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Members of the NeuroCentric Approach Online Academy meet regularly on Zoom for an informal, online coffee chat and case study.
Below you can find transcripts of this meeting and watch the video from YouTube if desired. To learn more about becoming a member, click below.
Sciatica After Wrist Fracture
Transcripts from the video above are below...
good morning people.
Apologies for being a wee bit late.
I am dealing with a bit of a
computer issue so we can chat here for a moment.
I don't know, depending on the way my laptop goes, we may shift over there or we can just do it here.
I'm working off of my phone here, which is a wee bit different than the perspective I would normally have. Looks like I got a few people in here. Are you guys able to hear me? We hear, okay. Alright then we might just stay here doing, doing it this way then sticks to one half a dozen. The other, how about that? For technological redundancy in a modern world, pivoting and all that bss.
So welcome in guys. We'll assume this is gonna be our cohort this morning and roll on 18 wheeler.
Thanks for coming in.
This is our NeuroCentric Approach online co case study Coffee house.
Slightly different this morning. We won't be rolling Facebook Live since I'm not able to get, I need both devices working for that. So apologies to those that are gonna be missing us on that, but we've got more than enough invites out for the zoom for that to happen.
So let's see.
Today I don't have a huge, you know, pressing case study. I've certainly got a, I had a couple that were interesting this past week, but not, you know, in incredibly engaging for conversation. But I'm happy to discuss those if you want. I'm also, I want to encourage you guys that are listening to bring your own stuff. If you've got a case that's, you know, fascinating to you or puzzling to you or whatever, let's, let's group think it and work through it and see what we can come up with on some of these items.
Let's see. First off, welcome from another atmospheric river.
It's been interesting weather in our part of the world. For the past week we finally came out of our ice storm. That was, we were in the throes of last week that you folks in Toronto can appreciate since you can have similar weather pat weather patterns with your lake effect there. But yeah, that's somewhat treacherous around here for quite a few days. I couldn't even get out of the house to walk to the, the street because of the ice. So it's fascinating.
Let's see, in the interim, things that I found that attracted me and got me fascinated by other things.
You guys, if you're not familiar with the name Andy Galpin, rj, I suspect you probably are. Does that name ring a bell to you? Andy's works good. He's also a local boy and Andy grew up in Washington.
He played football at Linfield College right here out down in your area. Aren't you down in that area rj? No. You're in Bend.
Yeah. Yeah, he's down in the McMinnville, was down in the McMinnville area.
Andy's, Andy's work is impeccable. He is been on several of the major podcasts that many of us know and love has been on. Peter Atia, Andrew Huberman, but he did a recent one on Tim Ferris, Tim Ferris's podcast. That was really quite outstanding. I am, I'm listening to it a second time 'cause it was dent and chewy and there were a lot of references there, including one for some breathing work from someone that he's fascinated by Brian McKenzie and Emily Hightower. And I picked up some of their work as well and have been sifting through that. And it got me interested once again on breadth as input and which of course in our model, this is great.
Now my computer boots up, this is great in our model for NCA and that's the cellular inputs typically, right? So if we can, I, I've been wondering and kind of tossing this idea out to other people in this space for a while, wondering if the observed benefits that we see for exercise, for breath work, and for meditation and perhaps even sauna all If you think about each one of those, one of the common physiological events that occurs when you do all of those exercise, all of those interventions is your breathing rate changes, your depth of breathing changes and the maybe even the location of your breathing changes.
So suffice it to say that across the board breathing changes and we have within the literature, if we just drill down on breathing, we have direct association between reduction in breathing rate and a deepening of, of each breath itself to be well associated with changes in the autonomic nervous system vis-a-vis a reduction well or or increase. It could work either way, but a balancing between sympathetic and parasympathetic. So if we slightly shorten our inbreath and extend our outbreath, then we tend to have an upregulation of parasympathetic. And on the flip side of that, we can have an upregulation of sympathetic.
That is some of what you see. And Wim, so-called Wim Hof breathing techniques, it's borrowed from some of the yogic pranayama traditions. It's borrowed from
holotropic breathing patterns. That Stanislau broth, who's one of the early pioneers in that psychol psychiatrist. This would've been back in the 1970s. I remember reading his work in the, in the 1980s and being fascinated by that.
