Nerve Treatment Beyond Flossing: Opening, Closing and Offloading

It's a coin flip sometimes for me. Yes, and that is real clinical life. You get to Friday afternoon, you're the last patient, you've got to get out on time because you've got family to meet. A patient won't stop talking. And I mean no disrespect to patients. This is a real clinical life. You've got, gee, I've got to do something. I'm not quite sure, but I've just got to try something that usually, and I'll do something that's quick and efficient, usually works and is safe. We often don't understand why, but in the end, if it works and it's safe, and it's within your healthcare system to provide that, I don't see a problem, but as long as it's couched in relation to a fostering independent.

You're listening to the Restoring Human Movement podcast, where movement experts discuss the latest evidence-based practices to help you and your clients move with mastery. And now, your host, Dr. Sebastian Gonzales. Hey, everyone. It's Dr. Sebastian Gonzales, your host with the Restoring Human Movement podcast. Thanks for joining the movement, movement. This is your first time. Welcome to the show. We are edging into about 170, 80 or so. We're way up there, so I think the episodes have gotten better over time. Hopefully you agree. And if you're a subscriber, you're hearing a lot of them in real time. So, please go back in the archives and start listening to some of the old stuff, which is still pretty relevant and useful.

But please subscribe. Subscribe. It's really the only way you're going to keep things up to date, as there are certain things suggested in a timely fashion as well. So, we have on Michael Shacklock today, who has been on once before as well. This is an interesting episode, actually, because I recorded it a long time ago, actually. Probably, I'd say, gosh, seven, eight months ago, probably. I had Michael on, and so he was going to be a part of Pro Chiropractic Online, which actually we just discontinued. We just shut down. So, sorry to see it go, but we didn't feel like we were able to nurture it quite that much.

So, when I have Michael on here, we might reference that a couple times, but it's actually, that's obsolete. But you can certainly learn from Michael in a different form, too, I'll tell you at the very end. Now, the whole point of this podcast is to improve our clinical outcome and also to improve how we communicate with our patients and if our patients can understand us. So, I try to keep things more conversational when at all possible, but if we get into the weeds a little bit, just go earmuffs patients. But I think we're all at a bar having a beer, and I decided to get a Port Mongo. You decided to get a West Coast IPA from Green Flash.

And our buddy, who is a, gosh, what is a, let's go with an HFAC guy, the guy who just gets up and just puts all the ducting and stuff into new developments and so on. He decided to get a shot. He just wanted to get ratted that night. Not quite sure. But we're going to get into the show today, and you heard that snippet from Michael Shacklock. Typically, in these shows, I like to share a little bit about myself via personal stories so you guys can understand who your host is and hopefully kind of grow with me through this journey of listening to these podcasts. And my analogy, which you've probably heard me say before, is that maybe I like Conan, but I don't like Oprah, so I don't want to follow Oprah's show, although she has great stuff to share.

So, hopefully you guys see me as a Conan and just want to hang out and spend the next 45 minutes to an hour with me. So, let's get into that personal story, and then we'll get right into the interview with Michael Shacklock. So, if you've already heard, I had a coffee roasting business, and we actually did nitrogen coffee, too. So, if you haven't had nitrogen coffee before, nitrogen coffee is basically cold-brewed coffee pressed really firmly with a lot of pressure of nitrogen, not nitric oxide. You won't get sick from it, but it's N2, so it's benign gas. But anyways, it makes all these little fine bubbles that come into it.

And if you've been, if you drank beer before, you see that nitro stout, or that nitro porter, they might, porter, I think, but I know they have nitro stouts. But it's on a certain, it's on a certain tap in the actual bar. So, there's only one or two or so, because it takes a different system to deal. And the one thing about nitrogen bubbles is it's really light. It's lighter than air. So, it'll actually come out, and it has to be pressed in really hard with like 70, 80 PSI to really get in. Carbon dioxide, I think, is around like 5 or 6 or something like that. So, it's not a lot. So, it stays in the fluid very well.

So, anyways, I went up to this place, and they had this great beer on nitro. And so, after we closed down this coffee business, I had all this leftover kegs and kegerators, and I had this home brewing stuff. And I didn't really have any more, but it had all this nitrogen system on it. So, I thought, you know what? This is a great opportunity to maybe do a nitrogen beer on tap, you know, and to have it at home, because who the hell can say they really had that? Most people have a beer one for standard beer with carbon dioxide, but this is different. Like, the nitro system, like, costs like an extra $300 to set up.

So, I'm like, screw it. I'm not going to have one for a very long time. Why don't I just get this beer at this place and then put it in the system, and I'll have this badass beer, right? So, I go up to the counter. I say, hey, so I want to get that nitrogen beer, and I want to put it in a keg. Can I do that? And they're like, well, we can't fill up kegs. And I said, great, cool. So, what if I just got some growlers or something and just took it home? And the lady's like, look, I can't control what you do with it after you leave this place, but we just can't put it in a keg for you. I said, great, cool.

I went home, came back, and I said, okay, so I got some growlers. Can I fill up that nitrogen beer right there? And she said, well, we can't put that nitrogen beer in that growler because it won't stay. And I said, well, why not? And she's like, well, the nitrogen bubbles won't stay. It won't be nitrode anymore. I'm like, I know, I get that. I'm like, earlier we spoke, and I told you I had a nitrogen system, so it's not a big deal. I don't mind at all. She's like, but we can't sell you that beer in there. We can't put that beer in that growler. And I said, why not? And she's like, because it won't stay.

I'm like, I know that. We just had this discussion. I'm going to put it in a keg. And she said, well, but we can't sell that beer. I'm like, why? Because it won't stay or because it's illegal? And she's like, we can't sell that beer in that growler. I said, why? And I looked at my girlfriend. I'm like, am I, like, after I left, I was like, was I asking the right questions? Like, was I going, like, fucking crazy with this thing? Like, I feel like I was going through that who's on first thing, you know? But anyways, couldn't get it in there. So it drove me damn insane because all I really wanted was a couple gallons of this beer on tap at my house.

I never got to do it because I got a little frustrated. But anyways, apparently you can't get nitrogen beer in a growler or in anything because I still don't know why. So ask, next time you go to a brewery, say, hey, can I get that thing in a growler or something to go, that nitro beer? And they're going to say, yeah, sure, no big deal. But they're going to tell you it won't stay, which is fine. It's fine. It's a whole different system. But can you legally do it or not? I still have no idea. Okay, sorry. Long one. Let's get to the content. So now that you're on the podcast, what's your name again?

