NeuroCentric Approach Case Study-SPECIAL GUEST GEOFF BOVE, DC, PhDJanuary 13, 2024
NeuroCentric Approach Case Study-72 yr old with sciatica after wrist fractureJanuary 27, 2024
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.
Transcripts from the video above are below...
Good morning over to the shoulder here on Facebook Live and good morning to my compatriots over here on the Zoom room.
Welcome to another Saturday morning NCA NeuroCentric. Approach Online Coffee Club.
Coffee chat case study. Although I will say, given that I've had about as much clinical contact this past week, it's many of my brethren and cistern in the cistern or word I think it is, but I think it's a water reservoir in the Pacific Northwest where we have had a, one of our delightful ice storms.
Things have been locked down here, quite honestly, that's had me in a bit of a lockdown mode, literally barely able to get out of the house because you can't walk, you really can't walk on this stuff. I, I made a joke to some friends the other day that I was sure the conditions were about to improve because I just saw a Zamboni go by. So it, it's been, it's been a fascinating week. But we do have these on occasion as some of you in other parts of the world have that live in these interesting transitional zones and have things like lake effect going on within your vicinities.
Let's see, A bit of commerce first couple of upcoming in-person courses.
I will be, well not a course of mine, but I'm gonna be at the R two P symposium. I'm flying down, what is that, two weeks from today? Yeah, that's February, no, yes, February 3rd and 4th in Dallas. I look forward to seeing my peeps in that part of the world. It'll be my first time on campus at Parker University.
So that will be a bit of fun.
R2P symposium, I was one of the speakers there at the very first one with where Steve Capobianco and Jason Brown and I joined in on that one. So I'm looking forward to seeing what Brett Winchester and others have to share on this particular one. Our next in-person NeuroCentric Approach course, that'll be a 12 hour course. The lower quarter course will be in Seattle on February 10th and 11th.
And just last week I also booked the next upper quarter course, which is gonna be in Portland, Portland, Oregon, on April 20 and 21st. That's gonna be at Evolution Healthcare and Fitness with Dr. Brad Farrah, who's a member on here as well.
So do come and join us there. Those of you that are lifetime members of the online academy, we'll get a hundred dollars discount off of that tuition for that course And all future courses that I teach in this material, you can find the schedule updated regularly. You can bookmark it at NeuroCentric Approach dot com slash events so you can find that there.
Our lifetime membership availability is periodic. It is not currently open, but do keep your eyes open for that if you want to get those kinds of perks every now and then.
I'm just thinking that around the time of those particular courses, those in-person courses might be a good time for me to open that up. I don't know, but keep your eyes open for that. Those of you that are lifetime members though, I appreciate you being over here in our Zoom recording.
What did you guys think of last week's discussion with Dr. Geoff Bove? Did you guys find that to be interesting? Glen, you're on here. I'd like to hear your thoughts on that and I'd also like to hear some information and maybe drop in the chat here a link to an upcoming course that you've got online, which is a very cool, almost online symposium that you have going on. So tell us more about that.
Hmm, I'm not hearing you Glen, and I'm seeing that you're unmuted on my end to double check your audio settings there. Yep, I got you now.
Alright. Thank you for the opportunity Philip, to tell a little bit about our, our dynasty course. We got the disc dynasty coming up on March 3rd. We have invited a bunch of professionals from around the world to share with us their experiences on a assessing and managing patients that have lumbar discogenic pain with or without radiculopathy. So we're gonna start off with Kathy Dooley chiropractor and anonymous from the East coast. She lives in Colorado now, but she actually teaches at several of the medical schools on the East coast. So she's gonna present to us just a little short summary of the anatomy of the disc, including the IVF, but really telling us a little bit about the anatomical structures that can mimic radicular pain down into the leg.
And we have a Dr of Kumar Doc Bar radiologist here in Toronto from CMCC. She's gonna present to us a little bit of a summary of the imaging considerations for the disc, both radiographic CT and mr. We're gonna have Dr. Stewart McGill talk to us about the the disc mechanics, particularly developing resiliency.
We're going to have yourself, Dr. Phillips Snell's gonna talk to us about assessment and management of the patient with discogenic back pain, including radiculopathy and without radiculopathy particular attention to symptom modification procedures and neurological assessment.
We're going to have a little bit of a recap on the flexion distraction technique with Dr. James Cox. He's gonna talk to us a bit about that. We're gonna have Dr. Irwin, Mark Irwin from Toronto who has published significant contributions to the literature and research into the degenerative process for the lumbar disc.
