Academy of Neurologic Physical Therapy



Academy of Neurologic Physical Therapy Historian Committee Inspirational ConversationInterviewee: Margaret Schenkman, PT, PhD, FAPTAInterviewers: Britta Smith and Dana LottDate of Interview: 2019Transcription of Full Audio InterviewStart of Transcription: Timestamp 00:01:45End of Transcription: Timestamp 00:37:25Interviewer 1 (I1): So it’s a beautiful day in Washington D.C. at Combined Sections Meeting for the year 2019. And I’m very happy to be sitting with Dr. Margaret Schenkman, the Anne-Shumway Cook Lecturer for this year, and with Dana Lott, a member of the Historian Committee, for this interview. And my name is Britta Smith. So Dr. Schenkman, if you will please allow me to read a brief summary of your curriculum vitae. So Dr. Schenkman began her professional education at Purdue University earning a Bachelor’s of Science in Chemistry in 1968 followed by a PhD in microbiology at Yale in 1974. She changed professional directions in 1980 when she earned her Master’s in Physical Therapy at Boston University. After a few years of clinical work at Spaulding Rehab and in a private practice for musicians with hand dysfunction, she transitioned to academia, first at Northeastern University. In 1986, she joined the faculty at the MGH Institute of Health Professions as an Assistant Professor and received a fellowship in biomechanical engineering at the Massachusetts Institute of Technology. In 1991, she moved to North Carolina and became a senior fellow of the Center for the Study of Aging and Human Development, and an Associate Professor at Duke University, as well as the Director of the Posture and Balance Lab at Durham Veterans Administration Hospital. Since 2000, she has been based at the University of Colorado as the Director of the Physical Therapy Program, and an Associate Dean of Physical Therapy Education at the School of Medicine. Her scholarly work has been varied, but highlights include study fo kinematics of human movements, most notably work on the sit-to-stand movement, and function in people with neurological diagnoses, especially Parkinson’s Disease. Dr. Schenkman is known also for her development of models and frameworks that guide interventions in neurologic conditions. Congratulations to you, Margaret, on your selection as an Anne Shumway-Cook Transitioning Knowledge to Practice Lecturer. I’m so glad you’re able to be with us today.Margaret Schenkman (MS): Thank you.(I1): So, the first question, and one you did address during lecture, is, you went from microbiologist to physical therapist, so how did that happen? (MS): That happened because I went to, um, graduate school very young, before I knew enough about what it really was. And loved science…thought I wanted to be a scientist. And realized very quickly that working with test tubes wasn’t really fun; was not where my heart was. And so after I finished, I left microbiology, I turned my post-docs, and said, “I’ve gotta do something else.” I actually coordinated human services, uh, emergency services, from Denver to the Kansas border for a year, talked my way into a job, coordinated human services in Indiana for a year, and then was working on a textbook for an uncle of mine who had a publishing company in Boston. And realized that I just needed to know people. So I called around to colleges one day and ended up teaching nine courses in one year. And decided I really liked teaching, but I’m not going to teach microbiology. So um, I had a roommate who was a physical therapist – she had just finished her program that year – and a cousin who was a physical therapist. And I think I watched one of them treat for about an hour, and thought, “I like teaching, I can teach anything. I guess I’ll be a physical therapist! They need people with PhDs…” (laughs) And so I made an application to BU that even I believed at that point, and got admitted, and it turned out to be a perfect profession for me, absolutely perfect, because I could, I loved working clinically…I ended up with problems with my hands, I couldn’t stay in the clinic…but I loved it and I loved working with students. And I loved being in a profession where there were so many questions and so few people asking them.