The Healthy Post Natal Body Podcast
The Healthy Post Natal Body Podcast
Exercise for postpartum back pain. W David Jeter
You keep asking about postpartum backpain so we keep talking about it :)
This week I have the pleasure of being joined by David Jeter who is an awesome physical therapist. We're talking post-partum back-pain and the benefits of physical therapy and exercise generally.
We discuss many, many things including;
What is post-partum back pain and what causes it?
Is surgery THE solution?
Why is post-partum backpain soo often ignored by both the medical community and those suffering from it?
Why are people not aware just how effective physical therapy is to deal with back-pain?
How the PT community is doing a terrible job of promoting the benefits of exercise and is spending too much time selling cheap-tricks.
And how you can help yourself if you're suffering from any sort of muscle related pain.
As always; HPNB still only has 5 billing cycles.
So this means that you not only get 3 months FREE access, no obligation!
BUT, if you decide you want to do the rest of the program, after only 5 months of paying $10/£8 a month you now get FREE LIFE TIME ACCESS! That's $50 max spend, in case you were wondering.
Though I'm not terribly active on Instagram and Facebook you can follow us there. I am however active on Threads so find me there!
And, of course, you can always find us on our YouTube channel if you like your podcast in video form :)
Visit healthypostnatalbody.com and get 3 months completely FREE access. No sales, no commitment, no BS.
Email peter@healthypostnatalbody.com if you have any questions, comments or want to suggest a guest/topic
Playing us out; "A game of chess" by Wicked Cinema
Hey, welcome to the Healthy Postnatal Body Podcast with your postnatal expert, peter Lap. That, as always, would be me. This is the podcast for the 3rd of November November 2024, and we're talking postpartum physical, postpartum back pain, with Dr David Jeter, who's a physical therapist. Because you know, like I've said before and like I say at the end of this podcast, I'm fed up listening to my own voice, so it's important that you hear somebody else talk about postpartum back pain rather than just me saying the same thing over and over again. So I've brought somebody on to say the same thing over and over again. I promise you this will be a great interview.
Peter:Dr David is one of those guys. He's not selling anything, he's an educator. I love this guy, so you're going to want to stick around for this one. So, without further ado, here we go. So we're talking postpartum back pain. You know, let's start with what you class. First of all, start this what you class as postpartum back pain? Because a lot of the doctors in the UK tend to only call it that if the woman is recently postpartum, and I personally class it as anything that is caused by having been pregnant or having given birth.
David:Well, I guess I want to answer that question by starting with probably half of the people that I see in my clinic have low back pain and, um, and I would probably say 70% of those patients are women. And of those of those women, I can't tell you how many times I've had a woman say, when I, when I asked him, okay, well, tell me about this back pain, when did it all start? And they say well, my youngest son is seven, so about seven and a half years, that's how long I've had this back pain. So it boggles my mind that women typically get some sort of low back pain during pregnancy and then it just never, ever gets resolved.
David:Postpartum and uh, and granted, obviously there there are plenty of women who get low back pain postpartum as well, which, again, just like you're saying, is anytime after, uh, the baby is no longer inside. Uh, then I I kind of, I kind of term it all, I kind of lump it all into the same category. But certainly pregnancy has a massive impact on the lumbopelvic hip region and clearly we are failing women in general about how we are addressing that.
Peter:Oh, yeah, for sure. No, I'm completely with you. I basically class any period, uh, as in the baby isn't in you anymore, that's postpartum or caused by cause. I obviously come across the same thing that that you are as in my back hurts, um, oh, that's just the price I have to pay for having a kid. It's quite often or it's because I'm lifting an awful lot more now that I'm shifting baby about an awful lot, and toddlers and you know kids grow.
Peter:You keep feeding the things, they, they, they keep growing and they keep getting heavier, but they still want to be picked up and all that sort of stuff. Yes to getting heavier, but they still want to be picked up and all that sort of stuff. Yes. Why do you think I have my own theory on this? Why do you think that solution because there is a solution to postpartum back pain, to most back pain, right? Why do you think that solution isn't being presented to women, or women are not getting that when they clearly should? No one should walk around with seven years worth of back pain, right, right?
Speaker 3:Well, first of all, there's a lot of questions in that question.
David:First of all, let's take some responsibility as physical therapists, because we or me, I don't know what your background is but we have not demonstrated that physical therapy can cure low back pain. True, definitively. You know, we do not have research that demonstrates if you do this type of physical therapy, we can solve your back pain, and so that's a failure of our profession to demonstrate that what we do has validity. And so, in the medical community, if we don't have that validity, then doctors are not necessarily keen on prescribing something that doesn't have a tremendous amount of validity. Now we have, we have anecdotal, noted um, anecdotal evidence, and and we all believe that our techniques are superior to other techniques, and and we feel like we can move the needle on on a whole host of things. But, but when it comes down to brass tacks, if you can't show a double-blind study that demonstrates that this type of either manual therapy or exercise therapy, or biopsychosocial or whatever you're doing, has a positive effect, then I think the medical community as a whole has a challenge uh, accepting it as something that that should be prescribed to everyone. Now, that's so. That's number one. That's our responsibility, that that we have failed so hard on producing research that actually demonstrates what we do works.