He's going to morph that into a discussion of management, the manual therapy considerations, including manipulation with patients with discogenic back pain, with and without radiculopathy. And we're gonna have csar InCopy from Switzerland. He's gonna talk to us a bit about also the manual therapy and that session will be moderated by Dr. Daniel Lawrence.
So we look forward to hosting that event. It's a late start time for us on the East coast here. It's gonna be 9:30 AM eastern standard time so we can allow our friends on the west coast to join us without too much of an early rise. I look forward, I'll put it the link in the chat. I look forward to seeing everyone at that event and, and thanks Phillip for that. Just a recap of my thoughts from Dr. Bo. Dr. Bo and I have been chatting for many years now about all of these concepts and we were looking at trying to have some type of symposium here in Toronto, but Covid got in the way of that.
I was really fascinated at the very end about, well this dorsal scapular nerve is only a motor and how can it actually be a nociceptive driver if it only has, you know, flow going one way. So I, I have sent that out to several of my colleagues and that actually spawned a quite a discussion all this week. So I, I hope we can chat about that at some point today, Philip, 'cause I, I'm a bit perplexed by, 'cause we, we see that clinically we, we palpate, we put them through some tension and seems to recreate symptoms but maybe it's something else that we're seeing there and not necessarily a neurological driver back from that, from that clinical entity.
But I found his work fascinating and he's done amazing contributions for understanding and clinical application for patient management.
Thank you for that. Thank you for calling and I'm gonna mute you so we don't get feedback there.
Yeah, that issue about the dorsal scapular nerve had me thinking a fair bit this weekend or this past week as well and it prompted me to dive a bit deeper and then I had a subsequent conversation or subsequent email string with Jeff there. The short story on that is that as you will find, as I have found as I have been, I've been going back into the course notes for the upper and primarily the lower quarter course right now since that's the next one up. And as I am prone to do when I'm teaching these courses, we put the the notes together and that's all fine and good, but the notes are not a static process. They're a dynamic process in the same way that the literature is dynamic.
And I always go back before I teach a course in person and do a literature review beforehand, typically in the week beforehand. This has been in the month beforehand since it's been so long since I've taught this stuff.
And among part of what I'm doing is going back in and checking to see have we learned anything new and the research. Because what is fascinating is despite the fact that we have, all of us, since the times of the ous have been playing around with gross anatomy and learning things about how the human body is put together,
there is always a a maturing process on that literature as well. And what I found on the dorsal scapular nerve is that true to what Jeff was saying historically, the dorsal scapular nerve has been viewed as a purely motor nerve.
The more up-to-date. Vantage point on that is that it's not, is that it does have apparently some sensory fibers available to it.
But we have to put an asterisk on that. The reason why we think that is because dysesthesia and, and allodynia and hyperalgesia hyperalgesia in the area over that particular region of the do of the mid scapular region, we do know is primarily the posterior ram eye coming off of the spine.
Now that's the dermatomal distribution. However, we have people that we have case studies at, at least at that level of sophistication of nerve blocks done on ultrasound guided nerve blocks done on the dorsal scapular nerve, which als also relieve that dermatomal symptomology as well. Now why do I say we should put an Astros on that procedure is probably at play there as well. You could imagine despite all of our sophisticated ultrasound imaging and such, which I don't know if you've ever actually watched someone do an injection of any kind using ultrasound guidance, but it's a fascinating process and I think it's a a relatively fluid process in and of itself.
But if your thumb on the application of the anesthetic starts a little bit early on your transit to the deeper structure, then you're also gonna be infiltrating a, you're also gonna be infiltrating that anesthetic over the posterior rami as well.
So you could be, I think it's probably one of these, another one of these situations where we probably need to keep our minds open and wait for the literature to mature.
And this is a, a perfect jumping off point to some stuff that I want to discuss as well, which has sort of came up in the subsequent conversations with Jeff over the week and e even preceding last week.
And that has to do with this sort of interesting dynamic balance that we all find ourselves in, all of us that are clinicians between the basic science and evidence base and clinical practice. And all of us that have been in this game playing clinically for a number of years know that probably a better way of framing our practice model is evidence informed as opposed to evidence-based because there is a bit of malleability in the end of one way that we apply what we know and what we think we might know.
So we have to balance that honestly intellectually by understanding what we think we know, what we think we don't know and try to make that make sense into something with a patient. That's why I like what we're doing with the NCA material and including the clinical audit process because that's where the rubber meets the road, right?
