ROUTINE, PERSEVERANCE, AND A LOT OF SELF LOVE HELPED KATE OVERCOME HER WEIGHT ISSUES.

For most of Kate’s adult life, she battled with her weight. From a loss of a partner to a stressful job, the reasons why she struggled were numerous. She tried many diets to lose the weight only to quickly regain the weight that she had lost. She was frustrated and felt hopeless that she would ever gain the control needed to keep the weight off. A lifestyle shift needed to take place. She made several changes in her life, from activity, medications, and explored her relationship with her food. She reached a milestone this year. She is now down over 100lbs and is still learning more and more about herself every day. This is her story.

What do you think was the largest contributor to your weight gain over the years?

Where do I begin? What do I say? There are so many factors: low self-esteem, being a workaholic, stress, no energy, bad eating habits, using food as a reward, depression, not exercising, feeling hopeless about where I was going in my life, and more. I suppose the largest contributor was my low self-esteem and lack of confidence. Perhaps if I believed in myself, I may not have gained the weight. It is too hard to know the one biggest factor for me.

There are many factors to your weight loss over the year. What do you think was the largest contributor to your weight loss?

It has taken me at least a year to hit my goal. I think there are four main factors that helped me with my weight loss:

First, I started walking every day. There were several starts as pain began to occur and I had to seek out physiotherapy. This slowed me down, but for some reason I knew that I needed to start moving and keep moving. Once my injuries healed, I was back to walking again.

Secondly, I started a routine around breakfast. I cannot tell you why (psychologically) that this ended up working as I have never been a breakfast eater once I left home. However, I retired and was perhaps more ready for the change. Somehow this stuck with me and it has been a mainstay of my eating pattern.

Thirdly, I started seeing Jason Hagen at Group23 to help coach and support my weight issues and personal issues. A person outside of my environment was crucial to my success. No matter how I felt when I went in, I left my sessions feeling more hopeful. I needed a lot of support and unlike family he has been there for me all the way and never tires of my feelings and thoughts regarding my weight.

Fourthly, I was feeling desperate to lose weight. By happenstance, my doctor said that she had some patients who were finding some success with Saxenda, a prescription weight-loss medication, and that I might want to give it a try. I decided that I needed a boost to start to see the scale move downwards. This did happen on Saxenda and helped motivate me to keep on going.

What advice would you give to anyone that is starting their lifestyle change?

My advice is to get a weight management coach. They are there to support you through the rough times and times of success. They help you to think differently and dig deep. They will be kinder to you than you will be to yourself and this support is invaluable.

Eventually, you become to understand that what you are eating and the exercising you are doing are connected to your weight. This sounds inane as we all know this. However, I believe we come to understand this at a deeper level than we have ever known.

Start walking or doing something that you like to do to move. Write it down.

Write down what you eat every day. Writing things down was a way to monitor, adjust, and feel like I was progressing whether it be my food intake, habits, and exercise

Weigh yourself and write it down.

Try not to be too hard on yourself when things do not go your way. Just keep on trying, eventually it works.

Do not diet! Try to find foods that you like, that are healthy for you and gradually add them to your eating pattern. Find out what you can eat that you can control the intake amounts. If you cannot control the intake of that food, keep it out of the house.

Do not give up cookies or any food. Just have them when you are out so you will not eat as many.

Be patient. I was never patient about my weight loss over the years. I had to realize that this was going to take a long time and I had to face that fact. It will be a slow and a sometimes-difficult journey, but persistence is key.

What do you think will always be a struggle in keeping your weight off?

My nighttime eating habits have been a struggle and continue to be a struggle.

My desire to eat sweets, especially when I feel low or need a pick me up.

Kate has since come off appetite regulating medications months ago. That takes courage. Her walking routine has become a protected, sacred time. She has moved from beating herself up to really understanding her environments and behaviours. She is gentle on herself allowing her to recognize behaviours and become a problem solver rather than a problem. Kate recognizes the behaviours that lead her to overeating and is continually working on them. Her willingness to continue to be self-aware is inspiring. Weight management is an awareness story. The goal is never a number on the scale, rather a way of living. We can’t predict everything in our life that may lead to weight gain, but we can recognize circumstances in our lives that may want our weight to go up, and respond accordingly.

