Good morning. I don't know if I'm supposed to introduce myself. I think I will. Welcome on this wonderful, beautiful May Day, May 1st, 2022, our first gathering together like this probably since 2019, post pandemic, and I am excited to be here. I'm from Alaska. My name is Byron Perkins. We're going to be talking today about low back pain. I like to see in my audience how many of you are actual clinicians, how many of you do clinical work and treat patients. That's good. So this lecture is directed more towards that aspect of what we do, and it's an honor and a privilege to be here today. The last presentation I gave was in Anaheim in 2019, and that morphed into a meeting with the Northwest Association or the Northwest Group in Anchorage, and I'm basically presenting the same information by request regarding back pain and an introduction to the fascial distortion model, which is something I do and use as an osteopathic physician daily in my practice. So that's Anchorage. That's where I live and play. That's Mount McKinley, our national park, and Denali is the name of that mountain. Let's talk a little bit about, I'm not seeing this down there, I guess I didn't, is there a chance that I can see this down there? That's who I am. It doesn't matter. I graduated from Kansas City in 1984, and I've been in Alaska in practice pretty much ever since. In 1986, I'm ringing a little bit, so you guys can help me back there, and I have nothing to disclose. I don't make money doing this, although I did get a discount on the registration fees, and I'm happy for that. So the lecture format today, we're going to talk about low back pain. You all experience and know people who have that, and then we'll talk a little bit about the guidelines. And for the second half of the morning, I'd like to talk about the fascial distortion model. I'll show you some video of treatments that we do. There'll be some case presentations that you might find interesting. So low back pain is very common. It's caused more disability around the world than any other condition. Most Americans have experienced this, maybe some of you in this room. In one study, it was the most common type of pain reported by patients. Twenty-five percent of adults reported low back pain in the last three months, a lot of people. I see them in my office. You see them in your practice. You see them in the work that you do in occupational and environmental medicine. It is one of the more common reasons that people see the doctor, second only to skin disorders, which surprised me. I always thought it was upper respiratory infections. The data suggests that skin disorders are number one, back pain number two, and then upper respiratory infections. Very common. Oh, I'm skipping past. All right. Here we go. It's costly. It costs a lot of money. And this afternoon, there's going to be a lecture, I think at 2 o'clock, I'm very interested in that, on disability and associated costs of low back pain in the workplace. I think that would be interesting. Wow, I'm ringing. Can you hear me okay? It's feedback to me. All right. Prevalence in the last three months, 33%. Community-developing adults, patients with back pain contribute $365 billion in all costs, medical costs. It's a lot of money we spend in that area. Osteoarthritis was the second most common thing. And those two together are very much a problem financially. I don't know where I'm at. There we go. Classification of low back pain is frequently classified based on the treatment of symptoms. The duration, the potential cause, the absence of radicular symptoms, et cetera. Acute back pain is defined as lasting less than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. Subacute back pain is defined as lasting longer than four weeks. I don't know where I'm at. There we go. Classification of low back pain is frequently classified based on the treatment of symptoms, the duration, the potential cause, the absence of radicular symptoms, et cetera. Acute back pain is defined as lasting less than four weeks. Subacute back pain, four to 12 weeks, and if it's been more than three months, we call it chronic. These are all just chronology type of diagnoses and definitions. Radicular low back pain results in lower extremity pain. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. This can be parasympathetic. I wonder if I touch this, it would change. There we go. Characteristics. Now, most people who get low back pain, it's self-limited. If we do nothing, 90% we're better in a month. That kind of data has been around for a long time. The fact is that seems to be changing. Patients who do seek medical care and the pain and disability will return to work. But 30% go on to report symptoms that last in moderate intensity for up to a year. That's a big number. A lot of people out there suffer from an injury that results in ongoing symptomatology. So diagnosis, low back pain. Majority? Way more than the majority. We don't know why. Let's be honest, we don't know why it hurts. We're going to be talking about it a little bit today in the fascial distortion model because we have a better understanding and idea of what might be the pain generators when we're talking about low back pain, and it gives us something that we can do. Lumbosacral strain is a diagnosis by default. We just call it that. Or lumbago used to be the word that we used a lot. We still do. That's no longer in the classification of diseases. You have to up-code that a little bit higher. It can be ascribed to sprains or strains or soft tissue injury, mechanical, myofascial pain syndromes, facet syndrome, et cetera. All of these are lumped into one category, low back pain, and we see this often in our patients, certainly in our workers, and they often need our input on how to manage that and how to get back to their workplace. There are no specific tests to diagnose this, okay? I mean, even the College of Radiology will tell you that the image on the x-ray doesn't really tell you what's going on. Millions of people have herniated discs and don't have back pain. Millions of people have osteoarthritis and don't have back pain. We can't ascribe it to what the image is on the x-ray, although sometimes it can be informative. So it's a clinical diagnosis. It's still based on history and physical, and that's what we do every day. Those are the new coats in the ICD-10, and they go on and on. And I believe that my slide deck will be in a PDF available to you later on, so if that's the case, you can look at these slides later. When we get into all of the guidelines that we're going to talk about, they'll be all there, so I don't want to belabor most of the possible causes. Certainly there are systemic causes, and we need to be aware of that and rule them out. Malignancy, infection, and abdominal aortic aneurysm can be a very significant problem, and if you just think it's back pain and miss that, somebody could die on your hands. Certainly any of the internal organs can contribute to low back pain. We have rheumatologic and structural conditions. I work in this field a lot, mechanical back pain, and that's what we treat with osteopathic manipulation. There are some lists of symptoms or diseases that can cause back pain. And the synovial subarachnoid cysts can mimic disc injury and herniated discs, et cetera. That's really only going to be picked up on the imaging when you need to do it. Finally, you have... Maybe I need a point there. I don't know. What we commonly think of, the herniated disc. And in fact, most of the time, that's not the pain generator in patients. So, all right. Brief summary on back pain. Key considerations in our physical exam, presence or absence of radiating pain. If it's going down the leg, we need to think about that differently. Now, I worked in the ER for seven years at the Alaska Native Medical Center in Anchorage, and it seemed like when a patient came in with back pain, that other physicians would avoid that chart and go around to the next chart and leave it for Dr. Perkins. It doesn't intimidate me at all, but for them, that was a challenge, and it was medical decision-making and so on. So depending on your orientation, back pain may not be that big a deal. It certainly isn't for me anymore. It's kind of a challenge, and it's fun, but it's real, and we see a lot of it. So the presence or absence of neurologic deficits based on the assessment of their muscle strength, their reflexes, all of those things are important. We do that routinely. That initial neurologic exam becomes the baseline from which other exams are compared, and that's an important finding in our charts and progress of a patient. Any progression of neurologic deficits over time may need surgical referral and consultation, and we have to pay attention to those things, obviously. Even so, patients with herniated discs and nerve root compression, conserve the treatment. It helps keep them as active as possible. It can be acetaminophen, which is no longer on the guidelines, and says that manipulation may avoid the need for surgery, and anything you can do to get your patient moving and keep them moving, get them back into the workforce, you're giving them their life back. So this is an important slide that I just picked up from the Academy meeting. The American Academy of Osteopathy had a conjoined meeting with the American Osteopathic College of Sports Medicine. Wow, it was in Orlando just last month, and it was talking about trauma and pain and neurobiology of pain and neuroplasticity and stuff that I haven't been fully aware of. It was very exciting, but the point is the extent of injury does not equal the extent of pain. It can be a minor injury, and you've seen this, and they have a lot of pain associated with that, or it can be a very extensive injury and hardly have any pain. So pain in the body is felt as pain in the body, but how we relate to our pain is from here up, and that's what we're going to be talking about this afternoon, I believe, as we talk about the psychology of low back pain. I have an abstract. It's coming in your handout. I'm going to skip through this because we're going to go right to the case presentation. You can look at that later, but this is a case report of a patient who came in my office several years back now, a 65-year-old male who came with a back spasm. Actually, he didn't come to my office initially. He went to his primary care physician. Pain came on driving from Kenai to Anchorage, a distance of about 150 miles. He'd been fishing, and just during the drive home, he developed back pain and spasm. He's had similar episodes like this in the past, nothing to this extent. By the end of the day, it had escalated. He had difficulty walking, and he found himself confined to the floor for several days, and over time, a period of two weeks, he lost about 25 pounds. His past medical and surgical history is pretty unremarkable. He went to see his PCP. He really didn't have any significant clinical findings except that it was flank pain reading to the groin. And so his GP said, let's check out the kidneys and did some lab work, and in fact, they did a stone study, and the stone study came back negative. He was put on some Norco and some Senna and some Flomax for his kidney stuff. I'm sorry this thing doesn't twitch. There we go. The stone study was negative. I already said that. I wish... maybe I can hit this button. I'm going to try. Nope. Nope. Can I read the case report for you? You can read it faster than I can. It's a waste of your time. Four days later, he went back. His pain's getting worse despite his ibuprofen and Norco. He had gotten some Valium as well for the spasms. He was laying on his back with his hip flex. That's what made it better. And even in the notes from the physician, it seems to be more inflammatory soft tissue rather than nerve root in nature. There doesn't appear to be any radiculopathy. Lumbar spine x-ray showed arthritis. He's 