ANPT Inspirational Conversation



ANPT Inspirational ConversationInterviewee: Steven Wolf, PT, PhD, FAPTAInterviewers: Britta Smith and Melissa BloomDate of Interview: 12/7/2015Transcription of Full Audio InterviewStart of Transcription: Timestamp 00:01:07End of Transcription: Timestamp 01:03:45Interviewer (I): Today is December 7th, 2015, and I'm sitting here with Dr. Steven Wolf, and with me is Melissa Bloom, a physical therapist, neurological specialist, and we're going to have a conversation with Dr. Wolf about all kinds of things. So thank you for agreeing to work with us.Steven Wolf (SW): Sure.(I): And I've already warned you it's not going to be a repeat of the Ann Shumway-Cook lecture.(SW): Got that.(I): (Laughs)(SW): And, um I'm free to say what I want right now?(I): Absolutely.(SW): So the only people who call me Dr. Wolf are my family members that's obligatory.(I): (Laughs)(SW): Do we have to say Dr. Wolf or can we just say Steve?(I): We can say Steve.(SW): That makes me feel much better, great.(I): Okay wonderful. Alright so you became a physical therapist after graduating from Columbia in 1966 and then I know Boston University, you got a Master's in 1969. And then you rapidly transitioned to research and you earned your PhD at Emory in 1973. Why did you become a PT?(SW): Well I became a PT because I wanted to do something that involved helping folks, uh that was much more personalized than medicine, and I thought physical therapy would be a very good option, and I became a PT because I wanted to treat patients. In fact I did for my first two years in the US public health service, and while I was in the public health service back in 1966 to 1968, I was in an environment that was way ahead of its time. One in which we didn't get prescriptions from physicians. The mandate was real simple. Here's the patient; evaluate and treat them. And I had not been exposed to this degree of openness during my clinical affiliations, and the response I had, a guy I received my after about prescriptions was very simple. You're supposed to know what to do, not us. So in that context it was very common for interns and residents in particular to come up through the curriculum of sort of doing their own patients. And in that context, I asked a lot of questions. And the most of those is well why are you doing what you're doing, how does it work? And so often I didn't know. And by the… (cell phone rings).(I): (Laughs) We'll wait for that to pass. I'm going to pause this for a second.(SW): I'm sharing, I'm using Sarah Blan's office because it's much quieter.(I): Oh yeah I saw that.(SW): Of course I wasn't expecting the phone to…(I): (Laughs) Sarah just wanted her input in.(SW): I'm wondering if I just take the....(I): I imagine it won't, will it ring off the hook?(SW): (Continuing from last train of thought) …And often.(I): You didn't know the answer.(SW): I didn't and that bothered me to the point where I decided I had to go back to school to start to learn more, and that inquire process simply stayed with me. What a lot of folks don't realize, is that why I was in the public health service, and while I was in graduate school, I got my master's in PT. I moonlighted running a PT clinic in the nursing home in Roxbury, Massachusetts. I did that for two years before I wound up going back down to Atlanta. Um, and what other folks don't realize is that for most of my research years, I spent a minimum of the equivalent of twenty percent of the time seeing patients. In fact, some of the ideas that have evolved over these many years came from suggestions that patients had, or observations that were made by trying to work with them, but there's always been this assumption that you have to be labeled and categorized as something which I think is unfortunate. So I'm very proud of the fact to answer your question that on maybe an educator and a researcher, I continued to treat patients until about three years ago.(I): What made you stop?(SW): Just too committed to the things that I'm doing now. I simply don't have enough time. I would like to think it's slightly age-related.(I): (Laughs)(SW): But more so time commitments, as you probably know I run several clinical trials, and have become involved in other activities so I figured many falls such as the involvement of an app, and now the frontiers in rehab science, and the technology initiative to the APTA which are very time consuming activities.(I): Right, so one of those patient questions or observations by a patient that kind of guided your inquiry. Do you remember one particular?(SW): Well absolutely. One of them was, "I know that I have had a stroke and that some of my muscles are tight, but I don't believe those muscles have to be totally relaxed in order for me to regain function." Now, you may recall that there's a time that many of us were trained to believe that a precursor to the restitution of meaningful function demanded that we inhibit hyperactive or spastic muscles as a precursor to engaging the antagonist, weakened muscles. And in fact that's how our entire EMG/biofeedback initiative got started back in the late 70s, early 80s. Now working on that basis, and I think this is a story worth telling because I think it was a game changer of sorts. We did that, we did studies of upper extremity and lower extremity stroke patients and run through this entire procedure that was based upon notions of reciprocal inhibition and precursors of down training hyperactive muscles before one of them recruits weakened antagonist muscles, and at the end of the day when all is said and done, we looked at the relationship between training measured at least electromyo graphically and function measured mostly on time based activities that individuals could succeed and restore the use of an impaired upper extremity. A chronic stroke, as well as, as long as twenty years post-stroke, and the predictors of those changes were not the inhibition of hyperactive muscles, but the change in the ratio of activity between hyperactive muscles, and weakened antagonist to the point where individuals could initiate movements out of synergy. Five, at least twenty degrees with your elbow, and can you raise the wrist and begin to open their fingers which became fundamental bases for what we call constraint-induced movement therapy today. Now one of my uprising graduate students at the time, a chap named Stuart Binder-Macleod, who is now chair of the PT program at Delaware, and now is going on to an associate deanship role. So we published papers in PT journal of our observations and got a lot of lack because we were suggesting that the notion of predominant inhibition of hyperactive muscles was not necessarily an increased precursor to training for function, in fact one could make the patient aware of this co-activation, but trained towards function and in that context, attempt to change these relationships which was precisely what patients did because although we trained them, when we looked at their activity in the context of real life movements, they were co-activated, and that was pretty bold thing to say in 1983, but that's what we saw and took a lot of heat from those observations, but nonetheless continued forward with our next iteration which became what we call forced use of the hemiparetic upper extremity.