Phillip Snell
Hello over there Facebook. Come on over here and join us on Zoom.

We are starting our NeuroCentric Approach Online Academy meeting today. Welcome everybody over here.

Adam, nice to see you again, sir. How are things in BenD today?

Okay. All right, looks like we're still waiting for folks to jump in here, so I will let them get set up, get comfy, welcome over here Facebook land as well. This is the NeuroCentric Approach Online Academy.

Why do we do this? These are case studies that we do on a weekly basis.

If you are a member, you can join over here on my Zoom link and ask questions and we can dialogue back and forth about case studies. Typically, I present case studies, but you are also, you guys that are members are cool to come in and bring your own cases as well and we can troubleshoot and talk about that. The goal with these is to try to improve your integration of this, the NeuroCentric Approach into your clinical sort of flow and get that conceptualization of ruling neuro in and out as the cause of the situation that is in front of you, presenting with the patient that you're dealing with.

Let's see other items. We have a course coming up in Portland on the 20th and 21st at Evolution Healthcare and Fitness. You know where that is? Adam?

And Adam and I used to share some spaces at the same office there at Evolution Healthcare and Fitness.

But that course is going to be the upper quarter, 12 hour in-person course.

And we also, our other major item is Dr. Scott Grogan and Tyler Lymburner are bringing me into St. Louis. And let me double check my date on that. That is going to be St. Louis July 13th and 14th.

So that I am in the process of putting the, the registration page and everything together for that. And that should be up on the neuro centric approach website under the events tab later today. I'll send that out to all of the members here as well.

So that's another course that is definitely on the docket.

The other thing that's of note, some of you that are listening are members but not lifetime members. Perhaps you got in on a monthly or an annual plan and you might've heard me talking about how periodically I will open up the portal for lifetime membership that's open now and it's open because of March Madness, y'all Final four this weekend.

North Carolina State Wolf Pack women unfortunately succumb to the South Carolina Gamecocks yesterday, but I will be rooting this afternoon for my homies at North Carolina State to see if they can actually take down Mr. Ed and company from Purdue. That would be, it's gonna be interesting to see that, that front court with NC State to see if they can hold him off and not, not foul out. What I'm candidly suspect is gonna happen is that Diara and Burns are probably gonna foul out before second half and then NC State will be left with a a pretty much without a, without a front court. So we'll see. Fingers crossed this team seems to be, have a little bit of that 1983 magic.

All right, so today I, I apologize, I'm a little bit less organized and I typically would be for these, my computer's updated last night and even though I got up started process this morning two hours early, it has literally taken me two hours to get my, my desktop managed and I'm still a bit behind, but wasn't interesting set of cases that came in for me this past weekend or this past week rather. Before I move on to those, let me open the floor up to anyone over here on Zoom. Any of you guys got anything that you want to address today that we can put on the, the agenda or are we a mark? You're good to go? All right, looks like you're headed out for another walk.

I like your inclusion of this on your walking regimen. Maybe I ought to start doing these as a, as a walking meeting as well for me since that would be delight as well, but be a little harder for me to work some of these buttons and be able to manage the phone and stuff too. Oh yeah. So we are moving on to the case studies.

I'm going to frame today's dialogue around lumbar instability.

Talk about a new test.

New to me, I described it briefly recently. Some of you may have joined in. I think Mark was there at Glenn Harris's

disc symposium that I was asked to present for. Stu McGill was presenting on that James Cox, Kathy Dooley and others.

And I presented in my portion on the flow of a person with low back pain, the flow of the clinical, of the assessment and clinical exam, mostly talking about how to integrate things in the way that, you know, approaches if you will. And the way that we do here with neuro centric approach. What I've tried to blend over the years and it's kind of fascinating 'cause you know I'm certainly not the first one to be doing that, right?

The, in the literature, if we go back to as far as I believe it's 2005

is a probably a good date. Yeah, the Hicks paper came out then with Fritz Alito and McGill and that was a bit of a stab then of integration of a variety of different tests for instability.

Mostly what they were trying to do, the, the PTs that were involved on that were Queensland PTs, so they were highly affected as a result by Paul Hodge's work and is at Queensland.

And Hodge's work was somewhat tangentially influenced by Yonda and Levitt and Prague school.

