NeuroCentric Approach Zoom Case Study-The 4 Nerves of Shoulder PainNovember 4, 2023
NeuroCentric Approach Zoom Case Study-Femoral Nerve 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.
Transcripts from the video above are below...
For our neuro centric approach. Coffee club meeting, we are coming at you from two directions today.
Over here we've got the over the shoulder look and over here we've got the Zoom look. The Zoom look is for members at the neuro centric Approach Online academy.
Although I see Catherine, Roddy is over here because Facebook live is a little easier over there, isn't it? Ka?
And looks like Jerome Friar is showing up with us here as well. Good morning Jerome.
And he's got a new model that he wants to show and just buzz that past me a bit ago. And I noticed that the model is along the lines of a case study that I wanted to talk about instability and some other issues from a case that I had this week that I thought would be worth discussing.
So let's see what's new this week as folks are coming in and my world, my wife is hiking Hadrian's Wall in the uk.
She's over there for a trip all by her lonesome and my doggie and I are getting some batch time this week and next week, but she's enjoying a nice little end-to-end kind of walk across Britain. Yeah, it's kind of cool.
Let's see what else. I have some of you that were on here last week, saw my son with us, let's, and after that we went out and had a lovely walk around in the woods on a beautiful, beautiful fall day.
And the C Cress are up at a thousand feet in the Columbia River Gorge. We got about six pounds CREs and had a real nice feed that night.
Let's see other things. There is apparently even right about now, partial eclipse going on, although you would know it here in Portland because it's cloudy, I guess down where you are. Catherine, you'd probably be able to poke your head out in about 30 minutes or so and see a, see a solar eclipse. Don't look at it, don't do that.
Go online first. Get some glasses or figure out how you can do it safely. Don't bake your rate your retina. Now, other things we have have a fascinating world situation right now with the Hamas invasion of Israel a couple of days ago or a week ago and just is an amazing time in the world right now. My heart goes out to all of my Jewish friends, Israeli friends, and to all of the civilians in Gaza that are dealing with the tumultuous times that are going on there, hope we can find our way on the other side of this crazy conflict laden time that we find ourselves in at some point in the not too distant future.
Okay, on slightly more on topic items, I thought today a topic of conversation I would lead into with was a, an interesting patient that I had this past week.
I will pull her
chart up and get it in front of me so that I can chat it out.
This was a patient referred over to me by an urgent care doc who is former resident of one of my colleagues who runs the Family Practice residency program at Providence.
And so he's known of me for some time. I've been working with him now for the last several weeks with a back issue that he's got. He had a prior history of a lumbar disc from several years ago that he rehabbed effectively, but he was struggling with some ongoing pain now that he is a father and has a,
I believe his child is about eight months old now and another one about a year old, a year and a half old and he's not getting very much sleep. So we can imagine the interleukin six concentrations relatively high in his body and he has near constant pain in his right lower back and that right lower back pain on evaluation.
I could palpate it and it correlated to the middle branch of the superior clonal nerve on the right.
It was so clonal neuralgia was not something that was in his zone of reference. So we've had a good time working with that. And then following up with some D N Ss work, he's been impressed with the results there and sent over a patient this past week, 48 year old female who moved to Portland several months ago with her husband from Boise, Idaho. Shout out to Dr. Ben Ramos over there in Boise.
She had a pretty interesting backstory.
She's had right lower back pain, posterior hip pain and right leg, what sounds like history of sciatica for the better part of 12 months after, as part of her moving packing boxes and everything almost a year ago. And she recalled trying to lift a box that weighed about a hundred, 150 pounds or so and she felt something move in her back according to her. And she had exquisite pain at that particular time. Over several weeks it got a bit better, but she's had some level of sciatica in that leg up until that point. And then once again, about two weeks ago, she had a really intense flare up, what she referred to as worst pain ever in her right anterior leg over her TBIs anterior ever area.
And that's what caused her to present to my doctor friend urgent care.
She was given a course prednisone, which seemed to help after about three days. Those symptoms were essentially resolved.
Past health history is deep and wide. As I mentioned, 40 year old female, two children, but one still alive. So a tragic story there. Her 12 year old child died in a rollover accident in a car that was submerged and he drowned. So she had that trauma in the last year. Her brother-in-law was murdered.
She's got that trauma on board. She is a type one diabetic lifetime. She is well managed there. She's using a Dexcom continuous glucose monitor with an onboard insulin pump. So sort of a plug and play solution that works quite well.
