#13 - Peripheral Nerve Entrapments with Drs. Olson and Lindholm

FAKTR, spelled F-A-K-T-R, stands for Functional and Kinetic Treatment with Rehabilitation. Over the past decade, this unique approach to treating pain and dysfunction has been utilized by healthcare providers on 6 continents. Serving as a framework that guides clinical decision-making in patient visits around the globe on a daily basis. With this podcast, our goal is simple: to bring the best and brightest in clinical education to the forefront and empower practitioners with cutting-edge, evidence-based content that improves patient outcomes and inspires healthcare providers to continually evolve their approach to treatment. In each episode, we will feature a training or interview with some of the top minds in healthcare. in a short format that is easy to digest, with actionable information that you can implement into practice right away. Let's get started. Hi guys, welcome to a new episode of The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. In today's episode, we feature a brand new training on adhering to the evidence-based guidelines in treating peripheral nerve entrapments. With Dr. Michael Olson. He is one of the co-developers of our newest Factor course offering, Factor Peripheral Nerve Entrapments, or Factor PNE, as we like to call it for short. Dr. Michael Olson practices at Big Fork Valley Hospital in northern Minnesota, where he has implemented the first chiropractic department within the hospital system. He has served as a post-grad instructor on soft tissue treatments and is an adjunct faculty member of Palmer College of Chiropractic in their new Multidisciplinary Environments elective program. Dr. Olsen has special interests in sports medicine, having obtained both his Certified Chiropractic Sports Physician certification from the American Chiropractic Board of Sports Physicians and his international certification in chiropractic sports medicine from the International Federation of Sports Chiropractic. He has been a contributor of numerous publications in regards to peripheral nerve entrapments, chiropractic management of concussion, and other sports injury-related ailments. Now, many of you may know that we launched this new Factor PNE, or peripheral nerve entrapment course, in December of 2019, shortly before COVID hit hard here in the United States and around the globe. Originally, this course was offered as a live, in-person, hands-on training, But with COVID's effects on the in-person training element, we decided in early 2020 to convert the course and transition it into a fully online course offering. So now you can take the full Factor PNE, or peripheral nerve entrapment course, online in a self-paced 8-hour format. Now, topics that are going to be discussed on today's training and in our episode today include defining PNE, What are peripheral nerve entrapments, and how exactly do these entrapments occur? We're also going to talk about some common patient presentations and the evidence-based medicine triad. Dr. Olson will also guide us into a deep dive of a real-world case of peripheral nerve entrapments, where he walks through his complete clinical workup and exam, differential and final diagnosis, and treatment. We will also discuss how to explain peripheral nerve entrapments in a way that makes sense to your patients, as well as some best practices for treatment during the acute phase. Now, if you're confused a little bit about what peripheral nerve entrapments are, you're in the right place. If you're in clinical practice, you're probably encountering them all of the time, and maybe just aren't realizing it. On the other hand, if you are a pro at treating PNE, then you're sure to enjoy this discussion today. I'm sure you'll pick up some clinical pearls along the way. As always, if you have questions as you're listening, you can submit your questions in our special Q&A link in the show notes. We will have Dr. Olson back on for a future special Q&A episode so that we can cover all of your burning questions. With all of that being said, let's dive into today's training.

