NeuroCentric Approach Zoom Case Study-Lumbar Disc Extrusion in PowerlifterOctober 30, 2023
NeuroCentric Approach Zoom Case Study-The 4 Nerves of Shoulder PainNovember 4, 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.
2 Powerlifters With Hip Pain
Transcripts from the video above are below...
Rained. So just so that some of you guys that are over here on Facebook Live can get a sense of what the heck we're doing over here I've got a Zoom meeting and this is how we roll with the neuro centric Approach Online Academy.
Some of you may be members on that.
We've got one member in the in the Zoom meeting right now. But the, what we do with these meetings periodically, right now we're just trying to get people familiar with it and that's why we're doing as much as we are on live Facebook Live.
But as we continue and grow the community here but larger than, what we will start to do is periodically we'll have special guests on our Zoom meetings and we will
curate that material that we record off of the Zoom meeting and make continuing education courses out of that as well. Those of you that are new to what we're doing over there at N C A with the courses there, neuro centric approach is our Dr. Justin Dean and i's attempt to try to put together a thoughtful integrated assessment and intervention process for all of the variety of named systems that many of us in Geek World in physical medicine
are, are involved in.
Mark Heller just asked a question, can you comment? Yes please. Come on, mark. Let me see.
It doesn't look like you're on yet, so we'll all just enjoy a little coffee for a moment while everybody gets going. Then I'm gonna discuss a couple of cases that I've been playing with this week and we will see what we learn.
Okay, Steven, is that capo? Which Steven is this on on here this morning on the Zoom?
Hello Cameron. Ross. Nice to see you on here.
let me see.
Wait for a few more.
I'm on here.
I am wondering is there anybody on here on Facebook Live that got the, the email to the members that I sent out for the Zoom meeting?
Did you try the Zoom link?
I'm wondering if I flubbed something there because I would typically expect this to have quite a few more people on here.
buddy sending a message here.
Let's see what we got.
Okay, there's Mark.
Well I, I have, I tried all kinds of different ways into the Zoom meeting and finally got there but had trouble getting on Zoom. Smart. So,
Facebook I, I don't know how to really use that one.
Yeah, yeah. I suspect we're gonna have that periodically with this, but thanks for your perseverance and getting on here. So folks, let's see, what would be the easiest way for me to put link? I think I have my Facebook or excuse me, my zoom link saved on here on Facebook. Let me see if I've got it
man, it is real. It is really pouring down rain out out here man.
Is it raining in Ashland? Mark?
Okay, there we go.
A Q I Is over 150 in Ashland so we're looking forward to that rain getting here. Which it's supposed to.
Yeah, I know what you mean. This will be that season ending for forest fire, right Thing that we're all kinda looking for.
All right. I think for you guys on Facebook Live, I have added a link on there for my,
for my, my Zoom link. If you guys over here on Facebook Live want to join over here, you can do that might be a little easier on all of us if we eventually coalesce around one platform or the other instead of keeping one foot on the dock and one foot in the boat here. Okie doke. So we got a quorum here and Mark and I have been pinging each other this morning a little bit offline about this topic of hip stuff that we're, that I proposed for a topic of conversation to get started with around a couple of cases that I had this week that have been ongoing for a while and basically I think I overlooked some things and I wanted to chat about that and own up to it and try to get better.
I'm gonna break those out initially and then we can use them as talking points and you guys can jump in here with comments as you like. If you're on the zoom meeting here, feel free to use the chat function and drop a question in there and then I can kind of come in and answer those periodically over here on Facebook Live. You can do it there as well and I can see if I can pick up on those. Okay, Maria, welcome in.
Okay, so two hip cases that I'd like to discuss this week, both of them as work for me, tens
sort of center around power lifting since I have one of my offices is in Kabuki strength lab.
So I've got two competitors worlds. One of the world meets is is coming up in the UK in a few weeks. So we've got some athletes traveling over there and one of those is someone that I have seen in the past, a female lifter with hip pain at the bottom of a squat primarily. And so for those of you that are aware of that movement and power lifting, it's a back squat where the weight is on your back and your squat down below thighs parallel and then come back up. And she was experiencing pretty significant pain about a year ago when she was doing meat prep for qualifying for worlds, which she did, but she was feeling pain at that point between the centric and concentric portion of the the lift and there's no pain at any other time.
I will admit to my bias when I see an athlete with, especially in that sport with pain that wraps around in the groin, it goes down the medial aspect of the thigh. I'm thinking operator nerve and my bias got the best of me on that and I worked it and kind of like what we saw last week when we were talking about some of brand and fros questions about his patient with ileal hypogastric nerve involvement.
One of the things that characterized our treatment previously with this athlete was that I would work on the neurology that I felt and had determined was sensitized and when I did her symptoms would get better but her the benefit was transient and her symptoms would keep coming back.
So I would like to introduce that as something that all of us playing this N N C A game she keep our eyes on. When you are treating a patient and you're getting good results with your D T M or your T N M or whatever leveraging against that, that interface between the nerve and the other tissues, if you're benefit is only temporary, then likely your problem is upstream and you're just treating symptomatically.