64. Of course there's arthritis there. And so they decided to do a trigger point injection. And they gave him a Medrel dose pack. Two days later, he had a minimal response to the injection, so he's referred to get a left SI joint block under fluoroscopy. It's because he was indicating some pain over the left SI joint and even into the gluteal area. They did an SI joint injection with Depimedrol and Marcane and said consider an MRI if his symptoms persist. Three days later, he's still having back pain despite the trigger point injection and the left SI joint injection. He had about four hours of pain relief from the injection and it wore off, which is not uncommon. It doesn't correspond to the usual anatomic considerations. And so now they do an MRI. The MRI shows multiple tears, angular tears at several levels. The largest is L5S1. I'll show you a picture of it in a minute. No severe canal stenosis. But, you know, here's the radiologist. It could be from this or that or the other thing. We see those kind of readings all the time. And unfortunately when patients see this, they think they're going to die. I have all this stuff going on in my back. And we take it as, yeah, this is normal stuff when you're 65, right? Okay, so findings that L5S1 could be related to the patient's current symptoms. And where's the picture? Ooh, that's not showing up very good. But you can barely see a little herniation at L5S1 in the transverse view. A little bit of projection to that left side, okay? So, I mean, they use that to justify now an epidural steroid. And he went for that. And he got modest but temporary relief of pain. And now three weeks in, after losing 25 pounds and barely being able to walk, his friend, his colleague, the funder person that went fishing with him, called me in my office and said, Byron, will you see this guy? I know he's on Medicare. He said, It's not true. I do see patients with Medicare by consultation all the time. I said, I'd be happy to send him over. And that was my first visit with him. Oops, skipped you there. Three weeks after onset of symptoms. And what he had was pain in his left flank, as before. And in our world, that's a herniated trigger point, which I treated. You don't have to know all this nomenclature. Until you take the course, you're kind of looking at some gobbledygook. But that means I treated those things. And I did give him some cyclobenzaprine and some tramadol. The important part of this point is that he had been laying on a heating pack and had a second-degree burn that hurt less than his back pain. I mean, it was that big, and it needed treatment. He had a blister on it, and he had not even paid attention to the burn. That's how bad off he was at the time I saw him. So I saw him three days later. And I got a good 50% improvement from my treatment, which I thought was pretty good. Not as good as I'd like to see it, but it was pretty good. He is eating now, and he's actually ambulating independently. That's a clinical improvement. Get him walking, keep him walking, get him moving, keep him moving. Body heals itself. So he's now sleeping through the night and doesn't have any of that referred pain from the treatment that I was able to provide him. And so we did some more treatment. And he comes in one week later, and he's reporting continued improvement. He has a pain of 5 over 10 on a 10 scale, so that's significant in my mind. But he's driving now, and he's been able to walk around the mall. And he self-reports that he's had more relief from the treatments that we've done than he had from all of the steroid injections. So that's a clinical response to me. And the burn is healing nicely. I was pleased about that. And we treated him some more. Two weeks out, two weeks from my initial consult, he reports continued improvement, feeling pretty stable. His pain is now 2 over 10. He's been able to drive. He's returned to his recreational activities, which means driving 150 miles down the Kenai to go fishing. So I think he's pretty well. And in fact, what gives me the biggest clue, he wants to address his right shoulder symptoms that he's had from a shoulder dislocation 45 years earlier. So his back's much better. Can you look at my shoulder? So the point I'm making here with all that is that he was treated allopathically with all of the common and accepted methods based on his physical symptoms and the radiographic findings, but with limited success. And you all have had patients with the same kind of outcome, I'm sure. I will tell you that the published guidelines we're going to discuss indicate that manual therapies have been proven effective in the management of acute low back pain, and it proved to be the case in this patient. Back clinicians should consider utilizing manipulation to reduce pain in disability in patients with mobility deficits and back-related buttocks or thigh pain. And if you don't do it and know somebody who does, find the connections because it can make a huge difference for your patients. If you're trying to get them back to work, the sooner you get them on their feet and moving, the more chance they have of returning to an active lifestyle and back to work. And this was with strong evidence. So I'm going to introduce the fascial distortion model later on and show you exactly what we did in not this particular case because I didn't videotape it, but another case or similar cases. And it is a patient-centered approach. It's symptom-based. The patients intuitively know what needs to happen to get better. They communicate that through both verbal and body language, and it's the body language that we key on. Patients show us every day how and where they hurt, and that's how we treat. Correcting that makes an immediate difference, and you can see the results. The patient can feel the results, and they are encouraged because what hurt before doesn't hurt now. They leave your office moving much better. And that is the goal of any treatment is to get them moving better. So I would usually stop for questions here, but that's just a distraction slide. That's in Seward. No, no, that's in Sitka, and that's Mount Edgecombe, and that's in the wintertime. And that idiot's surfing, not me, surfing. All right, so clinical practice guidelines. We'll divert a little bit of attention to that because that's the nature of this lecture. But guidelines are guidelines. In fact, a number of guidelines have been published over the years. How many of you were around in 1994? Yeah, a few of us. Okay, that's when I remember the first ones coming out. What are they? They are recommendations based on our current best evidence, published clinical studies, data-driven, existing at the time of publication, developed by specialty organizations reviewing the data. They are guidelines to improve care, and they are constantly shifting because data is constantly changing. In fact, the guidelines published today were developed on studies 5 to 10 years ago, and they are continually morphing. That's part of medicine, we expect that. What they are not, they are not guidelines for community standards of care. They are not telling you what you need to do, how to do it, and when to do it. They should not be seen as prescribing the type, frequency, or duration of the intervention. So recognize guidelines for what they are. They help us find our way and they help us kind of stay on task as professionals in what we do. So a number have been published dating from, oh, 1994 until most recently, 2021. The Agency for Healthcare Policy and Research, AC, whatever that says, this was initial. Get them moving, get them out of bed. No more bed rest, remember that one? Yeah, no more bed rest, get them moving. Exercise can prevent deconditioning. Medications, they strongly advocated acetaminophen at the time, NSAIDs, mouse relaxants, and opioids. We don't do opioids very much anymore, right? With the opioid thing. Manipulation was actually credited with having some value. Physical modalities and referral to spine specialists when indicated. It recognized the role of manipulation in the treatment of acute low back pain. Said it should be discontinued and reevaluated if there's no improvement after one month. I challenged that, but in fact, guidelines are guidelines. That's what the data showed at the time. Now recommended for long-term, and I treat patients who have had chronic pain and get them moving, but the data is less robust on chronic pain as it is for acute pain. And of course, there's all kinds of people who do manual medicine. How many of you use manual medicine in your practice? How many of you do that? That's awesome, so there's several of you that do that. Our physical therapists today, many of them have taken extra course training in manipulation, and they're good at it. Our chiropractic brothers do it all the time as well. Our athletic trainers, certified. Many of them are trained in manual medicine and do quite well in what they do. So I'm gonna run through a list of guidelines. 2007, I think this was the American College of Physicians. This has been updated in 2017. This is just a reference. This should be in the bibliography. It will also be on the slide deck when you get it. 2009, Evidence-Based Clinical Practice Guidelines from American Pain Society. Moving ahead. AHRQ, the original 1994 guidelines were updated in 2012 for acute and subacute low back pain, subacute being less than 12 weeks. All right, the orthopedic section of the American Physical Therapy Group published theirs in 2012. They just updated theirs in 2021. So again, guidelines are constantly shifting, constantly moving. And if I told you I've read every one of them, I would probably be lying. You'd think I'm a politician. I didn't read the whole bill before it passed, okay? The latest one published in 2020 has 120 pages. Yeah, that's huge. How many of you have time to read that? Not likely. But I did pull out the piece that's pertinent because it supports my idea that manipulation can be helpful. And I like to pat myself on the back sometimes. So the recent guidelines continue to reaffirm the role of manipulation in the treatment. It recognizes that methodologic quality remains a critical problem. And how do you do double-blinded and controlled studies on something that is so direct and hard to double-blind by any measure? So it's no evidence that it's superior to other standard forms of treatment. That's unfortunate for us, but it's real. Acupuncture, massage, chiropractic, the aspect of manipulations, they're not single well-defined modalities or well-defined monotherapies. Every one of us, when we practice with our hands, we use different aspects of what we do to get to the best outcome for the patient. And the beautiful thing about the fascial distortion model that I get to share with you today is that the patient is the expert. They're always right. And if you follow their guideline, what they're showing you, you're gonna be right every time. And in fact, it's a lot safer than what I used to do. So, fastidious trials that evaluate these complementary and alternative medicine treatments using restrictive protocols are difficult to initiate, although it's trying to be studied through the NIH and the CHAM stuff. Okay, so this is the most recent guideline that I've kind of been familiar with. And there's some key recommendations here. This was, again, from the American College of Physicians, updated from their 2007 guidelines. Non-pharmacologic treatment, including superficial heat, which I discourage, personally. Massage, acupuncture, or spinal manipulation should be used initially for most patients with acute or subacute low back pain, as they will improve over time regardless of treatment. You're not doing harm, you might help. That's kind of where they came up with on their recommendation. When pharmacologic treatment is desired, the non-steroidal anti-inflammatory drugs or skeletal muscle relaxers should