Chapters Transcript Video Factors Impacting Recover of Walking After Stroke Darcy Reisman, Ph.D., P.T., F.A.P.T.A. presents at the Johns Hopkins Department of PM&R’s Grand Rounds on December 11, 2020. Hey Pablo. Hey, pretty. How are you guys? Hey Darcy, nice to see you. Darcy. Thank you George. Good to see you guys too. I guess this is the only way, even though we're just up the road, this is the only way we're going to see each other for a while. It's a little bit longer in a tile format. That's how we all meet these days. Exactly, yes. So that's great. Great to have you here. See. And yes, we are all part of a big puzzle. These little tiles. Yes. Um, so how are things in Delaware? Good. Maggie just defended on friday and she did awesome. Um, as you can expect from Maggie. So yeah, so we're really, we're doing, we're doing great. That was a real highlight of 2020 for me. There hasn't been too many things to celebrate, But that was, that was a good one. Great. Yes. She's super excited to come down, come down and work with you guys. It's like her, she's coming full circle now. It's come full circle. We're excited to have her. So we stopped for a minute or two I think. And then we're gonna be launching Darcy. I think people are joining in. Um, maybe I just talk some stuff while, while we were stalling for, for folks to join in because what I'm gonna say, you know, it's always not as, it's important. And so, um, while we wait for more people to join in. I think this is great. Everybody. Thanks for coming. I will not talk too long so we don't need to delay. I hope that folks have been enjoying and appreciating the, the posters that we have all this morning through the clinical export that we do this year. This year. In a new format. The assume and him. Ah I um I think they're great. This is a great comprehensive demonstration of work that's happening in many different places and how vast activities are. I think that I join in some of those posters. So if I couldn't join into other folks posters don't get upset. There was not enough time to visit all of them. Um So let's get a little organized here. I just want to make a couple of announcements. One is if you're not talking, please keep your, your assume a mute. So we don't interfere with the conversation. Um I think maybe Jack is a the organizer in this room so he can keep away newt as as we go. Um I will let pretty do the formal introduction of darcy. Although I just want to say this is a great friend and colleague that we work together here many years ago when that used to be here long ago. Um in name is love. So it's great to have you back and completely from capacity. So it's awesome. Um I just want to make a little announcement for the entire uh criminal department or the folks who are joining here typically this time of the year. Besides celebrating the clinical research activities, we always announced that we have a holiday party as you probably know, there's not going to be a holiday party this year. Um which is unfortunate but but we we cannot get together and eat and so on all together. So they they they the holiday party committee got together and look for an alternative thing to do and they decided to uh and the proposal we have proved at this point that that we're gonna do a nice holiday gift for everybody in the in the department. Ah So um they work maybe a little bit slow because some people are getting sick with covid and so on. But the the intent is to have three options so people will be able to choose a nice gift coming from from PNR um It's going to be a choice of a backpack messenger bag or a donation if you prefer not to take um the the gift. And you wanna repurpose that money towards the donation. We will do that for those prefer to do that. So I just since I know there's a lot of attendance here today, I wanted to make that announcement. We also will be sending this be um email. So with that I let pretty do the formal introduction. Okay thank you Pablo it is my pleasure to introduce Dr. Darcy Reisman. She's our keynote speaker for the 10th annual PM in our research and clinical expo for many of us she needs no introduction but briefly she's a physical therapist by training with a focus in neuro rehabilitation from the College of ST Scholastica in Minnesota. She subsequently did her PhD in biomechanics and movement science at the University of Delaware under dr john Schultz. And then she did her postdoc right here um at Hopkins and Kennedy Krieger with dr Amy bastian. Um and that was a while ago but we uh there's been a longstanding association and now she's the chairperson of physical therapy at the University of Delaware and she will talk to us on factors impacting recovery of walking after stroke. So without further ado thank you darcy for coming and uh please take it away. Thanks so much. Pretty. It's fun. I was scrolling through the all of the tiles and recognize, I still recognize a lot of names even though that's not what I meant to share. Hold on. Um I still recognize a lot of names. Um so I saw jen Keller and Mark Hopkins and so it's fun fun to see all those names. I think Mike schubert's on there um as well. Alright, so I'm super glad to be here today. I did get to a couple posters um and it just, it always amazes me. I'm familiar with the expo because um I'm part of the residency that the neuro pt residency that johns Hopkins has with Delaware and so we've had residents present in the past. So um but I've never gotten to go. And so this was a this is one of the benefits of virtual right is that I actually could go and check it out and it was it was great to see all the I think the diversity of the work is what really impresses me the most. All right, So today I'm going to talk about one aspect of um the work that we're doing. We have sort of two lines of research in the lab. One is a more mechanistic line of research that's really looking at some basic things related to motor learning. And another line of research in the lab is a little bit more clinically oriented, um directly clinically oriented. Looking at factors that are impacting walking recovery. So, I'm gonna talk about that today. Um and then I'll just mention a little bit at the end, some of the work we're doing with