She's got a frozen right shoulder, she's got a bleeding disorder, a protein SS deficiency.
She's had a prior history of deep vein thrombosis. She is hypertensives.
She was diagnosed with acute myelogenous, my leukemia in 1998.
Let's see, she's had gallbladder and appendectomy 2003.
She had chemo in that leukemia episode in 1998.
Let's see what else?
Full hysterectomy, 2013
bilateral carpal tunnel tunnel release. She's had eight, eight trigger finger releases, eight trigger finger releases in the last two years. She had a left second toe joint removed, moved due to chronic pain and a failed fusion.
And she's had nine eye laser procedures for diabetic retinopathy.
Quite a deep history there.
Let's see, she's also on apocrine for low cortisol.
So she presented with
ongoing intermittent pain in her right posterior hip thigh and leg, which were a lot better than they were a couple of weeks ago.
And one thing I forgot to mention, she didn't mention on her intake, but it became apparent when I started getting her to move around, she was reluctant to lay on her back. And as she was reluctant to lay on her back, I asked why. And she said she gets vertiginous when she lays on her back.
So I asked her if she would mind demonstrating to me the process that seems to make her feel that way.
And she had no problems laying face down in a prone position, but when she rolled over onto her back, she could get down onto her right side. But as soon as she rolled over onto her back and got beyond midline, she would start to feel vertiginous. So I put on my vertigo hat and got her up, sat her on a, my swivel swivel chair, the swivel stool and I blocked her head. Some of you might have seen I've got on my YouTube channel, a patient that I worked through this rubric, which is the, the assessment of peripheral vertigo up to Epley maneuver.
So you can check that out on my YouTube channel.
But the swivel test block the head movement while the patient's looking forward. Then have them as I'm doing here, walk themselves all the way to one side and then to the other. So you've got effective end range rotation in cervical spine to the point that she could not move any further and she was not able to reproduce her symptoms doing that. So the idea there being we are trying to isolate the, the labyrinth, the vestibular apparatus and tease out the joint mechano receptors in the upper cervical spine and see if we've got any feed forward problems there that could be contributing to that. So we didn't have anything there. So next stage in that process, typically since it's important to note, she had a rapidly extinguishing pattern of vertigo.
Her symptoms last just a few seconds and they, what she had learned on her own was that she could make them go away just by focusing very strongly on something and by doing deep breathing, which she had noticed a correlation in her vertigo symptoms with, with stress. So that was kind of interesting.
And given her prior history of RA of trauma, that brought up some ideas for me. So the next place I would typically go in that out of that assessment is a Dick's Hu pipe maneuver or get her to lay on her back with her head fully rotated and extended and the neck and you know, to the right and to the left. And she could do it to the right.
And as soon as she started turning to the left, she reported feeling really vertiginous and really nauseous and was concerned she was going to throw up. However, she exhibited absolutely no nystagmus and she demonstrated to me that she could extinguish the symptoms in just in less than 30 seconds. So that's leading me to think that we're dealing with some sort of peripheral kind of issue or at least away from a centrally mediated issue at the brain that we need to do some sort of red flag rule out issue on.
So I pulled a page out of the graded exposure therapy and the world of psychology and tried to help her establish a bit of agency. She had noted that she could lay on her back with her neck flexed and she could turn her head to the left fully without symptoms. But if she let her head go back towards neutral and try to do it, she would get symptoms. So in the the, in some types of psychological treatment for exposure therapy, and I'm privy some of this being married to a psychologist, but this type of graded exposure in trauma patients, typically the the trauma, the patient has some sort of an idea about the things that might promote their trauma, the mental thought processes and such.
It might promote the trauma and those patients will then be instructed on how to use deep breathing mechanisms to reduce the physiological effect of the trauma.
And then the patient will be coached through something in this case sympathetic up upregulation breathing into a, a paper bag to change blood gases and get them a little bit sympathetically aroused. In this particular patient, since we knew that she could provoke her symptoms, we went right up to the edge of that. But first we coached her through deep breathing, four seconds inspiration, six seconds expiration where the best evidence tends to oscillate around the improvement of parasympathetic tone and downregulating the the sympathetic tone.
And at that, we then e started to move her into the provocation position. And as her symptoms came on, I stayed there with her and coached her through the deep breathing and also through some ocular motor reflex material that I learned once upon a time many years ago from Feldenkrais movement therapy.