David:Clearly again, as a physical therapist, I believe it works, because this is what I do all day, every day, and I see change happen in a lot of different people.
David:So I think the challenges in terms of a research standpoint, though, are how do you get a cohort of people that have a similar problem, such that you can perform a certain treatment to that person, that group of people that will demonstrate an effect that you can demonstrate that a control group doesn't have that effect with.
David:If you don't do that thing, too, I think that is incredibly challenging. I mean, even if you take postpartum women, who are probably of a relatively narrow age range, they uh, they have all had this event happen where, where there is some amount of trauma to the lumbopelic hip region, um, you can't do. You don't do the same things to every person who walks in the door. Yeah, you door. It has to be individualized. You're doing different stretches based on their movement dysfunction. You're doing different exercises based on their exercise, their weakness or their inability to control movement. So I don't know how to square that circle, in the sense that I don't know how to produce research that demonstrates that what we do actually works, but I think that's a massive piece of why the medical community as a whole hasn't embraced a routine physical therapy course postpartum, as this is how it goes.
Peter:Yeah, no, that's an interesting point, cause I did an episode a while ago where I was asked about some studies into diastasis recti and all that sort of stuff and the only studies that have been done into it, which is kind of more my specialty rather than, rather than, back pain, although everything, everything links together, right, I mean, everything is connected and therefore, by definition, one problem leads to another problem, which we'll get to in a little bit. But it's like I said, I was doing some, I was reading some studies, as I am prone to do, and all the studies into diastasis rectum are the studies that show what doesn't work, as in, crunches do not work. Uh, okay, yeah, yeah, cool. Every every physical therapist experience with diastasis recti knows that this is the case. But but that is essentially the only study you can do as in.
Peter:Does this particular exercise work? No, it doesn't. Okay, that's out there. The problem is then, of course, that those studies get out there and, before you know it, the only studies that are out there into something like back pain or or diastasis recti is stuff that doesn't work, which very quickly translates into the media and into, therefore, lay people and facebook support groups and all that sort of stuff, as exercise doesn't work yeah, I think the most classic of what you're talking about is that canadian study, that um, that demonstrated that chiropractic physical therapy and a walking program are all exactly the same in effectiveness for for low back pain treatment.
David:And so, you know, the canadian government, being the canadian government, just said forget it, we're not paying for, we're not paying for any of that treatment anymore If it's no, if it's no different than just go walk. Well, what they found was is that their LNI claims doubled in terms of costs, in terms of time off, in terms of medications, in terms of surgery, in terms of all of the all of the other aspects of LNI, in terms of surgery, in terms of all of the other aspects of L&I. And within a year, they reinstated doing physical therapy with L&I folks for back pain, because they said we don't know what you guys do, but clearly, if you don't do it, it costs us twice as much. So to me, that natural study was probably one of the best studies to date about why physical therapy actually is effective.
Peter:Yeah, and that is exactly the approach that I tend to take Because, like you said, every postpartum person, every individual overall, is completely an individual. So when you look at what they do in France, in France postpartum people get six standard appointments, six free appointments with a physical therapist or a physio. Boom, because they know that you need this postpartum. You're going to have some issues. They need to be resolved. What your issues are are your issues, and only a physical therapist can tell you what they are, and how to resolve these, but we know that it ends up costing us more when we don't do it.
Peter:In the same way that I have a corporate client that is very big that now tells all their employees that complain about back pain yeah, you need to go see Pete first.
David:You need to go see Peter first and get some exercise in before we spend a thousand pounds on a new chair and two grand on a new desk, and then the ergonomics expert comes in, there's another 1500 pounds and we have five grand in the whole where speed charges 150 bucks in total and that's it yeah, yeah, yeah, uh, um, I, I think in that, uh, in that same realm, uh, you know, we see a lot of people uh, pre-surgically for knees and shoulders and all sorts of things, and the number of times that we get the person moving better and they feel better and then all of a sudden they don't do surgery.
David:It's not as if anybody is counting that up and saying, hey, dave, thanks so much for saving the insurance company 10 grand on this surgical intervention. That didn't happen because you did. You know, six to eight visits of physical therapy, and so you know again to your point about having physical therapy immediately, not immediately after, but but when it's appropriate, uh, after, uh, after the baby's born. You say someone walks into my office and they, they look at me and they say I don't know why. I'm here, I feel great, I'm walking, I'm back to doing the things I want to do, I don't have any pain, all of those things I'm going to say get out of my office, you're fine.
David:Great, that's fantastic you know, go do the things that you want to do and enjoy your life, and if you ever need me, I'm here for you. I'm not going to do six visits on somebody who doesn't need therapy and I don't. I don't think that that one wasted visit quote unquote is is nearly as disadvantageous to the whole system as making sure that the person who actually does really need some specific intervention gets that intervention.
David:And and I guess the thing that's frustrating to me is the insurance companies know that physical therapy saves the money right, they know that they know every dollar that they spend on physical therapy is a dollar 50 that they're not spending elsewhere in that community of healthcare professionals, and yet they're still pushing back on visits and whatnot. Now, granted, I don't think somebody should have 60 visits of physical therapy for low back pain, that's clearly not how it should work for the most part, but someone doing 12 visits, someone doing 18 visits of physical therapy is incredibly cost effective versus the injections, the discectomies, the fusions, all of the other uh stuff.
