Phillip Snell
And we'll give a few moments for folks to check in here. Hope everybody's doing okay. Looks like here in Portland, we've got our weather starting to change a bit. I'm getting something that looks a little more like proper summertime weather here. Got my garden in last weekend, and irrigation systems all set up in advance of the upcoming trip that my family and I are gonna be taking to Italy and Morocco in month of June, which means we won't be here today. We're gonna be talking about extension, intolerant, back pain, and I'm gonna add one little subtitle to that beyond the si.

So we'll talk about a few different common presentations clinically that tend to show up. I'm talking about this this week because it seems that in the past week or two I've had a increased uptick in the number of patients I'm seeing with a variety of these. And I thought it would be helpful to discuss decision making process and screening to try to ferret out specific tissues and functional patterns that are associated with, so-called extension intolerance.

Intolerance before every, all the haters over here on social start to jump in on, you know, the intolerant remark. The intolerant remark is, does it mean that the spine's not made to extend? Does it mean it's not made to move in different directions?

It just means what at a given time it prefers to do or not do. You could just as easily insert some of Peter O'Sullivan's terminology here and just call him an extension pattern of back pain rather than an extension, intolerant pattern of back pain.

So all of those things are valid.

Now, a little bit of commerce to start with, the neuro centric approach Online Academy is available to you.

These people are over here, are already on it, they're already members and they can come and join me on a Zoom and we can talk shop on a regular basis and get a little deeper understanding on the neuro centric approach process.

Those of you over here on Facebook can join that by going to neuro centric approach.com and look for the links for online courses. The online academy is 35 hours of continuing education and a community where we workshop things throughout the week, but once a week, typically we get together like this at nine o'clock Pacific time on Zoom and talk chop.

The other perk that you get as a member is you get a hundred dollars off of in-person coursework and the in-person courses. We, our next one is in July in St. Louis, and we've got one now scheduled in.

We've got one now scheduled in Phoenix in December. I should have that registration page of this weekend now that I've gotten all of the Ps and Qs together with that. Good morning Dr. Heller.

And those, those are our online co, excuse me, our in-person courses and as I mentioned as a member on the site, hello Jerome Fryer. Good to see you mate. And congratulations on your son's success with fun geometry. Can Canada's got talent, the, you get your nice perk of a hundred dollars off with the membership there on the site.

Let's see, I don't think there's whole business beyond me just mentioning. Once again, I will not be doing this for the month of June as we are going to be my family and I on a trip abroad. So we're, we'll catch you in July. We'll still be here next week as well though. Okay, so let's talk a bit about extension intolerant back pain.

And I mentioned beyond the si because those of us that are trained as chiros learned to adjust the SI joint six ways from Sunday.

We learned to name various SI presentations and just off the top of my head, I can remember three, four, maybe even five different nomenclature naming systems for how that dastardly SI joint can get

in bad places.

I think it's always important if we're gonna talk about the SI joint to acknowledge it, it really doesn't matter all that much by na. It really doesn't move all that much by nature's design.

Jerome's on here and can talk a bit about that, I'm sure at some point, perhaps fiber cartilage on one side, synovial cartilage on the other side tends to wear with a characteristic groove pattern.

I always used to say to patients back in the day that yeah, you can get a bit of trauma through the joint and wind up in a position that you don't, don't favor perhaps. And in those cases, maybe a a sacroiliac joint manipulation would be worthwhile. Jerome's showing us a sacrum there and a picture. Jerome, why don't I open things up for you here and talk to us a little bit about the sacro iliac joint.

Let me see if I can get you up here on camera. My ma'am,

Jerome Fryer, DC
Can you hear me?

Phillip Snell
I can hear you, yes. All right. What do you got there? It looks like an authentic human sacrum.

Jerome Fryer, DC
It is, yeah. And I thought I'd just bring this to the viewers. I wanted to show kind of the size of the joint, we'll get some scale and how undulated it is.

So it interlocks you could see that it's not a right and not a kind of a smooth, you know, you know, convex and concave surface. Right? So, and you can see we've got some differences from left to right, right? So this is a natural specimen I can actually grab, let me grab some, let me grab another one. But, so I appreciate you thinking that perhaps I know some things,

but I'll leave that up to you, Phil.

