Speaker 1 (00:00:01):
Good evening everyone. Welcome to Hernia Talk Live, another Tuesday joining with joining me and my guest talking about everything related to hernias. As you know, my name is Dr. Shirin Towfigh. I’m a hernia and last laparoscopic surgery specialist. Many of you are currently live with us on Facebook at Dr. Towfigh. Thanks to those that are logging in on Zoom and after the show, I’ll make sure that my YouTube channel is listed as on my different social media panels at Hernia Doc on Twitter and at Hernia do on Instagram. So you can watch and share our of hernia talk from today. So we have a great guest. It’s someone I I’ve met very early on in kind of my Beverly Hills Hernia Center time. Her name is Stephanie Prendergast. She is a very talented physical therapist. Awesome with the pelvic floor is doing so much in California from northern to southern in treating patients with pelvic pain and you can follow her on Facebook at Pelvic Pain Physical Therapy and on Instagram and Twitter at Pelvic Health. She is the co-founder of the Pelvic Health and Rehabilitation Center. So please welcome Stephanie Prendergast. Hi.
Speaker 2 (00:01:21):
Hi. Thank you so much for having me.
Speaker 1 (00:01:24):
How are you?
Speaker 2 (00:01:25):
I’m doing wonderful. How are you?
Speaker 1 (00:01:27):
Good. So just a quick brief, when I started doing more and more of just hernias and started my own business, it’s kind of coincided when you, I think moved, you expanded from northern California to southern California with your pelvic pain and rehab center and everyone I talked to were like, oh, you’ve got to meet Prendergast, you have to meet Prendergast. I was like, okay. All the urologists knew you, which was great. And so that’s when I think we briefly met in person and we’ve been sharing patients ever since you’ve been at Godsend. So thank you for affording me an hour of your time.
Speaker 2 (00:02:08):
Oh, I’m happy to be here because you’ve done the same for us in cases where no one really knew what was going on. So yeah, this is a mutual connection
Speaker 1 (00:02:18):
And we’re trying to get more help up in Northern California, but there really aren’t that many hernia, like true hernia specialists. There are people that enjoy doing hernia surgery in Northern California, but they’re not doing the chronic pains, mes and all the evaluations of these kind of what I call hidden hernias or call hernias. So factors have also been referring to me and we’ve been able to help a lot of patients.
Speaker 2 (00:02:50):
Speaker 1 (00:02:53):
Thank you. Okay, so do you want to briefly tell us how you got into pelvic floor and what services? I think you mentioned to me earlier nine different offices.
Speaker 2 (00:03:06):
Speaker 2 (00:03:08):
So I’ve had the honor of being a pelvic floor PT for, oh my gosh, 21 years now. And I spent a little bit of time kind of doing orthopedics and then I really found my passion with pelvic floor physical therapy. I started my career working with a urologist. So at the beginning I was always part of more of an interdisciplinary group versus just PT and could quickly appreciate that a lot of the complex pelvic pain disorders involve interdisciplinary care to really truly get to the root of what’s happening with people. And I only saw pelvic pain at the beginning, so all genders from the get-go, which is a little unusual for physical therapists. A lot of times they may deal with postpartum or maybe some stress incontinence, but we were complicated pain from the beginning. So my particular areas of interest have always been pudendal neuralgia, other neuralgias, interstitial cystitis. And for men’s CPPS, well it isn’t difficult for us. I feel like if this is what we really have spent our career doing and we also know people like yourself and we know and we can’t help and that is honestly half of the issue is also having the right Collaborative network, which I’m really happy with the group that we have here in la. Yeah, I feel like we’re able to take care of our patients with whatever is going on with them.
Speaker 1 (00:04:30):
How many office do you have in Southern California?
Speaker 2 (00:04:32):
So in Southern California we are in Westlake Village. I see patients in our West LA office and we’re in Encinitas, Pasadena is coming, but that got put on hold with COVID. And then we’re in San Francisco, Los Gatos, Berkeley and Walnut Creek, and then Lexington, Massachusetts and New Hampshire.
Speaker 1 (00:04:51):
Oh, you have East coast too?
Speaker 2 (00:04:52):
We have two on the east coast.
Speaker 1 (00:04:53):
Oh wow. That’s very impressive. Yeah, very impressive. Good. That’s amazing. That’s just awesome. Thank you. My dream is to be able to get both coasts because in Texas I feel like I have so many people from the south Texas of Florida are two big ones where they come to see me because there’s like a void in that part of the world and Canada can need some help, but you kind of can’t be everywhere. And I’ve always struggled with how I would be able to provide care to those regions without kind of affecting what I do on the west side.
Speaker 2 (00:05:36):
And I think physical therapy’s a little different too. I mean you are the surgeon, whereas after all these years in clinical practice, we’ve been able to create effective training programs to get untrained physical therapists because everybody’s untrained. This is COVID floor PT is not taught in school to be able to take a physical therapist with passion for this and train them to be able to start to see patients and then mentor them throughout their careers. Is
Speaker 1 (00:06:01):
There an additional certification for pelvic floor or is that kind of on your own?
Speaker 2 (00:06:08):
It a lot of the pelvic floor PTs have had to spend their own time and money to get training. There are a few different certifications, but I don’t feel like anyone is actually fully recognized as this is what you need to be able to go and practice. So many people can just start without any type of entry qualifications and testing and some certifications are helpful for some aspects of pelvic floor but not others. So I think it’s kind of a mixed bag. But in our clinics we treat the whole range of things. So while my particular area is pelvic pain, we see everything from pediatrics to pregnancy and postpartum and then some of the age related changes that happen as people get into their forties, fifties and into menopause and all of those things. So
Speaker 1 (00:06:59):
That’s awesome. I must say I made this comment before, but I feel that doctors have lost their touch. So in my specialty, I’ve really honed down my fingertips so I can feel the slightest difference in texture in the groin where normal versus a hernia. Whereas the typical surgeon may not appreciate a difference unless there’s a big mass. But I feel that as doctors, we realize so much on CAT scan, MRI, all these blood tests and we don’t do a really good physical examination the way we were taught in medical school that art is lost at least in the United States, and yet the physical therapist that refer to me, man, they really know their stuff. They can feel which muscle is in spasm, which not which side is normal and which side is not the asymmetry. It’s really amazing how much more in depth and with such accuracy the physical therapist referred to me have been able to hone in on where problem areas are. I never appreciate that until I got into the specialty and it’s pretty amazing, pretty amazing. The pelvic four PT specialty,
Speaker 2 (00:08:18):
I make a joke sometimes that our fingers have to be as sensitive as the tongue of a sommelier. Oh yeah, that’s a good one. Could do it with my eyes closed. And it always surprises patients when we say to them, oh, I, there’s a problem here because usually if we feel a problem it hurts and they’re like, how do you know? Yeah, I’m like training lots of training those cortical areas in my brain would look a little different. I think
Speaker 1 (00:08:44):
You also have a blog I’ve contribute to your blog. I have a lot of people come to me. I personally think the blog I did for you guys was one of my best works.
