Pregnancy, C-Sections, & Back Pain Ft. Chip Yamaguchi, PT | EP. 05

What is the relationship between pregnancy, C-sections and back pain? Our guest, Chip Yamaguchi, expert in physical therapy raises some very interesting observations and questions!

Transcript

SPEAKER_01 0:00

I had a C-section. I've had both. I've had vaginal and a C-section, unfortunately. I thought I earned myself a great second delivery, but my daughter was breach and I pushed for three hours the first time around. So I've had the best of both worlds. Actually, the worst of both. I don't think people understand. Like C-section is a major abdominal surgery. It is. You get surgery and there's no sleep. You don't get recovery time. They put the baby right on your boob two hours later. You're like, okay, you still can't feel your legs. And then the next day, it's like your body cannot heal. It's there's no downtime from that.

SPEAKER_04 0:46

Hello everybody, and uh thanks again for joining us for our part two with uh physical therapist Chip Yamaguchi. And on this next episode, we're gonna be talking about a very interesting topic that actually I I've never really even thought about, but it's uh how should I say physical therapy concerns or issues following childbirth or c-section. So thanks again for continuing to have this uh discussion with us. But our next discussion topic is childbirth c-sections and some of the problems that are associated with that regarding physical function.

SPEAKER_03 1:25

Yeah, that, and I have some questions about almost like a follow-up from Dr. Kessel's talk about hormones and the effects on the musculoskeletal. Did you like that talk? Isn't he great?

SPEAKER_01 1:39

It's so great.

SPEAKER_03 1:40

I actually yeah, I thought it was really interesting.

SPEAKER_01 1:43

It's super interesting. And things that we all go through, but we really don't think about, you know.

SPEAKER_04 1:48

Well, I I think you know, it it is something that we don't talk about for women.

SPEAKER_01 1:54

We don't talk about it.

SPEAKER_04 1:55

And we don't talk about it for men as well.

SPEAKER_01 1:57

That's true, actually.

SPEAKER_04 1:58

You know, men's um, you know, declining testosterone levels and they go through hormonal changes as well. Yeah, and so hopefully, um, and I know we're I'm already at that age where you know where things are, you know, obviously not as good as it was before. So, you know, it's a and that'll be another topic for another day. But let's go ahead and start our questions about I'm super interested because I had a C-section.

SPEAKER_01 2:22

So I had both. I had vaginal and a C-section, unfortunately. I thought I earned myself a great second delivery, um, but my my daughter was breached second time around. Um, and I pushed for three hours the first time around. So I've had the best of both worlds.

SPEAKER_03 2:40

Oh, okay.

SPEAKER_01 2:41

Actually, the worst of both.

unknown 2:43

Yeah.

SPEAKER_03 2:43

Did they try to, did they try to, what do you guys call it? External manipulation turn the P.

SPEAKER_01 2:49

Um, you know, they they that is something that we often What is the name of that?

SPEAKER_04 2:53

There's a name of the doctor who did that, right, Doctor.

SPEAKER_01 2:55

It's called external cephalic version.

SPEAKER_04 2:57

No, but there's a isn't there a mnemonic? I'm not a mnemonic, but you know how they have a name like the Houston maneuver or whatever. You're like, isn't there, or am I misremembering that?

SPEAKER_01 3:06

We have ECV, which is basically like massaging or loaming the baby head up to head down.

SPEAKER_04 3:13

Okay. Does that actually work?

SPEAKER_01 3:15

You know, it's 50-50.

SPEAKER_04 3:16

Wow, that's pretty good, actually.

SPEAKER_01 3:18

Sometimes it works, sometimes it doesn't.

SPEAKER_04 3:19

I thought there was a doctor's name associated with that move.

SPEAKER_01 3:22

With the ECV?

SPEAKER_04 3:22

Yeah, maybe I'm I'm wrong though, because you know, orthopedically we have all these names associated with uh, you know, like Tommy John surgery, right? Do you know what I'm saying? We have all of these, yeah, the names of the surgeons who uh you know did that procedure, right?