And they used that holotropic breathing as a proxy for altered consciousness states and things of that sort. So that's one fascinating overlay of breathing. And we can see that change in breath work or with mindfulness type of meditation strategies.
The other inroads we see into all of that that overlaps with exercise is heart rate variability and heart rate variability was actually developed by a psychiatrist and researcher Steven.
And many of you have heard me talk over the years about porges polyvagal theory and his work was then subsequently kind of wrapped into some emerging, the emerging field of trauma psychology and treatments there and people like Bessel VanDerKolk and Steven Levine and other, you know, sort of icons, research icons in that world of trauma psychology. And I borrowed liberally from that research base, that evidence base for the type of work that we're doing, particularly with the lumbar spine in the NeuroCentric Approach viewing that those kinds of episodic radiculopathy cases with the locked back, the spasm, the, you know, remarkable pain often with the patient not having a clear narrative about what is going on in their body.
So feeling essentially powerless, losing their locus of control, not having agency of things to do for themselves as being somewhat reminiscent at worst, possibly I identical to posttraumatic stress disorder. And part of what we do and that, and the model that I use with this is to use a graded exposure technique that is similar to what's used in trauma psychology to work with those particular patients.
So there's a fascinating overlap there in what occurs when you do breath work to work with that particular population. Because in trauma psychology, essentially what you do is create a safe environment for the patient to explore emotional triggers for their physiological state of panic or anxiety.
And you create a safe environment for them to do that. And then we, the, the therapist would use some sort of input to mimic the physiological effects of anxiety or panic. So that usually is fast breathing or rebreathing of the, the, the person's exhalation, which means that they start to increase carbohydrate, excuse me, carbon dioxide. I keep doing that carbon dioxide concentration in their system.
And that as you'll learn in looking at Andy Galpin work both there on the Tim Ferris podcast and some of Andy finally, I've been nudging him for a bit and we've had some conversation back and forth. One of his grad students actually joined Justin and I at our original course down in Mark SI's place in LA a couple of years ago.
Andy couldn't make it to that 'cause he actually had covid that weekend. But what we,
what I'm fascinated by with the work that he is talking about there and how it overlaps with breath work and breathing patterns is this shift in the carbon of the carbon dioxide tolerance within the body. So here's a quick little thing that we could do together if you want that I think is I'm, I'm tossing around ideas about how we might be able to just leverage breath to make a systemic cellular change in neural sensitivity. And I don't know if it holds water or not, but I'm trying to put together maybe a study design that might actually be able to investigate that because if we can bring yet another way of measuring a cellular input and its effects on pain by changing carbon carbon dioxide tolerance, then that will be kind of a cool way to bring a, a more holistic vantage point to the patient in front of us on how their breathing pattern could be affecting their stress levels, could be affecting their pain and how they, and equally importantly, how they simply could measure that on the, on their own at home.
So the, this is a paper that came out several years ago, this is how to test your carbon dioxide tolerance.
Let's play together. I want you to get yourself in a relatively relaxed position and I'd like for you to just develop a normal breathing pattern, just standard. Whatever feels right to you there.
And in a moment I'm gonna cue you, I want you to set up a timer in a moment I'm gonna cue you to start your timer and you're gonna start your timer after you've taken a a relatively deep breath in, you're going to start your timer and then you're going to exhale consistently as slowly as possible for as long as possible.
And then you'll stop your timer when you either have felt the need to hold your breath, which you'll be able to do for longer than you will to consistently let your breath out or you feeling you're feeling panicky or you run outta air at the end. And then we'll look at your times and talk a little bit about what those things might mean. Cool. Okay, now Mark, you're out for a walk again today, so I wouldn't encourage you to do this. It's not an terribly, it's not a terribly bad way to make, make a person that's untrained in this stuff path right out. So you gotta be a little bit careful with those folks and some of you have heard about that and people that are doing like the Wim Hof breathing methodology, that is something that sometimes happens.
Folks check right out for a brief period of time. Okey doke, here we go. You're breathing normally and now start to take a deep breath in. Don't start your clock until you finish that breath and you start to exhale. And now,
okay, is anybody still going? If you are, just keep clocking it out.
Okay, that's kind of cool.