Peter:That's that's going on these days oh no, absolutely, and especially because the cost of health care, even in the uk, where we obviously have the national health service the actual cost of it is is is skyrocketing. It's going up all the time. Where's the cost of physiotherapy and physical therapy is relatively stable. I mean, I don't know about you, but okay, inflation is 10 percent.
Peter:I I haven't been able to jack my yeah, I haven't been able to jack my prices up by 10% this year just because I felt like it, so let's go back. Women come in to you and they say it's been seven years since I gave birth. What tends to be your starting point with your assessment when someone comes in, with regards to the physical side of it?
David:yeah, yeah, yeah, um, you know, obviously I'm. I'm a manual therapist, you know, by training, that's my um, that's my background. So I'm always into what does movement look like? What, you know, are all of the joints doing what they're supposed to do? Uh, are they able to stabilize through their normal range of motion? That is my go-to. So I'm always looking at what can the person do in terms of range of motion? What are the hips doing? What is the pelvis doing? What is the lumbar spine doing? What is the thoracic spine doing? What is the nervous system doing? All of those different aspects of movement are critical. And again, typically what you're finding in someone who has low back pain, postpartum or not, is they have a whole host of different regions that aren't doing their job.
David:And those regions may not be painful at all, but they may be creating a bunch of stress on the regions that are moving or moving abnormally, and so our focus is normalizing movement of joints, uh, throughout the whole system again, hips, pelvis, lumbar spine, thoracic spine, even down. I've moved some, some ankles sometimes I've moved some upper thoracic spines, sometimes, um, and then, once things are moving and mobility is restored, what you're finding is a lot less pain and when, when pain starts to go away, then we start to really start loading that system in all three planes of motion, loading that system and creating, uh, creating stress in a way where they can, that graded exposure of doing more and more and more, such that the person can tolerate more load than their average daily activities and they can progress on to their own home exercise program or daily exercise program on their own.
Peter:Yeah, because this is something that I used to talk with my clients a lot about. Quite a lot. For me, both spartan back pain or any sort of back pain even though I see this in my corporate clients as well it is very rarely a lower back problem, isn't it? I mean, it's always almost inevitably caused by something else not doing what it's supposed to be doing, and the lower back taking the strain of that.
David:I mean, I would say the vast majority of people with low back pain have irritation at the L4-5 segment. That's just like the most common thing. And if you think about what the L4-5 segment does, it does bending forward, it does bending backward, it goes to the side some amount, but it doesn't really do rotation. And so if you think about what the hips and pelvis do, they do a bunch of rotation. And if you think about what the mid-back, the thoracic spine, does, it does a bunch of rotation. And so if those two regions are not performing rotation, then the brain doesn't care. It just wants to walk or it wants to bend and lift or twist or do all the other things, and it's going to take that rotational motion from wherever it gets and put a rotational stress through L4-5. So it's not unusual at all to have it.
David:I would say not only is it not unusual, it is incredibly common. It is. It is probably the reason why people have, uh, the vast majority of low back pain is because their hips and pelvis aren't doing what they're supposed to do and creating that rotational stress into the, into the lower lumbar spine, which is why, again, we see a ton of low back pain in postpartum women because the pelvis and si joints and the hips are tremendously affected by pregnancy and I mean that's just, that's just an absolute no-brainer with with the hormonal um changes and and the increase in in movement of the whole pelvis, things tend to not move properly.
David:I know that sounds weird that that the hormones creating more movement make things not move properly. But it does. And and if you don't resolve that movement problem, then you have all of these different muscle strength and dynamic control problems. And I think I'm not a, as you can tell, I haven't talked at all about pelvic floor. I haven't talked at all about incontinence, because that's not my thing at all like I don't do.
David:I don't do what we would call women's health or or pelvic uh health. Uh, in my, in my practice, if someone is, someone has those kinds of issues, I definitely send them out and uh and I I don't. I don't pretend to do that at all, but I think that so often uh, women are just trying to do do kegels, or they're just trying to do transversus abdominus or they're just trying to do a bunch of exercises to get muscles in that region working, but they haven't resolved the movement problem first, getting the pelvis moving properly, getting the lumbar spine moving properly, getting the muscles in that region working, but they haven't resolved the movement problem first, getting the pelvis moving properly, getting the lumbar spine moving properly, getting the thoracic spine moving properly, such that all of these muscles that attach to all these different places can have an attachment that is doing what it's supposed to do. I think there's some inhibition of muscular contraction when you have restriction. I think part of that weakness is actually a restriction problem.
Peter:Yeah, and this is why I always talk about a holistic approach being required, and by holistic I don't mean hugging a tree, the body as a complete unit, rather than indeed just going to get your over. In the uk we call it a, a um, a mummy, mot, um. You just get basically postcard, you, you get a checkup, someone has a look at your pelvic floor and does an internal exam, if you're that way inclined, and all that sort of stuff. And then you have, on the other side of the spectrum, you have the standard indeed engage your TVA. Right, everybody and I literally just did something about that the other week If you're only looking at engaging your transverse abdominus, then you're missing out a whole section of things that your body is supposed to be able to do, a whole section of things that your body is supposed to be able to do. Um, and let's be honest, I had, I had someone on jessica marie rose legio, and I refer to her a lot.