So welcome everyone, and thanks for joining. What I'm gonna discuss today is peripheral nerve entrapments as kind of an introduction to this class that myself and Dr. Lindholm developed. The title of my presentation is gonna stick towards adhering to evidence-based guidelines to treat these peripheral nerve entrapments. And I think that's important today in modern medicine or integrative care or your standalone clinics. I think with so much knowledge to our exposure from just being able to hop online to read something about your condition, I think I think it's important that we as clinicians use evidence-based medicine to kind of guide our care. And specifically, I wanted to use this because there's a lack of evidence for some of these peripheral nerve entrapments that we do teach during this course. So I, I kind of wanted to show how to use the best guidelines that you have available to treat these conditions. I'm a 2011 Davenport grad from Palmer, so I am a chiropractor currently employed at integrated setting in Big Fork, Minnesota at a hospital here. Adjunct faculty member with Palmer, work with our local school to provide side and athletic care. And then as Jess mentioned, I just recently put this course together and we should see an online version of this course coming soon as well. So we're excited about that. So to start, I wanted to discuss what is evidence-based care. There's a lot of definitions and evidence-based care varies a little bit depending on what type of medicine you're practicing as well. However, I do, I think this one from the Cochrane Collaboration is probably one of my favorites. So I do just want to read it. And it says that evidence-based healthcare is the conscientious use of current best evidence in making decisions about the care of an individual or individual patients and the delivery of those health services. Currently, the best evidence is up-to-date information from relevant, valid research about the effects of different forms of healthcare and the potential for harm from exposure to particular agents, the accuracy of certain diagnostic tests, and the predictive power of, you know, how likely someone is to recover or respond to this care. So again, this is kind of an all-inclusive definition, and then you can get a little bit more specific depending on what type of medicine that you are practicing as well. But it is a good definition. This is a picture that I show a lot of my patients when it comes time to treat them for a case where they might have, or where there might be a lack of good evidence-based medicine, but still something that I think is a condition we can treat. I can also use that on the flip side if, let's say, Whether in concerns to low back pain, where there's a lot of evidence with chiropractic and physical therapy, how it can help. This is really easy to describe to a patient and go through said treatments and just use this as a discussion means with the patient. But I do like to show these rings if I'm starting to treat a case that might be hard, or I might have like a slight working diagnosis, or we know what it is and I've treated it in the past, but there's still not a lot of good evidence out there to suggest what I can do to be— is currently helpful. So we're going to use this model too, to show you how, if you're treating said conditions, how you can use evidence-based medicine to continue to provide good quality care. I think when it comes time to peripheral nerve entrapments, which is what we're going to gear this discussion around, I think how I got my foot in the door, as the image shows, into treating these is I first had to become really proficient in spine care itself. And we know that when treating the spine, oftentimes we're having to rule things in or rule things out. And a lot of times, especially with any type of spinal radiculopathy, we have to figure out, okay, is it Actually a spinal radiculopathy, or is it a true peripheral nerve entrapment? And I also use this slide in previous presentations if I'm just talking to students, and the role of chiropractic or physical therapy or conservative type of care in getting into this allopathic model for certain treatments is, you know what, I have to use— as a chiropractor, I have to use my portal of entry to get into an integrative setting. And my portal of entry, that be of spine pain, but also this evidence-based medicine triage down here to get in. But similarly, we can use this for— peripheral nerve entrapments and using it to efficiently treat these conditions. So this is kind of now, I think, what my personal practice looks like, and that is the majority of conditions that I treat is spine care. But every now and then, these patients are coming in with various other conditions, and I have to first and foremost rule out spine care. But then if it is a peripheral nerve entrapment, I want to be able to maintain that patient and effectively treat them because I think I'm equipped with the tools to be able to do that. And a lot of that is some of these factor protocols that have been developed. They work so well for various peripheral nerve entrapments, among other things. So again, I would say I specialize in a lot of the spine-related conditions. However, I do a lot more in peripheral nerve entrapments as one of those treatments. So when we're looking to treat peripheral nerve entrapments, I think we all know that there's a plethora of various treatments, and some of them have a lot of evidence-based medicines to suggest What these factor protocols and how they may help, such as things like occipital neuralgia or carpal tunnels, sciatica, nerve root impingements, tarsal tunnel. We see a bombardment of articles if one were to do like a Cochrane search or a PubMed search. Various physical therapy journals have standards for how to treat these conditions, but really a lot of these conditions are no different than some of these peripheral nerve entrapments that aren't as well documented, such as carpal tunnel of Guyon or a pudendal nerve entrapment or vagus nerve Morton's neuromas. It's just What nerve is being entrapped and what symptoms are being manifested as a result of that specific nerve entrapment. So you'll also see that in that evidence-based medicine triad that we can use some of our past experiences to help further guide good care. I use this as just an algorithm. I love algorithms for