SPEAKER_01 3:37

Yeah. Anyway, yeah, we they they do offer ECV. Um if you want to do that, sometimes we do it uh in the hospital because it can be painful. So sometimes they'll offer you a hospital ECV where they'll give you some um analgesia, and then we can sorry, what's the what does ECV stand for again? External cephalic version. So it's basically loaming the baby down.

SPEAKER_04 4:02

So it's it's massaging a breech baby.

SPEAKER_01 4:04

They call it a massage, but it's actually kind of is pretty painful.

SPEAKER_04 4:07

Okay, so it's it's an uncomfortable massage.

SPEAKER_01 4:09

It's an uncomfortable massage.

SPEAKER_04 4:10

That they're literally forcing trying to force the baby into the head-down position by pushing on it while it's in the uterus. Oh man, that does sound painful.

SPEAKER_01 4:18

Yeah, um, and it comes with its risks, right? So some people will opt for it and some people Yeah, you know, if you've had five kids and then all of a sudden this one and your sixth time is that you have a pretty good chance the baby's not too big and you have enough fluid in there. The uterus is looser. Yeah, you know, you can babies hopefully will go down with those, but like if it's your second one and you have a lot of fluid in there and the baby's kind of chunky, yeah, it's less likely to be. Yeah, I don't know. I I feel like OBGYNs, because we've seen all the worst things happen, sometimes we don't opt for those things. But you know, there's other other things to do too that are, I don't know, kind of midwife-y things and midwife's tails kind of things where you can put cold like peas and other things on like to kind of get the baby down. There's also this thing called spinning um technique where you can like lie upside down or like on an ironing board and try to manipulate gravity to have baby turn. There's all kinds of stuff that people try. I've tried it all. Moxybustion.

SPEAKER_04 5:22

What is that?

SPEAKER_01 5:23

We go to moxibustion. Where you like put uh, I don't know what it is. It's like this this stick in between your your toes and they light it on fire, and it's supposed to, I don't know, it's this old thing. Tried that too. I tried moxybustion. It didn't work, but sometimes it does, I hear. It's kind of yeah. But there's all kinds of stuff. But I opted not to, I just opted for the C-section. I can see why. It's just like, nope, it is what it is.

SPEAKER_04 5:51

So the question here is with the C-section and the disruption of the abdominal muscles, does it put you at increased risk for low back pain, low back pain.

SPEAKER_03 6:03

In the future. Right. And then, you know, if you develop, you know, it's not like you're gonna have back pain right away all the time. You know, say you develop it five, ten years, there's this disconnect because it's been so much time, right? So you don't realize, oh man, I guess maybe my c-section did affect my low back pain, right?

SPEAKER_01 6:20

I think anything that disrupts your core, uh whether it be C-section or GYN surgeries or oncology surgeries, I think anything in the abdomen would kind of affect the colour.

SPEAKER_03 6:33

And you know, the other thing, right, is so obviously when a woman is pregnant, right, and as she her abdomen gets bigger and bigger, the fluid and the and uh the baby in there basically is like a weight belt. It provides pressure to stabilize the back. Yes. So, and then I don't know when whenever the relaxin hormone starts to kick in, was that the last trimester?

SPEAKER_01 6:55

Yeah, this one is actually no, they say it's uh relaxin' is actually made by the corpus luteum early in pregnancy. So it peaks at six to ten weeks, and then relaxin kind of declines after 14-ish weeks, and then it falls pretty quickly after delivery. Oh, okay. Because it made by the corpus luteum and then kind of transfers to the placental tournament.

SPEAKER_04 7:17

What is the corpus luteum? So you remind the orthopedic surgeon. So um is that in the uterus or no?

SPEAKER_01 7:24

So the corpus luteum is a yellow body, it's um let me get you a correct definition.

SPEAKER_04 7:30

But that's part of the fetus.

SPEAKER_01 7:31

No, no, it is, and your ovary. So the corpus luteum is a structure that develops in the ovary after an ovum or an egg has been discharged, but it degenerates after a few days unless the pregnancy has.

SPEAKER_04 7:45

Yes.