Peter:She's a running postpartum running coach and she says, yeah, the tva and activation is one of the least interesting bits about postpartum health. I don't know why everybody focuses on it, other than it's easy. I can just say focus on this one muscle group and there you go. I'll focus on this one muscle group and that's simple.
Peter:Looking at everything is much more complex and this is why it's so useful to work with somebody who, other than the health, other than the pelvic floor sort of stuff, like you said, I outsource that as well. I'm a I'm a 48 year old white guy. I'm not going to poke and prod around pelvic floors. Nobody, nobody, wants to show me their pelvic floor postpartum right. I'm more than okay with that. But other than that, this is why it really helps to get in touch with someone who knows what they're talking about, because they can take a holistic approach and they can say to you like, yeah, okay, your TVA is important, but so is your soul acid and so is your upper back and you're supposed to be able to do rotational, anti-rotational stuff and make sure your hips move and all that sort of stuff.
David:Well, and not to not to just totally dive into a different subject, but you know, uh, you know, as a manual therapist, I want everything to be about mechanics, right, I want it to be about, hey, this joint isn't moving, and if I can just get this joint moving and, uh, give you some strength coming exercises, then everything's just going to be hunky dory. But it turns out that the brain's attached to the body and the body's attached to the brain and I think I'm finally this spectrum of mechanical to biopsychosocial and understanding about how people are feeling, about their pain. It has a tremendous impact on the pain experience People are feeling about the rest of their life issues tremendous back pain.
Peter:Yeah that's interesting.
Speaker 3:Can I freeze up? Yeah, you froze up. Can we freeze up there a little bit?
Peter:Yeah, you just froze up a little bit, but actually your audio was fine, just your, okay, okay, as long as my audio is fine, just your, uh, okay, your, your, yeah, that's fine and there's just market. Mentally in my head is roughly the 26 minute mark that I have some tiny bit of tidying up to do, but that's all, that's fine. It's interesting. One of my clients plays golf and as in is a golfer. And, uh, and it's interesting because they are really big on that mind-muscle connection, because they have what they call the golf thought.
Peter:As in, as you swing, you can think about one thing. You can't think about two or three things you can't. But every individual golfer has a different golf thought, they have a different cue. So, exactly like what you said, they have a different cue. So, exactly like what you said, if I say to someone, activate your glutes, and I say that same thing to someone else, they might engage their glutes in a completely different way because they have no idea what I'm talking about. They're just interpreting what I'm talking about. And for golfers it's the same thing. You have to really individualize that approach and that mind-muscle connection is remarkably powerful. So when you say to someone we want to get that rotational movement in, you almost have to demonstrate to them how it should work for them, if that makes any sense and again.
David:I would even go further and say you know, pain, pain is not damage and and I think that there's so many people that come in um having seen their primary care physician or having seen a whole host of other people and they've had different scans and x-rays I've got degenerative disc disease and I've got this, I've got this disc bulge and I've got all of these different things going on on on imaging and they are, they are very fearful of movement and they're very fearful that if I do the wrong, my back is just going to be demolished somehow or I'm going to break, and they feel very fragile and I think there's a vulnerability that has to do with postpartum women that is important to respect as well.
David:And just say you've gone through this pretty traumatic event, both carrying the baby and having the baby, regardless of how the baby came out. Now it feels like your body is a little bit broken, but at the same time, it's not broken. It's going to be okay if we can get you moving and we can get you strong, as this is the, this is the source of the pain and uh and again, looking at that movement dysfunction, but also just just recognizing that, if you believe that your back is fragile and you're unwilling to move because of that, that that is a massive inhibition to your success. You know, we've got to kind of untrain that mindset and get the person to feel good about movement.
Peter:And then it becomes a neuroplasticity exercise.
David:You know it becomes an exercise about how do we get this person. You know they come in and they feel incredibly fearful about moving in certain ways and, granted, I can, I can mobilize different things to get it actually moving. But if you don't, believe that it can move you're not going to move it that?
David:way, and so I've got to give you some exercises that teach the brain that says, hey, this is not a dangerous movement anymore, it can do this and we can tolerate this. And then having that great again, that graded exposure of feeling that movement and recognizing that movement is safe and recognizing that we can do a little bit more, and then taking that and encouraging the person to say, hey, you, you can do this now, and having them recognize and feel their body move, it's so crazy to me. It's amazing to me how people can't feel their body move. You know, when you ask them, hey, I want you to bend forward, I want you to bend from side to side, when you say, okay, I want you to bend from side to side, and you see one side that is dramatically worse in terms of movement and you say, can you feel that? Can you feel that you don't move to the right? And they say, nope, I can't feel that. I have no idea.
Peter:I can't tell at all, it just hurts.
David:And you say, okay, well, I want you to let's get rid of pain for a second, just for one second. I want you to get rid of pain for a second, just for one second. I want you to get rid of that. I want you to just feel your body move. I want you to feel whether you can move equally to both sides, and then hopefully they can kind of understand that. But I have lots and lots of people who are so focused just on that painful tissue that they can't get into this idea that normalizing movement, normalizing strength, is an incredibly important piece of how they're going to get better.
