#46 - Upper Extremity Neurodynamics with ChiroUp, Part 2

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Hi guys, welcome to The Factor Podcast. I'm your host, Jessica Riddle. If this is your first time tuning in, welcome and thanks for listening. Today's episode features a new training on upper extremity neurodynamics. With our friends from ChiroUp, co-founders Dr. Tim Bertelsmann and Dr. Brandon Steele. Dr. Steele and Bertelsmann founded ChiroUp.com, a company whose mission is to help evidence-based chiropractors produce exceptional outcomes, then market their brand of excellence to the people who matter: patients, physicians, and healthcare decision-makers. They do this through empowering docs with automated tools for clinical and business success. Today, we will discuss the current evidence regarding neurodynamic techniques. We'll review the most useful neurodynamic assessments for common upper extremity complaints, and we'll talk about practical nerve flossing and nerve tensioning maneuvers that can speed recovery. Guys, this episode is jam-packed with a ton of great information that you can implement in practice immediately. So turn up the volume and let's get started.

So we'll get to the losses in just a second. In fact, this might be a good time to talk about the losses themselves if we want to go full screen again. That when we talk about nerve tension tests— when we talk about the nerve tension test, remember We're wanting to stretch both ends of the nerve. So if we're doing that in a self-floss fashion, everybody can try that now if you'd like to stand up, as long as you don't have any upper extremity neuropathy or predilection to suprasenters. Try this at home. So if we're going to talk about the median nerve, we're going to contralaterally flex and then extend our opposite hand. And you may feel a little numbness or tingling into those first 3.5 digits. The radial nerve, very similar, contralateral flexion, but this time moving your hand into a butler tip position. And in that butler tip position, now we're getting irritation to the radial nerve. And finally, the ulnar nerve, that's the monocle. Flip it as though you're flicking your cheek and then turn your fingers all the way upside down so that your fingers are pointing downward. And if that causes numbness or tingling, now we know that there's a positive nerve tension for the ulnar. The good news is, when we talk about how to treat that, the self-flossing maneuvers are very similar. But instead of stretching both ends, we're going to stretch one end. Let's imagine just for a second that I have a garden hose. That'll be the only time you hear that word in this presentation. And we have a shoelace or a rope inside of it. And if that rope were bound down with some weak Elmer's glue, what would be the best way to free that shoelace or rope from the garden hose? It would be to pull one end while we create slack on the other. And then pull one end while we create slack. So we're going to perform a flossing maneuver. And that's generally how neurodynamic treatments start, with flossing exercises. So rather than pulling both ends of the median nerve, I'm going to pull one end. And the way that I teach patients to do that is, first of all, pull the top end while you put slack on the bottom, and then put slack on the top while you put tension on the bottom. So the way that you can think about this is somebody slaps you, and then you look to see who slapped you. And somebody slaps you and you look to see who slapped you. So patients can remember that fairly easily. The good news is the radial nerve is very similar. We're going to tension both ends this way. We're going to take tension off this way. So again, hand comes up and then hand goes down into a butler tip position as you're watching it. So somebody slaps you and then you look down at the butler tip position. And finally, with the ulnar nerve, even simpler. Once you have the stretch maneuver, out into a handshake, back into the stretch maneuver, out into a handshake. So with the flossing, the only difference between that and the tensioning is we're going to put tension on one end at a time as opposed to both ends. If somebody has a TOS, we're probably going to want to perform some flossing of the ulnar nerve. Now we'll move back into the slides where we talk about cubital tunnel syndrome or the funny bone. This is where Dr. Steele started a little bit, a few minutes ago, and it's something that, it's the 2nd most common peripheral neuropathy in the upper extremity.