(I1): Excellent…So you spent relatively little time in the clinic, just because of your hands? Or really because research was calling? (MS): It was really because of my hands. I had, I could not keep working clinically. I would’ve worked clinically for many years if I could have. But I was very fortunate because I’ve always worked with really skilled clinicians. I value clinical practice. I realize that you can’t ask the right questions if they don’t come out of your real clinical experience. And because I had so limited clinical experience, I partnered with really superb clinicians. (I1): Mmhmm. So one of your first research areas, and really my first exposure to your research, was um, your body of work in kinematics, most specifically the sit-to-stand movement. Why did you choose to look at this motion? (MS): (laughs) I was at the MGH Institute and they had just set up a – had just developed a very sophisticated for that time – motion analysis lab. There was very little research going on but I had the opportunity to work with the biomechanist there, and so it was my first foray into research. I don’t even remember how I managed to do it. I know…I think I was doing some work with them before I became a fellow. So MIT/MGH had a fellowship to train engineers to become in medical science and medical scientists to understand engineering. And it may be that I applied for that fellowship and that was what allowed me to work in the lab, or maybe I was already there, I can’t remember. But that was the work that was going on and so that was the work that I did. And um, it’s pretty funny because it was a long time ago, and yet I’ve been told that’s the work, the piece of work, that I’ve done that is the most cited.(I1): Yes! (laughs) (MS): It’s really funny because it’s so far in my distant past now. But I was working with a really good biomechanist and we just had fun doing it. (I1): Well don’t you think it was a springboard for other people’s research? (MS): Oh it became a springboard, well it became a springboard for my research.(I1): Uh huh… (MS): I think it’s turned out. I really credit Patrick O. Riley…he was the biomechanist. He was just very smart. And I just tagged along for the ride (laughs) (I1): Now, forgive my memory, but when I went through your publications, I didn’t see something on the movements from sit to and from supine, but did you do something with that too? (MS): I didn’t. I did do work with gait later. (I1): Okay… (MS): We did some gait work when I was at Duke University. But I don’t think I ever published sit-to-supine.(I1): Okay, maybe it was a colleague. I seem to remember reading those all together (laughs) (MS): Although I’ve always been interested in that movement. And it’s um, the work that I did with sit-to-stand really helped me to look at other movements from a more qualitative perspective and to really think about them.(I1): So yesterday at the Anne Shumway-Cook lecture, you did a really lovely job walking us through your research questions in Parkinson’s Disease and how one research study really led to another. So what did you, what inspired you to study Parkinson’s? (MS): I really started it because I was trying to understand the role of the trunk, the proximal musculature and structures, in control and stability of movement. And I was working with a neurologist who said to me, “You know, your profession used to do better with people with Parkinson’s than you do now, what happened?” And so he and I started trying to figure out what it is we do as physical therapists, and that was how we developed models. And we wanted to test them in people with Parkinson’s. So I knew nothing about Parkinson’s when I started. As you can see from my answers to your questions, my life is happenstance; it’s not very planned (laughs)(I1): (laughs) (MS): But I really haven’t worked with people with Parkinson’s but as I got into the work, I just found it was an incredible group of people to work with. And I loved working with them. And I could work with them without really challenging my hands. Because I was helping them learn to move but previous to that I had been working with people who have strokes, so I was really needing to do heavy lifting. So it was a combination of happenstance, loving the population, and actually being able to treat even though I had hand dysfunction. And it became my career… Unplanned.(I1): Unplanned. I like that the best. ---TIMESTAMP 00:11:43---(I1): So um, at a lecture today with Dr. Evan Cohen, he frequently said, “Flexibility is the cornerstone of mobility.” And I get the sense that you adopted that much earlier in your work with Parkinson’s, when you looked at axial mobility, and one of your philosophies was relaxing into motion rather than stretching into increased motion. Can you talk about that a second? (MS): Sure. Think about people with pain or people with Parkinson’s, um, moving’s hard. People with Parkinson’s don’t move much and so they become stiff. People with pain are uncomfortable, so they don’t move so they become stiff. With Parkinson’s, the not moving is because the muscles are on too much and they’re just on all the time, but not on to move, just on in a very stable way. And so the way I thought about, and I came to it from having known Feldenkrais practitioners who work with people with painful conditions, that we’re so used to stretching, but if you could just relax, the muscles will relax. And if you gradually relax them over time intentionally, they will get longer. So rather than go in and forcibly stretch, why don’t we help people learn how to move in a relaxed way and increase what they can do in a very gradual way. So if you think of muscles that are on too