So they sort of have a, a perspective on the idea of deep spine stabilization, but they come at it from a different perspective than the Prague school does.

And McGill has also had some crossover with some he before Yonda passed, some of you might recall, there's a somewhat iconic picture in one of Stew's books, I think it's Ultimate Back Fitness of Stu of Yonda with Stu on Stew's on his back as I recall in that photo.

And Yonda is reaching up under his sacrum and I've always wanted to caption that particular photo that it looks like they are, that Yonda is a obstetrician about to deliver some sort of

evidentiary baby that Stu McGill has been carrying for a period of time. But in that photo was around the topic of gluteal amnesia.

So yeah, this, this integration process has been going on for a while and, and I'm coming to the table with yet another application of it. I'm biased, but I think I've done a pretty decent job in making that integration a bit easier and even intuitive in such a way that students and people that are utilizing it don't get too lost in the weeds as they're working. I'm gonna share screen now and look at some of the slides that I did for that program with Glenn Harris.

I'll cover two major papers on instability and, and the lumbar spine. Talk a little bit about a third tangential paper and then discuss briefly two cases that I saw this past week that kind of helped put a a point on that. So here we go. I am going to share my desktop.

Okay, let's see somebody, are you guys able to see my screen? Somebody come on and gimme a thumbs up or something of sort copy. Thank you Tyler. Okey do. So this is,

this is a paper from 2005 I was referencing. This is the Hicks paper that I was describing as a mishmash between the, the, the, the Queensland approach and McGill's approach.

And essentially what they did here, they were trying to find, figure out a clinical prediction rule, A CPR.

And those clinical prediction rules are just a particular type of evidentiary paper to help decide whether a flow of examination or assessment procedures can help better help to determine a clinical scenario. And if it does, does it increase the likelihood that a particular intervention will help in that population?

And in this one, these are the primary assessments that they did in the Hicks paper. They were looking for aberrant movement with Trump range of motion. So mostly what they were looking for on that was did the person exhibit something called goer sign where you ask a patient to bend down and touch their toes and they run their hands down their legs in a very characteristic way to try to offload some of that somewhat. Some would call that a fear avoidant approach. Sometimes it is, sometimes it's legitimate because they feel, as Stu would put it, a micro movement that predicts that they're going to have pain and that's what they're really looking for with that aberrant movement.

One of my patients this week very clearly demonstrated that someone who had been teaching yoga for 27 years and was referred over by their chiropractor and they had lumbosacral pain right over their sacrum. And when he bent forward he was very careful demonstrating a Gower sign and also keeping the knees bent and only very carefully extending the legs once you got down there. Also in this hicks paper they used segmental posterior to anterior spinous process palpation, a little bit of contact like, so those of you that have done the lower quarter course with me know that in regards to the, the typical clinical flow that I suggest for all of us or, or this is in addition to the typical clinical flow that I would suggest for this because mostly what I'm having you do is check the interspinous spaces to look for some tenderness in the interspinous ligaments in the lumbar spine, the lower lumbar spine primarily, this is a bit different here.

This is the segmental palpation that we do as the preliminary portion of the prone instability test from Stu McGill. So we're just talking a couple of kilos of downward force from P to A on the spinous is looking for tenderness there.

Now over here that's the prone instability test.

So after you do that and that prone kneeling patient who then can grab the bench and elevate or extend the lumbar spine and lift their legs up off of the ground, you would repeat that segmental pa palpation at the spinous processes and see if they, if they still hurt on one that was previously determined on the relaxed PA palpation over here, be painful if they do, if they were painful over here when you did it while they were relaxed and they are not painful when you have them to actively contract the muscles in the lumbar spine, that is a positive prone sheer instability test per McGill. Now the difficult place we are in literature is there's, there is interrater reliability on that prone shear instability test, but there's really not any legitimate clinical evidence there, but it's about as good as we've got out there right now and that's why you see me use that in my own work in combination with two other tests.

Typically the rocking test shown here where you have a person to a supine patient, you bring both legs up and then you lean into that and look for some pain and that this particular paper came out in 2019 and showed a sensitivity of 95% for lumbar instability as compared to dynamic MO motion X-ray and a 90, 93% positive predictive value in that particular test if the patient reported pain on it. Now, prior to that, one of the more common tests done for instability was the passive lumbar extension.