Speaker 2 (00:08:55):
We appreciated it. It was definitely one of the most red blogs every year since it’s been posted, which I think was in 2017 when we met or maybe 2016 maybe
Speaker 1 (00:09:06):
Speaker 2 (00:09:08):
It blends together. And the COVID time warp. Yeah, because we did meet quickly after I moved here, which was in 2014. Yes,
Speaker 1 (00:09:14):
Speaker 2 (00:09:15):
Oh, I’m glad
Speaker 1 (00:09:16):
Shortly after that. Yeah, I really enjoyed writing it but I, I’ve had a lot of patients who’ve told me they read it and your blog in general is very robust. The amount of information on your website on Pelvic Health and Rehabilitation Center is enormous. More than I’ve seen in most websites. Thank you. And the blog is really, really informative. So you guys do a really nice job of being very thorough and educational and I get a lot of DMs from physical therapists, many of them affiliated with you that really show their passion and interest in their patients and try to get some advice and improving their patients. So just wanted, thank you for that.
Speaker 2 (00:09:56):
Thank you. We like doing the educational piece too. At this stage, so many people have questions and if we have the answers, we want to provide a reliable evidence-based source because as we know, there’s a lot of confusing and conflicting information out there too.
Speaker 1 (00:10:13):
So we have tons of questions
Speaker 2 (00:10:15):
Actually. I know we can talk all day, can talk through
Speaker 1 (00:10:17):
Them. For those of you that are watching, I will post the link to her. Well, she’s already linked on to her different social media accounts on our post, but I’ll also link the website if you guys want to just go to the website. It’s super great. Very well done website. It’s right, easier navigate. And then so the questions have been proposed are regard hernias in pelvic floor, but there’s also some sports hernia. Is that okay to go through that and just hernia questions? Let’s get started. Okay, question one. For sports hernia or what we call athletic pubalgia, which is a muscle strain usually and other muscle tendon tears or strains at the pubic bone, which exercises are appropriate to perform?
Speaker 2 (00:11:07):
So this can be a little tricky without an evaluation as we know, but this is a common symptom and a common pathology that we see. And unfortunately what I’m going to say here is it depends. So sometimes people develop the sports hernia and athletic pubalgia because of repetitive motion. Sometimes it was like a one-time thing where they potentially exerted more than maybe was expected. And so with the actual symptom and the hernia, there always is a host of myofascial impairments that are going to vary from person to person. And that’s going to involve both soft tissue structures, including the pelvic floor in many cases as well as at least the pelvic girdle, lumbar spine and hip. And so how we approach this is if we’re pre-surgery, the question is always do I need surgery or not? And so we take our objective findings with the symptoms combined with imaging and try to figure out, yes, no, we collaborate when we’re trying to decide because understandably patients are nervous about surgery. But that is really a reliable, and it is the option for many cases in which case that happens. Then we go to the postoperative rehab and everybody’s a little bit different. Some people have impairments in their abductors, some people have problems in the rectus abdominus. Some people can’t get their core to work with their pelvic floor. So what we do post-op is then decide what are the neuromuscular patterns that even proving what areas may need manual therapy. Sometimes injections are also needed depending on the pain. And then we go from there.
Speaker 1 (00:12:51):
And do you feel that, so LeBron James, perfect example, right? First it’s Russ, they do love injections and professional athletes, but he is comes back to playing basketball. It’s not like he can’t, but are there certain, the other second part to this question is are there things they shouldn’t be doing once they’ve already been diagnosed with that?
Speaker 2 (00:13:13):
I worry, and again, this is my clinical experience because I don’t think that there’s proven protocols for every single person, but knowing where these hernias are, if the muscle involved is the doctor, the rectus abdominus, we need to slowly work back into exercise that involves those muscle groups. And in some cases I think there’s certain exercises that are never appropriate. So for example, when you sit at the gym and are excessively squeezing your inner thighs against a lot of weight, that’s not really a functional activity or movement. And some people like to do those things.
Speaker 1 (00:13:49):
Yes, why? Why do they do that?
Speaker 2 (00:13:52):
There’s other ways to work your lower body. Other things that I find problematic sometimes can be excessive amounts of crunching, especially with weights or hanging off of some of the devices. With some of these hernias, you’re going to be more likely to create a problem again by overdoing some of these exercises with a lot of weight. And that’s going to vary from person to person. For some person people that may be 10 pounds for somebody else that may be 40. But also we have to get to why are we doing this exercise? Is there a different way to do it? And basically help people make better decisions.
Speaker 1 (00:14:28):
I would suspect if you have a rectus tear than kind of hyperextension stuff would be wrong. And some of those crunches where they kind of hyperextend
Speaker 2 (00:14:40):
Off of a bench
Speaker 1 (00:14:42):
And bench not the best. And then also that adductor strain. Are lunges bad for that?
Speaker 2 (00:14:49):
Not necessarily. I like lungs are more of a functional activity, but some people really can’t do them properly because they have altered limbo pelvic mechanics and if that’s the
Speaker 1 (00:14:59):
Speaker 2 (00:14:59):
And there’s asymmetry, that’s another example. If somebody has a lot of unilateral pain, which these hernias can be and trying to do a double limb activity, there may be more challenges with that.
Speaker 1 (00:15:12):
Okay. And what’s the gluteal lift? Is that the one where you kind of thrust the anterior pelvis up?
Speaker 2 (00:15:18):
Did I miss that question? Is that Yeah, was that a question? Is the gluteal lift? Okay. Right. So to me, a gluteal lift, I actually don’t know what they mean by that.
Speaker 1 (00:15:29):
I think it’s the one where you’re hanging off, your feet are on the ground, your shoulder is on something and you’re kind of hanging off and then you, it’s like a bridge where you lift up your, and some people put a weight over there, okay, lower pelvis and then they lift it up.
Speaker 2 (00:15:46):
Now in general, I find that usually a good exercise to do, okay, even with some of the sports hernias, because they’re usually not in that area and we want to, most people in general as we know have weaker posterior chains. And that is just a way to try to basically take some strain off of things like the ad actors.
