Karissa Simon 0:08
Welcome, everyone to our third episode of the resource roadmap show. I’m Karissa Simon. I’m your host, I am an OT with 10 years of experience. And this is our OT team, Johnny Rider and Megan Wilkinson. They are our writers and they’re the creative minds behind the resources that we are sharing each month here. So if you don’t know about our show, we talk about the resources that are released for therapy insights each month, will offer you guys some practical suggestions on how to use them give you some examples of how you can use them with your patients, give you a little bit of background about them. We’ll also discuss some resources each month and how you can focus your treatment on being more research based. So you can access these resources and hundreds more at therapyinsights.com. And if you have any questions or suggestions for us, we’d love for you to reach out at email@example.com, we would love to be able to discuss your questions here on our show, and give you a little more information to help you out. So with that, we are going to get started. Just as a quick reminder, we are offering this for a AOTA approved CEU credit. And you would just have to go to therapyinsights.com and click the episode and you would take a quiz, and then you get your certificate. All right. So I think we’re ready to get started with our first resource.
Karissa Simon 1:45
So the first resource we have this month is called Grooming Nails. It is one page and has some nice pictures of different adaptive equipment you can use for nail grooming. And I’m going to turn it over to Megan to tell us a little more about this resource.
Megan Wilkinson 2:02
Yeah, so I think this is a great resource. I love a one page handout, you know something really easy to just get some information off to our patients or their caregivers, supporting our education as well. I think grooming nails is one of those ADLs that there’s kind of some controversy over whose role it is sometimes in certain settings, right? Between nursing and an OT. But this is something that is important for us to definitely have an understanding of especially in the realm of adaptive equipment, which this first section goes into. How can we support our clients that you know, have hemiplegia or have balance conditions or weakness? How can we make sure that this is something they’re still doing because hygiene related to nail care is so important and can lead to some pretty severe consequences if it’s not taken care of. In especially, I feel like in the hospital settings, those things can kind of get really long and dirty. So we really want to be taking care of our nails. And this is a great handout to kind of talk about some of the adaptive equipment that can be used. These long handled toenail clippers is the first piece that we’re talking about. And this just allows them to really reach down and get, get to the toes without having to necessarily bend over. And to reach them it has a little button to be able to act and activate the mechanism makes it pretty simple. There’s also several different nail clippers like a tabletop one, the automatic nail fingernail clippers are excellent. They can be a little bit expensive. But for someone who has a vision or cognitive issues, which this is two really important aspects that we need to be thinking about with nail care is those who have cognitive deficits or vision vision deficits and how are they going to be able to take care of that the automatic nail clippers are really awesome for that because they have a guard on them so that if one safety is a concern maybe with with cognition, they can just put it in there and the clipper basically does it for them. And same thing with with a vision deficit as soon as they kind of figure out the device, they can very easily put their finger in there and the nail cover does it for them. So that’s a great one if if it’s affordable. There’s also some really awesome do it yourself options. I’ve seen a lot of people get really creative OT that’s our specialty, right? You know, if they’re not being supported in the financial area okay, let’s make it up. We got this we can figure this out. And the there’s a wonderful QR code on this that has a wonderful human on YouTube who has a C5 spinal cord injury and he shows just this really wonderful creative way on how he is able to clip his nails with that injury. And then the second section is looking at more, less adaptive equipment and more modification that you can be using in order to, to clip your nails. So talking about with low vision, which is one of the things we touched on already keeping them short more often like that way you can really use touch to to figure out where you’re kind of at. And then using more of a nail file instead of clippers. So if you’re frequently going back with the nail file, instead of using the sharper clippers, less likely to have injury in that strategy, so there’s several different types of strategies for for many different reasons that we might come upon for grooming nail.
Karissa Simon 5:38
I love the idea of the automatic fingernail clipper, I don’t think I’ve ever seen a patient with it. But I love that idea of providing them with, I guess safety, because they can’t cut themselves. Especially I know, our older populations or populations with diabetes, like any kind of little injury on the fingernail or toenail can cause such major health problems. So I love that idea. I’m sure it’s the most expensive option, of course, but it’s just such a cool thing that someone came up with.
Johnny Rider 6:10
I actually remember the first thing that I ever had to modify in real life as an OT after school was a tabletop nail clipper. And so I think it’s awesome that they have pictures too. And we can show them before we go down that road, whether we’re going to modify it for them, or we’re going to purchase a piece of equipment. I appreciate that you kind of mentioned that there are some other things like maybe we could recommend manicures, but I still remember being in a skilled nursing facility. And people having difficulty with that and us talking about it. And I remember this nurse came it’s like, well just go get a manicure. And we have to remember that not everyone can afford that. Or I worked in an area where we were kind of out in the middle of nowhere, we were in a rural area. So it wasn’t like there was an opportunity to go get that. And so if this is important to our clients here, we have other options, we can explore with them, and all levels of cost as well. So I think this is a great resource to educate our clients, maybe even some caregivers as well.
Karissa Simon 7:06
Yeah, nail care. it’s just so important to prevent infection and injury, disease. What people get when, when you have people who are wiping themselves and they’re not doing the greatest job and you’re getting stool underneath the nails, it’s kind of a great idea of something that that you should be addressing with them.
Karissa Simon 7:27
Well, thank you guys so much. Let’s move on to our next resource for the month. Which is Wheelchair Management in the Snow. This is a two page document that has a picture of the wheelchair skis on it. And, Megan, can you tell us a little more about this resource?