much all the time, if you’re learning how to get them to relax, then you can actually become more relaxed all the time. And the people that I’ve worked with who have Parkinson’s and have done this over prolonged periods of time and have kept doing it it, have gained their mobility back and retained it for years. But it does take deliberately doing it. (I1): So once they relax, do you find they’re weak? (MS): I didn’t really look at weakness at the time. This was more particularly focused on the axial muscles, um, although we were, the program we developed relaxed and stretched everything. We did do lower extremity, um, gastroc and hamstring stretching, which makes sense to me. But for the proximal muscles, um, I suspect they were weak and if I were to go back now, I probably would begin, I would work on the core strengthening control in a different way than I did…and probably equally as precisely and intentionally. But I know much more about that now…(I1): Sure.(MS): …than I knew at the time I was doing it.(I1): Right. Um, one of the things that came out at that time was your video program for axial motion. What was the intention of that video? (MS): We developed that video to, um, teach the people that were teaching the participants how to do the exercises so that we could be consistent, and we developed…so we had two; we had one for the instructor and one for the participants. And they would take it home and they could use it to remember how they were supposed to do their exercises. So they would get a video that they could then refer to.(I1): So was it a reference or was it a workout with the video? (MS): Um they could do it either way. But that was the program that we used in the, in both of my first two earlier studies. (I1): That’s really cool for, uh, something I think we are revisiting again now. (MS): (laughs)Interviewer 2 (I2): Um during your lecture you kind of made a call to physical therapists to determine how to assist chronic conditions for the long haul. What are your visions for our profession to, um, act on behalf of this population? (MS): I think we have to really think differently how we treat people with chronic conditions. We need to figure out what it is that they need in the short term, whether it is flexibility, strengthening, cardiovascular conditioning, they need us to get them on the right program. But then they need someone probably with lesser, um, training, lesser capability, to help them to keep going. But then they need to come back and see us, just as they see come back to see the neurologist, whether it’s once a year, whether it’s four times a year, they should be coming to see us and having us tweak their programs and help them and guide them. We should be available to them in some way or another as they have questions, so that they really can become lifetime exercisers, lifetime mobility people…have that guidance that requires a skilled, um, practitioner. So that’s not how we practice for the most part right now. But I dream of the day when it is just expected that they will come and see us, and they’ll be referred to us, and they will be reimbursed by insurance for it, because it will keep them more functional. That’s my dream, but…(I2): Just like they’re coming in for a physical every year! (laughs) (MS): Yeah, yeah, or they go to their neurologist every four months to change their medications or whatever. But right now what they’re doing is going to a trainer or a massage therapist or someone else…and they’re not getting the benefit of what we can help them with.---TIMESTAMP 00:17:48---(I1): So I know that you are also looking at treatment of newly diagnosed Parkinson’s, de nova Parkinson patients, or patients with Parkinson’s, those not on medications yet…is this relatively new as a population that you’ve been looking at? (MS): We began the study to test whether high intensity exercise is, um, useful for them, and for pragmatic reasons, just as I started with flexibility with Parkinson’s because I wanted to know about the trunk, I wanted to know about, um, endurance exercise for people with Parkinson’s. And if you work with them before they’re on medications, then any changes you’re seeing should be because of what you’re doing and not because of change in medications. So it’s pragmatic. But it became clear to me working with them, um, and it’s been clear for quite awhile, but the sooner we can begin to work with people the better because by the time they’re diagnosed they already have problems that are subtle enough that the neurologist isn’t really seeing them but as physical therapists we can see them. (I1): Would you anticipate that we’re able to change the neuroplasticity of the disease with this early intervention…is that even a thought…? (MS): That’s the question. (I1): (laughs) (MS): That’s exactly the question. If we get people on high intensity exercise early, can we slow down the changes in the brain? That is really hard to study because the PET scans that you would need or the MRIs or whatever you’re going to use, are so expensive that to, um, scan them before and to scan them after is just prohibitively expensive. Um, if as the medical profession becomes more understanding of how powerful exercise is, it may get easier to talk people into spending that kind of money to find out does it actually slow down the disease. (I1): That’s wonderful. So, what other areas in Parkinson’s would you like to see research be directed toward?