NeuroCentric Approach Zoom Case Study-Intermittent IncontinenceNovember 4, 2023
NeuroCentric Approach Zoom Discussion-Do Trigger Points Exist?November 18, 2023
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...
So good to see you guys over here on Facebook. We might have some guests from Logan in here today.
I had a, had an event this past week, spoke to the Logan University folks that are in the R two P club there, over here on this side on Zoom. We've got Guillermo and guests this morning.
I don't know if you remember him, Phil, it's Travis. You went to school with us. He was in my class.
Oh, far out.
I'm sorry. Sorry, Travis. I, I don't, I don't quite recognize you, but I've changed a wee bit too in 20 years.
It's been a while.
Yeah. Yeah. Where, where are you located, Travis?
I'm in Eugene.
Ah, far out.
Yeah. I'm not too far away. Yeah. We're gonna have another friend join us, Travis and him. Were together.
Tyler's a pt.
Oh, awesome. And is this a, tell me, this is not specifically an NCA weekend when you're gathering to, to do this. Hopefully you guys are barbecuing or something, huh?
We're mountain biking, man.
Awesome, awesome. Yeah. The weather should clear up. Maybe afternoon or so you can find a trail that's not too darn slippery.
Yeah. And a little drinking, of course. That started last night.
Just a Little bit. Nice. Nice. Very well done then. I'm glad to see you're getting, getting after it.
Welcome to Doris Mertons showing up from Toronto. It's nice to see you again, Doris.
lemme get you. Nice to see you too.
Yeah. How are things back that way?
Yeah. Yeah. We're, we're warm in this part of the world right now. It seems this El Nino pattern leaves us with a warmer than usual winter. So yeah, we're in the, the fifties Fahrenheit here on a daily basis right now still. So it's kind of balming
Yes, indeed. And you guys will have one of those lovely ice storms, no doubt.
Anytime. Oh, I Hope
Not. Yeah. It's about the only place I've seen that can rival Portland with some of ours that below in from the Columbia Gorge.
yeah, yeah. We, we know, we know what that's like. In fact, when I first toured Western States, we came the week after one of the biggest ice storms on record and almost all the trees that were on campus, the limbs were all off
and really like,
yeah, it was, it looked
yikes glass of them. So welcome in, appreciate you joining us. Let's see, looks like Kat's over here watching on the Facebook Live Katt from the, the R two P Club down south in California. Welcoming Kat. Hope you're doing well.
Let's see, few items.
As I said before, I had a Zoom meeting with the R two P club at Logan this past week at a very nice gathering with Tyler and Gina and the rest of the crew there.
And we may have some of them joining us today as well.
Things that come to mind in the past week, I got something new, no, I'm not promoting this or whatever. Just wanted to share it. It's a, it's a Nordic hamstringing device for about 25, 26 bucks. You slip this end under your door and it's a little strap here.
It looks like a decent little piece of equipment.
I've tried to put it into lay and find that it works relatively well, although, like many of us, I suspect my hamstrings don't work quite as well as I would like.
Part of what I'm doing there is trying to complete a rehab process of my own knee. I had a, these are the things that happen to you when you get older, right? I had a run in literally with a dog who decided to go right through sideways through my knee in a dog park and I was bending down on one leg to pick up my ball from my little doggy, right when my brother-in-Law decided to fling his ball over my head and his doberman went right through my leg. So grade two MCL and meniscus injury as well, but non-surgical. So I'm putting all that in and feeling a little older, but I will say I was able to weeded in the the garden yesterday and get, get back my full deep squat and stay there for a good period of time.
Weeding without, you know, feeling of swelling and pain.
Let's see, Guillermo just mentioned that they were getting their drink on last night. I went to a couple of my patients, they great, great guys. They're actually, they're business is primarily in construction.
Mostly. They cut their IT teeth on sustainable tiny homes. They almost had a show on HGTV about it, but impeccable work. They did a little side project and helped a friend build out a bar.
It's called Collector Bar. It's on 24th and Burnside. If any of you guys in Portland area are around, check 'em out on my list day. I want to let you guys know you guys that are members over here, you guys that are not over here potentially, well KA is, but she prefers pay Facebook.
I am going to open up that lifetime membership offer on Black Friday, again for 24 hours. So for those of you that are not members and are looking for a good deal, at the very least, even if you don't do anything with it and join us here, then if you're a clinician, it's pace accredited CE 35 hours now on the site and you can stick it in your back pocket. And as a lifetime member, you've always got backup for really good quality CE there.
