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| Transcript Tokyo, Japan June 16-18, 2006 Workshop |
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Workshop: Abnormal Biomechanics & Anti-Aging Process
AISET 2006
June 16 - 18, 2006Tokyo, Japan
Workshop by Dr. James Stoxen DC Team Doctors Treatment and Training Center of Champions 6432 S Pulaski, Chicago Il 60629 To contact Dr James Stoxen DC teamdoctors@aol.com (773) 735-5200
Good morning and thank you for coming this morning. I want to welcome all of you. First of all, I would like to make an introduction on how this is going to work today. I'm going to begin with a presentation. Dr. Goldman will then come in after he has started the proctoring session with the other doctors for the board examination.
I'm going to begin the presentation, and then Dr. Goldman will come in and give a presentation. Then I will be evaluating a young athlete back there on that examining table. I have not met this athlete. His mother asked me to look at him. You'll be able to see my examining and treatment techniques today, which is somewhat unusual at an international conference. However, I hope that you can gain a lot of insight as to how I approach the treatment of patients.
First of all, I want to set up my slides here and we're going to go ahead and get started. This will be a hands-on conference presentation. However, I'm going to very quickly go through some slides to talk about my treatment approach. This will give you an idea on how we approach the treatment of patients with musculoskeletal problems with anti-aging or wellness and prevention type of approach. What you're going to see is an approach that is somewhat different from the approach that you may be experiencing in your doctor's office. Or, if you are a doctor, you may be gaining some insight as to how we approach the treatment of a patient with an anti-aging format. This is the same approach that I use for the treatment of Olympic and world-class athletes in my office.
Team Doctors is in Chicago and what we have is a treatment and combined training center for the treatment and training of world-class athletes, as well as rehabilitative patients who have musculoskeletal complaints. My specialty is in sports medicine and the care of members of the entertainment industry.
This is a little fun thing that I brought with me. This would be a collection of what we call laminates. These are presented to you when you are invited to be a doctor at a theatre or at a concert for an entertainer. You put this on your shirt, and then you are actually a doctor inside a theatre. They set up an examining and treatment area for me. When various different entertainers come through Chicago, I go to the theatre and set up the treatment room and take care of them on site –so that's kind of fun.
But let's go ahead and get started. First, this is a slide of a herniated disc. One thing I want to mention is that when we are approaching the treatment of herniated discs, as doctors we are a lot of times focusing on the herniated discs. We are focusing on the body part that is injured, which is actually part of a large structure. How would you say? A building that has multiple floors and this is just one of the floors of the building that we are addressing. However, there are four or five additional floors underneath that floor that we should address and not ignore. If we ignore those floors underneath, there could be some disturbances in joint movement that will not allow this particular injury on this floor to __________. So this will be the focus of this discussion.
My approach is a little different from the typical chiropractic approach. That is because in medicine it is unfortunate that we have such specialization that has created some problems for us universally in the treatment of patients. The podiatrist takes care of the patient from the knee down. The chiropractor treats the patient from the hip up. The physical therapist does a lot of rehabilitation after surgery. In between was this approach that I adopted which incorporates the treatment of the patient from the head to the toe, examining all abnormal biomechanics incorporating the treatment of the patient that way -more holistic.
Disc degeneration arthroses of facets would be arthritis of facets and disc herniation on the MRI. When I have patients come to my office, they always arrive with stacks of MRI scans inside their envelopes. They always want me to evaluate their scans. I always like to set them aside, because yes that's information we can get to.
However, what I'd like to know is what's going on beneath the spine. I also want to look at the patient from my own perspective, rather than taint my opinion based on an MRI scan initially. If you put the MRI scan up on the view box, what's going to happen is the patient is going to focus on their herniated disc and not the approach that we're going to take today, which is more or less fixing all floors beneath the herniated disc to allow the herniated disc a proper environment for healing. That's what we're going to go through.
My care program is developed and designed in phases which we will review. What I like about this approach is that it incorporates all the aspects of inflammation as Dr. Sears, Dr. Anton and many doctors talked about at the presentations given this weekend.
I have about 500 or 600 scientific papers – stacks of them this thick in my library that I've copied from the medical library of the University of Illinois at Chicago. I have read through copious medical literature that talk about inflammation and its effects on disease processes.
