Back Pain Masterclass

She doesn't care either way. I'm the one. I'm the one pushing it.

Hello, everyone. Welcome. I'm going to give it just a minute to get. Let everybody jump on. We have about 315 people registered on this session today, so we might have some people coming in and going. We are recording it for all of you on this session live. But I've been super excited about sharing this topic with you all. Today we're going to be talking about back pain, specifically the lower back pain nightmare. If you're joining us live, if you could just do me a favor and mute yourself. I've got some admins on here. They're going to try to stay on top of muting everyone, but on your own, just mute yourself on zoom. The way that it's going to work today. I'm so excited. We're going to be talking about the back pain nightmare, the lower back pain nightmare. I've got two of my favorite doctors on who I'm going to introduce in just a moment. One is just a phenomenal surgeon. I've learned so much from him. Another one does stem cell and prp. So, so lots of great stuff we're going to be talking about. But you are in the right place today. You are in the right place today because we are going to be shedding some serious light on what causes lower back pain, the pain cycle, what that means, how to break through it. Some things you can do to fix it. Some are surgical, some are non invasive, some are things you can just do on your own, sitting in your living room. So going to be really, really eye opening today. And as you know, if you are on this session today, back pain can be super frustrating, right? I mean, I'm sure you're on your. It is frustrating. It feels like it takes over your life when it's happening. I have so been there. I have so been there. I work with many clients that have been there. For those of you that don't know me, if you came through Dr. Darrington or Dr. Kim or someplace else, don't know me. My name is Natalie Jill, and I kill fat for a living. And I say that because that's not just the fat on our bodies. It's also what I call false assumed truths.

It's.

It is beliefs that hold us back from achieving great things in life, like beliefs around pain. So that is who I am and I am so excited to dive in this with you today. Now, I also want to assure you we are in the right place today. Number one, I have Got countless years helping people get healthy, helping them knock down inflammation, get their bodies right, get their mindset right. I have got years and years of experience there. I have got Dr. Kim on. Dr. Kim, go ahead and wave just so everyone can see you. I'm going to put on gallery for a minute. I've got Dr. Kim on now. Dr. Kim is a double board certified minimally invasive orthopedic spine surgeon. He graduated cum laude from Harvard Medical School. So he's one of those. He graduated from Harvard Medical School and he completed his fellowship training in complex spine surgery at the renowned Mayo Clinic. I've also got Dr. Darrington on. Will you wave your hand, Dr. Darrington? He is also a board certified physical medicine and rehabilitation fellowship. Trained in intervention spine sports medicine and regenerative medicine. And he specializes in the field of interventional orthobiology. By saying that right? Orthobiology, biologics. Am I saying that right, Dr. Darrington? You might have to correct me.

Biologics.

Biologics, Biologics.

I'll explain what that means.

Okay, great. I can't wait to hear have you go into detail about this. Now I know both of these doctors personally. They have worked on me and they have changed my life dramatically. Just to give you an example. I'll talk more about this later. This is my spine right here and that is a huge rupture that I had a few years ago where I actually had foot drop sciatica, the whole bit. I literally have what people say and we roll our eyes at that bone on bone. Now I do not have a disc between L5 and S1. Dr. Kim can verify because he removed most of it. He removed most of it with laser endoscopic. So pain is something I get. I live with it. I've learned how to master it, how to manage it and I've helped walk countless clients through this. So you are really in the right place today. And I am telling you all of this right now because you today being here with an open mind, we can really help you. If you are will allow us, we can really help you. We have got a wealth of knowledge. We are going to give you some great insights here, recording it for you. So you have this to keep. But if you are open minded and you will allow us, then we can really help you here. So do I have just by show of hands. I would love just to see a show of hands if I kind of have your word that you'll have an open mind today. Just go like this. Open mind. Open mind. Yes, I Love to see that. Thanks for joining us. Ok. Open mind. I think it is critical. I think so many times we come on to things with we already know what you want to hear and I just want you to have an open mind today. So this is how it is going to work today. We are going to walk you through briefly first the different various causes of lower back pain going to go through that. Then we're going to walk you through the quadrants of solutions and there are four quadrants of solutions that we've broken this into. Okay? One is surgical, another one is more non invasive and then another one comes in the form of things you do on your own with nutrition and movement, believe it or not. So there's just, there's four quadrants there and you're going to want to stay on because then we're going to give you a bunch of options for things that will help change your life around this. We are going to give you an object, one in particular that I am really excited about that starts mid January that could truly change your life around this. And then after I share that opportunity, we are going to open it up and stay on as long as needed for all of your questions. So if you have got a question for me or one of the doctors, any of us, we will stay on and answer as many questions as we can. Sound good? Everybody just go like that if you. Sounds good. Amazing. Okay. At any time. Just. I know most of you are not new to Zoom, especially with this last year we've all gotten familiar with Zoom. But just so you know, I'd love when you have your video on, which is amazing because it feels like we're sitting right here with you talking with you. Just stay muted. If you at any time have comments or anything you want to ask, feel free to put it in the comment section. If for some reason, if for some reason you were to get booted off a zoom or technology happens and something goes wrong, just log right back on. We'll still be here, but there's been times when technology happens. Just know that we're still here during the time. So just log right back on and we will, we will pick up. Okay. All right, so I'm going to dive right in and we're going to start with sort of the causes. I want to talk about the causes and I'm going to bring Dr. Kim on in just a second. But, but I want to set the tone with this. If I were to do an MRI right now with pretty much anyone in their 40s, 50s, 60s and beyond, if we were to do an MRI right now, every single person would show some signs of disc degeneration. It is something that happens as we age. So when someone says, I have degenerative disc disease, that is not uncommon, believe it or not, it is very common. What is different, though, is some people feel it when others do not. And that is what I want to dive into today. Why do some of us really feel it? Why does it affect our lives so negatively when others, they don't even know they have anything wrong with their desk. So I wanted to share that first and then, Dr. Kim, I'm going to bring you on right now because I think you are the best one. Just to sort of set the tone and outline, what is it that causes this lower back pain?

Well, thank you. First of all, thank you for having me. I'm a huge fan. But to answer your question, if you have a degenerated disc, the body is very good at keeping it painless by kind of compensating for everything. And through a variety of mechanisms, you can make that disc become painful. The most common one is some kind of injury, either an acute injury, like a car accident or some type of cumulative trauma type of injury, either that is kind of repetitive or intermittent. But, you know, that's one category. There's a variety of other categories that involves how the body kind of maintains its homeostasis. And anything that throws that off can cause.

These degenerated discs from going from being painless to becoming painful. And basically, it's like winning the anti lottery in pain.

Now, you mentioned before, there's anatomic and there's neurobiomechanical. Can you kind of walk us through that? Like, what would set the tone on either of those for somebody?

Well, if you're talking about what types of things in the back cause pain, it can be something anatomic, like the disc, the bones, the muscles, the muscle, tendon, bone complex. That's a big one. The facet joints and the ligaments that surround the entire spine. So those are like anatomic regions. I think that's what you're asking me, right?

Yes, yes. And then you meant that there could be neurobiomechanical model. You said there's neurologic status, biomechanics and chemical. If you could just touch on a little bit of those too.

Yes. So things that activate a nerve's pain sensors can come in a variety of different forms. The first one is you can be stepping on the nerve and cause a mechanical activation of the nerve, sort of like, somebody standing on your toes or your feet, that's going to hurt. But you can also have just the inflammatory process, like an inflammatory storm around a nerve. That would be like when your knee joint kind of swells up and gets hot on a bad day. That's the inflammatory process. And then there's other more complex neural pathways. The person that knows a lot about that is Dr. Darrington, so I'm going to save that discussion with him. But it could be a variety of reasons, not just mechanical, but something that involves your. Your body's biology.

Great. Okay. Dr. Darrington, can you chime in there?

Sure. So, yeah, I mean, I think there's. There's a couple different ways that this can happen. Like Dr. Kim mentioned, you know, acutely causing an injury like you had several years ago with that disc, where it just went somewhere where it's not supposed to be over a short amount of time, really irritated the nerve, had pain from the disc injury as well as the associated nerve component to that. Sometimes it doesn't happen like that, and people don't even know what they did. That could be from a couple of different factors. One from just a repetition of smaller injuries or not moving the right way, but doing that over and over and over and leading to some irritation. But that neurologic component is really important, and that's something that, through other avenues, I think we'll talk a little bit about later. From nutrition and what you put in your body can affect inflammation. And sometimes when those nerves get turned up, they have a hard time getting turned down. Like Dr. Kim mentioned, with the knee getting swollen, for some people, you do something acutely, the knee swells up after a week or two, it calms back down, and that swelling goes away. But sometimes it just stays in that, turned on stage, and it never really goes back to where it's supposed to be. So, you know, that's kind of how this. These different components can. Can all factor in. And depending on the combination of how much of those are higher than what they're supposed to be, that can push it over a threshold. Where you went from recently not having symptoms to getting above that threshold and starting to notice it. And that's kind of part of. Of how people that have significant degenerative changes on imaging can walk around with no symptoms at all if they've got the other things under control. And again, keeping things, you know, at that lower inflammation state.

