediate therapeutics is, that I've got to teach the patient again. A lot of it is proprioception. I've actually got to teach the patient what craniocervical flexion is. And they'll go home that first time and they keep practicing the movement with the instruction of sliding the head up the back of the bed, et cetera. So, they'll practice that. People who can do the movement reasonably well, then we go on to stage two of the test, which is the important part. Because the function of your longus colli it helps you maintain your head and neck posture. So, it's tonic endurance basically, as you sit in front of your computer.

And the two training experiments have shown that, that people who tend to drift forward into a forward head posture, when they're doing computer work, if you actually rehab their deep neck flexors, they're actually able to maintain their posture better. So, their job is to just hold and support you.

So, the second part of the test is to test their endurance ability. Now, in training, we get them to do 10 by 10 second holds at each level. So, if they can only manage, for example, their training starts at 22, they do 10 by 10 second holds at 22. And once they can do that, they'll progress to 24. Now, in assessment to do 10 by 10 second holds at 22, 24, 26, et cetera, you'd be there all day. And so, you've got to make your examination more efficient.

So, if the patient can actually perform the test just the activation part, stage one, then you quickly go on to stage two. And I usually, just get them to hold at 22, say for about five seconds. And I repeat that around about three times. And if it looks as though they have no problem, I'll immediately quickly go on to 24 and do the same because what I'm aiming to find out very quickly is at the level they are having difficulty holding. So, for example, if they seem to do 22, okay. And did 24, okay. Then when I got them to do it on 26, you could see they were having difficulty. They're either having to keep readjusting the pressure. Or they just tell you, “I can't hold it here.” Or you see that they suddenly go back into retraction. You stop testing there because that says, “Well, I've got to start training on 24.” So, you're looking for that level they can't do. And that says, start training at the level below.

So, with the tests, I've got the treatment decisions that if they fail dismally in their movement performance in stage one, then my initial treatment is going to be to teach them how to do the movement properly. And then we'll go on to endurance training. If they can do the movement reasonably well, we move straight on to endurance. And then I've got to find the level at which they start their endurance training.

Because again, with the motor control, if you give them a task that's too difficult, you're going to train a substitution strategy, you're not going to train the muscles that you want. So, that's the craniocervical flexion and that can all happen within two or three minutes.

The extension, as you mentioned, we're looking for their ability to be able to do good craniocervical extension, proper craniocervical rotation. And remember that, so often proprioceptively they're quite poor at C1-C2 rotation. So, that'll give me the treatment direction to do that. And then for extension, we're looking that they can extend keeping their craniocervical area in neutral. By keeping their eyes on their book that they can extend up to about 20 degrees. So, if they can't do that, that gives me the indication of what level I'm going to start their extensive training in. If they can quite easily get up to 20 degrees, then I can start adding load. And we can go straight into a strengthening regime as necessary.

Again, your treatment directions depend on what the patient's presenting with.

David: So, you're using the successful level that they were able to achieve with their deep neck flexors, whether that was 20, 22, 24, whatever, they could do three sets of five seconds. And without any of those substitution strategies, that's your quick screen to find the level. And when they failed, you dropped it back down to the level they could succeed. And then you're aiming for the 10, lots of 10 seconds as their starting point.

Gwen: As their rehab.

David: Yeah, okay. So, they'll be going home to do that at home.

Gwen: And remember I mentioned that, I used the biofeedback for the assessment that we don't send that home. So, that you've got to actually teach the patient how to do the action and they've got to get the feel of the right movement using the biofeedback. And then they reproduce that feel at home basically. And, I think, I also mentioned last time about the importance of always doing eye facilitation. So, they keep looking down, looking down, looking down to facilitate their muscles.

David: And that if they get to 30 say, and they've managed the three sets of five seconds and that's all fine. Then, you basically eliminate that as a need to perform.

Gwen: Yeah, we get straight onto strength training.

David: Okay, great. And then you look at their deep neck extensors, you said. And the same with those, you screen those and see if they can achieve the 20 degrees of extension and..

Gwen: And if they can't, you rehab them up to that level. If they can, you get straight on to strength testing.

