#21 - GameChangers: Practical Research for Improving Clinical Outcomes, 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 consume. 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 thank you for listening. Today we continue our 2-part training titled Game Changers: Practical Research to Improve Patient Outcomes. with Drs. Brandon Steele and Tim Bertelsmann, the co-founders of ChiroUp.com. If you haven't yet visited the link in our show notes and taken advantage of the special offer from ChiroUp.com for our Factor Podcast listeners, I highly recommend you do so after today's episode. In episode 20, we discussed the highlights of some of the most impactful clinical research from the past year and talked about how we can apply these findings to your patient care. Today, we continue this discussion and talk more about the importance of tracking patient outcomes, carpal tunnel syndrome, and then wrap up with a lively Q&A segment where the topics discussed cover a broad range of conditions and best practices. This episode is full of great clinical pearls, so definitely give it a second listen so you can take notes. Let's now cue the music and get started.

So speaking of outcomes, one of the things One of the things that can be great outcomes or can be tough outcomes is carpal tunnel syndrome, depending upon our familiarity with the whole process. And we're all familiar with what happens in the carpal tunnel, that somehow the median nerve has become a little ischemic. And one of the clues to that process is to where's that ischemia happening. So there's some new tests and some new thought processes that we're going to go over that hopefully you can use in your clinical practice. Carpal tunnel, super common. This is the most common upper extremity peripheral neuropathy. You know the stats as well as I know the stats. If we move on to the next one here, we'll see that 20% of carpal tunnel syndrome patients will actually demonstrate other signs of ischemia in addition to just having the numbness and tingling into those first 3 digits. And so one of the places that we'll look is the patient's nails and fingers. If we see nails and fingers that look like this, those are signs of poor blood supply. If we start to see longitudinal lines, Spoon nails or fissuring, if we start to see skin that's flaking away, any of these things that say there's some sort of skin or nail dystrophy is a sign that there's poor blood supply. And if there's poor blood supply to the fingers, there's probably poor blood supply to the carpal tunnel as well. One of the things that you and I have is poor blood supply from clicking the mouse too much.

Uh-huh.

There's a lot of tests that we look at for carpal tunnel syndrome, but the most sensitive test of all is numbness and tingling into the distribution. So if you have 3.5 fingers of numbness and tingling that involve your fingers, That's 77% sensitive for a diagnosis of carpal tunnel syndrome.

I think that the highlight of this slide is not necessarily that one's better than the other, it's why. And when we do Phalen's sign and we do Tinel's sign, sometimes that's not enough load or not a big enough insult to reproduce someone's symptoms. But when you're sleeping and your wrists are like this or off in one position, that sustained compression or sustained tension on the nerve is enough time to reproduce that patient's symptoms. So sometimes taking that into consideration also with what they're doing at work, is this something that is sustained posture versus a quick insult?

Another clue that we use as to identifying the source of the numbness and tingling, is it truly coming from the carpal tunnel, is what's the distribution of that numbness and tingling? That we know that the median nerve as it comes under the carpal tunnel supplies the first 3.5 digits. So that's the green area. But as we take a look, that, that palmar branch of the median nerve actually travels outside the carpal tunnel and then supplies the palm, the blue area. So if a patient comes in and they always say, my whole hand is numb, right? It's all 5 fingers. So you have to make them go home that night and say, which was it? And we don't want to know, was it just these 3 fingers? Was it these 2? Was it the middle? Or was it all 5? We want to know, did it involve the palm? Because if it involved the palm, it's more than just the carpal tunnel. It had to affect the palmar branch of the median nerve, which didn't go through the carpal tunnel. So then we're going to be a lot more suspicious of what the ulnar entrapment would be. But pronator teres, very common source of numbness and tingling into the hand. If we can apply pressure over that pronator And the patient has an increase in symptoms, now we're much more suspicious. If we have them do resisted pronation and contract the pronator for an extended period of time, like 30 seconds against our resistance, and we create numbness and tingling, that's probably not carpal tunnel because the wrist was in a neutral position. So we look at the pronator, which is a hidden culprit for numbness and tingling when it's in the palm. Here's a good picture of the peak area of tenderness in that muscle and where we're going to apply pressure. There's the one very sensitive test for any neuropathy. It's called poke on it. And if you reproduce the symptoms, whether it be in the thoracic outlet or if we're talking about a carpal tunnel, tunnel with manual carpal compression, or if we're talking about a pronator teres syndrome, just smash it and see if a little extra ischemia provokes those symptoms.