As I've mentioned in the past, we, Dr. Dean, and I'll be rolling out in person courses here in the not too distant future. So if any of you want, if any of you anywhere other than Seattle or Portland want to wanna host us, then do let me know.
It seems like everybody in Portland and Seattle is interested in getting a course here. We've taught here already a time or two, but yeah, I think I've got three or four different clinics that want to bring us into Seattle.
So yeah, get in touch with me there and we can look at the possibility of making that happen. We've already got something in the works for the folks in St. Louis at Logan.
Kat. We've talked before about the possibility of coming back down to LA again as well. And Doris, we've not been to Toronto in a number of years, but would love to go back. I think that was the biggest course we ever did there. Glen. Glen put almost a hundred people in the room for us.
Say that again, Doris, with your mic on.
Sorry. I did mention to Glen recently that you guys are, are doing this so he's aware.
Cool. Let's see other items. I've got mushrooms on the brain, y'all.
I've not like the pilot locally that had to ground the plane because he took mushrooms and then had what apparently was a two day break with reality and then got on a plane and decided that he was gonna down the plane to get out of his dream that he thought he was in.
No, these are regular old culinary mushrooms. I'm just gonna try to grow some in buckets. Getting up to date on Paul Stan's work and gonna set up a little growth operation for some oyster mushrooms, maybe some shiitakes, but definitely for some lion's mane to try to keep my noodle working well.
So what else do we have anybody over here have any questions regarding cases that they want to lead with or you want me to take the baton for right now and roll with it?
I just wanna say I, I would really, really love to take an in person class and I'm more than willing to travel for it anywhere in the West Coast. So I hope that happens sometime soon. Either upper or lower. Philip,
Copy. Good, good to hear Mark, I hope you're doing well. Yeah, we, the west coast seems to be friendly for us if only because it's a time zone thing and you know, I guess apples don't fall far from the tree and all that stuff with UWS and such.
Okey-doke doke things on my mind for cases. Let's get down to brass tacks and talk a little bit about this.
Two of the cases that we've talked about in the past several weeks, one was our 58 year old female with left lateral hip pain and a concomitant history of osteoporosis and prior history of melanoma twice.
And exam was consistent with in some sort of femoral nerve sensitization that was across multiple peripheral nerves or entire anterior and lateral thighs. Sensory wise was hyper out hyperalgesic right to the edge of allodynia. I would say
the findings at the spine were suggestive of a possible very low grade compression fracture at what to my exam suggested probably L four. There was no hyperalgesia of the upper lumbar neurology there I'm referring to in the a lateral abdominal wall, subcostal nerve ileal hypogastric and ileal nerves. But as soon as we got around the corner and started working across the anterior thigh and all the way down the course of the saphenous nerve, she was experiencing hyperalgesia and it was plainly apparent to both of us that that was in place.
I've seen her now twice. Her pain has completely resolved using a combination of static openers to offload the involved neurology we had, we used two things as index movements. One, she had motor weakness on sit to stand on that particular side. She couldn't do a single rep of sit to stand from a chair height on the affected leg and could do three on the other side.
And we also used his index of the, just a, a basic pinchy test for sensory involvement on the anterior thigh and put her through both McKenzie interventions. I got no buy-in, had no directional preference on that.
But then when we did static openers on that side per shacklock, we got a, an immediate reduction in her sensory findings, marked reduction.
In fact, there was no sensory findings after doing that. And interestingly, she was able to knock out one rep of a sit to stand after that.
I will talk about that just a wee bit too. You and I, most of us here have been taught that motor findings like that are not likely to change relatively quickly on these cases.
I will definitely say that my clinical experiences pushes back against that heartily. I regularly see motor weakness, objective motor weakness change in the course of the exam when you offload the neuro. Does it happen always? No, but it does regularly and I think it happens primarily in those cases when the nerve has not, it is suffering a bit of intermittent compression or intermittent claudication and the metabolism of the nerve is healthy, but once it's been compromise for a good long period of time, we've got less benefit there. So that particular
individual Hey Phil?
Yes. Who we got? Hey,
I'm unfamiliar with these openers. Can you describe them for me?
Absolutely. Just let me check and see if I've got a quick graphic I can pull up.
I don't unfortunately, but this is real easy to understand. The idea is just to maximally open, the putatively involve neuroforamin. So you can imagine if this was her left leg we'd have her in sideline on a bench on the right and commonly you can take a bolster or something and slip under the lumbar area to act as a fulcrum to maximally open that neuroforamin on that side as Shacklock describes it.