So in this particular athlete we were able, I think it was nine months ago to get her through her qualifying competition. She set records, national records which qualified her to go to worlds. She set PRS for herself and she came in just last week reporting that her pain, which had been completely gone, came back after she recently had bout with Covid.
So she got knocked down with Covid again, I think this was her third round.
And for her, like many of you guys that are seeing Covid patients right now, the symptoms seem to be primarily what I've seen so far anyway, just fatigue, not a whole lot of nasal stuff, not a whole lot of GI distress but a whole lot of fatigue. And she got laid down hard for about a week and didn't train, barely got off the couch, which she did get off the couch, went back to the gym, she had worse pain than before and her hip. So she came in and as part of my screening this time she was suggesting that the pain now, rather than being very localized in the medial aspect of the proximal gro thigh, her pain was now radiating all the way down to the, to the distal part of the medial aspect of the thigh all the way down to the knee.
And you know, as I'm looking at that inner intake, I'm thinking, okay, what neurology services, that particular area and you know, my bias got the best of me again and what am I thinking? Saphenous nerve, maybe we got some saphenous involvement. 'cause right there in the mid thigh we have some saphenous overlap with the ator. So I'm gonna share screen now and pull up some graphics so we can all review a wee bit.
And let's start with this one here,
which is our dermatome reminder.
The saphenous is the purple down here and F and the D here is the obterator nerve.
And going up here a little more proximally is the generative femoral nerve.
So what I started to think and my clinical reasoning before I even saw the patient was okay if we've got overlap right here, maybe I missed something or did I miss it and it was saphenous all along or is it something proximal and upstream? So I did something that I've talked about in other classes. Some of you have taken the clinical companion to fix your own back.
I did something that I've talked about that I learned from a physiatrist a number of years ago by the name of Jay Shaw, he's at National Institutes of Health on, he told me about some PHY researchers that describes something called spinal segmental sensitization. And Mark, you're gonna love this one. This was a bunch of physiatrists basically looking at the same thing that osteopaths and chiropractors have been looking at for a number of years. And they defined what they referred to as spinal segmental sensitization in which for all the world sounds a hell of a lot like urban core's facilitated segment hypothesis that many of us learned in school.
But the way that they would work their patients up is they would take a, something that was a little bit sharp, you could use the little device for sharp and dull discrimination that some of you have on your reflex hammers, but you can also go low tech and just use a a paper clip and bend out one end to the pointy N and you just draw it down across the various dermatomes looking for patient report of hypersensitivity hyperalgesia or even allo allodynia. Sometimes you can also, sometimes when you do that, especially on the flanks, you'll get a little twitch sign that will pop up. But I was looking for a patient report of more or less sensation as I drew the paperclip around her thigh all the way 360 degrees from proximal to distal.
And I got her permission, I got her permission and used an ink pen and drew a mark to literally dermatome map out the area that was, that was showing up. And as I did, as I crossed over those particular areas, I started to see what looked like this.
I started to see something that pitched me back upstream. Now initially when I was working with this athlete, I thought she probably had an upper disc issue going on, but I always try to check my bias on that because the numbers are not good on it.
Most of you that when it comes to disc herniations in the lumbar spine, literally 95% occur at the lower two lumbar levels. So I'm on kind of thin ice statistically speaking if I'm pulling, if I'm looking at an upper lumbar. But if you don't look you won't see it.
So in this particular case as I wrapped around the thigh, she was showing me on the anterior thigh sensitivity that was starting midway right on the anterior thigh and it went all the way around to the posterior quarter of the medial aspect of the thigh as well. And I'm like, RO looks to me like we've got entire e femoral nerve involvement upstream.
So I tracked that out and lo and behold, what did we find? Well I asked her, 'cause previously we had done the, the motor testing, I asked her if she had had any weakness and she did not have any reported weakness.
And we had previously done the sit to stand on single leg for five reps and there was no apparent weakness on that to get me excitable.
So this time I went, went back and asked her if she had done any Copenhagen work to test the motor to that medial compartment and she said I can't do that, it's too painful. So we went in and I had her do that and indeed she had like an eight out of 10 pain when she tried to do a Copenhagen on that side.
So for some of you that are listening to that, don't know what a Copenhagen is, it is a static. I know that's probably you there Mark?
This was, that's good. It it's good to check that one out. There was a paper done several years ago, several papers actually by a research group of physical therapists that were working with professional footballers in the UK and they came up, I think it was the uk but it was training the ad ductors. So imagine sideline with a bench and sideline on the floor with a bench and you put your superior leg up on the bench and then you plank yourself using the adductors into a static plank so that you bring your entire body up and it's being held there by the, by the effort of the adductors, the hip adductors. And then you pull the downside leg up to bring those legs together and you can use that. We use that in some of our athletes as a a way of marking whether they are fully recovered from disc herniation when our competitive a power lifters are getting back under bar.