(I): So how did that go with the things that were being discovered and shared in the early 80s about motor learning and functional recovery?(SW): Well I think that was the emergence time of a concept that was foreign to all of us prior to that plasticity, functional plasticity of the nervous system. And then in fact one could see changes, both in animal models with stroke and other neurological deficits, and in humans, and that there was this possibility of relearning motion. That it could be done under a variety of circumstances, and that when you begin to drill down and look at the physiological correlates, they weren't as presumptuous as we thought they were stated to be in the past. And I think if one goes back to, for example, some of the original writings of the Bobath's, one will see that the information about the relationship of antagonist muscles and this need to inhibit hyperactive muscles before recruiting weakened antagonists. We're all extracted from animal models, and that was very, very important and significant at the time it was done, but what we failed to do in some systematic way, was to externally validate the observations that were taken from animal models as they applied to the new condition. And I think what we were discovering in the 80s is that when we look at elements of motor control and motor learning or relearning, that those could be accomplished with modifications of the mandates that were, we were instructed in prior to that time. So that's, I think that we were evolving into this recognition that we could do a lot to improve movement capabilities under pathological conditions that were more geared towards functional activity than the specific isolation of individual muscles or muscle groups and joints.(I): I think at that time there was a lot of research going on about, especially lower extremity reflexes and their role in balance, especially with perturbation and things like that. What were you doing at that time because I know you did some balance reflexes research?(SW): Yeah well there are two things, one that I know you know about, and that deals with the slow motion of reflex conditioning. When one of our colleagues Rick Segal was here and we finished some of the biofeedback, EMG biofeedback studies, we raised a real simple question: why train individual muscles when we may be able to train reflexes? And one of our colleagues, John Wilpaul, has been doing this in animal models, and met John in several meetings, and he suggested we try this on humans and spent quite a bit of time trying to condition reflexes of upper and lower extremities. To make a fairly long story short, one could demonstrate that indeed when the central nervous system is not too profoundly disrupted, at least at cortical/sub-cortical levels, you couldn't detrain a stretch reflex of the upper extremity, up train it or downtrain it enabled by individuals or individuals who had quadriparesis of a spinal cord injury. It was very difficult to do that when there are cognitive deficits that impact an individual's ability to take feedback and modify their motor outputs under reflex conditions. With postural perturbations, we saw that indeed you can elicit long and short leads to the reflexes. They could be modified, but in order for them to have long lasting impact, that activity needed to be trained for perhaps longer periods of time. The manifestation of that today, is that now as you probably know there are, Thompson, who worked with John Wilpaul in Albany, is now medical of south carolina, is actually doing stretch reflex conditioning in spinal cord injury using the H-reflex in folks who've had, and now we spoke with her last week and started getting stroke. So the notion that we may be able to control, joints of the lower extremity, under perturbation conditions or improved ambulation and movement control is not dead, it's being explored quite aggressively right now. So, I think a lot of that evolved from those observations, I'm smiling because we saw posturography in the late 80s as a center of pressure feedback device since we had the interest in feedback and in fact wanted to determine whether you could use the resolution of multiple force transducers to look at these manifestations of force resolution, center of pressure resolution, and the trained folks to increase the postural sway of those older folks who are fallers. Indeed as you well know, you can do that but at the same time we happen to have a gentlemen here at Emory, he's a Tai-Chi grandmaster, and he wanted to compare posturography to Tai-Chi activity, and while all this education is a control for exercise at a time when alternative medicine still in its profound infancy at the NIH,and we submitted a proposal, that's part of what became known as the fix-it trials. Some compare Tai-Chi to posturography, and our view that here we have low-tech, high-tech multiple people individualized. An intervention that's designed to have multiple impacts on an individual as their autonomic responses, as well as their postural responses versus posturography which is designed to correct postural abnormalities. They are most diametrically opposed, and fortunately that proposal was one of eight around the country that was accepted, and little did we realize at the time that Tai-Chi turned out to be the most potent intervention in the country to delay the onset of falls, and that then necessitated twelve years of study on the mechanisms going back to the question again. That's great, let's train older folks to do Tai-Chi and see if it has an impact on falls, and obviously it did, but then the question is, well how does it work? And so we explored that with collaborators at Georgia Tech and found out that what appears to happen is that those individuals, older individuals who are fallers, are able to improve their postural control because they create tight linkages between their center of mass and their postural sways measured by the center of pressure that is much more temporary liked just in sway or in gait initiation than older adults who fall that don't go through that kind of training. So there is some kind of problem with cortical recognition that becomes more apparent in this, as what some people refer to