We are pleased to share this interview from The Bee’s Knees Podcast and KNEE RADIO 1. Podcast host PJ Ewing interviews Nick Garsee from Texas. PJ and Nick explore ‘getting back to policing after TKA”.

Nick had seven surgeries on his knee over the course of 20 years. He was ready for a total knee replacement to get back to a normal gait with no limp. And to eliminate the extreme pain that he experienced during this extended period of time. It finally came down to job performance. Nick had an incident during his police work where his knee gave out on him. At that moment he realized that he could no longer do the job with his knee in its compromised condition. That started him on the road to total knee replacement.

Click on the play button above to listen to the interview with Nick.

This interview is available exclusively on The Bee’s Knees Podcast and on KNEE Radio 1, a new radio station engineered to help the millions of knee surgery patients each year. You can listen to KNEE RADIO 1 right here: KNEE RADIO 1

We call it a “Meta-Blog.” We step back and give you a broad perspective on all aspects of knee health as with this article on ‘Getting Back to Policing After TKA (Nick’s Recovery Story)’.

In this one-of-a-kind blog we gather together great thinkers, doers, and writers. All our work is related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. This is for you if you have a surgery upcoming, or in the rear-view mirror. Or maybe you just want to take care of your knees to avoid surgery. Executive Editor: PJ Ewing

To subscribe to the blog click here.

Two resources for you below to help with knee replacement pain management. Both are email series that we created to help those who need some additional thinking for pre-surgery and post-surgery.

An interview with Henrietta about knee surgery recovery using the X10. As published on The Bee’s Knees Podcast with PJ Ewing.

In Texas they use their knees… a lot. And when one or more knee begins to act up it really gets in the way. That’s what happened to Henrietta who ended up on the X10 Knee Recovery System™ to solve a challenging recovery.

Henrietta explains in this 14-minute podcast episode what the challenges were and how the X10 solved the problems. A great listen for anyone facing a difficult knee surgery recovery. X10 to the Rescue.

Our heartfelt thanks to Henrietta for granting us an interview.

We call it a “Meta-Blog.” In these articles, we step back and give you a broad perspective on all aspects of knee health. We explore surgery and recovery and such subjects as ‘X10 to the Rescue’.

This is a one-of-a-kind blog. We gather together great thinkers, doers, and writers. And it is all related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, and patients. And as many smart people as we can gather to create useful articles for you. You may have a surgery upcoming. Or in the rear-view mirror. Maybe you just want to take care of your knees to avoid surgery. In all cases you should find some value here. Executive Editor: PJ Ewing ([email protected])

An interview with Ed Bard (Two Times X10 Alumnus)

Air National Guardsman, Ed Bard, has two knees… that got a bit worn over the years in deployments to Bosnia and Iraq in addition to regular duty. He used the X10 to 1) solve a tough right knee replacement recovery in 2016, and 2) make it a quick recovery for his left knee in 2019.

Maryland Air National Guard units are considered to be Air Reserve Components (ARC) of the United States Air Force (USAF). Maryland ANG units are trained and equipped by the Air Force. They are operationally gained by a Major Command of the USAF if federalized. In addition, the Maryland Air National Guard forces are assigned to Air Expeditionary Forces. They are subject to deployment tasking orders along with their active duty and Air Force Reserve counterparts in their assigned cycle deployment window.

As state militia units the elements of the Maryland ANG are subject to being activated by order of the Governor. They provide protection of life and property, and preserve peace, order and public safety. State missions include disaster relief in times of earthquakes, hurricanes, floods and forest fires. Additionally they provide search and rescue, protection of vital public services, and support to civil defense. (Source: Wikipedia)

Our heartfelt thanks to Ed for granting us an interview. At X10 Therapy we are committed to helping as many U.S. Military Veterans as we can get back to their lives after knee surgery. We hope you enjoy our interview with Ed Bard above.

We call it a “Meta-Blog.” In these articles we step back and give you a broad perspective on all aspects of knee health. We explore surgery and recovery and such subjects as ‘National Guard Knee Replacement’.

