E61 | Keep It Real Talk #10: Back & Other Surgeries

Download Episode File

On today's episode, Greg, Doug and Trevor #KeepItReal while talking back & other surgeries.

Like this episode? You'll love our free training program (sign up below) & our Movement Foundations Online Course.

 

Episode Transcription: Welcome to the Resilient Performance Podcast This is Keep It Real number 10. So we're going to dive into surgeries in general and kind of talk about anything related to rehab, getting back to training and specifically with our partner, Doug here, a week out of some minor back procedure, but definitely doesn't feel minor early on. So we'll dive into that, how he's doing and kind of the process of it and what he's able to do physically now and what his plans are going forward and what we can do to help him as therapists. So Doug, you want to just sort of intro the background too. It's almost like a little case study we'll do essentially, and just kind of fill people in and then we'll just talk generally about surgeries after that. Yeah. So I'm like a week status post, um, uh, laminotomy at L4/L5 - L5 S/1 and then frame it onto me at both those. Levels. I'd just like to kind of preface, like I'm not using it usually more private about this stuff because you know, it's like, I've the world. It doesn't necessarily care that I had surgery. And like, I haven't really had much hardship in my life. A lot of times on social media we'll make them like, Oh, like, you know, I'm going through all this adversity. And like, I'm going to show you how I'm overcoming it. Like, that's not really. The point of this. Like I, frankly almost rather not talk about it, but I think there's value from a clinical standpoint because I've learned a lot just clinically, you know, when you're on the receiving end of care, versus the one doing the care and then even like, um, systemically in terms of a healthcare. So like, I guess a little bit of the history on it was as long as I can remember, even since I was like 20 years old, I just always had issues with the left side of my back, like left. Buttock region. And then when I was in, um, the military and jump school, I ended up breaking some ribs, but before they came to that conclusion, I had to get, um, various kinds of imaging to see what was going on. And they found, they told me at that point that I had congenital lumbar stenosis. And at the time I'm like 23 years old. So I didn't really think anything of it. But I remember them saying that my spinal canal, you know, in the lumbar spine was about like 40% of the. So with a normal and they attributed that, that being congenital. I mean, I was doing some training at that point and I had done even some heavy lifting, but maybe for like three years, like in three years you don't get 40% of the width of the spinal canal, even up history of it in my family. Like, I remember my father talking about having stenosis and my grandfather, even though they ended up not needing to have surgery for it, but that would always be an issue like when I would train and have a problem, like it would be, it would be that. Whether it was like through like heavy, dead lifting or squatting. If I kind of like pushed it too far, you know, carrying a pack over, you know, many, many miles like that, that would just always be the part that like, would feel stiff. And sometimes like, no matter how much I would try to like stretch it, mobilize it, get soft tissue work. Like it would always feel tight. And it kind of makes sense now, knowing what I know that there was probably some nerve root compression, even then, as we know as therapists, you can't really like stretch your way through. Neurological tone or tightness. Um, but so I dealt with that until like two years ago. Like it really wasn't a problem. It was something that like, I might like quote unquote, tweak my back and then be, you know, have to work around it for a week. But then that would be fine. But basically right around two years ago, like around Thanksgiving time in the weeks leading up to that, I had progressively worsening buttock pain to the point that. And you guys might remember. Cause we had our Christmas party early that year in like November, like we were just walking and I would have to like stop every like minute or two to like sit down. And it was at the point where like, I remember, you know, we were working at solace at the time. I would take the train subway to Penn station and then we had to walk. I had to walk the four or five blocks East to desal us where we were practicing. And like, I remember that like at one point like, Oh, like this is a pretty difficult walk. Like I feel like when I get to Saul, so I have to like. Sit down. And then I would get to the point where like I had to do half the walk and sit down and then like, then it got to the point where I couldn't really walk that much at all. And I was taking Uber's, um, to work, which is kind of weird because before I was getting this buttock pain, like I remember doing some tempo running at the field and just, just a test of myself. I'm like, I'm going to do a 400 and see if I could break 60 seconds. And, you know, I broke 60 seconds, but just not like a major athletic feat, but at 38 years old it's okay. And it speaks to the fact that like, You know, I'm running a sub 6,400 and then like four weeks later, I'm taking Uber's to work because I literally can't walk more than a block. So I ended up at the time didn't have any health care, except for the VA, went to the VA, told them what was going on. And they said that they're going to get me an MRI. This was on a Thursday. They're going to get me an MRI for the following Monday. So we're on Thursday. Now that Saturday, two days later, I collapsed in the shower and like, literally they could a crawl out of the shower, like into bed. And I was like on the side of the bed, I could barely move. My wife had to like, hold the bottle while I peed into it. Cause I didn't wanna go get up and go to the bathroom. So I'm like, all right, this is pretty bad. But because they didn't have health insurance, I didn't want to call an ambulance. So I ended up somehow like hours later, just like hopping on one leg down the stairs. Gotten a cab went to the ER there, and that's where, you know, some of the, um, you just see the disparity in care throughout different systems and providers, because I think because I was like young and healthy, when I went there a little bit dismissive of the fact that like, yeah, I mean, I was able to walk kind of gingerly and I didn't have motor weakness in the sense of like foot drop or I didn't have like caught a Aquinas. It's like, Oh, here's a guy who was like limping in, but. The, the ER doc, when I told them, you know, what I might normally capable of doing and how, like, I hadn't been able to walk more than a block over the last couple of weeks. He took it very seriously and like wanting to get me, you want it to actually send me to NYU to get an MRI right away. But because it was the weekend, you basically had to have like really, really serious, almost like life and death situation to get an MRI there on the weekend. The, um, the neurosurgery resident, in my opinion, when it's like a little bit green and he was kind of like, Oh, it's, you know, it's just sciatica. The ER doc was kind of advocating for me, trying to get more. And finally he was able to at least get me a CT scan, which showed, you know, that's not like the definitive thing. Like I needed an MRI, but the CT scan indicated there might've been a cyst that was pressing on a nerve at S one, which explained some of the. Neurological symptoms, but ultimately, like I needed to get an MRI. They told me to, to go in on, um, the following two days later on a Monday to see a specialist at the VA to kind of like. Get the remainder of the care that I needed. And it turned out that when I went to the ER, on that Saturday, I didn't have an MRI scheduled for the following Monday. I had a, a neurological. So I was under the impression that when I was at the ER, that I was gonna go an MRI, two days later, it was not an MRI. It was like, it was a consult to possibly get an MRI down the road. So there's a little bit of dysfunction there. So I showed up at the VA the following Monday, today after the ER. And again, they kind of like. We're a little bit dismissive. They just wanted to give me like some pain medication. They're like, Oh, it's just sciatica. I was like, and from being in the field, I'm like, can you kinda at least get an MRI to see like where this is coming from? Like, it's not normal for somebody at my functional capability to not be able to walk more than a block and be in this amount of pain where I was like, literally helpless. Um, and so they were like, well, we can't get you an MRI for six weeks. So that was one. And I was like, all right, like I'm just, I'm done with them. Luckily through the connections that we have as healthcare providers. And from my connections in the military, I called a physician friend, like it's able to get things done. He got me an