But in her she couldn't do that.
So we theorizing that there might be a disc which had been underappreciated previously and possibly some nerve root involvement.
We used the N C A approach or the N C A perspective and we went back upstream to the neurology at the spinal cord nerve root I V F place and we leveraged a couple of interventions towards that interface. We did prone press-ups and I did a over pressure at L three area while she did those and she did two sets of 15. And then I repeated the sensory testing with the paperclip around the thigh and the area, the distribution of the sensation that had been hyperalgesic had shrunk by 50%.
So that was kind of cool. That's the first time I've seen that.
And then we went back to the Copenhagen and she did an attempt on the Copenhagen plank and she had now had the ability to actually get up into that position but she can only hold it about five seconds.
So then we leveraged another input at the nerve root I V F and did static openers and also with the static openers she did some neuro mobilizations on that top leg. She went back, back onto the table, I did the sensory testing again and it had shrunk down yet again.
The dermatomal sensitivity area had shrunk down yet again. Now she went back to the the Copenhagen and she could perform that for about 15 seconds now. Now if we're gonna be intellectually honest, it's entirely possible that we've got all kinds of, you know, misreporting that it's going on there. It could be that she's just getting stronger and her body's getting more aware of the process she's doing with the Copenhagen issue. She's doing that and then she's just getting better. She's learning the motor behavior but I thought that was worthwhile enough with the observed sensory and motor changes to bring that up to the group to discuss a bit further, she is actually moving away so I won't have her as directly to be able to check and see how her symptomology is.
But I'm quite optimistic that when she goes for her next training session, if she leverages those two inputs, she's gonna feel a lot less pain and probably feels stronger there and we'll likely have another world record holder.
Now when Mark got in touch with me earlier and Dean Justin, welcome, welcome on.
When Mark got in touch with me a little bit earlier, he had some thoughts about anterior hip pain and so-called functional hip impingement. And when Mark's got thoughts about something, I think it's important for all of us to listen. There's not many of us out there in the world that have been doing this thing longer than Mark Heller and thinking of thinking about it critically. So Mark, what do you got on your mind, brother, Your
my observation about you Philip, is that you always focus on the nerves as the source. And I respect that 'cause it's like your unique thing. But when someone has anterior hip pain, I wanna know is that hip moving properly? And the typical pattern that I see, again, this is the work of Lucy White Ferguson, a chiropractic intelligence, New Mexico with some tweaks by me, the person will have tenderness over the head of the femur and you find the head of the femur by bisecting a line from the is a s i s down to the pews bisect that line go down about a centimeter and push in there.
And the, if the hip is subluxed in an anterior direction, that will be both stiffer than it should be. And it will often be, it'll be tender either exquisitely tender or somewhat tender. So that's one test. The other test I do, and I tend to do this supine in a 90 90 position, one could argue there's better positions to do it in, but I'm always assessing a range of motion of internal rotation of the hip. And a lot of these people will have lost internal rotation. The interesting part is, especially on females, you really have to compare side to side and hope they have a unilateral problem. Because for Mark Keller, if I get 15 degrees of internal rotation on this 73 year old male stiff body, I'm happy as a clam on some females, 20 means if they have 20 on one side, 40 on the other, that hip is stuck. And, and the third test is on manual muscle testing of the hip flexors, bringing the hip up to 30 or 40 degrees sometimes with the knee bend, sometimes with the knee straight and seen is the, the hip flexors get weak when the ligament in the front of the hip is being pressed on.
Now maybe it's a nerve thing it's being pressed on, but that's the three criteria for what I call a functional hip impingement. And the so that those would be, it's three index tests, not one. And then the first place I go with that, again using the c a P protocol, if the person's not a motor moron, I will show them a variation. I I call it side plank plus. And those in the d n s world, call it low diagonal oblique sit. So I, I watched Craig Levison teach low diagonal oblique sit many years ago and then repurpose that as a, as an exercise for the hip people. Do it, hold it for 10 seconds. It's a, i I probably have tweaked low diagonal oblique sit 'cause I'm having the person not push into the floor but pushed into a wall, a padded wall. And basically they're activating the side core and they're activating the glutes in a isometric or possibly eccentric manner and it pushes the femur back into the socket. So the idea is that this is a subluxed and I, I'm not big on chiropractors calling everything subluxation, but the hip
Is already calling you out over here. The hip
too far forward and stuck externally rotated. So what does a lay person do when their hip hurts? They go to yoga oriented, hip opening exercises, which is totally contraindicated in this because that takes the hip, the femur further forward and further external, which is the opposite of the direction we want to do. So sometimes I get great results by just telling them this is what you shouldn't do anymore. So, and that's a piece I'm always looking for in any anterior groin pain. I start there,
I like it. I, I think, and thanks for calling me out on my biases 'cause I certainly deserve it. We all do.
