NeuroCentric Approach Zoom Discussion-Do Trigger Points Exist?November 18, 2023
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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.
Pragmatic Pain Science Education
Transcripts from the video above are below...
We're recording this Zoom meeting. This is nine o'clock on November 25th. Today we're going to be talking about pragmatic pain neuroscience, using a case study from this past week in my clinic.
I will pull this little sticky note off of here for the moment that's there so that we can be HIPAA compliant and a little bit when we look at some of those items. How's your Thanksgiving folks? Those of you in the states.
Thanksgiving day was just what, two days ago and Black Friday was yesterday. Technically down here in the us Many of you that are watching this may also know that the lifetime membership is available for neuro centric approach and it is open until noon Pacific today. So you got three more hours to pay one time and get access for the rest of your life to all of the material. All of the online material at neuro centric Approach Online academy that currently has about 35 hours of online continuing education. It is PACE accredited for those of you chiros in the US that, and I believe Nova Scotia in Canada, which accepts PACE accredited ce.
That means that you can get continuing education for those. If you are a lifetime member as well, you'll get a hundred bucks off of future NCA in-person courses.
And we look forward to getting those out. So the past week, things in my life, day after Thanksgiving for my wife and I is always the day that we put up our Christmas tree.
So my wife is cute as all get out this time of year. She turns into a little girl about her Christmas excitement and such, and we love getting our tree up, trimming the tree.
For Thanksgiving, I made up a a roast duck and a chicken since it was just two of us. And we had leftovers from that with some Chelle gravy from mushrooms that we forged earlier in the year. And some cauliflower mashers caused keto y'all and some collards from the garden, which were incredible. I I grew some of those tree collars, which are really, I I, as I understand it, you guys can correct me if necessary, but as I understand it, those are
sort of a hybrid between collars and kale.
When we were hiking the Camino this past early summer in Spain, we, every garden had these behemoth kale slash collared plants growing in the garden along with potatoes. But man, it was good. It was some of the best collars I've ever had. Just did a little bacon from Laurel Hurst market in there and just an onion and called it good. It was some of the best colors I've ever had and just a simple baking and sweet potatoes and it was good. One of my buddies I talked about last week too, Kevin Smith and he and his business partner Taylor Thompson, run an incredibly solid construction company here in Portland. I've known Kevin since he was a high school freshman.
Kevin brought me a bottle of natural wine. It was a white wine or even more specifically an orange wine. It leaves the skins in contact with wine and for a bit of time and so it, the wine shows up a little bit on the cloudy side and is a little bit orange in color. So that's kind of, that was kind of good.
And let's see, what else have we got later on this afternoon? I'm going to be putting up the decorations outside of the house and we will, maybe I'll show some video or something of what that ultimately comes out to look like in the not too distant future welcoming in folks over here on the zoom. Good morning Dr. Heller. It is fine to see you, sir.
Let's see. What am I drinking today? I am having, I do a version, I don't want too much caffeine. Later in the day, I will do a orange spice tea, which I like to make up something that resembles an orange sickle. You guys remember those orange cream sickles when we were kids, used to love those pushup pops And I'd make some orange spice tea and mix in, you know, a, a nice keto profile, high fat concoction that's got some coconut cream in there. And I usually put vanilla.
And today I used some of Dr. Anthony Guston's, perfect keto,
keto ketone esters in here. That's vanilla flavored man. This is good. This stuff is tasty and I can feel myself getting smarter by the moment with all of those ketone esters rolling around in my brain.
Kudos to Dr. Guston. Anthony is a Western States grad from about 10 years ago.
He was an early adopter on the, the keto diet thing. Managed to get on the front edge of that curve and very thoughtfully just produced a ton of content about the ketogenic diet. And very early on became a, he indexed incredibly well for people searching for information about ketogenic diet. And Anthony is a incredibly persnickety about quality, quality in the products that they make.
And he started to produce a line of supplements and to go with that continuing education, various kinds of medium change, triglycerides, MCT powders and oils, the ketone esters that I've mentioned before.
The typical things that people trying to adopt a ketogenic diet will run into like the, so-called Keto Flu. When you start PNOA, a lot of your electrolytes early on you start to feel kind of punky because of that. So they put together a nice electrolyte replacement item that you can have as well.
So Mark, you having, you're having some Thanksgiving leftovers there mate.
Perfect. Well, well played.
