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Lecture Notes: Abnormal Biomechanics of Walking - The Effects on Accelerated Aging
Third Malaysian Anti-Aging and Aesthetic Medicine Conference and Exhibition
April 28th, 2006
Kuala Lumpur, Malaysia
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
Anti-Aging Medicine
• Anti-aging medicine, an extension of preventive health care, is the next great model of health care for the new millennium.
• This form of medicine is based on the very early detection, prevention, and reversal of age-related disease. 90% of all adult illness is due to the degenerative processes of aging.
The Paradigm Shift
• A profound paradigm shift in the way the medical establishment views aging and age-related disease is now underway.
• The paradigm shift comes when we practice analysis of faulty biomechanics for early detection, intervention and prevention.
• Biomechanics
Prediction of the Areas of Accelerated Aging
• As a doctor or scientist in anti-aging medicine who embraces the study of biomechanics you can become astute enough to recognize subtle abnormal biomechanics to make predictions of accelerated aging before it even shows its first sign or symptom.
• Using the study of biomechanics to predict which areas of potential areas of higher risk of injury or accelerated aging with respect to degenerative joint disease is the most progressive approach in modern medicine to prevent aging of them musculoskelital system and the path that anti-aging medicine doctors must consider.
“Abnormal Biomechanics of Walking”
Why its vital to the anti-aging practice
• Walking is the core exercise that all of your patients can and must do every day
• We take an average of 10,000 steps per day
• It improves circulation, cardiovascular, heightens mood and is the way we get from point A to B.
• Walking may be the only exercise your patient may get
• With that many movements of weight bearing joints even subtle abnormal biomechanics can cause accelerated aging of the joints over time
• Subtle abnormal biomechanics causes a constant and steady stimulation of the cascading domino effect of chronic inflammation
Chronic Inflammation
A “toxic Soup”that increases risk for disease
• How does inflammation relate to heart disease and stroke risk?
• “Inflammation” is the process by which the body responds to injury. Laboratory evidence and findings from clinical and population studies suggest that inflammation is important in atherosclerosis and other systemic diseases.
• C-reactive protein (CRP) is one of the acute phase proteins that increase during systemic inflammation. It’s been suggested that testing CRP levels in the blood may be a new way to assess cardiovascular disease risk. A high sensitivity assay for CRP test (hs-CRP) is now widely available.
• The American Heart Association and the Centers for Disease Control and Prevention recently published a joint scientific statement about using inflammatory markers in clinical and public health practice. This statement was developed after systematically reviewing the evidence of association between inflammatory markers (mainly CRP) and coronary heart disease and stroke.
Analysis of Biomechanics
A Huge Role in Early Detection and Prevention
• Biomechanics unites engineering sciences to biological science.
• The analysis of motion is the basic component in the field of biomechanics—the study of the mechanics of the human frame.
• There are general movement patterns and specific movement patterns
• Gait analysis is the way which doctors and scientists can determine where abnormal movement patterns exist
• So the study of effective prevention, intervention the effects of abnormal biomechanics of walking is vitally important to the medical model of the anti-aging doctor
• There are common patterns of abnormal movement patterns that exist in patient population making your job a little easier
Faulty Biomechanics of the Lower Extremities
A presentation of how a biomechanical dysfunction accelerates the aging process.
The most effective diagnosis, treatment and prevention.
James Stoxen, D.C. President, Team Doctors Treatment Centers
• Discussion of anti- aging issues with lack of care and how the body ages more rapidly with the cascading domino effect of this syndrome.
• We will discuss the risks and complications of the development of more life threatening diseases, which can manifest from the lack of treatment of inappropriate care to this simple biomechanical dysfunction. The dysfunction is easily treated with the care cycle outlined if caught early, given effective treatment and prevented, the biomarkers affect the aging process.
Abnormal Biomechanics
Most Common Cause of Chronic Arthritis, Inflammation and DJD
• Arthritis is the most common cause of disability in the elderly with 43 million cases in 1997
• Arthritis is a joint problem primarily from metabolic or inflammatory causes;
• Arthritis is a joint problem initially from mechanical abnormalities.
Eric L. Radon, MD., professor Emeritus of orthopedic surgery at Tufts University
Abnormal Biomechanics
The First Clinical Sign of a Disease Process not xrays
• X-rays show that by midlife, 50% of us will be effected, In the weight-bearing joints, particularly the hip and knee, this degeneration accelerates with age.
• By the seventh decade, it affects an astounding 85% of the population.
• We are not talking about catching abnormal biomechanics as arthritis as seen on x-rays.
• The effects on exercise and the acceleration of the aging process are seen far sooner than on X ray findings.