MRI. Literally that day I went to long Island that Monday afternoon, after going to the VA, I paid out of pocket for the MRI. And, um, luckily like unable to do that, but I wasn't going to wait six weeks for the MRI. And I'm like, I need to know what's going on because like we get paid by the hour and we run our own business. Like if I can't. Physically work then, you know, like business shuts down and on top of that, just for like, I want it to get out of pain and get it definitive treatment. In my, in my mind, I knew that I probably needed to get like an injection of some kind. So I got the MRI and the MRI showed that there was the stenosis, it showed some discal changes and some nerve root compression, but it was like a lot of stuff going on. And it was hard to tell if it was the disc or the stenosis or the cyst. But at that point I was able to at least, um, No start getting on track to see a specialist. And the funny thing is after I got my MRI, but I credit a pocket for the VA called me and they were like, Oh, you know, we, we heard that you were in the ER a couple of days ago. Do you want, do you want to, um, like make an appointment to see like a pain, pain management specialist, which I think is that's who it would do, what it would do, the injection. In the VA healthcare system. So like, yeah, like I think I need an injection. I actually have an MRI and all that I got privately. So maybe I can show this specialist at the VA the MRI, and then I can get on the fast track to an injection. And this is no, this is November mind you. And they were like, well, has next available appointments in March? And I'm kind of like, how do you. Say that with a straight face, like you expect me to wait, you know, December, January, February, four months to like actually get like a definitive treatment for this. So that's when I was like, all right, like I am done with the VA system completely. And again, I will say that there were some good people there that when I went like, especially the ER doctor was I think very responsive and took my case very seriously. But when you work in a dysfunctional system, even if you have some good people, it doesn't matter. So I think there's some. And this is a separate discussion that I want to have separate episode on like health care, like the, I think there's ways to, you know, get people access to healthcare, even people who can't normally afford it, but whether or not the government is the best vehicle to provide that, I think it could be. But I think it's a discussion that has to be had. I don't think it's clear because sometimes people who support the government sponsored healthcare for everybody, or like tout the VA as a success story for me, I would say it couldn't have been more disastrous. Um, So I ended up getting on my like maybe like a month or two later when I could getting all my wife's health insurance, which you I'm lucky that she had a job that had health, good health insurance, so they could do that. But then I went to a podiatrist that we know and trust and collaborate with on patients. And like he was, you know, outside of that, ER, doctor, like the first like competent person that I really dealt with that was like, look, you've got some nerve root compression here. Like there's some structural things going on that like, You know, we can't really change, but we can try to reduce the inflammation around the nerve. Um, and so I ended up getting a series of injections, which like I thought, like helped. And it got me back to being more functional. Like this happened in November when I went to the ER in around new year's I was actually skiing, which I wasn't a hundred percent. And I still had some parasthesia maybe a little bit of motor weakness, not really like any. Back pain. And that was the weird thing is like, when this was really bad, the, the pain was more of like a burning, um, electric type pain down my leg, never wasn't back pain. Um, but the injections allow me to be more functional. Like I was able to, to train and work around the problem. Um, I wasn't doing anything, you know, more like single leg stuff, core stuff, some like low level aerobic stuff. And then over the course of like the next couple of months, I was really at the point where I would say by maybe, um, Like March or April. I could almost do whatever I wanted to do, but I didn't have that like 90% gear, like when I would like play tennis. And I was like, I'm like, uh, College level, like for people to know USDA, like a 5.0 level player, like I could hit with a good player of my level when we're cooperative. But like, if we played a match, I didn't have that sent gear where like, if somebody had a short ball or a ball, a corner, like I knew that I had the capability to run and get up, but like, there was just an inhibition there where I didn't want to do it, but again, I'm like for the rest of my life, I don't know about 90% I can still do mainly what I want. I was skiing, kite surfing, doing martial arts and. Even doing martial arts, like when I would grapple, as long as the grappling was mainly operative, like, again, I couldn't in an awkward position, like torque, somebody, and like really, really like try to execute a throw or a hold. But if it was like an 80%, I felt good, then I'm like, well, I'm not professional fighter. So again, I was willing to accept that, like with the stenosis that I had and the nerve root compression that that might never come back. But then. Fast forward to like, um, maybe two months ago, right before my son was born, I started to get that thing where I was and walk and felt like I had to sit down. Um, and that it came on like really quick, nowhere, because again, I was very, very functional. I was sprinting at max velocity, you know, training, lower body, really hard. And then then two weeks later I'm like, wow, like I, I can sprint, but I can't like stand up for that long or I can't walk for that long. Um, and then when my son was born, I got to the point where like, I really. I couldn't stand up and Sue them for more than a couple of minutes without having to sit down. So I'm like, alright, like this is affecting my life. Now my ability to care for somebody else. So my wife and my son were in the hospital for a couple of days after the birth. I actually went to the physiatrist that we know in the middle of that to get an injection and try to buy myself some relief, which. Speaks to like how serious it was, because they wouldn't normally leave my wife and my son in that situation. I wanted to spend time with them. And I think that bought me again a little bit of relief, but then a couple of weeks after that, just got to the point where I really couldn't tolerate standing or sitting very long, got another MRI. And at this point I'm thinking like I probably, if the stenosis is bad enough, I'm going to have to remove that mechanical, fix that mechanical problems with this compression on the nerve. Like no matter how many. Injections you get, and you try to work on function and mobility, like there's a mechanical problem. So I started to think like, are I'm probably a candidate got the, got a newer MRI. Hadn't really changed that much from the last one. And that's when I ended up getting, um, three consults, one with a surgeon that I've collaborated with on patients. And he was kind of the one that, like, I knew that if I was going to have surgery, I wanted it to have it with. And then I had two remote ones with people in different parts of the country, just because. I want to just make sure that like, all three of them said, look, you are like a legitimate candidate for surgery and it wasn't going to be a case where one of them was like, yeah, you need surrogate. The other two were like, no, this is, you know, conservative treatment. But I explained to them that I try conservative treatment, you know, that I am a PT and kind of aware of what I can and can't do with this. And unanimously, they all said. That I was a candidate for surgery because there was just so much at L four L five, so much central stenosis, and so much foraminal stenosis. The nerve just couldn't breathe. They didn't say to get surgery right now. They're kind of like, well, you'll know when you need surgery. And then once I, once all three of them said that I was a candidate, I'm kind of like, well, I feel like I'm at that point now. Like I can't. Um, I can't really do normal quote unquote normal things, like forget about skiing and all the fun things I like to do. Like I couldn't walk to work. And even, you know, at that point I was treating patients, but I was taking Uber's or cabs because I didn't want to walk like even from the subway, a couple blocks to get here. And it's not that long walk. Um, but the interesting part with that, and again, this is where medicine, if you're not, um, And even backtracking, like if you're not in the field, it can be very hard to navigate all the specialists and people that you need to see. Like, luckily I had expertise and relationships, but I knew like what needed to get done so I can orchestrate it myself, but I don't