NeuroCentric Approach Zoom Case Study-Sacroiliac (SI) JointDecember 9, 2023
Superior Cluneal Nerve Entrapment Syndrome: Case Study and TreatmentDecember 22, 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.
Penile pain and thoracic disc herniation
Transcripts from the video above are below...
Okay, so it's 9:00 AM on Saturday morning on the Pacific Coast, which means it's time for a neuro centric approach, NCA Coffee Club case study. Woo-hoo.
Welcome in for all of you folks that are dropping in over here on Facebook. And for those of you folks that are coming in over here, ah, we got beautiful weather out there again today. Again, this is a fascinating winter in Portland.
Seems like we are getting a lot less rain and a lot more loose sky out there this past week. Things that I have been playing with astute observers over the shoulder might be able to see it, but I've got some, I've got a dongle hanging off of my computer there. I've been spending more time editing. I have been putting together something that has been asked for by some of our members, which is a specific nerve, smaller courses. So I'm putting together many courses that are nerve specific and I'm actually aiming them primarily at people in the general public who are finding information from other providers or they're suspicious that they've got a small peripheral nerve that is involved in their pain issue.
And I'm informed on the need for that by the traffic on my own website.
The articles that get the most traffic seem to be involved with specific, with articles that I've written about specific small nerves. Now those, those courses are gonna be available as home treatment using neuro centric approach for various items there. But the courses will also be available. I'll make 'em available to you guys that are on the lifetime membership for free and there'll be a nominal cost for others anyway. But I envision that it'll probably be also another way that people who are naive to what we're doing with neuro centric approach can get a little bit of a taste of how it works.
And ultimately over the longer term, I'll probably compile some of that information on specifics there into an app which members will have.
And that app would be the kind of thing that you know, you could use on your phone right quick when you're checking your, your chart notes and such. And you got a patient coming up and you kind of flip through and it's like, okay, they got pain in their, I don't know, their elbow. And you could go kind of like the way that I had originally set up the dermal traction method site. You can go on and poke on the elbow and boom, you get a quick idea of the most common nerves that are involved in elbow pain from a neuro centric approach. And then the other clinical aspects to consider as well. So keep an eye out for that.
Let's see, item, other items on the, that have been interesting in the past week for me, I kind of went down the rabbit hole on one of the cellular aspects from some of the things that we talk about in neuro centric approach. And those of you that are unfamiliar with what we're doing, we organize what we refer to as a graded neuro exam. We organize the clinician purely for convenience from bigger neuro down to smaller neuro in the evaluation of various patients that come in to see us typically for pain.
And the bigger neuro biggest neuro is gonna be the brain.
And then we move down to the spinal cord and query the body with specific ortho and neuro tests at spinal cord, nerve root interface. And then we query peripheral nerves using typically some of the classic neurodynamics issues that have been promoted over the years by folks like Bob Lv, folks like David Butler and folks like Michael Schlock and those peripheral nerves. And we get down to that level. We can evaluate their mechanical sensitivity with tension and with direct palpation as well.
Then when we get down to the smallest level, the superficial neurology, the cutaneous level, often then we can use dermal traction method, which is sort of an inverse screening method in that we can lift and create space around a putatively involved small nerve and then have the person to move and see if that makes their index movement better.
And then at very end we've got the, so-called cellular aspect and what we're dealing with there are the issues in emerging literature and some of it older, of course we all learned about polyneuropathies and how to screen for those when we've got patients in our clinic.
But the cellular aspect, I'm leaning more into the emerging evidence about things like oxidative stress on the organism and how that can sensitize neurology and the periphery. So things like diabetes, things like obesity, cardiovascular disease. And a lot of the data that we're getting on that is actually coming over from the longevity literature, the aging literature, the jero science, whatever you want to call it. And I know some of you guys are tracking that if only by, you know, paying attention to some of the excellent podcasts by Peter Atia and Andrew Huberman and such, we've made it a little more available to many folks and the, the general pop and, and also clinical side.
But the thing that caught my eye this week, not to be too self atory, but some of you may know, and this is I think worth bringing in on the conversation, you know, for for future as well.
I am in a 25th percentile of folks in genetics for a OE four.
I am heterozygous for a OE four, which means that I carry the gene that has been most strongly linked to early onset Alzheimer's disease.