And we've got it on the Ontario Health app as well that you can use and share with your patients as Shacklock describes it. Hip flexion would be, the knees would be stacked hip flexion 90 degrees, knees at 90 degrees. Patient sideline in such a way that their legs can drop off at the bench so their lower legs from the knee down can drop off at the bench. That provides an opening effect at the neural foramen. And the standard that he describes is 30 seconds of opening and then bring the legs back up to the bench for 10 seconds and then repeat for 30 seconds and then 10 seconds
Five reps per session is what he typically recommends. I use those as a really, what I find to be, I I find 'em to be at least as effective as any of McKenzie's work. But the downside on, as you can expect at home, the compliance is gonna be a little bit more difficult because they gotta be
on their bed. Yeah. And often their bed's not high
or the bed's too soft on the edge and it's difficult for 'em to do it. So I'm looking forward to some pictures at some point of my creative patients that have gotten on their kitchen counters and we can maybe have something that looks like a scene
and a half weeks or something.
No worries. So that particular patient, I've got her trying to see if she can talk her PCP into an X-ray of that putative compression fracture in the lumbar spine, which clinically at this stage of the game would be a dice roll as to whether it's indicated because the patient's getting remarkably better. But she has three DEXA scans done in the space of about 18 months. I think that we're all almost exactly the same.
And what I'm gaming for here is to write up a case study with her for an intervention for loaded caries to help with bone mineralization. So she happens to be a researcher herself, she's a principal in several different businesses that try to get drugs to market. And we were lamenting the, the, the impediments to doing that.
Many of them being that cost-wise, it's hard to get funding for any kind of research unless there's a profit to be made and there's no profit to be made from people picking up a couple of kettlebells or something similar and walking for 60 seconds and making their bones stronger. So what we regularly see in our athletes, kabuki strength, the power lifters, those women that are in that group that have almost all of them have had DEXA scans and their bone mineralization is off the charts. So we're looking in this particular case to do something simple. She didn't have kettlebells or anything, so I had her get two five gallon buckets, some pipe insulation to put on the handle and some pair of work gloves or cycling gloves and two, fill the buckets with water to start with and gravel later and keep 'em handy and do three by 62nd sessions two or three days weekly in addition to her normal now normal orange theory workouts, which my, to my mind, the decreased bone mineralization and the steady exposure to the rowing exercises that they're commonly exposed to in Orange Theory may have been the provocation for her.
She's keeping Up. Oh, Phillip, can I throw in a little something here? Sure.
One, I, I listened to your kind of basic nutritional thing you suggest for people and the one thing that was missing that the osteoporosis people do is vitamin K one and K two.
And the other thing is, again, Keith McCormick, a chiropractor, I, I'm not gonna do that work. It's like I don't, I'm not a integrative medicine doctor, but he, he's got a protocol for looking at whether the person is demineralizing or remineralizing based on their chemistry and has a sophisticated way of assessing and correcting that. And you're, you know, the stuff you're talking about is mechanical load, which obviously is important, but if, if someone is, you know, there's all this stuff with hormones and you know, it's just like there are more sophisticated approaches and if you have an integrative medicine doctor who the person wants to work with, who is, who could learn Keith McCormick's protocol that might improve it.
So anyway, just some thoughts on that.
Agreed. Yeah. And based on your recommendation of that book, mark, I do have it on my bedside table right now and I'm starting to work into it.
I agree with you heartily and, and also I, I will almost say that I, I would rather send that out. I did refer her to my naturopath that follows that kind of stuff and that I trust completely in these kinds of cases, but it does bog it down a little bit in my work. So I stay over where I'm, I typically tend to do better work on for her. She already was on
appropriate calcium vitamin D and vitamin K regimens and boron on her own.
I suggested collagen as well for a good measure to help with some of the other loading pattern stuff that we might see there.
But the other thing Keith McCormick recommends is that the, the source of calcium should be microcrystalline hydroxyapatite, which is bone, you know, so, but anyway, so yeah,
Yeah, a lot of variability there in the absorption capacity for whatever calcium you're using, it's only memory serves about 30% on calcium carbonate, which is the cheapest stuff out there. But,
So one, one other comment separate you, you know, the McKenzie versus the Shacklock.
I've heard Shacklock talks about, you know, even in a disc case you're, when you do chat lock's protocol, it's a flexion protocol, so you're opening the foramen and as people get older stenosis issues become more important to some, you know, just in a general way than a disc bulge disc herniation affecting their nerve. So that might be another protocol, but I love the way you do it. You know, it's like do they re, do they respond to the McKenzie? Does something change in their muscle tone, their indexes versus does the shacklock stuff change it? So that I, I love having a, in the moment criteria for it.