Now this side, just remind me again, this side has the Hyland cartilage and the other is the fibro cartilage. Is that correct? I've, I've just kind of forgotten now.

Phillip Snell
I gotta be honest with you. I'm not entirely sure myself.

Jerome Fryer, DC
Okay. So anyways, it's a very interesting joint of course. Right? Let me see if I can grab another specimen here.

Just gonna see if I can prop this up for you guys. So while I disappear,

Speaker 3
Let's see what else we have. What else do we have?

Phillip Snell
Yeah, one of the things that I've noticed over the last several years as well is a, a pretty dramatic uptick these days in our physical therapy brethren engaging in SI joint hijinks. It seems like it's become a pet joint in the, the, the world of physical therapy now, much in the way that it was historically in chiropractic. And I, I'm not entirely poo-pooing the benefits of a sacroiliac joint manipulation in the, in a well a well chosen patient population, but I I do have that it happens, it's seen as a source of some sort of discomfort and pathology far too much.

Jerome Fryer, DC
Yeah, I have, I I think, you know, as we were trained as chiropractors, we were trained that there were so many different ways to adjust the sacrum or the SI joint and there were, there was a paper published, I'd have to go dig that up. But that, you know, when we do the side posture manipulation and we place, you know, our forces, you know, our manual contact on the sacrum or if we, on the PSIS logically, I think logically we're gonna be seeing this joint gap first. This is likely we, we think we, you know, this big articular joint that's held in with so many ligaments and there's very minimal movement with it by rotation.

For the most part, this one will gap first. And, and if this one's res, this is my opinion, and if this one is restricted, L four five will pop first. Right. So I think, you know, we think we are being so specific, but I think the, the path of least resistance will gap first.

Phillip Snell
Jerome, let me ask you, have you, have you been to view any joint block procedures for the SI joint?

Jerome Fryer, DC
I haven't, no. Have you?

Phillip Snell
Yeah, I've, I've not. But in the description and talking with physiatrists to do that kind of work, I could see a lot of room for, for, we'll call it sloppy technique perhaps.

I, I see a lot of mileage made out of, in the world of physiatry joint block procedures to the SI joint or to the facet joint to quote unquote definitive definitively rule those joints in or out.

And, and yet I see that it's not terribly uncommon for a, the technique procedure before the needle actually pierces the joint for a bit of the, the anesthetic to be released and then on the withdrawal for a little bit to be trailed out such that you get some anesthetic in a surrounding area of the joint as well. And I've, I, I see that and see when I talk with those docs and see the, the possibility that these definitive procedures, there's a lot of room for error and we still probably need to keep our skepticism invol involved here even when we see that and probably also ought to keep a bias in check. Yeah,

Jerome Fryer, DC
Yeah, I agree. I think for me, the best sort of way to test to see if an SI joint may be a symptomatic structure is to get people, you know, we don't have, you know, access in clinically, you know, within our, within within our walls, but I just get people in an SI belt now you just crank it right, right up, right, A oli belt and I just crank it up as as tight as somebody can, can tolerate and then I get them to re you know, re reproduce the movements that, that cause symptoms. Like, you know, getting out of a chair or whatever, you know, movements that you can do pre and post, you know, with and without the C bill.

I think for me, that that's, that's a reasonable approach.

So

Phillip Snell
Yeah, I'm, I'm inclined to agree as well. So let, let's see. Mark's tossed something into the chat room here, which got there.

Jerome Fryer, DC
I just, I just just wanted to show you, this is a five-year old specimen. There's a five-year old sacrum. Oh

Phillip Snell
Wow. Yeah, look,

Jerome Fryer, DC
So I just wanted to show, right. Look, look at the SI joint, you know, it hasn't even formed yet

Really, but there's an early early development of of, of one

Phillip Snell
That's that and you know, seeing it as well as the joints still not having fused as well and as one to five.

And that's pretty cool.

Mark tossed into the chat here, I have a recent case negative on injection positive response to the belt positive provocation test.

