#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 2-part training on shockwave therapy for post-surgical care. With Dr. David Rednick. In part 1, 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 Dr. Rudnick integrates movement and rehab protocols like Faktor 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 nonunion and We incorporated the shockwave based on the literature and had excellent outcomes. So the prevalence of nonunion fracture ranges from 2.5% to 46%. I love percentages like that. Makes no sense. Obviously, it's a huge range. But as you can see, this is a substantial economic burden on the health system because of the bone graft and other health complications and prolonged physiotherapy that can arise from it. So if we can reduce the cost, not just to the patient but to the health systems, that's always economic medicine, and we're gonna 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 nonunions. 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 literature that we've built in our library on shockwave application. You'll see most of these studies are fairly new. This one was 2021. 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 ORIF 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 nonsurgical that could be enhanced with osteoblastic activity and shockwave.

Mm-hmm.

So the applications are endless when it comes to bone, and I think an underutilized area. So we're getting that adhesion kinase, focal adhesion 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 that enzymatic activity is being enhanced. When they're sleeping. Obviously diet and following through with your rehab protocols are integral as well. The patient's gonna improve that much more, but the cellular activity is, is happening. So you got your interleukin-10 enhancement and metalloproteinase downregulation. You're getting so much enzymatic activity in that tissue that you're, you're gonna get tissue healing in that individual. Here is another individual. This was a patient of ours who was competing in an obstacle course race and had a fracture of tib 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 in the other patient. This individual had a significant downtime with regards to being immobilized, first wheelchair, walking cast, then boot. So there was a lot of atrophy in the region and just delayed tissue healing. This person did not have a nonunion issue, but we were able to reduce the myofascial restrictions in that region on the plantar fascia, the Achilles, the gastroc soleus, and be able to get that person to have a little more range of motion. So their gait improved a little faster. Their dorsiflexion improved substantially faster with application of shockwave. So quick diagram of what's happening periosteally when you produce shockwave or apply shockwave on this region. So the image on your left is pretreatment, and the image on your right shows substantial thickening of that periosteum on that slide, on that bone slide. And you're getting stimulation of what's called the cambium 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 cambium 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 C15 head just because of the superficial nature of that tissue. Now, when we got to the gastroc soleus or tib anterior, we did use the larger D20 head over that region to reach the deeper tissue. Focus— this is a radial 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—he improved very quickly. He was back to running, I think, at like. 4 months, maybe 5 months post. And yeah, he improved very quickly. But this was fairly early on with his plyometric work that we were doing with the light-up pods, the Blaze pods for agility and explosion. And then obviously box jumps to work on plyometric 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 sport-specific rehab program with us with gradual return to play, and it will be guided accordingly. We talk to them after each practice, after 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 arthroplasty. We, we do this, or generally our older population, we don't see as much as our younger population. But hip arthroplasty, people improve very quickly with hip versus knee, and incorporating shockwave on these individuals enhances their ability to get functioning just in normal activities of daily living substantially faster. So we're focusing that shockwave over the piriformis, over glute med, over adductor, 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 and 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 OA. Obviously, you're gonna if you see an older population, you're gonna 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 fact that we're gonna push that patient a lot more than just some band work and some floor work early on. We're gonna push them to their limits and get a much favorable, more favorable outcome and reduce their comorbidity and their sedentariness post-surgery, especially 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 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 interleukin production and the enhancing the collagen formation with shockwave very 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 30 to 50% reduction in rehab time when applying shockwave to a region. I'll discuss how we discuss when we're gonna 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 beta suppression, which is going to improve tissue healing drastically in that individual. And again, if you need these studies, you can message me afterwards. I know we're coming close on time, but I wanna 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 trapezius during rotator cuff rehab and in regions of the body. But even our nonsurgical 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 immediate effect in that myofascial 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 scapula is not migrating laterally and they're not getting normal serratus activation. So they're using upper trap to produce shoulder abduction and flexion and end up with the upper trapezius, levator, scalene, 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 an extremity to enhance the muscle activation in that region to get 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 thoracolumbar 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 analgesical 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 1, weeks 1 to 3. We're moving them, we're getting them on the bike, we're getting them doing unweighted clamshells, short arc quad exercises, Heel slides, calf raises, sometimes assisted, sometimes unassisted, depending on that patient's fitness level. But we're moving them quick. We'll do that shockwave right on glute piriformis while that patient is doing a movement like a side-lying abduction exercise to enhance the effects on that tissue dynamically. Here's phase 2. We're getting into some wall sits, some sit-to-stand. Knee to chest, Trendelenburg exercises, standing 4-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 under load without compensation, we're going to get them doing ASAP. Later stages, obviously gait, 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 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, rehabbing them from a gait 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 4, basically just getting them back to their normal activities, maybe getting them on the tennis court, just volleying around a little bit, hitting some golf balls on the range, upregulating their functional capacity, producing an optimistic outlook on that individual, trying to build them up, not break them down. So if they can do it without pain, without compensation, the more the merrier. Obviously, higher impact stuff, no go. But they can stand on a tennis court or a pickleball 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 females that just want to look their best and go through these mommy makeovers that include breast augmentations and/or breast lifts and obviously abdominoplasties, tummy tucks. So we stumbled on this about a year or so ago and started doing shockwave on a couple of our abdominoplasty patients that had some more intense fibrous pain and myofascial pain post-surgically. So we started incorporating it. We've read in the literature that it's great for reducing scar 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-surgical patients, if it's somebody that we've referred to them and they're referring back to us. That communication's assumed. But in somebody like an abdominoplasty patient that's coming to us for other things, some other myofascial pains, or just in conversation, hey, we can do this, we are gonna talk to the surgeon, communicate and co-manage that and make sure that they're aware and comfortable that we're gonna incorporate that. So post-abdominoplasty reduction in scar formation, reduction in postoperative symptoms, increased angiogenesis. To systemic growth factor suppression, phenomenal outcomes. Never would have thought I would be incorporating that, but we're doing it, 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 C15 head and then graduated to the D20 for the deeper tissue. We were at a very high hertz. The lower the hertz, the The deeper the acoustic wave is gonna go. So initially we were very superficial over the scar, and then some of the deeper abdominal muscles, we were dropping the hertz down to 7, 8, 9, and trying to increase the power 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 it 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 patella in multiple places and had a fixation surgery to repair the patella fracture. They put in a STAR plate, which involves the guidewires into the patella.