Oh yeah, first carpal tunnel syndrome. This is very common. So this is whenever you get a thoracic outlet syndrome and just knowing that 90% are on the ulnar nerve distribution, I always think about way up here as far as where that compression can be. However, cubital tunnel syndrome is also a very common diagnosis to be causing this. A lot of this postural, it's the things that people are doing, it's the position that people are in. So once again, we're going to use the same ulnar nerve tension test. However, with this test, and unfortunately if you look at the videos that I did months ago, we'll give you access to those. One of the biggest things about the ulnar nerve tension test is creating that shoulder depression at the very beginning. Because then what you're going to do is you can actually preferentially first bend the elbow and see if you get reproduction of symptoms. And in that case, I probably have more of an elbow issue. If I do this and I really don't create too many issues, and then I also pull at the 4th and 5th digit into extension and then bring the arm up. Now I'm putting the most tension possible on that nerve. And then I'm thinking a little more superior. So it's really where you bend the first joint is where you're going to get your symptoms. However, we can see that the patients that get those kind of symptoms, it's really about not only doing the flossing, but it's avoiding the activities. The same thing happens with the radial tunnel syndrome. Now, We'll see a lot of radial tunnel syndrome in conjunction with lateral epicondylitis. And I'm not sure if it's quite that one causes the other, but I think long-lasting, not properly managed lateral epicondylitis leads to lateral epicondylopathy, you know, more of a tendinosis in that tissue. And longstanding tendinosis leads to radial tunnel syndrome. And that's not always the case. However, if you have some thickening there, cradle of Fröhse, if you have some longstanding irritation, maybe it's inflammation in that area, Then something's going to pay the price. And right there at the supinator muscle is where you're going to have that radial nerve going right across the elbow on the front part, right between the biceps and those wrist extensors. And we can have some irritation of the nerve. Now, if it's further down, maybe 4 to 6 centimeters down, it's usually more of just a posterior interosseous syndrome where you can have some weakness in there. If it's further up and it's just irritation, it could be the superficial part. Which is more sensory.

So this often mimics, you can see from this, this example, how close the extensor carpi radialis brevis is to that supinator muscle in the arcuate of Fröhse where there's oftentimes irritation of the radial nerve. One of the big differentiating factors between these 2 is where's the peak point of tenderness. That in a patient who has lateral epicondylopathy, typically they're going to have tenderness right on that radial head up near the joint. In someone who has a radial tunnel syndrome is going to be 3 or 4 finger breadths distal to that. And when we poke on that, which is one of the orthopedic tests that really for any neuropathy we're going to do compression of the area and then tension of the area. Same thing with radial tunnel syndrome. If the peak area of tenderness is 3 to 4 finger breadths distal to the lateral epicondyle, we're probably looking at a radial tunnel, which most of the time will have a little bit more distribution too than the typical lateral epicondylopathy. And this isn't something that's rare, that 10% of patients with lateral epicondylopathy don't have lateral epicondylopathy, they have radial tunnel syndrome. So 1 in 10 of our patients who fail our treatment, usually these are fairly home run cases, the lateral epicondylopathy might take a little time but they usually turn out well. If they're not turning out well, we certainly want to think of radial tunnel syndrome because they come on with really similar causes.

Or seeing a different doctor. Similar causes is probably the best thing. And the wrist extension, pronation, supination, the one thing that we might have forgot on this just because of the etiology and close relation with lateral condylitis is grip. Because grip really can exacerbate these symptoms, creating that longstanding compression, which obviously nerves don't like. One of the things with musculoskeletal pain, especially in the acute situation, is it's localized. Whenever we have a nerve-related symptom, it's not uncommon to get peripheralization of that symptom down the arm and more of a dull, diffuse ache in an area that it's affecting. So once you start to get that, that pain growing in area, size, and distribution, that's when we want to switch in the structure as far as what's the etiology behind that pain. So as far as radial tunnel compression, you just saw Dr. Burns, he used all the strength to try to get me to flinch, but he's just not strong enough. But no, just poke on it. If poking on it isn't irritating it, you can also stretch it, which is also what you saw him do the same thing, is putting stretch across that nerve and looking for reproduction of symptoms. Also keep in mind, before I go over this one, not only do you look for reproduction of symptoms, you're looking for reproduction of your patient's chief complaint. Sometimes patients will do a maneuver, even something like a Hawkins-Kennedy test is a common example. Well, that's a positive test for shoulder impingement syndrome, but if you get radiation of pain, numbness, and tingling going down your arm, that's still a positive Hawkins-Kennedy test, but not for impingement syndrome. It's positive for radial tunnel syndrome. So keeping in mind that just because you're doing a specific maneuver doesn't mean that's the diagnosis it's going to be causing. It depends on the symptoms you reproduce.

