A Painful "Crunch"

  A "crunching” in your knee when you crouch or squat may signal that you have the start of a degenerative condition called chondromalacia patella, a form of arthritis. 

This is a condition of abnormal wear-and-tear, and Is commonly caused by aberrant tracking of the patella, or kneecap. The kneecap is embedded in the tendon of the quadraceps (quads) muscles, and every time you bend your knee back or forth, which activates these muscles, the kneecap slides in a grove in the bone underneath.

Misalignment of the patella causes it to rub too far sideways in that groove. What causes this misalignment? Commonly, it is uneven action in the quads.

My treatment is two-fold---correction of the patellar misalignment with the Activator instrument, and teaching the patient how to do daily exercises to correct the action of their quads.

Whiplash Side Effects

 An acceleration / deceleration neck injury, aka whiplash, is not only painful, but can also result in weakness in the neck, loss of normal cervical curvature, hypertonic muscles, and impingement of nerves that exit the spine in the cervical region. 

This nerve impingement may manifest as Thoracic Outlet Syndrome (TOS), with symptoms including pain traveling down the arm, alteration of sensation in the arm and / or hand such as numbness, tingling, and lack of normal perception of touch---hypoesthesia (diminished sensation) or hyperesthesia (accentuated sensation) in the upper extremity.

Symptoms may not be immediately noticeable, but may appear slowly following the injury, and often take a while to resolve.

Proper treatment, including precise, gentle adjustments with the Activator instrument as soon as possible after the injury; rest; a neck brace if needed; ergonomic counseling; anti-inflammatory soft tissue therapy, including ice & topical arnica; and appropriate introduction of gentle stretches + exercises will assist healing and recovery.

A Painful Snap! at the Elbow

  Disturbance of the upper part (head) of the radius, the outermost bone in the forearm, where it attaches at the elbow, can cause a sudden sharp pain with movement of the forearm or hand.

The upper end of the radius is encased by, and rotates within, an annular ligament, which encircles it and holds it snug against the joint complex at the elbow. 

Misalignment of the head of the radius causes painful stress at this joint, and can cause abnormal wear & tear on the annular ligament.

Careful assessment and precise adjustments with the Activator instrument will re-align the bone, relieve the abnormal stress and ease the pain. A compression band should be worn just below the ligamentous attachment to protect the area as it heals. 

Tips to Stay Healthy / COVID-19

Include ORGANIC, UNREFINED COCONUT OIL in your diet---coconut oil is loaded with lauric acid, which is effective against viruses, as well as being anti-bacterial. Use it when sauteing vegetables, put it in your coffee or tea, use it in soups or stews.

QUERCETIN is a plant pigment that is an antioxidant, & it has anti-viral properties. The best way to get it is to eat foods high in quercetin. Foods high in quercetin include:

Red Onions—BEST source

Organic apples, grapes, and tomatoes

Dark berries like cherries, blueberries, and blackberries

Taragon, chives, coriander, and dill

Spinach and kale 

 AVOID SUGAR in all forms. Sugar suppresses our immune system.

---The amount of sugar in one soft drink suppresses immune function for up to 12 hours.

---There is a 50% decrease in the effectiveness of your white blood cells to fight infection for up to 4 hours after eating just 2 teaspoons of sugar.

---Read labels; divide the number of grams of sugar by 4 to tell how many teaspoons of sugar a product contains.

VITAMIN D is a key nutrient for supporting immune function. Your body makes Vit D  when you’re exposed to natural sunlight, so try to spend some time outdoors. You can supplement with Vit D---4,000 or 5,000 iu (international units) is recommended per day. Have your Vit D status checked if possible, and in the meantime get it in foods rich in Vit D, such as fatty fish (tuna, salmon, herring, sardines, mackerel), egg yolks, and mushrooms.

Rib Cage Distortion

  Distortion, or twisting, of the entire rib cage is something I see quite often in my practice. The subaxillary (under the arm) ribs on one side become stressed inferiorly, while the opposite subaxillary ribs are stressed superiorward.

Patients who present with this distortion, or torquing, of their rib cage range from youngsters who are active in sports, those who do active work with their upper bodies such as housecleaners, carpenters, plumbers, food service workers, etc., to those who may have reached too far or fast for something, twisted to grab something in the back seat of their car, or may have been securing a small child in a carseat. 