And this one was also from 2009, excuse me, no this wasn't 2019, this was quite a bit earlier. But this reference is the same paper that I previously mentioned because they were doing a comparison between this one, which is only 68, 60 9% sensitivity and specificity is only 20% on this one. The previous exam, let's see, the rocking test specificity is only 40% too. So what I've attempted to do and the NCA rubric is to stack these three clinical tests, the McGill prone instability test and these two into a bit of a flow. Now what they did in the paper back in 2005 was they did these, they also did a, the, the aberrant movement I mentioned they would take do the biting index, which you guys have already learned, a nine part test for a generalized hyper-mobility if you're greater than four, it's reported in the literature, typically in this paper I think their cutoff point was five.

But at any rate you remember the by index for generalized hypermobility. They also did a posterior shear test, which is a, you can see as I described this, how it could be frightfully nonspecific, but in a standing patient standing relaxed patient, the examiner places their hand on their belly and a hand on their sacrum and pushes posterior through the belly through the spine. So you get a bit of a sheer pressure, but you gotta go through all the guts to get there and you gotta, it's gonna change depending on whether the patient contracts their abs a bit and you just do a shear there in the lumbar spine.

So that was one of the tests they did on the Hicks paper.

They also tested the lumbar muscle strength using McGill's functional capacity evaluation, which realistically, according to McGill would be less of a measure of strength and more of a measure of endurance. And then they also compared the straight leg race and to see if the patient had less than 60 degrees on that.

So let's see, here's another slide I did for that. I think I've covered everyth everything here. I'll leave this up for long enough so that when this is recorded, if you guys want to go back and review these, you'll be able to stop the video here on the recording and look at these particular findings. Or you can pull this paper and, and inspect that yourself.

So on this hicks paper, they found that your, if the, that the positive predictive value if three or more of those tests were positive was 4.0, that's pretty compelling.

It also raised the, the specificity to 86% for clinical instability as measured by that dynamic motion X-ray as well.

If only one of those tests were positive, then yeah, the sensitivity is pretty high. But you would expect that because that's just, you know, that's just sensitivity. That just means they're, they're, they're likely to have the they're if that test is positive and they're unlikely to be, to be negative.

Now in 2022, this particular paper, I think this is a French Canadian researcher Lariviere , forgive me if I'm butchering that name, but they reported an even better positive prediction value and clinical prediction rule by pairing down some of those tests. So they kept the Beighton index, they kept the aberrant movement and they added two other tests.

And so we've already talked about the aberrant movement, we've already talked about the Beighton index and they described those thoroughly here. So again, in the recorded version of this, if you're watching this from the NCA community or on the NCA blog recording here, then you can stop the video here and expand this and see the actual procedures described here for the Beighton index and the aberrant movement.

But also these other two, I used this one this past week for the very first time. This was a new test to me called the PPT reach. That's pain provocation threshold is the acronym there. Gotta make sure I explain my, my acronyms for for mark there or he will read me the riot act here at some point. But the and the MCIS is motor control impairment syndrome for the hip active, you know, abduction and rotation passively to maximum movement. So that is basically a, as they describe it, it's abduction and lateral rotation of hip passively by the therapist and looking to see if the symptoms that are produced are similar to the symptoms that patient's presented with.

Helps to predict treatment success if at least one of the sides produces an increase in symptoms. Now those of you that are listening to the description of that, you can imagine that this is somewhat similar to a favor test, which classically was done to delineate pain from SI origin actually. So I think what they're trying to get to here is to see if we have hyper mobility and in the globally and locally in the hip and or SI joint, they've got some hyper mobility that they might be able to pick it up with those, those two tests.

Now the one I really wanted to kind of pull out was the PPT reach. It's kind of kind of interesting.

You put a patient in standing and you put their shoulder against the wall, I'll blow this up so you guys can see it.

You put their shoulder against the wall, you put a tape measure on the wall and you have 'em make a fist and they extend both hands empty and you make a measure of how far their hands go out. So the start of the tape is that their acromion and you take a measurement length of how much distance there is at their closed fist at the knuckles. And then in their, in their hand you put a bag or something like this and you put some weight and how much weight the patient's asked to hold the weight, 5% of their body weight up to five kilos. So up to about 10 pounds.