motor learning. And if people have questions about that, I'm certainly happy to take them if we have time. Um so the objectives, I'll just I won't read them for you. But really I just want you to, at the end of this talk to really be able to identify identify some factors that impact functional ability and physical activity after stroke and some potential novel interventions or at least um theoretical interventions that we could be applying to to directly affect those factors. I don't have any financial or non financial disclosures. Um I always like to start all of my talks with just kind of orienting everybody to sort of the the basis of the work that we do um in our lab regardless of whether it's more mechanistic or whether or whether it's more clinical, the overarching goal is to develop scientifically based therapies and advanced physical rehabilitation and recovery after stroke. And really the foundation of our work is based on the World Health Organization I CF model. I'm sure most of you on this call are familiar with this model. Um It's really relevant to the work I'm gonna be talking about today because um I think what we're really trying to do at this point in our in our work in the lab take a very comprehensive approach to how we're trying to understand the factors that are really impacting walking recovery and physical activity after stroke. That includes looking at the body function and structure, activity and participation level. Excuse me. But also considering environmental and personal factors um and how all of these things interact and how we can there um you know, after we understand that, then how we can we can tackle um these factors and more personalized type interventions. So I don't have to tell folks on this call that stroke is a major cause of disability in the United States and is a major health care problem and one of the primary concerns for people who experience stroke is the ability to regain walking function. And this is a really well founded concern because we know that the um regaining the ability to walk after stroke, predicts lots of things that are important to our patients, like whether they're going to be able to be discharged to home, whether they're going to be able to return to work etcetera, and therefore walking your training is a major focus of rehab following stroke. And with this major focus, 70-80% of stroke survivors recover the ability to walk short distances. But less than 20% recover unlimited walking in the community. And this is what's really, really critical I think about the work that we're doing now. Um of course it's, you know, a basic prerequisite to returning home to be able to walk those short distances, but really for our patients to be able to live the kind of lives that they want to live and the kind of lives that we would like them to be able to live, they really need to be able to have that community mobility And right now, you know, really less than 20% of of stroke survivors are able to do that. And so this really suggests to us that current locomotive, we have interventions while beneficial, really aren't leading to the recovery of that, of that true community functional mobility that we would like to see. And so for the majority of this talk we're gonna be talking about um why that might be the case and what you can do about it. So this is sort of the model that we have in our lab at the hub of the model is walking recovery and then we are tackling um the ability to recover walking after stroke from various facets. I mentioned that we have a lot of work in the area of motor learning, biomechanics, neurophysiology, cardiovascular physiology. But then what we're gonna be talking about a lot today sort of fall into this realm of sort of bio psychosocial factors and and a little bit in the realm of biomechanics and cardio vascular physiology but at the much more functional and clinical level. Um But again just with this this overarching approach, you know, we're trying to look at all the different aspects of of factors that might influence walking recovery. We know that walking activity after stroke is very limited. This is some work that we did um Back in 2012 with RG Reuss who is a PhD student at the time and is now a faculty member at um University of the sciences in philadelphia, she's a P. T. And essentially what this these graphs show is that when you take the classic hairy classifications of walking which break people down based on walking speed into household ambulance, limited community ambulance chasers, unlimited community ambulance and you look at the steps per day based on those category and the bouts of walking per day. What you see at least in our work is that there's really no difference between the household ambulances and limited community ambulance in the number of steps per day that they take, or in the bouts of walking per day that they do, and so we combine them into one group. Um, There is a significant difference between those, those who are household and limited community ambulances and those who are classified as unlimited community ambulance based on their walking speed. And then, um, yet again, another significant difference between those folks with living with chronic stroke in those categories and um, age and gender matched healthy adults. And what you can see here is that even those that are classified as unlimited community ambulance are taking a significantly lower number of steps per day than their healthy counterparts and um significantly lower have significantly lower bouts of walking per day. Um, and this is not unique to our work. This has been shown repeatedly in the literature. Um, I just have some some statistics up here for you. The average daily step counts in stroke really range between very, very low number of steps around 1000 steps per day. Up to a more respectable number of, of a little over 7000 steps per day. Just for comparison's sake. Um, if you look at the average number of steps in age matched controls to these step counts in patients living with chronic stroke, you're looking at averages between 6000 and 14,000 steps per day. So you can see that um this this amount of daily walking activity is really, really low in patients living with