as "movement meditation" that folks go through when they are doing this Tai-Chi and perhaps the added effect of learning movement and movement control through imagery rather than specific instruction which is what Tai-Chi does a lot of what we also have learned and more the emphases now for all postural control, this doing Tai-Chi system manifestation of that is that we tend to underestimate the importance of cognitive domain in divided attention in other resources that are critical to maintaining postural control and reducing or delaying the onset of falls. Whether it's a Tai-Chi intervention or any other for that matter, so a lot of our reference from now directed towards these behavioral elements that need to be considered and trained. So, if we had to do it all over again the one question that we would have asked and I think people should be asking of their clients, if their studying falls and fall behaviors, if they remember what they were thinking of when they fell. Specifically, was your attention truly divided so that you could not use your resources to evoke an appropriate notoric response to what could be seen as a perturbation because the sensory processing of the visual and or auditory cues for that particular perturbation certainly were not there because you couldn't share your existing resources to make the appropriate response. ---TIMESTAMP 00:18:30---(SW): I guess I'm getting way off target here.(I): No you're actually moving us along. Part of what you were talking about there, you know when you were talking about your one study and then it made you think about, you know, the kind of the why is that happening and what we were talking about was the, do you think a lot of times as physical therapists we get, you know, hopefully people are using the best research and stuff like that but if they're ignoring that basic science, underlying factor, and the why this stuff is happening, do you think that we're missing out as neuro physical therapists if people are not looking into that basic science underlay.(SW): I think we are and as our resources continued to dwindle, and we're queried more and more to justify for the treatment. It stands to reason that those who were decision makers who are going to say, on what basis do you think you can help this patient with this problem, if you're given X number more sessions? Well one can go to the evidence and inevitably there are going to be people who don't understand movement pathology but have to make these decisions, and I fear we're encountering more and more decision makers who come from MBA degrees with no understanding of the human suffering or rehabilitation at all. Who will ask the question, well okay if you're saying that, then what's going on? Help me to understand how this person is getting better. And inevitably that makes us think backwards to some of the fundamentals that underlie the decision that we make. And I think it behooves us where our teacher asks whether to sit in the classroom or in the clinic to emphasize those aspects of treatment that allow therapists, especially those with less experience, to better understand what they're doing and to challenge themselves.(I): So how did you get the inspiration for the constraint-induced program and all its evolution?(SW): That's interesting, that's a very interesting story. So, as a member of the what used to be called the biofeedback society of America, way back in my days of first coming here as a graduate student, my mentor was a chap named John Basmajian, who is very big in EMG biofeedback, and some people had described at one time or another as the father of EMG feedback and he introduced me to the biofeedback society of America, I would attend those meetings and of course there are various forms of biofeedback and you get to meet all of these folks and you have that interest in common. One of the individuals I met was a chap named Ed Taub, and Ed was at the biofeedback meetings, not because of the work he had done with deafferentation in monkeys which I'll get to in a moment, but because he was also interested in feedback, specifically changes in peripheral skin temperature as a basis for potentially treating Raynaud's disease in the absence of medications, and I have this interest in EMG feedback, and he used to be in these deafferentation studies in monkeys and suggested that maybe we ought to consider making folks who've had strokes use their impaired upper extremity by immobilizing their better limb. And that seemed pretty intriguing to me. At the same time, I started looking through the literature and that thought, as it's so often the case, was not new at all, it was actually suggested in 1917 by Ogden and Franz.(I): I didn't know that.(SW): 1917, and the way that came about, to divert just for a moment, is he was doing cortical lesions in monkeys, and observing their behaviors in their native cages to see whether they would use their impaired, their hemiparetic arm or leg, and so quite serendipitously, as it's often the case, tied down their better limb and found that they would still begin to navigate their cages with their impaired upper extremity. And he suggested that this be a treatment approach applied to veterans returning from the first world war who had sustained head injuries. That idea was so outrageous and perceived by the public as something that was unfair and beyond comprehension for war veterans that the idea literally went dormant for about thirty or forty years until it was resurrected again in animal models, and one of Dr. Taub's mentors, is a chap named Berman who started doing some of these experiments and had followed up on them. So at the same time he was interested in biofeedback and peripheral vascular problems, he was also interested in pursuing and was pursuing his work in deafferentation which is not quite the same as a central nervous system lesion.(I): Was the 1917, was the guy that made this recommendation, was he at, what was his background?(SW): So Ed Taub?(I): Oh was that the one in 1917?