[Case Studies] Neck pain and dizziness: unpacking a real patient case with Dr Julia Treleaven

In this episode with Dr Julia Treleaven, we explore an interesting case study on a real patient of hers who presented with neck pain and dizziness. We discuss: 

• Patient’s subjective history 
• Differential diagnosis in the neck/head region 
• Objective examination including brief overview of tests used and prioritisation of testing 
• The patient response to treatment of the neck 
• Choice of treatment for this case study 

This episode is closely tied to Julia’s case study she did with us. 

With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients. 

👉🏻 Watch Julia’s case study here with our 7-day free trial: https://physio.network/casestudy-treleaven 

Julia is a Lecturer and Researcher at the University of Queensland. She has been researching 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, and post-concussion. Julia works part-time as a physiotherapist in a private practice managing patients such as those with, whiplash, cervicogenic dizziness and post-concussion syndrome. 

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Our Podcast host is @sarah.yule from Physio Network.

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Transcript

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Welcome to the PhysioCase Study Podcast, where we are joined today by Julia Treleaven. In addition to her clinical work at Performance Rehab, Julia works part-time at the University of Queensland, leading the Neck and Head Research Unit. She is also a lecturer and clinical assessor for the Whiplash Physical Diagnostic Unit at UQ. Julia has extensive experience in assessing patients with whiplash injuries and providing recommendations for best practice management of these patients. She completed her PhD studies on dizziness and sent I'm Sarah Ewell and this is a physio case study. Music Well, welcome to the Physio Case Study podcast, where we have the opportunity today to dissect a case study so that we can hopefully elevate our own clinical practice. It's a delight today to be joined by Julia to explore a fascinating case of a neck pain patient with no doubt plenty of takeaways. So welcome, Julia. Thanks very much, Sarah. Well, let's get straight into it. Do you mind giving listeners a little bit of a run through of this case study? Yeah, so this lady, her name was Sue and she was a 58-year-old who does home duties and she'd had chronic neck pain, left-sided, a bit of headache. Her usual physio actually referred her to me because on and off for months now, she's been getting this onset of dizziness, which she described more as sun steadiness, some visual disturbances and some nausea. And she said that that was sort of increased when she was scrolling on her phone, driving on the highway, looking up and walking around the shops. Her neck pain was more related to sustained sitting and reading and a dizziness sort of tended to come and go in waves although she thought it seemed like it was always there at some point and she felt that it gradually increased during the day she was sleeping okay she'd had neck treatment and pilates and that normally helps with her neck tightness but it wasn't helping with these other symptoms that she was getting and she'd seen a vestibular physio in the past and was waiting a neurological appointment her general health was otherwise fine she wasn't taking any general medication medications. She'd had a brain scan and that was normal. And her next scan had some lower cervical degenerative changes, no past history of any trauma like with a flash or concussion. She had some vertigo before, so she knew the difference and it was BPPV and it had been successfully treated by a vestibular physio. She'd had her eyes tested and she's got some early cataracts, but no other problems. She'd had migraines in the past, although she said that these headaches were different and she usually gets an aura before her migraine all the time. She was menopausal for a few years now, and she'd had a lot of stress last year because her daughter had to have a kidney transplant. So where did you go to after that subjective? Yeah, so I guess my differential was that there was possibly a role of the neck. There were some things in there that made it sound that it could potentially be neck, but then there were other things like the fact that it hadn't changed with any neck kind of treatment that made me think maybe it was a vestibular migraine. Sometimes as people get older, they're migraines morph into vestibular migraines and she had significant amount of stress. So, you know, maybe that was the trigger for it. And then the other differential was, you know, some other vestibular or visual type problem going on that we weren't aware of, but nothing too red flaggy or anything that I was too concerned about. And so in my physical examination, I was really wanting to look at the neck really well, but from a sensory motor perspective, because she's already had neck treatment. And so it was more to see, you know, were there neck-related elements to her sensory motor control that might help put together whether this dizziness might be coming from there. So it's sounding like your differentials, that you're going through that neck pathway and then possibly vestibular migraines, because there's obviously a lot to get through subjectively. How did you prioritize your objective assessment? So I wanted to start with the neck, but