Speaker 1 (00:16:05):
And then another question I get all the time is often for hernias at least we say, oh, do whatever exercise you want. Most exercises with the exception of jumping type exercises and squats have not been shown to increase abdominal pressure. So sit-ups, for example, is considered completely to do with a hernia in my world. What else? Weightlifting, it’s considered safe because you’re not increasing abdominal pressure, you’re engaging the muscles. But then they say, oh, what I do so it hurts. So then what do I tell them is, what do you tell your patients when they say, you say, okay, technically such and such procedures should be safe, but then they say, but it hurts when I do it.
Speaker 2 (00:16:50):
There is always a reason why it hurts. And sometimes people need help figuring it out. But my first question is where, yeah, sometimes you think where they’re talking about and maybe it’s on the opposite side and down the back of the leg instead of the inner thigh on the other leg. So worsening a pain usually does give us some insight because are they doing the exercise correctly? Maybe they are trying to do the exercise correctly. They think they have good form, but there’s altered length tension relationships in some of the muscles and then they actually can’t do it correctly despite them knowing how to do it. So true. We usually can configure these things out. And I do think I tell people to foam roll before they exercise because it’s setting their muscles up to be in a better length tension position to then actually get a better contraction. A lot of people think to foam roll after to undo any tightness that may happen. But when people have been injured, foam rolling first actually makes more sense.
Speaker 1 (00:17:50):
Foam rolling is the best thing ever. It hurts, but it’s absolutely the
Speaker 2 (00:17:54):
Best and worst.
Speaker 1 (00:17:55):
Best and worst doing that before it’s the perfect kind of advice you can give. Everyone should own a foam roller and then you should own the ones that are a little bit, not the ones that are too soft because they kind of get destroyed under you, but not the ones that are also too hardy kind of wants something in the middle. Do you agree? Or
Speaker 2 (00:18:15):
Some of those are weapons, some of those are made out of metal and I’m like, oh my goodness. We see that people graduate, I think through some of them and they come in eventually. Let’s say they’ve been out of the clinic two years or just doing, it’s chopping, it vibrates, it shakes it’s metal. Oh my god. Big difference. Then the intel roll is what we use regularly and that’s really soft and comes in a few different versions and that info’s on our YouTube channel
Speaker 1 (00:18:40):
And intel roll or foam rolling just stretches your muscles vocally, right? Well,
Speaker 2 (00:18:46):
It helps. It’s almost like a little bit manual therapy. So sometimes you can stretch a muscle and do the compression of the foam roller, but I don’t want people to think that you should replace foam rolling with stretching or stretching with foam rolling because they actually do different things. And so I like the compression from the foam roller, which will help reduce muscle tone, but then a stretch will help lengthen the muscle and I feel like foam rolling and then stretching together really can make a difference when things are shortened and too tight.
Speaker 1 (00:19:14):
Cool. Okay, a live question. Mesh removal. This patient had Mesh removal in August of 2020 with residual nerve issues. He had a Shouldice procedure and he is now seeing, which is a tissue-based inguinal hernia repair. He’s now seeing a pelvic floor physical therapist for the last three months to get some relief. But I have no real diagnosis of how to mitigate my issue. I can’t afford to continue therapy every week, but I also, I can’t sit in a chair without irritating my nerves and crunching resonates throughout. Any advice? Well, I must say Mesh removal is not a benign procedure. Number one, it should be done by someone who is a specialist because there are a lot of nerves in that area that can be affected. So I’m curious what happened to your nerves during the Mesh removal process, but when you have people with nerve pain after a complicated operation are there’s certain things you do in your office that can help heal that in any way?
Speaker 2 (00:20:17):
So if there has been a Mesh removal and other issues around that area, again, we go back to the manual exam will help us identify the impairments, but if this person is having neuropathic pain, then I want to work with nerve blocks with a pain management doctor or potentially the surgeon. There’s some variants in who does what. Correct. And again, if there’s neuropathic pain, I do follow the recommendation of the pain docs and they recommend certain medications that are intended for that type of pain. Sometimes physical therapy is not the answer in those cases, as I’m sure if there’s an actual nerve entrapment, manual therapy may not work. And so I keep these things on a short leash and I expect to see functional changes four weeks, eight weeks, 12 weeks is a reasonable time. If for example, we’re seeing our patients once a week, if we’re not seeing changes or you still can’t return to the exercise that provokes it, it tells me there’s more going on than we may be able to handle. And that’s the team approach.
Speaker 1 (00:21:19):
So he says that he’s been doing pelvic stretches daily with the Rolo. That doesn’t help. His surgeon told him he may have tightened the opening of the spermatic cord too much. That’s actually misnomer for a tissue repair. It’s very, very difficult to make it too tight because the muscle stretches. I was going to say, right, so with the Mesh you can make it too tight and there are techniques to never do that as opposed to the typical keyhole technique. But with a tissue repair, it’s almost never a problem. I’ve never seen that. And all I do is hernia complication surgery. But what’s interesting is you told me that in this response that no nerves were compromised. That’s very hard to imagine with a Mesh removal operation unless the Mesh removal was done from a posterior aspect. So let’s say you had laparoscopic Mesh removal, but if the Mesh removal was done from the front, the nerves are always compromised. If they weren’t just, it
Speaker 2 (00:22:18):
Wouldn’t be neuropathic pain either,
Speaker 1 (00:22:21):
Right? So Well that’s the thing is that if you have the surgery and your doctor says, I don’t have to cutting nerves, the question is why not? Is it because you identified each nerve and they were intact or did you not seek it and you actually missed the fact that you injured nerves from the procedure? Because Mesh removal from the front, an open Mesh removal surgery in the groin almost always involves at least the ilio inguinal nerve as part of the problem. It’s like I explain it, it’s like putting Velcro on a cashmere sweater. You can’t take it off the sweater without the sweater kind of getting a little destroyed.
Speaker 2 (00:23:07):
And do you approach that from a medical perspective? I spoke about the pt. Yeah. What do you do after the fact when you see these issues that are persisting in patients? Some of
Speaker 1 (00:23:17):
It is very treatable without surgery. So local nerve blocks help and sounds like he is seeing a pain injection specialist in a few weeks. He’s been sent around to so many doctors, he says, I’m so exhausted, my doctor said nothing was compromised. So injections are first, but then your pain doctor needs to know where to inject you. There are certain anatomical areas where you should inject and they need to understand what procedure was done, what nerve is perhaps at risk. Usually that’s the ilio inguinal nerve. I do the injections myself in my office. I think it’s a good feedback for the patient to kind of know how they’re doing. And then patches, you can try patches, salon pods now cells, lidocaine patches over the counter. So buy the salon pods, lido, lidocaine patches and put it all over the area of your pain and see if it goes away. That’s a good way to get medical treatment that’s very fairly inexpensive, but no amount of physical therapy is going to treat a true neuroma. Agreed. Right,
Speaker 2 (00:24:25):
Right. Yeah. And this is exactly why we’ve got to keep it on a short leaf with functional goals. It shouldn’t go on and on forever. We’ve got to keep an eye on this.
