Neurocentric: What Does it Mean?December 3, 2023
NeuroCentric Approach Case Study-Penile Pain and Thoracic HerniationDecember 16, 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.
SI Joint With Top-Down Influence
Transcripts from the video above are below...
Good morning everyone.
Hello over here on Facebook.
It is time for yet another neuro centric approach Coffee club case study.
I've got my holiday red hat on, got my brain tee going on here.
Some of Dr. Anthony Guston's, perfect keto ketones in there, some MCT and we'll catch up on the week as folks join us here.
I hope you guys are having a good week and are still recovering from your atmospheric river.
It's been quite moist here in the Pacific Northwest.
I see Dr. Mark Heller joining us here on a walk in what appears to be a beautiful Ashland Day.
I hope things are going well for you there. Mark.
Let's see, for those of you that are uninitiated over here on Facebook, this is a weekly meeting that we do of case studies to highlight the neuro centric approach, which is a integration of several different areas of emerging research over the last 10 years. And it's my attempt to try to bring 'em all together to get them into clinical care a little bit better. And because it's a somewhat difficult process, a systems-based process if you will, it's a bit difficult sometimes to keep for a clinician to keep themselves organized and keep their eye on the ball without getting too overly structurally fascinated. I think.
So what I've attempted to do with all of this is put together a, a rubric heuristic if you will, to put a couple of words on it that sound, make me sound smart,
to keep you organized. While you're doing that, there is a link on the Facebook bit there firstname.lastname@example.org. We have an online academy.
You can pay one time and get 35 plus hours of continuing education recorded and when you're a lifetime member on that, you will get a hundred dollars off of upcoming in-person courses in the last week.
It is worth noting we've had a bit of a change in the overall organizational, call it the leadership of neuro centric approach and I am going to be focusing entirely on this now. I will be the principal at neuro centric approach.
Dr. Dean's plate is full enough in other areas that he is going to focus on those things. So you've got me one-on-one with neuro centric approach along with my current associates if we, and that means that future courses in person, I will be the lead instructor on that and assisted by my associates and former students as needed. So that is order of business to be taken care of there for my Jewish friends in the sphere out there. Happy third day of Hanukkah. Hope your festival of lights are wonderful in your own particular corner of the world as we typically do with these meetings. I'd like to each week try to bring a specific case and for my own work and talk about that. And then we'll do old business and then new business you guys that are watching are more than welcome to bring your own cases on too and just hit me up during the week, especially you guys that are members over here and let me know, hey, would it be okay to talk about this?
And what we generally try to do is a standard case conference presentation. The same kind of thing that is relatively structured in medical environment for those of you that are familiar with that you bring, you come and talk about it like you were, like you did in your student days. You know, patient presents as a, I don't know, 42-year-old female with a 10 year history of lumbosacral pain averaging, you know, four baseline, four over 10 pain. This is exactly our case conference today by the way, et cetera, et cetera. And then palliation, provocation. So you're look mat or you're, however you learned it in school, you wanna present like that.
Then you want to present your, your, that's your chief complaint. Then you want to talk a little bit about their past health history, their family history and their social history and all of those things are contributory. And then we'll take all of that and we'll tilt it, I'm gonna say about 45 degrees. I don't think we even need to go 90 degrees. We're just gonna tilt it a little bit to look at it from a neuro centric approach lens, which means that in your history you're going to pay specific attention to the four buckets of epigenetic influence into possible neuro sensitivity. So that will be sleep unmanaged stress, lifestyle issues and diet and under lifestyle issues that typically has to do with two subcategories, what degree of willful self poisoning they're doing in terms of drinking and drug use and whether or not they're exercising and if they are how much and what they're doing for their exercise. So that will catch in the history.
The other thing in the history from a neuro centric approach lens we will be quite interested in would be their prior health history. The prior diagnoses, what they've been told about the condition that they have their, their prior health history and diagnosis, what their belief systems are about, what it is that's going on in their body.
Prior diagnosis of things like HIV status and possibly or or cancer status or diabetes status would all factor into things that could cause some sort of polyneuropathy and have some some peripheral nerve sensitization issue.