know how quickly I would have gotten resolution even two years ago to get the injections. If I was just, if I didn't know what I needed and I had to go from specialist to specialist because no one really. Tends to take ownership of cases. It's kind of like, well, I did my part, go see this person. And then it's kind of like kick the can. Fortunately, I was able to like manage all these people and like orchestrate it. Um, and that's where I think that like, PT can actually be the, or physio can be the profession that does the orchestrating, because I think that in a lot of ways, because we're not the ones doing the. Changing the anatomy surgically, we can almost have a bigger picture idea of what's going on. I mean, we obviously, I think that we're more than qualified to know when somebody needs surgery, even though we can't do it, we also appreciate the functional piece. So I think that like where PTs can, I think, like distinguish themselves from other healthcare providers is to be that case manager. And then, you know, like I've worked with, I worked with somebody just now. Like ironically enough where she could potentially be a candidate for surgery or at a minimum, an epidural, because she had some nerve root compression and motor weakness. And like, I didn't, I literally did not treat her during the appointment or do much of an assessment. I looked over at her MRI report and I set up an appointment with, um, the spine surgeon tomorrow and physiatrist the next day. So it's like, look, go see the spine surgeon. He's very conservative. You have motor weakness if you need, if you need surgery. I think he's a trustworthy person to determine that because he's very conservative. And he, in fact, he wrote a book, convincing people to not get spine surgery. So I'm like if he looks at your MRI and says right away, based on your. Subjective and your imaging findings, you need surgery. You probably need it. If he says that you don't, then the next day you've got an epidural book with someone that we all know, and then you'll be on your road to either rail you'll know what needs to be done. But like, I, I did that for her. Like while she was there, I called these people. And I felt like at that point in time, that was the best way that I could help her. Like, yes, I probably could have had her do some nerve glides and some like help her desensitize the nerve, but like, that's not going to do as much as. Removing that mechanical constriction. Cause she had stenosis as well around the nerve or getting, you know, some kind of anti-inflammatory to reduce that inflammatory response. So then when it came to the surgeons, they all said that the stenosis was the problem. And they all said that the disc wasn't the problem. I said, yes, like you like everybody else has a disc bulge, but the disc is not, what's putting pressure on the nerve. It's the. The central and the framework of stenosis at those different levels. But what was interesting is they all wanted to do a slightly different procedure. One wanted to do, um, and to be fair to the ones that did the remote, um, consult, they didn't really have the best view of my MRI. They had to go to. Like a portal that had pictures of the images, but they didn't have the disc to really, really like maneuver around and focus in on what they wanted. But one surgeon wanted to do a full on laminectomy, five L five S one on both levels on both sides, even though I don't have any symptoms on my right side. So even remove the spinus process and just basically just remove the roof. Okay. Both sides, uh, at both levels. Oh, four Oh five and L five S one. The other one I wanted to just do, uh, a laminotomy at L four L five, which is basically a partial laminectomy. So just drilling up a hole in the laminate at both levels on the left side, to create some room for the nerve to breathe. Didn't mention anything really about the framing. Although again, that could have been because he didn't, um, have like really great view of the images and the person that ended up getting the surgery from, um, Wanted to do a laminotomy at L four L five and then a frame anatomy with those levels as well. So again, if you're a patient, you're kind of like, how do I know who to trust? I went with the local person number one, because he was local. I had a personal relationship, but what was really. Put me at ease too, was that I saw him in person and he spent an hour with me going over the MRI and frame by frame. And he's like, look, you know, I'm not telling you to get surgery right now, but you are a candidate because here is the problem. Like here is your frame and it , you could see in the right side there's space for the nerve and the left side, there's like, there's no space. It's completely constricted. Um, But having him go through that in person was just much more comforting than doing it remotely. And I'm not, that's not a criticism of the other providers because I knew going in, I wasn't looking to have them do the surgery. I just wanted an opinion. But what was funny was the one surgeon who wanted to do the remote one. I want it to do the laminotomy at L four Oh five and L five S one. I never actually talked to him like through zoom or any other platform. He was just like, I emailed, um, the office, cause they said that remote consult, and this is the person that has a very, or a practice that has an amazing reputation in the pro sports world. I contacted them about a virtual console thinking that like they were going to ask for my insurance and all that stuff. And like, I was going to set up an appointment to actually like talk to one of their physicians. They didn't ask for any of that. I was willing to pay. They basically just said. Give us a one paragraph summary of your, of your history and then access to your MRI. If you have it, I did that. And then I got contacted by one of their surgeons and their surgeon was like, yeah, you've got stenosis. I would recommend getting like a laminotomy at L four Oh five and L five S one. And like, that was it. There was no like, yeah, but I actually like want to talk to you and explain what's going on. It was kind of like, Yeah, just here's an email. Take my word for it. Like either get surgery or don't like, we kind of, it's almost like we're so busy that we don't know if you talk to us or not. Like they didn't interested in the and exchange of it. And I was perfectly willing again, to pay for that time to like talk to someone and have it explained to me because on a rational level, as a clinician, like, yes, I know that. I'm a candidate for surgery. That's why I'm reaching out after two years of trying to manage what I have conservatively, but it's still one up in comforting as like, as a human and as a patient, because you don't always want to wear the clinician hat as a, um, as a patient to like, just talk to somebody and be like, here's why I want to do surgery. And here's why, here's why other things. Didn't work and, you know, like even going through the MRI, like the person that I saw in New York did, he actually spent so much time with me in New York. He spent an hour where I had to cut him off. Cause I'm like, I've got to get back to work. So there is something to be said for, you know, like you could, you can have, if you didn't make the right clinical decision, but you know, like that human element of just saying like, look, I'm going to take total or ship over this. Here's what's going on. Here's the plan and doing that in person. Um, I think frankly just works better than, than a remote platform. So, you know, I think that virtual consults can work well for some things, but like, I don't necessarily know how I would want to make the decision to get surgery purely over a remote consult, but it was interesting. Again, it's like, these are all great well-renowned surgeons. They all wanted to do a slightly different procedure. And I think that they might've all quote unquote worked, but. What differentiated, you know, who I wanted to go with was more of the, the human element. And I just thought that he was more thorough because he spent more time and he literally showed me where the problem was. So some of the other people weren't capable of identifying where the problem was, but being shown on the MRI, like here's where the compression is, here's mechanically, what needs to be fixed to, um, to do that. So I ended up getting that, um, that surgery a week ago today with, uh, with a doctor here in New York. And, you know, again, some of the lessons learned, I mean, even with something like an MRI, like in our field, MRIs get a very bad, a bad rap almost. It's kind of like, Oh, well, MRIs lead to over-treatment and they lead to, um, you know, catastrophic, um, thoughts and these kind of things. But I look at it, Mariah's like an MRI is an absolute miracle because without that MRI, um, Like now you've got to do a much more invasive surgery to get to the root of the problem. And MRI at least allows you to identify like where the problem is. So now you can do a more minimally invasive procedure. Um, so I think it's a