Speaker 1 (00:24:34):
Yeah, yeah, that’s a tough one. But if the issue I have is if a surgeon says, oh, your traumatic cord was too tight on the tissue repair, that sounds like maybe they’re not used to doing these operations much because that’s not usually the answer for these kind of pains. And if they said, I took out a Mesh from the front and your nerves were not intact, I would like to read the opera report to see if they actually individually identified the nerves. I go in so many times with that same story and on the next surgeon and there it is, nervous hanging in the breeze and scar tissue or damaged and it’s unfortunate. Okay, next live question. This is a good one. I have significantly thinning abdominal wall on one side of my abdomen after abdominal Mesh removal. Are there any exercises that can help this area or anything specifically that made you more harm? Can you build up muscle if it’s partially missing?
Speaker 2 (00:25:39):
As far as my clinical experience with this, I do not have a lot of experience. A general rule of thumb I provide to patients is with therapeutic exercise, it’s okay if you get some discomfort, but if you start to get pain or the pain escalates, that may not be the right activity for you. As far as rebuilding the muscle, I would think that you can, I have not seen a ton of people have to go through that process. Maybe you can weigh in a little bit more on that, but I think it’s we want to get people returning to fitness and things that are going to keep them stable. As far as the appearance, I don’t know what to say about that.
Speaker 1 (00:26:17):
Yeah, it’s hard. So missing muscle is either because it’s surgically missing or affected or there’s like some nerve kind of injury to it where it’s no longer getting nutrition from the muscle. Those you can’t do anything about. But I think with physical therapy you can build around it, so build the muscles around it to support the area. So it’s not as bad, but you can’t kind of regrow muscle,
Speaker 2 (00:26:48):
Especially if there’s nerve damage that’s important or nerve involvement.
Speaker 1 (00:26:53):
Here’s another one. I just started with a physical therapist in pain management who has put me on gabapentin. I had sutures removed in January. I have had more nerve pain since the sutures were removed. I’m trying to hit all angles here still. I have a seroma, but it is smaller. You lovely doctors are speaking my language. Oh, that’s very sweet. Oh,
Speaker 2 (00:27:11):
Speaker 1 (00:27:12):
Very sweet. All right, let’s keep moving on. Let’s see, next question. Does a non painful angle hernia affect pelvic floor strength and structure?
Speaker 2 (00:27:25):
So if there’s a non painful hernia, does it directly compromise the pelvic floor? I am going to say no, but if there is a hernia, there may be something going on in their day-to-day habits that also may have affected the pelvic floor. No, so does a hernia directly. And I hope you can weigh in too. I mean I would say not as linear as it sounds like this question is asking, but a lot of times when people get hernias there is some sort of pelvic floor and core compromise. They may have constipation, lots of straining exercises, things like that that just may not be going as well as it could. It could lead to a hernia, it could also lead to pelvic floor dysfunction.
Speaker 1 (00:28:11):
Is pelvic floor dysfunction or weakness or any disorder genetic?
Speaker 2 (00:28:17):
So officially I think genetics, there are some studies that show that genetics do play a factor in if somebody’s going to get prolapse or not, which counts as a pelvic organ prolapse, which is when the uterus, the bladder, the rectum come through the vagina. So some of that is genetic, but then there’s also so many environmental and lifestyle factors that can play a role too, both in terms of helping you avoid it if you are somebody who has more laxity. And then again, if you’re somebody who isn’t, then it’s probably not going to be as important. But there’s varying degrees of flexibility that we all have and that’s a good indicator if someone can bend their thumb all the way back and various other tests for generalized hypermobility. Yeah, it’s going to affect your pelvic floor too.
Speaker 1 (00:29:05):
Yeah, and you’re the same. I feel that hiatal hernia, al hernias, pelvic floor weaknesses, they’re all part of the core and they’re all part of the same disease process. So for example, someone who has inguinal hernia may also have an umbilical hernia or a hiatal hernia If they have a pelvic floor disorder, you’re right, it could be related to constipation, which is also causing that inguinal hernia. They’re just not symptomatic for me yet. What I would like to say, which is something that I feel like I stumbled upon and I would love to write an article on it, I just feel that I’ve written chapters on it but not an actual article, which is that hernias, regardless of whether they’re symptomatic or not, can cause pelvic floor spasm. And that’s something that I think I discussed it with you once, but it’s something that I stumbled upon because I have patients that have anal hernias and they have pain with urination, screening to urinate, frequent urination, some even have rectal pain or constipation, painful intercourse, and then you fix the hernia and all that goes away. So it just leads to me to think that there is a, not everyone but some people that there is some type of pelvic floor spasm that is triggered, even pudendal type neuralgia where the nerve is maybe impinged or because of the pelvic floor spasm. And then although symptoms go with
Speaker 2 (00:30:39):
I, and we know that the pelvic girdle muscles, the fascia, the nerves in the lower abdominal area, they all have connections or are very closely situated on the spinal cord to the pelvic floor. So that would be something interesting to write up because people should maybe be thinking along those lines of screening for pelvic floor issues if they have been diagnosed with the hernia and versa. And we just want to make sure that we’re covering all of our bases.
Speaker 1 (00:31:05):
Yeah. Let’s see. Another live question. How soon after abdominal Mesh removal do you generally allow your patients to fully go back to contact sports and lifting weights and strengthening core muscles without worrying about damaging anything? And when can you start using foam rollers for back pain that’s a result of the core weakness after surgery, the small hernia with sutures with own tissues after removal? Well, I’ll tell you for inguinal hernias, our society strongly believes that there should be virtually no restrictions. So a laparoscopic surgery, I dunno, it was strict after a tissue repair, I do restrict a little bit, maybe two weeks if I restrict. I mean you could walk and do normal activities, but maybe the gym at two weeks, but with laparoscopic surgery can go same day if you wash. I don’t restrict revisional. Surgery is totally different animal. Often the repair is more tenuous. But I don’t know. Do you think that let’s say exercises or physical therapy or anything that is core based should be started early? I mean people get hip and knee replacements and they’re in physical therapy immediately.