(SW): No 1917, they were both neurologists. Ogden and Franz, were yes, European neurologists, and very famous people in their own right. Um, so Ed, unfortunately one of the side effects of deafferenting a limb is a monkey began to see that limb as a foreign object and will eat it. Start to gnaw at the limb, and that requires a great deal of care on the part of the caregivers for those animals, and Dr. Taub had a very viable, unsuccessful research laboratory in Silver Springs, Maryland. He hired a gentleman to be the director of those animal labs, and unbeknownst to Dr. Taub, he, Alex Pacheco was his name, was pretty much set against this kind of behavior. And on labor day weekend, 1981, strung up these animals, and exposed their bandages and literally had them tied to instruments in the lab and called the police who raided the Taub laboratories and that was the so-called "Silver Spring monkey incident" that lead to the founding of PETA by Alex Pacheco. So that led to a great deal of turmoil, as you might imagine, and the society for neuroscience spent quite a bit of money supporting Dr. Taub, and all those at stake, and the claims being made against him. But one of the conditions of the exoneration of Dr. Taub, is that he no longer worked with animals. And he moved to the University of Alabama at Birmingham. It was during that time that he had suggested we pursue this work in stroke survivors, but what is sometimes forgotten is that the suggestion was actually made before the Silver Springs monkey incident, because our first publication was in July of 1981, three months before Silver Springs monkey incident as a case study in the PT journal. Subsequent to that, we got funding to do a five year project on what we called "forced use" which basically was a two week time interval in which individuals, chronic stroke survivors, would be made to use their impaired upper extremity by immobilizing the better limb in a sling with a cuff around the end of it, and giving them instructions to work on their own at home to be distinguished from constraint-induced movement therapy, a term developed by Dr. Taub later, which required one on one formalized training and now all of its modifications of home based rather than distributed practice, rather than intense sometimes, called signature constraint-induced movement therapy.(I): Did the early people in constraint, forced use excuse me, did they have to have any movement available to them in that arm so there was…(SW): Yeah, so the movement criteria came from the biofeedback studies, sometimes people don't realize that Dr. Taub doesn't mention that very often in his publications, but this notion of twenty degrees of wrist extension and initiation, that doesn't just come out of thin air.(I): (Laughs)(SW): Those were the predictors from our earlier work in EMG biofeedback. So we know that but not everyone does so there's a history here, and the notion of multiple reflexes rather than individual muscles, exploring a way of behavioral intervention, that has a foundation based upon minimal movement criteria which you probably now know has multiple modifications of constraint therapy, but they are all basically variants of distributed practice over different periods of time. Most recently, I think that intervention has done very well and now has new iterations. One paper that was just published this year in Lancet Neurology by a German group has now had multiple clinics around Germany enrolling patients who would do their training at home with family members, with therapists coming in infrequently, just to check them, not train them, compared to a dosed matched therapy based, clinic based treatment of the upper extremity and they're quite equivalent, if not early on the constraint therapies had superior outcomes. So the notion is that you can use it at home or we'd like to explore what I think is far more practical and once again harped upon the successes of Tai Chi, not because of the Tai Chi itself, but the impact of the socialization and group time that began upon compliance with the exercise form as you consider a group activity of constraint therapy where patients lead one another under the auspices of the therapist who may be a therapist aide, who has been instructed in how to work with the group. So they're not depending on one on one or a periodic half hour treatment from a PT or an OT, but rather they work with themselves and reinforce one another. That notion has never been systematically explored at all. It seems quite viable and practical, and perhaps for nationally feasible. (I): Sounds cost-effective.(SW): Exactly.(I): And I agree with you that patients can be another patient's best motivator.(SW): Absolutely.(I): Been there done that.(SW): Yeah for sure, but we tend to underutilize that and in fact I think that one of the future values of what we do in neurorehabilitation is something that people have spoken about, and is becoming more sensitized to today, and that's the therapeutic relationship. I think that one of the great instigators of change is what the therapist brings to the relationship with their patient. The extent to which that can be motivational for both the therapist and the family unit, caregivers or care partners, because we are taught to believe in a multi-billion-dollar pharma industry that there is something you can take too that's going to make everything better. We've seen that and that can't be further from the truth in the field of neurorehabilitation. So if we can create a trusting relationship and recognize when working with patients to identify what they can do for themselves and what the expectations are for improvement. I think that speaks volumes, and I think that we're going to see more and more of this notion of a therapist as a facilitator in a more formalized way than what's existed before. Way back when I was a young whippersnapper, I asked the question, "why don't we monitor the impact we have on patient behaviors since we have this intimate one on one relationship?" Originally, I was told well that's what psychologists do, we don't do that. That made no sense to me and of course our one fallback where we do that is fear of falling, so we monitor fear behaviors right and try to change those in some capacity. But we do this all the time, and I was fortunate enough in 2002 to be asked to give the McMullan lecture. And in that lecture, I mentioned that: is physical therapy truly a physical therapy or is it to some extent a misnomer? Do we do more than physical, how much of the changes in the behaviors of our patients are driven by the physicality of what we do as opposed to how we influence their behaviors to induce further changes in their physicality. And I still think to this day that there is a lot of truth to that. And I suspect what we are going to start seeing more and more of are behavioral measures that we make that can impact or at least correlate with some of the functional measures, especially the participatory measures as we've talked about in neurorehab. That too has not been explored well enough so if we're looking at these time recovery curves that are not nearly as clean as we think they are, there is a lot of jittery noise in them. I think the piece that's missing in addition to tapping, trying to figure out new ways in which we can tap them. Residual functional capability is the extent to which this therapeutic relationship can bolster those rates of change at different points along the timeline continuum. So I think that's really an important aspect of who we are and what we bring to the therapeutic table. (I): So one of the things that you've been working on is an app for upper extremity recovery, and I know Melissa and I have played around with the app a little bit and it does seem to be somewhat addressing what you're talking about, but from the increase in the expertise of the therapist to select the right activities at the right point in a patient's recovery, can you talk about your app and how did this project come about?