Show Notes:

20: Whitney and Til discuss assessment and treatment considerations unique to working with the neck and cervical region; how their respective training programs are adapting to the challenges of COVID-19; and much more. 

In this episode,

  1. Neck issues: shifting from tissue fault to nociceptive driver 
  2. Can we treat the neck in isolation?
  3. Thoughts on “text neck,” and more. 

Get the full transcript at Til or Whitney's sites!

Resources discussed in this episode: 

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Your Hosts:

Til Luchau Advanced-Trainings        whitney lowe
Til Luchau                          Whitney Lowe

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Your Hosts:

Til Luchau Advanced-Trainings
Til Luchau

whitney lowe
Whitney Lowe

Thanks for listening and subscribing to the podcast! Make sure to connect with us on Twitter, Instagram and Facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on Apple Podcasts!

(The Thinking Practitioner Podcast is intended for professional practitioners of manual and movement therapies: bodywork, massage therapy, structural integration, chiropractic, myofascial and myotherapy, orthopedic, sports massage, physical therapy, osteopathy, yoga, strength and conditioning, and similar professions. It is not medical or treatment advice.)

Full Transcript:

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The Thinking Practitioner Podcast:
Episode 20: A Pain in the Neck: Cervical Challenges and Strategies

Broadcast date: 8/5/2020
©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe

Til Luchau:

Hey Whitney. What's up? 

Whitney Lowe:

Good afternoon sir. It's a hot afternoon in central Oregon here but looking forward to having a good chat with you today and that will be cool.

Til Luchau:

Likewise. Cooling off. Okay, so I'm hot here just outside of Boulder too, but looking forward to our conversation. We wanted to talk about the neck. Before we start, the neck and the cervical region. Before we start, I have to confess that about a year ago I was sitting at my treatment table working on somebody and the thought went through my mind, maybe I should just specialize in the neck only. Maybe I can be like a neck only practitioner and just sit here at the head of my table all day and just do necks. 

Whitney Lowe:

Right. 

Til Luchau:

I love that thought. 

Whitney Lowe:

Yeah. While we're in the midst of confessing, I'll make a brief confession here too. This was early on in my massage practice. I have a tendency sometimes to keep some very weird hours and I get sleepy in the afternoon, especially like right after that lunchtime time and I was working on somebody one time ... It was one of those ... I was back in the south. This is back in the hot Georgia afternoons and I was working on somebody and I dozed off while I was working. 

Til Luchau:

Oh my god. Yeah. 

Whitney Lowe:

It's that same sitting in the chair. Oh, this feels so relaxing. The stuff that I was doing working on the neck and everything. I just did a little head nod thing. Okay need to pay attention here. 

Til Luchau:

Okay, I got to tell you this story. It's not what we planned but I can't not tell you this. One of my colleagues in Italy tells the story about doing that. Actually falling asleep doing some really quiet cranial work at the end of a session. Jerking awake and his client said, "That was amazing. I've never had anything like that happen before." So he actually started incorporating that into his sessions as a closing technique. He put his hands on the client's head, put his head down on the table and take a little miniature doze at the end. 

Whitney Lowe:

Something magical happens during that period I think. 

Til Luchau:

Yeah. Maybe I'll put that as a book in our technique manual. 

Whitney Lowe:

Okay. It's an entrainment technique. 

Til Luchau:

That's right. But anyway, that's not what we're going to talk about. I wanted to find out something about the ways that you're working with the neck in your program. The way you assess it. How you're thinking about that whole region. And then we also wanted to talk about how we translate that online. 

Whitney Lowe:

Yeah. 

Til Luchau:

format. 

Whitney Lowe:

Yeah. Some modifications and tweaks and changes going on for lots of folks these days. So yeah, we'll talk a little bit about strategies and content too. That sounds good. 

Til Luchau:

Strategies, content, and how to learn all this stuff online perhaps. I'm looking forward to hearing a little more about what you do because we have these conversations but I don't get to know your work very well so I'm looking forward to digging into that. 

Whitney Lowe:

Okay. Let's do it. 

Til Luchau:

So what would you say are some of the more challenging factors in assessment and treatment for this region we're talking about the neck and cervical region? What would you say? What are the challenges? 

Whitney Lowe:

Yeah. There's some very significant challenges around identifying I think sort of like, what is the ... In the old days they used to think of this as what is the primary problem tissue, but now with sort of a lot of the new things that have come out, understanding and focusing on pain science and some revisions of biomechanics, and I like to think of what is the primary nociceptive driver instead of maybe like, what's at fault? They may be the same thing but sometimes they're not the same thing. 

Til Luchau:

So let me see if I get that distinction. You're saying, what is driving the sensitivity or nociception as opposed to what's driving a particular tissue quality or density, et cetera? 

Whitney Lowe:

Yeah, because I think formerly I was always looking for a tissue at fault having been injured, damaged, dysfunctional or something like that. And while that the may be the case in many instances, I think now I try to keep a little bit bigger tent and a bigger picture of this and think about them in terms of what is the sort of ... If the client says, "Hey, I turn my nick to the side and this makes it hurt." We try to identify what is it that's doing that that's making it hurt. And that's really essentially what the nociceptive driver is. But it may not be a muscle strain, a ligament sprain, a torn tissues, a nerve compression. It might be, that's the movement that has caused them pain from a previous injury and now it's sort of reestablishing or firing back up the neural irritation or something like that. So we think about that as a nociceptive driver more so than just what's the damaged tissue per se. A big challenge with this in the cervical region, it's a lot harder I think in the cervical region than many other parts of the body because of the complexity of the muscles in particular that lend movement in this region. 