When I first did this
about a week ago, I topped out at 45 seconds, which according to the research on this, would suggest that that would indicate a relatively good level of fitness and that would correlate relatively well with what my heart rate variability data for my age puts me in.
And I started doing things to improve my carbon dioxide tolerance.
Those things include something that looks like a five second in breath and then holding your breath for 10 seconds and then exhaling for five and then repeating that cycle.
And the other thing included a whole a held breath being physically active during the, or excuse me, a held exhalation and being physically active during that period of time for as long as you can until you start to get panicky and kind of exposing yourself to that high CO2 concentration in your body, which will cause that panicky feeling. And try to essentially condition yourself to be able to both appear and in the rest of you be able to manage that kind of estate.
And I'm curious as to how that might carry over in my interval training for my ability to knock out maybe an extra interval and I'll be testing that this week without doing anything else and just see if that change in the carb, the carbon dioxide tolerance is measurable in other domains.
One of the other things I'll be tracking is I have consistent data from my ora ring for three or four years now on nighttime respiratory rate.
It was fun to go back and considering all this and review that respiratory rate data, which started before the pandemic.
And then I had some consistent, you know, a few different pulses where I got ill before we had covid tests and suspected that my, that I had contracted covid wild type. This would've been early on 2020.
And you know, I looked at my respiratory rate data and it was pretty remarkable. I went from respiratory rate of 13 breaths per minute, up to 15 breaths per minute consistently for about a two month period. And subjectively, I remember with my runs during that period of time, I couldn't get myself into zone four. I could not get out of zone three, I could not push myself higher and it just felt really weird. And I had a bit of a come to Jesus moment where I had, I got really frustrated with this and I was like, screw it. I'm gonna run this out of me. Whatever this this residual is, I'm gonna run it out of me.
And this is before we knew much about the clotting aspects of that particular virus in the body.
And I went out and ran as hard as I could for as long as I could. That was all, those were the only metrics I used for the run that day.
And I finally got my heart rate up into a high, into a mid-range, zone four. And I was smiling, I was happy, it was at the end of my run I'm standing in front of my house and I'm looking at my heart rate and my heart rate is pegging at what would be typically about 90% of my maximum heart rate. And I'm like, yes, I did it sitting there with my hands on my, on my legs and feeling my heart race and now my heart is going at 90% and now my heart rate as I'm standing there doing absolutely nothing is going up to 95%.
And several minutes went by as my heart rate is climbing as I'm doing nothing.
And I had a precious moment of looking up and saying, okay, this is what my home looks like. And not knowing whether I was gonna check out right there or not.
And there was a very distinct feeling of something passing through, not at a consciousness level, it was at a physiological level. And if I'm to describe it as anything that makes sense to me, the narrative sounds like I passed a clot at that particular point in time and it was very abruptly. Within 30 seconds or so, my heart rate went D and then came right back to normal and I haven't had any further issues with it since then. But fun with covid, eh, fun with breath, yeah, we've, we've learned a little more about that particular critter and it's vagaries and how it affects certain physiological systems. But that, that was a scary moment and has made me that much more interested in breath work and all because I was, you know, it was shortly after that I was like, you know, my lungs have taken a beating from whatever this thing is and I'm gonna explore getting my, my lung capacity and function back.
So other things that I'm exploring in that regard that you'll hear in Andy Galpin podcast there, this is Bas Rutten O2 trainer.
Know some of you may or may not know a boss, but he used to be the heavyweight champ in both UFC and Pride Fighting Fighter and a lot of fun to listen to. But that is essentially a, a way to funnel the, or reduce and restrict your ability to get air in. So read how to be active and explore graded carbon dioxide tolerance and they're, what they're trying to explore with that. And this is part of what Galpin was talking about, was another variable that you could play with in breath, similar to your heart with ejection fraction with your breath.
It is how much air you're able to actually fit physically take in with each breath. And you know, we've got tidal respiration here in the mid range and you can go well above that intentionally with a conscious very deep breath and you can go well below that with a conscious exhalation. And what I would invite you to explore with that carbon dioxide tolerance is as you're looking at your time, which by the way I've put 30 seconds on that test in the period of a week of doing this type of work.
The, and I'm, I'm curious as how that might, you know, play out in those other domains.