Make sure you do this one thing to improve your post-operative outcome  

Did you know that the best thing you can do to improve your post-operative outcome is what you do before surgery? I am extremely passionate about pre-operative care to improve post-surgical results. Pre-operative care includes education to provide the necessary resources to best prepare individuals for their surgery and after care as well as individualized exercise prescription and progressions to improve mobility, flexibility and strength deficits, thus maximizing function post-surgery. The exercises that will be prescribed after surgery are also performed and reviewed thus increasing familiarity and ease of performance following surgery. 

Why is Pre-operative physiotherapy so important?  The literature has shown weakness and reduced range of motion to be direct prognostic indicators of successful results after surgery. The greater the weakness and stiffness prior to surgery, the poorer the outcomes after the surgical procedure. Studies have shown that pre-operative physiotherapy rehabilitation is effective in improving post-surgical status. This includes increased function, physical performance and strength.  

Having a pre-operative and post-operative team is crucial for care. I have collaborated with each of the surgeons here at Group 23 to ensure that the pre-operative visits cover all the vital facets they feel are important to promote the best results post-operatively. Having a collaborative team individualizes the care for each patient and is extremely important in managing outcomes. I enjoy assisting patients to make the most out of their surgical procedures and strive to help them reach their goals. Pre-operative care is a simple way to gain significant benefits following a surgery and that is why I absolutely love being a part of each patient’s journey in this way! 

Amy Bauerle, Group23 Physiotherapist

Suffering from elbow pain?

We only know too well how elbow pain can affect performance and enjoyment of every day activities. The EpiTrain brace will relieve pain and reduce tension on the joint/tendon.

Benefits of the EpiTrain brace are numerous including:

1. Helps alleviate pain and starts the process of relief of irritated muscle/joint intersection.

2. Increases Elbow mobility

3. Rapidly decreases swelling and inflammation

4. Anatomically perfect fit and allows for breathability

5. Highly flexible

If you’re suffering from elbow pain visit our AASIC clinic and let our health professionals and the brace support you!

ADAPTING TO ENVIRONMENTAL CHANGES ALLOWED KATIE TO STAY ON TRACK, EVEN WITH AN ARTHRITIS DIAGNOSIS.

I met Katie in December of 2018. She was attending university to become a music teacher. She had all the challenges you would expect in university; busy schedule, stress, cooking for one, and a social life. A primordial soup of triggers that can make weight loss difficult. She was determined to overcome them and become her own success story. She has since lost 60lbs on her journey. What makes her story unique is the stage of life she’s in. Many changes can happen in a short time at a young age. She was a student when we met, but during her journey she moved back to Calgary and has become a full-fledged teacher. Living by yourself and moving back home can be a challenge enough, however, what has also made a way into her life during this time is a diagnosis of rheumatoid arthritis (R.A). Her treatment team at Group23 Sports Medicine including Stacye Will (Physiotherapist specializing in hand therapy) and Dr. Ben Cameron (sports medicine physician) assessed Katie when she started to have difficulty moving her upper arms. Subsequently, she was diagnosed with R.A and started on a treatment plan. Today, she continues her weight loss and health journey. Here is her #RiseAbove story.

What do you think was the largest contributor to your weight gain over the years?

Starting university and moving away from home was probably the biggest contributor. I lacked routine or healthy habits – I ate what others did and was went from playing two competitive sports to no physical activities at all. 

There are many factors to your weight loss over the year. What do you think was the largest contributor to your weight loss?

I believe throughout all the changes in these last couple years, planning, creativity, and reliable constant routine was the largest contributor. No matter if I was in university, home on vacation or now teaching, I created a routine and plan that works for my environment and needs. Those routines are changed and develop and will continue to but I am better at analyzing and assessing what I need. 

What advice would you give to anyone that is starting their lifestyle change? 

Not to compare your journey with someone else’s. Your wants, needs, and emotions are unique to you and comparing yourself will limit your ability to see growth and potential within yourself. 

What do you think will always be a struggle in keeping your weight off?

I am an impulse eater whether its candy, baked goods, or that snack at the office. If its there, I will want it. I have learned not to hide from that feeling but to try to plan and analyze the situation instead.

