On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Elaine Lonnemann on the show to discuss the impacts of being diagnosed with degenerative disc disease. Elaine Lonnemann has served the public clinically as a Physical Therapist for over 30 years practicing in a variety of settings in Tennessee, Florida, Kentucky and Indiana. Her early clinical interests in treating patients with low back pain evolved into a clinical academic career with a focus on best practice in orthopaedics, teaching and leadership. She lives in Southern Indiana and is the mother of four boys with her partner and husband Paul Lonnemann who is also a Physical Therapist.
In this episode, we discuss:
-The American Academy of Orthopedic Manual Physical Therapists position on the opioid crisis
-Patient health outcomes following the diagnosis of degenerative disc disease
-The use of Clinical Practice Guidelines for low back pain in physical therapy practice
-Pain science education and the treatment of low back pain
-And so much more!
Resources:
Email: elonnemann@usa.edu
Battie et al. 2019: Degenerative Disc Disease: What is in a Name?
For more information on Elaine:
Dr. Elaine Lonnemann received a BS degree in PT from the University of Louisville in 1989, a MSPT from the University of St. Augustine (1996) and DPT (2004). She is the program director of the transitional Doctor of Physical Therapy program for the University of St. Augustine. She has served in several positions for the University of St. Augustine for Health Sciences since joining in 1998 including teaching in the online and continuing professional education divisions. Her responsibilities include oversight of the transitional DPT program as well as the orthopaedic and manual physical therapy residency and fellowship. She is a board-certified clinical specialist in Orthopedics, Certified Manual Physical Therapist and a Fellow of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT). Her clinical experience have been in private practice, home health, outpatient practice, and as Chief PT of outpatient services in a level II trauma center at a university hospital.
Dr. Lonnemann was an associate professor for Bellarmine University in Louisville KY and taught in the first professional program for fifteen years. She has presented nationally and internationally on the topics of spinal thrust manipulation, low back pain guidelines and leadership. She authored textbook chapters in orthopaedic physical therapy and has published in the areas of spine morphology and joint manipulation. She is passionate about leadership, postprofessional physical therapy education, manual physical therapy and integrating pain and movement sciences in the clinical management of clients. She is the current President of AAOMPT and has served two terms as Secretary and Chair of the AAOMPT International Federation of Manual Physical Therapists Educational Standards and International Monitoring Committee, member of the OMPT Description of Advanced Specialty Practice Task Force and committee member and author for the 2018 revision of the Manipulation Education Manual. She received the AAOMPT Mennell Service Award and the 2017 President Joseph and Maureen McGowan Prize for Faculty Development from Bellarmine University which provided the opportunity to study the history of manual therapy at Oxford University.
Read the full transcript below:
Karen Litzy: 00:01 Hello, Dr. Elaine Lonnemann, welcome to the podcast. I'm happy to have you on.
Elaine Lonnemann: 00:06 Thanks. I appreciate being here.
Karen Litzy: 00:08 Okay, so today we're going to be talking about degenerative disc disease. But first I would love for you to talk about what it is, why it exists and what do all those letters in AAOMPT stand for?
Elaine Lonnemann: 00:27 Absolutely. So AAOMPT stands for the American Academy of orthopedic manual physical therapists and it's an organization, it's an association that started in 1991 basically because some individuals felt like we needed a group that could present scholarly works that could meet, have conferences and also test clinicians based on international manual therapy standards. And so that group, several individuals got together and that's how it started in Michigan actually. So that now we have representing 3000 physical therapists.
Karen Litzy: 01:12 That's a lot of therapists. And how long have you been part of the organization?
Elaine Lonnemann: 01:19 I've been a member since actually 1994. So quite a lot of time. I was a resident and fellow in training and became a member of really when it was beginning. So I've been involved as a member and more recently as an officer.
Karen Litzy: 01:37 Awesome. That's great. So now let's talk about AAOMPT position on DDD or degenerative disc disease, which is something that I think is a very commonly diagnosed. I think it makes people nervous when they hear it because they hear the word disease. So can you talk a little bit about degenerative disc disease and the position AAOMPT has on that?