This is a great differentiation maneuver that any of our patients who have radial tunnel syndrome or lateral epicondylopathy probably won't like stretched because tendons don't like to stretch, neither does the radial nerve. So that's going to provoke symptoms in both of those patients of passive flexion of the wrist. But if we can increase the patient's pain significantly by having them do the middle finger extension, sometimes we call this the New Jersey sign, but if they're doing middle finger extension and that discomfort is worse than passively flexing the wrist, then we're more likely to have radial tunnel syndrome as the diagnosis. So what are we going to do for that patient?

Treatment, we already showed it, the radial nerve floss. We do this both in office and out of office, and I think that the Main clinical goal of doing it in office is to teach the patient not to do too much. Because if I'm going through and we touch that pain, then I'm instantly going to come back to that retreat position. And I go down and touch that pain and then go back to the retreat position. A lot of patients, especially your male patients, are going to think more is better. So they're going to get it really in the stretch as far as possible. And if you have nerves with adhesions that are angry, they're inflamed, and you really stretch them out more, they're going to be a little bit worse. And then of course we can do the release. So going across the radial nerve and the brachialis and actually taking that nerve, not compressing it really far, but going through a radial nerve floss while having your finger go along that nerve and just milking this essentially, taking and helping get rid of those adhesions and reduce the inflammation in that area. Anytime you can take a force and go along the fibers of that force, that structure is sedative. Anytime you go and you go cross friction across that force, especially your tendons, it's going to be inflammatory. So we don't want to hang out there for a long period of time. I don't want to do cross-friction massage, but I do want to create a little bit of a milking force to help get rid of some of that pain. And finally, taking the patient, sending them home with a radial nerve floss.

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Yeah, now on to the most common upper extremity neuropathy, carpal tunnel syndrome, which you and I treat on a regular basis. We know what those symptoms are: numbness and tingling into the first 3 and a half digits, And that compression can happen anywhere really along the chain. The symptoms that are classic for that is numbness and tingling into that distribution. When I hear that, I instantly jump to a diagnosis of carpal tunnel syndrome, but I'm wrong about a fourth of the time because this study told us that 77% of patients who have nocturnal awakening because of numbness and tingling in the median nerve distribution have carpal tunnel syndrome. That means that about 23% of them don't have carpal tunnel syndrome. Phalen's test and reverse Phalen's test were even lower likelihood of being predictive. One great clinical clue for what could be triggering this patient's compression, where along the chain, is it in the cervical spine? Is it happening as it comes through the pronator muscle? Is it happening through the carpal tunnel? Or oftentimes a combination of those. One great clinical clue is to determine where the numbness and tingling, because remember that the portion of the median nerve that travels beneath the transverse ligament of the carpal tunnel innervates the fingers, not the palm. The palm is innervated, as you can see on the other anatomical example, by the palmar branch of the median nerve, which travels outside the carpal tunnel over the top of that flexor retinaculum. When someone has numbness and tingling in their fingers and palm, it means that they have more than just carpal tunnel, because if the compression were solely in the tunnel, it would only be the fingers. We have to look upstream and the most likely scenario upstream is the pronator teres muscle.

That was a pretty good slide advance, wasn't it? I mean, just as you're finishing your sentence, I just figured out— We're using a wireless mouse.

You want to try again?

