From symptoms to solutions: a guide to neck pain and dizziness with Dr Julia Treleaven

In this episode with Dr Julia Treleaven, we cover what to look for in the subjective assessment to distinguish where someone's head and neck symptoms may be coming from. She covered what muscles may be giving us clues and what tests can be helpful. Julia then went into how different sensorimotor control exercises can be helpful as both assessments and treatments.

This episode is closely tied to Julia’s Practical she did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉  Watch Julia’s Practical here with our 7-day free trial:
https://physio.network/practicals-treleaven

Dr Julia Treleaven is a Lecturer and Researcher at the University of Queensland. She has been researching whiplash and neck pain since 2000 and in 2004 completed her PhD focusing on the necks influence on sensorimotor control. She has continued her research in this area in idiopathic neck pain, headache, the elderly and post concussion. 

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Transcript

SPEAKER_02 0:05

We know that muscles become inhibited straight away in response to pain and trauma. In Michelle Sterling's studies in Whiplash and in Julie Hyde's studies in back pain, even when the pain went away, the muscle function doesn't necessarily resolve. So I think in a lot of patients, particularly those patients who get recurrent episodes of neck pain, their pain might go away, but if we haven't adequately addressed the motor control, then that may be a driver for their recurrent episodes.

UNKNOWN 0:35

Music Bye.

SPEAKER_01 0:37

Distinguishing between types of headaches, types of dizziness, and types of neck pain can be a challenge. Well, today we had Dr. Julia Treleaven on board. Now, she's done a PhD in neck and sensorimotor control. She's been on 100 publications. She's been published in a book called The Management of Neck Disorders and Evidence-Based Approach. She was writing a book just before I jumped on the podcast with her. Now, she's done a wonderful practical, and in today's podcast episode, we went a little bit deeper on the type of assessments that would help you tell what type of headache or neck pain or dizziness the person in front of you had, as well as some novel treatments, some treatments that I hadn't really heard of before or considered doing in such a graded approach. And to see a lot more, I want you to check out the show notes and you could have a trial of the practical where we actually see how Julia assesses and treats people. I think you'll really enjoy this episode. My name is Michael Risk and this is PhysioExplained. Hi, Julia. Thank you for joining us.

SPEAKER_02 1:38

Thank you for having me, Michael.

SPEAKER_01 1:39

You've done a practical, which is new from Physio Network. You actually go to the studio, film with the patient, and it's on cervicogenic dizziness and headaches. We're going to put a link to that in the show notes. If people are interested, they can trial it. Julia, talk to me about patient comes in, they've got a bit of neck pain, they've got a What would you assess that maybe is a little bit different to what we were talking about off air of just tight muscles and pushing on some joints? How would your assessment look a bit different?

SPEAKER_02 2:10

So I think it would be really closely looking at the patient interview to really try and work out whether or not the headache sounds like it might be coming from the neck. And so is it unilateral? Does it not swap sides? Is it more an aching? It's not throbbing or pulsating. It's not a band around the head. All those sorts of things and things that aggravate it should be neck pain or neck movements and positions, not things like stress or fatigue or certain foods and things like that. So really find out whether it sounds like it might be cervicogenic and then doing a really good assessment to try and work out whether or not the symptoms and signs match up. You're looking for a pattern of musculoskeletal dysfunction. So you're not just looking for isolated findings. So for example, you might do range of motion and find a bit of restriction, but if you don't find any symptomatic joint signs, which means that you're feeling that hypomobility, that local muscle spasm, and the patient's reporting pain when you do that, then that's not an indication that it's a musculoskeletal sort of thing. And you'd also be expecting to find some deficits in their muscle function. So you might be looking at the cranial cervical flexion test, for example, or looking at the scapular control. And so you're looking for this pattern of dysfunction that matches what the signs and symptoms are saying. And so... The problem is sometimes there is a comorbid condition. So it might be that they have a neck condition, but they also have a migraine or a tension type headache. And that's common in patients who've had trauma. So for example, patients with whiplash. And so then it's difficult. So that's when you really have to say to yourself, all right, is this headache sounding like it's coming from the neck? And is it matching what I found in the neck? So if it's constant eight out of 10 pain, that doesn't vary that much. And you find I've got a bit of a C1-2 problem that probably doesn't match. It's sounding like it's probably more something like a migraine or some other kind of headache that you need to consider. So if that's the case, you may decide to have a trial of treatment because they have got some comorbid condition there and see if it does change the headache at all. But you'd certainly be very frank with your patient to sort of suggest that you don't really think that it's sounding like it's a neck-related headache and that you are going to give a trial of treatment to see if it has any benefit. So I think they're sorts of things. And then if they have got any dizziness or perhaps if they have had treatment before and things are not changing, you might also want to add in looking at sensory motor control as a potential driver for the condition as well. So that might be looking at things like joint position and movement, sense, balance, eye and trunk head coordination and ocular motor control. So they're the sorts of things that I'd be really looking for and being mindful of patients that just report pain. So you're really looking for true impairments. So we've had patients with migraine in our studies that get pain when they do the craniosophageal flexion test, but they actually look good doing it and they can hold it and they can get to all the levels. So they don't have an impairment, but they might have peripheral sensitization that's part of their migraine symptomology.

