NeuroCentric Approach Zoom Discussion-Top-Down Low Back PainNovember 26, 2023
Neurocentric: What Does it Mean?December 3, 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.
Obturator Nerve Mimicking Hip Arthralgia
Transcripts from the video above are below...
I assume by that profile picture. That must be Ryan Ondick.
How are you sir?
I'm doing good. Can you hear me?
I sure can. Have you been out trying to fill your freezer recently?
Yeah, ELLP season wasn't all that good, but we still have another shot. I got a late season.
Got it. I will let you know that I delved into the summer sausage that you made for me and we're kind enough to share for you as after I spoke with the R two P club last I, I just broke into that for a holiday party recently and it was very well appreciated.
Glad to hear that.
Yeah, thank you sir and welcome in to Kimmy as well.
I hope that you are doing well today. Kimmy. Kimmy, where are you in the world at this stage? Are you up in
I'm in the Bay Area, California.
Ah, I thought for some reason
you were in Toronto.
you? You were never in Toronto?
No, I saw you in the Bay Area a handful of years ago.
Right, right. Copy that. That must have been the San Jose.
Yes, Joe, that
we did. Very cool. Should be getting down there at some point in the coming year.
Looking forward to it.
Yeah, we're starting to line up a few events here and there and we'll announce those a little bit later. But thanks for joining us this morning and I look forward to any questions that you guys might have over here on the Zoom for you guys that are over here on Facebook Live, you're doing the over the shoulder bit that the members to the neuro Approach Online Academy are getting the neuro centric approach. Online Academy is a membership site currently about 35 hours of recorded online continuing education from mostly it's organized at this point in bite-sized hour to hour and a half continuing education courses that are regionally specific, regionally specific meaning like
lumal neuralgia or foot and ankle pain, et cetera, et cetera. We've also loaded up the dermal Traction Method course, which is about three hours I think in length.
The Clinical Companion to fix your own back, which is an eight hour course.
There is also one that I'm particularly fond of, which was a collaboration that I did with the coaches at Kabuki Strength Lab where I have an on office and that is a 13 hour behemoth, the fixer owned back for the strength athlete course. So that one is for folks that are a little more familiar with playing in the weight room and negotiating relatively large loads and ideally as an athlete probably trying to continue training for some sort of upcoming event. So we speak a lot about lateralization training options and safe training options to recover from a disc herniation and still stay active.
So please do come join us. There should be a link for those of you over here on Facebook land. There should be a link there on the video for you to come join us. If not, it's academy dot neuro centric approach.com or just go to the neuro centric approach.com site. Okey-doke. So we usually gather in this particular meeting and sort of organize ourselves around a case study. Welcome in Alex, appreciate you joining us.
The case study this week. I'll go ahead and get into, since it looks like many of you that are joining us are in the Pacific Northwest. We don't want to talk about weather today 'cause it is pissing down rain in an atmospheric river out there. It's got a current break, but hopefully I'll be able to get out and get my doggy in it.
Got a few folks still jumping in here. Maybe I'll just talk about the weather for a minute while folks are continuing to join. Brian, is that Brian Dinger?
Yes, it appears it is joining us live from South Dakota.
From his garage. Or are you in your basement today, Brian?
Hey Philip, I'm in my basement.
You don't have the 65 and sunny weather today, eh?
Yeah, we don't either. Alright, so let's go ahead and get into the meet and taters of today.
The case study for today was a delightful gentleman that joined me in this past week. He was referred in from another patient.
This particular gentleman came in, he's 79 years old. He is a competitive table tennis player of many years and that intrigued me because I have a a bit of a, of a passion for playing table tennis. I might actually join a local club on that this winter and to get a little community and to get some proper professional guidance on how to flail about a table a little bit, but keep my older eyes and, and reflexes going a little bit better.
But this gentleman showed up with right hip pain, he's right hand dominant and he was noticing the pain initially, mostly when he was playing table tennis when he would do a forehand smash. So think about a movement like this and the push off with the right leg, the plant and the rotation that occurs in that particular area.
