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Brian Lau and Matt Callison

Telemedicine Guide: A Low Back Case Study Matt Callison & Brian Lau

Hello and thanks for joining us today. This is the first of a series of webinars that we’re going to be doing discussing issues, topics, and featuring guests in sports and orthopedic acupuncture.

I’m here with my colleague, Matt Callison. Many of you probably know Matt. Matt’s been around for a long time. He’s sort of a fixture, especially in the sports acupuncture community. Many of you probably know him from various articles and books that he’s written. Matt is the President of AcuSport Education. He’s also the President of Sports Medicine Acupuncture Certification. He’s recently published his lifelong, really, work, it’s been over multiple decades of work, the Sports Medicine Acupuncture: An Integrated Approach Combining Sports Medicine and Traditional Chinese Medicine. Really a monumental amount of work, so a lot of congratulations goes to Matt. It’s going to be a game changer for the field. It’s so nice to see such important work coming out in field.

So, I’ve been working with Matt, initially as a student, when I took the program Sports Medicine Acupuncture Certification. Then I was asked to teach in 2014, quite an honor for me. Fortunately, despite the fact that the program is an incredible program, Matt gave me a lot of flexibility to also add and integrate information that I had coming from my field in structural integration, also in my work with qi gong and tai chi and tendon changing.

We worked to integrate a lot of work to build a model for the channel sinews. I’ve written quite a bit about the channel sinews. We feature a lot of that work in the Sports Medicine Acupuncture Certification.

We’ll start today. Matt’s going to set us up and discuss the case study for low back pain.

Brian, thank you very much, but the honor is mine just to be able to work with you, seriously. You are not only a brilliant academic, but you’ve got that combination of a true clinician and also an academic, so it’s great to be able to call you my friend as well.

Can we start the slides? Why don’t we actually go to the first slide here. Let’s talk about a quick, brief history of what we’re about to see here. This webinar is an abridged version of a blog article and also an accompanying video that shows highlights of our experience with developing, designing, and working through some of the logistical issues of a telemedicine consultation.

Initially, the information in this article and video that you can find on the Sports Medicine Acupuncture website, www.sportsmedicineacupuncture.com, blog article and also video in the April issue. It was initially intended to be presented as a live webinar, so this was like a trial run for us. We wanted to have a live webinar that contained the content for students and graduates of the SMAC program. It was intended to be a review of the recently completed module two, which was the low back, hip, and groin, held in New Jersey, which was right before actually New Jersey closed its door and the COVID-19 shutdown.

Our intention with this is try and be able to show practitioners how to apply some of the principles taught in SMAC and also our experience through telemedicine format, which was brand new for us. We wanted to go through the logistics of it and help practitioners to learn from what our mistakes and what was the best way of setting up patients, lighting, making sure the patient has consent forms, preparing the space for the patient. All of those categories that you see in the bullets here is in that article with explanation as well.

Now, the reason why we decided to publish this trial run was because the surge of demand for telemedicine consultations, we decided just to get it out there. When you do see the video, I really apologize because, like we said, this was a trial run. It was not intended to go public, and I just got out of bed. I don’t think I brushed my teeth. I have bed head. You can tell that this was a rough run for us. Brian, he’s always beautiful looking, so I’m not going to apologize for him at all with that.

Yeah, my hair looked about the same in this one as it did in this test.

What you’re about to see now, this next slide is going to be a video. The blog article and video contains us observing a patient with low back pain, which is something that practitioners could go ahead and do, asking her to perform static and functional assessments so that we get a working hypothesis of her injury and eventually develop a diagnosis, a virtual diagnosis, really.

Then, we can develop an acupuncture and motor point prescription for self-massage acupressure, and then prescribing corrective exercises based on her postural anomalies that we saw through the assessments.

Again, this short webinar is going to be the highlights of what you can find on the video and on the article. Should we go right into the video? Yeah, let’s do that.

Yeah.

It feels like here.

Okay.

And, that kind of feels bilateral.

That’s good.

[crosstalk 00:06:23]

That’s like a facet joint sign, okay.

