#17 - It’s Not Carpal Tunnel: Now What?! With Dr. Spencer Lindholm, Part 2

Factor, 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 wrap up our training with Dr. Spencer Lindholm titled It's Not Carpal Tunnel, So Now What? Carpal tunnel is the most common peripheral nerve entrapment diagnosis, accounting for 90%— let me say that again, guys— 90% of all peripheral nerve entrapments diagnosed. But is that because the prevalence of this condition is so profound, or are clinicians simply not well-versed on other similar conditions that present like carpal tunnel syndrome. In today's episode, Dr. Spencer Lindholm, one of the co-developers of the Factor P&E course, reveals his process for arriving at his final diagnosis for the case study presented, and he walks us step by step through his treatment plan. In this tactical portion of the training, we will discuss how to differentiate between multiple entrapment sites of the same nerve and how to progress with active treatment and rehabilitation. Dr. Lindholm will then walk us through what the literature says regarding the misdiagnosis of carpal tunnel syndrome and which other similar conditions are most commonly mistaken. With all that being said, let's dive in.

So working diagnosis, I was kind of down to that. Okay, is this still carpal tunnel syndrome, or are we looking at pronator teres syndrome? When we are testing nerves peripherally and we're looking for nerve entrapments, the stretch, compress, and activate is such a phenomenal tool for the reasons I said before. It just, it really can help provoke that nerve, which is what we want to do with a lot of diagnostic testing. And so you want to do resisted pronation when you're doing that, and basically giving the patient a handshake and making them go through resisted pronation. And then what we'll do differently is really locate where that pronator teres is and Add some compression on there as well, and can we also get that into a fully stretched position? So what's the big differences between carpal tunnel syndrome and pronator teres syndrome? If you don't know the differences between the two, it's really hard to land on a diagnosis of pronator teres syndrome, isn't it? A lot of times people just get confused and follow whatever that median nerve diagnosis is that they know. One of the big differences, forearm pain, right? They should have some type of pain, or most of the time they tend to, where that pronator teres is. Nighttime numbness, that's more characteristic of carpal tunnel syndrome and not any of the other median nerve entrapments. They're not characterized by that. But we did find a little bit of that nighttime numbness with the pronator teres syndrome. Due to the infrequency of it, I wouldn't look at that as a huge diagnostic factor. But that was also a little curveball that was making me still look at this carpal tunnel syndrome, right? Thenar muscle wasting. So you should only see this with carpal tunnel syndrome, but Based on anatomy and neuroanatomy is pronator teres syndrome, you can still have muscle wasting. They're both affecting that anterior interosseous nerve that supplies the muscles for that grip strength. And that's why we can see the hand weakness as well. And then the big characteristic symptom everybody knows, right? Tingling and numbness over that first 3 and a half fingers. Only the fingers though. So if you recall, our patient had a little bit of numbness and tingling in the thenar eminence. Due to where the nerve that supplies the sensory over the thenar eminence arises, it is actually proximal to where the median nerve goes through the carpal tunnel. So with pronator teres syndrome, that was a big giveaway besides the stretch, compress, activate, and the findings that I had locally at pronator teres was carpal tunnel syndrome should not create numbness or paresthesia over that thenar eminence. That's got to be a more proximal entrapment when we're looking at that. So a few big things there that really pointed me toward pronator teres syndrome. And then we discussed, well, should we confirm this, right? With confirm this or see what we get as far as diagnostic imaging or other testing results. And really during the report of findings, the patient and I discussed the different diagnostic testing that we could do and discussed the kind of the positives, negatives, all the stuff you should do in your report of findings. And he opted to go for an initial conservative treatment plan 6 visits. So a lot of times I'll do that with patients to create some buy-in, right? Is, hey, I know you've already done 12 visits of PT and you're not any better. And so there's some frustration when they come in, right? Then a chiropractor is telling them that their hand