So those are the kinds of things we wanna investigate into history and such.
So towards that, let's jump right into old cases and new cases.
Some of you might have seen some of the cases that I have presented in the past two months. They are up on the blog section of neuro centric approach.com. You'll find a transcript and a recording of these conversations in that Chris Harris, it's nice to see you here my friend. I hope you're, you're doing well in North Carolina and I would really love to have you on here if only just to joke back and forth and maybe even bring your mother on at some point. What a delightful relationship there.
The prior of our old case that we presented most recently, I think it was last week, was pinging pong player, 73-year-old guy with right hip pain when performing a forehand smash or a golf shot.
His pain was primarily and groin and summing the anterior hip and he also had lateral hip pain with squatting to a half squat depth and we put some interventions on, you guys might recall that I was able to get some transient benefit working sort of a DTM model, right? We used an offloading process with DTM over the putative area of the opterator nerve in the medial thigh, medial proximal thigh more specifically over the interface point where the operator nerve goes between the adductor muscles in that septa between the, the most proximal adductor muscles and can sometimes be vulnerable to an entrapment syndrome at that particular area. Did some work there and got some transient benefit. We worked laterally around the flank over the area where he was hurting in the lateral thigh, which correlated to the lateral branch of the ilio hypogastric nerve.
And we got some transient benefit in his index movements of the forehand smash golf swing and squat.
But they were only transient.
So we continued our exploration in this case we worked from peripheral to proximal and worked to back upstream and its static openers for the spine, for the lumbar spine. And we got some buy-in there and got much more long lived improvement in that patient's presentation and he was quite pleased that all of his pain was gone after performing those static openers. Oh yeah. So that was cool. Our working diagnosis was we had essentially a, a spondylosis driven osteoarthritic condition creating some stenosis at an upper lumbar, probably an L four neural radicular kind of situation that's going on there.
Sent the patient home with that information. He had a relatively sophisticated understanding of things. He's has worked in tech for a number of years and was a teacher, he was a delight to work with and a bit of a geek. So he was very receptive to my sometimes long-winded ex explanations of things.
And he came back this past week, his pain was better but he, this is a key point. He said something that we will often hear in our patients when we're working these models that only bring a transient benefit.
He was happy kind of not bulant about his, his pain reduction but he wasn't, you know, over the moon because the pain kept coming back.
So two things to my mind needed to be discussed at that point. One was we need to frame expectations appropriately.
This patient may actually be a surgical candidate for, you know, a rotor root or procedure at that particular level or some sort of, you know, osteotomy or laminectomy or something of that sort.
So we refer to it that way. But the other thing, since we're playing with nerves in these cases and those nerves are not uncommonly amenable to opening procedures where we can offload the nerve for a period of time and see this kind of benefit, we can pull a page out of McGill's work and stack benefit if so. For instance, in this patient I drilled down on the benefit that he perceived from the work that he had gotten when he did it himself. So he, when he did the corrective exercises, he felt benefit and I'm like okay so how long does the benefit last? And I got a range and his range was depending on what he was doing 30 minutes to two hours. Okay that's pretty darn cool.
But I suggested that he pay a bit more attention to that and he tried to find a place where he can come into that repetition of the beneficial exercise and do it more frequently, preferably before the onset of the next bit of pain there we're working a bit of a top down process so that he becomes a little less expectant that he's going to hurt with a specific movement.
And the other is a peripheral nerve physiology issue leaning into Jeff B's work.
If we have some sort of a compressive or less commonly a tensile phenomenology that is reducing blood flow to a nerve and possibly re reducing op plasmic flow, then that will alter the metabolism of the nerve itself and you'll wind up with some changes in connective tissue organization within the nerve which alters its elastic modulus.