Megan Wilkinson 7:50
Yeah, so I being someone who recently moved to the Midwest from the south, this has been a major consideration for me, I live in a place that’s very walkable. And I definitely have noticed that maybe things are not as thought out for our wheelchair using friends they they clear the the ways for walkers, but maybe not so much people in wheelchairs. And so this is something I’ve really been spinning with since I I’ve moved up here. And being able to kind of dive into this piece was really fascinating for me, because it was talking about there were so many studies that were talking about how people in wheelchairs, it talks about needing 80% of individuals using a mobility device need more assistance during the winter. And if you go further into that research, most people just don’t go outside. And so as OTs this is just a really, really important thing for us to be addressing. And this is a broad scope, right? I mean, this is just touching on kind of the surface of like, how do we make sure that we’re getting out and participating in all those different types of things. But one of the biggest limitations is mobility, and the ability to get out in those winter months and when that type of weather comes through. And so the piece kind of goes between manual wheelchair versus a power wheelchair, which those the stresses on the chair is very different. And a manual versus a power. Power wheelchairs do struggle significantly more out in in a wet cold environment, understandably so. So it goes into talking about safety precautions and preparation and that’s like 90% of the resource because before they even go out into the snow. There’s all these things we need to be thinking about before you’re entering that weather. So making sure that you have a support system if your chair gets stuck, you know, having someone with you is obviously the best answer but if you are trying to do something on your own have no one to come with you make sure that you’ve let somebody know, hey, I’m, you know, going down the street to the grocery store to get some groceries and I, you know, I should be back in an hour and, and I can call you if something happens kind of thing. So making sure you have a support system because getting stuck in the snow is not not a good thing in these conditions. And then as I kind of mentioned, it talks about the lack of accessibility, I had seen several studies when I was doing this talking about how sometimes the plows will actually move the snow from the parking lot into the wheelchair accessible parking spots. And so to just expect that what you may have been accustomed to, with getting used to your condition or your mobility in other months might be a little harder going out into the community. You know, I think education as an OT on this front to like just telling people about what this looks like for people in wheelchairs, caregivers, everyone that’s connected to these people so they can have expectations and understandings of how different these months can look. Tuning up the wheelchair before you go out into the snow, or before the winter comes. Making sure that you know everything is tightened, everything’s cleaned, just ready to go. Because it’s just going to be harder on the chair period. Making sure you have warm clothing, especially gloves if you’re both for manual and power wheelchairs, but especially manual because your hands are down there and potentially getting sprayed with that kind of like slushy ice cold stuff onto your hands. And so really good, warm gloves is excellent, making sure you have emergency stuff with you if you need it. And then it details a lot of special power chair considerations like making sure your battery is full because the battery is going to drain faster in the cold. And then for both manual and power chairs, it’s really important that they give either they or a caregiver gives the chair a kind of cleaning after they come inside. Because a lot of times we use rock salt to clean off the sidewalks and so then that is spraying up all over your chair and that will rust the chair and make it break down a lot quicker. So we really want to make sure that your equipment is lasting a long time. And then there’s these awesome pieces of equipment that you can add into your or onto your wheelchair to make it a lot easier to navigate over the difficult terrain. So all terrain tires are awesome. They really make it easy to go over different types of terrain. So not only the snow, but also like sand and some of those types of more difficult, excuse me, terrains that you might be going over, if you’re someone who likes to hike with family, get outside, maybe there’s gravel trails, like those all terrain tires are also beneficial during those types of situations. And then these traction skins are incredible. So they just go over the outside of the wheelchair. And they like whatever standard wheelchair you have, they add traction to the wheel to the tire. And so it makes it so that you’re not slipping all over the snow. And so very easy kind of on off, you’re not paying for the full wheelchair or like the all terrain tire not paying for the full tire. This just goes over the top of your chair already. And then we’ll blades these skis that you can kind of see on the picture if you’re watching on YouTube. They just secure to the front and it puts your tear on skis. And I just think that’s such a fun little addition to be able to kind of increase your your mobility and be participating in these winter activities.
Karissa Simon 13:44
I love the idea of the wheel blades. I also have moved to a very snowy area recently. And I’ve had to kind of like deal with this because people just don’t stop here when it snows like people are still going out. There’s a gentleman I noticed every day in my town who is getting out with his power wheelchair and the days that there are like feet and feet of snow. I’m very lucky my town like clear sidewalks everytime as soon as it’s snow. So he’s still out and about. And I have wondered like is that good for his power wheelchair? Obviously, it’s not. But who would have thought about like wiping off the wheelchair even when I lived in a less snowy area. Like patients who would go out every day to smoke and they would wheeled themselves out. They were still encountering like that salt. I’m bringing it back in. And sure it damages the wheelchairs quicker and we all know you have to wait five years for Medicare. So this is like very important that we keep these wheelchairs in good shape for people as long as possible.
Johnny Rider 14:51
So I actually have run a wheelchair clinic for many years and still do complex rehab technology. So what I’ve noticed though in the pig picture because everything on this is great as some therapists, some OTs are kind of a little bit uncomfortable with wheelchair stuff, and they know the basics. But I think the benefit of this handout is, you realize that you don’t have to know everything about the wheelchair to still provide a skilled service and to help your client. And this demonstrates that you can use this handout to have the discussion about the everyday uses and the concerns. The safety with this, and this gives you some of those pieces you may not be familiar with, like different kinds of tires, traction skins, wheel blades. But ultimately, we’re addressing something like safety, which we’re all doing everyday, we’re addressing that fear of going outside that occupational injustice, where they’re not able to engage in their community and complete their IADLs, which commonly happens with this type of weather. So I hope that, you know, occupational therapists and therapy practitioners who are a little bit uncomfortable with, you know, wheelchairs can realize from this handout that, hey, even if I don’t know what every piece is called, or know how to adjust everything, I still have something to offer from that perspective as a therapist, as a practitioner, but even some little things that we don’t consider is how is the fit going to be affected if they are wearing these big heavy coats or snow pants? And and how might that change the breakdown or the potential breakdown of skin? Those are those conversations that when we start talking about this, that that comes up as well. And here we are providing a very skilled service and helping them be more independent and more safe with their daily activities.
Karissa Simon 16:39
I love that. Thanks, Johnny. Okay, and let’s go to our next resource. Vehicle Modifications and Adaptive Equipment. This is a two page handout. It has some pictures of different adaptive equipment. And Megan, can you tell us a little more about this?