Let's get mark on. Yeah, talk to us about that. Mark, what do you got?

Marc Heller, DC
I have a, a, a recent patient in really nasty pain for quite a long time and she, she, she, she had a few, 10 years ago she had a problem with L five S one and had a discectomy that was successful but did leave her with weakness of the L five S one muscles, the to dose reflets. But basically I kind of crashed and burned on the first couple times I saw this lady and then on the, I have, she sent me over all her chart notes and her, one of her doctors who did a nerve conduction study said something about, oh, I think you have an SI problem.

And she did go and get injections, blocking injections and it didn't do her any good.

But then that third time I saw her, I poked around, the SI was tender, the provocation tests were positive kind of universally. And I, the interesting part is I didn't, I, I was listening to Jerome and Thisor belt story, I did not have the right size SI belt for her, so I took a yoga strap and strapped it around her pelvis and she said, oh, that feels so much better.

Phillip Snell
Yeah. And, and I'm ordering her, I told her to order the OPTP belt. So anyway, so that's the little mini story here with injections can be imperfect about this stuff. Yeah. So, and, and the, the other part of this story for me is for a long time I thought that the SI was not a player unless the person had positive provocation tests.

And then when I couldn't get over an injury, a twisting injury, I, I had shoveling snow. I went to my physical therapist friend who does osteopathic muscle energy. I thought for sure I had re irritated my disc.

He did, he realigned my sacroiliac joint in his, the way he does it and three treatments of that. And I, my back was okay again. So it's like, and and that's made me skeptical of the whole thing of saying you absolutely have to have positive provocation tests in order to address this sacroiliac. I'm kind of like back into, hey, I'm paying attention to the sacroiliac a lot more again.

Do you think though that with the procedures that your physical therapist did that other structures could also be coming along for the ride in that that might not have anything to do with the SI joint?

Marc Heller, DC
Absolutely. And and for sure it's like, like Jerome was just saying you do something to the SI and you're affecting the L five S one and probably the L four five joints as well. So yeah, and I, I kind of, for a long time my drill was, okay, it's really obvious that your ASISs are not even, and your rim is not even, and let's take care of the mang syndrome stuff. Let's take care of your discs and see if that stuff realign. So, you know, I had years of doing it that way and with mostly good success of course. But anyway, yeah.

Phillip Snell
Yeah. Many of us have, have, have certainly played that SI card relatively successfully over the years. I think the, the place that got me really starting to think about it was relatively early on in practice in the first few years.

I remember having those, one of those SI patients that I had seen and you know, they were one of those that came in with the, their, their little out card. Right. You remember the patients used to carry around and it's like they have their card

Marc Heller, DC
Yeah. As if they have the same subluxation every single time they go to the chiropractor.

Phillip Snell
Yeah. So they carry that around in their wallet and you know, when they travel they can pop in and see somebody. And I, I wound up with one of those patients showing up after their doc had retired.

And so I just gave them what they came in in for. That's what I've been trained to do. And I manipulated that SI joint, I manipulated that SI joint, I manipulated that SI joint, I did it, you know, in the way that they have been trained. It was good business, right? It was. So they came in, you know, weekly or you know, every, I don't know how long it was monthly or whatever, but I saw 'em several times manipulated the SI joint. They were quite happy with it. They'd come in and pain, they'd leave without paying piece of love and guitars. Right. And I hadn't see 'em for a good long period of time, like a year.

And they popped back in and I said, oh, you know, I see I haven't seen you in a good long period of time. You've been okay. And they're like, yeah, yeah. You know, something really weird happens.

I, I had a, I had a back pain episode that was remarkably different. It was just, it was like kind of pain I've never experienced before in my life. And you know, not only was it in my back, but more importantly and even more noticeably, it was really painful in my leg and down in my butt. And it was this searing hot electrical pain. And she's describing a radicular process and you know, I said, well how did that come on? Did you, did you have any kind of a, you know, a lifting injury or anything that kind of provoked it that you can recall? And like, no, it, nothing really happened. I just kind of woke up one morning and bent down to pick up my socks and I had this searing pain all the way down to my foot.