Regardless of what you do, if a presenting symptom gets better very quickly with something that you do, it's probably a decent thing for you to explore that, especially if that thing has putatively low risk and low cost is even better if it doesn't breed dependency, if it gives agency to the patient. So then we lean into several of those areas of research where we have a bit more maturation available to us there.
So all of that I'd like to discuss further today. I'm going to take a side tangent here for just a moment. I'll call this hats off day
to spend a moment. This has been a reflective week for me with, you know, necessarily so you get on lockdown, it's almost like being in the, the dark times of Covid and the, the ice storm here is really, you know, limited my ability to get out and get around. So I've, you know, tried to go inside a bit more and some of the things that have come up in all of that has been some thoughts about people who've come and people who've gone both in flesh and not in this type of work. And it affected the work that I've done. I've got a book on my desk for instance right here.
You guys can take a screenshot of that. But this is from theme T-H-I-E-M-E.
This book was recommended to me by Warren Hammer.
Gosh, I don't know, it's been 12 years or more.
I asked Warren specifically when I was taking the, the Stecco coursework from he and Antonio a Stecco. I said, Warren, what do you, you know, what's your secret to maintaining your, your inquisitiveness and your passion for the work that you do?
And he told me a few things that have stuck over the years and one of those is to be true to your patients. You know what you're, the trust that our patients put in us is should make you humble.
It should also bring gravity to what you bring to the clinical encounter.
He also said, don't get so busy that you lose sight of that hopefully your practice model, your economies of scale, your profit margins or such in the way that you run your business, that your clinical encounters can take priority.
And your realization that that patient in front of you is not only paying you for your A game, they're trusting you and that's important.
And the other thing that Warren said, he said, you can never learn too much about anatomy. And he said he kept this book on his desk and had for a number of years and in his idle moments and this was a time well before our idle moments were filled up with head down phone posture.
He would pick up that book and just open it up and read a little bit and he found it a source of both inspiration, call it his bible or call it his holy writ. But that was, that was something that kind of stuck with me. So Warren Hammer, if you ever get a chance to, to see any of this stuff or whatever, thank you.
Another thing I learned just this morning before going on of the passing just today or yesterday of Dr. Judith Campisi at the Buck Institute of Aging.
I followed her work for a number of years. Her work is primarily involved with senescent cells.
That is to say cells that have lost their, have been programmed to continue to live. Sometimes they're referred to as zombie cells, but they were the body and its decision making processes decided to keep it in, call it a state of suspended animation instead of programming it to die using the more the better known apoptosis kind of metabolic pathways that we've learned in school.
Senescent cells are the part of the sterile inflammation process that many of us have observed. That much research has observed in many chronic disease processes including degenerative disc disease. And Glenn, I hope that we learn a bit more from this. I believe you said it was Dr. Irwin talking about the degenerative process and I'm hoping that we'll have a q and a gathering there with that symposium as well.
But Dr. Campisi's work has morphed over into our physical medicine domain by virtue of her work with Gwen Sowa's lab at the University of Pittsburgh, which many of you know is highly involved with our primary spine care, spine care practitioner program that's at play there.
And Dr. Sowa's lab primarily my awareness is of Prashanti Patil was one of her grad students that really explored this, I believe last name is vo I think first name Von or Nam Vo. But those two researchers kind of leaned into this thing that we've seen in the literature over the years of how on imaging studies like MRI two discs can look equally pathological. But one can be in an asymptomatic patient and the other can be in asymptomatic patient. And we gotta figure out how to square that. And one of the things that we've learned over the years is that the painful disc that appears pathological on MRI, when we get down a little closer to it and say we perform a microdiscectomy and we pull some of that material out, then we find that that material, that nuclear material that we pull out is riddled with markers of inflammation and to a much greater degree than what is seen at least in animal models in in that particular material.
So we know that that inflammatory process, those inflammatory cytokines are quite high in a painful disc. The primary ones that we know about are tumor necrosis factor alpha, TNFA, interleukin six, interleukin eight, interleukin kappa B.
And there's some others as well.
But at Sal's lab working with Judith Campisi, they learned that in an animal model you can cause a disc herniation and you and disc extrusion and you can subsequently evaluate that nuclear material and see that it is quite high in inflammatory cytokines and using an animal model. These are rodents that Campisi had put, I guess derived or bred in her lab such that you could give a particular drug and it would cause, cause a senolytic process to occur in that animal. Meaning that all that systemically, the senescent cells in that animal were diminish. Now in humans this is done using a drug called dasatinib and a bit of quercetin too, which is a bio flavonoid that we often see in plant-based constituents that humans consume.
