Re-restarting an exercise program

With the coming new year, there is an inspiration to begin something new.  Resolutions are usually made to fix something that needs fixin.  So guess what is the number 1 thing in the US?  According to a small article out of Journal of Psychology this month-#1 goal is weight loss.  The study showed how greater than 50% will maintain the resolution for 4 weeks then the numbers drop steadily with a minority of well wishers continuing up to 6 months.  It is fitting that weight concerns are at the top of any wish list seeing how 1 in 3 Americans are obese (followed by the usual high blood pressure, high cholesterol and high sugar).  This speaks to that "spark" of an idea for getting back to high school weight always floating around somewhere in the frontal lobe of most US citizens.  Along side the thought bubble is the self defeating notion that "it's too big a task".  This negative feedback loop of failure to maintain change will become the dominant idea in greater than 50% of Americans who embark on the quest to look, feel and perform better in the New Year. 

The Saguil Approach to stack the odds of success in favor of the metabolically challenged well wisher is simple; Invest!!  Unfortunately, this 6 letter word has been associated with "stealing" in the last few decades beginning with vitamin/snake oil pushers, car salesmen, real estate investors, home mortgage officers, and wall street firms.  Taking away the greasy outer layer of this nugget of an idea will yield the essence of what I am proposing.  Taking something of value, placing it in a safe spot and increasing it's value with time.   Try now to translate the idea of 'value being monetary' to instead being in excellent health.  Imagine a pill you take 1-2 times a day that would insure a permanent high, no clouding of judgement, improved physical endurance and a perfect digestive system guaranteed weight loss without any side effects!  I think that most people would at least try the pill hoping for a way into a life that is only thought to exist in fiction. 

Investing in a lifestyle change is tough.  Where to start?  All my patients have "been there and done that" whether a virtual program or membership.  I see the frustration in going through another round of the "same ol failed routine" but the challenge is try not to generalize.  A DVD box set of changing exercise routines will probably be the same technique in a different package every year you order it.....there is only so much a charismatic trainer can do via recorded media.    A hired teacher/trainer is totally different experience.  You have a personal coach that cannot be paused, you have someone that dynamically changes the program based on what they see your likes and tolerances are.   Essentially, there is a human being paid to specifically fit a program into you and not the other way around.  A sustainable lifestyle change is one that you will want to do daily, one that will provide a sense of accomplishment and one that will leave you feeling like you are missing part of the day if not performed. Sounds too good to be possible?  Maybe, most people hit a plateau and stop making gains....at that point, revisit an expert and redesign another program to catapult to the next pinnacle.  Nothing lasts forever but if brainstorming with someone who 'changes lives for a living' increases the chance of you keeping a resolution.....it is worth the investment.

The next argument is affordability.  I will end the debate this way:
-solution B; don't make a lifestyle change, work as is, pay bills continue with unhealthy living, accumulate diseases, have a retirement fund but poor health, burn up the fund paying for medicines, surgeries, therapy or visits to every specialist in the doctor alphabet after you get on medicare.  Be well known by the ER staff not for the company you owned but for the frequent visits to the department...it will be a bad sign when the ER attendings call the residents in training to take a look at you and behold how a text book disease looks.
-solution A; give up something you love now in order to pay for the beginning of a change, maintain the change, reevaluate the next path to a pinnacle, get used to not having so many material things, love healthy food, embrace exercise, improve work performance, see the beauty of your immediate family, scale down the house, get a clean bill of health from your doctor to travel to Mt Everest in your late 60's, do volunteer work teaching the next generation how to work and live all the while keeping happiness in your heart. 

The 2 solutions are at opposite extremes with a large grey area between but should suffice for assisting in the picture of where most of my people who make excuses end up.  Postponing change will lead you to pay in the end with your health followed by your savings.  So where to start?  This should be where your health care team jumps in.  If your doc has helped to change lives in the past, he will have a collection of names and ideas from successful and charismatic facilitators.  The range will be from meditation gurus to exercise physiologists, to registered dietitians, lifestyle coaches, instructors in ancient practices like Qi Gong, Yoga, Tai Chi...even to other doctors who may serve as the first stepping stool to improve suffering before your journey.  Bottom line is it will take a few attempts.  One failure just means you are closer to a success. To exclaim you have tried that and it doesn't work is just setting you up for solution B.  Don't feel bad if in group B; western medicine does work to control symptoms but usually at the price of getting farther from the cause of your problems.  I cannot tell you how many times I used to see patients on medicare coming in with a long list of medicines often with interactions to each other because no one physician knew who was supposed to monitor the list.

