Phillip Snell
Hello over there on Facebook. Hello over here on Zoom and welcome to the March Madness edition of the Weekly Neuro Centric Approach Online Academy case study meeting.

We do this on a weekly basis right now, where we get together and chat about, eh, sometimes always case studies, sometimes other things that matter too, like the North Carolina State Wolfpack, my home team, whoop, whoop, into the Elite eight.

I was at NC State in 1983 when the cardiac pack with Jim Valvano and team won the NCAA Championship when I was quite a bit younger at 1974 when they won their only other NCAA championship. I was an Ardent fan. Then they had a poster posters of David Thompson and Monty Tao on my bedroom wall as a kid.

And it was not lost on me. That defeating Marquette.

That's the same team that they beat in the National championship in 1974.

And last night I thought Houston was gonna wind up beating Duke.

And if Houston had beaten Duke and State would be playing Houston tomorrow, that would've been a rematch of the NCAA championship in with North Carolina State in 1983 when they beat by Slam and jama, Mr. Keem, Elijah Juan and Clyde Drexler.

So go Wolf pack. Whoop, whoop.

You've been watching the tournament. Mark,

what'd you say?

Marc Heller
I've just been looking at highlights.

Phillip Snell
Yeah, I've, I've been impressed with the, the games and overall quality of ball this year. It's been a lot of fun. Been some really good games.

But yeah, the, I, it's the only time of year that I move into full on a CC support. You know, I, I don't even recognize the A CC or any of the other conferences for that matter these days. Like the PAC two.

Marc Heller
Well, well the PAC two women are in the, are in the elite age.

Phillip Snell
Yep, indeed. I know it's, it's fascinating. But yeah, I mean the, when, when I used to really be an, an ardent follower of this kind of stuff, I, the days of the A CC when there were six or 17 and Tobacco Road meant something and there were four, four primary teams that were always gonna show up and, and hold forth in this kind of tournament.

The, and then usually they would be squaring off in the finals against the Big East teams and the Big East and the A CC are pretty well represented this year.

So let's see, as I mentioned, we sometimes taught business and case studies and all that on these little commerce, the neuro centric Approach Online Academy, 35 hours of continuing education recorded online continuing education for you folks for your CE needs.

And I will give you a little heads up for those of you that are smart shoppers and keeping your eyes open.

I am so happy about this March Madness situation. And I'm gonna open up the lifetime membership portal again this weekend, although I probably should wait until after NC State Place tomorrow to, but I'm gonna open it up anyway just in the spirit of good basketball and for that, when I open that up and that's a limited time situation. You can pay one single price one time and get lifetime membership to the online academy. And what that grants you, probably one of the most valuable things is it'll get you a hundred dollars off of each in-person course that we hold. So I will send emails out to all of the people on our email list if you've signed up on the neuro centric approach site for, for those emails.

And I'll also be putting it over here on Facebook and such. You guys can feel free to take advantage of that.

Sometimes we talk about things that have absolutely nothing to do with neuro centric approach. And here's, well, I don't know if it's absolutely nothing. I mean think about it.

And neuro approach, we are looking at the effects of sensitized neurology from the biggest compartment, the brain down to the smallest compartment in succession. That would be spinal cord, nerve root IVF interface per the big mixed peripheral nerves.

And then finally the superficial cutta, excuse me, superficial cutaneous neuro.

And among the things that will tend to sensitize neurology are those four buckets, the epigenetic buckets that we've discussed in the past.

Poorly managed stress, poor sleep, a, a lifestyle that doesn't include much movement and possibly includes too much willful self poisoning like alcohol and drug use and tobacco and, and the vein of that in reducing just for instance alcohol consumption. Something that I've been keen to try to limit in recent years in my life.

I've been exploring, we've been exploring my wife and I in our household, various substitutes, kind of scratch that itch.

I like Topo Chico because it gives me a nice mouthfeel heavy bottle. Feels like I'm doing something substantial.

But we also started playing with the now very trendy beer substitute things.

So there's a brand called Partake Out there that's quite good.

There is also that one is a non-alcoholic beer.

So it's an actual beer that you know, contains barley products and things of that sort. And I've been keen too to limit grains a bit in my life. So we trialed another one that's very popular made by a company called Hop Lark, H-O-P-L-A-R-K.

And the hop products we found were quite good. And essentially that is a hop and black tea

drink that is carbonated.

And I found, I found that to be very tasty. And then, you know, you got decaffeinated black teeth, so you got your pro anthocyanins and your epi gallic catechins and all that fun stuff. So you got a lot of health promoting things in there. But here's the problem.

