NeuroCentric Approach Zoom Case Study-Femoral Nerve PainNovember 4, 2023
NeuroCentric Approach Zoom Case Study-Changes in HearingNovember 11, 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 it is nine in the morning on the Pacific Coast in Portland, Oregon. Be more specific. So it must be time for the NCA Coffee Club meeting. Woo-hoo.
You guys that are members to the neuro centric approach online Academy can join us at the link over here on the Zoom that'll be recorded and will be available on the community online.
For those of you over here on Facebook Live that are unfamiliar with what all of that is the neuro centric approach, it's created by Dr. Justin Dean and I, it's essentially an integrative approach for rehab, exercise, and manual therapy geeks primarily of the chiropractic persuasion.
It is a, as I said, integrative using a lot of those named acronym systems that many of us have taken continuing education in. And it's my attempt to try to blend those into a more effective clinical rubric that takes into account at least three things that are a bit different out there in the the literature these days from when I went through school 20 years ago. And one of those things is our improved understanding of mechanical sensitivity of neurology and how that could potentially drive motor behavior, which then will alter joint position and then those alter joint kinematics over time can cause arthralgias in between there. The motor behavior that changes often when we're in school.
We're taught about how to palpate for tight muscles or joints that don't move so much. And what we're attempting to do with this improved understanding of mechanical sensitivity of neurology is to try to s try to look beyond just that observation of the phenomena of tight muscles and hypermobile joints or hypermobile joints and to try to ask a simple question, why is this occurring in this particular individual at this particular time?
So part of what we're looking for is to improve our ability to query the patient in front of us as to whether or not that mechanical sensitivity is present. The other two things regarding neurology that have changed a bit since my day in school is the improved understanding of how the brain gets involved in all of this. And many of us are a bit more savvy to this these days. Blessedly, this field of pain or science has matured a bit more and now it's not necessarily seen as the be all and end all, but it is an a, an important thing for all of us as clinicians to consider with our patients.
So with the neuro centric approach, we try in our history to bring that information around into that clinical rubric as well.
And the final thing that I think we're bringing to the table that is different is for some of you that are geeky and are out there listening to folks like Andrew Huberman or Peter Atia or you're interested in the findings of the Buck Institute and looking at aging literature and longevity literature, we're seeing that there are oxidative stressors that can beyond just the standard polyneuropathy of alcohol, you know, diabetes, possibly drug-induced polyneuropathies, but that there are oxidative stressors call it hard living in a person's life that can make neurology a bit more sensitive. And it's that that we're also trying to capture somewhat in the history and then factor that in to our treatment plan with that particular patient.
So that is in a nutshell, the neuro centric approach. The online academy I launched, I think we're, we're at about two months out of the gate right now.
It is the beginnings of the online coursework. I've got about 35 hours of continuing education up there right now. Current price on that is a poultry $39 a month or 3 99 a year.
That price is gonna go up next week.
Both of those prices. So if you guys have got any, any friends that you want to get in on that, you can do that. And also it's worth noting periodically I'm gonna toss the lifetime membership, which is a single payment, just one payment. And then you get our process, the neuro centric approach gra for the rest of your life and mine and for just one payment. And that payment also gives you a discount on our in-person courses as we spool up those in-person courses and start teaching those. So keep an eye out for that. I don't know a standard time where that might occur is, I don't know, maybe Black Friday.
So keep that in mind and maybe start talking to your peeps out there and letting them know know that that opportunity is gonna be presenting itself here shortly.
Let's see things in my past week. Yesterday was my little doggies birthday,
she turned five yesterday and I did something kind of fun.
Many of you are aware of the the chat GPT and I've got the pro account on that which gives me access to chat GPT four, but also to the brand new doll e and doll E three is out there and I decided to play with that yesterday morning.
You might be able to see that over there on Facebook live just a little bit. Those of you that are here on the, the Zoom can see this clearly. So I put a prompt and produce a realistic photo of a five-year old black tribe miniature Australian shepherd dog sitting at a table with a birthday cake with five candles. The dog is wearing a birthday hat the cake has happy birthday, five written on it, and damned if the first one right out of the chute doesn't look almost exactly like our dog.
It was fascinating to see this. In fact, when that picture to my wife she said, is that, is that five?
And and that was, that was kind of fascinating.