Was it Fey said, first thing you, you need to realize is, is or in science, the first thing you need to do is to try not to get fooled and the fir the second thing you need to realize is the easiest person to fool is yourself. So, so yeah, I am, I am certainly biased and intentionally too in this particular forum since we are here ostensibly to describe this neuro centric approach that we're going to put neurology forward for what it's worth, the sports hernia. Mark and I have just been back and forth this morning talking about various ways of presenting material on the hip and I'm trying to figure out how to put the coursework together for it. And I'm leaning toward shorter bite-sized pieces of 30 to 60 minutes long, do the medial inside of the hip, maybe pelvic floor. I've got the sports hernia on the, the editing board right now, then one on anterior hip, then one on lateral hip, then one on deep gluteal pain syndrome and so forth. But for the, like the sports hernia right now, every one of those courses has a current evidence presentation of an orthopedic hip ex of, of an orthopedic exam, which is having a nice conversation with Rob 10 hove up in Kalari the other day. And part of what they're looking for in order to get the coursework on the, the N C A online academy possibly certified in Cal in providence of Calgary, which is a little challenging as my Canadian folks on here probably know, but was we gotta have, you know, best evidence for standard orthopedics and stuff is demonstrated as well. So we do, and all of the things that you just mentioned as well, mark are in that the, in a supine patient, I'm gonna do anvil test in a standing patient, I'm gonna have 'em do a, a heel drop, two leg and single leg.
I'm gonna do hip scouring, I'm gonna do a fader F A D I R test and I'm gonna do a Faber F A B E R test and then a supine internal rotation test with a hip at 90 degrees. All of those looking to rule out arthralgia frank hip joint issues that are pushing that.
So I'm with you, that is on my radar when I do it, but before I go there I check the, the other issues with the neurology to make sure I'm not overlooking a possible driver for that issue. I too see the, what I believe to be an anteriority there of the femur in the the acetabulum.
And this is, I will park that further comment on that for the moment and drop into the second case study that I wanted to talk about that I think will help to illustrate exactly that. And this will make you smile mark because I did exactly what you're talking about and I overlooked the arthralgia and prioritized the nerve and I got temporary benefit yet again. So this particular patient that I was seeing quite a bit older competitive power lifter and he presented with very proximal medial hip pain, primarily with deadlifting. It was initiating the deadlift but also with watting.
And the symptoms were only notable on the beginning of his workout session, primarily pulling. So he was doing a straight bared deadlift sessions and when he would warm up with 1 35 on the bar, he would have really nasty pain as high as eight out of 10 pain right up on the proximal ad duct in his hip only on one side.
And again, my bias in that area was I wanna rule out the obterator nerve. And I went in there and with tension testing and with palpation, thought I found a hot obterator nerve and I got all excited about how cool I was and then I leveraged a bunch of our cool N C A things on that operator nerve and he got remarkably better. And then the second session he came in and reported that, oh, and here's something important.
When he would start his workout at warming up with 1 35, he would start out with that eight outta 10 and he'd do a set of 10 and he'd do another set of 10. And by the time he gotten done with that, the pain in that area had dropped to something that was very manageable. It was one or a two or something like that. And then he'd go on and he'd do his deadlifting session and it would not get worse with his deadlifting session. So now what does that pain pattern sound like? That sounds for all the world like a tendinopathy, right? That is the tendinopathy screaming at you, it is worse at rest, it gets worse when you first start using it and then when you use it a bit it gets much better until you overuse it and then and so forth and so forth. But what do we know from Karen Silber Nigel's work, even going back to Albertson's work on tendinopathies and what we do with those, how would you address that? We'd use either isometrics or eccentrics or silber.
Nagel kind of brought us up to speed and said it's not about the eccentric versus concentric, it's about slow heavy loading of the tendon. Now for any of you familiar with power lifting, what does a power lifting session look like for this particular athlete? It looks like a lot of very slow, very heavy movements and indeed he would feel better but it doesn't get better over time. So either one, that loading was too much and we've got to pull him back, which is not what you want to do to an athlete who is prepping for competition in the next several weeks.
So I opted then to treat what I saw as the involved operator nerve.
He came back in after the first session, reported that his pulling session, that particular day was his warmups were 80% improved. I was like, rah rah.
So he came back a week later before his next pulling session and the goal then was what can we do to improve your warmups on that session so that you don't need me or anybody else working on you, let's develop a better pre-event, pre polling session warmup. So what I had done in that particular area that had helped him was mostly using a stecco approach, doing cross fiber friction at what would be media pelvis for them and and also media genu further downstream.
And lo and behold, we took him out onto the gym floor and took some of those very heavy weighted rollers that Kabuki's got laying around this particular variant, it's called the Geisha.
And it was, I think we had 135 pounds on that. And we got Rudy into a position to roll the inside of his thigh with that 135 pound bar. And he did that and to loosen that area up to work on the putative interface issue.