I do have a family history of that. It's what my father passed of. I also have a kind of a, a difficult pairing genetically with that and that other genetic predispositions I have suggest that I will likely have a pretty long life. So living a long time without a mind is, well there's lots of jokes that come to mind immediately to me right there on that, but most of them will be political and probably would get me in trouble. But the, the, I don't have a whole lot of desire to live a long life with a, with half a mind and be a burden on my family.
So I am actively regularly involved in the, so-called biohacking phenomena. And of, in addition to many of the things that I do, I am primarily on a ketogenic diet which shows well for neurogenic or neuro diseases of, of all sorts.
And I utilize intermittent fasting, a 16 to eight profile on a daily basis.
And I have been doing that now for six or seven years and have a a, a pretty solid meter, you might say in Zabe to know when I'm deep in ketosis and, and what that feels like. And probably the biggest thing is cognitively you feel razor sharp and your recall is just really crisp and I have a a, a strong desire to keep that going. So I'm always kind of monitoring that. That makes me, my wife would suggest sometimes hypervigilant. So I try to keep my eye on that too.
But things that, other things that I'm doing, I am taking rapamycin six milligrams once a week to improve my longevity and reduce oxidative stress, improve my immune system function, et cetera. Some of you are familiar with the ITP trials, a recent continuation on Peter Attias podcast about the ITPs is worthy of your exploration if you're interested at all in this stuff.
But the pairing of rapamycin and a carbos confer on their animal models a pretty consistent 30% increase in longevity.
To put that in perspective, it has been suggested in other research that if we were to eliminate all causes of cancer in humans, then we would only experience about a 3% improvement in lifespan.
And if we were to reduce or to eliminate all causes of cardiovascular disease, now we've got two biggest things that take people off of this mortal foil then that too would only re improve lifespan by about 3%. And you compare that with a 30% increase from taking rapamycin and a carbos together. So what does a carbos do? It is a
drug that was originally used for diabetes.
It inhibits the absorption of polysaccharides in the small intestine.
So those polysaccharides get pushed further downstream in the digestive tract to the small bowel.
And when you get a bunch, if, I mean just think about your, your basic physiology and biochemistry, if you take a bunch of undigested sugars and you shove them into the small bowel, what's gonna happen, right? You're gonna get fermentation from the bacteria that are in that part of the bowel and part of the product of that, of that fermentation's going to be some gas, which is one of the common side effects from taking acarbose.
The acarbose doesn't even get processed by the liver. It just goes straight into the gut and shunts that sugar digestion further downstream in the process.
It is worth noting that the, the side effects of flatulence do get better over time as your microbiota and your gut changes to be able to as your numbers increase there. So that's not entirely unlike what we've seen in the past from taking prebiotics or fructooligosaccharides and things of that sort. Inulin was one that people use quite a bit of there.
So what are the benefits from doing on that and why is it supposedly helpful in lifespan? Well, I mean the association that seems to be strongest is the fermentation in the lower bowel of these sugars causes a part of the metabolic output are short chain fatty acids. And the three primary ones there are propionate, butyrate and acetate.
And these specific short-chain fatty acids have known health benefits for gut integrity. So if you're suspicious of leaky gut in your patient, this might be a way of dealing with that.
If your patients have irritable bowel syndrome, probably look yes, look to the stressors that could be contributing to that, but also this might be a reasonable thing for you to consider.
A carbos requires a prescription to get it.
And then l-glutamine has a, to provide some substrate for making those junctions in the gut a little more, shall we say. Tight.
That's a pretty good regimen.
Now I'm fascinated because I have a lot of patients that are referred over to me by naturopaths and a lot of those patients are undergoing treatment for sibo, small intestinal bowel overgrowths or bacterial overgrowths. And the person, the researcher that originally coined that, if I'm not mistaken, is my former naturopath from 30 years ago when I used to live up on Orcas Island. His name is Steven Sandberg Lewis and Dr. Sandberg Lewis or SSL as he's known to his students at the at NCNM here, the naturopathic school in Portland.
Their protocols for treating SIBO is the old school kind of, you know, weeded and feed kind of idea in a presumptive overgrowth of some particular critter in the gut. You give the person some kind of thing that basically is everything. So sometimes that could be an antibiotic, sometimes it's a high terpene containing item like oregano oil or time oil or something of that sort.
And you try to knock down the existing flora and the gut and then selectively choose other critters that are thought to be quite a bit more helpful and you load those up in the gut to, and then try to feed 'em with prebiotics and things of that sort.