Who are you? My name is Michael Shacklock. I'm a physical therapist or physiotherapist trained in New Zealand originally in the late 1970s. And in the mid-80s, I went to Australia where I learned manual medicine, pain sciences, and urodynamics. Cool. And so for everyone, if they don't know already, this is going to be around a podcast of about 152, maybe something like that. And so last year, was it a year ago that I interviewed you? I have a feeling it was 2017. Was it really? It could have been, oh, well, it could have been early in the last year. Yeah, it could have been sometime in the last year, approximately.

I remember the episode number, it was 91. That's true. And so that was 50 weeks ago, so 60 weeks ago or so. So it was a while back. So everyone should go back and listen to that one because it was mind-blowing. Like, I actually got people sending emojis on Instagram to me with that mind-blown emoji. Oh, okay. Wow. Gee. I have to look for that emoji. Yeah. Maybe I'll send you a steak picture next time and you just send me that one emoji. Great. Beautiful. So since we spoke last, what do you think is recent developments in your field? I've been following a little more some of the biological effects of neural mobilization.

And there's some new studies now that show that in neuritis and neuropathy models, you can, with neural mobilization, change the nociceptive markers in the spinal cord and the expression of trophic factors in the nerve into muscle that innervates. Mm-hmm. So, go ahead. Yeah, well, basically, if you mobilize a nerve and a neuritis model, which is thought to be a model of nociceptive and possible pain production, that the nociceptive markers in the dorsal horn of the spinal cord diminish. So, nerve mobilization decreases nociceptive or pain response? Well, I think what we have to do is contextualize this.

And we know that pain is an experience. Right. And so, at what point does it become experienced or conscious or perceived? We don't acknowledge at this stage that nociceptive in the cord is pain because there's no one thing that indicates pain. But the scientific premise on which these studies are based is that if there's nociceptive expression in part of the nervous system, there is potential for it to trigger some sort of pain mechanism and response. So, there's a kind of a connection there, although one is not necessarily exactly the other. Mm-hmm. So, they're using nociceptive markers and neuroinflammatory markers as well.

There are many markers used to delineate or indicate that there could be something, some nociception going on in that model. So, does, based upon what you know now, does that change anything that you teach? Um, no. Other than it gives us more confidence that we're on the right track. Mm-hmm. So, for example, one of the key areas that I talk on the advanced courses about is at what level of analysis is our patient diagnosed and treated? So, we could go existentially. We could say, well, look, your personal life's not fantastic. Change that and your pain will improve. But that's not really my job.

I mean, I might be aware of it. I might be able to point the patient in the right direction. I might be able to give them a little bit of advice, but it's not my job to do psychological counselling so someone can change their personal life in a big way. It's a family situation or work or whatever. So, if we go further, we start scratching the surface by pushing on their, um, or giving them some practice to change their pain mechanisms. We go deeper. We get onto their skin. We go to superficial, deep fascia, epimycium, muscle, epineurium, nerve, and so forth, until finally we get into an area where we actually do operate on, which is in neurodynamics, mechanics, and physiology.

So, if we improve the mechanics of the nerve, then we may improve the physiology, and that may produce perceptual and movement changes in the patient. But we go too deep. We can get to iron channels. We can even get to subatomic particles. We know that iron channels can be in two places at once. But do you really do a neurodynamic test and make a diagnosis of what iron channels is misbehaving? Well, the answer to that is a clear no. I feel like that. Because the deeper we go, the less specific we get. Hmm. You, you, uh, you know that one emoji we just talked about? Mm-hmm. Yes. If I could, uh, just put it on this little screen right here.

You already, you validated that Ant-Man is a, is a realistic movie already. Well, well, good. I, I'm glad I went to part two. I think I'm going to do part two again now. Ah, well, yeah. Well, we discuss it, you know. We can't, look, you can't remember anything or everything on these courses. There's so much in them. But, and remember, this is 20, 30 years of work condensed into, you know, a few days. Yeah. But one of the things that I'm particular about is at what level of analysis should we make, um, a diagnosis and treatment? Because, you know, we do have a, this is the age-old discussion that's, you know, thousands of years old.

This is probably, certainly hundreds of years old. Is specific more important than general? Or is general more important than specific? Mm-hmm. Now, my view is that they work together anyway. And so we know that, for instance, nerves transmit forces, but with greater distance from the initial site of force application, you get a diminution of the effect. Pebble in the pool effect or butterfly effect, whatever you call it. So we have people out there who are mobilizing the right medium nerve for left carpal tunnel syndrome. Now, I don't reckon that's having any decent mechanical effect on the contralateral side, except maybe extremes of the end of a neurodynamic test.

So we're actually making use of other mechanisms rather than the direct mechanical one. Mm-hmm. And so how, at what point is it relevant, important, and so forth? So to me, level of analysis is a really important part of clinical science. Mm-hmm. And I think one of the most confusing aspects of clinical research and science is it's often studied at the wrong level of analysis. And that's why you get black hole studies that find nothing. Mm-hmm. So is there – actually, have you ever found anything that has been invalidated in a study, but you found it to be clinically useful? Mm-hmm. Yes, in a word.

Mm-hmm. For example, the early studies – there's several studies like this, but the early ones that were done on measuring longitudinal movement of the median nerve at the wrist in people with carpal tunnel syndrome compared with those who are asymptomatic. Now, the early studies didn't find an impairment. Well, one of the first studies, subsequent ones usually do, to the point where there is now systematic review evidence that nerves lose their capacity to move in carpal tunnel syndrome. And so for some people with carpal tunnel syndrome or a neurodynamic aspect to their wrist pain, neural mobilization is very useful.

Mm-hmm. Now, what mechanism does it operate? Is it physiology? Is it movement of the nerve? Is it scholastic behavior? It's probably a multitude of those mechanisms. Mm-hmm. But so, you know, one of my comments about science is – and I'm a part-time scientist – is whenever we get a study that doesn't find anything, be careful. Mm-hmm. That doesn't find anything. Mm-hmm. No. There's a study that doesn't find a mechanism that is being searched for, and the statement is it doesn't exist or doesn't work or doesn't operate that way, be careful. Because often they're wrong. Mm-hmm. Because – and one of my favorite things to do with science and a study is just step back and do a face value analysis.