This is a one-of-a-kind blog. We gather together great thinkers, doers, and writers. And it is all related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, and patients. And as many smart people as we can gather to create useful articles for you. You may have a surgery upcoming. Or in the rear-view mirror. Maybe you just want to take care of your knees to avoid surgery. In all cases you should find some value here. Executive Editor: PJ Ewing ([email protected])

by PJ Ewing (The Bee’s Kees Podcast)

We sit down with X10 Coach Erin Rempher to learn about this new means of helping knee surgery patients quickly recover and get back to their lives. Erin describes how she found X10 and how it has changed the recovery path of the X10 patients with whom she works.

To listen to the interview click the Play Button above.

Erin joined the X10 team in 2017 bringing her knowledge of knee recovery from nine (9) years of work in physical therapy, from work as a technician to working as a Physical Therapist Assistant.

Erin’s work as a PTA took her from Michigan to Texas and back again. She spent time in skilled rehab centers, home health care, and outpatient therapy. Across the country one thing never changed –  the feeling of frustration. It was hard seeing so many of her patients struggle immensely during total knee replacement recovery. “I knew there had to be a better way to do this,” and that’s when she found X10.

Intrigued and excited, Erin came onboard as an X10 Coach and is supporting and motivating patients on their journey through a faster, less painful, recovery with The X10 Knee Recovery System™.

You can read Erin’s article about Knee Replacement for a Younger Population here.

To learn more about X10 click here.

Read new research about The X10 as compared to the CPM machine by clicking here.

To listen to more podcast episodes from The Bee’s Knees Podcast, click here.

We call it a “Meta-Blog.” In these articles we step back and give you a broad perspective on all aspects of knee health. We explore surgery and recovery and such subjects as this ‘Interview with X10 Coach Erin Rempher PTA’.

This is a one-of-a-kind blog. We gather together great thinkers, doers, and writers. And it is all related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, and patients. And as many smart people as we can gather to create useful articles for you. You may have a surgery upcoming. Or in the rear-view mirror. Maybe you just want to take care of your knees to avoid surgery. In all cases you should find some value here. Executive Editor: PJ Ewing ([email protected])

We are so pleased to share this interview from The Bee’s Knees Podcast and KNEE RADIO 1. Podcast host Mary Elliott interviews orthopedic surgeon Dr. Meredith Heisey about her need for a knee replacement, her recovery with the X10, and women in medicine. A fascinating talk.

Dr. Heisey is a fellowship-trained surgeon specializing in the treatment of Sports Medicine, Shoulder, Knee and Elbow conditions. Dr. Heisey believes that her caring bedside manner and approachable personality provide the opportunity to develop a special rapport with her patients. Consistent, clear communication and education are the key components that allow her to build lasting relationships with patients and their loved ones. This approach allows for informed and shared decision-making to achieve customized solutions and a more satisfactory healing process.

Dr. Heisey is active in clinical research and is the team physician for Lansing Community College. She is involved in teaching in the Michigan State University/McLaren Greater Lansing orthopedic surgery residency program.

LISTEN NOW

This interview is available exclusively on The Bee’s Knees Podcast and on KNEE Radio 1, a new radio station engineered to help the millions of knee surgery patients each year. You can listen to KNEE RADIO 1 right here: KNEE RADIO 1

We call it a “Meta-Blog.” We step back and give you a broad perspective on all aspects of knee health as with this article on ‘Dr. Meredith Heisey.’

In this one-of-a-kind blog we gather together great thinkers, doers, and writers. All our work is related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. This is for you if you have a surgery upcoming, or in the rear-view mirror. Or maybe you just want to take care of your knees to avoid surgery. Executive Editor: PJ Ewing

To subscribe to the blog click here.

Two resources for you below to help with knee replacement pain management. Both are email series that we created to help those who need some additional thinking for pre-surgery and post-surgery.

We are so pleased to share this interview from The Bee’s Knees Podcast and KNEE RADIO 1. Podcast and radio host PJ Ewing interviews PTA Kaitlyn Gelen from X10 Home Health.