This New Year, commit to making a change, seek out someone who has helped others, set the intention of where you want to be in 6 months, 12 months, retirement.   Don't sweat the details of the whole journey, just take some baby steps.  Martin Luther King said "you don't have to see the whole staircase, you just have to take the first step".

Should I see a specialist? pt 2

So lesson from last time -"trust your gut feeling when someone hands you a bogus answer".   I expect my consultants to give an expert opinion on a diagnosis, then I expect them to get back to me.  Used to be in the 90's a phone call would be made after an evaluation and plan created.   I understand with low insurance reimbursement that docs have to move patients like cattle to pay the bills, call me old fashioned, I still expect when the door is closed, full attention to whom ever I send for second opinion . 

Here is the flipside:  my patients know I spent extra time after family practice residency in a sports medicine fellowship.  There are a handful of teaching centers in Illinois that many graduates apply for but only few get in.  Most of us in primary care sports medicine are dedicated athletes or just love the musculoskeletal part of healing/health.  I think it's fantastic to know how to prevent asthma attacks with changing shoulder and upper back strength or improve post partum sex with pelvic therapy.  (It aint just knowing how to test for an ACL tear or pop a shoulder back in)   Anyway.....I remember taking a state written exam one year with a bunch of docs, saw an old friend who graduated a year ahead of me.   I was psyched about my sportsmed fellowship and mentioned....."you should consider it as well for more clinical experience"  (your average family medicine residency entails 3 years of training and most programs offer 1 month of orthopedic assisting in surgery or a sports medicine rotation").   His reaction was "a sprain is a sprain".   I honored his opinion but thought to myself, no way am I going near his clinic with any body ache, sprain, tear or dismemberment.  It's good to know first aid, RICE and how to write a note for work/school ...but......spending 4 weeks with splints/narcotics and a pending second opinion vs just 1 week with a handicap when the injury should have been rehab-ed from the start is a gia-normous waste of time!!!!!  On top of that, after 2 weeks of time off the body has now deconditioned, gained a few pounds, developed constipation and drowsiness from the meds plus a little reactive depression from not being able to exercise.  My job as a doc is to help compress the time frame of healing.  Every case is a little different, every personality with its individual desires, every brain has its own tolerance to pain so not all treatment plans fit each person.   (I scoff at hand-outs that say do this 20 repetitions 3 times a day as the sole basis of "rehab")  It does make a difference to see a well trained doc for the symptoms suffered.  

Obviously I cant speak enough for the specialty of primary care sports medicine.  Even if you aren't an athlete, kinesiology/musculoskeletal medicine/disease pathology all play into designing the best way to get someone to optimal health.  (ie....if I have an out of control diabetic who is obese, I wont just say "lose weight by starting a walking program" ... I'd get physical therapy involved, make sure his/her nutrition knowledge is maximized for her activity, then steer her toward and exercise physiologist for brainstorming a sustainable fun calorie burning activity.)   True sports medicine looks deeper than just exercise injuries.   So how to choose a doctor:

