If we all agree that exercise is vital to health, then let’s figure out the best routine. The right mix of exercise can: Reduce the risk of premature death, reduce the risk of heart disease, reduce high blood pressure, reduce high cholesterol, reduce the risks of many cancers, including colon and breast cancer, reduce the risk of developing diabetes, reduce fat and optimize body weight, build and maintain healthy muscles, bones, and joints, reduce depression and anxiety, enhance performance in work and sport.
Believe it or not, running every day, won’t cut it. Going to the gym every day and working out with weights every day won’t cut it. The ideal exercise program includes cardio/aerobic exercise, strength training, weight-bearing exercise, stretching, breathing, and balance.
Cardio/aerobic exercise. This has to be some movement that is brisk enough that requires the heart and lungs to work harder to meet the body’s increased oxygen demand. Basically you are forcing the heart and lungs to work harder, and yet of low enough intensity to facilitate adequate oxygen transfer to the muscle cells so that no buildup of lactic acid is observed. Think repetitive movement of the arms, legs, and hips. Take your pick from running, jogging, and fast walking. Biking (either road or mountain), and swimming are also good. If you belong to a gym or have home equipment, there are treadmills, elliptical trainers, spin cycles, and rebounders.
Strength Training involves the use of free weights, kettlebells, weight machines, resistance bands or some other form of resistance to build muscle and increase strength. Its benefits include: Increased muscle strength, increased tendon and ligament strength, reduced body fat and increased muscle mass, better balance, lower blood cholesterol, improved glucose tolerance and insulin sensitivity. The key to strength training is to choose one you can do easily and are willing to do regularly.
Every patient of mine that wants to lose weight, I make sure that they are doing circuit weight training. Strength training builds muscle which increases your resting metabolic rate.
Weight bearing exercise is actually a subset of certain aerobic and strength training exercises. It helps slow down the rate of bone loss and osteoporosis. It is exercise in which you force your body to support weight (your own included) while exercising. The best weight bearing exercises are: weight-lifting, jogging, hiking with a back pack, stair-climbing, step aerobics, racquet sports, and other activities that require your muscles to work against gravity. Swimming and simple walking don’t do the trick. One exceptionally useful form of weight bearing exercise is rebounding. The act of rebounding makes use of g-forces, just like astronauts training in a centrifuge.
Stretching is the most over-looked area of fitness I have seen lately. Stretching reduces muscle tension and increases range of movement in the joints. I see tremendous tightness and restrictions in most clients bodies from a lack of variety of movement. Tightness and constriction cause a reduced blood flow to the muscles and soft tissues, this leads to a lack of oxygen to the tissues and this is a very painful situation. Yoga has become one of my pewrsonal favorites for stretching. Pilates works well too. If nothing else, just do 5-10 minutes of simple stretching after your daily exercise routine as part of your cool down time.
Proper breathing is often over-looked as much as stretching. The concept is simple: putting a device in your mouth that restricts (in a controlled manner) your inhalations and exhalations, which forces your lungs to work harder. This, in turn, strengthens the muscles that makes your lungs work and increases their capacity.
The last area is Balance. Balance diminishes with age unless we consciously exercise it. If you fall down and break your hip or wrist, the odds are you will have a long-slow recovery, if you fully recover.
The most simple balance exercise is to practice standing on one leg. If you need to hold on to a chair for support, with one hand, that’s fine. Slightly bend one leg so that the foot of the bent leg is projected out behind you. Get used to balancing on the one leg holding a chair or wall. Then take the hands off the chair and balance with one eye closed. Build up to balancing with your eyes closed for 30 seconds.
Please remember that you can not exercise your your way out of a bad diet. Increase your quality protein to build the muscles you are exercising. Avoid sugar but enjoy high quality fats such as Omega-3s.
Workout #1 All you need is a clock and just 10 minutes per session!
Walk in place for one minute.
Jump rope for one minute.
Do as many pushups as you can for one minute.
Do as many crunches as you can for one minute.
Jump rope for two minutes.
Do another round of pushups for one minute.
Do another round of crunches for one minute.
Jump rope for one minute.
Walk in place for one minute.