When I walk, it’s more here.

Yeah.

And then it could even go straight in here. This whole line even here and it goes into this ischial tuberosity.

All right, so with that, listening to the patient, describe this. Brian do you want to go ahead and share our thought process with that?

Yeah, I mean of course she’s just said a few words, she kind of gave a pathway of where the pain is. A couple of simple things. But you should already be starting to think what could be causing the pain, where is this next pain site coming from? And we haven’t tested yet, we haven’t done anything to rule out things or we haven’t done anything to confirm ideas. But already just from the body language, how she was saying it spreads across the back, that’s a very typical sign of facet joint injury. The referral that she was showing down, maybe not lumbar disc involvement, based on just going down to the behind, but we should definitely rule it out and check for it. Thoracolumbar junction syndrome is a common injury that’s becoming more common. Based on the pathway of pain as you’ll see in the coming up slides, that could be an issue. Sacroiliac joint injury could be an issue and also soft tissue strain. So again, we have to rule these out or confirm them, but they’re just preliminary thoughts based on her explanation of the pain.

Okay, good. So the postural observations. We observed the patient in a static and also functional positions. In the static position we asked the patient to move from left and right, so we could see the lateral view, look at the posterior view, look at the anterior sides. Just trying to gain as much information as possible. From there we surmised that the patient had the following postural disparities. She has, what would look like a bilateral anterior pelvic tilt, it was greater on the right. Slight posterior tilt of the ribcage. An anterior hip shift that we’re going to be talking about a little bit more real soon here and it’s relevance to qi and blood deficiency and kidney qi deficiency.

On the posterior view we could surmise that she’s got an elevated right ilium, also known as a left pelvic tilt. We could also see a left tilt of the L4-L5 vertebrae, which really helped to confirm the elevated ilium. Additional postural imbalances to check in the second and third office visit could be looking at the head, the scapula, the knee the feet positions and also the possible contributions to overall postural and myofascial imbalances.

Because this is a telemedicine conference, it was a little challenging to look at the entire picture, but we want to be able to see as much as we possibly could and design a protocol for her so we can get her out of pain. And like we said we can look at the other aspects on the second and third visit.

Brian we’ve got a video coming up here. Let’s go ahead and show that and do you want to chat afterward?

Sure.

What I see is an anterior hip shift.

Yeah, me too.

I see a possible pelvic rotation to the right.

A little bit of the ribcage coming back, it’s not extreme, but a little bit of the kidney qi, qi and blood deficiency posture.

I agree. Should we look at her other side?

Sure. Yeah more noticeable this side is the traction.

What I see is-

So, first of all the video clip doesn’t show the whole picture, because this was our first chance to look at her from the side view. And if you caught this Matt was talking when I was talking, that was maybe he did the recording, but not just this moment. So when we did the recording, the first time lining up sometimes you don’t see things correctly and now we have the added challenge of having a video camera and maybe the angle not being set up properly. Matt mentioned it looks like there was a right rotation to the pelvis as if the pelvis is turning and looking to the right. But as we switched over to the left, if that video would have played longer you would’ve heard us say, “No it actually looks like a left rotation.” And all the other assessments we’re doing later on we confirm that left rotation. Pelvis looking to the left.

The other main thing we’re talking about is this anterior hip shift where, if you look at this images on the screen now, especially the second image. Second and third you really see it, but the second image is the most like patient you’ll be working with. The hip is shifting anterior to a line that’s dropping through gallbladder 40. This anterior hip shift can have multiple implications, but when the ribcage starts going backwards, that’s consistent with people who have signs and symptoms of kidney qi deficiency, qi and blood deficiency. Matt presented on this information at the Pacific Symposium before, we can’t go into the whole details in the time frame that we have today, but each of these postures have a strong correlation with the various zang organ pathologies that are listed underneath them.

So this patient was most like, maybe not as severe as number two, but most like the kidney qi, qi and blood deficiency posture. I think we can go to the next slide, unless you wanted to add something to that, Matt?

