#69 - Shockwave Therapy for Post-Surgical Care, Part 2

Hi guys, Welcome to another episode of The Factor podcast. I'm your host Jessica Riddle. If this is your first time tuning in, welcome and thank you for listening. Today we wrap up our two part training on shockwave therapy for post surgical care with doctor David Rednick. In part one, we covered a wide array of topics, including the mechanisms of shockwave therapy, patient responses to care, and specific case studies where shockwave therapy had a tremendous impact on athletes with delayed bone healing. In today's episode, we chat about the successful implementation of shockwave therapy for various orthopedic cases and talk more about its potential to reduce the economic burden on the healthcare system and improve patient outcomes. One intriguing aspect highlighted in this episode that I really loved was how doctor Rednick integrates movement and rehab protocols like Factor with shockwave therapy. He emphasized the importance of dynamic application, where the therapy is actually used in conjunction with specific movements to enhance muscle activation and promote tissue healing. This dynamic approach not only fosters greater patient awareness of their condition, but it also contributes to more effective rehab outcomes. This is one episode you'll definitely want to listen to more than once. So go ahead, hit the download button, let's cue the intro music and get started. So this was obviously a case of non union, and we incorporated the shockwave based on the literature and had excellent outcomes. So the prevalence of non union fracture ranges from two and a half to forty six percent. I love percentages like that makes no sense. Obviously it's a huge range. But as you can see, this substantial economic burden on the health system because of the bonograft and other health complications and prolonged physiotherapy that can arise from it. So if we can reduce the cost just to the patient but to the health systems, that's always economic medicine and we're going to achieve a lot of goals, not just physical in those cases. Here's a great study on through the Journal of Orthopedics and Surgery and research on shockwave and non unions. If anybody can take screenshots of these, take pictures of the studies, if anybody wants these studies, I have tons of them, not just these, but tons others, So please, I'll give you my contact information at the end of the presentation. Please reach out to me and I will be more than happy to share our litercy sure that we've built in our library on shockwave application. You'll see most of these studies are fairly new. This one was twenty twenty one, so we try to stay extremely current and only go with the newest literature. What's happening in the bone when we use shockwave over bone over these or procedures. We're using it over stress fractures, which is highly applicable. We're using it over stress related injuries in youth baseball players. We're using it over fractures that are non surgical that could be enhanced with osteoblastic activity and shockwave management. So the applications are endless when it comes to when it comes to bone and I think an underutilized area. So we're getting that adhesion kinase total, ahesion kinase that's being activated substantially, the osteoblasts are being activated substantially, and again once that patient leaves that office, that cellular activity is being enhanced every hour, so you don't have to just be hitting it and hitting it and hitting it those cells and enzymatic activity is being enhanced when they're sleeping. Obviously, diet and following through with your rehab protocols or integral as well. The patient's going to improve that much more. But the cellular activity is happening, So get your interluken ten enhancement and the taliprotease down regulation. You're getting so much in zomatic activity in that tissue that you're going to get tissue dealing in that individual. Here is another individual. This was a patient of ours who was competing in a obstacle course race and had a fracture of tip fib They did not need to stabilize tib in this individual. They only did fibula, which was good just faster bone healing. They didn't have to put a rod all the way up the tibia like you saw on the other patient. This individual had a significant down time with regards to being immobilized first wheelchair, walking, cast and boot so there's a lot of atrophy in the region and just the late tissue healing. This person not have a non union issue, but we were able to reduce the myofascial restrictions in that region on the plantar fascia the Achilles the gas struck Solius and be able to get that person to have a little more range of motion, so they're gain improved a little faster. Their Dorsey flextion improves substantially faster with application of shockwave. So quick diagram of what's happening periosteally when you produce shockwave or apply shockwave in this region. So the image on your left is pre treatment and the image on your right shows substantial thickening of that periostium on that slide, on that bone slide, and you're getting stimulation of what's called the Cambian layer, which is the deeper layer of bone versus the outer fibrous layer of bone, and that deeper layer of bone is going to produce a much stronger, longer term enhancement of that region. So you're getting all the way down to that Cambian layer with shockwave, which is fantastic just producing the outer fibrous layer of bone. This was a video of us working on that soccer player over the surgical site. Sorry it doesn't work, but we were just showing the application in this individual. We used that C fifteen head just because of the superficial nature of that tissue. Now, when we got to the gastruk solius or tib interior, we did use the larger D twenty head over that region