My son was my son when he saw it. Said, did you upload photos of our dog to that to get that kind of rendering? And no they didn't. In fact, it won't take those uploads so well at least not at this particular point. But these are various renditions that came out. You guys, as you play with it, are gonna find that it, it, you know, is Im imperfect, this is all still beta, but you know, as you note I had to keep prompting it. He said that was a good rendering, but please have happy birthday. Five written on the cake and five candles on the cake. So he gave me another iteration. This cake's got six candles on it.
This cake's got nine candles on it. Both cakes have happy birthday fife on it said Now using the same prompts, produce the image and style of renoirs at a garden party. So this was intentional because some of the artists out there of course are justifiably concerned about the the wholesale imitation of their art style and such. And this is what chat or Dolly three gave back and says, to create images inspired by Rena's at a garden party, we would use descriptive terms such as quote, soft pastel tone and impressionistic along with the relevant scene description. However, since Renoir's last works were created after 1923, we cannot use his specific style for the image generation.
Instead we can generate images with an impressionistic style that predates 1923, capturing the essence of that era in the art. Would you like me to proceed with this approach? I said yes.
Here's what I get back, still got the wrong number of candles. This cake's got happy birthday five on it. Now I got a little puppy five, she's no longer five years old. She looks like she's about five months old and happy birthday. Something over here that's illegible. So that's kind of funny.
And then I threw it, now do it in Cuba style, reminiscent of Picasso. And here are the, the images I got now. I'm the Dutch style of Rembrandt and we got something a little, a little darker. So that was kind of fun. That was a play toy yesterday morning for my doggies birthday.
Welcome in Guillermo and nice to see you Kat over there. Katt, have you had any new information about your possible trip up here to the Pacific Northwest?
Hey Guillermo, good morning.
Hey Phil, how are you?
I'm well, how about yourself bro?
Pretty well, yeah, it's definitely wet and windy out here, isn't
it? It is indeed. It is completely sopping wet outside. I don't think I'm gonna be able to get to the dog park probably until one or two today if it opens up. But it's gonna be an indoor workout day today. Yep,
Yep. I, let's see, let's, let's do a recap as we move into our case of the week.
Let's do first an old business. Last week we talked about out last week we talked about a 58 year old female with complaint of lateral hip pain with radiation into the knee with orange theory workouts.
Her past health history was of note because she had
past health history was interesting of note because she had concomitant prior history of melanoma twice and she has a diagnosis of osteoporosis and subsequently, as we did that recall coming in off of there subsequently, as I did some work on her, we determined that she had femoral nerve sensitivity and across multiple peripheral nerve areas in her thigh, we trialed some MDT interventions to see if we could take that off, some heat off of that neural pathway. Upstream MDT didn't do so well. So we tried NDS Michael Shack lock's work and started with static openers.
Some might ask why I would do that and indeed, you know, why would I order it that way? Because some people that have taken shack lock's work.
Some people that would have taken shack lock's work would, would start right there.
Someone is definitely trying to get into my meeting this morning.
Hang on a second please.
It's not because of effectiveness that I opt for starting typically with MDT, part of it might be a bias because I was exposed to that earlier.
But I think the primary reason that I do that is because MDT interventions typically are easier for, for our, our patients to intervene with. And I'm, I'm more interested in that I want their compliance with homework. So I tend to to use MDT and in her case the static openers, they involve the need for something that she can lay on and you know, luckily she works from home so she can go to her bedroom and she can get up on her bed and do the static openers. But what happened over the course of a week, she, when she came in to see me, she had six weeks of near constant pain and that left lateral leg and after one week of doing static openers
between three and five times daily, she had zero pain. It was 100% resolved and she was able to continue her workouts without any aggravation based on the improved understanding of the mechanics that were likely picking the scab, if you will, on that condition. So there's old business from last week's issued. Does anybody have any questions about that before we get on with the next case?
Not seeing any questions over here on Facebook or over here in chat.
So without further ado, I had an interesting case this week.
As many of you are going to note, as you get more involved in this neuro centric approach, it tends to make people talk a little bit about you because often you're behaving in a way that's a bit different than what people are used to and you're likely to find, as I and others that have adopted this methodology that your outcomes improve quite a bit. So as that happens in your community, you're gonna start perhaps even unfortunately, but some of your softball cases are going to start falling away because your schedule's gonna be occupied by challenging cases.