treatment, especially when I'm working with a patient and let's say they are a complex low back pain and maybe I've plateaued with that patient or they haven't responded like I fully have thought they are. I can say, hey, look, this is where you're at on this treatment algorithm. And maybe I don't show it to them their first visit, but I can say, this is what we've done. I followed these guidelines. Here's where we're at. These are our next steps. This is what our evidence-based medicine literature states what we should do. And sometimes that might be a continuation of care, just be a little bit more patient. It might be a referral for an injection, or it might be physical therapy or massage or a better rehabilitative exercise program. And so using these algorithms is super easy when it comes time to spine care. However, when it comes time to peripheral nerve entrapments, unfortunately, we don't have a lot of these algorithms. Down yet, simply because we don't have enough studies published for various forms of treatment other than injections or sometimes a surgical release of that specific nerve entrapment. So sometimes I'll use these models and walk a patient through that, but again, relating it back to their specific condition. So what I'm going to do now is I'm going to break these 3 rings down for you and then give you a case and show you how I'm kind of using these 3 rings and also working up peripheral nerve entrapment. So again, when it comes time to evidence-based medicine, the 3 most important things we need are From the specific literature standpoint would be the best available evidence. So what do I have that's already published to work with? Then I need my own personal experience or your clinical knowledge, your clinical judgment, your expertise. I'm 9 years into practice now, so that's my experience and expertise is far surpassed than when I first started with, but again, it's very different from someone that's been in practice for 30 years. And then ultimately, I really make sure that the patient has to help me guide their care and what do they prefer. And sometimes a patient may have been referred into my clinic. But really, they have chronic low back pain. They just want to get the injection and be done with it and wait another three or four months to get the injection. And that's really going to skew how they're going to respond to my care if they're coming in with these set standards. Like it's not really going to help. So after I do my full exam, I really make sure you want to sit and talk with the patient and figure out what do they value? What do they want? If I start to give them on any active rehabilitation, are they going to listen? Are they going to do some of those exercises? And are they going to enjoy and tolerate my? Treatment as well. So with that being said, how I kind of divided this out for peripheral nerve entrapment or trying to differentiate that from a spinal nerve root impingement is when it comes time to the literature, in order to just properly assess and diagnose that, we know we're going to need to go through our NMS exam or orthopedic exam. And then during our functional nerve entrapment class, we put a strong emphasis on stretch, compress, activate, stretch, compress, activate, because sometimes these peripheral nerve entrapments are hard to elicit or there's not an ortho exam or maybe it's just a sensory nerve. So there's There's not gonna be a reflex or strength component to it. And really, with a lot of these peripheral nerve entrapments, part of that exam is our ability to, okay, if I put this nerve on tension, is it reproducing the symptoms? If I compress where I think the entrapment might be, is it making the symptoms worse? And same thing, if it has a motor component, can I try to activate the musculature that that nerve controls to see if I can elicit any symptoms? So that's something that we show a lot in our classes, how to, how to Kind of diagnose or find that specific entrapment beyond then just further treating it. And then your specialty, in my opinion, when treating peripheral nerve entrapments, if you're not able to differentiate between a spinal nerve root entrapment and peripheral nerve entrapment, this is going to be tough to treat. Furthermore, I think from a chiropractic standpoint, if there's many chiropractors that treat whiplash, a few less that probably treat concussion, but let's say someone has post-concussion syndrome and it's cervicogenic mediated, and then they have whiplash. A lot A lot of the treatment for post-concussion cervicogenic mediated is going to be similar to what we might do for whiplash. However, someone that manages whiplash, let's say it's an individual was in a motor vehicle accident, they got hit by a drunk driver. To me, that's kind of a red flag coming in where I know there's probably going to be some legal work and litigations involved. And the amount of note-taking and thoroughness in your documentation for that needs to be top-notch. And where some individuals, especially if you're coming right out of school as a student, treating that whiplash injury, you might have all the proper tools to treat it, but are you specialized enough to know how to document that? And there's many of us that aren't. So just because, let's say, I say I would specialize in whiplash and that treatment might be similar to post-concussion cervicogenic doesn't necessarily mean you're the right person to treat it if you've never worked with that concussion. So again, when it comes time to peripheral nerve entrapments, are you specialized in treating it? And I realize that that takes time as well. If it's something that you want to treat, it's just going to be getting comfortable with it, understanding your literature and your exams and your assessments and learning how to treat. And then obviously in that red we have patient preferences. So is this a treatment that they're going to want, they're going to follow through with, or would they rather have surgery, or, or etc.? So I think we can use that to begin to treat. So I'm going to bring you guys through this case history now and then kind of walk you through how my brain processes differentiating between a peripheral nerve entrapment and a spinal nerve and how I look at this. And I was told in school 90% of my diagnosis should from a case history. So I always make sure I really sit down