Physical Therapy and Neck Pain - Brent Dodge, PT

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have as my guest, Brent Dodge. Mr. Dodge has a Masters in Physical Therapy. He did his training at the University of Peugeot Sound. He also has several other certifications including a Board Certification in Orthopaedic Clinical Therapy. He is also a certified manual physical therapist. Good afternoon, Brent.

Brent Dodge: Thanks for having me.

Dr. Sechrest: Today what I would like to talk about is neck pain. I think everyone has had the epidemic in low back pain in the United States and all over the world really. One of the things that we don't talk a lot about is neck pain, and I think over the last decade we, as physicians, have recognized that neck pain is almost as prevalent as back pain. Now, when we evaluate neck pain as physicians, one of the first things that we turn to is the physical therapist to help reduce those symptoms and hopefully give the patient a strategy for not only reducing the pain at the time, but also reducing the occurrence of neck pain into the future. So let's go back and talk a little bit about what is the physical therapist's role in the treatment of neck pain? Where do you start?

Brent Dodge: Well, as with all patients that we see in physical therapy, we're going to do a thorough evaluation. We're going to check motion in the neck. We're going to check muscle strength and particularly muscle strength that relates to how the nerves are working at such a vital area; and from the evaluation then we can develop a treatment plan to help address symptomatology to help people get comfortable and know what they can do at home, at work, wherever, to be more comfortable and what to do when they have a symptom flare-up; and then design a program to help them for the long-term in terms of their posture, their shoulder strength which is a big part of helping people with neck pain, and then being able to just get back to their normal activities as best as possible realizing that neck pain can be an ongoing and troublesome problem.

Dr. Sechrest: It's interesting that you say that because I think that unlike back pain patients with back pain come in the clinic and their almost disabled by the back pain. I see that less frequently with neck pain. Generally speaking a patient with neck pain comes in and says, "You know, I've been putting up with this for 6 months, and it's just not getting any better, and it's not really impacting too much now, but it's just miserable, and I want something done about it."

Brent Dodge: I think you bring up an excellent point. You know, the people that I do see that have strong symptoms in the neck “ they are tough too cure - and I would say a handful of them end up requiring more of an invasive procedure to get over the hump. The typical run-of-the-mill neck patient, unfortunately, amortizes that pain into their life to say, "Well, I've got neck pain" and they live with that neck pain; like you said until maybe either someone talks to them about the benefits of physical therapy or they finally decide, you know, it's affecting their golf game or their tennis game to the point they need to get a little help.

Dr. Sechrest: When you do your initial evaluation as a physical therapist, I guess I'm interested in a couple of things. One is, is there anything that we, as physicians, can do to help with your evaluation? And that leads into my next question which really is, what do you do on that first evaluation? How do you evaluate the patient and determine whether they're appropriate for physical therapy?

Brent Dodge: Well, in terms of what the physician can do, I think just confirming with the client that physical therapy is a helpful avenue to go when there are problems with the neck in terms of pain, symptoms like jaw pain, headache, physical therapists treat those and often times effectively. So, providing that information, they are going into a little bit more optimistic than thinking that they're just going to be subjected to either massage on one hand or heavy weightlifting on the other hand. But there are a lot of new technologies, and particularly manual approaches, that can help people who have pain, particularly neck pain, that can help them get better, feel better, and then learn how to manage that condition.

Dr. Sechrest: As a physical therapist, what are the keys you're looking for to make a decision about which therapies you recommend for patients?

Brent Dodge: I'm looking for, do I have a range-of-motion problem? Is there something that's limiting the ability of a person to move his or her neck which leaves me to think, "Hey, is this muscle tightness? Is this postural from years of being hunched over a keyboard and a mouse or some other form of work like at a workbench." So I'm going to be thinking in terms of their work activities, their hobbies, so I know A) is this a postural or is this potentially joint tightness, soft tissue tightness that's going to benefit with more of a manual hands-on approach with mobilization of the joint, meaning just gentle movement of the joint, or more of a manipulation, which is a high velocity stretch to the joint, or whether it's simply going to be a matter of postural training as it relates to their daily activities and work.