And we worked on soft gaze into the dis into the distance while she was doing that incorporated d n s principles of leading the movement 'cause she would not use her eyes with the rotational movement. So I had her to initiate the movement before her s began by looking as far as she could to the left her, her provocation position and continue to look around the corner there to the left as she did it. And lo and behold, we were able to get her to go all the way into several repetitions of turning her head all the way to the left.
And the fascinating part, as some of you pain science geeks are already waiting for the other shoe to drop on this.
The fascinating part is she, after we did that, and I wasn't anticipating this, her leg pain and back pain were much improved. So her symptoms in the back of the leg, she had had an x-ray, a three view, X-ray done at the urgent care facility, which demonstrated, let me get this right.
Let's see, she had a four millimeter anterolisthesis of L five on SS one and a four millimeter retrolisthesis of L four on L five
and she reports that she's got some,
some sound, some clunk out of her back when she moves.
So as I mentioned, her X-ray was a three view x-ray.
We've got a patient with essentially some sort of interesting connective tissue disorder history.
On physical exam, she appears to be hypermobile and most vectors I would put her at a biting six over nine and I, on her instability tests, she was positive three out of three for the, the prone lumbar extension, the supine inflection test, and also McGill's prone instability test.
All of that making me think that the presenting sciatica that she's been having for the last gear is likely due to some foraminal and narrowing owing to the changes there from the list thesis that are going on.
So we gotta now go get another x-ray that shows us the status of the stability there. We do a flexion extension study and also an oblique to try to see what the, the status of the pars interarticularis is.
We could do a M R I follow up if the pars looks like it is challenged with a, the stir echo on the M R I to focus on that a bit better and learn more about the pars if that's the case.
But interestingly, on slump test on S L R, no symptoms, she had a restrictive range of motion, but no real symptoms and I was not able to modulate her symptoms on slump or SS l r with neck and ankle movement. So interesting case, I'll keep you guys posted on that.
The, let's see, it looks like Jerome has dropped off of our list there.
I think it's worth noting as well for those of you that are coming on here unaware, especially over here on the over the shoulder with Facebook Live.
This is the neuro centric approach coffee club, and we're talking the neuro centric approach and we're talking about the online academy that has been out now for a few weeks. Those of you that are unaware of that, please feel free to join us there at academy dot neuro centric approach.com.
I think there is a link, yes, it should be coming up on the,
the link right now on Facebook Live, but it's academy dot neuro centric approach.com.
So I would encourage you guys to come and join us over there. The price is stupidly low. You've got, I think we've got about 30 hours of online continuing education that's recorded there and that is PACE accredited for chiropractors for continuing education.
And you got 30 hours available to you, you can pay for it by the month or you can pay for it by the year to have access to it. So if you just need to get your CE taken care of in a short period of time, pay 39 bucks right now while we've still got that offer in place. And you can go there and get some continuing education as much as you need for the ridiculously low price of 39 bucks and change.
And, or if you just want to pay for an annual membership, you can save about a hundred bucks or so by paying for it annually, periodically. For those of you that are lifetime members, I'm gonna toss that out there as well. So you guys keep your eyes peeled for that. Periodically, we'll throw some, some single time payments for one flat fee and you can get lifetime membership to the site steadily adding content on a about a monthly basis. I put another piece of content out there and what I'm investigating now is also building an app for the neuro centric approach that, the way I'm conceptualizing it, and I'm open to feedback from those of you that are involved here, but the way I'm conceptualizing it is it'll look a lot like the, the original YAP or D t M course where the, the, the way that I could conceive of it being most useful is, let's say you got a patient that's getting ready to come in and they got shoulder pain and you just wanted a very quickly review what it is from a neuro centric approach, vantage point that you need to focus on.
So you find a map or a, a picture of the, of the body and you poke on the shoulder and shoulder detail for N C A would come up and the details from the shoulder course that is in the online site would pop up for you there. And your nerves of suspect, the suprascapular nerve, the radial nerve, the axillary nerve, all of those and, and the dorsal scapular nerve all commonly involved. Nerves with shoulder complaints would be reflected there.
It would talk a bit about the, the ways that you could use D T M or transverse nerve mobilization to offload the nerve or try to work on a putative interface area.