Speaker 2 (00:32:22):
They are. They are. And I feel like that’s a slightly different situation because they need full rehab usually to be able to do things again. I feel like sometimes with the hernia repair, we see a lot of patients that have complex situations with multiple things going on and one of the goals is often to help them get back to exercise, not just rehab after something like a repair. So I really feel like it’s individual depending on how many other comorbidities are happening with that particular person. And of course we don’t want things to become too aggressive too quickly and then end up in another problem situation either.
Speaker 1 (00:33:02):
So in the hernia world, we have not reached a consensus for abdominal wall for the groin, we do for primary, for revisional, there’s no consensus. And for abdominal wall there’s not much of a consensus. If you go to the ACHQC dot org website, there is a handout for patients on what to do after surgery and also for physical therapists on what to do while they’re inpatient After abdominal wall surgery, it’s very minimal. It’s not like they’re asking you to do diaphragmatic breathing and things like that early after surgery. So it’s not like they’re saying, oh, go do sit-ups immediately and they, it’s graduated to do more and more over eight weeks. We posted that on the website multiple times. We even talked with Dr. Ben Poulose I think in kind of fall of 2020 about his abdominal core health platform. But I would say that early after surgery I would talk to your surgeon because every patient’s a little different. There is no consensus.
Speaker 2 (00:34:13):
That’s helpful to know because it does seem like patients are confused about this and so it sounds like it should be individualized based on what the surgeon thinks based on their case.
Speaker 1 (00:34:25):
I would think so, but there’s the majority of surgeons who are general surgeons are not specialists. They will tell the patient after any surgery, don’t lift anything for six weeks. That’s very outdated. No one that does hernias for a living follows that at all. So that for sure is too much. And so if you’re three months or more, if your surgery for sure, you should be doing a hundred percent activities or at least work your way to it without restrictions. Hope that’s helpful.
Speaker 2 (00:34:57):
All good to know.
Speaker 1 (00:34:59):
I would also like to know if you’ve had to do a attack removal. If so, have you had any patients develop crawly ant type feelings as if the Mesh was suffering from the bottom? Oh yeah. I’ve never had anyone have that kind of feeling, but that may be related to how you’re healing or could be nerve related. Next question, what types of exercises do you recommend after Mesh removal?
Speaker 2 (00:35:31):
Do you want me to start with that one? Yeah.
Speaker 2 (00:35:34):
I think it’s safe to go for starting with the basic core activities. And when I say that I want the pelvic floor muscles to be working with the abdominal muscles, we want their gluteal muscles to be firing. And once we can get those neuromuscular patterns together, we tend to help people diversify towards whatever type of activity they want to be doing. Some people want to play tennis, some people want to go to CrossFit, but really one of the most important things is making sure that these muscles are actually working together. Basically when you inhale, your pelvic floor muscles lengthen a bit. When you exhale, they start to rise again when you exhale. Another important thing is like you don’t want to hold your breath when you’re starting to do some of this training. So upon the exhale you can also activate the TVA, which should bring your pelvic floor along for the ride.
Speaker 2 (00:36:24):
You’d be surprised at how many times this isn’t happening. And again, did this person have pelvic floor dysfunction before going into their surgery maybe? And so for us it’s more about the coordination and then from there we can ramp people up or down. I don’t think there’s any amount of exercise they have to do if this is a sedentary person and their main goal is to be able to walk around their neighborhood with their husband or their dogs, but if they want to return to CrossFit or do some more active types of things, then that’s going to be a different situation. Yeah. What’s
Speaker 1 (00:36:57):
Your thought on CrossFit? I feel like it’s a lot of jumping and a lot of squats. Two things that have been shown to increase a lot of abdominal pressure. I’m not a fan.
Speaker 2 (00:37:06):
Well, and it causes a lot of pelvic floor issues as well. My thing with any exercise is that some people just don’t know what the limit of their body is and it can really, you hurt yourself when you exceed what a particular muscle can do and there’s no way the lay person knows that. So whenever we’re talking about a high amount of impact, jumping, weighted, jumping often outside of my office without shoes on, running down West Olympic Boulevard carrying sandbags while I’m just going to get a coffee, I’m like, I don’t know about that. But I don’t think it’s bad for everybody. I just think you’re going to be more likely to hurt yourself doing that than some other types of exercise if you’re not careful.
Speaker 1 (00:37:48):
Yeah, no, I totally agree. I’m not a fan and I think I tweeted about that once and one of the
Speaker 2 (00:37:53):
Surgeons, oh, I bet you got in trouble.
Speaker 1 (00:37:55):
Well, most people were fine, but another hernia surgeon from the east coast was like, can’t say that we do cross. I’m like, dude, do your CrossFit. I’m just telling you it’s
Speaker 2 (00:38:06):
Not your preferred exercise.
Speaker 1 (00:38:08):
It’s not my preferred exercise, not just for myself, but I see so many injuries from P90X and all these kind of extreme exercises usually in people that are not that fit. And then also if you’re going to agree that exercises that include jumping and squats increase your abdominal pressure and therefore are not the best for hernias or pelvic floor, then CrossFit can’t be on your list.
Speaker 2 (00:38:33):
Speaker 1 (00:38:34):
They do. They do a lot of break training, but it involves a lot of jumping and
Speaker 2 (00:38:41):
Your body has to be able to move that way. Sometimes squatting on altered mechanics, that’s like one of the number one reasons people get pooed in on Neuralgia and that’s a very debilitating pelvic pain syndrome that can be difficult to undo. And so, oh yeah, I tend to err on the side of caution with my own choices with exercise, but we’ll help people get back to that if that’s what they want to do safely.
Speaker 1 (00:39:09):
Okay, next question. Okay, so I’m a 66 year old male with interstitial cystitis. I had a right inguinal hernia pair with lightweight Mesh in September, I think open after four weeks I began having penile pain and urinary pain. Urology and PT evaluation are normal. I’m interested in hearing your perspective. How do you think about this penile pain and urinary pain?
Speaker 2 (00:39:34):
They definitely both sound like pelvic floor dysfunction and so to me I’m like what type of physical therapy evaluation was this? Because this I agree. You mentioned earlier not all PT evals are the same. Yes. And I would say the one group that’s the most underserved are men with pelvic pain. So we have to think about the training of pelvic floor physical therapists. They learn on each other and all of them are women. And so when people are learning to treat pelvic pain disorders, they’re in a class filled with other therapists and they can only practice on each other. It is very unusual for them to actually have a male pelvis to be able to learn on our clinic is set up differently than that. We clearly have men who’ve been extremely generous with their bodies, but when we are hiring people, if men are coming here from other clinics, they may not have been fully evaluated the way that we did here.