Megan Wilkinson 16:58
Yeah, so in my work in neuro driving is one of the first conversations that I feel like is brought up even when we are not even close to ready to be having that conversation. But it’s, it is a very real fact that it is independence for a lot of people, right? Being able to take yourself somewhere by yourself when you want to, and is is huge. And there’s a lot of anxiety, I think, related to not being able to have that ability after having a significant injury or condition. And so this handout really talks about one it’s a good path in education, because I feel like there’s so many questions about well, how do I make sure that I can get back on the road, even if you think they’re fully going to be capable of returning to driving? It’s not just like, Yeah, okay, see, like, here’s the keys, it doesn’t work that way. And so this talks about working with certified driver rehabilitation specialists, and how they are trained extra, and it gives all of these wonderful QR codes and links to being able to find a CDRs in your location. So an OT can give that resource to their clients and say, Hey, like, let’s scan this, and let’s look and see who’s in your area and get you hooked up. So they have that resource when they’re leaving you or as they’re starting to leave you or however that’s going. And at the end, it also has some good links talking about funding because a lot of the modifications to vehicles are costly. But there are also a lot of options for funding. And so again, lots of questions about it. And I feel like this handout does a good job of, of kind of dipping the toes into to discussing some of those things. And so first entering and exiting the vehicle. This is actually one of the most challenging aspects for someone who is in a wheelchair, being able to enter a standard vehicle, especially if it’s someone who like uses their chair regularly so like they don’t they they aren’t able to ambulate to and from and use it sometimes it isn’t all the time then like someone who has a spinal cord injury, for example. Because you you have to have space for that you have to be able to safely navigate all of that there’s a lot of aspects to that. And so this has a couple of different options it talks about a drop floor minivan and how you enter an exit there’s a front entrance and a side entrance and all these different options for that the comparing a folding ramp for your vehicle versus an in-floor ramp for your vehicle and what the pros and cons are there. So in-floor ramp is more hidden, it’s quiet, it doesn’t take up as much room in the vehicle. But it also requires more maintenance. And so being able to kind of balance like what do we want to do, what’s the best options here. And then the EZ lock docking system, it dives into that a little bit too. And this is being able they remove the driver’s seat from the vehicle, and you’re using the ramp in your wheelchair to drive straight into the driver’s seat and your wheelchair is modified. So it locks in to the floor of your vehicle. And you are like very sternly locked into your car and you just roll in and you’re in your wheelchair. But that’s not always maybe the safest option. You know, again, we’re looking at all these different possibilities, what works best for the client, what are what is the client able to afford, and also what are they the most comfortable with. Then there’s also the power transfer, seat base. And so you, they roll in in their wheelchair, and then the chair or the vehicle chair moves so that it can rotate, and they can do a very smooth, easy transfer to the driver’s seat, and then it just flips around for them to be in the right spot. So there’s a nice place for the wheelchair, it’s an easy transfer, instead of moving from, you know, transferring from the road into the vehicle. That nice parallel transfer there. And then it also discuss the wheelchair lifts for pickup trucks, that’s a really popular modification, because it’s a nice place to store store the wheelchair. And I think coming from from the south, I feel like 50% of people have trucks. And so that was something I dealt with all the time. And then going into the steering and dashboard controls. So all sorts of different types of knobs. A Bluetooth knob is excellent because it also can control the turn signals, the windshield wipers, it has the horn on the knob and they’re not moving their hand wants from that knob to be able to control those things. A turn signal crossover moves the turn signal to the other side of the car for someone who might only have one upper extremity to drive the steering wheel. So this is actually a really good combination with a knob having the the turn signal crossover and the knob together. And then talking about accelerating and braking. So for people who only have the function of one lower extremity extremity, or someone who has a spinal cord injury and has no function in their lower extremities, how do you accelerate and break a car. So you can actually move all of that up to hand controls, and have everything be up at the steering wheel area. And then you can for like someone who has a stroke, you can do left foot acceleration and move it from the right side over to the left, pedal extensions for someone who might have a shorter stature, and then there’s lots of high tech driving options that there is actually an additional, like bonus certification for the CDRs to be able to do high tech stuff. There’s some crazy stuff out there that they can do to vehicles, and you need a lot of extra training to be able to do this. And that’s the interesting part about this is for individuals that you know, have had that stroke or brain injury or spinal cord injury later in their life, and they’ve been driving for a while, you have to completely retrain how you think about driving, and some of those automatic movements. Because driving can be very autopilot, right. And so if you are moving for, for example, the left foot accelerator, moving that to the other side of the vehicle, your brain needs to rewire like oh, the acceleration is actually now on the other side of the vehicle. So it’s a lot of training that has to happen to be able to use this equipment and then they also need to pass a test in order to be driving with that equipment and a lot of different states, they want to see that you took a test pass the test with this special equipment in your vehicle before you can be on the road or else you can actually be pulled over for that.
Karissa Simon 23:58
I love this handout, it kind of dipped your toes in the water. It’s just like you’re saying it kind of gives you if you’re a therapist that’s not very, like comfortable with this or you haven’t had much experience with driving it gives you the different categories to kind of speak with your patient about start thinking about where they have strengths, what what kind of modifications they might need, what kind of funding like there is and what they can afford, and kind of give them an idea of what to expect going to a driver rehab specialist so that they’re not just going in blind like oh, I don’t know what’s going to be happening or also you don’t want to send somebody there who really you don’t think has any chance even with all these modifications. I feel like it’s a good opening discussion for people not just about their physical abilities and if this is a good option, but funding wise because for some people, it’s just that’s never going to be a choice, and they’ll have to explore alternatives.
Johnny Rider 25:01
Yeah, I think these are topics, you know, both of these maybe wheelchair stuff, and now a vehicle modification that patients that we get like one lecture on an OT school, so we have to be aware that they exist, but we still get a little uncomfortable. And so that’s what this resource can help as both of you have said, but I appreciate that it’s even got the the links, you know, the QR codes to all of that list of certified driving rehab specialist. And of course, the funding opportunities, because as you have this discussion, they can then explore that a little bit on their own or with you. But then we’re able to address the concerns in whatever setting we are in within our scope. And even if we’re not a specialist in this area, it helps us feel a little more confident as we have this discussion.
Megan Wilkinson 25:45
I think opening the conversation in just in general, as an OT, even if you’re not super comfortable with it having somewhere where it’s like, okay, this is something that isn’t in our wheelhouse, something we need to be thinking about. And unfortunately, I think a lot of patients might leave without ever having talked about some of these topics, because a therapist might not be comfortable with it, or they think, Well, this is not my special area or whatever it is. And then they’re left without the resources. So this, this is just a very good way to say hey, like, here’s some resources, I’m I’m not a CDRs. But now you’re thinking about it. Now we can be talking about it, what types of goals do we want to set if this is something you want to be moving towards? Right.
Johnny Rider 26:27
And we I don’t think we’ve ever talked about this idea. But you know, if you’re working in an outpatient or an inpatient, a lot of times, there’s resources that are provided, you know, this is something that maybe you didn’t have a chance to talk about it. But you have a couple of key areas that come up a lot. Like we all know, in the neuro population, this is a big conversation. And so here’s a resource that the clinic can purchase that can be utilized to help them start the conversation, but also provide that preliminary education, with pictures with description, everything you would need.