So I commonly note that these patients that are treated with SIBO are for sibo.
One the diet's hard to stay on and two, so they often lapse. And two, the symptoms often just come back because they go back to, you know, previous behaviors.
And what I've seen with patients that are on a carbo is that that seems to improve.
So that's fascinating. Now, one of the ways they diagnose SIBO is by using a breath meter that picks up the presence of methane gas in the breath, which is a metabolic byproduct of those critters growing in the small intestine. Now that overlaps with something that some of us use that are following a ketogenic diet to determine whether or not we are in ketosis. And that is a little breath meter called a biosense breath meter, which measures the presence of acetone on your breath.
And that is a, a measure of one of the ketone bodies or possibly even two acetoacetate and acetate.
And I've been using that now for two or three years.
And I noticed when I intentionally went off of ketosis prior to trip to Europe back in May that I've had a hell of a time getting back into ketosis as measured by my breath meter.
Now previously I had measured my state of ketosis using a finger stick method, which measures concentration of another ketone called beta hydroxybutyrate in your blood. Now it's thought that BHB beta hydroxybutyrate blood measurements are superior as a way of determining ketosis STA status.
But the measurement of blood of breath acetone is so much easier and you can do it multiple times throughout the day and ultimately you save yourself a lot of money. Those ketone breath meters are not cheap. I think they're around 300 bucks, but you also pay for about a buck and a quarter for each of those strips that you're testing the blood.
So I have been testing and testing now for months trying to get back into ketosis. And even after a three day fast, I was only barely showing up in ketosis and I really was kind of stymied by this. I was like wow, is it really that easy? After only a month out of ketosis for the machinery on my, in my cells at the peroxisomes and at the mitochondria that allow for increased fatty fatty acid oxidation, is it that quick that those things change and should it be that hard for them to come to reboot?
And and you know, I asked myself, well subjectively how do you feel Philip? And you know, my sleep's good, my exercise level's good, my cognition felt spot on. So all the things that, other things that I would typically look at to determine my status and ketosis working pretty darn good.
And then I started to, I was reading a paper last week about these short chain fatty acids and thinking about acetate in the gut and then thinking about a carbo pushing some of that small intestine digestion into the, the large bowel and the light went on like maybe because I was taking the A carbos, which I started before the Europe trip in anticipation of eating a lot more bread and pasta and things of that sort.
Maybe the a carbos is pushing downstream far enough the products that would be making acetone that the breath meter is measuring.
So real quick, I went over and I took my breath meter and tested and I was had zero on the breath meter for presence, se acetone in my breath. And then I went and pulled out my blood meter and for about the first time in nine months, checked my blood ketones and I was at 1.1 millimolar, which would put me pretty solidly in ketosis. Anything over 0.6 is considered
considered in, in a state of ketosis.
And that would also correlate with what I've observed in the past when I was on rapamycin but not on a carbo and rap when on rapamycin it is a lot easier to stay in ketosis. It just about doubles your, your beta hydroxybutyrate levels in your blood when you're on, when you're on rapamycin, which is a fasting mimicking agent, which kind of makes a bit of sense there too. So I went deep down a rabbit hole on that. Now what I think I'm noticing and I'm trying to find other folks and part of the reason why I'm talking about this to all of you guys, if any of you that are watching this are on a ketogenic diet and you are measuring your, your state of ketosis by using a breath meter, then I would be very interested in chatting you up if only to do an anecdotal, you know, informal citizen science kind of investigation to see if you want to take a carbo and see what it does to your breath meter readings and then test the finger stick method and the breath meter method in the presence of a carbos and in the presence and in the absence of a carbo and see if we get any detail there. 'cause I've done a, a both a literature search, I've done a keyword search in various strings for a carbos and
ketosis and the biosense meter and I'm not getting any hits there at all. So I think it would be interesting to do a at least a little anecdotal paper there and I might or or article there and that might actually turn into a case study that would be worthy of publication. Okay, so speaking of case studies but boop, how's that for a transition our case study of the week?
Let me bring my
patient notes up or me while I shift a few things around on, On my desk and let me make sure that we are remaining HIPAA compliant.
Everything is running rather slowly 'cause I've got a lot of applications open,
all of my editing on my desktop, it's slowing things down.
Okay, so this particular
Okay, bear with me guys for half a second. Lemme see if I can open up Jane again.