Because we're musculoskeletal doctors, we're treating patients that have either A) active inflammation which is frank inflammation from pain, the initial injury process or a chronic problem that they're suffering from on a daily basis. Or B) they have silent inflammation.
Patients are geared toward pain; the pain is what brings them to your office. However, what Dr. Sears spoke about -the "silent inflammation", which is there; but it does not create frank pain or screaming pain, pain that the patient can feel. It's a subclincal disease process that goes on without the patient's knowledge. But it still causes destructive processes.
Now with the pointer, I'd like to point out the phases. The first phase is the patients' most important phase to them. That's the phase with the pain; that's the phase that brings them to your office. They have active inflammation and pain. During this phase, we're going to try to eliminate the pain and active inflammation to give the patient a little bit better quality of life following that phase.
Once the pain is gone, then we enter a phase of tissue repair, which is where scar tissue is being relayed down on the new and organized structure that has better movement patterns that we're after our treatment of rigorous and grueling treatment process. We're looking to make it in 2 to 3 weeks -and that's daily care. A lot of times I hear doctors talk about "I want you here 3 days a week." First of all, I'm wondering that Monday, Wednesday and Friday is our care treatment times. Why are we not treating them on Tuesday and Thursday? The patient wants to get out of pain quickly. When I tell the patient, "You'll have to be here daily for 2 weeks, and then we’ll re-evaluate you to see your progress. And if you need additional therapy to reduce the level of frank inflammation and pain, then we'll prescribe additional care." Our goal will then be to make it to the rehabilitation phase where the tissue repair will begin. That's incorporating exercises to strengthen the framework that has been weakened by the chronic degenerative process.
In this particular phase, the patient asks me, "Do I have to be here every day?" Then I ask them the question, "Do you want to get better quickly or slowly? Let me know, please." And they always say, "I want to get out of pain fast." Then be here every day. If you really want to get out of pain fast, you can sit here in my office for 6 hours while I work on you and we'll get you better in 2 or 3 days. They elect to take the daily care.
Shifting your patients from this mind of thought is called the "paradigm shift from disease-based medicine to an anti-aging medicine philosophy". Using the visual of this chart will help you to discuss with the patient and have a goal setting where you're going to go through goals of each phase so that they have something to look forward to. As we all know, in life to set goals for patients is very important, because they have to have an idea of where you're going with the treatment. Not just to provide on-going treatment and see where it goes, because they want to know how long this is going to take.
Sometimes they ask, "How much is this going to cost?” so on and so forth. We have to outline that for them in the beginning. Also, it's nice to do a diagnostic test to determine the levels of inflammation or the biomarkers of inflammation at this phase, because we can retest the patients' levels of inflammation here after we put them on a healthy diet and supplements and the treatment process to reduce inflammation. We can retest and have more of an objective idea rather than just rely on the pain. Because if we rely on the pain, once again we miss out on the opportunity to do the rehabilitation and reduce the level of silent inflammation, which is what the doctors have talked about throughout the entire weekend. This is the one detrimental biochemical process that is causing the rapid aging.
So these are the phases that I go through with the patient. I list their symptoms here and the problems that we're trying to eliminate or remedy. We then outline the level of inflammation that we're expecting to see and this is the pain level. This is the strength increase that we're going to see which we're banking on. As you can see, we're not doing any exercises during Phase 1.
However, because we're working with therapy and hands-on care, we're actually going to see an improvement in the strength. We're actually going to see an improvement in the patient's musculoskeletal system just by removing restriction and muscle spasms and activating muscles that have been in spasm, stiff and without good circulation, as well as removing the restriction from the frame: as the doctors spoke about yesterday, to allow the body to move a little more effectively. This is the treatment plan that I go over with them.
Then I have a selection process of the therapies that they can elect to choose and I get them involved in the selection process of what they want to see, how quickly they want to get better.
Depending upon course doctors we know, if we had an ideal environment where we had free care for every patient that came in, we can do all our fancy treatments that we want to do to move them from A to B very quickly. But remembering that in the real world, we are dealing with patients that maybe have no health insurance or limited budgets. These are unfortunate factors that get in the way of the treatment of the patient. They have to be brought into part of our discussion today because they are part of the treatment process of the patient.