His past health history was significant for two diagnoses of skin cancer, one basal cell and the other melanoma without metastasis. So we've got a 79-year-old presenting with back and hip pain and a prior history of melanoma. Of course some of our rule outs there are going to be, is this your first episode of back and or hip pain and have you had any other treatment? So asking those questions in the history. He has a 20 year ongoing low back pain with confirmed multiple level disc herniation history, the two lower lumbar segments L four five and L five S one prior history of sciatica involving the currently affected leg as well.
The, because as we've discussed before,
rotational athletes and I would include any racket sports including pinging pong bat to be potentially aggravating for a lateral disc herniation. The rotary forces presented regularly to the disc have been shown to start to de-laminate the connections between the lamely and the lumbar disc. And it puts a relatively interesting force on the disc such that you can get a lateral disc herniation.
And typically the pathognomonic sign for those is that patient's gonna tend when they're having an acute low back episode to be cocked off to the side sort of crooked if you will, walking a bit like John Wayne.
So don't miss those. If you see or if that comes up in the history and you ask about that, that's important because that would put them in a different pathway on the McKenzie protocols at least.
And often those particular patients don't have a whole lot of sciatica. They certainly can and this gentleman did, but he didn't have prior history of that sort of lateralization that was apparent.
He also has cardiovascular issues. He's hypertensive, he is has hypercholesterolemia, so he is on a statin. You know that these kinds of vague musculoskeletal pain issues are a bit more common in people with statins. There is some thinking now that perhaps many of us in alternative and complimentary health may have pushed that narrative a bit too hard.
The incidents of that is really, really, really low in statin users.
So the benefits probably far, far outweigh the negative potential side effects there.
Now in our particular patient, what is one of the first things, those of you over here on Zoom, what is one of the first things we want to do using our neuro centric approach? When we have a patient in reporting pain, what do we wanna ask them?
You guys shout out, give me some answers.
All right, I'll have,
there's What makes it, what makes it better or worse, you know, IANS time of day, you know, but in an old person like that, is the disc very well hydrated in your opinion to affect things like sitting to standing?
Nope. No, not typically. But this particular patient and sort of vis-a-vis or questioning there and your remarks about getting palliation and provocation, yes, I want an index test or an index movement. What is it that provokes the issue? And indeed one of his provocations was standing from a sitting position after he is been sitting for a prolonged period of time.
That's a tough index movement because in the course of an hour long new patient intake, I don't have the time, neither does he to sit him down and have us chat, chat about the weather while his hip bruise to a symptomatic status.
So I asked him what other things might be provocative and he came up with the forehand bat. So he demonstrated a movement that we could reliably reproduce the pain with. I had him repeat the movement several times so that we don't have an observed extinguishing of the index movement with repetitive, you know, reps of that movement.
And then I carried on or carried out my physical examination and cardinal planes, a movement forward bending quite limited, did not reproduce his presenting symptoms. The presenting symptoms fort and finger test, he points right to the lateral part of his hip and to the inside part of his hip, sort of in the groin anterior part of that hip.
And when I had him extend, he was fine. Rotation was fine.
Squatting. Squatting, he was able to squat fine to about a quarter squat depth. But when he went to a half squat depth with which at 79 he could actually achieve, but he had reproduction of the lateral hip pain, the forehand bat index caused the pain in the groin and on the inside of the thigh when I had him point where it was, he basically pointed to the upper inside part of his thigh.
So because it was, I had him standing up right then at that particular point,
I could do a couple of quick screens right there because his, oh I, I should have gone back and mentioned prior treatments.
He had seen his PCP virtually PCP had ordered X-ray of his hip.
He had MRI of his low back as recently as a year ago demonstrating the previous, previously mentioned degenerative processes at the lower two discs and the PCP, the X-ray demonstrated moderate osteoarthritis in the right hip, mild in the left 70 ti 79-year-old patient. I'm not getting terribly excited about moderate osteoarthritis. Right.