Kaitlyn Gelen is a PTA in Michigan who works for X10 Home Health, a home healthcare company in Michigan. She has been interested in helping people from a young age. Kaitlyn is a graduate of Baker College (2015). She worked very closely with orthopedic surgeons and physician’s assistants on the orthopedic floor of William Beaumont Hospital for five years. Kaitlyn has also had two ACL reconstruction surgeries (2016, 2020) in her past and knows first-hand what her knee patients are going through.

LISTEN NOW

This interview is available exclusively on The Bee’s Knees Podcast and on KNEE Radio 1, a new radio station engineered to help the millions of knee surgery patients each year. You can listen to KNEE RADIO 1 right here: KNEE RADIO 1

We call it a “Meta-Blog.” We step back and give you a broad perspective on all aspects of knee health as with this article on ‘Home Health with X10 Therapy.’

In this one-of-a-kind blog we gather together great thinkers, doers, and writers. All our work is related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. This is for you if you have a surgery upcoming, or in the rear-view mirror. Or maybe you just want to take care of your knees to avoid surgery. Executive Editor: PJ Ewing

To subscribe to the blog click here.

Two resources for you below to help with knee replacement pain management. Both are email series that we created to help those who need some additional thinking for pre-surgery and post-surgery.

We are so pleased to share this interview from The Bee’s Knees Podcast and KNEE RADIO 1. Podcast host Mary Elliott interviews a knee replacement patient about her journey to success. Here you can learn about making a knee replacement work for you.

Dr. Mayo is Board Certified by the American Board of Orthopaedic Surgery. He is a member of the American Academy of Orthopaedic Surgeons, American Association of Hip and Knee Surgeons, Michigan Orthopaedic Society, Detroit Orthopaedic Academy, Health Volunteers Overseas, and the National Osteonecrosis Foundation. Currently, he is on staff at William Beaumont Hospital in Royal Oak, MI where he has been involved in clinical research. Dr. Mayo is also active in the education and training of residents in orthopaedics, medical students, and other health care professionals.

For More About Dr. Mayo: Dr. David Mayo

This interview is available exclusively on The Bee’s Knees Podcast and on KNEE Radio 1, a new radio station engineered to help the millions of knee surgery patients each year. You can listen to KNEE RADIO 1 right here: KNEE RADIO 1

We call it a “Meta-Blog.” We step back and give you a broad perspective on all aspects of knee health as with this article on ‘Making a knee replacement work for you’.

In this one-of-a-kind blog we gather together great thinkers, doers, and writers. All our work is related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. This is for you if you have a surgery upcoming, or in the rear-view mirror. Or maybe you just want to take care of your knees to avoid surgery. Executive Editor: PJ Ewing

To subscribe to the blog click here.

Two resources for you below to help with knee replacement pain management. Both are email series that we created to help those who need some additional thinking for pre-surgery and post-surgery.

My name is Sandra, and I had a total knee replacement first on my left knee and then on my right knee a few months later.

In my late 40’s I was involved in a car accident that severely damaged my right knee. I was told to hold out as long as possible as new prostheses and better techniques were in the horizon for total knee replacements.

For the past fifteen years, I have tried countless approaches to avoid the surgery. This past year was the final turning point for me. My left knee which I called my “go to knee” had started to fail. I was waking up every 2-3 hours at night with unbearable pain in the left knee.

I could no longer walk more than 10 minutes and needed to rest. My love for exercising became extremely limited. I could no longer stand and cook, play on the ground with my granddaughters or enjoy any traveling experiences.

The quality of my life was diminishing in front of me.  My ‘moment of truth’ had arrived.  I am thrilled I was able to wait until 63 years of age before having my first total knee replacement in early summer.

My first order was to research and find the right surgeon for me. I took this order very seriously and saw four doctors before making my decision. Not everyone thinks alike and it was interesting but confusing to hear differences of opinion. I learned something new and was better informed from each office visit.

I found Dr. Mark Karadsheh to be the best choice for me. He is highly approachable, progressive and really listened when I asked questions. He explained why he was not in favor of not doing two knees at the same time. I wanted to move on as quickly as possible but so grateful I did one knee at a time. I really needed the support of the opposite knee for a strong recovery. I waited three months between my first and second surgeries. Although I am younger and healthy I could not imagine doing a bilateral surgery.