surgeon may have had the wrong diagnosis. So you can imagine how some patients might kind of look at you like, okay, so you think that you know better. And so part of that was, hey, give me 6 visits. Let me see. Our treatment goal here is going to be 50% improvement. And I use a kind of a general subjective rating with patients verbally a lot of times like that is overall improvement. And I'll tell them on follow-up visits, but really what I'm looking for with that is a shotgun answer, right? So they don't have time to think about it, analyze, and try and make their answer what they want it to be. It's what are you actually feeling? And that's taking into account frequency. So are they noticing it less often? Because they might still have the same intensity of pain or numbness or paresthesia, but it may be significantly less often, which is a huge win. It means that that nerve's not being provoked as easily, even if it is as dramatic or intense when they do feel it. Vice versa, they could have significantly less intense pain or nerve symptoms, but it might still be present all the time. And so that's just taken into account, what are we noticing as far as improvement with ADLs, frequency, intensity? And I wanted to see, can we get this patient 50% overall improvement of less frequent, less intense symptoms, and less impacted by function or activities of daily living? So we did 4 weeks, we did 6 visits, primarily using manual therapy. So instrument-assisted using factory tools, some active release therapy over that area, compression flossing, I really, really love for these nerve entrapments. And then doing nerve glides with cupping in the office. So putting a cup over that area of entrapment and then having them go through their median nerve glide protocols. We also did some dry needling with e-stim. So I do a fair amount of that in my practice, but it's never a standalone treatment. So I always incorporate some other type of manual therapy, movement-based therapy along with that. And then if you're familiar with Dynamic Tape, it's my absolute favorite tape. I was so happy when Todd introduced me to it through the factory seminars, and then I was able to get trained as an instructor. And the Dynamic Tape has been a game changer for a lot of these peripheral nerve entrapments. And that's one thing that we're looking at incorporating a little more into the peripheral nerve entrapment courses is some of the protocols that we found have really worked well with the taping. And so I did an offload pattern over the flexor muscles, so from elbow down over to the palm. And really tried to do some offload on those flexor muscles so that they weren't having to do as much work. And then same thing with the pronator teres muscle, which that's a little more of a spiral pattern trying to address that pronation around that forearm. Subsequent treatments, same thing, manual therapy. We would get into a little bit more of the forearm flexors and then the muscles within the hand too, rather than just that pronator teres initially. But right off the bat, we saw some really good improvements. And you'll see that with any of these factor treatments is that we should be able to make a discernible and really positive improvement as far as pain goes if we're doing movement-based treatments and we're addressing those painful movement dysfunctions. And so we can see the same thing with peripheral nerve entrapments where the patient oftentimes feels immediate improvement. I gave him at-home daily therapy. So the big thing there is doing the median nerve glides, right? Is I want him doing them frequently enough that we're not having overuse or just static positioning within those forearms and that we're really doing some neurodynamics to get things gliding and moving. And then we did some directional preference, kind of McKenzie method type stuff, of fully supinated elbow and then going through full wrist and elbow extension and really trying to increase that range of motion because some of it muscular tension, but some of it coming from that elbow joint. We were having really, really restricted end range of extension at the elbow and the wrist as well. And that places a lot of extra strain in that pronator teres muscle if we were constantly in this bent elbow. Positioning. One of the big things we looked at with this person was weightlifting. We did some video analysis and found that when he's weightlifting, it doesn't matter if he's doing a deadlift, a clean, just picking up a dumbbell, he is like a gorilla. His arms are just always bent, always bent, always bent. So that was one thing that, hey, we got to increase the range of motion here naturally, and then we got to transfer that into your function in the weight