But as you play with it, start to look at where it is it again, if we are looking at your entire full conscious intended expiration and inh exhalation and inhalation as being something like this, I'm envisioning one of those little things like in the the doctor movies and everything where you see the, you know, a person breathes in and you see the thing go up in the tube, I don't know what the hell you call that, but right in here in the mid range is your tidal respiration. And then you take a full deep breath in and it's up here. You take a full deep breath out and it drops all the way down to here.
So somewhere at the bottom of tidal respiration, the elastic modulus of your alveoli is done. So your passive exhalation has occurred and any further exhalation then re requires you to actively contract some of your respiratory muscles to squeeze the lungs further, to create a negative air pressure in the lungs and so forth and, and for or a positive air pressure in the lungs and force that breath out.
I would suggest keep start tracking where that range is when you get to the bottom of your elastic recoil of the alveoli and then you have to physically start pushing breaths out of your body. I'm finding that fascinating.
So fun with breath, some inroads there. I'd be interested in discussing that further over future weeks and stuff.
I'm going to be playing with as much of Andy Galpin's material as I can because I think it's another good adjunct for us to incorporate in the exercise and the cellular aspect buckets on the NeuroCentric Approach material and Andy is a good evidence-based evidence generator and accumulator of evidence there.
So other things, I sent an email out this morning to Douglas Zochodne, Z-O-C-H-O-D-N-E is professor of neurobiology at University of Calgary and I've been a consumer of his literature for a number of years.
He's got a lovely text out on regeneration of nerves, peripheral nerves after injury and I'd like to talk with him about that and about a recent paper he had about a more specific version of that specifically and people with diabetic neuropathy and possible ways to help with those conditions and those particular patients, he sent an email out to him and see if he would be willing to come and join us on one of these. And if that is indeed the case, then we'll have a session one day where we'll go back and review some of his papers to kind of get you guys warmed up and help you develop questions and think critically about material and maybe weigh in and ask him some questions and things like that.
Let's see what else. We're gonna talk about case studies this week. First off, has anybody got any questions about stuff we've already talked about or does anybody have any case studies of their own that you want to toss out in front of the group? Have us chat out.
Just two questions for you Dr. Snell. What, what frequency are you doing the, the CO2 tolerance training at like how many? Are you doing it every day? Are you doing it twice a day
As a i, I tried to put something together that I felt like would be relatively easy for me to incorporate and also, and to test that theory for a couple weeks to see how consistent I am with it.
Because ultimately I probably would like to put together either formally or informally maybe with this group, maybe with you know, social media with evidence-based chiropractic forum or with our mailing list or whatever.
I'd like to get others to kind of play with this and see what kind of data we might get. What I've come around to is 10 minutes cumulative throughout the day and that could be as simple as like while Mark is out on his walk, spending a few moments focusing on your breath and what you're doing with it and then consciously playing a specific rhythm, kind of like what I was talking about before. Five seconds in breath, holding for ten five seconds out and repeating and so forth and stopping short of feeling any kind of lightheadedness but right at that edge and playing that edge kind of like we would play that edge with our interval training and such.
So I think that might be a doable thing. And then tracking your, your carbon dioxide tolerance and see if it has any changes. And then if you have any other wearable data like your respiratory rate or if you have a pain situation, you want to keep a, a numerical pain scale, you know, at the start and then later to see if there's any change there. If you see any noted change changes in your sleep quality, your sleep scores on your aura data or your whoop data or some changes in your
deep sleep versus REM sleep kind of stuff, I think that would be fascinating. And HRV data if you, you know, most of us have got that on our Apple Health widget, that's not a very accurate way of measuring HRV, the, what is it, the root means squared da da da da thing that Omega wave is famous for kind of getting us all focused on is the, the industry standard there. But the the other, that's one of the products that one of Andy Galpin groups that he's playing with is coming out with. They've got a product that's un some, I think they're coming to market with it very soon in the next month or two and it's supposed to be two or $300.
I think it's a chest strap that you wear overnight and it has been shown to be as sensitive if not better than sleep polysomnography. So it will in that capacity probably kick aura's ass. But I, I'm still partial to Aura if only for the reasons of some of the other things that are going on in the periphery with Chris Din and others at Kabuki where kabuki will by intention over time.