Anti-aging Doctors
Intervene Before a Disease Manifests
• An astute doctor in aging medicine does not wait for pain to occur. He or she will look at lower limb alignment and biomechanics and ask the patient if there is pain and correct the alignment before the pain causes permanent damage.
• If there isn’t pain and there is poor biomechanics the doctor will still attempt to correct the alignment and biomechanical abnormality before it leads to a syndrome causing self-destruction.
Aging Baby boomers are a Prime Target
• The 60s 70s and 80s were sports boom years
• They were brought up with the NO PAIN NO GAIN philosophy of exercise
• Baby boomers were the generation of the exercise craze
• More women exercise in this generation.
• Emphasis was on Appearance
• Babyboomers began loosing exercise opportunity with modern technology
• Correct form and technique or Biomechanics was not well researched, taught and practiced by doctors, trainers and patients
• Correct biomechanics is still not practiced in training
• Obesity
RUSH-PRESBYTERIAN-ST. LUKES MEDICAL CENTER STUDY
Cortisone Injections and Analgesics
• 53 subjects with symptomatic radiographic evidence of wear-and-tear arthritis of the knee were studied.
• When some of the subjects took acetaminophen, their pain was relieved.
• When their gait was analyzed, those with decreased pain from the analgesics tend to increase the load on the degenerated portion of the knee.
• Simply put, they loaded the worn cartilage with forces high enough to do further damage to the joint.
Abnormal biomechanics of the foot - two types
• Right Supination 8%
• Left Pronation 92%
Which athlete has abnormal biomechanics?
In this photo, there is a normal amount of foot pronation and supination in each athlete according to the phase of the gait they are in.
Pronation and Supination
The hype is always with excessive Sub-talar joint motion
What is overpronation, biomechanically?
Is it foot position or foot motion?
• Some pronation is natural, and necessary
• It takes place around two mid-tarsal joint axes
• Oblique mid-tarsal joint axis, which enables dorsiflexion and plantarflexion, and the
• Longitudinal mid-tarsal joint axis enables pure inversion and eversion.
• The piece of the puzzle that was missing
• What scientific literature suggests
• If the calcaneus is in a varus position, the entire complex will collapse in overpronation
• If the calcaneus is not in a valgus position there will be no overpronation or excessive subtalar motion
There is an important component missing of this syndrome that wont allow us to prevent this cascading domino effect of aging
• How does the calcaneus slip into the varus position and how and why does the excessive subtalar motion or abnormal biomechaincs of the kinematic chain occur?
Excessive Pronation - Cause and Prevention
• Medial or lateral movements of the subtalar joint axis in relation to the plantar foot as little as 1mm to 2mm can cause abnormal foot function and can lead to foot and or lower extremity pathology
• The literature discusses calcaneal eversion and excessive movement at the sub-talar joint but never discusses the cause in over 160 scientific papers and peer review journal articles
• If we don’t know the cause of the excessive sub-talar motion occurs how are we as anti-aging doctors going to practice prevention, early detection and intervention?
“Arch - Spring Down” Shock Absorption Effect
“Arch - Spring Up” Effect
• The foot has 3 arches or trusses.
• These trusses are supposed to be flexible or springy
• When you walk you spring down and spring up (toe off)
• This is the missing component to every treatment plan discussed in the literature.
“Arch lock”
The Cause of Excessive Abnormal biomechanics of the Foot?
• When you stand on your feet longer than the aerobic capacity of this group of muscles stamina, the truss begins to collapse or lock
• When it locks it locks at the first and second metatarsal - cunieform joints
• When this joint locks, it causes excessive motion in the subtalar joint and abnormal movemet pattern in the entire kinematic chain
• You will actually see arthritic spurs in the area of the metatarsal cunieform joint
Pronator - Supinator Cuff of the Foot functions the same way as the Rotator Cuff of the Shoulder
• The health of the arch to maintain springiness is related to the strength of the muscle which support the arch called the pronator-supinator cuff
• This group of muscles have a certain aerobic capacity related to the amount of exercise they get in all ranges of motion.
• As you age you mostly just move the foot and ankle in flexion and extension.
“Arch Lock” - The Causes
• A lack of exercise - our lifestyles have become sedantary, Car, tv, computers
• A decrease in the aerobic capacity of the pronator supinator cuff muscles
• Weakness or reduction in the anaerobic capacity of the pronator supinator cuff muscles
• Mentioned in the literature is the tibialis posterior muscle There is a syndrome called Tibialis Posterior Tendon Dysfunction (TPTD)
• ‘Half of our society is overweight The heavier the load the stronger the truss must be to support it
• Poorly constructed footwear
Why do our feet weaken with age?