Karissa Simon 27:00
Yeah, really, everything you need. And I feel like there’s so many patients that just don’t even consider vehicle modification. They just have some sort of stroke injury. And they’re like, okay, that’s it. I’m done. I can’t drive anymore. My spouse is going to drive. So I guess I’ll get my daughter to drive me. I think it’s really important that we don’t just be like, okay, yeah, they don’t want to drive anymore. Like, actually bring this up and say, really? Like, do you want to drive? Like, is it something that’s important to you?
Johnny Rider 27:32
And the technology is only getting better, right? So we’re gonna see more opportunities in the future. And we’ll have to keep up to date with that.
Karissa Simon 27:38
Yeah, who knows what’s gonna be out there. All right, I think we’re ready for our next we’re gonna move on to our next resource for this month. And this is Alternatives to Shoes with Laces. So this is a three page document. And I love the colors on it. It has great colors. It’s just very visually engaging. And it has a bunch of different pictures of shoe adaptations. And, Megan, if you can tell us more about this.
Megan Wilkinson 28:09
Yeah, I personally love this resource so much, because I have run into so many young people in the neural population that loves shoes, oh my gosh, love shoes, it is just it’s a really important way to express yourself. And so the fact that people can feel so limited in their choices, I think in the past, and now look at all of these options, they have to be able to, one independently manage their shoes and to look stylish. They offer the support, they offer, the comfort that they need for transfers and mobility and all of the things that they need. And so so many different wonderful options for a variety of clients. Elastics shoe laces I feel like that one has been around for a while, but it’s just gotten broader. There’s so many more options even in elastic shoelaces. So there’s magnetic closures too. The Zubits specifically is a really nice easy one. And a lot of these come in all sorts of different colors as well. So you can pair it with your favorite pair of shoes, you can get all sorts of different types of sets. So just really honing in to a client’s individual style. I feel like in so much adaptive clothing for so long, it was like you have one color, you have one option, and we’re just really starting to explode in in this area which is amazing. I love in the elastic shoes. The lock laces are a really nice slip up and down that you can really get that one handed shoe tying going on there. Hickeys are this more. They’re kind of a little more plastic than elastic, rubbery. And those don’t even have a tie, they just make it so that you can stretch your your actual shoe. And the thing with elastic shoelace says you just add it to the shoe you already have. That’s another thing I run into a lot of times people like but this is my favorite pair of shoes, and I’ve had it for however many years and that’s great, let’s just get change your laces, that’s, that’s a easy fix. Velcro is is, again, like that’s an easy one, you can get most Velcro options at a good price without having to be super, you know, fancy with some of these ones on the next few pages. But Velcro has, again grown, there’s so many very stylish options that people aren’t just wearing it because they need it. It’s because it’s cool. And it looks good. So under each section, it talks about a lot of the pros and cons. So again, going back elastic shoe shoe laces very affordable, very easy to have multiple sets. But it might be a little difficult to slip your heels into a standard shoe depending on what your condition is. So under each section is talking about kind of pros and cons and considerations you might have as to why you might choose one avenue or another. The Friendly Shoes, this is probably one of my favorite ones on this resource because it was founded by an occupational therapist, and they make shoes that are intended for individuals to have conditions affecting their mobility and their independence. sSuper supportive, they’ve got like a really great base and a great arch in there for people who have these mobility conditions because again, thought about by and OT, and then there’s a zipper on the inside. So it’s very discreet looking from the outside, you wouldn’t necessarily know that it’s an adapted shoe. And it’s very easy to manage it has this nice little toggle on the on the zipper to be able to grab if you have reduced mobility and your grip strength as well. They have options for men, women and children. There is room within the toe box to accommodate people who wear orthotics and AFOs. And that’s one of the reasons I really liked this shoe. There is kind of a higher cost with this one. But again, we’re we’re going back and forth between the client’s needs.. And that’s that’s an an awesome option for someone that again, like if you make the investment in something that’s really going to hold up and really going to work well for you, this is a really great option for that. And there’s a lovely QR code for the friendly ones to get to their their website pretty easily on there. And then the Kizik Shoes I’ve seen this one really going around. There are ads everywhere for this one. So this is the one that you can just step into it and the heel just pops right right over, you don’t have to touch the shoe at all. And so they have tons of tons of styles. So they’ve got athletic styles, they’ve got more formal styles, lots of different styles that you can have with this one, this is probably the most expensive option on on the handout. But again, what fits for everyone is, is different. And so the thing to consider with this one is you need to be able to have that lower extremity kind of control to really push into it. And, you know, I watched a video of someone with a spinal cord injury that was able to kind of you know, push into their their knee and get into the shoe anyway, so if this is something a client’s interested in, but you’re concerned about that work with them on it. So another really great fashionable option. And then the Nike FlyEase, again, one of those more expensive designer shoes, but again, and it’s actually designed for people who have these types of conditions. So this one’s really, really interesting, it kind of opens, folds and opens up to be able to get into it. So sliding in is easier. When you’re you’re not trying to get the heel to push through that kind of back thing. So it’s a different solution and the Kizik to the the heel push right where the Kizik just has this nice little rubber pop in the flies just takes that the heel away. And once your toes kind of in it clicks the the heel over it. And so lots of different options to be able to have alternatives to wearing shoes. And I think the wonderful thing for OTs in this day and age is there are so many stylish of fashion people that aren’t wearing tie shoes, right? I mean, it’s not something that you would look at at someone and say, oh, well, they’re not wearing that. So there might be something you know, the reason why they’re wearing that shoe. There’s lots of people in the fashion industry that are wearing these types of shoes right now and so just so many different options for them that can both support their condition and make things easier on them make them more independent but also feel like they’re not needing to feel insecure about that and you’re also not having to teach them one handed shoe tying shoelace tying or whatever whatever it is, if you don’t have to if that’s not a avenues they want to go down or you want to go down either. I mean, there’s I’ve had, many people are like no, like, I’m good with my slip-ons. And so you know, if that’s what’s comfortable for them, then that’s what’s comfortable for them. So love this handout, just so many beautiful options.
Karissa Simon 35:19
You can go first, Johnny.