So step out of there and say, okay, all those words, all those beautiful pictures, those molecules, whatever it is, wow, this is fantastic. But is it really what I – does it represent what I see on a daily basis? Mm-hmm. Or is there a corollary of what I see that isn't being found in the study? And so there are a lot of studies out there. So it's a very glamorous and elaborate study, but it's of no value to me. Mm-hmm. And I think we're really bad at doing that. Well, I think it's – I know that with – like I dig into just very – I guess I'd say fundamental research. It's kind of like bathroom readers to me, you know.

Oh, yeah. And it's funny when you go through stuff, you – like I remember seeing – I don't remember what the exact thing was, but I use certain things in the office that tend to work. I don't know why they work, but they tend to work. And then I see a paper saying that it doesn't work, and it kind of makes me angry. And it makes me feel – makes me feel like I – it just confuses me, quite honestly. You know, and it's – I bet there's a lot of clinicians like that where at some point it's kind of like you shut your brain off to what the science says because, you know, clinically it's working for you.

You know, or for the patient, rather, you know. Yes. I think – I think a lot of people who do these studies probably wouldn't dispute that you observe improvement. Yeah. I think what – what the – the main thing is how does it happen and what are the mechanisms? Is it placebo? Is it a patient's expectation? Are they now more confident? Therefore, they're moving better. Maybe their confidence has helped their pain. Was it a relationship with the clinician that motivated them, helped them be motivated? Or was it really a mechanical effect or was it a musky – an anatomical type mechanism as well or a physiology mechanism?

I think the key is finding the mechanisms, personally. And my advice to clinicians, and I've been a clinician for way more than 30 years, is if something works and it's safe and it's within your – it's kosher, acceptable within your healthcare system, then don't stop using it. The science is not – has not caught up with the clinic and clinic is much more complex than the scientific study. And I've said to patients, look, remember, your problem is more complicated than Einstein's theory of relativity. And that puts it in perspective. Mm-hmm. Good. I feel better now. Look, if it works, we may not be able to explain why sometimes.

But I think also we've got to put it in an ethical framework where if it works once, it doesn't mean, say, we do it a thousand times over the next five years for that patient. Yeah, you know, we still have to move them into an independence – a strategy that fosters independence. Yeah. And so we've got to put that into perspective as well. And so – and probably this is a good tangent point to what I was – like, the one thing I text you about is the – it's funny. I've had a couple patients, like, with this recently, and I was talking to Philip about it as well. It's like, have you ever noticed that, like, someone comes in with a certain type of – you know, you see a radiating lumbar symptom patterns.

And so one of the things in his fixed drone back, which is we kind of start off in a prone, prone, prone McKinsey extension. And a lot of times it reduces their symptoms, right? And sometimes it doesn't. And you follow that progression, and sometimes it works with the sideline openers, and sometimes the McKinsey's work better. And so I asked him, like, how do you pick? And he's like, I just figure out which one works best for the patient. I'm like, I kind of do two, but I wish I – I kind of – it's like a – it's a coin flip sometimes for me. Yes. And that is real clinical life. You get to Friday afternoon, you're in the last patient.

You've got to get out. You've got to get out on time because you've got family to meet. A patient won't stop talking. And I mean no disrespect to patients. This is a real clinical life. You've got, gee, I've got to do something. I'm not quite sure, but I've just got to try something that usually – and I'll do something that's quick and efficient, usually works and is safe. And we often don't understand why. But in the end, if it works and it's safe and it's within your healthcare system to provide that, I don't see a problem. But as long as it's couched in relation to fostering independence. So, yeah, I'm not deterred by science not catching up with the clinic.

Okay. But at the same time, we use science to justify clinical activities, which is also a two-way street, which we should do. So I don't see things competing. I think we do see, particularly on social media these days, a lot of disputes and philosophical differences. But I see a lot of them as not being mutually exclusive. And for some reason, people do. I don't understand that personally. Well, I would imagine if they – it's kind of like – it's like their favorite sports team. You know, you just like – you don't want to see them lose, although it's still a good game either way, you know. Yes, it's your favorite reference or your viewpoint.

Yeah, exactly. Well, just going on the McKenzie approach, for instance, you could do an extension procedure for someone's radiating pain down their leg. But you could also do a flexion procedure. Now, there are some people I feel that they need opening of the foramen because they're primarily ridiculous and they need pressure off their nerve root. And if you do evaluation on those people carefully, you extend them and their neurological status gets worse. I've seen it happen. So, those people do not respond to closing. And so, we're teasing out a subgroup, so to speak. But there's another group on the other end that don't respond to opening.

In fact, they get better with closing. And they are mutually exclusive. Do the wrong thing and they do not get better. In fact, you probably provoke them. But unfortunately, there's a big group in the middle, which is probably the largest of the three groups, the two ends plus the middle, that actually get better with both. And we get confused by those people. Now, but I think one of the ways of resolving it is that you have common mechanisms that do respond to both. And it's been now shown in the median nerve at the wrist, where if you have carpal tunnel syndrome, there's edema in the nerve, you immobilize the nerve, and the edema improves.

But by the same token, if you give patients with edematous nerves with carpal tunnel syndrome a splint for the night, and the edema reduces or can reduce. So, edema may come from different mechanisms. One might be compression congestion on venous blood vessels, so you get, as I said, congestive mechanism. The other one could be mechanical irritation and inflammation where you get edema. So, you could treat it from two different angles and get a similar response. It does not mean they're mutually exclusive. There's a few people on either end that might be mutually exclusive. So, usually I'll ask for the listeners, but I'm going to ask myself then, so in that carpal tunnel patient, how do you decide which is the best route to take on that?

Probably by clinical features. And in the end, we can't always make, we can't get a clinical feature and say, you have edema in your nerve. So, that's an anatomical thing, it's morphological, and they need radiology to know that. So, what we can say is the evidence that we know, the research that we know, prolifically shows edema in nerves with carpal tunnel syndrome. So, we're going to do something that fits your clinical pattern, which is you have mechanical or movement-related pain. We're going to help your movement of that nerve, desensitize it, hopefully. These are mechanisms, hypotheses.

And then, if you get better, the hypothesis, the working mechanisms, hypothesis, is that maybe the edema in your nerve has got better. But how you couch that in terms for your patient, you've got to be careful with, of course, because you don't want to make them focus too much on pathology and disease. So, you want to make them focus on what's positive. But to say, commonly, edema is shown to occur in nerve, and commonly, movement has been shown to help edema, and therefore, this is what I'm offering you. Let's see how it affects you. Let's do a reassessment a minute after you've done the treatment.