That's a later thing for us to deal with in our rehab programs. And on the front end earlier, we generally see that when we improve the perfusion of a nerve that is having poor perfusion that very quickly we have changes in pain less commonly numbness and tingling. But here's the other one, we commonly have changes in strength. Now that goes against what many of us were taught in school that those strength changes were very late to come on. So if we do our motor tests in the way that we learned them in NCA, which is typically a patient performed motor tests, which is more objective in this case if we're testing S one, I'm gonna have them do repetitive single leg toe stands and try to get to 20 reps or so and then I'll have them do 20 reps of single leg heel stands and try to get to five reps or so. Those are just numbers that I've come have adopted over the years in playing this particular model, which is an expansion of a paper by a researcher by the name of Sui, SURI, where you have people to walk on their heels to walk on their toes to try to get more objective data there. What I'm looking for is a more objective way of quantifying the, the motor weakness than a manual motor test.
You know, five over five kind of thing, which many of us have experienced to be a highly subjective way of testing motor strength. But you can often, I have found over the years in working this model, you can often find that you can do these procedures on the involved neurology and get a reduction not only in a reduction in pain but also an improvement of motor function. And since motor function, the diminishment thereof is one of the primary drivers of pushing that patient out of your clinic if they've got progressive motor weakness that's worthwhile for us to pay close attention to. And then it also anchors the patient around something that they can do on a regular basis to determine what their trend is.
And then you've got the patient helping you in between visits, tracking data that will give you some kind of clinical trigger point of whether or not you're going to continue to work with that patient or whether it's time to send them on to a more interventionist kind of an approach.
So we did that. This particular patient is a snowbird and they are going to the Phoenix area. So I'm sending them to clinicians down in that area that know this kind of work and hopefully they will continue to improve.
And this particular case, I then went in and did I put a Mackenzie flexion pattern on him, I put a static opener on him, had him to increase the frequency of that and then I went in and did TNM and DTM, that's transverse nerve mobilization and dermal traction method over the involved peripheral neurology.
And then I manipulated his spine and manipulated his hips and did some more immobilization in his hips and he was unable to reproduce his pain when he left the clinical encounter, which according to the cap clinical audit process would suggest that long-term he's going to do. Okay, so there's old business, old case study.
If any of you guys have any questions on this one then feel free to weigh in. It's gonna be difficult for me to fill questions over here on Facebook. You guys should be members. Follow the link there. Get 35 hours of online continuing education so you can come play with us over here on the zoom link and manage questions throughout the week and brainstorm on this kind of stuff.
Seriously guys, there's a hell of a lot of value in your continuing education right over there on that link on Facebook email@example.com. Chris Zaki just joined us. Welcome Chris. Nice to see you here brother.
Hmm, I am also wide open. I know Chris is gonna respond to this 'cause he has in the past trying to get us to us. I say and I need to change that to trying to get me to come and teach an in-person course in Seattle. We will be going up there. I'm not sure exactly where Chris you are. You were a little bit, I think you were the third person in Seattle to hit me up for a site. So we'll, we'll run into each other at some point there. Oh yeah, I do not see any questions over here on the Facebook, nor do I see any questions regarding that case over here on Zoom.
So I am going to plow into this week's case study, which is a real live SI joint.
Many of you that have been playing with me for a while, especially through the clinical companion of to fix your on back, which by the way is basically the neuro centric approach leveraged towards back pain, more specifically towards the disc injured back.
Know that I am not quite as enthralled about a sacroiliac joint quote unquote dysfunction.
Yeah, we can find it. How do we find it? Using the best available orthopedic heuristic that we have there, which is the las lit cluster from from Mark las.
The inclusion criteria on that is the patient doesn't improve in pain or have any centralization phenomena noted with repetitive end range extension.
So typically you wouldn't even launch into that until you'd applied that McKenzie process of end range extension and seeing no benefit or possibly worsening.
And indeed in this particular patient, which was a 41-year-old female veterinarian emergency vet with a 10 year history of lumbosacral pain, onset ha occurred when she was kneeling in a tub at outside of a tub bathing her young child and reached over to grab them and felt a pulling sensation in her lower back.
Got Eric Haroldson joining us over here.
Welcome in Eric, nice to see you here this morning.