We don't, so you get a manual prompt and you'd also get a a bit of functional exercise recommendation as well and some home care to address the structure that's actually talking. So that's in the works right now. I've gotta get that out of the gate for the, the Fix Your Own Back program, which is also online and I'm just building the app out for that right now as well. So eventually we'll have actually that that app is built out and it's now available, the, the fixture on back app. It's now available on Apple and Google on the app store. Whoop, whoop. So do we have any comments or questions from any of you folks over there on live
or from any of you folks over here on our Zoom meeting?
Okay, so I see Michael Holstein, Josh Paloma, David Brown on Welcome guys. Appreciate you joining us today, Josh, I hope you're well.
It's nice to see your text representation of your being here.
If you guys don't have any specific questions, then call it a short one today then, and we will reconvene next week. Those of you that are, were unable to join us today can check in on the, at the end of this, you can find us at the recorded version at the online community. Actually I see, I'm seeing Doris Merton show up and Doris has been trying to get in for a while.
So let me stay on here and see if we can chat with Doris.
Doris, welcome. It's nice to see you.
So unmute yourself there and chat me up about Toronto. How are things going,
going? No, No, I, I was listening to you on Facebook. Thank you.
It's nice to see you too. I've been listening to you on Facebook, but this is the first chance I had to get to my com laptop to get onto Zoom.
So I know we had some difficulty before, I think because of my own ineptitude and trying to get the, the links properly shared out there. So No,
this one worked perfectly fine.
Perfect. Then I, I think you're on your coaching there and the things that you had learned was what I needed. Apparently I was just going on to Zoom instead of going specifically over to my,
the, the actual event that was saved on Zoom that was being sent out. So good, I'm glad to see that, that worked.
Much appreciated. And,
And Jerome is back on as well, and he is, so we are, we're well represented by Canada here this morning because Jerome's in Vancouver or Kelowna, but you, you guys have got a new citizen up there from my household. My son just got Canadian citizenship last week or two weeks ago now. So I, I gave you my best and brightest.
So what's new in Toronto these days?
just have to mute myself. Nothing, nothing really. I mean, you know, I think all major cities are still sort of, i I work right in the downtown core still recovering from all the craziness from Covid still not quite what it used to be.
But it's slowly, slowly coming back.
Yeah, I I, I understand how you feel. I mean it's mostly back to normal here, but you know, like the, the certainly the continuing education in-person kind of stuff is still still lackluster and that's part of the reason why I put the, the online site together there. Have you gone on and checked out any of the online coursework?
I have. I've done a couple. They've been great. I've been slowly
your, gimme some feedback on that. What could we do to make 'em better?
I actually really quite enjoyed that. I I sort of, I haven't quite finished the fix your own back, but I did do, what did I do? I did the knee and maybe the ankle and foot. I know you had mentioned once that you're considering on these chats, maybe, you know, walking a ner walking through the full nerve. That would be really interesting Okay. To do.
Okay, that's a, yeah, I, I think the, the way that this process is likely to evolve over time is we'll have a variety of different ways to access the information.
One, I think you may have caught over on Facebook live a moment or so ago, but I was talking about the, the app that I'll build out at some point in the not too distant future with all the extra time, all the extra time that I've got.
But the, the idea being to have something that's ready referenced that you can very quickly get, you know, alright, this, this, this, this, this. I need to keep that in mind with this patient that I'm getting ready to see versus bite-sized courses on the site that are an hour to an hour and a half long, possibly even a micro course in between of length. I'm, I'm thinking about it in the way that most of us tend to behave and we, we tend to have certain little time blocks that we have, we're free that we can be able to check some of this stuff out and then longer courses available online that are eight to 12 hours. And then finally, of course the in-person courses where we'll be able to get people's hands working a bit more again and be able to, to actually feel what it is we're talking about. And Justin and I can come out and teach coursework in that as well, or both of us if numbers warrant or just Justin will come out and teach that as well. So the, I'm thinking that in between micro course kind of thing is probably something along the lines of what you're talking about. So we isolate one specific nerve and say, okay, this is where it comes off of the, the spinal cord, you know, this is a spinal derivation, this is the, the actual course of it. This is how the course is challenged or mechanically challenged mechanically or you have potential interface issues along different aspects of it, et cetera, et cetera. Yeah, I think that could be fun.
I'll also just say I really appreciate all the references that you give, all the research. It's been great just to, to hear all of that again or, you know, be updated. So much appreciated for that.