I wanna throw more, one more thing out. I cannot go from sit to stand on one leg. I'm 74, I do not have an L three nerve problem, you know, but that's, that's a tough test. I I routinely muscle test the quads and the hip flexors and I, you know, I'm, I'm trying to say, well what are we, what are we, I assume we're, we're testing, are we testing hip flexors? Are we testing knee extensors? I, I guess you know what, what's that test and what's a peel back on that test for someone who just doesn't have the strengths? But
Excellent question. So the, what we're looking for there on the examination, those of you that are familiar with either the clinical companion to fix your own back course that I do or, or this work with the motor examination, I'm looking for a test for the involved neurology, the involved motor neurology that is more objective than what we all learned in school. I think most of you would agree that the, the manual motor testing five over five kind of testing that we learn is highly subjective and it doesn't leave any room for the patient to be able to see directly or indirectly what is actually happening there. They just have to kind of trust your judgment.
However, if you put a person in a standing position, I even organize my treatment rooms with this with a shelf where they can put their hands on them to help with their balance. Go up on two legs to a toe standing position on two legs, then offload one leg, bend the knee and then do sit just like Mark is doing right now. And then do toe raises repetitively on one leg to test the S one myotome. And then we rock back on the heels and raise the toes on both legs on both feet and then take one foot off of the floor and then tap the front of the foot on the floor testing the tib anterior and putatively an L five myone there to get upstream is why we're doing, to get upstream of L five is why we're doing the sit to stand.
And that's going to get us for L three and L four typically for femoral derivatives. Now you ask if there's a peel back, absolutely just raise the bench if you've got a high low table, just raise it up. What we're looking for is a comparison.
I would suggest you raise the, the seat height up and if you don't have a high low table, which I don't in my clinic, just a series of Erics pads underneath them or something of that seat, sort to bring the seat up until you can get in the unaffected leg or in either leg you can get at least one rep and then you've got something you can compare it to from side to side. Do also know, and I do give them permission as wellmark to if I see immediately as they start to do it that they are not, you know, able to do it very strictly, I'll say it's okay to launch yourself, I just want to get some kind of measurement that's a bit more objective of their ability to do that.
Now there is a learning mechanism there in doing that as well. So sometimes if they can't do it at all on one side I'll say well try the other side. And then once they've done it on the other side, they're like, they know how to organize themselves a little bit better and you can go back to the other leg they couldn't do anything on and you retest it. So it's not perfect.
But I do think that it's, it's better objectively than what most of us have been historically using clinically.
Moving on to our next old case, you guys recall I had the veteran that had a prior history of three level lumbar fracture and has intermittent incontinence. Now since then for something like 15 years I've seen him again.
We've very carefully moved into that.
My working theory on that particular case, based on his information that extension was highly provocative and for his back pain and extension was combined stepping with his left leg and forward, he's a contractor so he finds himself in awkward position stepping forward and around that, that was the most risky position for him to have an episode of bowel and or bladder incontinence.
He came in with his MRI report from 2018.
He'd had full appropriate healing of all of the fracture sites. He had a only A grade one anthesis of L five on S one and a central disc protrusion at that level as well. So we've got a protrusion and a listhesis and my mind you this person, when they're laying on their back in supine in a an MRI tube, that's gonna be a significantly different mechanical process on that motion segment as opposed to standing where we now add compression and any movement. So my working theory was that I had an unstable segment there that was indeed his surgeon's recommendation or or idea. And he had been recommended to have a spinal fusion.
He was seeing me because he didn't wanna have a spinal fusion if he didn't have to. So we're doing a trial of care to see if we can improve his outcomes.
I'm not in the, the habit of taking incontinent people and putting them through my highly biased systems when they will be better served by a, by a surgeon in those cases. So, but in this case we've got, we've got a chaperone.
What I'm am working on with him is peeling him back to the DNS studs for stabilization strategies and he's actually responding well. We were able to put him through several positions in supine that involved hip flexion and he was not provoked for pain. And once we changed his stabilization strategy to something that's more as DNS would suggest, appropriate for a low threshold stabilization strategy for the lumbar spine using intraabdominal pressure, he was able to do those movements that previously were painful, like standing hip flexion and then progressing to standing hip flexion with concomitant external rotation.
And he had no pain with that. So I'm encouraged by those findings, but we'll see if it's enough to keep him out of that particular situation.
As a follow up study crossed my desk this morning, cohort of 45 people with chronic episodic incontinence due to ca Aquinas syndrome that had been subsequently managed surgically.