That's not going backwards, I can tell you that. Pronator teres is a muscle that's solely in your supination and pronation. So think about that with your patients and their hobby, their sport, their activities. A lot of patients, what did they do all day long? Their arms like this and they're rested on something. So we can see based on how they use their mouse or how they type, you see some long-lasting compression to the pronator teres. So what can you do for carpal tunnel syndrome? Once again, we're going to push on it. Create some compression to see if we're going to get some reproduction of symptoms. Almost 90% specificity of finding carpal tunnel syndrome and 96— I'm sorry, sensitivity. Specificity was 96%. So we can really see just by compressing that nerve, we're going to see a lot of reproduction of symptoms. I can also compress it with Phalen's test with my, using a little bit of a lever arm with my hand. Or I can put stretch on the median nerve with reverse Phalen's test. All these things can help differentiate between a cervical radiculopathy and a carpal tunnel syndrome based upon where that numbness and tingling is going. The median nerve tension test, like we talked about before, we've already demonstrated. Please get good at this test. This is something that you can do in your office to help differentiate where the nerve pain is coming from, but also builds confidence with your patient that you know what you're talking about, that you can reproduce their symptoms. Finally, it's not just the pronator teres. It's not just the carpal tunnel. It could be anywhere. It could be where the subscap comes out of the shoulder. It could be in the neck. So don't have your blinders on and you saw a seminar today, so everything's TOS the next week. I know I do that all the time. I learn about a new diagnosis and magically that next week everybody has that diagnosis. However, don't forget about the nuances. Like we said with thoracic outlet syndrome, 90% have symptomology and the ulnar nerve distribution. That's huge. We need to remember that. 10% of people with autochondritis have symptoms going and actually have a radial tunnel syndrome. So while we can treat the 90%, we really want to treat every patient as a case study of one, give them the right evaluation so hopefully we can provide the right treatments.

One of the routine procedures that we give our patients is a nerve release of the median nerve at the wrist, and then we also give them a median nerve glide. So the median nerve release, remember that median nerve is coming through the carpal tunnel. We can have that patient, we can strip out their carpal tunnel. So by stretching the carpal bones apart and then having them go into extension, we can also strip through that as they're coming down, being cautious not to reproduce numbness or tingling. Some patients, some providers will use factor tools or other types of instruments to help release those adhesions. Fantastic tools in that process. One simple thing that we can give our patients is again the desensitization maneuvers. There's probably not been any other condition that has more support for utilizing these therapies than carpal tunnel syndrome. We showed you some of these studies in the beginning. We've already talked about the median nerve floss, but the one thing that we want to cover is the median nerve glide. And the way the median nerve glide works is we're going to have that— have the patient make a fist. We're then going to bend their fist downward, and then we're going to come back to a neutral position, straighten out their fingers, and then we're going to bring the thumb away from the palm as we come up into a stop sign while we continue pulling that thumb downward. So this is real simple. You can try it on yourself right now. First of all, make a fist. Flex your fist downward. Then bring your fist back to a neutral position. Straighten out your fingers so that all 5 fingers are pointing forward. Make that stop sign and then traction your thumb downward. And you'll probably feel some stretching, not only of the muscles of the thumb adductors, but also of the median nerve. And that's something that has proven beneficial. There's a couple of studies, including this one, that said that even moderate carpal tunnel syndrome cases benefit from neurodynamic maneuvers. Once somebody has atrophy, that becomes a little bit tougher. One of the things that we should be proud of as manual therapy providers and chiropractors is that we have a very high level of patient satisfaction, that those of us who lay hands on patients, whether you're an athletic trainer, a physical therapist, a chiropractor, any type of manual therapist, we have a much greater opportunity to positively impact that patient's life. And our patient satisfaction scores are very high. Our net promoter scores are very high as well, and our net promoter score helps to define the success of a business, and manual therapist net promoter scores are exceptionally high. One thing that we make sure that we do is educate our patients. I remember a few years ago that we monitor outcomes, and this year some of the data that you've just seen on those last 2 slides came from something called our COP synopsis of patient satisfaction and clinical outcomes from manual therapists. And we saw out of 662,000 presentations, those sort of statistics. One thing that we do is we monitor the outcomes of those providers. So when a provider prescribes a report through our system, we collect the outcomes and say, how did it turn out 30 days later? And we had a provider not very far from this office who was the top provider for 5 different diagnoses. And that's very hard to do. In fact, I'm not the top provider out of any of our 2,500 providers for any diagnosis.