Peter:Oh no, absolutely I think we've, and again, the healthcare profession is a lot to blame for that and I think it's changing. Now. One of my clients is going in for a hernia operation next week and not keyhole, so there's a lot of work to be done there, so to speak. Um, and the interesting thing is now that for hernia recovery they they advise people to move, whereas they used to say now, you're not going to do anything for the next six weeks, you're just going to lie on a bed, or two weeks or whatever it is, it's going to lie on your bed, you're going to lie on the couch and you're not going to move, you can't lift, lift anything, you can't do anything. Whereas now they're saying oh no, after two days I expect you to start walking and the week after I expect you to go back to your PT, because the surgeons here are pretty good and they consult and they get in touch with me just to make sure I kind of know what I'm talking about.
Peter:I'm not allowed to drive, but that has nothing to do with the inability to drive. It's to do with the inability to take an airbag to the chest without stuff opening up should you get in an accident, um, but for a long time we have been, especially post-Fighter. Women have been told two things Everything's going to be rainbows and unicorns, everything's amazing because you're going to have a new baby, which is nonsense, and after that everything is going to bounce back by itself.
Peter:Right as if you know, because magic happens in the human body and because the human body is very this is how it's framed the human body is very resilient. There are women in Vietnam that just poop out the kids in the middle of a rice field and they get straight back to work. That was always the one that we were told in Holland, where I'm from originally. And then you have the other side of the coin, which is almost just as bad, which is you'll be very fragile postpartum and you can't do anything you can't do anything.
Peter:Yes and I always say movement. When it comes to muscle, muscle pain, muscle imbalance, movement is almost always the solution yeah, yes avoidance is almost always going to make your problem significantly worse yeah, and it goes.
David:I mean again I, I, I. I don't want to take this away from postpartum, but it happens all the time you know, my, my father-in-law, strained his ankle, uh, and he went to an urgent care and they just said, okay, I want you in this boot and I don't want you to move it for three weeks and I was, was like oh my God, is it fractured Cause?
David:if it's not fractured, you should be moving it Just, gentle, move it Just just back and forth. Can you stand on it? Can you do a little bit of a weight shift, can you do? I mean, what can you do with it without it, without it lighting up? And he was so hesitant to do anything because this, this uh, uh, urgent care person had just said okay, don't do anything for three weeks. And I was like that is not right.
Peter:No that's why people are still saying that and frozen ankles happen.
David:Yeah, exactly. Exactly.
Peter:Yeah.
David:So it's, and then the flip side of that just like you were saying where you know you have. You have these women who come in, I'm sure, postpartum, for all of their different checkups and they say, oh, I have all this back pain That'll probably just go away. You know that's normal to have, it's probably just going to go away, just you know do do, I don't know, maybe put some heat or ice on it and you'll be fine.
Peter:Yeah, I absolutely love the solution. Heat or ice, as if that is the same solution and as if those two are not different solutions to different things. Right, but yeah, you're quite right. They go to a GP because that's usually the first visit and, let's be honest, nobody wants to go past a GP anyways. Nobody wants to go past a general practitioner, because then you're in the system and it becomes a whole thing. And in the UK you have waiting lists and it's a pain in the ass and all that sort of thing. So your GP says, yeah, yeah, yeah, you gave birth. That's really tough on the body. So indeed, you're going to have some back pains. Just stop holding your baby for a little while, stop carrying your kid around.
David:Right, don't worry about the bonding thing that you're supposed to be doing.
Peter:Yes, exactly, just ignore that bit and just take a couple of weeks off, because that's what everybody can do and movement, in the UK at least, is very rarely prescribed as a solution.
David:Well, let me speak to that just a little bit Because, you know, in the United States people like to disparage the UK and Canada for their socialized medical systems. Right, you know, we love to disparage uh the uk and canada for their uh socialized um medical systems right you know, we love that, we love to disparage that, um, but I see that as somewhat of a feature in some ways, because you can't get a total knee in two weeks in the uk, am I? Am I right?
David:on that you know, I, I, I need, I feel like I need a total knee. You can't get that in two weeks, but I know a surgeon who can do that to you in my town whenever you'd like it done Right and so and so the the the feature of that friction is that there is some time and hopefully the person is doing something like physical therapy in that timeframe and and maybe improving how they're moving and maybe improving their pain and maybe feeling like, oh, maybe I don't need this knee surgery.
Peter:Yeah, no, that's absolutely true. I mean, I tend not to. There are bits to the American healthcare system that I really like and there are bits to the UK healthcare system that I really appreciate. And yeah, the NHS is a mess. Don't get me wrong. I'm Dutch and therefore I'm slightly biased in favor of the Dutch medical care system, which I think is significantly better. We pay more in tax and we pay more per capita than the UK does for the healthcare system. It's amazing.
David:And it's probably still half of what we pay. Oh God, yes, it's a lot cheaper.