And of the, the presenting symptomology, their saddle paresthesias were, what I think that was the prevalence was something like 70% of that cohort had saddle paraesthesia after surgery only, I think 25% of those remained. And it was similar kind of like a, a 75% improvement in urinary symptoms, bowel symptoms, erectile dysfunction in the male population was less responsive to that. It was only about 50% improved. But just to give you an idea that for those patients that we have that are suffering from those kinds of intermittent qu kind of situations, that'll help to give you an idea about how much likely benefit they're gonna be receiving from a decision to go ahead and get that surgically managed.
Any ideas, thoughts or inputs after all of that?
I have a patient who's coming about to come up to see me. She had severe sciatica. She had a microdiscectomy at L five S one after the microdiscectomy. She started developing saddle anesthesia and it, it apparently it was more unilateral. I haven't examined her yet, but, so what with cla aquina the, just to, if you would review the anatomy physiology, the, the court is compromised and they're, they're not getting proper sensory to that area, to the S one S two area. Is that what's
happening? Well, it's more for spinal cord. It's a central positional issue typically with a,
typically it's a, pardon me, I was just getting a nudge from one of our members that should be on here. He's got a full on disc herniation and he was like, what do I do? I'm like, I told you what to do.
You took the course, man.
So the, in this particular case, those central presentations are, are usually going to be, sometimes they fly under the radar in many offices because they don't show up with positive findings on a, a slump test or an SLR commonly because the, the bulge or protrusion or extrusion does not go laterally enough to affect a single nerve root. So you wind it up with a bulge backwards that often is putting pressure on the fecal sac. That pressure on the fecal sac makes everything very sensitive. Those patients will tend to be very hyper, hyper reflexive and you know, any kind of boo on a movement that the body perceives as threatening will cause them to really be very, very jumpy.
So that is the, the issue and the sensory and the motor is the sensories to the perineum and to the genitals and the, the motorist to those areas as well, but also motor to the bowel and bladder function as well.
No worries. Thoughts from anyone on what we've covered so far?
I got I guess a, a an interesting case that I'm as well with some bowel and bladder incontinence. I don't, my patient gets it at night and we're waiting on surgical consults and she also ends up, I'm a Mackenzie trained therapist and so like for me, I call it an acute lateral shift. So we've been working on shift corrections with good results, but she's still getting bowel incontinence at night and that's the only time she kind of gets it provoked. Any ideas on sleep position changing that might be able to limit that
That, yeah, that's where that sort of blend with the, the shacklock openers I find in those lateral presentations
I'll in those cases trial static opener to see if we can get similar sorts of benefit and symptomology that we get from a standing side glide or from a prone hip shift with additional extension.
if, if we can get that in a static opener in a sideline position, then I might coach the patient to adopt a sideline sleeping position on that side to see if we can give them a little bit of improvement. But dollars to donuts, she's probably getting those symptoms when she rolls from one position to the other and she's temporarily unraced at that particular point, likely is not. The result of that has made her body a bit aware when she starts to do a transitional movement. So she'll come up out of, in her sleep cycle from something that looks like REM sleep typically at that stage to, you know, a light sleep or or an awake status.
And that's a point where she can be coached into a bracing strategy using intraabdominal pressure. So I would put her in the, in a, you know, coach her in a rolling pattern from side to side with a braced core. My external queuing strategies on that or your torso is like a sheet of plywood so your shoulders and your hips move together as one and you're pushing with one arm off to the other side to try to get that roll without a whole lot of twist
the Excellent. Thank you.
Yeah, it no worries. See how that, see how that works If you're able to
get a little bit I'll Yeah, definitely
Phil, I I, if we're done with that little piece, I, I've looked at the il nerve course and I've been doing clonal nerves forever, ever since you started doing Yap you know, how many years ago is that anyway?
Oh my, I think, you know, I don't think it's more than like six years.
Yeah, that's what I, I thought it was five or six and the other course I just took, which I loved of yours, was the sports hernia, which is a misnamed course, but you know, the abdominal issues, right? And, and the, i I sent you my article on the hip and I find on all these things, the patterns where the upper lumbar, it, it's not an upper lumbar herniation, but it's an upper lumbar, you know, man's work who
did manipulate. Yeah, it's a man syndrome.