Johnny Rider 35:21
I’ll just say we actually bought a few of these for our clinics so that we can show them obviously, we just have one size, so not everyone gets to try them on. But because we don’t have all of them, I wish we had this resource back, you know, when we started doing this, because it’s hard sometimes to explain this or for them to envision it. But if they see these pictures, I think this really helps them with that buy in. And we’re just seeing more accessibility, you used to have to go through like, these companies that sold medical devices even for like elastic shoe laces back in the day. Now, you can find all of this online, and you have QR codes. And there’s even kind of it’s becoming mainstream, or some of the shoes with zippers around that are really good for AFOs like the Billy Footwear, my daughter came home with those shoes. And I said, oh, I was talking to my wife, I said, Where the heck did you get those, and I’m looking at the,, and they’re not that adaptive brand. And they were Target shoes. And they made her life easier. But they’re the exact same shoes, like you mentioned, Megan, that we used to have to special order for someone with an AFO or someone in a wheelchair that was dependent for their assistance, and now they’re becoming the popular shoe and mainstream. So it’s really exciting for people that may benefit from these, how accessible they are, and how mainstream they are.
Karissa Simon 36:38
Yeah, I love how this resource has, um, shoes and options that are like really all price ranges. So if someone really can’t afford more than the elastic shoelaces, then yes, we have that we can work with that. But it does give people like these options that they can try and see if it works for them. Some of the things like the Nike FlyEase, to hopefully they have them in some stores. Because Nike is such a popular brand that people could go and try them, what you never would have been able to do before you just would have had to order and hope that it would work for the,. So I love that too.
Megan Wilkinson 37:14
I think too, it’s another great intro piece. Like if you bring this up early on, then they can order the shoe and you can practice it and make sure that it is absolutely something that fits them and works well for them. And then that’s it, that’s a check off your list, you’ve accomplished them being able to independently on and off their shoes. So
Johnny Rider 37:32
just the fact that we can give them options, right, that’s, that’s what we want to do, we want to let them have a say in their rehabilitation, their recovery, their their whatever. But now it’s not like, Oh, you have these base shoe laces and or one hand and tying technique. Now we have a plethora of options. And so they can they can choose right, they get to choose the way that they dress themselves.
Karissa Simon 37:56
Yeah, and it’s a good reminder that we should be bringing this up with people, every time we see them, when we have a client, we should be addressing all these issues, it shouldn’t just be, oh, your husband’s gonna do that, or oh, your wife’s gonna do that for you. Okay, and move on, which oftentimes, I feel like patients like brush us off and are like, oh, my wife, you just helped me I’m fine. But really, we shouldn’t be having this discussion. There’s no reason not to.
Karissa Simon 38:22
And we’re gonna go to our final resource for the month, The Importance of Standing, standing. Oh, you go ahead, Megan, you can explain the rest of it. It’s a two page document, it has some pictures of people in different standing frames and Megan give us a little more information.
Megan Wilkinson 38:40
So again, this one coming from neuro, I find that the standing frame can be a little intimidating, it looks a little scary, I think, for someone who is maybe going to get into it for the first time, especially if they don’t have a lot of trust for their ability to be upright. But this is also a really good handout for someone who has the capability of standing, you’re working on standing tolerance, but maybe are hesitant, they need a little bit more encouragement. And this really frames it in the kind of positive light of like, look at all of the benefits that you have from getting into that standing position. And so beautiful kind of separation. Again, I love when we make these handouts where it’s like, maybe just the first page would be appropriate. And that that’s enough to someone who doesn’t need all of the detailed information. It’s very clear, has nice pictures, easy to read. And a nice happy guy standing in a standing frame and he’s happy to be standing. So you could use just the first one if that’s appropriate or for someone who needs a more detailed information or maybe you’re giving the first page to the client and the second page to the caregiver to read up on that information and why do you want to encourage your loved one to get into standing. So sections it off to increasing alertness and attention. And also, as a side note, I think that this is helpful to be supporting in speech therapy as well. And talking about the cognitive improvements that can kind of happen from being in that that standing position, I know that a lot of times, especially in the more dependent area of neuro, a lot of the clients would be wanting to work, maybe more in speech, heavy type things, and fighting some of these types of things. And so what we would do is get a co-treat and get them into that standing framing, bring the speech therapist, and while they’re more alert, because they’re in the standing frame, and then they can work on those cognitive skills, and then they go, Whoa, because they were so much more alert, they’re not feeling that lethargy necessary, necessarily, and they can be more attentive in that session. So it’s great for for all of the disciplines, in my opinion, also improved circulation and blood pressure, it helps with digestion, bowel function, bladder drainage, this is one that that too, is an interesting side effect of being in that seated position all the time after an injury, when they’re in the wheelchair all the time are in bed all the time. Lots of complaints about the digestion. And I’m always amazed at how many of my clients are very interested in this aspect of standing like this, this helps get things moving, and you will feel so much better. If we get into standing more often. And they’re like, wait, I want that. So that’s a really good pro, enhances respiration and voice control, again, speech therapy, working on voice control, getting up into that, that standing position, stretches the muscles to prevent contractures. and spasticity. This is a really big one, for getting into that standing position, increases bone density and postural alignment and reduces the risk of fractures, improve skin integrity, again, this is very vital, I feel like why a big reason, we have that kind of in the back of our heads when we’re trying to get some of these very specific clients into that standing frame into the standing position, when we’re really concerned about that, and then enhances social interaction, you know, being able to be up and more at eye level with people not feeling like people are kind of looking down on you as much. Oh, really, really positive for being in that standing position. And I think sometimes this can be one of the biggest barriers early on in recovery is there’s a lot of fear and a lot of, well, if it’s a condition where they’re not really ambulating. Well, why do like I can’t walk. So why get into standing, you know, some some of those kind of negative thought processes that can come along with doing stance, like being in standing, or using the standing frame, this is a really good, again, encouraging positive. This is why we want this for you. This is so important. Remember how the other day we’re talking about how you’re so tired all the time, or how, again, your your bowels are bugging you, or whatever it is that there’s so many pros to getting you into this position. And so again, one of those wonderful conversation starters, that can be a great reminder, the first page could be something that goes on a wall, if it’s really something you’re trying to to work on reminders every single day why you should get into the standing frame or why you should be working on your standing tolerance.
Karissa Simon 43:32
Yeah, and even though we have a picture of someone in a standing frame, I think you could use this with so many other clients too, who are just standing with a walker, and it’s just painful for them or it’s hard. And they just prefer to be in a wheelchair. We all have clients like that as well. And I love that it gives you talking points as a therapist like these are the reasons like it’s very clear what the reasons are these benefits. And you can even use these to document like why you’re doing this standing frame if their goal is not to walk again, like why you’re standing with them because it it helps all of these things as well, not just they’re not just working towards walking.