Elaine Lonnemann: 02:03 Yeah, so our position is we just oppose the use of that term. It's commonly used as you said, and it's really used to diagnose an age related condition. And that age-related condition shouldn't be considered a disease. It shouldn't be considered degenerative. So it happens whenever on imaging you see changes in the shape or the size of the disks in the spinal column. So that's how it's identified. And, you know, we know several things that nearly everyone's discs change over time. And the interesting thing about that is that not everyone feels pain even when they have those changes in their discs. So, that's why we oppose it or one of the reasons.
Karen Litzy: 02:52 And you know, like we said, it is so highly diagnosed and when people hear that disease, they think of something that like cancer is a disease or Parkinson's is a disease or a syndrome. But I think it's kind of scary terminology and words matter. So what does AAOMPT feel should be a better descriptor?
Elaine Lonnemann: 03:19 Well, you know, I don't know that we have a descriptor in terms of a substitute, but I think, you know, patients really have the right to accurate healthcare information. And when, like you said, when they are given that diagnosis, you know, not only disease, disease puts a lot of fear in their mind, but degenerative, I mean they start to lose hope because they degenerative just sounds like, you know, they're gone down a pathway, you know, if it is just described as mechanical back pain or radiating back pain, you know, and our healthcare system really looks at trying to find a tissue or a pathoanatomic cause for low back pain. And the research clearly indicates that and has over time that it's very difficult to find a specific cause for low back pain. So we really need to move away from that model.
Elaine Lonnemann: 04:16 And, you know, the other part of that is the patients lose fear, they lose hope. And they also began to believe they can't manage their own pain. So they lose self efficacy. And we know how important that is for our patients. And I think that's the one thing I love about our profession is that we really help patients manage and control their symptoms, their condition, and improve their function. And, whenever they're given that label, it really it can misguide them, you know, because they lose hope. And then they might start choosing, you know, riskier treatment options.
Karen Litzy: 04:53 Surgeries, medications, even less invasive procedures, things like that that maybe may not be necessary. But like you said, if you're the patient getting this diagnosis of degenerative disc disease, it can maybe feel like you're at the end of your rope and you don't have much more to go.
Elaine Lonnemann: 05:16 That's right. And patients need to know that their situation is real, that the findings that they have, because most people are diagnosed after they've had imaging. And so I think it's really important that we emphasize, yes, those findings are real, but this isn't a disease and this can be managed. And you know, the other thing is that oftentimes those imaging findings stay, but their pain goes away after they're treated. So, you know, that helps to give them some hope. I recently had a student who was 26 years old who came up to me and said, you know, I'm really concerned. I went to see a healthcare provider and because I was having some back pain and they diagnosed me with degenerative disc disease, what am I going to do? And then she just went in, almost fell apart because she said, you know, I love to run.
Elaine Lonnemann: 06:06 I don't, you know, I don't know what I should do. Can I continue to exercise? And I'm thinking about getting an epidural injections because I don't want this to progress. And so I had to kind of step back for a minute and say, okay, it just explained to me why you went, you know, tell me about your pain cause you're not going to, she told me, I'm not even in pain now. She said she had had pain for a week and then went in. Because her sister had structural scoliosis, so she was fearful even though that was at 16, she was fearful that she might have a condition that would be a problem. And now she's fearful because she's been labeled as having degenerative disc disease. So, you know, it really took a while to counsel her and you know, to again, affirm these findings are real, there are changes in our discs but these are normal changes that occur with aging and they shouldn't be considered degenerative. The studies indicate that, you know, there's oftentimes when those findings are present, they don't correlate with the exact clinical presentation of the patient. And that's what we want to get. That's the message we want to get up.
Karen Litzy: 07:16 And as physical therapists we can certainly relay that message to our patients. But if the patient hears that from the physician first, it makes it a little bit more difficult. Our job becomes a little bit more difficult because now it makes it seem like we're giving two different diagnoses. Maybe it starts with us as individuals, but how can we as the physical therapist who is maybe seeing this patient after they were given that diagnosis from the doctor communicate to the physicians or you know, cause this is a medical system wide use of terminology and it really needs to change from top to bottom. And I feel like sometimes yeah we're that point of entry but oftentimes where people are coming to see us after they get that diagnosis. So how do we as a profession advocate for this change to the greater health care system?