We rely more on “time saving” technology
Technology takes exercise opportunities away from us
We are in a modern society of “Time saving” advances in technology
That is why we don’t have time to exercise because we are too busy working on “time saving” technology advances
What is scary is that children are starting with this trend earlier than we did
Why we stopped exercising
• Bad experience in the past
• Don’t want people at the health club to see their bodies
• May not have been very good at sports as a youth
• The “No Pain – No Gain” concept scares people
• Don’t want to sweat
• They just don’t like exercise
• Exercise is boring
• We don’t know what to do
Lack of awareness of the effects of abnormal biomechanics of the foot is causing an epidemic of rapidly aging, arthritic patients…
• The foot is a complex anatomical structure that is not well understood.
• Because of this, abnormalities of foot motion continue to cause chronic joint damage in multiple areas of the kinematic chain with no hope in site of change.
• The use of drugs, inserts and neglect take the place of appropriate care and prevention
• The foot is the area that all bodybuilding, “how to” exercise books and magazines patients read have neglected
• Most exercise fanatics, personal trainers, athletic trainers and doctors don’t know what to do to reverse the effects of the abnormal biomechanics of the foot
• There isn’t even any equipment in the gym to use to properly strengthen this area of the body
Its time we get a better understanding of abnormal biomechanics of walking and exercise prescription to prevent this epidemic
• We need to take back the exercise prescription area of medicine from the pseudo experts
• At Team Doctors we have a private rehabilitation training center
• Now over 500 hospitals have added a full rehabilitation and training center for prevention
• An exercise prescription center is a great addition to your anti-aging practice
Excessive Pronation
Three Static Evaluation Methods
• The medial border of the midfoot will demonstrates a convex shape within the transverse plane
• The soft-tissue contour of the talar head and neck of the anterior ankle joint area will be medially positioned and internally rotated in relation to the calcaneous.
• In a standing position, there will be increased convexity in the medical midfoot area just inferior and anterior to the medial maleolus.
• The abnormal medial position of the talar head in relation to the calcaneous and the rest of the foot directly cause all of these clinical signs
Arches Develop in Childhood
• Arch development was faster during the first 2 years with supportive footwear and healthy activity like “tag” and other activites
• The literature states that rearfoot varus deformity, which stems from failure of the tibia and/or calcaneus to straighten during infancy, is the prime cause of simple foot pronation.
• In 90 percent of the children who reportedly had growing pains actually had some degree of overpronation of the feet.
• Foot orthosis removed a majority of these “growing pains”
Excessive Pronation Causes
Tibial Torsion
• The tibia rotates internally by 20 degrees in less than a .10 second.
• Muscles and tendons work to dampen this torque, this strain can cause stress and strain in joints.
• As the lower leg compensates for these problems, shin splints and tibial stress fractures are possible, according to the literature.
• In our practice, we have found that other maladies, involving the knees, hips, and back, stem from pronation.
• Overpronation “Destructive Foot” Gait
• When the foot locks at the metatarsal cunieform joint, the foot cannot flex the foot to allow toe off
• Because you cannot get toe off, the foot cannot follow through so it compensates with a premature toe off
• The patient also turns the foot out to avoid this fixation in the foot
• The patients commonly do both toe out and premature toe off
• Because the patient cannot push through the toe off motion, the calf does not propel the body through space
• Instead the patient lifts the hip with the illiopsoas muscle causing strain on the hip socket and lower back
• This also causes weakness in the gluteus medius and maximus
• The worst part of the story is that the calf and muscles of the pronator supinator cuff don’t contract through the walking mechanics. This gait causes a reduced venous return to the heart
• The deep muscles of the calf spasm and that causes not only a reduced contraction but a restriction of circulation causing possible increased risk of infection to the foot, further cardiac output and other accelerated aging effects.
Demo the G5
Abnormal Walking Biomechanics cause a cascading domino effect of accelerated aging of all the body’s systems
• Because the feet are the very foundation from which all other joints align, excessive pronation can cause a domino effect of stresses and strains on every joint of the body, literally from toe to head. This in turn will predispose a patient to an acceleration of the aging process that can include advanced arthritis
• The abnormal gait may create abnormal forces on the hip joint that becomes the primary driving force of the degenerative process. This abnormal gait may result from problems anywhere from the lower spine to the foot *
• You can nail the mechanics down to a particular foot problem. But of them all, there are two abnormalities that cause most of the wear and tear in the body. Pronation is called “Arch Lock Destructive Foot” Syndrome **
Foot & Ankle Symptoms
Patients suspected of having abnormal biomechanics of walking
• Plantar Fascitis
• Heel spurs
• Shin splints
• Foot and ankle pain
• Adductovalgus muscle strain
• Bunions and claw toes
• Achilles tendon strain or tear
Achilles Tendon Tears
Patients suspected of having abnormal biomechanics of walking
• With chronic pronator supinator cuff weakness the body shifts the weight to other muscles and serious injuries can occur
• This occurs because the muscles which support the arch and heel are weak due to long standing tonic protective spasms.