Now, in Phase I, as I mentioned yesterday in my talk, there are fixations in the mid portion of the arch of the foot that we have to manipulate. I'm going to go over that with you. The mid portion of the arch is locked, so the movement pattern of the body is not good. It creates damaging forces of the structure and does not allow these joints to move, specifically the lower back as well as excessive movements in the subtalar joint. In the motion palpation, or evaluation of joint movement, called "joint play" or the movement that occurs between the articular structures.
What we have to understand is if there is a lack of movement or lacking movement in one area of the body. That area will have been made up for excessive movement in other areas. So as doctors, if we understand that the lack of movement in the mid arch of the foot, or the metatarsal cuneiform joint, which we're going to go over later will create an excessive movement pattern in the subtalar area and instability of the structure.
So when we're evaluating the patient, what we're trying to do is stabilize the structure and mobilize the structures that are not moving enough. It's very simple.
The diet that we're going to place the patient on is an anti-inflammatory diet that Dr. Sears talked about, similar to the Zone Diet. And yes, we are going to give the patients supplements and fish oil, or flaccid oil. We can even tell them to have a healthy diet; that might be good. Flaccid oil and different diets that will decrease their level of inflammation, and we're going to check with them every day to see what they ate for lunch, dinner and breakfast because we mean business. We are serious about getting them well.
They may laugh at you. You need to be stern and structured about your discussion with the patient because this is not fun when the patient does not get the results and looks at you as the reason they didn't get those results. When in reality, the patient did not do what they were told. Therefore, we're going to also look at the gait pattern and the flexibility of the kinematic chain. Fruits, vegetables, lean meats, Omega 3 fatty acids are very important: reduction of high glycemic index carbohydrates and mostly fruits and vegetables. If you're advanced, you can do hormone assays to determine the level of growth hormone and testosterone. If you feel you really want to accelerate the healing process, you can incorporate those anti-aging treatments in your program.
The objective findings that we're going to see are on an unfortunate patient. As you can see, the foot is very deformed. However, it took 6 months to a year before this foot was fully restructured. It can be done, even on a crippled foot as this one. As you can see, there are calcifications of the metatarsal cuneiform joint.
I have seen thousands of these calcifications that will restrict the movement in the mid arch of the foot not allowing proper biomechanics of the entire structure. This must be mobilized at this level. You will see that patients have a destruction of the kinematic chain; or the mechanics on the right that this calcification will be larger on the right side than it is on the left.
When you see your patients on Monday, you should have them remove their shoes and socks. Take a look and see what you can find, you'll see that you'll be very surprised. Now when we see a foot like this, as we remember, there is not too much movement here and too much movement in the subtalar area, so we need to stabilize the foot.
We're going to use a shoe that is called "motion control". Footwear manufacturers such as Adidas, Acix, and large manufacturers have produced what we call "motion control footwear" for runners that are high runners. There are approximately 25 million runners in the United States that run three times a week. 16 million of them will receive one injury that will take them out of their training every year.
So the footwear manufacturers recognized through high level elite sports doctors advising them, that it is important to produce a footwear that will restrict the abnormal movement of the calcaneus in a varus position.
If you're looking to advise your patient, you're looking to check the shoes like a piece of fruit. The shoe should be leather or a hard material and should protect the calcaneus from various movements. If the patient is a larger individual, 100 kilos, they have to have an even more structured shoe. Depending on their weight will depend on how structured the shoe can be.
There are five levels of stability in Motion Control footwear to investigate. I urge you to put motion control in Google and start looking around, as well as look in the scientific literature.
Orthotics have been used for years and they are very helpful if you don't have the skill set to be able to rebuild the foot by hand like I'm going to demonstrate to you today. If you don't have the skill set to be able to rebuild the foot and the entire lower extremity by hand, then you might have to resort to orthotics. There are some drawbacks. Patients don't like them: they're an additional thing for them to worry about: their wallet, cell phone, and car keys. Oh, my orthotics. They have to transfer them from shoe to shoe.
There's another drawback: there is no perfect orthotic. They are designed by the doctor and you're trying to put a rigid structure in a three dimensional moveable structure which is the foot, which is very complex and has multiple movement patterns. It's not exactly the perfect structure. They're expensive. Also orthotics alone cannot mobilize the mid arch, which we talked about yesterday, it is vitally important for the spring down and the spring up movements that the foot has to maintain to absorb the shock and spring your body through the space.