Yeah, something real quick. When you see postures like this, you can pretty much predict what the tongue and the pulse is going to end up being, which is really a great thing. That helps the practitioner to direct their questioning to what organs could be contributing to this type of posture. This was a lot of research, I started in 2010, I presented at 2011 symposium and also in 2019. We talk about it in a module in the SMAC program, it itself is its own webinar for sure.

We asked the patient to show us her tongue and lighting was a big issue with this. When there was poor lighting, you can’t be able to see the tongue very well, so she was able to move her device closer to a window and we were able to see… Now obviously this is a screenshot from the video, so you can’t see it very well, but when you look at the video, that’s online at the website you can clearly see a pale tongue, teeth marks qi and blood deficiency in that tongue. Also, what’s helpful, if you have a white card you could put that card right next to the tongue, it gives a little color differentiation as well. Let’s go to the next slide. Brian you want to go for that?

Yeah, so I’ll just follow up to the tongue. The rest of the video is going to be focusing on posture, focusing on orthopedic evaluation, functional tests, that kind of stuff, which in enough themselves are testing the channel sinews. But if this was a full evaluation, and the video doesn’t reflect this, because it was really set up as a webinar for a review for low back and hip injuries. As Matt said you’d be asking questions based on multiple things that we were looking at, so looking at a full picture. We’re going to go back now to look at some of the indications that we saw from where she had pain. We both didn’t think that there was lumbar disc involvement with it, but it’s good to be thorough and rule it out.

We have the patient get on the floor and do a straight leg raise. Normally in clinic you would do this to the patient, but she was able to bring her leg up, it was negative. We asked her to do a passive one, which is more like the test you would do clinically, if the practitioner was doing it and again it was negative, but it was good to rule out that there didn’t seem to be any signs of lumbar disc involvement based on straight leg raise.

And if, by chance this was going to be a positive test, the practitioner would need to guide the patient through the different steps of straight leg raise. All right so let’s go to the next one.

Okay, so we were thinking that, with this particular video that you saw and with information that’s coming, facet joint injury seemed like it was going to be more the primary pain generator. Again, we’re just on a working hypothesis right now. We asked the patient to perform lumbar extension, because the facet joints usually get aggravated with extension. Because she has a bilateral anterior pelvic tilt, she’s already going to have a jamming of those facet joints. So the picture is really starting to make sense.

There’s two common body movements when describing facet joint pain that patients will commonly do. One is you’ll see there on the left where a fist or some kind of indication there at the spine and also that body language of starting at the spine and then going out lateral. So I believe we’ve got another video that we can watch to go see more information.

Matt, before you switch that. Just to highlight, also Matt mentioned the bilateral anterior tilt, also the elevation of the right ilium that she gets into when we look at the postural assessment. But you can see it in both those views, I would start to side bend the lumbar spine to the right and also approximate those facets on the right, which is primarily where she was describing the pain.

Yeah, good, thanks Brian. Okay, ready video?

Can you go into extension please? Does that cause pain?

Yeah, a little bit.

And where’s the pain?

Right there.

Can you go into extension please-

Okay, she already did. I have it on loop. All right, so she indicated, so we’re kind of leaning more toward facet joints. So let’s use some more examinations that can aggravate the facet. Do you want to talk about stork standing Brian?

I’ll let you continue with it, because it’s kind of a similar theme to the extension.

All right, so a stork standing test. You’re going to have to describe to your patient how to perform these tests, and this particular one because it requires balance is to have them close to a wall or a chair of course would be very useful. In stork standing test you can see how she’s going into lumbar extension and also rotation. This particular image on the left is aggravated the pain. Now here, what’s really interesting, she didn’t take her fist and put it into the spine at all, she actually went lateral. Where she’s indicating there is giving us a lot of information. So let’s go to the next slide and Brian we can start chatting about that and then set the sinew channels. Or maybe we should just say it now, do you want to describe the three sinew channels there that can be-

Yeah, so in the Sports Medicine Acupuncture Certification program we talk about… First of all we have a very developed model of the channel sinews and when you look at the descriptions or you look at images and there’s a line across the body, it doesn’t give the precise anatomy, we’re working on a model to really hone in on what particular structures are in which channel.