chronic stroke compared to age and gender matched controls, or healthy healthy people, I should say. Um There was a recent study that I want to draw your attention to that I think was really informative. Um taking data from the leaps trial. The leaps trial was a very large clinical trial. Um looking at interventions to improve um walking speed in patients in the sub acute phase of stroke. And but they did also collect step activity data using a step watch activity monitor. And um what they found from when they looked at this data was that um really there was a if you look at the if you look at the 12 month time point, which was their final time point in this study, um Step activity factor that could really distinguish between those who took 50 greater than 5500 steps per day, compared to those who took less than 5500 steps per day, were really the bouts of walking per day and the steps per about. And so those things really distinguished who were in this higher category of steps per day and who were in this lower category of steps per day. And what they concluded in this paper is that in addition to encouraging longer bouts of walking, it may be very practical to be encouraging patients to take more short bouts of walking. And I think this is a really, really important recommendation that is going to play into a bit more of what we're talking about later. But I just want to introduce that and have you keep that in the back of your mind as I'm talking. We know that in addition to stroke survivors not taking, not being very active in terms of in terms of their steps per day. And by the way, these steps per day are typically measured with, you know, basically fancy speedometers or research grade odometers um that really give us a good bit of information about what people are doing outside of the clinic, right? This is what's happening in their real world um activity. These monitors are usually patients are wearing them from you know 3 to 7 days and asked to wait to wear them usually either all the time or at least during waking hours to give us a good sense of what's happening in their everyday life. And it should be no surprise that if this information is telling us that they have low steps per day. But the converse of that is that patients living with chronic stroke are very sedentary. Um and this is sedentary behavior measured using the active power, which is a research grade activity monitor At 16 and 12 months after stroke. It's important to recognize that in this study they did have patients wearing the active Pal 24 hours a day. So this is including sleeping time. But what you can see is that um out of the 24 hours in a day um Um the sedentary time is around 20 hours. So really there's only four hours of the day at the 12 month mark that patients with stroke are not completely sedentary. And you know, even if this is not your area of research study, you certainly know from the popular press that the Secretary Time high levels of sedentary time have very, very significant health consequences and that's no different for patients with throw. So okay, patients with stroke, I hope I've convinced you now they're not as active as they need to be in terms of their walking activity in their everyday lives and they're highly sedentary. So what are we gonna do about this? Well we know from a pretty large body of literature at this point that um walking training at higher intensities appears to result in greater changes in things like walking speed and walking endurance. And in fact I was part of a clinical practice guideline group that just um we just published this large clinical practice guideline that really um really the one of the major outcomes I think of importance from this clinical practice guideline was this idea that it seems like training intensity repetition is really, really important to have significant outcomes and changes in walking speed and walking endurance. Um but that's we're not really talking about laboratory measured or clinically measured walking speed and endurance in this talk, we're really talking about sort of this more real world walking activity. There's things like steps per day bouts of walking per day, what's happening in our patients everyday life. And so, you know, when you're when you're thinking about what we understand about the effects of walking training after stroke on um speed and endurance, you might think, well, okay, if we can positively affect people slow walking speed and poor endurance through these interventions, well, that should have a positive effect on in activity and hopefully break this vicious cycle that we see in patients living with stroke between physical activity disability and increased health risks. Right? So we know that not being very physically active and being highly sedentary um is a major contributor to this, this vicious cycle of disability and increased health risks. And so, given what we know about the importance of of um these interventions in improving walking speed and endurance, one might think that this would be a great way to intervene and um and impact this vicious cycle, but it turns out that training at higher intensities does not generally result in substantial changes in real world walking activity. So while this these training at higher intensities and with high repetitions does seem to have a very significant impact on walking speed and endurance. That's not, it's not a given that that translates into people's everyday activity when they're living with chronic stroke. And I'm sure if you think about this, um it probably makes a lot of sense to you. If you work with patients with stroke, why this might be the case. Um There's probably lots of things other than just someone's physical ability to walk. That impacts how much walking they do. I'm gonna give you a perfect example that Covid has really highlighted for me. So up until late summer, early fall, I was working primarily from home and On average, I was pathetically getting about 22,500 steps per day. Um if I didn't actively try to do something other than than sit at my computer all day long. Um I certainly have the physical walking speed ability, walking endurance ability to be much more physically active. But my circumstances