Peter:It's a lot cheaper than what you guys pay Because, like you said, you have the guy there in your town that says I have a solution, I'll just put a knee in, yeah, I'll be fine, and 10 years later you come back, you get another one, because the life expectancy or the lifespan of a knee, if you get it replaced and you don't do any physical therapy and all that sort of stuff around it, it's about 10 years. If, however, you do all the exercise around it, you can make that thing last 25 years. There's no need to actually get that thing replaced. Yeah, um, nine out of ten times the. The issue is, of course, we are very much as a society and I'm as guilty of that as anyone, this is, anyone of looking for the easy solution, right, um?
David:right, oh, absolutely if someone physical therapy is not.
David:The physical therapy is not the easy solution, clearly, right. We're asking you to come for several weeks, maybe a couple of times a week. We're asking you to do all of these different home exercises and and whatever, whatever we're gonna have you do, um, it is going to be, and and, frankly, at the end of it it's almost more like kind of a life change kind of thing, where we're saying, hey, you need to move like this, you need to do exercise like this in some capacity to be healthy. And I think there's lots of people out there that look at that and say, man, I don't really, I'm not really interested in that. What else do you have? Do you have an injection for me? Why don't you just do a surgery on this shoulder? Can?
Peter:that make it better. Exactly. It sounds like that is the easiest. It feels like a surgery is the easiest solution. It never is.
David:I guess here's the other thing too. We also think of things that are expensive are better, sure Right. So you know, if you buy a Mercedes, that is clearly going to be better than a Kia Mm-hmm. You know, physical therapy is probably the best solution for the vast majority of people with low back pain, because the movement problem is their actual problem. It's not the painful tissue that needs to just calm down, right. Everybody just wants that pain to go away, and if they didn't have the pain there, they wouldn't care they wouldn't care that their hip doesn't internally rotate at all they wouldn't care that they're
David:know that anything doesn't move right or is super weak, or they can't balance or all of those other different things that we're looking at. They only care about whether or not it hurts or not, and it's a very binary thing. And if it doesn't hurt, then I don't need to do anything, and if it does hurt, then I have to do something. Hurt, then I have to do something. And, um, and so you know, with physical therapy, uh, versus a lot of the other, a lot of the other treatments, it's not only are we asking the person to buy in and, uh, do their homework and and take a active role in making themselves healthy. Um, it's, it's a, it's a.
Peter:It's a longer process, and because it's less expensive than surgery, then clearly the surgery is the expensive thing that could fix this problem, but it's just too expensive yeah, and exactly like you said, surgery is science and we don't necessarily have that to back us up in the same, because you know, someone puts a new knee and it's a shiny new knee, I don't care what you say. That's going to function really well, but you still have to.
David:We're still doing surgeries that we know don't work. In the United States, at least, they're still seeing a person who's 60 years old with degenerative meniscus in their knee and doing a scope to clean it up in the United States. I imagine that doesn't happen in the UK. I imagine that orthopedic surgeons are not performing knee scopes for people with OA or degenerative meniscus because we have demonstrated that that surgery does not work.
Peter:No, as far as I know, because we have a panel in the UK called the National Institute for Clinical Excellence, NICE, and they kind of determine all the things that the NHS will pay for. They're going to say this works, so we'll pay X amount for it, or this is too expensive because certain treatments are remarkably expensive. So the benefit of that system is indeed that every now and again, things that get found to not work, they have a look at it. Okay, well, stop paying for them, because we have a finite amount of money in the system, whereas in the case of private healthcare and to be fair, I also have private healthcare I have like a top-up sort of thing. So I'm 48 years old, I'm going to start falling apart soon, so I need to jump ahead in the queue a little bit every now and again. But even those guys are not willing to just randomly throw money at stuff. So in the UK the profit incentive is significantly less than you have over in the States significantly less than you have over in the States.
David:Yeah, especially again when you look at different healthcare organizations that if they do an injection in an office, just a medical office, they get paid, say, $350, $400 for that injection. But if they do it in a surgical center, they get paid $1,500 because they're doing it in a surgical, even though it's the exact same injection. And so what do they do? They build a surgical center because they can get more money for all of the people that are walking through the door, but even though they're going to do the same exact procedure as they would do in their office.
Peter:So do you find, because obviously a lot of these surgical things are useful, right? So as in, we need surgeons to be kicking about because they do a fairly decent job of surgeries, do you find that there is a reluctance then in your environment where the surgeons are not that keen to work with physical therapists, or is that changing the overall patient care sort of thing becomes?
David:no, okay, so I'm going to speak to two things. Um, no, because the surgeons are very busy. They have, they have lines, they have plenty of people to do surgery on. So they, they're fine. If you want to go to physical therapy, that's totally fine. They, I don't think that they, um, they, and they prescribe it. Um, they prescribe it quite often and quite often presurgically and whatnot. And the good surgeons again, uh, obviously, in all professions there's bad physical therapists and and whatever too, you know great there's.
David:I, I know that there's some great surgeons around. When people come into my office and they're very unhappy because their surgeon sent me here instead of just doing that surgery, and I'm like, well, you know, if the surgeon didn't want to do the surgery, you should probably listen to that person because you know that's what they do and that's what they want to do. And if they don't think it's going to benefit you, then it's probably not going to benefit you. But I have, but I also I mean, I'll even say this too it's crazy to me. It's crazy to me to think about how often, how often, the question being asked is not what is my outcome going to be? Three, to six months after the surgery.