Yeah. So there's, there's the, the pattern, there's the missing piece. There is a meat piece where the hip isn't moving correctly and the, basically I learned this, this work from a woman named Lucy White Ferguson who did an article in the now defunct Journal of Mo Body Work and Movement therapy. And she also wrote a book and she had this, you know, manipulation protocol called the Wishbone Maneuver for functional hip impingement. And there's so many patients who have functional hip impingement who show, it just seems to correlate with all this lateral stuff that people have. So, you know, the mang syndrome people, the ileal hypogastric nerve lateral abdominal people, if you check that hip and then give them something, you know, the the basic thing I tell 'em is, you know, all those people who have hip pain do stupid stuff yoga, opening to the
which is contraindicated because positionally what Lucy White Ferguson says. And what I've found true, although I don't have any other science behind it, is, although, you know, it's really similar to what Shirley Sarin was saying, that hip is that femur, the head of the femur is no, is not settled into the acetabulum properly. And so you need to have them stop externally rotating and find some kind of either the, I use the manipulation, but I'm like, what I got from Craig is start with an exercise, find an exercise that fixes it. 'cause they can take that home and I, I use just a sitting hip internal rotation against resistance and if the patient is not completely decrepit, I show them my little variation on low diagonal oblique sit. And I've never taken, i, I don't know it from DNSI just know it from watching Craig teach what he learned from STO and I modified it to have the person push into a wall rather than diagonally push into the floor. And it's, that's a magical exercise for this hip impingement.
It, it gets 'em, they immediately have way better motion, way less tenderness and they, the, the hip flexor gets weak when there's pressure on those ligaments. And I'm totally with you that we can change motor function with simple stuff. I'm an old AK doc, right? I I I I've seen lots and lots of muscle weakness change immediately after something I do. So anyway, that's, that's my, i I think it's an important piece that, you know, nobody seems to know. A patient of mine who had hip pain went to her PT who had wanted to fix your SI and went to her sports medicine doc who said, oh, you should get an MRI arthrogram to make sure you don't have a labral tear, which fixing labral tears is stupid and doesn't work very well.
And you know, so fortunately she went to her other orthopedist who had done a shoulder surgery and he discouraged her from getting that MR arthrogram. And by that she got to me two visits. She's good at doing the homework and now she's pain-free and able to walk up hills if she couldn't do it before. And it was the, the main thing was that functional hip impingement.
So yeah, I would, I would agree with most of what you said there, mark. The, I would note that, you know, the, the topic at hand and what we're doing with neuro centric approach is a nerve biased system. Intentionally, it does not obviate the need for seeing meat-based issues and addressing those.
The, what I've tried to do with the system as well is to keep it principles based so that you can incorporate all of the things that you just talked about based on your own experience and the other coursework and everything that you've done. And those are modular things that you can put in. You can do mobilizations there, you can do manipulations there.
The situations that you're describing there clinically, I see all the time as well.
My primary interventions there are DNS focused, which Craig's were as well.
The, the, it, it is interesting that you raised Shirley's name there as well. Her recent interview with Tim, Tim Ferris had me practically jumping up and down with, i, I won't say horror or anything like that, it's a bit, a bit hyperbolic, but it was, it was amazing to see that there was so much very old school kind of un unevolved thinking about meat-based systems that she was still really doubling down on the, and and part of that doubling down is resulting in a whole lot to my mind of physical therapists now starting to adopt that hip shift si kind of mindset that chiropractors played for decades and then kind of evolved out of.
So I'd, I'd love to to avoid that, that scenario for my brethren in, in physical therapy to, to just take a sidestep off of that and go more along the lines of what you're talking about with that mark and center the hip. What we see with that as far as the weakness, which I, you know, yoda's ideas about cross syndromes and stuff really haven't held up well in the literature. We do observe a quote unquote weakness of the hip flexors there and the way that DNS these days would kind of model that is if the, if the joint, if the involved joint is not well crated, you won't get green light feed forward to the somatosensory cortex to load that system. And we see that in our lifters all the time.
So a lot of what we're working on is to try to center joints as best as possible so that there's less interference from putatively from this somatosensory cortex to allow that movement to occur.
Let's park this topic for a moment and I want to go a little bit off piece with a case that showed up in our community forum yesterday.
We've got about 10 minutes left and we'll see if I can encapsulate this. I'm gonna share screen
and we'll go over here somewhere. Where are you? There we are.
Okay, so this is from, pardon me doc if I bot your name, but J yo lee I think is the pronunciation came to us with on the forum with this case. Need advice for a patient I'm treating right now. Patient is suffering from right hearing fullness all the time. She says it's constantly silent wheezing sounds all the time she can hear it when she taps her ox of it.
She's been to many ENTs and her hearing is fine. The only condition she can think of making the condition potentially worse is vasculitis.
She can alleviate the signs and symptoms by blowing her nose but it plugs back up again.