Regardless of the biomechanical cause, I correct the distortion quickly, gently, and comfortably with the Activator instrument.

Toe Cramps

  Ever had one or more of your toes start to cramp while walking or hiking?

This is often caused by overly enthusiastic “toe-off” during the gait cycle. “Pushing off” a bit too hard as one moves from one foot forward to the other when walking can stress a toe or toes, and start a cramp.

Try easing back on the force with which you use your toes to propel you as you walk. If you do get a cramp, take off your shoe, give your foot a rest, and massage the involved toe(s).

If the problem persists, I’ll be happy to check and adjust your feet, including your toes. Precisely and gently correcting misalignments may be necessary for the issue to completely resolve.

 

Nerve Impingement in the Neck

  Our shoulders, arms, and hands have sensory nerves that originate in the neck. These nerves exit the spine and pass through openings, called foramen, between the vertebrae on each side, then travel down through the shoulder and upper extremity all the way to the hand.

Numbness, tingling, pain, altered sensation (hypoesthesia, which is a decrease of normal sensation, or hyperesthesia, abnormally heightened or pronounced, sensations) are signs that the nerves originating in the neck are experiencing interference, or impingement.

Impingement of nerves may to due to physical encroachment such as  pressure, abrasion, or stretching, and can be caused by abnormal misalignments of cervical vertebrae or by degenerative changes in spinal structures.

When patients present in my office with these problems, an appropriate course of conservative Activator Chiropractic care, including gentle, precise, directional adjustments with the Activator instrument, ergonomic and postural counseling, prescribed stretches and exercises, and sometimes application of gentle traction, is often the solution.

Post-Traumatic Headache

 Headache following some kind if trauma, such as whiplash or a blow to the head, has a special classification as post-traumatic. 

Diagnostic codes are unique for this type of headache, and distinguish it from other headaches, such as migraines, tension headaches, sinus headaches, etc.

A post-traumatic headache may require a more extensive course of treatment. Your doctor’s use of the pertinent diagnostic codes alerts insurance companies and auxiliary caregivers, and are important to justify additional care that may be needed by the patient.

What is An Activator Chiropractor?

   Distinctions between Chiropractors who use an Activator instrument and Chiropractors who are trained and Certified in Activator Method protocols are often not clearly understood.

Any Chiropractor can purchase an Activator instrument----so if you were to call 50 Chiropractic offices today and ask if the doctor uses Activator, they would tell you, “Yes.”

This does not mean, however, that the doctor is trained in Activator Chiropractic Technique, a research-backed, carefully developed and tested, specifically designed protocol for restoring normal balance to the entire body.

Qualified Activator Chiropractors are highly trained, required to complete courses of study in the protocol, and must pass written and practical exams in order to obtain Certification. They must complete an annual Continuing Education course in Activator Chiropractic Method to maintain their Certification. 

All Certified Activator doctors are listed on the website www.activator.com.  A doctor not listed here either does not have proper Activator training to become Certified, or has discontinued keeping up with their training and allowed their Certification to lapse.

What is Pelvic Complexity, & Why Should You Care?

  Patients with pelvic disequilibrium often exhibit nuances in the various articulations of their pelvic girdle. The pelvis is a multi-jointed, weight-bearing, essential foundation for the spine, and is integrally related to the status of the body above and below. 

Imbalances in the pelvis not only cause pain, but frequently result in one of the patient’s legs being shorter than the other. When this happens, it is a functional short leg, not an actual short leg. Correcting the imbalances brings the legs back to even.

Trouble-making pelvic imbalances are often quite complex, consisting not just of inferior /superior components, but also having internal or external rotational, or medial / lateral components to the aberrant pelvic pattern.

As an Advanced Proficiency Rated Activator Chiropractor, I am trained to precisely assess and correct the complex components of pelvic aberrance, reintroduce balance, relieve discomfort, even the legs, and restore normal functioning.    

Medicare and Chiropractic

  Medicare covers chiropractic, but only treatment to one or more regions of the spine. So, if you have a knee problem, for example, you must pay your chiropractor "out of pocket" for helping you with your knee.

The Chiropractic profession is diligently and consistently working to have Medicare cover Chiropractic care for the entire human frame, all the bones and joints. We hope this will happen soon.