Speaker 2 (00:40:28):
And I’m just very suspicious if there’s absolutely no musculoskeletal findings, both in the abdominal wall, pelvic girdle and the pelvic floor that you should get a, we should look for prostatitis actual, but it probably is not that that’s not that common. But if there is going to be an age bracket where prostatitis may be more likely like a true prostate infection or prostate inflammation without infection, this may be one of those situations if really everything else is clear. Yeah, but can you tell this gets me worked up a little bit? Yes. I mean sometimes it may just be a biofeedback sensor for all we know. And I also think that there can be inflammation without infection. That is really a challenge I think for these gentlemen to clear that prostate is like this porous thing and if there was an infection, it takes months for it to actually become uninflamed. And I don’t think a lot of our patients have been educated enough about that and they don’t really understand what’s going on.
Speaker 1 (00:41:32):
I think you’re right on. I think you’re absolutely right on this is a male. He may have had a PT but not a pelvic floor PT evaluation. This completely sounds like pelvic floor. Now I also understand that hernia surgery itself can instigate a pelvic floor spasm depending on the type of repair it was done. If it was done laparoscopically and the Mesh is placed too low and it’s irritating the bladder or the psoas or it’s too tight on the pelvic floor, that can make it worse. Or if you have a hernia recurrence and that’s the cause of the pain, any type of groin pain I think can also cause pelvic floor spasm. So I would definitely see someone like you who’s pelvic floor specialist and yeah, men have it rough with that problem. Yeah, it definitely sounds like it’s a pelvic floor. Okay, next one.
Speaker 1 (00:42:33):
I started PT about two months ago to try and help with tightness and pain I have after hernia surgery. How long do you think PT should be required before I see results? Also, is there a point where I should stop PT if I see little or no improvement and begin at looking other at other reasons such as from the surgery, I don’t want to go through removal surgery. I also don’t want to have this constant issue. I also have joint pain and constant fatigue. That’s a great question. How long should they expect a result and when should they start looking for something else as the cause?
Speaker 2 (00:43:07):
Yeah, I think that’s a wonderful question and thinking about it the right way, because physical therapy shouldn’t be required for any length of time. We are goal directed. And so typically we have short-term goals and long-term goals for our patients. And the short-term goals are set in four week increments is what it really takes to make a manual change and a little bit longer for strength and coordination changes depending on again, how involved the person is. But every four weeks we want to see a change leading to the longer-term goal. So an example of a short-term goal for PT would be that the patient will not urinate more than, or a short-term goal would be to normalize pelvic floor muscle tone to reduce urinary frequency and painful sex. And so we would expect that in four weeks we should be able to start to reduce that tone.
Speaker 2 (00:43:57):
Now the longer term goal will be to be able to have pleasurable intercourse again, but it’s not just that muscle impairment that’s tied to getting to be able to have pleasurable sex or total normal urinary function. It’s also the pelvic girdle. It’s also the connective tissue. If there’s nerve involvement, people really need to understand that nerves don’t respond the same way muscles do and that things take longer. And so we can clear the myofascial things and there can still be nerve pain. And that’s just because the burner hasn’t been turned off long enough to let that nerve settle down. And I think this is what people struggle with when they’re trying to figure out, did my surgery not work? Do I need another surgery? I mean it may not be that, but I think that’s where the team effort comes in. If you’re not changing in physical therapy, the physical therapist should be able to tell you why.
Speaker 2 (00:44:45):
For example, if someone comes back week after week, their pelvic floor is still tight. Well maybe the manual therapy and these exercises are not enough. Should we consider Botox because what I’m doing is taking too long and it’s maybe not working for a reason. I can’t figure out, from my perspective, Botox should never be done in my opinion for pain. But if there’s definitely muscle dysfunction that’s causing pain and the regular mechanisms aren’t working, we can go up the chain to things that are a little more invasive but are also researched and we know they work.
Speaker 1 (00:45:19):
Yeah, we had Dr. Michael Hibner on as one of our guests. He’s a great specialist of P Dental neurologist, so on. He was saying that a lot of women or men have so much pelvic floor spasm that PT is very uncomfortable for them. So he pretreats them with a vaginal or rectal suppository. That’s a muscle relaxant, maybe even Botox like you mentioned to kind of, it’s like the foam roller, I guess you kind of get yourself ready for the pt so it’s not too painful and you can actually therefore benefit from correct pelvic four pt, otherwise you’re not going to get the PT that you need. I would also add that in people who get pelvic four pt, let’s say they grow their gynecologist and there’s told you have pelvic four spasm. Unclear why, I mean, yeah, unclear why. Then they go to come to you and you do pelvic floor pt and they actually have more pain after the pt. In my experience, those people have hernias and the pelvic floor PT for some reason exacerbates the hernia pain. Whereas once the hernia is resolved, then the pelvic floor spasm goes away. So I always ask my patients who I know how hernia is, how did pelvic PT help? It didn’t help. And actually I felt worse out. I didn’t want to go back cause I more pain, which is not normal, in which case the underlying problem is not so much the pelvic floor is the primary problem is a hernia.
Speaker 2 (00:46:56):
And we got to keep that in mind too because sometimes PTs cannot recognize that in a clinical setting. And so there can be hernias, there can be pudendal nerve problems that make you respond badly to the therapy. There can be vestibular. There’s so many things. And so we need to take that as a red flag that this may not be right for that person at that time and help them figure out why. Yeah.
Speaker 1 (00:47:18):
Now with the sport hernia question we had earlier, the athletic pubalgia, rectus tears, adductor tears. If they go do physical therapy and that’s painful, should they stop
Speaker 2 (00:47:31):
Or not necessarily, okay, it’s okay to be sore, but if it increases their own symptoms, yeah, that’s a different story. So soreness may happen as we start to help with the manual therapy. I mean it shouldn’t be necessarily, it should never be excruciating and it should be tolerable. Got it. And I think with most of our patients, they, they’re always like, oh, that feels therapeutic. They don’t want to say it feels good because it certainly doesn’t, but they can tell something’s happening that’s necessary. If they’re like, oh my gosh, when is this person going to stop? That’s a different situation. And I think sometimes people don’t know the difference unfortunately. Yeah.
Speaker 1 (00:48:09):
And also surgery is part of the algorithm of treating sports tears and hernia muscle strains. It’s not number one or number two or even number three. But it’s possible that if you’re in such severe pain that you actually need to get fast tracked onto surgery, perhaps a physical therapy is not going to be able to be something that will help you. Okay. This one’s a bit long question, but I think the answering should be easy. Can you continue to exercise even if the healing is at a slower pace but are having some pain but not severe? Does this mean stopping exercising mentally get no pain at all? Is a little pain to continue exercising or to be on the cautious side and don’t take the chance even if there’s a little pain associated with the exercise. Is it also possible if you don’t exercise in time that you’ll develop a scar tissue and permanent core issues as a result of not exercising? That last one’s a good question.