So correlation and causation are so interesting in our profession, and especially when it comes to blood flow. However, in this case, we see coronary artery disease so frequently associated with these neuropathies and tendinopathies that we really need to focus on that as a component of their care. Because when we notice these things, it can have a dramatic impact on our care. So we really wanna focus on that and also decrease the amount of postural stresses and really focus on nerve function. And I say that as far as chiropractic, but does the nerve move? And unfortunately, with sustained loads and repetitive traumas or even traumatic incidents, we have these spots or spot welds where these nerves get caught up, whether it's the intervertebral foramen or the pronator teres. We need to make sure that these patients are able to have those nerves floss and tension and really stress those nerves because if we can do that, we can have a dramatic impact.

Yeah, so that study told us that position certainly matters if somebody's sleeping or holding their wrist in an awkward position. And you and I know as clinicians that wrist braces tend to help the patient have a more comfortable night of sleep. In fact, American Family Physicians said that there are 4 braces that typically work pretty well. Wrist splints work well for carpal tunnel syndrome. A thumb spica splint works for osteoarthritis. A patellar stabilizer works to help for patellofemoral pain syndrome, especially if it's arthritic in nature. And then a functional ankle brace works really well for sprains and strains, something along the lines of an Aircaster. There's lots of varieties of those, but those are the 4 braces that do have a lot of support. The other thing that has a lot of support is nerve mobilization and nerve treatments.

Yeah, neurodynamics has been an increasing part of my practice. I know I have the Michael Shacklock book. I know David Butler's book and his book on Explained Pain are really critical in our understanding of how nerves work, but also how we can explain that to our patients. And what we know is with nerve desensitization maneuvers, They can be really good short-term, but they can also have some really nice long-term effects. Is that after we're done, and let's assume that we can have our patients doing these nerve flossing exercises for 6 months after, we can still see the positive effects of nerve mobilization techniques. The good news is while I probably can't spell nerve mobilization very well or neurodynamics, having patients do these exercises is very simple. If you do want access to any of these videos, we'll give you access at the very end of this. This current platform doesn't have the videos on here. I didn't upload them. However, doing nerve flossing exercises, in this case for carpal tunnel syndrome, are just as important for lower lumbar radicular symptoms and really anything else.

So we're used to doing nerve tension tests on a regular basis that we wouldn't think of assessing a patient who has a sciatic problem without doing a straight leg raise, probably one of the most valuable tests. But too often, we'll assess somebody who has an upper extremity radiculopathy without having done that same homework, without looking at the nerve tension tests. Of what happens when I stretch this entire nerve. The difference between the nerve tension test and these treatments that are now so supported by the literature is that a nerve tension test is gonna stretch the nerve at both ends as far as possible. What we do with a neurodynamic maneuver or a nerve flossing or a nerve release is we're not gonna stretch both ends, at least not right off the bat. We're going to try to release any adhesions because when that nerve has been irritated, think of sciatica, but now let's make it an upper extremity radiculopathy. When there's been irritation and inflammation at the IVF, the whole nerve has some degree of swelling. And things that have swelling leak fluid, and things that leak fluid with that increased hydrostatic pressure, it comes out and it starts to glue things together. And so now that's when we develop the spot welds underneath the pronator teres or an ulnar issue, ulnar nerve issue, a carpal tunnel issue. And so we have all these spot welds and they're weak spot welds. They're not really good because it was just wept fluid. So we wanna break that up. And the way that we're gonna do that is think that you have a hose with a piece of shoestring in it that somebody poured some weak Elmer's glue. And if you wanted to break that shoestring up, you would probably pull one end and then pull the other end and just pull it back, flossing it back and forth in that tube. And so that's what nerve flossing exercises do. We want to put stretch on one end and relax the other end, and then we want to put relaxation on one end and stretch the other end. I don't think there's been many things that have changed my practice more than the nerve mobilization techniques in the past couple of years, really the past decade, that these are game changers, that there are things that we can do in office and things that we can teach the patient to do. And again, like Dr. Steele said, we'll give you access. I apologize that we can't play play the videos on this platform, but we'll give you access to each of these nerve mobilizations. You'll want to make sure that you review those, and if you do nothing else than give the patient the median nerve floss, that patient is going to be thankful for that exercise at home.