and save a lot of time to talk with this individual. So this patient presented, he was a 61-year-old male. He presented into my clinic with right-sided foot drop. The symptoms had been going on for 9 days and he initially saw a medical doctor when they first came on and the medical doctor kind of told him, they said, oh, I think it'll go away in 10 days. If it is not gone, to follow back up. Well, obviously, see, on day 9, he was too anxious. He couldn't wait for the 10th day. And really, he said there's no change in the symptoms whatsoever. So he really didn't think he'd just wake up the next day and they'd be gone. So that is why he came and saw me. And I had treated him for various other things in the past, and he kind of knew the work that I did, and other people had told him, I think you should see the local chiropractor for this. This started after he had been trapping leeches in a canoe, and basically what that entailed is 3 long days of 8+ hours where he's literally just sitting, pulling traps from the side of the canoe, dumping the leeches into his bucket, and paddling around these swamps and bogs. And a lot of times it's a lot of heavy hiking in and out of some of these swamps as well. At the end of his last day, he went to walk up a big hill to bring his canoe up to his truck and be done, and he noticed that he could have dorsiflexed his hip— it should be foot— he could not dorsiflex his foot, so he was falling into a foot drop. He arrived home 1 hour later and he took his boots off, and then he started to notice that he had numbness on the top of his right foot, and again, still no ability to dorsiflex that foot. So his specific words were, it's like, yeah, I really I had to bring my hip up when I took a step, otherwise my foot would drag. From that history alone, I think as a clinician, we should be formulating the exam that we're gonna do. So is this forming that differential diagnosis? So is this going to be a lumbar radiculopathy case? Could it be a peripheral nerve entrapment case? I put here, don't know, refer somewhere else. And that might be the case for some individuals. They might, might present to them and they have no idea what's going on. It's not in their wheelhouse. Well, that individual should recognize a referral needs to be made, or probably worst case scenario, would be a lower entrapment compartment syndrome. Usually those are brought on by a prolonged— usually when I think of lower compartment, I think of these marathon runners where they develop that compartment syndrome and then they need an immediate surgical release. So really in this case, what I was thinking is either a lumbar radiculopathy or a peripheral nerve entrapment. So before I kind of start to give away what this is, I'm going to kind of show you the very basic exam and then And let everyone kind of think to themselves what route would they go down. So he stood at 67 inches tall. He's a little bit obese, coming in at 235 pounds. His lower extremity reflexes were both intact for the patellar and Achilles. Now, in his lower extremity strength, they're all 5 out of 5 except that right foot dorsiflexion. I noted a 2 out of 5, and the right foot eversion was a 3 minus. From a sensory standpoint, he's unable to distinguish between sharp and dull sensation along that dorsum of his foot. And I put these lower extremity sensory charts up because I don't always have them memorized to an exact T, especially when it comes time to peripheral nerve entrapments. I would say I'm pretty good with my dermatomes as a chiropractor, but I often refer to these charts and they're on my exam wall. So when I need to differentiate between a lower extremity nerve root entrapment or a spinal nerve entrapment, I can start to skew my sensory exam a little bit to see, okay, is this just the peripheral nerve entrapment or do I need to follow that dermatome more? So with this individual, it's primarily along just that dorsum of his foot again, where he had a hard time telling between sharp and dull sensation. Everything just felt dull if he could feel it at all. So what now? Again, a lumbar or peripheral nerve exam. And to me, this seemed to be pretty easy where I was thinking peripheral nerve almost right from the get-go. However, again too, I also don't like to be wrong. So if for those of you that are still maybe thinking lumbar, I will happily tell you I did a lumbar exam that will show you to further rule some things out. So during the subjective findings, one of my questions was, do you have low back pain? And he said, no, absolutely none. My back feels great. So usually if I were to be thinking a lumbar radiculopathy, a lot of times there's going to be some amount of pain with that. Furthermore, I'm still going to bring that individual through lumbar range of motion. And for a 61-year-old obese man, I felt his lumbar range of motion was in normal limits. And again, no pain with any movements. There was also no trigger points or muscular spasms. Throughout his low back. I also do some end-range loading stuff. So what I didn't mark on here is then I proceeded to take that individual through weighted, so standing repetitive lumbar extensions. So this likely, if it was coming from a nerve root, either would have made the symptoms better or it may have made the symptoms worse. And really it didn't do anything for this individual. He felt no better, no worse while going through end-range loading. And that was primarily repetitive of extension is what I brought him through. So from there, I'm sitting there thinking, okay, I probably ruled out lumbar spine, but what do I need to do next? And there still might be some people thinking, well, you probably should x-ray the lumbar spine or maybe get an MRI of the lumbar spine. To me, those didn't seem necessary at this point because of just full range of motion, lack of pain in the lumbar spine. Besides, reflexes were intact, obviously just this— a little bit of sensory and strength component. And so from there, diagnostically, you're looking at EMG or NCV, which I think could have been done. I still feel like I didn't feel the need to order those yet. Then we have our diagnostic musculoskeletal ultrasound. Again, those 2 things might be something that I resort to if I'm not seeing improvements with the patients, but not something that I felt like I needed to order right from the get-go, so I did not.