But that's so-called D&Q protocol has been used in organ transplant patients to reduce immune response to an a transplanted organ.
And what campisi in her lab at the Buck Institute and elsewhere, I believe she was at USC previously as well, what they had explored was that the reduction of senescent cells in those animals also conferred a longevity benefit and a health span benefit. Meaning those animals when they died were healthier.
So they had less of a period of that nasty twilight of mortality that many of us don't look forward to.
So that's the bit of Judith Camp's work. Why I'm interested in her, how it carries over into the work that you and I do. And my hat's off today for Judith Campisi
leaning back into the conversations about basic science and clinical practice.
Some of the thinking that I've had over the week, Jeff is stringent, Jeff, both is stringent in his, and I would, I would even say that it by some he's been referred to as intolerant in his
approach to people, especially in our own profession as chiropractors who insist on sloppy language sometimes intentionally and insist on proselytizing, evangelizing
to try to sell things as opposed to try to deliver better quality care.
That was certainly a, has always been a meeting point between he and I and the years that we've had conversations together.
I try to be a little more tolerant, understanding that we're all fumbling, farting and falling through this world and our ability to understand some of these things and even when we are sure like that the dorsal scapular nerve is primarily or is only a motor nerve, that it can indeed, at least in some people and maybe in all but that research hasn't been done yet, carry sensory fibers that those sensory fibers may or may not inc. Include cutaneous fibers that they may or may not include deeper sensory fibers that go to the scapula.
That research, there is research but it's small level stuff, case studies primarily that suggest that.
So these are things that we're still learning about even though we've been playing with the same tissue for several thousand years now in a variety of different labs. So I think we all probably need to reflect back on what some of our elders, like Carl Levitt have said, that most of what you think you know right now or at least much of what you think you know, like right now in 10 years you'll probably find out wasn't true. Your challenge on a day in, day out basis is to try to figure out which 50%.
So good luck with that but keep the lights on in the process of doing it.
The other dynamic that I'd like to
enjoy conversation with you guys if you're willing to is how does that evidence base affect us clinically to Geoff's mind as a bench researcher who admittedly hasn't had much of a clinical practice over the years, he's uncomfortable talking about things that he doesn't know and certainly doesn't want to say that things are in any particular way when the evidence is murky. And I really appreciate and respect that about his work. I've tried to carry that on in my own work over the years as well.
I, I think that tension that I find in my own clinical work is probably best reflected on something that I said in that talked last week and I've said several times over the years is that why not go out on a limb? Isn't that where the fruit is? And I think we have to balance that, shall we say possibly naivete with some intellectual maturation as well.
We are, we know from research we are the easiest folks to fool, I believe it was Richard Dawkins that maybe first coined that phrase that our bias, that human bias is rife in all of us and it's very difficult to see in each of us. But a very good start in the science model is to understand that and to always question your thinking and your biases. Now this from a philosophical perspective is where we can start to slip and slide towards what I've referred to over the years is clinical nihilism.
And that's to my mind where, and you can see this in some maybe even more in other professions like personal training and exercise, the exercise world, you can see it a bit more maybe there where people suggest that it doesn't really matter what you do and I, I'm not, I, I don't accept, I don't accept that that rubs against my bias that we probably should try to explore if we think we don't know something, explore other ways of looking at that to see if there are other things to be learned about it. And I think that's what we're trying to do with this NeuroCentric Approach model.
You know that others are doing this as well. I like what Jerome said over here, clear your cache frequently, which is probably a another good way of looking at that over on the evidence-based chiropractors form, which if you guys are not, not forum but the, the Facebook page, if you guys are not members of that community, you should be evidence-based chiropractic on Facebook. There's over 10,000 members there. Mark Bronson did a great job of getting that thing up and running. I think Dean Smith is mostly working things there now. And Gerald, I believe is how we pronounce his last name.
I believe Gerald is a, or Gerard Keown is a naturopath out of Australia. He posted a nice paper just this morning that I was looking at, let me see if I've got that. I think I left that up. Yeah, it's called the effectiveness of nerve mechanical interface treatment for entrapment neuropathies in the lens, A systematic review with meta-analysis. (https://doi.org/10.1016/j.msksp.2024.102907) So does any of that sound kind of familiar to some of the things that we're talking about with NCA?