He likes demonstrating that one because I was close to him and he was trying to smack me, but I moved if you guys didn't see that. And with nerve mobilization, and in this case carpal tunnel syndrome, don't just do the things you did 30 years ago when you graduated. It's always good to take a multimodal approach and to really dive into the research and see what is effective and what's not. And just because you don't provide that treatment in your office, that's okay. You can only be great at a certain number of things. Like I said, I'm not good at nutrition, so I don't do any nutrition in my office. I don't do acupuncture, but that doesn't mean it doesn't work. So if you do hit a brick wall with any kind of a diagnosis, find someone in your area that is great at that. That's their jam. That's what they do. So don't forget about acupuncture as an improvement. But forget about some things. Just because it was right and it was the in thing to do 20 years ago doesn't mean it's still okay. Putting someone in a splint, doing ultrasound, those things are not as beneficial as the things that we're finding are more beneficial, which is find a way to get it moving, find a way to keep it moving, and give the patient a little bit of time to heal in between. And that really is how we're going to help a lot of our patients get out of pain.

Was that 30 years ago, another shot at me?

No, no, I was trying to give you a little bit of a break. Let's go into plantar fasciitis. Although if you do listen to Dr. Burleson, talk, he'll always talk about major revelations in his practice about 10 years ago when someone else joined his practice.

So I realized I should have a solo practice.

And I will say one thing out of that is that when you do have communication, you have a network of people around you, you really do challenge yourself to, to think a little bit differently. And him and I do think differently, but it's very interesting because a lot of times we'll come up with the same results. And it's fun to learn from people who think differently than you and maybe incorporate 5%, 10% of what they say and do into your practice and try something new. It keeps things interesting and it really makes a dramatic impact on your care and your patient satisfaction. So to get into the last 2 diagnoses, and we'll make it fairly quick, the first one being plantar fasciitis, which is the diagnosis that everybody already comes to you with their diagnosis. They've already talked to their doctor and they've talked to Google and they've talked to Facebook and Pinterest and they know this is their diagnosis. It's important to know that this is a very overly diagnosed condition because it's not just plantar fasciitis. Meaning it's impacting a lot of people, but it's not just an irritation, an inflammatory process that's happening right at that proximal part of the calcaneus. In fact, we just do a lot of things. We have postural loads, we have repetitive loads where that foot is supposed to be a mobile adapter. It's supposed to be able to adapt to the terrain and then form a rigid lever to push off so we can run and we can do sports and that kind of stuff. And it's up to us to find out what's causing their problem and find some ways to offload that tissue.

Plantar fascia plays a big role in that process. So when you think about having to run outside on rocks in your driveway, you're running on your toes and you're running with soft feet. But then in order to propel yourself forward during a race, especially a sprint, you've got to have something much more rigid. You wouldn't want to hit a baseball with a flexible bat. You want it to be rigid. So to incorporate that load transfer, that power, we need to transition from that flexible shock absorber to a rigid lever. And pronation is the process that does that. And the plantar fascia is heavily involved in that pronation process. That when our toes roll up, we tighten the plantar fascia, lock out the tarsal bones, and allow that rigid lever to happen. Now, when we step back down, that's when our foot goes back into pronation. And there's a certain amount of pronation that's reasonable, but too often you and I see that patient who goes a little bit too far where there's hyperpronation. And this is a graphic that talks about just the whole chain effects, that this isn't just plantar fasciitis. This is going to go up chain because when that foot hyperpronates, it's going to be coupled biomechanically with internal rotation of the tibia. So now we start to see things like shin splints, and we also start to see a calcaneal rock, which then puts stress on the Achilles tendon, which we'll talk about next. We're also gonna see that torque go through the knee, and there are things in the knee that aren't really fond of torque, like the anterior cruciate ligament or even the collateral ligaments. And as that torque goes up chain, it doesn't stop at the knee. Now it moves up into the thigh. So we're torquing the thigh, and since the thigh at the top is L-shaped, throws the pelvis backwards and then forces the patient to lean into hyperextension. So yes, that hyperpronation of the foot travels all the way up chain so that we're aggravating back pain and we're trying to treat that patient's lumbar facet problem. Until we address the whole chain, it won't matter. One of the big things up top that does matter is the gluteus medius. That's the muscle that comes off of the iliac crest and down onto the greater trochanter. And when that muscle is strong, it helps to hold your thigh into abduction. It holds your knees apart. And so when that muscle is failing, now we see our knees knock in and it comes right back down chain the same way it went up chain. When our knees are knocking in, now the medial collateral ligament is going So now the patella, the lateral facet of the patella, is going to be rubbing up against the lateral condyle of the femur, creating the number one cause of knee pain, runner's knee or patellofemoral pain syndrome, which turns into chondromalacia, which turns into osteoarthritis. And that's going to also cause the same internal rotation and go back down chain. So we want to make sure that anytime we address the foot, we're looking at the hyperpronation issues, but we're also looking at, is that gluteus medius competent? Having that patient do a single leg squat and watching what happens in the knee is a great way to do that. Yeah, and I think that's a great point. And there's a lot more complex ways to assess that, but that's a simple way that we can assess that. So we wanna make sure that we're looking whole chain.