In the meantime, if you guys have got any questions or thoughts about what I was talking about, feel free to load 'em up in the comments over there on Facebook and I'll try to get to 'em here. And a moment
or hard driving with solid state is spinning to beat the band over here.
Here we go.
So my patient here, how old is my patient is a 30 5-year-old, 30 5-year-old male personal trainer previously known to my clinic.
This particular patient came in this time with three primary complaints.
All three of them are things that he's been seen for previously in our clinic.
Those three things Are left elbow pain and a sense of catching significant past history there playing hockey in his youth.
He took a puck to the elbow and was unsure as to the exact injury, but huge amount of bruising and such.
And he, after that started having paresthesias in the arm, which have persisted over the years and he's gotten a steadily worsening catching in the arm.
The examination there on that elbow issue, we've that well from a neuro centric approach by going from the spine out and the ulnar quadrant, the peripheral neurology was definitely implicated there. It was curious as to whether the owner neurology was primarily being involved from the lower part of the brachial plexus or more locally around the elbow. And then when I got out into the elbow and investigated the elbow, we had a very flagrant Suboxone ulnar nerve and he recalled that he took the the puck right on the medial aspect of the elbow.
So what I suspect happened with that is he actually had a fracture there of the tip of that at the attachment of osborne's ligament, that restraining ligament for the ulnar nerve. And he's now got a subluxing subluxing nerve there and I encouraged him to go get that, go get that fixed orthopedically and I suspect that in all likelihood an X-ray of that elbow would also show that he has a loose body and that that's part of the catching, right? So there's one complaint that he had.
The other primary complaint that he came in with is he's got mid scapular paresthesia and his mid scapular paresthesias are a known problem that's been in place for a number of years going back to I think 2017.
And at that point in time I actually, one of our members here seeing him clinically had ordered MRIs of his thoracic spine and the MRI noted a
at T eight nine, a two millimeter right paracentral disc extrusion that slightly EF faces the right ventral cord and a small annular fissure noted within the extrusion.
That particular issue came about after another hockey injury where he got jammed into the boards and shoved laterally into a position against the boards.
And he's had since then. And this MRI, by the way, was done
is the date of this imaging, I think it was 27, no exam date was 2021.
The injury was actually in 2017.
So also fascinating that this extrusion hadn't over a several year period of time.
Resorbed, which brings up a paper that just came out today showing from Rush Medical Center in Chicago that in 90 patients that had disc herniation and actually specifically disc extrusion, 100% of them that were given gabapentin and acupuncture for 12 visits to manage the pain but no NSAIDs or steroids to manage inflammation, 100% of them had full resorption of the extruded disc material within a year. So that's a relatively small sample of 90 patients.
But how does it compare to what we see in the literature? Well the meta recent meta-analysis shows that only about 66, 60 7% of people have full resorption of the extruded disc material. And most commonly we've known that cigarette smoking is the biggest in in impedance to that resorption process.
But back to our patient, his symptoms were present with paraesthesia as determined by using a wharten bird pinwheel up and down his back. And I scoped it out to an area about this big that was to the left of T eight and soft touch was also off in that area. So sharp, dull discrimination and soft touch were diminished over the involved area.
So I put him through a McKenzie
investigation with end range loading, used extension first, both in from press ups, got no benefit there, used extension more using a chair and doing the thoracic extension over the back of the chair and got a little bit of benefit. But then I tried a lateral extension by having him wrap up like this. And then I got sideways like you're doing a motion palpation in that area and did 10 reps of lateral movement towards the side of the paraesthesia and he had 100% reduction in his paraesthesia as measured both objectively and his perception in that area as well. So that was kind of nice.
So I thought about that and how he might be able to do that. And we got a little creative and I imagined him taking large jump stretch bands, the big thick ones or something that looks like a
webbing belt like he might use for mulligan mobilizations and strapping that off to some, you know, part of a squat rack or something of that sort in the gym where he works, it's a trainer and then putting it around his back in that area and then doing lateral bends with and extensions combined in that particular area. So that's something for you to consider as a way of getting extension in those relatively unusual thoracic spine disc herniations that we get.
Now his third issue, which I was concerned might have some overlap with this particular area was he has intermittent
numbness and tingling and pain at the base of his penis on the right side and in his right testicle.
And the most common ways for that to manifest are lunges, leg raises.
And what else did we have? There was one third thing, lunges, high box step ups and leg raises. I'm sorry, it wasn't the right, it was the left it testicle and left base of the penis.