David: Strength testing. Okay, great. So, let's talk about that then. Let's talk about some of the strength tests.

Gwen: Okay. I usually use gravity as far as the neck flexors are concerned. So, for example, you can have the patient in reclined lying and to see if they can lift their head weight off the bed. But again, the most important things is that they can control their craniocervical areas, that we get them to do that same thing as feel the back of your head slide up the bed to nod your chin. Now, hold your chin there. And now, just lift your head, a couple of centimeters off the bed and hold.

And you are looking not only for their endurance time, but we’re looking at whether their chin drifts forward. And you can progress that down, and intuitively you'll know when you see some of these patients where the start off. But they can do head lifts off couple of pillows, head lifts off one pillow. But they normally can't do that terribly well to start with. So, your training usually starts at a point where they're starting to have trouble. And so, my training will often start lifting their head off a wall or lifting their head off a reclined position before they progress down to two or three pillows, two pillows, one pillow to the head lift.

Now, with the extension, I usually will get an idea of what their extensors are like with a manual muscle test for strength. So, that it's like deciding whether they're in the old-fashioned muscle testing, a grade four or a grade five. You can, if you like, if you've got any sort of handheld dynamometer. And you can do that with the flexors as well, you can get a more objective result. But I often for time will do a manual muscle test. And then for strengthening, if we get onto actually exercise regimes, you can use a variety of equipment. So, I'll often get a bike helmet, people have pushbike helmet, cycle helmet. And even that, by the way, is a fair bit of resistance. And then you can either tape very gentle weights onto that to increase their resistance or we can add other sorts of things or other sorts of weights or you can use TheraBands or whatever you want to for your strengthening type of things.

David: So, you're looking at, once they can achieve the motor control, that's when you start to look at incorporating the strength tests.

Gwen: And also, when they're getting close, and there's various opinions about this, like Shaun O'Leary, who I work with, he'll start the strength training probably a little bit earlier than I will. I like to make sure. So, for example, once the patient can happily do their holds at 26, 28, I'll start getting them to do... It is strength training, but it's movement training. So, for example, one of the functional things that we've got to do for our eccentric activity of our neck flexors is look up to the ceiling, which is all eccentric play out. And so, I'll often get the patient to my first progression rather than straight head lifts. My first progression is to get them to control their head movement through range, so that they'll practice in extension. So, they do an eccentric play out and a concentric contraction back to neutral. Again, controlling their head load. So that, they can control their head load through range. And then get onto the strengthening of head lifts. And as I said, you can use equipment but I often find head weight is enough resistance. Head weight and gravity is enough.

David: Do you ever incorporate TheraBand or anything like that into it?

Gwen: For the extensors more than the flexors, the extensors I do. You've also got to just be careful with TheraBand is that you've got something rough. Because people who have nice, shiny hair TheraBand can get a slip off too easily. You can do static resistance with a towel, so that they can do isometrics against the towel is probably better. But that's where with the TheraBand often, if you put it over a bike helmet, there's more grip. Bike helmets are quite cheap and many people have them. So, it's an easy piece of equipment that they can use at home. David: Especially now with isolation everyone seems to be out on their bike since ...

Gwen: That's right. Everybody's got a bike now.

David: For sure. So, you use the bike helmet. They've got it there. And you can just either start with that to load it up and then start to add weights to that if they need the extra resistance. Gwen: We haven't mentioned a lot about axioscapular muscles. And that can be a very, very important area to rehabilitate. Particularly, for people who you've proven in your physical examination, the axioscapular muscles are one of the drivers to their neck pain. So, for example, I think, we mentioned it last time, where I'll look at, for example, their range of rotation. And then correct their scapular position to a basic neutral type position and see what effect that has on their neck pain and neck movement.