the sensory motor part of the neck. And so as I was going through the tests, If they were coming out negative, then I may have added some more vestibular sorts of things as it was progressing. So I did do some musculoskeletal examination, but not as much as I would in a normal neck pain patient where I was trying to work out all the impairments. It was more initially to really look at that sensory motor stuff to see if it could be related to the dizziness and those other sort of sensory motor kind of symptoms. So I had to look at a range of motion. She had some decreased flexion, rotation, lateral flexion to the left, and it was a height. I had a quick feel of a neck and CO1 on the left. She had positive joint signs and she was stiff in the CT junction and stiff in that thoracic spine. And then I looked at narrow stance, eyes closed, and she had slight increase in sway in that AP with her eyes closed. I looked a bit walking and got her to do some large head range motions up and down. And then I compared it to fast, small movements and she didn't get any symptoms, but she got some symptoms when she did the large ones. So That made me think that it's probably more neck than vestibular. Then I looked at sustained torsion. So I kept her head in the neutral position, put her into a torsion position and with her eyes closed. And she did get some dizziness sensation when I did that. And then I just looked at on block and she got a little bit of dizziness with her eyes closed, but it wasn't as bad as the torsion. So again, that made me think there is a neck component. Maybe there's a vestibular component, but it seems like the neck's there. Smooth pursuit neck torsion test. She had had some increased saccades on the left and she was also dizzy. And she also had some deficits in trunk head coordination, eye head coordination, gaze stability. So all of those made me think there's enough in the neck. There's certainly some musculoskeletal features, enough in the neck, but also these sensory nodal features that were suggesting it was the neck. And then I didn't do joint position or movement sense because that doesn't give me any more information. So my differential at the end of that was that my Maybe there was this sparkle component. How much there was, whether it was mild all the way through to moderate, not sure. Probably complicated by stress, but she may have some visual sensitivity as well and maybe this vestibular component and possibly still keeping in my mind vestibular migraine complicated by stress as well, just if things didn't really improve. So I guess the things that made me think it could be cervical was that she reported unsteadiness. She had blurred vision. It seemed to be aggravated by a neck kind of movements and positions and eye movements. She did have this cluster of signs that were suggestive more of the neck than vestibular. And so I was happy then to go ahead and treat her neck first, thinking that it didn't seem to be any dangerous vestibular type thing. And if it is vestibular, we still want to sort her neck out first. And then that may resolve itself anyway. That sounds like a really detailed assessment. And it sounds like you were trying to replicate those subjective descriptors of walking in the shopping centre, slow movements, those sorts of things. Were you completing those tests with the subjective in mind or do you have a set list of when you suspect this cervicogenic component that you go through sort of regardless of subjective, as you said, that cluster of tests? Yeah, I guess I still would do most of those tests anyway. I forgot to mention that I did actually look at saccharin hard saccades because I just wanted to see whether it was just the eye movements with the scrolling. And she got a slight with the vertical. So I did kind of look at a couple of things that helped to replicate her subjective features as well. If there were other things, then I may have focused a bit more on the musculoskeletal side of things, but certainly wanting to sort out what might be causing these other symptoms. And so from your provisional diagnosis, what was the treatment plan? So I felt that it was definitely worth having a trial of management of the addressing the neck, musculoskeletal and sensory motor. And I'd be expecting to see as I got improvements with those things, then her symptoms should change. And if they weren't, then I would be thinking perhaps go back to vestibular migraine. I wasn't too concerned because she did have an appointment with the neurologist already booked in. So I knew that we had a bit of room to have a try and see if this worked. And yeah, and maybe if If there was no change, then I would be thinking about referring her to maybe a vestibular physio. That was going to be my next question. Had the neurologist not been booked in, what might your pathway have been and what sort of timeframes for not seeing that convincing change have been? I think even if she didn't have an appointment with the neurologist, I still would have been happy to do that. There was no sort of benign, horrible things going on and no really super obvious vestibular stuff. So I think I would be happy to see her two or three times. If I was getting improvements in her neck and her neck sensory motor tests and there was no change in her other symptoms, then I'd be probably doing some additional vestibular testing and then having enough ammunition to sort of send her off to the vestibular physio for a full assessment.