And, and they grab the weight initially close to their chest and then extend their arms until they feel pain. If they feel pain. Okay, so you've got one measurement of unloaded arms, the distance, straight arms of the knuckles and then you take the bag, put the appropriate amount of weight in it, they start the weight at their chest and then extend their elbows until they report that they start to feel pain. You measure the number there and then you do a ratio of that number divided by the first number. And if the ratio is greater than 0.75, then the that test helps to predict the treatment success. So in one patient that I had this past week, I was able to determine that they were 0.81 on this test and they were also positive on the McGill prone shear instability test.

In this particular patient they presented, they were presenting three years after a lumbar disc herniation that we rehab them for and they presented with a history of what you would expect over a three year period of rehab and that of intermittent flare-ups of their low back pain and their intermittent flare-ups looked like shorter duration, lower severity episodes as they go forward.

But they were still concerned that it seemed like every time they'd go out and start trying to get back to lifting, this person was a personal trainer.

Every time they would get back to lifting and trying to be a bit more active, they would seem to have flare ups. And on the clinical examination, what's our rubric? As you have noted in the past with NCA for the lower quarter, we want to first find out what the nature of the threat is. And we, in this particular individual, I knew they had had some top down issues before they were very fear avoidance from before, so I was taking that into account.

But in their, and their index was a standing anterior pelvic tilt and they could reliably, when they presented, reproduce the pain in the low back when they did that.

So I had them do the index, the pain was there, I then tried to take the disc off of the table. I very quickly moved into a motor test motor was fine at L five and S one and L four myotomes put 'em in the slump. Slump was completely clear, they were symmetrical intention on both legs. They had no reproduction of symptoms and their legs or in their back with that the, the seat of compression test was completely normal. That didn't reproduce any symptoms as well.

So in their index position of anterior pelvic tilt, I put my hands on them before they do that. And the resting tone in the low back was really quite high. And in standing, they were standing in a hyperextended position and showing me that stuff that we talk about in DNS of the what collage talks about, of the sausage rolls of the lumbar erectors on both sides of the spine.

And I had a point where he was feeling pain and he pointed right to the right hand side roughly at about L 3. So I took one of my big silicone massage cups and stuck it right there and then had him do the same movement and it completely took his pain away. Okay, so to my mind there, I'm probably looking at a main syndrome kind of presentation, something that looks like antalgia paraesthetica versus superior clonal nerve involvement.

And the way that I frame that to the patient is you are a distributed network of multiple inputs of a pain experience that's happened in the past. And now this ping out of a nociceptor there, this could I think potentially be referred to as a neuropathic pain of a cutaneous nerve from a cutaneous nerve has now been factored into the complex algebra, if you will, and the brain of the prior pain experience as a trigger. And that is enough to start to create a sense of liability. Now I also was thinking though that if we had some ongoing problems with stability because the, remember once you've had a disc injury, you have less hydrostatic pressure at the disc and as a result you're gonna have increased shear at the disc.

And sometimes that lingering shear instability is the threat that is triggering this. And now I'm working two models. One that we've got a possible threat that's being generated by cutaneous neurology and the other is the possible threat from from instability. Now if we really wanted to rule that out, well we would do our instability tests as I mentioned in this particular in individual this PPT reach was positive and the McGill's prone instability was positive. They are not hypermobile. The NCIS was not painful. They did have aberrant movement, they were very loathed to bend forward and touch ground. So I'm doing this by the books for study.

I might send this patient out for dynamic motion x-ray, but I'd rather first see if clinically we can just lean into function with this individual and get 'em a bit stronger, help 'em control things better. Because according to the clinical prediction rule here, if we've got a couple of these that are,

a couple of these that are positive, the two or more the sensitivity would be right at 80% in specificity for this particular test would be 95%. That's pretty damn good. So if, and that's predicting that if we do a stabilization strategy, then the stabilization should help this person with their back pain.

It's kind of cool. And interestingly, the stabilization in both this REASE study and also in the prior mention Hicks study, the stabilization program is a mishmash of McGill's big three with Hodge's work overlaid on it. And that's the motor control stuff. And for those of you that have been paying attention to that motor control impairment stuff over the years, basically what we're looking at there, those are the folks that are trying to coach people with back pain to selectively activate the transverses AB dominance. So that's sucking the navel in and trying to recruit the multifidi and the, and the transverses.