be used. They took acetaminophen out of their mix because it didn't seem to be that effective. Remember when osteoarthritis was treated principally with acetaminophen because of its safety profile doesn't always work for acute low back pain in the same way, although we still use it. Non-pharmacologic treatment, including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness, that's the new thing, right? Stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeed, all kinds of modalities can be helpful and should be used initially for most patients who have chronic low back pain. So people with chronic pain can benefit from these types of interventions. And for patients who have chronic low back pain and do not respond to non-pharmacologic therapy, NSAIDs should be used. Pramodol or duloxetine should be considered for those patients who do not respond to or do not tolerate NSAIDs. Opioids should only be considered if other treatments are unsuccessful or when potential benefits outweigh the risks and see the full recommendations. This is just the same thing in bullet form and it's in your handout. The American College of Family, or the American Academy of Family Physicians endorsed this back pain guideline. I'm part of that. And it's the same and it's not turning, there we go. There was a new guideline came out in 2018. I believe this was from Europe. Yep, the Europeans have to get in on the act. They have their own ideas of what we should do and it's very similar. That's the point. What we do here and what we do there is very commonly the same because it has good outcomes and can be recommended. All right. This is the 120-page document that was bare to look through. I'm just telling you. But in fact, they had Q1 recommendations for patients with acute or chronic low back pain. Spinal manipulative therapy is an option to improve pain and function. For patients with acute low back pain, the spinal manipulative therapy results in similar outcomes to no treatment, to medication, or to other modalities. Periodically short-term improvement is statistically better, but clinical significance is uncertain. They gave it a recommendation grade of A. So manual medicine for your acutely injured low back pain patients can be helpful. If you don't do it, find somebody in your community who does that you trust. Develop a working relationship with that person and find out if they can help you get your patients back to work and back to their lives in a more fastidious manner. So patients with low back pain, conflicting evidence. Doesn't seem to be that much better than other modalities. I still do it. I treat patients with chronic pain all the time who have been treated by every other modality known, and now I'm dealing with scar tissue and instrumentation and post-surgical stuff, and I'm still able to help them in the fascial distortion model. I'm looking for a clock. I think we're going good. The physical therapist upgraded their guidelines, and there's even a guideline for when and how to image by the American College of Radiologists. For acute, uncomplicated low back pain, it's not necessary. MRI of a lumbar spine should be considered for those patients presenting with red flags, and the red flags are those radicular symptoms, motor weakness, neurologic progression, et cetera, and that's a clear indication for that approach. Patients with a history of low-velocity trauma, osteoporosis, clinical or chronic steroid use, may want to consider at least initial radiographs to begin with, and MRI is the imaging procedure of choice for people having suspected cord. I see these patients most of the time, they've already been imaged. I don't image hardly anything, because when I treat them, it's either better or it's not, and the model kind of defines whether they're going to recover or not. Imaging is often done well before I ever see them in my office, but there are times when I have to send patients, because if they're not responding to what I do, that's a clinical red sign, and that's what we do. So, indications for surgical referral in sciatica, it's important, and know who your surgical consultants are, know who they work with, know how you connect with them. We have neurosurgeons in our community, and we have orthopedic surgeons in our community, and you define what kind of surgical procedure you might want to do, and send them to the person that you might want to have see them in your community. So, that's another break slide. So, people want to know what is an osteopath, want to know what we do. I'm family practice, but 15 years ago, I was introduced to, 16 years now, to the fascial distortion model, and it changed my life. And now, I just do manual medicine. 90 plus percent of my work involves treating patients in pain, and it's very rewarding, because I can see the response, and I can see the outcome. Anybody in my world can treat hypertension, diabetes, thyroid, all the common things that we deal with in primary care. Not everyone gets to do what I do, and help people get their lives back, so this is my new thing. I teach students, I have residents, I travel around the world, and different presentations like this, and that's very personally rewarding for me. It's what I went into Alaska for. So, we quack backs. What is osteopathic manipulative therapy? And, the therapeutic application of manually guided forces to an osteopathic position to improve physiologic function, blah, blah, blah. There are codes for this. We actually build these procedures as medical procedures, because they are medical procedures. They have potential implications. We have to go through risk-benefit, and we have to talk about alternatives, very important. We do informed consent. I do it, it's part of my presentation. Every time I do a new patient, we go through an informed consent presentation, much like a surgeon would. There are many kinds of treatments that are in the osteopathic world. Most people think of manipulation as one thing, cracking backs. The fact is, I rarely crack backs, but they sometimes crack. I do a lot of other stuff that makes a lot of difference. And, we're gonna talk about this particular one down at the bottom, the fascial distortion model, because now, all of my treatment is through this lens. And, all these other things that I do are through that lens. It's a whole new orientation, a whole new perspective. Somatic dysfunction is what we call it when something hurts. It is an impaired or altered function of related components of the body framework system, the skeletal, arthrodial, myofascial structures related vascular, lymphatic, and natural. This is the stuff we have to produce on a board exam. You don't have to know any of it. It's the sore spot on the back. That's what we call a somatic dysfunction. And, we have codes for these things, actually. ICDM codes, the non-allopathic lesion, or somatic dysfunction. In that turn, it did. So, osteopaths think in four concepts. And, this is being introduced now in our training programs because we've gone to a combined graduate medical education program. So, what used to be our core is now kind of, I don't know how it's working. My residents are a little bit confused, as well. But, this integration of systems between the allopathic and the osteopathic world, these are what we hang our hats on. The human being is a dynamic unit of function. Its body has self-regulatory mechanisms. There's self-healing in nature. Body heals itself. We say that all the time. All we're doing is pointing it in that direction. And, if we can find what hurts and get rid of it with movement and activity, that's how the body heals. Structure and function are interrelated at all levels. And, everything we do is designed to bring those principles into play in a rational treatment process. So, what is fascia? We're gonna talk a lot about fascia from here on. I'm on my fun stuff. It's that connective tissue that holds us all together. It forms a whole body continuous three-dimensional matrix of structural support. If you've not heard much about fascia in the last 20 years, it is like exploding in the international community. And, anybody who does body work, fascia is gonna be part of it. The International Fascia Congress, the sixth International Fascia Congress will be in Montreal in September. I plan to attend. And, the two others, just, you're putting all these people in a room. Some work in like the basement of their university doing this stuff with the cell. Okay, that's what they live for. I don't get that. And then, there's the body workers like perhaps me and maybe the, whatever they do, Rolfers over there. And then, you've got the clinical researchers and the medical folks in the physical medicine rehab. We're all talking in the same room about the same stuff with different perspective. The crosstalk is amazing. It's a lot of things you can learn from that. So, it's everywhere. It's everywhere. Most of you have seen pictures like this. And, it's that continuous sheet of tissue that extends. And, I have to do this because I talk to people who don't know what I'm talking about. It's this continuous sheet of tissue, but it's more than the covering of the muscle. It's the integrative tissue that everything is invested in. And, from head to toe, all systems of the body are organized by fascia. It's proprioceptive. It's supportive. It's conductive. It's contractile. It is separate and identifiable from the central nervous system and its function. And, it actually begins the contraction before the muscle does. It's pretty amazing stuff. And, that we know just in the last 20 years. So, that's a fascial skeleton, if you will. This is from Gil Hedley, an anonymous PhD. And, the female patient on the right, and that's her fascial envelope that she lives in on, I guess, on your left and right. And, that's a superficial fascia. That doesn't include all the other stuff inside. So, really dynamic stuff, really informative stuff. So, we as osteopathic physicians consider the fascia to be an organ system, much like our skin. It tells us what's going on inside our body the way our skin tells us what's going on outside our body. It's neurosensory, proprioceptive. I already said that. It has structural and mechanical integrity. And, we actually talk about fascia having memory. The engram of memory, the traumatic experience of the injury is stored in the fascia somehow. And, as we're treating fascia, we can sometimes release that, and the patient will have a total body response as that mind-body connection occurs in the treatment process. Okay, so it allows the body to move as a function, as a cohesive unit. It causes pain when it doesn't work right. And, that's what we're gonna talk about today. They consistently describe this pain, and that's what we're gonna do. So, what's a model? It's an analogy. It's to help us understand. What I'm showing you today is a model. It's an idea. I cannot give you an MRI or a ultrasound picture showing you this fascia is doing this stuff. We may get there, but we're not there yet. It's a model. So, what is the fascial distortion model? It's an idea. It's an anatomic perspective in which most musculoskeletal injuries in certain medical conditions are envisioned as consisting of one or more of six principal fascial distortion types. Each have their own clinical signature presentation. There's six things. That's what changed my life. All that year and years of study in the medical school, and the patient is smarter than I am. They intuitively know what needs to happen, and there's only six things. All musculoskeletal pain is some combination of one or more of six things. It brought my world into focus, and that's all I do now. And, until you experience that and see that, it sounds kind of unbelievable. So, Dr. DePaul has found this idea. He came to Alaska in 2004 and gave a presentation, and it rocked my world and basically changed my life. He's published, he had a textbook