to reach the deeper tissue. This is a radio unit the superficial regions. It does work very well. If we were to do it over a deeper region, focused shockwave would be a little bit more applicable to get down to the deeper bone. This is I wish I could play this. This is the individual a soccer player. I don't remember whether we were three months post here or where we were. He improved very quickly. He was back to running I think at like four months maybe five months post and yeah, he improved very quickly. But this was fairly early on with his pliometric work that we were doing with the light up pods, the blaze pods, f agility and an explosion, and then obviously Box jumps to work on bliometric activity. So we do extensive rehab. We don't just get patients where they can get out of a car, out of a chair, out of a bed without pain and just do normal daily activities, activities of daily living without problems. That person is going to go through a very focused sports specific rehab program with us with gradual return to play, and it would be guided accordingly. We talked to them after each practice for each game via email, via phone, via text, And the psychological component of a trauma like this is great. I know they're going to progress physically well. I want to know how they're doing mentally, and their outcomes are going to be substantially higher. So I know this is not just a shockwave presentation but a rehab presentation, and the psychological rehab that we do with our athletes and our active individuals is paramount in their recovery. All right, Hip Arthur plasty we do this generally our older population we don't see as much as our younger population, but hip Arthur plasty people improve very quickly with hip versus n and incorporating shockwave on these individuals enhances their ability to get functioning just in normal activities daily living substantially faster. So we're focusing that shockwave over the pure formance, over gloutmeaed over aductor, a lot more tender over adductor. In the hip arthroplasty population. We're going to do quad, We're going to do hamstring. We're not just going to do the surgical incision site, which obviously is critical because you're going to reduce scar formation in that general tightness that that patient feels when they sit down and they go to stand up and start to ambulate, but over the surrounding musculature to work on tissue elasticity and extensibility so that individual has less load transfer onto that surgical incision site early on, and they build their confidence with movement. So OHA. Obviously, if you see an older population, you're going to see a lot of OA. We push these patients, I feel a lot more than general physiotherapy. Some actually come to us from physiotherapy once they're like three four weeks in because they don't feel like they're being pushed. The more active population, the surgeons will send them to us before even sending them to their own physiotherapy sites because of the that we're going to push that patient a lot more than just some bandwork and some floor work early on. We're gonna we're gonna push them to their limits and can get a bunch favorable more favorable outcome and reduce their comorbidity and their sedentaryness post surgery. Interesting in the older population, the more you can get them moving early on and reduce their sedentariness the better. So if you've never witnessed a hip arthroplasty surgery, I would highly encourage it. It's barbaric and people wonder why they hurt post. I mean, these surgeons are phenomenal at what they do. They could do this in their sleep, but it's a barbaric procedure. There's drilling into bone, and there's hammering, and there's there's moving the hip around passively under anesthesia. So there's a lot of trauma to the tissues. So we can get that anti inflammatory effect with the nitric oxide production and the interluken production and the enhancing the college information with shockwave very quickly quickly and producing that extracellular matrix of tissue with the acoustic wave. So range of motion is going to improve, pains are going to reduce. Remember your anatomy, there's a lot of musculature that works around that hip, and especially in the older population, if we can produce new blood vessel formation, endothelial activation, and angiogenic production in that region, we're going to improve that patient's outcomes drastically. Generally, we find a thirty to fifty percent reduction in in rehab time. When applying shockwave to a region, I'll discuss how we discuss when we're going to utilize that on a patient in a little bit later. So, tissue inflammation, here's your nitric oxide production to reduce inflammation, endothelial nitric oxide synthase and necrosis factor bait suppression, which is going to improve tissue healing drastically in that individual. And again, if you need these studies, give messages me afterwards. I know we're coming close on time, but I want to make sure we get time for questions. I got quite a few more slides. So trigger points. I know this is not surgical, but well it can be because you can produce trigger points in upper trapezis during rotator cuff rehab and in regions of the body. But even our non surgical patients, applying shockwave on that trigger point is almost an immediate effect. We utilize dry needling in our practice as well, and we see a very similar effect of shockwave and dry needling, and when done in combination, the effects are substantially better. But even just one or the other, that patient's going to produce a pretty much an immediate effect in that male fashional trigger point in that region. So we do work on those with regards to our post surgical patients so they don't produce those compensatory factors, such as our cuff patients that are utilizing upper trap because their scalpula is