Has it helped or not? And if it does, then you would proceed and continue. So, I kind of mix them up, but match them as well, and try and link clinical features, particularly patient, subjective, and movement features. Okay. With mechanisms, hypotheses. So, when, also, too, since you're sending them home, because I had this experience the other day with, someone came in with a hot neck type of thing. You know, closing dysfunction, just couldn't get that way, and talgic and everything. So, I had heard about a clinician who actually tends to prove to the patient that the other direction is worse, so that they can get them to go home to do the position that's better.

Oh, okay. That's a good idea. And so, they'll, so they'll, but they'll, in, in, what I hear is they kind of light them up a little bit in order. Oh, I see. Oh, yes. And now I get, I know I know where you're going. So. Yeah. So, hmm. Well, so my question is then, because with, I prefer not to light them up unless I have to. Um, and with, with this guy in particular, um, I, I, I wanted him to do, just do a certain thing is all. And, um, I find that with some people, they, I have to really explain the reason why I'm asking them to go into a position that's comfortable, because comfortable, although it reduces pain, it's not, they're like, they're fixated on the idea that they can't do the other thing.

And so, when you send them home with homework, what kind of communication do you have with them about that? Yeah, look, I have a detailed, detailed information. But at the same time, if you've got a, what we call a level one patient on the courses, which is hot, as you say, easily lit up, um, then that, remember, they're, they're often distressed. They're distracted by their pain. They find it much more difficult to remember instructions, um, and, and, and move appropriately. So, I will show them how to do a pain relieving technique in the clinic themselves, and it will show them that it relieves their pain, uh, and then teach them how to do this at home.

But I don't release them into the wild until they can do it properly, do it accurately. And I say, look, it's just a bit early. I want you to, I'll do this now. I want to, I'll ring you up this afternoon or this evening or tomorrow, whatever. I want to, we'll talk about how, how the response was, um, or you can call whatever, and then you'll see in a day or two's time or whatever it is. My procedure is to try and see them early and quickly in quick succession for a short time and spread it quickly into independent strategies. So, that's how I would approach it. But you've got to, I think we have to be aware that patient, people who are in a lot of pain find it more difficult to learn than people who are not in pain.

Mm-hmm. And so, we've got to, we've got to help them with that. Hey guys, real quick break from myself to sponsor the show. Um, obviously this, this show is a free show. I don't make any money off it, so I've got to use it a little bit for this section. So, please work with me on these things. Um, actually, I shouldn't apologize for that. Um, I believe in what this message is going to be today. And if you've been listening to the other shows, you're going to know that I'm going to talk about a couple workshops I'm putting on this year. So, the workshops I put on last year were very successful.

Everybody had a great time, or at least I did. Uh, we had steaks, we had beer, we hung out at the garage and just, like, I remember one girl from my class, she's like, dude, this is so chill. Like, we should do this every year just because it's fun. And I don't know when workshops stop being really fun and informative, but this one is cheap, is informative, and fun. So, please come to those. There's a student one, which is May 30th, and there's a doctor one, which does have CEUs available, 12 hours for California, for the 25th and 26th of April. So, I call this workshop putting it all together because, uh, as I've learned with some of my interns and even some docs that, um, I've spoken to about these topics, is like, well, corrective exercise is cool, but how do you use it, you know?

How would I use it with this case? Well, soft tissue work is cool, but how do I use it with this case? And so, every technique has its thing that it's useful for, um, in certain situations. So, I'm going to show you how I evaluate patients as well as how I integrate some of these tools into play. So, we're going to have a good time. There's no pressure. It's, it's just limited spots. It's going to be 20 people at my gym, uh, in Huntington Beach, California. Love to see you guys there. It's a good place to vacation. So, um, but now back into the show. Oh, I guess I should tell you how to reach out to me.

So, that is Instagram. That is performancehb or email me, seb at p2sportscare.com. Do you, do you find that then, because, because I've never really taken that first, uh, approach that I mentioned. Do you find, but I, I guess I equate it to when you're training a dog, do you train him with treats or a whip? Um, do you. Positive or negative reinforcement. Yeah. So, have you, have you had experiences with, it sounds like you go towards the, the, probably the positive. Um, look, I, that's my first shot, really positive. But unfortunately, we're in a, we're in a world at the moment where political, political correctness and sensitivity to people's feelings prevail.

Um, and you, we're, we're not exactly in a, we, we, we're not, well, we could do Dr. Phil and we'd say, no, you have it wrong. Don't do that movement. That's bad for your pain. Um, now some people would say, well, that's catastrophizing, it's giving people negative thoughts, it's blah, blah, blah. But, but we're also allowed to tell the truth. If someone's closing maneuver provokes their nerve root and makes their neurological status worse, we are allowed to tell them the truth. We're allowed to say, look, if you do that, your nerve is compressing more, getting compressed more, and it's going to provoke you.

So this is something that takes pressure off your nerve, albeit transiently, but we're hoping there are carryover effects that build over time. So I'm, I'm still not averse to saying to someone, you have got it wrong. Do not do that. It is not good for your back. It's my professional decision, and you've come to me for, for, for my advice. But I, I, truthfully, I do that quite rarely, because most people are quite happy to listen, and, and the positive reinforcement for them is that they get pain relief when they do the right thing. Yeah. But, but there's this spectrum, of course. Okay. Yeah, I was just curious.

I, I don't have a lot of them there. Uh, well, actually, even that guy was, he was not, um, he was, uh, distracted by it, for sure. Um, but there, there's only been, there's only been a few people, and it's usually people that I, I have a good relationship with, and they'll come in, and it's kind of like a joke, and like, ha, ha, ha, this, this, this shoulder thing, it's still, when's it going to go away? I'm like, dude, we've talked about this. If you're not doing what I've asked, it's not going to get better, you know? And, um, but it's usually someone that I can be a little bit more direct with, you know, versus someone who's.

Yes. You have to choose your patients carefully. Yeah. I don't want to beat them when they're down either. No, no, exactly. You know, I've, I've watched some, you know, really experienced clinicians. You know, one of the most experienced ones that I ever saw was Jeff Maitland, and, and, um, he would palpate someone's neck and, and push on joints. And a lot of patients go, yes, no, yes, no, as you palpate, well, some patients, they think you want an indication of whether they're hurting when you're pushing. And not all, not a lot, but a few. And this patient was a garrulous one who wouldn't stop talking, and Jeff would push, he'd say, oh, yes, that hurts.