So when she points to an area like this, you might be pointing to the iliocostalis lumborum, that would be on the urinary bladder channel, part of the continuous myofascial plane up the body, from foot to head. Maybe deeper, because she’s also at the attachment of the quadratus lumborum at the top end. The quadratus lumborum would be on a continuous myofascial plane which is part of the liver sinew channel. And there’s also a plane of tissue that’s coming up through the quadriceps and up through the abdominals and to the side and into and wrapping around to the back, which forms a seam where all the fascia come together, that’s called the lateral raphe. And that’s affected and part of the stomach sinew channel. So there’s really three potential sinew channels that this one little spot can be pointed op based on the precise location in the back.

So this helps a lot because the practitioner’s now starting to think about those three different channels and what acupressure points that we can be able to use. Xi-cleft, luo points, for example. In order to be able to move qi and blood. Brian, I just noticed that we’re kind of running behind, because we love talking about this so much, but it’s such a short webinar. So I’m going to fly through these next four, and then we’ll get you back up on that rotation, is that all right?

Okay, sure.

So here we’ve got the injury assessment. If you look at the image on the left, these are lumbar facet joint referral patterns. So this is where the actual facet joint itself, when it’s degenerative can be able to have its own referral patterns. You can see she’s indicating the areas of L3-L4, L4-L5, possibly L5-S1. Knowing these patterns, we’re really starting to go down the road of this injury coming from facet joint, having postural imbalances which lead to myofascial sinew channel imbalances.

In addition, is that her tracing going into the gluteal area and also toward the greater trochanter, it could be thoracolumbar junction syndrome. The assessment for this is for the practitioner to actually be there on site and trying to be able to provoke that thoracolumbar junction syndrome pain by doing some mobilizations of the spine. We can’t do that, obviously so we have to try to be able to see it. When we had her go into a lumbopelvic rhythm, what we noticed on the image to the right, you can see the thoracolumbar junction of T11-T12, L1-L2 kind of pops up a little bit. It actually goes into extension. When she was moving into trunk flexion, that part of her spine actually didn’t move as well, and popped up. That could be a sign of a possibility of instability in the region, causing thoracolumbar junction syndrome. We put that into our back pocket as part of the assessment.

The practitioner can also examine the sacroiliac joint with various functional exams. We weren’t thinking it was going to be SI joint, but we might as well. We ran her through a number of different examinations for the sacroiliac joint. Practitioners that are experienced with this, you know that these particular examinations can also provoke pain in other places. Your idea’s trying to provoke pain in the sacroiliac joint, and see if that’s going to be positive, but each one of these exams also caused other pain that was indicative of possibly facet joint or hip joint problem.

And actually I don’t think it did cause SI joint pain, specifically.

Yeah, none of them did. The lower image on the right is Gillet’s test, which is a video that we’re going to show you right now. This is an easy one for a practitioner to do with a patient. Let’s show you this Gillet’s test, you’ll see that it’s positive on the left.

You really see the elevated ilium om the right, so lateral tilt of the pelvis. You can see L4-L5 tilting to the left. And then coming back to midline around L3?

Yeah that’s what it looks like. It doesn’t seem to go up really high.

Uh-huh (affirmative). So, Lily can you weight bear on one leg and then on the opposite leg, raise it at least 90 degrees, slowly. A little bit higher. Okay, thank you and down. Yeah there it is. So you could see that left hip innominate bone raising up. Brian do you want to take it from here?

Yeah, so the Gillet’s was positive on the left, the PSIS wasn’t able to drop down when she brought the hip into flexion. That does show that there is a jamming of the SI joint. We’re moving on now to looking at rotation. Rotation would just be a functional test. There would give us some ideas of imbalances of the channel sinews in the body, but it could also suggest things like thoracolumbar junction syndrome.

We’ve confirmed through postural assessment that she had a left rotation of the pelvis, the pelvis is turning to the left. It’s very typical then that the torso would start turning back towards the right. We have a seated test to be able to confirm this. Because if she has the torso turning back to the right, the tissue shortens in a way that allows her to turn more easily to the right, and it starts to pull on that shortening of tissues and the abdominal obliques as she turns to the left.