not migrating laterally and they're not getting normal serraenus activation, so they're using upper trap to produce shoulder abduction, inflection and end up with the upper trapezius elevator, scaling and SCM trigger points. So we will do this modality over the region as well. So location, location, location, know your anatomy. And something that we also utilize shockwave or do with shockwave is movement. We will have that person abduct or flex or externally, rotate, internally, rotate in an extremity to enhance the muscle activation in that region to get this to some of the deeper fibers, and that patient will sometimes feel the effects of that a lot more drastically than if they were just in a static position. So play with movement. We'll sometimes have a patient squatting and working over the thrackle lumbard junction while they're squatting. If low back pain is an issue with their squat and deadlift, and they'll be able to reproduce their pain during that movement pattern. And then you're treating that tissue in a dynamic situation, which enhances the patient's awareness of that region and gets the brain talking to that tissue in a dynamic situation and producing the energy Jesuical effect at that moment. The outcomes are phenomenal. So if you're not utilizing movement with shockwave, get going on it. Total hip arthroplasty rehab protocol early on. This is phase one, week one to three. We're moving them. We're getting them on the bike. We're getting them doing unweighted clamshells, short oar quad exercises, deal slides, calf phrases, sometimes assisted, sometimes unassisted, depending on that patient's fitness level. Well, we're moving them quick. We'll do that shockwave right on glut pereformance while that patient is doing a movement like a sideline abduction exercise to enhance the effects on that tissue dynamically. Here's phase two. We're getting into some wall sits, some sit to stand, need a chess Trannella berg exercises, standing four way hip. If they're super functional. We'll even get them doing some single leg Romanian deadlifts that are assisted. Whatever that patient can tolerate underload without compensation, We're gon we're gonna get them doing asap later stages obviously GATE reducing that lateral sway, reducing the especially if that patient was dealing with OA for quite some time, they're obviously developing that limp related to unloading that that hip. So we're trying to reduce that old compensatory pattern that they've developed from the OA, and now that the joint is more functional, re having them from a gate standpoint is absolutely critical so they can reduce stress on the knees and other regions of the body while they're getting back to their normal activities. Phase four basically just getting them back to their normal activities, maybe getting them on the tennis court, just following around a little bit, hitting some golf balls in the range up, regulating their functional capacity, producing an optimistic outlook on that individual. Trying to build them out, not break them down. So if they can do it without pain without compensation, the more the merrier. Obviously higher impact stuff WI go. But they can stand on a tennis court or a pickle ball court and just volley back and forth without high impact so they can start getting the mechanics back with whatever their activity level is. This is another cool post surgical application that we've stumbled upon. Being in South Florida, we have a group of of females that just want to look their best and go through these mommy makeovers that include breast augmentations and or breastlifts and obviously abdominoplastyse tummy tucks. So we stumbled on this about a year or so ago and started doing Shockwave on a couple of our domino plasty patients that had some more intense fibrous pain and milefascial pain post surgically, so we started incorporating it. We've read in the literature that it's great for reducing star tissue formation and tissue elasticity, and obviously we're getting that analgesic effect immediately on that individual and they were feeling this pulling sensation. So we started to incorporate it and almost immediately they got that analgesic effect that sharper pulling sensation subsided, and we would work through the entire abdomen and improve angiogenic benefits in that region and that person's function and pain just reduced very very quickly. So we've been advertising it with our plastic surgeons that we work with and they're seeing the benefit of it. And obviously, whenever we do shockwave over a post surgical region, we are communicating that with the surgeon via office notes and verbally on the phone. Now, if it's a surgeon that knows what we do and what we implement with their post phyfical patients, if it's somebody that we've referred to them and they're referring back to us, that communications assumed. But in somebody like an a dominoplasty patient that's coming to us for other things, some other mild fashional pains, or just in conversation, hey, we can do this. We are going to talk to the surgeon, communicate and co manage that and make sure that they're aware and comfortable that we're going to incorporate that. So post the doominoplasty reduction and scar formation reduction and post operative symptoms, increased angiogenesis to systemic growth factors, suppression, phenomenal outcomes. Never would have thought I would be incorporating that, but we're doing getting great results. And just another avenue that you can incorporate your shockwave with. This happened to be that patient. The parameters are on your right. We worked through with the C fifteen head and then graduated to D twenty for the deeper tissue. We were at a very high hurts. The lower the hurts, the deeper the acoustic wave is going to go. So initially we were very superficial over the scar and