#105 - Game-Changing Research Every Clinician Should Know with Dr. Tim Bertelsman and Dr. Brandon Steele, Part 1

Welcome to The Factor Podcast, where we talk about the stuff they didn't teach you in school, how to grow your practice, refine your clinical skills, and get better results for your patients. We're here to help you navigate the real-world challenges of being a healthcare provider, from delivering top-notch patient care to running a business that doesn't run you into the ground. Whether you're fresh out of school or scaling your practice, we're diving into effective cutting-edge treatments to get patients better faster. We'll also talk about business strategies and tactics to help you work smarter and not harder, and the mindset shifts required to thrive as a top performer in your field so you can build a career you love without burning out. If you're ready to learn what works and what doesn't from leading experts, industry innovators, and respected clinicians across a wide range of specialties, you're in the right place, my friend. Let's dive in. Welcome back to The Factor Podcast. I'm your host, Jessica Riddle, and in today's episode, we're joined by 2 powerhouse presenters and some of my favorite guests. Dr. Tim Bertelsmann and Dr. Brandon Steele, the co-founders of ChiroUp.com. This episode takes an evidence-based look at topics that matter right now, like the real data behind cervical manipulation and stroke, emerging evidence on nerve flossing and neurodynamics, and a lesser-known cause of stubborn low back pain, cluneal neuropathy, also known as Maine syndrome. If you're looking to sharpen your clinical decision-making, improve outcomes, and expand your diagnostic thinking, This episode is one you'll wanna bookmark and share. Let's get into it.

Fantastic. Welcome everybody. Thanks for joining us today. We're gonna try to provide some insights that you can go back this afternoon or tomorrow, whenever you're going back into clinical practice. Over the past year, our team has gone through the research as they do every year, and they came up with a lot of studies the past year that have taught us some things. Better ways to do things and more knowledge about some of the things that, that you and I deal with on a regular basis. This webinar over the next hour will cover some interesting conditions, hidden things like Maine syndrome and cluneal neuropathy that's responsible for a lot of back pain and often goes overlooked. We'll also talk about what we've learned about the rotator cuff, that there were more than 1,500 studies in the past year on the rotator cuff alone, 135 systematic reviews. So we've boiled that down into a couple studies that you'll like. We'll also talk about what's the latest information on manipulation and stroke. Is there a causation or just a correlation? And finally, one of everybody's favorite emerging topics, and that's neurodynamics. What can we do in our practices to get better outcomes really for a lot of conditions? So we'll have some high-level information that hopefully you can use, and we'll jump right in right now. This QR code that you see, if you scan that, you'll get all the resources that we'll talk about. So we'll have some infographics. We'll also have some videos and things that you can access. So if you see anything, hit the QR code. I'll put this up again at the end so that you can jump in now. The first topic that we'll talk about, and probably one of the heaviest ones for us as manual therapists and then especially chiropractors, is the link between cervical manipulation and stroke. Now, this year there were a couple of studies that came out that added to our lake of evidence. This was one of them out of the Journal of Forensic and Legal Medicine. Said, no, there's no convincing evidence between a causation of cervical spine manipulation and stroke. In fact, this second study said that the strains on the vertebral artery when we manipulate a neck are actually smaller than those that occur when the patient just turns their head from side to side. So a couple of things that have added to this body of evidence that we've known in the past that these studies, the next 5 or 6 studies that I'll show you, were not from the past 12 months.

Right.