Dr. Sechrest: It's interesting, because when we always compare neck pain to low back pain, and there's this concept in low back pain of the red flags. Things that either physicians or physical therapists are always on the lookout to try to determine whether this patient has a more serious problem and something that might need a more aggressive evaluation such as an MRI scan, maybe some more aggressive treatment even. Is there something comparable in the neck that you look for as a physical therapist to sort of warn you that maybe this patient is not quite ready for physical therapy, and may need to see the physician again and have a more exTENSive evaluation. What do you look for?

Brent Dodge: I think there are some similarities with an examination of the low back in terms of pain that comes out of nowhere. We always get a little bit concerned. We kind of become a P.I. (private investigator) to try to figure out then is this a musculoskeletal problem, meaning joint, muscle, disc, that kind of thing? I think, as well, I'm always questioning people about any vision problems that might be a little bit out of the realm of physical therapy if there's effect there. Arm pain that radiates particularly with coughing or sneezing that says we have an extremely irritable nerve situation as opposed to more somatic pain or muscular pain in a zone, this is spreading pain that may be more concerning. I'm particularly interested in bowel or bladder function as it relates to the spinal cord which is traveling through the neck zone, and when there are problems with discs or degeneration that's changing the space within the spinal canal, if there's potential for involvement of the spinal cord that could show up as a bowel or bladder issue. It could show up with a funky gait, what we call ataxic gait; a clumsiness in the hands, and particularly on both sides make me think that's not just a nerve, that's not just a joint that's swollen that's creating problems with the nerve. That's a little bigger deal, and specifically, if I have weakness through the arm in more than one zone, in other words affected by more than one nerve coming from the neck. If I see two, I'm going to be a little bit more cautious and concerned that there may be something more than just a single level disc, joint problem.

Dr. Sechrest: Let's talk a bit about going the other direction and it's very common to see patients who have primarily neck problems come in with headaches, and they're usually headaches in the back of the head or that may radiate up, but it's a very specific type of a headache. We call it a cervicogenic headache. Can you as a physical therapist improve that symptom? Do you find that either modalities or a manipulation or traction or even an exercise program, do any of those things affect that headache and improve the headache?

Brent Dodge: I would say most TENSion type and I say that as opposed to a migraine, a pure migraine headache, that's a little bit different venue; but in terms of the cervicogenic headache where it's potentially a joint issue, my approach as a manual physical therapist is I get my hands in there and I'm going to work the joints, particularly the upper neck. The top two joints seem to have more of an interplay with headaches, and particularly the ones that are behind the eye, or temple, or along the side, and so there's a lot of work the physical therapist can do at the upper part of the neck that can help with headaches. There are other headaches, particularly in the back, where there can be a potential crimping of the nerve in the back when the head is held forward. That may become more of a postural situation where we need to do stretching in the back to allow the head and neck to be upright and balanced atop the spine. But definitely physical therapists have a lot of new tools and technologies to help with even the headaches that are associated with neck pain.

Dr. Sechrest: Let's talk a little bit about this concept of modalities. We mentioned that earlier, I think I mentioned it, and in the neck we have all sorts of modalities. We have the TENS unit that people use. We've got the ultrasound. We've got hot packs, ice packs. I think there's something that physical therapists use called the ˜spray and stretch' working mainly with the muscles and that sort of stuff, and ultrasound. Do you utilize any of these modalities and do you find that some of these modalities are beneficial in treating neck pain?

Brent Dodge: I think there's always a place for modalities in the right situation. I think sometimes they can be overused and, truthfully, among physical therapists we'll say, "Well, we'll use ultrasound when we can't figure out what's going on." That's not always the case. Ultrasound can be a fantastic way, and by the way that's just high frequency sound that can be used to generate a deep heat source so that's great for preparing an area if something's tight to be able to stretch that structure. Ultrasound can be great for overriding pain, what we call being a counter-irritant where the spinal situation overrides the pain so they feel more comfortable. But I think it's best used in combination with manual therapy as opposed to a stand-alone treatment.