Yes. Amazing. And then what I want to add here, and we've all discussed this before separately before this session today, is A number of mechanical things that happen are things like underactive glutes and we tend to overlook that. So going on the idea that if you were to do an MRI on every one of you on the call, we'd all have some type of degeneration in our disc. What we're not accounting for is our lifestyle. So now, for example, women, are we wearing heels? When we're wearing heels, a lot of times we're taking our lower disc out of the equation. We're training different muscles and then we're not strong there all of a sudden. Or if this is very, very common as we age to inactive glutes. So we're working out, we're moving, but we're ignoring the working those glute areas. So our lower back is taking a lot of that pressure. So we're now feeling pain where if we have developed glutes, we might not ever notice it or feel it. Okay. Same thing with core, with your midsection in that area, we could have the same similar mri. But depending on what muscles we're working, what we're using, do we have imbalances, do we have things taking over? We might feel the pain more. And then the other thing I want to add to that is inflammation is very real. When there's something wrong in our body, our body produces inflammation. And you can control, control a lot of your inflammation just from the foods that we're eating. Believe it or not, there's certain foods. We're going to get into that a little bit later that by changing our diet slightly, by adding in some more of the right anti inflammatory foods and taking out these inflammation causing foods, we can create a huge difference in how we feel pain and how we feel it. So no matter what you're on for now, whatever your reason for lower back pain, I just wanted you to hear yourself in this, that pretty much everyone has degeneration. We all are built and structured differently. We have different lifestyles. So are we wearing heels? Where are we working out what's going on with our body that we're feeling it or not? As we're recording this right now, I happened to have foot surgery last week and I was telling the doctors before we started that I'm walking funny from that and I feel it in my back because my back is not used to that small difference of movement. So when we are sitting all day or we're inactive in certain areas, we're going to feel that more in our lower back. Okay. Okay.

What I want to go through is a different quadrants of what? And I'm going to start with Dr. Kim, because surgery seems to be the thing that people think they need first. I've got to have surgery. Dr. Kim, I would love to bring you on, and I want to talk about what the surgeries are for lower back and then why, what the issue is with traditional surgery. Let's start with that.

All righty. But just to back up real quick about the importance of the muscles. One of the ways to think about it is that the muscles that surround your spine should not only be strong, but they should be very coordinated, so they act like the world's greatest back brace. The combination of being physically fit as well as being in a state of low inflammation is really important for our body's ability to compensate for the discs as they wear out.

Having said that, as a spine surgeon, most patients come and see me about surgery, but it turns out I spend most of my time doing non operative treatment because the vast majority of patients, I would say 1 in 20 patients need surgery. So the other 19 I basically treat non operatively. And the majority of those patients are treated with things that I wish more people listen to Natalie Jill about, because that part of it is the best way to get better, because surgery has risk. But the typical story is not like Natalie's, where you have a huge disc herniation, you have a foot drop and it's kind of like an emergency, and people will kind of perk up and jump on the cause and try to treat her. Most people kind of fall into a category, and I suspect many of you are in this category or know people in this category. We are still young, 40s, 50s, 60s. When you're 60 in today's age, you should. There's no reason why you shouldn't feel really young and be able to go snowboarding during the first week of January at Mammoth and kickbox for your exercise and do 8 hours surgery standing up. There's no reason for that. So I would say that's a group of people that are young. I'm 57, so I can say that we're busy with something, either work or home life or a project or something. And we have this nagging back pain because we have a painful, degenerated disc and you've tried a few things and you're not getting better and you come and see me. And most of the time I push people to do more non operative treatments so that we exhaust that. But there's a group of patients that try everything and still have pain. And they have, for example, a Disc problem, like an annular tear. That's very common. I suspect almost everybody has that. And if your annular tear is painful, then it doesn't matter that 98% of other people that have annular tears do not have pain for you. You have a painful annular tear, and it's 100% for you. And typically you go to a regular doctor. And I was one of those doctors 20 years ago, and really the only treatment for that was either just live with it or have a fusion. That's what we call the F word. And my mom had a two level fusion. So there's a reason and a time and place to do fusion surgery when you need it. But most of the time, you do not need to have a fusion surgery for low back pain because it's too big of a surgery. So patients leave, they get discouraged, and they just kind of muddle through life and suffer, which should be like an incredible time in their lives. So up until recently, we didn't really have a treatment for that very common patient that has what I call nagging low back pain. It's bad enough to make your life miserable, but you're still working, you're still climbing the ladder, but struggling. But it's not bad enough to warrant a big operation like a fusion surgery. You'd rather just be a cranky old cynical guy like me and just suffer and just get through life. Until recently when we started to do more and more laser endoscopic surgery. So one of the reasons why I'm here is that for most of you that are trying to stay healthy and follow Natalie's kind of teachings, which I follow as well, you're never gonna have a fusion surgery unless it is horrible. But with this endoscopic surgery, at least now we have an ability to take care of those patients and have a surgery that you can go on the same day you get a band aid. And for most people, you can start kind of limited work the very next day. So that's a laser endoscopic surgery. I'm an expert in that, and I'm here to answer questions about that. And of course I want to promote that surgery. But it's really for that small group of patients that have tried reasonable non operative treatment, because once again, most patients should get better without surgery. But that's all patients. That's the best surgery.

Dr. Kim, can you explain what laser endoscopic surgery is? And why do most. Why do so many surgeons not do it? Like, why are you. Why have you gravitated towards this? Why are you an expert on it, and why is it becoming more popular, at least in your practice?

Well, the difference in the two surgeries would be, for example, let's say this is your spine, right? And you have a herniated disc in there and you want to do a discectomy. Basically, Natalie surgery, the most typical way to do it is to do like a little tube like this. You make a little window and you reach in and you pluck out the disc herniation. You're looking down there with your eyeballs. But the other way to do it is through a little tube like a straw going through the natural opening and use an endoscope and look on TV like they do in knees and shoulders and. And a lot of other specialties. Spine is just really behind on things. The laser endoscopic surgery is the same goal, but a straw versus a tube, this is still a great operation. That's like a 1 inch incision, but it can't beat that.

To answer the next question, well, if it's so great, why doesn't everybody do that? There's two reasons for that. One, spine surgeons, we just hate change. We're like little old ladies, like, nope, never done it like that. This is the way we've always done it. It's really difficult to change spine surgeons because we spent so much time training to do something. And once we finish our residency and fellowship, we're just like, we're done with more teaching. So that's that big kind of hurdle of taking on that step. And the second thing is that the procedure itself, to do a surgery through a little straw like cannula, it's not easy. In fact, it is a total pain. And it's really challenging to learn. And we have something called the learning curve. So when you have a learning curve as a resident, that's one thing because you have your attending to help you, you're in training. But once you're a grown up and you're taking care of patients on your own, you don't want to go through learning curves anymore. So you have a difficult learning curve. And now you can imagine people combined with a good surgery alternative that's pretty good. You can see why it's so hard to get other surgeons to do this. And then the final kick in the pants is that it's new. So guess what? Insurance companies don't want to pay for it. And spine surgeons are funny. They kind of like getting paid for surgery funny in that way. So I do want to say something.

About negatives, Dr. Kim. I want to say something about insurance while you just brought that up really quick because this is something I've worked with countless clients on too. It's interesting how we tend to let insurance dictate treatment for our health. And I just want to caution everyone listening and I can say this because I'm not the doctor on here, but insurance is a business. It's a business. It doesn't always have our best health in mind. So sometimes the best treatments for us are not covered by insurance right now. And that's not a bad thing because insurance shouldn't always be dictating our treatment. So just to give you an example, when I had that laser endoscopic surgery for some of you, saw at the beginning this was my rupture because this is a huge rupture. So most people with a disc rupture or bulging disc don't have anything close to the size right here. But that was my rupture. The traditional insurance would have paid not only for a fusion but would have paid for a dissect me like this, which was going to be a really long term healing process, a huge recovery for this and not even really solid guarantees on it. It had a lot of sight, lot of risk, but insurance would have paid fully for that. Where a laser endoscopic did not pay at all insurance wise for it. However, I was doing chin ups like three days later after having this done. There was no downtime. I think I came home and slept the day he did it and I was fully active two days later which allowed me to do the exercises and change things that would have healed me and gotten me out of pain had I let insurance dictate treatment. Yes, early on it sounds great. Like yes, that saves me money. It's. But long term it caused more issues and it would have taken longer to get back to functionality. So I really want people to be aware of that that it's not always ideal to let insurance dictate treatment. It's a consideration, but not the full reason for choice there. And I also say that for years and years and years I was actually in medical device sales and I saw it over and over again that some of the best cutting edge treatments were not yet covered by insurance. And that wasn't always ideal because the best treatment for patients sometimes were the things not covered by insurance. So I wanted, I wanted to throw that out there. So to please not make that a ruling out factor of because insurance isn't paying, I shouldn't look at it. We don't want to let them dictate that.

Okay, so laser endoscopic. One more question before I get on to Dr. Darrington. Dr. Kim. Is anyone not a candidate for laser endoscopic?

That's an interesting question. Yes, because it's a tool in a toolbox. And even though my Phillips head screwdriver is my favorite screwdriver, I'm not going to try to take a flathead screw out with it. So it's very important to match up the technology to the disease state and the disease state to the treatment. So everything has to be customized. And I would say many patients are not candidates for laser endoscopic surgery. Either they don't need surgery or they just need a much bigger surgery.

Okay. I also want to say, if it's something that you think, if you're listening, you're like, you know what I need to explore that I would highly suggest, and we're going to put all this information in here too, to go to Dr. Kim for that consultation. Don't just go to any random surgeon for it because this is his specialty and we want to go to go. You want a surgeon that actually knows this, lives, this works. This is what he does most of the time in the OR. In the OR. Okay. Dr. Darrington, you do some pretty cutting edge stuff. We've, a lot of us have heard about prp. We've heard of stem cell, but we don't fully understand it. Could you get into what those are, why you, you specialize in that and who those are? Things are for sure.