David:You know when I'm fully healed from this surgery. Quote unquote what is? What is this outcome going to be versus what I am today? You know, and I say this to people, I say this to patients, and I just say I just want you to think about this. You, where are you at today and what is your expected outcome right now? If it's, you know what? I can barely really walk 10 minutes before my knee is killing me. I can't go up and down stairs, I can't play with my grandkids, I can't do the things that I want to do, and I've done a bunch of exercises and PT and whatnot. Then your expectation is, by getting a total knee, you're going to have a significant benefit. Six months down the road, when you're healed, you should be able to do a lot more function with a lot less pain. That sounds like a great reason to have a knee surgery.
David:If you have, let's go back to the back because we're supposed to be, we're supposed to be talking about the low back. If you have, you know, rad low back. Um, if you have, you know radiculopathy. You know radiculopathy being a compression of a nerve root in the in the low back, because you have a disc that's herniating and pushing on that, on that nerve root. If it's causing muscle weakness in your legs so that's causing your foot to be incredibly weak. If you have a bunch of numbness and tingling, if you have a bunch of balance problems because of this and a lot of pain and inability to perform function and you have an MRI that shows that you have a disc in the same distribution of all of these neurologic symptoms, then yeah, that makes sense. Then have a discectomy or you know, I mean whatever the surgeon thinks is the best surgery there.
David:That I'm definitely not anti-surgery, but the the so often I feel like the question is not being asked what is my expected outcome going to be? Because you get people in who are 50, 60 years old. They've had back pain for 20 years, it's, it's pretty amorphous, it doesn't really it's, it's not uh, it's not going into their legs, it's not causing a bunch of specific muscle weakness and and they're saying, oh, I think I'm gonna have surgery. I'm like what do you think the outcome is going to be of that? There's no indication that a surgical intervention is going to improve this situation by a measurable amount. And and I always, I always put it to people, like if you had a brain tumor and someone said, hey, I want, I'm we're thinking about.
Peter:This is the surgical intervention.
David:The. The question should again this is.
Peter:It's the same question what is it going to look like?
David:six months down the road. Is it going to be that I'm not going to be able to see out of my left eye and I won't be able to use my arm, but I'm going to live to see another day? Okay, there's some benefits, there's some costs there, um, or, or if I, if I don't do this surgery, uh, is it, is it potential that I could? I could die within the next month. So I don't know. There's there's so many that I, people see, people see a lot of these musculoskeletal problems and they, they see this, the solutions as a, as a menu.
David:Right, I can do an injection, or I could do surgery, or I could do physical therapy, or I could do chiropractic, or I could do acupuncture or whatever. And I think people should start looking at this more like it is a process. It is a road that you go down. Right, you have this back pain. This back pain started, however, it started maybe during pregnancy. You should always start with a movement-based solution. Right?
David:What happens when we get the system moving better and we improve the strength of this system? Does the tissue that is irritated, does it resolve? Does it calm down? Does, does it get better? If that isn't the case right, if you get moving and you get strong and that tissue doesn't calm down, well, maybe we should go down the road further and maybe maybe it's time for an injection, to see what happens when we inject it with something. Again, it's not for, not for everybody, but I'm just saying like that's a potential, you know, and if an injection works for a period of time, but it doesn't work for a long period of time, then maybe we should think about some sort of surgical intervention and that we can improve something. But but but thinking about it not as if like, oh, I can either do this or that or this or that.
Peter:It's like no start with movement always yes, and especially, like I said, when it comes to any sort of muscular issues. Any sort of muscular issues, I have no. Okay, if your bicep is completely torn off, you're going to need to get a surgeon to look, maybe, but maybe, I mean again so let's, I'll be devil's advocate here.
David:If you're 80, 80 years old and you're you're not going to use that arm in a powerful way and you're diabetic, and you have some, some other, uh, some other issues where surgery is um potentially dangerous for you, then you say well, you know my arm works okay and maybe I have some pain, but the the risks of doing surgery are are greater than that yeah, no, yeah, yeah, of course you're absolutely right in in that.
Peter:generally speaking, I always, always think surgery, especially for postpartum women surgery, should really be the last resort. It is never an easy option. There are easier options available, and exercise is almost always it the trick of it.
David:Yeah and again, especially when you're talking about postpartum women. The trick, yeah and again, especially especially when you're talking about postpartum women. You're you're, for the most part, talking about younger yeah healthy women right for the most part, you know. I mean obviously there's. There's exception, exceptions to that. But if you're talking about a 25 year old woman, like the idea that someone's going to jump into surgery straight away without trying to get that system moving better, it just blows my mind that that could even happen.
Peter:Yeah, I have one client who's a personal training client, who I see who had her tummy tuck surgery or diastasis recti surgery before she saw me. So she had it done. She went to see an excellent surgeon. I happened to know the surgeon, he's superb and then six months later she came to me and said I want to strengthen up my core muscles. I said, well, I could have saved you 15 grand. Yeah, you could have saved yourself a ton of money and, let's be honest, a big scar.
Peter:And any surgery comes with risk. It just, it just does. It is not the easy solution that people think it is.