Elaine Lonnemann: 08:22 Well I think we definitely need to partner with our medical colleagues with APTA and we are already partners but definitely get the word out that you know, this type of diagnosis really does misinformed patients. There is research and AAOMPT has developed a white paper that explains the research related to how this misinformation can potentially guide their treatment or lead them to choose, like you said, riskier treatment options. And you know, one of those, obviously the opioid epidemic is something that we have to think about. And not to say that it's going to lead them directly into that path, but it does. There has been some research that indicates that, you know, the healthcare costs are driven because we aren't following the practice clinical practice guidelines for back pain. So I think the biggest message that needs to come out is we need to follow those clinical practice guidelines.
Elaine Lonnemann: 09:22 And I just heard Tony Toledo, do you have his keynote presentation at the interprofessional collaborative spine conference? And there were physical therapists and physicians and chiropractors all together in a room and you know, it was a great opportunity to meet, you know, as partners with them and you know, what can we do for the greater good of our patients? And I think the biggest, yeah, and he actually presented some of the challenges and what can we do from here forward really to improve this situation. And you know, he was talking to all of this. It wasn't just physical therapists, but one of the things that he did address was the continuity of care. And he said it's really important that patients don't wait, that we get them in early and not that every patient would and I don't want to, I don't, I want to make sure this is clear.
Elaine Lonnemann: 10:12 Not every patient who has low back pain needs to be seen by a healthcare provider, whether it be a physical therapist or other conservative type of clinician. Sometimes that pain will go away, but if it's very intense and if it doesn't go away, then they should seek care and it should be early. So talking about the continuity of care, you know, in terms of who sees the patient first and whoever does it should follow the clinical practice guidelines that recognize, you know, with some time with some activity, with some coaching, a reassurance and a comprehensive medical exam that really does rule out a systemic cause or something more sinister because that's the other thing. Patients are fearful. My 26 year old student was fearful that this was something sinister. So I think that is a really important message to get out that comprehensive physical exam can really help to rule out some of the medical disorders that, you know, are uncommon in low back pain, but that our patients are concerned about.
Elaine Lonnemann: 11:21 So, continuity of care was one thing he mentioned. Oh, and the other thing he mentioned is variation in care. Of course, you know, it's a big problem because you know, whatever healthcare provider you see with low back pain, there's a ton of variation in how the providers performing interventions. So, you know, he highlighted that and I couldn't agree more but one of the things that he mentioned and you know, of course president of the Academy of orthopedic manual therapy, you know, so one would think I'm going to mention manual therapy, but really it's because that is part of the clinic, one of the recommendations of the clinical practice guidelines, is manual therapy for back pain. And again, not every patient needs it, but he mentioned, you know, manipulation, mobilization, those are forms of manual therapy along with exercise. And so I think that following the clinical practice guidelines, trying to reduce our variation in care and also recognizing that, you know, as physical therapists, we need to refer on or we need to know when not to treat and when we do need to treat consistently and follow those guidelines.
Elaine Lonnemann: 12:36 So that's probably a long answer to your question, but as far as the message that needs to get out, I really just think highlighting those things are important.
Karen Litzy: 12:45 No, and I don't think that was a long answer at all. I think that was a very good comprehensive answer. And you know, we're talking about clinical practice guidelines. Where can people find these clinical practice guidelines? I know the orthopedic section of the APTA has clinical practice guidelines on their website. Are there other places where people can search for these guidelines? Because oftentimes we talk about clinical practice guidelines, but people are like, I don't have any idea where to find them. I don't know where to look.
Elaine Lonnemann: 13:21 Well, so that's a good, good point. In terms of looking at websites, you know, I think the orthopedic Academy, their clinical practice guidelines follow the majority of practice guidelines that are out there. The American family practice group also has clinical guidelines. Ciao, published a group of guidelines and they're all fairly consistent. In turn there are some variations and you know, sometimes people ask what, well, why are there, you know, so many variations. And part of it's because the different groups, there might be some bias in those. Just if you break them down and look at the commonalities, you know, again, at least for back pain, I think those are the things that you have to look at. So I know APTA has some links. And now that you mentioned it, we will put links on our website as well to the clinical practice guidelines that are out there. And we'll have a a link to this white paper as well that the Alicia Emerson led that charge along with Gail dial and, and Dan Roan and other Jason's silver. Now other a PTA members amped members that, um, we're working in this area.