SPEAKER_01 7:46

Until the placenta uh the placenta is mature enough to start producing relaxin.

SPEAKER_04 7:50

So for the audience.

SPEAKER_01 7:51

From what I know, I don't know. I'm not an endocrinologist.

SPEAKER_04 7:53

So But the um the relaxin, just for the audience, right, is a hormone or a peptide. It's a peptide in the body that is thought to soften and relax the cartilaginous tissues that hold your bones together. And the reason this is important is because obviously, when you're pregnant and the baby has to come through your pelvis, you want the joints, so to speak, to be a little bit flexible so that it'll stretch to accommodate the baby's head and body coming through the you know the birth canal. And then later on, hopefully, we'll get but your question about the relaxing is because um if the joints between the pelvis and all of these cartilaginous structures that are generally very, very tough become softer and more lax, it can lead to some musculoskeletal uh symptoms that you know baby are not so well defined.

SPEAKER_03 8:48

Yeah, and so you know, during the period where the woman is pregnant, right, and then the fluid and the the baby are creating some stability for the body.

SPEAKER_02 8:58

Yep.

SPEAKER_03 8:59

Um and then you and then the woman gives birth and then you lose all that pressure, intra-abdominal pressure on a very deep relatively deconditioned woman. Yes, right? Because she's obviously been less active than she was prior to being born.

SPEAKER_04 9:16

At least in the last trimester. You know, I've I've noticed that women in the last trimester they get really big.

SPEAKER_00 9:23

Yeah.

SPEAKER_04 9:23

Right? They get big from the first six months or whatever. And so obviously, they're not lifting. I mean, some women do. Hats off to those women that still exercise. Oh, yeah, and those people, they they just bounce back. I've seen they just bounce back from pregnancy.

SPEAKER_02 9:38

Yeah.

SPEAKER_04 9:39

We had um one of my PAs uh, you know, was pregnant during work, and she was obviously in great shape. Uh uh and man, she she was also Chinese, so you know, maybe Chinese women are really super tough. That's why there are a billion Chinese, right? You know what I mean? But anyway, she just like gave birth and then like back in work and like you know, just so tough, right? Like, you know what I mean? Like nothing happened, but she kept herself in good shape, right? So people would always remark, like, oh my god, you just gave birth and you look like nothing happened, right?

SPEAKER_01 10:13

You know, she just looks like everything changes when your your whole anatomy, your posture, right? Doesn't your spine it's very gets more curved, it gets more curved because of the the weight in the you have to lean backwards a little bit more.

SPEAKER_03 10:25

And then and the thing, when you actually then when a woman gives birth, right? Now the work begins because you're constantly bending over and picking up this baby and reaching into the crib.

SPEAKER_01 10:38

And I don't think people understand like C-section is a major abdominal surgery, it is, and to you get surgery and there's no sleep, you don't get recovery time. They put the baby right on your boob two hours later, you're like, okay, you know, you don't can't you still can't feel your legs, and then the next day it's like your your body cannot heal. It's there's no downtime from that.

SPEAKER_04 11:00

Yeah. Um, and I I'm not sure how long the relaxing drops off pretty quickly. Pretty quickly, they said. Yeah. But you're right though, in that time period, your core is completely stretched out and right?

SPEAKER_03 11:14

I would, yeah. I mean, even for the woman who hasn't had a C-section, right? Yeah. Is kind of set up to have problems. And then you introduce a C-section, and then you're cutting through the abdominal wall and you know, and disrupting potentially the whole um stabilization system, right? And then, you know, so I've always wondered that is, you know, if um routinely why women are not sent, even if it's only a short course of therapy to say, look, you can do these exercises, you know, on this, and you can progress at this rate or whatever, right?

SPEAKER_01 11:47

So um I it would be very helpful to have physical therapy after a C-section. I just don't think number one, gotta be insurance, right? Like that's a big barrier. Nobody's gonna who's gonna pay for women having physical therapy. Yeah, they don't pay for even six weeks uh maternity leave, right? That's six to eight weeks maternity leave. That's what women get. And then after that, could you imagine paying for insurance companies and pay for physical therapy for women? I don't I don't think that they find that valuable, although it would be extremely valuable.