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So then I wanted to go into my peripheral nerve exam. Okay. So from an assessment standpoint, I think we've probably safely ruled out a lumbar radiculopathy. And so now we need to look at that peripheral nerve exam. So first and foremost, in our head we need to think, well, what helps us dorsiflex that foot as well as provide a little eversion? And we know from a muscular standpoint, those peroneal muscles are involved with that. And so then we should also be thinking back to our anatomy and physiology that, oh, drop foot, lumbar radiculopathy, or a peroneal nerve entrapment. Okay, and then that entails knowing the course of that peroneal nerve. So I noted that he had moderate edema around that fibular head proximal aspect of the peroneal and anterior tibialis muscle. So kind of just all along that anterolateral shin region around that fibular head, as well as significant pain and tenderness in the proximal aspects of those muscle groups, that anterior tib and peroneal muscles. From there, I mentioned to you guys about stretch, compress, activate, stretch, compress, activate. Well, a peroneal nerve stretch— so he was completely numb when I put him in through a peroneal nerve stretch, it immediately caused significant burning in the top of his foot. But when I compressed at the site of entrapment, it took that burning. So I compressed literally like right after I stretched it and it immediately caused complete numbness again. So that to me was kind of an indicator that something had been, that been compressed. From there, I kind of further asked him, how is this compressed? And he had no idea that that was tender. And after I compressed there, he said, while I was canoeing, that lateral leg, it literally, I had a 5-gallon bucket right between my legs and that was kind of pushing my legs into the lateral, into the what's called the gunnels of the canoe. So for 8 hours, 3 days in a row, he literally was compressing his anterior shin into the gunnel of a canoe. And then obviously I kind of gave you these muscle strengths for ankle or foot dorsiflexion at that 2 out of 5, then with eversion, 3 out of 5. So right there we have a pretty thorough assessment, and actually you can realize that it can be done very quickly. Even like myself in this case was pretty confident that it was going to be a peripheral nerve entrapment. Just from the history. But again, to solidify that, you guys, and for the sake of this webinar, you guys can see that from an assessment standpoint, I use my differential diagnosis and use my exam to rule in a peripheral nerve entrapment as compared to a lumbar radiculopathy. From there, it's treatment. Again, now I tell the patient, this is what you have, here's the treatment that I'm going to provide, and are you okay with this? So I take those 3 rings of that evidence-based medicine image that I displayed earlier and we diagnosed it. The thing with this type of treatment is I kind of told the patient there's literature in there that states individuals can work with this. However, if you were to search the treatment for a peroneal nerve, there's not that algorithm. And I'll explain that to a patient. There's a lot of case studies on this and the literature that's out there states like physical therapy and other means of conservative care may be helpful, but it doesn't tell you exactly what should be done or what works better, whether it be pin and stretch or nerve flossing or instrument-assisted And then again, that's having that conversation with the patient. Do you want to proceed with this? Other types of care might be to try an injection here to see if we can't reduce some of this swelling. And he obviously, coming into seeing me and knowing me, he wanted me to proceed forward with care. And so we started treatment that day right after the exam, after I explained this condition to him and how we were gonna work to try to fix it. And literally we went through kind of an active warm-up, and I like to do some of my active warm-ups using some of that compression floss. Floss. And obviously it was— this was a compression injury, so I don't want to overly compress the nerve to make it worse. But at the same time, I want to use the floss to provide some of that shearing through the soft tissue dysfunction. So we did that while we were providing range of motion exercises, and that was with resistance and without resistance as care progressed. And again, a lot of with the resistance is I'm also trying to strengthen and get that dorsiflexion and eversion back, as well as using instrument-assisted soft tissue. Again, same with progression. So the first day was definitely more passive, but as he's able to improve his walking and his balance, and I would start to challenge him in various stances or gait patterns while I'm still providing some of this treatment, again, restore his function. I did some fibular head mobilizations as well. There's some stuff in the literature that states that that can be beneficial for this peroneal nerve entrapment. And then I, I do like to use kinesio tape, and with him I wanted to to kind of tape him into some of that dorsiflexion as well, but also providing a decompressive type of treatment to where I felt that nerve entrapment was around that fibular head and border between the anterior tib and peroneal group. And then a lot of his take-home again was strengthening his foot dorsiflexion, but also bringing himself through peroneal nerve flossing. So nerve flossing or neuromobilization, as some individuals call it, is highly beneficial. And you can almost floss just about every peripheral nerve that there is. And so this individual was taught how to do peroneal nerve flossing, and that was one of his main take-home exercises that he was to do. And he would tell you every time he got done flossing, his foot was numb, then it'd go back to like tingling and burning. And as we continued to progress him with care, that tingling and burning finally started to come back to a normal feeling. And if he were to get a little bit of tingling and burning, he'd go right into that nerve flossing. So a lot of neuromobilization was was beneficial with this patient. And so really my care with this case was a full resolution of symptoms after 8 weeks. And during this 8 weeks, there was 11 treatments that were provided. Some individuals are gonna respond faster, some a little bit slower. When I look at this and I see this, to me, in recalling this patient, it was a little bit tougher of a case. Usually I don't treat my patients 11 times. Usually they respond quicker. And, but that also depends on the acuity. This was obviously a A lot of prolonged compression for 3 days in a row of 8 hours, so, and with significant muscular weakness. I mean, he had full-on foot drops. So I reminded the patient of that as we were going through care as well, because I think there are sometimes he'd come in feeling frustrated. I think it was somewhere between treatments 5 to 8, we kind of hit this little plateau and we didn't see, see much improvement after each session. And then finally we kind of got over that last hump until we We had full resolution of symptoms. So here's a question that I like to pose. Did I follow evidence-based guidelines with this? And I think for some of these peripheral nerve entrapments that are not very common, this slide works a little bit better. But being with foot drop, most of us know it's either going to be the pudendal nerve entrapment or a lumbar radiculopathy. And there's a little bit more literature in regards to peroneal nerve entrapments than, say, a pudendal nerve entrapment. And I would say this one was a little bit easier to Follow evidence-based guidelines. But again, still, like I said, there's not that algorithm like there is for low back pain or neck pain where you can check, yep, I did this with the patient, check, check, check, I followed it to a T. These guidelines for this are probably a little bit more abstract. Obviously, this was a pretty good study that I have here, and in the abstract where I have highlighted, just talks about many patients benefit from nonsurgical measures to include activity modification, bracing, physical therapy, and medications. So a little bit more loosely defined here, it mentions surgical decompression should be considered for refractory cases and those with compressive masses or acute lacerations or such severe conduction changes. So if you were to order that EMG and ECV, and depending on what that finding was, if it was severe, they would try to go in and do a surgical release with that. So again, these are just things that I like to have on hand for various conditions that I treat to also So walk patients through this so that they know I am up to date with my literature, and it helps give me some credibility that they know I can comfortably treat if it— for the said condition. So again, I kind of talked about these algorithms and the importance of using them in evidence-based care, and obviously there's plenty, like I've said, for the low back, a little bit less for the— some peripheral nerve entrapments. Real quick before I close and then open this up To discussion if this is something that interests you, or maybe it's something like, wow, that does seem pretty easy, but I wasn't thinking peroneal nerve entrapment at all. I was only thinking lumbar radiculopathy, and maybe I would've ordered that MRI of the low back first before I even went through care. Or maybe I would've done that EMG. And this does interest you. I think this factor peripheral nerve entrapment, to put a little plug in just for this class, is gonna be highly beneficial. I treat these nerve entrapments on a daily basis in practice now, and I've treated so many of them, and they're all the same. And once you get a feel for them, usually they're all pretty easy to treat. And you can take these same factor concepts or any type of active rehabilitation that you may do and apply it to various conditions. Anytime you know how to treat a neuropathy, there's a lot of different tools that you can use to treat these. And just in the course of care, in some of these things that I've tried to like put into publications so that we can have better literature in regards to treating these, so all these patients don't necessarily just wind up in surgery. For example, we have this pudendal nerve entrapment in here. We need more of this stuff, and this is which is also why I feel this factor peripheral nerve entrapment course can be so beneficial. Here's another case of pudendal neuralgia. Jess will have something on the factor website soon about a pudendal nerve entrapment that I treated that I did a webinar on very similar to this if that interests you. But there's treated some recurrent laryngeal nerve entrapments. Various here's another drop foot one. Just like we have lateral femoral cutaneous nerve palsy, there's some medial femoral. I had a colleague treat treat this one down in in an integrated setting and use a lot of similar methodology of treatment that I use in order to treat one. So peripheral nerve entrapments are very common. I think there are a lot of times clinicians are missing them. I think there are a lot of times they're being misdiagnosed as spinal nerve entrapments. And so here's this class and here's some information on if this is something that you're. you're interested in treating. Jess, I think that's about all I got, and I can open it up for questions if anyone has any. Absolutely.