room. And so we spent a lot of time trying to really retrain that. Long-standing pattern. And then simple thing for people at home, right? Give them a lacrosse ball, tell them to roll stuff out when it's tight. And then we decrease the volume of upper body weightlifting. So typically I'll do that for about 2 to 3 weeks with athletes that are having any nerve entrapment symptoms is they still want to get in there. It's good for them, good for their physical but mental health. And so usually we'll just take that volume down and take a few days off and let things get a little bit of a break from that stimulus. And then with technology use, just take a break every little bit. So if it's about 30 minutes that those symptoms set in of being on your computer is Every 20, 25 minutes, once you've taken a 1 to 2 minute break. So we did reexamination after 6 visits and the patient had exceeded their improvement that I wanted. And they were ecstatic. They were ecstatic because they said, I can avoid surgery, which was the main goal, right? So we had about 75% overall improvement. We had a decrease in both the intensity and the frequency of symptoms. The symptoms that he was experiencing at night, the paresthesia, went away relatively quickly. That was within the first couple of weeks. And then we had increased length of time while doing provoking activities like weightlifting and being at the computer. He was making it well over 90 minutes, and then he would start to feel some light symptoms. And so we were just slowly progressing that over time. The left hand was the one that— and you'll see this not just with nerve entrapments, but in general, whenever a patient has bilateral symptoms, a lot of times the side that's worse is going to take a little longer to get better, and the side that's not as bad, you get better a little quicker. So We saw the left hand actually fully resolved. He, by the time that we were at 4 weeks, he was 5 to 7 days at that point where he was not having any symptoms in that left hand, which was great to see. And the right hand was significantly better. Much less tenderness and much less hypertonicity in the pronator teres and flexor muscles. We were getting to full elbow extension and full wrist extension, but sometimes it would still be a little stiff in the mornings and he'd have to go through some exercises and stretches to really loosen things up. And then rechecking some of our nerve entrapment tests. Most of them he passed with flying colors, right? So resisted pronation with compression on the left was negative, and then it was mildly provocative on the right. And we really had to hold a sustained contraction with that compression for greater than 10 seconds to even provoke that at that point. We continued the treatment plan for about 4 more visits. That's what it took to get the rest of that right side to really calm down and abolish those symptoms. And then, then I always transition patients into some strengthening exercises. To try and address any of those dysfunctional movement patterns or posture dysfunction, things for long-term benefit that we need to. So we did a reexamination 4 weeks later. So this would've been after our 4-week treatment plan plus the extra 4 weeks. So we were at 8 months total and he was still completely resolved and no symptoms bilaterally. So doing great. Yeah, this is the frustrating part sometimes. And maybe I've misdiagnosed a few things and other people have found them along the way. But yeah, when you get somebody that comes in and, and they say, oh, this other doctor told me this is what's going on. It can be a little frustrating when you find that it's not that. I mean, this patient was going in for a bunch of treatments, but it's not just with carpal tunnel syndrome, but it's with a lot of these nerve entrapments. Not every median nerve entrapment is carpal tunnel syndrome. It's the most frequent diagnosis, and therefore it's just the top of the mind for most of us as clinicians. And I'm no different than anybody else where that's going to be one of the first things I look at because it is the most common, but it shouldn't be the only thing you look at. It shares symptoms with numerous other conditions. Our differential diagnosis slide we looked at before, that was, I would say, maybe half of the conditions you can include when you're looking at true differential diagnoses that have overlapping symptoms. Part of the problem is that there's really no clear-cut consensus on carpal tunnel syndrome diagnostic criteria. Now we have really, really good evidence that supports different diagnostic criteria, but none of them are all-inclusive, right? It doesn't say if this is positive, therefore they have carpal tunnel syndrome.

Right.