Yeah. So it's. That's something that has definitely been much more popular over the last several years. It's really something that's been around at least in the United States for over a decade, really 16, 17 years. But basically what you're doing with these kind of procedures is you're using the body's normal innate ability to heal and directing it somewhere where our body has a hard time getting that signal too. Like you mentioned, what we're using is oftentimes prp, which is platelet rich plasma. Basically, it's a component of our blood. And you can think of the platelets like our first responders, like the EMS system in our body. When you cut your skin, the platelets are what gets activated and starts the spotting cascade so that bleeding stops. And then they release a bunch of signals called growth factors that help to initiate that healing response. And before you know it, that big cut turns into a maybe itty bitty scar, or maybe you don't even, you can't even tell where that scratch was.

And kind of there's other things called stem cells. We've got stem cells all over our body. The biggest reservoir for them is in our bone marrow. And similar to platelets being used for repair and initiating that process, the stem cells are also being utilized on a daily basis. But certain places, and there's several places in the back that our body can't get that signal to very well because it lacks a direct blood supply. So we have all this potential healing there, but just a barrier to getting to that place. So basically, we are using these category of treatments which are under the umbrella of orthobiologics, basically using things from our own biology to treat orthopedic issues. There's different times to use either one of these. They're kind of in a spectrum to an extent. And like Dr. Kim said, patient selection and deciding which treatment to use for what kind of problem is definitely important.

Some people are not necessarily a candidate for stem cell. Can you speak a little bit into that? I know with prp, it's a little bit different because you're using your own blood, but can you talk a little bit about how do you decide that? How do you know if someone's should look at that or not?

Yeah, I know.

Like, for instance, doctor, with mine, I was not a stem cell, but I was a PRP candidate.

Right? Yeah.

So there. So I guess first of all, because. Because you came to me, I believe, after you had the surgery with Dr. Kim, when you already had that big disc herniation removed. You know, because there's. When you. When someone has those kind of weakness changes or bowel or bladder changes or things that we, in the medical field, we call red flags for something concerning that if you don't do something more invasive like surgery, it could become a permanent problem. But for a lot of other back conditions that have been kind of slowly building over the years and kind of getting more and more chronic, these are oftentimes options for them. And the kind of patients that usually come to my office that are candidates for what I do are either people that are just in too much pain but not having some of those red flags that I mentioned, too much pain to do the physical kind of things that they want to do, whether it's just taking care of their grandkids or going for walks around the park, or people that have more athletic kind of endeavors that they want to do what they're struggling to do. And then sometimes it's patients that can still be active but are having a hard time being as active as they want to be, or they're just being extra sore and kind of having nagging symptoms that linger longer than what they should after being active?

There's definitely some patients that are not appropriate, and I'm happy to give that information to patients when they come in. And as much I'd like to help everybody, I don't have the perfect magic bullet for everything. Like Dr. Kim said, these are tools that I have, and for the right kind of problem, that can be a great tool, but it's making sure to use the right tool for the right patient.

This is great. Brittany, do you mind putting in Dr. Darrington's information if you've got that there? He just said it. As I was saying it, it occurred.

To me that you're probably asking a much more specific question. Would it be fair to say, Dr. Darrington, that PRP is to try to encourage healing and decrease inflammation, and stem cells are for regeneration, and then things like laser endoscopic surgery are really best for treating disc problems like annular tears and disc herniations? Just to be really specific about. Yeah. What these different tools are used for.

Yeah, exactly. I think that's good. Yeah. So in general, what these kind of treatments do, and really, most of the spine procedures that I do are using prp, not using stem cells. There's a subset where the stem cells have a really good niche. But for most of the time, we don't have big tears, whether it's in the disc that are causing pain by themselves, or tears to the ligaments or joints that are so arthritic that there's too much damage there. Most of the time.

It'S about stabilizing and strengthening using these kind of injections. It's about changing inflammation levels and allowing people to get back to the kind of physical things. And we kind of mentioned before about biomechanics and how you move. Natalie talked a little bit about glutes and using muscles to be able to use that muscular stability component. You can do these injections to make some of those changes so you can go out and be more active and do the things that you struggle to do.

Then.

Yeah, there's certain kinds of issues, like disc tears, where stem cells are oftentimes good options for some people. Even the PRP can be a good option. But, yeah, injecting it into the places where those tears are to help basically patch those injuries up. And.

The pain in the back coming from those disc tears is one component. Some people get more nerve irritation from those disc tears because there's irritating chemicals that are leaking from that disc. If you can change some of that biochemistry near where that disc is irritating the nerve, that can sometimes be the thing that pushes you forward so you don't have to go to something more invasive and can get back to more of that physical activity that you've been struggling to do.

Thank you. So we talked about earlier, I mentioned there's different quadrants. There's the surgical, there's looking at what Dr. Darrington does with PRP and with stem cell. But there's two other quadrants I want to jump into right now. Because both the surgical and what you do, Dr. Darrington, really, are designed to get you into a place where you can do the movement aspect because it's is critical. What you don't want to do is have surgery and then not take on the movement stuff because you go back to having issues again. A lot of times people will have a surgery and they say, well, I had surgery, but it didn't work. It's not. The surgery didn't work. We didn't then work on the restorative side on rebuilding on. On changing things later. And I want to talk about that. And where I want to start with is the pain cycle. And what I want to share about the pain cycle is when we're in pain and most of you on here can relate because you're on here because you have pain in your lower back. When you are in pain, some things tend to happen. One, we don't want to move, right? We are in pain and we think, I am in pain. I don't want to work out. It makes my pain worse. So we feel that when we are in pain and we don't want to move, we then tend to sit around more, right? When we sit around more, some things happen there too, where maybe our diet now is not so on point and our mood is not so on point because we are technically stuck in a pain cycle. What I want to challenge you to start thinking about is the idea of breaking through the pain cycle, because actually moving through things is what gets us to the other side of things. And I want to set the disclaimer that this is if your doctor says you can move. So I want to say that if your doctor says you're on bed rest, you can't move. I'm not talking into that right now. I'm talking specifically into your doctor looks at you and says, I understand it hurts, but yes, you can move. You can move when you can move. Working through things to break through the pain cycle is absolutely Critical. To give you an example, most lower back, if you look at it, we tend to have either an under, underactive glutes or a core that's not really working right. Dr. Kim talked earlier about those muscles that are around your lower back that are surrounding it. All those are your core. When our core or our glutes are not firing correctly, we're not using those right. Our lower back is going to feel a lot of the pressure on things. So, for example, take walking. If we're walking with not using our glutes correctly or our core, we are going to feel every step in our lower back. If we're sitting all day, our hip flexors are tight. Now we're in that sitting position and we're not used to using our core and our glutes, we are going to feel it more. So we sit all day and we stand up and we go, ah, that hurts. That's because we are in the pain cycle. So one of the most critical things to do to get out of lower back pain is to break that pain cycle. Now, how do we do that? One? We first make sure. Are we allowed to move? Is this an option for us? Did our doctor give us any reason we can't move other than we feel it? If yes, we can move, we've got to force ourselves to move. That doesn't mean you go and sprint or you do an Olympic training session. It means we start with, are we walking? Can we start moving more? Then we have to look at where are we not firing our muscles that need to get fired, like underactive glutes? And this is so common. I see this all the time with clients as we age, we think our glutes are active. However, if you think of bending right now, like, if you're standing up and you bend down, if you think, oh, that hurts my back, believe it or not, you're not using your glutes to bend down. And this is something you can try a little bit later. You can even try it now. If you're in a place where you can stand. If you stand up and you squeeze your glutes and you use your glutes in the back of your legs, your hamstrings, to lower you down, you should not feel that in your lower back at all. That's sort of the test. Most people, when they bend, they're using their lower back. So we've got that wear and tear there, that degeneration. Now we keep bending, we keep feeling it. Where if we start training our glutes and our Hamstrings to do that work. We're not going to feel that in our lower back. That area starts overtaking and you don't feel that lower pain. I showed you earlier, this rupture I have on my lower back, this is gone. We remove the rupture, but the disc, there's nothing there anymore. So it's essentially bone on bone right there. If I don't fire my glutes and spend a lot of time on there, I would be texting Dr. Kim probably every day in pain and say that my lower back hurts. I need a fusion. But because of learning to fire those glutes and really activate and train those glutes, that has taken me out of pain, where instead of being a level 10 pain, I could be a level one or two and know how to control that there. So what do we do for that? What do we do for glutes? And I'm not going to demo all these exercises right now, but I want to sort of plant the seed one. If you think of a traditional deadlift, and some of you might not know a lot of working out, but that's basically that leaning over. If you use your glutes and your hamstrings to do that, bend over without any weight at all. But you start practicing lowering and lifting using those glutes, glute muscles, you start firing your glutes, you start activating them. Another one is a really standard exercise. It's called a glute bridge. You can just write this down and look it up later. If you lay on your back on the ground, your feet are. Your knees are up, your feet, your feet are flat on the ground, and you lift your glutes up through that movement, pressing through your heels, you fire those glutes, that starts to take over for your lower back. So it's just two examples. Two examples. An example of how core can help with this. If you're sitting in a chair right now, I want you to sort of try this. If you're sitting in a chair, just put your feet on the ground, put your shoulders back so you're sitting sort of straight. What I want you to do right now is I want you to squeeze your ribs sort of down, a little bit of a crunch position, but keep your shoulders back so you really tighten that core right there. Just tightening that core, that position right there should take pressure off your lower back. So lots of little movements. And I'm going to show you where you can access more movements like this. But if you start thinking, how do I get my core muscles and my glutes to activate, right? That'll take that pressure off the lower back. So before you're even looking at surgery or stem cell or anything else you have to do there, if I can strengthen those muscles there, I'm going to dramatically change what I'm feeling in that lower back. Another thing to consider with that would be the sitting idea. When we sit, we are really using our hip flexors and we are in probably the worst positions for lower back. When you're sitting.