Those products that don't have any alcohol in them cost the same as those that do. So you go out and, and for a, something that is supposed to be mimicking, say a northwest IPA, you're paying 10, 11, even $12 for a six pack of essentially tea.

And lo and behold, the Hop Lark stuff got so popular that you can't even find it now.

And when you can buy it, if you buy it online, it's gonna cost you twice that. There's no way in hell I'm paying 20 bucks for a six pack of tea.

So I got my thinking hat on about all of that. You know what I did? I got on chat GPT and I appealed to the AI Oracle and I said make me a recipe for something that approximates, that Hop La tea with and approximates a taste of a northwest IPA in terms of international bitter bitterness units and provides some information about mouthfeel and waste to play with that. And damned if it didn't come up with a pretty good recipe. And I went out and tried it and then I've been testing it. So I'm gonna share a little bit of what I did in case you guys are interested in that. 'cause it is dirt cheap. All right, so here you go.

You go out to your local brewing store, your your home brew supply store and you ask 'em where their hops are. They're usually gonna be in a refrigerated case. So those of you over here, I chose two bittering hops and one aromatic hop. I'll talk to you a little bit about how to use that. But I chose Simco and Mosaic for bittering hops and the Simco and the Mosaic are the ones that Hop Lark uses in their product.

So that's showing you guys over here on Facebook. They'll come in little bag like this and they're pellets, they look like rabbit foods. Basically you take a total of a half ounce of those pellets and you gonna boil 'em for about two minutes. Okay? You are gonna set that aside, pull it off, and when you pull it off from the boil, then you're gonna mix in some decaffeinated black tea. You can put caffeinated too if you want, but you don't wanna be drinking that at night. Now I made mine up, this recipe was for 64 ounce finished product and I actually cut it in half 'cause that's too big a, our refrigerator's got too much stuff in it.

So I cut that in half and made a total end product of 32 ounces using 0.5 ounces, a half ounce of bitterness hops boiled for two minutes.

And then after the boil is done, pull that off and pitch or put eight tea bags of decaffeinated tea in there and grab a handful of these guys, which are your aromatic hops. And these are just dried whole hop cones.

And you grab a small handful of those, toss 'em in there and that won't give any extra bitterness. That'll just give you that nice aromatic nose, a citrusy nose that is a Citra C-I-T-R-A hop. And I'm gonna grow some of those hops over the summer to lower the cost that much more 'cause hops grow like crazy. Y'all and I will continue to make this and what I've been doing is that makes up in that 32 ounce concoction that you make up, I can fit that Nalgene bottle. Now it fits into my refrigerator. Oh, and in there a little bit of sweetness. So I use Trader Joe's liquid Stevia and now I've got a keto product and I can take two dropper fools of this and put in that same batch, ba boom ba bing.

That gives you a nice little balancing act with that bitterness.

And then I take about a quarter cup of that concoction and I mix it with Topo Chico and that gives me a nice head on top. And damn if it doesn't taste pretty good and it is 100% healthy for you, the hops are great for your sleep and for relaxation. The tea is great for just about everything and Stevia doesn't have any nasty side effects, not gonna raise any blood sugar.

So it's all peace, love and guitars folks. So you heard it here first.

I think my per unit cost went from, I think it's a, a buck, no, what is it?

Almost $2 for buying that Hop Lark product when it was available down to, I think I got it down to 30 cents per unit. So smart shoppers.

All right, what are we gonna talk about this week? I need to put some Stevie in my T.

Let's talk a little bit about a couple of previous cases that we've talked about.

I got one in process you guys might recall.

Next weekend is a power lifting event that several of our lifters at Kabuki are attending, including one that I've shared with you. A 42-year-old female master's level world, current world record holder in her age and weight class.

And she was having nasty pain in her right anterior shoulder and that that shoulder pain was interfering with her at the very bottom of her bench press.

And the very first thing we did per neuro centric approach is I provided some traction while she was performing an upright chest press, which was painful. So that was my index movement and her pain completely went away with just cervical traction. So we did a bunch of cervical traction, did some cervical manipulation to try to open a putatively encroached upon neural foramen and IVF and, and she had some benefit but not, it didn't maintain. So then per, per the NCA processes that we've talked about in the past, I went downstream and sourced the nerves that were involved in the periphery and the ones that I found that were the one that I found that was primarily involved suprascapular nerve.

And yet when I did my work on the suprascapular nerve it, if anything, it made her a little bit worse. So I went to other nerves that service that particular region and you guys will, will review some of these and workshop them in the upcoming in-person course. April 20 and 21 in Portland. That's the upper quarter course, but the other nerves that service that particular area, the lateral pectoral nerve and the what else is there and the suprascapular and the axillary nerve and those service, the bursa subacromial bursa, the corco acromial ligaments and joint capsule there at the AC and varying portions of the glenohumeral joint.