Carpal tunnel syndrome is a diagnosis primarily of history, physical examination, nerve conduction studies, diagnostic imaging, and response to conservative treatment. So you got to use all those things when you're looking at carpal tunnel syndrome, and I would say pretty much any other nerve entrapment. And that really sounds a lot like evidence-based medicine, doesn't it? We're using the best available evidence, but then you got to correlate that with, or use that in conjunction with, your clinical knowledge and your experience. Some clinicians are just a little too cavalier sometimes when diagnosing carpal tunnel syndrome. And you just need to make sure that you're looking at what else could this be and doing a thorough examination and not just throwing stuff at the wall and seeing what sticks. The lack of consensus on the diagnostic criteria. So there's a lot of studies and if anybody's interested, kind of the variances in the sensitivity and specificity of the different diagnostic criteria, I put a few in here, but Tinel's sign, there's numerous research articles that look at this for carpal tunnel syndrome. And wide range of sensitivity, 38 to 100%, and 55 to 100% specificity, depending on what study you're looking at. Phalen's maneuver, same thing, right? Very wide range there. And EMG can be very helpful, and the same can be said of nerve conduction studies. Those are even more helpful. But they are only helpful when they are done completely, which we saw in this case that it was not a complete one. Technically sound, right? You got to do it right and then interpret it carefully. You can't just look at, oh, they had distal latency and then there's also distal latency further up the course of that nerve, but you're just going to look at the one that you want to look at there, right? So you got to interpret those correctly. But there's lots of room for error with the diagnostic criteria when we're looking at peripheral nerve entrapments and especially carpal tunnel syndrome. So relatively few studies, right, that actually look at misdiagnosis or overdiagnosis of carpal tunnel syndrome. But there are numerous studies that discuss it. They're more so looking at successful surgical outcomes versus failures, and they'll have a nice discussion, but there's no comprehensive studies that have really looked at why do we have misdiagnosis or overdiagnosis, or what is the rate of misdiagnosis or overdiagnosis of carpal tunnel syndrome. Most of the studies on carpal tunnel syndrome from that standpoint are looking at those surgical success rates, and the only focus there is Why did the surgery fail? They're only concerned with why did that CTR, that carpal tunnel release, why was that not effective? And one of the things they'll discuss is misdiagnosis, is, oh well, the surgery is great, that works just fine, that's not the problem, it's we just didn't have the right diagnosis. And I think that's a little bigger of a discussion and something that doing case studies like this, it brings more attention to that. And that's why research is so important because Are we practicing evidence-based medicine when the evidence says that pronator teres syndrome is extremely rare compared to carpal tunnel syndrome? And at times you feel like, oh gosh, am I branching out of evidence-based medicine? Is this off the beaten path? And I would say, no, we're still utilizing the best available evidence. The best available evidence in this case says that you need to have a proper evaluation of the patient and that if they meet all of those classic symptoms of carpal tunnel syndrome, and they have delayed median nerve conduction in the carpal tunnel, and these are the only clinical electrodiagnostic findings, then the diagnosis of carpal tunnel syndrome can be pretty straightforward.

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It's not very straightforward if you have other symptoms and other examination or diagnostic testing findings that make the water a little murkier, right? So in this case, I would say no. I still use evidence-based medicine. I would maybe say this was evidence-informed medicine. I use the evidence that carpal tunnel syndrome states, which is if you don't meet this criteria that is very clear-cut for carpal tunnel syndrome, you should be looking at something else. And that's exactly what we did in this case. And so use the evidence for things that you're trying to find a different diagnosis for if the one that you're looking at doesn't have a lot of evidence. And with pronator teres syndrome, there's definitely research out there, but it's relatively limited. And a lot of the surgeons have a little debate over how prevalent it truly is. But I think if we look at those carpal tunnel release outcomes, up to 50% of surgeries fail depending on what study you're looking at. So there's got to be a little bit more when it comes to diagnosis if, if there's putting people under the knife and having that many surgeries fail for those releases. So knowledge is power, right? I mean, you've heard me say it multiple times, is you got to know your anatomy, you got to know your examination, and you got to know where all those peripheral nerve entrapments are. Is carpal tunnel syndrome being overdiagnosed or misdiagnosed just because people don't know what other conditions mimic it, or is it just a shotgun diagnosis? You know, diagnosis of awareness, we'll say. It accounts for 90% of all peripheral