Just by changing to using a stand up desk or walking more, sitting less, you're going to make a big difference in how you feel your lower back. A huge difference there and how you feel it. So behind me, I have a stand up desk. I am sitting as I record this. But most of the day I have to be really aware. Let me turn a light on here. I have to be really aware to not be sitting because the more I sit, the more I am going to create that pressure. Ladies, same thing with high heels. I love high heels too. But the more we are wearing them, we are putting ourselves in that position where we are not using our glutes, we are not using our core correctly, and we're going to feel it more. So just some control things right there around those.

Then. I want to share just a story really quick on this. I'm going to show you a couple. So this is one of my clients. This was Allison. This is her when I met her. Now, granted, Allison definitely had some excess weight on her too. So. And I'm going to talk about that in a minute because excess weight is not helping us with the pain cycle or our lower back problems at all. But the bigger thing aside, the weight here was the pain that she had and she was really in that pain cycle. Everything was hurting and it was painful for her to move her body and work out. So what we had to work through here was the idea of that pain cycle first. What does that mean? Do you have permission to work out from your doctor? Are you cleared to work out? Yes, she was. And then it was, okay, let's start with walking, but can we fire our glutes? So as we're taking each step, are we really activating those glutes? Are we really activating that core? Which by. Yes, when she started doing that, she was out of pain, able to start shifting, get out of the pain cycle. And just so you can have an idea, not only is she not in pain now, but she's down almost 80 pounds just from breaking that pain connection there, that pain cycle breaking through it. So the pain cycle is super real. And the two things I want you to remember there are the glutes and the core. No matter what's going on in your back, are we working those muscles? And if you think, gosh, doing those exercises hurt my back, then it's learning how to do them correctly. So you're not feeling it in your lower back when you're doing a plank correctly, when you're doing a squat correctly, when you're doing a deadlift correctly, when you're doing those correctly, you should not feel them in your lower back at all. The only reason we ever feel those in our lower back is if we're not activating the right muscles. The only reason a plank should ever hurt your lower back is if you're not using your body correctly in the plank. If we're letting our lower back take over for that. And I know that was a lot of information fast, but I hope that's. That's resonating.

Okay.

Okay. The next, I imagine in a fourth quadrant. The fourth quadrant.

I just want to mention that I put in the chat how awesome those examples are and how much I totally agree with you.

Thank you, doctor.

In case you guys aren't looking at.

The chat box, and that's a surgeon that. From Harvard there. So thank you. Thank you, Dr. Kim. I think this is so important because I do so many times hear clients say, but my surgeon said, and I don't know that they've fully had that conversation with their surgeon. I don't know of a surgeon that wouldn't agree with those. Those moves. And that's saying that, that stuff, it's so critical. But I also get what's happening when you're in pain, you don't want to move. And I get that. I fully get that position.

And all that is important not only before surgery and to try to avoid surgery, but to if you end up having surgery to make the surgical results better and then after surgery to continue those types of activities, they'd be different after surgery. But it's really important to do that to maximize your recovery and achievement of the results. Yes, that surgery.

These are things I counsel my patients on all the time also. They really should have tried and failed and not got enough improvement from these kind of movement improvements and strengthening and muscle engagement. And then afterwards, that's a huge important part afterwards, because if you expect the surgery or the injections or whatever to just undo the problem, but you've been moving incorrectly before, that Whatever benefit you get is not going to last as long or be as significant if you're not changing how you move.

And just a quick funny story on this here. I was a fitness expert for years, so I taught core training, I taught all this, but I don't think I even fully got it until about a year ago. Share this story I was walking with my daughter and my daughter said to me, mom, your butt's flat. My daughter is 14 and you know, part of me wanted to smack her. What do you mean my butt's flat? I'm 50. OK, fine, it's flat. But when she said it, I started noticing and I started getting hyper focused on wait a minute, is my, is it flat more from a functional standpoint? Like I don't. What is that creating? And we do lose muscle as we age. So I started hyper focusing on correcting it. And as I focused on correcting it and building my glutes, my lower back pain completely went away. It was unbelievable. And I was someone who had gone through the different procedures and had it under control, but I would get flare ups. But by developing my glutes I was able to almost completely take away that pain. So I really tied in that connection and what I realized had been missing so long for me and for so many of you and is understanding how to correctly work those glutes. Because we're doing the exercises that we see on YouTube or we see on the video, but we're not putting the mind body connection to that and we're not actually activating our glutes. Instead, we're using our lower back, which is not where we're supposed to be feeling it. And we need that prompt to know it's your glutes that are supposed to be using that, not your lower back.

The next question I want to share and I could, we could talk hours on each of these topics, but the next quadrant I want to share is specifically about nutrition. And why is this important? Well, when we feel pain, we are typically inflamed. We are inflamed and by getting inflammation under control, we can drastically change how we feel, which gets us to a place of being able to move and break through the pain cycle. So really looking at nutrition not just for fat loss. You know, I am a fat loss expert, but I tell people it is not just about the appearance and how we look, it is about how we feel. We have got to get that inflammation under control. What was going on with Allison, aside from that pain cycle, was that inflammation? Was that inflammation? So what Causes inflammation. Well, injury trauma can start to create it. But I want to explain what diet has to do with things too. Now most of us, most people walk around eating a highly processed food diet. Now process, what does that mean? That means food that didn't once grow, foods that are not in their natural state. When we start adding junk to our food, lots of processed ingredients, our body has to work harder to digest it and to process it. It's not adding any benefit to us. So the number one rule with unprocessing our diet and eating anti inflammatory is number one, just start with eating unprocessed natural real food. So that's eating real foods that once grew in their natural state. That's a very general statement, but starting with that, eating natural foods that once grew in their most natural state. However, if you want to take it up a notch, there's three specific food groups that cause massive inflammation. And a lot of you aren't going to like it when I say it, but I'm going to say it anyway. And I know Dr. Kim and Dr. Darrington will agree with me. And I know that this is, I'm not saying this is easy to do by any means, but I'm going to tell you it's necessary. Especially if you're dealing with pain. There's three things that hyper create pain and inflammation. Ok? First one, you definitely know of sugar. When we eat sugar that creates inflammation in our bodies. You're going to have more pain flare ups when you eat sugar. Sugar. I'm not talking about the fructose in fruit. I'm not talking about eating strawberries. I'm not even talking about eating carrots. I know there's some sugar and carrots. I'm talking about eating gummy bears, jelly beans, Christmas cookies, that sugar, our body doesn't know what to do with that processed sugar. And we create inflammation, we create more pain. But there's two more groups that you're not going to love when I say it. But I'm going to say it anyway because I have every one of my clients when they're dealing with pain, take this out of their diet and is life changing for them, okay? And that is grains and dairy. Grains and dairy both cause inflammation. Now I told you you wouldn't like that I said it. But it makes a huge difference. One of my best selling books is called Aging in Reverse. I published it a few years ago. And what I took people through on there is a grain and dairy free diet which totally changed people's relationship with pain. When you Remove dairy and grains from your diet along with sugar. Your level of what you feel inflammation wise, changes drastically. Now I want to show you another example here. This was Jim, this was my client, Jim Walters. This is him. When I met him, he was not only overweight, but he was in a lot of pain. He felt it everywhere. He had back pain, he had elbow, he had pain everywhere in his body. Inflammation was a huge thing. And if you were to ask Jim what was going on, not only would he list out his injuries, he would also list out his genetics. He would tell you about his family history, about everything that he's navigated. And anyone looking at him would have said, I understand, I get it. He was middle aged, overweight, he was in pain, he had gone through the doctors. That all validated. This is what's wrong with Jim. So with Jim, we had to talk through the pain cycle and we had to talk through this idea of changing the nutrition. And Jim wasn't on board right away, just like many of you were, like, I don't want to change all that. Like, I like my life. What I had to get Jim thinking of is the idea of deciding, do you want to change this? Like, do you want to live the second half of your life as a thriving person? Do you want to change this? Jim said, yes, I've decided. So that was step one and I ask everybody always, have you actually decided you want to be out of pain, that you want to be healthy? Jim made a decision. Once you actually make the decision, making the changes becomes a lot easier. So Jim's decision was not only to break the pain cycle, but it was to change his nutrition and get the inflammation under control. So we worked together on what I'm going to share with you in a little bit on how you can actually work with me on this, but how he could focus on adding in so much of the good that it made less room for this ant, this stuff that was causing the inflammation and would change his whole body. And I just want to show you Jim right now. This is Jim now, okay? Not only does he not have any pain, but he looks incredible. And what is really funny about Jim is if anyone meets him right now, they'd say, oh, that's just genetics. But they said that here.

There'S no such thing as just genetics. I'm just going to share that with you all. There's no such thing. This was genetically Jim and this is genetically Jim. The difference is the decision and what he stepped into. So Jim had to take on. I'm going to Eat anti inflammatory. I'm going to break through the pain cycle. But look at him, he's completely thriving.

That's what Jim would look like 10,000 years ago if he lived.