SPEAKER_03 12:24

Well, any any kind of pain or functional deficit will be pretty easily covered by by insurance, I would think, you know. But you know, you know, the old uh thing, right, is that uh it's been done this way forever.

SPEAKER_01 12:39

You know, like well, also right, women are just expected to kind of suck it up.

SPEAKER_03 12:44

I have heard that response from um some physicians that uh you know back pain is just part of pregnancy.

SPEAKER_01 12:52

Right.

SPEAKER_03 12:53

You know, that's you know that's just how it is.

SPEAKER_01 12:54

Yeah, right? It is the most uncomfortable feeling ever to be pregnant. There's a lot of women that you know do really well, but the majority of women, it's very uncomfortable. Pregnancy in general, and then postpartum, you're sleep deprived, you don't feel well, you're bleeding from everywhere, you're breastfeeding, and then you're expected to you know heal. It's it's very difficult for women, but we don't really say anything, you know.

SPEAKER_03 13:24

It's amazing how women recover from c-sections.

SPEAKER_01 13:27

It's amazing.

SPEAKER_03 13:29

If men had to do that, yeah, we no man would ever yeah it the the we would go extinct.

SPEAKER_01 13:37

Yeah. And to think you get just an extra two weeks for if you have a c-section versus a vaginal delivery, sometimes even vaginal delivery though, the outcome of that, you're like, man, maybe a c-section would have been better because there are certain vaginal deliveries that can go really really rough, you know, and have a lot of uh postpartum problems after that, you know, third and fourth degree tears, things like that, where you have anal incontinence. There's certain things you guys have it rough, yeah. It's not fun, it is not fun.

SPEAKER_03 14:14

But at least, you know, with a c-section, they let you stay in the hospital for another day.

SPEAKER_01 14:17

One more day. Woo-hoo. Woohoo. Yeah, yeah. And you know, these days they don't give you any, which is great because you know, it has its own problems, but it's just Tylenol and Motrin. That's all you get after a C-section. That's all you get. You don't get any narcotics, yeah, nothing more than Tylenol and Motrin. Same as if you sprain an ankle, right? So it's it to me, it's just very interesting how women are. The pain. Yeah. Everybody always asks me what was worse, vaginal or c-section. I say both are bad. Both are rough. It is faster, but you do have other things that happen. Like, God forbid a sneeze comes out of nowhere after a vaginal delivery. You're leaking everywhere. Sorry, TMI. But she she just comes right out, you know. So, whereas C-section, you not don't necessarily have those problems, but you have other problems, right?

SPEAKER_03 15:26

So it's amazing to me, too. Is it true, right, that when you when you perform a C-section, how how fast can you get to the baby?

SPEAKER_01 15:35

Usually under a minute.

SPEAKER_03 15:36

So if they're and how long does it take to actually put everything together?

SPEAKER_01 15:40

Um, depends. Um there's certain surgeons that are faster, and there's certain surgeons, it depends on kind of your idea and philosophy of it. We've had kind of old school surgeons who their belief is you repair every layer that you've disrupted, and then uh there's some evidence now that you don't need to repair every single layer.

SPEAKER_03 16:01

All of that wasn't put back exactly how it's supposed to be.

SPEAKER_01 16:04

No, no. So I mean, there's different thoughts and some evidence on each layer whether or not it needs to be repaired or should be repaired. Um, that's another great topic though. But yeah, not every layer needs to be repaired necessarily. And then as far as scar tissue is concerned, we don't have a lot of great like adhesion barriers or adhesion prevention during the C-section. So we don't really have there there's certain things that we use called like separate film, but the evidence really isn't there that it helps with adhesions or scar tissue. We don't really have some great things to use to prevent a lot of scarring.

SPEAKER_04 16:45

So, you know, I was just looking up a little bit on the C-section thing, and they were saying that the incidence of um of back pain following C-sections was significantly higher for women, you know, than vaginal birth. At least according to the city.