I've treated her splenius cap, TMJ breathing mechanics, long discipline capita and various neck musculature. I can't seem to get any relief. Any ideas So you guys can think on your own about possibilities there.
the first thing that popped into my head on that, well if you've got an index or something she can do that makes her symptoms better, then you really kind of, you gotta get your fingernails into that and explore that. So why in the world would she be able to Ali alleviate any kind of neural symptoms if she can do it by, if she can temporarily blow her nose and it plugs back up again or popping her jaw and the way that she might do when you're on an airplane and the pressure changes are happening. So the first place that go comes to mind to me there is that eustachian tube involvement, right proximal third of the eustachian tubes, mucosal tissue. If we've got some sort of an allergic response then we're gonna get some rhinitis, some mucosal engorgement in the sinuses, but also that tissue that of course can lead to a buildup of sterile fluid in the inner, in the middle ear.
And we can get symptoms in our patients there. Sterile otitis media, many of us I know, all of us at Western States at least got our lovely little fix for that endonasal technique that we subjected all of our significant others and children to when we were in school and then perhaps based on their responses, decided to never ever do it again. But I, I still have probably three patients that about this time of year I can count on them coming into my clinic with this particular issue that this doc describes and they want me to basically glove up and reach my finger back to Rosa Mueller's fossa and try not to stimulate the uvula and get a gag reflex in the moment and then just give a real quick ream out of Rose Mueller's fossa.
And often they get a whole lot of drainage in the back of their throat after that time and their ear symptoms get better. So that was the first thing that came to mind as I put in the community there. I said per her, her vasculitis, candidly I was, that's an area that has an unknown potential effect me. So what I do, what all docs do these days probably I hit up chat GBT woo-hoo and here's what chat GPT threw back at me and I would, I I have not checked these references yet to make sure that they are solid. Make sure you do because they will chat GBT will mix and match your authors journal and journal titles from various researchers and give you something that looks for all in the world, like something that that particular author has put out in in previous situations. So, but chat GPT gives me this vasculitis can affect hearing primarily through its impact on blood vessels, vasculitis and inflammation of the blood vessels, which can lead to changes in blood flow when it involves the vessels that supply the inner ear. It can potentially cause hearing loss or other auditory symptoms. The inner ears highly sensitive to blood flow alterations due to its high metabolic demands. Inflammation and subsequent damage to the vessels can lead to ischemia or hemorrhage impacting the cochlea and the auditory nerve.
This can result in sensory neural hearing loss, which is often sudden and may be accompanied by tinnitus or vertigo studied by B Helman and colleagues published in clinical rheumatology in 2015. Again, do your own research here guys and check the veracity of these references. They sound really good, don't they? Sensory neural hearing loss in patients with ANCA associated vasculitis, they found a higher prevalence of hearing loss in these patients compared to the general population. This suggested vasculitis can indeed have a significant impact on the auditory function. Another study conducted by yida published in Laryngoscope in 2005 investigated hearing loss in patients with systematic vasculitis. They also reported cases of sensory neural hearing loss highlighting the importance of early diagnosis and treatment to prevent or mitigate auditory damage. So I thought I would share that I'm on thin ice doing it without doing my homework on that but we're all docs here and we've all got access to pub meds so you can check those as well.
But that's something that I wasn't aware of from a vasculitis standpoint on its potential intervention or its potential impact on hearing loss from an NCA perspective. Is there anything we could do on that?
Probably not quite honestly. Hearing issues, changes in hearing probably I find the most benefit from this green guy here.
The auricular temporal nerve does include partial innervation of the typa membrane, your eardrum. And we do have auricular temporal nerve available to us. It's from the mandibular division of trigeminal nerve.
So we've got some potential ways to work into that. You can see its relationship to the temporalis as well. So in these particular patients with hearing issues, I'm also gonna look at TMJ function and look for any potential issues there. So sometimes if we've got a concomitant TMJ issue that's causing some hyperactivity of the temporalis, then we can get theoretically a bit of, call it bing of the fascia in and around this area that could potentially help cause some entrapment issues involving the auricular temporal nerve. I suspect that either that or the greater auricular nerve back here has to do with some of those things that many of us were taught in Chio school of doing, you know, pen of tugs on people for the ear when they've got issues like that.
But for us, the way that I would consider working on this particular patient with that issue, I'd evaluate TMJ gait look for lateral deviation. If I see that then I'll coach the patient into intraoral work. I'll glove up and go in and and work on the medial and lateral OIDs bilaterally and see if we can get some changes in that. At the nerve end of things here we can do variants of pen and stretch or DTM over the auricular temporal nerve while they open and close.