• The body shifts the load off these muscles and onto the achilles tendon
• The tendon overloads and even a simple movement can cause a devastating tear
Knee Symptoms
Patients suspected of having abnormal biomechanics of walking
• Overpronation causes internal rotation torque of the tibia and fibula, tibial torsion
• Lateral Calf Muscle Strain and Spasms
• Pronation/Supination Cuff Spasms and weakness
• Misalignment of Patella in the trochlear grove chondromalacia patella, periarticular pain
• TFL spasms
• Lateral hamstring tightness
Thighs, Hips and Lower Back Symptoms
Patients suspected of having abnormal biomechanics of walking
• Legs are tired and achey
• Frequent leg cramps
• Illiotibial band syndrome
• Crepitus in the hip
• History of hip pain and arthrosis
• Lower back pain
• Frequent back injuries
• Herniated discs that don’t improve
EXCESSIVE PRONATION TIBIAL TORSION AND
CONTRALATERAL LEG ROTATION FORCES
• An area of abnormal walking biomechanics which is not neglected in the scientific literatur is the
• When you walk with overpronation movement actions on joints from the contralateral leg rotation coupled with tibial torsion and excessive weight in the frame causes excessive, abnormal and compressive torsion forces through the knee, hip and lower back areas
• This is because both feet are touching the ground during walking.
• This leads to chronic wear and tear or degenerative joint disease in the hip and lower back areas
• Idiopathic lower back back pains and injuries that don’t heal.
• Herniated disc conditions go to surgery before they have a chance to heal
• After disc surgery the patient is still left with the abnormal biomechanics
Overpronation & Mechanical Lower Back Conditions
Virtually a Direct Clinical Correlation
• There is almost a direct coorelation between excessive pronation/supination and lower back complaints.
• Overpronation creates stress on the lower back through the kinematic chain.
• This is the primary cause of degenerative joint disease than any other single cause of arthritis
Is it fibromyalgia, chronic fatigue syndrome
or is it overpronation syndrome?
• Achiness all over
• Legs feel heavy
• Brain Fog
• Negative laboratory
• Decreased sex drive
• Poor sleep
• Patients are tired all the time
• They are chronic coffee drinkers
• Many of these patients have resorted to stimulants to supplement for a lack of energy
• Diagnosis becomes confusing
• Misunderstood by doctors
Objective findings of
Overpronation Syndrome
Objective Findings - Foot, Ankle and Calf
Patients suspected of having abnormal biomechanics of walking
• Calcium Spurs above and below the metatarsal-cunieform joint
• Swolen Ankles
• Bunions
• Calcaneal Eversion
• Inflexibility in Plantar Flexion
• Painful Spasms under 1st Metatarsal-Cuniform Joint
• Painful Lateral Calf Spasms
• Gait Analysis Reveals Tibial Torsion and of course overpronation gait
Objective Findings - Knee
Patients suspected of having abnormal biomechanics of walking
• Clarks Test +
• Crepitus on extension
• Waldron’s Test +
• Medial Knee Pain
• Posterior lateral knee spasms from spastic lateral hamstrings
• Chondromalacia patella radiographic findings of calcium deposits superior and inferior patella border
Objective Findings - Thigh
Patients suspected of having abnormal biomechanics of walking
• Biceps femoris - weak and painful (on deep palpation)
• Tensor fascia latae - weak and painful (on deep palpation)
• Modified Obers + (TFL)
• Nobles Test + (TFL)
Objective Findings - Hip Joint
Patients suspected of having abnormal biomechanics of walking
• Gluteus maximus - stiff, weak & painful (upon deep palpation)
• Gluteus minimus and medius weak & painful
• Piriformis - weak & painful
• Internal rotation - restricted
• Patrick Fabres +
Objective Findings - Hip
Patients suspected of having abnormal biomechanics of walking
• Protective Spasms in the Gluteus Medius Area
• Trendelenburg Test + for weakness in the gluteus medius muscles
• Balance is compromised
• Difficulty getting up from seated position
• Hip joint arthrosis
Objective Findings - Lower Back - Abdominals
Patients suspected of having abnormal biomechanics of walking
• Weak Painful Rectus Abdominus Spasms
• Flexion fixation subluxation in the sacroillac joint
• Hibs +
• Elys +
• Bilateral leg raise +
• Straight leg raise +
Lower back x ray findings
Patients suspected of having abnormal biomechanics of walking
• Disc degeneration
• Arthrosis of facets
• Disc herniation on MRI
Phases of Care for an Anti-aging Practice
The Paradigm Shift
Disease Based Medicine to Anti-Aging Medicine
Outline the Patients New Approach to Healthy Aging
• Shifting your patients from disease based medicine model to the anti-aging medicine model is a paradigm shift in thought, which must be explained thoroughly
• This visual is an easy to understand phase by phase approach will help you educate your patients on the biomarkers you plan to index and the approach you plan on taking along the way to get them to a more healthy rate of aging.