So back to our case study, 41-year-old female vet getting her child out of the back bathtub 10 years ago she had immediate pain in the lower back. It was her first back pain episode.
She reported that since then she has had ongoing pain that is 100% of the time present.
That is four to five over 10 and severity and worsens to about a seven.
It is typically worse with prolonged standing, it's worse with backward bending and it's worse with her lifting, which she has to do a fair bit of in her work as a veterinarian or of as a veterinarian and an emergency vet situation where often there's lots of interesting lifting and such that's involved to try to get benefits. So that was provocation. Now palliation,
she has not had a whole lot that helps her, but she gets acupuncture every other week and the acupuncture every other week tends to help for just a short period of time.
She tried seeing, she also, she was referred over by her naturopath and the naturopath is actually a patient of mine who deals with a lot of very chronic pain conditions and the patient was not very interested in coming to see a chiropractor because three years ago they had been to see a chiropractor and saw them three times and the chiropractor noted an SI issue and the SI issue they tried to manipulate and the patient reported that they felt worse after every visit and their words were, they felt traumatized.
So continuing on in our locus mat, they did not have a history of radiation.
They did have a history, did not have a history of any numbness or tingling and no saddle paraesthesia, no changes in bowel or bladder current or past associated with this.
No other past health issue issues that raised a suspicion of any other kind of untoward, contributory issues, but interesting other things going on in their life and past health.
Last, a couple of years ago, they started to experience the, a couple of years ago they started to experience PVCs, which were extensively investigated. She wore a halter monitor twice, according to her, the follow-up with the halter monitor with the electrophysiologist did not note any specific pathology, which makes me wonder how she had a diagnosis of PDCs and as I leaned into that, she felt that she was having PVCs reminder here she's a veterinarian and a self-professed geek.
She's been trying to sort her issues here and it became more apparent that she had had, she was self diagnosing the PVCs. She was not tracking them using an Apple watch or anything of that sort that will give you that
cardiac output widget on the the Apple watch.
So that finding that she was noted, that prompted some follow up. How's your sleep? I've leaned into the four buckets, right for the epigenetic factors, how's your sleep? Sleep was actually relatively good, so I was looking for a sleep.
The dominoes line up the poor, the stress leading to poor sleep, leading to increased caffeination leading to the heart, observed heart issues.
Sleep was relatively well managed. Caffeine intake was down to eight ounces of coffee in the morning, but her stress is through the roof. Further questioning on that,
she has, she's married Elizabeth, a husband who is drum roll one week sober, diagnosed alcoholic with repetitive lapses and relapses over the years.
They have two children, one child is 14, the other child is four.
I noted that the time of the onset would've been when the other child was, the first child was young and that was the one that was in the tub.
And then you've got a 10 year span between the kids and I'm just imagining the possibility that, you know, there were some questions of whether or not to have a child and continue that pregnancy, the possibility that there were all kinds of things. So I left that door open for her to explore also and to report to me if she felt comfortable with it. But you know, I'm not her therapist at the end of the day and that, but I wanted her to feel comfortable enough talking about that and to feel that she was being heard.
I also made a bit more specific door opening about the possibility of physical abuse and or emotional abuse at the hands of her husband. Given that he is substance dependent, she denied and left, I left the door open there and moved on regarding her past health history with that. So
Welcome in. Jerome, welcome in Bill Martindale.
Jerome, the zoom link would've appeared in your email earlier this week.
And the what do I believe is the method of accu of action for acupuncture?
Very briefly and very topically since I don't want to get too off piece here.
I would suggest that the most consistent, notable benefit I see with acupuncture is it's a place for people that are undervaluing time to themselves, to lay down and be quiet and let somebody else take care of them.
Put hands on them, administrate in some way that is somewhat interesting, apparently compassionate, and let somebody put them in a caring environment. I think that probably is the most consistent benefit that I see at the local level. I've always been fascinated by Helene Lange's papers that showed that with dipping and twirling acupuncture movements under ultrasound. You can see the superficial fascia being tugged on with those movements as you move the needle.