Dr. Karadsheh is all about the patient getting the best result possible.  He explained the benefit of using the X10 machine for pre-surgery and rehabbing the knee. I love finding ways to get the best results possible, and welcomed the opportunity to use the machine. The machine was delivered to my home three weeks before my first surgery and was returned to my home before the second surgery. It is also very helpful that I have an X10 coach that I could call if any questions arise. I love using the machine and tracking my progress before and after both surgeries. I have found the X10 to be fun, easy to use, and allows me to work day or night to speed up my recovery time. It has especially helped in regaining my extension/flexion in a very short period of time. I returned to 0/130 after my first surgery in two weeks! Three weeks after my second surgery I am at 0/122. The second surgery was harder because I had more swelling and pain, but my family and friends still marvel at how quickly I am progressing.

You must be invested in your recovery if you want a great outcome. The surgeon has done his part and the ball is in the patient’s court for the final outcome. The tools are all there for success. I am grateful that the X10 was available at this time of my life as it was not available fifteen years ago. It is even more wonderful that my insurance company sees the value and covers the cost! The X10 along with in- home, outpatient PT, and a great surgeon are allowing me to regain the quality of life I had lost.  I am on the road to pain free, cooking, exercise, travel and play time with my granddaughters. No one needs to settle for pain and discomfort any more. Join me by staying positive and working hard for what you want to achieve.

One knee replacement down, and the other is well on it’s way.

To watch a short video of my story, One Knee Replacement at a Time, click on the play button below.

We call it a “Meta-Blog” because we step back and give you a broad perspective on all aspects of knee health, surgery and recovery.

In this one-of-a-kind blog we gather together great thinkers, doers, writers related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. Whether you have a surgery upcoming, in the rear-view mirror, or just want to take care of your knees to avoid surgery, you should find some value here. Executive Editor: PJ Ewing ([email protected])

By John McKay, RN

From the moment we take our first health class in elementary school we are taught how to take care of our bodies to live a happy, healthy life. We all know the basics: drink plenty of water, eat your fruits and vegetables, and get outside for some cardio a few times every week. Of course all of these things are important. But there is another major indicator that is key to longevity that many people don’t know about: leg strength.

The advancements our medical community has made is nothing short of remarkable. We have medications, surgeries and therapy’s. These can cure or treat almost every injury or disease mother nature can throw at us. But outside of taking a pill or having an operation, an increase in leg strength can increase how long you live as well as your quality of life as you age.

A 2010 study set out to find the correlation between muscle mass, muscle strength, fat mass and physical function. The study included 1,280 adults over the age of 55. In the study it was found that the leg strength and fat mass were equally the best predictors of physical function and mortality in older adults (Bouchard, et al, 2010). This may seem surprising to some. But the stronger an individual’s legs are, the more likely they will be to participate in cardiovascular activity, hence improving overall health. Looking to get into better overall cardiovascular health?  The results of this study suggest improving your leg strength would be a great place to start.

Now let’s discuss falls. Unfortunately, falls are a serious issue as we age. Of course, environmental hazards like rug or a cord pose a risk for an individual to trip and fall, but more often than not, falls are caused by personal risk hazards. Of these factors, the two largest risk factors are leg weakness and poor balance (which is typically prefaced by weak leg muscles). Many individuals with these risk factors may also have other comorbidities that would make recovering from a fall far more difficult.  So not only do weak leg muscles make it more likely that someone will fall, it will make the recovery from that fall far more challenging.  This is a perfect example of why X10 patient’s have such great results when they’re able to strengthen with our prehab program.

One study that focused on the loss of quadriceps strength after a knee replacement (TKA) found a 62% postoperative decrease in patient quad strength compared to before surgery (Mizner, et al, 2005). This is the reason behind prehab.  Every patient will experience a loss in muscle strength and flexibility after surgery.  However, the more strength and flexibility one is able to add prior to surgery, the better off they will be after surgery.