Yeah. Hey Philip, I have a question in low back and leg stuff for, for number one. I really hope you're gonna announce someday or another in-person classes 'cause I'm looking forward to that. But for the moment there's two videos, two long videos that seem to focus on the low back. One is for strength athletes, the other is a class that I took a long time ago, clinical Companion, fictional back. It's the Clinical Companion Fix back been updated or is it the same thing? I took three, four years ago before the pandemic.
It was updated as of when I put it out, which was during the pandemic. And that was something that I was trying to do like many of us as a pivot during the pandemic and I couldn't teach the in-person classes.
So I went ahead and loaded that, loaded that up as an online presentation admittedly in the intervening, what would that have been two or three years between when you took it in person with me? I think in Seattle, wasn't it? And and the online course for the Clinical Companion to fix your own back. I don't think there's probably that you're going to note that there was a whole lot that's different now the fixer own back course for strength athletes.
I gotta be honest mate, I I think that's some of the best work I've done.
The, that is the first of something that I was hoping to do when I originally launched a the Fix Your Own Back program, which was to steadily over time produce a fix your own back course, if you will, for specific avatars of people that are suffering from a disc injury. So in that case it's strength athletes that are suffering from a disc injury.
I'd like to do one for other specific sports and lifestyles as well. Like one for single PA parents, one for desk jockeys and computer users.
One for maybe CrossFitters, one for Orange Theory folks and try to over time just get more and more granular with that.
But the, the Fixer own Back program for Strength Athletes, it's 13 hours and it's a collaboration with me and the several of the coaches at Kabuki lab, including one of them, the head coach Kyle Young who is the US Power Lifting Association head coach for the US team. And Kyle had the, the, the misfortune of suffering from a pretty nasty lower lumbar disc herniation about, what was it now two years ago? I think we're two years in. And we were rehabbing Kyle effectively using the program or about three months. And then Kyle had, he was feeling it a little bit too much and got into a workout a little bit too hard, too fast and wound up with a full on nasty extrusion with the extruded content. Nuclear contents moved centrally and were up on his spinal cord and we had to push the surgical algorithm a little faster there because we started to have some CES kind of symptoms and stuff.
So Kyle and I then subsequently worked together over a period of about a year moving him from a post-surgical status back to about six weeks ago. He competed again in his first power lifting beat after having that surgery. And it was about a year out from the surgery.
So that was kind of cool. So we chronicle that in the, the program for Strength Athletes.
That program is available yes on the online program at NCA. It's also available at the kabuki strength educational platform, which is stu another Stupid Value. It's about 39 bucks a month I think or something like 300 hours of content they've put together over the years.
And that's a really good resource for people that spend a fair bit of time in the gym and want to get more nuanced training tips and things of that sort there.
And then of course you can get it over on the fixer own, excuse me, the neuro centric Approach online academy, which is probably a little more notable or a little more applicable for people that are more in the clinical domain.
So that is, I I would suggest that people that aren't familiar with any of that material, the Fix your Own back program is like disc rehab, call it one oh one and 2 0 1 and then if you actually work in a work out in a gym or you work with patients that do tend to work out in that way, then this is like the 4 0 1 and graduate level coursework for that population. So it will assume that you have going into it that you have some understanding of exercise science and that you're familiar with terminology growth science and things of that sort that get commonly tossed around in a facility where people are managing a lot of weight.
So yeah, I'm, I'm very pleased with that program and it needs to get out there more and I'm starting to produce a little more written content to try to drive some traffic over there to it. 'cause that one's gonna help a lot of people that are trying to figure out how to work out after they've had that injury.
So let's get into our case for the week
today. I think one of the cases that I have this week, for those of you over here that are on Facebook Live, you can join us over here on my zoom link if you'd like to answer questions. I won't be able to handle questions back and forth over there, but questions are welcome over here on the Zoom platform.
This particular case is one that I will see quite honestly in a blessedly infrequently these days.
And I'll use the next statements that I'm going to make as a jumping off point for some things that I've seen unfortunately in some of my former students and others out there that are trying to make a name for themselves online these days. And I appreciate that pressure that people have are experiencing out there. I would like to encourage young doctors and people trying to navigate social media that for god's sake guys, keep your integrity and you know who I'm speaking to.
The things that we're trying to do here involve trust, trust in the people that we, that we treat. This is important.