Speaker 2 (00:49:07):
I’d say no, there’s not a, yeah, most of the time we’re not seeing permanent things happen just from not exercising enough. You would do agree? Yeah.
Speaker 1 (00:49:15):
Yeah. No, I totally
Speaker 2 (00:49:16):
Agree. And as I said earlier, I think some pain is okay if you’re rehabbing yourself, if the pain escalates or if it persists or if you’re really not getting better and there’s a triggering activity you’re doing, we can always, again, go short term. What happens if you don’t do that for a week? How do you feel now? What happens when you try to start again? It just depends on where they are in their healing process too.
Speaker 1 (00:49:39):
Yeah, I would also say that being deconditioned is not helpful.
Speaker 2 (00:49:45):
Speaker 1 (00:49:46):
Does push you back.
Speaker 2 (00:49:47):
I feel like it. I think we’ve got the opposite problem with most of our patients. They want to maybe do too much too fast, right?
Speaker 1 (00:49:55):
Yeah. We have crazy people in Los Angeles.
Speaker 2 (00:49:58):
They’re running down West Olympic Boulevard with sandbags and no shoes on. Yes.
Speaker 1 (00:50:02):
Makes no sense to me.
Speaker 2 (00:50:04):
It looks hard.
Speaker 1 (00:50:05):
Yeah. I’ll tell you So quick story. I started with a trainer and he works out of Gold’s Gym. So you may have heard of Gold’s Gym. It’s like that famous gym in Venice. There’s a branch of it on Venice Beach where it’s like Muscle, muscle Beach, Arnold Schwarzenegger goes to that gym all of like Mr. Olympia, Mrs. Olympia, Mr. And there’s like little me going to the same gym and it’s so hilarious. So the, my trainer’s very like, he used to be an assistant physical therapist or physical therapy assistant and used to work for the MBA. Like he’s very well versed in what’s right and correct, and he just looks at these people and some of the stuff they do, and I just, I’m like, that’s wrong, right? You shouldn’t be doing that. Pointing at some of the people at the gym and he’s like, oh yeah, the form is so wrong and the stuff they do is so wrong. But
Speaker 2 (00:51:05):
Is it intimidating? I’ve been past that, Jim. I’m like, Ooh, that’s, there’s also somebody outside of there that can hold a surfboard out of her vagina. Have you seen this person on a, if you Googled it right now, you will find her. She is somebody with stronger than normal pelvic floor strength and she will hang a surfboard from her vagina and hang out down on Venice. Oh yeah.
Speaker 1 (00:51:29):
Speaker 2 (00:51:29):
Now I don’t think anyone really needs to get to that level of fitness with your pelvic floor, but you may see this one day by your gym Now that we’re,
Speaker 1 (00:51:39):
Okay, that’s interesting. Okay, let’s go on with question. We digress.
Speaker 2 (00:51:46):
We digress. It’s almost happy hour time.
Speaker 1 (00:51:49):
Yes, it’s, we’re actually almost done. How could PT help with scar tissue from surgery?
Speaker 2 (00:51:55):
So scar tissue is something that is a normal part of the healing process, but what we want to do in physical therapy is help keep the tissue as mobile as possible. We don’t want it adhering to underlying muscles or cramping on other nerves. So we employ a number of manual therapy techniques, both with our hands, with cupping. I really like working with acupuncturists or PTs are in states where they can dry needle. That can help tremendously and some laser therapy.
Speaker 1 (00:52:23):
What about red light therapy and ultrasound therapy? What are those?
Speaker 2 (00:52:28):
So there’s really no evidence to support the use of ultrasound therapy, but there is some, for some of the low light level lasers and some of the red lasers and things that people have at home, yeah. Cannot have also shown to have some effect.
Speaker 1 (00:52:43):
Okay. That’s really good to know. Sometimes I have soreness in my abdominal muscles where I feel the urge to massage it to calm the area. Is this soreness related to the muscles or the nerves?
Speaker 2 (00:52:55):
Usually that’s muscle.
Speaker 1 (00:52:58):
If an occult hernia is suspected but not seen on scan, how can you move forward with proper evaluation? So first of all, they are seen on scan just not by the first reviewing the scan. So that’s what I’d like to say. In my study, which we published twice in two different sets of patients, up to 75% of images are incorrect and misdiagnosed occult hernias. So it is there, you just, it’s just not red. So part of what I do is people send me their images as part of a telehealth or virtual consultation or online consultation and I re-review their imaging and almost always find the culprit hernia as private.
Speaker 2 (00:53:46):
I’ve seen you do that a number of times with our patients. Yeah, I
Speaker 1 (00:53:49):
Know, right? But yes, that’s to my point. You guys feel it
Speaker 2 (00:53:54):
Or we know something’s wrong or
Speaker 1 (00:53:56):
Something’s wrong, even though it’s very, very petite. And just because even a cold hernia doesn’t make the treatment any more difficult, it’s the diagnosis that makes it, this is, oh, so someone actually has read the story on the training that this pelvic floor surfboard carrier lady does. Oh
Speaker 2 (00:54:18):
See, she said people know who this is. I was like, oh my gosh.
Speaker 1 (00:54:25):
Yeah. Pretty crazy.
Speaker 2 (00:54:27):
Yeah. You never need to hang weights out of your vagina as part of your treatment plan ever. No, you
Speaker 1 (00:54:33):
Guys don’t offer that, right?
Speaker 2 (00:54:34):
No pelvic floor muscles are always active, so you don’t need to wait and strength train them.
Speaker 1 (00:54:42):
Can you talk a little bit about how to find a good physical therapist? Are there some that know more about endometriosis, for example, than others? And then what is insurance? I feel that at least in Los Angeles, because I’ve called around a lot from my patients physical therapists around here that are in network first insurances often don’t have the full cadre of bells and whistles that they can offer patients. But those that are out of network tend to be a bit more kind of complete. What do you think about that?