Activator Chiropractic care is excellent support for seniors’ health, wellness, vitality, and function. Low-force and gentle, precise and specific, Activator Chiropractic is comfortable and effective.

As an Advanced Proficiency Rated Activator Chiropractor, I welcome Medicare patients in my practice, and am happy to be of service to seniors. 

Status of the Feet Affects the Whole Body

  What’s happening at our feet is integrally related to the state of our entire frame---our skeleton, our bones, our joints---to its overall equilibrium or disequilibrium.

For example, people who have fallen arches or who pronate need to support their feet with orthotics, not just for comfort, but also because these conditions in the feet reverberate up into the knees, hips, and pelvis and cause problems. 

Some may need prescription orthotics, but many people will find over-the-counter orthotics can do the job.

When the inside of your foot drops inward toward the floor when you’re standing, it’s called “pronation,” and is often seen in combination with fallen arches, or “flat feet.” This often creates abnormal stress on the Achilles tendon, causing a visible and abnormal inward curving. You can see this by standing behind someone who pronates and looking at the backs of their ankles. 

Pronation can cause foot pain and fatigue, but it also negatively affects the knees, and can reverberate upward to cause abnormal stresses in the hips and pelvis.

These abnormal stresses cause wear and tear that can lead to instability, pain, impairment of function, and eventually to osteoarthritis.

     Abnormalities at the feet should be properly addressed. My treatment plan includes precise assessment of feet, ankles, knees, hips, and pelvic joints and gentle, precise corrections with the  Activator instrument,.

Five "Secrets" About Fender Benders

1.  Despite insurance companies’ using it as the main criterion, the visual damage to your car is not necessarily an indicator of the consequences of the collision on your body.

2.  Feeling confused, "fuzzy," disoriented, and irritable often follows even a minor collision.

3. Symptoms may have delayed onset; you may "feel fine" for the first few days, or even longer. Be cautious about signing off on an insurance claim too soon; give yourself time for any consequences to your body to show up.

4. The sooner you receive proper care, the sooner you will recover. I encourage patients to come in as soon as possible after (an even minor) collision, to get their entire body checked & balanced, to better their chances for a speedy recovery.

5.  If you don't have Medpay on your auto policy, get it. If you have it, and you're in an accident, your own insurance will cover your care, so you or your doctor won't have to wait for the other party's insurance to pay. It's insurance that's reasonably priced and really worthwhile.

A Fall That Affects the Shoulder

  Instinctively in a fall, we reach out to brace our body’s impact with our arm(s) and hand(s). Among the upper extremity consequences of this instinctive reaction are injuries to the shoulder(s), which can be serious and painful.

Depending on the angle and direction of impact, forces driven up the arm may cause the head of the humerus, the bone in our upper arm, to misalign from its normal position at the glenoid fossa, a shallow “cup-like” socket which is part of the scapula.

This painful misalignment is commonly posterior, or backwards, occurring in falls forward such as tripping or stumbling, but can be anterior / superior, as when one’s foot slips forward and the body falls backward, with arm(s) instinctively extended backward to break the fall.

Carelul assessment of the shoulder after a fall and gentle, precise corrections of misalignments are essential to relieve pain, support healing, maintain normal range of motion, and prevent future degenerative changes that lead to arthritis.

Gratitude Is Healing

  Taking time to be grateful for the good in one’s life has positive physiological and psychological affects on our health. Focusing on gratitude relieves stress and unhappiness, and actually stimulates healing from illnesses.

Gratitude triggers release of mood-regulating neurotransmitters such as serotonin, inhibits the stress hormone cortisol, and stimulates the areas of the brain that produce pleasurable feelings.

Being grateful helps depression, reduces pain and inflammation, lowers blood sugar, and helps immune function.

Learn more at:

https://articles.mercola.com/sites/articles/archive/2019/11/28/effects-of-gratitude-on-health.aspx?cid_source=dnl&cid_medium=email&cid_content=art1HL&cid=20191128Z1&et_cid=DM398041&et_rid=759098228

The Pubic Symphysis

 An often overlooked or forgotten joint in the pelvis is the pubic symphysis. It is a small, movable, flexible joint in the front of the pelvic "girdle" (the bones and articulations that make up the pelvis in the human skeleton).

      There is a disc in this joint, similar to the discs in our spine. In women, the joint is able to expand during childbirth. 