SPEAKER_01 17:00

Is that like immediate back pain or just far out?

SPEAKER_04 17:02

This is no, this is um short-term back pain. Short-term. So in the immediate period, right, like they said it was like something like 44% back pain with C-sections versus 30% with vaginal delivery. So not actually 10% difference, it's not tremendously greater, but I think the question of long-term, yeah, long-term is long-term. I don't know if anybody's really studied that.

SPEAKER_01 17:24

Because you know, short term, my back was probably more sore with the vaginal delivery and pushing for that long, and the baby, if they're you know, sunny side up, putting pressure on your back, it's really painful.

SPEAKER_04 17:35

Yeah, they also said that you know, there's other contributing factors, right? Like uh spinal or epidural uh anesthesia, um incidence of back pain is higher. You know, so I don't know.

SPEAKER_01 17:47

Oh, spinal versus epidural.

SPEAKER_04 17:49

Spinal or uh, you know, there's women with spinal or epidural anesthesia tended to have more back pain as well. So those are some of the contributing factors, right? Um they talk about postural strain, but it's all short-term studies on the incidence of back pain. But I think your question about the long term, like these women are now 70, they've had two or three C-sections, right? Or even just one. If the surgeon didn't repair the uh the rectus, or it'll be that's such an interesting question.

SPEAKER_03 18:23

Not only that, but that's whatever you're reading and they talk about short-term back pain, that's probably defined as someone who had back pain and then it goes away, obviously. But it doesn't actually necessarily answer did the back pain return later.

SPEAKER_04 18:38

Yes, that's what I'm saying. So the long term so like you know, if if somebody were to design a study um that you know interviewed 70 or 80 year year old women, right, who had back pain, clinically significant back pain, and then you asked them, you know, I don't know if anybody's really done that study, right? Plus, to find the records of when they were 30 years or something.

SPEAKER_00 18:57

I think it's just so hard to like tin it down to it is just that it's very, very difficult.

SPEAKER_04 19:03

But from a just from a logical anatomic standpoint, it makes a lot of sense. Yeah, it wouldn't be like your core was cut, yeah, and if it wasn't repaired, or even if it's scar tissue, scar tissue is not the same as a healthy fascial attack. You know what I mean? Yeah, scar tissue is not as strong as normal tissue. People think that oh scar tissue is extra thick, but it's not as it's not normal.

SPEAKER_03 19:27

Yeah, when it comes to back pain, um, you know, you can you can ask ten different therapists, and ten different therapists are gonna have their you know their top reason as to why people get back pain. Personally, uh a wise therapist once told me that joints that are relatively loose or move around an incorrect axis of motion produce pain. Tight joints generally do not, particularly in the spine. So when you start interrupting the whole fascial system and stabilization, I can see how people have hypermobility in their back and then you know they have chronic back pain from that.

SPEAKER_01 20:07

Yeah.

SPEAKER_03 20:08

Well, that's why, you know, I mean surgical treatment is fusion.

SPEAKER_04 20:11

Yeah, right?

SPEAKER_01 20:12

Yeah.

SPEAKER_04 20:12

I mean, I mean, I I'm probably saying that incorrectly because there's more reasons for the fusion, maybe they're trying to give you more space for your nerves, et cetera, et cetera. But it's usually the joint above or below, if I'm not mistaken, and um, you know, that that starts to cause pain because now you have a stiff joint, and then the a joint above is relatively hypermobile. Yeah.

SPEAKER_01 20:34

I don't know if this makes a difference, but they uh there is uh they do say that most studies do not find a strong link between C-section and chronic back pain when controlling for other factors such as age, weight, parity, pre-existing back pain and physical activity.

SPEAKER_04 20:48

But it would make sense if they did have. But you know, I I think the other thing too is it is extremely difficult to isolate.

SPEAKER_01 20:56

It's extremely difficult. Yeah.

SPEAKER_04 20:58

Because it is so multifactorial that it is very, very difficult to have a study that's going to show you that that is. But very interesting, um thought-provoking question.