published in 2002 that's somewhat dated. In fact, you can't find it in print now, but it is on the internet. There are several texts that have been updated since then. But, it was only experience. He broke his arm when he was in his internship, and they put it back together, but he couldn't use it, couldn't open the three-ring binder. Remember what those were? Couldn't get into the door at the cafeteria. He had pain in the arm, even though it was well. Every time he went back to the orthopedic surgeon, they said, it looks great, x-ray looks good. And, three times in a row, they said, it looks good, and he said, but I can't use it. And, though, one of the docs said, well, you know, we could break it and put it back together again, but you have to go through the whole process. And, he didn't think that was a very good idea. So, one day, in a fit of frustration, he said, I'm gonna break it or fix it trying. I'm gonna fix it or break it trying, said the doctor. And, that's what he did, stood in the shower, got as high as he could, pulled his arm up, felt the most god-awful pain, snapped like he'd broke it all over again, but it hadn't, and now he could move it. He didn't know what he'd done that day, but he'd corrected what we now call a folding distortion in the interosseous membrane of the forearm. Bones looked great, they healed nice, x-rays were perfect. It didn't tell him why his arm couldn't function without pain, and that was his beginning. And, over time, he developed this idea that, you know what, patients are smarter than I am. Patient came into the office and said, I have a pain, it starts here and goes there. He did an osteopathic thing, sent him out the door. Next patient came in and said, I have a pain, it starts here and goes there. Thought to himself, loser, did his osteopathic thing, sent him out the door. Third patient walks in, I have this pain, it starts here and goes there. And, he said to himself, self, what is this pain that starts here and goes there? They didn't teach us that in medical school. It wasn't part of my residency training. I don't know what that is anatomically. And, he excused himself and went to his anatomic books to look for it and found nothing. I mean, splenius capitis, there's a bunch of muscles that go there, but what is this pain that starts here and goes there? And, then it came to him. Patients should know. I somehow knew how to fix that thing in my arm. I don't know how I did it. I'm gonna go ask that patient. And, that's what he did. And, the patient looked at him and said, but you're the doctor. He said, I don't know what this is. I've never seen it before. Tell me what you think I need to do to make this better. She said, give me your knuckle. Knuckle. Now, push on that thing. And, he's going like, what thing? That thing. And, so he put his knuckle into her back where she said this thing started and started pushing. She said, now follow it. He said, follow what? He said, follow that thing. And, he followed that thing from where she said it started till where it ended at the base of the occiput. She's now crying. She had one of those somato-emotional responses that we talk about when fascia is released. She said, I've had that pain for 22 years, and I've wanted someone to do that for me. And you're the best doctor, and he said, I don't know what I did that day, but it was powerful and I wanted to learn more. So then patients come in and they have this diagnosis, right? What's that? You all know this. Yeah, bicep tendonitis, right? I mean, we are taught to look for pattern recognition in what we do. And so that's bicep tendonitis, except it doesn't have any of the findings of bicep tendonitis that hurts here and goes there. So he took his knuckle and did that, and the patient said, ow, and then he said, wow, that's better. And so anything that starts here and goes there, he began defining as a band of fascia that's twisted, and he called it a trigger band. We're going to talk about trigger bands today. And the rest is kind of history. This system of knowing and communicating is inherent in the fascia. It is the same when I go to Africa. It's the same when I'm in Mongolia. It's the same when I'm in Japan. Everybody's language of pain is consistent, and we call it universal. Yeah, we're good. I think we're good. You holding up? You guys getting sleepy yet? Need more coffee? All right. So I think I skipped one. There we go. So in the fascial distortion model, the manipulative practice, each injury is envisioned in a model. The complaints, their body language, and that's the key. I think Dr. Tbaltas was a genius in discovering the body language approach to this because the patient consistently shows us certain body gestures, they call them gestures in Europe now, that are classic for one of the six distortions. They have a mechanism of injury. If you can ascertain that, that's great, but what do you do with a guy who's had a trachnea since football in high school, and he's now 65? That's a folding distortion that can be treated. You can resolve his pain, but it started with an injury in high school football, and he's lived with it all his life. It's a fascial distortion. It's a wrinkle in the fascia, which when treated ceases to exist, by the way, and they can do things they couldn't do. We create a meaningful diagnosis with practical applications. The treatment is directed to specific anatomical distortions of this fascia, whether it's the capsule, the ligaments, the surrounding fascia. We are physically reversing it. We are doing something anatomically to the fascia. It's an important concept. When the fascial distortions are corrected, that anatomical injury no longer exists. The patient can resume normal function and is pain-free. That is my goal on every patient, every visit, 100% pain-free, moving like they should before they leave my office. Now, that's a challenge with a frozen shoulder, but I've done it, and so I know that it can be done, and the point is I don't have to do that all in one visit. Get it moving partially, and over time, it's better, but in the old days of treating somebody for six, eight, 12 weeks, plus six months of physical therapy to get a frozen shoulder moving, we talked about that in Anaheim, and to be able to get that shoulder moving today means they're well on the road to recovery, and that's what the fascial distortion model can do. The model allows for strikingly effective treatment to otherwise difficult and diverse conditions, things that we kind of looked the other way on and said, I don't know what to do about that. It's not a surgical problem. It'll heal. Give it time, and it does most of the time. But if you can make that better today, that patient is well on the road to recovery. I wanted to design a study using a sprained ankle, so I treat patients not only with sprains, but third-degree sprains, and not only third-degree sprains, but sprains with fractures, and I get them walking out of the office on the same day. That's pretty cool, without crutches, by the way, without splints, and often with limited numbers of pain medications. That's in the model. You treat the, you correct the fascial distortion. It's immediately better, and the patient knows it. I'd like to do a study that treated it that way versus the usual and customary, RICE, rest, ice, compress, elevate, four to six weeks, get them moving on crutches. How does that work for your patient who needs to be back at work next week, or the basketball player who has a game on Saturday, or the track runner who is competing for track? If you can get them moving today and moving in the right direction, that thing will heal quicker, better, faster, because you corrected the anatomic distortion responsible for their pain and dysfunction, and that's the fascial distortion model. All right. We're going to get to some fun stuff here in a minute. This slide changed my life. Dr. DePaul just came to Anchorage and demonstrated this. He didn't just say it. He demonstrated it with patients. We brought our most difficult, challenging patients to him. I took a patient that I'd already been treating with a frozen shoulder to him, and he corrected it in one treatment in about 20 minutes, and I'm like, I've never seen that before. We took a third-degree sprained ankle. The guy couldn't walk on it. He walked out. Actually, he jogged out of the room on a third-degree sprained ankle without his boot. It was pretty amazing. It's immediate. Results are immediate. It's either better or it's not. You can't fool the patient. You can't fool yourself. You see the results. It's measurable. It's objective. It's not like kind of, sort of, maybe. It's either better or it's not, and you can see it. The patient knows it. It's predictable, meaning if somebody comes in and says they have this pain right here, it's predictable that that's a trigger band, and if you treat it, it's reproducible. It's going to happen over and over. My practice, and over the years, I've treated thousands of ends of one. I don't have a clinical study that compares 500 of these people against 500 who weren't treated that way, so these are all what they call experiential. The fact is, I see the results every day, and you will too if you use this in your practice, and it's pretty rewarding. So there are six principal types of distortions. We've mentioned that a few times. All musculoskeletal pain is one of these or more of these things in combination. When we do a seminar, and we teach this as seminars, we have a full 20-hour weekend course, and you learn how to do this stuff in a 20-hour course, and the first module is ankle, knee, and shoulder, and we use that because in the osteopathic world, many of us were trained in manipulative medicine, but we didn't get a lot of treatment techniques for shoulder, knee, and ankle. So this is vital, and you can go home from that seminar and be able to treat patients effectively immediately in your practice that week. Then we do the spine in module two, and for our medical colleagues and our physical therapy colleagues, they're a little scared about the spine, right? I'm not touching the neck, right? And so we use that as a module two. The principles are the same. The patient shows you where and how it hurts. You treat that. We're going to look at that stuff today in the videos that I present for you. Folding or continuum distortion, blah, blah, blah. Those are the six things. Module three is head and neck, and other things that we don't touch on in module one and two. If you take all three, you can get certified internationally for this process, so not necessary. So how do we approach a diagnosis? The same way we do in any other medical field, history and mechanism of injury. What happened? How did it happen? All the things you do when you're evaluating an injured worker, right? You've got to get that information, but we're looking at their body language and the verbal associations that go along with that body language, and that's your diagnosis. And they don't even know they're telling you that until you bring it up afterwards. You do a physical exam, and we do a before and after physical exam so we can quantify the result. And we want to establish a treatment goal before we begin treatment so that the patient knows we know how they know it's better. How we know it's better when it's done? It's better it's not. How do you know? What will you be able to do without pain that you can't do without pain right now? It's not what I think. It's what the patient says. If I could bend over and tie my shoe, I would know it's better. If I could reach up here and snap my clothing in the back, I'll know it's better. So I treat to that level. If I get that much done, they may still have other things hanging out. We got them to where their goal was, and we can move forward. So in summary, what is the fascial distortion model? It's an anatomic model. It's a model envisioning, diagnosing, and