And this one over here, let me get this outta my way over here. Remember herbs point, we got herbs point here where all of these branches off of the cervical plexus C two and C three primarily derivatives these four nerves including the greater auricular nerve and the lesser occipital nerve play into that same meat in that particular area and they're worthy of your consideration for DTM or TNM of those particular areas. In those patients, typically I would find they've got a typical occipital to temporal or peri even periorbital headache distribution commonly as well. But a little DTMA tug right there, mid belly of the SCM and to see if you can have benefit on that particular patient might be worthwhile as well.
They will commonly have concomitant symptoms if that herbs point is affected with shoulder pain owing to the supraclavicular nerve and its distribution down into the shoulder as well.
So that's what I have on that we are nearing or have just exceeded our one hour time.
But I will leave a little bit of time here if anybody wants to ask questions. I see a couple of questions over here on Facebook Live and admittedly guys, I'm gonna prioritize over here the zoom 'cause these guys are members and those of you that want those questions managed come join us.
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Bill, I had a case like very similar to that about 15 years ago and I remember telling the patient that, yep, I remember telling the patient that I know what it was, but that I suspected some kind of nerve entrapment. She came with a diagnosis of cranial nerve nerve eight neuritis and I did pretty much exactly what you just said. I worked on the jaw, all the temporal area down the neck, but I used Graston and quite aggressively, you know, all the way around the ear and around the jaw, two treatments in, she started noticing improvement and it literally took four treatments and her, all her symptoms resolved.
Resolved. The only difference being from what you said is I used Graston instead and I use grafting instead and I also did ultrasound around the jaw, all around the temporal area and up and down the neck and yeah. For treatments and get resolved.
Wow, you did ultrasound up there that close to the brain.
You're braver, you're braver than I am. Three,
3.3 0.5. Man, you can do it,
you know. Yeah, Keep it, keep it very super. Just keep it very
superficial. Yeah. With a 50% pulse rate, 50 or 10, I can't remember. I did it really, really low and I just told her, if you feel any heating, let me know.
She, You know, if you, if you feel you, if you feel your, the, the popping sounds like an egg on a skillet in your ear and let me know.
Now the temporal bone would heat up pretty quickly, right? Yeah. Before it heats up anything else. So I wasn't really too concerned.
Cool. In relation to, you know, all of us are taught to do intraoral release of the musculature within the jaw. I had the opportunity to study with a physical therapist who specialized in the jaw and one of the simple things he taught me was to put my fingers in and pull the mandible downward. It's kind of AJ it's once you, you just compare the sides, one of them feels jammed, right? I'm a joint guy, I wanna create more space in the joint. So you just pull down and slightly forward and then I show the patient how to do that. And there's another variation on it that I'm not gonna try to show here in 30 seconds, but I, I just have the person go in, put their thumb of the opposite on the bottom teeth and pull down and slightly out and, you know, do that for 30 seconds gently.
And it's just another really useful TMJ release 'cause you're releasing a jammed joint. So,
Yeah, I like it. I think for, and I, I play with that as well and try to get a pure, pure distraction. We all have to be a little careful thinking about that mandible and it's hammock with that little cartilaginous pad there. And that if, if that cartilaginous pad when you drop down and have that anterior displacement of the mandible doesn't negotiate that, that that excursion very well, then you can get a pinch of that and that can, that can be horrible. And those patients for long-term, those are your locked jaws.
Yeah, we had, we've got ATMJ specialist in Portland, a dentist that, one of my former coworkers at Hawthorne Wellness when I was there.
He studied with them for two years that we used to play with Jaws a fair bit in our clinic, but mostly I would just punt him over to him 'cause he had a much deeper toolbox for that kind of stuff.
Okey doke. Well, I think we've, we've exceeded our time here. I want to thank you guys. We had a pretty good representative audience here today.
Some of you that are savvy will have noted that I'm recording these particular course, these particular gatherings, and I'm putting them up both on my YouTube channel and also I've created a place for them to live on the neuro centric approach site as well, so that hopefully folks that haven't seen this weren't able to join us in person here, folks in the general community can, you know, go and peruse that and, and share it with their colleagues and stuff. Do share with your colleagues.
Appreciate your help in getting the word out on all of this.
I do think that we're onto something. I am highly biased and I leave my biases right out there on the table for you guys to examine and play with in your own clinical practice and see if they hold water. And, but as always, do keep your biases in check and try to keep your sciencey skeptic hat firmly in place on your head.
Until next week on Saturday at 9:00 AM Pacific time. I wish you all a delightful and lovely week. Go help some people. Stay curious. Bye-Bye.