Good. Thanks Doris. I really appreciate the feedback there. Yeah, a lot of work goes into this and
it's, I am hoping that a few folks, you know, if you want to do something out there on Facebook, share this with your friends and in your feed so we can get a few more people consuming this.
Jerome, you've got, do you have your ears on there, mate?
Jerome this morning had a,
we had mentioned he, he was sharing with me a paper, let me unmute him, sharing with
Jerome Fryer DC
a paper about lumbar instability. Talk to me, Jerome, what do you, what do you got on your mind there about that?
Jerome Fryer DC
I, I think it's just a common, I think it's extremely common finding that often we don't have the diagnostic capabilities to discern, you know, the specificity, but you know, these little movements that cause patient's pain, You know, in particular when the spine is moving.
I just think it's, you know, I think for the most part we're on to it, right? But sometimes it's a little difficult communicating that to a patient. Like how do you help them understand, you know, oh it hurts and what does that look like and what do you do to mitigate that? That sort of thing. So anyways, I just thought that was interesting that that just came across my, you know, my feed there on my, you know, the searches that I have on auto there every week on when, you know, Saturday morning it comes in off PubMed and I've got certain, you know, certain keywords that, you know, I'm kind of dialed into. At first I had a, a whole plethora of, of keywords and I, there was too much to sif sift through, so I kind of narrowed things down so I could be a little bit more, I don't know, just a little bit more, you can't read it all right, but you've gotta sort of read the stuff that's pertinent to you, you'd think, or at least what you know, what you hone in on in clinic.
So that's all.
Jerome Fryer DC
I've got the same thing up For those of you here and here, the paper that Jerome is referencing is brand new paper that admittedly I haven't read yet.
I'm gonna throw you the PubMed ID number as well that you can search.
It is 3 7 8 1 0 2 8 6. So if you just go onto PubMed and put that P ID number N the paper will pop up. The paper's called facet joint thickness and lumbar instability documented on mylo computed tomography studies in patients with lumbar degenerative disease.
Appears to be a Japanese study, appears to be all Japanese authors here.
Looks like at cursory review it's 120 patients 45 with lumbar degenerative spondylolisthesis. So that patient that we had on the case study that I was discussing earlier, that would be one that we would be interested in possibly applicable there and 75 patients that had lumbar spinal stenosis alone
and the myelo CT findings were indicative of lumbar, of indicative of instability, which included facet joint thickness and you and facet tropism fluid in the facet joint.
Yeah, this is fascinating stuff I'm recalling as well in the fixture on back course and Doris, I think you might've been at that course when I taught in Toronto, but there's a paper that Michael Shacklock brought to my attention a number of years ago that both of us were very intrigued by, by Dombrowski where they did a ct.
They had, I, I believe if memory serves, they had CT set up on patients and had them go through full flexion extension. So as you know, Jerome, we would typically try to clinically rule in or out an instability issue in a lumbar spine. We do a flexion, lumbar flexion lateral and take a still shot and then have them do an extension and take a still shot. But what we don't know is what happens in between.
And that live CT that Dombrowski did that was incredible. Those of you that are on the online academy for N C A, that course, the clinical companion of Fix Your Own Back is on there. You can find that dombrowski paper I'm referencing in that particular course.
But the, they showed that not, it's not a purely sagittal plane movement. There's all kinds of interesting deviation. And it's patient specific too. I mean it was a very small, small study. I don't think you can imagine trying to set something like that up. It would be impossible to do a very large cohort, but I think they had, You know, 5, 6, 7 Patients or something. So what have you done with your model? Show us what you got there.
Jerome Fryer DC
Let's see here. So, well here is a two through five and this disc here has been created with half the stiffness as these two.
And with the Hyland cartilage that I've tried to recreate here, you can see the white, it's an elastic meric tissue here. So helping patients kind of understand, you know, oh, okay. Oh, that, that's the cartilage there.
Interesting. Okay. So, but with movement you can see how the one segment moves in excess.
Jerome Fryer DC
right, right. So, and then I've peeled away the hylan at that particular level. So if you wanna talk about and help the patients understand the movement, the excessive MO movement, I don't usually use the word instability because you know, as soon as you use the word instability, people think they're unstable and something's gonna fall apart. It's not the case. These are subtle movements. And I also like to help patients understand that these movements are small and it's not like something's out of place. You have these subtle motions that if you have a motion imbalance and likely due to, like I had a case there yesterday.