But they're from the past couple of years. And this data has said when we look at all published data, this was Annals of Medicine, it said no, there's no increased risk of stroke via manipulation. This study from Church, this was out of Curious, said there's no causal link between cervical manipulation and CAD. This study, Cassidy, this was kind of the pioneering study that he looked at 100 million patient years of data and said no, no increased risk of stroke associated with chiropractic care versus PC care. This study from Kosloff, 39 million patients, concluded the same thing. And then we've got a couple of studies from Whedon that were excellent studies. One, 53 million Medicare patients, that said even seniors who have cervical manipulation, the risk of cervical artery dissection is no greater than seeing a PCP. And finally, this study, second study from Cassidy. His first study looked at the vertebral artery. This one looked at the carotid artery, which was also a concern in some cases. And said, no, when we look at the carotid artery, again, there's not a causative factor here. What we know is that there is a correlation between 1 patient out of 1 to 3 million patients goes on to have a stroke after having cervical manipulation. And in fact, what's happening here is that the manipulation is not causing the process. The patient was in the process of having a stroke when they saw the provider, whether that be a chiropractor, an osteopath, a PT. Really, those patients come to us as providers with pre-stroke symptoms. They have headaches, they have neck pain, they have dizziness, the types of things that you and I address. And what we're seeing is that those very subtle early signs of stroke, which are very difficult to pick up, are what they're presenting to our clinic with. It didn't matter what we did, if it was a PCP prescribing a medication or a DC or an osteopath performing a manipulation. It was— the patient was going to go on to that process anyway. So it was the problem triggered the doctor visit. It wasn't the doctor visit that set things in motion. In fact, this great study out of Annals of Medicine a couple of years ago said that the reason this myth is perpetuated is because of all these case reports. I can tell you from seeing the research over the past year, there wasn't a week that went by that there wasn't a case report about manipulation and stroke and someone pointing a finger at that. And I think Annals said it best here, that this is usually a neurologist who lacks the substantial methodological quality to establish causality. So they're trying to serve their patients. There's no harm intended here, but looking at a single event doesn't have the weight of what these studies do. So yet one more year that we see tons of research saying, no, manipulation is a safe and effective tool for our patients. Now, something that is also highly effective for our patients is we know that if we can add things to spinal manipulation, it tends to work even better. That there's tons of data saying manipulation works really well for treating a whole slew of conditions. But we know that if we could add exercises, it works better. If we can add ADLs so the patient understands what they should and shouldn't be doing, it works better. And nerve flossing is probably the top of that list that many of you, being Factor followers and hopefully Factor students, have learned the benefits of nerve flossing. I'm going to run through a couple of the studies that have come out in the past year, or a couple of years for some of them. And we'll just hit the highlights here, and then we're Then we'll dive into nerve flossing. What are some practical applications that we can start using right away? Peripheral neuropathies in general, nerve mobilization, the process of the things that we'll teach just here in a second, actually improves the cross-sectional area. It also improves the EMG NCV, the nerve conduction portion of that at least. Rotator cuff patients have a 2-point improvement in VAS. We know that rotator cuff patients can be tough to treat. So if we can add one tool that's pretty simple, both in office and for the patient to do at home, that gets their VAS down 2 points, I definitely want to know about that tool. When we take a look at tennis elbow, nerve mobilization improves range of motion. Tennis elbow nerve mobilization improves pain pressure thresholds, grip strength, neurodynamic tests, and pain scores. One more on carpal tunnel, neurodynamics superior to exercise. We know that exercise is one of those things that works really well for our carpal tunnel patients. Well, here's something that's said, well, maybe this is even superior to exercise. Lots of studies on carpal tunnel. This next one said that we have decreased edema, we have improved mobility, decreased neural adhesions, and again, improved NCV.

I think one of the most intriguing things about these is that a lot of these diagnoses are not even nerve problems, they're muscle problems. So just because you have a musculoskeletal diagnosis does not mean you need to consider just doing musculoskeletal treatments. Obviously, the nerves contribute to whatever that painful syndrome may be, and also it can can be retrograde. I mean, you can have a musculoskeletal problem that's now sensitizing that nerve and allowing them to have that musculoskeletal pain. So don't just think about if you have carpal tunnel syndrome, in this case where they have neurologic loss, as I should be doing nerve floss. It's actually for anything that that could be, you know, that's connected to that nerve.

Yeah.

One other interesting thing that's in there that was on that last slide is that you can actually improve EMG and NCV studies. That's unreal. If you would've told me that back in school, I would've never believed it. But just by getting these nerves to function better, you're gonna get them Oh, look at you. Oh, tech-savvy you. You can actually get those nerves to improve in function. One other, one other last piece is that we do a lot of stuff with sciatic issues and we don't think anything of it. It's a nerve problem. But we often forget about the upper extremity issue. So taking care of the median, ulnar, and radial nerve will go a long way.