SPEAKER_01 21:08

It is, but I do think that that it has a lot more to do with like weight, obesity, or the amount of scarring that's in the exercise, lifetime exercise. Yeah. And you know, it's interesting when we go into an uh an abdomen, it doesn't really matter. It's very individualized. Like if I go in for a repeat c section number two, that could be the worst scarring ever. And then I go into a repeat c section number five, and it's beautiful. Yeah, you know, so you can never tell who's gonna heal how.

SPEAKER_04 21:42

Yeah, and I think that's another thing that um patients don't understand is that there's a lot of genetic, you know, like um genetic differences with people. Yes. How do you how does the body heal? Do you get are you a real big scar developer? Are you not a scar developer?

SPEAKER_01 21:58

And people associate their outward scar with how they heal inside and they have no correlation.

SPEAKER_04 22:04

Absolutely true. So I think um a lot of our patients will say oh you know you got you did such a good job the scar looks so good.

SPEAKER_01 22:11

Right.

SPEAKER_04 22:11

I was you know it always I mean it's it's funny but I they have no idea that it has that has nothing to do with with what's going on on the inside. Yeah.

SPEAKER_01 22:21

So so you can heal beautifully on the outside and I get in there and it's just cement.

SPEAKER_04 22:26

Yeah.

SPEAKER_01 22:26

And you're like oh my goodness I didn't anticipate this bad of scarring. Yeah. But yeah I've had it where the set my worst C section ever was a a number three and usually number three not too bad you get some scarring in there but it was absolutely yeah interesting.

SPEAKER_03 22:43

Any other qu questions or um observations about post GYN or birth not too specifically about uh childbirth but I do have a to kind of switch gears if you don't mind um I wanted to get your thoughts on you know when you guys were talking to Dr. Kessel and you guys brought up the average age of menopause which was 51 or 52 correct correct and then he said that um in terms of perimenopause yeah right hormone levels can be all over the place. All over the place.

SPEAKER_01 23:19

Okay so you it's it's pretty widely accepted and known right that women I mean people who get tight shoulders or frozen shoulders just out of the blue typically are women in their perimenopause menopause years right so but we so whenever you try to do like a little search and find out the reason why there is I've never found a specific reason why so I don't know if when you know it's estrogen levels that drop right is what is the correlation do you have any thoughts on why that's so I think again it's probably multifactorial so not just one thing and everything's kind of going a little nutty but we did find some studies that showed like estrogen helps regulate collagen turnover and joint elasticity maybe so maybe that's why and just with low estrogen and menopause in the age you have increased like fibrosis and uh reduced capsule elasticity I'm not sure um and then also your inflammatory responses are different I think during that whole period menopausal kind of time um so I don't know they they think that menopause actually puts you and I'm not sure about this in a very low inflammatory state a low inflammatory state that's what they say menopause is associated with a low grade inflammatory state um and so it's just metabolically baseline I don't know these are just all like you know sure theories or thoughts yeah and thoughts about why this might happen.

SPEAKER_04 25:00

Your other question you asked about is frozen shoulder more common at uh after menopause and it is associated with it. Yeah because but I don't think they have one reason yeah but for some reason necessarily why and it might be just an age thing too right like yeah because uh I tell you like right now probably 90 80 90% of my days seen shoulder patients.

SPEAKER_01 25:22

Really that many?

SPEAKER_04 25:24

Yeah wow um and all menopausal age lots right it's the same thing but you know back in the day what what is a frozen shoulder though like this is when your capsule gets tighter it's painful so what happens is people start having shoulder pain. Yeah and then it's it's from inflammation right and then because it's sore they stop moving it.

SPEAKER_01 25:42

Yeah so then oh but it's not like an arthritis.

SPEAKER_04 25:45

It can be caused by arthritis or anything that causes some kind of inflammation in the joint.

SPEAKER_01 25:50

But basically it's inactivity that causes it to be frozen.

SPEAKER_04 25:54

What happens is you your response to it right people get sore shoulder. Yeah then they don't want oh that hurts so they stop moving it so pretty soon it's gonna get tighter and tighter because they stop moving it to the point.