Don't mortgage that trust to try to get clicks in your online presence. But I've seen some people throwing shade at people like Stu McGill again.
And by throwing shade, I mean you know, going back to the time honored method of the myth of this and just because this person says this and it doesn't matter in this case that this person they're referring to has 300 or more peer reviewed articles with their name on it.
No, they've done their own research and online they are now going to be the expert for the next few minutes while they've got your retention in your attention and your clicks.
But I'm going to talk a little bit about Stu McGill because this patient comes in to me with, I'll just read their presentation. Their primary area of complaint is low back slash flexion intolerance. They say I'm not a doctor but it feels like L four dash L five and also some SI joint pain on the left side. And those of you that have been doing this kind of work for a minute always kind of smile when we see that, you know, the patient has that stage of the game. When I see that and I see the words flexion intolerance and you guys know that stew has taken, taken it on the chin over the years for using aptt particular remark, flexion intolerance has been mischaracterized as meaning that the lumbar splt and the lumbar spine should not flex Stew never said that he is commonly misinterpreted in that way.
I have by extension been misinterpreted I think at times for that. So I'll say it on the record for right now. Yeah, the lumbar spine flexes, it should flex. It does flex when we do many of the activities like deadlifting and squatting that we are maybe focusing on trying not to over flex, but it's still gonna flex some, it doesn't tend to manage full flexion under load very well with repeated episodes exposure to enough frequency, enough intensity, enough load in the left volume that starts to, will start to exceed the mechanical properties of that tissue to maintain that load. You'll start to get injur injuries to show up there.
There might even be room for the, in the well chosen person to do some very light loaded lumbar flexion. But some of the stuff I see that's starting to show up online again will cause an uptick in my clinic of patients that are trying to help themselves and they're starting to expose themselves to more of this kind of load and it often doesn't end very well.
So you've been warned. But that said, when you know I'm, I'm 20 going on close to 25 years now out from my desk herniation and a lot of the work that I do on my own back these days to continue to manage that is now I'm a more extension intolerant kind of person. So I do a lot more unloaded ab work. Mark knows this one from a recent little one-on-one that we had together. And I do stuff that I borrow, I kind of mix in DNS elements with pro school elements and then use things that people have had maybe some exposure to like gymnastics and I'll maybe do a riff that looks like log rolling for those of you that have seen that.
And then moved from log rolling to hollow body and then from from gymnastics and then from hollow body maybe to plow pose from yoga. And in between there there's some very nice bridge ups of a wall bug exercise at an OS R was very fond of back in the day. And you know, it was another person who was taking some of the DNS material and kind of riffed on it. But yeah, I'll, I'll commonly use that. But that, let's get back to our case study here.
Next question on the form is, when did you first notice this problem? It says he injured his back specifically it gives a date in 2022 and it was doing bench press now that immediately makes me go, hmm, it was a bench press variation, which he says required a lot of force near max weight accelerating fast due to band assistance near the bottom. Which also made me go, hmm, 'cause you know I am not unfamiliar with, with bench press setups and given that right down the hallway on any given day at my, one of my offices at Kabuki Strength Lab, I'm likely to walk in on any one of a number of world record holders doing bench press.
And I've never seen a band set up that would for band assistance that would meet that description. So I was curious about that. But I believe that believe that bad form led to pretty severe energy leakage directly into the lower back. So many of you, you start hearing words like this, you gotta wonder, well what does this guy do? You could imagine he's a software engineer and I love working with engineers 'cause you, if you give them a, a good narrative that makes sense objectively and you, you give them an action plan and by God they will do it. They're great patients but you do have to create a believable narrative.
If you don't, they won't do it. They'll, they'll write you completely off. So he goes on to say I believe an oblique injury prior to this, this would've been about six months earlier, likely compromise my back's ability to support itself. And then here's the Give Stewart McGill talks about guy wires in the back and I believe one side of my spine's radio tower was really not functioning fully when I injured my back in September, excuse me for that interruption.
But it stemmed from a lack of spinal stability. Going back to the oblique injury says he feels pain 100% of the time. Which also always makes me a little bit interested because most people with back issues, if even if they, they've got an intense disc herniation and some kind of radicular process, when they lay down and in completely quiet often they can, they can find that they have some moments without pain
and provocation and palliation. Questions?
Oh and the radiating question, oh I'll just go through these. What percentage your waking hours do you feel pain 100% some descriptive terms for quality dull and achy. So not sharp and shooting, not not electrical or burning.