(SW): Okay, um the truth is that I had been working as a reviewer for the Canadian stroke network, and happened to be invited to England to give a talk in Nottingham and went over in Norwich, and I was being transported from Norwich to Nottingham and we met, the exchange was at a pub in early, well late morning. And we decided to have a few beers before we made the exchange and started lamenting the fact that we have no systematic, evidence-based usability that is contemporary, and said we need to something about that so I did have the international phone with me. I called NIH and some friends I had there, we called the Canadian stroke network, to make a long story short, we give them ten thousand dollars to put together a think-tank team, this is March of 2010, where we meet at October of 2010 at the combined ACRM, american society for neuro rehab meeting in Montreal. And those ten thousand dollars were to be used to keep people staying on after the regular meeting was over to determine whether in fact we could come up with the makings of an app, and we realized there had to be at least two components of this. One, looking an algorithm, a rational approach in decision making.(I): Clinical decision rule?(SW): Exactly, what the algorithm is and the appropriate match of validated outcome measures for which there was evidence at that moment in time in that person's recovery that would be potentially usable. Well that sounds like pretty straightforward tasks but given the fact that everyone did this voluntarily and we had, I sent out quite a few feelers globally and came up with twenty-four people who felt they were committed to this and have stayed the course. Most of our meetings had been electronic. We have met periodically at annual meetings and this evolved, it took a long time because we did this out of our own pockets so to speak and at our own time. The notion was quickly appreciated that if one wanted this to be a global application, had to take into consideration what people could really do in the environments in which they find themselves. So when we went through this procedure we asked ourselves two questions continuously. One is how important are the interventions at any one moment in time, not once we agreed upon what they should be, and how feasible are they because the two are not necessarily one in the same because feasibility in one environment doesn't mean the same as it does in another. And so what you see in that app are options, and those options are based upon what is available to the user at that moment in time, and the other thing are filters because not all stroke patients are the same. So, the decisions are made not just based upon well here's the person in this moment in time, and this is their movement capability, but there are corollaries like which they had aphasia, language communications, cognitive compromise, just dysphagia, there's just a host of factors that can impact what one does. So those, if you have looked at the app, can be added to your decision tree because they begin to thin out what one can do based upon the existing evidence. So that's kind of where we are, what we have stuck with funds now to finish this up, and we may have to take this down as a free app is our resources to insert videos and visuals that will hopefully be a bit more explanatory. And in that process, have to figure out a way of sustaining the app. Having a person who will address any questions that any potential user has, coming up with mechanisms that are reasonable for funding, this is not a for profit endeavor. Not an endeavor as a matter of fact, that was one of the criteria for signing up. We were not trying to make money off of this, we were trying to sustain this and use this as a model for then exploring lower extremity and to other diagnostic categories so we're at this point now where we're, we've got to figure out what do you charge people and how do you monitor that, and how we sustain it, who's going to continuously update the referencing and the database for it. It takes money to do that, and so the only salary person we can begin to think of is the app keeper. We have to pay that person for the time they're putting into this. So we're very blessed in that the company, Pivot, that we're working with out of Toronto where Mark Bailey has been very fortunate to get funds is doing this almost grattis and that's, well the wild part isn't because by coincidence not by design the CEO's wife is an OT.---TIMESTAMP 00:39:15---(I): I was about to ask you where's the OT community in terms of embracing something like this?(SW): Well we think everyone's there, much like the constraint therapy, if anyone reads any of our papers, we've never made reference to physical therapists or occupational therapists, we make references to the therapists because it is, what that means is different in different localities of the environments so we welcome the knowledge utilization for anyone who wants to use it and don't try to draw sides.(I): Well what do you think, so when I was looking at the app, I thought it was really well done and the, some of it when you would look on the yes and no questions, they were very, like I could imagine a patient looking through because you had described the arm motion. What do you think like as far as if patients would maybe go on to the app, and you know the pros and cons of that or like where do you see the future as far as like if patients would go on and kind of, is that a positive or negative, if they would go on and try to do some self-treatment or I don't know?