1-Primary care sports medicine fellowship trained (just ask the office if the doc completed a fellowship)
2-Orthopedic surgery is different in that all specialist can "cut".  I like sending my patients to an orthopod that has trained specifically for the region of the body involved.  (ie.....one of my favorite shoulder guys is Tony Romeo from Rush/White Sox,  most young grads have gone through enough knee scopes that they all know about ACL/meniscus repairs-so for the knee guy I go for the best bedside manner, hand injuries still go preferentially to hand surgeons.)   A must for any of my "Pods" is good bedside manner.  There used to be a magnificent hand surgeon that worked down the street when I was with CDH.  His talent in the OR was famous.....so was his anger.   Dude used to throw sterile instruments to the ground and have a tantrum if everything wasnt perfect.  I guess thats ok if he is looking out for you but I dont use healers that hurt inside or outside the office.
3-Chiropractic physicians have excellent training around Illinois so I like the ones that listen in and get the true dynamics of the patients pain.  The chiros I use have turned pain/function around faster than patients going through conventional methods.  Dr Joe Musolino in my office does great work, graduate from National University in Lombard.  Great communicator with me and physical therapy and this is what gets people better fast-coordinated efforts between all providers.   You have to research training and experience and see how they are active in the community.   Just like medical schools, if the chiro school has been around for years and continues to expand curiculum, probably a good school.  On the flipside, I spoke with a DC that took care profighters in MMA, he just wanted to refer patients to me for writing scripts of anabolic steroids, saying alot of docs he refers to do it for him.  (obviously fell into the dark side of healing for the glory of rubbing shoulders with the rich and famous.....doesnt have to be that way-see my pics!)
4-Medical Acupuncturists are powerful in their own world of healing (and have been for the last 2500 years)  When combined with conventional healing, I consider bringing them in like calling a left handed pitcher to a tie game.  For any injury that has plateaued or if an athlete needs to get better fast for a fight, game or match in 2 weeks-call in the needle doc!   I originally studied medical acupuncture at UCLA to see if I could speed up healing while waiting for the physical therapy HMO referal to be approved.  When I used it, it worked like a charm, sometime the patients would get better and not need therapy or surgery second opinion any more.  Ahh...unfortunately, insurance caught on and discontinued covering acupuncture as a benefit so I had to retire my skill.  (Only bring them out for special cases like in getting my pro MMA fighters to relax before a fight....see my pics!)

 

So if you are injured at work, in a league event, or during training; dont be embarassed to ask your provider what kind of training s/he went through.   If it seems like the injury is taking longer than expected, seek out one of us (see above) and get better faster!!!!  A "sprain is not just a sprain".     

 

Colorado Springs Olympic Training Center

Illinois Gynmastics Association Bravo Meet

Chris Chelios ex-Chicago Blackhawks

David Reid Gold Medalist 1996

DonWilson martial arts 1990's

Sean Murnane Chicago Bears

Felice Herrig Bellatore Fighter (the non athlete is Julian from B96 morning radio show jumped into the pic as he was leaving my office)

 

Yoga....ain't just for Girls!

 

(DrRic the Teacher)

 

     Why is it that when I advise "you should try yoga", the immediate response is, "I'm not flexible"!   I did mention "consider yoga" to one of my patients drafted by the Chicago Bears and he comment, "I want to be able to do some of the things you do" ........................"when I get older" (eeyowch!...this turning 50 business sucks)  Truthfully, yoga as a form of movement/exercise is one of the oldest forms of healing.  The true beginning of all martial arts stems from humans trying to stretch and move "energy channels" on the body that would maximize their health.  (This was before medicine and surgery....before Einstein, Newton and Aristotle)   Tai Chi involves stretching things called meridia's.  There's 12 that go up and down the front and back of the body that correspond to the positions you see in classic pictures of Tai Chi or Qi Gong.     Although time periods apart and a continent away, yoga as well uses Indian based energy channels and moves chakras with poses you see in classic pictures ....the same ones that are now the rage with most wellness centers, healing clinics, sports teams even churches and businesses.  I see practitioners trying it once and immediately professing great feelings of health and release from stress.  After my first Meditative Yoga class at Northwest Community Hospital Wellness, I had been over to get my ID picture taken and a lady approached me and said she attended the class and she felt the most positive response in pain relief from her fibromyalgia in years. 

   So the reason I bring this up is unfortunately if you attend any yoga class, the majority of participants will be women.  Some haters would say women choose yoga because they are naturally flexible so opting for an "easy" sport they can excel in is natural.  Or it's a nice way to get an hour work out if you don't want to sweat.   Or it's a good way for someone that isnt athletic to start learning about flexibility before they begin a real sport.  ( I have actually heard these excuses from men)   I politely say "you'd be surprise at what it entails.  Yoga is a combination of balance, flexibility and strength.   My ex-olympians from Cirque Du Soleil-La Nouba knew the value of having all three; imagine a male body builder pushing an object over head equal to his own body weight.  Seems easy right?  Now how about if he uses one hand; and is upside down!  Regarding the sweat, well there are some students who sweat during practice, then there are some that don't push too hard-both can be in the same class, not to mention Bikram Yoga this multimillion dollar world wide chain of studios all designed to keep you focused on the instruction in a room heated to 105 (anyone remember wrestling practice?)  Finally, professional athletes usually go to yoga after maximizing on their individual sport in hopes of getting an edge ahead of the competition. 