You can see as she turns to the right she has greater range of the motion. As she turns to the left she is not able to turn as far. The patient mentioned herself that she felt like she couldn’t turn as far to the left. That indicates a right rotation of the trunk in relationship to the pelvis. There are certain tissues that are associated with that shortness.

The other test on the right where she has her hands out is starting to involve more of the lats. As she turns to the left, the right latissimus dorsi has to lengthen, and she has limited range of motion, she should be able to turn about 80 to 90 degrees. Then we have her cross the left ankle over the right knee, which starts to engage the glutes and multiple things could happen. In her case she was able to turn a little bit more, suggests an inhibition of the glute max. Those tissues, the lats to the contralateral glute max communicate with each other through the thoracolumbar fascia and they can form a sort of sling through the body that can have dysfunction.

So we have shortness in the right lats, there’s actually shortness in the left lats too, which you don’t see because in the still she’s not turning in that direction. Then there’s suggestion of inhibited glute max. I think we can go to the next one.

Good. So the diagnosis and what we’ve found so far with the patient is, because of her posture and also from the TCM differential diagnosis questioning that we do not have on the video, something that practitioners can go ahead and do of course, looking at the zang organs. Kidney qi and qi and blood deficiency is her posture and also her tongue did support that as well. The questions that we had supported that as well. Long term knee pain and so on and so forth. I don’t want to go into this because our time is flying by as my light source just flew by.

Here we are. So let’s just go back. So we’ve got a right elevated ilium and myofascial channel imbalances. If it’s alright you can see that this image on the right is an anterior view, what we’ve been showing you is a posterior view. There is a particular combination of locked long abductors and locked short abductors. Locked long adductors, locked short adductors. With liver jingjin and gallbladder jingjin that has its own protocol, not only with acupuncture, but also with corrective exercises. Brian I know we could talk about this all day, but we have to keep moving.

Okay.

Brian do you want to do this one?

So this is just reviewing what we just talked about, really. That there’s rotation, the pelvis going to the left so that would mean your right ASIS is forward and the whole pelvic structure is turning to the left. And then the torso is coming back to the right. You can almost see at liver 13, the left side going down to about gallbladder 27 on the right, towards the ASIS on the right. That line from left to right ASIS is shorter than it is from the right liver 13 to the left ASIS. That shows that shortening in the obliques and that kind of tightening and screwing, and like a jar tightened too much it starts to put compression into the trunk and into the spine. So we want to unwind her with the exercises and acupressure. Also, with self-massage you want to untwist that jar if it’s too tight.

Brian wouldn’t that this is a common finding to have a pelvic rotation, also a trunk rotation?

Yeah. When the pelvis is rotated to the left, it’s unlikely that the person’s going to be working and steering themselves over to that direction. So somewhere it’s going to come back to midline, most often the trunk. If things are really locked up I guess it could be the neck, or somewhere else, but it’s more often than not it’s going to be the trunk that starts to come back on midline. It’s just part of the way that the body finds balance when there’s injury that caused imbalance, overuse or whatever it is. It’s just the way the body gets itself oriented back to the front.

This is a common posture found in low back pain. Next, here we go. Bilateral anterior pelvic tilt, more on the right. That tells us point prescription gallbladder 39 and a half and liver 4, which we really need to be able to get to soon here. We’ve got possible thoracolumbar junction syndrome. I talked about earlier, watching the lumbopelvic rhythm, seeing that thoracolumbar junction pop up, not moving smoothly in the lumbopelvic rhythm. We’re looking at a L2 to L4 region facet joint from the patient’s description of the pain and also the referral pattern and worse with extension. Actually flexion makes it better and alleviates some of the pain, so we can put that in our back pocket as far as giving corrective exercises.