Absolutely. Not just go a long way, but some of the data says that it might even work just as well as surgery, that there were a couple of studies that have said that conservative care works better than surgery for a lot of rotator cuff issues. And now we're starting to see some of that data for carpal tunnel syndrome as well. Not just peripheral problems that benefit from mobilizing those peripheral nerves, but cervical radiculopathy as well, improving mobility. We looked at this one for cervical radiculopathy— improved intraneural edema dispersion. So that's key to why nerves get trapped, why nerves don't bend. We'll have a little neurodynamics primer here in a second. But nerves don't glide well when they're swollen. And we can improve that with neurodynamic techniques and treatments. Lumbar radiculopathy, decreased pain intensity, significantly improved disability. Those are things that our patients are wanting. These are things that we see. The top things that we see as primary care musculoskeletal providers is neck and back pain. And anything that can have that positive effect, let's learn more about it. So many of you are very familiar with this. For those of you who aren't, Or somebody who might want a refresher, we put together a couple of slides that help us understand neurodynamics. That when we were in the anatomy lab, you remember that the spinal nerves and then the peripheral nerves in particular kind of looked like beef jerky, as did most everything else in the anatomy lab. But in reality, these are much more like bungee cords, that nerves need to be able to stretch and glide. And if they don't stretch and glide, there's a problem. So these beef jerkies here actually have to move in real life, and we know that. We'll pull up the ultrasound. Jessica, if you could play this ultrasound video for us, it's very interesting. First, I think the— what we have is a video where we're going to see what happens with a nerve. So this is the median nerve in the arm, and what this patient is doing is they're flexing, extending their wrist, and watch the nerve. So here's the nerve. I always like the ultrasounds that have the arrows. It makes it a lot easier to interpret. Same with the MRIs and x-rays. But you can see that nerve moving in relation to the tissues around it. And if it doesn't move, that's a problem. And that's when the nerve starts to be stretched more than it should. And now we start to see, see issues with that. So we can jump into the, the next couple of slides here again. That's us. And we need to bring up the presentation. There we go. So that's the nerve and that's the video. And now here's the process that happens that when that nerve moved through that channel, a couple of things had to happen. First thing that had to happen is that it took up slack. So let's imagine that I have just a loose ribbon running down my arm. If I stretch my arm out, basically doing a straight arm raise, straight leg raise, the first thing that's going to happen to that loose ribbon is it's going to take up the slack. And then if I have a couple of rubber bands down my arm, it's going to slide underneath those rubber bands. So we're going to have this neural sliding. And then once we've taken up all the slack, And all the slack spaces are gone, it's going to start to stretch, and nerves can stretch. But when we get to tension to where that nerve stretches beyond its physiologic limit, we get ischemia, and that's where problems happen. I think of it like this, that if we had a bungee cord running the length of a football field and we pulled— I know football fields sucks, sad subject today for you— but we pulled it the length of the football field, and let's say that we stretched it. 10 yards, 10% of its length. Well, that entire nerve, that entire bungee cord would stretch, and that's okay because we don't exceed the threshold. But now, if somebody were standing on that bungee cord at the 20-yard line, and now we pulled it 10 yards, now we get significantly more stretch in that portion between the pole and where somebody's trapping the nerve. Well, that's what's happening when a nerve gets swollen. When there's altered neurodynamics, now we stretch that nerve, and a stretch of a nerve Is okay to a point that the blood flow starts to diminish at about 7% stretch. So once you get 7% stretch of that nerve, which is beyond its physiologic limit, ischemia starts. But when we get to 15% stretch, in this example, standing on the 20-yard line and now pulling it 10 yards, now we've got significant stretch and now we have complete arrest of blood flow, which you and I know that leads to problems, that nerves don't like it. And a lot of the things that we discussed, whether it be a rotator cuff tendinopathy, which we know, and as Dr. Steele will cover in a couple of minutes, is a degenerative ischemic problem, or carpal tunnel syndrome is an ischemic problem. Those are symptoms. And one of those symptoms, we know that any type of mechanical obstruction is going to create a progressive neurologic issue. This study said that when somebody has carpal tunnel syndrome, the entire median nerve had lost its ability to glide, because anytime a nerve gets irritated, whether it be at the spine Or all the way down at the periphery, that entire nerve swells a little bit. And when that nerve swells a little bit, it loses its ability to glide in that tube that it's supposed to glide in, like we saw in that ultrasound. Eventually, we can start to get irritation, and now maybe there's some swelling, there's some leaking of fluid, some fibrous adhesions, and now we've got bigger and bigger problems that, that tend to become more permanent at that point.