That's important to preserve your energy, because when we lose the spring down, and spring up mechanism of the foot, then we have to move harder just for basic walking. That's what makes you tired at the end of the day at 3:00 or 4:00 in the afternoon. Orthotics don't strengthen the area of weakness through the kinematic chain or the bones that go in the foot, calf, thigh, hip, lower back and higher. They can't strengthen that area by themselves. This treatment program will do that.
Also orthotics cannot be worn with sandals or bare feet. Ladies, I know you know it's important in the summer to wear sandals and go barefoot. It's much better to strengthen the structure that you've been given and allow it to function like it did before rather than use an external device such as an orthotic.
Because the cuboid bone, which I don't have a description of, interlocks with the calcaneus, or because all the bones of the foot interlock with the heel or calcaneus, if we stabilize the calcaneus with a rigid structure that has good counters, (We call them counters.), then the foot will maintain its form and the bones will stack up straight on top of the foot.
As you can see, it's easy to see that we have a stacking of the bones, which is very obvious, and common sense. When I talk about this to the patients, they say, "Of course, that makes good sense, but why don't doctors do it?"
So, we're going to give them the motion control footwear that will provide proper fit and structural support to the foot. My recommendation is that you give them a list of approved footwear and stores where they can buy them, because you're going to want them to buy the shoes and have it on their foot by the second or third office visit. When you give them the shoe, have them bring the shoe to you at your office and keep the receipt because you're going to do a visual and manual inspection of the shoe to ensure that it will do the job that you want it to do. The shoe has to support the heel to allow the strain to come off the structure so it can heal.
If it does not work, it does not stabilize the foot, and then you tell the patient to return the shoes and get their money back and get something that will work. This is the motion control footwear. They have structural support mechanisms in the shoe to help stabilize the back of the heel. It's very important.
Let's go over the objective findings. First of all, in this slide you're going to see me examine this patient. We're going to go over this quickly, because I'm going to show you that later. I'm checking for cracking, or what we call crepitus in the kneecap. Because when the foot plants in the wrong position, it throws off the positioning of the knee. The knee is a hinge joint and if the positioning of the kneecap is not in the center of the trochlear groove, then we're going to see some wear and tear on the undersurface of the patella. And that will create what we call "periarticuar pain" or pain around the outer rim of the kneecap.
This is examination of tensor fasciae latae, or the illiotibial band area. This is a muscle that is trying to prevent the knee from rolling inward movement when it moves from its aberrant or irregular movement pattern, or bad biomechanics. It's trying to say, "Wait a minute, don't go too far in the midline because that will cause damage." So the muscle is trying to inhibit this movement. I'm going to go over that with you later. I'm also going to evaluate and do muscle testing of the region which we'll go over later to check for a weakness in the hip socket, particularly the gluteus medius area. A modified Trendelenburg's test will help us to define where the weakness in the gluteus medius will be.
As you can see, we're finding structural problems all the way up the leg into the hip. Here we're checking the hip socket. We'll go over that later when we're finding painful areas. This is an evaluation of the abdominal area. What we're going to find is that the rectus abdominus will be weak and there will be painful spasms in the rectus abdominus. I also find that the patient has decreased gastric acidity, which means that their bowel movements are a little slow because the pressure from the abdominal muscles helps to move fecal material through the path quicker if there is good strength there.
Here I am treating this gentleman. This is an athlete that I've been working with for 6 years. His management people brought him to me 6 years ago. They said to me, "Would you please do whatever it takes to make him a world champion." His name is Andre Arlovsky. He is the World Heavy Weight Ultimate Fighting Champion who is fighting in the cage; he is the current champion. We're very proud of that.
Here we have a picture of electrical muscle stimulation. The removal of protective spasms or restriction of muscle spasms in the lower extremity is a very grueling process by hand. It's very difficult to perform without some help. I use electrical muscle stimulation in a tetanizing mode for approximately 10 minutes. Up the area of the kinematic chain, in the lateral calf area, the tibialis posterior, the tensor fasciae latae which is the lateral calf area, the gluteus medius area which we talked about earlier to remove as much spasm with the machines or the therapy before I put my hands on the patient, because I am going to be very tired at the end of the day. This is very helpful.