Again, I ain't the one that started this stuff.
I'm just trying to put together something that they speak to right here in the abstract.
The, and again, I'm struck by the fact that there, this is a systematic review with meta-analysis which means that there's enough papers out there, enough case studies and enough RCTs for someone to gather them up and to try to get a, you know, a rough vantage point of what we're looking at and say okay this is generally true.
So they say in the background they do note neurodynamic approach employs neuro mobilization and mechanical nerve interface techniques, plural, while published studies investigated the efficacy of neuro mobilization, it is currently unknown where the manual treatment of the nerve mechanical interface is effective in the treatment of people with entrapment neuropathies.
They put together this systematic review with a meta-analysis.
They had two independent reviewers and as you might expect, those of you that have been playing with us here on NCA, it's this would be a very early stage systematic review 'cause there ain't all that many studies investigating this specific topic. And in their inclusion they were only able to find 11 studies and they were all investigating carpal tunnel syndrome.
So here's their conclusion. Mechanical interface techniques are effective for improving pain and function in people with carpal tunnel syndrome.
However, the marked heterogeneity of included interventions and comparator events, clin prevent comparators, prevents CL clinical recommendation of specific treatments there that is intellectually honest and that is indeed what I think I'm trying to do with this NCA thing is to better define what it is and how it is that we're doing these things where we're doing it when we're doing it. But if we're going to think about the overarching sort of principles, it is a combination of first thinking about the neurology that is involved in that patient globally, holistically and locally and evaluating that with the best available current evidence.
Whether that evidence be aimed at top-down processes, brain-based chemistry, brain-based psychology and and such. And pain from a pain neuroscience perspective or whether it is reflective of the evidence that we've gleaned from working at the nerve root IVF spinal cord interface. And there we have the wonderful careers of people like Robin McKenzie and Michael Shacklock has leaned into this area pretty well and other researchers that are bench scientists, more like Kobayashi and such that have given us more information about how nerve roots behave when they are compressed or tethered at that particular interface.
And then we go down to a smaller level in our clinical model with NeuroCentric Approach and consider peripheral neurology.
That peripheral neurology could be mixed as in it, the peripheral neurology has motor fibers, sensory fibers and possibly sympathetic fibers as well included.
Or it could be purely sensory cutaneous models. And we've got some interesting research in that area from people like
Bob Elvy, Michael Shacklock, David Butler, et cetera.
So again that has mostly been done at the peripheral level. Jeff Bove has done some bench science in that world as well of course.
And then we get down to the cutaneous level, the small neuro and that's the domain of what many of us have learned over the years to call. In all likelihood this is what we currently think, well that the best available maturation of the evidence would point to that phenomena, which we have historically called a myofascial trigger point being primarily a phenomenology of how a nerve in this case mostly a peripheral nerve, mostly a peripheral cutaneous nerve interacts with the myofascial compartment And at that interface if that interface is problematic, we'll say from the nerves local point of view, then the nerve will do things locally to try to improve that interface, particularly to wall itself off from that interface and to make a fluid interface there.
So it secretes factors locally in that area.
Things like calcitonin gene related peptide and substance P which help to create a fluid interface and trophic factors as well that help to make bring fiberglass in in that area and cause a bit of a walling off of it. So to my mind when I look at it, I'm struck by how it looks very much like a 10 synovial arrangement.
So that is what we, you know, started this NCA process with now over, as I mentioned over the past couple of weeks I've been going back in and re reviewing and doing a literature search more deeply on the course material on for the upper quarter and lower quarter courses. Those 12 hour courses again, the next one's coming up in February in Seattle. And then we got another one currently booked in Portland in April.
Glenn Harris and I are trying to find a date in November and Toronto, some of you that are on here, I saw Ian Boonstra on here and Richard Bale oil, you guys are up in Vancouver and I would love to come up there and talk with you guys if you want to host. I think you guys have worked together at some venue up there so if you're interested in bringing me in up there, just chat me up about it.
But part of what I'm seeing is that standing on a limb and reaching for the fruit and possibly another way of looking at is skating on thin ice apropos for our weather.
But I am open to being intellectually honest with that dynamic tension if you guys are and exploring possibilities.
Here's what I think and here's what Justin before he partied ways with his set, NeuroCentric Approach and what he was exploring and this had kind of grown out of some of his work with people like Voer.