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So one last study here on neurodynamics is that we saw that patients who had cervical radiculopathy had loss of median nerve excursion at both the elbow and the wrist and the cervical spine. No doubt nerve flossing helps, helps that nerve move better, and that improved movement means that the patient's symptoms are going to improve. So we're seeing more and more data. I don't think there have been many topics that have had more data than neurodynamics as to the utility For you and I in clinical practice. In the spine, here's something that's very familiar to those of us who, who treat spines. The opening mechanism of nerve is reduced when things get stiff. We see stiff local motion segments in lots of our patients because they're sitting at workstations, they're doing things that perpetuate that. And in that case, the nerve root is never completely relieved of pressure. There's going to be swelling, there's going to be changes in blood flow, and there's going to be altered neurodynamics. The result of that is this neurogenic pain. This was a great study out of J— it's actually JMMT. And this was done— actually, this was done by the director of research for the McKenzie Directional Institute. And they looked at what percent of extremity pain comes from an asymptomatic spine. We can see that almost 3/4 of hip pain comes from an asymptomatic spine. Almost half of shoulder pain comes from an asymptomatic spine. So the things that we see in the spine that, that contribute to this can oftentimes be helped not just with spinal manipulation and myofascial release locally, but nerve mobilization, because that whole nerve is going to pay. There's a couple of tests that we can do in order to determine, does somebody have a nerve, nerve issue? Much like the straight leg raise in the lower extremity, none of us would consider treating a patient with peripheral pain into their leg without having done a straight leg raise to see what's going on. But how many times do we do that in the upper extremity without having done the equivalent of a straight arm raise?

The proper reference was on that picture. It just was the wrong on the bottom. So that was my mistake. Sorry. I think that the easiest thing as a chiropractor is to attribute most of these neurologic problems to the intervertebral foramen because that's how we were trained. But just think about that closing mechanism at the intervertebral foramen and at the other parts of the spine. So in this case, we can actually look, do we have a peripheral problem or more of a spinal problem? So with the median nerve, in fact, we can all do this together. Separate your fingers as far as you can. Slowly extend your wrist and then start to bring it behind your body as far as extension. And some of you, not all of you, will start to feel a pulling, a numbness, a tingling, a burning going to the first 3, maybe 3.5 fingers depending on how you're wired. And then you can— that's how you're going to start to pull at that nerve root. Well, if that reproduces symptoms associated with carpal tunnel syndrome, well, that's how we all expect it to do, but it can also reproduce problems different places along the arm. And you can use neurodynamic self-tests to not only identify Is this a nerve problem, but also is this a problem associated with my lateral elbow pain or medial elbow pain? So just by— because you're doing the test doesn't mean it's always going to produce symptoms in that characteristic reason. We always want to make sure, say, median nerve tension test is positive for lateral elbow pain or numbness and tingling in the first 3 fingers. You can also do the same thing for the radial nerve and then the ulnar nerve. The ulnar nerve is a little fun to do with your patients. If you take your pointer finger and your thumb and put them together, And then all you're going to do is try to look through the opposite side of your hand, just like you're seeing in that picture. And you're looking for numbness and tingling in the 4th and 5th fingers. So these are self-tests that patients can do. Within a couple of seconds, you can now identify exactly, is this nerve involved? Next slide. There are also things you can do in practice. So you can actually modify the elevation and depression of the shoulder, modify elbow angles or wrist angles to see where is the chief complaints or the chief complaint coming from.