So I went in there and worked on those a bit and got a similar effect.

Some, it basically made it a bit worse doing manual therapy, deeper work like TNM transverse nerve mobilization over those particular nerves, which is a little more traumatic to a sensitive nerve. DTM would be symptom modification process, right? You are lifting, creating a little more room around the nerve and that wouldn't piss it off, but it didn't last on these. And it's difficult to use DTM to get to those slightly deeper structures. You can approximate it over the superscapular nerve, especially with a a cup directly over the, the, the suprascapular notch there on the scapular spine. But we had, I had, I had sent her home with some home traction after we had trialed McKenzie and we trialed neurodynamics and didn't get any buy-in there.

So we were just looking to try to modify things as much as we could with what we had seen beneficial. And in this case it was making more space, space at the IVF and we had some, some positive findings and then some negative findings. She flared up. We noted that if she got handoffs, meaning someone was delivering the weight on her bench press to her helping her to get it off of the rack, which is the way it's done in competition, then she had zero pain. So we insisted that all of her training sessions be include, that her target, the world record is 194 pounds. When she came to see me, where she was in her training, she was upwards of 180 1 was her PR I think at that particular point in time.

And we were able to get her with the handoffs and the traction up to 180 7 for a single in one session or, or over the course of two or three weeks in one workout session, she was able to get to that number. So we were within striking distance of hitting it. And then she flared up on one day when she didn't have anybody to hold to, to give her liftoffs. So I got angry at that because then I got the clay cleanup and then her body has to focus more on healing damaged tissue than it does on building to try to accomplish a physiological task.

And we did a calming session on that. And then the following session, she still had some flare up and I was really not optimistic, but I just leaned into it hard functionally. And I used the regional interdependence model, remember mobile, upper spine, stable, lower spine mobile, thoracic spine, stable lumbar spine and so forth.

And I really worked on her upper back mobility. And as you guys know, I focus on things that the patient can do first. So I had her to do quaded thoracic rotation, the knee with the heels, hips on the heels so that we isolate the material, the, the movement more in the thoracic spine.

And then I had her to do her wall squats.

Then I did mobilizations in the thoracic spine.

I did overhead squat press from Jersey Gregory, and that's, that's the primary one for lifters that I like to use because it's, it's a little more like a regular lift and they can scale it on their own and it's impossible to hurt yourself and they can measure their progress with it.

And we'll go over that one as well in the upper quarter course.

The, and then I gave her the Carl Levitt T four mobilization and I said, I want you to do that, all of those exercises twice daily, every day before your next bench session, which was three days later she did that.

And then I got backward a couple of days ago in her peaking session before, before the competition, which many of you know will be, she will peak this week, rest this week, this past week, rest this week and compete next week, next weekend.

And lo and behold, she had zero pain in any of her bench and she had, and she was able to work up to a personal record of 1 91 for a single rep. And according to her coach, she had plenty of gas in the tank. So I am very encouraged that she will be able to set a new world record in cumulative total and in the bench. So keep our fingers crossed on that.

One other thing that we're playing with with her is capsaicin and that will bridge us over to my second follow up, which will be a bit more brief. You guys might remember the anterior cervical disc fusion patient that I had, that was a top down process.

She had, what was it, three months after her procedure.

The approach was on the left side anterior of course, but she had seven out of 10 near constant pain in the back of her neck and a distribution that was sort of overlaying the upper trapezius bilateral.

And I did some DTM locally on that and it helped a bit, but all we needed to do was just a little bit of extra skin rolling on that area and it flared her up. So to my mind, that's representing hyperalgesia at best or allodynia at worst. And you guys know that that's a, a function of central sensitization.

And what happens to the nerves locally, those local nociceptors in the skin that we're playing with is that the body will input an an extra number of TR PV one and probably PIO one and two receptors on that membrane. I'm gonna focus for the remainder of our, of our discussion today on that TRP V one receptor and talk about why we think it's important.

More so these days that TRP V one is an ion channel for calcium ions and the Nobel Prize in physiology and medicine in 2021 was co-shared by one guy that I've talked about recently on here, tum Patian Patian who discovered the PEO one and PEO two receptors, which gave us a window into what actually happens to make a nerve mechanically sensitive to take it from baseline to being more sensitive to both pressure and tension.

And then we've got a, the more recent, or excuse me, the person that he co-shared the, the Nobel Prize with was researcher by the name of David Julius and Julius gave us, is the one who did most of the original research on TRP V one.

Now these TRPV that stands for transient receptor potential and the V stands for vanilla oil. So TRP is a class of ion channels on nerves. All of them have to do with a variety of different stimuli that changed the sensitivity of the nerve to the various things that make nociceptors a bit ping. And you guys remember those are temperature, mechanical stimulus and chemical stimulus.