Yeah.

And I'm sure you're not. And so, That's hard to accomplish. And this doctor had 5. So we went out to his office to figure out what's he doing differently. And I was waiting to see the magic. Brought cameras around and watched him for a couple of hours. And I realized there's really not a lot that he was doing differently. That is, one of my friends talks about— he's a medical physician— he said that manual therapists are kind of like Taco Bell, that you have ground beef and you have lettuce and you have tomato and black olives, and you just mix them up depending on the diagnosis to produce an enchilada or a burrito or whatever you might want. And we in medicine have a Merck Manual with a Physician's Desk Reference of billions of possibilities in that taco bar. And as I thought about it, I thought, that's true, but how you put those ingredients together makes all the difference in the world. That one recipe is very different than another. So I was eager to see this provider's recipes, and I was disappointed for a moment in recognizing, you know what, the recipes really weren't that different. I do that, and I do that, and I do that, but I don't get That same outcome. And on the way home, I figured out what it was— that this provider spent a whole lot more time with his patients educating them as to what was going on and educating that patient as to why it was crucial that they're performing their home exercises, why nerve flosses are important, why they should be stretching their pecs and strengthening their interscapular muscles to get rid of their forward head, forward shoulder posture. And by doing that, he had more engaged patients, and his patients were the reason that he was getting better outcomes. So we take great pride in making sure that we give each of our patients the right information about here's what's wrong, here's what we're going to do in order to treat that condition, whether it be therapy modalities, myofascial release, home exercises. And then we make sure that that patient has their own home exercises that they can view video demonstrations of. If this is something that you'd like to check out a little bit closer, you can scan this QR code. You'll be able to download the resources from today's presentation. And you'll also be able to try out that system if you're interested.

I think that the doctor you're talking about, the main difference is an educated patient is a compliant patient. So if you ever have an issue with a patient not coming back, or they're not quite understanding what you're, what you're delivering, even though you may know exactly what to do with that patient, we have failed as far as describing what that patient needs. So the average reading ability and comprehension of a U.S. citizen Most people around the world is the 6th grade, which isn't great. And we're in Southern Illinois, it's probably a touch lower. However, we have to educate our patients on everything we know about a condition and give that to the patient in a comprehensible format. So that's why we use different formats, whether it's print, email, text, different ways to deliver the exercises, deliver patient education, and explain what we're going to do. Because if they're educated just as much as we are in their condition, Like for cubital tunnel syndrome, they're going to find those hobbies, those habits, those sports that are leading to that condition. There's no cubital tunnel fairy that came down and gave them that diagnosis. They created themselves. Now we're challenged with getting rid of that diagnosis, but it comes a lot through education. Obviously manual therapy is a big piece of what we do, manipulation, mobilization. Don't care what you do, just find some evidence behind it. But making sure you're doing the right treatment for the right diagnosis. And I can't speak highly enough of nerve mobilization techniques. You've got Butler's book, you've got Shacklock's book, and obviously at ChiroUp we have all those resources all rolled into one digital format that's easy for you to use. So I did not keep track of all the questions. I don't know if you did, but Jessica, are there questions that we have in the queue?