As you get more noted for this kind of stuff, you will find that you'll get more and more complicated cases, sorry for that, but you're, you're gonna be able to help the people across a broader spectrum than possibly you previously were. I think this patient might be one of those, I don't know yet.
This particular patient is a 48 year old male, a marine on 50% disability.
He is, he moved to Portland just a little bit ago and is working at a construction firm that some of my other patients own and they sent him in because of the symptoms that he was presenting on the job that they thought were worthy of him coming in and getting assessed by me.
So he's been seen by VA docs for 15 years after he had, while in reserves a motorcycle accident and in his motorcycle accident he had a three level lumbar spine fracture, L three, L four and L five.
Lumbar vertebral bodies were, were fractured, not severely but apparently, and I'm saying apparently because he's not yet produced the actual reports or images to to me, so I had to fly blind. I said, Hey, I told him, I said, Hey, you're asking me to do mechanics here with the hood down on the car. So you know, we'll do the best we can, but a lot of this is gonna be me guessing about things and I prefer to guess less with some of your information. So all of that's pending.
We'll follow up on this particular case hopefully next week as well.
Presenting symptoms, the one that of course stuck out the most to me was he has about seven times a year an incontinence episode associated with movement and the incontinence is bowel and bladder daily. He has pain into the base of his penis and pain into his scrotum.
He has very reliable movements that he can do that will reproduce that pain.
So we've got caught aquina syndrome symptoms right out of the gate, but they're intermittent and they've been investigated by other docs previously and surgery has been offered to him to stabilize the segments in the lumbar spine that were injured in that motorcycle crash and the patient's reticent to get the surgery candidly, and it sounds to me like that probably would be a decent idea as well. But he presents to me with a desire to try to avoid surgery and improve his symptoms. So I'm gonna try to meet him where he is and I told him that I would do my level best to see if we could find a happy meeting place there and improve his symptoms somewhat.
Most of you that are familiar with our work know that the nature of the exam that we do and that many of us do is provocative by nature to try to bring the pain symptoms up a bit so that we can both see them, the patient and eye and typically that infers some things that the patient might be doing that are inadvertently provoking their symptoms and would also infer some things that we might be able to do to reduce their symptoms and use an A systems-based approach. We perturb the system, we apply an intervention and we look for an output on the back end of that to see if the patient is feeling better since part of our output on perturbations in this particular individual system is incontinence and neither of us wants that to incur to occur in the clinical encounter.
We had a a discussion about that right out of the gate that if I was coaching him into anything that he'd already identified as pote, potentially provocative there to let me know.
So regarding the incontinence, we laid some ground rules out on that in our physical exam and then we tried to establish some ground rules around pain.
Per his history, all pain, all movement is painful. Every single movement that he does, he feels pain, he feels a constant baseline level of pain at about a three and his pain increases to about a five with any movement leaning into the incontinence. Symptomology asked him if he could reliably reproduce those symptoms and he said not reliably, but the most consistent provocation he had was if he was on a job site and he does most of the bidding for their construction projects. So he goes out and you know, he's crawling around in attics and, and you know, interesting places and he said reli most reliably if he steps forward and then has to reach his leg around something, then he has to immediately stop and really kind of tighten things down or he feels like he's vulnerable in that moment to possibly having some slippage of both bowel and bladder. So I watched him as he described this while he was standing and I noted his movements.
He showed me an extension and a reach with his leg. So in my mind, thinking into the area of interest at the spinal cord and the nerve root and the IVF, I'm seeing extension and I'm seeing SOAs activity happening at the same time.
So I kind of catalog that in my mind and roll with that as I get him, coach him through the cardinal planes of movement. In his case I say, are you able to do these particular movements and what do you think the symptoms might be if you did them?
And we made informed decisions about whether or not we were going to do those movements based on his presenting symptomology in his, in his case
he said he can get to the floor close to his toes as long as he does it slowly and carefully.
So he showed me that and he didn't have much in the way of increase in symptoms in contrast to what he said that all movement would hurt.
But as soon as he started any movement backwards, it was no bueno and he was moving into, he's like, that is very reliably going to make a lot more pain and it might even make my incontinence symptoms come on.
So that I thought was kind of interesting.
I flagged that because in that department I start to look at an instability pattern as being the provocation and spondylolisthesis comes up relatively high on my list in that query.
We did a neuro exam. He already had admitted to sensory diminishment on bilateral lateral thighs and, and he also had some diminished sensation in his history and saddle paraesthesia distribution.