(SW): Well right now our intention, I don't have the answer to your question, but our intention is not to have it available to lay folks because we don't trust their decision making. How a therapist chooses to use that with their patient is up to their professional discretion. It's going to be hard enough now assuring ourselves that these apps, this app and its ramifications are not being misused, and the probability of that happening is greater of course in the hands of lay individuals who do things that may not necessarily be appropriate so that's a question to be answered down the road. Uh, we can't, the way this will work right now is even if there will be a license to use it, and anyone who uses the app will have to log on with their own user code, and so we will know who those people are whether they're individual therapists, institutional licenses, is way out of my league. I don't know the best way to do this, but we want to avoid our individual users, I mean if we want to do this as a large for profit endeavor and not care who uses it, I think the long term devastation of that strategy would be beyond repair because our intentions as I said before was to build this into other opportunities, in fact we put together a proposal to, I forgot what it's called now, it used to be called NIDILRR, but now it's called the national institute of independent living dadadada. Uh at Shepherd, with Debbie Bacas to expand this app into different domains including lower extremity for stroke, upper extremity for posture or injury related to MS, but we didn't get funded unfortunately, we extracted this from a failed rehab engineering center grant that Shepherd had submitted, and this is one core of that grant, and we simply took that core and morphed it into its own application, but the reviewers I think had some issues with why we weren't doing this on our own, and I feel that unfortunately the reviewers don't realize the amount of work that goes into skillsets in developing an app, you really need to know what you're doing, and I would suggest that most clinicians would fail to the point where it would cost more to try to do something that's rather than to partner with a group that knows what they're doing. And I've learned a lot just in this app, you may not even notice it, but even to the point of the color backgrounds that are used, are based upon several indices that I know nothing about such as what color combinations that are most appealing to the eye. So that one is bound to look at for a longer period of time. What font size should be for what circumstance, and these are things professionals do that none of us have any clue about. Even the notion of therapy, we want to make something more exciting, and we literally were lectured to us to why these names come up the way they do, and people have studied the longevity of recollection of names. But it's again something that I don't think any of us would think about, but that's why you work with folks who are invested and believe in what you want to do, but you have to their expertise just as they rely upon ours. So let me come back to us in the middle of this app for example and say, "Okay you've listed what the inclusion criteria are and what the therapist, now drop that down to 25 virtualists."(I): (Laughs)(SW): Why? Well that's because you just want so many words per role, and you don't want multiple roles, you want to be able to absorb a piece of information as quickly as you can and as accurately without having to spend a lot of time on it. Well you're going to lose people so that makes perfect sense but if that's your business and you know what you're doing, you will listen to that and that takes a lot of time. We thought it was time consuming just to amass all of the evidence and kind of lay it out, but then you really have to drill down to the specifics of what goes into that app and how it should appear. (I): So have you been involved in telemedicine recently?(SW): Yes.(I): How so?(SW): Well the first, the first stroke net rehab and recovery grant that's been funded nationally is in telerehabilitation and this is a grant that was submitted by Steve Kramer who's a neuro rehabilitationist, neurologist out of the University of California-Irvine, and he sought multiple sites, eight sites, within stroke network to partner and executing this project, and we were one of them. So the question that's being posed here, is can we educate folks who've had strokes by having them do gaming of very specifically based upper extremity activities in their home environment for eight weeks, six times a week where three of those six times is one on one with the therapist here so we two systems: one we're working with and one they're working with. And three times a week, there are questions they pose by coming online and asking questions about what they're doing without the one on one training, and over the course of those eight weeks to do basically six weeks a few times, eighteen sessions of specific training, but the sessions get dwindled down over time because the whole idea is to withdraw the therapist as the patient learns more and more. And this is an equivalency study so the question we are asking is across these eight sites that are participating with the exact same equipment. Can the outcomes, which is mostly the ARAT, the arm research action test, and quality of life measures mostly drawn from the stroke impact scale. Do we get comparable improvements in that versus a one on one training as opposed to being a superiority trial right now so this is a glorified proof of principle. Can you take this stuff, put it in some of its own, get them to work on it, and succeed? And this is a precursor to what's actually going to be happening in the real world so that's the telerehab project, it's the very first of the rehab recovery projects within the stroke network, which as explained to you previously, is a NINDS, national institute of neurological disease and stroke, national initiative of twenty-five centers where "join the strokement" is one of them that designed to do novel multi-site clinical trials either acute interventions, prevention of secondary stroke, or rehab recovery. So I'm the Georgia site co-PI of rehab and recovery and we have working groups at twelve of the twenty-five sights that have representatives in them from these three different core areas, and for reasons I'm not quite sure I understand, I was asked to be the co-chair of a working group for the country which gives me some insights into what people are thinking and some of the ideas that are coming down the pipe that hopefully will pass muster to get funded so it's not just a question of oh he had a the stroke network to just come up with an idea we can get funded. The idea has to be vetted, and then individually putting together as a clinical trial approved by study sections of the NIH, so it's quite a process. There's some neat ideas coming down the pike include some special interventions on language aphasia, one that I'm very interested in and I hope will work, it's such a fundamental question, and that's what's the relationship between time post stroke and intensity of training dosing and outcome.? Such a fundamental question we have not done a really good job systematically studying, of course a lot of the work Catherine Lang has done on looking at dosing has been a tremendous impetus to realizing how foundly undertreated many of our stroke survivors are and I wouldn't be surprised if that's true for other neuro diagnostic entities as well. So that, I hope that gets funded because that could be a really big, an important study.