So when those, when the body winds up that neural synapse that we're talking about there, here we're talking about it in the periphery, you've got that first order neuron that is being sensitized by those T rrp D one receptors placed on the membrane.

And then you've got another windup potential at the second order, synapse in the spinal cord and lamina tube of the dorsal horn.

And what happens in there and, and then again at the second to third order neuron in the thalamus and hypothalamus, and that's where we have the handoff to the amygdala, the handoff to the the hippocampus. So we have things that alarm us for the amygdala and we wanna remember 'em for the hippocampus. And then we put all of that into some sort of meaning in the cortex.

And that's our top down process. There's our central sensitization 1, 2, 3. And from a pragmatic standpoint, we could lean into that the way that I'm doing with these two case studies, which is to use, ironically an agonist, something that stimulates TR PV one. And what is that? It is capsaicin. So capsaicin you guys know is the active ingredient in hot peppers and people, there's a high degree of genetic difference in the ability for people to tolerate it at all places in their body, whether it's eating hot peppers or whether it's excreting hot peppers or whether it's wearing hot peppers on your skin.

And there's also a, a tolerance that builds up to that. So what actually happens on the cell membrane is that TRP V one receptor or ion channel is occupied by the capsaicin and if you just occupy it, it can't do its thing and ping such that the other two inter neurons upstream will get a signal.

Now that's a temporary process with a low,

a low concentration of capsaicin. So what I've taken to experimenting with, with my patients to see, you know, since we've got a high variability there, most entry level topicals are 0.025% and most over the counter topicals will go up to 0.1%.

So we can trial that it takes about 30 minutes after you put it on for it to, if, if that's a concentration that their body is sensitive to, then it takes about 30 minutes for it to start working and it'll stay on there.

They'll feel warmth and a burning sensation, which is similar to a reproduction of the burning pain that they feel when they have a neuropathic kind of scenario that's going on.

Now what we've described so far for our lifter is not a true neuropathic pain, but I am bullish enough on the idea that a, that the mechanical and thermal sensitivity of this neurology is that may be our international association for the study of pain of noci plastic neuropathic and nociceptive pain that just like we recently added the category of no aplastic pain that we probably are still learning in all of this. And I'm willing to take a chance with something that has very low side effect and it's only temporary and there's no long-term negative effects from putting topical capsaicin on.

I'm willing to give that a shot and I suspect, you know, if we liberalize our definition of what neuropathic pain is there, I'm thinking that we include myofascial trigger points as well because that is probably a, an interface problem with a cutaneous nerve and it in, its

in its movement through the tissues.

So in my patient with the anterior cervical disc fusion, she, she went from just doing the manual therapy to doing the manual therapy with the addition of the cream once a day and she's 75% better y'all after, after a couple of weeks. That's pretty cool. And I would also say that part of the benefit was the top down portion of having a clear narrative about what she's doing or what she can do to help herself agency and having something other than what she had gotten from up to that point. The information from her surgeon, which her surgeon threw up his hand and she's like, I can't explain why you have pain back there when we did all of our work up here and physical therapist did the same thing.

So her two experts she was relying on did not provide any kind of compelling narrative to her. The closest they came, which I was able to lean into and to exploit was an idea that she had, she was just more sensitive and it might take longer for her to heal. So there's the A CDF, the other one we'll learn more about and I'll give you more about the information on next week. I'll throw my hat in the ring on this one too. I've got a, i I jumped on the bandwagon here to give it a trial.

I've got a full on neuropathy in the back of one heel. It's pressure induced from my walk on the Camino. Last year I day one my feet got really wet. I was wearing minimalist shoes and my heel just got the daylights beat out of it and I had the worst blisters I have ever had and I'm not usually bothered by them.

And literally the entire back portion of my heel sloughed off over the, the course of the two weeks on trail and it was incredibly painful and I've had hyperalgesia across the whole back of my heel. Now this is going on a year at this point and I have, I've just been kind of being patient with it, but it hurts to go walk a whole bunch or run a whole bunch and I've got a, another one of those trips planned in June. So I started using the capsaicin and lo and behold seems to be working on me as well. It will not work on all of your patients if I'm to believe the literature on this, but I think it is well worth a try.

The most significant downside people put it on and it causes the pain that brought 'em in to see you.

It is an agonist of those TRP V ones blessedly the pain typically doesn't last a long time. It usually lasts about 30 minutes or so. So if they can tough it out, great if it's a barrier to them using it and being compliant with it, the research on it suggests that you can apply a a coal pack when you put it on and that will minimize the burning feeling, but you'll still get the effect on the TRP V one receptors.