I probably got that and many of you watching here probably do as well.
So this particular situation, we go back to our, our provocation.
I've got him standing right there able to do the two provocations in standing. So I decided to see if I could modulate those in standing and just do some tissue discrimination right there. Now this goes a bit off piece of what we've described previously as a method of trying to keep you organized in your thinking process by going from bigger neuro down to smaller neuro.
Well in the bigger neuro, where do we get that info? We get that in the history and the history. In the history we find out that it's prior diagnosis of degenerative disc disease and prior sciatica, prior injections at the lumbar spine. All of that had prompted his physicians.
The his PCP sent him to a physiatrist who met with him again virtually. So nobody's actually done a physical exam on this guy yet, but they're already ready to discuss based on findings on a, you know, of a 79-year-old with hip pain. They're already in conversation about the possibility of a hip replacement and prior to that a, an injection of the trocanter bursa to try to go for a putative trocanter bursitis.
And the patient had talked to his friend and they referred him over to see me.
So in standing I had him do his forehand movement index test and thinking about the area where he's having pain on the upper inside part of his thigh. You guys with your spidey sense of NCA perspective here, when a patient points to that area and you think of the neurology that services that area, what comes to mind?
Shout it out.
Theoral nerve. Ator nerve.
I like the second one. The op femoral nerve. Yes, possibly, but this was around a little bit more medial and on the upper inside part of the thigh. So that is more opterator nerve. It does share some fem femoral innervation. There's a discreet opterator nerve point somewhat analogous to what we're taught for neuralgia. Para athea being a discreet area on the lateral part of the thigh for the opterator operator nerve. That discreet area is about midway down the thigh for sensory changes in that area. And if they've got sensory changes in that area, hyperalgesia with skin rolling or even diminished or heightened even sensory
sensation in that part of the leg, then that is almost pathognomonic for ator nerve involvement.
So we think along the course of the opterator nerve and entrapment sites that are common for the opterator nerve are above the isum right about the, the interface be in the fascial compartment around the SOAs. The opterator nerve cruise is right up next to there and sometimes can get bound up in that tissue right next to the SOAs. And then we'll report when the person is using the SOAs further downstream. The most far and away, the most commonplace that I see in entrapment issues involving the opterator nerve is beyond the anguinal ligament and beyond the isum where the nerve is sandwiched by a couple of the adductor muscles right there.
And you can kind of follow the nerve down at that area. You get over a, about a centimeter medial to the, the cubic ramus there and you can kind of find the obterator nerve across the front side of the isum. Just make sure you're not rolling over a spermatic cord and you're in your male patients that will not make them happy.
And in this particular situation, I decided to try an unloading test by doing dermal traction over that area. So I did a big horse bite with my hand and grabbed that area after preparing him and asked him to place a hand over his genitals to avoid any collateral damage and pull 'em up outta my way.
And we have a good laugh with that. And then I grab the upper inside part of his thigh and make myself a little better known in his world.
Then I ask him to move while he is doing that. So he repeats his index movement and notes that when he does it, while my hand is in that position, he feels much less pain. So I want a quantification and only because over the years I've come around to this number, but if it's less than 30%, I don't get too interested in that.
He said it was about 40 or 50%. So then I took my hand away and had him repeat the movement several times and it, the benefit persisted after several movements. So I'm like, cool, that's an area I want to keep in my notes as a possible area for me to have an impact on with his pain.
And at that stage of the game, mind you, I find the DTM material at this stage in a patient encounter to be possibly most effective at decoupling top-down processes. Because often an older patient with hip pain is already in that mindset of thinking I might need a new hip. And this one indeed had been primed for that with a prompt from his PCP that that might be what's going on. So when I do that with my hand and the DTM and his symptoms get better, then I have a little bit of a confrontation, good natured of course, but now do you, can you imagine sir how what I just did might have impacted the joint itself?