of working from home, we're having a major major impact on how many steps per day I take when I am in the office as I am today. I just by the very nature of being in my office and taking on the order of 8-10,000 steps per day and nothing really changed about my physical ability during Covid, it was really just um you know, my, my social circumstances of where I was working. So I think, you know, it makes a lot of sense then that, you know, it's not just someone's physical ability that really impacts how physically active they are in their everyday life. And so just tackling um improvements in their ability to, you know, walk faster and walk longer may not be enough. And in fact, um in some large systematic reviews that have been done, we know that physical capacity really only accounts for about 35-40% of the variants in real world walking activity, after stroke. and there's lots of other factors that really play into how active people are in their everyday life. And you can see some of those on this, on this schematic here, things like um self efficacy, depression, environmental factors and in fact in the systematic review, um they really broke down these these factors into non modifiable factors, things like age and sex um and potentially modifiable factors, things like physical function, fatigue, false self efficacy, balance self efficacy, depression, health related quality of life. These are things that over a series of studies seem to potentially be factors that really are impacting um step activity and physical activity and people living with chronic stroke and are potentially modifiable. And I think that we can all really appreciate that a lot of the interventions that that we do in in my research and in physical therapy in general are really targeting physical function, um but not necessarily targeting some of these other factors that are that are accounting for that, you know, Um you know, 60-65% of the variants that's not accounted for just by physical capacity. And you know, one of the things that we're really trying to understand in our lab is not only what are these factors but how do they interact with each other? And so we did a some work back in in 2016 with a team of folks in my lab where we looked at this in about 55 chronic stroke, not about and exactly 55 chronic stroke survivors. And what we did is basically a higher hierarchical regression, where we put in some measures of walking capacity. First into the hierarchical regression and then we put in to the regression, bio psychosocial factors. Um uh We use the geriatric depression scale which is a screening tool for depression. We use the fatigue severity scale and the modified cumulative illness rating scale. To try to capture this, this measure tries to capture comorbidities, put those next into the hierarchical hierarchical regression. Then after that we put in measures of self efficacy, specifically the walk 12 and the activities balance confidence scale, the abc and then finally into the hierarchical progression. We put interactions and specifically um an interaction that we were interested in was the interaction between the activities balance confidence skill and the functional gait assessment and what you can see down here is the R squared values um at each of these different blocks of the hierarchical regression and what you can see is that walking capacity as as we would have predicted. Um does account for about 36% of the variants in um step activity. I should have mentioned that what we were trying to predict in this hierarchical regression was step activity measured using a step watch activity monitor. Um that the patients wore in their daily daily life. So outside of the clinic And you can see as you would have expected as I said as you would expect walking capacity accounts for about 36% of the variants. Um interestingly the bio psychosocial factors. When they were included in the model, they did increase the R squared value um to just about 41% but it was not a significant statistically significant increase. When we added the measures of self efficacy R squared value went up to about 57%. Um And this was a significant increase. And then when we added the interaction between self efficacy and our physical capacity is measured by the F. D. A. Or functional gait assessment on the R. Squared value again significantly increased To about 61%. So this model, when all of these factors were included um accounted for about 61% of the variants in daily physical or daily walking activity in our patients with stroke and the the overall model was significant. So again this is an example of how these various factors above and beyond physical capacity are playing a role in um in you know essentially how how active folks are in their everyday lives. But what we were very interested in was this interaction, this interaction between self efficacy and functional capacity is measured by the FDA. So I want to describe that a little bit further here with this figure from the paper, we have the F. D. A. On the X axis and steps per day on the y axis. And um we have um one standard deviation below the mean. The mean is represented here in the middle. We have one standard deviation below the mean on the F. G. A represented in this left most circle and the right most circle is plus one standard deviation of the scores on the F. D. A. And that each line here represents either a high abc score that means uh scores that were above one standard deviation of the mean abc score, the mean abc score is represented by the dark black line and then this medium gray line representing a low abc score. And what you can see is that four people with low balance confidence, self efficacy, there's a strong relationship um between their physical capacity is measured by the FDA and their steps per day, such that the people with the highest scores on the F. D. A. Have the highest steps per day. However, in direct contrast for people with very high self balance self efficacy, the line is flat, but the relationship between the FDA and steps per day is flat. And so what this suggests is that even people with low scores on the F. D. A. Have relatively high steps per day if they have high balance self efficacy. So this