Dr. Dave Walton is a physiotherapist, clinician, researcher and professor at Western University in London Ontario. With his name on well over 200 published papers, Dr. Walton is a leading researcher in Canada and around the world. In this email interview, Jeff Begg talks with Dave Walton about his recent publication "A Healthy Neck Should Disappear" as well as:
The latest findings and directions in WAD research ---- Reimagining how we conceptualize neck pain ---- The Body Gestalt: a holistic approach emphasizing that the whole is more than the sum of its parts, ---- Questioning the NDI as an outcome measure ---- A new approach to asking neck pain patients how they are feeling
JB: Hi Dave. Thanks for taking the time to do this interview. It happens to be Halloween as we speak, and I remember a decade ago being part of the data gathering team for some neck pain research you did. I recall your Halloween message to us was to keep sending you some “Whiplashy treats.” Did you get enough whiplashy treats for that study? I never found out.
DW: Thanks Jeff, and thanks again for the opportunity to chat and reconnect! Yes you’re quite right we did indeed have the chance to work together on a research project back in 2007 or 2008. The data collected for that project were used for creating the Traumatic Injuries Distress Scale or TIDS, which has since been published. Interestingly, the hypothesis I was working with at the time was that the experience of the spectrum of signs and symptoms we’ve called whiplash-associated disorder, and recovery from it, was more a function of the distress of the situation compounded on all sorts of other biological, psychological, and social stressors, rather than the mechanics of the event itself – the speed and direction of colliding vehicles for example. That hypothesis was tested even further in a follow-up study I ran called the ‘SYMBIOME’ study, which expanded the original concept.
JB: Well, we've known for years that the mechanics of how a collision occurred has very little correlation with outcome. So I see why you were exploring other options.
DW: Right. So now we’ve created a ‘car crash simulator’ in my lab that integrates virtual reality with a programmable chair to give people the experience of a car crash without actually causing enough movement to damage anything and can be done under tightly-controlled laboratory settings with participants fully sensorized before exposure to the index trauma. This should allow us to test all sorts of distress-related hypotheses without actually having to wait for people to get into real-world crashes.
JB: Virtual reality for the win, because, you know, what if car crash incidence goes down in the future with self-driving cars - how will we study it then? You may be well positioned for that, Dave.
DW: As an interesting addendum to this, Vania Apkarian and his team from Northwestern University in Chicago recently published a paper in which they scanned the brains of 110 people within days of a car crash and followed them for a year and found that those who reported chronic pain at follow-up could be identified within days of a crash by the magnitude of connectivity between the hippocampus and the amygdala – brain regions largely responsible for emotional processing and regulation, and that the magnitude of the association was influenced by self-rated anxiety shortly after the crash. What’s interesting about that is that it adds to an already large and growing body of evidence that provides biological support for the distress hypotheses I, you, and others were involved in going back in the mid-2000s.
JB: Ok, so it’s not a hard sell for clinicians to appreciate that there is a massive role the emotional side of the brain plays in dealing with trauma. But let's talk more about this recent article you wrote. Dave, you’ve been a clinician, researcher and educator for decades, deeply imbedded in the academic world. You are recognized as one of the world’s foremost researchers on neck pain. A true clinician's scientist. So what caused you to go off the deep end and write “A Healthy Neck Should Disappear?” I mean, in it you quote a french philosopher for heaven’s sake.
DW: Listen I’d love to say you can blame Dave Nicholls for it, and that would be partly true, but it’s grown out of what I’d call a growing dissatisfaction with the state of knowledge on neck pain and a desire to consider what we think we’re doing with the phenomenon of neck pain through other philosophical lenses. One thing I’ve always found strange is that despite the degree that hangs on my wall being called a ‘Doctorate of Philosophy’, philosophy as an academic pursuit was only barely represented in my higher education.
So one factor was my early exposure to thinkers like Dave Nicholls and others, physiotherapists who have found a way to expand their thinking beyond the disciplinary boundaries of the professional schools and bring knowledge that challenged my entrenched ways of thinking about the body. Those experiences combined with many others, and research that seems to indicate that
1) most physio interventions for neck pain have small if any significant effect (contrary to what clinicians know to be true)
and
2) the relative global burden of neck pain has remained stable or even worsened since 1990,
...which signalled to me that the way I was thinking about the problems of pain and mobility were at least incomplete.
So, out of a desire to do better, I started consuming critical social scholarship – a LOT of it. Critical Feminist scholarship, Black scholarship, Queer scholarship, Indigenous scholarship, Disability scholarship, and the so-called ‘continental philosophers’ of the mid-20th century, of which David Merleau-Ponty was one. After 7 years of engaging with this work I still very much feel like a novice in the field, but that seems to me to be what true critical scholarship is all about. The day I think I know everything is the day I might as well hang up the gloves and move on. While it’s been a challenging, sometimes difficult, journey, the opportunity to be shown what you don’t know is such a gift.