And in those patients that it has quite a significant, well, a moderate to significant effect, you've got to spend a fair bit of time looking at rehabbing their axioscapular muscles. And so, often we see patients with a downwardly rotated or anteriorly tilted scapular. And so, it's that common synergy of the three parts of trapezius and serratus anterior that are not functioning the way that they should. So, we talk about the flexors and extensors of the neck. But equally as important, is to start getting the activation of those muscles correct or address the activation, make sure that they can activate them, control them and then start adding a bit of load to those as well. And in your postural exercises, the axioscapular muscles are an important part that you learn to contract them. So, as I said, we've spent a fair bit of time on that, but your axioscapular muscles are equally as important.

David: You're looking to identify if you change their scapular position or something to do with… It could be their lumbar position when they're in flexion or you've changed some of the postural position. And you look for a change in their pain.

Gwen: Then in your assessment, which I should have done first before I suddenly leapt into treatment. I do nothing fancy for their assessment. So, we're looking at what they're like in their sitting posture.

We'll look at their control through range of arm movement. The same as you would in a shoulder type of situation. And then, we tend to use straight, ordinary arm muscle testing. It's the 101 muscle testing for the axioscapular muscles. The only difference that we make is that we probably test them at the level of about a grade two. So, if you remember way back, your grade three test of your lower trapezius, for example, was prone with their arm in the scapular plane above their head.

And they had to be able to lift their arm off the bed. So, we just take it down one and we put the arm by their side. And then passively position their scapular onto their chest wall and ask the patient to hold. So, we've taken away armload and have a look at their holding ability.

We do that for middle trapezius, lower trapezius. And the reason that we take away armload is that you can often pick up their inability to hold more easily. Because when there's no load, you can really target it to a particular muscle. So, when you've got load, a whole lot of muscles have got to come in to cope with the load. So, taking the load off, we can really target it to lower trapezius or target it to mid-trapezius. And then looking at upper trapezius, it's really important we'll do that in standing. And really important to just watch their pattern, that it's just not a gross shoulder elevation, that they can really rotate their tip of their acromion up towards their shoulder. So, you look at that quality of movement. And then serratus anterior in the initial stages tends to be that straight retraction tests that you can do in sitting or in lying.

So, we start off at that level and if necessary, for example, if the patient can't hold their scapular on their chest wall for their lower trapezius that what they'll practice first to get that right. They may practice their upper trapezius in relative isolation to get that right rotation. And then, the way you progress it is to put it into their functional movements. And then ultimately, you load it, put some load on it. But make sure that their pattern of elevation, their posture is correct as you can get it. And then you load the system.

David: So, you've identified for instance, that they don't have great scapular control and you've identified that that's also related to their symptoms and you can get a change in their symptoms and their function with that when you manually correct it or change the position of it. So, how do you go about explaining to the patient how that's relevant and what's going to happen with their treatment of that?

Gwen: I think, they can see it's relevant if you change their pain. So, that's what the relevance is about. And if you can change your pain, I'll quickly say to the patient, “So, this is why this is important. Because you're holding your shoulder blade the way you're doing it is obviously aggravating your neck because you get it into a better position, suddenly your neck feels a lot better.” So, if you can link what exercise or what postural strategy or whatever it is, if you can link that to a change in their pain, your patient's compliance and understanding, I think, increases dramatically.

Now, with teaching them, I'll teach them separate little exercises, which is fine. In teaching them postural corrections, et cetera, I think, it's almost like the KISS principle. It’s “Keep it simple”. Because again, there are a thousand ways that you can teach patients to correct their scapular positions. And I found that, it really is important that it's simple and understandable. Because if you make it too complex, patients will give up before they start.

So, I had this thing that people actually don't know what they look like at their back. But they do know what they look like at their front. They see their front every day in the mirror sort of thing. And so, I usually, align their correction to something that's happening at the front. So, I use imaginary rubber bands. And so, for example, if the patient has, their major problem is protraction of their scapulars. Then, I'll talk to them about this rubber band that goes straight across their chest. And then, all they've got to do is very gently lengthen that rubber band to correct any sort of protraction problem. If it's mainly anterior tilt, we talk about rubber band braces. And so, they've got to now stretch their braces. So, that they've got to lift their shoulders up and take it back onto their chests. They've just got to lengthen those braces. If it's a downwardly rotated scapular… An English physio, Sarah Mottram did some research that showed that if you ask the patient to put their finger in line with their pec minor. And then if they just lifted tip of their acromion up and away from their finger, that that actually activated the three parts of trapezius and corrected that downward rotation.