miraculous tool and I'm sure that like most good physios don't mean to demonize it, but sometimes the narrative on social media, because physio is want to make it like, Oh, you know, we're good and surgeons are bad. I am very grateful that there are MRIs and I think MRIs are an amazing tool. And if they're used in process, totally, it's not the fault of the MRI. It's the fault of the provider that misinterpreted it, or that used it for the wrong purpose. But like, I think we should all be very grateful for it. I hope we get to a point where are cheaper and more accessible because in an ideal world, to me, if you can, if an MRI would cost, let's say like $5. Everyone should get an MRI because it's a piece of information. And as long as you're not a moron and you don't, you don't misinterpret the MRI. And you know, if someone has back pain and they have no radicular symptoms, no motor weakness, but they have a disclosure on the MRI. Like as long as that, as long as you as the clinician, doesn't say like, you need to have back surgery or injection. The MRI is great. Like it's going to rule out the worst case scenario. It's an, it's a piece of information that basically allows you to get an anatomical view without having surgery. So. I think MRIs are great. Um, they should be used responsibly and the problem is not MRIs. It's how clinicians are educated and trained. And we should try to fix that and not demonize MRIs, which kind of leads me to the next thing is, you know, when I was, um, when I was immediately postop, like. I was in a ton of pain just from what was done locally. I didn't, I woke up with a lot less nerve pain in my leg and I was able to stand for much longer, but it felt like, you know, um, like kind of like, like a, well rumble, the w to old school WWF, everybody on one team just took a chair and hit me in the back, which that's what it's supposed to do. Right. Like I I've literally had my muscles in my back pried apart to access. The, the deeper structures. And I had parts of my bone shaved away and ligamentum flavum and connected tissue to free up that nerve. So like, it should, should hurt. And again, it's, it's like pain, medications are bad. Opiates are bad. Ironically enough, I was in so much pain when I got discharged that I had to go in my dosage of, of, you know, uh, pain medication, um, elevated. And it turns out that in. And the government's infinite wisdom because of this opioid epidemic. They have mandated that this is according to my surgeon, that physicians in New York state are not allowed to prescribe opiates more than every eight hours, even though more frequently than every eight hours. Even though what I found was I would have relief for about four or five hours, and then I'd be in excruciating pain. Um, And so ideally these opiates would be prescribed for every four or five hours create. So I ended up having to get put on like, um, another anti-inflammatory a non-opiate in between the opiate doses, because I was like in so much pain that I couldn't sleep. And we talk about things like bed mobility and stuff like that, which an outpatient PT, you don't think much about it, but when you're in excruciating pain from the surgery and like, You can't get out of bed. Cause they're in so much pain, you appreciate pain mitigation. So just like with MRIs, like opiates have a place, um, and, and acute pain, like people who have chronic, you know, chronic pain probably shouldn't be topic opiates, like, um, like M&Ms so there's no real. Um, like trauma there, but even like when I was in the military did search and rescue, like we gave people fentanyl. We gave people ketamine that got their, you know, blown up or shot. And it's, it's the heat like pain management is one of the most humane things that you can do as a health care provider. So to take away a tool, um, just because some people might've used that tool, I think it's debatable. Like what, what, what side you should err on? Do you err, on the side of wealth, like we should have, we should have people who are in legitimate pain. Remain in more pain because some people have used it or should we allow physicians to prescribe these, um, these drugs that are at their own discretion with the potential that some people might have used them? Um, again, it's like, who's who are you? Who do you ideologically want to hold the other party hostage? It's more of a philosophical question, but I mean, pain, pain management acutely is obviously like very, very important and I'm very appreciative. To, to have had that, because I can't imagine not having that after that surgery, it would have made, you know, the first, first week postop, just like very, very, very rough. And then, you know, the other kind of like takeaway and lesson learned from there is, you know, I don't, luckily I can like kind of rehab myself, but just thinking about, you know, postop pain, it, I w and I don't think we were ever of the school where like, if someone's post off that we should be. Cranking on a joint to get range of motion. And my postdoc guidelines were no bending, lifting or twisting, which I didn't need to be told that because acute pain is a very good kind of reminder of what you shouldn't should or shouldn't be doing. And even with. Pain medication on board. Like I'm literally, like the last thing that I want to do is do a freaking day left or throw a medicine ball the first week after my surgery. I didn't need, but obviously I understand why I was told that. But, um, you know, in situations where like you might be told that look like with knee postop, try to get the range, you know, early range of motion. I don't think that there's ever a place to crank on people's joints. And put them in excruciating pain, just so that you can get a better reading on a goniometer. I mean, if you look at what happens when people have invasive joint surgery is whether it's like an ACL surgery, knee replacement, hip replacement, like when they're asleep, they have full range of motion when they wake up and their nervous system sort of becomes alive, so to speak and they can perceive pain, then they get all that inhibition. So it's not like they, they, they, that range of motion is not necessarily available to them. It's that. It's inhibited because they're in so much pain. And so just to, just to crank on somebody and put them in pain to temporarily get a higher goniometer reading, when we all know that if we work against the nervous system, that even if we get an acute change in range of motion, five minutes later, they're going to stiffen up again. So I'm not saying that we shouldn't go after early range of motion if it's indicated after a surgery, but like there is a way to work with the patient and do it in a way where you're not eliciting eliciting panic. I think it's inhumane at this point, especially after having. Gone through a surgery to crank out a joint, to get range of motion, if you're competent and you know what you're doing, you should be able to get range of motion without really, really hurting somebody. So, and make sure I touched on all of my, uh, kind of like bigger picture points, but I want to make it about like, who cares? I had surgery, a lot of people have it, but I think from like a clinical standpoint and like, uh, you know, overall like healthcare standpoint, like these are the kinds of the things. You know, who's going to be, who's going to be the case manager, you know, not, not vilifying imaging. Um, even like, how do you know, went to have surgery? For me, they always said like that the patient knows, like I knew when it was time. Cause I just like, how is that my limit? And when they told me that I was a candidate, it's like how much? Yeah. Maybe I could tolerate taking cabs and Uber's to work for another year and not walk for more than five minutes or stand for more than five minutes. But like that's, if these surgeries are available, like then. I want to have it and just, and resolve the problem definitively, especially when my prognosis was that I'd be able to return to doing whatever I wanted to do without restriction. And there wasn't going to be any, um, any structural compromise or instability in the Fossette joint. Like they were able to maintain the integrity of the process with the foraminal. Let me, so again, it was kind of like a no brainer at that point. Um, you talked about the surgical disparity. How do you really know who to trust and what procedure to go with when. People will come up with the same diagnosis, but they want to solve the problem surgically in a slight different way, pain meds, kind of same thing as MRI. Like they have a place, they shouldn't be abused, but it's, it's the humane thing to do to control somebody's pain acutely. Um, and then, you know, again, just not, not crushing people with, um, with triangles, the range of motion after a surgery, and then kind of the last thing is that, you know, having a surgery is very inconvenient. Um, Like, especially if you have a surgery where you've got an, I've got to go to physical therapy three, three times a week, or whatever, like now in