nerve entrapments, and that's including upper and lower extremity. Carpal tunnel syndrome is very, very prevalent as far as diagnosis goes. Why wouldn't you correlate that with carpal tunnel syndrome, right? Is that's a very common disorder. You're getting a patient with numbness and tingling in the distribution of the median nerve. So yeah, that's, that should be the top of your list. It was the top of my list as well too. But just don't get tunnel vision. You got to make sure that you're checking out those other differential diagnoses and those other possible nerve entrapments along the course of that nerve. So some clinicians just tend to do this based on limited knowledge. It's not that anybody's not trying to get to the right diagnosis, right? But if you don't look at peripheral nerve entrapments often, or you've never had training in it, it's really hard to know what to look at. What tests to do, what symptoms are overlapping, and what differentiates them even, like the differences between carpal tunnel syndrome and pronator teres syndrome. Just knowing, hey, this is what is different between these 2, even though they're the same nerve and they're only getting entrapped, what, I mean, 12, 14 inches apart from each other. It's not that different, but we have some very, very significant differences from a symptom and clinical standpoint to point to there. If it looks like a duck, quacks like a duck, it's maybe not a duck. Not all the time, right? It can't just be, it looks like this, so we're going to make that the diagnosis and try and prove that that's the diagnosis. That's called confirmation bias. You need to have the clinical knowledge to go, okay, this is the most likely diagnosis based on etiology and what we know as far as the rates of people that have it. But that doesn't mean that it's it automatically. So do you know multiple other median nerve entrapments to be able to look at in that scenario even? How many do you know? Do you know 3 of them? So you're looking at a partial picture. Do you know 7, 8, 9? And then what differentiates those from one another? It's almost impossible to land on the correct diagnosis if you can't even locate the pronator teres, if you don't know what the symptoms of pronator teres syndrome are, you're unsure how to examine it or test it, and you don't know how to compare that with those differential diagnoses. So you really, really gotta fill your brain with some of that knowledge to be able to look at the multiple different areas that that could be coming from. And then the most difficult thing is really just a thorough examination. It's really easy to get a little short-sighted and kind of go to the area of pain or provocation that they're describing because you got to get the correct diagnosis, right? If you don't know what to fix or if you're fixing— you're trying to fix the wrong thing, it's really, really hard to get those results and resolve that for that patient. So first find what it is, then the fixing is the easy part, right? You use a lot of the stuff you already know to accomplish that. So a few studies. I know we're getting close to an hour here, so if anybody needs to get taken off here soon, totally understand it. Thank you for spending your time with us. We'll be wrapping up here in just about 5 minutes though, so if you want to hang on. Looking at electrodiagnosis of the carpal tunnel, right? So a lot of people, if you don't order any EMGs, NCVs in your office, I think it's at least helpful to do a little review of those and know a little bit more about them and how to interpret them. Because sometimes when you look at a lab report on that or a radiology report on that, You're going to see that it's a little confusing. You're comparing to reference values, and there's actually a few different techniques for doing it. So this is a great article here, and I can email that out to anybody that wants it, that goes over the full electrodiagnosis of carpal tunnel syndrome and all the different variances. And then they actually do a really good job too of looking at all the other diagnostic factors, talking about Tinel's sign and what are the error rates on that with different conditions. So the EMG NCV can be extremely helpful, but it's also, it's about how do you interpret it? And you got to be the one to interpret it, that if you're the one ordering Okay. And know what you're looking at there. So this one was a Mayo Clinic study and it was a case series essentially that they took patients that had failed carpal tunnel release and they tried to figure out why did they fail the carpal tunnel release even though they had EMG findings that were suggestive of carpal tunnel syndrome. So they say there's growing evidence that carpal tunnel release can be performed with a high degree of confidence for a good outcome without a confirmatory EMG. And this is when symptom examination findings are typical. So again, if they fit into that CTS diagnosis criteria. However, an operation should be considered cautiously when atypical clinical or electrodiagnostic features are present. And they demonstrated that in their series of cases. And in my case, that's what we found was atypical clinical findings, but— atypical electrodiagnostic findings as well, and that was more so related to, we'll say, an incomplete picture. But this is a great article, and this is where they have some good discussion with the surgeons that wrote this, looking at the possible