Remember, the—

first joint that you actually bend is where you get the most compression and you're creating that. I think what Dr. Burrows said, you're stepping on the 20-yard line. So the question is, what joint do you want to step on first? And you can help localize exactly what area of the spine, or in this case extremity, is causing the, the chief complaint.

Awesome. So obviously in our synopsis of the research that we're going through today in these 50 minutes, we really can't go through all of the self-tests, all of the treatments. But for those of you who want to dive deeper, there's a couple of resources. One, I'll put the QR code up again at the end so that you can get access to any of the videos that will give you the videos and the demonstrations for all of these things so you can do some self-learning. And really, this is something that probably takes a little bit even deeper orientation to get a good grasp of. And this is one of the things that Factor does so well, that the types of things that you learn in a Factor class with regard to the testing and the treatment is invaluable. And this is one of the things that's It's the top of their hit list. In fact, they have specialty classes on this. So make sure that you check out that website. Make sure that you, if you're not familiar with the classes, by all means jump in and see what can you do to start implementing to make a difference. One of the— the last caveat, the last slide on this one actually, is the difference between a nerve tension test and a nerve flossing or gliding treatment. Now, generally, the test is always going to be a tensioning process, like a straight leg raise. And we're generally going to start with treatment with a flossing or a gliding. Now, treatment can advance to a tensioning again later on, but most of the time we're going to do a flossing or gliding, at least at the beginning. And the difference is that in a nerve tension test, we're going to stretch both ends of the nerve. We're pulling from both end zones. With a nerve flossing test, we're going to be pulling from one end zone and letting the other one go, and then pulling it back as though that, that Nerve were trapped or the bungee cord were trapped on the football field, we're going to floss it and pull it back and forth. So that's the big difference. And again, a deeper dive into that will pay big dividends. So by, by all means, check out the videos and more importantly, check out a class. All right. Tip number 3 here, and we've got 5 for you today, is something that I've overlooked many times and it's called Maine syndrome or cluneal neuropathy. There was a study that came out in the past year that said 14% of patients with lower back pain had entrapment of those cluneal nerves. So they had a cluneal neuropathy. And when it is present, it's oftentimes present bilaterally. Now, in prior years, there were studies that said up to a third of our patients with lower back pain had involvement of the cluneal nerves. And once you get a little better understanding of it, you'll see why it is such a common process, that this is something that often goes unnoticed, that the Maine syndrome is basically a mini sciatica. So if we had sciatica, one of the lumbar nerve roots would be irritated, sending pain down the patient's leg. Their pain is in their leg, but the problem is in their back at a disc or degeneration. Maine syndrome is, is a very similar process except it's a mini sciatica of the thoracolumbar junction where there's irritation to this dorsal ramus and that nerve comes down and then comes behind the thoracolumbar fascia, emerges through these orifices in the thoracolumbar fascia over the iliac crest, and then spreads out over the buttock here. So this, this study said that it could be contributed in up to 40% of lower back pain cases. Well, of course, if you have tightness in these muscles, irritation in the fascia, we're going to see potential irritation in that nerve. It becomes swollen, stuck, it doesn't move, and now we have symptoms. So, so many of our patients have irritation either here for the mini sciatica, or they have this peripheral neuropathy of the cluneal nerve. So we would call this cluneal neuropathy. We would call this Maine syndrome. Cluneal neuropathy is something that we see in tons of our patients. And the good news is it's something that's relatively treatable. Now, while we can't get deep into these tissues here, we know that the tissues, especially this posterior ramus at the thoracolumbar junction, comes back and supplies the skin. So when there's an irritation here or peripherally, we're going to see that there are symptoms in the distribution of that nerve, which is generally into the buttock area here, as we played before. That's gonna cause low back pain. It's going to cause buttock pain and sometimes even radiation of pain sclerotogenously toward the groin. So our patient that we've done everything for, and their lower back pain or this pain in their iliac crest and upper buttock— how many of your patients have that pain in that iliac crest and upper buttock? Most of them. We'll poke along the iliac crest and find out, is there some tenderness there? Because if so, there could be some cluneal nerve involvement. We know that this is something that is common because of the postures involved. So this could come on from somebody who's in hyperextension because they're wearing a heavy backpack, which isn't quite as common as it used to be now that everything has turned to e-learning and we're using an iPad as opposed to 30 books in a book bag. But some of our patients still have hyperextension issues. More of our patients, now that we've changed to e-learning and we're on an iPad, have this, this flexion issue. Where you're constantly stressing your back, you're creating that as a fulcrum point, and we get some irritation to those nerves. So one of the ways to determine is the nerve irritated is the, the top clinical test for any neuropathy. It's called the poke on it test. Doesn't matter if it's carpal tunnel syndrome or a thoracic outlet syndrome or a radial tunnel syndrome, we poke on it. So for cluneal neuropathy, poke on it. The first nerve of the, of the cluneal nerves comes out about 3 centimeters Off of the PSIS, about 7 centimeters and about 9 centimeters off of there. So just palpating along that iliac crest and saying, do I reproduce your pain when I touch these nerves? And then there are a number of tests that we can do to say, is there an increase in pain if I provoke the junction? So having patients do a Sphinx test, a lot of that motion happens at the base of the thorax where the ribs end. So we stress that area with a Sphinx test. We can also stress it with a Kemp's test. Putting the patient into hyperextension and lateral flexion. We can also do a PA shear of the thoracolumbar junction. Now, this is one that is really useful. That patient that you've treated 3 or 4 times and they're not a lot better, shear their thoracolumbar junction and say— see what they say. If they say, yeah, that's really uncomfortable. And then the last thing that we can do, or one of the other more valuable things that we can do, is skin rolling. And skin rolling is just as it sounds. We're going to take that patient's skin, we're going to pinch it over the top of the cluneal nerves, And we're going to say, does that hurt? Is that uncomfortable? Because if the nerve is hypersensitized, it's going to be uncomfortable to pinch that nerve. If the patient has a lumbosacral problem and a lumbar disc lesion or degeneration, it's not going to hurt to pinch the skin over the iliac crest. So if it hurts over the iliac crest, it means the nerve that supplies that iliac crest is irritated. In this case, it's probably one of the thoracolumbar nerve roots. So the next video, Jessica, if you could play this for us. The cluneal nerve release. Dr. Steele described this. There's a good way, just like we nerve floss an arm or a leg, we can nerve floss the cluneal nerves.