And that's the normal biomechanics. Think of the things that normal medicine does is you have plantar fasciitis, we'll just cut that. So you take that hyperpronation response, which is that tissue starting to fail and causing upstream issues, but now you throw in maybe an ACL tear, you throw in a cut patellofemoral joint, patellofemoral tendon due to, you know, runner's knee or jumper's knee, and then you can have a whole slew of issues that aren't necessarily local to the initial insult. So what we find is That if we can just take these issues and instead of masking them, instead of giving ibuprofen and injections, that if we can just create an inflammatory reaction and allow this tissue to heal, that we can have a great improvement in patient care. So one, get the pain to go down, but also rebuild that tissue and prevent those upstream and downstream issues from ever happening. Because remember, pronation is normal. It's okay to have pronation of your feet. It's just not okay when it's abnormal on one side compared to the other, or due to that repetitive or postural load that you're putting on it. The methods that we look at are so important. There's a great quote by Ralph Waldo Emerson. It's escaping me now, but methods there are many, but principles there are few. A man that masters methods is lost. So really, we have to go back to our methods and what we're doing and why we're doing it and just stop randomly applying techniques. I know the FACTOR method is one of those, but a lot of people look at FACTOR as a tool, and that's just not the case. It's a method of assessment that incorporates some of this treatment into it. But I think that as long as we can have an understanding of not only what we're doing, but why we're doing it, we can hopefully prevent this kind of plantar fasciitis and result in other issues up and down the chain like Dr. Burlesman talked about, is when we can have the greatest impact on our patients.

It incorporates these sort of tools like the IASTM that we've seen throughout this research, and we have a part 2 of this as well, and it's probably even more pronounced there as far as the things that work are the things that are going to stimulate some blood flow. Using an IASTM tool like a factor tool, performing eccentric rehab of the area, teaching the patients the proper at-home rehab, The nerve flossing maneuvers and all the things that are incorporated in the Faktor Method are state-of-the-art. This was genius to have developed it years ago, and it's truly a mission to move that forward. So kudos to Faktor. We are not paid spokespeople for Faktor, but there's not a better partner to be with in this instance because the types of things that you're learning in those classes are exactly what the research is promoting, and these types of methods came out before the research even confirmed that. Now, you and I, one of the things that we definitely want to incorporate is soft tissue work into that. There's not a plantar fasciitis patient who doesn't have some tightness in their plantar flexors. Well, that's a problem because now instead of the plantar flexor being the spring that absorbs that shock, if it's tight, the plantar fascia is going to absorb that shock, and that's not a happy fascia to start with. So we're going to work out those tissues that are tight. We're going to stimulate that controlled inflammatory reaction, and we can use outside tools. One of the things that we see a lot of now is there's a ton of data on shockwave therapy, that shockwave therapy, This initially started as lithotripsy to break up kidney stones, and then it moved into the ED market. I'm not sure who first tested that, but then it, then it moved into treating tendinopathies, and we found probably the greatest utility in treating tendinopathies in order to send in a shockwave, break up that tissue. It's something that's certainly worth checking into. We had a shockwave machine in our office.