misdiagnosis idea of why did these patients have failed surgeries, is that other conditions can masquerade or mimic carpal tunnel syndrome, and that, that's what happened in these 12 cases that they Another one here. So again, this is that 50% of all surgeries that have carpal tunnel release have a failure rate as far as what the literature shows. I've seen some numbers that they have a little higher success rate. 50% is a little bit on the lower end, but usually it's about 60% of what you see in studies as far as carpal tunnel release success rates and 40% failure. The Actual surgery of carpal tunnel release accounts for 11% of all surgeries performed. That is huge. That's a large number, and there's a significant amount of people going through carpal tunnel syndrome each year in the US, and there's likely a good portion of those that may have carpal tunnel syndrome in conjunction with another diagnosis or carpal tunnel syndrome that isn't actually carpal tunnel syndrome, right? The other thing that this study looks at is how the multiple screening tests We think that they increase accuracy, and you would think the more tests you do, the more accurate that your diagnosis is going to be. But the results actually show that specificity decreases when we start to use more results. And so we really get a less specific idea of what's going on there when we just start hammering in multiple different screenings and tests on that. And then this one's looking specifically at pronator teres syndrome. Honestly, this is just a great article if anybody wants more information on pronator teres syndrome. It does very similar to a lot of the stuff we try and provide within our peripheral nerve entrapment course, which is going over everything from introduction of this condition. These are the nerve roots that that median nerve is supplied by. This is where it can get entrapped. This is how prevalent it is, how to diagnose it. But they say in this study as well, and their discussion is pronator teres syndrome can often be misdiagnosed as it shares symptoms with the more common carpal tunnel syndrome. And so it's not new or novel to think that, hey, PTS and CTS could have some overlap there. And it's something that other providers are seeing as well. And it's interesting that surgeons are seeing it so frequently too and choosing to analyze why these surgeries are failing on that carpal tunnel. So when we, when we look at your practice, right, is we all kind of have our general scope. You can be a jack of all trades and master of none, but you also can be a jack of all trades and then be really, really focused or good or specialized in certain areas. And so For chiropractors, spine care tends to be that big wheel that keeps turning your practice as far as why patients come in. For a physical therapist, that might be post-op rehab, but whatever that is that kind of keeps your practice turning and brings in the majority of people. And then what other things do you do that you specialize in that people tend to come in and see you, or they're really seeking out your care? For me, it's always been a little bit more of the exercise rehab side of things. That's where I see a lot of people. I do some concussion management because I work with a lot of the youth sports athletes in the area. Extremities has been a huge focus of mine, and I've curved out a little niche in my area as far as extremities go. And then peripheral nerve entrapments, and that has really, really started to build within my practice over the last few years. I can't believe how many people I get referred specifically for peripheral nerve entrapments. And I've even had medical doctors that have come in to see me and then started referring their patients to me because 2 different medical doctors that actually had tarsal tunnel syndrome. In the foot for one of them, and then a different one, quadrilateral space syndrome. So axillary nerve compression or entrapment there. And both of them were so wowed. I'll say they were within the Kaiser system, but they could not find anybody to help them within their own system where they get very affordable care. And so they wound up at my office and I run a cash practice. And so to have a medical doctor come in and not use the insurance within their own system and come pay you a cash rate, To say, hey, I've heard you can fix this. That tells you word's getting around that you've got a little kind of niche in your area to help with those things. All right. Well, that is kind of my overview of why carpal tunnel syndrome is possibly very overdiagnosed and misdiagnosed. And it just, it drives me nuts sometimes when I get some of these diagnoses that somebody that you would think would land on a correct diagnosis, like a hand surgeon, calling something carpal tunnel syndrome when you know what you're looking for and you do a thorough examination. It's pretty apparent that it's not carpal tunnel syndrome. And then same thing, you know, that trial of conservative treatment was just eye-opening. We should see improvement. If you're helping your patients, the biggest factor that you can look at is intra-treatment improvement. Did that person get better when they left your office? And peripheral nerve entrapments are the same way, is we should have immediate improvement. We should have intra-treatment improvement. And to go through 12 PT visits and have nothing, so something that just blows my mind, but Guys, you got to know