Johnny Rider 44:15
The other cool thing is I write a good three to four letters of medical necessity every week. And I don’t think every therapist does that depending on where you work. But you might have a little bit of a mini panic attack when you have to write one and you’re like, I haven’t written one since school or it’s been a few years. This is literally the outline for a letter of medical necessity for a standing frame. So if you have to write one of those, you as the therapist are going to justify what are the benefits? How is this piece of equipment going to help my client or this client that wants this because we’re trying to show the the insurance company basically why their money is going to, in the end help improve quality of life and prevent further decline. So anyone that has this handout has basically a letter of medical necessity, or at least an outline for them to write that. So another benefit to this.
Karissa Simon 45:09
Yeah, that’s such a great idea, Johnny, thank you for bringing that up. Well thank you guys. And now we’re gonna move into some of our articles snapshots. So the first one is called Telehealth Guided Virtual Reality for Recovery of Upper Extremity Function Following Stroke. And Johnny, can you tell us about this article?
Johnny Rider 45:28
Yeah, so we tried to make our articles connect to what the handouts are. But this month, we felt like highlighting two hot off the press articles from occupational therapy journals that were literally published within weeks of us announcing these. And so you can you can find the full articles, but telehealth is a hot topic. Right now it’s being talked about at AOTA at the conference that just happened a lot, but also virtual reality. So now we’re starting to add to things that you know, the price is coming down to. So it may be something that you and your clinic want to investigate further. And this was a randomized control trial, where they looked at the effectiveness of something called the GRASP, you know, that’s their acronym for Glove Rehabilitation Application for Stroke Patients. And it’s a virtual reality home exercise program, focusing on upper extremity motor movements, and that recovery following stroke. So the GRASP system, most people have probably seen a Saebo Glove before, but it’s from that company, it’s Saebo VR Virtual Reality Software, where they use like a Kinect-based motion capture to allow the virtual practice of instrumental activities of daily living. So you have this glove orthosis, that’s tracking the movements in the wrist, the fingers, right, the upper extremity to engage in these virtual objects, like you are manually engaging with them. And so they use this all as telehealth there was an occupational therapist providing synchronous visits via telehealth bi-weekly. And they looked at the results. And they looked at the Fugl Meyer Upper Extremity Assessment, which is used commonly and a motor activity log. And they found clinically important and statistically significant differences between these groups of those that completed this protocol, compared to those that were just getting usual or customary care. And so they found very large differences for you know, this kind of flexor synergy of moving the hands between kind of the the knee and the face that we use for self care for eating, they also found big changes in grasp. So being able to grab something, and volitional movement. So we can see how this is probably going to be studied even more and more now that we’re seeing these benefits. But it may be an option for those rural patients and maybe an option for, you know, a clinic that can’t see everybody. There’s going to be more and more opportunities for billing as well and telehealth and these monitoring codes that are coming out. But we do know that preliminary there’s support for these, it has the potential to improve motor function. And and I like this idea of calling it technology enhanced therapy sessions, rather than being afraid of like, oh, you know, there’s a robot doing my job, which is not what’s happening. We’re just enhancing our impact with some technology. And one of the thought processes here is that by doing this, they’re getting more and more repetitions, which is necessary for that neuroplasticity. And so if it helps our patients, if we can utilize it, we can still make it fun, we can improve their life, why would we not start to investigate it, especially as the cost is coming down and down.
Karissa Simon 48:36
This is just so cool. And I think a lot of times, we know that people engage more, and with things that are like almost like a video game, and it will help engage like some of the younger patients, even older patients just because like I know, they’ve studied video games, and there’s like an increase in dopamine that you get from doing it. So it’s actually going to encourage people to exercise more, because it’s enjoyable. It’s fun. And like you said, it gives them those repetitions because they’re choosing to do it because it’s not hard. It’s not boring, not annoying.
Johnny Rider 49:14
There’s a whole yeah, there’s a whole body of literature on this idea of gamification. And so that’s kind of what this is a little bit of, but it’s also kind of exciting for them, and maybe they’ve tried the clinic, they didn’t have a good experience. Maybe there’s some social concerns or some, you know, concerns about getting there as well, this this could be a solution for a lot of things that weren’t even mentioned in this article.
Megan Wilkinson 49:35
I think to the ability to reach people in rural places is just the most amazing part that has come out of telehealth because a lot of times they can’t necessarily afford to just come be have an inpatient stay. And so if it becomes more affordable for someone to reach them through a computer via telehealth and they can get the same types of repetitions that they would be getting in a short inpatient stay, then why not? I mean, that’s, that’s incredible. That’s, that’s improved so many lives.
Johnny Rider 50:11
We might even find that they can get more repetitions with this in their home environment. You know, we don’t know, that’s kind of what we’re, the preliminary evidence is definitely positive. And there may be opportunities for certain clienteles, where this is actually the better solution where they get better, a little bit quicker.
Karissa Simon 50:28
I can see that. Well, let’s go to our next article, Predictors of Hospital Readmissions for People with Chronic Conditions. Johnny, can you let us know a little bit about this article?
Johnny Rider 50:37
Yeah. So again, very, very recent one that we can kind of use to support what we’re doing and think about the big picture. And because we’re all trying to prevent, you know, that readmission, we want to help someone in the long run. This was a cross sectional study where they, they looked at people hospitalized with chronic conditions, and they completed measures of you know, self care function, functional cognition, occupational competence, environmental impact all these things. And then they kind of looked at their medical review, they pulled up kind of their medical chart and reviewed that, and then and then follow them up to see, okay, who went back to the hospital within 30 days of discharge? That question that, you know, we need to keep looking at and see if it’s changing. And they found that greater levels of occupational competence, okay, decrease the likelihood of hospital readmissions, and greater impairments in functional cognition. So lower functional cognition, increase the likelihood of readmission. And, and who’s the the only profession that really talks a lot about functional cognition, I know SLPs address cognition as well. But I feel like we kind of kind of coined that term. And we should all be addressing that in tandem with our colleagues. Right? This tells us that we should be addressing that in the hospital setting, which sometimes we push that to outpatient, but we shouldn’t, right. The other part of this study is they kind of asked practitioners about, you know, which of these assessments that are used quite commonly, from the OT perspective, are most acceptable, most appropriate, most feasible, especially with standardized measures, because we need to be using those standardized measures to get larger data so that we can understand what’s happening. And so they interviewed a bunch of them, and basically found out that overall, the AM-PAC, which is actually pretty common in a lot of areas, and some of the big name hospitals, a lot of research has been on the AM-PAC, overwhelmingly, the therapist said that that’s the most acceptable for the hospital setting, it was the most appropriate, it was the most feasible and it helped them the most, to understand what was going on with their client and see some some changes. So the other thing we can kind of think about is if you’re working somewhere where they are not using the AM-PAC, maybe you should look more into that maybe you can show this article, maybe you can look up some of the other research and see, are we using the best measure to understand what our clients need to track progress, and to demonstrate the value of occupational therapy and the entire rehabilitation team?