No, that doesn't, Mr. Maitland. Yes, that does. And he finally stops, he says, would you be quiet? And he said, and the guy looked up and said, what? You don't want me to tell you that it hurts? He said, no. Oh, I'm trying to, he said, you're distracting me. I'm trying to feel what I feel with my hands. And in a minute, I'll ask you whether it hurts or not. He said, oh, okay. So sometimes a direct approach is okay, but you've got to be polite and, you know, tactful about it. Yeah. Good. So let me go backwards a little bit in the conversation there, because I think that, I know you covered this in level one of your course, but we mentioned opening and closing dysfunctions in correlation to McKinsey extension and flexion protocols.

And so how does a clinician, actually, what are the closing, opening and closing first, I guess? This is, now we're getting really more into the basic part. Look, one of the, I think one of the most important statements I could make about clinical neurodynamics is it is not neural mobilization plus the neurosciences. It is not flossing and is not tensioning. But it is, well, it is, but it's much more than that. It's diagnostic categories based on specific functional problems that integrate with musculoskeletal function. So if you get to the patient and you're not sure what to do, flossing is fantastic, but it is relatively nonspecific.

So what I try and do in the patients is come to a specific functional diagnosis. And so we talk about opening and closing. Now, some people, when they flex their spine, they get better. Their leg pain or arm pain improves. Other people, it gets worse when they flex. They're two different functional problems because they are caused by different mechanisms. So we've got to treat them differently. And so a closing problem is provoked with extension and insulateral lateral flexion movements. It's eased with opening movements, soft flexion and contralateral lateral flexion movements. And it's heavily based on canal and dynamic function, canal and interverteal frame and dynamics.

But an opening dysfunction, if it's provoked with flexion and contralateral lateral flexion, is a problem of stretch. And so the closing of the problem is a problem of compression, but the opening is a problem of stretch. They're functionally different and we treat them differently. And so when it comes to choosing what's best for this patient, then I know we're going to go round and round circles a couple of times with this. I apologize. Yeah, sure. No, it's fine. This is how we engage. It's good. So when it comes to choosing the correct thing for a patient, how would one know what's the right one?

Physical, well, partly the subject of, for me, the subject of helps us develop hypotheses about what might be the case. So I would say to a patient, look, okay, what provokes your leg pain? If they say when I walk, I'll say, okay, what part of the walking bothers you? It's when my heel hits the ground. Ah, so my hypothesis would be a compression mechanism and, or even a straight leg raise type mechanism. So the physical examination would, and I know what's actually said to the patient, is it just before you hit the ground or is it as you hit the ground? So if it's just before, that could be a straight leg raise mechanism.

Whereas if it's a compressive mechanism, it's going to be on heel strike. And so I will then test that physically. Is it the straight leg raise that bothers them or is it compression? And I'll do some closing techniques. And so I'll figure out which is, is it compressive or is it a stretch mechanism or a tension mechanism? And then we treat it differently based on the mechanisms. Where throughout gait do you think an opening mechanism would be a problem? They're much less common in the gait pattern. They're much more flexing forward as you're standing or something like that. It would have to be in someone who's got quite a, who's using their leg raise prolifically.

It might be a runner, a hurdler or someone, a performing artist or something like that. He's got to raise their leg a long way. Typically, they're in range sort of stuff with repeated use. Mind you, we had some, I was just consulting with a patient recently who had a complete rupture of her hamstrings of thoracic tuberosity and a severe injury. But at the same time, because it ruptured, the hamstrings did not stop the leg raise coming up. So they rupt, they damaged this, the sciatic nerve as well. They actually got a stretch injury to the sciatic nerve. And now that we're dealing with neuropathic pain.

So that's a, that's an example of the difference. Okay. Just a couple of stories for you. Actually, it's funny. You just, you dem it or you just described a patient I had this week. It was a heel pain while running at, at not just heel strike, but as the leg goes out, it was duplicated with stretching her calf on a stairwell. Positive straight leg test decreased with openers and further reduced with the consulateral sliders. Just no symptoms whatsoever anymore. So that was a fun one. Great. You know, one of the things that is really important with neurodynamics is that we, we've gone from flossing and tensioning to a whole system of the progressives from first aid to rehab to performance, which we do in MSK, but we typically don't do that in neurodynamics.

So the new development is how to offload the nerve. And what you've described me is offloading techniques. So I don't think I'm going to ask you this. How long do you have people do like their first aid, their openers, their sliders? Typically, if it's an opener technique for an acute sciatica, it would be one minute openers with the lumbar spine position in the open position. And then that's repeated, that's performed about up to 10 times depending on how they respond. And for the contralateral stuff, we'd hold them for about 15 seconds because we apply tension to the nerves on one side to bring the cord down and reduce tension on the nerves on the ipsid lateral side.

And the contralateral limb is held in a neurodynamic position. So we don't do that for more than about 15, 30 seconds. Well, so how many days roughly does it typically take, like for the duration to kind of complete, like you're done with that first aid type of process? Oh, five to 10. Okay. Typically. I mean, horses for courses, as we say, meaning choose the right horse for the right race course. Meaning you have to tailor make it for each patient, how they move and what doses they have. But that's difficult. That's common. Okay. The, and we were talking about this the last time I saw you and I don't know how deep you want to get into this or if you want to talk about it at all.

But exercise progression after they get beyond those, you'd mentioned some things that you were kind of dabbling into and were interested in. Exercise, oh yes. Well, one of my, the areas of development at the moment we're doing is progressing neurodynamic activities into movement control and performance of muscle function. And so if you have someone who has a hamstring injury, they typically lose the ability to contract the hamstrings optimally, of course. But what we sometimes find is you put them in the slump position and you do a knee, active knee extension and then active reversal into flexion really quickly, which is what the hamstrings do.

Starts off as eccentric, then contraction, put them in the slump position, they're a whole lot worse. They're slower, they're weaker and they're more, sometimes it's more painful. So the idea is that pain might be inhibiting the hamstring function, but it's in the neurodynamic position. So they may have a neurodynamic aspect to their pain inhibition and loss of muscle function. Do, so open chain, have you thought about closed chain in that? On the contralateral, yes. Now closed chain, I hadn't thought so much about, but it's an important area for development. So typically what we do in a high-end rehab for hamstring and sciatic nerve is get them standing on one leg, the contralateral leg.