But I think that the model that we're playing with with NeuroCentric Approach, I think that it may also carry over into sensory areas that address deeper structures that aren't cutaneous like bony structures and joint structures. So if we are correct on that, then what we should see is that manual therapies and or mobilization techniques
and or things like what we're doing with the NeuroCentric Approach addressing top down and the graded neuro neural neurological evaluation of bigger neuro to smaller neuro and working those interface points, then we should see an improvement in joint related complaints when we involve this model. So what the hell am I talking about here?
Let's go back to our dorsal scapular nerve that we were talking about Glen.
The dorsal scapular nerve we do know has sensory components to the scapula itself.
As Jeff pointed out to me, Hilton's law is not always correct. That's the idea that the nerves that innervate a muscle that crosses the joint also typically provide, typically there is the asterisk not always typically provide innervation to the joint itself. Well the, the scapula is innervated there and the scapula has sort of an articulation, does have an articulation but is it a joint, I don't know with the ribs.
And I suspect that if we are doing something like a transverse nerve mobilization, which you'll see in those in-person courses to address a putative dorsal scapular nerve, no susceptive process that's going on, then we would possibly be influencing those fibers that go to the scapula as well. Now do we typically see that the scapula itself is a painful process or a painful structure in that I, I don't know that I typically see that. Probably not on bony palpation or vibrational palpation of the scapula itself, but certainly when we do a side lying scapular lift off manual therapy technique and try to get our fingers under there like Vladimir Yonda used to teach us to get, try to get up to our second knuckles in there to see if that is an appropriately mobile interface.
You know articulation certainly you find that to be quite painful in people all the time. But how about other structures? And this is where we're leaning into in the coursework like the knee and like the hip. So what we're doing with the hip with our work in our in-person courses is we're exploring the overlay between things like capsular pattern from James cxs, some of the work of Voer in looking at the fibrous orientation of the capsules in various joints.
Overlying that with the anesthesiology literature that shows us how sensory the dense, the density and the geographic location within the joint of sensory afferent where those sensory afferent are derived from.
And then try to devise ways of possibly, again, intellectually honest here could be I'm on thin ice, but possibly having an even greater effect as chiros and as physical medicine specialists on our joint based treatments by including this NeuroCentric Approach perspective on what we think we're doing there. So how would that play out?
So in the coursework, what we'll do, let's say for instance we'll talk about the hip joint.
The hip joint has three primary ligaments, which as all of you that have played with anatomy and looked in the anatomy literature enough, you know that ligament in these cases is
probably a generous use of the word. It's really a thickening locally in one area of the joint capsule from a gross histological perspective.
I saw Mark Heller just drop in there. I know Mark's chomping it a bit now because he knows that some of the things that I'm talking about are historical osteopathic techniques. Voer is a, is a, an osteopath by training and this is somato visceral and visceral somatic kind of thinking processes. So we'll get to you in a moment Mark, I know you're chopping at a bit right now and it looks like you're enjoying a lovely walk probably out in the snow on Mount Ashland but we'll get there in a moment.
So lemme keep rambling for just a second.
So what we're trying to do with this newer model, and I think others are kind of leaning into this when they talk about, and I think maybe even Janet Tve and David Simons were leaning into this because remember they had a section talking about ligamentous trigger points and tenderness trigger points.
Now how in the hell can you get from their model of an energy crisis,
a local energy crisis and a TP and local A-T-A-T-P depletion and a local essentially minor rigor process to explain the taught band that's going, that's observed there by all of us in clinical treatment. How can you get from that to explaining a tendonous trigger point or a ligamentous trigger point? It doesn't quite rub, but if I look at this through our model of NCA, I can see some agreement there. I can see a lot of agreement there.
And at the tenderness level, I think what we might be looking at here is extra weight onto the currently emerging 20 years of emergence in the model for tendinopathy and why a tendonitis can go to a tendinopathy in some people and not others.
The research would suggest in that particular model that one of the things that we see, one people have morphological changes in a tendon that are associated with tendinopathy.
Interestingly, those changes don't tend to change after the tendon is no longer painful.
But they do predate a painful tendon and in a relatively homogeneous population, in this case it was professional soccer players monitored over a one year period ultra sonography of tendons preseason and identification using ultrasound of morph morphological changes in specific tendons observed before the season in a non-painful tendon predicted a four x four times higher likelihood that that athlete would be afflicted by pain in that tendon in the sub in the subsequent season. I think it was the upcoming sporting season, to the point that they would miss a game from pain associated with that particular tendon.