treating mechanical soft tissue injuries based on those six fascial distortion types, each with their own signature verbal and body language. And once you start seeing this, you can't unsee it. Every time you see a trigger band from here on, after seeing one treated, you go, oh, that's one of those trigger band things, and it's pretty cool. The model allows for a better anatomic understanding of, and therefore predictability in, diagnosing and treating previously difficult to treat, often inadequately treated soft tissue injuries. Bill Smith was the medical director for Boeing in Seattle. He came to Alaska in 2004 and 2005 when Dr. DeBaldis was there. He had six physicians on his team underneath him, and he said, this is the holy grail of soft tissue. If we could get this into the hands of our occupational medicine specialists and our physical rehab folks, we can get people back to work, we can give them their lives back. All of that disability that results from not getting adequately treated and chronic pain and surgery down the road, all the stuff that happens often because it doesn't get resolved, we could have obviate debt. And Bill used those words, the holy grail of soft tissue. Okay. Okay. Now another pause question, but getting into the meat. I will take questions now. We're talking about back pain, low back pain, we're going to be talking a little bit about guidelines that's done. Now we're going to talk about what is this model that I'm so passionate about. If you don't hear my passion and get my excitement, I'm a poor communicator, because what I'm about to share next is why I do this. No questions from the audience, and yes? Yes. How do you differentiate what you're describing from muscle imbalance in general? Okay. So muscle imbalance is a functional assessment, correct? Oh, how would we differentiate this model and what we're doing in this model from, say, testing muscle imbalance or muscle differences is how I'm interpreting your question. Is that correct? Right. So in a fascial distortion model, we're treating fascia. The muscle is activated by that fascia. It's a whole new perspective. Okay. Yeah, you can find muscle imbalance. Why is there a muscle imbalance? What's not firing correctly to make that muscle imbalance present? What physical exercise is necessary to get them back on track? And that's what our physical therapy colleagues do. That's what athletic trainers do. They find those imbalances and get them working on weaknesses. We got to treat the painful stuff, the things that kept them from doing what was normal to begin with, get it moving, keep it moving, and now with the physical exercise, they can get their strength and balance and muscle activation back online. So recognize that fascia is its own unique system, and if you didn't take that home from today, I didn't communicate very well as well. There's some questions online, but I think they're having problems with the technology, not with me. Okay. Can an APP enroll in the course for manual medicine? Anybody? I guess that's a physician assistant or a nurse practitioner. I interpret APP on mid-levels attend our courses. You have to have a medical license or a license to practice, and we will train you if you are using manual medicine in your practice. Okay. Yes? I could not hear your question very well. You asked about chiropractors, physiatrists. What I do? What's the difference? What is the overlap? Oh. This question comes up often in my practice. How are you different than my chiropractor? I say, well, your chiropractor is oriented to your spine and does a lot of treatment related to your spine, and in fact, the chiropractor understands that's the primary cause of any problems that you have in your body is this malalignment or dysregulation of your central nervous system. They have branched out beyond that now, but that's their basic philosophical underpinning, and they treat the spine very well, and they're very competent in doing that. Some of them are introducing soft tissue techniques through massage in their clinic or even some dry needling in their clinics, et cetera, but in fact, the goal is the same. Get it moving. Keep it moving. The body will heal itself. We are philosophically oriented differently. An osteopathic physician treats the whole person. Mind-body-spirit treats the whole system, nerve, artery, vein, fascia, lymphatics, and we differentiate ourselves in that way. All right. Another question? Yes. Yes. That's correct. That's good. So I want you to listen through the entire course. Chronic pain and acute pain are two different bugs, and we're going to understand that better in the future. Acute pain is what happens after an injury, and all the evidence says treating them in that way can be effective and should be encouraged. Okay? No. It says that it did. It's no better than any other treatment, but it can be helpful and it's encouraged to do. So that would be no better than any other modality or any other like medication treatment or other intervention for acute pain. Chronic pain has not got the same kind of evidence for it. Chronic pain, somebody's been in back pain for 10 years because it's a multidisciplinary approach and we all understand that. I treat patients multidisciplinarily as an osteopathic physician, so I will treat their pain because if I can get them out of their pain today, they will know that, and that's what I'm giving you evidence for on the two patients that I'm going to present, and these are case presentations, so it's not a evidence-based 20-person study. I tried to explain that. Or even a 100-patient study. Take it for what it's worth. Okay. Is everyone in agreement with that? Anecdotal reporting is not evidence-based? Okay. All right. We'll receive that from you. Thank you for that observation. All right. So this is a case presentation. A 62-year-old female patient came into my office with her husband for an osteopathic consult for a closed compression fracture of L1. She had been seen in the ER four days earlier. She had slipped on the ice. She's going to tell her story, and we're going to see what that looks like for her, and then we're going to treat her, and I'll show you a before and after treatment, and then in the presentation, I'll show you the actual treatment so you can see how the FDM model works. All right? She was referred to orthopedics. She had a turtle brace on. She had not seen the orthopedist yet, and she didn't even know why she was seeing me. Somebody said, you need to go see Dr. Perkins. He can help you. Okay? That's her spine film. See the L1 compression fracture there on the CT? Not too bad. What looks like to me a morals node in the plain film, but diagnosed with acute compression fracture. And this is her story. So I'll just let her tell her story, and we'll go from there. How does that load? Plays in the back. Is it playing in the back? »» I was taking the trash out. I took one out and it went fine. When I came back I guess I walked in the same tracks and didn't have traction on the ice. And so I was pushing it down and just went boom, right on her tailbone and landed just like that. And it was very, very painful. »» You have pain today? »» Yes. »» Can you show us where it hurts right now? You're going to have to stand and turn around so we can see where you feel it. »» Every language. »» You're going to eventually take that brace off, but that was provided to her by the ER. »» It's mainly right here. »» And up and down. »» But mainly it's right in there. »» So we're going to do an exam and we're going to see what evokes that pain. We're going to treat that and see if it's better afterwards. »» Okay. »» So for the viewing audience, this is the first follow-up she's had since the ER. She hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. So we're going to treat that and see if it's better afterwards. »» Okay. »» So for the viewing audience, this is the first follow-up she's had since the ER. She hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedics for a consultation, but hasn't seen her primary care physician. She was referred to orthopedI made a difference, that's the main thing. We're going to test it, let's see if we made a difference. Alright, same thing. Go ahead and bend forward at the waist like you're going to touch the floor. Keep going, keep going, keep going. Neutral, moving like it's supposed to. Come back up. Now before you couldn't hear that change, it was painful. Oh yeah. Now you can. Lean back towards me, this was not that painful. Lean back, don't, yeah arch back. There you go. Keep going, keep going. That's what your brain is telling you needs to happen to get well. So we're going to suggest to you that you get a bumper or a wool towel or something and arch your back over the towel. And that's going to help stabilize that fracture and help it to heal. So before and after lumbar, she's moving, she's moving with less pain. I see a question. There's two questions. How long does a typical treatment usually last? Does it run if the patient tolerates it or when they tell you, I think we're at a point where we can stop. And then the second question, would a foam roller also work in a, I guess similarly, like a towel? Is she wearing the towel with the break? Or is she rolling on it like on the floor? Just laying on the floor relaxing in that area. Not necessarily, but it won't fix the problem. So I see a lot of patients who have foam rollers and they've got every kind in a model because that's what they've been told and they do it in physical therapy. A trigger band is a trigger band. It needs to be treated. Once it's treated, it's gone. It's immediately better. You see the result. And a foam roller is not going to fix a trigger band. So this is her second treatment, before and after. And we'll go ahead and look at that. I'm doing a lot better than I was the last time I was here. Still painful. I'm walking on a treadmill. I'm doing the exercises that you gave me every day, two or three times a day. Awesome. Are they painful when you're doing them or just sore afterwards? Just sore. Okay. And I'm up to about five minutes walking. Awesome. Sometimes a little bit less, just depends on if it's hurting. I stop when it starts hurting. If it starts hurting, you stop. Good for you. And I try to do it three to four times a day. Standing is still hurtful. Okay. Not fun. Show us where it hurts when you're standing. In that. Turn around and show us where you feel it. In this area right here. So that's still there. Mm-hmm. Any numbness or tingling or weakness or loss of sensation? No. Maybe weakness just because I'm not using muscles as much as I. Are you able to lay flat at night to sleep? Yeah. And I've been on my stomach. Is that bad? No. Feel good? Yeah. So that's what you wanted? You want it to be an extension? Mm-hmm. So you put a bumper pillow under there and lean back a little bit. Yeah. So that's going to be part of the stabilization. Yeah. So are you in pain right now? Does it hurt when you do things? You can feel it? Yeah, I can feel it. Five or a little bit less. It's not. That's pretty good pain. It's not anywhere near what it was when I was here before. I was over the top. And you were taking the pain medicine every day all the time. Yeah. When was the last time you had to take the hydrocodone pain medicine? Probably last Tuesday, I think. Oh, already a week. Uh-huh, it's been a week. So on treatment, definitely improved. We still have healing to take place. The bone still has to bend, but we're on the way of doing that. And you're moving much better, so that's going to help for a more stable recovery. I'm sorry? How would you know it's better today when we're done? I don't hurt. I don't. What will you be able to do without pain that you can't do without pain right now? Well, I guess walk further and go to the store, because I can't go to the store. But right here, right now, how would you know before you leave that