So for example, let's say comparing this to something like the knee or thigh region where your motion is really simple in these pretty much straightforward planes. Motion in the sagittal plane of flexion and extension of the knee. If something hurts on your anterior thigh it's pretty easy to narrow that down to structures that are going to be somehow or other stressed during those motions of flexion and extension. But in the cervical region, this becomes really complicated because of the coordinated action of these muscles because you have muscles that are ipsilateral rotators and some that are contralateral rotators. And for example, for those of you who may be not as familiar with those terms, ipsilateral rotators referring to those muscles that are on the same side of the neck as you're turning to. So for example, something like the splenius capitis muscle on the right side turns the head to the right. But the SEM or sternocleidomastoid muscle on the right side turns the head to the left. So you've got to be thinking about those different movement patterns when you try to isolate which motion reproduces the discomfort a person's feeling and where do they feel it. And that can get pretty messy trying to tease those things apart. 

And I think that's one of the things that kind of keeps people from zeroing in on what really is the problem region or problem tissues or structures or nociceptive drivers, whatever we want to call them, as easily. That's a pretty challenging thing. That's one of the things that I've been looking at a lot over the years is how do we try to simplify that process and give people some tools for looking at that more effectively. And we'll catch up, touch base on a few of those strategies in the second half when we talk about some of those strategies. So those are some of the things that I see as particularly challenging. What about you? Challenging factors in-

Til Luchau:

That's good. Just this first idea you brought up for us that sensitivity is different than tissue quality. Or at least you're thinking about them as independent factors. That's really helpful for me too in both my work with clients and in training with students. To really tease those apart. And it's really rare that a client comes in and says, "Hey, I got this funny stiff spot in my neck that I felt with my hand and I really would like you to help me soften that." It's rare they say that. They come and say, "Hey, I've got this stiff movement. When I turn my head it hurts." So I'm actually thinking I want to impact what the client experiences, which is much closer to the poin experience than say the actual tissue quality per se. So I'm with you on that. And that is a challenge because most of our training had us orienting toward what is the muscle, what is the tissue that we want to target, and which fascial layer say, do we want to target to get desired results? 

So I think though that I found pretty simple ways around that and the simple way around that is probably somewhat what you're using. I used the movements as an assessment. I want to find the movement that's sensitized or the position that's sensitized and use that as our touchstone or as our guide as we work through the neck, say, joint by joint. That's the first challenge. The second challenge is, it's tempting, like the temptation I had at my table, just to think about the neck in isolation. And the neck like nowhere else in the body responds to what else is going on in the body. So the neck is what we use to right the head with, it's what we use to adjust our perceptive apparatus with and so it's all the time adjusting and adapting to what's going on below. And so often it's easy to get that narrow focus on what is hurting in the neck and forget to step back and go okay, so how does the neck reflect what's going all the way up and down in my spine, the way I'm sitting in my chair or the way I'm even standing, like the leg for example. 

Whitney Lowe:

Yeah. So what do you see as like, some of those sort of connective patterns with different regions? Are there any of those in particular that you think are really important for us to focus on in terms of when we have somebody that comes in with neck complaints? Are there places that you go to say well, we definitely want to look at this also and see how much that's related or do you-

Til Luchau:

That's such an important question and it's the one I get from students that I never quite know how to answer because the only real answer is everything. The only real answer is everything. Because things are so interconnected and because we function as an interconnected whole, I can't predict with any reliability, even after 35 plus years, whatever it's been, where exactly I'm going to have to work in the body to help the neck feel better. I can say, here's some things that I want to make sure that I've also stepped back and looked at. One are spinal curves and spinal movements. How does the spine move in its entirety? The neck is part of the spine and if I'm not mobile or not comfortable in let's say my lumbars, then it's pretty predictable that's going to show up the neck somehow too. So one is spinal issues. The other I could say was jaw. The neck and the jaw are really a functional pairing. And just the way that we hold our jaw or let our jaw go or what we do with our mouth as we're using our head is going to have a big influence on the neck as well too. 

Now I could go down the list. And then it goes to the eyes. Then it goes to the arms. The arm and the shoulder girdle to be part of the picture too. But how about you? How do you keep that big picture or how do you deal with those challenges that you see? 

Whitney Lowe:

I would say very much in a similar way and I wanted to call attention back to something you mentioned a moment ago and just kind of maybe discuss this or talk about this because it's something I don't hear talked about a great deal. But what you mentioned when we were talking about related areas and you talk about the jaw and its similarity to what's going on with the neck region. This seems to me an area which does not get taught very much in most of our at least entry level training programs and certainly in very few advanced training programs too and it's a pretty complex biomechanical area. And I do think like you mentioned, there's a lot of relationship with what goes on in the cervical region and I wonder how many things kind of get missed because people aren't sort of looking at some of those kinds of relationships because that certainly is pertinent here. And then of course the entire upper extremity has a lot of relationship with what's going on in the cervical region especially because of neuro pathways from the neck down to the upper arms. So just the whole biomechanical kinetic chain from the upper extremities through what's happening in the upper traps and into the cervical area too. So a lot of those things seem also very, very related with what-

Til Luchau:

Eye hand functional patterns. 