They stand there and they put their spine into the slump position, so they're balancing in the slump position on the contralateral leg. And they flex their ipsilateral hip up to 90 degrees, so it's horizontal. And then their knee's at 90, so their thigh's not, their femur's at horizontal and their knee's down toward the ground, so it's not touching the ground, of course. And they flip their leg up into the knee-extended position and straight back down again. And they're stabilizing proximally with the contralateral limb, and they're doing neurodynamic ballistic exercises as they do an eccentric and concentric hamstring reversal.

So it's not really, that particular exercise is not really closed kinetic chain, but it's heading in that direction. But you would do closed kinetic chain work in neurodynamic position. This is like a new, this is like a newer part for you, right, like that you were thinking about? Oh, look, I've been dealing with this for a good 10 years. But it takes me, I don't know about other people, but I'm a slow learner, and I don't release a lot of stuff until I give it a pretty careful thought and used it a bit. And that's something I've been doing for about 10 years now. That's why you haven't released your recipes for the best Brussels sprouts?

That's right. Brussels, yeah, grilled Brussels sprouts and pork belly or bacon or whatever it was we had to use. That's right. That was nice. Yeah. Another thing, too, on just a couple of things I've been playing with at the office here that I always tell the patient, I have no idea if this is going to work or not. Let's just see. And so there was a couple people recently that had, one girl actually had a, she had a hamstring tear, a visible bruise that was there prior, three weeks prior. And so we did just a resisted hamstring test just to see if it was able to have a load. And so it lit her up a little bit, or at least it was like a yellow flag.

It was like, hey, you know, something's going on there. And so we did some sliders, and those symptoms then went away. Another person that we had just the other day is that he kind of had some issues into the, like the medial aspect of the knee, kind of like, I guess it would be maybe the infrapatellar nerve area. So your high lumbar contribution. And so I remember that case that we had over at level two that had the positive, what was the face down, knockless test? Face down, bent knee, the hips rise. It was a prone test. Oh, yes, that's right. Yeah, I don't know what you call it, but it's… It was like a mid-lumbar test.

Yes, that's right. Only for mid-lumbar pain, yes. You've been on the course. That was the course, yeah, the second course. Yes, that's right. That's right. We had someone with midline, it was midline mid-lumbar pain as well, yes. Basically, prone knee bend is similar to the straight leg raise in the respect that it produces pelvis movement through the rectus femoris mechanism on the ASIS. So they get anti-rotational pelvis, therefore lumbar extension during the prone knee bend. So the prone knee bend itself is not specifically a neurodermic test, although it does produce nerve movement. Got it.

So then we repeat the test, but stabilize the pelvis. So we're reducing MSK during the neurodermic test. If the pain decreases between the first and second steps, then it's musculoskeletal. If it doesn't decrease or it increases, you've reduced musculoskeletal, so it's not that. So it's neurodermic. I got to go through that one and get on that patient, but we did proceed a little bit further with prone-resisted hamstring stuff, and his hamstring cramped quickly. Oh, okay. And so we did an opener, a couple minutes, and we tried it again, five solid reps. I mean, he's a big, strong guy anyways. I mean, his leg was about the size of my head kind of guy.

And so he shouldn't have a loss of ability to do that. And so five, six, really hard. I ripped as hard as I wanted to on him, and he didn't cramp up or anything. Good. But it was interesting that even those types of symptoms would reduce with some type of opener, at least for me. I don't know the exact mechanism or why it worked, but it seemed like it worked. Any thoughts on that one? Well, it would make you suspicious. If the response is specific to improving his problem, it might be suspicious he had a nerve. When you say openers, you mean for the foramen, lumbar foramen? That was, sorry, that was, yeah, it was foramen openers.

We used to general lumbar openers. It makes you suspicious that he had some spinal element to a nerve rate mechanism that might have been activating his hamstrings. In both those cases, it was interesting that the hamstrings would, the response would change that quickly, just with sliders in the first case, and then general foramen openers in the second. Yeah, yeah. We looked at this in a simulated MILS manipulation with neurodynamic testing. We did EMG tests on pit major, lower traps, upper traps, biceps, brachylar radius, and so forth, and found that if you put the arm in 90 degrees abduction, the straight arm in a MILS manipulation position, so you've got wrist flexion, coronation, finger flexion, and you apply a strong stretch to elbow extension, which is the menstrual manipulation.

Just hold it there and measure EMG activity, get a certain profile of muscle contractions up right through to the neck. But when you do ipsilateral lateral flexion, taking the tension off the nerves into the elbow, everything decreases except the elbow stuff. Sorry, bigger pardon, most of it stayed the same except the elbow muscles, brachioradialis, and biceps decrease their contractions, their activity with the ipsilateral lateral flexion. So the idea is that changing nerve changes muscle protective mechanisms for MSK. Yeah, that makes sense. I mean, it's funny, all this, there was, did you ever follow the whole lifespan of, I guess it's still going, there's a mobility crave, like it's just a craze of getting more mobility.

It started probably about five years ago or so. Did you ever follow that on social media? No, no, I didn't. I'm sorry. It was kind of like, I guess it was, I think it started with Kelly Starrett's mobility wad and it kind of went rampant through like the CrossFit community and just everyone's just doing mobility this, mobility that. It didn't matter what mobility it was on, it was just more mobility. They wanted more mobility. Yeah, well, these fads happen, don't they? And so, I mean, I think there was some usefulness to it, but I think it's funny, there was, at least from what I saw, there was no nerve-based aspect to it.

Rolling, mash work, prize, kind of forced, more forced movements. But I thought, like, this is something probably where some of the listeners, if they've been through that craze, they have not thought about the nerve aspect to the protective mechanism of the musculature. Yeah, that's a good point. Well, firstly, I think the amount of movement we have is an important aspect of how we move. If we don't have enough movement, then we're never going to move enough. So, mobility is important, but when you get to end range stuff, particularly straight they're grazed, like slumping or hamstring stretches, stretching your arm right out with your neck pulled across to the other side, these are all risk factors for producing neuropraxias or even damaging nerves and producing neuropathic pain.

And so, we've got one-on-one consideration we have, be careful with the nerve. On the other hand, we have the idea that nerves need to move like MSK tissues. And so, the idea is to get that fine balance. And so, you can, during a muscle stretch, for instance, add a bit of nerve or take out a bit of nerve, depending on what you want to do. Or you can do mostly nerve and you don't put too much on the muscle, because we can actually do things a little more specifically than we thought. So, we can emphasize nerve or both or one or the other. Do you happen to think if, at some point is, I'm going to guess I know your answer, but I'll ask you anyways.