your busy life, you have to find a way to do something three times a week. When most of us are like probably pretty saturated what we're doing already. So, and that's where I think, you know, if you're treating a patient, especially it's postop, number one, it's probably, I must have had a surgery before, like the worst moment of their life or the most pain that they've been in. So if they're in kind of a, like a bad mood, Like, I think that should be somewhat expected and there needs to be some compassion for that. Not like, well, you know, like, you know, why you, you, you need to elevate them versus you expecting them to elevate you. Because again, they went through a traumatic experience, probably the worst thing that's happened to them medically. And they also have to see somebody three days a week. They probably didn't want to have to see like, yes, people like their physical therapist and they might enjoy the experience. But I think most people would rather not have to do it. So just appreciating that, like, this is probably the last time I think most people would have to be doing. And we've kind of talked about this sort of, you know, as much as we can making it about them. And even though they're not going to be at their best and trying to work around their constraints versus being dogmatic and saying like, you know, here's what you have to do because you know, they really don't, they don't want to be here. And like, I don't want to have to like rehab. My back after a surgery and do you know, um, very like remedial things to get myself back to where it was, but I'll do it. Um, because, because I have to out of necessity. So that's, that's kind it, I mean, I don't know if there's more than, Oh, that was awesome. Doug. That was a great explanation. I think, you know, Everybody has their own experience and, and you know, of going in after an injury and needing a surgery and all that kind of stuff. So, I mean, it's an interest in me here, like the length of the process from somebody who was educated, you know, medically, and let's be honest. Like most of the people we work with that have surgeries don't have the same kind of medical education that we do. So. I think there's so much value, like you talked about, and I'm like w doing the multiple consults with three different surgeons like you did, and then finding the one that made you for the most comfortable, because whether you're going in for a surgery or you're coming to us just for physical therapy in general, it's like, as a patient you're so vulnerable, whether you're vulnerable physically or emotionally, or it doesn't matter. But like, you know, you're not necessarily like your normal self quote unquote. So I think somebody that like takes the time to listen to you and takes the time to. Appreciate your story. Even if like some of the information they give you, like doesn't necessarily matter. It's not going to change what they do. It's not going to change the intervention. Like, you know, all the history. Cause, cause it seems like all the three surgeons that you mentioned all had the same goal in terms of letting the nerve breathe. Right. And they're just different approaches to it. And like you said, probably all three of them would have worked to some degree. So assuming you would get the same outcome, the surgery itself doesn't matter, but you're going to choose the person. To, to perform the surgery that you feel the best with. Um, like I said, who kind of makes you feel like a person, not just a patient and not just like, you're this, you're this spine and I'm an operate on this spine and I don't really care about anything else that's going on because you know, you see people who do need to get a surgery and it's like, They come in and talk to us about it. And they have no idea, like kind of what the process of, of, of the surgery is. And they need to be educated on like what the surgery is actually kind of trying to do and the reason for getting it. And, uh, you know, I think that like the person who did your surgery and all the different people that. We have good relationships with other medical providers that we send people to. We send them to them specifically because they do such a great job of not just, not just from an intervention standpoint, they do a great job, but they do a great job of making people feel comfortable and feeling, feeling safe, uh, in their, in their clinic. Yeah. It's like, who would you want to send a family member to? You know, and if the answer to that is, well, I wouldn't send my mother, my brother, my sister, whatever. Then. No matter how competent the person is, they probably should go somewhere else. There's plenty of competent people who also have, you know, it's kind of like a restaurant, like it's plenty of restaurants that have good food and bad service, but in a place like New York, especially where you've got plenty of restaurants that have great food and great service, like why don't have both, you know, and when you're going to make yourself that vulnerable, then the human element and the interactive piece is just so important. And one thing I wanted to touch on too, that I forgot to mention is, you know, People often, especially now, like it's, it's very easy to get kind of self righteous about what, like certain kinds of treatments that don't work or don't have evidence behind them. And I'm not until you've been in like really, really like just difficult situation and been very vulnerable. I've been a lot of pain. Not that I ever had any desire to get things that might be, um, considered to be like non-evidence based or like snake oil, whatever, but I can totally see why someone who's like in a ton of pain would do things that physical therapists and like traditional medical providers tend to demonize because like, you will literally do anything, especially to avoid surgery. And if it's like, all right, someone's going to rub some. You know, some kind of a thing on your, on your body or they're gonna, you know, put magic beads on you. Like, yeah. I don't like, I don't think that stuff works. I wouldn't do it for myself, but I would never, I never like a patient that did that because I understand, especially having gone through this, like why, why they would do it and chances are most people who do that stuff. I've tried like physical therapy. They've tried traditional meds care. And in many cases they're, they're seeking the crazy stuff because traditional metal medical care. Has failed them sometimes it's just not, sometimes you just can't fix everything, but sometimes it's because, you know, they went to physical therapy and the physical therapist spent five minutes with them. They went to a mill or they went to an orthopedist who spent two minutes and was kind of like, Hey, here's some ibuprofen and be on your way. So I totally get why people would do that. Then I would not that I before with like, make fun of somebody that would do that, but it's like, I totally get why someone would do seek some of these treatments. So then. The only other thing was like, you know, people always want to know like, well, why did this happen? What's the root cause? Like there's seldom a root cause. I mean, for me, you know, if I didn't have the congenital thing with the narrow spinal canal, I probably wouldn't be in this situation. But if I didn't have the athletic history that I had the training history and then, you know, like the military occupational history that I probably wouldn't have had an either cause like my father had the same thing, but didn't put his body through as much. So. They're seldom kind of one, one causative factor. And it's at the end of the day, it's kind of like, who cares? Like once you've identified the problem, you just have to have to fix it. And you can, what if it's a death? Like, what if I didn't do this? And what if I didn't do that? But you know, you get to a point where when it's time, you, you know, when you, when you, once you've arrived there, it's, it's very clear, like when you need the surgery, because you're just like, all right, like I, how much more do I want to live? The way that I'm living. And going back to like some of the, you know, surgeries, a modern miracle MRIs, or a modern miracle. Like, I can only imagine if this surgery wasn't available. I'm 40 years old, like granted 500 years ago, I probably would have been dead by now because I would have gotten killed by a wild animal or some kind of disease that we didn't have a vaccine for. But like, you know, if this procedure wasn't available now, I'm 40 years old, I've got a six week old kid, like. You know that that nerve is not going to free itself up. So then what, like, so I, you know, I, not that I didn't have a ton of respect for the other people that we collaborate with clinically before, but you know, again, I think it's, it's popular in physio to kind of demonize surgeons because they it's like, Oh, they do too many procedures. They don't, that don't need to be done. But you know, again, surgeons, every time they, somebody goes under anesthesia and every time a surgeon