Whitney Lowe:

Yes. 

Til Luchau:

The ways the shoulder girdle drapes around the upper thoracic segment. All those factors play into the fact of the upper extremity and the shoulders being a really relevant factor whenever there's neck pain. 

Whitney Lowe:

Yeah. So when we look at this in terms of how do we try to address some of these problems, I would say that I've been less inclined to want to look for a solo cause and more frequently, like you mentioned, look for broad scale patterns of things that might be relationships in there. But there are also instances where I think it's valuable to look at. Can we nail this down to something that looks like it might be a more singular type of thing that you need to pinpoint some specific focus and attention on? That certainly has been my rationale and reason for putting so much emphasis on assessment is that it seems like there are times when it is particularly helpful to do that. And when you're looking at certain types of evaluation procedures and things like that. 

Til Luchau:

Do you have an example for us? 

Whitney Lowe:

Yeah. So for example, trying to make some discriminations. When let's say a client comes in and says they have a sharp kind of neurological sensation in the neck that seems to be maybe going down the upper extremity, and we're trying to make some distinctions between the potential possibility of cervical or nerve root compression by let's say disks or bone spurs or spinal tumors or something like that, versus a more peripheral nerve entrapment problem in the neck region possibly still like in the thoracic outlet area there that might produce ... Both of those would produce neurological sensations down the upper extremity. But your treatment approach would vary significantly in addressing those things. And so that's one of the reasons why I still do think it's really valuable in a lot of instances to try to pinpoint some of those things when possible. 

Til Luchau:

So you're saying, is it the quality of pain that would help you discriminate between say those different conditions you named? 

Whitney Lowe:

Those would be really difficult to identify by quality of pain. Now for example, making a distinction between something like a muscle strain versus a nerve compression problem might be a little bit more easy with quality. But the others that we mentioned-

Til Luchau:

What are some of the qualities people would see that would cue you in? 

Whitney Lowe:

The tendency is with neurological sensations for people to report very sharp, highly delineated sensations. Burning, searing, electrical kinds of things are some of the terms that they might be tending to use. And then the pattern of where that's felt. Like in particular is it down like on the back edge of the ulnar side of the hand which would tend to indicate some ulnar nerve involvement versus something else that might be a different specific nerve. So knowing some of those patterns and where they would tend to occur with the symptoms, that's particularly helpful as well. If it's a broader pattern throughout the whole upper extremity then we might be looking more specifically at something closer to nerve root level where several of those never roots are feeding different portions of nerve structures or maybe it's something else again. So looking at those quality of sensations might be helpful. But like what we were talking about before in terms of making that distinction between something like cervical nerve root involvement versus something in the thoracic outlet, that's where biomechanically stressing those different areas with different evaluation procedures and see does one of those irritate those symptoms more than the other is particularly helpful to make those kinds of comparisons I think. 

Til Luchau:

So you'll do some gentle pain provoking tests to see what movements and where that pain gets provoked? Is that right? 

Whitney Lowe:

Yeah. Right. 

Til Luchau:

Yep. Great. Me too. 

Whitney Lowe:

Which, it's interesting, I think there's a lot of people have had sort of challenges understanding this whole idea of like, why would we want to make our clients have more pain? The whole point is you're trying to identify what is it that really lights this up so you can know where are you going to target your approach essentially.

Til Luchau:

That's true. 

Whitney Lowe:

I think that is still very helpful there. And what you said a moment ago. Gentle pain provoke or something along those lines of gentle pain provoking procedures. Not go in and wrench somebody's injured area around until they scream. That is certainly not what we're trying to get at. 

Til Luchau:

Well it's an exploration and really getting the client in that frame of mind so that we're looking together for what movement exactly does make it hurt and when and how much and what's the quality? So that investigative attitude. And then once we find out that movement or that place, then that gives me lots of ideas about how to work with it. 

Whitney Lowe:

Yeah. Yeah. 

Til Luchau:

Sometimes just with the actual movement itself. We might back it off and play with that. Turn that into a gentle mobilization or desensitization kind of intervention or something to play with together.

Whitney Lowe:

Yeah. And I think what you're talking about there too is also such a key part of so many of our different treatment strategies is finding those things that can help restore and move towards pain free movement in a variety of different ways. And you may not always have to know exactly what did it, but you know some things that make it better and you can reinforce and help those. 

Til Luchau:

That's an important distinction too. That a lot of times on the table even we can find things to change it. Once we gently provoke it so we get some sense of what's the irritant, then we can tease it apart with our touch or with our movements or with our awareness. And that's really what they're after too. They want a way to change it. 

Whitney Lowe:

Yeah. 

Til Luchau:

Yeah. 