Peter:And physical therapy, especially for things like back pain, okay, assuming you work with a good physio, um, and that should also be someone that you feel comfortable with. By the way, just in case anybody's listening, you don't just go to the best, you go to the best person you have a relationship with. That doesn't uh, that doesn't annoy you because you're going to need to spend an hour in their company uh, once a week or once a, depending how often you see them, uh, or more often. And you know you need to be able to have real open and honest conversations with your physical therapist, because if you can't, if, if I go ceo and and I cannot tell you where things really hurt or what movement really feels like, then we have an issue and I, like I said, I'm a middle-aged white guy, I'm of the generation that you know no pain, no gain. So dave will go.
Peter:Uh, does this hurt a little bit? No tears streaming down my face, but no, dave, push through, we're okay, we're good. But if you feel comfortable, you can just open up and say that this is, this is comfortable, this feels uncomfortable, or even things like I don't know what you're talking about, because quite often I don't know about you. But you know, I describe something to a client of mine or one of the HPMB members and they look at me and I can see their eyes glaze off, I can see them going. I have no idea what you mean.
David:That's one of the things that I you know, I take a lot of students and that's one thing that I tell them just constantly.
David:All the time I said you have to tell the person what's going on and what we're, what our plan is, and then you have to tell it to them in a different way, and every time they come in you tell them a different way of saying the same exact thing, because I promise you they didn't, they're not going to remember, or they didn't get it.
David:They're, they're, they're being polite, so they're saying, they're nodding their head and saying yes, but almost no one really understands what we're talking about the first time we talk about it. And we have to continue to use metaphors, we have to continue to communicate in a way and connect with patients where they can feel like what we're saying is is making sense and and they can they can understand that that the solution, a lot of the solution to this problem is getting moving properly, getting their body to move properly, getting everything doing what it's supposed to do, and then gradually loading it in and in that recognition that you're, you're not broken and you're not fragile, and if we can get everything doing what it's supposed to do, then you can enjoy your life and enjoy your new baby.
Peter:Yes, exactly, I always tell people because I'm bang on with that. I always tell people that, listen, I can't give you your pre-baby body back. Right, you had a baby. That's going to have an impact, it just is, but it's stretch marks or whatever. But I can make you stronger and I can make you more confident and I can make you fitter than you've ever been in your entire life.
Peter:Yeah, it doesn't matter that you had a baby in between, whether you're 23 or 42, if you work on this, if it's fundamentally, and when you're talking about lower back pain and all that sort of stuff, the things that back pain prevents you from doing, even just the fear of like what you spoke about, the fear I'm going to do my back in if I lift this. So I'm not going to be in with my kids, I'm not going to play tennis, I'm not going to go to the gym. I'm not going to play tennis. I'm not going to go to the gym. I'm not going to go swimming or, even worse, I'll only go swimming because that's the only exercise, the only safe exercise. You're restricting your quality of life, even if you're not aware that you're doing it.
David:And I think also to that point. I think I've heard several different women say that they exceeded their previous physical activity in the year or two after a baby because of having the baby. So you know, um, you know running a half marathon, you know they, they, um, they find out relatively quickly that uh, their baby will sleep in that Bob stroller Uh, and so those runs tend to get a little bit longer. And you are pushing this stroller and then all of a sudden it's race day and no one's making you push the stroller, you, you pr, you, pr this half marathon because nobody's making you push the bomb stroller uh anymore. And you've been pushing it for um for longer and longer periods of time because baby will sleep, uh, while you're well, while it's in there. So I don't know, I I think there's, there's a lot of opportunity for women postpartum to take the time to get their body moving better, take the time to really start feeling good um, uh, by getting moving and strong and and enjoy, enjoy their new family member.
Peter:Yeah, no, absolutely. I couldn't agree more on that Happy note. Was there anything else you wanted to cover? Because I think we went over.
David:Basically we solved all the world's problems, I believe healthcare, healthcare system and everything you know. I think we got it Exactly.
Peter:So, on that happy note, I will press stop record, and press stop record is exactly what I did. Thanks so much to David for coming on. He's one of those guys. He's like I said, he's a physical therapist. He got nothing to sell. He doesn't have a book out, doesn't have a podcast or anything like that. He doesn't need you to listen to anything other than his advice and that's why I love the guy. He gave up an hour of his time and he didn't need to just helping me out, because otherwise it's just me talking to myself continuously. And I know that I'm charming, of course, and I'm great company, but even I get tired of my voice and you know I for one am fed up listening to my voice.
Peter:The next month we have interviews everywhere Alison Yamamoto, dr Emily Wilson and Dr Jesse Haymeyer coming on. We're talking many things regular menstrual cycles, energy availability, overeating, overtraining sorry, undereating and why postpartum that's a problem. We're talking the week after Dr Emily Wilson is on to talk about postpartum prep, and then we're at the end of November already with Dr Jesse Heymeyer, who is going to talk to us about functional medicine and why so many people are in that particular field. Now You're going to love that episode. That's really good. That's a great episode. Anyways, that's it for now. That's a great episode. Anyways, that's it for now, peter at HealthyPostnatalBodycom. If you have any questions or comments, just give me a shout. Here's a new bit of music. You take care of yourself. Bye now. Thank you ©. Transcript Emily Beynon. Thank you, thank you.