(I): You have such a wide spectrum of research that you've a part of. Do you have one area or one question that you feel as if you are most passionate about?(SW): The one, at this point in my life, the one thing I'm most passionate about is the unknown and trying to get some sense of what needs to be known. Both in terms of foster survival mode and being contemporary. I can give you an example, I started to talk to you earlier about something that came out of a 2009 APTA physical therapy society summit, the past meeting. I was fortunate enough to be on the steering committee for that meeting and several of us on that committee agreed to do that, just to remind you this an external review of the professions mandated by the 2006 house of delegates with report back to the house by June, 2009 to have other groups look at our mission statement and offer a critical assessment of where we are and where we should be going. So there are over twenty-four different agencies and groups that have participated in this and we agreed to organize and help run this meeting which was quite successful, with a proviso that we, the steering committee had total control over the assimilation effort. We certainly will provide a report back to the house, which by the way was approved unanimously, which was the impetus of what I am about to tell you. And several publications that we controlled, not the board of directors of the APTA. So among the recommendations that came forth was the recognition that there are core areas in physical therapy that are being underappreciated and underserved that will be critical to the future of the profession, and those four areas are: telehealth, telerehabilitation, genomic rehab interfaces, sensing technology and virtual environments and genomic rehabilitation interfaces and regenerative rehabilitation. So those, from that we got some funding from the APTA to create interdisciplinary groups, PTs and non-PTs working in these four areas to develop informational bases that can be shared and are being shared with anyone who has an APTA representation that wants to do that. The problem at this point is that the IT resources that APTA written are not that great, so we are getting very frustrated because for a variety of reasons. Educational units were not easily accessing this information as it was being generated in terms of powerpoints, journal articles, podcasts, the kinds of things you would think you would might want to have. Um, and so there was a need to do something about this. So, we've kind of come to a standstill because I personally think this is critical to the future of our profession because these are contemporaries that are not going to go away. Um, we've had an opportunity now at two education leadership meetings to talk to all the PT programs about this and there is no one who fails to buy into any program, and the reason for that is we've never presented this as something for the haves and have nots, and for the research one institutions can have great access to this information and use it while the smaller programs cannot. We are deliberately making this accessible to everyone. So, everyone buys into that. The problem is the ease of accessibility, and that's been a stumbling block at this point. What we've been able to propose now and hopefully will be approved is the development of a council, a first, what we call ourselves frontiers of rehab science and technology, council made up of representation of PTs and non-PTs. No one gets paid for this, that means doing this out of the kindness of their hearts, and section representatives to cover these four areas, and perhaps potentially future areas have yet to be described to create this group that will work together cohesively to move these initiatives forward. So that's kind of where we are. The proposal is just not ready to go to the board, in terms of the APTA. We hope we'll have something out in front of everyone by the combined sections meeting. So that's, you asked me where my passions are right now, yeah. And you know, as you've been around for several years, at this point I don't particularly care what people think.(I): (Laughs)(SW): I just do what I want to do and like to think it might have some meaning, and that's what drives me to answer your question. I love the work that we're doing, we've got lots of neat research projects, but you want to be spurred on by what you see and what you hear, and when I hear people talking about genomic rehab interfaces like brain-derived neural growth factor and polymorphisms, we all have our genome and we know that the polymorphism for brain-derived neural growth factor is manifested in those 25% of people who have it as an inability to learn notoric movements. And they come to us and say: "how are you going to use this when you treat patients?" What are we going to say? I mean I can give you example after example, it's happening exponentially, and we need to be positioned to address these questions, first from amount of education we get and from the applications. Another example is a protein-derived factor that is part of a genetic engineering process right now that is going to infuse, and create the proliferation of osteoblasts in osteoporosis, especially for women who are osteoporotic. So the question, is what influence that will have on how we teach weight-bearing activities? Do we do it the same way? Do we do it differently? You could ask one question after another, and this is simply an effort to try and take these resources and bring them together because the days of living and working in isolation with science and technology, they're gone. They are absolutely gone, and I would argue that tomorrow's patient who was brought up on technologies is going to demand that these kind of interfaces exist and we need to be prepared to make best use of them.(I): So, you're a busy guy. Are you going to retire?(SW): Uh, I guess so at some point or another, I haven't really thought much about it.(I): So what is…(SW): Well I am retired. I mean I just, I spend a lot of time with my family, my grandkids. I spend a much time watching them grow up and play ball as I do other things, and when I feel like noone cares what I have to say, or I look at my colleagues around here and can honestly say to myself, well let's step back, and I'm starting to do that now by the way, and I feel really good about the fact that I'm not needed as I define what value is, then that's the time to retire. But while I still have a couple of neurons that are functioning, and someone that wants to listen, then I'm willing to give it a go.