So one person was asking about how you explain to patients what's going on with them. So you have a patient, you discovered it's peripheral nerve entrapment. Clearly there's a lot of patients that are familiar with terms like pinched nerve and things like that.

How do you go about explaining to a patient what's going on with them when they have Yeah, my fallback to that is always carpal tunnel syndrome because everyone pretty much knows what carpal tunnel syndrome is, or they have a general understanding. And so I can educate them on, okay, what is carpal tunnel? And then I have diagrams and figures for about every anatomy part sitting in my room, and I'll just kind of take that out or point them to a picture and state, hey, here's what's going on. This nerve should be going through this tunnel. That tunnel is being compromised, whether it be by edema or some tissue tonicity or Or if we feel if they have a lot of neural tension, I can bring them into that neural tension. So another common one would be sciatica. If I can really bring them into some sciatic nerve tension and elicit those symptoms, that I kind of use that. And then from a treatment standpoint, everyone understands carpal tunnel, and most people know like, oh, I went in for carpal tunnel surgery. So I'll tell the patient when I'm explaining their various options, and I said, just like carpal tunnel surgery where the doctor will go in and clip that ligament, you might be able to go in and they might be able to like decompress this, or they might be able to release some of that fascia there and give that a little bit more room. But just like carpal tunnel, which I can treat myself as well by doing this and loosening that up and providing more room and stretching that nerve or mobilizing that nerve a little bit, I can do the same thing in this location. And same thing if it were a lumbar radiculopathy. I use those analogies, but for sure carpal tunnel, the carpal tunnel analogy is what I use most.