And I'm like, well damn, why didn't I see that? You know, because you would like to think that that one had, that would be a herald. And then I started to ruminate on that as a young doc will do. And I'm like, you know, maybe that SI joint was actually a herald of something else that was going on. And that got me thinking a little bit differently and maybe more deep deeply. I don't know about this, but with all of that in mind, I wanna talk about a few cases that I've seen recently.

One is a chronic pain patient that I mentioned recently. 72-year-old male. He had a, an SI joint fusion.

He's been in chronic pain, a classic failed back patient.

He's had I think five different surgeries on his lumbar spine. He was a college soccer player and in the 1980s had his first radicular episode and then subsequently had a laminectomy and then a fusion and then revisions after tethering of the nerve root with scars and, and you know, hit at this particular point, it's quality of life, it's been incredibly impacted for 30, almost 40 years now.

And his, his most recent procedure was an SI joint fusion last year at the age of 72.

No change in his pain for what it's worth is our functional approach right now that we're working. And I'm leveraging mostly a DNS card there 'cause he has practically no strength and you know, he can barely move it, he can only stay upright, either sitting or standing for four hours a day before it's intolerable. And he spends the rest of the day laying down. And that's been his pattern for a number of years. So, you know, if for, for that particular patient stabilization exercise is, is the route that we're playing and I'm using more of the stabilization kind of calling card that hicks et al and part of that et al was Stuart McGill would be playing McGill's work with some of the DNS work as well and combining those two approaches.

But another one recently that I've been dealing with is a, a young, very young patient, 18 high school with a MRI demonstrated L five s one disc herniation.

And she's had the full gamut from what I've seen.

The, the herniation present is a lateral presentation. And the lateral presentation will tend to present with a, a lateral antalgia. And to my mind that lateral antalgia places those interesting, perhaps unequal forces across the SI joint that can cause perhaps a bit of a pelvic up slip is to QL on one side it'll tend to be a bit hypertonic and that pelvic up slip on that side and some of the classic listings would make that an as ileum on that particular side.

And the hypertenicity on that particular side also causes some palpable tenderness over the medial branch to the superior clonal nerve.

So with her, we're dealing with a disc that is flexion intolerant, but she's also, she's got a combo platter. If we extend her pure extension, that lateral presentation doesn't like it very much. And the s the superior cornal nerve doesn't like it too much. So she has been a very difficult case to manage because it's almost like playing whack-a-mole with her. And we've had injections with, you know, transient benefit and mostly I've just been training her around these episodes to improve her stabilization capacity in the low back as well. But just a a, a terribly difficult case to try to manage because it's like I'll get three good weeks of very good work with her training and get moving her up from a strength program to a power program.

And then we get her running up to a hundred percent. I saw her and she was running a hundred percent capacity and then she went and sat on a plane for about six hours and flared up with her disc symptoms prone, press up are no good, we gotta do the lateral McKenzie protocols and do the lateral glides and then once the lateral lateralization clears, then we can move into extensions and all. So just a bit of frustration there. So what I've come up with over the years and some of my, one of my courses, I can't even remember which one now, I was just looking for it a moment ago, wanted to pull up a graphic, but I did a, a chronology of what I most commonly see in these, these patients in an, in most of our back pain to patients over time and far and away.

What I see most commonly is that it in a younger patient, the most likely structure in a back pain patient that's going to be talking is commonly, I won't say far and away, especially owing to the recent paper that showed that close to 50% of our adolescent athletes that have back pain actually have a pars fracture.

And that, that number kind of blew me away.

But in many of those youngsters we're dealing with a disc of some sort. If they're a rotational athlete, the lateral presentation is much more common in that disc presentation.

In the younger patients, according to Michael Adams research with his wife, in those younger patients, the disc injury is much more commonly gonna be in the upper limb and in the older, as they get a bit older, the disc is much more likely to be a

lower lumbar. It should

just reading Jerome's chat stuff there, we can follow up on that in a moment Jerome, but the, what I generally see is the injury in most back starts off as a disc in the lower lumbar spine because of the injury in the disc. We have a reduction in hydrostatic pressure in the motion segment there and that allows a bit of extra shear, which Jerome could speak to as well. And he's modeled quite nicely in his work with dynamic disc designs that allows for extra shear at that level.