this is better? Because you're going to go test it as soon as you get out of here. Just that it's not hurting. I don't feel stiff, because I feel stiff. A lot of stiffness. Yeah, I feel stiff. Like I'm, it's, it hurts. We're going to have you stand. We'll walk through a quick exam. Okay. I'm going to have you come up and down on your toes a few times. Still a little slow getting off the table. Yeah. Do you see her face at all? Sorry. On your heels. Okay, bring your knee up to your chest one at a time. And the other side. And that's fine. That doesn't hurt to do that. I'm going to have you turn and face that direction. I'm going to have you squat down on your haunches like a catcher holding the table. Uh-huh. That's a little bit stiff. Yeah. That didn't go very far. No. Okay. So if you can squat without pain today, you know I made a difference, right? Oh, yeah. Pretty obvious. I'm going to lift this shirt back here and touch your tailbone area. I'm going to have you gently bend forward at the waist like you're going to touch the floor. Keep going, keep going, keep going. Your sacrum is in. All right? Last time this was all locked up and you couldn't move, come back up. You couldn't even bend 15 degrees. You can almost touch the floor. Yeah. Lean back towards me. This is what feels good. Uh-huh. You don't mind doing that at all. So rotate to the left. And rotate to the right. And that's fine. No pain. So squatting seems to hurt sometimes. Show me what hurts when you squat. Well, my knee for one thing. Your knee. Not here, it's there. Okay. Well, what do we need to do to make your knee better? It's not bad. Oh, it still starts hurting a little. Yeah. All right. Yeah. So we're going to go ahead and do some treatment. That looks like it's moving quicker and easier. Uh-huh. Does that feel better to you? Yeah, it feels better. Leaning back is not painful to do. No. I want you to go ahead and do some of that at home, because that's good for you. And that compression down is what you need to correct it. Uh-huh. Weight-bearing exercise, so weight-bearing just walking, is important. Uh-huh. If you're standing at the sink and bent forward, it doesn't like that. No. If you were standing at the sink like this, it would be okay. So that position of comfort, even weight-bearing, is okay for you to do. Yeah. That's about 10 pounds. Take that out and move it around. That's heavier than your Pyrex. Yeah. I guess, though, you know, having to... It's bending over. Yeah. It's bending over. When I'm having to go down like that, that's when it hurts. We'll tell you to use your knees more. Yeah. And if your knees already hurt, that's going to be a challenge. Let's see if you can squat without that pain in your knees. We made a difference already. How far can you go? Uh-huh. Do that a few more times. We need to probably focus a little attention on your knees. Uh-huh. Because they're keeping you from squatting. Yeah. And they're shaking your back a little bit. She didn't give me the privilege of doing her knees, but she got better. And I only saw her those two times. So that's a lumbar fracture. If we did nothing, it would get better on its own, right? Isn't that what you would tell them? Give it time? Four, six, eight weeks. She's better in one week and knows it and is doing things that she otherwise wouldn't do because we got rid of the cause of her pain, which is not the fracture, by the way. The cause of the pain is a trigger band and a folding distortion, a refolding distortion at that L1 level. It's a fascial distortion, which when treated, ceases to exist. It's immediately better. Patient knows it. So we're going to show you some of the treatment. And some of this is going to be weird because you've never seen it before. And the first time I saw it, I said, that's nonsense, I'm not going to do that. And then I got over my stinking pride and started doing it, and I had better results. So those are the six different distortions by definition. She had trigger bands up and down. These are fascial bands. A tendon is a banded fascia made up of long strands of linearly oriented fascia with cross-linking that holds them together. Anything that starts here and goes there is a trigger band by definition. And treated, it's either better or it's not. And you will notice that. She showed a folding distortion. We'll get into more detail. That's a three-dimensional alteration of an entire fascial plane. So a joint can have folding distortions in it. But folding distortions occur in interosseous membranes, in intermuscular septum, and so on. So once you understand the principle of what that fascia is doing, the function of the fascia that's involved, you can design and develop treatment directed towards that distortion. So that's a trigger band artist's rendition. Maybe it looks like that, maybe it doesn't. Who knows? It's distorted fascial bands. Their body language is sweeping movements with fingers along a painful linear pathway. That's all you have to know. It hurts right here. It hurts right there. How many of you see headaches? I have a headache. It's right there. It's a trigger band headache. We call them tension headaches. You can treat that, and it's immediately better. Prove me wrong, okay? Symptoms are usually of a burning sensation. Seven out of ten people use that word to describe it. It's a burning sensation, particularly when you're treating it. Or a pulling or a tightness. There's a tightness associated with it. You use your thumb to untwist it. That's all we're doing. It corrects the fascial bands by physical force from your thumb. You can use other tools. People use the Theracane tool that's provided to them by their physical therapist and other devices that might be helpful. I use my thumb because it's convenient. I have two of them, and they work all day long. So this is her treatment. For the viewing audience, she has restricted forward flexion. It's painful. When she does it, she shows me a line across her back right here. The trigger bands are running from tailbone up, and that's what we're going to treat first. So this starts right on the sacrocoxial joint. This starts in a peculiar way, and it has a unique kind of sensation to it. So what does that feel like to you? Oh, my goodness. Yeah, my goodness. What's that hurt like? I don't know, but it hurts. Yes, and how would you describe that? Sharp. Sharp. Okay. We're going to go right past the fracture area and go right up to between your shoulder blades. Okay? You done okay? Yeah. All right. Sharp like what? How would you describe that again? Like a knife. You've got a knife in your hand, huh? Yeah, it feels like you have a knife. Oh, my gosh. We're getting over it. It's starting to ease up, isn't it? Yeah. Yeah, it doesn't feel like a knife anymore. Okay. All right, same thing other side. Okay. Okay. And what's that feel like? It's not a knife. Watching a trigger and treatment is like watching paint dry. Are you sure you don't have a knife? It feels like a knife, but no, I don't. Okay, I feel like you have a knife. A puppy can swear at that. Any other descriptors, or is it a knife? No, it's just a knife. People will use one word and over and over say that. You need a trimmy nail doc, you're ripping my skin. Well, that's what it feels like, you have a big bed. You need a trimmy nail. But you didn't say that, you said knife, and you keep saying that. So that's how your brain perceives it. Something sharp, that's all I know. So we're past the fracture site, and we're taking that right up to its end point. And for the viewing audience, this lumbar star trigger band usually stops at about T7, T6, somewhere in that range. Occasionally it will go all the way up to her neck, but I didn't see that in her neck when we were doing that. And that's our ease up. You feel the change? Uh-huh. All right. Now, just bend over at the waist, we'll see if that's any better. That's how long the treatment took. Oh, gosh, yeah. Keep going, keep going, keep going. Oh, gosh. Keep going, keep going, keep going. That's better. She could not do that before. I couldn't do that before. Pain is not generated from the fracture. It's a trigger band. When treated, she's set to exist immediately better. She can do things without pain that she couldn't do without pain before. And she knows it. She knows it made a difference. Okay? So that took, what, three minutes? Five? I don't recall. Another distortion we don't see on this patient is a herniated trigger point. That's what the patient had in his left flank when he came in to see me from referral by his colleague, the surgeon, his friend, saying, see if you can help him. It was a flank herniated trigger point. Many of you have worked with patients who have kidney stones. What's their body language? I've had one. If we walk around with our thumb jammed in there because it kind of feels good, why do we do that? Because our unconscious brain says that's what we need to do to make it better. Take it the rest of the way. Push that hernia in, and you get a lot of relief from that. It's a fascial hernia. It's not a surgical hernia. Don't let anyone try to talk you into doing surgery on a herniated trigger point. But we're not going to demonstrate that because I don't have that in my back pain lecture today. Continuum is an alteration of the transition zone between a ligament, tendon, or other fascia and bone. Hurts right there. They say it just like that. Hurts right there. If you're from Oklahoma, it's right there. It's a CD on the elbow that produces lateral epicondylitis or on the elbow with medial epicondylitis. Spot of pain right where that emphasis is. We call them emphazopathies, beginning of a tendonitis. And sometimes it's connected to a trigger band. It starts here, goes there, but it hurts right there. Treat the CD first with direct pressure, and you've treated their tennis elbow. How many good treatments do we have for tennis elbow? How many overuse injuries do you diagnose every year in your practices because they're doing the same thing over and over? They didn't have it before, and now they do. It's a continuum, and in the fascia, it's a continuum with a trigger band. And you can treat that. So the body language is spot or spots of pain. It's a spot. Whenever you see somebody going with their finger to spot, it's a continuum. It's on the bone. It can be a fracture. Fracture is a wrinkle in the periosteum that is a continuum distortion by definition. And you just hold it until it shifts. So that's an ankle. We treat lots of continuums around sprained ankles and around knees that hurt because they are immediately better, and they can do things on them without pain afterwards. You force that osseous component to shift and get it moving. Folding distortion is what this lady demonstrates. It's a three-dimensional alteration of the fascial plane. That happens to be a shoulder, but in this case, it's in her lumbar spine. It's at around L1. And its body language is placing the hands over the affected joint or pushing fingers into an intermuscular septum or interosseous membrane. The symptoms are a deep ache, deep ache in the joint or in the injured folding fascia. And we use folding technique, which we're going to describe in a minute. Think of a road map. If you open a road map and close it and you follow the folds, it does it very well. But if you take that road map, it gets twisted, and you try to push it back, it won't work. So you have to take it all the way back out and refold it along its planes to make it work. That's a folding distortion. So you can unfold, and you can refold. So an unfolding is when the fascia was pulled out, twisted, and it won't go back in right. To fix it, you have to unfold it and let it go back in right. That would be an unfolding distortion, like a dislocated shoulder type of thing. A refolding is when the fascia has been compressed, torqued, and can't come back out. So to treat it, you have to compress it so