(MS): Oh my gosh…it could be directed in so many ways (laughs)(I1): (laughs)(MS): Um we need to understand why people with Parkinson’s are fatigued. And we need to figure out how we can help them. And so far that has eluded physiologists, physical therapists, we just don’t know that answer. We need to understand how people with Parkinson’s, how we can help people, um, change their behaviors. And Parkinson’s is particularly hard because they have, um, associated with the disease, they can have reduced motivation and increased depression. And that makes it really hard to become a self-motivator to take care of your health rather than just take a pill. And so we also need to figure out who can do it and who can’t do it…and how do we know which one. Because to try to spend a lot of time getting someone to do something they’re not going to do, is not productive. Or the other way to ask it is there a group of people where if we knew how to approach them better, we could get them to want to do it. There’s just a lot to translate what we’ve learned into real life. And I think that needs a lot of good intention.(I2): I’m happy you brought that up because…so I’m at Duke…(MS): Oh you’re at Duke!(I2): I know! I was happy to see another fellow Duke, um, and we’re having that same problem…where do you draw a line in the sand of what’s our role and what perhaps might be more of a psychology, you know, involvement kind of…we have our hand in the behavioral change but there’s been a real push in our department to interact more with the psychology department. And they have taken on the incredible task of training cohorts of therapists on how to essentially do cognitive behavioral therapy with all types of patients…our chronic pain patients, our neurological patients with chronic conditions…because of that exact reason – we’ve got the literature that supports that you’ve got to exercise, but if you have someone who has never exercised a day in their life, telling them that it’s going to potentially help slow the progression of their disease, is just, it’s just not going to do anything unless they’re in that right, you know, stage of behavioral change, so it’s really nice to hear that side of, um, thought, that it isn’t just about rigidity and axial mobility, there’s just the psychology of…it’s great that you have the proof but if you can’t get someone to do it, now what? We learn so much but then, you know, it’s like, “You’ll never know the answer and you just have to learn to love the questions”…it’s just like you have constant questions. (MS): I love that quote of Anne Shumway-Cook’s. I was so appreciative that she mentioned it and I said, “Can I quote you” and she said, “Yes.” Umm…that’s why I love Cory Christiansen’s work. He and I have worked together for a long time. He worked with me on the Parkinson’s studies, developed his own line of research, and I mentored him on his K Award, so I’ve had the privilege on this, peripherally, on the behavior change, he’s really the one doing it, but I’ve gotten to kind of go along for the ride. And it’s clear that we need to do it in conjunction with people who know that area, and he has very good people working with him, we need to cross disciples and cross professions, because if we just stick to our profession or if the psychologists just stick to their profession, we don’t get where we need to go with the patients or the participants. And uh, so I think that relationship between the physical therapist and the psychologist in behavior change is critical if we really want to help people with chronic conditions. And I’m moving to Durham, by the way, eventually! I just bought a house there…I’m coming back! (laughs)(I1): Congratulations!(I2): It’s a different place now!(MS): So are you in the clinic or on the faculty?(I2): Uhh I am in the clinic…I’m on the neuro ICU and neuro step-down floors.(MS): Really…that’s why I know your name! Because of Amy Nordon-Craft.(I2): Ohh!(MS): I didn’t talk about that work at all, but I was part of the ICU study.