Our grand goal there is to turn that into essentially a lifestyle brand. How to bring strength into better respect beyond the meathead kind of mentality that exists out there to being something that is pursued with the same level of veracity and intent that cardiovascular fitness is for reasons that it is enjoying more research that's showing that it is as important as maintaining the cardiovascular health in health span and lifespan. So among the people that are interested in helping to fund those kinds of long-term endeavors are angel investors that are also behind Aura and also behind other major lifestyle brands and even major sporting teams and stuff out there in the big four of professional athletics.
So we've got some very interesting years of playing together ahead of us at Kabuki and there's some materials that Chris has designed that will be playing into
what again, grand goals. We don't under think things there.
This would very possibly be change the face of how people
use resistance exercise in a gym type environment, a clinic type environment or home type environment. Essentially some of the products they're bringing to market will be able to reduce the cost of gym equipment, reduce the amount of space that that gym equipment occupies and look better and, and and, and look really effing cool.
So when you're able to, you know, check off the good, fast or cheap pick any two and now you get all three, it's, that's, that's pretty cool.
They're, one of the things that they're integrating with is a product rj, you'll be interested in checking this out, it's called arena A-R-E-N-A.
It's a little box that you stand on right now is the way that it's designed and it looks and behaves a lot like a K box for flywheel training, but rather than a flywheel in it attached to a cable, it's a motor and that motor is controlled by a, an app that can exist on a, a little stand on an iPad or you can hook it up an app to your phone and the, the arena box right now is com comparatively, it doesn't cost all that much, it's about 1500 bucks, but what you get out of it is you can tailor it to produce any kind of force curve you want on the exercise. So you can mimic something that looks like, you know, a barbell movement pattern with chains on it or with resistance bands on it.
So your force curve is different throughout the range.
You can change, like one of the things that I particularly liked as a, as a skinny guy, scared of getting squished under big loads put on my back with a back squat, you can get a, a lovely back squat feeling out of it. And part of what Chris is doing is designing program designing equipment that dovetails with this product.
So you can put a, you know, a, a harness on your back and at the very bottom of your squat there's no load.
So you don't get that sense of, I don't know if I can come out of this hole and I'm not sure if that's, if we're taking away a very valuable training effect right there or not. But you start your squat up and it's like intense, intense and intense and intense all the way up and then you come down and you get to the bottom of your hole and you feel like you're gonna get squashed in the logos away and then you start your load going back up in intense and intense, intense so cool stuff. And they're also designing it so that the box that's currently only provides you with that angle to work off of from standing on, it can be mounted to a rack kind of environment so then you can do upper body work quite a bit more easily.
So anyway, keep an eye out for that. They're currently, you know, working deals with 24 hour fitness on and putting together prototypes for this. So it's entirely possible if you think about the economics of running, owning and running a gym, whether that's in a gym itself or whether it's in a clinical environment, the footprint, how many square feet that gym occupies and what your return on your investment per square foot is.
This, this trend will likely improve both of those metrics. So getting into it and including strength training and a clinical environment would be less cost, mean less area outta your clinic that needs to be used and potentially if the evidence holds out, the outcomes would be in a superior and overall clinical care as well. So there's that
I'll throw out a patient I had this week,
72-year-old female presents with
severe right posterior leg pain identified as by her as sciatica of three weeks duration and gradual onset after a slip and fall before the ice occurred.
And a clean fracture of the distal radius and onna. She was casted treated by orthopedics casted for the standard period and she had a lot of pain in the arm of course. So she carried her arm like this and in a painful antalgic right lateral bending position for several weeks. During that period of time she started to experience some pretty significant right leg pain, very significant when she presented, she described it as a, on her zero to 10 scale of severity as 14
as I was, I got a, it was her neighbor who brought her in, her neighbor who I've seen him and his entire family for a number of years.
And he brought her in and he gave me a heads up that she was a handful as he said she was, she lived alone, she was a widower or a widow of two years duration, still processing the grief from losing her husband of 50 years marriage, partly processing that grief with alcohol and cigarettes and no kind of exercise but well to do, sharing her time and sharing her money for good philanthropic endeavors around the Portland area.