     The pubic symphysis is an essential joint because it is integrally involved in motion of the pelvis during our gait cycle (walking), and in stability and equilibrium of the pelvic girdle. 

     I often find this joint misaligned when the patient’s pelvis is distorted, especially when the distortion is severe. A patient who complains of groin symptoms will often exhibit an aberrant alignment of the pubic symphysis, and correcting it will bring relief.

      I make precise, directional corrections to the pubic symphysis with the ACTIVATOR instrument to relieve groin & pelvic pain and help the pelvis to stabilize. 

Kneecap Troubles

      If the kneecap is misaligned, there is resulting abnormal wear-&-tear underneath it, which can eventually lead to arthritis of the knee.

     The kneecap, or patella, is imbedded in the tendon of the quadriceps (quads) muscles. Whenever the quads are activated by bending the knee, the kneecap moves with the tendon, sliding up and down in a groove on the front and lower end of the femur (the bone of the upper leg).

     As long as the kneecap slides smoothly and evenly in this groove, all is well. But if the kneecap begins to rub unevenly against the side(s) of the groove, trouble---abnormal wear & tear---and eventual development of arthritis---will result.  

     A misaligned patella easy to correct with ACTIVATOR Chiropractic, once a careful and precise assessment of the knee is done. I evaluate and then correct the misalignment, and I give the patient special exercises help the correction to hold.

Got (Cranial) Rhythms?

      Got cranial rhythms?  Yes, in fact we all do. 

      The "cranial rhythms" are very subtle, predictable rhythmical motions of the bones in the head. These motions are so subtle that it often takes a long time and a lot of practice to learn to discern them.

     To detect them, I place my hands gently on the patient's head, then wait. Depending on which movements I'm checking, I "listen" with my hands for the tactile sensations of movement. 

     The bones in the head move in these rhythms in pairs---the temporal bones have a characteristic rhythm, as do the parietal bones, the occiput, etc. We know what normal is, and feel for it. 

     Sometimes the rhythmical motions get "stuck" or out of synch. Then I gently encourage them back to normal. This is particularly good for headaches, and often helps with vertigo, sinus congestion, and sometimes tinnitus. 

     Cranial balancing is part of every treatment in my office. 

Tennis Elbow

      Pain and tenderness just below and near the outside of the elbow is commonly due to inflammation of the tendon of the wrist extensor muscles in the forearm (the muscles that bend your hand backward). It is a form of extensor tendonitis. 

     Called "tennis elbow" because it's common in tennis players, it is an overuse or improper use syndrome. Chronic or excessive contraction of he wrist extensor muscles causes inflammation of the tendon attaching these muscles at the elbow. Every time the muscles are activated, it causes pain in the tendon and at the tendon attachment.  

     The wrist extensor muscles in the forearm should be massaged, then iced and rested. The inflamed tendon must be protected so it can heal; this is done by a compression band worn just below the tendonous attachment to relieve stress on the tendon. 

     As an ACTIVATOR Chiropractor, I find tennis elbow is associated with particular misalignments of the bones in the forearm, the ulna and radius, and often of the carpal bones in the wrist. Correcting these misalignments is an essential part of my treatment plan.

Loss of Cervical Curve

  Often after an injury such as whiplash, there is a “straightening” of the normally forward-facing curve in the neck. This can happen in absence of injury, and may be unexplained. 

Sometimes called “military neck,” it can have various consequences. 

The altered curve changes biomechanical function in the cervical spine, affects posture, and may result in chronic discomfort. 

The cervical vertebrae should be gently and precisely aligned, and appropriate exercises and stretches prescribed. Traction is often part of my treatment plan for this.

Magnificent Magnesium

          Magnesium is important to our health in multiple ways. It is required for functioning of over 300 enzyme systems, important for efficient energy production in our cells, and for heart health and cognition.

It is involved in the metabolism and activation of other nutrients, including Vit. D.

There is a link between magnesium and Type II diabetes; magnesium helps regulate blood sugar by improving insulin sensitivity. Studies show that magnesium deficiency may be linked to an increased risk for diabetes.

Magnesium-rich foods include leafy greens, nuts, whole grains, avocados, and legumes.

Medicare Patients Welcome!

 If you have Medicare, you are welcome in my office---I enjoy serving Medicare patients in my practice. My low-force Activator Method is especially suitable for elders because it is gentle, comfortable, and safe.