Karen Litzy: 14:38 Yeah. Because I think it's, there is a breakdown from, so you graduate with your PT degree, you start working and if you don't keep, you don't know where to look. You're, you're kind of just sort of floating along using maybe what you learned in school, which is great because hopefully you won't kill anybody or do major harm to somebody. But I think when it comes to diving deeper into treatment paradigms, these clinical practice guidelines, people have to be proactive about that. And so knowing where to look and knowing where to find them is great. Um, and I also want to touch back on the variation of care. And when you're talking about variation of care, are you talking between physical therapists themselves or between a PT versus a doctor versus a chiropractor? Uh, manual therapist versus non-manual therapist? I mean I think there is a lot of variation to care and that can also be quite confusing to the patient. So I don't know in that keynote if he sort of touched on what he meant by variation of care.
Elaine Lonnemann: 15:50 Yeah. He met within physical therapists and or within profession and, and really looking at, you know, and all the individuals in the room, many of us are providing very similar [inaudible] at least are able to provide similar treatment options. And so his, his point was that, you know, we really should be looking at more consistent care model following the practice guidelines and not, um, varying to other types of, of treatment approaches that may not have the evidence and, and so variation and care, but also that evidence, um, the care that is supported by the evidence
Karen Litzy: 16:28 of course. And you know, that brings me to, this is going slightly off topic, but, well, no, not really. It's still on topic. It, it reminds me of a, a post that I saw in a Facebook group, a physical therapist, and it was a newer ish grad, maybe out a year or two. And he said something to the effect, I'm paraphrasing. Um, when we advertise to the public about what we do as physical therapists, you know, everyone tends to say, you know, we're evidence-based profession. You said, shouldn't the consumer already know that? And how important is it? Like, don't you just have to do what the patient wants? Because all we're worried about is our job is to make a person feel better. So what does it really matter what you use to get them there? Meaning does it matter if you use something that's evidence-based or not?
Elaine Lonnemann: 17:28 Well, and I think, you know, part of that is patient education and having a relationship with your patient so that they do trust you. So you have, you know, I think they have to be able to trust you and you have to develop that therapeutic Alliance with them too. Help them understand that, you know, these are treatment options and it should be patient centered. You know, we want to be patient centered and we want to help them understand that, that these are the best approaches and it's not a one size fits all. I mean there are some outliers, but the extreme variation that has been shown is the problem. It's not the occasional patient who, well yeah, sure. Maybe that PA it's more patient centered to do a different approach, but there's extreme variation.
Elaine Lonnemann: 18:16 And I think even if we just reduce that by 50%, I think it would have a huge impact on care and the research that's coming out of university of Pittsburgh that I'm not involved with this, so I'm just, I'm just reading and trying to do the same thing, everyone else's. But there's some big research that's coming out to talk about that will speak to, you know, following the guidelines when there is variation of care or if there is a variation of care. Okay. Yeah. What's different?
Karen Litzy: 18:51 Yeah. And I know there was a study that came out a couple of weeks ago that showed that, you know, with different diagnoses, less than half of physical therapists actually follow best evidence to treat.
Elaine Lonnemann: 19:08 Yup. And the thing that you mentioned before too is how do we avoid that? I think as you mentioned, a PTA or being a member of the American physical therapy association really helps. It's made to streamline my direction of understanding so I can go to PT in motion. I can look at, you know, there's a lot of great white papers that they have position statements, you know, on the opioid epidemic. There's just a ton of great resources there. And it was another thing that I would emphasize for clinicians.
Karen Litzy: 19:43 Yeah. Because you know, in the end, you want to treat people using best evidence, you know, and I think it was Jason Silvernail in a comment said something. Again, I'm paraphrasing, but something to the effect of why would I waste my time doing something that I know doesn't have evidence behind it, when I could be spending that time, precious time with our patients. Sometimes you get an hour, sometimes a half an hour, sometimes 15 minutes, right? So why would you waste that precious time on something that you know, doesn't have the evidence behind it when instead you can be doing something that has been shown to help and that goes back to, and then you'll hear the argument against that was like, well, the patient really wanted it. So that's how I'm developing my therapeutic Alliance.
Elaine Lonnemann: 20:39 Yeah. But I would still argue against that.
Karen Litzy: 20:43 And that's where like you said, patient education comes in, you want to explain to the patient, Hey listen, I understand that you like treatment X, Y, Z, but right now we know that treatment ABC is more appropriate for you given where you're at. And explain to them why. And I've done that plenty of times and patients are like, okay, so right.