     From the mountain tops I say...... at 50 I have competed in body building, run marathons, climbed mountains, finished triathalons but the most rewarding (just like that lady who approached me) has been yoga.  I learned the concepts and essentials of yoga from Total Body Yoga in Illinois and was taught the deeper concepts and health benefits from Deepak Chopra/The Chopra Center in Cali.  Yoga grounded me to understand that practicing medicine wasnt about getting rich, it was about service to others.  It helped me with all my years of practice and study get through the helplessness of not being able to do anything while my mom slowly died from a terrible cancer.   As my mentor/classmate Davidji points out to me, when you feel you dont have time for yoga, it is probably the one thing you should be doing before healing the world.   So as a species I say, those that are the most inflexible, the most "relaxation response-lacking", the most muscle bound, top heavy (chicken legged), the most testosterone based/adrenaline addicted individuals that think grounding has to do with electricity are the ones who need the practice of yoga the most.  All a neophyte has to do is find a local studio, contact the teacher, explain your curiosity and try it.   9 times out of 10, you will feel the same benefit that a fibromyalgia sufferer had after countless years of no help and taking one class; the same benefit I experienced after seeking multiple adrenaline sports to satisfy my "man-liness" (from competitive shooting to rock climbing to racecar driving.....all pale in comparison to the lasting effects I get when I finish the last pose of the class-svasana!)   The effects of yoga are truly like a drug, and when you get addicted to it, you lose addictions to food, alcohol, caffeine, TV......without taking one prescription or attending one counseling session!

    I used to warm up my powerlifting routine with a few yoga poses, now I use a few powerlifting movements to warm up for a fulfilling class of yoga.   I can still sharp shoot, drift a car, dyno a rock ledge and break boards............but then again, yoga tells me I dont have to.   It ain't just for girls.

.....how to start?   Usually once a month, studios offer "community class"- to give back to the locals and entice others to come and socialize.  Most places offer your first class for free as well.  Call and ask about which class/instructor would be good for beginners.  Ask about shower facilities if you decide to check out a lunchtime class.   Be prepared to pay for renting a mat/towel (or just buy your own at walmart or target).   IMHO the hottest of hot yoga is not for beginners (I began with Bikram and loved it but the intense heat scares off some of my patients that are on the fence) , especially if you take medicine for blood pressure.  There are so many "classic" practices and modern hybrids that it would take forever to list.   I teach a meditative yoga practice at Northwest Community Hospital Wellness Center and I often teach meditation classes/topics at Bodhi Prem Yoga.   My goal with guiding people to make lifestyle changes is always embrace sustainability.  Weekly yoga practice in a studio (open class or private) is wise until you are comfortable to practice on your own.  Once you get hooked, you can usually purchase memberships or a block of studio visits to cut back on price.  Average "drop in fee" is 14-19$, cut that down by 3$ if you buy in bulk.  Enjoy-Namaste!  

Should I see a Specialist?

Patient of mine came back for his annual physical.  I reviewed last years notes.  He had a big problem back in summer of 2011.  Told me that he noticed blood in his ejaculate (dont have to go through details....but think about it, pause, get over it and get back to reading the blog).  Sometimes common with one episode with "aggressive sex", trauma, blood thinners....but if it recurs, big warning sign for prostate cancer.  I did the usual tests for cancer screening in any guy over 50-digital rectal exam and PSA.  All ok but didnt feel right about saying "ok, all is clear, see me in a year".  (which is really wrong with healthcare-we screen and due to lack of time; if the standard things we check are all normal, the thinking is- what you are doing as a human is ok.  In all reality doctors are supposed to be guiding the patient to say, "everything looks good this year but you should add more fiber, cut back on red meat, meditate and walk more".  True, some patients say "I dont have time" but then the great docs think of ways to take the individual personalities and adapt a timeline of change to make sustainable habits.  I believe it takes a visionary [Andy Weil]  to hear, test, plan, see ahead and apply.) 