Today Katie continues her journey, but during her diagnosis, she has become a champion of exercise. She is focused on her rehabilitation and her pounds lost has changed to the number of exercise sessions and freedom of movement. She is choosing to #RiseAbove Rheumatoid Arthritis and not let it define her future, but to continue to overcome the challenges that may rise and continue to do the things she loves to do like dance and teach music to the kids she cares for! I hope her story inspires you to start and continue your own story. If you want to meet your personal care team at Group23 Sports Medicine, click learn more below.

Wouldn’t it be amazing if you could simply surgically remove or ‘cut out’ the cause of your knee pain? I think everyone, from doctors to patients, would love it if things were so simple. Unfortunately, they’re not.

By far one of the most common questions Sport Medicine Physicians and Orthopedic Surgeons at Group23 get from patients suffering from knee pain of any type is “can’t I just have surgery for this?”.   Many of our patients are very active individuals and have likely had a friend, family member, teammate (or maybe even themselves) who has had a knee “scoped” or “cleaned out” with good success (return to activity, decreased pain). For this reason, it’s logical that they may think that arthroscopic knee surgery is exactly what they need to get back in the game so to speak. Unfortunately, the decision to proceed to surgery is not black and white. Many factors determine whether or not someone is a surgical candidate or whether their condition can be managed effectively using non-surgical treatments. Ultimately, the decision to proceed to surgery will be determined based on several considerations: 

1. Is surgery indicated for the diagnosis? In other words, is there a surgical procedure that can fix the problem at hand.

2. Has the patient weighed the risks of surgery (risk of anesthetic, infection, damage to nerves, blood clots, no change in pain despite the surgery etc.) against the potential benefits of surgery and determined that the potential benefits outweigh the risks?

3. What role does surgery play in your personal health journey to help you reach your goals? Are there other pathways to reach your goals besides surgery?

4. What are the timelines involved? Access to elective surgery in Canada is slow (very slow). Recovery times can vary from weeks to years depending on surgery performed.

Let’s examine some of the key factors that determine whether or not surgery can help for your knee pain: 

1.    What is the diagnosis and what does research say about the role for surgery? There are some conditions that are clearly surgical: displaced fractures, complete tears of multiple ligaments in the knee which would render the knee unstable, recurrent dislocations of the kneecap despite physiotherapy and bracing, “loose bodies” or tears of the meniscus (shock absorbing cushions between the bones) which if torn significantly can become flipped over and “lock” the knee (can’t move it — think a bunched up carpet stuck behind a door making if unable to open/close).   Research tends to support surgical management of these types of conditions.  Thankfully, these injuries are rare.  The far more common causes of knee pain which include diagnoses of degenerative meniscal tears/knee osteoarthritis, patellofemoral pain syndrome or “tendinopathy” are no longer managed with surgery as a 1st line treatment (see #4 below and links at end of blog) on surgery for knee osteoarthritis). 

2.    Although some of us hate to admit it, AGE is unfortunately a huge factor in determining whether you are a surgery candidate.  Tears of the meniscus or anterior cruciate ligament (ACL) are very often managed surgically if you are 20 years old but would be managed non-surgically if you are 50 years old.  This is because our choices of activities change as we get older.  Most older patients can get back to doing the things they love WITHOUT needing a surgery, while most younger patients would not.   

3.    Have you thoroughly exhausted non-surgical treatments?  Most of us like to take shortcuts whenever possible and naturally we conceptualize surgery as the quickest way to eliminating pain and getting back to the activities that we love.  The only problem with this approach is that surgery is not without some risk, therefore, most surgeons in public health care system will want to be sure you have done everything you can to have gotten better short of doing surgery.  At Group23 we teach our patients that one of the most important parts of your visit with the Orthopedic surgeon is when he or she asks you the question “What have you done to treat your knee pain so far?”  If you answer “Nothing…. I’ve just been waiting a year to see you” they will very likely send you away for 6-12 months to try non-surgical management i.e. prove that you can’t reach your goals with aggressive non-operative treatments (physiotherapy, injections, bracing, weight-management etc.) and then we’ll talk about whether surgery is appropriate.  We try to ensure that when a Group23 patient is asked this question by the surgeon, they blow them away with their answer.  Group23 patients demonstrate to the surgeon that they have undertaken a comprehensive, progressive and aggressive non-operative treatment course but, despite all this, they have not reached their goals.  Expect to hear the next words from the surgeon to be: “when would you like to come in for surgery?” 