Whitney Lowe:

I still do believe that at least for me in my perspective, and this is probably just the way that I look at things, that it is valuable still for practitioners to have an understanding of some basic principles of biomechanics that help get us there. Like for example, just the very idea that when a person comes in and says, "My neck has been hurting me and it hurts especially when I do these movements," and they lie down supine on the table, that alone has changed the mechanics in their cervical region pretty significantly. And that can lead to something that really makes some beneficial and significant change for them just by changing the load on there. So it's important and valuable to remember those things as we look at what we're doing in there. 

Til Luchau:

So that's also an important point. If you can't find the discomfort, if I can't find the trigger while they're lying down, sit them back up. Sometimes that's useful too. But yeah, what you're saying is very true. Just lying down is a therapeutic intervention and just mobilization in that supine position or whatever position you're using can be really helpful. 

Whitney Lowe:

Yeah. And there's a caveat on that. I would also encourage people when you're thinking about this from the treatment perspective and working with your clients especially if they have had some significant neck pain coming in, you do some work with them. It feels really good. You've gotten them looser, they feel wonderful and they feel like they can move more freely. Give them some important coaching about how to get off the table because you're not going to be in the room very likely when they do that to get up and get dressed. Let them know it is really important that they move slowly and carefully at the outset because there's that sort of radical change in proprioception that has occurred during the treatment that all of the sudden the body may not have those patterns organized yet. And we see this frequently where people get up and they go back into a sudden spasm or a super contracture because they just moved a little too quickly or moved a little bit in an odd pattern or direction there. That's an important one I think to keep in touch with with our clients. 

Til Luchau:

Those are good points. Those are good points. There was a thread recently on one of the Facebook groups about learning more special orthopedic tests. Think this is one of the massage therapy threads. That's something that you've been doing for a while. That's like your bread and butter. Where do you see those special orthopedic tests fitting in with treatment sessions when you're working with neck complaints? 

Whitney Lowe:

Yeah. My perception about the value of those tests has changed a lot over the years and I think my personal opinion is that a lot of practitioners put too much emphasis on those procedures and see them as a bit simplistic in terms of the evaluation process. So for example, you may have a really beneficial special orthopedic test that's designed to highlight the likelihood of a certain type of complaint being present. But you can't just go right to that procedure performance and say oh, okay, well that must be what's going on because this hurt them, without taking into consideration the entire context of what was in their history. What did you see during observation? What's happening as you palpate these tissues? What motions and movements are painful actively, passively? All of those things are a big picture that should then give us a wrapper with which to understand and interpret the results of that orthopedic test. 

Because too often people I think put too much emphasis on those tests and then don't think about the other things that are pertinent around there. And the reality is there's a lot of these procedures that don't have great reliability factors to them in terms of accuracy. So they shouldn't be taken alone in isolation but really used in conjunction with those other forms of evaluation I think to form an overall picture. I like to think of them just as one of a number of clues that we want to pursue. 

Til Luchau:

Okay. So you're saying specific tests such as ... Give us an example of a special orthopedic test that we need to remember in this-

Whitney Lowe:

So a really good example of that in the cervical region is you have the common condition that we hear a lot of people complain about of thoracic outlet syndrome. And one of the most common evaluation procedures, special orthopedic tests that's used to evaluate that potential problem existing is something called the Adson's maneuver. Where you feel a person's pulse and you put their shoulder and neck into a certain position, you see if that changes the intensity of the pulse indicating a compression of the neurovascular structures in the cervical thoracic outlet region. That particular evaluation procedure despite the fact that it's used a great deal has a sort of mediocre level of reliability just because there's a lot of false positives. And so just relying on that alone can take you down a wrong path I think. And so this is why we want people to be the thinking practitioner. There's a plug for our name again. 

Til Luchau:

That's our podcast. Yeah. That's interesting that you say that because I used to teach that in my thoracic outlet class. And then I stopped. Because it turned out that no matter what the results ... It's fun. It's fun to do that testing. It gives us a sense of oh, there it is, we caught it. But in the end we're going to go do the work anyway and see if it helps. So that the work becomes the actual test. The work becomes the pragmatic test. Can I affect the symptom? Can I affect the sensitivity with this particular approach? And that's the test and guess what? If the results are negative I can't affect it, then I try a different approach. And you change tacts. 

Whitney Lowe:

Right. 

Til Luchau:

That's the evolution in what you just talked about. 

Whitney Lowe:

Right. On the flip side of that I will say there is other types of procedures. Something like the upper limb neural dynamic tests that are used a lot in the neural mobilization techniques. I find those to be really valuable because they can help you narrow down where you might be looking at a problem. Even if it doesn't tell you exactly what's happening, it really does add in a lot of valuable information about where some neuro mobility might potentially be restricted. And so that's an example of something used again, in conjunction with a lot of other information that I think can provide some valuable clinical fodder for us. 

Til Luchau:

Well, I was hoping you would actually share at least one of your tests with us. Actually tell us how to do that. Would that be a good one? 