(I): What would you do? Anything out of the ordinary?(SW): Yeah, what I've always wanted to do is be a writer. Um, I like to, well I write fiction.(I): Well you're writing now.(SW): Well I want to be a fiction writer…a lot of people will claim they look at my publications and say they are fiction.(I): (Laughs)(SW): But yeah, I would be a writer.(I): Nice.(SW): Yeah, I am a strong admirer of Mark Twain, and I would like to write humorous stories then have them amalled. That's my job dream, that's what I would be doing.Interviewer: Is there anything you want to share right now?(SW): Yeah, I mean I would say this to any therapist and not just those who are interested in improving the nervous system of patients with pathologies that affect movement and cognition, that if you have an idea, and I hope this will be derived from this discussion, never allow anyone to talk you out of it, and follow your dreams because unless someone can convince me that reincarnation is viable, you only go around once so you better make the best use of it, and feel as though you're doing something for humanity that goes beyond your own self interests.(I): Well thank you very, very much for taking this time to talk with us.(SW): It's a pleasure, it was fun.(I): And Melissa thank you for joining us, this was great.(SW): It was great, it was terrific yes. I'm glad you were tolerating this as well as you have. Melissa Bloom (MB): No this is great.(I): Well alright, so we'll see you at CSM?(SW): Yeah for sure, for sure, we'll be doing that, just saying that I was telling Brita that I sent in the outline for the two-hour symposium just about two or three hours ago.(I): How nice.(SW): Something that is predicting the models of stroke. So it will be great, it will be terrific, a terrific cast of characters.(I): Yeah.(SW): Yeah, anyway I hope that was the kind of thing you wanted.(I): Yeah it was perfect, it was great. And so much for our 15 minutes, we are not at an hour and three minutes.(SW): Is that what it is?(I): Yeah, time flew it really did, all of a sudden I looked up at the clock and thought oh my goodness.(SW): You really want to keep these things down to fifteen minutes?(I): What we're going to do is kind of select a few things and put a little podcast together, and then we will keep the full length, so people have the option of doing a mini.(MB): I think it's great, it's all really interesting(I): Yeah, definitely.(SW): It's just try to think outside the box, we need to do that. The hardest part of all this is change. Change is difficult for people. There is so much that is being discovered that if you don't embrace change, you will be left behind, and we can't afford to do that. (MB): That's what Tom, you talked to Tom, my partner before you did the podcast for the neuro segment. (SW): I guess, yeah.(MB): I think you just did a run through, but he does the IT or technology consulting and he's always asking like: what are you guys doing? Do you think you could do this into an app. You know it's just all the technology side is moving and if we're not like moving into it.(SW): That's why we have this course here, that Andy and I teach, we take third year DPT students in their last semester and put them in the classroom with bioengineering students, and they have to come up with a problem that is presented by a patient, not by us, by a patient. And then they have to work in pairs, as separate teams, and come up with problem solving solutions in the form of a grant application, and they will sometimes give them bogus information, as though they have gotten it, and then they critique each other's work.(MB): That's excellent and that's in the PT program?(SW): It's an elective, yeah. I don't know of any rule, by the way, that says a PT needs be educated exclusively in a classroom without other people. As a matter of fact, I would argue it's a disservice today.(MB): Yeah.(SW): I'm off my meds so you better be careful.(MB): (Laughs) Have you ever been to, have you been to, I went to school at Washington University for undergrad, and we went to Hannibal, Missouri.(SW): I've been there, matter of fact there was a neuroscience meeting there in 1989, and a group of us including Rick Seal and John Wilpon, at each of these meetings we would get there a day early and we would rent the car and go somewhere, and for the St. Louis neuroscience meeting, we went to Hannibal and then went to, John is, his hobby is a Civil War. There was a, wherever Daniel Boone is from in Missouri, there was a Daniel Boone historical society meeting and we rushed from Hannibal to get to that meeting so that John could attend that.(MB): That's amazing.(SW): And this old rickety car that we get very on the cheap for traveling through Missouri. We covered a lot of territory.(MB): Yeah I bet.(SW): So yeah I've been to Hannibal, right?(MB): Yeah when you were saying there was a meeting there, I was like no way there was a meeting in Hannibal.(SW): No it was in St. Louis, but we always would used to get, now they start the meetings earlier, but they used to start them on Sundays, and we would get there on Friday and Saturday traveling somewhere, doing something as a group of guys who usually rented a van, and we would go somewhere.(MB): That would be a van, so you and Rick and?(SW): So one year we went down to Houma, Louisiana when the meeting.(MB): Was it Hanan or Homa?(SW): Houma, H-O-U-M-A, looking for David Duke stickers, David Duke who is a racist.(MB): Oh my god. (Laughs). Oh that's so funny. What meeting was this?(SW): These were all the society for neuroscience meetings.(MB): I would like to go on that van trip. We have to ask Rick next time at CSM, ask him if we're invited. We should go.(SW): I don't think we can do it anymore because now they start the meetings earlier. So it used to be nice where you would want to get there before seven, and there used to be a time where if you stay over on Saturday night, the plane rides were cheaper. But they didn't start the meeting until Sunday, so we'd get there on Friday night, and we would all meet up and already have a pre plan for where we were going to travel for that Saturday.(MB): That would be great, like great minds going on a like just fun adventure.(SW): I wouldn't call it great minds if you were listening to us. (I): I think that great minds, any researcher that develops a great idea over a beer in England, I think is on the right way on the right path.(SW): You know I've been thinking awhile about, I mean you've got to do something to make things available and accessible to people to synthesize information in a very dynamic way.(I): That's great, I look forward to if your theory works.(SW): Alright.(MB): Well thank you so much. ................
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