tells us that balance self efficacy moderates the relationship between this measure of walking capacity and steps per day. Now on the one hand that could be a very good thing right? That you if you have high confidence in your balance abilities, you know you're going that's going to moderate your physical capacity, impact of your physical capacity on your steps per day. On the other hand that could be a very very bad thing if someone has a very low score on the F. D. A. But feels very confident in their walking, they may be out and about and getting higher steps per day that maybe then potentially putting them at risk or complications relative to falls etcetera. Um but the important point that I want to draw out here is that there's these complicated potentially these complicated relationships between many of these measures that are impacting real real world walking and it's really important if we're going to design targeted interventions that are really going to be optimal for individual patients that we begin to really understand these relationships even even more so. And so that's the work that we're currently doing in our lab and you know, one of the things that we really wanted to understand is how are these factors interacting and how might we understand sort of subgroups of stroke survivors that might exist with respect to their walking behavior. And so that's the work that we're really embarking on now. Um we don't really know how these different factors interact in potentially different subgroups that might then help us understand okay if there's a sub group of people that have particular characteristics that might be impacting their real world walking that would be really helpful to know. So if my patient fell in this into this subgroup I would understand then the factors that I might need to be tackling with that particular patient if I wanted them to be able to walk more. Um And this is really the research question that we're tackling at this point in our lab and this is really being spearheaded by Allison Miller. She's a PhD student in my lab right now, she's a P. T. Um and an N. C. S. And her basic research question that she's tackling in her in her dissertation is um you know what variables are important in distinguishing subgroups of stroke survivors with respect to the real world walking activity. And then how once we understand that how might we develop targeted interventions? So the sample that we're using is actually a sample of subjects that are part of a large political trial that I'll be talking about that we're doing called pro walks. Um That's a foresight clinical trial and it's I'm the P. I. And it's being led out of the University of Delaware. These are the other sites that are involved in this study. But what we've been able to do is take the baseline measurements um from this study. All of the folks in this study. Whereas um where a Fitbit activity monitor for their baseline um pre intervention um to collect pre intervention data and were able to use this data for this study. This is just the basic information about the sample. Um It's a large sample right now we're at 280 for participants that we're trying to be a fairly broad inclusion exclusion criteria because we're trying to capture a sample that is best represents folks that we might be seeing in physical therapy um living with chronic stroke. Um And so our criteria are fairly broad as you can see here. Um as I mentioned right now we've got this the data that I'm gonna present for you today is a sample of about 200, not about it's exactly a sample of 283 participants um living with chronic stroke. And here's their basic information um That just sort of gives you some ideas of the study sample. Um Specifically what I want to draw your attention to is these are folks that are at least six months post stroke. And they and they also have to have a gate speed of at least 0.3 m per second um to be enrolled in the study. And that's due to the fact that the Fitbit activity monitor that they're wearing on their ankle um is not very accurate below for people with stroke with walking speeds below 0.3 liters per second. Um And so really the statistical analysis is the statistical approach that we're taking here um is to really understand the variables that differentiates subgroups of stroke survivors with respect to their real world walking behavior. So we did a latent class analysis for actually really to be more specific. We did a mixture model but the basis of it is really a latent class analysis And um what we're really trying to do here is to identify the subgroups within within our sample of 283 people. So in this type of analysis, the individuals were classified um into subgroups based on similar characteristics, with the goal of really creating homogeneous subgroups within our diverse sample. So if you take this figure as an example here would be our whole population of stroke survivors. And what we're really trying to do is using the characteristics that we have in our study were trying to break them out into homogeneous subgroups um where the characteristics are are similar in each subgroup but distinct amongst the subgroups. And um this is this latent class analysis approaches really, therefore a person centered approach which really differs from a variable centered approach, which is often seen in, for example, like the regression models that I showed you earlier that we had done, which is really trying to understand the relationship between the variables here. What we're trying to do is we're trying to understand the characteristics of the sample of the people in each subgroup and so the variables of interest that we were entering into our latent class analysis or a mixture model. We broke down into um various categories that the literature has really suggested might be important um categories for variables that impact, real world walking and chronic stroke. So we have our category of physical capacity. Our category of cognition are category of physical health, our category of psychosocial variables and our category of social and physical environmental variables representing the physical capacity. We have the six minute walk test and self selected gait speed, representing