And ironically many of you also know that McGill took issue with that and he kind of called Hodges out on it and he was suggesting that you can't do that selective recruitment of the abdominal musculature and that you'd be better looking to try to use the, the prog approach of generating intraabdominal pressure in a robust hoop stress of the lumbar spine before you do that.

So rather than saying right out for x-ray, I would do this and then, or do rather this stuff and actually what am I doing? I'm mixing the prone shear instability in here with this. So there I am making things muddy for y'all again. But we're gonna do the, the, the exercises and see if we can make them feel less pain.

And even if we do send out for motion x-ray, which is, you know, according to White and Punjabi, that's our best evidence for clinical instability. But remember the dombroski paper that I cite and my coursework that shows that where they showed with dynamic motion x-ray and clinical, excuse me, computer tomography of that, that when you have a person and standing bend forward and backwards like that, it's not a pure sagittal plane translation. These, the motion segment is moving all over the place in that segment. And indeed, if this is sagittal plane, as that person bends forward and at least one patient in this small sample size, I think it was seven patients here, the person's full, the greatest amount of sagittal translation was observed not at end range in one patient, it was in the course of the movement tilting forward.

So it was almost like the, the motion segment moved as far as it could and then the body responded at end range and pulled it back a bit.

So just something to keep in mind there, to my mind, this is a pretty good paper to suggest that McGills onto something when he talks about those micro movements and trying to improve stability and in Sue's world. And you know, you guys know he's taken a bit of heat from other camps about coaching people into a high threshold stabilization strategy and then, you know, they, they walk around like that for a long, long time and they start having pain because of that muscle tension because of the other satellite effects of that, like what I was seeing in this patient compression of cutaneous neurology as a result of that.

But this gives stew a buy on this because most of what he's seeing in a one offs of acute presentations and that's an appropriate thing to teach a patient that that kind of hard bracing strategy for a shorter period of time. But if you follow up with them, you should take them off of that later. And it might be in this particular patient that we didn't stick with them long enough to get them clearly off of that or they didn't, you know, internalize some of the coaching that we've done to back off on that.

So this patient had not picked up anything heavier. Mind you, he's a personal trainer still working with clients. He hasn't picked up anything heavier than 50 pounds for, I think it was somewhere between six and nine months.

'cause every time he did he would hurt and he was afraid.

So we went to supine three and a half month old position in the gym, coached him into that, stacking his tho capel canister, developing a relatively relaxed brace there. And then we did a flow that many of you have seen me use in the coursework and talk about and hear earlier of moving to five month position and just practicing elevating the, the sacrum off of the ground and holding it there. So that would be supine position, legs up, flexion in the knees but not full flexion, like not a 90 degree flexion like in the log rolling more like about 30 degrees of flexion. And then in that position, lifting the pelvis, get it, clearing the sacrum off of the ground and holding, practicing that.

And when you do that, you'll really clearly feel the, the lowest and deepest level of the lumbar coarse stabilization musculature really kick in. And then from there I'll blend sometimes into plow pose from yoga and have them slowly work on motor control of each final segment. So here again, an integrated process but bringing a bit more Prague into the mix, bringing a bit of Hodges into the mix, bringing a bit of McGill into the mix, bringing a bit of gymnastics into the mix, bringing a bit of yoga into the mix.

And then we stood this particular individual up, had him practice that stacking position and integrating intraabdominal pressure. And then we had a confrontation and this then would be in integrating Linton and Valle worked on graded exposure for chronic low back pain. I took him over to the trap bar in the gym and we put a 45 pound plate on each side. And I know this person to have been someone in the past who would've been easily able to pull twice their body weight from the floor. And I think they were walking around at about 1 75 when I was seeing, so we put one 50 on the bar and you know, then there's the confrontation, the fear confrontation point.

It's like, I know you're afraid, I could see that he was afraid but we were going to test waters here. And he said, you know, I haven't lifted anything heavier than 50 pounds for more than six months even.

We went over, actually I had started, I think we started with 45 pounds and then I moved up to 80 pounds and then we went to the trap bar and in each one of those graded bits of 45 and 85, I was testing the four quadrants of the, the lumbar or the core two points on the front in their abs, two points on the back to make sure they were able to pressurize and hold that while they were doing the lift. And I could feel that they were doing that well with those lower weights. So we moved over to the bar, the trap bar, I had him set up for it. I was able to demonstrate that he or he was able to demonstrate to me that he was able to pressurize in those four quadrants.