Are you just getting started with exercise? Congratulations! Whatever your motivation is, improved health, fitting back into your ‘skinny jeans’, or you want more energy, it’s important to come up with goals. Here are some things to think about:
Goal 1: Find a Time & Remain Committed
Figure out when you’re going to head to the gym or workout at home. Whether it’s weight loss or building new muscles you have to have a regular, consistent time to workout.
Goal 2: Follow Through
Start out with three days a week for two to three months. The amount of time doesn’t matter – it could be ten minutes, twenty minutes and even longer. Let’s just get started and get it into your schedule. Short bouts are better than nothing and makes it easier to stick with exercise for the long haul.
Goal 3: Keep a Workout Diary
Exercise is a priority in my life. Every day I work out I write down what I did and I might include how much weight I lifted or the number of reps completed. I like looking over a few weeks of my workouts. If weight loss is your goal, get a body fat analysis performed, or once a week write down your weight. Over time, you’ll be able to see improvements in all these areas. Just pick a statistic and follow it, such as your lowered blood pressure or how much longer you can stay on the treadmill now than when you first began.
I use the Functional Movement Screen (FMS) on a daily basis in my Chiropractic practice to watch how clients move through the most basic and fundamental movements. The FMS helps me to determine the risk of injury a person has, and limitations of movements, and right and left side imbalances during movement. I like to use the FMS to establish a base-line score in my non-acute patients.
I have found it beneficial to test low load maneuvers and exercises (before using loads) first. This has provided me with an overall exercise prescription that 1) Establishes mobility first (Gray Cook & Lee Burton strongly teach this point). This involves mobilization, manipulation, teaching clients how to perform self myofascial release using the foam roll, Deep Muscle Stimulator (DMS), stretch and lengthen, etc 2) Perform movements that recruit slow motor units. I make sure the stabilisers are working. The smallest muscles in the body need to contribute to holding spinal joints still while the arms and legs produce motion. It is better to use low load, or minimal load to primarily recruit slow motor units. Teaching patients the “primative” movement patterns are very useful here. All of this helps the spine to isometrically hold a position to sustain postural alignment or support functional trunk or limb load. I use exercises that transition slow motor units to optimize rapid/accelerated movement and the production of high force or power. 3) I teach exercises that eccentrically control the return through range (limb lowering against gravity). 4) Control whatever functional range is available. Here the global stabilisers should demonstrate efficient control of both normal and hypermobile ranges of motion. Gray & Lee call this RNT (Reactive Neuromuscular Training). 5) Then I reevaluate the dysfunctional movement pattern found on the Functional Movement Screen to see if this made a positive change. If the movement pattern improves, my patient and I know we are on the right track, if the movement pattern did not improve, I need to rethink the corrective exercise prescription. All of this takes one on one time..worth it!
The Sacroiliac Joint (SIJ) does need to move during normal daily activities such as walking and running.
Movement in the SIJ and symphysis pubis is made possible by the fibrocartaligenous structure of these joints. It is both necessary and desirable that they move, so that they can act as shock absorbers between the lower limbs and spine, and to act as a proprioceptive feedback mechanism for coordinated movement and control between trunk and lower limbs.
As the SIJ is capable of some movement, this must be controlled for effective force transfer to take place between trunk and lower limbs.
Force Closure & Form Closure
The concept of force closure relates to the ability of a muscle system, through its attachment into connective tissue (ligaments and fascia), to compress two joint surfaces together and provide stability.
This is in contrast to ‘form closure’, in which the combination of joint structures (eg congruency or architecture) and related ligaments provide passive joint stability. To the therapist and trainer, ‘force closure’ is of greater interest because we can influence this through exercise and retraining.
The ‘slings’ that provide force closure in the pelvic girdle include the posterior oblique sling, the anterior oblique sling and the posterior longitudinal sling. These are made up as follows:
Posterior oblique sling: consists of the superficial fibres of the latissimus dorsi blending with the superficial fibres of the contralateral gluteus maximus through the posterior layer of the thoraco-lumbar fascia. The superficial gluteus maximus then blends with the superficial fascia lata of the thigh, in particular the superficial iliotibial band (ITB). This sling system runs at a right angle to the joint plane of the SIJ and in effect will cause closure of the joint when the latissimus and contralateral gluteus maximus contract. Furthermore, the gluteus maximus and thoracolumbar fascia have investments into the sacrotuberous ligament. Tension in this ligament will also cause closure of the SIJ.