the category of cognition. We have the mocha representing the category of physical health. We have their LDL levels there, charleston co morbidity index, age adjusted and their B. M. I. Representing the category of psychosocial factors. We have that that abc balance, self confidence or self efficacy measure again. And we have the P. H. Q. Which is a measure a screening tool for depression and representing the social and physical environment. We have living situation and marital status, work, status, the area deprivation index and the walk score. And these are measures that specifically the area deprivation index is a measure some of you may not be familiar with. It's just a composite index of neighborhood socioeconomic disadvantage that uses various indicators of poverty, education, housing and employment with within regions of the US. And were able to get this based on knowing the exact address of all the participants in our study. Um And the walk score is similar in the sense that it uses the patient's address to get a it uses a geographically based algorithm to provide an estimate of neighborhood walk ability. So we enter all of those variables into the model. And then the what the model does the model does is um using basically Selection criteria and I don't want to get into all of those details in this sort of more 30,000 ft um view but I can talk about that and answer questions more at the end. But basically there's lots of um objective model selection criteria that we use to try to figure out what is the best number of models Um or best number of subgroups that really represent our data. And based on that different model selection criteria. We ended up with three groups um in Group one, we had 70 part, 70 of the participants. Group two had 92 participants and group three had 100 and 21 participants. So now at this point, what we know is that based on the variables we put in, we can separate our participants into these three groups. And then the next question we want to understand is what are the variables that significantly differentiate these three subgroups? And so that's what I'm showing you here. The variables in red are the variables that differentiated the subjects in these three subgroups. So we have both of our measures of physical capacity, we have the mocha, we have the abc we have work status A, D I and walk score. And these are the variables that significantly differentiated our three subgroups. The next question that we're asking ourselves is okay, what are the characteristics of the people in these these three subgroups relative to these variables that differentiate the subgroups? So in group one we have our measures of physical capacity, self efficacy, cognition and and the environment. And it turns out that all of the people in group one have the lowest measures on these variables. in contrast in subjects, all the subjects in group three have the highest um measures on these variables. And then all of the subjects in group two are the subjects that are kind of in the middle on these variables. Okay. Um normally it's the time if we weren't in such a big group, I would pause and ask for questions because I know this is a lot and maybe a little bit of a complicated analysis. Hopefully you're hanging in there with me because we're getting to the punch line and the punch line is that after we analyze these differences in the variables of interest and how they differentiate these, these people in these different subgroups, the next question is really, or the next piece of the analysis is really get really gets at answering our research question and what we're trying to understand now is are these groups actually different in terms of their their daily stepping activity? And so that was the next step in the analysis. And what we found is that indeed they are so class one had the lowest number of steps per day. Class to had a medium number of steps per day, and class three had the highest number of steps per day. And these were significantly different across these subgroups. So now what we can see is group one remember had our lowest measures on physical capacity, self efficacy, cognition, and environmental factors. And this also was the group that had the lowest level of walking activity. On the flip side. Our group three with the highest scores in all of these domains, also had the highest highest amount of walking activity. The thing that is really, really important to understand about this analysis is that um an alternative possibility could have been very, very could have easily happened. It could have been, it could have happened that we have these subgroups that we were able to um determine based on these variables of interest but differed on these variables of interest, but that didn't differ on their steps per day. And if that would have happened, what it would have told us is that yes, there are these subgroups but they they're not really meaningful when it comes to understanding real world walking activity and that's not what happened here. But if that had happened um it really, the fact that that didn't happen really sends a powerful message because we did not enter steps per day as a variable of interest into our model. Yeah, it turns out that based on these other variables, we came up with these subgroups and then we asked the question, do these subgroups differ on steps per day? And they and it turns out that they do without steps per day even being included in the model. And so we can feel very confident that these factors um that differentiate these subgroups also are very important in differentiating people on these steps per day um variables and so they become potentially uh it tells us that these variables that differentiate these subgroups potentially are very important targets for intervention. And so now that we understand these subgroups of people and the factors that differentiate these subgroups, these become targets that we could attack when we're trying to improve steps per day or real world walking after stroke. The question then becomes how would we do this? And so I want to quickly end with um you know, an intervention that we're really tact that we're implementing in our lab that really uses step activity