• Patients need to see where they are going and how they are going to get there. This visual will help you and the patient establish goals of the anti-aging approach.
• Establishing goals will keep the surprises out of the approach.
• The planned anti-aging approach gets the patient focused on the process they must follow to reach healthy aging.
Anti-aging approach to care in phases I - IV
Treatment Challenges to Healthy Aging
Phase I to Phase II
• Fixation of the Metatarsal Cunieform Joint, Excessive motion of the subtalar joint and calcaneal eversion as well as muscle spasms through the kinematic chain
• Abnormal biomechanics causes an abnormal generalized movement pattern of an abnormal gait
• Abnormal gait causes pain and inflammation and inactivity
• Inactivity causes weakness in the pronator supinator cuff
• Inactivity, pain and chronic inflammation a catabolic state and rapid musculoskelital weakness
• Pro-inflammatory and pro-catabolic state creates hormonal changes and challenges in managing weight
• Patient may have depression
Anti-aging Approach to Abnormal Biomechanics of Walking
Phase I to Phase II
• Diet - Pro-Anabolic, Anti-Inflammatory, Weight Reduction Diet
• Evaluate and treat hormone levels
• Motion Control Footwear reduces Subtalar joint movement and stabilizes calcaneal eversion
• Mobilization of Metatarsal-Cunieform Joints and Spine
• Physiotherapy and Neuromuscular Reeducation of Kinematic Chain muscles
• Kinematic chain flexibility
• Gait retraining - General Movement Pattern to Specific Movement Patter
• Motivate constantly
-----------------
• Frequency - Daily Care
• Duration - (2 - 3 weeks)
Phase 1 - Relief
Obvious Inflammation - Intensive Care - Stop Activity
Anti-Aging biochemistry promotes rapid healing
• Diet - Pro-Anabolic, Anti-Inflammatory, Weight Reduction Diet
• Evaluate and treat hormone levels
• Fruits, Vegetables and Lean Meats, Omega 3s
• Low Glycemic Index Carbohydrates
• Supplements to shift and maintain anabolic state
• Hormone Assay and treatment or referral to physician who can manage hormone levels
Phase I to Phase II
Motion Control Footwear - Considered a Prescribed Brace
• Reduces subtalar joint movement and stabilizes calcaneal eversion
• They have strong counters, made of durable leather, have rubber soles for shock absorption and lace Up
Patient Compliance
• Give the patient a list of approved footwear and if shoes are not purchased within the first three visits the patient is dismissed
• Save the receipt until after “fit inspection”
• Buy two pair and wear alternate pairs daily to preserve structural support
Phase I to Phase II
Orthodics and Wedges - The Positives
• Foot orthodics have a significant effect on calcaneal eversion but shoes should be considered in conjunction with foot orthodics
• Forefoot and rear foot wedge posting is helpful in reducing pronation
Phase I to Phase II
Orthodics and Wedges - The Drawbacks
• Patients don’t like them
• There is no perfect orthodic
• They can be costly
• Orthodics, alone, cannot mobilize the metatarsal cunieform joint area
• Orthodics cannot reduce protective spasms
• Orthodics alone do not strengthen the pronator supinator cuff muscles
• They occupy space in the shoe which can cause compression of the truss
• Some “arch support” orthodics restrict the “spring down” shock absorption effect
• They cannot be worn while barefoot or with sandals
Phase I to Phase II
Counter support footwear stabilizes the rearfoot and subtalar motion
• Because the cuboid inerlocks with the calcaneous and the ligaments and tendons that interlace connecting the bones of the arch to the heel it is virtually impossible for the arch to drop when the heel is stabilized in the neutral position
• This is the principle which voids the need for an “orthodic” or “arch support” to support the arch or stabilize the foot.