You were speaking earlier about your patient. He had compression as a component of some of the mechanism of injury. As foot drop is an entrapment injury, so further expressing, compressing it, does that exacerbate the condition? How important is really looking at the mechanism of injury to figure out how you're going to go about treating these entrapments?

Yeah, I think it's very important. And how I kind of had to word this for the presentation so I wouldn't specifically give it away, but during my history too, I also sometimes I'll just show the patient like what position or how are you sitting, describe how you're sitting, could you move around a lot. And especially when he told me there's no low back pain at at all. He feels he has so much longer range of motion. And then me knowing my anatomy with foot drop, knowing, okay, how is this going to be compressed? I just asked him like, show me how you're sitting in a canoe. And he was the one that then specifically said, well, I was sitting in the canoe like this. My legs were open, kind of like ankles together. The 5-gallon bucket was right between my legs. And then my legs were literally resting on the gunwales of the canoe. So yeah, I mean, but from that standpoint, as I mentioned, I used some compression floss on there. Using compression floss In that manner versus someone who may have foot drop following prolonged running where they have such severe anterior shin splints, I can be a little bit more aggressive with the compression floss there because there I'm really trying to get a lot more tissue shearing, and I know the injury wasn't from traumatic compression, it was more from like repetitive overuse injury. So when I use the compression floss on this individual, like I said, I stayed light enough to provide a little bit of tissue shearing as I could bring him through his exercises, but not enough where I felt like it would be Like as strong as his legs were resting on that gunnel.

Someone is asking about different treatment protocols or options for brachial neuritis. He says he has a patient that has a definite entrapment with brachial neuritis. They've done diaphragmatic breathing exercising and retraining, isometric exercises, postural retraining, in-range loading, as well as flossing.

Are there other suggested treatments or things that they should be looking at or considering when it comes to Yeah, I mean, I think there's a lot of different ways to treat brachial neuritis, whether it be simplified massage around the brachial plexus to chiropractic intervention to physical therapy. It is tough, and again, it always relates back to how long has this been ongoing? Was it acute? Is it chronic? I also think that they meant that— it looks like this individual mentioned isometric. I still think you can still try to start doing exercises that that aren't also bringing the patient through movement. With that being said though, I mean, obviously it's hard to give advice when you're not the—

Sure.

The clinical doc evaluating the treatment, but I think just, yeah, there probably still is maybe some various forms of soft tissue from like an instrument-assisted soft tissue or decompressive cupping. A lot of times if an individual is not responding to instrument-assisted soft tissue where they're using that compressive instrument, I might try some decompression So I'm getting more of a traction away from the tissues surrounding the nerves, I guess. I know I'm not fully answering that question to probably what the individual hopes, but I mean, I always think there's usually a little bit more, and sometimes it might just be a referral to someone else in the same line of care, but they just are going to analyze that patient a little bit differently than yourself.

Other systemic diseases often are characterized by loss of sensation in the distal extremities. How do you differentiate between those type of diseases where you have that sensation loss versus nerve entrapments?

A good history. A common one that I see is obviously pregnancy-induced carpal tunnel. So obviously, as the individual is becoming more pregnant, they're retaining more fluid and swelling more, they're more apt to develop things like that. And then it's just taking a good health history and looking, do they have a systemic infection or some type of rheumatoid arthritis that may be contributing to it? There you're looking at Trying to break that inflammatory cycle somehow as well.