His reflexes at the patella and the Achilles were hyper reflexive.
And then on our motor exam, which you guys know I prefer to do as a more objective patient performed
examination of S one with repetitive toe stands on single leg and then L five myotome with repetitive heel stands on one leg and then L four and above myatt tone by having a single leg sit to stand.
As we started to do the S one on the right hand side, he noted that one he had more pain, which is not uncommon, but he noted that it felt weaker and he noted that it felt weaker in a particular way. He said he felt like it was ratcheting, that was his words. And you guys know that when we, we think of ratcheting in a neuro neurological condition, it pushes this right upstream to the spinal cord and we start to think about something that looks like cau a aquina syndrome or something that looks like myelopathy.
And in his particular case, now adding that to what appears in my emerging narrative to be an instability at the lumbar spine at an unknown number of levels seems to be contributing to some spinal cord involvement. I decided to in the moment, see if we could explore that IVF and see if that is somehow implicated.
So I had him, he was doing the S one on one leg on his right leg doing toe stand. So I had him alter his position of his lumbar spine while he's doing it. So he was upright while he was doing it and reporting ratcheting. So I put him in a position, a forward antalgia and a little bit of leaning away from the affected side to ostensibly open the cross-sectional area of the neural foramen of the nerve root that we were testing.
And as he did that, he said, huh, that feels stronger and I'm no longer ratcheting. So that was kind of interesting. And then when we, he was fine on L five myotome on that, that side, when we did L five myoma on the other side, he had a similar ratcheting and weakness complaint on the left side. So I did the same thing there and moved him into a forward antalgia and a slight lean away. And once again, opening the neural foramen on that side, his strength in the L five myoma appeared on that side. So now I got a rock in a hard place, right? It looks like I've got one nerve root that is responding to an opening procedure and the oth and one direction and the other nerve root below it or above it behaving in a similar way with the opposite movements.
Oh my god, this is, this is gonna be, this is gonna be a challenging one.
So I, I decided in the moment to see, okay, if we've got an instability pattern and we have a change in his stabilization strategy, are we able to have a change in his symptoms? So I saw it off the cuff if about possible ways that we might be able to change his stabilization strategies with these and I felt like it would be a little bit ahead of the curve to try this with his motor testing. So I decided to try using his, leaning into his provocative reach with his leg.
So I'm thinking SOAs activation potentially anatomically unstable segment and the SOAs activation is pulling into pulling the spine into an anterior position. So if you've got an anthesis, we could be worsening that.
So in standing I had him just do a very careful knee raise, single leg knee raise and he had worse pain raising the knee on both sides, no provocation of his, of his incontinence, subjective incontinence feeling.
And at that point I sort of called a stabilization audible. And my stabilization audible is almost always going to lean towards DNS. So in that rubric we've got the desire to create a low threshold stabilization strategy, a more efficient stabilization strategy at the lumbar spine using deep spinal stabilizers like the diaphragm, the pelvic floor, the internal and external oblique, the transversus abdominus and the multi eye. And we're going to not preferentially try to recruit something like the transversus abdominus using Hodges earlier material. We're going to use more of a robust McGill and DNS hybridized sort of blending of all of that, but mostly leaning on DNS principles there.
So I sat him down and I did, and I sat behind him and I did a, a intraabdominal pressure and IAP assessment per DNS the way that I was taught, the way that I do that with my patients is I put my hands on their flank with four contacts, two in the front, two in the back, and I have my patients to put their hands just over the top of mine and then I bring their attention to that area and ask them to breathe diaphragmatically.
And then we both see if they're able to expand in that area. So I give them a rough or two of breath to see how they do. And then dependent on how they do, I'll work on coaching cues there. So I'll say, I'll put my hand in front of them as I'm sitting behind them and I'll say, your diaphragm is cup shaped and as you breathe in at, you make the muscle tight and as it tightens it pushes down. And as such it should expand that cylinder, that canister that we both have our hands on here and we're looking then to get a sense of that expansion. And then I give them another few reps to see if they could work on that.
So in this particular patient, he was breathing paradoxically as he inhaled his, his he would, his abdominal canister would contract and everything went north. All of his breathing went up here. Other interesting things. And his person's life, he's going through a divorce, there's custody battles for the kids, he's living in a new city, he's got a new job, he's trying to negotiate all of these new things. So he's got a fair bit on his plate.