As you can see from my treatment, this is moving a little too fast, I'm applying pressure to the muscles between the first and second metatarsal. The first metatarsal is exposed a little more from three sides. But the second metatarsal is exposed only from two, protected by the first metatarsal. What I find is kind of a cracking movement in the first metatarsal (hand cracking motion) type of movement in the first metatarsal. Then the second metatarsal is usually frozen at the metatarsal cuneiform joint because the second metatarsal must flex and extend at the metatarsal cuneiform joint or have the spring up from the second metatarsal joint.
If it's frozen, then the patient has to walk around the frozen second metatarsal to be able to just complete the walking process. That's what causes all the wear and tear up the lower extremity. As a result, mobilization of the second metatarsal is critically important in removing this abnormal biomechanics of the lower extremity. Here I'm applying pressure to the muscles that support the arch area to remove spasms to activate those muscles so that they can support the springy arch structure to allow the arch of the foot to be balanced and helpful in maintaining the spring foundation for the foot.
As you can see, in the slide we used yesterday, I love this slide because there is the heel. We're looking at the foot from the back and we have these bands or support wires, the tendons of the pronator/supinator cuff. These are muscles that come from either side and have strategic attachments n the arch to maintain its integrity.
These muscles attach in various positions in the arch to allow the arch to be structurally solid and springy. A lot of times we talk about flat foot. Everyone, even if you have what appears to be a flat foot on visual inspection, every patient has an arch. It's just not as visible as others and it's not necessarily important that we have a large arch or a flatter arch. What is important is that we have a spring to our arch and proper movement of the foot through the walking or running gait.
Here we have a treatment to the neuromuscular reeducation, which I'm going to demonstrate which will remove the spasms from the kinematic chain. I estimate approximately 10% of the muscle spasms will be removed from the pattern of muscle spasticity. Each visit, or pass, I call it. A pass is what I described when I start from the outer hip. I work inch by inch through the gluteus medius, inch by inch through the tensor fasciae latae, the lateral thigh muscle, the lateral calf area or the tibialis posterior and the first and second toes, which is where all the muscle spasms are.
If you allowed me to evaluate 10,000 patients with pronation syndrome or abnormal biomechanics of the lower extremities I will find 990 patients with this pattern of spasticity exactly in the same place. These patterns repeat in patient after patient, which is good for you as doctors. It makes your job a lot easier. It also describes to you or gives you an idea how common this problem is and how important it is so that it does not cause wear and tear throughout the patient's life.
Here I'm applying pressure to the muscle. It works on the spindle cell in the center of the fiber. The spindle cell is a receptor that gives the brain information on the positioning or the stretch of the muscle. For instance, an Olympic athlete standing on the balance beam knows exactly where she is based upon the position sense that the spindle cells in the muscle fiber will provide. So these spindle cells are actually used. We treat them and we are actually tricking or fooling the brain into thinking that the region is okay. We do this by approximating the fibers with our digital contact.
By approximating the fibers, it will unload the reflex that is given as a ferrent fiber to the brain, and the brain will reorganize the muscle spasm and shut off the muscle spasm because were communicating information that the body is improving. Not only that, but when we put the motion control footwear on the patient's foot, it removes the abnormal excessive movement pattern that establishes the spasm, allowing the body to relax and heal.
We're doing the neuromuscular reeducation on the abdominal area as well. We'll go into that later and I'm sure you understand how that works. This looks very scary, doesn't it? How many of you think these adjustments look scary?
Now let me explain to you some dynamics of the foot that are very unique. If you weigh 50 kilos, when you walk the pressure on your foot is 100 to 150 kilos. If you weigh 50 kilos and you run, the pressure and the forces on the foot are between 250 and 300 kilos.
Obviously my hands cannot deliver the force of 250 kilos to this man's foot, so the adjustments of his foot are not hurting the man. It is helping to break loose the fixation or the restriction of movement in the mid arch area.
Not only that, but what's really interesting is that as doctors, we do muscle testing to determine if there's weakness in the structure. What I found is that muscle testing of the lower extremity is effective only in the hip area. Because when you're working with the foot, having to absorb pressures of 10 to 250 kilos, manual muscle testing is not sensitive enough or effective enough to find weakness in abduction adduction, internal rotation and external rotation of the foot.