that it can untorque and come back out. That's an unfolding. This lady is describing an unfolding. The thing that makes it better is compression. Gravity is her friend. It's part of the mechanism of injury and also what makes it feel better, what makes it feel worse. She doesn't want that to be pulled apart. She would do terrible in traction. She wants to be in extension. She gets relief from that, and that's the treatment that we're going to use because we're going to compress a compression fracture to restore the normal shock-absorbing capacity of that three-dimensional alteration of the tissue. So that's also if I'm treating it in compression and it hurts, I should be doing something else. If I'm treating it in traction and it hurts, I should be doing something else. So the patient is the expert, and you will never hurt them or injure them because they're always giving you feedback, and you'll see that when I do the treatment. These usually get lumped into what we would call HVLA, high-velocity low-amplitude manipulation, or low-velocity high-amplitude manipulation. You're moving a joint through a broad range of motion to accomplish the same thing. In the fascial distortion model, we use those same modalities that we've already learned as part of our manipulative practice, and we're just applying the model to it. Which way to go? The way the patient says, not the way I think it should go. And that was hard for me, I'll be honest. After 25-plus years of practice, I thought I was smarter than the patient. I still sometimes think I am, but I know I'm not. They intuitively know what needs to happen. They're never wrong, and that's where I've benefited the most in practice is paying attention to them. And it was kind of egotistonic to come to that place, but I became a better doctor when I decided to listen to them and do what they asked me to do, not what I thought was best for them. So we're going to talk about an SI joint dysfunction, a very common cause of low back pain. Now I'm going to check her sacrum again and see if it's moving or not, because she said her right side was tense. After treating the trigger bands, now she can move. And it's stuck right there. Come back up. That's where it hurts, right? Right there. We need to treat that, too. That's very important. So, now I do need to have you lay down. Can you lay on your back for me, please? Yeah. Be careful that you don't hurt yourself. We're going to use a muscle energy technique where we activate the patient's own muscle strength to correct the problem. It's a folding distortion. How we treat it is immaterial, but we're just going to get it moving. Put your hands up. Relax your back. Does my back need to be... You can come back if you want. I'm going to let this down in a moment. Okay. I just didn't want your head to go down all at once. Yeah, that's fine. You can go slowly. She wants extension. She does not want flexion. Extension was what she said helped me. Do you feel that? Yeah, a little bit. Where do you feel that at? Side. So, we're going to bring your knees up together. One at a time. Lift this knee up. That feels a lot better. Lift your hips up off the table. Back down. Legs out straight. For the viewing audience, we just leveled her pelvis. What we found was a positive standing flexion test. PSIS rising on the right inflection. And what we're seeing, her ASIS is inferior on this side. It's superior on her left side. That is anterior helium rotation. So, when you fell on your tailbone, you charged your pelvis and rotated it. It's stuck on the right side. That's what was sore. And it's not moving like it's supposed to. So, we're going to correct that now. This one does not hurt. You get to do all the work. I get paid for it. But you're going to pull it back into place. And then you'll walk normally again. And relieve a lot of this discomfort you have. Okay? So, bring this knee up, please. This one? Yep. I'm going to have you push against my shoulder. Now, if you watch carefully, I'll teach you how to do this at home. Talking to her husband. Why not teach him how to take care of it at home? I do it all the time. Not dangerous. Not going to injure her. And relax. I teach couples how to do this all the time. It's a very common low back pain injury when we rotate the pelvis. Push again. And relax. So, this is a form of folding technique. Again, to the viewing audience. We're treating the sacroiliac joint, which is a folding distortion. Push against my shoulder. The primary folding distortion is L1, compression fracture. And relax. Easy folding, both by body language, by mechanism of action, and what makes it feel better and what makes it feel worse. Let your leg drop out to the side, just like that. You may feel a schlonk, clunk, or a pop when this moves. Oh! That's a drop. Oh! Oh, I heard a pop. Was that a big pop? Yeah. I don't know if Pam heard that, but. I did. Should we mobilize the sacroiliac joint? That's an unfolding of the outside joint. We're gonna drop this leg off the table, please. So, this hip, relative to that hip, is rotated backward. So, we treat it that way. Lift this thigh up toward the ceiling. Lift up. I treat both sides of the SI when I treat. Just get some more work done in a short amount of time. Others have different ways of treating it. I'll treat the pubes at the same time. For two extra minutes, I get a lot more mileage out of the treatment. Bring the knee up. And this is OMT 101. For most of us. This may or may not clunk, because it won't stop, but we go through the motions anyway. Head rolling. Okay. Bring knees up together. In the front of the pelvis, where the two ilium meet in the front, called the pubic symphysis, that can get torqued when you twist yourself. So, we're gonna treat that next. Have you pull your knees apart. And relax. And again. And relax. And again. And relax. Keep your feet together. Let your knees drop apart. Squeeze together and break my arm. Sit up together so they break my arm. Get strong and relax. Do that again. Nothing there. Sometimes it's a nice little correction in the pubic symphysis. Squeeze together and break like this. That's fine. Lift your hips up off the table. Back down. Legs out straight. All right. That's about as level as I can get it. I heard a nice little, oh, she's already feeling better. So, to get out of that position safely, we want you to roll on your side. And repeat. So, how long did it take? I've got 10 minutes invested there, plus the 10 minutes of history taking. I book 45 minutes for a new patient. I have the luxury of doing that. I do 30 minutes for follow-up. Doesn't take that long, but that's my practice. This is the second visit. This is gonna show you something a little bit unusual. I wouldn't advise you to go out and do this on your very first day, but I can tell you that it would be okay if you chose to do it. We're gonna compress her lumbar spine the way she's asking me to do it. And we're gonna use two different methods of doing it. One's a thrusting manipulation. One is actually called riding the horse, and you're gonna see that. So, I want your feet flat on the ground so you can support yourself. Flat on the ground. So, I'm going to put some pressure downward on this area. For the viewing audience, she's showing me the sweeping line across here. That's her L1 compression fracture. That's a refolding body language. I'd like you to fold your arms in front of you. I'm gonna come around and put my weight on you. Is this painful? No. So, I don't have but about 150 pounds to put in here, and she hit with a lot more force than that, but we are compressing and rotating. Does this hurt at all? No. Does that feel good at all? Uh-huh. Yeah. Her brain is saying, I need more of that. And we are doing a downward compression thrust. And we are hoping to get some pops and clicks. That feels good. And you're going, wait a minute. She's got no one compression fracture. What is he doing that for? That's what needs to happen. Somebody thought that already, right? To bring that to normal. The model predicts that. If you do that, it's gonna feel good. Tell me it's not hurt. That's what she needs to correct. We did not. Well, it popped. It popped a minute ago. You felt a little of it, all right. Question, I didn't feel it. So, did it pop when I came off, or did it pop while I was going for it? It was actually when you had me twisting. Okay, same thing. I'm gonna put weight down. This should not hurt. You tell me if it does. Okay. Basically, neutral or extended spinal mechanics. There's one. Did you feel that? A little bit. It seems counterintuitive that you would want to compress a compression fracture. It's the compression that caused the injury, and it's compression we have to reset to allow it to spring back. Now, we're gonna ride the horse. Final. This is called riding of the horse, okay? Literally. I'm not calling you a horse, but it looks like I'm riding a horse. And we want to have your spine pretty neutral. All my weight's gonna go right up and down on that spinal column. Does that hurt? A little bit. Okay. Lean just a little bit. Okay, lean just a little back. Is that better? Mm-hmm. So, I'm not putting all my weight. I weigh about 175 pounds. Some might consider this an indirect myofascial technique, where we're just taking the body to where it wants to go and letting it reset on its own. As we compress the spine, we can see it's holding distortion. We reengage all those shock absorbers. You're having pain? A little bit. All right. So, when it starts to hurt, I'm gonna come out of there. Is that better? A little bit, yeah. Okay. Sometimes you'll feel a nice clunk. What I want to do is come off and you tell me what you feel when I come off, okay? Okay. What's that feel like? Oh, that feels better. What did you experience? It was like I sprung back up. Like you're coming up, right? Like floating up. Yeah. Did you feel any clunks in there? No. Okay. The look of relief on her face is pretty good, and I'll take that for what it's worth. So, cylinders, we're gonna home-scratch this, because we have less than five minutes to finish this discussion. Cylinders are technically a cylindrical fascia, or the superficial fascia. I have a real good video of that, but I'm not gonna have time to show it to you. But think of the slinky man. And so you have the superficial fascia, that envelope that we looked at earlier. Every circular structure in your body is invested with circular fascia. Twists and wrinkles in the circular fascia cause pain. In the heart and the coronary artery, you've got squeezing chest pain. That's the body language, squeezing. Repetitive motion, or repetitive squeezing of a non-jointed area is a cylinder distortion. And it's bizarre. These are the weird ones. These are the ones that come in with, it hurts here, it hurts there, it hurts everywhere. And cylinder distortions are the only reasonable explanation we can make, other than sending to the psychiatrist because we think they need an attitude adjustment. Treat the cylinder fascia, you give them a lot of reason to live again. So, I am sorry, but I don't have time to show this. Because I have to stop on time, and it's 1024. This is about three minutes. I won't have time for questions if I show you this. This would only be a before and after. We'll skip it. We'll skip it. Tectonic fixations are like a frozen shoulder. Something that's stuck, something that's stiff. How many of you find yourself doing that kind of stuff? Doesn't hurt, your brain is telling you that needs to move, it's stuck. It's a tectonic fixation. A lot of the manipulations that we do, both us and our chiropractic brothers, are addressing tectonic fixations. Not particularly painful, but stiff and tight. That's why we pop our knuckles, right? And it's stiff joint movement. It feels like it needs to pop. Patients come in and use that language, and I say, who taught you that? I don't know, it just feels like it needs to