I believe if memory serves four to six centimeters distant from the point of the needle and in my own mind with my own biases, when I combine that with the multiple sets of data out there, going all the way back to Ron Meza, I think it was his paper, suggesting a 70 to 80% positive correlation between commonly needle acupuncture points and myofascial trigger points.
And when I lay on that, lay down on that, the, the stecco fascial manipulation centers of coordination. There's a, yeah, an interesting, I find correlation between all of those systems probably. I think what we're looking at is the blind man. Blind man on the elephant, hands on the elephant. And we're trying to make some sense out of that. We're looking at all of these points and I think the best current available science would suggest that what we're looking at is a mechanical interface issue with peripheral neurology in that particular tissue. So there you have it Jerome. That's my 2 cents worth. I'm open to discussion there, but I'm gonna move back now to our case of the week.
The case of the week. This 41-year-old veterinarian, we just covered the history, now we're moving on to the physical examination to sheet. I'm gonna go back over here,
pull her details up and
make sure I'm HIPAA compliant.
I am on the, Jane will not take the person's name off the top there.
But then our physical exam, let's see, just make sure I didn't overlook anything. She was positive on the PH Q2, which is buried in my intake form. So that two question depression inventory, she was positive two over two in that.
So that opened the door for a bit more communication about what it was that during the last month has made her feel down, depressed or hopeless or have and have little interest or pleasure in doing things.
She smokes five cigarettes a day, also managing her stress using that.
Her stated desire was to be free of chronic pain and immobility wants to be able to chase her four-year-old around and move freely without always thinking about how she's moving to avoid pain and injury. Wants to feel strong and wants to feel safe, safe in our body. There's that safe word again, always makes us lean into the the top down issues.
So many of you that have played with me over the years in that regard will recall a story I talked about, some point outstanding outside of the treatment room door as I walked in, taking a deep breath and for whatever reason the, the first thought that came to mind was find the threat, find the threat, find what is the most acute threat. So in this particular patient as I go through the history, she's looking a lot like a top down patient to me in many ways. And at that point, the leading indicators for me are that she's got primarily a top-down driven issue. There's a lot of support there when a person with a 10 year chronicity of back pain that she's going to have, at least in part a lot of it is gonna be top-down phenomenology.
So one of the things I've got right on my desktop is a QR code for the curable app that that QR code for the curable app is, that's some of Adrian Luo and others that have put together that app. And I find that it is probably the industry standard right now for helping our patients with top-down issues and pain, depression, anxiety, comorbidities to leverage A CBT input on that. And they can get it for free using, you know, your own, you, you can set up an account and then your patients can get it for free for six weeks. They can then do group classes on there for a little bit more. They can then do,
they can also do individual virtual meetings as well with a therapist. Okay, so now we move on. Mark, you were unmuted there for a moment. Do you have a question?
You'll need to unmute again, brother.
Okay here I I'm throw in before you do it, but to me a positive, you haven't gotten to this yet, but if she has a positive LASETTE test, which I also use that and appreciate that, that means her SI is unstable and the ligaments are damaged And no, You don't think that's the case?
Nope. All it tells us is that there's nociception at the SI joint.
Yeah, but how are you're creating the nociception by stretching ligaments and my, anyway, my take on it is if you have a positive LALO sign, you absolutely should not be doing high velocity manipulation to that joint. It's like, and, and people confuse si dysfunction or si misalignment stuff with si true si pain, which is what Laslo tells us. So
Yeah, I I would, I would agree with you, I would agree with you partly there, sorry you were breaking up there for a bit. I would agree with you and, and part there as well about the manipulation.
The way that I would line those dominoes up, mark, and this is according to my reading of L'S work and the other work regarding the SI that I'm aware of, Fleming's work and such is the lite cluster will give us an idea of whether or not there is nociception at the SI joint and then the next place of the clinical algorithm that they would work on, we'd ask the question why. And I think you've got a very good one, very good possible reason for nociception at the SI as a hyper mobility construct.