Now here's the cool part. Prescription capsaicin patches are available. They are 8%, y'all 8%.

So that's what, 80 times more potent than the, the most potent that I'm aware of that you can get over the counter.

And the effect of that is it literally the ion, the, the axon fibers that preferentially the body has increased the concentration of TRP V one on 'em. And mind you, that TRP V one receptor is not upregulated on most axons, but when that nociceptor pings a lot, that's when it gets input on there. Now at this point in my understanding, I don't know what the half-life is on those recept, on those TRP V one channels.

One would assume that over time they would wash out and your body would, you know, make a would recalibrate to something that's a bit more normal.

But what we have learned from the research on this is if you put a high concentration of

of capsaicin on there, it opens all of those TRP V one receptors, which means calcium ions flow in and that basically for that axon is neurotoxic but highly elective.

So it prunes selectively that portion of the neuron that has those TRP V ones on it, the rest of the neuron is fine, the nerve is fine, the cell body and the nerve is fine. So it will regenerate that portion. And what the emerging evidence right now is suggesting is that the portion that grows back in will have fewer if any of those TRP V ones on it. So that's a home run again, does it work for everybody because of genetic differences and possibly epigenetic differences.

But the places that they have expanded on that is to, because it's only very local, you can't get it deep to nerves that are affected, that are deeper like sensory articular sensory branches. So they're working with injections to get the capsaicin deeper and they're also, there are human trials right now ongoing that the preliminary responses are very encouraging of injecting it intraarticular as well.

So we'll keep our fingers crossed and see what we learn what you got Brian?

Bryan Dingsor
So if they do that, a high percentage capsaicin, is it just a one time application?

Phillip Snell
Yeah, the, the papers on it suggests that the benefit takes about 30 minutes to take effect to put it on for 30 minutes, typically with a, with an ice pack and you wear the patch for 30 minutes and you take the patch off and most people it lasts for 12 weeks. Wow, not bad. Yeah. So just like your,

Bryan Dingsor
Just like your hops brew, could you do your own home brew of capsaicin patch?

Phillip Snell
I you, you, you're getting to know me a little bit here may I I am thinking about, you know, putting together something, trying to see if I can figure out the con using the scoville unit metrics for hot peppers. If I can find an equivalency between scoville units and the percentage of capsaicin and then try to put together something and just make my own,

call it a massage oil or something of that and maybe make it a out of scotch bonnets or you know, something similar habaneros, some of mark's son's scorpion peppers or you know, Carolina, Carolina Reapers would be, would be an appropriate one given the, the some of what we entered in with today. But yeah, I think I could What about, what about with some coconut oil and, and make something yummy

Marc Heller
Another over the counter tool that drives things deeper into the tissues would be DMSO?

Phillip Snell
Yeah, I, I don't have, I dunno if there's anything in the research or if you've played with that, but it would be a way to get played.

I've played with it with other items to do exactly that and then, you know, even in some cases like duffin, Chris Duffin has played with some of that with various things to try to stimulate healing for injured tendons and muscles and then use phonophoresis or un I guess the broader extracorporeal shockwave therapy as well, just exploring different ways to try to drive things into tissues with, with sound.

But yeah, that's, I think DMSO would be another issue, but you know, you can't grow DMSO on a vine mark and, and it's a little harder to get over the counter too.

Yeah, I think, yeah, we'll keep a, we'll keep an eye out for the, the topical coconut oil, scotch bonnet, pepper concoction mark. We'll work with your son who's Mark who's making the, the, the, the culinary products. And then we'll make a product and rub it on your shoulder, put it on your food

and yeah, I think that could, that could go quite nice, you know, mix it in with a curry and then take a bath in your curry.

Bryan Dingsor
So, so Phillip, is capsaicin the only thing that defects that TRP V one or you know, how does the other analgesics like your, my area, a lot of people like that deep blue, you know, it's an essential oil. Is that just a distraction to your sensory nerves basically, or what's the

Phillip Snell
It's an excellent question. Remember I said the, the, the TRP V one is part of a family that we're learning more about of these T RRP V receptors and there are other TRPV receptors that work on slightly different stimuli, one of those stimuli menthol.

So that's the counter irritant effect that we've known. You know, you and I and all the rest of us for years of, you know, athletes back in the day using Kramer cheese, I remember one of the, the nasty, nasty tricks that everybody would play and you know, one person every, every year in football when, you know, some, some guy gets creamer cheeses or, or ice, you know, that kind of icy hot put on his jock strap and midway through practice you see 'em go running off the field. But the, you know, guys are guys are interesting, but the, that's one class of receptors on that. There are other things other than capsaicin that stimulate the TRP V one as well.