cuts somebody, like there's a risk that somebody could be. Killed a permanently disabled. Like they have a ton of skin in the game and a ton of risks that they assume every time they work. So it's very easy to have a job where like the most dangerous thing that we can do is maybe have somebody hurt themselves doing a trap bar deadlift. Like, let's just be careful. I'm not saying that surgeons should be beyond school, but you know, fi you know, if you, your experience with surgeons is that they're like tend to overprescribe surgery, or they're not careful then. That's you know, like your fault as a provider for not having the right network. Right. So then, you know, then fine find quote unquote, good surgeons that you can refer your patients to because like, I have never, I have all the surgeons that we collaborate with on our network. I've never felt like, Oh, I'm really worried that this person is just going to prescribe prescribed surgery when it's not needed. You know, I think there's a reason why we work with the people that we do, because we think that they are ethical and they are careful. So again, I'm, I'm very appreciative for surgery and the, these. Things are available. Cause I don't know what the alternative for me at this point in my life would be without it, like, I don't think I could rehab myself out of it at this point. There's a mechanical problem. And the only way to fix that is to create, you know, more room for that nerve to breed, so to speak. Yeah, definitely just touch on too. I had a conversation with a patient yesterday and he had spoken to three different hand surgeons and it was, he ultimately chose the one that he felt most comfortable with personally. And. Not that we expect to be in, you know, personal contact and like calling and texting doctors. But yeah, the doctor had offered his cell phone number to the patient. I assume he is doing with most patients, if not all. And like that, even that goes a long way where like, yeah, you might, I've never actually needed to contact her physician. And like, you really shouldn't have to your surgeon, like after you had the surgery, but like just knowing that. This person is extending themselves a little bit more than the others, like, sort of goes a long way. And I mean, I know there's a lot of patients that will have come in and they, they, uh, they feel like it's different because we just listen to them. And that's something like, as a therapist, it's such a big thing. Like that's a luxury of ours because of our model too. Like, you know, we were working in a, in a clinic where we had to see four patients an hour. Like you can't do that stuff as much. So no matter how good of a. Therapists you are like you're limited by your model. Um, and then it could be the same way for any strength coaches that are listening to, if you're in a, a model where you're seeing 12 athletes at a time, like you can't get to know them as well, and you can't sort of figure out what makes them tick or, you know, what are those quote unquote soft skills that each athlete might need to, you know, motivate them or make them reach whatever their specific goals are. So that's just something. I think is super important. Um, and then I wanted to just go back and touch on. You had, uh, brought up just like timing and how you would know, you know, like you'll know when the time is. Right. And I think a lot of it just goes back to like what you said, you, you don't want to just be able to walk down the block. And back and like, that's all you want to be able to do. Cause it's like, Oh, well you're like 38. Like you don't need to do stuff. Um, you know, and just another patient of mine, um, had scheduled, uh, a knee replacement surgery and he's somewhere around 50 years old, 55 years old. And. Again, it goes back to like, his goals are different than potentially other people, his age with the same knee issues, because he's a baseball coach. He's very active. If he does private lessons, one-on-one he has multiple age level teams that he's working with. So he's got. A very active life. Um, you know, potentially probably more than most people his age. So for his goals, like if he doesn't have his surgery, you know, sooner than later, and he's gone through conservative stuff for two, three years or so at this point with injections and everything, if he doesn't get that surgery now, And they just sort of push it back because it's like, well, you might have to do it again. Cause the surgery has like an expiration, you know, having a knee replacement, you might have to have a revision or whatever. Um, if he doesn't do the surgery now, like he probably won't be able to coach now as opposed to like, if you wait and push it back, like you'll be, you'll be suffering now. But yeah, maybe when you're 80, you'll be able to walk a little bit more. Like, well, you know, when you, when you get to those later ages, like you don't need to do the things like this guy is making a living off of coaching. I would think most again, it's like ages and potentially, but like most 80 year olds, aren't coaching, uh, you know, multiple level, age group, uh, baseball players and doing the things that he's doing. So I think that's huge and like, And pairing your surgery, timing with your goals. Um, and you, you don't want to just be able to walk, like you want to be able to get back to the martial arts stuff you were doing and kiteboarding and skiing and doing all the badass stuff that you're used to doing. The funny about that though, is that like the point at which I couldn't walk, you know, when that, when it got really bad, but like, there was a point where I could barely walk more than two blocks, but. I was like, I could sprint, um, I could, I did a workout on the VersaClimber where like, I would go like six seconds as hard as I could do five swings with a 50 pound 50 kilogram kettlebell. I would do that. I did that on the minute for 30 minutes at a time when I couldn't walk more than two blocks. So like, it was weird because I probably, if I had the time, like, could have kiteboard it too, when I was. Flip the switch. And I was like really busy and doing stuff. I can totally fool people and be very, very functional. And I even like two days or three days before the surgery, we actually played tennis. Um, like again, cooperative hitting. I wouldn't have been able to like, play a match against a great player, but if you watch me play and you didn't know where like an early day you'd be like, this guy looks totally fine, so people can fool you. But when, when, when there's no negotiating, like when you can't walk, then. Well, you can't stand up for very long then that's that's, that's when it's time. And then to your point about, um, people following through, like my surgeon called me three or four times a day, the first couple of days postop to check in. So I didn't expect that, but it was like very, very comforting that he did. And then, you know, the surgeons that I tend to refer to, I've heard from their patients, that they will receive texts from the surgeon. Like, you know, the D the day after the surgery of the day of the surgery to make sure they're feeling okay. So yeah, that might be built in that might even be open to like their front office staff, actually sending those messages from a text message. Like, it might be a number that's not even the actual doctor's number, but like, if it seems like it is, and the patients perceiving that as like, Oh, I'm, I'm being cared for. Like, that's a huge benefit. And that's something that we try and do with, like, we're going to email you back and forth and we're going to be here. If you have any questions, feel free to email us. We can hop on a call or. Zoom to sort of fit you in between your appointments if you're not coming for another month or whatever. Um, so yeah, that's, that's awesome that they would do that. And like, even, you know, I mean, I had this thought where, you know, what, if the surgery goes wrong, because I had situations in my family where like my father had a medical procedure that went wrong and it ended up basically permanently putting them on a pacemaker. And like, that's a case where like, If you're going to Sue somebody, that's like a legitimate case to do it. He didn't do it because he's kind of like, what's, what's the point? Like I'm going to ruin this guy's life. There. Isn't an inherent risk in medicine. And like, as all indications are that my surgery went really well, but I had a thought like, well, what if, what if the surgery didn't go well? And I woke up and like, now I'm worse than I was before. Like, I wouldn't even have the thought to take any legal action against my surgeon because. He was so thorough. So kind so compassionate. It's like this guy has done thousands of surgeries. If you read his Google reviews, like the only bad reviews he has are from people who didn't actually have surgery from him. And maybe like, you know, you always have someone where they misinterpret what you say. And like, no matter who they see, they woke up with the wrong side of the bed, but like