Elaine Lonnemann: 21:04 And then there's an opportunity to negotiate, you know, let's just try this. If it doesn't work, you know, this seems to be more effective than, and it is more efficient. And like Jason said, why, why would you waste your time and their time? You know? And that's what I tell the patient, I respect your time and this is what we understand and this is what we know at this point and is best care. So, you know, if you're willing to go along with me on this, you know, I think we can try it out. And if it doesn't work, you can fire me. You can find another physical therapist or, you know, I'll find you someone that it works, you know, or the treatment, you know. So yeah, I think you have to be really,
Karen Litzy: 21:45 And I think, like we said in the beginning and going back to degenerative disc disease, words matter, right? And how you explain things matter.
Elaine Lonnemann: 21:55 Yes. Well and Michelle just published a systematic review in spine, she looked at the term degenerative disc disease and the name of the article is what's in a name. And, also found that there's so much variation in what, you know, healthcare providers are calling degenerative disc disease and you know, in summary found that it's just, it's inconclusive and there's not evidence to support this as a disease and there's so much variation in it that they also recommend not using it as a term.
Karen Litzy: 22:37 And so from what we talked about from a sort of 30,000 foot view as to what associations can do to kind of help clean up terminology, this kind of medical terminology and that may, like you said, partnering with our physician colleagues partnering with maybe our chiropractic colleagues to kind of change the narrative. But what can, for all the listeners out there, let's say you're an individual therapist, what can you do to kind of help change the narrative around that term degenerative disc disease? So your patient comes into you, they're fraught with worry, what can you do?
Elaine Lonnemann: 23:19 Okay. You know, I think the biggest thing is to get our patients as our advocates. And so taking the time to educate them about it and say, yes, you know, this is real. Your changes are real. This isn't a disease. And to help them to understand that and then give them the tools, you know, say, Hey, you know, when you go back to your physician or your other provider, whoever referred, or maybe they didn't refer, you know, get the word out to these medical providers, get the word out too, you know, senators, legislators and because they're speaking to them as well and support, you know, this aspect of, you know, whether it's conservative care, you know, and also having pamphlets or educational materials, you know, that really do talk about, you know, if you are referred to a physical therapist first, that there's, I believe it's an 89 point something percent less likelihood for that patient to be prescribed opiates in the following year.
Elaine Lonnemann: 24:23 And that's a huge statistic, you know, and everybody's concerned about the opioid epidemic right now. So, you know, following practice guidelines and physical therapists should be considered, you know, first primary contact providers, then we can do a comprehensive medical exam, we can screen, we know when not to treat, we know when to refer on. And following those guidelines I think is the other part of what I educate my patients about. So I would say, you know, these are the guidelines and having this material. So if you're interested in sharing this with other people and you know, there are certain patients that are more vocal than others and whenever I hit those patients, I really get them and hit them hard and say, you know, help share this information. If you found this valuable, please advocate for not only yourself but for the next person that comes down the road. So they don't have to worry that there are 26 year old now and they have, you know, this label.
Karen Litzy: 25:28 Yeah. He had this quote unquote disease. That is not all right. So is there anything else that from your perspective or for AAOMPT's perspective that we missed that you're like, you know, I really want, whether it be other physical therapists or healthcare providers, even the general public to know.
Elaine Lonnemann: 25:52 You know, I think it's important that I'm clear on this. I'm not saying that imaging isn't useful. Because you know, I've talked to us a little bit on the downside of it, you know, but in the absence of trauma or any other systemic medical concern, imaging studies aren't necessary for, you know, low back pain, a comprehensive medical exam is. So I think that's something that I would like to emphasize, but there are times when imaging is necessary and I don't want to come across as saying that, you know, we're downplaying it all the time because sometimes it certainly is necessary. But I think that, you know, the biggest thing that people don't understand is that these are common age related changes in the spine. They don't correlate with symptoms. You know, that's hard for the patients to understand and providers because we are so focused on finding, you know, some type of pain generating tissue as the cause, you know, so sometimes I'll share stories too with patients and say, you know, because they've now got this disease, they've got imaging, they've got findings and you have to kind of talk them off the ledge to a certain extent.