But yeah, it was very apparent early on that she was, she didn't have high hopes or high expectations. She felt like she was being busy bodied into the clinic but dam it all she hurt and she decided to give it a shot but she wasn't gonna be anything other than crochety as hell throughout the entire process.
And I love that. I like that piss and vinegar.
So our, we've got those interesting comorbidities,
visual inspection, she's still carrying the arm like this even though it's casted.
She's got, she reported that her pain was directly over the brake and distal to that and she's got visible swelling throughout the entire distal part of her hand.
She reports though that her pain in her hand is not all that noticeable. She's also carrying her shoulder in a very intelligent position and she's bent like this. So very first thing that I did, just looking at her visually as she's in the waiting room, she had found a recovery or a relief position by pitching forward in her chair while she's sitting.
So you know, we're thinking, you know, what makes the most sense to me is we've got someone with some concomitant lateral recess stenosis from spondylosis normal in a lifetime at her age that likely has become symptomatic as a radiculitis with her antalgic position, which she keeps adopting to favor the right arm. And now that's become to my mind more of a maladaptive motor behavior than anything else. So I just explored very first thing while she's sitting in the chair. I said, okay, I want you to stay where you are there, but I just want you to tilt over to the left. So now I'm trying to get her away from that threat of putatively, of a spondylotic laying on lower lumbar nerve root.
And as she stayed in that position and I had to keep coaching her to go back there while I played with her hand, while I played with her arm, while I played with her behavior of that. And while I brought her attention to the shoulder and I told her, I said, you know, I'm not all that concerned about the pain that you came in here with in your leg 'cause I think we can do a lot to fix that relatively quickly.
I'm mostly concerned about your shoulder and said you've been carrying that shoulder in a fixed position like this for a long time and shoulders don't like that and everything will tighten up around that shoulder in a way that will prevent movement going forward. And then we'll have another kettle of fish to deal with after your hand stops hurting and after your leg stops hurting.
So partly I'm being truthful to her from my line of wishing, but partly I'm also trying to distract her mind, her conscious mind from what's going on in her hand and what's going on in her leg. So I had her just start to move the shoulder and do some rounding positions and I had her to consciously keep straightening her elbow. Not even really focused on the hand or where the brake was, I'm just looking at changes in behavior and as she keeps readopting the right lateral bend, I'd move her back to the left and I'd say, yeah, you, I'm not all that concerned about your about your leg. And she looked at me just like with heat and venom coming out of her le eyes and she's like, what do you mean you're not cared about my leg?
That's why I came. It's a 14. And I said, are you sure? I said, check in with your leg, how bad's your leg? And she's like,
I said, well how bad is it?
Zero to 10. So about a six. I'm like, okay, so you've had better than 50% improvement in your pain just sitting here and sitting in that way. Okay, so I want you to keep doing that. And then I went and started doing a little more focal work on the hand and on the arm kind of exploring different positions and see if we've got a little, if the swelling that I'm observing is swelling is of a neurogenic origin or whether that's swelling is you know, from other causes. And she's got somebody else riding her, she start on this, she's starting PT in two weeks and we don't need to get too many cooks in the kitchen, but nobody's talked to her about this and nobody really talked to her or orthopedist that, you know, she mentioned her leg hurting so much or orthopedist said, well it's because of the way you're carrying yourself here, don't do that.
And that's all they gave her. I said, well what do you mean what can I do about all this? And they said, whatev we treat risks, that's what we treat.
And that was what she got from orthopedics. She said, talk to your, your physical therapist whom you're not going to see at that point for three weeks.
So that was an interesting encounter there because we went from that point of just offloading the nerve in a sitting position because she consistently had her symptoms. They wouldn't be present in the morning when she first wake up and they really weren't very noticeable and until two 30 or three 30 or two 30 to three o'clock in the afternoon and that was reliable. So I asked her, what are you doing for the hour or two before then? And she was spending time at a computer during that period of time and trying to use a mouse with her injured right hand had her in that right lateral bend that much more. So we talked about that and ways to work around that.
And she also would experience it with prolonged walking. So I started working on other postures to try to take the heat off of that area and what's the best opening position that we know of based on the work that we've done together with NCA and its incorporation of other models, static opener in sideline right with that affected leg up. So I put her on her side in that position.