Dr. Sechrest: When you're talking about manual therapy, you're talking about actually manipulating the neck, doing what some folks would say is similar to an osteopathic manipulation, a chiropractic manipulation, that's the sort of manipulation that's you're talking about, correct?

Brent Dodge: Well, physical therapists do what's called ˜mobilization' which can include manipulation. Mobilization is on a spectrum of something that's very light and gentle, what we call a Grade 1, up to a Grade 5, which is in this case a spinal manipulation if we're manipulating the spine, and that is where it's really out of the patient's control, it's a high velocity, low force or low amplitude stretch to a joint, basically, and the structures around the joint; and that's occasionally a very beneficial form of treatment that physical therapists would use. Some people would say, "Well, it's just like a chiropractor", but I always tell people, "What I'm about to do is a physical therapy stretch. You may or may not hear a pop", and oftentimes it's not really the pop it's the stretch that seems to give the benefit.

Dr. Sechrest: What about these Class 1s? You mentioned this continuum where you start out very gentle. What is that doing?

Brent Dodge: A Grade 1, if you look at the scale between a Grade 1, 2, 3, up to a Grade 5; Grade 1 is a very gentle movement of the joint within the neck, it's almost imperceptible, and the idea is that you're sort of fooling the nervous system so that, again, as a counter-irritant, overrides the pain, and allows those muscles to relax, and as soon as we get those muscle spasm to relax, then we can start working on stabilizing the joint, working on proper movement, posture, and things like that. So, Grade 1, even though it's very minimal movement, it's not an aggressive stretch, can be a really beneficial way to help people start feeling better quickly.

Dr. Sechrest: Now, cervical traction. I think that we see a lot of physical therapists, and in fact, we prescribe a lot of cervical traction in people, even people who have pinched nerve because we think that it opens up those little openings, the foramen, and gives that nerve a little bit more breathing room and may reduce the pain, the irritation on the nerve, and perhaps the pain down the arm and that sort of thing. I know today there are lots of home cervical traction units that you can even rent, buy, or borrow from the physical therapist. What's your take on cervical traction? Do you use it? Do you find it beneficial, and if so, what type of cervical traction do you think is best?

Brent Dodge: I think there are a lot of times where I, as a physical therapist, will use my hands to actually create a traction or a spreading of the joint to open up the foramen. Not every situation that we will use traction for, is for a nerve-based problem. If a joint's tight, traction can actually help to stretch the structures around the joint and improve mobility. But I find the best application of traction is when there is a nerve potentially being pinched where the nerve is coming out and the hole is small or there is a spur, something's crowding that spot to take pressure off that nerve root. But what I've found in clinical practice is that it's hit and miss. When it works, it works extremely well. When it doesn't, it can be very challenging and people can end up flared up and then you have to calm those symptoms. So, as a physical therapist, the first thing I'm going to try to do is with my hands determine are they irritable to the point that they wouldn't be able to tolerate doing it at home in an unsupervised setting. Again, sometimes you do it, they feel great. They're appropriate for a home device, and we offer different types of home traction systems; some as simple as a little holster that your head sits in, a little strap that goes up over a door with a weight or a weighted bag, say with water, that will allow that stretch to occur; and some that are much more involved as far as lying down and having a pump that will actually work the neck into traction. That's hit and miss, too, is which one's best, and I'm not seeing a lot of great literature defining that one's going to work better than the other. But when traction works, traction works.

Dr. Sechrest: You're approach would be to try the tried and true simple method with your hands, test it in the clinic, and then, if you're getting some response, then maybe try one of these units that people could use on a daily basis at home.

Brent Dodge: Exactly.

Dr. Sechrest: And is this a short-term sort of fix? Or is this something that people can get some benefit over a period of time?