So in his,
he actually was, his interception was sufficient enough that he could feel that he was breathing in the wrong area. So that's where I break out my next coaching cue, which I like or diaphragmatic breathing. I said, all right, I want you to imagine as you sit here that your torso is a big giant water pitcher.
And I tap the top of his head and I say, this is where the top is. And I tap the bench and I say, this is where the bottom is. And then I ask him a question. Now if I pour water into the top of that pitcher, where does it land first? And he says, in the bottom. I said, okay, now I want you to imagine that the air that you're breathing in is heavy like water and that it flows in through the top of the pitcher and I want you to fill the bottom of the pitcher first and only fill up to where our hands are. Okay? So he doesn't even get a chance to come up here into the chest.
And he did a few reps there and he demonstrated that he was able to produce a diaphragmatic breath. So now this is part of what we do or what the kabuki system of their progressive loading processes incorporate how they incorporate the DNS material. So first we want to try to see if that individual can vol volitionally breed into all four of those quadrants.
Now in our athletes, what we will commonly find when they are injured is that they are off in one of those quadrants. And when you palpate those and you have them try to breathe into it, commonly one of those quadrants is not getting expansion. And commonly that's if they have back pain, that's the quadrant, that's where they feel their back pain.
And for those of you with thinking about possible GTM contributors there, often you can lay them on the side in that back pain and do deep out through that abdominal wall and you'll probably localize a small nerve, nerve ileal, inguinal ileal hypogastric, sometimes subcostal in that abdominal wall. And they'll note that it's really painful and you can do some, my DTM in that particular area involves using transverse nerve mobilization, bending that nerve laterally while the patient twists on the, on the, the plump or the table.
If you wanna see that, those of you that are members, that's in the clonal neuralgia and groin pain course that's there. That how to videos in there on.
So in this particular patient's case, we were able to volitionally breathe in all four quadrants and now we wanna see if you can brace in all four quadrants. And we think about the brace as being on rheostat, a dimmer switch. We don't want the patient to walk out of here with the same kind of attitude that many, you know, Stu McGill got bashed on this and social media for years or making patients hypervigilant about the need to brace and all of this, talking about bracing left a lot of people walking around with a real hard brace all the time. And for those patients I always say, no, that's not the goal because that'll just make you walk funny and make dogs bark at you. So we want only the amount of brace that's necessary for the desired goal and just reaching out for a coffee cup is gonna be just a little bit of bracing there. So we practice just a little bit of brace and I wanted him to imagine a 10% brace as we put our hands on there and I'd have him close his glottis and I make the sound, some of your patients, when they try that, do what they go, Hmm hmm It's not boom And we want boom, we want control, we want control of that intraabdominal pressure very quickly, why McGill gave us a paper a number of years ago on investigating Bruce Lee's double pulse idea of the idea that when you generate a quick movement, you have to first be stiff and then ironically you have to be very loose to allow the movement to occur and then you have to be stiff again when you have the contact with the length in order to achieve an energy transfer into the target, whether it's kick or punch or strike or some sort.
So McGill showed in that paper that which was done at George St. Pierre's training facility up near Toronto, that all of the athletes in that environment were able to very quickly muster that, that intraabdominal pressure on EMG testing. But the best athletes in the, in their facility were the ones that could turn it off quicker. So there you think cat-like, and that ability to be completely relaxed and then boom, just to explode and then to chill again.
So that's the kind of message as we start to play with this stabilization that we want to impart to the patient and the DNS principles, these low threshold stabilization ironically only requires a little bit of stabilization. So I've found, and I've got one MD right now, an urgent care doc that we've been working through prior disc herniation that now most of his pain is clonal neuralgia and the most valuable thing to help him with that pain was to teach him to breathe into that area and to, to stop trying to muscle up to protect his back. So he has been walking around for years with an an a body awareness that if he rounds his lower back, he's, his disc is vulnerable and he has inculcated a posture into his body of muscling up all the time. So he is walking around with a proud chest and the most effective visit we had was when I gave him permission to just let his back go. And that sounds a lot like some of Peter O'Sullivan's, you know, work and how he would get all uppity and talk about, you know, those patients that we get like this, that, you know, and he would bitch about Stu McGill's, you know, causing more harm than good. And that's, that's, that's crap.