So I reveiwed the note from the specialist.  Ooops.....no note sent to me.  What the F___? Why dont these guys draft a note or send me a copy of office visit?!?!  So I asked the patient to tell me what the doc did.  The specialist did the same thing I did, reviewed the blood tests I did ans said "ok, all is clear, no need to follow up".   So the patient is still having blood in his semen, no pain, no other problems.   Suffice it to say, I didnt send him back to urologist, I did the work up myself: semen analysis, repeat PSA, and called my radiology friends at Northwest Community Hospital and asked if there was a tech in ultrasound who was "very good at sounding the prostate".  (just ordering a test at a hospital-you are only as good as the tech doing the proceedure and the radiologist interpreting the images....so if you have a under trained tech, or someone pulled from another department to do ultrasounds that morning, or a radiologist who has 1000 cases to review before a department meeting in 2 hours....you might get a mediocre test that misses things and is reported as "all clear-Normal Results"!!!!)

My patient's work up is under way, luckily I am comfortable with the initiating steps for prostate cancer screening.  But the lesson is if something seems wrong....you have to be your own advocate to make sure the entire work up is performed. Don't take the statement; "ok all is clear" as no cancer yet so lets wait until next year to find it....ask for help on how to make intelligent, research supported sustainable changes to a healthier life. 

DrRic's Yoga Style

I had been called "Gumby" back during high school track and field (MVP 1984 Bishop Eustace Prep) but as I look at pics in the yearbook, my flexibility was poor compared to what I can do now. As I recall, I had to learn my flexibility routine from previous team captains or coach. So the basis to what I knew as an adult is on the backs of coaches and captains from school days. Fast-forward to present, I had a talk with the guy who runs women’s track at Montini HS, when I volunteered my services to run a clinic on sprinting, he mentioned a study that said stretching is not necessary for competition. What the hell?!!! Is there some vacuum I have been in during my training as a sports medicine doctor? Are the 80's really that archaic? Anyway.....if you are blessed with a great coach, you will succeed in staying injury free as you "get back into exercise to control weight, blood pressure and cholesterol. If you were not an athlete in school or were coached by Mr. Woodcock (Billy Thornton circa 2007) then you are setting yourself up for a non-sustainable reintroduction to living healthy. Had a patient yesterday who said she has done all the diets, been to all the trainers and is exercising 4 days a week with no success. The nutrition review I left to Tom Jordan (the registered dietician/marathoner/trainer) in my clinic. Her maximal effort with movement I trusted, then I did an exam and found limited knee flexibility with severe pop/snap (crepitation) a right shoulder she couldn’t life to 90 degrees, a core that was shaky with ventral hernia protruding out. So what I took for granted as "I guess she really has a good fund of knowledge", was so wrong. Whatever she has been told or taught, she does have regional pathology that may not be surgical and just need the right "coaching/guidance" to gain full, pain free range and strength. So everything she does now in her planet fitness gym is based on very poor body mechanics and instable joint motion. This is bound for injury and failure-this will be non-sustainable. When a lifestyle is embarked on, it should not be for losing weight to fit into a gown, it should be to make a lifestyle change and (as I tell patients) push back the time of death. If a heart attack is predicted at 50 years of age, push it back to 80 years with changing and sustaining a healthy life. What good is a summer endeavor is you can’t sustain it in the winter?

 Here comes the reason I teach my form of yoga: In my opinion, Deepak Chopra and Claire Diab have put together a great yoga teacher training program. It takes the ancient wisdom of Yoga/Ayurveda and defines it in real-world terms and understanding. It is very difficult for an average American to fathom what meditation is. It is hard to "concentrate on breath". There is no formal school introduction to cultivating the relaxation response aside from sitting in the corner for a time out (solitude) or fishing/gardening after school. So most people who pick up a mat and walk into a yoga class for the first time can be intimidated (eesssssspecially my male patients!!) by people who are super flexible, know the flow and can keep their eyes closed and sit in stillness like monks. One bad experience with yoga and the newbie is not going back. I feel a class can go through basic and advanced poses and flow but still be a mixed class of experience levels. If you hit the fullest expression of a pose-go for it! If the knee is too tight, speak to the instructor before class but don’t be embarrassed to practice yoga arthritis-style (it just so happens one of the best treatments for arthritis before prescription meds is tai chi and/or yoga!!!) For a class of 1 or 100 students, true practice is the individual expression of the pose suggested by the teacher. What I learned at Total Body Yoga and The Chopra Center (200 hours each) was to offer a class that imparts to a practitioner the highest sense of success. I feel teaching a pose safely without re-aggravating and old injury is easy. Teaching students that the breath observation and control is more important than flexibility is a challenge. I design my classes to be more breath awareness; you can actually stay in child’s pose or seated in a chair and just listen to the routine cue’s without doing the poses (asana) and leave feeling just as refreshed/relaxed in 60 minutes.