The treatment plan protocol with this, putting it all together. Of course strengthen kidney qi and systemic qi and blood with this, we’ve got to be able to do this so that we can be able to hold the treatments. Otherwise, the patient just won’t hold the treatment, we’ve got to build the internal to help the external. We need to balance the postural deviations. By balancing the posture deviations it’s going to help with the pulley lever system, the musculoskeletal system, but it would also decrease the amount of internal torsion of the organs. Let’s think about also what postural disparities do to the internal organs. Decrease pain in the UB, stomach and gallbladder jingjin of the low back. That’s what we saw from the assessment.

The treatment protocol, we’re going to give acupressure prescriptions. There are ways of doing acupressure, you can find some suggestions that we have in the blog article on sportsmedicineacupuncture.com. Dietary recommendations we normally can do this. Chinese herbal medicine, let’s make sure that we can send the patient the Chinese herbs. Corrective exercises which we have the patient go ahead and do, we watch them do the exercises, make sure they’re performing them. And also qi gong exercises would be wonderful to be able to show the patient. I’m going to give a little highlight to Brian here. He’s teaching, three times a week, some really wonderful qi gong classes. If you wanted more information on that anatomyofthesinewchannels.com. You can actually have your patient go to that, it’s excellent I’ve been doing it with him for a long time, it’s really great, Brian’s an excellent teacher with this.

Oh thanks, Matt. It’s sinewchannels.com but the blog is called Anatomy of the Sinew Channels, but I don’t think that will bring it up, just sinewchannels.com will have the schedule on it. Thanks for mentioning that.

Let’s go into the acupressure point protocol. You want to start that off?

These are based on the assessment that we had, so gallbladder 41, San Jiao 5, is on the left. For multiple reasons you could think about for the channel sinews, but specifically for the Gillet’s test. Those points will change a positive Gillet’s. We do this in sports medicine acupuncture of course with needles, where we’ll do it just to highlight this where somebody has a positive Gillet’s, we put those points in and it changes instantly. That’s the good news, the problem is those by themselves, you take them out or you have the person massage them and they got it changed and they walked around for a second and came back. The positive Gillet’s will often come back. So by themselves these points have an influence on the movement of the sacrum and the movement of the SI joint, but it needs to be reinforced with a full, comprehensive treatment. It’s going to be part of the treatment, nonetheless.

I’ll go ahead and take the next one too Matt, we have kidney 3 and kidney 4. In this case you want to massage that whole region and affect the kidney low channel, because that goes through the region of the facet, it’s probably having a strong effect on the deep lumbar multifidi muscles. That can be a really good combination to reduce pain in the facets, also with the kidney qi and qi blood deficiency signs, this would be a good combination, working with that aspect too. Particularly on the right, but we have the bilateral because we weren’t able to in and palpate and put our finger right on, let’s say it was a facet in L3 or L4 that’s causing the pain, we weren’t able to go and confirm that with palpation. So we just went ahead and included that bilateral in this treatment.

I’m not sure if we’re still live or not, because it’s after the time left, so I don’t know if just you and I are doing this or if everybody’s still there. I don’t know. We’ll try to fly through this as fast as possible, because I know we’re very strict on time here.

We’re on still.

Oh, okay. Spleen 3, stomach 4 being the source or luo point combination which helps with the abdominal muscles. UB 58, liver 5, stomach 40, as we know luo points that can be able to move qi and blood through those channels when we saw the patient indicating with her fist on the lateral aspect of her back, looking at the iliocostalis, the lateral raphe tissue and the quadratus lumborum. We’re looking at the luo points there to try to be able to change that pain pattern.

Using gallbladder 39.5, which is located halfway between 39 and 40, in addition to liver 4, does decrease the innominate bone of an anterior pelvic tilt. That’s been shown numerous times, we’ve got a YouTube video on that and there’s a whole story behind that, how I was able to come up with that. Another day, another story.

You’ve got a classic point combination to be able to tonify qi and blood, calm the spirit and also move liver qi there from the liver 3, spleen 6, P6, stomach 36, LI 10. Yoga tune up balls are excellent to be able to have your patient get them. The link for them is going to be in the contact, it’s the very last slide of this presentation. We can also have that person do some massage with yoga tune up balls there, or a foam roller if you’d like. Also, having do yoga tune up balls or a foam roller on the piriformis motor point, bilateral will help to set the structure well.