your stuff, and we got to get to the correct diagnoses on some of these peripheral nerve entrapments. Because boy, if you think about patients getting sent in for surgery for things that they shouldn't be having surgery on, that, that's mind-blowing. And that's a lot of the time our job can be to help get the correct diagnosis there, because we might be that first person that they come into with that. So I hope that you guys enjoyed the presentation and that this was a fun little webinar with lots of information, but it kind of made you think about all these Different peripheral nerve entrapments and how they can really mimic other conditions and that it takes a lot of knowledge and experience, but that experience is not hard to gain because I bet you, you're seeing more of them in your practice than you think. So if you have any questions from today's content, you want to reach out to me, my email's at the bottom there. Otherwise, any questions on courses, products, things like that, general questions for Factor, there's the email there. If you're interested in the PNE course, please reach out. I'm happy to chat about it with anybody. Dr. Olson and myself are really proud of that course. We put a lot of time and thought into how we could best develop this course for both students but also the active clinician to be able to take this material and utilize it in practice right away. If you're interested in any more webinars, there's a link there you can sign up. And then yeah, please, any questions, I think Jessica is going to help moderate, and I'm happy to answer any questions you guys have.

Thank you so much, Dr. Lindholm. Everyone else, if you haven't had a chance input a question yet, please type that in now. I'll be asking those here for Dr. Lindholm. One of those that came through earlier, there's a doc on here that says, I'm familiar with the offloading of flexors with dynamic tape, but how did you isolate the pronator specifically, and how did you utilize the spiral pattern for that?

Good question. Yeah, so that one's probably a little better when you have a visual on that, but there's not specifically a dynamic tape offload pattern, but When you learn a technique, you can take those principles of that technique and apply it elsewhere. And dynamic tape is really kind of— they encourage that is, hey, think about how you're going to use this tape from biomechanics standpoint. And so it's not that I isolate pronator teres specifically. I mean, I would say with a flexor offload, it's hard to say, well, which muscles specifically are you isolating? Really trying to offload the pronation. So if we offload pronation, there's only 2 main pronators there, and that's pronator teres and pronator quadratus. And And then you've got to cross the wrist joint to be able to anchor that off. And so sometimes I'll anchor that off on the distal end on the back of the hand. Sometimes I'll cross over the thumb joint, but really you just get them into a shortened pronated position and you want the elbow bent to about 90 degrees when you're doing that. And then you're choosing to do a spiral pattern that's going to offload that pronation in that sense.

Wonderful. Thank you. Another person here had a question about sciatica and how much of that is Yeah, good question.

So sciatica is, I believe it is the first nerve entrapment that we cover in the lower extremity. Oh, sorry. No, we go distal to proximal. So not, but we, we have spent a good amount of time on it. So we talk about some of the standard neurodynamics that happen, but then we show a couple different ways that you can use nerve glides and neurodynamics with sciatica. And then we present a little bit of research there too on sciatica and differentiating that from lumbar radiculopathy, but I would say sciatica is definitely one of the Sciatica, we cover it. Sciatica is a pretty well-known condition like carpal tunnel syndrome and stuff. With sciatica, we're looking a little more at it from a functional perspective of how is that provoked? Is that with— do you have a runner that they're getting their hip up into hip flexion and that's provoking it? And then later that day they're having numbness and tingling down the leg. And we go through a little more functional screens with that— quadruped rock, modified Thomas. Like, we do a lot more of the functional screening with the lower extremity, but Yes, sciatica we cover in the nerve entrapment course. We cover a lot in the nerve entrapment course. It is very information heavy. As you can see, you kind of need all that information. And the first day of the course is the longer day when we do the live course, and that is the whole upper extremity. So upper extremity, including coming from the neck, shoulder, all the way down the arm for median nerve, ulnar nerve, radial nerve, nerve roots. And then the second day is lower extremity. And so For lower extremity, we'll go through all the entrapments that are happening within the torso. So at the psoas, are we having ilioinguinal nerve entrapment? Are we having pudendal nerve entrapment, obturator? And so sciatica is, yeah, it's definitely on that list. We cover it. And I think sciatica is one of those ones too that it's a little simpler than you think if it ever confuses you when you start to look at it through the lens that we do with the P&E course and some of the simple diagnoses of stretch, compress, activate to figure out where that's coming from.