Yeah, it worked wonderful. And just finding a way to create an inflammatory reaction and let that tissue heal, not only shockwave but also looking at things like laser. It helps speed up the metabolic powerhouse of that cell to make sure that it's able to recover and decrease inflammation. So while we're loosening things up and while they're doing their exercise, if we can help speed up that healing process, we can have a dramatic impact on that patient care. Dry needling is, is another thing that we don't do in our practice. However, I know we just put together our protocol for myofascial pain syndrome, and dry needling is phenomenal for decreasing pain and also decreasing inflammation for a lot of these painful tissues. Something that we refer out for. But plays an integral part in our care for a lot of our patients.

And then the big one is patient education, making sure that your patients have the expectations that they may get sore, the understanding of what's going on, the understanding of why you're sticking needles in or why you're using a dull screwdriver to rub on the area, why you're giving them exercises that are uncomfortable. Once they understand the importance of that, they'll embrace that. They're empowered patients who say, now that's what I see, a reason why I'm supposed to be doing So one of the things that we've included in the attachments is a condition report, a piece of education that you can send to your patients. We did that for carpal tunnel syndrome, and so I think we have one in there for— or we'll have one in there for plantar fasciitis as well. So you can take a look at those and say, this is some information that we might want to share with patients. One piece of information here is that 16% of our plantar fascia patients actually have an underlying inflammatory arthropathy. So we'll wanna make sure that if that patient's not responding to our care, do they have other signs and symptoms? And we put together this chart of the most common inflammatory arthropathies. This took a good amount of time. It's something that you can get through the downloads. And just in a second here, we'll show you how to get all of those downloads. That piece of paper I laminated, I keep in each treatment room, and there's not a month that goes by that it doesn't save my hide because somebody comes in and says, I have this discomfort, and they've got a couple other suspicious things. I know the questions to ask. I know what to look for in the lab tests that I'm going to do. So it saved me many times. I use it repeatedly. If you do one thing, go to the references at the end here, download that inflammatory arthropathy infographic.

Last diagnosis, a couple quick slides here on Achilles tendinopathy. But the reason I like this one so much is because the research is riddled with one population or demographic of patients that has one problem and another demographic has the same problem, but they have the same activity. And in the case of running, We'll see one population have Achilles tendinopathy and one couch-to-5Ker have plantar fasciitis, and I would argue that it's probably not the running, it's the way they run. So going back to the automated and the 99%, yes, I can perform the same treatments. They both have a tendinosis. I still need to do eccentric loading. While a little bit different, I can have that standardized recipe for treating those 2 different diagnoses, but I need to understand the mechanism by which they're causing that, whereas we have a rearfoot striker With a plantar fasciitis versus a forefoot striker with an Achilles tendinopathy most frequently. Obviously, that's not one-to-one. But things to think about, not just going after and finding tissue that's injured and cutting it or injecting it, and really finding out what has decreased the capacity of that tissue, whether it's the activity or postural load, and going about eliminating that postural load or that stress, and then finding out what we can do as conservative musculoskeletal practitioners to now build that tissue back up and get that And not settling for just doing one thing to make that happen, that so many of these conditions—