Yeah, and this is one that you're really going to do mobilization. It's tough as a chiropractor not to just drop on this and get it moving. However, you can see from my left thumb there that I'm supporting the thoracolumbar junction, and I'm going right over the PSIS to perform some mobilization, stretching out that cluneal nerve. One little side note is before you do that skin rolling test, make sure you tell the patient what you're doing before just pinching their— Their little bit of belly fat there. But this is a great way to stretch things out. With that being said, with any kind of nerve problem, if you get sharp pain or shooting pain, that's when you want to just back it off. It doesn't mean that you have to stop doing any kind of nerve flossing. It just means you're going a little too far or a little too fast. If you could show the next video, Jessica, it's going to actually show the actual at-home test. So it's always good, like a McKenzie directional therapy provider, Is to say, let's make it easy. What's that?

The floss, nerve floss.

Yep. Make the test the treatment. So in this case, we're going to make the test, as far as what Dr. Brosnan talked about, we're going to turn it into a treatment, which is the video I just showed. And now we need to send the patient home with something that's going to also do the same thing. So with the cluneal nerve floss, you're going to see how you bring the head down into flexion, pulling the nerve from above. And now you're going to actually stretch it from below while keeping the, in this case, the left Hip up into abduction and flexion. So this is a great way to teach the patient how to keep that nerve mobile while opening up the intervertebral foramen. And this is going to be another one that during any kind of nerve mobilization exercise, we really want to make sure the patient understands that they can actually do a little more damage. So more is not better. Just go in and touch the pain, and then you want to back off that pain.

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