Is there a radiating component into the arms and legs? None of these apply. What's another full on disc herniation? Maybe even with extrusion case that can show up and the lumbar spine that can show up and not have any sciatica type of leg symptoms? Well if you've got a central disc bulge, you can very often not have radicular symptoms that show up down the leg. So your slump test and your SLR would not come into the room at all. And yet if you press on with those questions about CAU aquina syndrome, you might find they've got some saddle paresthesia or some recent changes in bowel, bladder or sexual function.
So this particular patient has no radiating component.
I should have mentioned at the outset age. He is, as I mentioned, a computer software engineer and he is 38 and has at home a young one that is 18 months old, worsening activities flexion, which he mentioned specifically or holding a load out where there is sheer force being applied to the spine. These are his words now for example, holding a child out in front of me, also prolonged sitting in a car, car rides, et cetera.
That is things that make it worse, things that make it better. Movement getting out, going for walks. I've had some luck recently doing some SI joint specific exercise.
I believe my glutes and especially my left side glutes are very sleepy and not putting in work I've been doing Stuart McGill's big three and generally trying to limit spinal flexion as much as much as possible in life. So again, there's a nice give current pain severity was too average pain severity of four with a worst of 10 over 10 pain is worst in the morning and with prolonged sitting, prolonged standing and when he's inactive, pain is best in the evening. And with exercise secondary areas of complaint, he notes I believe some of the pain is also causing a general tightness, a fight or flight defensive response that in general is causing some back rhomboid et cetera tightness.
But I believe these symptoms and not the root problem are symptoms and not the root problem itself.
He also notes that he's found himself in a weird anxiety depression world as he wondered if, if he was gonna be okay, if he was gonna heal from all this, if he'd be able to pick up his child from his crib ever again. I've largely worked through that and am in a much better head space now, but I've definitely resonated with what you said on the fixer on back.com program. Whoa. He is been on FYOB too around the injury. Also having spillover to mental health. Something I've never struggled with before.
Okay, so now we've gotta give he notes that he's been exposed to Stu McGill's work. I'm gonna probably assume he is read the back mechanic.
He's been exposed to my work on fixer own back. He also me mentioned some others here. He's seen a primary care doctor who got, gave him pain meds and muscle relaxants for a few days a month after his injury. He tried a local canned, one of those private equity physical therapy firms had 10 sessions after the injury. They pegged it as an SI issue and he'd been doing some of the the SI injury things there, which that coupled with some of the things I mentioned before about radicular complaints.
Often a person with a lateral disc herniation might not have the radiculopathy as being the major portion of their presentation and often that lateral disc herniation doesn't show up very well on a slump or on a an SLR. So in those or you might get a paradoxical effect where when they do those particular movements as they put more neural tension on the nerve with a slump or an SLR, they might actually note that their symptoms get better when they take tension, excuse me, get worse when they take tension off of that system.
So if at this particular point in history I might ask that patient if they ever felt like they, when their back was com con flared particularly flared up if they were kind of crooked, if they were pitched off to the side. And if they're old enough to know what that means, I might say something like, did you walk like John Wayne used to, you know, hello pilgrim kind of slouched over to the side.
And often I found that in a physical therapy environment these days when a patient presents like that and the physical therapist is less savvy to McKenzie's work, then they will often try to play an SI joint card on that patient and start working in the SI issue. And some of you that were here last week on our case conference there, we'll note that I really would love it if our, if our physical therapy colleagues don't run off on the same snipe hunt that many of us chiros did for SI joint dysfunction years ago. But many of the, many of the icons in physical therapy still adhere to that folks like Shirley Saron. So anyway, he'd had that leverage, this patient had had that leveraged on his back in general health history. He notes that he had LOC the day after hernia himself on the bench bench press. He passed out when he stepped out of bed the next morning and then he almost passed out when he sat down and tried to move his bowel on the toilet.
Past health history, mild seasonal allergies, some mild GI issues, notes that he had, some stomach issues maybe after the ep, the episode. But those were gone if those were some sort of latent cau aquina syndrome issues, they were not present any longer.
No medications takes creatine when lifting family health history, significant for migraines. He's never had anything like that.
Notes that his job is not particularly stressful as we start to move into the social health history. Biggest quote unquote stress in his life is just sitting for prolonged periods. But he does meet that out using a standing desk at home as well.