Finally, and perhaps most surprisingly, just last year a study was published showing the association of muscle mass, strength and all-cause mortality with adults in the United States. The study followed 4449 individuals, all over the age of 50. The results of the study found that low muscle strength was independently associated with an elevated risk of all-cause mortality.  This includes metabolic syndrome risk factors (Li, et al, 2018). Metabolic syndrome risk factors include high blood pressure, high blood sugar, and abnormal cholesterol levels, which all increase the risk of stroke, heart disease and diabetes. In other words, a patient’s muscle strength is a good indicator of how long they will live. This is regardless of an individual having any of these other risk factors. So be sure to get that strength training in!

This research demonstrates the critical role leg strength has not only in our day-to-day lives but in planning for happy healthy lives in years to come. These results show how important it is to build strength and take care of ourselves. Happy strengthening!

We call it a “Meta-Blog” because we step back and give you a broad perspective on all aspects of knee health, surgery and recovery and such subjects as how to live longer.

In this one-of-a-kind blog we gather together great thinkers, doers, writers related to Knee Surgery, Recovery, Preparation, Care, Success and Failure. Meet physical therapists, coaches, surgeons, patients, and as many smart people as we can gather to create useful articles for you. Whether you have a surgery upcoming, in the rear-view mirror, or just want to take care of your knees to avoid surgery, you should find some value here. Executive Editor: PJ Ewing ([email protected])

Constant pain in the front and center of your knee. The inability to bend your knee into a crouched position. Not enough leg strength to stand up from a crouched position. Does this sound familiar? If so, there’s a chance you may have Patella Baja.

Patella Baja is a condition where the knee cap is positioned too low. It can make bending your leg past 90 degrees difficult to impossible. As if this lack of mobility isn’t bad enough, it will also usually lead to weak leg muscles. More specifically, weak quadriceps muscles.

With your knee cap sitting so low, the tendon above your knee is constantly being stretched more than it should, just to reach your knee cap. When you bend your leg farther and farther, it continues to stretch that tendon even more, and eventually it just refuses to stretch any more, usually around 90 degrees.  If your leg can’t bend past 90 degrees, then any leg exercise you might do is only going to be strengthening over a limited range of motion. This may allow you to fairly comfortably sit up from a high seated-chair, but crouching down to pick something up isn’t an activity you would attempt in your wildest dreams.

People who have had previous knee injuries, from bone fractures to tendon/ligament tears, are at an increased risk of developing Patella Baja. You may think you’re out-of-the-woods if you’ve had a TKA (Total Knee Arthroplasty), but that’s far from the truth. Surprisingly enough, people who have had a total knee replacement have a higher increased risk of developing Patella Baja. Studies have found that the prevalence of the condition occurs in anywhere from 25-34% of TKA patients. This typically starts a month after surgery, and progressively worsens for up to four (4) years post-surgery.

Lois' left knee has added up to more than $300,000, at least. And this knee has occupied more than 10 months of her life so far. Listen to Lois' story here.

Bucket Handle Meniscus Tear (Solving the Recovery). Learn how Patrick solved the MUA, Manipulation Under Anesthesia, and these injuries using The X10 Knee Recovery System.

We share an interview with Gina who had a tibial plateau fracture recovery with the X10. She started on the X10 ten weeks after the surgery when she was very disappointed with her recovery. Within two weeks she solved her knee surgery recovery problem.

People talk about self-driving cars. That's all part of robotics and is incredibly interesting. It’s important work that Elon Musk and others are doing in that area. This knee robot, unlike self-driving cars, which is really technology for the future, it's already there.

What often happens is after an individual has a TKA, they go through at home and clinical physical therapy. Once that is complete, after typically 4-8 weeks, they return to a mostly sedentary lifestyle. The longer they are inactive, the weaker their quadriceps muscles become. And the farther their knee cap will continue to drop. After a while the knee cap drops so far that the quadriceps tendon is overly stretched. Then it won’t allow the knee to bend much farther than 90 degrees, sometimes not even that far. Once their range of motion becomes limited like this, their strength just continues to diminish, making the likelihood of regaining adequate range of motion even smaller. So, one problem causes another problem, and so continues this vicious cycle.