And so there is a tendon sensory interface that I'm interested in.
There are those in the world of tendinopathy research that are less, there's one particular researcher by the name of Neil Miller, M-I-L-L-A-R.
He's out of I think Sweden, one of the Scandinavian countries.
But he has prioritized the, the, the, the sensory ingrowth that we know occurs by nature's design when we have an injured tendon and the sensory nerves in the teno synovial sheath which occur there normally grow into the normally a neural structure of the deeper tendon after that deeper tendon structure has had its mechanical properties exceeded.
That is normal physiology, it's observed in all tendon injuries. But in a tendinopathy, the normal outgrowth after a two to three week period as I understand it does not occur.
And we are left with the question why we don't know why and what I'm theorizing and when I question, if I try to take our template of N NeuroCentric Approach and lay it down over the top of that, then the question would come would be what do we have other components that are making that sense that neurology sensitive?
I just saw Scott Morrison jumped on here. Scott, I hope you listened to this whole thing. I'd love your input on some of this 'cause I used your tendinopathy infographic with your permission by the way, sir, with patient education all the time, physio praxis.com I believe is Scott's bit, you can leave a a little note here for a link to that if you like Scott.
But what, what we know from the sort of global research on tendinopathy from Craig Perdam, Joe Cook, Rio Boni and others, is that there are other factors that result that have been associated with the prevalence of tendinopathy in different populations.
We know that people that have cardiovascular disease or diabetes are at a two to three times higher risk.
The that two to three times risk we think some think relates to other associations that we see in the longevity and aging literature to suggest high oxidative stress, call it hard living, willful self, a lot of willful self poisoning, a lack of exercise, a lousy diet, obesity, things of these sorts.
They do have a pretty high positive association with development of tendinopathy in an individual.
Now let's look at that from a ligamentous standpoint and what we're going to explore in our coursework at the, the NeuroCentric Approach in-person courses, this idea that sensory nerves go into a joint and have a relatively predictable distribution density within a joint. So specifically the hip joint, you've got a really three primary ligaments that are
places where the capsule gathers a bit more densely and those areas are most of the sensory afferent input to that joint is on the anterior and superior aspect of the joint.
Most of those sensory afferent to those particular ligamentous structures and those parts of the capsule come from the femoral nerve and they come from the obterator nerve or from derivatives of those nerves.
And in the coursework we'll review how tho the femoral nerve, the mechanical pathway that the femoral nerve takes to get to the joint and how the mechanical pathway that the obterator nerve takes to get to the joint, how they are similar and how they're slightly different. And how we could overlay that with mobilization of that joint. Borrowing from procedures from osteopaths like voer, borrowing from physical therapists like Brian Mulligan and using pragmatic manual therapy skills to do joint mobilizations. Grade four mobilizations, perhaps grade five manipulations to use maybe belt assisted kinds of things ala Brian Mulligan to use osteopathic techniques like muscle energy technique, contract, relax, agonist contract, positional release, et cetera, et cetera.
We've all had our, our individual hands and others have as well on this same elephant for a long time and are trying to make sense of it. And again, I'm not really inventing anything new here, I'm just trying to take something that makes sense of it at a distance so that we can have an overlying kind of homogeneous, more homogeneous way of addressing this thing that, that paper that I was talking about there that Gerard Cohen put up on the evidence-based chiropractic form today bemoaning the heterogeneity of those particular posts. So wow, I've talked a lot today.
You guys haven't talked very much.
Probably you guys need to talk some floor's. Yours. Mark, I see you chomping what you got for me.
I I appreciate the overview you're giving Phillip. It's, it's helpful and, and the dancing back and forth between the clinical and the research. It's great and I don't have anything really real specific to add.
The one other person that I would name my, my teacher on the hip is a chiropractor who I think is still in practice in Taos, New Mexico. Lucy White Ferguson who wrote a great book on myofascial stuff and she taught me this manipulation called the Wishbone Maneuver, which is basically an using the adductors eccentrically to reset the hip into its socket. At least that's what it seems to do, which is neither here nor there. We all have lots of different ways to do that and when we get up in Seattle, I will be happy to demonstrate that. So that'll be fun.
Cool, cool. I'd, I'd love to see that. Another, another PT that I would hardly recommend here is Allison Grimaldi for their work on the, the, the hip.