That is what he would look like 10,000 years ago. So what I want you to take on from this, and I know we went through a lot of information quick is that there are those different quadrants appealing and they really all can be used together. But the least expensive thing, the thing that you can make a change right away, that is least invasive is by breaking through this pain cycle by changing how you move your body, by taking on these great nutrients and making it a mission that I am going to eat and live this way.

I share this coming at you as a 50 year old woman who had a major disc rupture that understands pain. I mean as I am talking to you, I had a foot surgery last week. So I am not prone, I am not immune to things happening in my life to injury. But what I am an expert at is helping people kill these false assumed truths that you have to live in pain, you can absolutely thrive in midlife, but you have to learn to take on being responsible and taking on that. You are going to be your own health advocate and make some of these changes.

Before I get into the next step, Dr. Kim, Dr. Darren, can anything you want to add to that or that we missed about some of these?

No, I think those are amazing points And I think Dr. Kim, you'd echo this too. But these are things when I'm sitting down seeing patients for the first time and I think there actually may be a patient of mine on here that knows as well. But talking about what you put on your body and how you move is a foundation for no matter what other options you're looking at, those have to be looked at and evaluated. And oftentimes just making those changes can make a dramatic difference in how someone feels. And they may never need to actually have to see me or have a procedure with me or Dr. Kim if they can get those things dialed in.

Yes, absolutely. Dr. Kim. Anything to add to that or.

I just don't know how to say how much I agree with you in the strongest possible terms because that is so important, but it's so hard to do. Yes, I get it.

Yes. And Larry, I'm going to come back to your question in just a minute because it's so important. So that's an exact. This is actually really interesting. So Larry is eating what most people would consider a healthy breakfast. He's saying I have Oatmeal, yogurt, milk for morning breakfast, which is interesting. A lot of us would look at it and go, oh, that's a healthy meal. But it's all grains, dairy and sugar, all of it. So we're not doing anything to help with inflammation and pain. And the whole goal is I want people to be out of pain, to live a healthy life. This doesn't mean oatmeal is innately bad or milk's innately bad, but we're dealing with something different right now when we've entered the state of being in pain and we want to conquer that. So I'm going to come back to some examples.

Can I just say something about oatmeal, yogurt and milk? Just think about 10,000 years ago. You know, we're evolving from. For a million years and 10,000 years ago, we didn't have farms and seven elevens and things like that. Have you tried eating oatmeal before you cook it?

And then can you imagine chasing after a pregnant sow trying to squeeze milk out of their breasts while they're still alive? That is so bizarre. So to think that that is something natural that you eat and would be healthy makes no logical sense. And it turns out, and it's really hard to overcome this because the dairy industry is very strong and we have people that make a living off of growing cows and making milk. So I get it. But, yes, you should not be eating stuff like that every single morning, especially.

When dealing with pain. So I'm going to share with you all something that we are opening up in mid January, and I'm going to bring it up now because it's super relevant for what we're talking about. And then after I share that, if you're a candidate for that, I'm going to let you know. But then we're going to stay on and answer as many questions as you have about the foods, about the surgical, about everything. So you want to stay on for this? If you've joined us late on this, I just want you to know we've recorded this, so a lot of what we've already covered we'll be sending out in the replay. So if you feel like you missed something, don't worry, I've got that there. But this is what I want to share. And the doctors and I talked about this ahead of time. Number one, back pain does not have to be forever. It does not have to be forever. Does that mean you could be restored to brand new? Not necessarily. I mean, we are not going to Ever get completely back to how we were before we ever aged or had life or had injuries. But you can absolutely go from a level 10 pain to a level 1 or 2 or 2 even less. It is very, very possible. But what has to change, number one, is, number one, a decision. You have to literally make a decision that you are done looking at excuses or reasons or validating, I call this with my clients, false assumed truths. Because when we believe something has to be our permanent truth, we're going to stay stuck there. So if you believe, for instance, gosh, my disc are all completely shot, I've got arthritis everywhere, my MRI is jacked, I already had one fusion. It's my age, it's my job. If you believe all of that by us, by Dr. Kim, by Dr. Darrington, by me, by all saying, you're right, that sucks. We don't fix anything. We literally fix nothing. You stay in a state of pain and misery. So the other option is to make a decision that there is another way out of that. And to make a decision, there is another way out. That means being your own health advocate and taking all of these necessary steps to get your nutrition under control, to get your mindset under control here, to do the movements and to look at treatments. That is the decision. The alternative is not amazing. The alternative just means we accept that we're going to deteriorate. And I don't know about you, but I'm just getting started at 50. I refuse to accept that as my setback. So that's number one, is make that decision. The next step I am going to encourage you to do is ask yourself, like, what is my vision? What is it that I actually want? And I do this with my weight loss clients all the time. You know when someone says, give me the diet to do, Natalie, or give me the workout, I stop them and I say, but what do you want? I want to know from you, like, what do you actually want? And I believe most of you on this session right now, you want to be pain free, you want to thrive, you want to enjoy your life, you want to be able to be free from living in back pain and making that your story. So getting really clear on what is it that you want and why that you want it. And then, and only then, do you take that action. And the action is what the action is taking it on that you are going to learn movements. You are going to do this, even if it is in your own home, five minutes a day, you're going to take on movements, take on that. You're going to learn nutrition. Take on that you're going to explore is laser endoscopic right for me, is PRP right for me. But take on make a decision that it's not insurance that's going to dictate. It's not my genetics that is going to dictate. It's not my friend, my wife, my this, my that. It's me. I'm making a decision that I'm going to thrive and I'm going to live healthy. That's what I'm going to encourage you to do and not validate that there's something wrong with me. There's something wrong with me. Look, I could have easily walked into Dr. Kim's office and had a cry session about this blown out disc, got an effusion and not been doing this class right now and said just this is it, that's it, my life's done, I can't work out anymore, I can't do this, I can't thrive. But it was a decision to do the opposite. Ok. So I'm going to ask you just in the comments right now if this is resonating with you. I just want you to write I decide. There's power in declaring that and say I decide. Like literally just write it in the comments because that is that first step in transformation, in changing everything is making a powerful decision. Ok. Yes. Awesome. Liana just said I decide. Yes. Deciding is that first step, like make a decision. I decide. I decide. Yes. Love it. Jim. Rita. I decide. Yes. This is great. That is your first most powerful step. Okay. If you want to take it on a level. And again, I'm going to get to questions in just a minute. I promise I'm not missing any of your questions here. I am going to invite you to something I haven't even opened up to my audience yet. It starts mid January. I start my total body thrive again. And Dr. Darrington endorses it. Dr. Kim endorses it. This is a really powerful program that is eight weeks long, that is going to get rid of inflammation, that is going to teach you the right moves, it is going to get you in the right mindset. It is going to change your life and get you out of pain. If this is something you want, it is a fat loss program. I am going to be real. We do lose some fat with it. But it is not just the fat you are thinking about. It's not just the body fat. It's those false esteemed truths. But you learn how to do this. My clients that go through this, like Jim, like Allison and 250,000 other people that have gone through this method, it changes their life. It changes their life. I'm going to put a link. Liana, do you mind putting that link in here? We limit the spots in this. I start launching it. You'll see me on social media launching it in a couple of weeks. So I'm giving you all early access if you want in. But this changes your life. Not only is it a detailed program, when you get it, you'll have access right away to the program. But it's a live program, meaning in mid January, we start where you have this program which teaches you everything. But you've also got me live on Zoom. Every single week we do a group session on Zoom just like this. You've got detailed meal plans to help you. You've got all the resources you need, follow along workouts, everything that you need to get you not only healthy, but get you out of pain. So we start that mid January. I'm going to invite you, if you think you're a candidate for it, grab one of those spots right now. This will, this will help change everything for you. It'll help change everything for you. Okay, I'm going to open up to questions about everything and everything. Okay, so let's go ahead. You can either physically raise your hand, which is what I'm going to recommend if you've got it, or we're going to read some comments here. It could be for any of us, it could be for one of the doctors specifically. But I want to start taking on your questions and I'm going to start with just some of the ones that I saw right away. But feel free to put your hand up. If you're not on video, you can put the cartoon hand up so we can see. I want to make sure I'm seeing these questions here. When said, could you be specific on grains and what you should avoid? Birdman. Okay. I don't know if that's your first name or your last name, but I see you. Hi, Birdman. Okay, great. So grain is anything. So a grain is rice. It is quinoa. It is oatmeal. It is. Those are all grains. It is wheat. Those are grains. Now, grains in there on their own. There are healthy things about grains, I'm not going to lie. But they do cause inflammation. They cause inflammation especially as we're aging. So for some of us, that's not ideal. So how do you replace a grain? You do it with unprocessed natural foods. If you love Starches. A potato is not a grain, for example. So you're not going to that same reaction to a potato as you are going to have to a grain. A grain lingers and it does create issues with, with inflammation. Okay. Dairy is mucus producing. So dairy really causes inflammation in people. Some of us don't know it's causing inflammation, but we've got high levels of pain by removing grains and dairy. Birdman, if you took those out for a week, just a week, you'll notice a huge difference in your body. So you don't have to even say I'm doing this permanently. Just notice it for a week, how you feel removing those. Okay. I know that you'll see a difference. Ok, let's see more questions here. What are some substitutes for oatmeal, yogurt, milk. So the what I would teach in my programs and I go so into this with Total Body Thrive. We show so many different examples. But for example, like what I had for breakfast this morning is I had eggs, protein, ok, I had eggs, I had a huge bowl of berries because that's a carb. But it's not a grain, it's not a starchy carb, it's a healthy carb. I had lots of berries. I had half an avocado for breakfast. That was my breakfast this morning. I felt great. Focused energy, all anti inflammatory made me feel great. No issues there with that. Lots of things you could do. Smoothies you could do. There are so many you could do turkey bacon. There's a lot of foods you can have that don't involve those traditional things.