Brent Dodge: Most of what I've seen, and obviously there are some situations where you do traction, people get relief, their problem resolves because they've stretched that tissue to the point now we can stabilize, we work on their posture, and they manage that situation without the need for traction. But if there's a spur that's not going away, short of some procedure, those people when traction works, tend to get long-term results where they use that at home on a long-term basis.

Dr. Sechrest: Now, another modality that I think is commonly prescribed for neck pain as well as any sort of pain in the spine is a TENS unit. Do you use TENS units and do you find them effective?

Brent Dodge: You know, as a manual physical therapist the first line of defense is I want to get my hands on the area. I want to find out if there are imbalances. I want to find out if there are spasms, any joint tightness, and I want to help to treat those things first, and I want to know if I've introduced a benefit with my hands before I put a TENS unit on and think which one actually worked. But as I'm getting improvements with my hands a lot of times I may not need that modality. If there's a struggle and there's a spasm that's not calming, then I'll introduce the TENS early on, and that way I can get the spasm out, then get back to stretching and things, posture, that will help that person get moving again. Particularly for long-term chronic pain problems, when maybe somebody's tried other therapies and approaches and haven't gotten results, TENS can be a powerful and effective way to help people at least keep their symptoms at bay.

Dr. Sechrest: Now we probably, for people who are unfamiliar with a TENS unit, explain to them exactly what a TENS unit does. Take it away.

Brent Dodge: Well, TENS stands for transcutaneous electrical nerve stimulation, a big long word that means we're going to introduce an electrical current across your skin, and we do that typically through a portable device though we do have units within the clinic that are very similar, they're just bigger. The TENS unit that I'm thinking of is a typically a portable unit that a person can literally wear like a cell phone on his or her belt with cords that go to pads or electrodes that you can place on different parts of the neck or upper back; and those are things that can be used, we have settings on a TENS unit that can be used literally 24 hours a day, and we have other settings where we really try to get more of an endorphin release. Endorphins are natural pain killers that our body will release to help fight pain, and those settings typically can be used for up to 30 minutes. It's less comfortable but it has a lot longer pain relief following the treatment.

Dr. Sechrest: If I understand what you said earlier, you don't jump right to a TENS unit, you really try to do your manual therapies and then when the problem turns chronic you may utilize a TENS unit or recommend a TENS unit for long-term use to perhaps get some pain relief, reduce the need for pain medications and that sort of thing.

Brent Dodge: Exactly. Particularly in the acute stage, if a person's having a hard time tolerating any kind of manual therapies, that may be a time too to use the TENS to stop the spasm, instead of being locked up, then they start moving a little better. But then, like you mentioned, on the more chronic side, before I want to use a TENS unit I want to see if I can make an impact. Can I help this person regain motion, posture, strength, to get back to being able to manage or even overcome the problem before I try the TENS unit.

Dr. Sechrest: Let's go back and talk a little bit about physical therapy in general for neck pain. What are we talking about? Are we talking about 2 sessions? Are we talking about a patient with an acute, or even that subacute neck pain that he's been putting up with it for 6 months and finally decides to go to the doctor. The doctor sends him to the physical therapist. How long are you going to work with that patient? Are you going to train him and then turn him loose on his own? Or is this something that's prolonged?

Brent Dodge: I would say for the most part, at least in the population that I see, I expect to get pretty good results within 4-6 weeks, and part of that is that in most cases of neck pain it's not just a simple “ like I've got this joint that's not working. A lot of times it's this lifelong postural habit, specific types of work postures that people have used and didn't happen overnight, it took a while to get there. So when something has been short and tight for a long time and has created an imbalance where something else is now weak, that's going to take a little bit more hands-on work and then those visits begin to span over that 4, 6, or 8 week period to the point that people are able to work at home doing very specific exercises to help regain the balance that then let's them have that better posture and overcome the problem.