And then he, I coached him through some very wide horse stance movements where he would take a ke kettlebell and alternately push it and pull it to keep him in a safe zone so that he's actively working while he's got that area at length. And he came back and reported that he was much better. So we were gonzo that we were on the right thing. Now what I didn't say is the initial exam that I did on Rudy, the hip screen, he was positive on several of those tests. His internal rotation reproduced the pain at at ccc. At CCC and supine when I challenged that joint and internal rotation, we had pain there and his fader F A D I R test was positive for a possible impingement situation going on there. This guy's 75 now he's been powerlifting ongoing for 10 years, been at the top of his game for 10 years.
And here's where we go into the other part of what Mark was talking about in the D N SS world, which is where Craig got the information that you were citing there, mark, about the low oblique sit stuff in the d n s world.
If the spine is not being held in a stable configuration, when you ask the SOAs to do work, then the SOAs will, according to G N SS principles, need to first pull slop, if you will, out of the spine to create a stable origin to have an effect on the femur. And there we can go back to one of Stu McGill's papers where he was asking is the SOAs a prime mover or is it a stabilizer of the spine?
And from a D n S perspective, it can be both.
It should be both, but it, but the spine should first, in order for it to be a good phasic muscle, a functional phasic muscle, the spine should first be held in a stable position so that the SOAs can take action more effectively on the hip.
Now in, so in D N SS world, if the SOAs if is getting a read the spine is not first stable as it pulls lop out of the spine, and Jerome can comment on this from probably some of his research, then the spine will be pulled into rather interesting positions.
You'll be pulled into an exaggerated lordosis and a little bit of lateral flexion. If it's a unilateral pull and owing to the attachment on the femur, the femur will be pulled anterior into the, in the acetabulum.
And the combination of those things will give you an anterior pelvic tilt and an anteriority in the femur and the acetabulum, which will cause an impingement process on the anterior part of that hip. And I think that's probably what you're seeing there, mark, that you're describing.
So what's one of the ways that d n s would suggest that we assess the intraabdominal pressurization in that particular individual?
We might check I a P by having them in supine do a two leg raise six inches off the ground and look for erectus diastasis root. This particular individual that's having this has been, I've been letting this go without comment, watching him around the gym for months. But he is got a progressively worsening rectus diastasis and I haven't been saying anything about it because I didn't feel like my skinny behind had any right to tell the world record holder of 10 years that he needs to change his form in any particular way. Seemed to be working for him pretty well, but now I decided, well let's go see what we can do.
So I took him out onto the floor and we tried a wall bug, which mark, you might remember that from some of Craig's classes.
And I put him up on a phone roll, put his palms on the wall, had him depress the ribs and try to get the TL junction pinned into the foam roll.
And then with knees at 90 degrees alternately flex the each leg and touch the heel to the floor.
He couldn't do it, he couldn't do it at all. He was coming off of the roll. So we pulled the roll out, put him on the floor, he couldn't keep his legs up above night above his belt line with his hands on the wall. So we peeled him back to log rolling and I had him to do log rolling what Craig would call your, you know, your best, the, the, the what you're most proficient at and on the edge of your ability and had him to do some log rolling and then his index test that we were using, which was him pulling the leg up in a position to cause a snapping hip, which was what he was showing me. He couldn't make that happen and he couldn't make the hip ha hip pain happen anymore. And that was just from the functional intervention. I hadn't done any manual therapy, no treatment on the ator nerve. So made me think, we're looking at a couple of things going on structurally, I'm probably looking at an ator nerve that is a bit unhappy and I'm also looking at a hit that's a bit unhappy and I'm looking at the reason for that.
My narrative right now is that the, the stabilization strategy that he's demonstrating is off base that's re resulting in the anteriority in the hip joint and causing that. And the combination of all of that and the lack of stabilization on the front of the abdominal wall is what's probably giving us, and the hypertonicity in the SOAs is probably giving us the interface dysfunction that I'm observing at the ator nerve. So hindsight's 2020, right?
And all of it is about creating a compelling narrative at the end of the day.
That makes sense to me. But I'd be interested to hear what anybody else has got to think about. Justin, you have any input there?
Jerome? You have any input there? Brother?
Hey Phil, it's Maria.
Hey Maria, how are you?
I'm great, I'm really good. No input on the second case. It's just, it's great to go back to basics. Do you know, want to not overlook like the really, like, I don't know, the foundational stuff that we started in our rehab?
I have a question really about the first case. What's your theory? I mean it's so unusual to have an upper lumbar disc and especially in a young like super fit athlete.
What's your, what's your theory of why that might have occurred for her?
You know, I would first take, I would first take your statement very interesting to have an upper lumbar disc in a fit young person.
And to that I would reply with Michael Adams paper on this.
He's the researcher that interviewed a number of years ago. He is a biomechanist at University of Bristol in the UK and he co-wrote the book Biomechanics of the Spine.
Nicholas Bog Duck was third author I think on that. And so one of Adam's papers he showed us that there are two phenotypes in disc herniation in terms of older versus younger and upper lumbar. In younger athletes they are more likely to have a upper lumbar disc herniation.
The other thing that I would toss out there for your, towards your question is and asking why the, I might be seeing this, this is an interesting sport, you know, power lifting, so they are taking a whole lot of load in that particular area.