My specialty is low-force, full-body balancing, and my adjustments are comfortable and gentle. My goal is to help you feel better, recover full functioning, and resume the activities that you enjoy.

"Just" a Head Bump?

      Bumping your head can be more than just an embarrassment or a temporary discomfort.  It can disturb the cranial rhythms, possibly setting you up for future headaches. 

      The cranial rhythms are subtle movement patterns of the cranial bones. These rhythms aren't synchronized with our pulse or respiration. They are related to the circulation of the cerebrospinal fluid, which bathes our brain and our spinal cord.

     Disturbance of these movement patterns is frequently associated with headaches, and sometimes with vertigo.

     Balancing the cranial rhythms and restoring them to normal is part of every full-body treatment that I do. If you bump your head, or if you suffer from headaches, I will be happy to help.

Fire Safe Santa Cruz County

                      

    I am proud to be a  Community Partner 

      with

Fire Safe Council of Santa Cruz County

A 501(c)(3) Nonprofit Corporation

Whose Mission is to Educate and Mobilize the People of Santa Cruz County

to Protect Their Community, Homes, and Environment from Wildfires 

Learn how your tax deductible contribution to 

become a Community Partner can help at:

https://www.firesafesantacruz.org/community-partners-2019

    
             

"Pelvic Distortion"--Is That a Rock Band?

      Actually, no, although it may sound like it. 

      Pelvic distortion is a very real, fairly common condition of the pelvis that causes, among other problems, a person to have one leg shorter than the other. 

      It also creates a tilted pelvis, making an unstable foundation for the spine and the rest of the body above. 

      Don't go through life with a pelvic condition that may sound like a rock band; come see me; I will adjust and balance your pelvis with low-force, comfortable ACTIVATOR Chiropractic.

Foot, Ankle, Knee, Hip

 An aberrant condition in the foot often affects the related ankle, knee, and hip. This is known as a “kinematic chain.” Vice-versa, a hip or knee problem can reverberate downward and affect the ankle and foot.

For example, pronation in the foot causes ankle destabilization and results in rotation of the knee. This is easy to demonstrate in someone who pronates by having them stand barefooted, without support for the arch of the foot.

Abnormal rotation at the knee causes stress in the joint, leads to abnormal wear-and-tear, and contributes to degenerative breakdown of the joint tissues.

In turn, this aberrance at the knee reverberates upward and creates abnormal stress in the hip joint.

When patients present in my office with foot pronation, I check and balance their pelvis and entire lower extremities, and prescribe orthotics to support the foot and correct pronation.

Unrelieved Rib Pain

 Pain along a rib that has no preceeding trauma, is unresponsive to chiropractic adjustments, and persistently worsens may be the first stage of an outbreak of shingles. 

Anyone who has had chicken pox carries the herpes zoster virus in the nerve ganglia alongside their spine. The virus is dormant until conditions such as hyperthermia or stress trigger an outbreak.

A shingles viral outbreak follows the path of the related sensory nerve, called a “dermatome.” Dermatomes wrapping around from the thoracic spine resemble the paths of our ribs, so initial symptoms of shingles are often misinterpreted as rib pain.

Nature's "Pest Control Experts"

      Owls are Nature's "pest control experts"---they feed on rats, mice, and gophers.

      Rat poisons can sicken and kill wildlife and pets, because after rodents eat the poison, they go back into the wild and can take more than a week to die. Any animal that preys on them also becomes poisoned. 

     "Using poison to kill rodents has the long-term effect of actually increasing the rodent population, since the poison kills off the rodents’ natural predators, allowing the rodents to breed unchecked."

    Owls are one of the best non-toxic methods of rodent control. Attract owls to your property by putting up nest boxes; one owl can devour 1400+ rodents per year!

    Learn more at  https://www.raptorsarethesolution.org

What Does Medicare Cover?

  For Chiropractic care, Medicare currently covers only treatment of the spine. So shoulder, knee, ankle, wrist, etc., problems aren’t covered. 

The Chiropractic profession is working on changing this---on getting Medicare coverage for the whole body---and hopefully, it will happen soon.

In the meantime, when I see Medicare patients, I make careful documentation of their spinal symptoms and treatment, and report these to Medicare on the required forms and according to the specific Medicare coding system. Medicare patients in my office pay my fee at the time of service. 