Your muscle testing techniques are useless in these areas of determining weakness in the foot. Here we're doing a joint adjustment or manipulation of the patient's sacroiliac joint and as you can see, he's given a good adjustment. This man weighs approximately 110 kilos. He's a world heavy weight champion. This is what happens: if my adjustment application is not done in the right direction, then we will cause a problem. Because my adjustment is actually removing the pressure from the spine, it is not going to hurt the patient. It's not possible to hurt the patient, because the adjustment is actually delivered to the patient in a healthy direction.
We've never had a patient complain of pain after an adjustment of the sacroiliac area in that way because we're removing pressure from the spine, not adding pressure to the spine. This is the phase of care after the patient's inflammation is reduced.
We begin Phase II. Phase II is when we have achieved the reduction in pain and inflammation. We have reduced muscle spasms, which allow the patient to be energized or have additional energy. That's where the chronic fatigue syndrome and the fibromyalgia syndromes come into play; or the patients are just tired or depressed and feel as if they're getting old. I felt as if I was getting old at age 27 because of so many problems in my legs, which helped me discover this approach.
Improvements of circulation and energy come when we remove the spasms in the deep muscles in the calf and lower extremity. When the muscle is in spasm, it's in contraction 24 hours a day, even when the patient is sleeping. So while were supposed to go to bed and sleep and have restful sleep to be able to recuperate and recover lost energy through the day: because our muscles are in a chronic protective state in spasm, they are deleting the energy or removing energy from our systems, and we wake up tired. Then we go for the coffee and more coffee. We get through the end of the day; we're tired and we go home. We say after 8 hours of work, "It was a long day". "It was a tiring day". In reality your body is not functioning at its optimum potential. After you get the treatments, you'll see your energy will come back very quickly and it will be very satisfying.
Treatment continues with adjustments of the articulation of the mid arch as well as the lower back, and stretching begins as well as training or rehabilitative active exercises to strengthen the muscles that have been weakened by the abnormal movement pattern in the lower extremity. Not only are we using anaerobic muscle sets of 4, 6, 8 and 10 repetitions. That's anaerobic to build the power or the strength in the foot and the lower half of the body.
We're also doing aerobic exercises. Aerobic exercises on a half ball, where we stand on the ball and do movements of the foot and side movements on the Bosu ball, for multiple movements such as 10, 15, 20 minutes, a half our to establish increased aerobic capacity of the muscles that support the arch. Because of the requirements of our daily activities that we stand on our feet for sometimes 15 minutes, sometimes an hour, sometimes 3 or 4 hours. If we exceed the aerobic capacity of our feet by standing on our feet too long, then the weakness in the muscles that support the arch will cause the arch to drop and lock. You will then be faced with abnormal biomechanics or movement patterns causing arthritis and degenerative processes throughout the frame.
After we have removed the pain from the patient's lower extremities, they feel better. They have increased energy. They're very grateful to you. You finally fixed their problem and at this point, they could go home satisfied with their result and think you're a great doctor.
However, you know this is just the beginning because they're out of pain, but still the abnormal movement pattern exists because the structure is not fully strengthened. Not only that, but because of the abnormal movement pattern there still lies silent inflammation that will create damage in their systems and the walking style is still not correct. Not only that, but they must still rely on structurally supportive footwear 24 hours a day or any time they're walking or standing. When in reality, they would sometimes prefer to have supportive footwear and other times wear sandals or high-heeled shoes. This is reality. Ladies I know you would rather not wear orthopedic shoes at a function. Therefore, we're going to teach them and instruct them on the proper form and technique of rebuilding the kinematic chain. These are the muscles that we're going to work with. I'm going to go through them quickly. But, as you can see, it's very interesting. The muscles that we don't study much in medical school are the ones that are the most important. The attachment of this particular called the "peroneus longus" which is lying on the outside calf is attaching at the very joint of which I showed you had the calcium deposits and the fixation.
It has two attachments: one on one side and one on the other. You see how it loops around the ankle bone and attaches on the outer portion of the calf. Many doctors, as well as patients don't remember this because it's reviewed very quickly in medical school as well as in Chiropractor College.