And it all has to do typically for them, if they're having that pain at the bottom and it is disc related, it has to do at with at what point in their descent they lose the ability to keep a somewhat neutral spine and they start to lapse into that butt wink phenomena that we see at the bottom at two, two young athletes that were exactly that situation this past week.
Both of them having pain in the hole on squats. Both of them have been coached previously to initiate their, they're squat with a strong anterior pelvic tilt and strong extensor tone and no recruitment of the abdominal muscles. And both of them, when we looked at them, you know, on film and sideline in side position or lateral position, both of them exhibited a wink right there at the bottom. And one of them was earlier in that and he was, he was showing that hyper-mobility at the, at an upper lumbar segment as well around L three. And remember McGill also taught us about assessing for that in a quadricep position.
And the clinician will look from the side and have the per the patient in quaded to rock back taking their butt towards their heels and they rock back slowly until you see that the spine loses a neutral position. And you mark that particular point that they go initially into, they start flexion in the lumbar spine and that usually is your, your hinge point that they're having issues with. So that's what I, what I think is a decent answer to your question. Maria, how'd they do?
I think you did great and, and I think that was really the point of my question, like are we really looking at mechanics like in these, it it, even though they're advanced athletes, are you just looking at a simple squat movement pattern to to just see if you see anything like in the, in the adductors with the buck wink are, are you really looking at ankle mobility? Are you looking at mid-thoracic mobility? Are you even looking at eye patterns? Like all of those things could greatly affect squat compensation that
to that kind of disc
Agreed completely. And a lot of it sounds like a lot of what you're, you're nudging us towards theirs to consider the other schools of thought on this, like, you know what Gray and Greg did with F M S and S F M A and indeed what you'll see as you go through the courses there on the site, what we do in our clinic, what I teach my students is an upper and a lower quarter basic orthopedic and neurological examination. And that high level organization, the high level organization of that looks, incorporates those el some of those elements of the top tier investigations of F M S and or S F M A. So I will have that patient squat to depth and I want 'em to stay there as well. And I wanna look at 'em from the front, I wanna look at 'em from the side. I want to see how their foot is bearing weight, are they collapsing in and showing me algos at the ankle?
Are they showing me strong anteriority in, in the, in the foot bed and they're not able to keep their heels down? What does that show me about from the side whether they have that anterior pelvic tilt and they're going into the butt wink and all of that fun stuff. So yeah, all of that is baked into this and to my mind, the difference in what we're trying to do with N C A is we still mark that we still check that box and we make a note of it, we keep it in mind, but all I'm really trying to do is to take the neurology and specifically the mechanical sensitivity of the neurology and put it for front end of clinician's mind so that they don't let it escape their attention and instead go lapsing onto the well worn path that we have of meat-based issues of looking for hypertonicity in a muscle, looking for fibrosis and tissues, looking for joint hyper hypomobility and just wadding into that with a big chiropractic hammer to hammer down high spots and try to restore mobility in those areas without asking why is that happening there? Because over the years, as I've asked that why over and over and over again, I keep coming back to there's a neural driver in that pain syndrome that's going on that has not been thoroughly investigated yet.
And when we do that, the hypertonicity often gets better and the joint position often gets better, especially when we put a d n s foundation underneath that. And here's, here's a dirty secret right there. If we want to dispense with all this silly n c Aness, we could all just go back and be d n s practitioners. I swear I, I do think Carl Levitt was right, you know, Craig used to tell a story about being over in Prague and walking around the hospital with Carl Levitt and this is in the early days of Pablo collage getting, you know, describing what he thought he was seeing with D n s and according to Craig's telling, telling of the story, Carl says, I want to take you down here and show you this.
And collage was lecturing in a room and Levitt says to levison, this guy might have the answer we've all been looking for, but I don't know how in the hell he's gonna teach it.
And therein you get to a lot of the frustration that many of us over the years have had with D n s that it is incredibly powerful, but it's hard to describe, it's hard to feel ironically because we're talking about holographic motor template that we're all supposedly carrying in our brain that in that is innately there and yet we can't, we spend an inordinate amount of time talking about it with our patients trying to tell them how to do it, which is against the literature that would suggest that internal queuing strategies are inferior to external queuing strategies. But collage does not want to give up on the internal queuing strategies in working with patients.
But what we don't have evidence on that Jeff Kubo brought up Adroitly a number of years ago was we don't have any evidence about whether the combination of what D N Ss actually does at the end of the day, which is kinesthetic queuing combined with internal queuing. So remember your passive assistance of positions, you put the patient in a one of those developmental postures, you, you see whether they can actually do the developmental movement and if they can't, you passively help them by unloading somewhat so that they can get a little bit of a rolling start on the movement and see if they can do it better.