4.    Understanding WHEN surgery is appropriate and WHAT KIND of surgery is required.  This applies most commonly to KNEE OSTEOARTHRITIS (OA) and degenerative meniscal tearing.  To keep it simple, there are 3 different types of surgeries which may be considered if you have knee OA. 1) Arthroscopic debridement (“Scoping the knee to clean it out”), 2) Arthroplasty (Joint replacement surgery – “knee replacement”) and 3) Osteotomies (“realignment of the bones”).  Based on all the research in the past 40 years where are we at in 2021 with respect to best evidence? 

1. Arthroscopy (scopes) are very rarely used in 2021 for knee OA or degenerative meniscal tears UNLESS you have a mechanical locking of the joint (see links to articles at end of blog for more information)

2. Arthroplasty (Knee replacements) are the “end-of-the line” treatment for knees with advanced osteoarthritis that have failed every non-operative treatment outlined in the G23 #RiseAbove Personal Health Journey – see www.group23.ca/riseabove )

These surgeries are typically very successful, but note that 1 in 5 patient will still have pain after getting a knee replacement.  

At Group23, our purpose is to deliver positive healthcare experiences and empower individuals to #RiseAbove injury and get back to movement. Understanding your diagnosis (what we call “becoming an EXPERT in your condition”) is a critical part of every Group23 #RiseAbove health journey. Hopefully this article helps answer some of the questions many patients with knee pain have when it comes to deciding if surgery is appropriate for their condition. If you are suffering from pain and would like access to the sport medicine physicians, you can do so by SELF-REFERRAL click here.

Sources

https://www.health.harvard.edu/blog/knee-arthroscopy-should-this-common-knee-surgery-be-performed-less-often-2020042019507 

 http://blog.arthritis.org/news/doctors-patients-say-no-arthroscopy-arthritis/ 

When I ask someone in my office what diet(s) have they tried in the past, the common response is “What haven’t I tried” or “You name it, I’ve tried it”.  Their concern is that they have “permanently damaged” their metabolism. I hear statements like, I’m hear to “fix my broken metabolism” or “all the dieting has ruined my metabolism”. So is this true? Can yo-yo dieting permanently damage one’s metabolism?

As usual, lets look to the science!

 In a study conducted by Wadden and colleagues (1992) at the University of Pennsylvania School of Medicine, they found the answer to this question.

 They took 50 obese females with a mean age of 40 years old and weight and height of 224lbs and  5”2’, respectively. They all consumed 1200 calories at the start of the study and were then randomly assigned to three very low calorie diet groups for 11 weeks.

 These groups were:

 1.      420 calories

2.      660 calories

3.      800 calories.

 After the 11 weeks, each participant consumed a balanced diet of 1000-1500 calories for 5 weeks.

Here is what they found: They found that weight cycling had no effect on metabolism. Moreover, they also found no increases in depression, disordered eating, or percentage of weight as fat.

This means that weight cycling will not metabolically impact the success of a future dieting. That’s good news. However, we really don’t want to weight cycle for other reasons. We want to lose weight and keep it off.  So if the metabolism isn’t permanently damaged with weight cycling, why is it so hard to keep the weight off?

I am only going to address one issue here (and there are a multitude of factors that make weight management difficult). The metabolism will always match the circumstance. When I gain weight my metabolism becomes inefficient, on the other hand when I lose weight my metabolism become efficient. Inefficiency in an energy usage perspective means I use more energy for any given task, including maintaining my body in homeostasis. The opposite is true for efficiency; my body requires less energy to maintain itself. So when we lose weight we require less energy over time, when we gain weight, our bodies will require more energy to maintain. This is why we plateau as we gain weight and we plateau when we lose weight. This is normal, and why diets can be so ineffective. As coaches, that is our job. To help you understand the science of the body but also give you the tools to help manage the circumstances. Lean into the scientific truth, equip yourself with the understanding of what your body does under certain circumstances, and get the tools to help manage these changes. When we lose weight there will be things that will help manage. One of these is exercise. Exercise is one of the best weight management tools we have, not a great weight loser, but a great weight manager.

Research Wadden, T. A, Bartlett, S., Letizia, K.A., Foster, G.D., Stunkard, A.J., and Conill, A. Relationship of dieting history to resting metabolic rate, body composition, eating behaviour, and subsequent weight loss. American Society for Clinical Nutrition, 1992; 56:203S-8S.