monitoring programs. Some key pieces of a step active activity monitoring program are that you use some kind of device to monitor step activity. Um We're using um the Fitbit um one or the Fitbit ultra on the ankle of the non periodic limb because that is the place where you can get the most accurate measurements from the Fitbit. Although I will mention that the Fitbit is not accurate for people with walking speeds below 0.3 m per second that are living with chronic stroke. The other key piece of a step activity monitoring program is to set a daily stepping activity goal and that goal setting should occur in partnership with the patients. Ultimately, patients should arrive at their own goal and we'll talk about that in a minute. And then the third key piece of a step activity monitoring program is to identify barriers to activity and strategies to overcome them. Um at each session it's really important that patients that we did you discuss with patients the number of steps per day that they're taking and that you discuss with them whether or not those steps per day attain the goal that they've set for themselves. If Petey is delivering this intervention as they are for our study, the PTS role is really as a facilitator um and a facilitator of the patient, not as a deliverer of information about what the patient should do. And I want to talk about this for in a minute for a minute because this is really important. um in our study where you utilizing techniques from motivational interviewing and really the goal of motivational interviewing is to strengthen the importance of change from the patient's perspective. And the reason we're using this is because it's been shown in lots of behavioral intervention studies like alcohol or smoking cessation. Um that it's that this is a technique that is very very helpful when you're trying to get people to change their behavior. And ultimately when we're tackling a lot of these factors that we're talking about that we've identified in the previous study, we're really trying to get people to change their behavior. And there's four basic principles to enhance motivation in motivational interviewing which I've identified here expressions of empathy development of discrepancy rolling with resistance from the participant and the support of self efficacy. And so when we're talking with our patients, some examples of things that we're saying rather than saying to the patient um like I would have done before I was informed about these things, you know, I would have said to the patient, you know, look, you're not meeting your goal, you really need to work harder on on getting more steps per day using a more motivational interviewing technique. I might say something like from what you've been sharing with me. I know you feel as though it will be difficult to walk more. But what are the ways in which you think you can prove your daily walking activity or I understand you feel it's much harder to walk physically since you've had your stroke, but we're working on building up your endurance and week by week we're doing this in physical therapy and we're doing this goal by goal with the aim being that you know you'll be able to walk more by the end of the monitoring program. So that is sort of helping to build their self efficacy, explaining to them what we're doing to try to help make it easier for them also to build self efficacy. Saying things like you did a really nice job of meeting your current goal. How are you going to tackle meeting your advanced goal for next week helping them identify the barriers and then thinking about ways helping them think about ways they could attack those barriers. So saying something like I know in bad weather you normally choose to walk in the mall if it rains next this week, like it's projected will you do more laps in the mall as opposed to the outdoor track like you've been doing. So you can see here that the approach really is more one of engaging the patient in coming up with solutions rather than the therapist or the medical practitioner telling the patient what to do. And it's been shown in research with motivational interviewing relative to behavioral change but this really enhances um behavioral change. So when it comes to identifying barriers, think back now to our previous study and what we discussed about the physical environment in its role, remember we said neighborhood walk ability. Um And so um and measures of of of socio economic disadvantage in the place where the person lives is really important in distinguishing these subgroups. So if social support or the physical environment is a barrier, what about taking more frequent short walks in and around their home? Remember the P. T. J. Paper that I talked to you about early from the leap study. And they, one of the recommendations was hey maybe we need to be encouraging our patients to take more bouts of walking in more short boats. Well that plays right into um what we have found that if if the environment is a big, if you can mute yourself, that would be really great. Thanks. Um So you know, based on what we found in our study, remember that these environmental and social factors were a key a key in sub grouping. And so if you if you have a patient who you know has in particular a neighborhood that's not very walkable, this might be a really, really relevant suggestion to help them improve their daily walking activity. Think back to what we talked about relative to cognition. We said that, you know, one of the distinguishing factors for that low walking activity group was low scores on the mocha. And so if you know that you've got to think about, maybe we need to think about a reminder system via alarms or a schedule um to remind these patients to get up and walk right, um if they have these these cognitive deficits that might make make it difficult for them to be um self initiating. Um and indeed we found in a very small study of stroke survivors that using a step activity monitoring program with all of these characteristics I talked about and just simply doing that, having patients come in once a week meeting with us, doing nothing else. Not No other physical intervention, we were able to get about a 1500 steps per day increase. We