There's a, they have isolated a pharmaceutical that will stimulate, will turn that receptor on and won't turn it off and, and it, so it's irreversible so that, that holds some promise as well for that selective pruning of those affected axons. But in all likelihood, what we have seen from, you know, call it folk science or bro science or whatever else, and all these various lineaments that people have made and done, you know, made oils and things of that sort for use and body work and all those are probably working on some of those other various channels. I'm just looking at three of the, the three papers that I was reading this morning on all of this.

Let's see if I can get to the part regarding that. So

Bryan Dingsor
Phil would, would you mind posting those on the NCA site? That'd be great.

Phillip Snell
Sure. I can drop those papers in the,

in the community forum there when I post the link for the recording later on today.

Yeah, yeah, there's,

Bryan Dingsor
Yeah. Are you telling patients then, like the one with your anterior fusion that it's gonna be a long process of that pruning like a three month process or,

Phillip Snell
Well actually no, the pruning process only takes it potentially depending on the concentration, somewhere between 30 minutes and two weeks. Oh, depending,

Bryan Dingsor
That's not bad.

Phillip Snell
Yeah, yeah. So what I'm, what I'm doing to minimize discomfort and to try to maximize compliance is I get 'em to start off with the lowest concentration and you can pick that up for like 10, 12 bucks on Amazon, right?

The 0.025% and then when they notice that it doesn't burn anymore, then graduate to the next one.

And then if it's a really severe case, I mean this has been used for postherpetic neuralgia, the 8% has been used for postherpetic neuralgia and diabetic neuropathy successfully. And again, 12 weeks of benefit there. So I think I recall you and I had some conversations about ideas about managing some of those neuropathic pain patients and here's, here's a place to consider to lean in on, but you're probably going to need to get a, a physician in your community to get a prescription to that 8% to have the real long lasting benefit I would imagine.

Bryan Dingsor
Yeah. And with the neuropathy, that's gotta be a pretty big patch or maybe you just do it on the heels where they're having a problem or

Phillip Snell
Exactly right. Okay.

Bryan Dingsor
Well, Phillip, by The effect's very local, the effect's very local and so the, it's wherever they're having their symptoms, it's that those are the axons that are expressing those t rrp the wound channels.

Marc Heller
No, I'm just, Go ahead,

I, I missed some of the earlier discussions on top down and I thought for top down you were gonna go into some psychology component of it and I, I'm tickled to hear this, this particular approach to top down that I'm not familiar with and is more purely physiological, not to negate the psychological component, but to have something that would change that top down pain net quickly.

Fabulous. So thank

Phillip Snell
You. Yeah. Mark, mark, sure. Were you was Rich Gillette at Western States when you were there?

Marc Heller
I never went to western states. I was at Western States. I was in Portland for a few months after I graduated, getting ready to take the board and late 79, early eighties. So

Phillip Snell
Alex is on here. I know, I know Rich was there when Alex was there, but I, I still remember sitting in Rich Gillette's class and getting the emerging science at that point, you know, 20, 21, 22 years ago on windup at each one of those first order, second order, third order neural synapses and also on the nerve him itself at the, at that point Alex says that was an, that was exciting at the time and yeah, it really was. And Rich was so into it. I mean he was a legitimate neurophysiologist who was doing bench research on that kind of material.

But yeah, he's the one that introduced me to do HEB and heavy in assemblies and do heb. Some of you know, he was at McGill University and his grad student was Ron Meza, who we are aware of for coming up with a neuromatrix of pain description.

So that, that was a very heady time of figuring out these different inputs. And Mark, I think it was two or three weeks back, one our Saturday conversation. I talked more that time too about

Marc Heller
Dale's there. I'm,

Phillip Snell
I talked, okay, hang on a second. I'm gonna, I'm gonna mute mute you there.

I think I talked more at that particular point in time about those that first order, second order, third order place in clinical process and how to intervene at each one of those points. But yeah, there's a full on physiological event that's going on there and then, you know, quarterly we get to the, the brain based stuff and that's us trying to make sense of the, the physi physiological event that's going on in the body downstream. So, alright, that, that

Alexe Bellingham
All sounds really cool right now. I was just gonna say, I have a, an interesting patient that we had as a presentation for, we have this regional presentation that goes on for docs that don't know what to do with a patient that we do on Thursdays. And this one patient that was presented is a young guy that had his first flu in immunization in the end of October and within a day or two developed pain and then started to have what looked like especially LA lateral, anti, anti brachial cutaneous nerve distribution of pain.