So one of the things while Jessica's bringing up those questions is that something that I often overlook, and today we talked about a lot of structural diagnoses about nerve-type problems, a couple of tendon-type problems, and what's easy to overlook are those functional deficits that might be delaying our patient's recovery. Things— and by functional deficits, I mean the things like an upper cross syndrome or scapular dyskinesis, somebody who has an unstable core— that if we have a pitcher who has an unstable core and an unstable scapula, the symptoms of his Little League elbow or medial epicondylopathy are truly that. They're symptoms of something bigger. And one of the things that we learned in researching the best practice protocols for the 110 conditions is that there's a common set of functional deficits along the way that make that happen. Those 7 functional deficits that we've described so many times, and I think that providers, and especially providers in the FACTOR system, have such a great grasp of doing that, that you have a distinct advantage. You just need to make sure that there's a way that you can relay that. So not just getting the outcomes, But relaying those outcomes to the people who matter, relaying them to your patients, the public, and healthcare decision makers to make sure that we continue to have a seat at the table. I'd encourage everyone today to find one way to relay your positive clinical outcomes, whether that be notes to the primary care physician, asking your patients to provide you with Google reviews, or sending research articles to the medical community or to healthcare decision makers. If we all took that step, we can advance manual therapy and advance those types of those systems that we love, like, like FACTOR.

So.

If everybody takes one step today, that'd be a great, great movement in a positive direction. And any questions along the way? Dr. Steele, what is one tip that you give your radial tunnel syndrome patients who aren't improving with your lateral epicondylopathy care, especially related to braces?

All my patients get better.

That would be one tip.

Avoid compression. So you'll get those patients with, uh, they're sleeping on their arm like this. Long-lasting compression is just a bad deal for a lot of those patients. I think most of our patients are actually causing their own problems. So if you get someone with long-lasting lateral condylitis, they've got one of those tennis elbow braces on them and it's creating that compression. They're actually causing their own diagnosis. So I'd say out of everything, I'd always look for what the patient's doing to themselves to help them solve their problem because chances are it's just perpetuating it. It's kind of that patient with lumbar spine disc lesion. They wake up every morning and just stretch it out. Like, oh, you're causing your own problem. And then convincing them to do just the opposite and go into extension.

And why are symptoms more common at nighttime? You know, I think there's a couple of diagnoses that symptoms are more common at nighttime and, well, a couple of bad ones, but also a couple of common ones that you and I treat that certainly, yes, anytime somebody has nighttime pain, we're concerned about some sort of a threatening diagnosis, especially a neoplasm or an infection. But when it comes to tendinopathies and neuropathies, those are often provoked at nighttime, whether that be from a positional standpoint where we're getting compression of that area, or if it's from a lack of cardiac flow because the blood flow is down, or from things just get tight and they heal at night, right?

Oh, that's— well, when you sleep is when you heal, so that's the best time to do it. Your body has nothing else going on.

Okay guys, our first question involves specific patient occupations that may commonly develop these conditions. Are there any that are surprising or that you would not necessarily expect to see these type of upper extremity neuropathies with?

I would say more often than not, what surprises me is it's not repetitive stress. So, so many people look at what did I do to cause my pain or my problem, neurologic symptoms or MSK symptoms. And I think it's more often body habitus, body posture. It's the sustained pressures that we put on our bodies. So we all have seen a secretary that's been at work for 60 years. They all kind of look like this. We all see how a carpenter walks with their knees that are osteoarthritic. A lot of that time it's postural, it's not repetitive stress. And also it's not necessarily a waste of our time, but the more time you spend trying to go back into a patient history and find out what's causing their problem, I think it's wasting the time that we can get curious and get creative with our our treatments. So I don't try to avoid their history. But also, if you have lumbar spine degeneration, if you have, you know, grade 3 osteoarthritis or knee, there's nothing you did 2 weeks ago that made that get to that point. This is years of dysfunction that have caused these problems. So I try to focus on the present and a little less on the past because really any profession or any person can cause any diagnosis at any time.

As a follow-up to our first question, when you look at the research, Are there any groups that are considered high risk for these type of conditions?