So, just instead of putting your finger there, I'll say to patients that they've got to imagine that, they've got a diagonal, their rubber bands are on a diagonal from the middle of their sternum up to the tips of their shoulders. So, that they've just now to correct a downward rotated shoulder, lift the tips of their acromion up and then, spread open their chest, so that they literally lift away from.

You can stand at the back and have a look at how successfully the patient is correcting their scapular position. And as long as they're about 80% there, I'm happy with that to start with. And again, making the instructions really simple I found that patients complied better than making it too hard or trying to be too exact, et cetera. And then as far as re-educating a movement through range, I do a lot of hands-on facilitation. So that, they can get that rotation of the scapular coming in, et cetera. Or feel where they're not controlling it and try to rehab that way.

David: So, you're looking to not achieve perfection with this. You're just looking to get them in the general percentage so you mentioned 80%. So, you having them close, you're finding what works best with some of those cues you mentioned there to get them into an optimal posture that actually improves their neck pain and symptoms. And they can then feel that relationship between their symptoms and then the changes that are happening with their scapular position.

Gwen: Yes, at the beginning, I'm satisfied with 80%. Once the patient gets more familiar with it and they can start to actually feel where their shoulder blades are, if you feel the need, you can make it more precise if you want to. It is the trade-off for compliance against perfection. If things get too complex for them to do, you start losing your compliance. And 80% is pretty good.

David: Definitely. Okay. And we know within the shoulder there's a close relationship between the rotator cuff, whether that's working well or whether it's tendinopathy. And also the scapular position as well. So, do you tend to incorporate shoulder activation or whether it's like including their rotator cuff or shoulder exercises into your neck treatment?

Gwen: I do, but my focus is probably not on the rotator cuff. It's on the control of the scapular while they're doing arm movements. When you think about it, we do a lot of our functioning within about 30 degrees of elevation of our arm. If you can think of us working on keyboards, you think of physios doing PAs. You think of cooking activities, you think of a lot of the below the bench top activities. A lot of what we do is within that 30 degrees of elevation. Now at that point, your scapular hasn't rotated. So that, what we want to see is that people can do these activities with their arms and yet maintain the control of their scapular, so their base of support, basically. Because if they start hanging off their levator scapulae, for example, that could do some compressive forces down their spine.

So, we will do a lot of our rehab of those scapular postures using arm exercises. So, we start off with literally holding the scapular posture and doing shoulder flexion to 30 degrees abduction to 30 degrees, external rotation. We add TheraBand to that to add a bit of load to the arm movements or weights up to about two kilos to do that, but as I said, and rightly or wrongly, my thought isn't about I'm educating the rotator cuff. My thought is more, that I'm doing functional arm activities with progressive load that are analogous to what they're acquiring function to scapular control.

David: Great stuff. Excellent. And I think, that that covers that axioscapular area nicely. And we'll come back to how you tie it all together within your treatment. And how to prioritise and incorporate the different aspects. But any other areas that you're mostly interested in identifying or assessing as you go through this sort of assessment phase?

Gwen: Well, again, it does depend on the patient's presentation. And we've mentioned nothing about sensory motor. We've mentioned nothing about neural tissue. We've mentioned nothing about a neurological examination. Basically, what we've concentrated on is the really core part of the examination. And all of those other systems, the importance of examining them depends on what the patient presentation is.

As I said, if I have a patient who presents with local unilateral neck pain and nothing else, I wouldn't prioritise neurological examination or a neural tissue examination. But if the patient's presenting with neck and arm pain, I am going to prioritise those sorts of examinations.

And in a way it's the same as sensory motor control. So if the patient is complaining about dizziness, or unsteadiness, or problems with vision, or those sorts of complaints, then that would encourage me to look at sensory motor control. And we find that patients after whiplash often complain of those sorts of symptoms. So, that you're testing your sensory motor control, literally is almost routine in a person after whiplash injury.