And he was like, no, you're not working the joint. And that made it better, huh? So now his mind is open to the possibility that something else could be at play here. So I've just set the hook, okay, now we still got pain that happens on the lateral side of the hip with a deep squat. So I went right over to that area and did a similar DTM kind of process over the lateral part of the hip. And what is our chief suspect? Neurology at that particular area?
this would be the right over the TFL. There's a good hint.
lateral femoral cutaneous
that's just a bit further around the corner on the front over the TFL is the lateral branch of the ileal hypogastric nerve.
So that is probably the target tissue that most of our patients that have been diagnosed with ITB syndrome.
Remember when you hear the word syndrome attached to a diagnosis, I would hope that at this stage of the game, your spidey sense for the possibility of unexplored or unrecognized neural contributors might be at play and you should go and do due diligence there to make sure that that tissue is being accounted for.
So when I provide a little bit of traction over that area and he squatted several times, he had again about 50% improvement and his symptoms and it persisted after the hand went away. So that's great. Now I've got two areas that I think based on very rudimentary and very preliminary evaluation, we may have some superficial neurology that's contributing to that particular issue. Okay? So I kind of catalog that I don't jump right into that in the way that I would heartily discourage any of you that have been exposed to dermal traction method or DTM YAP or or NCA, this, that would be my horror if you did those movements and rendered a diagnosis that the issue was only due to that. You want to also ask the question why might that neurology be unhappy in that particular area?
So I continued my examination, went ahead and did the lower quarter exam, did his motor testing, did his slump test, did his CTIC compression test, did the SLR and those actually all came up relatively negative. He had a little bit of lingering tension or asymmetry in the right leg, but there was no reproduction of any of his symptoms on that particular side.
So I've, in a 79-year-old patient, I am going to be less keen about leading at the spine level to rule things in or out with a McKenzie playbook.
There's nothing wrong with going and exploring it, but for time's sake, I usually in an older patient with prior history of, you know, a diagnosis of disc degeneration there, I'm going to expect that there's probably some stenotic process in the lateral recess and I'm probably not gonna get a huge buy-in from doing prone press-ups, possibly I get some buy-in from lateral, from wall glides or from flexion based movements from a McKenzie perspective. But I've got this patient right now in a, on the bench by at this point in the examination and in a side lying position and in the side lying position, I perform a neural tension test for the femoral nerve and he had no reproduction of symptoms with the standard femoral nerve tension test. But when I added in David Butler's little tweak of ab ducting and internally rotating that right thigh, I was able to reproduce his medial thigh pain.
And so at that point I decided to, before I did my next input, stand him back up. Now that I've done some provocative tests and repeat his index. And when he repeated his in his two index movements, the pain had returned in both of those with the squat he had lateral hip pain and with the mimicked forehand he had pain on the upper inside part of the side.
So now I'm seeing that that coolness factor of the DTM working seemed to be a relatively temporary thing. Sometimes it just is that way, but I've not yet explored back upstream at the spine to see if there might be something going on there. So I put him in a static opener position for the right leg and we did five reps 30 seconds on each time, 10 seconds off of static opener to maximally open the neural foramen in the lumbar spine, not specific to L four five or L five S one or L three four or L two three. It just opened it biggers in the cross-sectional area of the neural foramen of the entire lumbar spine.
And he stood up from that. And this was the cool one and you guys, if you've not seen it already, you will get to know this. There's a look on the patient's face when they're, and their affect, everything changes when they go back and they repeat the index test using the clinical audit process that we teach and they're fully expecting and anticipating a pain that's been familiar to them for a long period of time and they do the movement and it's not there.
And there's that again, it's like that, you know, a little jolt almost to their central nervous system. It's like, oh wow, that's what it, I remember it feeling like to not hurt with that movement. And he did the movement, he did several of those of the forehand and then he started cranking it up and you could see the motor memory coming in, you know, he's like letting go and he's doing the the forehand smash now and and he just looks up with this big smile on his face and he said, that doesn't hurt at all, not at all.