Lives with his partner, also enjoys indoor rock climbing and it does not aggravate his back at all and he tries to climb a couple times a week.
Other interesting hobbies, power lifting started power lifting in 2020, took a break after the injury in September of 2022.
Was able to resume power lifting and by that we're just ref, were referring to the three big lifts, bench press, back, squat and deadlift.
And he is still doing resistance training in that effect.
Returned to about a 50% of the load that he'd been playing with starting in November of this year.
It's found that if he tries to ramp back up to one rep max, his back starts hurting again.
Let's see, less than 150 minutes of aerobic exercise. Stress is listed as mild. He's negative on a two question depression inventory, sleep quality is good but could be better. Gets eight to 10 hours. Is willful self poisoning in terms of smoking and alcohol are low?
He finally finishes.
I leave a question on the end of my intake that says what are your goals with this visit? Are there bucket list items influenced by the things that by your presentation that we can help with? How can we help you be the best version of yourself? And he says, I believe I have the basics of how the back works. Having spent some time watching your content with fix your own back and also reading Stu McGill's back mechanic. I've also read through Rebuilding Milo with Dr. Dr Aaron sing from Squat University.
I know my back is healing but I also know that I can't protect it from flexion forever and having cut back on some of the things I love like disc golf and power lifting aren't long-term sustainable solutions and I wanna get back to them however I do, I wanna do it responsibly and not set myself back. He says, your reputation from working with kabuki athletes and a recommendation from a local friend who used to be a kabuki member and your content from fix your own back has me coming to you.
And he specifically says he wants to get confirmation of some of my own interpretations of my injury. He wants to gain any additional insight and things he might've missed and to build a comeback plan to get strong again, don't you love this? You know when a patient is that crystal clear about what they hope the encounter to mean, he says, my goals are to do the things I love, but I want to do it in a safe way where I don't ever go back to where I was after I injured myself. Benching where the next several weeks I couldn't bend down to change my child's diaper or to pick her up out of out of the crib. Okay, so cool, there is our patient history, that's what they provided.
Let's orient this from a neuro centric approach, shall we?
Let me pull up one of the programs or one of the courses that are available on the site.
This is the from the neuro centric approach, online theory and basis for application. This is like the introductory course on the OME Back Online Academy. It's an hour long as I recall.
And I'm gonna go over here and share screen so you guys can kind of keep track with me here.
So this'll help provide a bit of insight on how I organize my thinking process is when I start working with a patient that has a presentation like this,
find the, the detail and looking for here, I think we could probably start right here with this slide.
Remember that part of what we do with this program is to
try to organize our thinking process and keep ourselves organized so we don't get in the weeds with a case like this. So as I take a history, I'm thinking about the brain-based aspects and the cellular level aspects of what contributors might be playing into this patient presentation.
So let's review that and we'll start with the cellular level stuff. Since they're blessedly smaller, this is a person who is doing a good job to try to help themselves. They don't have a lot of willful self poison. So remember our four buckets for leaning into cellular level of stuff that will tend to sensitize neurology. There's diet, there's lifestyle, there's stress and there's sleep. He's already noted that his sleep is good. He is getting eight to 10 hours of sleep, his stress is well managed and relatively low. His willful self poisoning is low. His lifestyle, I'd love to see a little more aerobic activity but he is got less than 150 minutes going. But you know, he does wanna do disc golf a couple times a week and a climb a couple times a week. And both of those things can be managed to take a heart rate up to get into zone two for a good bit of that time.
So I'm not terribly concerned about cellular aspects with this particular individual. When we go to brain base though, all kinds of yellow flags are going off on this patient though, right? We're getting lots of cues in the way that he is speaking about his fear. The cool part about that is this individual has insight. He very clearly has insight. He's learned some stuff from reading stew's work reading and being exposed to my work to make him wonder about how much of his current symptoms might be associated with a little bit of extra brain-based material that's going on.
So, so that has me thinking about that and at this particular point to, as I put it at the case study, you know as we, you know, launch this one today, I am a big advocate for pragmatic use of pain neuroscience education.