Mm-hmm.

And then a star plate over the patella with usually 3, 2 to 3 screws per fracture site. So this individual had about 6 to 8 screws, I believe, into a patella. And he was producing an adhesed joint fairly early on in rehab, which would have caused him to have to go for manipulation under anesthesia. But we, we talked about the— 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 80 degrees of flexion, and that was uncomfortable for the individual. the patient. And post-treatment, just one treatment, we were able to gain 10 degrees just post-shockwave. And about 6 to 8 sessions in, I don't even know if we did that many, maybe just 6 sessions in, we were able to get that patient to 115 degrees where 3 weeks of work only got us to 80, 90, 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, pain reduction awareness in that region and getting them 115, 120 degrees, which got them a lot more functional. We could start onto the weight-bearing activities, a lot easier for them on the stationary bike. So just implement— implementing shockwave and avoided a more difficult MUA procedure and more costly procedure for them. So another cool implication of shockwave post-surgically.

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All right, so that is the end of what I have. I'd love to hear any questions. Jessica will go in and read any of these back to me. If you guys have them, great. My email address, let me give you that real quick, is davidrudnick, so D-A-V-I-D Rudnick, R-U-D-N-I-C-K, dc@gmail.com. davidrudnickdc@gmail.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, be more than happy to oblige. There you go, Jessica. Just post it in the chat.