Whitney Lowe:

Sure. That would be a good one. It's a little difficult from just the audio only version but tempting to explain here the idea behind a neuro dynamic test is neural tissues need to have a certain degree of mobility to them. And there's all kinds of things that might limit that. The common nerve compression problems like cervical disk impingement or thoracic outlet syndrome. And again, when we say thoracic outlet syndrome, we may be talking about a number of different variations where those nerves are potentially getting compressed between anterior and middle scalene muscles or underneath the clavicle or underneath the pec minor. Those are all variations on that. But again, there's multiple locations throughout the pathway where you might see that occurring. So in a neuro dynamic test it's a procedure that has a sequence of movements that gradually add tension to the nervous system and will eventually end up in a position that fully lengthens that nerve as much as possible. So you add each one of these sequential positions and see are their symptoms increased at each step? And then you go through a series of procedures. Some of them involve stretching more in the neck region. Others involve stretching more at the distal end of that nerve down near the wrist and hand. 

And it's really valuable to kind of look and see where are those symptoms aggravated the most. And then you can take that and reverse the order. Like start at the hand first. Stretching them at the hand first. So here's an example. If you did one of those neural evaluation tests and you got some symptoms down into the hand and you started stretching the neck region first, then you stretch the shoulder region and then you stretch the arm and down into the hand and you've got some symptoms aggravated. Yeah. 

Til Luchau:

Yeah. I'm trying it out. 

Whitney Lowe:

So then might this be something where like a neural involvement there. Like maybe the median nerve is involved or something like that. Well, let's go backwards. Start at the hand first and if those symptoms are aggravated first when you stretch the hand before you even start getting to the neck, that's a pretty good indication that that's probably close to the region where those neural tissues are either bound or restricted to some degree as opposed to up in the cervical or upper shoulder area. If you don't get any symptoms at all in the hand-

Til Luchau:

Let me catch up with you there. 

Whitney Lowe:

Yeah. 

Til Luchau:

And I know I'm probably over simplifying, but let me see if I get it so far. If I can do a stretch ... And you have some fairly systematic ways to check that. But if I can do a stretch that makes the symptom get worse, the nerve symptom, the tingling and numbness, either with my head or with my hand, then you're saying I can break that down and kind of reverse engineer that starting systematically at one end or the other, and re-mobilize or at least specify where that unhappy nerve might be occurring. Is that right? 

Whitney Lowe:

Exactly. And again, keeping in mind this is not an absolute process that you can rely on that's not going to have any flaws or confounding factors because it's not an exact science. 

Til Luchau:

The nerves aren't even an exact linear structure either. 

Whitney Lowe:

Yeah. 

Til Luchau:

And I should just say from my point of view, sometimes it's compression as you mentioned. Sometimes it's tethering. Things just don't slide like they might. Interface issues between two surfaces that don't slide as much. There's some good evidence that sometimes it's actual inflammation of nearby structures that are causing the nerves to be sensitized to those movements as well.

Whitney Lowe:

And that's exact where things like your history come into that as being an important factor because you might want to identify, well maybe there's previous injuries in a nearby area or maybe there's some type of systemic inflammatory disorder a person is grappling with and that might be making those nerves more sensitized. So if you just jump to that orthopedic test alone without taking in those other factors, you miss important pieces of the puzzle. 

Til Luchau:

This is such a important point. Such a challenge too for me as an educator. And I think it works out. But really there's this drive in all of us to get the technique to know exactly the one thing I can do and to try to reduce it down to tangible variables that give me a sense of satisfaction when I observe them. And then the promise that when I treat them, things will be better. 

Whitney Lowe:

Yeah. 

Til Luchau:

And of course sometimes it's like that. And a lot of times it's not. And that's where the mastery level really comes in. When I can take all of those understandings and simple tangible tools and weave them together into a treatment approach that does bring out all those contextual variables and those more complex things that you've mentioned. 

Whitney Lowe:

Yeah. And we have ... I guess this is just a human nature thing. But I know I'm certainly far more susceptible to this because I'm kind of a left brain analytical type of person. But we have this tendency to want to put things-

Til Luchau:

You? 

Whitney Lowe:

Sometimes. Some days. 

Til Luchau:

Okay. 

Whitney Lowe:

Yeah. We do have a tendency sometimes to want to kind of organize, categorize and compartmentalize things into discrete sets of things that we can deal with and think about. So that what leads to ... I think a lot of times people simply have pain in the neck problems that might be multifaceted from a lot of different directions but we like to put them into some narrow box or category like we hear nowadays a whole lot about text neck. So that's a good example about just because people are sitting on their phones with their head down a lot. But there's a lot of similarities between that and typesetter's neck and cobblers neck. And all those other occupations that people had for many years where they were doing the same sorts of things. So is it about texting or ... What do you think about text neck? It's a big thing that we hear about these days. 

Til Luchau:

Do we got time to go into that before our halftime? 

Whitney Lowe:

I'll tell you what, why don't we ... We'll take a quick break from our halftime and then we'll talk about text and we'll pick it up with text neck after that. 

Til Luchau:

I'm for that. 

Whitney Lowe:

So our halftime sponsor today we're going to hear from Books of Discovery. So Andrew Biel the Author of Trail Guide to the Body's going to give us a quick little note about some offers from Books of Discovery. 

Andrew Biel:

Books of Discovery might be best known for producing Trail Guide to the Body but we're also a whole lot more. We bring you the clinical learning tools you need to inform your intentional bodywork. Check out our kinesiology, pathology, and A and P texts. They not only build the foundation upon which great educators like Til and Whitney rely, but will also support you through your entire career. Books of Discovery is proud to support The Thinking Practitioner and are offering a 15% discount when a listener enters thinking at the booksofdiscovery.com checkout page. Enjoy the show. 