(I1): I just was about to mention that! That you did the neuro ICU and the medical ICU, and some of the, um, chronic…(I2): I love the dabbles in the acute care, in the obesity…and I just was like “She’s got her hand in everything, it’s fantastic!” (MS & I1): (laughs) (I2): I think that’s what makes you a good clinician, but as a researcher…I think it probably just makes you feel like you’ve just gained experience from so may different…(MS): Yeah, I was invited to join that study, it was run by just a superb pulmonologist critical care doc, who…he’s a great scientist, um, Mark Moss. And he was working with Amy Nordon-Craft who was on our faculty and had just joined faculty. And she said, you know, “There’s this guy who came from Atlanta,” he was at Emory, “and he wants to do this study, and we need someone like you who is a clinical trials person”, so I said, “Sure”. And I…Do you want all this?(I1 & I2): Sure!(MS): You can delete it from the tape…(I1): I’ll listen to you (laughs)(MS): So I came along and, um, looked at what they were doing. I said, “You’ve got to have a model. You’ve gotta have a framework of what you’re doing.” And he just like blew me off. So he sent it to a friend after they wrote it and the friend said, “You’ve gotta have a model.”(I1 & I2): (laughs)(MS): So he came back to me, he said, “Margaret, we need a model.” So I sort of put up what I thought we were doing, and it got funded, and he swears it got funded because it had the model in it.(I1 & I2): (laughs)(MS): But I used to laugh…and I’d say, “Well when Amy’s not there, I can go treat in the ICU.” And they would just crack up because there was no way I could go treat in the ICU.(I1): Right, right, that’s great.(MS): No way at all. I actually went to the ICU a couple times with them to round with them just to see what it was. That’s as close as I got to treatment in the ICU. (I2): (laughs)---TIMESTAMP 00:26:48---(I1): Well in all your free time you managed to have a book called “Clinical Neuroscience for Rehabilitation.” So what did you feel, or why did you feel your book was needed? Was there a gap in the educational literature on neuroscience?(MS): Well, again, it was happenstance. There is a gap. I think. But um, there was a neuroscientist in Fort Collins at, uh, Colorado State University who approached me and said, “I’ve written this book but I need to turn it into something more clinical.” And he and the publisher approached me and asked me if I would look at it and help them with it. And I met with them and I looked at some chapters, and he wrote really well and he had the right content, but not organized in a way that was useful. And I thought about it for about 6 months and I finally said, “Okay, I’ll help you with it.” And we had gotten about 80% of the way there and he pulled out, so I ended up having to finish it, which is why it’s under my name. But I was not looking to write a book on neuroscience (laughs)(I1 & I2): (laughs)(MS): However I have always felt that one of the reasons neuroscience, neuroanatomy, um, is hard to understand is, because unless you have a 3-Dimensional mind, which I don’t, it’s very complicated to figure out, you know, you just get these cross sections and it’s like, “I don’t know what they’re talking about…I have no idea what this is.” So I had to learn it by understanding the big picture and then building, and I’ve always wanted a book written that way. And so I took the advantage of structuring the book that way.(I1): That’s great…wow…(MS): It hasn’t done very well, which is unfortunate because I actually think it’s a good book. And I really, it’s my co-author really, not me, that made it such a good book. I just did the sort of how you organize it. But for some reason it’s not adopted much.(I1): I’m going to take a look at it…make some recommendations.(I2): I know! Who’s the publisher…are they here?(MS): It’s Prentice Hall. They’re not here.(I2): I was going to say…I saw McGraw Hill and Elsevier and…(MS): No, they don’t come here.(I1): So what are you most proud of in your professional life?(MS): Honestly? I’m not. I mean it’s just what I do.(I1): All right…you’re too modest for words!(I2): (laughs)(MS): No, no, it’s just that I do it because I love it not because, you know, it’s just kind of what I do. I’m not trying to be…(I1): Right…Well I must ask, I know you from when it was the, uh, the Neurology Section and now it’s the Academy of Neurologic Physical Therapy. And uh, you held a position on the Board?(MS): I did.(I1): Which was secretary if I recall correctly.(MS): Yes. (I1): Do you remember anything that struck you about that time – in our professional section life – that was going on at that time?(MS): It was a great time to be on the Board. Um and I haven’t been active in the Section since then, so I’m sure it’s still a great time. But at the time that I was on the Board, first Lisa (indistinct last name) and then, um, Sue Whitney were Presidents of the Section…very different people and very different approaches. But they were really moving things forward. I believe that Neuro Notes turned into Neurology Report at that time, under Lisa I think. (I1): It was under Lisa.(MS): Yes it was under Lisa’s guidance. Which was a huge step. And then I became active, let’s think, so then it became…I’m trying to think when it became JNPT…I think it was…(I1): Judy Deutsch.