And that is at least one that could happen in a variety of different circumstances. Perhaps that individual is pregnant and in last trimester or first few months after delivery. It could also happen in people that are, you know, biting index four over nine or greater or have a history of LERs Danlos syndrome or some sort of hyper mobility issue. But all of that should be preceded with a question of why is the SI talking? And one of the primary things that we need to rule out from a disease standpoint is some sort of sacroiliitis. So does this patient have any particular past health or family health issue that gets us interested in the SI as maybe an early, an early onset or something of that, some sort of onset with a autoimmune issue and there was nothing in her prior health history and nothing in her past health history. And moreover, her symptoms began with an, an actual movement.
I did not note that she had an MRI within a year of the original injury that did note a disc injury but did not show any kind of nerve root involvement in that particular situation. Also, she had an X-ray that was performed this year just a few months ago and did note some sclerotic changes at the sacroiliac joint and more on one side of the sacro iliac joint.
And it also noted a one centimeter anatomical leg length disparity, but it did not note any changes in the, the sacral ilia or the, the IA or the SI joint. So the SI joint was level, at least in a supine position where the MRI was taken and, but the, the femurs were different lengths. So
that does lean into a bit about the possibility if we have some sort of sacro iliac dysfunction, what would we as chiros or physical therapists do for that. But typically we do a manipulation procedure and chiros are taught ation study how to manipulate an SI joint.
This patient by the way, on physical examination leaning into all of those things was biting index four over nine. So she is a bit potentially hypermobile, but let's continue on now and get into our physical examination.
So with the exam, the significant findings
on motor, she had subjective and objective deficits in the right L five myotome and in the repetitive single leg sit to stand, she had objective deficits in the left leg.
We were not able to perform the instability testing because of pain.
When I moved her into McKenzie testing, she was very reluctant to perform anything ex in extension. When she was in standing and performed extension, she had pain at CC when I put her in prone she had pain at CC and she was unwilling to progress into,
into that any further.
So I, I've got some reasonable data there to suggest I've got an extension pattern.
I did put her into a McKinsey flexion movement pattern that did not change her cc, which was merely standing up, just standing would give her the pain.
I trialed a static openers on both sides and that didn't change it at all either.
What did change it? My visual observation was the patient was in a pronounced anterior pelvic tilt.
She had a large Q angle, she did have a prior history of lateral release in one knee after dislocate dislocating a patella.
So I started to imagine that I'm looking at a potential instability pattern overall that is potentially historically affecting a lumbar and sacroiliac segment with a top-down primary driver. And my first goal in that, that first treatment is to develop a narrative that makes sense to both of us, patient and me.
And within that narrative I have to support it by providing some sort of movement. First I have to give the patient a story that they can believe and I will continue to say that it doesn't matter if it's right or wrong, if the patient doesn't trust you, even if you are right then it, or if your story doesn't make sense, then you're not gonna get much benefit with that patient.
But we develop a narrative, convey that narrative to the patient of what you think is going on and then based on your cap, your clinical audit press test process of testing your inputs into that system and seeing if they modulate the index test, then you, you give the patient agency with something that they can do. So you send them home after that first visit with an understanding of what's going on in their body and something they can do to help themselves.
That's job one.
And this top down patient, the things that with a, you know, some bottom up contributors, but the chief threat I think is top down.
I want to help manage her stress that it's contributing. So I've got her on the curable app, there's input one
in our narrative and discussing those particular possible stress inputs. I ask when her symptoms come on and it's after prolonged standing and her workday. So I want some sort of input that she can do during the day when she is standing. She also has pain with prolonged sitting, so I want some sort of input that she can do there.
Those things have to do with creating a, a mindfulness about what's going on in her body without creating hyper vigilance. So we lean into that with some mindfulness type meditation. So I kicked her onto a few different apps to get a regular process on that and I leaned her into breath work or anything that increases her breathing to a deep breathing status, which she's not doing right now. She's not doing any kind of exercise, she doesn't have any kind of athletic background. So she's naive to a lot of exercise.