Anterior oblique sling: consists of the external oblique, internal oblique and the transversus abdominis via the rectus sheath, blending with the contralateral adductor muscles via the adductor-abdominal fascia. This will cause force closure of the symphysis pubis when contracted.
Posterior longitudinal sling: consists of the deep multifidus attaching to the sacrum with the deep layer of the thoracolumbar fascia, blending with the long dorsal sacroiliac joint ligament and continuing on into the sacrotuberous ligament. In a proportion of the population, the sacrotuberous ligament extends on to the biceps femoris muscle. This causes compression of the L5/S1 joint and compression of the SIJ.
Training the myofascial slings
The key principles apply as follows:
- The exercise is performed standing up.
- There is slight knee and hip flexion. This will pre-tense the gluteus maximus and quadriceps. This is necessary to activate the tension mechanisms in these muscles in order to stabilise the distal element of the posterior oblique sling. The close relationship of quadriceps to the fascia lata of the thigh allows tension to develop in the superficial ITB.
- There is slight forward lean with anterior pelvic tilt. This activates the deep multifidus, a component of the posterior longitudinal sling. Flexion of the hip in the form of partial squat also activates the hamstring muscles, another part of the posterior longitudinal sling.
- There is trunk rotation against resistance. This activates the oblique muscles, part of the anterior oblique sling. The rectus must be isometrically contracted to allow the lateral bands of the rectus sheath to provide a stable base for the obliques to work from. It is also important that the participant understands how to activate the transversus abdominis in the form of a hollowing action, to allow pre-tension in the thoracolumbar fascia.
- A broomstick sits on the shoulders. Pulling the broomstick into the shoulders allows isometric latissimus dorsi contraction. A stable closed chain system is then created for the posterior oblique sling to work effectively.
How to perform the exercise
This exercise was originally developed at the Australian Institute of Sport in Canberra. Tape or otherwise fix the resistance bands firmly to the broomstick.
As a yardstick, an appropriate level of resistance (band strength and length) should allow the client to perform 3 sets x 10 reps without great difficulty. Progress from there.
As a therapist, follow a good demonstration with good instruction. Verbalise the following points and cues:
- Keep quadriceps and glutes tight.
- Keep transversus hollow and tense rectus abdominis.
- Don’t rotate the pelvis, just the trunk. If the athlete has trouble dissociating pelvis and trunk rotation, have them perch their buttocks on the back of the chair, which takes about 25% of their body weight through the ischial tuberosities. This will give them feedback and position awareness so they can learn to maintain a stable pelvic position.
- Maintain a slight arch in the lumbar spine.
- Keep looking straight ahead, do not allow the head to turn with trunk rotation.
- Keep broomstick firm on shoulders in order to keep latissimus dorsi activated.
Note: one full repetition of this exercise involves rotating from x degrees backward trunk rotation to x degree forward trunk rotation, and then returning to the backward start point.
- Use a single band.
- Move through a small range of rotation 10 degrees to 10 degrees each direction (total arc of 20 degrees).
- Perform three sets of 10 reps each direction (band at left, then band at right).
- Use two bands, one either side of the broomstick.
- Rotate through 20 degrees to 20 degrees.
- Perform three sets of 10 reps in each direction.
- Can double up number of bands (or more, and/or use tougher bands etc), depending on the athlete’s available rotation strength
- extend range of rotation up to 45 degrees to 45 degrees.
- Perform three sets of 10 reps in each direction.
- Place one foot on a step to increase the range of hip flexion. This is particularly effective for sports requiring stability in positions of hip flexion, eg rowing and cycling.
- Decrease the width of the base of support by adopting a lunge stride position.
Myofascial slings: further reading
- Lavignolle B, Vital J M, Senegas J et al (1983): An approach to the functional anatomy of the sacroiliac joints in vivo. Anatomica Clinica 5: 169-176.
- Richardson C A, Jull G A (1995): Muscle control-pain control. What exercise should you prescribe? Manual Therapy 1: 2-10.
- Pool-Goudzwaard A L, Vleeming A, Stoeckart R, Snijders C J and Mens J M A (1998): Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to ‘a-specific’ low back pain. Manual Therapy 3(1): 12-20.
- Vleeming A, Stoeckart R, Volkers A C W, Snijders C A (1990a): Relation between form and function in the sacroiliac joint. Part 1: Clinical anatomical concepts. Spine 15(2): 130-132.