Somebody was, yeah, you know, I suspect that there's a hypermobile segment and gets shot down the leg. You know, he gets pain down the leg with certain movements and he's coming to me and I'm helping with stabilization, you know, through. And it's been very helpful for him.
And we just had an x-ray, and you can see this excessive, there's excessive osteophytosis at this one particular 11, actually three four. So very likely over the course of his life, whenever he bends, there's a focal point, there's a fulcrum at that particular segment and he just keeps moving. So I have to train him to move a little bit differently to reduce the hypermobility at that particular level. So anyways, I just find that, you know, using the model helps them, oh, okay, so really it's not that bad, I just have to do this. And they do, you know, and if they do the hip hinging or they, you know, move in a better weight and not trigger this, all of a sudden they're like, Hey, I've seen it.
I know what needs to happen. Then I talk about the progression associated with adaptation and changes over time with degenerative disc disease, how this will likely stiffen in time. Because often their, their mindset is like, oh my gosh, am I going, you know, what's like, what am I gonna look like at the future? Right when they're laying in bed at night, right. So you can tell 'em, you know what, in time you take care of this, this will likely stiffen and this will reduce in pain and you know what your prognosis is good. So I just find that, you know, using the model really kind of empowers the patient with these, these movements that aren't, that, you know, they have these exaggerated movements in their mind thinking that something is like way outta place and, but they're subtle, right? These are small movements and Yeah.
And you know, and for those of you that don't know Jerome, this is Dr. Jerome Friar and up in Kelowna points around Kelowna. Where are you?
Jerome Fryer DC
No, I'm I'm on Vancouver Island.
Oh, you were on the island. What?
Jerome Fryer DC
What town are you in?
Jerome Fryer DC
Jerome Fryer DC
Nanaimo. I was, I was in Tino for seven years and then we moved to the inside here for our kids.
Oh, far out man. It's gorgeous country up there. My son did a, a clerkship over there in, gosh, I think
Jerome Fryer DC
No, no, no, it was little town. He did an inpatient or an outpatient internal medicine clerkship. It started with a d was it Duncan?
Jerome Fryer DC
Jerome Fryer DC
Just a little town.
Jerome Fryer DC
Oh, it's not that little. Yeah. Well that's all a matter of perspective. Yeah,
Yeah, there's that, right. But
Jerome Fryer DC
Yeah, he was, he was over the moon about how beautiful it was up there. But I used to live up on Orcas Island, so I can appreciate the, the topography of that
Jerome Fryer DC
part of the world. The, you hit on several really germane points there, Jerome and I, you know, I, I know there was a time where you as the, the founder and the, the wizard at Dynamic dis Designs, you're wearing your, you're in your shop, the, the master in his, at his craft with your, your your dirty vest and everything. I'm, I can only imagine you get the same kind of crap from your wife that I get from about, about the, the work stuff all around the house.
But you, you've gotten a ration of crap at various times over the years about the possibility of
Jerome Fryer DC
Re creating fear or,
you know, creating
Jerome Fryer DC
fear avoidance, that kind
Jerome Fryer DC
Yeah, right. Yeah, it was interesting. Yeah, yeah, right around the time of the inception of the company I was like, you know, built it for the, the purpose of empowering patients and, you know, revealing the sources of the, of, of potential causes. And then, yeah, it was really interesting.
Jerome Fryer DC
Yeah, it's, it, it's, and I, you know, I, it feels to me certainly in my own clinical practice and in the, the teaching that I do, but it, and seems also in the, the sort of overall vibe of the way that people are talking about pain science and stuff these days, that it's also gotten sort of, it's taken it on the chin from, you know, some of the, the major researchers being involved in some huge papers that ultimately found out that, well, it's not all just about pain science.
You, you know, the, the Traeger paper from Australia was a watershed and Mosley was a co-author on that.
And they were looking at ways to try to demonstrate whether pain science education in patients that had acute low back pain could reduce the progression of acute low back pain to chronic low back pain. And they found in a very well done study that it was no better than the placebo. And the placebo was just general recommendations to be active.
So it was some education, but not specifically pain science education. So it doesn't mean that that stuff isn't important. It doesn't mean that micro movements of a, of a a a spine that is dealing with that, that that's not important. It just all needs to be framed as part of a more integrated process. And that's what we are trying to do with N C A. How do we bring the brain and the patient's understanding of their condition, some agency there, how do we bring that into a viable, pragmatic solution to help that patient reduce threat, putative threat to spinal cord nerve root elements of their central nervous system right there next to a segment That's the body's a little bit on high alert about that, that segment moving too much.