Now, with the more idiopathic neck pain or mechanical neck pain, it's probably headaches. It's about only a third of those people complain of those sorts of things. So, for idiopathic neck pain, as a whole, it's probably only 20% that you would do sensory motor testing on. As a routine in response to symptoms.

The other indication to do sensory motor testing in those sorts of patients is, if the pattern's fitted and you've started a treatment program. And then you find, “Well, they're just not improving the way I thought they might.”

Sometimes it's then good when you're reflecting back on what you've done so far is to just have a look at their sensory motor function because sometimes they might complain about symptoms. And I've mentioned that they're not good proprioceptively a couple of times, and sometimes they do have sensory motor deficits that need to be addressed.

And, I suppose, if we go on to sensory motor testing and in our group, it's Julia Treleaven who's really led the research into this area. It's not 100% my area of research, but the fundamental things that we'll do in a clinical examination is probably look at joint position sense, which we can do with a laser and a target quite easily. Movement sense is important. So again, using a laser, we can get them to trace different patterns to see what their movement sensors are like. Balance, and that's regular balance from narrow stance to one legged stance, to standing on soft surfaces. And often with neck pain patients, you do need to test them at these higher levels. But, I think, one of the things that really amazed me in clinical practice was how neck pain does affect balance. Several years ago, I would never have ever thought of testing balance in a neck pain patient. But with Julia researching it, and so, immediately, we tested it out on all our patients in the clinic. I was horrified to think of how many times I'd missed quite significant balance disturbances in some of our neck pain patients. And then, the other one is eye movement control. It's your position sense, movement sense, balance, eye movement control are your fundamental package to do a screen on.

David: So, do you now routinely test balance in your neck pain patients?

Gwen: I do. I must admit I do because it takes no time. And you can take shortcuts and put them in tandem stance. And again, if you're under 40s, they should be able to stay in tandem stance, even with their eyes closed for up to 30 seconds. You've got to be a little bit more lenient on your older people who will get age changes in balance. But you'll find a lot of them can't do it.

David: And can you just clarify a tandem stance for us?

Gwen: Heel-toe stand. Standing with one foot in front of the other heel-to-toe.

David: On one line or a...

Gwen: Preferably if you're a purist.

David: Great. Okay. Well, that's interesting. I'm going to start trying that with my neck pain patients and seeing what their balance is like. That could be interesting.

Gwen: You'll be surprised.

David: Definitely. So, sensory motor. There's so many areas we could explore.

Gwen: Julia Treleaven you should speak to her on sensory motor. She is very well-versed in the area and differentiating cervicogenic dizziness from vestibular dizziness, et cetera. It's a huge, huge area.

David: Excellent. Well, we'll have to have her on the podcast and have a chat about those areas then.

Gwen: Good.

David: Any other particular things that you want to cover? We've really explored the fact that throughout your objective, you're looking to really tie that to their treatment. As you're going through them, your manual palpation, you're looking to identify levels that you might be interested in and then working on those immediately. You're looking at their deep neck flexors, you're starting to test them and then retrain those immediately. You've looked at the movement that you incorporated with your archer exercises. So, you basically, you almost guide them as you're doing your assessment, you're guiding them through different parts of the treatment there. And, I think, that's strongly come through that, that assessment is then helping to guide your treatment there, as we go through.

Gwen: Well, the assessment tells me exactly what to do in treatment really.

David: So, before we get going to just a couple more of the aspects around treatment. Is there anything else in the assessment you want to cover quickly? Or are they the main things? Gwen: No, I think, they're the main things at this point.

David: So, you mentioned there, and we've just discussed all these aspects within the treatment. So, on this regular neck pain patient, just say that painter that we talked about before, he's got some neck pain when looking up, what sort of stuff would you often send him home with? We've identified that he was getting most of his extension in his upper cervical spine and he had that decreased movement at his low cervical spine and upper thoracic area. You've then gone on to assess that and manually checked it. In that first session, what would you generally incorporate as far as assessment treatment? Could you sort of sum that up for us, what you often get to?