Do you recommend doing nerve flossing using the Factor instrument over the site of suspected entrapment at the same time? Obviously nerve flossing in the upper extremities for sure.

Yeah, for sure. And in the class we demonstrate that. So with our nerve flossing, we also demonstrate if I'm giving someone a sciatic nerve floss and they're lying on their side, it's pretty easy for me to continue to use that Factor instrument while they're in that side-lying position doing the nerve floss. And obviously with our factor progressions, we have those 5 various progressions, and that's bringing them through movement and proprioceptive exercises and trying to provoke some of that. So you could also try to get them into a mild sciatic nerve tension. Usually I don't like to fully tension it, but you could get— you could bring them into some mild neural tension and again use that instrument and see if it reduces the tension. But for sure, I treat a lot with, as the patient, once they have that nerve flossing down, especially if it's upper extremity, or for this brachial neuritis patient, I may have them nerve flossing while I'm also using my factor instrument over that lateral aspect of the neck and shoulder.

Can we do nerve flossing in acute PIVD? What is the role of the same? I'm not sure what PIVD stands for.

Yeah, I'm trying to wonder that.

I'm assuming if they're in an acute phase where they're still very inflammatory, still very much in pain when you put them into those positions of provocation?

Okay, I have a student with me right now and these are a lot of the same questions that she's asking me and my cop-out answer is it depends. Some things that I take into consideration, has this patient ever had any type of treatment that I'm about to deliver? If they haven't and they're already a little bit nervous or hesitant on receiving care, I'm probably not going to be provoking it too heavily on their very first treatment. I'm going to let them get comfortable with me, I'm going to let them get comfortable with what the treatment feels like. If that nerve flossing is going to give them a lot of discomfort, I might not do it. Now, if this person has seen me all the time, maybe they're training for a marathon and the marathon's in a week and they're gonna do everything in their best power to not let this affect them and they wanna start treatment, hit the ground running, I'm gonna do a little bit more. Or maybe in this acute sensation, maybe your neuroflossing was the only thing that gets them relief. So I think, again, it depends. I teach my students that work with me me to really develop a good rapport with the patients so that they understand you. I'm very talkative with all of them so that they're comfortable, and it's just, I think, trying to gauge your patient to the best of your ability helps.

Thank you so much. Are there any other questions we have? Anything else? And to clarify the earlier question, the PID stood for a type of disc prolapse.

Okay, so when there's an acute disc prolapse, yeah, I do a lot of end-range loading for that too. So again, that's to depend on is that disc lateral or medial, are they antalgic, can I get them into a position that's not going to aggravate the disc but still allow me to nerve floss. So some of my sciatic nerve flossing I can do from a seated position, but if I feel that seated is too much or they can't tolerate any weight-bearing position, maybe I'll try it in a side-lying. Again, it depends on how that patient's presenting and, and what they're tolerating.

Thank you so much. And once again, Dr. Olson's information, so if anyone has any questions, they can email Dr. Olson there. And of course, we'll be providing you all with more information as our FACTOR P&E course goes online this month. We're in the final editing phases now, so within the next 2 weeks, we're gonna have that course live, and you guys will be able to learn much more about how Dr. Olson and Dr. Lindholm have applied the FACTOR protocol and the FACTOR concepts to treating peripheral nerve entrapments. Thank you so much, everyone. Have a great day.

Thank you.

Alrighty, guys, that is it for today. Be sure to tune in for episode 14, where we will unpack a brand new training with Dr. Rob Pape on Quadrant Movement Analysis: Taming the Clinical Gray Area. Between pop and pray and diagnostic-based treatment protocols, there exists a vast gray area where most of our patient care lives. We'll be talking about this in episode 14. You won't want to miss it. Our next episode drops in 2 weeks, or 1 if you're one of our Patreon subscribers. You can subscribe to The Factor Podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a 5-star rating to help us grow the show. Every little bit helps. Also, be sure to leave a review if you like what you heard today. We'd love to receive your feedback and hear Be sure to also look for our Patreon link in the show notes to access additional bonus content, early release episodes, and an ad-free listening experience, along with bonus content and special offers. We are constantly adding more benefits for our patrons, so get in early for maximum value. And last but not least, please remember to visit the show notes for a link to download today's PDF of our full presentation. We'll see you next time. Hey guys, if you like what you heard today, I encourage you to visit our website at factor-store.com. That's spelled F-A-K-T-R-store.com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands-on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.