So they were thinking and what the group consensus was is we're either looking at parsonage turner syndrome or we're looking at, or we're looking at the, there's a vaccine injury site one also. It could be that one, but it really sounds like capsaicin might be a bete for him, especially if we do the workup where we do increasing, increasing

concentrations so that he can tolerate it and start to get those nerves to quiet down it's terrible pain. So it sounds like it'd be really helpful.

Phillip Snell
I think one of the things you mentioned there too, Alex, it's worth keeping in mind is either the right where they, that there, there are some good reports in the literature of case studies demonstrating act injection injury to the radial nerve from, you know, shooting a little bit too low there and sometimes it appears that the injury to the nerve is a result of the local inflammatory response. Yeah. And sometime it, sometimes it appears that it is direct physical trauma where they actually skewer a good, a good portion of the nerve and then down, unfortunately

Alexe Bellingham
The, yeah, unfortunately the administration of the immunization was not by a doctor, it was by the cook, the cook on the ship. And so I suspect you're, you're right on that. So we're gonna be looking for a couple of things on that one too.

Phillip Snell
Yeah, we saw a lot more of that too in the covid pandemic because you know, people were being recruited to just get jabs in arms, you know, and there people very, very, yeah, they were just getting an in service of just an hour or two. Yeah. And or sticking needles in arms. My, my wife is a psychologist and she was, she was strained that way at Kaiser to go and deliver injections.

Alexe Bellingham
Yeah, yeah. One of the, one of the things we're considering is some hydro dissection also for this guy. So they'll be looking at a couple different places. But the interesting thing was is that he is showing that LAC component of the, of the pain. So they're probably gonna request an EMG just to make sure, 'cause he still has weakness.

There's some persistent weakness as well.

Phillip Snell
Well if you still got persistent weakness, then yeah, that does look like radial nerve injury rather than Yeah. You know, they, they probably skewed it and that if, if that's the case, that's, that's gonna be a harder one to fix if it is a, you know, if an aroma has formed.

But that said, I did find some papers that suggested that the caps patches are helpful in phantom limb pain as well.

Alexe Bellingham
Brilliant. You know, with those neurites and the neuromas that form after that, they're the source of that excitable signaling that's going on locally that the body's confused about and that that's brilliant. And rp, those are TRP V one, yeah. Axons.

Yeah, I appreciate it. I, I mean this is really good input for us. He's one of the lucky ones. He, he is local at Bremerton so he's gonna be coming to our program eventually, but he won't start with our program for a while. But his PA in our program has already seen him and I can give her some intel on this and how to maybe help him out with it.

Phillip Snell
Yeah, sounds good. I look forward to a report on that at some point in the future.

Alexe Bellingham
You got it. Alright, we're about ready to quit here, but Brian says he, he's got a quick question about shoulders and NCA versus meat-based ortho tests.

So go with question Brian.

Bryan Dingsor
I'll keep it short because I know we all have live, but, so I had a patient this week weightlifter for many years and basically, you know, a test and just muscle test for all the rotator cuff muscles and everything was strong, but he couldn't abduct above 90 degrees very well or reach behind.

And I thought, well, with where his pain was at, I just did a little cupping over the supraspinatus nerve and within a minute he had full ab

Phillip Snell
Scapular nerve Sup suprascapular nerve. Yes. And he had full abduction with that.

So my question is, when, when you're doing your exam, if you do see full strength on most of your tests for all your rotator cuffs, you pretty much probably rule out any tendon pathology. Correct? Or, or do you still, so what I learned from that is I'm like, well let's just go in and check all the nerves and lo and behold they're quite sensitive and that notch there in the scapula and just doing a little bit of DTM and TNM, he was amazed with how quickly he saw results. Yeah. And we rolled out, we rolled out cervical spine, we checked all that out. So,

So we cover all of that flow in the in-person course. The but to, to give it to you based on how it's delivered first.

Generally with most shoulders you've got, you can get an index movement relatively quickly and for most of those patients with shoulder pain, it's usually gonna be elevation of some sort, either flexion or abduction.

And at the first thing that I'll do, like I was mentioning with a power lifter that I was talking about earlier, they do their index movement and I say, all right, go up to pain. And let's say they get up to, you know, 1 21 40 degrees. It's like, okay, there's my pain and I'll get behind 'em on the bench and I'll just provide traction and hold it there for a second and say, and quite honestly commonly, if that is the issue, then almost immediately you'll see them go higher and they'll, and then they'll be this kind of interesting pause where they'll go, Hmm. And then they'll put their arm down and they'll work it through several times while you continue to provide some traction.

And then I take my hands away and they move their arm and often it's remarkably better. Now that would suggest at least part of it is here and I always encourage to capture what percentage of change there was in their pain and I don't get excited until around about 30%.