I took a particular interest in it because I wanted to make the biomechanics perfect and this is basically where my research lies. So as you can see, this is the most important muscle here, called the tibialis posterior: because of its attachment on the metatarsal cuneiform joint. As I mentioned yesterday, the tibialis posterior muscle even has a syndrome that doctors describe as the tibialis posterior tendon dysfunction syndrome
There are approximately 30 scientific literature papers that are written about this syndrome by doctors and scientists all over the world. However, they don't mention the fixation of the metatarsal cuneiform as the reason why the patient does not have good strength in the metatarsal cuneiform joint.
We're going to go up the leg and here to demonstrate using the four way hip machine. This is the most important exercise machine in the health club, the fitness center and in your rehab center. It's the least used because it develops muscles along the outer area of the hip which are not necessarily the Hollywood muscles, but it's the most important to stabilize the lateral hip.
As we get older, we only walk forward. We no longer play tag with our children, we no longer run through the park. We're not chasing squirrels in the back, or chasing animals through the forest, like we did in the old days hundreds of years ago. What happens in your 60's, 70's and 80's is that when you reach for a can of tomato juice and because you lack strength in the lateral compartment of the hip, you fall and fracture your hip. Then you're in big trouble because you don't have the ability to recuperate. You cannot stand up on the fractured hip; it's a big problem.
So maintaining the structural integrity of the lateral hip for your aging patients as well as the young ones is extremely important for prevention as well as osteoporosis. As you can see, the attachment is between her leg and we are structurally supporting the abductor muscles of the medial compartment of the leg.
Ladies, men, when you go to the health club, you'll begin to perform these activities. This is strengthening of the foot. This is actually strengthening the eversion muscles. Yesterday, I noticed that my digital was not working well with my technology, so I re-input the digital movie into the slide. As you can see, we have a cuff attached to the foot and this wire attaches to a low pulley, which is like a pull down machine or a rowing machine that's attached at the floor level.
As you can see, she is performing activities (I'm going to go backward and forward so you can see that one more time) that this activity is called eversion. Notice that her leg is still maintaining its neutral position. In other words, she is not moving her whole leg: that is cheating. She is stabilizing the calf and only moving the foot. That's how we isolate those muscles, otherwise that's not done properly. You need to teach your patients those exercises so they can do them properly.
As you can see, this is abduction. It's more of a scooping with the foot. You could see the heel and the foot moving in a scooping fashion that develops the muscles of the arch.
This is adduction. It's very difficult. I think that if you're using 2.5 pounds initially, that may feel like you're weak, but that's where people are at. It's very difficult to do and takes a lot of coordination to perform this activity, but it will structurally support your foot.
Then after we feel that the patient has acquired more structural support to the foot, we can begin to start adding some exercises that are more sports or fitness orientated.
Here we're moving into Phase III where the tissue is remodeling. Because we are exercising, the scar tissue is laying its fibers down along the lines of the tissue, along the lines of force. So the exercise actually stimulates the fiber alignment of scar tissue to make a healthier, structurally supportive bond for the joint so that it does not re-injure itself so the exercises are very important.
There is a study at Pepperdine University in California, where the doctors had the patients do pronation and supination exercises for 8 to 12 weeks. They found excellent improvement in arch, integrity and strength. These exercises were a little more advanced than I would recommend for your average patients. These are types of lateral movement exercises I would prefer you start with exercises we looked at before with the cables. These are exercises that are performed in Phase III and IV to athletes and patients that have a little better strength and confidence.
Here is an exercise for the abdominal area. I have never allowed one patient to do a floor sit-up in my office in 20 years. It is a useless exercise; it's damaging and dangerous to the patients. First of all, my athletes and my patients are not allowed to do these floor sit-ups.
When you are doing floor sit-ups you are saying that the weight of my body from the waist to my head is the recommended weight that we begin with to start his exercise program.
If I have a frame that is an ideal body weight, 50 kilos, but from here to here we weigh 50 kilos, because we are overweight, then that is not a match. In other words, the abdominal muscles can only be able to lift 20 kilos. However, the body weighs 50 kilos from the waist to the head.