Wonderful. Someone else asked about the online PNE course. How deep do you go into the rehab and taping of peripheral nerve entrapments?

Ooh, good question. In the online course, I'll say those components are discussed and especially like in the actual presentation format. Within the video format, we give examples of the rehab that we cover. We don't have a comprehensive rehab database of for this nerve entrapment in this area, this is your full rehab protocol, right? Like I said, the The main thing is figuring out what the diagnosis is. And so we review all of our factor treatments at the beginning of the course. And then throughout the course, when we do a live course, we do breakout sessions just like in any other course. And then we take all these different principles and protocols that we know how to use, or that you're maybe playing with and figuring out how to use, and essentially use those or try them out on the different nerve entrapment sites. And so that's kind of what we show in the online course as well in the videos. Is I picked an example in kind of each area of— for median nerve entrapment, here's where it's entrapped at all these locations, and then here's some things that we could do for rehab for that. Unfortunately, right now the taping is not involved in our online course or our live course, and that's something that we will be incorporating. We, we have plans to incorporate that here in 2021, and before this pandemic locked us all up inside and made things a little more difficult on the CE side of trying to bring that course to you guys. We really wanted to get that content out, and so we filmed it, got it online so that we could get that out to everybody, but we just have not had a chance to get the dynamic tape in there because Dr. Olson has still got to complete his certification on that. And so once he's certified, we are able to film the videos and stuff. We would love to get that dynamic tape information in there. Absolutely.

And I will say kind of Adding on to that, dynamic tape is used a great deal when it comes to nerve entrapments and when it even comes to conditions that involve innervated issues, dysfunction, and things of that nature. So that is something to look for in the future. Likewise, if you register for any of our online courses, you do get the updated content when that is released. So we won't essentially launch a whole new P&E course with brand new content, we'll add that new content to the existing P&E course so that you can continue to get updated on that. So just kind of a quick word about the online courses. Again, this was an incredibly informative webinar today. Dr. Lindholm, thank you so much. We really appreciate you taking the time to put this together. Thank you all so much.

Thank you guys very much. I hope you enjoyed it. Reach out with any questions, and hopefully we'll see you at a course in the future too.

That's it for today's episode. Be sure to tune in for episode 18, where we kick off a new training focused on growing your business titled 3 Online Must-Dos for Your Practice with Dr. Colin Swala. As we round the corner on 2021 and look ahead to 2022, we thought it would be important to shift our focus a bit to some tactical strategies you can utilize to grow and expand your practice. Let's face it, there's no shortage of marketing gurus out there willing to take your money for the latest and greatest next new thing. But how do you filter through all the noise to know which strategies to implement to really grow your bottom line? In this 2-part training, we sit down with Dr. Swala to discuss how to pandemic-proof your practice, best practices for Facebook ads, simple tactics you can utilize to boost your search engine ranking, And the most important social media platform you should be engaging with. You won't want to miss it. Episode 18 drops in 2 weeks, or 1 week for 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. And last, but certainly not least, be sure to visit the show notes for a link to download the PDF of today's full presentation, As well as learn more about our special offers featured in today's episode. 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.