This stretch is important for those who sit for the majority of their day.

The goal is to feel it in the front of the hip. If needed, place a soft cushion under the knee. If you need a deeper stretch, lift the back leg up onto a step.

How To: Hip Flexor Stretch

1) With the leg you want to stretch, start with one knee on the ground.

2) Pull your pelvis up and back.

3) Push your hips forward until a stretch in the front of the leg is felt.

4) Hold for 30 seconds, then switch sides.

See the photo below to see a Group 23 physiotherapist performing the exercise.

A CHANGE IN MINDSET WAS ONE OF THE KEYS TO SUCCESS IN ALEX’S STORY.

I met Alex in November of 2018. He was referred to me from a friend of his.  He was always active in his life and ate healthy but felt that his weight wasn’t indicative of all his healthy behaviours. He needed to connect a few dots. He wasn’t interested in doing a diet, and he wanted something he could incorporate into his everyday life.  Alex has busy work life that requires a lot of computer work and sitting; a desk jockey if you will. However, his exercise level is quite high, including in the summer biking to and from work. Through his journey he was able to reduce his weight from 23o to 174 lbs and his fat percentage from 32% to 16%. This his #RiseAbove story.

What do you think was the largest contributor to your weight gain over the years?

There were multiple factors, but I think that the largest impact on my weight gain was the change to a more sedentary type of work. Trying to compensate that, I’ve started increasing my regular physical activity. Now I’m realizing that the balance between that and the eating habits wasn’t quite right.   

There are many factors to your weight loss over the first year. What do you think was the largest contributor to your weight loss?

I would say that there were two main factors.  Firstly, the mindset. Understanding the real necessity of certain habits and deciding whether those actually were indeed important to me. Secondly, the regular exercise and the proper balance between eating and workout activities.

What advice would you give to anyone that is starting their lifestyle change? 

I think there is a need for commitment. It will probably be a long journey, sometimes frustrating, but keeping the goal in mind helps, because it is a nice feeling looking back at the end and see how much you’ve accomplished.  

What do you think will always be a struggle in keeping your weight off?

When I deviate from my daily routines for longer periods of time (vacations, holiday season, COVID, etc.) is when I struggle. So, I need to make adjustments from time to time.

Alex has been able to keep his weight off for two years so far, including some holiday travel and COVID lockdown. Exercising has become much easier and he’s ready to take on spring and summer cycling.  His focus on body fat percentage has changed to frequency of exercising and how far and fast he can cycle. He wants to age well in the season of COVID, work, and the demands of life.  I admire the active life he lives in a world that can sometimes make it difficult. I have seen him connect the dots and has become fitter than he can imagine.  I hope his story inspires you. 

To learn more about how to start your #RiseAbove weight management journey, click learn more below.

KNEE CAP REMOVAL AND UNDUE STRESS DIDN’T STOP MIRIAM FROM REACHING HER GOALS.

Miriam’s story began years ago. While at work, an unfortunate event took place that resulted in a hole in the middle of her patella (knee cap). After a couple of scopes, a knee brace, and pain with every step- the kneecap was removed a year and a half later. After years of not being very active, and gaining weight, Miriam decided in 2008 to start to invest in her health and by 2011, she had lost 47 pounds with us. She felt fantastic and rejuvenated. But the same year, she moved away and took on a very stressful job. It was certainly much more stressful than she could have imagined. We all understand stress can play a major role in our health journey. In fact, the stress was a larger trigger than removal of her kneecap. Slowly, the weight drifted back on. That is what I love about Miriam, she noticed a new trigger yet was bound to learn how to overcome it just as much as she did with knee surgeries. She fought back. She has lost all that weight and ventures to lose more. This is her #RiseAbove story.

What do you think was the largest contributor to your weight gain over the years?

Between 2011-2018, it was definitely work-related stress (and the inevitable food and wine that comes with that!). But other major contributors were some loneliness, some major personal losses, and the inactive periods before having both knees replaced in 2014 and 2016.

There are many factors to your weight loss. What do you think was the largest contributor?

Hands down it was working with Group23 and the Weight and Lifestyle Program. Jason is a fabulous, supportive, and highly knowledgeable coach (and I’d like to also thank Tracy and Ashley for their support). Checking in every week, fine tuning your program, and receiving that level of support is absolutely critical! And it’s so important if you had a discouraging week, since I always leave my session inspired to have a better week ahead.