JB: You just touched on something quite important: The language of humility.
Aren’t we at our best when we seek to learn, rather than to prove we know?
Now back to “A Healthy Neck”… You speak of philosophy and use terms like “the body gestalt”. Do clinicians have to get weird and start reading Nietzsche in order to understand where you’re going with things?
DW: Well I suppose ‘weird’ is somewhat in the eye of the beholder, though I will also acknowledge that Nietzsche is on the weird side. Do clinicians need to start reading philosophy? If they’re interested in it, then yes of course, and in doing so I’m continuing to be presented with the precious opportunities to challenge what I thought I knew and am invited to think otherwise about some of the concepts I had previously held dear.
Now if I wanted to be provocative, I might say that I believe that clinicians, the ones on the front lines providing direct hands-on patient care, probably tacitly understand and apply many of these concepts on a daily basis, even if they don’t put those specific words to their practice.
JB: Thanks for saying that - I believe that to be true. You don’t have to be an academic or a philosophical expert to be an expert clinician.
DW: So, rather, it’s the researchers, people like me, who either by choice, familiarity, or force have become entrenched within a world of reduction and numbers and have for decades applied that type of thinking to something as ambiguous, amorphous, and relativist as something called human wellbeing. Which is not to suggest research is wrong, nor am I forwarding some kind of anti-data agenda. I am a measurement scientist after all, but I do think that
by creating the space for other ways of knowing to contribute to this thing we call ‘physiotherapy evidence’, we may find ways of being with and helping our patients that go beyond the numbers.
Now, if you were to ask me what that looks like, well we’ve pretty much reached the limits of where my thinking on these topics currently sit.
JB: How about this idea: Are we on the cusp of a cultural and linguistic change in describing neck pain, and pain in general? Three hundred years ago, we might have spoken about pain with terms like “miasma”, “humours” and “demons.” Now we speak about a ‘crick in the neck’ and a “knot in my shoulder.” What language do you think we should be moving towards in the future?
DW: “Should” is such a dangerous word, almost as dangerous as “normal”. I’m reminded of the many attempts made at changing the word ‘whiplash’ over the last two decades, none of which have really stuck. Words are powerful. [Philosopher Jaques] Derrida would even say ‘violent’, and any conversation around change in how we signify subjective lived phenomena needs to be approached carefully with due consideration of all potential (often unintended) consequences.
There are interesting questions that arise as we start talking this way, not the least of which is ‘are we ready for a post-diagnostic, post-labeling world?’ and I don’t think we are. However, I do think that at some point we need to step back and reflect upon why it is that we’ve not really changed much about the burden of neck pain for at least 30 years. In a way this is what our paper was attempting to accomplish. To create a space for us to collectively ask ‘have we been thinking about this problem in a way that has not been adequately targeted to addressing the real magnitude of the burden?’
JB: In “A Healthy Neck Should Disappear” you and your co-authors question the overall validity of the Neck Disability Index as a truly meaningful measure of neck function. I find that uncomfortable. It's been drilled into us. The NDI is ubiquitous. It’s like, there’s Taylor Swift, Tik-Tok, and the NDI. No one can escape those 3 phenomena. If it’s time to move on from the NDI, how do we un-imbed the idea that it is the ultimate neck pain outcome measure for clinicians and researchers who’ve come to rely on it?
DW: You’re striking right at the heart of much of what consumes my mindspace and has for some time. For context, I believe we could substitute ‘NDI’ for any of what I’ll call ‘legacy’ measures in the rehab space. I'm referring to those measures that were developed at the sort of “dawn of PROMs” in the late ‘80s to early 2000’s. A lot has changed since that time, even the very frameworks we use to think about things like health and disability.
Keep in mind most of those PROMs were developed when the accepted framework of disability was the International Classification of Impairment, Disability, and Health (ICIDH) which has since been replaced by the International Classification of Functioning, Disability, and Health (ICF), which itself is being talked about in some circles as requiring further revision.
Here’s a contentious, but I believe defensible statement:
If the NDI were to be submitted for publication today it would be rejected as below-standard for PROM development.
The challenge however, as you’ve alluded to, is that it is very difficult to dislodge entrenched practices especially when such a huge volume of published rehabilitation evidence has used these tools as the outcome.
There’s a risk in me saying that we ought to stop using something, because if we adopt a post-empirical approach to practice this may open the door to ‘pseudo-science’ or snake oil-type interventions. One way of moving forward would be to collectively declare that we need a better ruler when it comes to doing things like measuring the health of another person, and I would support that.