think of migraine, that it's really a glass, and when you put enough triggers into it, it overflows. But all the other things that we treat are kind of that glass as well. And rarely it's a single pour from an auto accident or a sports injury, but most of the time it's a drip here, it's a drip there. It's a bad pillow, it's a bad workstation, it's stress, and it's a bad diet. And you put enough of those drips together and something fails. And I like to think that each of our joints has its own glass. And so why does one person Who plays softball develop carpal tunnel syndrome and another one develops a rotator cuff tendinopathy, it's because they had different amounts of water in each glass. So the same type of stressors that go into an empty glass are tolerated. But if your glass is almost full to start with because you have cardiovascular disease and you have some hypertension and all those things come together, now we're going to overflow that glass a whole lot more easily. So our job is not to decrease that water a little bit because that's what we do in practice. We treat the patient with our nerve mobilization manipulation or whatever we We may use and we make the patient feel better, and then they come back the next day and maybe it's returned. Unless we identify those underlying functional deficits and all of the contributors like their lifestyle and diet, we're not emptying the glass. So you and I need to seek to empty glasses as opposed to bring them down a little bit, and then that patient is going to be happy, as well as increasing the capacity, making that glass a little bit taller by building strength and giving them the tools that they can use to stay comfortable the rest of their life. Life. So one of the things that we told you that we'd give you access to is all the infographics. We have a library of a couple of dozen infographics. We also have access to the videos that we described in this protocol as well as a bunch of other videos. And the way that you can access that, if you just go to our website which is chiroup.com, put in the referral code FACTR, F-A-K-T-R, and from that a couple of things will happen. Number one, you'll get our weekly blog. So anytime there's a new piece of research that comes out, we'll be able to summarize that and give it to you. Number 2, you'll have access to the forms library. So once you get in here, we'll shoot you an email telling you how to access all those tools. And number 3, you'll also have the ability to see the condition reports, like what you're going to look at in the attachment here. And we will also welcome you into that trial and into part of the ChiroUp family. So as a successful evidence-based chiropractor, you want 3 things: to deliver the best possible treatment that resolves problems quickly, to attract existing and potential patients with your outstanding care, and access to simple, scalable solutions that save you time. And with reimbursement increasingly based on outcomes rather than services delivered, shifting your focus from merely treating patients to applying best practices is more important than ever. Which is why you're going to love ChiroUp. But don't just take our word for it. Join the nearly 1,000 ChiroUp providers from around the world who are working together to become the undeniable best choice for patients and payers alike.

You can't afford not to give us a try.

Visit ChiroUp.com today to learn more. Thank you for watching our presentation. I hope that we've been able to provide some information that's useful in practice. We would love to entertain any questions that may have come along the way.

And also, we'll take those questions. Uh, the carpal tunnel syndrome, the condition report is in the file section. You'll be able to access it there. Also, Dr. Bertelsmann's email is tim@chiroup.com. My email is brandon@chiroup.com. We're always happy to answer any kind of clinical or business questions you may have. Jessica, do we have any questions over the last hour?

Yes, we have. So thank you guys so much. But one person was asking about ultrasound, if that's something that you guys Do not recommend for plantar fasciitis. Do you recommend ultrasound for any treatments when it comes to plantar fasciitis or these tendinopathies?

So the literature tells us that ultrasound doesn't work for plantar fasciitis. So it's not a tool that I use. That we'll use a shockwave, but more importantly than that, I'm going to work out the patient's calves. I'm going to perform some instrument-assisted manipulation to the plantar fascia. I'm going to make sure that they have adequate arch support. I'm going to teach them how to strengthen their tibialis muscles, and I'm going to generally stay away from ultrasound. We have an ultrasound in the office and there are certain things that it is valuable for. I haven't found a ton of value in the plantar fascia management though.

Wonderful. Thank you. Another question going back to migraine. You guys had mentioned that it's really important that you address kind of the worst case, the scary, and rule out some of the scary possible diagnoses before you kind of really zero in on the cause of migraine. How do you handle kind of taking into consideration not catastrophizing the scenario for your patient and not scaring them? How do you ask those questions in an appropriate way without causing red flags to come up for your patient?

I think you—

I use HELP. If anybody has young kids, when you go to your pediatrician, they don't remember the 20 questions they ask their kid when they're sitting there at the table. They have a list of things that they're going to ask them, and I have the same thing. In fact, in ChiroUp, in our cervical exam menu, we have the worrisome headache questions. What does systematic review say? The questions you should be asking someone if they're having a headache and you suspect something more sinister that is lurking. So identifying, is this an acute? Have they never had this? Is this just unilateral pulsating headaches? Those are the kind of questions that I need to have in front of me. Similar to what Dr. Burleson said about the autoimmune issues, I have little things in my office. I don't need to remember everything. But having those resources at your fingertips that if you do have a question, Looking at your exam form or looking back at any kind of a resource and trying to understand what should I be asking or what should I be doing in these situations.

Jill Cook mentioned recently in one of her talks that she does not recommend shockwave for tendinopathy, at least for lower limb tendinopathy. Do you guys have any insight into what the research says about specific areas of the body where it may be more effective for tendinopathy than others?