 It ain't about the pose; it's about giving the brain/mind 60 minutes of "stillness" without having to react to every thought, sound, action or feeling.

Ice

My team met with a prominent Orthopedic Surgeon yesterday. "Orthopods" are great, most have a very strong demeanor and emphatic about the doctrines they follow. I too would want someone like that on my side if I was contemplating a life changing alteration of body structure. The good ones will know "their business"down to the "micronutia" of bad outcome, good outcome, randomized controlled trials, failed collegue trials.... Aaahhh! but this comes at a sacrifice. Easily explained in yogic terms, this personality type is referred to as a "pitta" dosha. Hot, light, intense, penetrating, pungent, sharp, acidic.....fiery in nature. http://www.chopra.com/pitta Being a balanced "pitta", is not bad...in fact-many successful people in business and politics fall into this dosha-Donald Trump, Lance Armstrong, Bill Clinton, Denzel Washington. The problem with being in any dosha is when the human gets "out of balance". Then we have the presentation of what we know of in western terms as symptoms of disease. 5000 years ago there were no blood test, mri's, Hamilton Depression Rating scales.....Freud was probably a cat to be reincarnated a few times! So healers relied on community, exercise, meditation herbs and food. Going back to my "orthopod", he is very pitta and I embrace it. Those that are not used to this fiery personality, would immediately conceive-"this guy is too pushy with his doctrines". In a battle, people flock behind this personality; in peaceful times-people move away and seek shelter (especially when the pitta's are out of balance). So, I came loaded for battle-(I too am a pitta!) But with my Chopra Center Yoga Instructor training, I balanced myself out with daily meditation and yogic living...in addition to some acupuncture from Dr Zhu. I let him speak.....at times, I let him erupt while trying to interject some "zingers" back to him so as to keep him on track to why he was meeting us. I feel that in dealing with a high functioning pitta, one has to allow the raging river to erupt at first but then, a precise controlled force will be required to direct how the flow continues. In the end, I saw the innocence and beauty of this man with his genuine desire to help others. I mean, where do you find a "pod" that doesn't want to use prescription medicines to control inflammation!!! He actually believes in allowing inflammation, swelling and heat to go its course stating that "from evolution, the human body was meant to use inflammation to allow the body to heal-signals of pain and swelling tell the injured person to "take it easy" and stop using the extremity especially if surgery is contemplated so fibrous collagen pulls torn muscle fiber together and defects close up. However.......(deep breath in)......for those suffering from "non surgical" injuries where inflammation can be a lifetime, or those that are on "pro-inflammatory diets, or those that deal with stressful events by getting more stressfully "oxidated".....inflammation if allowed to continue will stimulate a casade of poor metabolism that leads us like a dog with a leash to the end product of heart disease, obesity, depression or cancer. (People that attend my Whole Foods Market lectures know I always make reference to get on an "anti-inflammatory diet" for any disease process.) This path of detruction, dna mutation, bad gene expression can blossom and perpetuate even if the initial bad joint is taken care of. This is where my "pod" lacks foresight. A bold statement that inflammation should be allowed is wrong. Every human has to be evaluated in a "whole system" approach. Western medicine is powerful but we tend to get too involved with specific studies and outcomes and details that take us into microscopic views of symptoms, forgetting there is a living breathing complex human with a body-mind-spirit connected to those symptoms. Anyone who chooses to ignore the "whole system" approach to decision making will not have the best interest of the individual in mind. It would be like giving you only 2 choices to contemplate versus empowering you with information to make a decision on your own. BTW-I usually start with Tumeric/piperine (1500mg daily divided), high vitamin D3 (2000-5000IU daily divided with fatty meal), glucosamine sulfate( 1500 mg daily divided if not shellfish allergic), valerian (30-40 mg 3 times a day), magnesium glycinate (400 twice a day if no diarrhea), helicrysum (hourly to affected area), acupuncture (3times a week) and healing visualization maybe arnica montana (low strength 30c) . My prescription pad is always ready to go if everything else fails in addition to physical therapy/hands on healing.