Speaker 2 (00:55:15):
I’d agree. And to go back to the, anybody can call themselves a pelvic floor physical therapist. We’re not really sure about the training that anybody has. Okay. But in general, there is a range of disorders that physical therapists treat, and the one end of the spectrum is pregnancy, postpartum, and stress incontinence. Pelvic pain is something completely different. And so we do recommend using, there’s several databases that are out because we know that people do need to find people who are within network a lot of the time. And sometimes it just may take a few tries to figure out who actually treats pain as the majority of their day. Because with endometriosis there’s a lot of musculoskeletal issues. This is a surgical situation. There’s central sensitization, so medication may also be involved. And you really want to work with somebody who’s aware and connected to providers that can really help because this is a Collaborative diagnosis.
Speaker 2 (00:56:15):
I like the pelvic guru website. They’ve got a great directory. Herman and Wallace has a find a provider section. And then the American Physical Therapy Association also has a list. So I would take a look at all of them and cross check and then look at the websites, see if these people are on social media. And sometimes you have to make a few phone calls and actually ask, but I know that’s awkward and not the easiest thing to do. I think Nancy’s nook is becoming a resource that I believe list physical therapist. I’m not even sure if we’re on there, but yeah, I think talking to other patients that are in your geographical location may also help to figure out where they went.
Speaker 1 (00:56:58):
Yeah, totally agree. Is it possible for women to get hernia? Oh, let’s just, and then they disappear clinically. This is more of a sports hernia question. Complications of hernias. I’d like to kind of focus on the pelvic floor. A lot of these are medical school like lecturers.
Speaker 2 (00:57:26):
I know. I was going to say, I actually would love to hear your answers to these. I need to take some notes.
Speaker 1 (00:57:34):
Okay. This is about prehabilitation. This patient’s going for sports hernia surgery. Is there any prehabilitation recommended? Can you explain what that may be? And
Speaker 2 (00:57:43):
So prehabilitation been something that’s become a little bit more popular lady lately with some pelvic diagnoses, especially prostatectomy and pelvic organ prolapse repair. So studies have shown that going into these surgeries, if you get started on some therapeutic exercise, that the outcomes may be better. And I don’t know if that’s because you’re already tied to your physical therapist or it just approves compliance, but there can be exercises that you can do to help rehabilitate, rehabilitate yourself even prior to going, which many people are doing anyway is they try to figure out what the source of their pain is. And again, if the exercise is tolerated, I think it’s great thing to do before you start and then again following up afterwards because lots happens.
Speaker 1 (00:58:29):
Yeah. We have a diastasis question. I’m surprised we didn’t get one earlier.
Speaker 2 (00:58:34):
You know what I am too.
Speaker 1 (00:58:35):
Yeah. I’m one and a half years postpartum and I have a bulge with pain in my lower abdomen and groin ultrasound CT show, no hernia. Is it possible to just have overstretched muscles and skin, which cause the bulge? This is what my surgeon told me.
Speaker 2 (00:58:52):
Lower. Now wouldn’t you think that is a hernia or wouldn’t you think
Speaker 1 (00:58:57):
Lower ab? It’s hard. So when you’re postpartum, I mean correct me if I’m wrong, if you have a diastasis, it can be in the lower abdomen. Uncommonly it’s isolated. Lower abdomens usually doesn’t. Does involve the belly button and upper abdomen Two, just kind of the way your belly is Ultrasound and CT should show a diastasis if it’s a true diastasis. But if you’ve had a C-section, you could have incisional hernia from your C-section. I would reevaluate that because regardless, it shouldn’t be painful. If it’s not a hernia, if it’s a diastasis, it should not be painful. It should, if it’s a hernia, it can be.
Speaker 2 (00:59:37):
What do you think? Just, but we just said this before we started regarding one of our mutual patients. Yeah, yeah. Diastasis should not hurt. And so when it does, I mean that makes me suspect that something more is going on. And then similar to what you said, I’m, I’m often cautious with how these exams and these imaging things are interpreted. Yes. Cause there can be some variants. So it’s always worth it to get a second opinion if you’re not getting better or if things aren’t changing. Yeah.
Speaker 1 (01:00:05):
This is the bulge on the lower right side. So diastasis or muscle stretching is not, it’s always in the middle on the sides. So this is not a diastasis, it’s not a muscle stretching, it’s a hernia or a nerve damage or definitely not something to ignore, especially if you have pain. Alright. That’s it. We’re done.
Speaker 2 (01:00:28):
That went fast.
Speaker 1 (01:00:29):
I know. Oh, we had so much fun.
Speaker 2 (01:00:31):
Thank you so much for having me.
Speaker 1 (01:00:34):
So do you see patients, well, you personally, which you personally, where do you go?
Speaker 2 (01:00:40):
I see patients in West Los Angeles. Okay, perfect. And we do have digital health appointments available too. Great. We we’re doing that in COVID. And again, they’re not usually with our patients, they’re with people from all over who have questions about pelvic pain.
Speaker 1 (01:00:54):
Great. Great. So if I have a patient like in Canada or someone who they can do virtual with
Speaker 2 (01:01:01):
You, they can have a virtual appointment.
Speaker 1 (01:01:03):
Yeah. Okay. That’s really great because that’ll be so helpful. Sometimes they just need guidance as to where they should go next with their pelvic floor or PT or whatever. And then if a patient wants to make an appointment with anyone in your office, they just go to the website or what do you recommend?
Speaker 2 (01:01:19):
You can go to the website. We have a schedule, an appointment button on there. Someone will get back within a business day. They can also call the office that they’re interested in. All this phone numbers for the Northern Cal, Southern Cal and New England offices are on the website.
Speaker 1 (01:01:36):
There you go. And lots of thanks from our viewers. Thank you so much. Oh,
Speaker 2 (01:01:44):
Speaker 1 (01:01:45):
So should call it a day and let you move on. You’re sure you had a long day already seeing lots of patients. We’ve been so busy since things have opened up in California. I’m very grateful. Another comment, we love this. I’ve helped two people this week, but I think have a hernia and they’re watching your interview with Tracy as well. Tracy. She, she’s been a great person too. All right, everyone, thank you for joining us. It’s been just a bit over an hour. We have tons of questions. I have tons more, but we’ll have to bring Stephanie Prendergast back because I’ve learned so much from her. I feel like I couldn’t have done this Beverly Hills Hernia center without having a partner like her locally. I’m so glad that she’s here and that I coincided when I started my practice. And hernia talk has been great. Thanks for everyone who join us. I will post a couple links to her website, to the ACHQC dot org on our social media. And once this is up on YouTube, you guys can watch and share and like it and subscribe and all that good stuff. Thanks everyone, and thank you Stephanie for joining me. Hope to see you in person soon. I
Speaker 2 (01:03:02):
Hope so too. Thank you
Speaker 1 (01:03:04):
So much. Thank you. Thanks everyone. Take care. See you next week.