It hasn't been like that for nine months.
Wow. And I said, okay, cool. Now squat. And he squatted and he squatted once and he squatted twice and he squatted three times and each time he's getting a little bit lower and he's doing it a little faster and with less reticence. And he looked up and smiled again and he's like, that doesn't hurt either.
So it's very cool to see that.
And now theoretically we've tracked back upstream to the spine, we provided a little more room for that neurology at the spine and it seems to help with this patient's hip pain. Now I did a hip ortho exam as well and he had pain with internal rotation of the hip at 90 degrees with the knee at 90 degrees. He also had pain in the anterior hip with the, the FAI or the so-called fader test, F-A-D-I-R test.
And that improved a little bit with DTM over the front part of the hip, but not a whole lot. And that kind of leads me to think, well the, you know, the X-ray shows its moderate osteoarthritis, there's probably some of that going on as well and we probably have a combo platter here in an aging patient. A little bit of irritation from the hip, a little bit of irritation from the, the neurology upstream. Those of you that have taken the lower quarter course might recall that the opterator nerve is part of the innervation to the anterior hip capsule. So if we've got demonstrated irritation of the opterator nerve in the area that we were working on the upper inside part of the thigh, then in it's likely that further downstream as well that neurology is going to be mechanically sensitive across the front side of that hip as well.
So that makes me think we got a combo platter. Okay, so visit number one, the main job is to help the patient understand what the hell it is that's going on in their body, what tissues are complaining, and to help to develop a narrative about why those tissues might be complaining as well.
We give the patient that narrative, remembering that the narrative might be the most important part of that first meeting because you gain with a good narrative whether the narrative is right or wrong, you gain trust and you gain compliance in a treatment plan. So at the very least, even if your narrative is wrong, you're going to be able to test against it. If you give them some things to do at home and they do them, you gather more data that can be useful possibly in changing a wrong narrative at the next visit. But don't get caught up too much in being exactly right about all of your things. Develop a good working theory and test your theories.
Be a good engineer in that, in that construct.
Now the, after we help the patient understand that, the other thing in the first visit is giving them something that they can do to help themselves hurt less. So what do you think? I gave this guy, he got static openers, he got DTM for the two areas that we had identified. And for good measure, I also threw in some flex based movements from McKenzie. That would be the supine double leg rotation, opening that neural foramen on that affected side. So I will see this particular patient later this week in this upcoming week and we'll see how things held up for before I move on to possible functional contributors here that we can start to work on.
Are there any questions from the field out here?
Anybody ever on zoom with questions?
I got a,
ahead. I'm sorry.
Ryan or Brian? Either of you. Brian, why don't you go,
you say Brian or Ryan go
on on Dick. Why don't you go,
Hey, I, I'm just curious, did you, is is he continuing to play table tennis?
No, he is not been able to play table tennis for a while because of the pain.
Okay. Did you have a conversation about like potentially returning
Since he felt so good?
Absolutely I did. And it, it went around cautious. The, the nature of that was around cautious optimism, valid expectation or, or shall we say sane expectations. We don't want to overload the tissues for a period of time.
But the other thing that the, that conversation part came around to also to help hook him into a, to provide some hope and some, some agency, he identified in his history that this particular injury had really affected his mental processes. He was feeling a bit depressed. How did I know that? Because I have a two question depression inventory baked right into my intake paperwork. So he was negative on one of those, but the other indicated some low level depression. So when I see that, I open that door in the history and ask him, so what is it that's got you down? Is, is it something about this injury or is it something else that's going on in your life that you might want to chat about?
And he said, no, it's about this. He said A lot of the joy that I find physically in life right now is around two activities. One of those is fly fishing and the other is is playing table tennis. And he said I can't do either of those right now. He said, I certainly can't put on waiters and go wander around in a river when I'm afraid that I'm likely to fall walking on level ground.