Whitney Lowe:

And thank you to Andrew Biel and Books of Discovery for their support. We certainly appreciate you supporting The Thinking Practitioner podcast. Do be sure to checkout their great offer and the multiple wonderful resources that they have available there. And while you're reading your book, make sure you don't get book neck while you're sitting there reading. But we were going to talk about text neck here. 

Til Luchau:

Text neck. 

Whitney Lowe:

Yeah. What do you think? Is it a thing? 

Til Luchau:

Is it a thing? Is text neck a thing? Yeah. I think it's a thing. Like you were alluding to in some of your comments about cobbler's neck et cetera, there's a lot of things. And is text neck a new level of threat to our existence as humans? I'm not so sure. And I'll put it in the show notes because I don't have pulled up right here, but there's some really interesting research that's tried to tease this apart. Is text neck or neck problems more frequent in people who text a lot? It's not a closed question. There's studies that proponents and opponents of that point of view use to argue both sides of that. Seems like that we're not having a huge epidemic of heads falling off or et cetera from people texting. But maybe there are some ... You could probably kind of commonsensically predict, there are some impacts the more time you spend doing one thing and not others. There are some definite impacts of that. 

Whitney Lowe:

Yeah. 

Til Luchau:

So I'm probably a little more liberal or tolerant in my thinking you could say around texting. Especially after having fought that battles with my own son coming through his teenage years and seeing that his head did not fall off and he's basically a great young man. But then it's also this question, can we adapt as humans to what we're doing? Yeah. Adapting being the key. And maybe variety being the key there as much as don't look down to text. It's like, make sure you do some other stuff besides that in your life. 

Whitney Lowe:

Yeah. 

Til Luchau:

That's what it comes down to.

Whitney Lowe:

So, I got to follow this for just a second because you mentioned something that caught my ear and I was thinking about this. I hadn't really thought about it this way very much. But so much I think probably of the concern around something like text neck does happen because we see so many young people spending a lot of time on their devices during the time when they're in their really formative neuromuscular programming stages. So sure, there's a lot of occupations where people had to tilt their head down and put their head down like I was mentioning, but maybe it's a bigger concern because we're dealing a lot with people during their biomechanically formative years when they're establishing a lot of these neuromuscular patterns and maybe that does lend to a more longterm propensity for some of those posturally driven neuromuscular skeletal challenges somewhere later on but it may be too early to know what that's really going to look like when those people who've been texting a lot are in their 50s, 60s and 70s, et cetera. 

Til Luchau:

Yes. That's right. And my son, from his sake, he says no. Now that he's 21. He's saying no. Kids should not be texting all the time. He doesn't put in the part like I was when I was that age. But it's true that ... Well I don't know if it's true. But it's a useful point of view to say, everything is bad in the wrong dose. It's more of a dose question and the variety of life kind of question that comes up there. Including the kind of attention and intelligence and impulse gratification that happens on your device. That's an even bigger topic. Those are wonderful things and maybe we need other inputs. Other ways of thinking and being as well too. 

Whitney Lowe:

Yeah. So we also wanted to look at this from sort of the teaching angle as well since we have a situation now where lots of people are not doing classroom courses because of the covid-19 situation and we're all having to kind of look at new strategies or methods. What kind of things have you been doing, changing, tweaking, et cetera? I know you've had some stuff with a cervical course that you did recently and some really innovative kinds of teaching strategies. What kind of things have you-

Til Luchau:

Well we're just wrapping it up now. It's a two month live online course that's a hybrid model where people watch demonstrations of me working. We do that by recording. And then they listen to a live lecture of me talking about the principles involved. And then they meet in a small group to discuss their questions, their successes or challenges in applying the work. Some people are practicing so they get a chance to go actually do that. Many people have a practice partner or someone they can try the things out on. But then we also are working with adapting the work into self care techniques. Those are some of the homework assignments is to take what they see as a hands on technique and use it for something that they can do or feel or experience or learn about at least themselves. And then we get together and share those things real time. And it's proving to be really rich and really detailed.

Whitney Lowe:

So here's the question I have. When this is all over, do you foresee this as something that you might keep trying to do to some degree or do you feel like you will go back to doing things exclusively ... Well, you weren't doing things exclusively in the classroom to begin with. But do you think you'll incorporate some of these kinds of models in some of your-

Til Luchau:

Oh, without question. Without question. And the students and participants and professionals in the training are saying that too. They're saying, "I don't want to learn without this kind of interaction over time again because it's really allowing us much deeper discussions on a more theoretical level, but also on the experiential level than just say a weekend intensive would. Or longer in person training."

Whitney Lowe:

Right.

Til Luchau:

But how about you Whitney? I know you've been working hard on your platform and you're a forward thinking guy. How is this whole scenario changing the way you teach and how is that manifesting in what you're offering?