I'm, I don't wanna spend a lot of time talking about pain neuroscience with a patient unless it is really important. Now in this particular individual I suspect that it is pretty darn important and he's also shown me already that his mind is open to the possibility that that is there. So I don't have to try to change his mind too much. But I will point out that one of the very first, since he's already given me that door to walk through, one of the first things that I did to try to shift his perspective actually was all the way down here on item four with superficial cutaneous nerves. So many of you that have played with this enough here know that I've got a pretty standardized lower quarter examination that's going to take into effect into consideration all of these things and go through and assess brain and cellular level in the history and then start a movement program that evaluates the spinal cord, nerve root and IVF, then the mixed peripheral nerves and then the superficial cutaneous nerves and so forth.
And in the physical examination one of the very first things that I had him do was just standard trunk range of motion, stand up, put your feet together, keeping your knees straight, bend down and touch your toes. And then I want to just watch and see how he tries to organize himself to do that. And he is very slow. He gives me a look when I ask him to touch his toes, like are you sure is that going to hurt me?
And I say, if you don't feel comfortable with it and only go as far as you feel comfortable with.
And he goes down and gets his hands about 12 inches from the floor and stops and then stands back up. And I ask him if that caused some pain And he's like, yeah, I've got a little bit of pain. Okay, where's the pain? The pain is all local and an area that he points to. Yeah. And says it's over my SI joint. Okay, so now I've got a belief of si I've got a belief of flexion intolerance, I've got a belief about a disc injury and I've got a history that doesn't really support a disc injury. I don't generally see discs get injured primarily at the, in a bench press. It's mostly an extension based movement for people that are trying to do a power lifting type bench press.
what I did was I pulled out one of my little, one of my patients used to call it my squeezy jams, it's those silicone massage cups. And I pulled out that big one suckers like as big around as my coffee cup here. And I showed it to him. I told him a little bit about what it was so you could see that it's not something exotic. And then I put that sucker literally right over the area he pointed to where it was hurting over his SI joint, which was over the PSIS and maybe over the, the ileal lumbar ligament there. And I put it over that and then asked him to repeat his, his forward bending and he did. And as he did his forward bending that time, he had remarkably less pain. Now that's cool isn't it?
And he gave me the look, which is something that I've talked about before, about ways that you can creatively lean in to pain neuroscience and expose the patient and their belief systems to a little bit of a changed perspective by doing something that they don't expect his mind at that point when he bends forward and goes from feeling his cardinal symptoms or or his chief complaint to feeling no pain and having improved range of motion, there's a lot of cognitive dissonance that's going on. So I lean right into it and I say, now can you imagine how that cup on your back is altering your si?
No we can't, that's obviously not changing the joint.
Can you imagine how it might be changing something four inches deeper at the disc?
No, he's struggling there as well. So what else could it be? And I said, and I parked it there and I said, let's just leave that where it is. You know, the, that those thoughts I took the cup off and continue our exam. So we go through our exam, I do my standing motor examination where we have the patient do repetitive heel and single leg heel and toe stands and he's got zero motor deficits.
I do my slump test. I, there is no neural tension along the, the motor, peripheral motor nerves or mixed nerves and the sciatic, I do my CTIC compression test that putatively would help to identify either an nplate fracture that was still reporting this patient. There's been plenty of time for a fracture to heal unless there was a non-union issue.
So I do the compression tests and in upright posture, no pain in slumped posture, no pain slump posture there putatively would help to increase bulging disc. And if there's a mechanical influence of compression on neurology, that might make it more notable. Or if there is an active inflammatory component, a source of nociception at a injured disc and you put that under a little bit of stretch that mechanical pinging could cause that disc to talk and for the, the mine to pick that up. And I didn't get any positives on that straight leg raise. SLR was about 60 degrees on the, on one side, about 70 degrees on the other.
You know, is that something I'm interested in? No, it didn't, it didn't reproduce any of his presenting pain.
The sensitizing movements were not apparent as well because he believes he's got an SI issue.
I do lasic cluster. Lasic cluster is negative five over five.
There's not a single painful thing going on there in that back that I could cause with orthopedic testing targeting the disc or orthopedic testing targeting the SI joint.
So then we've got orthopedic testing involving the set joints, which we can lump in with the SI joint. When we do our McKenzie screen for repetitive end range loading, we do repetitive end range loading and his back feels better. Cool. So IL look at that history and now I've got, and I did a little palpation, I do some palpation in the spine spaces of the lumbar spine. There's a wee bit of tenderness at L five S one, although mind you this patient is, shall shall we say, coached well enough from his exposure to my work and stews and already has admitted suspicion that the issue that's going on in his back is coming from that particular level that he reports some tenderness right there at those inner spinous spaces.