I'm not aware of research that talks about anything upper versus lower. That, that a lot of the joints in the— throughout the body, in fact, even the lower back, that, that's not a tendinopathy, there's a pretty good amount of data that says that it works. As Dr. Steele and I had mentioned too earlier, we had a shockwave therapy unit in our office for a period of time and we didn't keep it. And so that should be one clue as to what our overall feel for it. And I think that it wasn't because it didn't work. But it didn't change our outcomes radically. I think because we were already using tools that accomplished a controlled inflammatory reaction via factor, via transverse friction massage, via the eccentric loading, we were able to achieve that and we didn't need one more tool to achieve the same thing. So there's abundant data. I don't think there's any topic. So our team scans the literature and there's 3 chiropractors who look at 102 different conditions on a weekly basis. And so there's hundreds of research studies that come across my desk on a weekly basis. I don't think there's any topic that's hotter or has more support than shockwave therapy. In the past 3 or 4 years, I'm not aware of anything that says upper versus lower.

I'm not either. And there is a little bit of discrepancy when you look at, I mean, someone like Joe Cook, as far as a researcher, that when you try to take musculoskeletal care and really take one treatment to one diagnosis, it's difficult. And what we know is that everything needs to be multidimensional. So I'm not sure why the upper versus lower, so I won't get into that. I have a feeling it's something to do with postural load and not letting that tissue recover. However, theoretically, it makes sense. I can say clinically, it makes sense. And my experience tells me that as long as it's a part of a strategy to get that person out of pain, it works really well.

Awesome. Someone else here was asking if you could elaborate or give any insight into the new research about ginger supplementation and migraine headaches.

Yep. So there was a study maybe 2 months ago that said ginger, especially in combination with other And if you go into this last slide here and click on that free trial, look at migraines, the protocol for migraines underneath management, which would be the last section in that report. It will mention that new research about ginger. But yes, it was one of those studies. Migraines, there's a lot of things that, that may benefit migraines, all the way from water through supplements and feverfew and everything in between. But we've kind of whittled that down and talked about the 4 or 5 things that have the most data. Magnesium is certainly one of those. Vitamin D is one of those. And now ginger has come onto the scene as well. Yeah.

Okay. Another question here, and this may take a little time to answer. Do you guys have like a list of favorite kind of must-read clinical textbooks or resources, or maybe some of the, your favorite clinical books that you've been reading recently?

That's a tough question. I love Sports Injuries by Hyden Gengenbach, and there's a number of books that have certainly been influential to me. But one of the challenges is that when research comes out, by the time that it's absorbed by an author, turned into By the time it gets into a book and distributed to the public, usually via schools, it's already old news. That on average, it takes 17 years for research to make it through the walls of our treatment room into practice. And that just doesn't work. The speed of care today and the way things are evolving almost preclude books from being something that is overly pertinent. And there are definitely books that I have appreciated, but I like the data that comes out and making sure that I'm keeping on track of Medline and any research that comes out. That's a little bit of a challenge because there's about 25 million articles that come out a year. But you can whittle those down with your favorite tools and pick the topics that you want. So for me, I would much rather have access to the internet and be able to look at my favorite topics for real-time research that just came out last week as opposed to a book. But love the Shacklack, love the Butler book, huge fan of James Cox's Inflection Distraction, a big fan of directional therapy. All of those books have been very useful in my life.

And I would just second that. I cheat all the time. Reading a book is tough and sometimes antiquated. Find a network of people. People who think like you think and want what you want. And then you can go to the different techniques and different methods, and they're the people staying on top of it. People like Rhett Winchester with Assault Education, people like Directional Therapy, people like Factor— those are the people who are on top of their game and can help point you in a direction very quickly. I'm not saying you can't do your homework. I think that's important. However, I often look to people who are a lot smarter than I am, and if I have a question, I ask them that Wonderful.

Thank you. Another person was asking about if you can speak to any exercise rehab protocols for tendinopathy presentations, or where do you guys look to to find those?