In the meantime though, a glimpse into my thinking these days is to question whether we need a ruler at all, but if we don’t then what is the alternative that can still provide trustworthy guidance in clinical decision making while also respecting the autonomy and breadth of rich experiences of our patients? I wish I had an answer for that – in the paper I allude to some emerging directions like Naturalized Phenomenology as a research method and the potential for natural language processing to use narrative as an indicator of health status.
JB: There is so much rich tradition in using narrative.
I think when we're at our best during a patient interview, it's because we've stopped worrying about filling in all the boxes in our chart note template .
Instead, we start with a blank page, ask the patient to "tell me the story" and let them run with it. I find that much more open-ended, and it allows me to truly discover what it is the patient finds important, and perhaps even what it is they hope to achieve by accessing physiotherapy.
DW: I’d be happy to hear from your readers on these topics as well. My gut says that something isn’t right but every time I work through potential alternatives I commonly abut new challenges for which I’ve yet to come up with a terrific solution.
JB: The College of Physical Therapists of Alberta (for one) requires standardized measures like the NDI to be used during assessment. The guidelines state that a PT
“applies appropriate assessment procedures to evaluate clients’ health status using standardized measures as available.”
But astute practitioners enlightened in the way you've just described may not in fact use any standardized outcome measures, in favour of individualized ones, or something else. Are Colleges going to be out of line on this? Have we trained the whole PT world so well on the use of PROMs, that a new gestalt-focussed approach might put us offside with our regulators?
DW: Hoo, these are big questions Jeff, though I suppose they need to be asked.
I’m not advocating for some anti-measurement agenda. There is value to be had from well-designed, person-centric, (typically) multi-dimensional evaluations of people’s health. Much of medical advancement has been based on ability to quantify some aspect of healthiness. And putting numbers on subjective experiences does have value for translating complex experiences to a sort of universal language – which is to say that while my 6/10 pain may be different than your 6/10 pain, at least we can both agree that 6 is more than 5 and less than 7.
So what I’ve been advocating for is that clinicians make note of not only the summed score of the entire scale, but also look at the patterns of individual responses and use those to open further dialog. Personally I find that may be the most valuable part of PROMs for clinical practice – being able to say ‘I can see that based on your responses you seem to be having real trouble sleeping – is that accurate? Can you tell me more about that?’
JB: I find that a refreshingly funny statement. Some of us have been coached to think that bringing down the NDI score is the only thing that matters. Perhaps using the NDI to initiate a dialogue is more important. I'm going to chew on that for a while.
And one other thing - based on this article of yours, I've taken up a new habit of questioning my neck pain patients. Rather than asking "how is your neck feeling", I tend to say
"When everything is working as it should in life, we don't even notice our necks. Have you been noticing your neck much lately?"
I hope what I'm doing is setting a normal expectation for them of what a healthy neck is, and then asking them to compare themselves to that. In practice, I'm finding that it does seem to elicit a different response than the typical "how's your neck today?"
DW: I should also say that “A Healthy Neck…” isn’t necessarily written for clinicians. If anything I think clinicians have always just tacitly been better at seeing the person sitting in front of them as more than a series of checked boxes or circled numbers. I do fear that as the world seems to be collectively moving towards a ‘fully quantified’ human and the reliance on ‘hard’ numeric data for making decisions,
we risk losing the gestalt of what it is to be a person in the world.
One thing I’d really hope the paper does is speak to researchers, the people just like me who for years have believed the only way we can create ‘physiotherapy knowledge’ is by assigning numbers to experience. There are times when that’s likely appropriate, but I also want to open conversation around the times that’s not appropriate, or what the numbers can’t tell us about human experience and how evidence could be created otherwise.
JB: Dave, thanks for taking the time. Oddly, I feel a bit like the Unfrozen Caveman Lawyer from Saturday Night Live:
Sometimes your world frightens and confuses me.
In any event, my best to you, Dave.
DW: Hopefully this provides some food for thought, though as you can likely hear I’m continuing to develop these ideas in my own head so if you ask me these again in a few months some answers may well have changed by then.
Addendum:
For those readers interested, the TIDS and its user manual including English, French, Spanish, and Persian translations, can be accessed here: https://ir.lib.uwo.ca/ptpub/78/.
The papers that came out of the SYMBIOME study can be found here: https://www.ncbi.nlm.nih.gov/sites/myncbi/david.walton.1/collections/62576812/public/.
The Apkarian study mentioned is available online here: https://www.nature.com/articles/s44220-024-00329-8?utm_source=miragenews&utm_medium=miragenews&utm_campaign=news
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