We get some patients that are in this bowl and we get other patients that are in the other bowl that if they flex their spine, they've got a more acute injury or you know, other things are involved and they're a very flexion in intolerant pattern. So it all depends on the patient that's in front of you, which brings us back to our case study and the patient that's in front of us.
So he was, his interoception was very good. Clearly he had some athletic training, he some marine, I expect him to be, at least at some point in his life to be physically proficient.
And he was able to brace effectively in four quadrants. So we went back to our standing single leg knee raises or hip flexion, which previously caused pain. And first I coached him into a little bit of bracing in that area and then had him to flex the hip. And when he did, he reported that it was well over 50% less pain. So we worked on dialing that brace a little more and as he up three a stat on the bracing, using that bracing strategy, he was able to raise his leg with no pain. Very cool.
Okay, so in this particular circumstance, now we've got a person, I mean, let's be honest. If you had the possible symptoms that you're gonna piss yourself or shit yourself on a job when you move in a certain way, do you think that would involve your nut at all?
Do you think your head is gonna be involved in that? Do you think that's gonna make you feel less secure, worried at your job site?
The fact that this guy is carrying a backpack and I already know what's in his backpack. It's a change of clothes and possibly it depends.
And this guy's 48, so I'm, I'm gonna be happy and this first encounter, if I can take away some of the presenting threat that's making him feel less secure on the job at a place where right now with a change of venue, a change of scenery, kid issues, relationship issues with the divorce, he needs to feel some sense of control there. So we start to blow that up a wee bit and let's talk about a, okay, the other positions I said, okay, so now we've identified that that reaching position with your leg likely involving the, the, the SOAs pulling on the spine. I showed him the anatomy and suggested that if he provides that little brace, if he anticipates and sees that situation, one, if he can identify a better way or a way that's less threatening to move rather than exposing himself to that, then by all means do it.
But he's probably already doing that. But the second thing is to, if he has to do something like that to practice this bracing strategy when he does, the other movement that we identified that was provocative for the back pain was extension. So we worked on that rib down position to try to keep that a little bit more and then work on using a squat mechanic to get lower rather than an extension to try to avoid that, that particular provocation.
And candidly, that's where we left it on this particular event. This was a complicated enough case that I wasn't gonna do a slump test on it. I wasn't gonna do a CED compression test on it, I wasn't gonna do an SLRI based on the, the physical findings on the neuro and the historical data collected. I'm working a narrative that suggests that I've got a, an instability pattern that is presenting threat to the spinal cord and the nerve roots. And I'm going to see if we can institute an improved stabilization strategy using DNS principles and try to improve his function at work. We'll see how that goes and do a conservative trial for a number of visits and then consider whether or not this is most likely a surgical intervention to stabilize that particular area.
And if it is, then we'll follow up with that with rehab to bring it back up to high level of function.
So that is our case study for this week.
Questions? Anybody over here on Zoom?
Anybody over here on Facebook Live?
Gotta say that is one difficult case.
Yeah, it, it was Guillermo, You know,
and I think what you were saying about your concern, 'cause there's gotta be a mental component to it for sure, in addition to, you know, the stability issues.
Yeah, absolutely. The, you know, I think back about two, two events early on and, and the first couple of years of my practice, I remember one at that particular point in time, I was working two rooms and working back and forth from room to room and you know, I, like many of us that do that kind of work, it's always a challenge to
put to, to encapsulate or to, I don't know what the word I'm looking for is to, to, to try to take what happened in the last room and categorize it, stick it away and not trail it in to the, to the, the next patient encounter, trail it in like a piece of toilet paper on your shoe walking out of the bathroom.
So I would always stop in front of the, the door as I've got the patient's chart in my hand and flipping 'em open in the old days of paper charts.
And I'd take a deep breath stop there in front of the door and I closed my eyes and then one day the, the words show me where the greatest threat is popped into my head. And I'm like, wow, that kind of is what we're doing, isn't it? Where is the greatest threat?
And that is where I want to try to double down and get my first lever under. And in this particular individual, I could only imagine that the security issues are bound to be very high up in his world. The toilet paper idea Guillermo comes to mind. Oh my and Dave Panzer just dropped in over here on, on Facebook Live.
hello. It's so good to see you in there.
So when we were doing OSCEs Guillermo, you know, I was a a bit of an older student going through that.
And I remember as we were there in our nice starch white jackets in our little groups of three standing at, at the treatment room door and we hadn't yet started our, our vignettes and we had just a moment and I could just feel the tension, you know, and, and again, I I was an older student so I felt kind of like a, a, you know, father figure at that time to some of these kids.