Karissa Simon 53:05
Yeah, at our hospital, we use AM-PAC And it is great, it’s really quick, it takes five minutes or less, really, and it does give you a way to track the patient’s progress. If we see them multiple times we do it every time we see them. In the hospital. And some patients, we regularly see people like five times a week, so you get to see some progress sometimes.
Johnny Rider 53:27
Yeah, there’s a lot of research on the AM-PAC, and Johns Hopkins is doing a lot as well looking at that. And so some of them are, you know, they’re really fancy statistical stuff. But they’re finding overall the consensus as it’s probably the best. And we know the most about it, and how to utilize it and how to kind of pull that information that we need to see the effectiveness of our interventions.
Megan Wilkinson 53:52
I love to that bringing up that functional cognition is something that we should be addressing early on. Because if we’re honest, the continuum of care isn’t always smooth. We can’t depend that they’re going to move through that process and get those types of things. And so we should be thinking of the whole scope in that in that moment and addressing those things early on, because it is is so vital, and you don’t know what hiccups are going to come along and they end up home when you weren’t expecting them to necessarily be home at that point in their rehab journey.
Johnny Rider 54:28
Or even how long it’s going to take before they get the referral or they get that that next level of care and so that may be a part of if we investigate further, you know, they’re coming back pretty quickly, or they didn’t have to follow through because of the concerns with cognition or the concerns with occupational competence.
Karissa Simon 54:47
Yeah, I love that this article to gives clinicians a resource to go to their leadership and say look like OT is so important. We all know in hospitals that PT is pushed. And often like, if the PT comes in and clears them, they’ll be like, Oh, don’t worry about the, like I saw him, he’s walking, he’s fine. And it’s so important that we remind people the importance of what we do, just because a person is walking and can get up and down the stairs doesn’t mean that they’re not going to go home and make a really poor medication choice or do something that’s really harmful and end up right back where they were.
Johnny Rider 55:25
Yeah, I did want to point out for our listeners and viewers that this is from the Open Journal of Occupational Therapy, and depending on when you went to school, this, this journal is relatively new. And it’s an open access journal. So everyone has access to these articles. I don’t work for them, I don’t make any money. I just I think it’s great that we have these open access journals, because not all of them are. But I’d encourage you, if you are looking for research, you want to read this in this full article, go to the Open Journal of Occupational Therapy, and then plug that into Google and you’ll find that you can you can read all of these journals that sorry, these articles that are published and you know, they’re designed for our profession.
Karissa Simon 56:08
Awesome. Okay, and now we’re going to do our case study. So Mrs. Peterson is a 34 year old female who was admitted to an inpatient psych unit with severe postpartum depression and anxiety with suicidal ideation. She is married and has three children ages 6, 4 and 1. She is a stay at home mom and homeschools her two oldest children. Per Mrs. Peterson, her husband is very supportive and is planning on taking a leave of absence from his job for a month to take care of the children. And to assist when she returns home. He is a pilot and will be gone for several days at a time when he returns to work. Mrs. Peterson is taking part in group occupational therapy in her inpatient psych unit during her stay.
Karissa Simon 56:55
So we’re all going to talk about the resources we picked to address this case, study some of our archive resources, and different ways that you can treat Mrs. Peterson or someone similar to her. So my resource that I picked was the Workbook: Impacted of Mental Health on Daily Routines. I love this resource, because it is kind of introducing her to the idea of journaling, which is just so important. And it’s very guided. So it gives her like a step by step of what to do. So the first like thing is do you understand your health condition? What questions do you have? So just really like giving her that chance to reflect on like, what’s actually going on giving her a chance to like write down her questions, so she has it and can ask the doctor next time that she sees him. And I just love this idea of like introducing you to journaling. And we all know that journaling is such a good way to kind of take a step back and see what your emotions are, and really what you’re feeling and kind of help you find like those triggers to what you’re feeling. So I just really love this resource. And I think it’s great and guides you through exactly what to do. So I just thought it was a great resource.
Megan Wilkinson 58:15
Yeah, this is so valuable. Because when a lot of times when you’re going through those moments where anxiety, depression, those things are, are fogging up your ability to see reality or the way the world is being able to write these things down on paper and have like that concrete information in front of you I was able to the support network part is probably my favorite part of being able to when you are feeling overwhelmed by those feelings, having this resource to look back and say, okay, here’s my list of friends, family, I can call health care professionals who have my back, they support me, they believe me, whatever, whatever they’re dealing with, but being able to break out of the fog that those conditions can cause and have it on a concrete piece of paper and a resource that they can reflect back on.
Karissa Simon 59:13
And then go to the next resource, Johnny selected this one, Motivational Interviewing.
Johnny Rider 59:21
So I thought a lot about this case and kind of aware of the skills that sometimes we feel a little less confident with. And interestingly, motivational interviewing is commonly reported as one of those things that OTs wish they got a little more in school, and when they get advanced training, or they understand a little bit better, they come back and say, wow, I should have been doing more of this. And I wish that I had practiced this a little more. And so this is that resource more for the clinician, right to beef up your skills to review them and think about how can I talk to miss Peterson and maybe explore a little bit more of some ambivalence there. How can I help Miss Peterson work through some of the things and identify goals. And it’s also though, beyond this case, it’s just something that we can use MI, motivational interviewing so much in our practice. And I think the only reason we may not is because we’re not that comfortable with it. And so here’s another resource that goes through kind of the process, what we can do the key components of that, and remembering and even that resource that we just looked at, use some of that components by asking open ended questions and allowing the client to do that. So it just gets gives us an opportunity to explore a little bit deeper. And in keep that client in the driver’s seat as as we go through what recovery means to them, what wellness means to them, and how we can support them through that journey.