That shear increased shear is what gives us what we are starting to see as a much more common presentation than perhaps previously. We've been trained to think of as a functional instability at that motion segment, at least for a period of time. And it from the cellular level all the way out to gross histology at muscle and joint level of histology, everything in that area from the, the cellular strata at the annulus, the strata and the nucleus, everything is attempting to become more stable. The stiffness increases in that area seemingly by design to try to take care of that functional instability. Now the other thing that happens when you have a loss in that hydrostatic pressure is the facet joints bear a lot more load with, especially with any kind of extension.

And you couple that with the protective tightening or hypertenicity of the lumbar erectors and now you've got person that with that disc injury that walks around for a number of years with an anterior pelvic tilt and lumbar muscle hypertonicity and possible tissue acidosis that causes a secondary source of nociception there in the pain in the muscles and potentially in the superior clonal nerves that reside in those muscles.

So in those, in that chronology starts as disc relatively soon after that the adaptive postural splinting can cause involvement of the superior clonal nerves and the extension effects at the upper lumbar spine that can cause our main syndrome over a period of time, that particular patient with that un unexplored or underexplored will have some changes in the mechanics of the hip joint and then the hip joint becomes problematic and now you've got potentially gluteal pain that could be of hip origin, could be of sacroiliac origin, could be of SI origin, could be of

facet of clonal origin that everything could make that butter. Then you gotta do your deep gluteal pain syndrome, strata, all of that. So that's the, a lot of the fixture on back horse and the the lower quarter neuro centric approach course. Now over time those facets bearing more load and I think probably mark with his older disc herniation and certainly me with mine can attest to is that I've become a hell of a lot more extension intolerant and a hell of a lot less flexion intolerant and I can move into flexion quite a bit more now, but I'm still loathed to do that under load. I'm not going out and doing Jefferson curls, but these are patients that might be cruising online and looking and seeing that Jefferson curl as a possible option there.

And as we've mentioned before, I generally would prefer to do that by taking compression a little more out of that equation by using a supine DNS kind of log rolling stimulation of the deep abdominal muscles and a lower abdominal muscles to try to get a little less of that anterior pelvic tilt and a little more of a centered position on the pelvis.

So I, I generally see that to be the, you know, what starts off as a flexion intolerance over time turns into an extension intolerance and then the structures that could be involved if they're, if they're much younger, I'm thinking more lateral presentation on the disc and possible SI involvement independent of age. I'm gonna screen for the SI joint as they get older. I'm much more bullish on the facet joints and much more likely to do a engage in manipulation on that particular patient. And that is consistent with the clinical prediction rule that was put together by Alito and Fritz and her Hebert a number of years ago, Jeff Hebert.

So that's the way that I generally approach these and trying to, to make sense out of these cases.

And sometimes you get patients that are kind of in be Twix and in between there you just gotta roll with it empirically for a period of time. And trial, trial something I do recall, you know, one of my former coworkers, Dr. Bruce chaser clue me into a a, a manipulation he used to do, he called it an, the anatomical listing for it was an anterior sacrum.

So the sacral base theoretically being pitched a bit anteriorly there. But the, the setup on it and I found the manipulation to be very, very well enjoyed by our older patients. It's a side posture and it's a scoop on a superior to inferior tissue pull just broadly on the, the, the, the sacrum and trying to, to put a little bit of counter mutation on that, that sacrum. And I've found that to be helpful for a lot of those particular patients. So now, you know, we've got some some long in the tooth docs on here. You guys have seen a lot of these kinds of patients over the years.

Any thoughts, anything that you wanna share there?

Marc Heller, DC
The one thing I wanna share is that

if the, you know, provocation testing to me says when I put more motion into the sacroiliac joint, it causes pain.