So one of the interesting things about exercise and mindfulness meditation, compassion meditation and other types of meditation and secular breath work is they all involve deep breathing and deep breathing. When you lean into that even more in the literature that oscillates around about a four second inspiration and a six second expiration. So a prolonged expiratory tendency, and it's during that that we see when that trend happens, a decrease in sympathetic nervous system tone and an increase in parasympathetic nervous system tone. If we take that half a step further, there is research that shows that in that sympathetically up me upregulated state, we will have upregulation of inflammatory cytokines and things like cortisol.
When we increase parasitic nerve nervous system state, we see a decrease in release of those cytokines from the spleen and other areas. So one of the inputs that we want on this particular patient at home, her agency is going to be breathing in that particular way. So during the day when she feels pain, don't just ignore it, don't overfocus on it, but apply some sort of intervention in this case a four second inbreath and a six second outbreath and then try to build that into her day while she is to, to continue that. Thank you Jerome. I'm just reading your input there.
I'll cover that in just a moment.
So I've got her doing that now how about her bottom up issues in standing Now as I'm giving her her review of findings, she's been standing for a bit and she's starting to move around and she's a bit uncomfortable. So now I've got her in a testable state. We've got her in an index position. So I coach her into a little bit of posterior pelvic tilt and a little bit of tone in her with kinesthetic queuing in her lower abs when I nudge her in that particular direction and leave her there for more than about 30 seconds. She reported that her pain was getting better and she smiled and she shook her head and she's like, wow, is it that simple? And I don't know if it's that simple, but that is at least something that she can do in the moment to help with that.
Okay, so to help foster that, I moved her into A-A-D-N-F-D-N-S pattern there and layer log rolling. And then here's where we have the intersection between breathing and bracing and posture and pain and stabilization. All of those things were in the boxes that had been checked in this particular patient workup.
So I sent her home with that now sign of things to come.
The, the process that I generally use to progress that when I see it in a patient leans into heavily on the DNS stuff. I like Evan Oars approach of the DNS stuff with his wall, you know, log rolling to wall bug to two further progressions of the wall bug that both involve in the log rolling position, elevating the pelvis off of the floor, getting the sacrum up off of the floor, which we're, we're really focusing on transverses abdominus and low AB incorporation there. And then I take that from the knee vent position to a knee straight position and I can take that out in supine and do a hollow body position in supine and then progress that to a pipe position and then progress that to legs overhead into something that starts to look like plow poses from yoga. And that we can then, depending on the patient, stand them up and put them hanging from a bar and move from the, the hollow body position hanging from a bar to a knee, knee raise position to a knee curl up position in the beginnings of an inversion to a pike position to a straight inverted position hanging from a bar again, depending on the patient. I don't think this patient, this patient's a particularly good candidate for that, but I do think it's fascinating and we will continue that work with this patient over well. I'll see her this week and we'll do a follow up next week at nine o'clock.
Drum says your clinical workup and process sound will be in line with the recent WHO guidelines. Indeed, I reviewed those and was pleased that it looks like I'm at least in agreement with the most current clinical guidelines from large organizational bodies. So nice to know that I'm still between the lines on that not too far field As far as other items that have come up, those of you that are on that are members I will share with you or Jerome, you can do this yourself, share in the community a paper from this past week that was released. This was
actually, it was released in Mar July, nope, September of 2023.
And the Journal of Orthopedic Research in Spine, is that right?
Yeah. JOR Spine.
It is full text available.
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This particular paper was entitled Mechanical Crosstalk Between the Intervertebral Disc to Set Joints and Vertebral Nplate Following Acute Disc injury and a Rabbit Model. The Rabbit model is a valid and reliable model for investigating lumbar
disc issues at Arm's reach. When I first read the,
read this paper, the, the, the verb, the choice and Mechanical crosstalk, I thought to be, you know, another one of those Click beatty kind of things. I don't know what mechanical crosstalk means. I don't know that we have an operational definition there, but it, the, the main thrust of this paper is it's in agreement with other research that has shown that when you have an injury at a lumbar disc, which was the first domino that they set up in this, there's within that rabbit model, they can demon, they can provoke a disc injury by sticking a certain gauge needle in the disc and then you will observe a degenerative predictive degenerative process over time in the disc. But then they noted some researchers noted that that then causes, or, or is associated with, I should say an important designation there some research shows an that you'll also see downstream as the degeneration progresses typical degenerative processes at the endplate and at the facet joints as well.