That's like saying, "Go to the exercise equipment and lift 50 pounds with the arm." It's not an appropriate weight for this muscle to lift. Instead we have the patient seated and we use the selectorized equipment to choose a weight that is suitable to match up the strength requirement of the abdominal muscle as it is in that state. In other words, if the patient has weakened abdominal muscles that are only able to lift one or two plates, that's where we begin and not with the body weight.
It does not make sense. It is not an appropriate rehabilitation approach. And as you can see from this exercise, this is one of my athletes. He's a World Heavy Weight Champion, Fernando Hernandez, and he is demonstrating this exercise. Notice that the bottom of the ribcage comes closer to the pubic bone, and we have a shortening of the abdominal muscle. We have no movement in the hips or the pelvis or in the neck, just in the abdominal area.
Here we can increase or decrease the amount of weight according to the strength match of his abdominal muscles and he can begin to add weight, which will improve his strength through the rehabilitation program. It's probably an unlimited level we can achieve with this kind of approach. Here we have a more advanced exercise where the hip is to remain stable and the movement will occur in the abdominal area. The attachment is obviously at the ribs. You'll see this is a very interesting exercise and it develops the stomach muscles. You can see the flexion of the spine, the stabilization of the hip. It's a very good exercise.
Like I said you can also add weight to the equipment. As you can see, his body weight is maybe 25 kilos from here to here. Part of this weight that he's lifting is part of his body. We then add additional weight to increase strength to his frame. Here we're doing another exercise that I love. It's for the side muscles or what we call abdominal oblique. Ladies, if you want a slim waistline, if you can remember, here we have him doing the exercise. He is moving his body from side to side and it's developing the oblique muscles. If you take a wet towel and twist it, it will shrink. That is what happens to your waistline when you're doing these exercises. Here we have the rotary torso, which I also like. This is good for boxers because it develops the power. As I mentioned earlier, you can increase the weight accordingly to increase the strength.
Also what I like for fighters and athletes is that I can also increase the speed of contraction, which will increase the power that the athlete can deliver in the sports activity. This is a picture of my training center in my office. Here we have all the championship posters; they're all over the office. Here you see this window into my treatment room and then a mirror. So when I'm treating a patient and I'm looking into the rehabilitation area, I'm monitoring the activities of the strength and condition and active rehabilitation occurring in my facility to ensure that no one gets hurt.
Since 1992 we've had no injuries, thus far. This is the final phase. This is the anti-aging lifestyle. When we have reduced the level of inflammation to 1.5 to 3 or at least under 5, as well as we have improved the strength of the patient's kinematic chain, removed all restriction and they have good education on proper exercise technique, form and intervals 3 days a week. However they want to exercise.
I'll give you an interesting point. The world champion or the athlete who broke 80 world records during the time I cared for him at Cohen, he was in the 100 kilo weight class and lifted 450 kilos squat and he held the record. He weighed 220 pounds; he held the world record in the 220, 242, and 265 and 300 and heavier weight classes. He held the record usually in Olympic sports. What you'll see is as the size of the athlete increases, the amount of weight they can lift increases because they have a bigger frame. He was holding the world records in every weight class above him.
Therefore, the reason why I feel he was able to do so was because I removed every restriction from his kinematic chain in his lower half of his body. Three days a week for one hour a day I worked on his muscles with deep tissue and adjustments to mobilize and make his structure biomechanically perfect; therefore he could put the maximum amount of load on the frame. His exercise regime, exercise program consisted of exercising only 4 days a week. You can get very strong exercising only 4 days a week. Encourage your patients to do activities that are not just running.
When I talk to my athletes that run, I explain to them and show them the muscles that are more important that structurally stabilize the foot; they are from the sides. I tell them to run in a 15-diameter circle and then increase the size of the circle, then do zigzag patterns, run around trees for approximately 15 to 20 minutes to activate, stimulate and bring blood flow in circulation and strengthen the pronator/supinator cuff. Then go ahead and do their 2 kilometer or 10 kilometer distance run and this has been very helpful. This is what you can talk to your patients about. They should be doing other things besides just walking straight.
With that, I'd like to thank you for attending my presentation today. I encourage you to listen to Dr. Goldman's talk and stick around while we evaluate this young man, a young athlete. There will be a table in the back of the room. I am going to evaluate his structure and talk about treatment. You will be able to see first hand my treatment to athletes.
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