I think that tells us don't do heavy duty side posture manipulation of the si and I, I don't think this group is probably that way, but I suspect that most chiros, you know, someone comes in with the low back, they end up getting a side posture manipulation and I, I think that has more chance to irritate a truly painful SI than to help it. And if they, God forbid they have already a herniated disc, there's some risk that we're gonna make that worse also. So I'm back to learn low force methodologies of moving those joints. So enough said on that.

Phillip Snell
Yeah, yeah, I'm, I'm inclined to agree with you Mark. I am and I think general, generally good principle is to start with lower force, lower risk techniques for all of the, in all of our patients, but certainly for those where you, if you're wrong, you could potentially worsen the condition significantly. You're just gonna play devil's advocate though for the, I don't know, PR PRI trained people or even classic chiro trained people and maybe ask if, if Jerome wants to weigh in on that, if you're, you still got your ears on Jerome about the classic bone out of place model. 'cause it always seemed that, that people leaned on that very heavily in in those those systems with the idea, as I was mentioned earlier, that owing to that interesting configuration of the sacred iliac joint, we can literally wind up a little bit outta your groove and a quick little nudge in that particular area seems to be quite helpful for people.

Jerome, what do you, what do you think there, lemme get you unmuted. There we go.

Jerome Fryer, DC
Great questions.

You know, so,

you know over, I don't even know where to start. There's so much in my cortex, you know,

Phillip Snell
Buddy.

Jerome Fryer, DC
Yeah, what do, what do you, is there something specific you wanna ask me? Like No,

Phillip Snell
No. I I want to know if you have any, any opinions about a classic bone out of place model on the sacroiliac joint.

Jerome Fryer, DC
So the sacrum's outta place or the ilium is outta place?

Phillip Snell
Yeah, yeah, I mean that any kind of contact that we would be doing to shove the, the sacrum or the ileum in any given direction with the therapeutic goal to try to level the, as we hear all of the time, the hips that are out of place.

Jerome Fryer, DC
Oh gosh, so likely not, I'll just be frank about it. Right. You know, the, you might be able to nudge the hypermobile joint in a particular direction and hope to bias it in a, in a spot that may be less symptomatic, you know, working through some other functional strategies using muscles and things, but the actual like gap, the SI joint to fit into a new slot that's subluxed highly unlikely just based on the anatomy.

It's just straight up there's like, we've gotta be reasonable with our thought processes here. That's the way I feel anyways.

Phillip Snell
Got it. So if, what is it about the sacroiliac joint that you think anatomically makes it less

amenable to that movement? Is it what you were talking about before that the general processes and positions that we put our patients in are much more likely to capitate the L five S one or L four five joints? Well correct. Before, well before we get that beast of a joint that you're showing us right there to actually cavitate or distract.

Jerome Fryer, DC
Yeah. Yes, absolutely.

Phillip Snell
Got it. Okay. So we just put a heel lift in, right?

Oh

Jerome Fryer, DC
Yeah. It's, you know, it's,

Phillip Snell
It's tough. I get us all in hot. I'm gonna get us all in the chiropractic hot water

Jerome Fryer, DC
Here. Oh, it's okay. You know, it's okay. We've gotta move, you know, we've gotta move forward with these, with these ideas, you know, I know our, our training, I'd be very interested to move through the whole DC program again and see what they're, what they're pushing, you know, it'd be very, very interesting. Right.

Phillip Snell
I I've actually thought about going out and auditing classes and just sit in the back and, and see where we are now with some of this.

Jerome Fryer, DC
How things like, you know, I, yeah, I, you know, I understand you get somebody inside, you know, they come in and they claim, oh, I got an SI problem. I need my SI joint adjusted, my hips are outta place. Okay, we're gonna get you on your side. Oh wow. Look at that. Okay, well that feels way better. Thanks Dr. Ching. There you go. Like you said, there are other things that are happening in the room and we have to be mindful of you even just explained a case about, you know, likely it was a, you know, L five one or a 4 4 5 disc that was symptomatic and we keep pushing on that and we've, we get, luckily we got a pop and, and we get a gapping of the facet joint.