Gwen: Well, hopefully assessment, as I said, I hopefully, I've screened everything. Like I've looked at his posture, I've corrected it. I've looked at his active movements and analysed his movements. I've looked at his neuromuscular function, the manual examination, et cetera. And my prediction with him would be that he would also stand to have possibly weak deep neck flexors which is maybe compounding his control of his upper cervical spine, plus or minus his neck extensors, I don't know. The examination would inform me about that.

But I would treat those things and I would send him home again with that multimodal type things. One of the important things would be, that he tries to improve his movement control when he's painting areas above his head. Because we've got to get rid of that provocative factor because we could mobilise and exercise every muscle everywhere. But if he just goes back and does it in exactly the same way, he's never going to get anywhere in the long-term.

So, there'd be a lot of initial instruction on that on how to do it. And then, I would probably let him concentrate on that trying to improve his movement pattern in that functional position. And I would start him on the neck flexor training. And possibly depending on my examination findings, the neck extensive training. I know that treating pain in the articular system by itself is not going to get the muscle function going adequately. So, I'll send him home with those two aspects from treatment one. So, I'll concentrate on those things in treatment and then the home program should really reflect on what I've picked in treatment to be the most important things.

David: And if you also identified that he had some axioscapular control, would you then go, “Okay, that's going to be into the next session.” Do you think that you're then going to target that? Or…

Gwen: Yeah, it depends on how complex it is. So, if he can cope with that, I'd get him onto axioscapular control then. Or possibly if I rate say it's number one, neck flexor is number two, axioscapular, number three, extensors, I might leave the extensors to the next time. You can't give them too much, it becomes a bit overwhelming. So, you've got to pick it, but pick the most important aspects first and then add to the program as you go. By the way, you can teach people movement strategies, et cetera. It's very rare that they get it on the first go and they'll often come back doing things that you don't recognise at all. And so, then you've got to reteach. So, don't give them 4,000 things because they won't be able to cope, but I definitely want to start on the movement system and the muscle system from the word go. So, you prioritise it and then build it up.

David: Well, if you look at it from the initial session onwards, where would you find manual therapy fits within your sort of treatment program or paradigm?

Gwen: It depends. See, I'll look at the balance between the neuromuscular control, or what effect the muscle system is having on the articular system and vice versa. So, I think, we mentioned last time that you can do your palpation examination. And then get a rating of the patient's pain on palpation and then test the scapular, like middle and lower trapezius, which will cause a reciprocal relaxation. And then retest the manual examination and see how much it's changed.

Now, if they say, said that, “I've got a five out of 10 pain on my zygapophysial joint,” initially and then I test their scapular muscles, induce the reciprocal relaxation of their extensor muscles or the dorsal muscles, and then re palpate. And they now say, “My pain is now reduced to a one out of 10.” Now that indicates to me that the muscle loading is the critical thing here. And so, in that patient, I'd be putting sort of more of my emphasis on re-educating their muscle system to take the load off their joint. And manual therapy would come very much a secondary thing.

Now, if we've got the same scenario that they've got five out of 10 on that joint pain, I do the reciprocal relaxation. So, I take the muscle loading off and I re-palpate and they say, “It's still four or maybe five.” Then I know that the muscle loading, even though I've got to rehab their system, their muscle loading is not critical to their pain. So, for example, this may be people with OA in their neck, et cetera. And they've got genuine joint pain and genuine joint change. Well, then my emphasis on my manual therapy will become stronger in that patient. Whereas the first patient I might spend 80% on my movement muscle retraining and 20% on manual therapy is just a figure, on the second patient it may be 50-50 or 60-40 to start with, ‘till I get that joint pain down. So, every patient is variable and again, let your assessment tell you that.

David: Just say, you've got those two different patients and you've identified that, in one you're much more interested in the muscular system and the other in the more articular. Do you tend to incorporate still in subsequent sessions or how do you tend to use it there?

Gwen: Well, you would hope in the first patient where it was 80% say neuromuscular, that the need for your manual therapy would become less and less as they started to rehab their muscle system. You would still check. Don't make a presumption that it's all happening, but you may do your manual therapy. I would do it until I had pretty well made their joint relatively painless. But your role of manual therapy would assume a lesser and lesser and lesser role as you went.