She had worsening of her pain of pain now for the first time in her shoulder and in her arm laying on her side with her leg tilted over.
So now what it looked like to me is we've had some adaptive shortening of the, all of the structures in this area and both neural and probably the scions as well. And then when her head tilts over like this, we've got a mechanism to worsen the neural entrapment of all of the involved neurology downstream here, downstream here. So what we do, just prop, you know, put a pillow under her head, take that strain off and then this is okay for her to lay in that position.
And we stayed in that position while I continued to play with the hand and work on her of doing various positions of rotation and such that she said that she couldn't do and she was able to subsequently regain as we stayed in this position.
She reported after three or four 32nd reps there in opposition that her pain had dropped to a two.
So I then went into explaining to her, and this is the pain in her leg, I went to the next shot of explaining to her what we were doing and why I brought out the models and showed her and I said, you know, this is like a bruise, a bruise anywhere else on your body except this bruise happens to be on a neural structure on a nerve if you will. And if you keep tapping that bruised area, it's hard for it to heal. So we're going to just get off of it frequently and repetitively throughout the day so we can give it a break.
And then I gave her some similar, I said, we want you to get out and move a little bit. So now we want to get her moving to try to work on that cellular aspect, get her rest involved in here and such so, so we want to get you out moving and walking some more. So you're, we're going to anticipate that when you do your symptoms might come on. So when they do, here are some things you can do in standing. And I gave her some antalgic positions to kind of work into to do repetitively. And then we challenged that before she left and she was indeed able to reduce the symptoms when they came on. And I said, if that's not enough, then find a bench to sit down on, sit down on it and adopt the sitting posture.
So now we've got a standing, a sitting and a lying relief posture and instructions about why that helps so that she has a little better understanding and a narrative. So it starts to make sense from the top down approach. And we have some recommendations on frequency of how often to do that during the day to just string together acute times of cumulative benefit so that the nerve gets a break metabolically and is able to essentially heal and later we can start working on the mobilizations and everything to restore its elastic modulus to restore neuro neuro mobilization of its movement versus other structures and to start weighing in on the shoulder and the wrist and to tag team that with PT when she starts that.
So that was kind of a fun one.
She liked me better when, when she left.
Yeah, going down from a 14 to a two was kind of kind of lovely, but thoughts, considerations, input,
Look at that. 10 o'clock. So we got an hour in today,
Glen, you requested last week the
session on peripheral neuropathy and DDX in the clinic.
I am still still eyeballing that with and understand that's part of the reason why I got in touch with Dr. Ney. 'cause I think, you know, going to the source of some of that research might helpful and quite honestly because I would like to weigh in on that topic with something more than the, the big three or possibly four polyneuropathies that people in a physical medicine environment are most, most likely to see. You know, so that polyneuropathy is gonna look like B12 deficiency, alcoholism and diabetes. And I don't know what the actual numbers there, but off the top of my head and just based on my clinical experience and probably yours as well, I would suggest that of all the polyneuropathies that I see those probably make up, which are few, those probably make up 90% of those.
And then you have some that are, you know, a result of after chemotherapy, which you would, you know, have a very clear understanding of. You'd have some that are related to patients with
diagnosis of HIV that are a bit older and some of those early antiretroviral co cocktails were actually using chemotherapeutic agents and those chemotherapeutic agents, you actually dial the, you titrate the dosage on them according to the patient's individualized tolerance of the neurotoxicity side effect. So there's going to be some long-term differences there. And I've had some, some interesting patients over the years that have concomitant lumbar radiculopathy with that anti retroviral cocktail cause polyneuropathy and trying to tease clinical data out of that's sometimes quite challenging.
What else? Then you'd have, you know, things like MS and RA and things of that sort to consider, but blessedly in a physical medicine environment, those things are relatively, are, are quite infrequent. I don't think I've ever seen a patient with gang ra. Not knowingly. I don't know if you guys have, Lynn, you probably have a much higher need to know on that since you're, as I understand and you still managing interns in the school clinic.
Yeah, so we, we have a very large Asian population, so I have a very high prevalence of diabetes within the group. So we do see a fair bit of the, the polyneuropathies.
Do you guys integrate at all with Dr. Fung there in Toronto?
I, it, it is very difficult. I've been trying to send some patients to him, but it's very difficult to get the patients to actually see him.