So he did boom, he pulled the weight, he put the weight down huge gr on his face and he's like, that felt light.

So it was awesome And that, that has been the, the main thing for him was that he was, he was very pleased to find that it the weight, even though he hadn't touched it in six to nine months, that amount of weight still felt light. So that was good. Now we're working with his trainer setting up essentially an easy strength program.

Not too much, not too fast progression. So let's just kind of work into his head space and get some gradual exposure to some load there. So there was one case.

Any questions on that one case?

Okay, I'm not seeing anybody jump in here.

So the other case was an interesting one that local chiros sent in

the, this is someone that they've seen for years whe and they had sacral pain specifically right over the S sacrum and just lateral to the sacrum.

They had subsequently been referred to, it was a little network here within the Portland area network of providers that are pretty, they consistently refer to each other.

I'm sort of on the tangent of that sometimes.

But in this particular case, this patient had been referred out their X-Ray showed a a bit of what appeared to be a compression fracture at L three

and a bit of listhesis there.

Some the IVF on the, they did an oblique was showing as being pretty crowded. So they did an MRI.

The patient had numbness in the right leg, intermittently in the thigh constantly over the dorsum of the foot. The dorsum of the foot had been numb for well over a year.

The thigh had been intermittently problematic but not reliably problematic with the things that we would generally consider with intermittent neurogenic claudication like prolonged standing or or prolonged walking. They could get some really long walking and relatively long standing without symptom presentation there.

But whenever they did have symptoms, their symptoms reliably got better with sitting and with forward bending.

Again, this person's taught yoga for 27 years, they're in their mid sixties.

So based on that MRI and X-ray findings, the people that he'd been seeing were highly suspicious of neurogenic claudication versus cytogenic pain.

So he was sent out to a physiatrist that did first joint block procedures at the facet joints of L three four, L four five, and L five S one and had about 12 hours of improvement after the, actually no it was the second one. They did epidural steroid injections after the facet joint blocks didn't do anything. They did epidural, epidural steroid injections at those levels and with that one they got some improvement for about 12 hours

but came right back after that to the same level of severity.

With this particular patient using both using a McKenzie protocols, doing ex repetitive extension, we were able to worsen their symptoms.

Repetitive flexion seemed to improve them.

But the, when I explored locally where he was talking about his pain being, I was able to clearly put my fingers on and Provo and provoke his pain by working along the medial branch of the clonal nerves of of the superior clonal nerves and doing DTM and TNM over the medial branches of the superior clonal nerves bilateral. His resting pain which was four out of 10, just walking around constant in that area, completely resolved. So that was my diagnosis and that was what we were working on.

I showed him how to do dynamic cupping there and gave him the recommendations of using capsaicin.

We had talked about a week, a week or two ago and we will see how that one turns out over the coming weeks. But if that doesn't get it the rest of the way, then I'll send him back to the physiatrist to do specific injections locally over those superior clonal nerves. So think let's think a little bit about the, the procedures for that that he had received and how he might've gotten 12 hours of benefit from the epidural steroid injection that ESI if often when they're doing that, they're trying to get local in the general vicinity of the nerve root and drop that steroid and sometimes they'll get in, make sure they're in the right area, inject wait a moment, inject a little more and then inject and back out.

And as they back out they're injecting. Think about that. Now they're starting to get into the other spaces nearby that that superior clonal nerve, that medial branch, the superior clonal nerve might occupy. And I suspect they got a little bit of a, call it a collateral improvement because of that. So we're gonna try that, see if we get any improvement and roll from there.

There's my cases this week. Peeps go wolf pack. You guys got any questions?

Marc Heller
I do. What you got Mark?

Well this is the first time I've heard, you know, you introduced that capsicum thing I think last week was the first time I heard it. And what you're saying is that that capsicum as a tool might be useful as a treatment for cluneal neuralgia. Is that another thing besides DTM or CFM to use over those cluneal nerves?