And I was like, well, you know, how do we diffuse this with a little humor? So I asked, Hey, have I got time to hit the Lulu right quick? So I went into the bathroom and I grabbed a piece of toilet paper and ran off about a 15 foot long piece of toilet paper and I tucked one in the back of my shoe and as I walked outta the door, I dropped it and then I just trailed this piece of toilet paper in my shoe all the way down the hall until the whole, the whole hallway, everybody was just cackling. I'm like, okay guys, it's not all that serious. We can get through this.
But the other story I mentioned that had come to mind that when thinking about, remember how we were just discussing how I was doing a motor exam with a single leg heel and toe stands, and then in this particular patient who was presenting with a ratcheting type of motor behavior, theorizing that we've got some instability and a spinal cord presentation of sorts there. As a result of that, I was trying to move him into a position with his body of forward and lateral antalgia to maximally open the surface area of the putatively evolved neural foramen.
And that part of why I have thought that along those lines is in the very first year of practice I remember getting an MVA patient that came in and in my workup of this particular patient, they had been in a really severe accident as I'm doing dtrs, they were hyper reflexive and their biceps and on one side, so I tapped the bicep and then on the fly I just thought, wow, I wonder what that would look like if we altered the IVF.
And as I was doing the, the biceps DTRI said, do me a favor, tilt your head back.
And he tilted his head back and as he did, the hyperreflexia stopped and it became normal.
And then I said, okay, now bring your head back to, to neutral and continued this. And Hyperreflexia came back and doing that as this is an output, this is an input with head position. We just started to explore ranges of motion or head positions to offset or to reduce putative threat presentation at that particular level. And then basically showed him that with clear inputs and outputs, that if he is feeling sensitive or sent symptoms, that this might be a rescue posture for him. Hmm. And it seemed to help in the moment. I, in fact, I think I told Dave Peterson about that, Dave and, and Dave said in his typical way, Hmm, sounds like that'd be a good, good case study. Yeah, you wanna write that up,
Phil, with this patient, did he, does he have ed erectile dysfunction?
he does. Okay. Now he, you had the provocative tests, most of 'em were steady, if I recall. Did you try to do any of those with him just laying on the table on his back and see if he can reproduce?
I didn't. Probably the only reason at that point was one time. 'cause and it's, as you've noted, this is a complicated case and there's a lot of history in this because we didn't want to have an incontinence event right there in the room for either one of us.
And for, for him with the instability issues and such, just the changes in posture were enough to, to make me concerned about what we were going to be having happen there. So I punted on that one.
That will be the first thing that I explore in all likelihood when I see him this week, because that I'm gonna lean into those DNS three and a half month supine position exercises and I'm gonna see how well he manages that and I'm gonna coach him into what he's already learned with just abdominal bracing and in the transitional movements to get to different places. And first we'll check his issues with the, the reach, the hip flexion and the reach, which were potentially provocative as well.
Yeah, the reason why I asked you that question, because it's, that's something I I like to do is one, take out gravity.
But once they're laying on the table and you can provoke the pain, like in his case hip flexion and I'm suspecting some kind of instability, if, if I have positioned the, the patient right before he feels discomfort and I have him break his hands up, I give my back to them and I have them push against my back. That causes the bracing. If the pain improves and a lot of times it does or it goes away, then that's another confirmation and it makes it easier to be able to coach the patient. And abdominal brace basic.
I like that Guillermo, that's, that's really tight and very tidy and concise and you don't have to talk about it a whole lot. You can just have him do it.
I like that. That's a really good kinesthetic cue.
It's reminiscent of some of the stuff that Andrea Espina does with his FRC kind of stuff.
I've got a, an exercise that Kat Kat, you, you would appreciate this 'cause I think you've done some of pina's work if I'm, if memory serves, but I do one called claim this land and I'll take a, you know, a staff or something like that and I'll have them stick it in the floor and I say, this is your flag, plant your flag, own this ground and really shove it down into the ground. And that'll be part of what we work with, with this patient again, again next week. That shoving that down into ground and then, and that providing anterior oblique kinetic chain closure force closure across the front of the pelvis should theoretically improve their lumbar stabilization capability.