And he would also have, this is key, some sensory paresthesias in the lower abdominal region on the abdominal wall. Okay, so that's key.
All right, so when he presented with all of this part of my thinking clinically, I will admit that when I get confused or I've got a big complicated case like this, we've got an elbow issue, we've got a thoracic disc herniation, I've got symptoms in the groin, I generally lay a DNS card and I pull my DNS lens out and I look at the patient through my DNS lens and what do I see? Well, in his past health history, he's got a prior history of of depression and anxiety.
The depression and anxiety mostly were related due to issues going on in during the pandemic. Being a personal trainer, I had a really tough go of it trying to survive professionally during that period of time.
But he's also been troubled by that over the years.
Some body awareness issues and wanting to, you know, look the part as a personal trainer and looking the part in that world often involves this kind of proud chess sort of position which DNS would look at as being problematic. Why do I mention the depression issue as well? Many of you familiar with Prague school and the the forebearers of Pablo collages DNS program know that Carl Levitt was one of the early founders of the Prague School of Physical Medicine. And I remember one of the things that he was fond of saying was that in musculoskeletal pain syndromes, the first domino that falls is disrupted breathing.
The idea there being that when disrupted breathing patterns, typically an apical breathing pattern occurs, it disrupts the diaphragm's ability to participate in core stabilization and low threshold stabilization strategy, which is a precedent for most limb movement. And that's borne out by the research in the nineties of Paul Hodges showing us that when you or I move our arms or our legs, the deepest muscles of the core are the first muscles that contract.
And then we affect muscle contraction of the stabilization muscles of the shoulder, like the serato anterior and stabilization muscles for the spine or ancillary stabilization muscles of the spine. So as in this case, primarily to try to pull slop out of the spine before it can take action on the hip. Okay, so stay with me on this. I'll actually come to the point in a moment.
So I'm looking at an individual that has these, the possible manifestation of a breathing pattern domino that falls disrupted core stabilization, and then the altered core stabilization when you're using the the legs to do lunges, high box step-ups and leg raises would be, the SOAs would be hypertonic to try to pull the slop out of the spine that's not being stabilized in the absence of the diaphragm contribution
before the SOAs can take action on the hip.
So that will make a functionally tight SOAs and a functionally inhibited gluteal compartment per DNS thinking. Okay, and I underline that per DNS thinking 'cause the, the evidence that I'm aware of there is relatively scanty, but I can say clinically, anecdotally, that's borne out over the years for me in practice.
So how do I put all of that together with this particular patient?
I wanted to find out if the observed stuff at the spinal cord might be effacing the ventral sac and causing the symptoms downstream in the groin.
And so after we had the reduction in his paresthesias locally with the McKinsey input, I retested his, his issues and the groin by having him do the aforementioned provocation items.
Actually no, I take that back. I did not do that because his provocation was latent. He would find that the high box step ups, the leg raises and the lunges would cause symptoms the following day in the groin.
So we're kind of stuck with that one in terms of having a clinical audit process to retest against.
But I was thinking that we might have a hypertonic SOAs on that side. I tested Obert or Thomas Gaines's on that side. Indeed he is shorter on that side. So I laid him down on his, on his side and palpated on that left side of the abdomen doing the thing that we've talked about before of kind of a big finger deep palpation of the abdominal wall and found not a whole lot of interest.
Interesting ropey badness over the ileal inin, aurel hypo gastric nerves, which do have some innervation into the goin, but not specifically to the areas that he mentioned. But what areas, what nerve does go directly to the areas that he's very specifically mentioned, the genital femoral nerve. What is the proximal relationship of the degenerative femoral nerve with the the SOAs muscle? It pierces it. So my thinking is that possibly then we could have a hypertonic SOAs with the involved activities. When he asked the SOAs to do more work and he's in a position, a proud chest, the SOAs goes hypertonic. And then in the presence of that hypertonicity of the SOAs, the genital femoral nerve would in experience a fair bit more of compression.
So I decided then to go try to get to the genital femoral nerve with him laying right there in that position.
So I went into a deep abdominal palpation with my fingertips and had him alternately flex his hip so that I could find the SOAs and then got on the SOAs and rolled over to the anterior aspect. And while I'm doing that and searching, what do you think he said? He said, oh there it is. I'm like, what are you feeling? And he said, there's the tingling and the pain at the base of my penis and left testicle. Boom. Love it. Love it when that happens. So not for him when you're able to put a finger right on it and cause it. So there again, remember we've got palpation as a way to try to investigate some of these peripheral nerve involvements.