Phase I to Phase II
Passive Therapy to reduce protective muscle spasms
• Electrical muscle stimulation, vibrational massage and neuromuscular reeducation reduces protective spasms along the kinematic chain
• These muscle spasms cause restriction in motion, alter biomechanics, prohibit mobilization of the fixed joints and burn energy
• Ultrasound is used for the Arthritic Joints
Phase I to Phase II
Neuromuscular reeducation reduce protective muscle spasms
• Reorganizes reflex patterns in the brain activated by acute or chronic overload related to fatigue caused by improper biomechanics.
• Ischemic compression 10 - 1 to effect the golgi tendon reflex organs and muscle spindle cells
• Tonic protective reflexes lie latent and are discovered with severe pain on deep palpation.
• Contraindicated in patients who are suspected or at risk of developing clots in the deep veins of the calf
Phase I to Phase II
Neuromuscular reeducation pronator - supinator cuff
• This is performed from the base of the achilles, up the lateral calf to the knee in the pronator supinator cuff primarily the peroneal muscles and the tibialis posterior muscles
• Strength in the pronator supinator cuff muscles which support the arch improves by 10% per application which will pull the heel out of eversion, add spring to the step and therefore help reverse overpronation syndrome
• This improves venous return to the heart, reduces nocturnal leg cramps is great for restless leg syndrome and as well as.
Phase I to Phase II
Pronator Supinator Cuff Tendons
• Tibialis Posterior
• Flexor Digitorum Longus
• Tibialis Anterior
• Flexor Hallusis Longus
• Peroneus Longus
• Peroneus Brevis
Phase I to Phase II
Neuromuscular Reeducation - thigh area muscles
• NMRE to the vastus lateralis, tensor fascia latae and biceps femoris
• Strength improves by 10% per application which will pull the patella back in the center of the trochlear grove reducing chondromalacia patella
Phase I to Phase II
Neuromuscular reeducation hip and low back
• NMRE to the gluteus medius
• Blood flows better with the treatment
• As strength improves in the hips, the load is shifted back to the hips taking strain off the lower back
• Balance will improve quickly
• Ability to get up from a seated poisition will improve as wel
Phase I to Phase II
Neuromuscular reeducation abdominal muscles
• Performed from the base of the pubic bone to the edge of the lower border of the anterior ribs
• This will strengthen the rectus abdominus which reduces pelvic tilt improves support for the lower back reducing hyperlordosis
• This also reduces stress and helps to increase gastric motility
Phase I to Phase II
Manipulation of the Metatarsal Cunieform Joint
• Manipulation of the Metatarsal Cunieform joint is medically necessary to reestablish the “Arch Spring Up” for shock absorption and “Arch Spring Down” effect for full movement of the foot through the stance and toe off phase
• Without establishing normal springy movement, normal biomechanics cannot be reestablished in the kinematic chain.
Phase I to Phase II
Manipulation of the sacroilliac and lumbosacral area
• Joint manipulation must be performed on the lower back to normalize the motion lost with the chronic hyperextension of the lumbar spine
• The upper sacroilliac joint is adjusted and when it is mobilized the sacrotransverse ligaments pull the lumber vertebra into position, reducing pressure on the posterior disc and back into good healthy motion
Treatment Challenges to Healthy Aging
Phase II to Phase III
• Patients disease based medicine mentality
• “No pain” means good health
• Patient is in “silent inflammation” still aging still catabolic
• Kinematic Chain is still weak
• Gait is in the specific movement pattern state
Phase II to III
Focus on biomarkers for Inflammation and restate anti-aging focus
• Reevaluate the patient for objective findings
• Focus on the biomarkers of rapid aging.
• Reevaluate ideal body fat percentage
• Recheck for levels of inflammation (cytokines and c-reactive protein levels) and other biomarkers of rapid aging
• Sandwich areas for focus between motivate and congratulation on patients achievements every day
Phase II to Phase IV
Purchase Motion Control Training Shoes
• “MOTION CONTROL” FOOTWEAR The most rigid, durable and control-oriented running shoes.
• Stiff heel counters are designed to limit overpronation
• Medial post (a firm section under the inner edge of the foot)
• Polyurethane midsole (for midsole durability)
• Carbon rubber outsole (for outsole durability).
• Many are built on a straight last, which offers stability and maximum support on the inner side of your foot.