then some of the dominances we were dropping the herts down to seven, eight nine and trying to increase stars as much as we could to tolerance for that patient. Another I did not put it in here, but actually I wanted to share another case study of a patient that was more recent, and I didn't have any time to put it in here, but it was a actually was a jiu jitsu athlete who didn't get hurt in jiu jitsu. He was actually running into a grocery store and slipped in the parking lot on an oil slick and fractured his paatella in multiple places and had a fixation surgery. To repair the patella fracture, they put in a star plate which involves the guide wires into the patella and then a star plate over the patella with usually three two to three screws per fracture site. So this individual had about six to eight screws I believe into a paatella and he was producing an adhased joint fairly early on in rehab, which would have caused him to have to go for manipulation in their anesthesia. But we talked about the implications of that versus the cost benefit of shockwave, and we would know fairly quickly whether we were going to gain range in that individual. So we focused shockwave over or used radial shockwave focused over the retinaculum and the distal quad in this individual, and we were sitting at about eighty degrees of flextion and that was uncomfortable for the individual the patient, and post treatment, just one treatment, we were able to gain ten degrees just post shockwave and about six to eight sessions in I don't even know if we did that many, maybe just six sessions in we were able to get that patient to one hundred and fifteen degrees, where three weeks of work only got us to eighty ninety and it was very uncomfortable. But the focus over the retinaculum was highly beneficial for reducing the adhesion and the thickening of that tissue and pain awareness production awareness in that region and getting them one hundred and fifteen hundred and twenty degrees which got them a lot more functional. We could start on the weight braining activities a lot easier for them on the stationary bike, So just implementing Shockwave and avoided a more difficult MUA procedure and more costly procedure for them. So another cool implication of shockwave post surgically. The holiday season is upon us and it is truly the most wonderful time of the year. And while we had a ton of fun with Black Friday and Cyber Monday, we've been counting down the days until December's arrival and the kickoff of our twenty twenty three Season of Giving. Each week we will be sending out a new special offer, freebie, or exclusive limited time flash sale. It's a ton of fun and this year is even more extra with the launch of four new certification programs and the new Factor F five handlebar, a soft tissue tool unlike any other. So be sure to click the Season of Giving link in the show notes to get all of the details join us in celebrating the spirit of giving this holiday season. Happy holidays from factor. All right, so that is the end of what I have. I'd love to hear any questions, jessicare going in read the these back to me if you guys have them, great. My email address, let me give you that real quick is David Rudnick SO D A v I. D Rudnick r U, D N I C K d C at gmail dot com. David Reudnick DC at gmail dot com. Email me ask me any questions you have on clinical applications. I'll be more than happy to send research if you want, or anything you want to ask me more than happy to oblige you. There you go, Jessica to thank chat. Thanks. Yes, I posted that in the chat for everyone. Doctor David Rednick d C. And David Rednick DC at gmail dot com is the email address there. So we did have a few questions that came in. I'll go ahead and read some of those now. One of the first ones we received was can you talk on the use of shockwave after percutaneous needle tenotomy with units such as ten X. Specifically, they said shockwave on the area of procedure. Do you wait for a period after procedure to do the shockwave treatment? How long? And do you know of any research regarding this. I'm not so familiar with percutaneous ten X procedures, but let's actually and I did not cover this, I and I should have, and I'm glad everyone's still logged in, and hopefully one's logged in. But there are some precautions with regards to shockwave. One of them is actually cortizone. You want to wait about six weeks before using extracorporeal shockwave over an area that was treated with cortizone. Now, obviously that's right on that region. So if a person had their plantar fascia treated with cortizone, we could still treat the surrounding area like the gastruk, the solius, the poster, your tib and perenials to support that region from a mile fashion standpoint, but right on the area that was injected, you're going to avoid that for about six up to six weeks. Obviously, pregnancy, you're going to avoid, lung tissue, you're going to avoid particularly with focused shockwave. But the ten X, I would say typically any area that was treated with types of things like that at least are week or two I would say is safe and something that you can talk to the individual that performed the procedure and see if they have any input on that specific one. Wonderful, thank you. Another question was regarding treatment over bone. What specific parameters are we looking at in terms of energy hurts or number of shots or number of pulses, and how do you determine the exact placement of the head for treatment technique is absolutely critical because this acoustic wave comes out at a certain angle, and if you don't angle it correctly, particularly around something that's curvilinear or like a tibia that has a rounded nature to it and it's not flat, you're going to miss your target tissue. So usually feedback from the patient. You do shock wave of over