Okay? So trying to put all of this together into a treatment plan for this individual.
I've got essentially a software problem to my mind that as viewed through the DNS issue, DNS lens of a stabilization strategy here. That's a low, probably a high threshold stabilization strategy that would be improved with a low threshold DNS kind of pattern of stacking the ribs, getting the diaphragm over the pelvic floor and then working on stabilization strategies using intraabdominal pressure.
But I also wanna see if we got a basic hardware problem.
So for the hardware solution for core stabilization, I find when I start talking about core stabilization, my patients get, they will, they will hear that and think, oh my core must be weak. Well, we have actual some data to suggest what weak and strong means in regards to the core. That's some of Stuart McGill's work.
So I put him through a lumbar functional capacity evaluation and we tested extension and flexion and lateral stabilizers and lateral stabilizers. We used side plank of course, and I primed him by noting that I typically, and most of my patients would only ask for them to demonstrate normative endurance values in all of those tested quadrants. And the normative is a mean there.
And I primed him by saying that in my staff and in me and in people that are high functioning like personal trainers, I would heartily encourage them to maintain one standard deviation above the means. So I set that as his measurement.
And in extension he achieved one standard deviation of the mean above inflection. He did the same in right stabilization, he did the same and in left stabilization the only quadrant where he was off, he was not able to reach the mean, not even get, not just get one standard deviation above, but he wasn't able to reach the mean in the involved left side. So that was kind of interesting. We will see if that holds any water. That treatment plan holds any water by checking him. I think he's due back in, in a couple or three weeks after working on this. But the, what I sent him home with for the, for this was a reminder of the left elbow was to go get that orthopedically evaluated and likely an x-ray there and see if a loose body is affecting the, the joint and needs to be removed and or to get stabilization of osborne's ligament there so that that older nerve is not bouncing all over the place for his thoracic disc herniation.
I'm playing a DNS card for functional improvement of that. And for the hardware issue, I'm playing a McKinsey card with a lateral presentation on that disc and he'll use that.
And then for the functional aspect of the issues in the groin, we're going to work on improving that stacked stabilization strategy of increasing intraabdominal pressure to try to see if we can get him to do the previously offensive lunges, high box step-ups and leg raises without having the symptoms the following day if he's able to do those in a position with that stacked thorac lapel canister. So that is our case study for this particular week with that delivery. Do we have any questions over here on Facebook or any questions over here on Zoom?
Hmm. And by the way, happy holidays to everybody out there.
Hanukkah has officially ended Christmas season is really coming into full swing right now.
Okay. I am not seeing questions on either side here.
And for those of you that are watching, I know a lot of you guys are waiting, I get a lot of feedback from folks that are watching the, the recordings here. Some of you might have noted at the beginning that I am recording the this using rewatch. So I get the transcript from rewatch and I'm recording it on Zoom and then I'll take the zoom recording and the rewatch transcription and I put 'em together and then I'm parking them on the community for the neuro centric approach online community. And I'm also parking 'em for public consumption on the email@example.com. So you guys feel free to share that.
rj, I see you're on here. I hope you're doing well, my friend.
Feel free to share that with the R two P folks for their evaluation.
Note that we still have the lifetime membership open. That door is still open on the neuro centric approach online academy.
That cost of that is going to go up by another a hundred dollars at the beginning of the year. So there is a student discount on there right now and there's also a professional's discount. So you guys get out there and take advantage of that. The price will steadily go up on that and not come down.
And the lifetime membership will only temporarily be made available as we continue to build a community here and with the nerve snacks that I mentioned earlier, as more people in the general public start to become aware of this methodology and ask, well I wonder if there is a doc somewhere near me that has this, that has this knowledge of neuro centric approach, then they're gonna go on to the NCA site and we've got a
a clinician locator widget there on the page. So when you guys come and take the in-person courses with me, then you will, once you've taken both of those in person, those two 12 hour courses you can get placed on that
locator page. Okay? So there's a few incentives for you guys and I appreciate your attention and coming out here and hanging out with me on your weekend. So in the meantime, until we meet again next week, please stay curious and take your curiosity and things that you've learned here and elsewhere and go out there and help some people. You guys be well, ciao.