So you know, other things that are going to go into my mindset as I move on to the next level about how we're gonna work for a bit of a longer term, we'll work around those two particular activities and how we can returning to some level of function, we'll make some anticipations about the mechanics that are involved walking on slippery surfaces and big old hip waiters and dealing with eyesight changes and balance changes there. So we might start with, you know, balance assessment and then maybe some prescriptions, the Yale sink exercises, we could progress from there to all kinds of fun and interesting things that I like to do in clinic where we can walk into the gym and then using any kind, any amount of the equipment that's available to us, we can start modeling the movements that the patient wants to do.
So we can start working with something that looks like fly casting. Is he just a regular fly rod or is he using a spay cast Rod needs to get something that to my mind in the gym starts to look a little bit like a shoulder rock that I can start to have him to move with table tennis. Can we get him to bring his bat or bring a racketball racket? Sorry if that triggered you right there Alex. She's got note famous people in her household regarding racket ball, but yeah, if they bring their racket in I might have them to model that and we can just do some volleys right off of a wall in the gym with, with a racket ball or with tennis ball.
So those were the things that, that came to mind when we started working with that. Any other input there Ryan?
No, I'm glad to hear that you're using it sounds like the dad seven and PHQ nine.
You got it.
Do you ever use the fed queue?
Yeah, I do. Not all that much though.
You know, I find again, you, you, you know me to be pragmatic in the application of these sorts of things in your environment there at Western States, certainly you want to make sure that the boxes are checked and the fence is minded and as an evaluator you're gonna be able to very clearly look at that note and say, okay, we're having a change over time or we're not for me, I'm going more towards that pragmatic function and a patient's perception of their score on an FABQ or you know, a K phobia scale is going to be far less important than it is on the other instruments. Sure.
Mentioning as in I was able to go fly fishing and I caught a eight pounder and I didn't feel any pain in my hip and you know, and that route I might actually get some salmon out of that dude where I've never gotten a salmon for an improvement of an on an FABQ.
Okay. Brian, I think you're on deck. What do you got for me?
You know, with the DTM and it working well, so you, you know, with disc patients, do you think the irritated neurology causes all the muscles in that area to just tighten up and eventually densify the ator nerve at that area or do you think that's a separate issue from the spine issue? You know,
hard To say. You know, I think I'd be on thin eyes trying to go that far in any sort of etiology at this point.
At this point I would just lean on what I've observed.
I've got downstream peripheral nerve sensitization that responds well when I open the tissues around that nerve that does not tell me why the nerve is mechanically sensitive and I test that theory or test that or or question against that by providing openers of sorts at the spine for the nerve root and got an immediate benefit. So to my mind, in all likelihood, we're dealing with some sort of osteophyte process that's there at that particular level in a 79-year-old. I'm less interested in the disc at that point as a source of nociception.
I far more commonly at that point will find that the, the body has relatively well managed any kind of repair process to an inflammatory response at the, the annulus at that point, the nuclear material in the center of the disc is no longer anything resembling a viscous fluid like substance. It's very dense and dense, meaty at that point.
So the body will do all of those things, of course to reduce movement, reduce shear particularly at that particular segment.
and the the instead in that older patient, what I will generally see that is irritated and is an ongoing source of nociception at that area is more often than not, it is the nerve root and more often than not, the reason the nerve root is irritable is because of a compressive etiology as opposed to an chemical, a surrounding nearby chemical or inflammatory change from a disc. So the compressive etiology, most commonly there is a disc osteophyte complex, some bing of the, the various ligamentous structures in that area, the A LL and the PLL and that would be the thing that I would be much more concerned with.
Now in all possibility we might find that it's great that we can get some temporary benefit from this gentleman for this gentleman with those exercises, but it might be that he's a surgical case that he needs to have a bit of a laminectomy or a, you know, you know, take the, get the Roto-Rooter surgery there. But at the very least at this particular stage of the game, we have an observed temporary benefit on that particular involved structure in this case an upper lumbar nerve root and sometimes using some of McGill's ideas about stacking phases of benefit or or periods of benefit.