Karissa Simon 1:00:49
I love this idea of always trying to improve, improve our skills as clinicians and finding different ways to reach people, I think it’s easy to get into kind of like a routine where you have been a therapist forever, like, this is the way you do it. And it works well for you. And it’s fine. But I think it’s really important that we challenge ourselves to improve and be better for our clients.
Johnny Rider 1:01:14
Using MI reminds us it’s a collaborative process, right. And it makes sure that we don’t feel like we’re ever superior. Sometimes they say, you know, I guide and you decide as a term about, MI and that’s what we’re really doing. And so it kind of puts us in check sometimes to if we review this process, so that we remember that they’re the experts and and we’re there to kind of guide them and help them find the resources that they need and kind of explore, or they may be ambivalent, but ultimately, it’s the client that is deciding what’s best for them. And then we help them with that.
Karissa Simon 1:01:50
And then our final one, Megan picked Coping Skills.
Megan Wilkinson 1:01:55
So this one, I think, again, would maybe be a good follow up to the one that Karissa picked. So as the Mrs. Peterson is moving on, and in her process, being able to have, again, a simple one page handout, it’s not overwhelming, it’s not this huge packet of information, how do you manage all, you know, I think that’s really important, something that is easy to digest something that is easy to pull out and look at when you need to. And this, again, I think is a really kind of going off of, of Johnny, a really great way to show that this is part of our scope, this is something that we can be helping with mental health that doesn’t have to feel intimidating. And give them some tools to be helping themselves in those moments where they’re really struggling with anxiety or depression. And I love that this has a lot of different options too. Because to me, that is one of the most important parts of mental health is what works for me does not work for Johnny does not work for Karissa. And so being able to have options to try you know, you can go through grounding and mindfulness with the client. And if they’re like, like, I didn’t really feel it in that moment. It’s like, okay, that’s great. Let’s move on, let’s try distractions. Let’s see how that works for you, you know, and being able to have other options. And even in the moment, maybe all of these work. But in that one specific moment of of anxiety that’s taking over. Mindfulness isn’t working, you’re too distracted, there’s too much going on. Okay, let me go use a different, a different strategy, having options, having that tool belt right to be able to pull from when you’re in those moments. So again, having a nice simple handout with resources, it’s pretty simple, clear, it walks you through how to complete these things. So very, you know, one sentence for grounding one’s one sentence for mindfulness. Very simple options with distractions, I love just go for a walk, being able to read a book some things that very achievable ways to cope in those moments where the depression and anxiety seems to have a hold.
Johnny Rider 1:04:15
With a lot of these, like, they’re all multipurpose, and that’s how we try to design them. But you could show this to the client, right? They could consider it later. But even sometimes I’ve used resources where I haven’t thought about this for a while as I’m gonna see my next patient I’m prepping a quick glance at this gives me some ideas, right. And even though we know these things, we’ve learned about one point if we haven’t talked about this in a while, because maybe we don’t see a lot of patients with concerns like this. These resources can be that that quick refresher course, they can be something for us to study and a little more in depth and kind of get our ideas from they can be something to give to the patient. They can be something to share with the caregiver. They can be posted in the clinic or the hospital like it’s whatever works or is necessary for you in your setting.
Megan Wilkinson 1:05:03
I love the idea, especially in this specific case study of the husband may be having access to this when he sees his wife, struggling being able to go to distraction. So like, Hey babe, you want to go on a walk? Or you know, here’s your book, remember, you know where you left off on your chapter or, you know, being able to have that resource for him to support her as well. So yes, very versatile resources.
Karissa Simon 1:05:25
Yeah, and he’s gonna be coping skills with taking care of the kid. And then he’s going to be going back to work and having to leave her alone for long stretches of time.
Karissa Simon 1:05:34
And that’s a good segue. Do you guys have any other thoughts on the case study or how you would treat Mrs. Peterson?
Johnny Rider 1:05:43
No, the only other thing that I think is important to recognize is that concern with suicidal ideations and, and maybe a very brief plug for remembering that when best practice for someone that’s experiencing suicidal ideation, someone that’s at risk for suicide is to be direct with those questions. And you know, when we look at things like mental health first aid, and we look at QBR trainings are those different trainings that provide therapists with how to assess and intervene for suicide risk, they all have something in common, and that is that we need to ask those direct questions. And it can be uncomfortable sometimes. But it’s our duty. It’s our responsibility. And we want to make sure that we have that conversation, in case someone else hasn’t asked those direct questions. And so we can think about, are we comfortable with that? Have we considered this? Are we asking those questions then providing the resources necessary? And we could talk about that for a long time, but I just think that’s a good reminder for us, if we haven’t had to deal with that in a while in our clinical practice.
Karissa Simon 1:06:51
Yeah, I definitely agree. And something that struck me as I was going through this case study is that she has, Mrs. Peterson just has so many stresses on her. She’s homeschooling, her husband has gone for long periods of time. She has three children. And just maybe, while she’s impatient, like talking to her about how she can reduce some of the stress, like maybe consider letting your her two oldest go to school, rather than homeschooling to give her a break and not have so much stress on her or her husband having some sort of schedule where when he leaves, someone else is going to be there with her and offering that support. And that was just my other thought about the case study.
Megan Wilkinson 1:07:29
I think using the resource you picked and looking at that support network would be so vital in those moments, does she not write a lot of stuff down? If she doesn’t? How do we grow her support network? How do we connect her to people? There’s so many young moms, new moms, groups and stuff where you can at least just get that validation of like, this is hard. And that’s really important, too. So our if she has a long list, and then it’s like, well, how often are you calling these people? How often are you asking for help? So using that resource to be able to guide this? Because absolutely, she has a lot on her plate.
Karissa Simon 1:08:09
Thank you guys so much. And at this time, we just want to verbalize our disclosures real quick, since we didn’t do that at the beginning. So we all work for Therapy Insights, we help create this content, and we’re discussing handouts that are available at therapyinsights.com, obviously. So I offer these resources and hundreds more, go to therapyinsights.com. All of the links are going to be available in the show notes. And you can watch this on YouTube, listen to it on your favorite podcast platform. If you have any questions like we said, please feel free to reach out to our team at firstname.lastname@example.org. We would love for you to vote for what resources we’re creating next. We always love to hear from you guys and know what you’re really looking for. And our new episodes will be dropping June 1 So we’ll see you then. Thanks so much.
Johnny Rider 1:09:01