It makes me think as well about another patient I had not too long ago that they had prior history of multiple lumbar disc herniations, some pretty marked lumbar disc disease.
Patient was an engineer so very much into a mechanical idea about what was going on.
They had previously responded quite well in their lumbar disc herniation to McKenzie extension end range loading.
And now any kind of end range extension caused symptoms very specifically into the middle buttock and palpation. It was not over the sciatic nerve palpation, it was kind of over the middle clonal nerves. So I'm like, do we have some middle clonal involvement? Yeah, possibly.
But you know, the, the one structure that this paper that Jerome brings to our attention that we have the poorest sensitivity and specificity for with orthopedic testing are the facets.
And you know, Kemp's seated and standing were positive on him.
He could reliably make his symptoms worse with walking and then he could only take about 10 steps before he would start feeling a progressively worsening pain that stayed right in the center of his butt.
And I had a difficult time actually palpating in that area and ice and localizing it with palpation. So he subsequently, I sent him out and he had a facet block and his symptoms were remarkably better for a week. So they promoted the idea of, of a, a medial branch ablation and this patient being the type of geek that he is, he did his research on that medial branch ablation. And mind you, he had a, a spondylolisthesis, it was a grade one, it was about four millimeter slippage.
But his point very well thought out was, if I get that medial branch ablated, is that medial branch is also, is not just sensory, it's also motor to the multifidus. Is that going to hasten my list thesis?
So, beautiful question. 'cause there was once upon a time, and when Jerome and I were going through school, we were taught that the, that medial branch is pure sensory. So, but subsequently we've learned that
Jerome Fryer DC
there's motor involved in that, in that medial branch. And when we are ablating it because of the, the facet, the involvement of facet, we are also indirectly reducing the motor al output to the multifidi. So if we've got that tendency for slippage that the restrain facets are restraining, then it's kind of borrowing from Peter to pay Paul.
Jerome Fryer DC
Yeah, that is so interesting. Thanks for the reminder that just that had slipped my mind regarding the motor innovation there, so thanks for the refresher.
Certainly. Okay, well we managed to talk for another 30 minutes about some interesting topics there we're coming up on an hour.
Does anyone have any questions or comments before we sign off in a few minutes
Just to say thank you, that was actually really interesting and, and a really great, I had not actually thought about the motor component of that nerve and, and the impact of that so
helpful. Yeah, I think,
I think that's one that we will, I think all of us as, as someone who has experienced lumbar disc herniation in my past as part of what got me very interested in all of this and I was, you know, a, a smaller subset yet because mine was an upper lumbar herniation and then subsequently going through all the D N Ss material and always being told that I was weird because I couldn't get rid of my open scissors and I couldn't make certain portions of my abdominal region actually fire the motor for those abdominal muscles, the obliques coming from the area that I had a, the disc herniation and a radicular process involving that that affected the motor for those nerve, those muscles.
Yeah. And now, you know, after years of really being very careful about trying to manage that lordosis and I find myself now with more of an extension pattern and my facets are talking to me under certain times. So it's more challenging now for me to swing a kettlebell, do swings as part of my workout. So you'll see this as many of us get a little bit older and you'll certainly see it as all of us get a little older and wiser. And you, you should probably be a little bit suspicious if all of the people that are giving whose information you're following on social media happen to be 20 something or 30 something and they're giving you all kinds of information about how you should manage a particular issue in your back or in your knee and and such, you should take all of that with a grain of salt because time tends to make things a bit apparent.
You know, there are those online that really coach willy-nilly going in all the way under load into deep knee flexion as well, which will work really well for some conditions for a period of time. But it's in that position under load that we put the root of the medial meniscus into a maximum compression and then rotation moment and that's where the blood supply and, and for the meniscus lives. And that probably will hasten degeneration, which probably a sweet spot right in the middle of loading like that, that all of us should pay a bit more attention to. Same thing with lumbar spines. So here's to a good finish on today's coffee club where we will bang the drum for, we'll call it the middle path, if not mediocrity.
Thanks for all your efforts,
Phil. Yeah, thanks so much guys, for your time, your attention. This will be up
your review or for others if you want to share it on the community also on my, the recording will also be available on my YouTube channel. You guys be well, take care. I'll see you next week.