Ah, But I, I do leverage a lot of his literature on some of my patients to be honest and using that, the intermittent fasting to, to try to help them manage some of their things and be careful, really careful with the diabetic. So he's got that little case series of the three that has some pretty imp and pretty impressive numbers on Yeah. But we just be super careful managing those because of, you know, the side effects that might happen if they don't get nutrition.
Yeah. And that, that has been fascinating to me as well in the past. I have and, and now that you mentioned that I can recall that three patients right off the top of my head that I've had that had some kind of peripheral neurological issue that was concomitant with what was probably a diabetic neuropathy but had not been frankly diagnosed and they were very resistant to dietary changes that involved a reduction in that base note calorically in a lot of that part of the world's diet of rice and in particular white rice. And you know, it's fascinating to see that, that someone with an HBA one C that's high and they've got a, you know, a even I've, I've even had physicians that were of from that part of the world that were suffering from those issues that had sought out my care from, you know, finding me online with your own back and stuff like that.
And they would not change their diet to reduce that insulin response and that hyperglycemic, you know, load. And so we, you know, in those patients we've just worked with, let's look at metformin and Acarbose and talk about that with your primary care and let's try to grease the skids to that referral and get this taken care of there.
I think it, it, it might be this the cultural authority that we may carry and that might not have the, the, you know, the authority that they see in us as a, a provider. But what I found historically with my patients and the co-management with the endocrinologists and the dieticians is we're not historically doing a good job magnesium through a dietary perspective.
Yeah, yeah, yeah. Same here. And that I think
Somebody's got a, sorry, sorry, Phil. I think somebody's gotta, you know, show them the consequences of long-term poor management with regards to amputation, losing a kidney, having a heart attack, going blind dying.
Yeah. And that, That's pretty strong. But sometimes
That, and the population that I grew up in is, is rife and undermanaged in the, the black population as well. And you know, it's a, an all too frequent
scene to be rolling down a, a rural southern road and to see black, black people on the porch and a rocker with, you know, amputation stumps from the knee down and you know, they even got a word for it. They call it the sugar. Yeah, the sugar d me, you know, I, and well, do you have diabetes? No, I got the sugar. It's, you know, it seems a completely underserved population in that regard. And I certainly saw that as well in the first Nations population there in the Winnipeg area when I, I taught there, I remember when Ian Ledger and Tim Petrick hosted me there. They, they brought me into the, the medical school for, which is where we did the presentation and we went and had lunch in the, the cafeteria there.
And it was amazing the indigenous population there. It wa in the cafeteria it was almost completely people over 300 pounds of indigenous heritage.
And as you walk by with your tray, us, you know, trying to do the right thing, calorically just marveling at the simple carbohydrate on the trays. And, you know, I asked what is, what is the relationship here specifically in this space with that population? And they're like, this is a diabetes treatment facility. And like, so, you know, that disconnect is just amazing to, to see. And you know, I, I applaud you for trying to find ways in our little niche of the world to at least get one more lever under there of pain as a way to motivate people to behavioral change for systemic health.
Yeah. Doing the Lord's work.
All right, what else we got before we close, close shot peeps
Reminder, as we close on the next two weeks, we will be offline. We're not gonna be meeting here.
I know I'll see Mark in two weeks in Seattle. He'll be joining us there and next week I might see some of you at the R two P symposium in Dallas. I'm not presenting, I'm just going to learn and hang out with compatriots here at Brett Winchester present.
I might even throw my beat up shoulder that I just put in front of my primary care yesterday to see if I can get an MR arthrogram and see if it's time to tack down a slap lesion. That's been, I've been nursing for 15 years and recently blew up on me to the point that I couldn't even do a side posture manipulation with my shoulder. That's no good because believe it or not, Snell does manipulate a spine every now and then.
All right, peeps, it's good chatting with you. I have no idea what the recording quality and all this is gonna come out with since I'm doing it on my phone today because of the, the snag with the computer right there at the end of the day. But if we've got a, a usable recording here on Zoom, then I'll post that for others on the blog at NeuroCentric Approach and I'll also put a link to that on the community. In the meantime, you guys stay curious, stay compassionate, take what you learn and go help some people.
Be well as always.