Matt, I know we don’t have a lot of time, I just want to mention this will take a second, one thing. That resource it’s in the slide, but the blog post which really has the full case study on sportsmedicineacupuncture.com, and the video on our YouTube channel has the full case study, the full video. And all of those resources are listed both on the YouTube video in the description, but also in the blog posts. I think that’s what people will have… You won’t be getting the slides for the presentation, because this is very truncated, better off to look at the old blog posts, it has all the information.

Excellent, that’s a good point, thanks Brian. The corrective exercises for the initial visit. We prescribe the exercises to prioritize the patient’s postural imbalances that’s contributing to the pain. The patient had disparities which was a bilateral anterior pelvic tilt that we saw, an elevated ilium, which is going to offset the lumbars and increase facet joint jamming with an anterior pelvic tilt. And also the pelvic and the trunk rotation, we need to be able to try to be able to change that as fast as possible.

These exercises help to balance the structural deviations by activating the biao-li pairs, the internal external pairs of UB and kidney, liver and gallbladder and spleen and stomach. This is in our thought process, not only by prescribing exercises to the core and to postural anomalies or dysfunctions, but what’s happening with the myofascial sinew channels and how they communicate.

As discussed previously, also having the patient apply acupressure massage to the suggested points prior to the exercise helps the proprioceptive signaling. How do we know that, because we do that in the SMAC program. We see that consistently by using intradermal needles on points and how it changes the exercise before and after, dramatically. That’s a big one, have your patient perform these right before the exercises, that would be really good.

Here are some of the exercises that we were giving. The exercise on the left here is figure for a cross-over which is an excellent exercise to work on the liver and the gallbladder sinew channels and decrease that elevated ilium. The center image is a foam roll on some ashi points on the lock sure glute medius side, excess, localized gallbladder sinew channel. And then strengthening the weakened gallbladder sinew channel on the opposite side with some clam shells. This is not all the exercises, this is just a highlight. All of the exercises for this particular patient is in the blog article on the website, so there you can be able to see the whole thing, again this is just the highlights.

Brian do you want to say anything real quick before we go-

No, I think we’re probably getting close to time. I think that’s the last slide just real quick on the prognosis.

The prognosis, make sure in the follow up visits is in the next few days that they’re doing the exercises correctly. You want to make sure that the posture and the orthopedic and the functional exams are hopefully about 20 to 30 percent better. It’s a positive sign, also when the patient is not tracing that referral pain. They’re not doing that body language of tracing down her buttock or into the greater trochanter. Maybe it’s just going to be more localized in the back. So it’s not peripheralization, it’s now centralization which is a much better sign.

Make sure that they’ve received herbs in the mail, make sure they’re doing the dietary changes, are they doing their qi gong exercises that Brian has…

I know we’re flying through this real quick, we didn’t have very much time, but we have to go ahead and say thank you very much to the American Acupuncture Council for hosting this webinar, we really appreciate that. And also to Lesley Spencer that took a lot of time with the video and putting it all together. Brian to you as well, this was not a one day feed, this was not a two day feed or a week. We put a lot of work into this and we really hope that it helps practitioners to gain some insight to be able to help their patients during this very challenging time. Brian?

Thanks Matt, and we have the guests coming next week?

Virginia Duran?

Virginia Doran, yes. So tune in next week for that and we will be back then in a few episodes and probably with a guest and we’ll be looking at some more topics within the sports and orthopedic acupuncture world.

I want to say one more thing, there’s a lot of digital formats that are out there, platforms that you can be able to use for telehealth, telemedicine. Unified Practice subscribers, they have one that’s brand new, they’ve worked out all of the kinks, it’s actually working really well and it’s free to Unified Practice subscribers. So you might want to check that out. Zoom is a popular one, it’s got really nice features, but if you’re already a subscriber to Unified Practice you might want to go ahead and just give them a jingle and contact them and see what they have.

Thank you everybody, we really appreciate all your time.

Yes, thank you.

Okay, bye-bye now.

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