Yes, I posted that in the chat for everyone. Dr. David Rudnick, DC, and davidrudnickdc@gmail.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 Tenex? 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 Tenex. Procedures. But let's actually— and I did not cover this, and I should have. And I'm glad everyone's still logged in. Hopefully everyone's logged in. But there are some precautions with regards to shockwave. One of them is actually cortisone. You want to wait about 6 weeks before using extracorporeal shockwave over an area that was treated with cortisone. Now, obviously, that's right on that region. So if a person had their plantar fascia treated with cortisone, We can still treat the surrounding area like the gastroc, the soleus, the posterior tib, and peroneals to support that region from a myofascial standpoint. But right on the area that was injected, you're going to avoid that for about 6, up to 6 weeks. Obviously pregnancy, you're going to avoid lung tissue, you're going to avoid particularly with focused shockwave. But the 10x, I would say typically any area that was treated with types of things like that, At least a week or 2, 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, hertz, 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 shockwave over a non-injured area and the person's 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 head 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 2,000 to 3,000 pulses. Obviously, if it's a So if it's a greater depth, you're gonna use lower hertz in that individual. If it's a more superficial bone, like around a wrist or an elbow, you're gonna use a higher number of hertz 'cause you don't necessarily need to get the depth that you would on deeper bone. The bar or the amount of joules that you're gonna be utilizing is gonna be to patient tolerance. That's pretty much it. You're not gonna blast them with 3.5 bar if they can't handle it. And usually with bone, just producing that mechanical effect on that tissue 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 bone. 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, patella or a medial or lateral malleolus 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 your 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 pathophysiology. Some like to know that stuff and we'll talk to them about it just like we're talking in 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 by 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 is 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 a 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 3 visits, typically, which is not very many, we're going to probably discontinue that treatment. And if we're gaining that, that desired 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 some— I'm not big on physiotherapy modalities, like we don't use ultrasound and we don't use muscle stim and do 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 shockwave is it. We use dry needling, we use our myofascial techniques. So this They're coming in with a trust factor already, typically being referred by another patient or a physician. And they, 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, and one thing you said was so key there is that it, 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, yeah, I would say they're in a lot of pain, right? Especially when they're acute. Now, if we're doing it more in a subacute realm and they're 3, 4, 5 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 nano head, over the bony areas because it's a lot less abrasive and the person can tolerate it a lot better. Or we use the C15 at a much more tolerable parameter, hertz 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 gonna 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 capsulitis, 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 it depends on the stage. If we can catch that patient at an 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 synovitis 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 will obviously end up keeping that person from having 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 50% loss in all planes of range of motion like typically see with a with a frozen shoulder patient, but they're coming in with a synovitis. 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 into rehab, The earlier the better. But yeah, excellent results. Obviously very, very painful. Focused shockwave is fantastic for the adhesive capsulitis. I think even a little bit better than radial depending on the body habitus of the patient. And radial can get into there as well. We're going to hit the deeper 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 sit up.

Yeah.

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 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 knee osteoarthritis is my least responsive. So just a pure primary knee OA patient, They are my least responsive to shockwave, but typically the tendinopathy patients are very responsive. My I guess my my lateral epicondylitis and medial epicondylitis patients because before shockwave, I would say if I didn't have to see a medial lateral epicondylitis patient again, I would be okay with that because generally the people don't come in day one with that condition; they come in day. 101. 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 Eccentric exercises and loading on a forearm. It's boring. It's boring rehab. So usually the outcomes are, that I've seen, have been more poor in the chronic epicondylitis patient. But incorporating shockwave and particularly with that and dry needling applications, I've said I've seen a much greater outcome in that population. So I guess if I were to answer that question, epicondylitis.

So again, thank you so much, Dr. Rudnick. We really appreciate you presenting today. Thank you everyone for joining us.

Be sure to tune in on December 29th for our last episode of 2023. 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 wanna miss it. Episode 70 drops in 2 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 Christmas and happy holiday.

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