But yeah, I mean I, I saw this years ago when, you know, students from my clinic after working with me, seeing patients with disc injuries walked into D N SS practices by that and worked in D n s practices and they were being shown in those D n s practices ways to manage a lumbar disc herniation just by going through evaluation of intraabdominal pressure and coaching developmental postures and getting that patient out of harm's way with that lumbar disc herniation. And you know what, it worked but you know what else, it literally took them twice to three times as long to get better than it did leveraging the integrated approach that I had taught that student, which also integrated D N Ss. So on that patient, those of you that have taken a clinical companion to the F Y O B course, we would leverage McKenzie, we would leverage static openers to take the threat off of that particular involved neurology and then we would come up underneath them with that functional fix from A D N SS perspective and people get better faster with less treatment. So
what else have we got out there Jerome? You sent me a couple of papers this morning. They were cool. Are you within earshot over there? You want to talk 'em?
I could see if I can pull those up.
I am not on screen share right now am I?
Doesn't look like it. Okay. Looks like you guys might be getting tired.
Alright Justin, you have any input before we take off?
So to give you guys a little bit of an idea of the way that we're gonna work some of these in the future,
Justin has set up a film studio setting at his place and in advance like some of these meetings, maybe the next one I'm gonna do a deep dive on one specific nerve. So we'll just pull one nerve out, we'll look at its origins, we'll look at what it does, we'll look at how it interacts with other tissues and how we address it.
And then we'll we will, we will use those likely as continuing education.
I'll put a slide deck together for it. We'll try to come in under an hour on it and then Justin will use a model and demonstrate the manual techniques of both assessment manual and exercise intervention from from his place down in LA And let's see other things, my associate is now back from his vacation, so we will be filming on Monday to get the practical portion of the sports hernia course out and that will likely be dropped on the site in the next week.
The tendinopathy course. I've followed up with an email to one of the, the primary researchers that I'm really fascinated in where our work kind of at N C A kind of dovetails with his, his name for those of you that are geeky and interested is Paul Ackerman.
He's a Swedish researcher. So Ackerman is a c k e r m a n n.
Paul Ackerman has been bird dogging the effect of neurology on tendinopathy since back in the around I first paper. I'm aware of that he did. There was like between 2006 and 2009. And from a historical standpoint, this was at the same time that Jill Cook was really coming on with her research on tendinopathy and Cook has cook gave us a lot of the, how the dominoes line up on a reactive tendon that then you'd have a proliferative phase and a failed healing and a degeneration phase. And it was ackerman's work though that again Cook being, and and Craig Perham as well, which Joe Cook being very, very focused on
the meat, if you will, is a Ackerman was swinging us around to nerve and his research shows us that the source of the nociception on a painful tendon is not due to vascularity and not due to something in the tendon itself. It is the in-growth of nerve buds. And I've had a couple of conversations now via email as well with Jeff Bove and I, I'd like, I've talked to Paul Ackerman about coming on and doing a presentation for us here, but it's gonna cost a fair bit for us to get him on there. I've got a little bit of a relationship with Dr and we might be able to get him on here out of the goodness of his heart and to help create a little bit of a stir for the, the neurodynamics colloquium that they, that Michael Shacklock has got going on down in Dallas Parker.
So Bo's gonna be there,
I think Antonio Stecco is coming into town for that. And Annie O'Connor from World of Hurt as well. It'd be a good show. You guys should keep, keep that on your radar and go check it out if you like.
Anybody got, anybody
Dean’s Iphone (2)
got? Hey Philip, can you unmute me? I can't figure out how to unmute my microphone and my, my back's being kinda weird.
Dean’s Iphone (2)
Can you hear me?
Dean’s Iphone (2)
Yes sir. Okay. Yeah, sorry. So you asked me about a anything to add and more just from like a structural organization of N C a as far as the thought process. And this was related to Mark's question when we were talking about the hip and how we seemed to be very biased towards the nerve, which is of course is true. One of the things that, the way I look at, the way we structured this, the system and approach is kind of to separate into two different models in a way, the pain model and the overall functional performance model. The thing that we're trying to bring, and I think Philip you'll agree, is with N C A is, is a roadmap to get people out of pain very quickly, but that does not negate biomechanics, orthopedics and, and the str like the structure of the hip and, and, and every other aspect of clinical care.
It's just a very quick roadmap to get somebody outta pain and then it likely will address some of these biomechanical issues that you'll see like a anterior superior position hip. And it doesn't mean that necessarily you wouldn't do the other interventions to additionally direct address that it, it n c a where it shines is to reduce pain very quickly and then you can move on to, let's say more a more functional roadmap.
Dean’s Iphone (2)
Yeah. We've, and Justin and I have gone back and forth about this over the years, a few times of how to behave responsibly with that because you know, mark, I think you probably saw this early on as well, I know you were really keen to the, the Yap d t m stuff that, that we were playing, but Justin and I saw at least once, maybe a few times, that we were able to do something that could take po pain out of a motor program very quickly.
But if you don't assess for the other meat-based biomechanical arthralgias and things of that sort and the functional reasons for them to be there and you just keep taking the pain away, you may be doing a disservice to that particular individual.