- Vleeming A, Volkers A C W, Snijders C A Stoeckart R (1990b): Relation between form and function in the sacroiliac joint. Part 2: Biomechanical concepts. Spine 15(2): 133-136.
Developing lower-limb strength and then power helps improve speed, acceleration and jumping. This in turn helps improve many track and field events, as well as field sports, gymnastics, weightlifting and martial arts.
Developing maximal strength in the lower body is an essential prerequisite of developing power. I still think the barbell squat is the king of all strength exercises. That’s because the squat exercise uses most of the major muscle groups in the lower body, overlapping with those used in running and jumping, so it is very suited to most sports.
At the very least, you should keep bodyweight squats in as one of your core exercises. I always say that we should be able to do our age in bodyweight squats. For my advanced clients I recommend that you have a minimum strength base of squatting one rep maximum (1RM) of the equivalent to your own bodyweight.
Strength training develops the muscles’ ability to exert force, for example pushing a heavy object. Power training develops the ability to exert this force in less time – ie to make the movement quicker, for example throwing a ball. Sprinters can generate forces of up to three and half times their bodyweight when racing, so having sufficient leg strength to generate this force without injury is necessary. This explains the commonly quoted guideline that a power athlete needs to be able to squat a weight equivalent to twice their body weight – eg an 80kg male rugby player should be able to squat 160kg.
All exercise is the same, right? Not so fast, suggests a small study of teens out of Scotland that found that high-intensity exercise may be better than endurance training for preventing cardiovascular disease because it can be done in less time.
The study included 57 adolescent schoolchildren (47 boys and 10 girls) who were randomly assigned to high-intensity or moderate-intensity exercise groups.
Both groups did three exercise sessions a week for seven weeks. The high-intensity group’s program consisted of a series of 20-meter sprints over 30 seconds, while the children in the moderate-intensity group ran steadily for 20 minutes.
By the end of the seven weeks, teens in the moderate-intensity group had completed a total of 420 minutes of exercise, compared to 63 minutes for those in the high-intensity group. Estimated total energy expenditures per child were 4,410 kcal for those in the moderate-intensity group and 907.2 kcal for those in the high-intensity group.
Both groups of children showed significant improvements in cardio-respiratory fitness, blood pressure, body composition and insulin resistance. But the teens in the high-intensity group achieved those health benefits with only 15% of the exercise time put in by those in the moderate-intensity group.
The findings, published April 5 in the American Journal of Human Biology, suggest that brief, intense workouts offer a time-efficient way to reduce cardiovascular disease risk factors in teens, said study author Duncan Buchan, of the University of the West of Scotland, and his colleagues.
However, further research is needed, they added.
Sometimes patients have to take a step backward to move forward, and sometimes their voyage is not so much about discovery as rediscovery. Stiffness is not the major chief complaint I hear from clients, but it is often checked off on their intake forms. Stiffness can be associated with pain, inflammation, fatigue, and any other complaint that bring clients in my office. The most common reason for stiffness is the effects of immobilization of the joints and muscles. The spinal joints, hip joints, knee joints, shoulder joints, and ankle joints are the most commonly involved. Muscle and joint pain commonly originates from bad habits of sitting, standing, sleeping, and walking. Stiffness has real consequences if ignored.