SPEAKER_01 5:19

That's a really good overview. Is it okay if I go back and ask some questions? Sure. You said that if we're ruling out that it comes from the neck. So what are other common presentations that aren't coming from the neck that would give you the headache and dizziness?

SPEAKER_02 5:34

So migraine can.

SPEAKER_01 5:35

Yep.

SPEAKER_02 5:35

Tension type headache, probably not so much dizziness, but certainly they will get headache as well. So they're the two common ones that we would see as physiotherapists. Yep. Then from a red flag perspective, we also need to be mindful of people who are having a cervical arterial dissection. And so those patients may be present as their very initial presentation with acute, unusual neck pain and headache. And so it's something they've never had before. So if somebody's had migraine before, for example, that's acute and it's intense and severe, but they've had it before. So that's not unusual, but certainly if they've had migraine before, but this is different and their symptoms are different, then you should still consider it because patients with migraine have a higher incidence of dissection and they're usually younger. And sometimes it's associated with really trivial trauma. So it might be they hit their head on the car door or they did a big gym workout or something like that. So being mindful of that. And so that can cause obviously headache and sometimes dizziness as part of the symptomology. They'll might report very transient neurological symptoms in those early stages as well that relate to vertebral artery. So it might be dysphagia, word finding difficulties, those sorts of things. So that's the one thing that, again, it's quite rare, but certainly we may come across it at some time in our thing and it should be crossing our mind as a potential problem. VBI doesn't often present with headache, but certainly can present with dizziness. And in those patients, then often they're older, they might have some degenerative changes associated so that when they get their head into certain positions and sustain it, then that can bring on dizziness, often vertigo, and often associated with signs of vertebral artery dysfunction. So nystagmus, nausea, all those sorts of things. So it's not proprioceptive type dizziness, that's normally more unsteadiness and a general feeling of vague imbalance. Whereas VBI can be that, but certainly they hold in that position, it stays there and it gets worse. Whereas proprioceptive dizziness may not do that. It might come on while they do the movement, but then when they stop, then it eases off.

SPEAKER_01 7:55

And the migraine and tension type headache, just a quick tangent before we get back into cervicogenic Is there any physiotherapy treatment for those two? What do you do differently for those two?

SPEAKER_02 8:08

Yeah. So at the moment, we don't have strong evidence for treatment for migraine intention type headache. So from my PhD student, Ziggy Liang, she did a study and she looked at people with migraine, with neck pain, and she found about 40% of them did have a musculoskeletal disorder. Now, whether or not that related to their headache or not, we didn't look at that, but they certainly did have Pattern of dysfunction. So maybe in those patients, treating the neck may be helpful, but we don't have strong evidence for that. But certainly, I think in patients, they seek treatment to the neck, they prefer treatment to the neck. And so if you find that they've got these deficits, then you could suggest that you treat those deficits to see if, well, it should improve their neck pain and might improve their headache. If they've got what we would call peripheral sensitization, so they're generally sensitized, touching the neck, moving the neck causes pain, but they don't really have any deficits. There is a possibility that if we treat the neck, we may be able to modulate some of that pain at the cervical trigeminal nucleus by providing good normal afferent input into the system. But we don't know that and we don't have strong evidence for that yet. But I would suggest that that's a potential thing you could try. But I think you need to be really mindful of not making things worse. So a lot of patients we interviewed and they were actually going to physio and even saying, oh, every time I go, I come home with a migraine.

SPEAKER_01 9:34

Yeah.

SPEAKER_02 9:35

And I have to go to bed, you know, so... Again, it might not have been the physio's fault because neck pain can be a precursor to migraine. So it can actually be one of the symptoms of migraine. So it may be that they've got neck pain and they're going to get migraine no matter what they do, but we still need to be mindful of that. And often patients also get post-dromal neck pain. So they get neck pain and stiffness after they've had the migraine. And again, we may be able to help with that, but there's not been a lot of research in that area. And that's something that we're really trying to look at. But I think in those circumstances, you need to be really objective. Are you making a difference or not? If you're not, then you probably should be. And also we should be combining it with good effective medication, lifestyle advice, that sort of stuff, aerobic exercise, exercise, those sorts of things have all been shown to be helpful in migraines. So I think in those cases, and then there are cases where it's actually referred pain. So they only get the neck pain primarily when they have the migraine. And if they get the neck pain, that might just be an indication that they're going to get a migraine and perhaps they should be just then taking their preventative medication at that point. to help them manage their migraines better rather than thinking it's neck pain and having treatment for it. So I think there's different things that happen and we need to be thinking about what the potential things are and then changing our treatment accordingly.

SPEAKER_01 11:00

That's good context. I'm glad you covered that off actually. And you mentioned a couple of tests, the cranioservical flexion test and SCAP control. What would you be looking for and what might they tell us?