pretty much unanimous, like anyone who's had surgery from him, it's like, Five star review, totally raving in terms of like his clinical competence and his bedside manner. So that's something that you always hear when it comes to like medical malpractice, is that people, the medical providers that are essentially liked are the ones that are least likely to be prosecuted legally. Um, I might even bring this up, cause at no point, like when I want to suggest anything negative about my experience with the surgeon, but in the abstract, like if something bad were to have happened to me, It's like, alright. You know, why, why? Like this guy was so good to me. He has a dangerous job. Like what's like, I would be fine financially, regardless of whether I would work to get money in a lawsuit. And if, if there was irreversible damage from the surgery at that, can't be undone by anybody. Then what's the point. Like I'm going to, I would have a numb leg or if my back would hurt the rest of my life regardless. So now, like I'm going to make myself better by, you know, make myself feel better emotionally by like, Trying to ruin somebody else's life who had good intentions. And by all indications, she is very, very competent and professional. Now I'm not saying there aren't situations where, you know, legal action against the medical provider isn't warranted and they're there isn't such thing as negligence. But again, like, based on what this physician, the surgeon did prior to the surgery, like he had my like complete trust and, you know, even, even knowing that there's a risk, something could go wrong. Like what. I would never, I would never think to do anything to try to like hurt her personally or professionally. I think that just goes to the, to your point before about like the value of interviewing multiple clinicians, all regardless, whether they're surgeons or not, certainly it doesn't matter. Just making sure you have someone that you genuinely feel comfortable and you have trust with, because if you don't trust the provider, you're going to be. You, and then with, you know, devil on one shoulder and being a, when that's not really going to help you achieve a better outcome, versus if you'd go in and work with somebody that you have have faith in and that you trust. I think, you know, your chance of a better outcome is going to be higher just because you have a better overall attitude about what's about to happen. Yeah. And that's a nice part of the process. It's like, if you don't believe that placebo, if you don't believe that what you're going to be doing, where are you going to. Going to do is going to work then like now you're more likely to have like a negative, um, kind of attitude towards rehab and like that's going to affect your recovery. So you can't separate these interactive things from like the quote unquote, you know, actual treatment. Um, so yeah, it's a, it's good medicine be nice to people. And you could say like, well, that's not really treat like cookie, you know, again in the totality. You, so it's all one, it's all part of the big picture and all this stuff matters. Be a good person. Right. Awesome. Yeah. So we'll, uh, we'll wrap this one up. I know you have somebody coming in to see you right now, Doug. Um, thank you for all this background. Cause I think it's huge that, you know, you talk about back surgeries. I think people often think they just hear like the horror stories and they don't hear the good experiences that people have and they don't hear, you know, hear from a provider. Yeah. And their experience with their own surgery. So thank you for that. Um, and then, uh, yeah, we'll wrap up this episode now and take any questions from people. Um, so thank you for listening and we hope to see you next week. Thanks everybody. Yeah. I mean, I guess like, um, from, I guess from like the model that you guys have, and you, you know, you were saying before, how, you know, you have this luxury of seeing patients for that amount of time and getting to know them, especially like we see some of these patients for, you know, multiple times a week, we know a lot about their lives. Do you think that like, especially like therapists in this kind of setting have more of like an moral obligation or like duty for. You know, kind of directing these patients. Cause they're coming to asking you, like, should I get surgery? Should I not? I've been talking to these surgeons, they told me this. And they're kind of relying on us to kind of tell them what the, what if they should get surgery or not. Do you think that because we know more like subjective things and the surgeon, may we have more of like a moral obligation or responsibility to tell them, um, have you guys ever felt that way for patients for like coming in. I think we ever, we do have responsibility to like, be fully transparent and honest with them about the information that we have access to and like the information that actually influences our decisions, um, versus like what the surgeon does. Like again, like I said, you know, totally different contexts in terms of, you know, in our setting say we see somebody for. Two times a week for the hour sessions that we do, but they get to spend 15 minutes with our surgeon and there are surgeons call in for surgery right away, because you know, they didn't, they see the imaging that, yeah. Maybe based upon their imaging and their training would say that surgery is necessary. But in our mind, you know, from a function in symptomatic standpoint, maybe they're not experiencing. The limitations in function or the type of stuff that would correlate with that type of MRI finding we have to, I think, morally and ethically present that to them. And then it is kind of up to the patient to make the decision themselves. And I always tell patients that I'm like, I know the body better than you do, you know your body better than I do. So I can't tell you what you feel. I can't tell you what you're experiencing. I can't, um, You know, make the call for you. And like Doug said, and we've had like the, the physiatrist that he mentioned, who he had seen is the guy who, uh, had, I had first say this, that like patients know women need surgery. Um, so like, I always recommend, like, don't go into a surgery, like with kind of a halfassed, uh, View of it, like, meaning like don't go into surgery being like, Oh, I don't know. I dunno if I really need it. It's like, that's the last thing you should do is like get a surgery if you don't really think you need it. Um, so just because, you know, a surgeon may say you need a surgery, like Doug did get multiple opinions. Um, and that's why like, you know, we kind of check each other and stuff like I'll ask great questions. I'm like, dude, can you check this dude shoulder out? Like, should I, I think he needs. To get referred out. Cause I think this could be going on. Like I want to be double checked. That's why like a good surgeon. And we had a case, um, I have a case like that right now where like her surgeon is sending her to another surgeon to get a second opinion on it, to make sure that she didn't miss anything. And I'm like, that's an awesome, awesome practitioner. That's an awesome doctor. Who's like really trying to, you know, cross every T and dot every I before going to the really invasive route of actually getting a surgery. So again, like, I think. From what we do as therapists and based upon our model and the time that we have with people, like, yeah, we definitely are. I would say morally obligated to try to like direct people in. The right path and whether that's referring to good people. And like we said before, the network we've created with the other people and practitioners that we collaborate with, like it's taken a long time to find the different doctors that we genuinely trust. And they're all ones that we can shoot a text about a patient about, and we can have a conversation about, and actually be able to, where should this come from? So surgery is not some people take surgery lately, where if you've had a bunch of surgeries, like, yeah, whatever, it's just another surgery. It's not a big deal. Um, but you kind of always have to look at like what the flip side of the coin is like, like Doug was talking about there at the end. It's like, well, what if something bad happened? Like there's always a risk with surgery. Um, and I think, I think from a, the. Things that I've tried to do with clients when they come in. And they're either in a, you know, maybe looking at a surgery, whether it's scheduled or whether they like are probably going to need a surgery at some point in time, it's trying to educate them on like what the process actually is about the surgery and what can they expect? Because oftentimes, like Doug had a great experience with us where Doug was actually told, like, he, like he said, spent an hour with the doctor and got a great rapport and trusted him and could ask questions and all that kind of stuff. But like, I've had clients get in and they're like, yeah, the doctor, like I'm scheduled for surgery, like in a