Elaine Lonnemann: 27:14 And I say, you know, if I had a group of 20 year olds, 120 year olds in a group, and then I have a group of 80 year olds, 180 year olds on, on the other side of the room and none of them have back pain. Now they may, probably 90% of us have back pain at some point in our life. But at this point in this room, none of them have back pain. But then if I sent them all into the MRI or imaging room, then 37% of those 20 year olds would come back with degenerative changes in there. There's fine or changes by positive findings and if you then look at the 80 year old group who then goes in and has the MRI, that number goes up to 96% so that kind of gives them a little bit of a balance. So I guess that's the other thing I would share, you know, just that these findings on imaging don't necessarily have to lead individuals to go down a path for riskier treatment options.
Karen Litzy: 28:15 I think that's a great statistic. And thanks for sharing that because now that's something that if there are any therapists listening, they can kind of use those statistics to say, Hey, listen this is common as you get older. And I think, you know, the downfall that I can see from having this conversation with the patient is then the patient's saying, do you think it's all in my head?
Elaine Lonnemann: 28:40 Right. And that's what I emphasize. Yeah.
Karen Litzy: 28:42 Oh, real. Yeah. That's why I'm glad that you said like, listen, your pain is here. It's real. You're experiencing this. This is not made up. But let's see if we can, like you said, follow these guidelines get you to move, do exercise, feel more comfortable in your body in order to help reduce your symptoms, reduce the pain. Cause I know, I mean when in my early days of explaining things like that to patients, I've had someone say so it's all in my head and I was like, Oh, that is not what I meant. I definitely screwed that up. And with experience you learn, right? You learn how to do that better. You learn how to relate to the patient. And the best thing to do, like you said, is to use stories and to use statistics and to use metaphors and things like that so that people can kind of understand where you're coming from. But yeah, that's the only downfall that I could think of. That devil's advocate here. Right?
Elaine Lonnemann: 29:41 Absolutely. Yeah. And I think as physical therapists we have to kind of get outside of ourselves. Yes, we know that pain is, you know, it may begin in the brain and the synapses and all of that, but do we really have to say that specifically to the patient? Can't we just say, you know, it's a normal, natural physiological response. You've had it, what you have is real and it's impacted by a lot of things. That's a complex issue. But what you have is real. And I have never argued, that was probably some of the best advice I learned in my fellowship training when the patient has pain. And this was way back when before a lot of the pain science research has come out. But when the patient says they have pain is their pain, that is what they have, you don't argue with them about that. You know, regardless of what type of physiological response you're seeing, what they have is real. And so, yeah, I do hear what you're saying about the downside of it. Yeah. They do have physiological changes, but pain is a complex matter.
Karen Litzy: 30:43 Well, thank you for all of that info. And I think that this will definitely give therapists something to think about. It'll give therapists a great way to move forward with treatment. People now know how to access the clinical practice guidelines. And that leads me to the last question for you and that is knowing where you are now in your practice and in your life, what advice would you give to yourself as a new grad, fresh out of physical therapy school?
Elaine Lonnemann: 31:16 I would probably recommend to take more time to reflect on my patients. Not necessarily bringing them home, but to take a little more time to reflect on the things that they said personally related to their care. And also reflect on outcomes to a greater degree.
Karen Litzy: 31:44 Great advice. I always say that I would like to go back to my patients in my early days and just, you're like, I'm sorry.
Karen Litzy: 31:57 I mean, you know, I was doing the best I could with the information at the time. But you know, of course as you gain more knowledge, you gain more experience. You look back on things and you're like, Oh man, I could've done that better. But that is part of that reflection process. So you look back on patients and you reflect and you think, Hmm, you know, maybe I could've done X, Y and Z. So then the next patient comes along and you do better. So I think that's great advice. I love it. And yeah, where can people find more information about AAOMPT and more information about you if they have questions or anything like that?
Elaine Lonnemann: 32:30 Oh, absolutely. So, the AAOMPT website is https://aaompt.org/ and you can certainly email me. I'm happy to answer any questions or talk to you more about, the Academy of orthopedic manual physical therapy, APTA, where to find guidelines, research on low back pain. It's just something I'm very passionate about and always enjoy talking about and working with patients with as well.
Karen Litzy: Awesome. Well thank you so much and thank you for coming on sharing all this info. I appreciate it. Everyone else, thank you so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart.
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