Is there a point where there's too much mobility in a certain area? Is more mobility always good? Certainly not for the nervous system, no. Ehlers-Danlos syndrome is a good example where you get MSK instability or too much movement. And these people get long-term pain issues, of course. But in those people, I've seen a few, they tend to have normal neurodynamic test responses to their end range, but they have a ton of movement. And so, I wouldn't be stretching or mobilizing someone's nerve to improve their flexibility of nerve for Ehlers-Danlos-type patients. I might be flossing them to ease nerve pain if they get provoked with certain activities.

So, maybe that's a different profile, but I'd be more interested in giving them nerve relief techniques rather than nerve strip end range stuff. This might be a whole different thought of it. So, people who are hypermobile and it's possibly creating an issue in a certain area, can you do the opposite for a nerve to make it so there's more tension or less range and so it produces a better muscle-guarding effect? Oh, I see. Don't move it. That'll tighten it up. So, you just brace them? Well, I mean, the idea, it's not really being tested as far as I know, but we know that nerves are viscoelastic.

And there's a ton of clinical observations that show that if someone moves a nerve, the neurodynamic test can get better and better. There might be a limit or how quickly you can achieve that, and we see it clinically. And there's a study recently that's not yet been published, but I'm aware of, where they did some shear wave elastography on a nerve in healthy subjects. And they gave end range stretch techniques and it got softer. And so, the shear wave elastography is a way of measuring soft tissue stiffness indirectly through ultrasound. And so, they actually showed that the nerve got softer and more pliable with a nerve stretch technique.

Trouble is, it was not a safe nerve stretch technique. Oh, was this the, there's ripped on them kind of thing? I can't talk too much about it because it's not published, but they basically put people very in range position for a longer time than I've ever done in my life. And it was not, if you do that even on healthy subjects, someone's going to get hurt. So, they were basically creating like a neuropraxia kind of effect. Well, they didn't do, yeah. Well, they didn't, they didn't create, that we know of, they didn't create a problem in these people. But, from the experience I've had in the early studies, when we were studying neurodentic tests, normal responses, is that if you put someone at the end range position too far or for too long, you can give them a neuropraxia.

And so, we've got to be really careful. And someone who has a tight nerve, I'd be pretty circumspect about how you treat them. Okay. And I know there's people who don't believe you get tight nerves, but in a case a while ago where a patient had hamstring problems, they ended up having surgery because they had a tendinopathy and they needed surgery for it or something at the hamstring insertion. And radiology showed scarring around the sciatic nerve at that level of near disc tuberosity. And the surgeon debrided it all. And interestingly, intraoperatively, they did the straight leg raise and did nerve mobilizations and watched the nerve move at disc tuberosity.

Closed them all up and so forth and told the patient afterwards, look, sorry, but you've just got a tight sciatic nerve. And it's not, unless you, you know, you're going to stretch this regularly, it's just going to stay tight. So, you know, I think some people, not been studied yet, but some people have tight nerves and it's not always safe to stretch them. Why didn't you show, I think you showed a pamphlet back in the, was it back 1800s or something like that, where they were doing, they would just line you up in an alleyway back in, you know, old England and just do a bunch of aggressive nerve stretching.

I've spoken about Simonton and Marshall's work in the 1880s where they did anatomical presentations to their colleagues in the theater situation that they used to do in those days. And they would hang heavy weights off sciatic nerves out of a fresh cadaver. And they'd get 50 pound on them without a problem, without breaking them. But still, we don't know what force we're applying to nerves yet. It's quite studyable. It could be done, but it's not yet been done. Just curious, I'm going to tangent to something here. I'm going to screen share with you. This was, by the way, with any of this stuff, we can cut out stuff if you don't feel comfortable talking about some of these.

So, this is a thread that was going on. So, they had a patient that was looking like this. And you see the picture that I'm showing you? Yes, yes, I do. I know what I thought on this. Is this kind of a – what do you think of this? Is this a – I guess I'll – Yeah, look, I'd palpate it personally. And that goes over the clavicle. So, it's not the scapular nerve. Actually, let me describe it real quick to the viewers. There is a forward-thinking chiropractic alliance. There's a Facebook thread. And so, there's a picture of someone with a – how would you describe that? Tenting? I'd almost call it tenting or cording.

Cording over the – I'm forgetting the triangular space. Is that where the necklace goes? Yes, that's right. So, you can actually – if you follow it right up, it's coming off the side of the neck, of course. I actually – I've seen bits and pieces like that. And I reckon it's partly platysma fascia. And it could even be integrated with the supraclavicular nerves because that does go over the clavicle. So, I'd palpate it in detail. And you can actually palpate the supraclavicular nerve or nerves quite easily. And you can tell if it's nerve or not. I'd palpate it in and out of tension to see if it behaves like skin fascia or platysma.

There you go with the palpation stuff again there. Yeah, I'm a – yeah, I know. Interestingly, I got someone – like, I made a post on social media about nerve palpation. And someone said, yeah, but what about all the other 200 times that you didn't get it right? And I said, are you saying that nerve palpation is not reliable or something? Yeah, no, palpation is not reliable. I've said, well, have you read the literature? And the room went quiet because there are studies that show really good reliability in responses with nerve palpation. And so, I'm still a fan of palpation in certain situations.

Good. Yeah, thanks for commenting on that. I was looking at it and I'm like, hmm, I don't know what Michael would say about this. And we just happened to be talking today. Yeah, yeah. I think there's a bit of platysma in that, the muscle. But you could take the tension off the muscle and see if the nerve passes immediately under that area, over the supraclavicular area. And you might find it's a supraclavicular nerve. So, as we start to finish up on this, we're about 40, 45 minutes in. Is there anything that you want to talk about today? I'd like to highlight the importance of neurodynamics being not just nerve flossing and nerve tensioning.

A lot of people will say, oh, yeah, I learned that at undergrad. I did two hours on it. I did my day or four hours, whatever it was. And that's it. Well, no. It's a lot more than that. It's gone right into a diagnosis and treatment system that integrates heavily with the muscle and skeletal system. Because that's the way problems really happen. Now, nerve mobilisation is now starting to show good effects from therapeutic efficacy studies. There's now a systematic review that shows in certain kind of conditions it's useful. But to me, that's only part of the story. And if we have to go right back to the basics and fundamentals in those studies, it's difficult to tease out whether it's a neuromobilisation effect or just a movement effect generally of a limb or body.