Ok, let's see. Any more questions about anything?

Leanna, I might have you help me answer some of these questions here too. If I'm missing some here. I had a fusion L5S1. Been in physical therapy for two years. I can't seem to do exercises correctly at home without reentering. So yes, Celeste, great question. So L5S1 is where I had my rupture. So. So what happens is your movement gets limited in those areas. Dr. Kim, chime in if I'm missing something here. But your movement's going to get limited when you have fusion. So if we don't learn to do exercises correctly, it's even more critical to learn to do them correctly because what happens is your other discs start taking over. So the key is to learn how to really activate your glutes and activate things that are going to take your disc out of the equation. So it's even more important to learn how to do Things like a glute bridge or correct deadlift. Because if you don't, what happens is those disc above start taking over, and then you start getting problems there. More important.

And one of the issues here, like she was saying, she's done PT for two years, but when she takes it home, struggles to consistently do it. So that's. That's a fault, honestly, I'd say, of the instruction that you're getting, they're not doing a good enough job of educating you on how to take the things that they see. Yes, you do in when you're in the office with them, that you can actually translate to home. And that consistency is important because what a lot of times people do, they go to PT for a while, they feel better when they either stop doing the exercises or they stop doing them correctly. And then the pain cycle comes back. So really, I think it's about having a better education from the people that are giving you the instruction to be able to maintain that so you can actually do it at home and stay feeling good.

And I would speak up and tell them that. Tell them specifically that. Say, I'm not this. There's a disconnect. And also making sure you're feeling it in the right places when you're there. Just because somebody's a physical therapist doesn't mean they're a great physical therapist. So just be really vocal about what it is that you need, what it is that you need to feel. There should be very detailed home instruction. Dr. Kim knows, for me, I was super difficult with physical therapists because I was picky and I know what I need. So you've got to be your own health advocate there and really speak up for what you need and get the right physical therapist so you get that training to do at home. I see that happen all the time. I'm sure you do too, Dr. Kim, about somebody not learning the right exercises.

Exactly. Physical therapy is not like surgery surgery. You kind of just go to sleep and get operated on. Physical therapy should be very customized to you because the body's really complicated, and one exercise that may help one person can actually cause more pain and the nearly identical person in all other respects. So doing PT for two years is not as important as doing the right pt. And that requires that you have to really kind of make a strong relationship with your physical therapist so that you guys really know each other and you can customize that program, including making sure that you keep on doing the exercises once pt, the formal PT ends.

That's great.

Tammy needs some help.

Coaches Natalie Jills of the world to kind of keep you going because it's, I, I get it is hard. I have a hard time doing all the things that I tell my patients to do.

And what I try to do in my programs at least is get you the right instruction that you don't have to rely on a trainer all the time too. Because I also don't want people to have to rely on somebody constantly helping them. So it's learning the right connection with things so you can do things on your own. Tammy, you had L4, L5 fusion, you take grass fed whey. Tammy, the question that I have back is, are you in pain right now? Are you okay if you are in pain and you are getting inflammation around that? I personally just stopped taking whey after I had my issues. So I do not do whey protein anymore. I use, I use hemp, I use pe, I use other things other than whey because dairy is not, does not work with me. And inflammation I have, I can feel things more when I'm including dairy in my diet. So I have switched out from that. If you're not feeling pain, it's fine. My husband, for instance, he has no issue with grains or dairy, but he doesn't have inflammation or have these issues. So it's different for different people. Michelle, does my program involve learning about macros? So I don't call it macros, but we do learn to balance protein, carbs and fat. So it's a similar idea to that. And it works if you are counting macros. My program works whether you're doing intermittent fasting or macros. If you're doing anything that's based on natural real foods, it can work in my program, but I have a very specific method I teach of balancing protein, carbs and fats and balancing using a natural unprocessed food diet. That's what I teach in there.

Let's see. Oh, that's interesting. So Tammy saying that her doctor is recommending L3 L4 fusion now that she had L4 L5. Dr. Kim, any comments on that?

Well, it depends. But the first thing is to make sure that you've pursued reasonable non operative treatment like we're talking about today. And if after all that.

Then it would be reasonable. But I would just recommend one thing, that they make sure that the L4.5 level is your pain generator. And they can easily do that by doing a targeted anesthetic injection like at the dentist office to try to figure out which tooth may be causing has a cavity and causing pain. If you go and do a targeted L3.4 injection with an anesthetic and you get a few hours of marked relief. That confirms that that's the pain generator. If all those things occur, then it would be reasonable to do adjacent level surgery. But I would do it minimally, invasively on top of all that.

And I, and I, that's definitely that. My biggest fear always with fusions with people is you fuse one together. If you don't learn to really correct and activate other muscles, you're just going to keep moving up the chain and then you have it. We I see it all the time with people. I'm sure you see it even more than me, Dr. Kim. If you don.

If I was in, if I was just betting for all comers, people that are considering adjacent level surgery would probably get just as good of a result, if not better. By getting really healthy and fit without surgery, I really push my patients that have what seems to be adjacent level problems to focus on health and well being. Because you don't want to just keep going one level up over and over again.

Obviously, yes, it's a quote, easy surgical fix just to keep adding on fusion levels, but really it should be a bottom up foundational building from that nutrition from the biomechanics, exhausting appropriate non surgical options like Dr. Kim mentioned. And then as a last resort, going to that next level. But most of the time by optimizing all the other things that are harder to do for you just because it takes effort and it takes consistency, but it's something that is a lot less likely to give you problems down the road where adding on another fusion level could very well turn into another level in another five years and just kind of opens up a different can of worms.

And don't forget, even if you end up having surgery, it's better to have the surgery under conditions where you're really healthy and fit because the surgery will be better in terms of just the recovery and the long term benefits. So it's a win win no matter how you slice it.

I thought Dano had his hand up. Are you still on there? Dano? Do you have a question?

Go ahead and unmute if you are.

Maybe not right now. Oh, there we are.

Can you hear me now?

Yes, we can hear you.

Okay, I have no disc.

L4 or 5 had a lot of sciatica.

Also I have a 7 millimeter bony protrusion into my spinal cord at C5, C6. Is orthoscopic surgery valid for that?

Probably not for the big bone spur in your neck that probably would require a minimally invasive mini open surgery where you can mechanically go in there for your lumbar spine.

If you have stenosis, it may be amenable to like a minimal invasive endoscopic surgery, but you may be amenable to just the mini open surgery as well. There's more than one flavor of minimal invasive surgery, so it's possible. But again, I encourage you to make sure that there's no non operative treatment, treatment measures that you should pursue first before pursuing surgery.

A few years ago and you helped me a lot and I still haven't had surgery. I'm doing pretty good. I've lost £25.

Play golf, try to go surfing. I'm 73 years old, so I'm hanging in there.

Yeah.

Wow.

Okay. Fantastic news. That's great news. All my stuff. Spinal injuries are from surfing. Waves of consequence in a whole bunch of places. Thank you so much. Thanks for letting us know. Thank you.

I saw a question here. It says Jim, as a pilot he sits an awful lot and unfortunately I don't have the option to stand performing my job. Yeah, this is, this is great. Yes, this is very common too, that a lot of people don't have the option. So Jim, it's going to be most important for you what you're doing when you're not flying. So it's not about the time that I have to sit and that's the option. It's what am I doing. So for example, I just flew to Hawaii. I was in Hawaii last week. And so I had the six hours of sitting. The first thing I did after I checked into the hotel was I went to the gym. Not what I felt like doing. I didn't go to get like a hard workout. I went to go do the glute exercises to get myself out of pain and it worked like a charm. So my back was flared up. I'm carrying my bags, I'm lopsided, I'm sitting all day. All the things. I made it a point. 20 minutes in the gym, I'm going to run through these exercises, I'm going to do deadlifts, I'm going to do glute bridges, I'm going to activate my glutes, I'm going to do some core stabilizing exercises, I'm going to eat on point. Anti inflammatory. And I did not have pain, but it was having to unwind that. What a lot of people do is they say, oh, my back is flared up. I've been flying all day. I'm not going to work out now because it's flared up now I'm in the pain cycle. I'm going to go eat what I feel like eating and we just continue it. So it's just getting very proactive and committing to. I'm going to. That is my focus. It's 20 minutes of this or whatever it is, but it comes back to that decision and being consistent with that. It's so critical. Just even before you board the plane, there's some things that you could do. I mean, even from your chair, before you even take off, like the stand up, sit down. But really thinking, I've got to activate my glutes. There's some other things I teach in pride, in thrive, by the way. Ten, for example, Jim, you probably have this going on. Most people that have lower back, we tend to be overactive with our quads to the front of our leg too. So there's things we can do, like foam. Rolling our quads, for example, will sort of shut it off the way you would think of stretching a quad so it forces the backside. It forces your glutes and your hamstrings to do the work. So I use a foam roller a lot, but not to roll out my back, because that just feels good. I do it to intentionally shut down my quads, so my glutes and my hamstring are doing the work. So it just takes a little practice. But those are the types of things you can do that will make a big difference with pain.