What advice would you give to anyone who is starting their lifestyle change?

Learn to love yourself, since you need to believe that you are worthy of excellent health and fitness! It is a long journey, but it’s worthwhile. Remember that Group23 is a partner- and they will be with you through every step. Don’t waste energy beating yourself up for getting heavy – none of us can change that, but we can change our future.

What do you think will always be a struggle in keeping your weight off?

I don’t think I will struggle at all for a couple of reasons. I have great ‘tools’ from Group23, and an awesome team with Jason and Chase, my trainer at Winsport. I have also completely changed my environment. I moved back to Calgary, became an avid cyclist (700kms this past summer), and feel both blessed and lucky that I have a home gym, a high energy dog – Spencer – who needs lots of walks, and I have now retired, which frees me to do lots of writing and exercise. Because I feel so healthy, my body feels awful – almost right away – if I eat too much, or have any food that is fatty or sweet. And I always ask myself how much weight do I want to have to haul up those hills when cycling?!

Miriam has learned that weight loss isn’t a number on a scale. She recognizes that weight management is complex and we can’t always predict the future. We don’t plan for broken knee caps and lots of stress. Life happens and we just need the tools to overcome adversity to allow us to be in the best health possible. Miriam is on the other side and has traded her weight number for heart rate and distance goals. On one of her cycling routes, there’s a really steep hill that she calls ‘Lucifer’. The first time up, she had to stop at least three times and was completely winded. By the end of the season, she rode straight up Lucifer and was always the first to the top. I am absolutely inspired by Miriam’s fight to be better every day. We all have our ‘Lucifers’ and I hope Miriam’s story inspires you to climb yours.

To learn more about how to start your #RiseAbove weight management journey, click learn more below.

The offering of telehealth appointments allows for Group23 to be flexible with our patient population and their needs, especially during a time of uncertainty. Read an interview with Lisa, one of our physiotherapists, so see how we can help you reach your goals virtually.

What is telehealth? Telehealth is a visit between you and your healthcare provider. Telehealth uses video conferencing or just audio conferencing to provide a connection between patients and their doctors, physical therapists, psychologists, or other health care providers.

Do you need special equipment? It is suitable for anyone who has access to a landline phone, a cell phone, or tablet or a computer and a reasonable internet connection.

Who would want to use telehealth? There are lots of people who love the opportunity to talk to their provider without coming into the clinic. These reasons could include:

• You don’t WANT to leave your home (you are isolating due to health concerns or poor weather).

• You are UNABLE or not supposed to leave your home (caregiving or quarantine)

• You may not have time to come into the clinic for an update with your practitioner

• You don’t need hands on assessment or care

Many people are waiting for the COVID crisis to end before they take care of themselves. Health professionals concerned that they are suffering unnecessarily. We have no idea of when the COVID crisis might end.

How does someone get a telehealth appointment? Ask at your clinic if they offer telehealth (most do). Book a telehealth appointment. If you are doing a phone call visit, the doctor or therapist will call you at the appointed time. If you are doing a video telehealth visit, the clinic will send you an email with a link to click at your telehealth time. Click the link at the appointment time and your therapist, if not present already, will appear shortly.

Is there anything special about telehealth that you don’t get in clinic? As a therapist you get to see people in their natural habitat. You design home exercises using what people have at home and you trouble shoot the little things that can prevent people from doing the exercises that will make them better.

Does every therapist or doctor do telehealth? Some people like it more so than others. I personally enjoy telehealth. It is satisfying to reach people who otherwise would be waiting in pain and get them started on their recovery. I like that it relies on people to help themselves. Many people are concerned that they will be reliant on the healthcare provider and not be able to help themselves. Sometimes they are frustrated because they aren’t sure HOW to help themselves. A little bit of solid information about what they are experiencing and how they can get better can go a long way to help someone feel less anxiety, use less medication, sleep better, and be more active on a daily basis.

What if you start telehealth but it isn’t what’s best for you? While you are talking to your healthcare provider, it will become clear to one or both of you that it would be best if you came to the clinic. You shouldn’t need to repeat all of history of assessment so your first in clinic visit can be shorter. Telehealth is not meant for those who would best be served with hands on assessment or hands on care.