pop. Okay, they're telling you what needs to happen to get better, and you can do that. So, what are the side effects? This is important. In the interest of full disclosure, there's pain and discomfort during treatment. It's normal. I tell them that. There can be erythema of the skin following treatment. There can be bruising. I'll show you some pictures. Hemorrhagic pedicure when we use cupping and plungers, and rebound tenderness or soreness. So, this guy, I had a cup on his shoulder, and we did a trigger band up his arm, and a continuum on his glenohumeral joint. He's non-cuminant. I told him he's gonna bruise. As long as I give him informed consent, he comes back for more treatment and says, do it again. That's the best I've felt in months. So, there you go. That's some bruising along an anterior shoulder trigger band pathway, often called bicep tendonitis, and along the adductor angular trigger band pathway. These pathways are common, and they're commonly found in common places. So, you can look and find them where the patient says it is, or they have textbooks that actually kind of show you where to be looking. You don't need a textbook when the patient says it hurts right here. They're smarter than that. That was a continuum in the back of the knee, popliteal continuum. Couldn't flex the knee completely, and we did a trigger band up the IT band afterwards. That looks to me like it may have been a cupping. There's cupping with hemorrhagic pedicure. Those are erythematous streaks afterwards. Some people have wheel and flare and dermatographism, et cetera. No worries. But what are the relative contraindications? Certainly, if they have an open wound, I'm not going through there with a trigger band treatment, right? Pretty smart, wouldn't do that. If they've got osteomyelitis, you've got to be aware of this stuff. You can treat all around it. For doctor-patient rapport, that's one of the things that comes up often. How do you get away with doing what you're doing to people? You're hurting them, and they feel better afterwards, but I've never had a problem. Most of the time, I spend a little bit of extra time explaining what we're gonna do and why, and when I do that, they accept it. If at any point during a treatment, they need me to stop, I tell them, you say, stop, I'm stopping. You're in control of the treatment. They need to be in control, particularly in chronic pain. People in chronic pain need to have a sense of control given back to them to get over their psychological aspect of their chronic pain. So there are several resources. These are in your handouts, just the informed consent that we use, and also what is the FDM. That textbook is available on amazon.com. I didn't write it. Dr. Kappa Stratton Fairbanks did. It basically explains everything that I've talked to you about today, and it's written for patients. And this is the latest and newest edition that just came out last year. Actually has pictures of how to treat. This is gonna be used as our course syllabus when we're doing treatment. That's the original textbook by Dr. DeBaldas. Now we can do questions, and I will conclude my presentation. Thank you very much for your attention. Thank you for the opportunity. It is that time. Yes, there's a question in the back. The question is, is this why people hurt both before and after surgery? The answer is that's why people hurt all the time. It's the fascia, okay? I've had patients who have had their total knee done, and they have the same pain that they had before they went in for their total knee. They weren't able to do it. They weren't able to do it. They went in for their total knee. They weren't diagnosed in the model. They sure probably needed the total knee, but it didn't fix the problem that they really wanted fixed, which was the pain in their knee. Does that make sense? Same thing with the lumbar spine. They get fused, and now they have a whole nother level of inability to move, and the fascia is talking to her. Those trigger bands were present. The SI joint dysfunction and folding distortion was present. Her fracture was at L1, and everyone's gonna focus on that, right? All of her treatment, we're addressing the lumbar L1 fracture. We treat the other stuff. She's moving better. She's gonna heal better. She's gonna have a better outcome. Yes, sir. Are there any... I'm sorry. I've got a question back there I was looking at. I didn't recognize. I'm sorry. Is dysfunctional distortion a lot of evidence applying to juvenile or congenital scoliosis? I'm curious. I do. I cannot correct congenital scoliosis. I can get rid of their pain associated with their congenital scoliosis. That make sense? So if it hurts, the fascia's talking to you. If they got a curve in their spine and it doesn't hurt, if it ain't broke, don't fix it. That's one of our mantras in the osteopathic world. If it ain't broke, don't fix it. But when it hurts, you can treat the fascial component, get them moving better, give them better function and quality of life. I treat kids down to birth. I mean, I don't do... Well, let's take that back. We had a child born with a brachial plexus injury and couldn't raise the arm. And at four weeks of postpartum, I treated a herniated trigger point in that child's... It's very easy. And now they were moving their arm. So that hernia occurred as a result of their birth injury and would have been probably a long-term problem over time if it hadn't been corrected. You had a question, sir. By the practitioner of the monument, would you say that you were advised in this term of your name that there was a variety of diagnoses? Or were you saying certain structural conditions you would rather have them go through our usual additional type of treatment that you would give them in the lab, keeping in mind those contraindications? So for example, let's say it's a great BMCF sprain. We know anatomy that you have to be in for that treatment at the time of birth. Or would you rather use an indiscriminate treatment? This is a very good question because it changed my whole worldview when it was introduced to me. When a third degree ankle sprain, can't walk, big swollen, black and blue, walks out, where did his pain go? That question was asked to us by Dr. Topaldas. And we couldn't answer it. We're like, not gonna step into that. He says, the pain is in the altered fascial structure, which when treated ceases to exist. He's still got a hemarthroma. He's still got torn ligaments in there. He still has to heal that injury. But the thing that's causing him his pain is in the fascial distortion model, trigger band CD and a folding distortion. And when he treated that, he could walk on it now without pain. He came back two days later and wasn't wearing a boot and had his normal shoe on. The amount of progression and improvement in 48 hours was unbelievable for me. Like, I gotta learn how to do that. Never seen that before. And I treat fractures now, okay? Fractures don't intimidate me. If they're stable fractures, you can treat them because you're treating the periosteal wrinkle and correcting it, yeah. Yes, sir. So, these are passive techniques. Can you not use an active technique and get the fascia to unfold? Is that not what a yoga would do? Only it's slower, but are you achieving the same result? Well, I would not define what I do as passive. This is a direct technique. I am on the thing that hurts and I'm moving it and the patient knows it. When I'm manipulating that SI joint, that's an active dynamic technique. It's not a passive technique. Riding the horse is more of a passive technique. But there's times when I've gotten up there and I'm bouncing on that because that's what they want. You have to recreate the force and mechanism of injury in the force vectors to correct the folding distortion that exists where the pain has come. My question was, passive meaning you're doing it to the patient. Okay, what can the patient do? Oh, okay. The patient's doing it for themselves. Definition of active-passive. I continually advise patients on exercises they should do after every treatment that I provide them because in my mind, if you keep doing what I've encouraged you to do and you can do it now without pain, you're gonna heal. Body heals itself, all it's doing is pointing in that direction. But when it hurts, patients don't do it. They're smarter than that. I can't do this, I won't do this. And that's why they don't go back to work. Every time I do this, it hurts. I'm not going back to work when it hurts like this. And we give them two weeks off, four weeks off, six weeks off, disability. When you could correct that and get them moving and when they know they can use it without pain, unless they've got a real dysfunctional work environment that they don't want to go back to or they really want a note to go to Hawaii for a week, once they know they can functionally use that, they will do it. Yoga is great. I encourage yoga, tai chi, any kind of physical exercise to get moving. We all need to do that more. I agree, I do that. But they may not, let's say this, of the six distortions I mentioned, the only one that cannot be self-corrected by activity is the herniated trigger point. It has to be reduced. A trigger band can get better, come and go. A continuum can get better and come and go. A cylinder fascial distortion can get better, come and go. Tectonic takes a lot of work, but it's usually the painful things that got them stuck in the first place, which you gotta treat before they can move. Did that answer your question? Active movement, always encouraged and recommended. That's what our physical therapists are good at. We're past our hour, but I don't know if the room is emptying. You're welcome to keep asking questions, but you're also welcome to leave. So I'm happy to address any questions you have. Go ahead. Okay. From a workability standpoint, I think that patients, I think this is a very related and abstract report that they have. Can you perform them during an amelioration of the state of low back pain? Do you have to report a treatment for it, or how do you avoid that? I'm doing treatment. I don't do back pain disability evaluations. They go to somebody who's smarter than I am who does that stuff. I do back pain treatment. I do chronic pain management. I do chronic pain treatment. I'm treating you to wellness. I treat you to it's well or until you've had enough of me. You asked that question, how long do you treat? They ought to be showing me some improvement when I'm treating them in this model. And when I don't see that, either I'm missing the diagnosis or there may be some super tentorial overlay that I'm not fully aware of and I start to explore those issues with the patient. What does this pain mean to you? And what are you hoping to get out of it? Yes, ma'am. How did I find out about this conference? Oh, one of my conferences. Okay, on the handout, there's how to contact us, the American FDM Association has a website. They're announced all the time. There's the FDM Academy, www, just Google fascial distortion model. But Dr. Tapalda's son, Alex, is an attorney who went a different direction from the rest of us and has his own little thing going on, that we are not them. You see gargoyles all over the page, that's not us. And we don't know what they're doing. We know what we're doing and we're connected to the international community and we're bringing this forward to, actually, we hope to change the way we do medicine in our country and around the world. All right, I thank you for your time, your attention. I'll be over in the back if anyone has further questions. This delights me that you're interested. And thank you all very much. Have a great conference. I'm going home tonight. I'm only here for today.

video

physician

Byron Perkins

fascial distortion model

FDM

musculoskeletal conditions

imbalances

fascial system

fascial distortions

movement

pain

safety

effectiveness