So what I did then was my report of findings for most patients that I suspect a disc injury that is ongoing and poor movement quality that is contributing and that that they are ignorant of.
I will go into a very different report of findings right in this patient.
I I am suspecting that what I'm observing is essentially what some researchers would call a maladaptive motor behavior. This is a patient that is avoiding lumbar flexion because they are afraid that if they do, they will reinjure their back.
And based on my findings on the physical examination, they don't have an ongoing inflammatory process or no susceptive pinging going on at the disc. And they don't have an ongoing neural sensitivity either motor or sensory in the sciatic one I should mention or the femoral compartment. 'cause I did a femoral nerve tension test as well.
So what this looks like to me is a patient that had possibly a disc injury, but I don't know, based on what I'm able to to learn in this possibly a disc injury, I'll, I'll give them that. So that will reinforce the possibility in their mind that they've had that, that maybe they accurately diagnosed themselves and that the other providers that saw them, you know, accurately saw an active acute disc when they saw them.
But I reinforce the notion in this patient, the discs heal if you stop picking the scab, which due to his fear and his coaching from a gill and maybe even from me, he's reduced his exposure to lumbar flexion.
And during that period of time, he's remained somewhat active and yet he still has pain during that period of time. You can imagine that the disc would've had an opportunity to heal itself. And indeed, based on my findings, it looked like it had, you could also see that the, the peripheral neurology might be affected, that might've been affected, might have calmed down and the mixed peripheral neurology had. But it appeared to me based on that cup finding that the clonal nerves probably were involved in this. So why would the clonal nerves become involved in a patient with this kind of presentation?
My thinking is remember that nerves nociceptive neurons will respond to three primary stimuli, intense pressure, intense heat or chemical changes. And one of those chemical changes could be inflammation. I'm not seeing clear signs that an an ongoing inflammatory component is going on in this patient. Moreover, I'm able to affect his pain by doing something very superficially. And my understanding of the anatomy there locally would suggest that the clonal neuralgia either middle or superior CLINs might be contributory here.
And indeed I can go and palpate in that area and find tenderness two that starts to mimic his presenting complaint.
So when I've got palpatory findings, I've got an opening procedure that I can do locally with the cup that improves the symptoms. I'm gonna lean into that as being the, the source of nociception that he's primarily feeling and or the source of nociception that he's primarily feeling is possibly lactic acidosis in the large muscles of extensor muscles in the low back. Why wouldn't he be experiencing lactic acidosis in those muscles? Because he's keeping those muscles which are type two skeletal muscles, poorly designed for pos, ongoing postural support. He's keeping them tight because he's afraid because he's essentially been coached not to.
Which brings me back to McGill's coaching and the back mechanic.
I spoke with Stu, we ha we had him, we hosted him here in Portland about two weeks after the back mechanic was released. And Stu was candid enough in talking with me, he said, Philip, you know that book has been on my desk for five years.
And he said, I haven't released it because my, I was unwilling to do the things that my publisher said I had to, to make that book a sales success.
He said what my publisher wanted me to do was to make it scarier.
Ew knew that if he did that there was gonna be some fallout, but the book was more likely to be a commercial success.
What I would love to see now that the book has been a commercial success is some backend stuff to maybe maybe a a, you know, an an updated edition that speaks to some of this kind of stuff that many of you that are clinicians and I do occasionally see of these patients that have read some of the remarks in there, like the toothpaste getting squeezed out of the tube and will it ever go back in, will my disc ever heal?
Can I ever flex my back again? You know, is that something I should always avoid?
Those are things that I think probably would be best addressed. And candidly, I think Stu knows that and would and and likely will at some point address those. But in the meantime, the vac mechanic is an incredible resource for most people. Most people read it and they don't have this kind of, this kind of effect. But I do occasionally see it clinically.
So what I did was to coach the patient that a disc is more vulnerable when we apply compression plus flexion. And that we will, in our exploration together, work on returning to his power lifting movements, making sure that that doesn't occur. And we'll use the things that we've found effective at Kabuki Strength Lab, integrating DNS principles for lumbar stabilization vis-a-vis stacking the lumbar spine and using intraabdominal pressure to stabilize the spine rather than excessive erector tone, which we have identified as po probably the putative mechanism for the ongoing pain from a functional perspective that this patient is having in their low back.