Whitney Lowe:

We actually just launched a new, completely revised and updated cervical course for an online platform that's been around for a couple of years. But the big change in this is that our goal in doing this whole updated was to try to take a lot of the content that was in my assessment book and integrate that into the online platform so that it was part of what was going on in the course. And one of the things ... This kind of gets back to our discussion earlier on when I was talking about some basic principles of biomechanics. One of the things that I had found being a little bit frustrated with over the years past of trying to teach a lot of stuff was trying to find some tools to help the students understand more about ... Let's say a person says with their neck, "Well, it hurts when I turn to the right." What's happening when you turn to the right? What's happening to all these different tissues? One of the things that we did in this new course that we were putting together is I made these charts that were ... I mean, they're very complex and very tedious, but I think really helpful in the clinic, that break down, for example, every motion and all the major potential tissues that are going to be either pulled, stretched, compressed or what's happening to them in those motions.

So for example, we take active rotation to the right and then list out in a chart what are the tissues getting stretched during that motion, what tissues are getting compressed, what tissues are passively shortening, which tissues are passively lengthening, that kind of thing. So people really have a map essentially to go to to figure out what might be the cause of certain pain problems. And then we take those charts and have another series of charts that take those exact same motions and say during right rotation if the person has ... Or let's say active right rotation. If a person has pain on the left side of their neck during active right rotation, what might be causing that? And breaking that down into those different things and they can match that with those other tissue structures to look at what was happening with them.

So by the time we get through with all these courses, this will be a huge series of what I hope to be kind of very helpful, quick reference charts of understanding the biomechanics of what's happening in every one of these different motions throughout the body.

Til Luchau:

Sounds comprehensive. So if I have your chart, do I need your training?

Whitney Lowe:

Well, it helps, I think, to take that training to understand what to do with the charts. Because the other thing that we do with the charts is we use them as kind of the structure of how to look up and start thinking about these things. But then the more complex process of this is helping people understand how to decipher patterns. So for example, in the neck region a person has pain with active forward flexion, passive extension, and resisted extension. Like that pattern of those things. What does that mean? And that's not really one single place to look that up in the chart. That's kind of putting different pieces together and we do a lot of activities in our course to try to get people to look at those kinds of patterns of evaluation and then see what they might be pointing to and then of course how do you figure out what to do about it. That's the big question we all want to know.

Til Luchau:

You showed me some of the earlier versions of those and I was impressed with the logic and the systematic use of those different movements and concepts. And I can really see them laying the groundwork for some in depth training together and building that critical thinking process to understand the logic involved and how to employ that clinically.

Whitney Lowe:

Yeah. And different people will drill down to different levels of depth with it. I find that stuff really fascinating, but I know not everybody is that much of a biomechanics geek about all those kinds of things. But take it when you have a client that has a certain type of thing and be able to go back and know where you can get that information when you might need to access it and have it be helpful. That's the kind of thing that I hope to be a real more effective and useful tool for people.

Til Luchau:

And how do you see that playing out online? Why did you choose the platform you did? What opportunity does that give you? That kind of thing.

Whitney Lowe:

Well, mainly it's because ... And that kind of goes back to my whole theory and process of why I went to doing stuff online to begin with, which this kind of complex clinical reasoning stuff is really difficult to teach in the two day weekend workshop format. So we went to asynchronous, online learning strategies because I like to build a lot of these activities that can be spread out over time and students can practice, get feedback, make errors. But errors are a really important part of the learning process. And then have immediate feedback. So in the online modules when they're doing things and a question asks them what kind of problem might have these group of symptoms and they answer a question, they get immediate feedback popping up about whether or not they're correct or incorrect and why. And that is so, so very important for really getting the learning at the moment.

Til Luchau:

That's fantastic. And you say that's asynchronous, meaning I do that on my own time?

Whitney Lowe:

Yeah.

Til Luchau:

I go and do that on my own and I can work through these problems and get that immediate feedback on my own?

Whitney Lowe:

Yeah. Exactly. And then put it in smaller chunks. Because a lot of people like to just, "Okay, my client didn't show up. I got 30 minutes that I'm not busy. I can go do something right now." As opposed to when there is a designated time period to come together and do some things. There is clearly value in both of those different types of strategies, but I really found a lot more of the complex clinical reasoning processes and things like that were most effective when we did those in asynchronous types of environments.

Til Luchau:

That's what we're finding too. We're having more detailed, conceptual discussions and understanding I think is deepening. We're also getting a chance to go try things and bring them back for more discussion and interaction. So there's a lot of advantage that's coming in being able to be more engaged online. And we've just got to acknowledge ... I don't know how you think about it. We've got to acknowledge the limitations. This is not the same as in person learning and there's a whole in person component that we need to find and build into this process to really make it holistic.

Whitney Lowe:

My hope for the future is that what this really helps us do is to build some really high quality hybrid learning approaches. Because there's no question each one of these learning strategies has its advantages and disadvantages. I still don't think, despite the innovative ways that people have been attempting to do things, that it's the best way to teach manual skills online. I still think that is best done in an in person environment in the classroom. Not to say you can't learn some things, but there's still places where that potential learning strategy works best. I think trying to teach complex clinical reasoning in a classroom is not the best strategy for doing it. So each one of those things has their benefits and if we can kind of look at that from creating hybrid learning environments that take advantage of each one of those, that's what's I think going to make us make some real good headway out of this whole mess that we're in.