a non injured area and the person is not going to have as much of a pain response as they are over the injured tissue. So feedback from the patient is absolutely critical. To know your angle, know your anatomy. If you know your anatomy, you can position that ahead accordingly, and then just the more you utilize it, the better you're going to get at the positioning of that head. As far as number of pulses, generally the literature points to two thousand to three thousand pulses. Obviously, if it's a greater depth, you're going to use lower hurts in that individual. If it's a more superficial bone like around a wrist or an elbow, you're going to use a higher number of hurts because you don't necessarily need to get the depth that you would on deeper bone. The bar or the amount of jewels that you're going to be utilizing is going to be to patient tolerance. That's pretty much it. You're not going to blast them with three and a half bar if they can't handle it. And usually with bone, just producing that mechanical mechanical effect on that issue is going to produce the osteoblastic activity that you're looking for, so it doesn't necessarily have to be high. But the literature does say the higher the better. Actually with bones, so whatever the patient can tolerate focused is a lot better with regards to outcomes on bone than radial. But the more superficial areas like a wrist or an elbow, a patella, or a medial or lateral malliolis are going to respond to both modalities. Very good. Thank you. When you have a patient that's coming in and you might be utilizing a shockwave treatment on them for the first time, how do you explain what shockwave is to your patients in a way that makes sense to them and helps them prepare for the loud noise that sometimes accompanies the treatment or even the discomfort. Obviously, you got to know your patient, right. Some patients don't care. They just want to get better. They don't want to hear the why, they don't want to hear the what. They just they lay down and they take it and they're just looking for the effect. So you got to know audience. Some ask a ton of questions. They want to know the who, what, where, and when and why. Obviously we're not getting down to the deeper physics and the path of physiology. Some like to know that stuff, and we'll talk to them about it, just like we're talking this webinar. But basically, when I guess, first of all, when we're going to use it, let's say that obviously there's a cost involved with it and it's not a covered entity when insurance. Now we have to talk outside of clinical parameters and talk as practice owners and clinicians that are incorporating a cost based treatment to a patient, but that person's going to typically end up spending less money on treatment in the long run when they incorporate shockwave into most entities. So we just say, it's so much quicker modality, and we're going to do a trial with it, and if we're not gaining the physiological improvement and the functional improvement that we're looking for in three visits typically, which is not very many, we're going to probably discontinue that treatment. And if we're gaining that that ed effect, we're going to then continue through normal clinical protocols. So we just talked to them about this is the newer research, this is the newer technology out there, and we try to stay up on that. And I'm not a big on physiotherapy modalities like we don't use ultrasan and we don't use muscle stem and view those things very very sparingly, if any. So we're only going to incorporate passive modalities that we find are highly effective, and this is what's out there, so shockwavesit we use dry needling, we use our milefascil techniques. So they're coming in with a trust factor already typically being referred by another patient or a physician, and they know they're coming to us already for a specific outcome, and whatever we need to do, there's a trust factor there to make that person better. They're pretty much usually on board, absolutely, And one thing you said was so key there is that it really depends upon the patient themselves and how they typically are when it comes to a lot of treatments. Do you find that post surgical patients tend to be the most hesitant to get this treatment? Are they the ones that tend to guard a bit and still have a little bit of fear, especially after an injury or I would say surely they're a lot of pain, right, especially when they are acute. Now, if we're doing it more in a subacute realm and they're three, four or five weeks post surgery, there's a little less hesitancy with it. But obviously the sound of it is very abrupt. But we use that silicone head that nanohead over the onnier areas because it's a lot less abrasive and the person can tolerate a lot better. Or we use the C fifteen at a much more tolerable parameter Kurtz and bar setting for that individual, and they see we'll do it on an area that was not surgically repaired initially, just so they can kind of feel what it should feel like, and then we'll find their tolerance level over that tissue. But yeah, they are, but a lot of them are also very They're ready to just get better and whatever's going to enhance that healing faster, they will be on board and just suck it up. One thing you had talked about earlier was the treatment of adhesive capsule ititis or commonly known as frozen shoulder. I know that this is a very difficult condition to treat, but there as you mentioned, the literature has shown that shockwave can be successful. How quickly are you seeing improvements in range of motion or reductions of pain with this particular condition. Yeah, so obviously depends on the stage. If we can catch that patient at a earlier stage, we can avoid a lot of the later stage issues in that individual. So if that person's coming in with just pain and