A lot of Allison's work is around the interface of the gluteal tendons and the agonist and antagonist relationships between the hip ad doctors and ab doctors around the hip. She's got a lovely series of online courses at her site. Allison Grimaldi, GRIM, just like grim a LDI and you guys can get online coursework like that.
Okie doke. I'm just looking to see Scott Morrison following up here. Okay Scott, yeah, I'd love to have you on here at some point and maybe chat up some of this stuff. Scott, those of you that don't know Scott Morrison's work, Scott's somebody that I would consider a friend, but at the very least I would always expect and appreciate that Scott will call bullshit on me when I get too far out onto that thin ice.
Or at least he'll ask me, he'll, he'll demand clinical references and I I've always appreciated that about our relationship as well.
So we have reached the end of an hour being here. Glen, did you have any, any follow ups, any follow up remarks there?
No, no. Maybe moving forward at some point Philip, if we could talk about like polyneuropathies, 'cause we're discussing a lot of, you know, entrapment neuropathies, but maybe we should dive into differential diagnosis and the etiologies in the future. 'cause I find that often a bit of a challenge. So if we could do that maybe in a future one, that
Would be, oh, I'd love to that that's a, that's a nice suggestion. I like it a lot. I try to, I I have admittedly avoided going there because I find I have found in the past, since that falls within that systemic bucket in the NCA platform and I've got the course on epigenetic influence on that, on the, the the NCA online site.
But I've found, you know, just in looking at viewership and talking with people and everything that my fascination with that particular topic might be a little more unusual and others find it to be a little bit too deep in the weeds. But I'm happy to explore it, especially from the vantage point that you just mentioned. From a, a differential diagnosis, polyneuropathy kind of vantage point. 'cause we certainly see those and you don't have to get, you know, ridiculously deep into the functional medicine kind of domain there in order to have at least a, we'll call it a 15,000 foot view instead of a, you know, 15 foot view of that phenomenology to
Excellent. I I would appreciate that. That would be amazing for me clinically.
Absolutely. So you guys make sure you go over and look at MSK plus Say it out loud again. The link for that site or for your registration for the disc dynasty course.
Very good. So you guys get to that if you want to take part in that symposium, that is gonna be a fun one. Let's see others that we've got on here. Love your, your designation now, Ryan Onik of old man winner, but I recognize your, your, your picture there of the Elk is definitely Ryan Onik.
Yeah, I had a meeting with my students yesterday and I felt it was appropriate.
Ryan, your Ryan is the faculty
overlord of the R two PR two P club at University of Western States. Ryan, are you or any of the folks there going to the symposium in Dallas a couple weeks from now?
I'm not going, I'm contemplating I think that they're still doing the virtual access and so I'm, I'm trying to finagle some things so I have some time to, to view it and I think maybe some of our reps are going, I think that that's what they told me. Hey, real, real quick question for you. Sure.
Is there, what's the easiest way to access these meetings for students? Or is it accessible for a student?
It is. I'll define access better. All of these are accessible to anyone.
These meetings are recorded. I realize that a lot of you have kids and other commitments and things this hour. But we get a really good viewership of the recordings of these, which can be found at the NeuroCentric Approach dot com slash blog. That's just the blog. Just find the tab on the NeuroCentric Approach site.
That's not the online academy, that's just the regular one. You can also find a link to that if you are a, a member of NeuroCentric Approach, the online academy and you go to the community, there's a community
bucket there that I made for the Zoom recording so you can always find 'em there. But the easiest way I will drop the transcript and the recording at the NeuroCentric Approach blog. Now that's accessibility 24 7. If you actually want to come on and sit in and you know, listen to me drone for an hour between nine and 10 on a Saturday.
If you're a member you can come on and do that on Zoom using my Zoom link.
If you're not a member you can come on over here at Facebook live on my feed, my feed, personal feed for Philip Snell on Facebook.
And that will be a way that you can get a glimpse of that and those Facebook live recordings will be available for 30 days each of them on that. So that's a good way for folks to get that.
Awesome, thank you so much.
No worries brother. We still gotta get together with Cap and all those guys and go over to the triple, go over to the triple nickel and shoot.
Sounds like a plan. Sounds like a plan. I'll reach out to Kelly.
Alright. Alright everybody, it's time to go have a Saturday. I'll go see if the skating rink outside is accessible and take my doggie out for a little leg stretch. I hope you guys are well, I look forward to seeing you next week as well. And in the meantime, stay curious, take what you've learned, share it with others. Go help some people. Be well.