And so my feeling is we've got to go much further into how it relates to musculoskeletal, functional diagnostic categories, and treatments for those particular categories. And so if we think of a neurodynamic system as having the four main parts, inclusion, exclusion criteria, functional diagnoses, progressions, exit strategy. We have a system which has those four things. It's a great system. And we have those for neurodynamics. Yeah, I think it's important, especially having like the – so when you say exit system, like I feel like there's a lot of systems that you're just in it forever. You know, there's never really a thought.

Yeah, you've got to have – yeah, I think it's an ethical consideration. You've got to have an exit strategy. I know that if you're in a tech company trying to scale your business, you don't want an exit strategy. You want to keep them in forever. But we're in a different situation. I like to give my patients an exit strategy, which is, you know, are you good enough to finish? Can you maintain this yourself? Can you treat it yourself? So here's some things you can do. And if you need a bit of maintenance occasionally, well, so be it, as long as it's within your healthcare system that provides for that.

Some do, some don't. But I think it's important to offer the patient an exit strategy, as long as it's commensurate with their clinical problem. So when you say that it was interesting you picked that to actually – to talk about it as the thing that – to close everything up here, because you must have seen stuff. You must see things that make you think that people are being too general with all this. Yeah, absolutely. The people who have had neural mobilisation, it's failed. But then when you look at all the mechanisms, the nerve isn't actually the cause of the problem. It's MSK. Now, one of the approaches, and it's really common and quite legitimate, if the MSK is causing the neural problem, fix the MSK, and the neural problem will go away.

But unfortunately, that doesn't always happen. So then they, oh, next step, mobilise the nerve. Oh, that hasn't fixed it either. But what's often not considered is the interaction between the two, and that's what we work on. It's like one-on-one make three. And unless you work on the third, it may not necessarily solve the problem. Interesting. Ken, just because, just to make sure that we're speaking a little bit more than generalities, explain that with a hamstring patient. Okay. There are different types of hamstring injury, of course. We would, let's just say, they've had a mid-belly muscle rupture, a grade one or two.

Say one, so it's not too bad. And they get to a good level of function, and they're an athlete, and no longer are they improving. They really push it. It just hurts. It's intrusive enough to diminish their performance, and they need help. And so what we can do is figure out if there's a neurodynamic aspect to that problem by doing high-end or advanced neurodynamic testing with that patient. So we would test their hamstrings. Hmm, not too bad. Test their standard slump test. Hmm, not too bad. But when you put them together, you put them in a long-sitting position, or you put them in a slump position, and you get them to resist or actively contract their hamstrings while they're in a slump position.

That often reproduces their pain and can change with dorsiflexion or neck movements. Mm-hmm. And so they could have a neurodynamic aspect to their muscle problem, and that can be treated specifically. Hmm. I'm glad that we gave the hamstring example because that really goes full circle with the examples we gave in the beginning part of the podcast. So that was good. Perfect. Good. Thank you very much. Yeah. What – how can everyone reach you? Okay. And all your threads and handles and everything. Okay. The most direct way of getting a hold of me is by going to neurodynamicsolutions.com and hitting the contact tab and just type an email and we'll get it and respond.

But we're also available on Facebook, Neurodynamic Solutions, Twitter, Neurodynamics, Instagram, Neurodynamics, and I guess we'll branch out into Snapchat and the dark web sometime, but we haven't done that yet. Yeah, so we're available on all the social media. You can Google Michael Shacklock or Neurodynamic Solutions or those handles on the social media. And what type of information should they expect when they go through these? You mean if they contact us or see our posts? See the posts. I want to tease them. I want them to be like, dude, I want that. Yeah, okay. Well, what we – particularly on Instagram and Facebook, we post things on techniques, clinical problems, events, and stuff like that.

So I think the two main ones would be Facebook and Instagram. I think Twitter is good for conversations, but for me, conversations rarely change people's opinion on Twitter. And so I'm not as active on Twitter, but we do put the same posts on Twitter that we put on other social media. So you can find us there too. Okay. Sounds good. If you were to create your own gravestone, what would you put on it? Oh, that's a good one. Wow. Well, I don't have to – I don't think I'm ever going to die, and if I do, I'm going to be really upset. What would I put on my gravestone? I've never even asked that question before.

Yeah, I find that a very difficult answer. That's a hard one? Yeah. I don't know. You said something earlier that worked for the – you've got to use your product to make your product. What, your brother's the engineer? Oh, that's right. My brother and father are and we're engineers, and one of the common complaints they would have – and I have a similar complaint. When you buy an object, it doesn't quite work properly, something – they say, well, the designer clearly didn't use what they designed. And so I guess you could say use what you designed. But I think my motive in neurodynamics and education and research and development is to provide benefit to others.

That, to me, if you can make a contribution, then that's made your life worthwhile in that aspect anyway. So I would say, you know, in the end, it's about helping people. If you did his best to help the community or whatever it is, helping and contributing, to me, is the motivator. And so I would want to say something like that on my gravestone if I were to choose something that related to my professional activities. Okay. Well, I bet, too, you wouldn't actually get a gravestone. You'd probably get a park bench because you'd be helping them still be on the grave. Any homeless people, please sit here.

We'll give you some food and some soup or something like that. Help them out. Yeah. I think I'd rather be a drinking fountain then. All right. Well, thanks so much for being on. Just pause and I'll come back in a second. Okay. Michael, thanks for being on. I do apologize, everyone. Again, just to reiterate, ProCiro, where we might have referenced where you can get some of this information, is actually no longer with us. So if you're looking to learn anything from Michael Shacklock, I always think a great start is actually to buy his book, Clinical Neurodynamics. You can get it on Amazon. I've read it quite a few times.

And every intern that I have come in to work with me here, I suggest that they get it. It's a good starting point, especially his workshops are, they're four days. There are a couple that are two days, but it's more lower quarter, upper quarter. Well worth the money. And I'd strongly, I could stand by this statement and say that by going to his course, it made a lot of other courses that I've encountered kind of, not necessarily obsolete, but just less relevant. And so a lot of students out of school, they're like, well, should I take this and this and that? I say, no, no, let's just read the book.

And I think what you're going to find out is when you go to Clinical Neurodynamics, that all of a sudden your mind has been expanded for all the things that you never really thought you could do with neurological. So I would strongly suggest going to Michael's course. That is, you can look up his schedule on Clinical Neurodynamics or just Google Michael Shacklock. Great presenter, makes it really fun. It's a long four days, but at the same time, it is amazing. So thank you, Michael, for being on. And everybody, I will see you next time. Thanks for being part of the movement.