Any groups that are considered high risk? Yeah, I think that for carpal tunnel syndrome, we're all aware of who those patients are. In addition to the body habitus issues, the biggest risk for carpal tunnel syndrome and neuropathies exactly is somebody who has cardiovascular risk factors. One thing that we'll see that we are seeing now is that manual therapists often thought of musculoskeletal problems as purely mechanical. And yes, there's a huge mechanical component, but there's also 2 other things. Number one, a biopsychosocial component that if you believe you're not going to get better or pain is bad, you're probably right. And number 2, the vascular aspect of that, that we know that there's such a vascular aspect to lower back pain. There's such a vascular aspect to tendinopathy, and there's absolutely a vascular aspect to neuropathy. Patients who have had cardiovascular disease are much more likely to also suffer from tendinopathies And neuropathy, so carpal tunnel syndrome. So we're all aware of the mechanical factors. Certainly a supermarket checker, anybody who uses their hands a whole lot is at risk, especially if you're flexed a lot or if you're sleeping. Positions do change the vascular flow of that tendon. So people who put their hands into repetitive flexion in particular, or a lot of gripping with their forearm to tighten up the forearm and the supinator muscles, we're going to have bigger issues with. When it comes to a radial tunnel syndrome, same thing as lateral epicondylopathy, racket sports, but most people who who have tennis elbow have never gripped a tennis racket. It's usually somebody who does something similar, whether that be a carpenter or someone who's repetitively using their wrist in extension. So manual trades would be really high. And for the thoracic outlet syndrome, it's somebody who's forced to sit at a desk and is developing approximation of the costoclavicular region and tightness of the pec minor. And maybe for the scalenes, which seems to be the least common of the 3 TOSs, somebody who's either, yes, in a bad forward head posture, Or carries carpet rolls or something on their head that they're using their head as a clamp and tightening their scalenes. But certainly somebody who's not breathing well, somebody who's using all the accessory muscles to help themselves breathe, like their scalenes and their SCM, are more likely to have tight scalenes and SCM. So I would say those would be the big, big factors.

Pregnancy. Your blood doubles. So unfortunately, going into that vascular component, peripheral neuropathies in pregnancy are like peanut butter and jelly.

Yes, that absolutely makes sense. Dr. Steele, you were reading a question from Dr. Tom Hyde that just came through. For those of you who may not be familiar, Dr. Tom Hyde is the co-founder of the Factor Rehab System. So we're excited to have him live in our audience today.

We can read Dr. Hyde's comment.

You guys are wonderful.

Yep.

You guys are a wealth of knowledge. How would you recommend the use of Factor instruments be used with these entities? I have found it very useful along with— Excellent. So Dr. Hyde, one of our heroes who's advanced manual therapy so much, thank you for everything you've done. We probably wouldn't be giving these talks if it weren't for you and people like you who made that happen. So thank you for doing that. Thank you for the question as well. And absolutely that we kind of assuming that the factor crowd is an expert. On instrument. So we stay away a little bit from instruments, teaching the experts on how to do that. But in our practice, we're going to use FACTOR tools on all of these neuropathies that certainly anybody who can benefit from having greater nerve mobility is going to benefit from that. And what I love about the FACTOR system is that you're able to combine so many other things with that to get the eccentric strengthening for the tendinopathies, to get the stretching, to get the rehab, to include the manual therapies. And the whole system, the whole recipe put together. So like any recipe, if you take the flour out of cookies, they're not going to turn out as well. And I think if you take any component out of that factor system, the ingredients aren't going to be quite the same product. So certainly something that we would use and consider the most important components of that, or one of the more important components of that, maybe not the most for neuropathies, but certainly more important. And I would defer to The experts on that side of the camera as to how do you use it. I know how I use it, but I use it the same as, as they do.

Just as a quick point of reference, we do have an online FACTOR Peripheral Nerve Entrapment course that I highly recommend our listeners and live attendees check out if they're interested in learning more about these peripheral nerve entrapment treatments using the FACTOR Protocol. It's an 8-hour online on-demand course, and everything our speakers are talking about today is covered in that course, we do a deep dive on the different assessments and treatments for these conditions. So I have to say, guys, your recommendations are spot on with everything that, that we also have been covering in that course and, and that we see in the research.