We, we can find out from him, well I do my static openers and I get a half hour of pain. Well you're retired. Is there a possibility that at 25 minute intervals before the pain actually sets in, you could do another set of those and then we can stack pain relief periods on top of each other. Now what is actually going on physiologically during those pain relief events, physiologically, locally you're seeing an improvement in the overall metabolism of the neurology, you're improving the blood flow. If we're gonna buy in to Jeff Bo's op plasmic flow hypothesis and what he's actually demonstrated in lab animals, we could have an improvement in op plasmic flow.
So there again, another aspect of the metabolism of the nerve is improved as a result then we can potentially start to move a bit more and now the elastic modulus of the nerve itself starts to change a bit more.
So it's important to have some understanding of that because that helps you to talk about, talk about these things to the patient as well. Because many of you that are doing the playing the the DTM card and the YAP card with patients have heard them over time come back in and they say, yeah, my pain's back.
You say, oh, well is that little DTM thing that we were doing is that, is that not working now? No, it works.
Are you doing it? No, no, I stopped doing it. Well why'd you stop doing it if it worked? Because it only helps for a little while.
So part of your, your, your dialogue with the patient also involves maybe fleshing out a little better understanding of them, of these metabolic processes of a, of a nerve when it becomes mechanically sensitive and how you can take that transient benefit and stack it over time to allow the body to take a structure that is currently just overly sensitive and have a legitimate opportunity to clear it and to make it less sensitive. And then they can get back to relatively, you know, something that looks like a more normal behavior.
Any other questions
I was gonna ask? Oh, go ahead.
I Just, you my friend. Yes, Brian.
Oh, do you still, I think I heard you say somewhere, do you still stick to found patients like three weeks of DTM daily or every other day? Or what,
what do you,
what do you kind of tell 'em as far as getting that nerve to or area to calm down as far as how long they should do it for?
There's a, there's a lot going on when we do that stuff, right? I mean, part of it is the nerve itself for all of the reasons that I just described. Another is potential change in the interface between the neurology and the other structures it's interacting with. And you know, that goes to the, the, you know, the, the arguments we can have out there about what you're doing with manual therapy.
Certainly I don't think we're releasing or breaking up scar tissue or anything of that sort. It's just the body's repair processes and, you know, remodeling of tissues in response to load. And we, the thing that we're more concerned about is how that remodeling process might have impacted a nerve by compressing it or tethering it in such a way that it is getting tension forces beyond its likability. And that might take a good long period of time, I'll have them to do it. I mean, hell, I've got a, I've got a spot back here, an old neck issue from old injury that, you know, I do a little bit of DTM over the, the lesser occipital nerve. Pretty much any time I ever feel any kind of tension in that area and it sorts it out.
And when I get ready to go and throw the ball for my little doggy in the park and I'm gonna be winding up and getting that twisting movement, I'll do that on the way to the dog park. So just a little helpful household hints and you know, it doesn't necessarily fix the thing at the moment, but it, I mean beyond the moment, but certainly may cumulatively do it over time.
What else have we got,
Phillip? I have a question on these cases.
Many of us have flexion distraction tables.
Obviously you don't, but
it flexion distraction table distracts and opens the facets and hopefully the, the foramen and
it, it may, what I find when I'm doing flexion distraction on somebody like this is there will be a particular level where I can feel like, oh, that one's restricted. And then I'm opening that as a particularly useful manual therapy for these kind of cases. I think the original understanding of flexion distraction for discs, it, it may not be optimal for those, but especially in these older people, it really makes sense. And the other thing about flexion distraction is I, I don't know that it really puts the spine into deflection. It, it's mostly distraction. So anyway, thoughts on that?
I, I like all of that. In fact, one of the guys that I went to school with Onik knows Dan Capitano. Dan's a good friend and Dan, Dan, when he graduated the path he went down was Cox flexion distraction. And he's got, you know, several, several tables in his clinic.