So, the second patient, let's say they had real joint pain and joint change, et cetera. It may stay 50-50 until that point of discharge. It really does depend. I love Mulligan's concept actually of mobilisation with movement. And, I think, teaching patients how to self-mobilise after you've mobilised them is just so important, again, for maintaining what gains that you've made in the treatment and for the health of the joint. They've got to be able to move at a segmental level. So, I would say it's 50-50 on manual therapy. I probably should say 50 on articular and 50 on neuromuscular because at 50% on articular could be morphing into more the self-mobilisation, mobilisation with movements, self-management et cetera for their articular system. Because, I mean, if the patient has got an OA joint, it's a matter of you settling it and then, the patient maintaining it, really. You're trying to sort of slow what's happening to the joint. You're not going to make it a 21-year-old joint again, type of thing.

David: Unfortunately, not.

Gwen: No.

David: Excellent. Well, that gives us some really good ideas. We've explored a lot of areas here and there's obviously so much more we can dive into. But anything else that you want to just cover before we wind this up?

Gwen: I think, like I said, last time, I think, we've got to keep thinking of long-term, that it's not just the single episode that the real burden of neck pain is in recurrence.

And so, it's to keep that in mind and to make sure that the patient is well equipped for a maintenance program because their chances of it coming back are high. And I discuss that with the patient. And so, we're trying to decrease that recurrence rate or at the minimum slow so-called disease progression in the long-term. So, to make sure that they have an adequate maintenance program, that should be simple. And then also a relapse prevention program. So, if they feel that the neck pain is starting to build up again, what should they do? And that could be that they restart their mobilisation with movement activity. That they restart the formal training of their flexors extensors or their axioscapular ones, whichever the key exercises that you had in treatment, that they have a little program that they can start, that they can try to knock a recurrent episode on the head before it really develops.

So, it's those two things, simple maintenance. And we talked about the posture correction and maybe the archery exercise as a simple maintenance program for range of movement as well as keeping their muscles active. But also, the importance of relapse prevention. You will develop that relapse prevention program with the patient on the key things that were helpful for the patient while you treated them.

Just one other little thing is, physio can do an awful lot for people with neck pain. And I don't think we should ever forget that fact. And this is where I get so frustrated really well that the first line treatment is, or suggested we just give them advice and education and all that sort of stuff. We can do a lot for them. And many of the studies have shown that we get rid of their symptoms faster than wait and see, or just giving them advice. That's a pretty consistent finding. And that's something that we should capitalise on that we can relieve their symptoms faster, and then focus on a maintenance program and a relapse prevention program. Hopefully, we give them that better sort of prognosis through the next 10 or 20 years. It's much more efficient than just advising them and then waiting for the next episode to occur, which is what happens with doing nothing.

I think, we've got to believe in ourselves and I really believe that we can help people with neck pain quite significantly.

David: I agree. That's an inspiring message that we really can make a big difference to people's lives that do have these really disabling neck pain. And help to prevent that recurrence as well as getting through their current experience of neck pain but help them to more of an ongoing way with some pretty simple stuff.

Gwen: For sure.

David: So, you've shared tons of great stuff, Gwen. And it's been an absolute pleasure to have you on the podcast. And be able to explore all these areas and get your experience and expertise and share that with people listening to the podcast. So, I really appreciate you coming on the podcast and sharing all that with us.

Gwen: My pleasure, David. My pleasure.

David: Also everyone should go out and get the textbook that Gwen's a lead author on, on neck pain. It's an excellent textbook. So, everyone head on out, we'll have links to that in the show notes as well. But you should get that textbook it's a great one.

Gwen: Thank you.

David: Thanks very much, Gwen. And we appreciate it. And any way you'd like people to follow you on social media or any of those sort of places?

Gwen: No, I'm too old for that.

David: Too many other good things to do?

Gwen: Yeah.

David: Excellent. All right. Well, thanks very much, Gwen. You have a great day.

Gwen: Thank you, David.

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