Phillip Snell
It's something to try. I think so I think the, the bench evidence on what capsaicin does is maturing. It's improving. Again, it's historically, most of the evidence on this has been what has been from physiatrists and instead of using agonists, they've used antagonists, they've used lidocaine. Okay. And the research on that for clonal neuralgia is good, but the long-term improvement for using an agonist and actually changing the landscape of that involved neurology is also good. And this is superficial. So I'm trialing this on my own patients to see if we can get a little better improvement on some of these and we'll see if we, if we can, you know, more clearly directly answer your question and say yeah, try it.

I mean I would say yeah, try it right now. There's no, I mean you got some side effects from the pain that the capsaicin will produce, but it's relatively self-limiting and to my mind is a bit of, you know, also a bit of graded exposure, which I kind of like too. It leans into other areas of the pain experience. So I don't know, give it a shot, see what you think, see what your patients think.

Marc Heller
My other question is, there's some I'm watching on my phone so I can't see the fine print. Those tests you introduced today, today that you had slides on, is that available somewhere on the NCA website?

Phillip Snell
That slide deck is not But you took Glenn Harris's program, right? The disc? Yeah,

Marc Heller
I did.

Phillip Snell
Yeah, it's in there. It's in my presentation on that full presentation. Okay. Is all of

Marc Heller
This, I can go back to that.

Phillip Snell
Yeah, So one more thing if we have time, my, my personal case this week is me and I, I lifted, I was at my coast house and somebody had put heavy, heavy stuff in the garbage and my job was to take the garbage out and the gar, the wheeled garbage can must have weighed a hundred pounds. And I, I did, I injured myself, you know, and I, I did all my things I do for my discogenic pain and didn't feel like I was really getting anywhere until I said, oh I'm, my sacrum is torqued. And I did and I couldn't get ahold of my, my guy who does muscle energy manipulation of the si.

But one of the things he did with me in the past is show me a bunch of self-correction techniques for sacroiliac dysfunction. And I know you're skeptical of sacroiliac dysfunction and I've been skeptical of sacroiliac dysfunction till this guy helped me when I have a disc floop. You know, so it's just another, I just don't think we should push away the sacroiliac work and 'cause you know, it felt like a disc injury but it was, I had this uni, I was antalgic to the left and my left scrum heart and hurt and you know, last night I fi, after a week I finally did these things, woke up this morning and Beth tells me, oh you're not bent over anymore.

That's nice and I feel better for the first time. So that's just another piece. I don't know how we fit it in with the evidence, but it's another useful tool.

I'll try to set up how we fit it in with the evidence and as you talk about that,

it brings to mind a slide in my clinical companion

course. Let's see.

So there was, you recall I talked about

in the clinical companion course the B duck and SCHWARTZER papers going back to, I think it was right about memory serves 19 94, 19 95, something like that.

Now here we go. Share screen.

There we go. Okay, now share screen.

There we go. You might recall this slide from back in the day Mark,

this was buk and schwartzer and when they did three different papers looking at patients with chronic lower back pain and they did joint blocks of the SI joint blocks of the facet joint and they did, this is before we got the Eugene carriage papers on

discography, they did discography and they found that in these are the findings for disc versus facet joint versus SI joint in terms of turning off the pain or or turning off the pain. It would be a symptom modification for the SI joint or the facet joint or provoking the pain by virtue of this discography for that.

So in 43% plus or minus 10% according to their papers about 40%, somewhere between 30 and 50% of patients with chronic low back pain, they found a marked improvement, or excuse me, a marked worsening with discography in 35% roughly they had 90% reduction with injections of the, of the facet joint, but only 12% of those facet injections completely took the pain away. So that suggests that facets are probably gonna be comorbid on many of these conditions.

And then similar findings with the SI joint between 13 and 30% of the SI joint injections to the pain away. So again, I think what we have to do, we don't throw the SI joint out with the bath water, don't throw that baby out with the bath water. We include it in with. And when I see the SI joint being contributory there, I'm thinking two primary things. The first place my mind goes to is probably we had a lateral disc at some point and that lateral disc caused that lateral antalgia, which secondarily brought the SI joint into play.