And you know, for, for those patients that I'm not able to get the benefit that I like there, I just punt 'em down to Dan and let him do flexion distraction on 'em for, for several sessions. It's crazy effective. I've just, the only reason I haven't jumped into that full on is the cost of the tables and they, the tables are heavy as hell and most of my treatment environments historically over the years have been in treatment rooms where I like to be able to have the flexibility of literally moving my table over to the side to clear the, clear the floor and make more room for movement. But all of those things, I love what you're talking about with deflection, distraction stuff and even the old Williams exercises that everybody, you know, we all, we all used to get, you know, we've always been in, in a state where we have to somehow choose sides, right? You're either a Williams guy or you're a Mackenzie guy, you know, and it's, it's just silly. But as you noted, we probably don't really put the spine in very much flexion with a, a cox type environment or even a leaner table kind of an environment.
And I've, in the times when I've worked in offices that did have those, I would really crank out that distraction first before we do any kind of movement so that there's very little in the way of any potential flexion that's going on at that segment. And think about it, what is the, the characteristic antalgic posture person with a lumbar disc herniation and radiculopathy?
Yeah, it's gonna be a forward and or lateral and antalgia. And the reason for that is that slight forward antalgia opens the neural foramen a bit more.
So we'll find of course, in those
patients, we'll find that with, if they flex a bit further than that, and a, an inflamed disc is then placed under a bit of tension and they go into world hurt. Or if they're a younger patient with a little more of a viscous nucleus on that disc and they flex more than they have the potential for more bulging and a fence to the nerve root. But there's a sweet spot in between those two where we can get very little irritation of the disc and maximal room for the nerve root to be able to occupy. You've probably noted over the years as well mark that with flexion distraction in an acute patient, even when you don't flex them and they've got a a, an acute disc injury, if you just put traction on that disc, often it'll hurt because if they've got an where the annulus attaches to the vertebral body, that is a common attachment point that can be compromised with quick loading of the disc. And that's an, an nplate type of lesion, a variant of a fissure that then if you put traction on that can be quite noxious to that particular person. So we just have to qualify the, the patient and often what's the best way to do that in empiricism rules today?
Lay 'em down on the table, give it a shot. But I like your, your idea that you can put your hands on there, you can feel where things move relatively well. Now I'll, I'll I'll take you back to recently when you and I played together a little bit and you can feel when you lay on your back and that now is taking the compressive load mostly out of the spine.
And if we're working in an older patient with trying to move them out of a historical anterior pelvic tilt to try to provide a little more opening on the neural foramen and we do something that looks like a log rolling and then maybe we extend the legs up to a pipe position and then maybe move into a leg overhead, something that resembles a plow pose from yoga. If you do that slowly as you go up and down, you can kinesthetically feel and the patients will feel it too.
And, and you can put your fingers on it. You can even watch them and see, oh, there's a segment or two that's not moving so well, let's slow down back up and let's play there for just a little bit and see if you can gain some motor control over the muscles that are controlling that particular segment. And if that is, say, in an older patient maladaptive motor behavior around that particular segment, it no longer needs to be restricting that range of motion. And that might be a way of going back and exploring it. How else might, might we explore adding motion to that segment? Well, I don't know. We might have learned something in chiropractic school about how to do that.
Right. We are coming up on the end of our hour together. Does anybody else have any questions, any input?
I would invite you all to those of you over here or members, those of you over here that aren't members, go explore using the link here on Facebook Live.
Go explore the the online academy at neuro centric approach.
It's a dirt cheap continuing education option for you.
Before I leave, I see Chad Buell is on here. You're welcome, Nathaniel. I'm glad you came and joined us.
Let's see if Chad's still around.
Nope, looks like not.
All right gang, I will be on here next Saturday at 9:00 AM Pacific time. In the meantime, you guys stay curious and get out there and help some folks.
Take care guys.
Thanks. Take care, brother.
Absolutely. Bye bye-Bye