A Functional Workout
It doesn’t matter if my client is young, middleaged, or a senior citizen; I use the functional training approach as part of my treatment, especially for relief of stiffness. I start my rehab recovery teaching patients body-weight maneuvers and floor exercises. Then, I progress patients to use bands. I incorporate Thera- Bands for rehabilitation, functional movement training, sport-specific conditioning, and group classes. The next progression I use is to free weights and Kettlebells. Our profession was inundated with laser therapy and decompression tables, while the strength-training world was invaded by Kettlebells. I like to think that I have access to every kind of equipment out there, but through it all, I am still a big proponent of the minimal and inexpensive need for equipment in “authentic” functional training, like Thera-Bands. Thera-Bands can provide the basis for an authentic functional workout limited only by the imagination and knowledge of the practitioner. Functional exercise is based on its outcome, not how the exercise looks. Don’t ask me how to activate specific muscles (that question was answered years ago). Instead, ask: Why did this person lose the movement pattern in the first place?” Thera-Bands help me get rid of stiffness and improve functional strength, which is usable strength. Functional strength is hard to measure. That’s why I attempt to identify it by using many unorthodox movements, such as assisted posterior reaches. his exercise is one of the best methods of developing functional abdominal strength in overhead athletes, or athletes in sports that bring the arms overhead, such as tennis and basketball. Stand on both legs (eventually progress to one-legged stands) facing away from a Thera-Band firmly held in place. Hold the band in both hands, and extend your arms straight up above your head. Bring the hips forward and the hands back. Lean backward as far as you can without feeling pressure in your lower back. Engage the lower abdominals to return to the starting position. Using the Thera-Bands, I teach movements that train the body to do what it was meant to do. These can simply be broken down into four pillars: 1) Standing and locomotion (gait). One of my favorite exercises that improve the hip rotator stabilizers (gluteus) is to have clients wrap the Thera-Band (usually the green band) around the ankles and walk sideways across the room or down a hall to activate the gluteus. This one maneuver alone has helped more patients improve altered gait than any other. 2) Movements that lower or raise the body’s center of mass, such as squatting, lunging, and climbing. I have clients stand on a band and hold the ends of the band in their hands while doing squats, and perform an overhead press on the way up. 3) Pushing and pulling, such as standing rows and pressing maneuvers. 4) Rotation. These are changes in direction. For example, torso rotation and proprioceptive neuromuscular facilitation (PNF) band chops are a functional way to train the abdominals.
Everyone talks about the core, which includes the major muscles attached to the trunk, above the ischial tuberosity, and below the superior aspect of the sternum. Approximately 87% of the core muscles are oriented either diagonally or horizontally and have rotation as one of their actions. Our body was made for rotation, yet very little rotational training is addressed in today’s standard training protocols. Thera-Bands make rotational training easy. The most annoying things about the bands is getting the latex powder on your clothes and occasionally the bands break while you are in the middle of a set. An advantage to band assessing and training is the observation of symmetrical or asymmetrical movements. The link between uncontrolled spinal and joint intersegmental translation or uncontrolled range of motion, and the development of musculoskeletal pain and degenerative pathology, is well-known. Often, patients are not even aware of the bad movement pattern that they are doing over and over that is causing the stiffness. Sometimes, it is only clearly seen when the muscles fatigue and pain sets in. The inefficient control of muscles and bones, poor movement habits, and poor posture give rise to very subtle and unique imbalances in the body-stability system. This puts mechanical stress and strain on the joints; and the muscular, neurological, and connective tissue systems of the body. This leads to cumulative microinflammation, which leads to pain and pathology. This predisposes joints to early aging and stiffness. A significant amount of injuries and stiffness occurs in clients with right- to left-sided strength and flexibility imbalances. My recommendations with the Thera-Band are to put the core first and to look for the following asymmetries:
and realizes how critical it is for the inner core of the body—namely, those joints closer to the spine, to be supported by the postural muscles designed with strength. You can create strength using the tubing made by Thera-Band. If you don’t tend to strengthen, the natural progression is for the body to lose it.
I usually recommend that stretching is the last thing a person does once he or she is pain-free. I see many patients that injure themselves from overstretching in yoga class and with Pilates. Stretch to increase flexibility, but don’t overdo it. I encourage patients to feel the muscle barrier and don’t go past that point. Otherwise, you start pulling on the ligaments and these were not meant to be pulled apart. Neuromusculoskeletal function involves a complex integration of proprioceptors facilitating; muscles reacting and joints moving simultaneously in sagital, frontal, and transverse planes of motion in a groundforce kinetic chain reaction response. This is facilitated by the moving body in relation to the ground and gravity. Use Thera-Bands to put patients through movements that allow you to see how an individual can control outside forces that are irregular in intensity, speed, load, symmetry, nd direction, just like sports and real life.
The purpose of flexibility varies for the different muscles around the joints. For the major power muscles, it is important that flexibility allows freedom of movement for the pelvis, hips, trunk, scapula, and humerus. Freedom of movement needs to be symmetrical.