Typical allowances for Chiropractic patients in Santa Cruz County are between about $48.00 and $33.00 per visit, depending on the patient’s complaints and the concomitant treatment. 

        Of these allowances, Medicare will reimburse the patient 80%, and the typical Medicare supplement policy will cover the other 20%.  Allowances do change annually, but often by only a few cents.

Nerve Impingement in the Neck

 “Impingement” of a nerve simply means the nerve is somehow negatively affected. It might be pressure, abrasion, stretching, or other constriction, causing symptoms such as pain, numbness, tingling, burning, hyper- or hypoesthesia.

In the neck, nerves exit the spine and travel out into the shoulders and down both arms & hands. These nerves are called the “brachial plexus.” Impingement of the brachial plexus is called “thoracic outlet syndrome." 

There are several common sites of impingement of the brachial plexus, including between muscles on either side of the neck, and between the clavicle and the first rib. The patient may complain of pain or numbness or tingling in the arm(s) or hand(s).

This can be due to, among other causes, poor posture, trauma such as whiplash, over-exercising or imbalanced exercising, stress, or unaccustomed activities--often some kind of work with the arms over the head.

Once I identify the site(s) of impingement, I make precise, directional adjustments with the Activator instrument and give the patient ergonomic and home care counseling and appropriate stretches.

A "Winged" Scapula

  A common cause of discomfort and restriction in the upper back and shoulder is an outwardly rotated, or “winged” scapula.

When this occurs, symptoms can present around or underneath the shoulder blade itself, or in the involved shoulder and arm. Muscles may be in reactive contraction; the range of motion of the shoulder and arm is often restricted.

I reposition the scapula to its normal orientation, using the Activator instrument. It is also necessary to adjust the humerus, the upper bone in the arm which articulates with the scapula, as well as the radius or ulna in the forearm, and some of the bones in the wrist, because the “winging” of the scapula reverberates all the way into the shoulder and down the arm.

Ouch! Pain in the Toes

  Recurring pain in a toe or toes, which may feel like a cramp, can be related to an aberrant gait cycle. When a patient presents with this complaint, I watch them walk. 

Commonly, during toe-off, when the weight-bearing foot is rolling forward as the heel of the opposite foot takes the body’s weight, the toes on the “rolling” foot are "pushing." This not only assists in balance, but helps propel the walker forward.

If this action of the toes is unnecessarily strong, toe pain, either from stress on the joints or overly-contracted muscles, can be the result. This is common with vigorous walkers or “power” walkers.

Shoes that are too stiff can also be part of the problem. The walker must work harder during the gait cycle to overcome a stiff shoe. 

When a patient has this toe pain, I adjust the lower extremities, with careful attention to the feet and toes. then advise about proper walking shoes. I show the patient how to moderate their gait to help this condition resolve.

Lateral Ankle Pain

  Pain on the outside (lateral side) of the ankle can be due to a misaligned lower fibula. 

The lower end of the fibula, the smaller bone in the lower leg, forms the “bump” on the outside of the ankle. It is attached to the lower end of the larger bone, the tibia, by ligaments. Even a mild sprain of these ligaments can bring on pain.

Aside from a ligamentous sprain, however, the lower fibula may become stressed, or misaligned, in multiple directions, which results in pain, An inferior misalignment is quite common, as is a posterior misalignment. 

I correct these misalignments with the Activator instrument, precisely and comfortably for the patient, bringing relief.

Tension Headache

  Possibly the most common type of headache, tension headache, manifests as dull, aching pain and feelings of tension, tightness, and / or pressure in the head.

The sufferer may also have tender spots on their scalp and in the muscles of their neck, upper back, and shoulders.

With patients presenting in my office with this type of headache, I frequently find hypertonicity (abnormal tightness) or spasms in the suboccipital muscles at the base of the skull, in the muscles of the jaw, and in the muscles of the neck, upper back, and shoulders.

Sound familiar?

My treatment includes adjustments with the Activator to correct misalignments in the neck and upper body, and I use the Activator to relieve the hypertonicity in affected muscles.

Since these headaches are often posture - related, I counsel the patient about stressful postures which may be causing them, teach patients how to avoid these tension-producing postures, and give the patients stretches for the involved muscles.