Well, no, let's just go back a little bit with, with regards to, you talked about hydrostatic pressure and shear, right? And now in an, you know, you moved into an older patient that's got arthritic facets, you know, so, you know, the act of shear for me, I was kind of, you know, they didn't teach us much about shear, right? They didn't teach us about these movements related to that. And it took me a little while to understand the concept of shear. I just wanted to share with people here that when you lose a little bit of high hydrostatic pressure, likely because the nucleus is now migrated into, it's not in, in a contained space, it's now moved into the annulus and the hydrostatic pressure can't be sustained because now the nucleus has more volume to move into.

You're gonna lose disc height and now you've got this disc that's moving around more. So, and the shearer that you talked about relates to now you've got the facets that are bearing much more load. So I just wanted to share that with people and when we ga and now the facets are symptomatic and if we gap a facet joint, well guess what? Now you've increased laxity in the facet joint patient walks out, oh wow, yeah, that feels much better in the refractory period. Okay, where do I pay? Okay, great. Now they sit down in their car and they go into flexion. All right. Oh, you know what feels good? Oh yeah, that chiro, he's awesome, right?

He is so awesome. Oh, oh, I felt a little bit when I got outta the car. Oh, it must be just part of the whole experience. Alright, so I get, well you know what, it feels pretty good now you're still within the refractory period of about an hour. It could be an hour and a half if the joint continues to move the refractory period likely based on the research that I've done can expands. So it extends, it can go, you know, within the 20 minutes to now an hour. If you keep a joint moving after it's been adjusted, it it doesn't, the refractory period will increase over time because the, the, the, the little bubble doesn't get a chance to kind of suck away with the little, little pumps that are happening within the synovial joint.

So yeah, I know there's a whole clinical experience with our patients that are, it's very interesting. We're thinking we're doing one thing and we're often doing something else. And that's why I developed these models to help us just be a little bit more clear on what we're approaching and targeting from a therapeutic standpoint so we can understand symptoms.

I just, you know, I don't wanna take up your space here and you know, all I wanna be is helpful, but I just wanted to, the, the research that I did back in 2010 using upright mr looking at offloading the disc. Okay? So if you've got, if you, if you have a patient that's like, oh gosh, I gotta go on a plane ride and they're, they're worried about it because often prolonged sitting is going to, is gonna flare them up. And the research that we did was we looked at an offloading strategy where you use your up upper extremities, basically your shoulders and your arms to basically increase the disc height by pushing down on the seat back or on your armrest holding it for five seconds and just pumping this reduced hydrostatic disc up a little bit.

And if you can prevent this thing from, I'm gonna say bottoming out, but it's not really bottoming out, but at the bottom part of the disc height loss and keep it just pumped up the, I've had so many patients tell me that, you know, previously and long plane rides, they would be get symptomatic, but if they offload periodically then this thing doesn't bottom out. So anyways, that's enough of me.

Phillip Snell
No, that's, that's, that's really good. That might be worth the price of the mission here for any of the viewers on the that and, and worthwhile for this to, to be out there as a, you know, something that people can see as a recorded item, which by the way, you guys record these and they reside on the neuro centric approach blog and you can find those and also on Facebook live there for a period of time too. Jerome, thank you. That was helpful and I can see that already. We're probably going to start seeing a whole lot more people if we get a little exposure on that. A lot of people doing that offloading procedure on, on planes next to us.

Now we just have to fight over who gets the arm rest and when in order to do that.

Alright, so that's about all I've got for this week.

Unless anyone's got any questions or comments I think I'm gonna head to, to my next, I think I'm gonna head to my next project, which is gonna be supplying today. So lucky me guys take care.

Marc Heller, DC
I just wanna thank Jerome for all that he, and appreciate him being out here and showing the models

Phillip Snell
And thanks a lot Jerome. Yeah, it's nice, very nice to have you on board with us, Jerome, and giving us an opportunity to see your incredible body of work that you've put together there. It's very impressive what you've done mate.

Jerome Fryer, DC
Well thank you. If I'm still on here, I am just trying to contribute and make more sense for our patients.

Phillip Snell
Alright, well to all of you that are watching either currently or by recording, I would encourage you as always, to remain compassionate, stay curious, take what you learn and go help some folks be well. I'll see you guys next weekend. Take care. Bye-Bye.