General Muscle Strength
Once the foundational issues of consistency, core stability, flexibility, and balance control are being implemented, I then look at the bigger picture of the “outer core.” The rest of your body will need strength to carry you into your 80s and 90s. Performance as you age will be improved
Jeffrey Tucker, DC, DACRB
has been in continuous private practice for over 25 years in Los Angeles. His practice includes stretching, yoga, Kettlebells, & FMS training. He teaches courses in rehabilitation. Contact him at www.DrJeffreyTucker.com
I am so sick of clients doing excessive cardio – I mean mindless long runs, or bouts on the bike or eliptical. I hear about clients doing 60 minute cardio sessions and they are stiff as a board and in pain. The part that ‘kills me’ is that they won’t stretch or even listen to me when I talk to them about doing some weight lifting. I know cardio is one fat burning strategy, but it is time consuming and the reality is that aerobic activities burn far fewer calories than you think. After doing 20-30 minutes of cardio you may feel as though you’ve burned 600 calories but the cold reality is far different. For example, researchers measured the number of calories burned when walking versus running. The study showed that the average man burns just 124 calories when running a mile and only 88 when walking the same distance. So by running three miles you can expect to burn about 396 calories and by walking three miles you will burn about 240.
Figures for other aerobic activities are shown below (these are calculated using a man who weighs 190 pounds).
• Stationary bike (light): 474 calories per hour;
• Walking uphill (3.5 miles per hour): 518 calories per hour;
• High impact aerobics: 604 calories per hour;
• Stationary bike (moderate): 604 calories per hour;
• Jogging (light pace): 604 calories per hour;
• Running (5 miles per hour): 690 calories per hour;
• Stationary bike (vigorous): 906 calories per hour;
To lose one pound of body weight – you have to burn calories through exercise activity, or decrease your intake of food calories by approximately 3,000 calories. One strategy I use is to decrease 250 calories of food daily and increase your activity by 250 calories per day to reach the 3,000 calorie mark each week to lose a pound a week. Make sense? Do 30 minutes of cardio (intervals = sprints) to burn body fat and then do some weight lifting to build muscle which automatically burns more calories during rest. Or you can combine cardio + resistance. That’s what I personally do.
Too much aerobic exercise will burn calories from fat but can burn fuel from muscle cells—resulting in a loss of muscle mass—now you are screwed. The reason this happens is that periods of aerobic exercise cause the body to shift into survival mode. In this state, it strives to preserve access to fat cells by also burning fuel derived from muscle cells. It does this because the body is incapable of understanding our motivation for doing cardio. As far as it is concerned, it just needs to maintain fat reserves for any pending emergency situations where we might not have access to food.
By combining your workouts with resistance + cardio activities, you can burn up to 44% more calories. The bottom line is that resistance + cardio workouts burn considerably more calories and fat than ordinary cardio alone.
Just tell me what you like to do and I can turn any of your activities into a cardio + resistance workout. For example, if you like to walk or jog you can pick up a set of dumbbells, some ankle weights or even a weight vest. If biking is your thing, just kick up the resistance. Whatever cardio activity it is that you like to do, I’ll show you how to add some resistance and not only will you burn more fat but you’ll also be able to maintain more of your hard-earned muscle mass.
Come in for a few sessions and I’ll teach you how to do a cardio + restance workout. This will help you lean out!
The first session I started my client on the Paleo diet. The second session I taught her a 30-minute workout program that she could do at home on her own two to three times per week. I didn’t give her any cardio. She began to see results in lowered blood pressure even without much attention to the diet. By the end of the first month she gradually began cleaning up the diet to a more Paleo program (grass fed meat, seeds, organic vegetables and fruits, low carb) and saw results in terms of more rapid weight loss, easing of GURD symptoms, and dropping sinus allergy meds.
She said to me that she felt like she was on the right track regarding her diet and exercise program. I didn’t force her into everything at once, I let her go at her own pace. I monitored her lean fat mass and body fat composition and showed her the improvements. Then, after another few months I introduced the concepts of intermittent fasting and fasting before morning workouts. Her body responded and the fat loss got even more rapid. Her lousy sleep patterns were also improving.
I did suggest some supplements. I recommeded the Metagenics Wellness Essentials for Women. Simple and reasonable. Take a packet in the morning and another in the night. Because of her work schedule she rarely got outside to enjoy the sun. So, I suggested taking some additional vitamin D3 (2000 IU daily) and omega 3 fish oil (3-4 g total per day).
As I recount the history and results of this successful patient, now more than 4 months later she has achieved her weight loss goal of 20 pounds.