• The American College of Podiatric Sports Medicine comes out with a list of athletic shoe recommendations that are recognized by the prestigeous American College of Sports Medicine on their web site at http://www.aapsm.org/runshoe.html
Phase II to III
Reduced Inflammation - Light Rehabilitation - Stretching
Achievements of Phase I
• Reduced pain and inflammation
• Reduced spasms increases energy
• Improvements in circulation
Diagnostic Action Plan
• Passive therapy is discontinued
• Full physical examination
• Cardiovascular diagnostic tests
Treatment Plan
• Continue joint mobilization
• PNF stretching for flexibility
• Balance training continues
• Anarobic training strength training of the kinematic chain with active rehabilitation
• Aerobic training of the kinematic chain
• 3 days a week for 3 - 4 weeks
Phase II to Phase IV
Rehabilitation and Training of the Pronator Supinator Cuff
FLEXOR HALLUCIS LONGUS
ACTIONS:
• Strong plantar flexor of the ankle join
• Weak subtalar joint supinator
• Assists in preventing overpronation
Phase II to Phase IV
Rehabilitation and Training of the Pronator Supinator Cuff
PERONEUS LONGUS
ACTIONS:
• Strong plantar flexor of first ray
• Pronator of the forefoot around the longitudinal midtarsal joint axis
• Assists in preventing overpronation.
• Also, during the push off phase of gait, pronation is reduced when the peroneus longus is strengthened to insure that toe off will occur with a stable first, second and third digit
Phase II to Phase IV
Rehabilitation and Training of the Pronator Supinator Cuff
FLEXOR DIGITORUM LONGUS
• Strong ankle joint plantar flexor
• Moderate subtalar joint supinator
• Very strong supinator of the forefoot around the midtarsal joint
• Assists in preventing overpronation
Phase II to Phase IV
Rehabilitation and Training of the Pronator Supinator Cuff
Extensor Digitorum Longus
ACTIONS:
• Strong plantar flexor of the ankle joint
• Moderate pronator of the forefoot
Phase II to Phase IV
Rehabilitation and Training of the Pronator Supinator Cuff
TIBIALIS ANTERIOR
• Strong supinator of the forefoot
• Slightly weaker supinator of the subtalar joint
• Does not effect the midtarsal joint axis
• Patients over use this muscle if stressed causes permanent dorsiflexion of the foot
Phase II to Phase IV
Rehabilitation and Training of the Pronator Supinator Cuff
TIBIALIS POSTERIOR
• Plantar flexes and inverts foot.
• Supports med longitudinal arch of foot
Phase II to Phase IV
Intrinsic muscles of the foot and ankle
• They don’t have the same leverage advantage as the pronator supinator cuff
Phase II to Phase IV
Foot Flexibility
• PNF stretching creates improvements in foot flexibility which increase dorsiflexion and plantarflexion of the foot.
• Stretch these muscles
• Extensor Hallucis Longus
• Extensor Longus & Brevis
• Tibialis Anterior
Phase II to Phase IV
Active rehabilitation of the kinematic chain
Hip adduction
• Gluteus medius is trained
• Movement is in pure adduction so there is no external hip rotation or foot flair
• Adduction is 30 degrees
• Body is centered and does not come out of center so patients build gluteus and abdominal stabilizers
• 3 sets of 10 reps
Phase II to Phase IV
Active rehabilitation of the kinematic chain
Hip abduction
• Movement is in pure abduction training the adductor compartment
• No spinal extension
• Adduction is 30 degrees
• Body is centered and does not come out of center so patients build the abductors and abdominal stabilizers
• 3 sets of 10 reps
Phase II to Phase IV
Active rehabilitation of the pronation supination cuff
Foot inversion muscles
• Movement is in pure eversion so no rotation of the tibia fibula is allowed
• Initially the tibia fibula might need to be stabilized manually
• 3 sets of 10 reps
• Start with 5 pounds and move up
Phase II to Phase IV
Active rehabilitation of the pronation supination cuff
Foot inversion muscles
• Movement is in pure inversion so no rotation of the tibia fibula is allowed
• Initially the tibia fibula might need to be stabilized manually
• 3 sets of 10 reps
• Start with 5 pounds and move up
Phase II to Phase IV
Active rehabilitation of the pronation supination cuff
Foot abduction muscles
• Movement is in pure foot abduction
• No motion of the tibia fibula is allowed
• Initially the tibia fibula might need to be stabilized manually
• 3 sets of 10 reps
• Start with 5 pounds and move up
Phase II to Phase IV
Active rehabilitation of the pronation supination cuff
Foot adduction muscles
• Movement is in pure in pure adduction so no motion of the tibia fibula is allowed
• Initially the tibia fibula might need to be stabilized manually
• 3 sets of 10 reps
• Start with 5 pounds and move up
Phase III to Phase IV
Minimum Inflammation - Advanced Rehabilitation
Emphysise organized sports and active lifestyle
Achievements of Phase II
• Reduced inflammation
• Increases energy and circulation
• Increased balance
• Improved confidence
Treatment Plan
• Continue joint mobilization
• PNF stretching for flexibility
• Balance training continues
• Anaerobic training strength training of the kinematic chain with active rehabilitation
• Aerobic training of the kinematic chain
• Sports specific training - the patient can begin jogging and other leisure activity
• 3 days a week for 3 - 4 weeks
Phase II to Phase IV
Peperdine study
Active rehabilitation can reverse overpronation
• The investigators examined isokinetic and nonisokinetic strength training programs for the inversion and eversion muscles on pronation during running
• Each group trained three times a week for 8 - 12 weeks
• The isokinetic group showed significantly concentric and eccentric strength increases for all the inversion for all inversion test conditions and three of the four eversion conditions.