I saw a couple of questions on here. One from someone from the Lawson team, which sound like they've had some great success with PRP in several areas of their body. And sign up for the class, which I think is going to be great. That's going to be a good thing to jumpstart. Leading into your next question about who to see for physical therapy. You know, it's hard to say for sure, not knowing where you're at, but things to look for in a physical therapy place is somewhere that you're actually getting attention from the physical therapist. Like Dr. Kim mentioned, you know, the rehab program should be customized to you. It's not the same sheet of paper they give to the same person, whether they're the same age with back pain or one person's 20, one person's 80. It depends on how basically what your issues are and how you're moving, how you're not activating correctly. And if they're not able to spend the time with you to really get that analysis done so they can give you a Good program. And then also educate you on how to do the things they want you to do correctly, not only when you're there, but also when you leave. Those are things to look for to help determine if that's going to be a good fit for you. Some of that information is kind of able to be gathered through websites online. You could probably also even call and say, am I going to be spending time with the therapist or am I going to be with the assistant? And just ask a little bit about what the experience is like. And you can always switch if you find someplace that is not giving you good quality care.

Yes. And you could definitely be your own advocate. I know that I have a pretty loud mouth when I'm in physical therapy. When they put me with the assistant and have me do random exercises, I'm like, that's not what I'm in here for. So you can take control and say, this is what I'm here to help with, to get help with and take control of that for sure, to learn those things. Because that's a really good point, Dr. Darrington, about them putting, with assistance, doing little, like, activities. Nobody's really actually even watching you. It's just these standard exercises. We have to take control on that.

Yeah.

Denise, looks like you're local here. So honestly, what I'd say, come in and see me. I'll evaluate you and I'll make sure you get directed to a good therapist. I've got a network of people that I trust in around San Diego, Orange County, Riverside county, and I know places that I would trust to send my patients to. So that'd probably be the easiest thing to really give you something concrete.

Any other questions that we're missing here?

I agree with that so much I'm not gonna even say one word, even though I said a few words already.

There's a couple questions too, about radiofrequency ablation. And then SI joint injections and or fusions or things along those lines. I'm not a big fan of radio frequency ablation. Basically what that is is taking.

Special needles and heating up the nerves that receive pain signals from the joints in your back. So it's really kind of a band aid problem to stop your body from even knowing that things are in pain. So you end up reinforcing the things that are causing that pain in the first place while that signal is temporarily muted. The problem is that tends to. The nerves tend to regrow and the pain comes back. But also there's very important stabilizing muscles that are right next to where those nerves are. So when they burn those nerves, they also burn those muscles so they're not able to be online and doing the job they're supposed to do. So it's really.

It'S a thing where, like I said, it's a band aid. You are reducing symptoms for a period of time, but you have some collateral issues that are, that are happening and it's still just a short term treatment. And then getting into the SI joint. SI joint, kind of an interesting joint. Dr. Kim, I'm not sure what your thoughts are on this, but used to be that we thought that the SI joint couldn't move and couldn't cause pain.

We now know that it does move and it can cause pain. And surgeons are oftentimes quick to talk about doing a fusion where you basically put little dowel rods in between that joint to stop it from moving. But that's oftentimes undervaluing why that joint is having the issues that it's having in the first place. And sometimes it may not even be the SI joint, even if you think that it is. But a lot of times when the low back joints and the nerves and the discs and the muscles are not working right, it causes enough of an imbalance and some friction that that can irritate the SI joint. So again, we need to be thinking from the bottom up, from the foundation of how you're moving and controlling inflammation through better intake of what you put in your body. A lot of times these things go away and you don't need to have that fusion or that ablation to block that pain signal or to stop that area from moving.

Agreed. Having said that, I noticed that I order radio frequency ablations and I recommend regular frequency ablations on a lot of my patients. And it's usually in the setting that it's temporary. So while they're temporarily better, I really push them to use that opportunity when they're in pain remission to ramp up their exercise program so that when the effects of the RFA wear off, it doesn't matter because you're getting better through the best program of your treatment, which is being healthy and fit and exercising and undergoing the proper movements and just paying attention to your body. Same thing with SI fusion. If you are going to need an SI fusion, that's temp, that's permanent, I would do it minimally, invasively, but again, make sure that that's.

A decision that you've made. Once you've tried reasonable non operative treatment, then you've made sure that it is the SI joint cut the pain. And you can easily do that with a anesthetic diagnostic injection. Just remember that the dentist that figures out which tooth is causing your jaw pain by just injecting an anesthetic into each tooth. And if that's the case, the few patients that I've done that surgery on minimum invasively, they've done well.

Dr. Kim, do you remind. Do you mind sharing your example that you gave me years ago that stuck about the fusion, about the highway. Because I want.

Because it's interesting.

Just even the comments, so many people asking about Fusion.

Yeah, Fusion is. When we talk about fusion, it's talking about any surgery of high magnitude. It is kind of like balancing the risks and benefits of life. So if I drove on the freeway at 100 miles an hour and I didn't get into an accident or get a ticket, I'd get home really fast and think it was wonderful. But every once in a while, I'm going to get into an accident. And you get into an accident 100 miles an hour, it can be bad. So when you're trying to decide on treatments like surgery, especially a big surgery like a fusion surgery, because even a minimally invasive fusion is still a big surgery, you have to take that into consideration. So when you're thinking about any treatment, especially Fusion, you want to just make sure that you understand the risks versus the benefits.

Dano, did you have another question? I see his hand up.

You're muted, though. I don't know.

I'm fixing. I fixed it.

Got it.

Yeah. If any of you folks can talk about or if you value acupuncture for pain relief and heat and cold therapy for pain relief, I'll go first.

I think all of it's amazing. I think it's all. But it all goes to part of that whole decision piece. And being your own health advocate, all of it does help. I think that's our whole point behind this is it's. There's not just one thing that fixes everything. It's a whole combination. So the number one first step is the right exercises and nutrition. That's so critical. And we put that last because this thing people don't want to do, but it's the most important thing with. With creating a better solid foundation. Then after that, it is all of those treatments. Like, there is so much to be said for hot and cold. There's so much to be said for acu puncture, acupressure. There's so much to be said for all of this. It's great. But all of it has to be done under the whole idea of being able to decide you want to break through the pain cycle and being determined to go through all of those instead of relying on just one particular thing.

I really appreciate that support. I would want to caution everybody, stay away from opioids. I've been on them for 10 years and I want off of them.

Yeah, fortunately doctors don't prescribe them as much as they used to, so. But that used to be a real huge.

I am really glad you said that because it's so painful.

To see our patients suffering and it's so easy to write a pain medications. But you know, I personally have seen in my patient population, in my office that now that I really am strict about those opiates, that in the long run I have lots of patients that are having pain but they're not, they're okay. But back in the day when I was prescribing opiates liberally because I believed that you should, I had so many patients that were just suffering and not doing well. So those were designed for short term pain problems like surgery or injury or end of life things. But as a long term treatment it is really scary.

Well, one of the worst things is.

You get treated like a criminal even though you're a law abiding and that whole side of it causes stress which aggravates the pain. So I would, I would not tell anybody. Find another modality. And for acupuncture I'm up in Carlsbad. My daughter has a master's from the Pacific College of Oriental Medicine specializing in acupuncture. And they have a really low cost clinic in their Mission Valley school. That's a great idea.

That's great. Thank you.

$35 for an hour and it's supervised by a master acupuncturist. Anyways, I just said that.

Thank you for sharing that. Dr. Darrington. John has a question about PRP and stem cells. At one time, thing or multiple?

It depends on what the issue is.

The degenerative process of course is kind of happening regardless. We can't stop and completely reverse that. But there are a number of back issues where you can do a single treatment and address that issue. And then again coming back to that foundation, you lock in the movement and the nutrition part of it and you can really lengthen and maximize the time of benefit from these kind of procedures. Some things, especially if it's more kind of complex degenerative situation, oftentimes does benefit from having another procedure at some point down the road, it just kind of depends on what the actual issue is.

We've got a question about are they. Linda's asking, are you a good diet anesthetician? I would say both those. The doctors are extremely great at that. But I will also say, anyone asking that question, Linda, I'm saying this for everybody else that might be thinking that too, that it's so important for you to be your own patient advocate and ask questions if they don't sit right with you, from doctors, too. So if you don't like the answer from a surgeon, make sure you're getting other opinions and getting to the root of things, because I think we all intuitively know what's right for us. We just need help getting to that answer.

And yes, being a good diagnostician is directly correlated with your surgical success. And I care about my success rate and all my numbers because I'm just a guy.

Yeah, I tell patients a lot. You know, I could have the best treatment in the world. You know, I have these injections that I do that I think are very, very effective for the right conditions. But if I'm not putting it in the right place, it's not going to work near as well. So getting that diagnosis right is absolutely paramount to having the best outcome from injection surgery or, you know, the physical movement part of it.

Tammy's asking a question. Is stevia, organic extract a decent sugar replacement? I'm going to give an answer that is going to be a little bit different than that. The short answer is possibly, but the better answer is I want to get people off, even craving sugar. So in Thrive, we work at that, we don't even want it, we don't need it. Because as soon as we're like, what's a good replacement for sugar or for fat or for whatever it is, we start looking for these other options. And we're not addressing the problem. When we eat a balanced, unprocessed, natural, real food diet, then strawberries taste sweet Swiss. So my goal with clients that go through those programs like Thrive is that all of a sudden berries taste like a treat, which is pretty amazing. So I'd rather that, you know, I could say the short answer, stevia is okay, but there's even data coming out with stevia about risk there. So anytime we go to an artificial sweetener or something else, you've got other consequences that we're dealing with. Look for years about people turn to aspartame and sweet and low and all that. And there's all kinds of issues with that now. So Stevia is the lesser of the evils. But there's even research now with that showing concerns. So the better answer is to get to a point where we don't even crave sugar, we don't need it. Which is, which is the ideal.