Yeah. So one thing I appreciate about FACTOR as compared to some other tools or, or, or companies is that it's a system. It's not just using the tool. So there's multiple approaches you can take with the FACTOR tool. I think That really a lot of this can also just be peripheral sensitization from that primary neuron. That if you look at the fascia research and we can use tools to help desensitize fascia and to help elongate fascia, that we can have a dramatic impact on a patient presentation also. So we're making assumptions in this 1-hour class that this is a true compression right at the cubital tunnel, but we all know there's a lot more that goes into it. And a tool like that can help desensitize that primary neuron. And help with that diagnosis also.

Another question from our audience here. You mentioned earlier that there is usually a need to recommend that a patient avoids the repetitive movements that may be exacerbating their symptoms or possibly delaying their healing. How do you typically approach this when the repetitive movement is a necessary component of their job? It's something they have to do day after day after day in their occupation.

Absolutely. So I have to work. Everybody has to work. So I get that. A lot of times just changing your mechanics while you're doing that job. I know I had a patient, this is not necessarily a nerve-related symptom, but she was the imaging person who does the imaging of pregnant patients. So she had the ultrasound wand or orb right here. She's looking at a computer screen and she gave herself impingement syndrome because she had her arm in an abducted position for 8 hours a day. The only thing we did for her, I treated her at the same time, but we didn't have very good success in the first 14 days until I dug a little bit deeper into her history and found out what she did for a living. We just change your position every single patient. So the same thing can go with nerve-related symptoms, is not necessarily stopping their job, but also breaking up that Elmer's glue where that compression is and doing some nerve flossing throughout the day will help with their symptoms and help get them through the day without having less problems.

Yeah, get blood flowing would be the key concept for nerves. And usually all the things that we talked about today, the flossing is trying to prevent either compression or tension, that the nerve needs to be a bungee cord, that my ulnar nerve as it comes out of my neck behind my medial epicondyle and down into my fingers has a certain length at this, it has a certain length in this position. In fact, when I flex my elbow, it needs to— the ulnar nerve needs to bend half a centimeter Behind my medial epicondyle. If I would take that and spot weld it in any one place, rather than it being a bungee cord where the entire cord absorbs that shock, now we're absorbing that shock in a much smaller area, which creates tension, and the tissue just doesn't like tension, like pulling on your skin. It creates ischemia. So anything that we can do to improve the vascular supply, whether that be the patient not being pregnant, whether that be getting their blood supply pumping by getting them to exercise, Or simply changing positions. Don't maintain sustained positions of compression or stretch. And sometimes that's an individual based upon what, what their occupation is, what their hobbies are, but just trying to get blood flowing, get them up and moving. That blood is, is the reason that they're going to recover.

All right, that is all for our Q&A segment today. Thank you so much, Dr. Steele, Dr. Bertelsmann, for joining us, and for our live audience for hopping on and joining us today for this event. I highly recommend everyone visit chiroup.com to learn more about all of the great resources that these docs offer to support practitioners in practice. Where we kick off a new training on LGBTQ+ and healthcare, What You Need to Know with Dr. Philippa Oakley. In this 2-part training, Dr. Oakley will provide an engaging and informative overview of some of the key barriers that prevent LGBTQ+ people from accessing equitable and affirming healthcare. You won't want to miss it. Episode 46 drops in 2 weeks. If you enjoyed today's episode and find value in our content, I'd like to ask a quick favor. Would you mind sending this episode or just sharing the podcast with 3 of your friends? We've been working hard to put out valuable content to support healthcare providers and students, and I wanna make sure it gets into the hands of the people that need it most. So grab the link to this episode or this podcast, text it to 3 friends, or you can just click the share button where you're listening to this podcast and send it that way. Whatever works for you. But I would be forever grateful, so just wanted to put that out there. You can also 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 certainly last but not least, we invite you to join us for a live hands-on Factor training in a city near you. This year we'll be in cities around the globe and just added a few new dates to our schedule this week. So be sure to visit factoreducation.com to learn more. That's factor, F-A-K-T-R, education.com. Thanks guys, we'll see you next time.

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