• They also demonstrated significant decreases in the rearfoot and pronation and supination angles at heel strike.
• The findings suggest an isokenitic strength-training program for the inversion and eversion muscles can treat that pronation/supination.
Why your patients wont exercise
• I don’t have time
• It's not important
• I don’t like exercise
• I'll exercise next week
• I'm not a gym kinda person
• No Pain No Gain -
• I don’t want to sweat
• Health club - I don’t want anyone to see my body and too expensive
• have children
Main Reason…
• Exercise is like work
• Exercise is boring!
Phase III to Phase IV
Pepperdine study exercises that reverse overpronation
• Balance boards
• Surgical tubing exercises
• One and two legged jumps over obstacles
• One and two legged jump rope exercises
• Running and hopping through figured eight triangular and zig zag courses
• Running in small diameter circles
• Intensity was to increase by 10% weekly all of which were tolerated just fine
• Strength increases were 34% for inverters and 31% for everters
Phase III to Phase IV
Active Rehabilitation and training for the rectus abdominus
• Seated abdominals
• The weight is applied to the chest and the chest slides along the bar but the bar does not move
• The athlete approximates the lower ribs to the pubic bone
• This will reduce hyperlordosis thus removing extension stress from the LS spine
Phase III to Phase IV
Active Rehabilitation and training for the rectus abdominus
• Kneeling cable abdominals
• The weight is applied through the cable as the patient extends the lumbar spine to stretch the abdominals and curls the abdominals to approximate the lower edge of the rib cage to the pubic symphysis
• This will reduce hyperlordosis thus removing extension stress from the LS spine
Phase III to Phase IV
Active Rehabilitation and training for the abdominal obilues
• Hanging Side Laterals
• Patient hangs relaxed from the harnesses
• Hips are in a piked position removing the lordosis
• Patient elevates the hip to the lateral edge of the ribs
• Patient moves right and left lateral breathing on every repetition
• Repetitions are to exhaustion
Phase III to Phase IV
Active Rehabilitation and training for the abdominal obliques
• Rotary torso obliques
• Patient is seated locking the hips into the stabilization center bar
• Shoulders, torso and head move as one unit with the motion coming only from the midsection
• Patient is not allowed to rotate shoulders
• 10 repetitions 3 sets
Exercise prescription vs a fun active lifestyle
• Diet and exercise is a principle component of anti-aging medicine
• You learned that lack of exercise, poorly designed exercise programs and poor form and technique lead to a cascading domino effect accelerating the aging process
• Anti-aging doctors have exercise facilities in their centers or have referral sources for exercise prescription to be carried out to transition your patients into an active lifestyle
• Patients don’t like exercise so in this transition phase in a patients life you as the guide must use as the goal to transition them into activities they can enjoy and are fun play rather than activities they need special equipment and are boring and like work to the patient
Phase IV - Very Little Inflammation - Resistance Exercise and Cardio Healthy Exercise and Sports Participation - Stretching
Anabolic Phase
• Maintain a stable kinematic chain
• Do exercises that work the foot from all angles
• Do sports specific training and activities that work the lower extremities in all ranges to maintain a biomechanically strong
• Encourage activities and sports like tennis, dancing, “tag”, socccer, hiking, frisbee, volleyball, yoga, tai chi and many others
• You are in the anabolic phase
• This is the Anti-aging Lifestyle!
Fun exercise activities that rebuild the foot
• Walking
• Playing tag
• Dancing
• Tennis
• Yoga
• Tai Chi
• Roller Skating
• Bicycling
Thank you!
• American Academy of Anti-aging Medicine, Dr Bob Goldman and Dr Ron Klatz
• Society for Anti-Aging and Aesthetic Medicine Malaysia
• Dr Dato Harnam and his organizing committe
• Delegates of the 3rd Malaysian Conference and Exhibition on Anti-Aging and Aesthetic Medicine
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