And if they say, you know, 30%, then I kind of make a note of that we want to apply inputs to the spine, both at home and in clinic and then go downstream and work downstream and see if we can get any additional percentage improvement. And then we just stack those cumulative improvements. Now in that patient, I don't assume anything about the tendon or the joint until I've ruled out all of my nerves.

Okay. Now, once I've gone in and ruled those nerves out, and you've seen the shoulder video online, the online course, there's four primary nerves that most commonly show up there and they all come off at C six nerve root, C seven nerve root.

And we can usually lean into that and get a good bit of that shoulder pain taken care of. But here's the spicy part about dealing with shoulders and with any of these, if you've got a pissed off nerve, our model shows that local muscles will tighten to try to preserve the health of that nerve. So they will try to offload movements to reduce the impact on the nerve and that alters joint kinematics and that could cause joint problems. And in the shoulder that you usually can start to cause enough change in the art kinematics that they will shrug the shrugging narrows and pi narrows the subacromial space and pitches the shoulder forward.

And in that position, they will more likely have either a closing phenomenology on the joint, on the rotator cuff when they do overhead work or with the forward pitch, create more tension on it. So depending on, you know, which side of the argument you want to get on with subacromial pain syndrome versus subacromial impingement syndrome, that's rife in the literature out there these days for both of those elevation and forward movement, it changes the impact on the tendon somehow and that can make the tendon an issue. So then you got a combo platter that you gotta deal with. Yes, you gotta get rid of the cause by getting the neuro calm down and get it out of the way as much as possible.

But you're probably gonna need to go in and do some joint mobilization, do a little bit of McKenzie, you know, extensions and internal rotations to try to stretch the capsule a wee bit and do your, your loading parameters like I was talking about with you on email or excuse me, on the community earlier today for the isometrical loading and such. Cool.

Bryan Dingsor
No good flow chart. No thank you.

Phillip Snell
Yeah. ok. Do that's it for the weekend guys. Go wolf pack.

Listen, you guys had a, a North Dakota boy on, what was the team the other night?

God, he was a kid that dismantled, dismantled Carolina when they played the other night. It was a North Dakota,

Bryan Dingsor
Well NDSU kid. Yeah.

Phillip Snell
I can't think of his name. He was awesome. That kid got,

Alexe Bellingham
What's that you? Oregon State fight, fight, fight

Phillip Snell
Yes.

Alexe Bellingham
For women Looking good. Yep. No doubt. Lead

Eight took out. I'm happy with that.

Phillip Snell
Yep, no doubt. All right, so I'm gonna go see if I can get me a 20 miler in at some point this weekend, Alex, and we'll see how the leg holds up.

Alexe Bellingham
I hope that heel feels good. Yeah, my dog. What

Shoes are you wearing these days?

Phillip Snell
I'm in hocus speed goat fives.

Alexe Bellingham
Oh, nice. Yeah, they, they suit me well, especially walking 'cause of the rocker heel.

Yep. I love that rocker bottom man. It's nice. Patients love it too.

Phillip Snell
Yeah. They manage that impact a lot better on walking than Yeah. The other items that I've used before

Alexe Bellingham
Haven't graduated out of the hokey Hoka bondy yet, but I started trying the, there's a new one shoot that I just got super soft. Really feels nice for the older structure of the heel and the tissues associated with it.

It is, yeah. I'll send you a picture.

Phillip Snell
Yeah, yeah. It's fa it's fascinating to see the, shall we say maturation Yeah. Of that whole process. I've been a, a minimalist shoe advocate for most of my career. Yeah. And then arthritic changes from old turf toes. Yeah. And yeah, I had one toe with turf toe when I was a teenager and I've got some pretty significant arthritis and Hal Limitus in that. And then the other toe was in Hawaii a few years ago and wound up, I think we were over on Kauai and I was trying to get out of the surf zone

Alexe Bellingham
Oh.

Phillip Snell
Swimming and in a swell I went over a rocky area when I kicked, I hit a sea urchin on the rock. Oh no. And it went right into the capsule of my other MTP. And it's funny, I used some BPC 1 57 on that trying to, to work it out and, you know, it wasn't an intracapsular injection, it was just subq. But that stimulated something on what I assume must have been an inclusion cyst on that because the, the whole area turned the same blue that it was with the, you know, the sea urchin ink.

Alexe Bellingham
Holy smokes. It was fascinating. Those were,

They were socky triumph twenties.

Phillip Snell
Yeah. Okay. And everyone has 'em on sale right now. They, they're like really nice heel cup. Cool. And, and has a lot of forming to foot

Capability. Awesome. Yeah. Okay, well let's get out there and enjoy a beautiful weekend. Happy Easter. And happy Easter. I will see you guys next week.

Roger that copy. I.