week and a half. And it's like, Oh, did they like what they talk about? And like, nothing. They just told me that they just like showed me my MRI and show me what's what's wrong. And then they're going to do a procedure. That's called this. And then I'm scheduled for the surgery. And it's like, okay, did they talk about the answer, your questions? It was like, usually like patients are so frazzled in that moment because they don't know that they are like, Coming to grips with the emotion coming to grips with the fact that you're about to get a surgery can be scary. So it's like educating them on like, okay, after the surgery, here's what you're gonna expect. You're going to be in a brace for three weeks, not putting any weight on it or whatever. Just kind of giving them an idea of like, what's about to happen to them, helps them emotionally calm down and not be so stressed out and anxious about what's going to happen. And I'd say the good surgeons, meaning like they did a good surgery, but like, Good people. Surgeons are the ones who, whether it's the surgeons themselves or their team that they've created, educates the patients on what they can expect before and after. And like during the whole process of it, that just makes the patient have a much better overall experience. And I was say, outcome also depends on like how long I've known this person for too. Like if they're coming in day one and they're like, Should I get the surgery in a month and be like, I don't friggin know, like I haven't, I don't know what you've been able to do. I don't know what you want to be able to do. Um, I don't know if we could do anything that changes how you feel in a month. So like, that's an impossible question to answer. Cause like termiticide, they know themselves more than you know them. Um, but uh, yeah, mostly the people that we're talking about are people that come in, we've done things conservatively. Um, that sometimes they help really well and they can give people relief for a really long time. Sometimes it's like, yeah, that doesn't really work. So you probably do need something else, like an injection or medicine or surgery. Um, so that's a huge part of it too, is like how well that, how well we actually know the patient is definitely going to determine like how I viewed it to a surgery that they're being recommended to do. Uh, How about, like, how does, um, like a patient's prognosis, like say a patient, you know, it's not, they're not going to be motivated, but they need surgery and like say a total knee replacement, but they're not going to put in the work like afterwards getting the surgery, but they're in so much pain. Like, Oh, I need it. How do you deal with like a situation like that with like a patient where, you know, they're not going to have a good outcome. But they need the surgery, but would it be beneficial for them to even get it? I think it depends on the surgery. So for an example, if they're saying a knee replacement, I think that's a relatively like easy rehab process where if it is somebody that might be more lazy or less motivated to be physically active, I think they should probably still get the surgery if it's gotten to that point, um, where. Even then even if you can get them to just like go up and down their stairs and extra few times a day, like they're going to benefit from that from like a rehab perspective, because those people are probably at the point where they're not really into physical activity as much, and they're not as motivated. They're not going to do the things they need to do to get back to being in a good physical state. So I would think for specifically talking about surgeries like a knee replacement, I think would still benefit somebody. Who might not, might not necessarily be motivated to like come to PT and get a program and, you know, do things on their own. Whereas like, uh, you know, like Tommy, John surgery, I'm seeing these UCLA all the time. Like you can't get Tommy John surgery and then just like half ass it and kind of just show up in a year and pitch like, so that would be a situation like, no, like you need to. You're not a good candidate because of the, your, uh, your motivation or so I think, yeah, I think that that answers your question, but yeah, there's definitely some surgeries that I think would still be useful regardless if they even go to a physical therapist afterwards or not. I think part of that too is like being realistic. Being like us being realistic with them and trying to get the patient to be realistic with themselves. I'm like, what are they actually trying to get out of the surgery? And what do they want to be able to do after the surgery? Like I've had people, um, who, who, you know, like they're fine being like 80% and that's fine for them. Like, cool. Like, you know, we, like, I think part of why. We kind of have a different approach to things it's like, we always want to get people to be able to maximize what they can possibly do, but unfortunately, or fortunately, whatever way you want to look at, like, some people just don't care. Like, like if Doug, Doug was kind of said to myself, he didn't want to like go back and like actually play tennis really hard. And like not in a cooperative kind of chill that way. If you wanted to actually do some of the higher level things, he wants to be able to do, like, he kind of needs the surgery and then after the surgery, he's going to have to train smart and do all the stuff to be able to get where it needs to go. Um, cause like some people will say it's like, you know, Oh, I want to be able to run a marathon after the surgery. And it's like, If I know you're somebody who won't put in the time, it's going to take to be able to do it after the surgery. Like, I'm going to tell you that I got, I'm going to be very honest because otherwise they're going to be disappointed. Like they have a level of expectation going in. That's just unrealistic. Um, so I think like they kind of defeat themselves. By choosing that intervention. If there don't know what the process is to get where they need to go. That's why I think education is always such a huge part of, of what we do, whether it's like education about physical therapy, like, you know, what the process is going to be with us when they're, when they're in our care or whether the, what the process is like after the surgery to get to where they want to go eventually. Cause I think there's some misinformation or not even misinformation, maybe. Um, Too. There's just assumptions that patients make some times that. You know, it's like, it's like the same thing of like, you know, it's like, I don't want to lift weights and get bulky. It's like, you're not going to lift. You're not going to touch a weight one day a week. And like, look like a bodybuilder, like just like completely unrealistic. But people genuinely think that sometimes. So they have to be educated that like, yeah, just because like, you want to go and play pickup hoops after your ACL surgery. If you're, you know, a 40 year old man, it's like, yeah, you're not, unless you put in the work, you're not going to be able to like, actually just go back up and like pick up a basketball and like play five on five with your friends after work. Like, you'd be like, there's going to be some time involved, um, that you need to spend to be able to do what you want to do. So I think being realistic, getting them to be realistic with themselves and then educating them on if they really want that. How do they get there is, is, is part of the thing too, in terms of like choosing a surgeon, we are not gonna remember. Uh, Joe, when you were a student with us, there was a particular patient, which you probably could remember where he, um, had some disc issues in his back. He's had it for a decade and. He, he can get to a level considered definitely for a long time where he's able to do everything he wants to do, which is he wants to be able to cycle in his house and like on a Peloton, something like that. He wants to be able to walk the dog for half an hour, um, go for walks with his wife. Um, potentially do like some like the whole of, you know, like body weight type exercise stuff, like once or twice a week. Like it's very. Very sort of simple stuff in our minds because we're so used to like working with an athlete after a surgery, he wants to get back to whatever. And like for that guy, yeah. He might, he would probably need a surgery if he wanted to do more. Um, but he's extremely happy. And he's even said to me, like, this is I'm doing really well and I feel great. I'm able to walk for an hour and like, that's awesome. And it just goes back to like what their goals are versus what. We think their goals should be. So, um, it's always something to keep in mind and it's like, almost like every visit when somebody comes in, I'm like thinking about like, what are they, what is this person's goal? And that's going to change what I do with them versus somebody with a different goal. Obviously, thank you for listening to the Resilient Performance Podcast. We hope to see you next week.