But it's also been noted that when you don't injure the disc but you do immobilize the disc, you also see those kinds of changes in some of those structures.
The NPLS will change and get thicker when you immobilize the disc, the facet joints start to exhibit osteophytes. It's kind of fascinating. So I think we're looking at multiple signaling processes, some of them probably mechano transduction, some of them prob you know, through tension in the, the cytoskeleton and the, the, the extracellular matrix where we'll have the mechanical tensions that that's donning versus 10 seg model going all the way back to 1995 when that was published in nature.
But when you have a change in that cytoskeletal arrangement of the, the micro filaments and such, you'll have mechano transduction that causes fiberblast to be recruited to an area to deposit a payload of collagen. Well those fibroblasts are also recruited by chemical signaling, which is probably another thing that we're observing in these kinds of models that will, that kind of chemical signaling.
Typically one of the first dominoes in the chemical signaling is gonna be tumor necrosis factor alpha and then downstream you'll get interleukin six, interleukin and interleukin one beta and a handful of others. But those are the ones that are best studied that I'm aware of.
And that in turn will cause other cell signaling processes like releases of vascular endothelial growth factor, which causes blood vessels to grow into places. That's important in things like disc injury because you then have blood vessels that grow into previously avascular areas like the interior of the disc. You ha it's important in tendinopathy models because you'll have blood vessels to grow from the tenon synovial sheath where there are blood vessels into the interior of the tendon where there aren't blood vessels.
When the blood vessels go. There's also a release of brain derived neurotrophic factor and other nerve trophic factors that will cause the nerves. Sensory neurons typically, although sympathetic nerves also run in tandem with them, they'll piggyback on top of the neurology. So now you've got a neurovascular input into some of these areas and then the sensory nerves as part of that inflammatory cascade will then become sort of the controllers of the ongoing inflammatory type of response.
You add to that in this particular PA paper they observed that the, the cartilage didn't change. It didn't point out that in other research when you take, when you injure in an experimental model injure cartilage and then you unload the cartilage either in vivo or in situ, when you unload the cartilage, it will tend towards improvements in the anabolic nature of that cartilage matrix. Remember that cartilage matrix is essentially a vascular, so you're working then with a cans and protag glycans and the metabolic processes there. The homeostatic process is primarily driven by matrix metalloprotein, ais and that last that I did any kind of research on this, there were something like 24 of those that had been identified and they're in a, you know, a scale tilting process of that either tilts towards catabolism or towards anabolism. And that's kind of a fascinating tilt because in those papers, if you injure cartilage up to a certain point in an individual or in in an animal, you'll observe If you then apply that kind of unloading process, a anabolic process, and if you injure the cartilage beyond a certain point, you will not see that corresponding change from unloading.
It will be a net and continued catabolic process.
So that then brings us around to some of this stuff that I'm trying to bring into NCA of an understanding of what we're better understanding of what we're learning into aging and longevity research. And this is where, when Saba and Judis Campisi work with senescent cells and inflammatory cytokines and painful discs and what we see there, all of that tends to move us into a way of seeing that the individual's overall health can be potentially changed by with exposure to oxidative stressors. And those are four buckets of epidem, of epigenetic influence that I've been talking about. So that's when you start to see those kinds of things in an individual, it's important to lean into those four buckets and see if there are other areas that we can be contributing in that patient for that patient's behalf to help to manage pain.
So there's a nice little arms length look at things. We are six minutes overdue on our hour long visit here.
Does anyone have any questions before I close this off?
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Alright, thank you for joining us everybody. I very much appreciate your curiosity.
Stay curious in the meantime and take what you've learned and go out there and help some people. You guys, be well. Happy holidays and I will see you next week at nine o'clock Pacific Coast Time.