SPEAKER_02 11:15

Yeah. So for the craniosavagal flexion, you're looking to see that they can actually perform the craniosavagal flexion action initially. And often patients with neck pain, they retract, they can't do that nice pure rotation in supine. And then you can use the pressure by feedback to actually measure their ability to perform the incremental increases in range from 20 to 22, 20 to 24, all the way up to 30. And what you're looking for as a physio is, are they able to perform that nicely? So normal people should be able to go all the way through and perform it and keep going with that cranial cervical flexion, not changing their strategy. And they also should not be using too much of the superficial muscles. So the sternocleidomastoid and scalene muscles. So you can be palpating those as they're going through the test. And obviously by the time patients get to 30, it does go up a little bit, but not excessive. And often patients with neck pain, their muscles are on at rest even. So they're on and they need to try and not be on and trying to be using those deeper muscles. So for that, that's what we do. And then for the scapula, we can look at the position of the scapula, see if it's abnormal and then look We know that nobody's got a pure symmetrical scapula really, but what we can do is position it to a more normal position and then reassess if it's changed neck pain at rest or if it's changed range of motion, for example. And if it has, then that might indicate that the scapula is involved in the neck pain. And then you can also assess whether or not they've got that good holding capacity of the middle and large pesius or serratus anterior activation. And often they can't hold that position. They overuse upper trap and levator scap, for example. So there's ways that we can sort of look at motor control around the scapula and the neck to see whether there's impairments there that we can address.

UNKNOWN 13:11

Music

SPEAKER_00 13:12

Thank you.

SPEAKER_01 13:44

Julia, do we have any insight or research into are those things because of the pain they're in, like how someone braces when they're in back pain, or are those things the driver, for lack of a better word, or do they go hand in hand? How do you approach that?

SPEAKER_02 13:59

Yeah, I think they go hand in hand and it's very hard to do research where you sort of get people who don't have neck pain and assess them and then wait till they get neck pain and then assess them. although we did 100 normal people when we were doing the Whiplash Clinic, setting it up. And we had a few healthy controls who were young students who had terrible muscle control and then subsequently ended up in clinic a couple of years later with neck pain. So very anecdotal.

SPEAKER_01 14:27

Observational, but interesting.

SPEAKER_02 14:29

But I think if we know that muscles become inhibited straight away in response to pain and trauma, In Michelle Sterling's studies in whiplash and in Julie Hyde's studies in back pain, even when the pain went away, the muscle function doesn't necessarily resolve. So I think in a lot of patients, particularly those patients who get recurrent episodes of neck pain, their pain might go away. But if we haven't adequately addressed the motor control, then that may be a driver for their recurrent episodes. So I think that's important that we consider that. And similarly, with sensory motor control, there's some evidence that if they have got impaired sensory motor control and we address that, there may be a better outcome with respect to recurrence rates.

SPEAKER_01 15:16

And that's important because in the practical, you'll show examples of how you actually do that. And there's some evidence pointing to that whilst those things might be symptomatic, if we address them, there's better outcomes for people when we have addressed those things that we notice. Is that right?

SPEAKER_02 15:31

Yeah, definitely.

SPEAKER_01 15:32

And I remember a little bit last time I spoke to you, but could you describe some of the treatments that to me sounded quite novel? I hadn't heard of doing those motor control treatments. exercises around the neck and the oculomotor exercises as well.

SPEAKER_02 15:46

So we know that the evidence is for a multimodal approach. And so that includes manual therapy and exercise. And so manual therapy has a good place, but not on its own. We always include exercise. And so we'd start off generally starting off trying to activate those muscles that are not working well, trying to reestablish that activation. So we start off with quite low load exercise. So it might be practicing that cranioservical flexion motion. We might have somebody in sideline trying to activate those scapular muscles without activating the upper trapezius and levator scap, for example. We might have them in four-point kneeling doing isolated C1-2 rotation to try and get the suboccipital muscles going. Once they've got some activation, then we can start progressing into a more strength and endurance phase because we know that even the scalenes and sternocleidomastodes, for example, even though they're overactive, they're often weak. So the second phase of the program is really to add in that sort of strengthening endurance and how far we need to go with that will depend on their functional demands. But when you think about it, most people have to get out of bed and lift their head off the bed and things like that. So being able to just lift their head off the bed on one pillow is probably the minimal that they should be able to do. And then if you've got people doing Pilates and yoga and all those sorts of things, they are often putting their head in positions where they have to hold against gravity. So I think depending on their functional demands, that's what we should be aiming for.

SPEAKER_01 17:15

Yeah, truly we've We're running out of time pretty quickly. Thank you so much for that overview. And I'm keen to watch the practical. We'll put the link in the show notes so people can trial it, but we'll see the assessments that you do and we'll see the treatments you do. But thank you so much for your time.

SPEAKER_02 17:30

No worries at all. Thanks for having me.

UNKNOWN 17:33

Thank you.