And then when they ask the SOAs to take moment on the hip by virtue of stabilization at spawn, we should have less symptoms. And that would be a way to scale that exercise plan as well. And then we could take one out of F-M-S-S-F-M-A, they've got some lovely supine progressions as well of using a cable stack apparatus overhead and getting, you know, legs up in a supine three and a half month per DNS position and doing cable rows over the top to work on that closure across the front. And I would add to that, when not only bilateral, but also unilateral and working individual poles on that too.
Just some thoughts.
Well, this was fun.
We'll see hopefully next week if this patient is responding to the queuing and such or if they are indeed a surgical case.
I don't think, I think we're gonna give it, I mean, based on, I think he's got 15 years of chronicity here with this intermittent kind of presentation of incontinence. I think we'll probably give it a few visits at least before I weigh in with an opinion on that.
But that is the bit for today.
I usually would want to end right at 10, but I've, I've got to see if I'm able to bring Dave in here.
So I'm not seeing that Dave has got that activated.
I gotta say, Phil, I get my share of complicated cases,
I'm certainly glad that I didn't get this one and I hope I never do.
You know, it's, it's,
I'm a little traumatized right now, Megan, I hope I never get that.
You'll, you'll, you'll, you'll be all right Bri, you'll be all right. Give yourself a hug, man. The, no,
I mean the, at this stage, the, I I guess the blessed part of where I am practice-wise and all is I, I've got enough room in my day clinically, I, I put a fair bit of time in between patients. I don't have to be, you know, like jamming patients through and such. So I can, I can do relatively, I can take a case like this and spend a bit more time if necessary. And quite honestly, it is, I find it perversely engaging 'cause it, it's like, all right, a puzzle. You know, I do whirl every morning.
It, I like doing puzzles and these complicated cases, I'm, I'm humble enough to know that I might not have an answer. But I am also real enough to know that a lot of these patients, they don't have any options.
And, and I'm, I'm also aware that this, this heuristic that we're playing here with this neuro centric approach is different enough that it's, in all likelihood, it's stuff that hasn't been applied in this particular patient's case before. So we'll at least give it to college, try and see how things go, and then be very honest with the patient. I don't know if we're gonna be able to make you better. I have no idea, but I'm willing to try
we'll give it a shot and not set unrealistic expectations in the patient. Here I'm bringing, let's see if Cat wants to come on. Kat, are you dressed appropriately?
All right. Looks like everybody's shy this morning. All right, well that's cool to everybody that came in this morning, thanks. Over here on Zoom. Thanks. Over here on Facebook Live.
This will go up on Facebook Live for 30 days. You can watch the whole thing over here on Zoom. I'm going to take the transcript and the recording there. Did you see that one last week, Guillermo? The, I've got a recorder on here from rewatch so you can see the video and then at the same time have the transcript handy. And what I'm doing is taking all of that and putting it up on my YouTube channel as well so that anybody can see that the idea here being to get the word out about this process that we're working so that others can understand it, as I said before, we will probably hold or drop a another lifetime membership deal on Black Friday. So if you've got colleagues, other students in your world cat folks at R two P and such, send out a message to them and let 'em know to, to keep their eyes peeled. You start showing up on these katt.
If you want to just shout out to the R two P folks at the different schools and such and maybe get in touch with Corey, Corey Bailey and let 'em know. So I would love to see some of the R two P students showing up in this environment and just getting some exposure to this, to, to prick their knowledge, not to make them pricks as, as students, as, as Dave can appreciate, if you get students too far afield in some of the other stuff to the, the course curricula is already busy enough to occupy enough of the cranial real estate there that if we get students too far afield doing other interesting, perhaps very useful, but distracting kinds of things, and they start to think, oh, my education is no good. But I think the, the first order of business is to take the, is to value the, the opportunity that is placed on you guys as students when you're in the program, to learn from your professors and to learn to be effective doctors so that you can wade into that case as a responsible provider of neuro musculoskeletal interventions as a re respected member of the care team with our medical counterparts and so forth. So do that first, and then we add this kind of stuff that we're doing, which is an integrative rehab approach. Onto the top of that as a way to keep you organized and not getting lost in the weeds with your clinical encounters when they get a bit complicated like this one that we covered today.
Big hugs to all of you.
Stay dry out there today if you're in the Pacific Northwest. And I will see you guys next week at 9:00 AM Pacific time for a cup of coffee.
We take care of people. Do good work.
Take care, pal. Thanks
Guillermo. Be well brother.