TAKE THE X10 QUIZ: A quick Flashcard approach to learning about X10 and the knee surgery recovery challenges that X10 solves.

Avoid MUA 12 Weeks Post Surgery (Dianne's Story) | From X10 Therapy | Available in 23 states solving difficult knee surgery recoveries.

Avoid Manipulation Under Anesthesia (12-weeks after knee replacement). Dianne in Oklahoma, facing MUA after her knee replacement... avoids it with X10.

Knee Replacement Recovery for Women: Your Guide to Strength & Renewed Mobility - Meet Susanna | The Bee's Knees Podcast.

We have done some research recently on the incidence of MUA after TKA: Women This is considered a Literature Review.

Discover how Robert Douglas overcame multiple knee surgeries using the X10 therapy device, expert coaching, and faith.

We examine the Continuous Passive Motion machine for knee surgery recovery. Robert Salter (MD) and John Saringer (an engineer) commercialized the CPM in 1978. Extensive research and clinical references included here.

Mindy Avoids Manipulation Under Anesthesia in Michigan. At six weeks post surgery things were definitely not looking up. Problem solved, MUA Avoided.

Protective Muscle Spasm | What to know | How it Works | Physical Therapist Solutions to this pervasive problem.

Mari's Knee Flexion | Solving Knee Recovery | Solving Knee Flexion with the X10 Knee Recovery System.

The new X10 patented technology provides an increase in flexion after standard physical therapy has failed. The X10 is not surgical, does not require anesthesia, is not painful, and does not require additional physical therapy upon completion.

Managing a Difficult Recovery | An interview with PJ Ewing on the radio program Solutions for Seniors. The Bee's Knees Podcast.

Avoid Manipulation Under Anesthesia with Therapist Halima Curry | The Bee's Knees Podcast

How to Avoid MUA | A Patient Recovery Story About Knee Manipulation Under Anesthesia and Two Knee Replacements. Nicole's Story.

The last thing she expected were knee Manipulation Under Anesthesia complications... in Lois' case a patellar tendon tear. A lady with a great attitude and a fascinating life story this is Part 1 of a two part interview.

2,500 Miles For Knee Recovery, Rick's incredible story of recovery from total knee replacement. Sometimes it takes great lengths to get that knee to bend.

We are pleased to share this interview from The Bee's Knees Podcast and KNEE RADIO 1. Podcast host PJ Ewing interviews Larry Sallings from Texas. PJ and Larry explore getting back to life a year after TKA.

The total knee replacement (TKA) was on December 3, 2019. By mid-January, it was apparent that the recovery had stalled. On February 4, 2020, two months after his knee replacement, at only 88º of flexion, Gary started on X10.

Both of my knees were injured on 9/11. I was crushed in Tower Two when it collapsed. I had immediate surgeries, right after 9/11. On August 21, 2019, I had my left knee replaced. It was robotic surgery. Everything went well with the surgery and the replacement, but the recovery was a different story.

Although there is no known method of reversing Patella Baja once you have developed the condition, there are ways of treating it, and even better, ways of preventing it from happening in the first place. Promisingly, studies have found that regimented daily stretching and strengthening routines can bring back much of, sometimes even all of, the range of motion. Increased flexibility will continue to improve their strength. And with good strength and flexibility, the person can live an active, normal life.

In order to avoid developing Patella Baja after TKA, take the same steps as you would to rehab it. Patella Baja after TKA usually occurs due to inactivity. By staying consistent in your strength and mobility routines, you will almost surely avoid developing the nasty condition. As with most injuries that result in pain or swelling, post-exercise icing and elevating can go a long way during the rehab process as well.

One mistake people with knee problems often make is only working to improve either their range of motion OR their strength. If you only work to improve your range of motion, your quadriceps may remain unable to support you. In this instance your condition will see very little improvement. If you only work on strengthening your quadriceps, they will get stronger, but you may end up with less  flexibility. The key is to consistently stretch and strengthen. And, over time, your condition can improve markedly.

If you think there’s a chance you may have this condition, run it by your doctor before attempting to treat it. This is because other types of knee injuries can have similar symptoms but very different forms of treatment.