And the other is that we've got an ongoing instability issue likely at L five S one and that's playing a role in that and those micro movements at the, the lower lumbar spine and SI joint in that chronic issue, which I think you would probably better fit into Mark that we likely got a little bit of sheer instability in that area and when you and I played in the past together directly with each other, that that would be where my mind goes to with it. All of that could just be me trying to confirm my own bias that I think SI joints are less important than we tend to to be trained in, in chiropractic. But I'm o I'm open to being influenced by that and, and seen and I do still manipulate an SI when I see it as symptomatic but I make sure that I'm also addressing something that might be putatively going on and driving that si si joint presentation as well.

I rarely see an SI joint without really overt trauma through it or in a pregnant patient. And even in a pregnant patient I usually see a flexion pattern from a lifting injury and that pregnant or recently pregnant woman.

Just my thoughts. One thing I will say, well,

Marc Heller
Go ahead.

Phillip Snell
One, one thing I will say with you is I think I'm, I'm gonna make a travel to down to see you in Ashland. 'cause I I am gonna give a therapeutic trial of extra corporeal shockwave therapy on my shoulder. Before we go much further on that, I, I had a orthopedic consult yesterday and I got a, a surgical consult coming up soon. But the, the downtime from, that's unacceptable and I think it's worthwhile giving it college try and letting you beat me up a little bit on that and maybe get some PRP done locally as well and throw some peptides on it again and see if I can jumpstart it. I've, I mind you, I've I've done all of those things except for the shockwave and the PRP.

I've done various loading strategies on this now aggressively for six months with no benefit. So, but we'll give it a shot man because I I, I gotta get some upper body workouts and again, I'm starting to feel pretty wimpy.

Marc Heller
I look forward to seeing you down here. Yeah, and you know, the one thing on this thing I'll say is I, I don't love chiropractic side posture manipulation of sacroiliac, you know, especially in someone where there's a potentially discogenic piece going on as well and the, the sophistication and gentleness of the osteopathic techniques that aim at working on the sacroiliac are very, very different. And for this, for my case this week, I didn't even have anybody working on me. I, I came up with self-correction strategies for the sacroiliac. I didn't come up with them, but between me and my pt we came up with self-correction strategies for the SI that are specific movements to try to correct that.

Anyway, I just, you know, it is great to have a bunch of tools and to be able to trial 'em. So

Phillip Snell
Yeah, I, I agree. You know, I, I don't even remember, you probably remember the origins of where this approach came from, but I don't even remember exactly where I got this. But I remember learning an SI assessment in prone reaching to the anterior side of the pelvis, getting to the A SIS with the lateral hand and then with the medial hand placing a downward pressure on the, the sacrum on the lateral margin of the sacrum on the, the side you're testing and providing a shear. So you press downward on the sacrum and you pull upward on the, the ileum with your contact at the A SIS and see and have the patient do a, a prone press up in that position and see if the prone press up without that contact causes pain, then they lay flat, then you provide a, a gapping there essentially pulling the into a an as static kind of positioning and see if that helps with the pain that they have there.

That would infer that that would be an as ilium on that side. And then in that position, the way that I learned it, you'd do a contract relax or an MET kind of thing where they would try to rotate the pelvis back or the ileum back down into the table again and you do repetitions on that along the lines of MET. And if it did, then I would stand that patient up and the home correction would be to put that involved leg that involved foot up on a chair or up on a bench and then rock into it rotating that wing of the pelvis in deflection and place their hand on the opposite side on extension. So you get a pi LM on the other side and an as on the involved side, pull the knee into the chest on the involved side and bounce into extension with the other hand on the other side of the si.

And that, that's the, the home correction that I've used over the years for those cases that I've seen seems to work relatively well. We can go over that when I see you in April here in Portland. If I don't see you before

Alex, what are you talking about With Morgan Exercise. That's a new one.

Alexe Bellingham
I I sorry, it wasn't supposed to be appointment Morgan, this supposed to be Captain Morgan exercise. What you were describing is something I teach my patients also and call it the Captain Morgan exercise so they have it in their head because it looks like the guy on the front of the rum bottle.

Phillip Snell
Yep, yep, yep. That's that's good. I love cues like that to sticky cues.

Yep. Alright. Okay, we're overdue guys. Thanks for coming in. I appreciate it and I hope you're gonna be rooting for my wolf pack this afternoon, but hopefully I won't be too down in the mouth of around six o'clock and, and we'll have another game on Monday.

Be well, stay curious.

Take your curiosity, take your compassion, go help some people. You guys be awesome. See you later.