So, that's what, in all fairness, that's what ChiroUp is. It's really looking at the research, which we probably put about, what, 50 to 75 research articles a month out of a couple hundred that we've come across our desk and say, what should we be doing? What is the recipe for treating Achilles tendinopathy? What are the most effective and efficient evaluations? We videotape them, put them What are the best treatments? We videotape and put them on there. What are the best exercises? What are the best patient education pieces? And we find a way to educate our providers in what we could be doing, not what you have to do, but what you could be doing, what the research says you can be doing. And then I think possibly more innovative is to take all the information that we can find in the literature and educate our providers, but also find a way to educate patients on those things. Because sometimes it's difficult to translate everything that you have in your head to your patient in an 8-minute window. So that's one thing that we do with our condition reports, which we put on there as far as carpal tunnel syndrome is finding a very simplistic way to educate our patients on what's wrong. Because if they can understand their condition just as well as you understand their condition, then you guys can work together towards a common solution. So we are a bit biased as far as the exercise programs because there are some very good ones. However, as a complete multimodal treatment plan, that's what we do at ChiroUp, and we deliver that to our patients on a daily basis. In fact, I think we send out about, as far as our network, about 65,000 condition reports a month that go out to try to educate our patients on what we should be doing for each Do you guys keep up with latest findings related to the role of fascia and how that may play into a number of soft tissue injuries? I know exactly who asked that question.

Was that Dr. Hyde? Soft lob from Dr. Hyde.

That totally was.

It was. Well, I don't think we should comment on fascia considering the group that we're talking to and the people in the audience who probably know a whole lot more about that than We do. But yeah, we just finished our 102nd protocol was on myofascial pain syndrome. And so trigger points and adhesions that develop throughout the muscles of the body and all the fascia. Dr. Hyde has been instrumental in shooting us a lot of information as to, as to things that are really helpful. One resource that he shared with us was a video that many of you have probably seen. It's called Strolling Beneath the Skin, and you can go on to YouTube and pick that up. It's just a tremendous video of fascia and the intricacies. And this would be an interesting seminar from Dr. Hyde to talk about the Yeah. And how it has dramatic roles, that it connects throughout the body and communicates throughout the body and has effects throughout the immune system, the lymphatic system, and everything else. So we don't keep up on that level, but from a mechanical perspective, I think we've tried to do a good job in summarizing what's the current evidence on myofascial pain syndrome and what goes wrong with fascia. But really, the people on the other side of the camera are the experts on fascia, that all of you who have interest in FACTOR, you clearly understand fascia and you understand the importance of managing fascia. That it's so much more than using a modality. It's so much more than teaching a patient an exercise or giving that patient a dull screwdriver over what tendon hurts. It's managing that whole system and the whole complaint, and fascia is integral to that system.

Wonderful. Another question came in, and this, this may just be asking about if you guys have some resources within ChiroUp. Do you have any that kind of address plica in the knee and then the treatment options for Where would they find a list of conditions, I guess, is the question, that are included in ChiroUp?

Yep. So if you go, once you open it up, you'll see condition reference. It's called clinical resources and then condition reference. And so once you open that, you'll be able to divide it by region. We have multiple conditions of the knee, but plica was not one of those. It's one that's a little bit elusive. In fact, if you do an internet search on that, you'll find a whole lot of nothing information-wise, but it's on our list to address. But at this point in time, it's not been one of the 102 most common musculoskeletal diagnoses. So apologize, that one's not on there.

Someone mentioned that the ChiroUp student sign-up, the university they attend is not on the list. So I'm assuming they'd want to find out more about that. How would they contact you guys to get their university on the list?

Yeah. So first off, all students are free. We do that so hopefully everybody has access to learning the evidence-based way of treating stuff. I don't know what school they're in. You can email me, Brandon, brandon@chiroup.com. And I'll be sure to look into that, that we give it to all schools. So please let me know and we can get you added to the list.

Wonderful, guys. Thank you so much. That's it for today's episode. Be sure to tune in for episode 22, where we launch a new training with Christopher Kelly titled Integrating Gait Training and Positional Breathing into Fitness and Therapy. Therapy. In this two-part training, we discuss simple assessments that you can use to determine positional limitations of the pelvis and the rib cage, positional breathing drills to incorporate into training and therapy, and exercise modifications that can immediately improve control of the pelvis, rib cage, and foot. You won't want to miss it. Episode 22 drops in two weeks, or one week for our Patreon subscribers. In the near future, we're also planning a few special Q&A episodes with our past instructors. So please be sure to click on the Q&A link in our show notes and ask any burning questions you might have. They may be featured on a future Q&A episode with one of our past instructors. 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, please 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 any of the 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.