(MS): …just towards the end of when I was on the board because it was under Judy Deutsch. So, Judy, I got to know Judy very well…I got to know Sue Whitney very well. Sue is a riot; she’s kept me laughing for years. I worked with a lot of really terrific people on the Board and I watched the Neurology Section really evolve from, um, fairly unfocused to really focused over that period of time I think.(I1): Mmhmm. And grow…double, triple in membership if I recall.(MS): Yes, yes. The membership exploded during that time. I got to work with you some. I worked with a lot of people that have meant a lot to me. (I1): Great. Well I definitely appreciate your contributions to the Board, for sure, at that time. (MS): I think I just kept people laughing as they tried to keep me under control! (laughs)(I2): Sometimes you need that! (laughs)(I1): Well you mentioned being able to sit and think with one of your mentors, it was a physician. (MS): Mmhmm.(I1): And I think that’s what the Board at that time did well. Was that they would have these Strategic Planning Meetings, where they would sit down and just think and strategize and really take time to, uh, try to focus what our mission is and where we feel like we can help neurologic therapy move into new frontiers, and support financially, and um, educationally, and things like that. So I think that’s one of the turning points, was during that time when you were a member of the Board.(MS): We had two of those meetings at my home. One before…while I was still on the Board, and then one after I wasn’t on the Board anymore (laughs). But they all came out and we had slumber parties at my home…everyone stayed there and we slept on mattresses on the floor. And it was great. It was fun.(I1): That’s great. Like camping out!(MS): Mmhmm. (I1): Alright…---TIMESTAMP 00:33:06---(I2): Umm I’d like to take a left turn, to coin the phrase that you used during your lecture. You say that you took a real left turn, um, in getting involved with investigations of heartfulness, meditation, uh, in terms of stress relief and health responses. Can you talk to us a little bit more about that?(MS): Sure. Well I’ve meditated, um, intentionally, seriously, whatever you want to call it, for 30 years now. And have been a trainer in meditation for 25, or more than that, um, through this heartfulness practice, which is a very unknown practice because it’s not commercial. But it’s, um, been just hugely important in my life. And as I’m moving toward, um, reducing what I’m doing in terms of research in Parkinson’s and the work I’ve been doing, um, the Heartfulness Institute has been developing just as the Board was developing at the time that I was on it; it’s trying to come into its own. And we’re looking at, um, research, you know there’s a lot of research out there about mindfulness now, well there is some, but it’s well known now. Heartfulness is not; it’s a very different kind of practice. And um, we’d like to understand…we’d like to…experientially I understand it very deeply, but in terms of evidence about it, there’s very little. And so I am helping to begin to move into, um, research in that area. And one of the things that a neurologist colleague of mine, who has been practicing this meditation for even longer or the same amount of time, approached me recently and said, you know, “it’d be great to look at the epigenetics of heartfulness” because we know that as we, um, we know that environment affects genetics, and there are 4 generations of people who have been meditating heartfulness…um, is there a way to study this. So we’ve been grappling with how do you study epigenetics, learning the methodology of it, and really, um, beginning to figure out how to set up some studies to look at the effects of it.(I2): What is the difference between heartfulness and mindfulness?(MS): Mindfulness, as I understand it, you learn to observe your mind and direct it. That’s sort of a very superficial explanation. But you become more conscious of where your mind is going and try to learn how to, um, let go of things that you don’t need to be worried about and reduce your stress that way. Heartfulness teaches you to pay attention to your heart and allow your mind stop directing us. Because the heart actually knows everything. The mind only knows what you put into it. It turns out that the heart is hugely broad, but we don’t know our hearts because we don’t pay attention to them. And so the more I’ve practiced this meditation, the more I work from inner knowledge that has nothing to do with what my mind is telling me. And it’s a much more intuitive way of being and it allows for a much fuller, um, experience of life, than I could’ve imagined. (I2): Wow…that is beautiful.(I1): That is beautiful. Well I’d like to thank you – we’d both like to thank you – for joining us today, and sharing your thoughts, and being such a contribution to the profession, Margaret. I’m so glad you came.(MS): Thank you. ................
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