Til Luchau:

That's really the silver lining if there is one. And we're finding in this process too, it pushed us to get a lot more online and got a whole lot more people interested in being part of the online program than were previously. We are finding some great surprises. We're able to go farther like you said with a lot of the conceptual understanding and a lot of the discussions and really understand the rationale or the principles behind the techniques.

Whitney Lowe:

There's some particularly valuable things too, and I think you're probably getting some experience of this, is that a lot of times in the classroom some students who might be a little bit more on the shy side are not going to feel comfortable speaking up about something, especially if there's other students in there that are, let's say really bright and outgoing and vivacious and always want to answer questions and things like that. It does tend to cause some students to back off a little bit from their participation. And I don't know if you have seen this, but I've seen this a lot in the online environment with discussions and individualized activities, when a student can have the opportunity, not necessarily in a synchronous activity, but in something that is asynchronous to think about things, to go back, reflect, talk about it and then come back and answer some questions. Oftentimes there's a deeper thought process and a deeper answer that they engage in. And some of those really shy people just ... They shine. They just really come out in that environment. I love seeing that.

Til Luchau:

We're finding that too. And then we're also finding how important it is to have multiple ways to engage.

Whitney Lowe:

Yeah.

Til Luchau:

Yeah. Like you said, the real time voice discussions over Zoom in a small group. We have people doing it only by phone. We have people only doing it by write in. And I think there's a whole frontier there for us to learn about that. How to make online learning multimodal. We're doing movement exercises that we lead together. We're having ones you explore on your own. And that's the biggest challenge of course, how do you make this embodied? But we're finding ways and it's pretty cool to think about how to bring all of what we know about learning theory into this arena.

Whitney Lowe:

Yeah.

Til Luchau:

What else do we want to talk about before we wrap it for the day?

Whitney Lowe:

I mean, I think there's a lot of fascinating things that we can be doing in these areas and I hope also applying some of these concepts to different body regions and things like that. You've got a new thing that you're heading down to the hip and pelvis next? Is that correct?

Til Luchau:

No. We're actually going to spine, ribs, and low back.

Whitney Lowe:

Okay. Yeah.

Til Luchau:

Spine, ribs, and low back. That starts early September and by the nature of it you can jump into it throughout the month of September, although it starts early September. And then we'll keep doing the experiments and refining them as we go along. How about you Whitney? What's on the horizon for people that want to come do something with you?

Whitney Lowe:

Well, the next things we're doing, we're going to completely revise our ... Again, this is part of turning the assessment book into the online environment. The next thing is sort of revising our introductory assessment and treatment concepts to sort of take in a lot of content from both of my previous books. That's going to be a fundamental module that will be before the others. And then we're moving to our next regional course, which I believe is probably going to be the shoulder course. So we're going to ramp up and accelerate all the revision process because I'm really eager to get those courses updated into the new format and incorporate all this new interesting stuff that we're doing. So that's certainly where we're headed with that.

Til Luchau:

I'm looking forward to that. Anything else you want to say before we wrap up?

Whitney Lowe:

I think that's kind of got a good touchpoint on it for the things that we're talking about today. Lots of fascinating things to explore here. The thing that I would encourage everybody is don't let this covid-19 situation where we are unfortunately not able to get together with people be too much of a detriment and close down your ability to continue looking into stuff. Because there's a lot of fascinating things to learn and move yourself forward with your exploration process while we're in this unusual time that we are in here.

Til Luchau:

That's well said. And I'll reiterate it. We don't know what the future holds. Some people are working, some people are not. We have no idea how this is going to go. But developing ourselves professionally and personally in the meantime is going to leave us in an amazing position to move forward with whatever comes.

Whitney Lowe:

I want to say a special thanks to our sponsors. I thank you very much for your support, supporting the podcast. And as always a very big thank you to all of the listeners, the people who are taking time out of their lives to listen to these conversations. We certainly hope they bring you some beneficial things for your clinic work as well.

Til Luchau:

Yay listeners and yay listener feedback. I love hearing from you. Thank you for that. And if you heard us drop a reference about something you'd like to know more about, we'll put all of that in the show notes. Remember to visit our sites to check out the studies or references you heard today as well as a full transcript of what we said so it's searchable and you can dial down to exactly what did Whitney say again? And Whitney, where would people find that for you?

Whitney Lowe:

They can find that for me over on theacademyofclinicalmassage.com. And Til, where can people find you and our locations there?

Til Luchau:

Our site is advanced-trainings.com. Advanced-trainings.com or social media just under my name, Til Luchau. How about you Whitney? On social media?

Whitney Lowe:

Yeah, also on social just under my name. You can find me there. And @whitlowe I believe is my Twitter handle. Also got some stuff that we put out over there periodically as well. If you will, make sure to send us some input feedback or you can send an email to us about the show. Questions that you want to ask or anything like that. We love hearing from you. You can send that to info@thethinkingpractitioner.com as well.

Til Luchau:

Great. And follow us on Spotify, rate us on Apple Podcasts or wherever else you listen. Tell a friend. Be in touch. Thanks Whitney.

Whitney Lowe:

Thank you sir. Great talking about this and we'll look forward to doing it again too in a couple of weeks.

Til Luchau:

See you next time.

Whitney Lowe:

Okie-doke.

 

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