SPEAKER_01 26:03

Like a stiff net.

SPEAKER_04 26:04

So actually the treatment is stretching you have to actually you know stretch it stretch stretch it and anyway we'll we'll have Dr. Weldon on one day and talk about that because it's another that's a super common super interest top with a very very simple but um simple solution of stretching but you gotta be diligent.

SPEAKER_03 26:24

Yeah yeah but do you find it like it most of them recover most do oh you know sometimes it's harder than others um occasionally I know that I'll ask like Dr. Weldon what his thoughts are on is this person a candidate for manipulation under anesthesia.

SPEAKER_04 26:44

Uh-huh um you know and so sometimes I think you're right though I think it just more has to do with kind of maybe age well this is saying that the the peak incidence of frozen shoulder occurs around age 55 and this is in both men and women.

SPEAKER_03 26:58

Both men and women that's important that's both you know if I see a uh uh a guy who's say you know his late 40s 50s yeah come in with a frozen shoulder for no reason at all my first question is does he do you have diabetes?

SPEAKER_04 27:10

Oh almost always they have yeah diabetes is definitely yeah yeah but the mechanism I'm I'm not sure I gotta I would have to look that up and see.

SPEAKER_01 27:19

But you know when women are in their perimenopausal menopause with years it takes very little for some to push them over the edge to get a frozen shoulder like I've seen during the pandemic say you get you know you get the vaccination it kind of hurts your deltoid yeah they don't move it oh frozen shoulder really they that quick oh yeah real quick or um I'm working from home now frozen shoulder because they're not getting dressed brushing their hair opening doors driving right yeah yeah decreased activity boom frozen shoulder yeah so yeah this says statistically um uh patients with diabetes on a meta-analysis of 13 studies almost four times more likely yeah to have a lot of shoulder is more common than people with diabetes yeah so but also says here that postmenopausal women often experience changes in insulin insulin insensitivity um and lipid metabolism when they're older too so maybe that has some sort of weird link but I don't know I think the I think the uh the the the principle or the uh how should I say the um universal truth is that aging is associated with a lot of bad stuff a lot of bad stuff right don't get old yeah you know and keep moving like you're you gotta keep moving yep and the only way you can combat all of these things as we've said before is really is exercise exercise that that's the that's the only thing you can do you cannot control your genetics you cannot change aging but the one thing you can do is try to exercise right even diet we don't know much about diet yeah maybe one day we'll have a nutritionist on here nutritionist that's right I forgot about that I have my master's in nutrition that's right that's right but right but I'm not a nutritionist so they're amazing and we got we are let's get a but we should get a uh nutritionist but even though there's really no I mean as far as I know yeah there's no studies that tell me if you eat more asparagus you're gonna have less likely you know but nutrition is a preventative yeah but a healthy balanced diet I would say is great right yes very important yeah so it's just you know like I said we don't know the specifics of it but you know trying not to eat McDonald's every day or I shouldn't even say that because you know that's probably um not that there's anything bad about McDonald's we'll edit that out yeah but you know you basically try to try McDonald's yeah I love McDonald's too but you know try to do it once in a while really moderation yeah moderation that's my whole theme you can price said right everything in moderation everything in moderation you know it's okay to drink a beer once in a while have it 12 beers a day maybe not so not so good yeah not so good yeah yeah but anyway okay anyway I uh I don't know do you have any other you know those are good questions are the main ones okay well anyway I don't know why um because we have scary things going on with Alexa uh or whatever so we'll uh cut here but um we have cats we have snoring dogs and ghosts affecting our speakers in the in the in the in the house amazing anyway uh Chip thanks a lot for being with us here hopefully that was a really interesting discussion for those two topics yeah on um you know OBGYN considerations and you know physical therapy issues etc etc so well thank you for joining us from the inside out so I think that beeping is our cue that we need to leave we need to leave yes yep yep we can so anyway again uh if you can like and describe that'll be very helpful. Please take care of each other um aloha kikahi kikahi and take care of each other from the inside out thank you goodbye what in the world what is that