the sinovitis in the early stage, we could help reduce that inflammation and that synovial fluid effect that's going on and hopefully reduce the thickening of the capsule in that individual, which we'll obviously end up keeping that person from hoving the typical stage two, stage three range of motion deficits, because you could catch a person very early on and they're not coming in with fifty percent loss in all planes of range of motion like you typically see with the with a frozen shoulder patient, but they're coming in with a sinovitis presentation. So shockwave would be very applicable in that individual, and you're obviously not going to incorporate rehab early on in that individual because you could produce you could end up pushing them into later stages of adhesive capsulitis and producing more of the range of motion deficits. So it's a very fine line. So if we can reduce that synovial fluid inflammation and the pain and then slowly progress in the rehab, the earlier the better, but yeah, excellent results obviously, very very painful. Focused shockwave is fantastic for the hesive capsulitis. I think even a little bit better than radial depending on the body habitus of patient and radio can get into there as well. We're going to hit the deep ra areas of the subscap and get in some really uncomfortable positions. But if they can tolerate it, the outcomes are incredible. And the patient sees that immediately, they'll set up and they will go and take their shoulder through active assisted or even active range of motion, and there's range of motion improvement. And you don't need to convince somebody when they see objective improvement. Immediately they go, whatever you did last time, do again, and they'll tolerate the pain absolutely. And it's key. Like you said, everybody's just trying. They're trying to get better, they're trying to feel better, they're trying to move better as quickly as possible. Have there been any conditions you've treated with shockwave that were surprising in terms of how well they responded to the treatment, or you've received a better outcome than you expected. I think we generally try to do it on the areas that have high validity and we're not just experimenting. Let me comment on the opposite end of that question. I would say neoste arthritis is my least responsive. So just a pure primary NEOA patient, they're my least responsive to shockwave. But typically the tendinopathy patients are very responsive. I guess my later upicondulosis and medio upicondylosis patients because before Shockwave, I would say, if I didn't have to see a medial lateralpicondylosis patient again, I would be okay with that, because generally the people that don't come in day one with that condition, they come in day one hundred and one. They've been dealing with for some time. There's a lot of adhesion around the area, there's a lot more micro tears that have been produced, there's a lot of compensatory issues that have been built around that, and the compliance is low because it doesn't impact them every moment of every day. It impacts them during certain activities, so maybe the person avoids that activity, maybe they've compensated around it. So usually people don't want to sit and do ecentric exercises and loading on a forum that it's boring, it's boring rehab. So usually the outcomes are that I've seen have been more poor in the chronic epicondylosis patient. But incorporating Shockwave and particularly with that android needling and applications, I've said, I've seen a much greater outcome in that population, So I guess if I were to answer that question apicondalosis. So again, thank you so much, Doctor Rednet. We really appreciate you presenting today. Thank you everyone for joining us. Be sure to tune in on December twenty ninth for our last episode of twenty twenty three. I'll have a few special guests on that serve on the sports medicine team for USA Gymnastics. We'll chat about the path to working with elite athletes and the crucial components of what it's like to work on a diverse healthcare team where several professions and specialties are represented. You won't want to miss it. Episode seventy drops in two weeks. Be sure to check our show notes and click the link to get on our season of giving email list so you can get a new free offer, discount, or exclusive flash sale access in your inbox each Friday. There's only a few Fridays remaining in December, so be sure to go now to the show notes, click the link get on that list so that you can get one starting today. Like always, you'll also find the webinar replay link for the training that was featured in today's episode. You can click the link, view the full presentation, and view the slide deck. If you're more of a visual learner, you can subscribe to the Factor podcast on Apple, Spotify, iHeartRadio, or the podcast app that works best for you. Give us a five star rating to help us grow the show and be sure to share episodes that you enjoy with a friend. From all of us at Factor to all of you around the globe, we wish you a very merry and happy holiday. Hey guys, if you like what you heard today, I encourage you to visit our website at Factor hyphenstore dot com that's spelled fa k tr hyphenstore dot com to find out more information about all that we have to offer. We have a variety of online offerings as well as our hands on Factor Rehab System course scheduled in cities around the globe. Be sure to also check out our event calendar and bookmark any of these upcoming live webinar dates coming up in the near future so you can join us live. And of course, the biggest compliment we can receive is for you to help us spread the word to your friends, colleagues, and classmates. You'll find all the important links as well as info about our sponsors in the show notes, so be sure to check those out.