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Ever wished you could see how experts treat real patients of theirs? With Case Studies by PhysioNetwork, now you can. Watch presentations where top clinicians break down real-life patient cases, step by step, showing how they assess and treat even the trickiest conditions. It's the best way to improve your clinical reasoning and build confidence in the clinic. Click the link in the show notes to start your free trial today. I suppose subjectively,

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what sort of things from a flag perspective in this context might you have been looking for that would have changed your course of management and assessment? So I guess if she was saying that it was true vertigo, if it was not really related to any neck movements or positions, I guess the red flags that you're thinking about are things like vertebral artery dissection and VBI, and it didn't sound like any of those things, or perhaps some kind of brain brain problem, acoustic neuroma, but she'd already had a brain scan. And so fortunately, she'd had that workup, which was great. So you could almost rule out a lot of those things to start with, which was good. Absolutely. And so what did your treatment end up looking like? So on the first day, of course, that assessment takes a while. So I just decided that I would give her some sensory motor exercises and some exercises to try and improve her thoracic range of motion So I didn't do any actual treatment on that day. I gave her a home program that consisted of foam rolling. I gave her the start of just some cranial cervical flexion training because I figured that would activate reciprocal relaxation of that suboccipitals and CO1. And then I asked her to do some gaze stabilizing, some eye head coordination, trunk head coordination in the mirror. And I just mentioned stress and had she been doing that. And she said, oh, she used to use the Smiling Mind app. And I said, oh, well, you know, maybe you could have a go at that. And I asked to see her in a couple of weeks just to keep a bit of a diary of her symptoms because I just wanted to make sure that we were making some change. And if some of the symptoms resolve, they start to really pick out when they get things, you know, like, oh, it's always we're not doing this or always, oh, when my head's down or, you know, they get better at identifying it. So that's what we did for day one. Fantastic. Yeah, the diary can be very useful for filtering through what's useful and what's not useful information. Yeah. It sounds like an outcome measure for you was her diary entries. Did you use or do you use any other outcome measures typically for these kinds of patients? So you can, you know, you can use things like the dizziness handicap inventory. There's a short form. She probably wasn't getting enough to, I mean, you could have used it, but I think for her, it was probably more important to know the specific things like scrolling on a phone, you know, driving on the freeway, more of the patient specific functional tasks was much more important. And so you could get her to rate that. You could get her to rate how out of 10, 10 being normal and zero being the worst. So I could have used that. And then I use the objective things. So things like range of motion, trunk head coordination, eye head coordination, smooth pursuit, those sorts of things. And if it causes dizziness or symptoms. Fantastic. And so what did your review look like a couple of weeks later? So she was meant to come two weeks later, but she actually ended up coming three weeks later because she had to go to Canberra to see her daughter so she cancelled that week. But the good news was that despite that she came and she said she hadn't had any major episodes. She'd been doing her exercises and she really liked the foam roller. The trunk head she said feels tight. She found that she was only getting symptoms occasionally when scrolling now, not all the time. She had one actual migraine with an aura prior but she hadn't tried freeway driving. She was still a bit nervous to to do that, and so she had tried that. So on her physical examination, she still had some range of motion deficits, still positive joint signs on CO1. I also found that her rib on that left-hand side, first rib, was stiff as well. Her deep neck flexor pattern was improved, and so she was getting to 22 with her activation. And walking with large, slow head movements up and down, she only got slight symptoms. Trunk head coordination was okay now, same with gaze stability. Her eye-head coordination had improved and her smooth pursuit, she still had some increased saccades on the left. So that kind of suggested to me that the things that she'd been doing had helped her symptoms, which is good. And also that coincided with objective improvements in her cervical sensory motor control. So that I thought was a good sign. And so I was happy to continue treating the neck and then again, seeing the response to the treatment. What did your neck treatment look like? Yeah. So today, because I had more time, I did want to actually treat the musculoskeletal system. So I had to do some needling. And so I did some dry needling in the upper trap, lobatus gap and that CO1 on the left, and then did some mobilizations at CO1 and also mobilized her first rib, her CT and her thoracic spine. Her thoracic spine was better, but still stiff. And then I checked all her exercises and then I added to her home program to do walking with head movements. So those large range slow head movements. I added bow and arrow to try and get that CT junction mobilization and then some cranial cervical flexion holds. And again, I asked her if she could try some freeway driving for me. She was a bit nervous to do it, but I sort of said, look, if you can, because her husband had been driving her. So I said, look, if you can, could you drive and get him to obviously be in the car and then if you need to, then you can pull over. Yeah, that was the next treatment. So things that went well, things that didn't go well? Yeah. So I think it went really well, this one, which is great. And you know, it doesn't always, but I think it did well. And the other thing that really went well is that she did her exercises. She was really diligent and she, if patients don't do their exercises, especially in this case, especially in that first week, all I did was give her exercises and But also, I guess, you know, just reassurance that we were onto it. I did talk to her about the possibility of vestibular migraine, you know, as a differential. So this doesn't work. This is what we'll do. So sometimes just having that advice and education and reassurance just helps with symptoms as well because I don't get so freaked out by them. Absolutely. It's sounding like that combination of factors required for success. It's that patient compliance. It's the accurate and thorough subjective, objective, and therefore treatment. And it also sounds like you haven't overcomplicated your treatment, which is certainly an art and a skill in itself. It's distilling the complex down into something that is not simple, but at face value can seem simple, but is the product of a really thorough and accurate subjective and objective approach. Yeah. So what would your thoughts be in terms of what listeners can take away from this type of patient presentation? So really, I think the key for her was the sensory motor stuff. That was a turning point. If I'd just done manual therapy and needling and musculoskeletal treatment on the first day, it may not have gotten very far. It might have, but may not have. So I think that's the thing is if you think it's cervical sensory motor, then probably address that first. I think those are some fantastic takeaways for listeners as well, because there are lots of things to consider when those sorts of presentations come through. So if you're Thank you for running through a fantastic case. I think there's lots of takeaways in that. Oh, good. I hope people can get something out of it. Yeah, and all the best with their treatment of these patients because they're really interesting. Absolutely. Thank you so much, Julia. Thank you.