And we might be essentially just applying some kind of manual aspirin that pushes the patient further into lesion and causes a worsening of an orthopedic condition that they had.
So I think we need to be responsible in the way that we address this is ability to be able to take the pain away by addressing some of that sensory neurology is a pretty cool thing, but like any kind of power when you get it, you gotta be aware of the responsibility that you've got and behave responsibly with it.
Dean’s Iphone (2)
Yeah, I'll just, oh, sorry.
Go with it.
Dean’s Iphone (2)
All right. So yeah, absolutely. So another way of, of thinking about this from a, hold on. I'm getting a phone call.
I'm not here.
Dean’s Iphone (2)
not here. Did
Dean’s Iphone (2)
something happen? We're good. Okay.
Another way of thinking about this is like, let's, let's look at this over a series of visits, right? Where does N C A fit into a new patient to start to finish with a patient? It's really most important in let's say like the first three sessions and, and then that's usually what it takes for most, for most, let's just say basic cases, hip pain, back pain, neck pain, neck knee pain, that kinda stuff to reduce the pain by a significant margin. And then you could trans transition into other systems and approaches and with the N C A lens still attached. So it's, it's really the how do we make a huge difference in what the person is paying us to do, which is get rid of their pain so they can do what they love to do as quickly as possible.
Yeah. I've got another, another lifter that is a perfect consideration of that. Those of you, if you have seen, if you haven't already go look at the shoulder course that I put on the online academy.
The shoulder shoulders are a perfect example of this commonly and, and the hip as well. You know, your two big knots that Pablo Soline talks about. The, these inherently mobile joints, often from a biomechanical standpoint might become a little less functional because a neural driver is causing the, the, the muscles in that area to act differently. So I had a lifter that was doing, as she was preparing for an odd type of meet that combined elements of Olympic lifting or so-called weightlifting and power lifting. And she had previously competed in both and she came in, you know, with really, really nasty pain in a, a catch position for a clean and jerk and a really nasty pain in a high bar back squat position.
And her pain was right on the front side of the shoulder and working through the neck, we were able to get her through that competition and then she stopped seeing me. She didn't come back and her, when she came back in, she had a full on adhesive capsulitis, so we were able to take, to make things better going through the neck. But then her lack of movement and lack of addressing the actual capsular issue, she, she wound up with an adhesive capsulitis. And here's one for you guys as well. I had been, I sent her out to a local pain interventionist to do capsular distension, which has the best evidence for that, but it doesn't, it's not terribly profitable in a pain interventionist practice.
I sent her out, they took an m r i, the m r I showed a lot of degeneration of the rotator cuff tendons and they prescribed p r P for those tendons followed by extracorporeal shockwave therapy.
Now, both of which have about a 50%, you know, success rating in the literature. Both of them cost a lot more too. So they wanted her to book in for extra corporeal shockwave therapy at $300 a session for an hour twice weekly for a month after doing p R p. Okay, so what's the p r P doing? Stimulating a, a local inflammatory reaction and collagen lay down to try to buttress and make that tendon stronger. And then watch the, or extracorporeal shockwave therapy do well beyond what we don't know. What we think it does, does the same thing as the the, the P R P injection.
And they pushed her, I had gotten her back to a position of probably 50% of improvement in her adhesive capsulitis. And after we got through the intervention that they did, 'cause they didn't do what I sent her over and suggested should be done.
After they did that, she wound up with a worsening of her adhesive capsulitis.
And now we're, we're just, we're eight weeks later in the same presentation, it's taken me three sessions to get her back to where she was before she ever went in for the intervention that they did.
Just makes a person irritable. And then they, and they said, well, if that doesn't work, yeah, they're not happy with the way things are going, maybe we'll have to do that. Capsular distension.
So maybe we can leave there with me sounding like I know what I'm doing and making me smart.
That's a good spot in my, for my ego for to leave us with. Anybody have any input thoughts?
All right, you guys are awesome. This one's been recorded. I will post it up on the community board for you to review if you like. Please feel free to leave comments also in the community forum guys, as you watch Mark, I know you and some of the others have left reviews, do that. That's helpful.
Really this is not about us promoting this process that we're doing as much as it is making it better.
So I want your help in that. That's why you're lifetime members and I, and that includes as well. Shoot me some, some information about what you think this is worth.
We're trying to find a, you know, like any of us putting anything out there in the public, what a good product market fit is.
I'm trying a monthly process right now 'cause that makes it a little easier for some of the students that are out there wanting to do this. But my wife pointed out recently that if I'm selling continuing education courses here, most people buy continuing education and they want to know that they have it and not have to continue to pay for it. So she likes the, the lifetime membership and I'm thinking that we'll just keep nudging the price of the on of the lifetime membership up over time. And we will periodically do sales to get people buzzing and create a, you know, a little bit more interest in people coming on board.
But at some point we all have to, to actually demonstrate that this is a viable product and is serving a need out there in the world.
Oh, okay. Kids.
I think that's good. I appreciate your involvement and I will see you guys next week.