Dr. Sechrest: Now is neck pain like low back pain in the sense that, one of the biggest problems with low back pain is that it recurs. You get better on your own, but then 2 years later you may have another episode, and 6 months later you may have another episode, and we know that 90% of folks are going to have recurrent attacks of low back pain. Is it the same for neck pain? Do you see the same pattern in neck pain that you do in low back pain?

Brent Dodge: I see a lot of people with neck pain and I see a fair amount of people that have a recurring situation. When they come back to the clinic for a new episode it might not be exactly the same thing, and then we have to get back and look at what they are doing in terms of their work. Have their work demands changed? Has their posture changed? Is this a completely new situation in the neck? But I think there are cases where they come back and it is a somewhat recurring problem. Maybe they've had trauma and the joint isn't being held by the muscles well enough “ what we call a hyper mobility “ something's moving too much and that becomes a problem area and it's tough sometimes to stabilize that. We do everything we can in terms of building up the back muscles in the area of the shoulder blades to get a nice platform for that 15 pound head to be able to work on during the day, and then refresh on posture, ergonomics, helping them to be able to manage that potentially life-long problem.

Dr. Sechrest: There's a special type of neck pain that we probably should talk about for a few minutes and see if there are any differences in the way you approach patients with whiplash. It's one thing to have a patient who just sort of develops this wear and tear phenomenon, degenerative disc disease, whatever you want to call it, and just slowly develops neck pain. Then there are patients who've been in a motor vehicle accident who have whiplash, who have persistent pain after either a rear-end collision or a front-end collision, whatever. What's the difference and how do you approach those patients differently than you do the patient with neck pain that has developed slowly, what we would call insidiously, over a period of time. Are there differences?

Brent Dodge: Oh, absolutely, and part of that's in the acute phases after whiplash. We're going to have a little bit different approach in terms of our manual exam to the neck. We're of the opinion that there's likely been some stretching to the ligaments and we don't want to add to that by stressing the ligaments, so we're probably going to hold off on our stress tests, meaning where we take a ligament and try to stretch it and see if that's the pain generator or if it's leading to other symptoms. We're going to hold off for about 6 weeks to allow healing to occur. We may end up using a supportive device like a soft collar, something where they can allow their body to heal. The first line of business is support, protect, position, calm symptoms, and then later we can go back in and start looking more specifically at the ligaments through the neck. So that's probably the biggest one is our order of examination. I think from a treatment standpoint anything that we can do to help them position their neck, keep their neck from hurting whether that's, again, using a soft collar for a short period of time, to the way that they approach their task, what we call ergonomics; very specific exercises that we guide them to say, "We're not working into pain." This is all about pain freedom. That gives that whole system a chance to heal and that takes time. It doesn't happen overnight.

Dr. Sechrest: Yeah, I think whiplash could be a whole separate discussion, and I think that maybe we'll have that discussion one day. Today I think we should probably just suffice it to say, whiplash, that type of neck pain is different than degenerative neck pain, and treated totally different.

Brent Dodge: Yep. It's going to be managed a little bit differently early on and likely later on as well.

Dr. Sechrest: Well, I think we've covered a lot of the basics of treating neck pain, especially the degenerative slow onset neck pain. Is there anything you can think of that patients should know that we have not discussed today?

Brent Dodge: I would just like to emphasize again that pain, first of all, isn't normal, nor is neck pain; and if people are having neck pain that's not something they should just choose to live with. I think there's so much new technology available, and oftentimes we can find out, "Hey, this is the problem. This is the culprit." The postures you're using when you're at work, or when you're working on your hobby are playing into this, and here are some simple remedies. People find that they can get really good results in short order for those kinds of problems and I would hope that they would seek it out and get a remedy for it.

Dr. Sechrest: Well, I think you've raised the awareness of the possibilities and, hopefully, both physicians will be more likely to refer to physical therapists, and patients may be more likely to request to see a physical therapist, perhaps even just call up and make an appointment at the physical therapist. So thank you very much.

Brent Dodge: You bet. Thanks for having me over today.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.