And I licensed him to do some flex to round his back and we worked together. I said, I want you to put your shoes on now, let your back go.
Laid him out on his back and did that flow that I talked about of laying on your back, stacking pressurizing, doing the log rolling, then moving to hollow bodies, stacking, pressurizing, doing the rolling.
And then we started to move into the plow pose stuff. Why do I like that? The compressive forces are lower. Yeah, you've got some because you've got bilateral SOAs contraction, but to my mind it's gonna be less of a compressive mechanism than the torso's weight and the standing position. And I just started coaching him over into that and long story, a little shorter by the time we stood him back up and he went to touch his toes now without a cup, he has zero pain with the previous index movement, which was standing lumbar flexion and he's got a 50 50% improvement in his range of motion.
His fingers are now four inches from the floor instead of eight inches from the floor. So overall I coached him that he can let his fear go. He can start moving. I got a little funny with it. I got a little jiggy with it. We did some dance steps, I showed him how to do 'em meringue, I showed him how to hula hoop. I showed him how to swing his hips and get some dance moves on, that kind of stuff. So we lighten up, we said, I want you to relax more, I want you to chill out more. You don't need to be so tight. So that starts to look a little more like Peter O'Sullivan's work and it doesn't need to throw shade at Stu McGill in the process. So there's our case study for this week and it's, we're 60 minutes into our gathering.
How am I doing there, Dr. Heller? I'm starting to get pretty good at nailing this in 60 minutes, huh?
That that was good. It, it reminds me of one of the things that you've said for a long time that Stu McGill's word for it is, quit crushing your back, you know, by quit over activating the lumbar extensors. When you do, you end up with a mang syndrome kind of pattern with tho recal lumbar restriction and irritation of superior clonal. Typically the only question on this is I kind of differentiate the SI ligaments, which are a little more medial from the superior clonal, which is maybe another one or two centimeters lateral. And there's usually a specific spot where did, were you putting the cup over the tender spot in the clonal or just generally over the SI area?
I think the best answer that I could give given the size of the cup is yes.
Okay. Got it.
Yeah, it would've, it would've covered both areas. Okay.
And, and I think quite honestly, mark, you, you know, and you and I'll collegially you know, occasionally disagree over the, the, the structural issues sometimes in all of this. And I think that's absolutely fine. 'cause at the end of the day, neither one of us knows that we're really truly right, but we've got our own clinical experiences and our own life experience that kind of frames that. The, my personal choice on there is that the over izing, some of these procedures can quickly kind of get in, we get into the weeds and a lot of dead end rabbit holes that I've found clinically over the years because ultimately many of those things,
it's difficult to, I've found anyway, I find it difficult for patients to find a place to access an agency in that usually that si joint explanation at the other end of it requires a chiropractor to manipulate their joint or a physical therapist to show them how to do some kind of exotic PRI kind of, you know, weird things. And, and in that PRI world, they wind up ultimately getting their frenulum snip or something stupid. So whatever I, I, now I'm throwing shade at PRI, shame on me. But the, the, yeah, I, I've
actually, I, I have to, I have to throw in here that for years and years, years I had a fear of flexion and a simple PRI exercise that encouraged sacral flexion and encourage lowering the diaphragm, which is similar to what you're doing in DNS like cure that in my brain, I think, you know, allowed me to start flexing again. So I, I think that strategy of get the person back to be able to flex pain-free is really important in these old disc injuries. So. Yep.
I appreciate, I appreciate you pulling me up short there and my apologies to the PRI world and to Ron Ruka who contributed some wonderful things out there.
Yeah, that's, that's good stuff.
All right, so we've got a, we've got, we've come to the end of another week. I will be here again next week at 9:00 AM Pacific.
For those of you that are watching this before noon on Saturday, November 25th, which is two hours from now, the Black Friday deal for lifetime membership for the online academy for neuro centric approach ends at noon today.
Get on that and pay one time and get currently 30 hours of continuing education for the single lifetime price is 4 99.
There's 35 hours on there right now, and you'll get a hundred dollars off if you're a lifetime member, you'll get a hundred dollars off of the upcoming in-person courses that we do. Okey-doke. That's enough.
I will see you guys later. Enjoy a cool crisp fall day in the Pacific Northwest or wherever you are. Happy holidays, people stay curious. Go help some people.