Let's see another hundred percent guarantee agreement.

Let's see a few more questions.

I have a story for you. My wife, who's my age, 57, she's kind of listening in. She's a Natalie Jill fan. But independently, they basically are the same people in terms of all their thoughts. And the great thing is, is that all the things that Natalie is talking about I see in my wife because she does all these things. And so if you ever saw us together, you'd realize who the, who the evolved human being is. And it makes a huge difference.

And you know the way, this is the way that I'm going to give an example because people will hear things. What I teach on diet. Go. That's crazy. I shared with the doctors before we started the call that I had a gluten free donut today. It's not that I never have sugar, but this is the way I want to. If you picture a body of water, it's an analogy I use a lot. And it's a super dirty body of water. Like just picture that in your head right now. It's this mucky body of water with trash and junk in it. If I were to throw another piece of trash in it, you don't even notice it. It just looks like this dirty body of water. We don't know what's making it dirty. But if you walk by a really crystal clear, smooth, clean body of water, if I throw one piece of trash in there, it stands out like a sore thumb. I know exactly what's going on. The way I teach eating is to give us that control. So when I do eat pizza or whatever it is that I want, that's not necessarily on my plan. I know exactly why I have a flare up. I know exactly why my back is flared up. It gives me more control versus not knowing why I'm always walking around in pain. So the goal is not to have perfect eating, but it's that be in such a healthy state that you know exactly what's creating an imbalance or creating an issue. And that's the power that gives us a lot more control. So I'm not about saying you're never going to have something. It's about learning how to eat in a way that helps us thrive. And we don't have the cravings, and then once in a while, when you want the whatever, it's not going to make that big of a deal. That's the overall.

There's a question I saw from Gabriella asking about, I think, directed to Both myself and Dr. Kim, about how often and why we work together. And I think it's a great question. And something like I was mentioning before about physical therapy having places that I. That I trust to send my patients to, you know, having that network of physicians is very important as well. And Dr. Kim is one of the few surgeons that I will refer my patients to when they're looking for surgical options, because I know he's going to give them a really good evaluation. He's going to give them, you know, reasonable things to work on prior to any kind of surgical solution, if that's what they need. And I know it's going to be an excellent surgery if they do have to go down that route. So, you know, we share patients. I don't know, kind of depends. But every. Every few months or so, I think I send patients to him, and I've seen some of his patients as well. You know, when it's appropriate, I send people out to trusted individuals. And, you know, he's one of the best surgeons that I'm aware of, and I know that he's going to give excellent care for those people that I send that direction.

That was awesome. That was just like we practiced earlier.

There's some people asking how they find a surgeon in their area. You can work with patients out of state. Correct. You've got people that fly in all over to work with both of you?

Yeah. Dr. Darrington's on my short list of people that I know and trust, and I have a short list of everything. Pain doctors, physical therapists, shoulder doctors.

Neurologists, and things like that. So we work together kind of on an ongoing basis, like many of my consultants. And if I have a patient that is near his office up in Oceanside, because we're really far apart, actually physically, and I have a lot of patients from that area, that's where they go.

Work together very frequently, but. But not. We're not in the same practice or anything like that.

So, Tammy, I don't know if you heard when I started this, but I'm going to say it again, because I just think it's important is just to encourage you to not let insurance dictate the treatment because of the other problems associated with that. So I totally get us wanting to be in network with insurance, but just Remember that insurance isn't a, is a business. They don't always have our best interests. So sometimes it's worth having a consultation for things that might be out of network just to have a better understanding. Because for instance, if it's going to cost you a little bit more out of pocket, but you're going to have the long term benefit of something, it might be worth choosing to go out of network. I will say I went out of network to have the laser endoscopic and it was one of the best decisions I could have made because I would have had additional issues from having an in network procedure done. So just want to encourage that perspective. Just to not always let insurance dictate treatment. I know it's scary, we've all learned to do that. But insurance does not have our best interest. It is a business, it is 100% a business and they're looking at bottom line. So it's not always the best treatment that they're okay. So just, just a thought there. It doesn't mean you have to move forward, but just to have those consultations and not let that be the deciding factor. I've also found that some of the best surgeons, they're very aware of this too and insurance is a headache for them. I mean they get paid significantly less by taking insurance. I'm saying it, not the doctors. I know they don't want to say it but, but it's true. So sometimes you're not getting the best treatment by just letting insurance dictate treatment. Sorry, I knew you weren't going to say it, Dr. Kim. So I'm saying it.

Yeah, I don't even want to get started on the whole insurance medical care situation. So complicated. I'm so torn because I'm a big believer in everyone deserves health care, especially in a country like ours.

Yes.

At the same time.

You know, I can only see about 25 patients a day and I had three PAs and most of my colleagues see 50 to 75 patients a day. So I just don't. It doesn't mesh with the type of care that I provide, which is much more customized.

So, so I'm just gonna, I'll leave it at opinions. Yes, just get other opinions. And, and no insurance is there when we need it sometimes, but sometimes the options are not in insurance.

Most of the time you can get your, get excellent care through your insurance, but they're going to be times where it just, it doesn't solve everything. So yeah, unfortunately the less procedure and PRP and stem cells, they're just Too new. And that's commonly. New things commonly just take a long time to get accepted and we can't wait that long sometimes because our physiology is progressing. A year or two is not that long for an insurance company, but it's a lot for us.

And then Justin just said something really nice about Dr. Darrington and he's asked me if he could send review consultation justin to Dr. Kim. I'm sure you can reach out to Dr. Kim's office for that. For that as well. That's amazing. Okay, so from here, I just want to sort of wind it down and just kind of recap a few things. So basically, if you missed the beginning, we're going to send out the replay. So you've got this whole recording here. But there's basically, we covered the causes of lower back pain that are pretty. That most of you would have seen yourself in, but there's really just four. There's four quadrants that you can look at for where you're going to fix things. Whether that's surgical, using stem cell or PIP PRP on alternative treatments, and then just the foundation looking at your how you're eating and how you're moving, which are really key whether you go with surgical options or not. Those are so critical. They are the things that will get you and keep you out of pain. I'll tell you the long term they are the guarantee on those things. If you do surgery or PRP without those things, you don't have the same results. It's just you've got to have that nutrition and that stuff in place. If you add that you're eating inflammatory and you've got excess weight on you. Another thing really to look at. I'm just going to be direct and say it. Carrying excess, unhealthy weights is not helping with the pain. It's not helping with the pain. And if we're eating an inflammatory diet, we're not helping with the pain either. So all of those things are going to help contribute to breaking the pain cycle. From here, you really have a choice and I hope that you got that. The number one thing is, have you made a decision? The decision is just simply, I've made a decision. I've decided that I'm going to take this into my own hands and I'm. This is going to be the year that I don't have pain. This is the year that I'm going to thrive. This is the year that I'm going to have great results. And yes, Tammy, men or women can do this. I've got a number of men clients. The reason that it a lot of females have done it is I'm a 50 year old female so I tend to attract a lot of 50 year old females. But I've had a lot of men successfully do the program. Jim Walters, for example, he was one of my Thrive clients with this. So there's that. So if you think there's something to movement and nutrition and you've got the excess weight and inflammation, I'm going to highly suggest do thrive. And if you don't trust yourself, I'm going to ask you to trust me. I have a history of helping literally over 250,000 women and men do this. I've got doctors endorsing it here. This is something, this is what I teach, what I'm great at. And what I also want to share with you is that we do something in thrive called an action takers guarantee. Just so you know. Which means if you do thrive, if you show up fully and participate and do the program, you show up for the zoom calls, you're in the Facebook group, you do the program fully. If you do not get results, I don't deserve to get paid. So we would refund you so you really have nothing to lose but the pain and the over the weight. Because we do guarantee results. Assuming to do the work doesn't mean you just get the program and sit on it. Assuming you show up and do it. We only want to get paid if you get results. So. So there's that. So put the link in there for that. I'll be promoting it on social in the next coming weeks so we won't have open spots that I'm opening these early for this group here. We also put it again, Brittany, if you don't mind, just put the contact information for Dr. Kim and for Dr. Darrington. Whether you're in California or out of state, it's worth having a consultation if this is you. And yeah, that's where we are. Any final questions before we go?

Any final things you want to say, Dr. Kim?

Dr. Darrington, I want to say thank you to Natalie Jill and her team because you are doing really important work.

Well, thank you. I feel the same about you. Thank you.

Yeah, I echo that completely. Like I mentioned, I talk about nutrition and movement all the time with my patients, but I can only spend so much time actually doing that education. So having a program like this for people that are in pain can really optimize that and a lot of times get out of pain and even if it doesn't make the problem go away completely, that puts you in a much better position to respond well to whatever other things you may have to do.

Yes, we truly kill the fat in there and I say that again, but fat is not just fat on our bodies. It is what I call false assumed truths. I can't tell you how many people have come to me with this diagnosis and this genetic thing and this whatever and when we work on that piece first, everything changes because you start realizing that, wow, I have been validating what is going on versus looking for solutions and that is a scary thing to accept initially, but it is what changes everything because there are always other solutions. There are always solutions but we have to be in that frame of mind first. So thank you everyone for your time tonight. I hope this was helpful. I hope you enjoyed it. We will be sending the replay out with links. You've got everything. And thank you everyone for joining us tonight. Thank you.

Thank you everyone.