then combined that with a with a physical intervention where we had people do treadmill and overground walking training. Again, a small pilot feasibility and efficacy study. Pilot efficacy study where we combine the step activity monitoring program with a program of trying to build up their physical capacity Training for three times a week for 12 weeks. And these are some basic characteristics of the study and the sample. And there's the reference for you if you want to look in more detail. But what we found in this really early study is that um there was this interaction um peace between peoples um physical abilities and how they benefited from the combined um physical and step activity activity monitoring intervention such that people with the lowest levels of pre training steps per day had the biggest change in steps per day in the combined intervention program. The program where we were combining building up their physical capacity with the step activity monitoring program. And even though this was done pre the study where we identified the subgroups, it lines up perfectly right with what we would expect that the people who are taking these lowest steps per day are probably the people who really need this very multifaceted approach to if we're going to see improvements in their daily walking activity. And this is just this these subgroups of people um plot in a bar graph over here in terms of their changing steps per day. You can see in that very low sub group the people who had the combined intervention really tackling many of the different features that put them sort of in that subgroup relative to low low walking activity. When they got that combined intervention, you know, they did far better than people in their subgroup. Um that just got the intervention that was just attacking physical capacity. So now we're looking at a larger clinical trial, a phase two clinical trial where we're um this foresight pro walk study where we're trying to really expand the intervention, um not just having the physical capacity building plus the step activity monitoring program, but also looking at the physical capacity building alone and the step activity monitoring alone. Because based on those subgroups that you saw, you might expect that depending on the sub the persons in these various interventions might lead to different improvements um for people in the different subgroups and that's one of the things that we hypothesized that we're gonna be able to look at in this large clinical trial. We've just got a little schematic here at the large clinical trial and here's our clinical trials dot gov number if people are interested. Um our primary outcome for this study is steps per day, here's our secondary and exploratory outcomes. Um and we're um we're our goal is to randomize about 250 people and we're just over the 200 mark. So we're getting their covid has dealt us a serious blow in our ability, but we're back up and running now. And so we're hoping to finish out our recruitment of the clinical trial this year. Um so stay tuned on whether these targeted interventions really do impact these people in these different subgroups, as you might predict. So in summary, I just want to leave you with, you know, this, this the main thing that we know from the literature is that stroke survivors are generally pretty sedentary and um not as physically active um in the real world as we would like both for their community community mobility, but also to prevent them from developing future health conditions that are related to the sedentary behavior. We know that there are multiple factors that impact real world walking activity after stroke, including not only their physical capacity but also balance self efficacy, cognition and physical and social environmental factors. Um We preliminarily have begun to look at programs aimed at improving all of these factors and it looks preliminarily like those um those programs that address those multiple factors for those people that are in that subgroup with low scores in cognition, social and physical environment, physical capacity um and self efficacy that those very multifaceted approach may be the most beneficial but more to come on that. Um I also just wanted to mention we have lots of other work going on our lab that I think is probably of interest to the very diverse group of people we have in the audience. Most specifically we have um a lot of work going on, looking at the interaction of um cognition and motor learning after stroke. And this is Maggie french who who many of you know from her time at Hopkins, she came to Delaware to get her PhD and she successfully defended Yeah Maggie on friday and it's going to be coming back down to Hopkins for a post doc. And Maggie has been very instrumental in um a lot of the work in the lab looking at the interaction of cognition, cognition and motor learning after stroke stroke specifically as it relates to walking. Um And joseph kim at U. D. Is also involved in this work as well as Suzanne morton, who many of you know, I saw jen Keller's name um Pop up and jen jen and Suzanne go way back. And so we're all collaborating on this work. Um We also have some computational modeling work relative to um both this work that I've presented today as well as our motor learning pieces that I'd be happy to talk to people about either in the question and answer or. Um at another time we have lower extremity, robotics work with Jill Higginson and Fabrizio surrogate here at U. D. Some work looking at balance and falls with jeremy Crenshaw custom built orthotics with ELISA arch. These are all folks that you d and then I'm part of a three site clinical trial looking at high intensity interval training um in people with living with chronic stroke and that's a clinical trial led by Pearse Point and Kerrie Dunning at the University of Cincinnati, University of Delaware as a site as well as um Sandy Bellinger as a site P. I at the University of Kansas. Um Of course, you know, all of this work really is the result of the many people currently in the lab and and past. Um I've asked people in the lab, I've been super lucky to work with just amazing and talented people. Um And um you know, they're really the ones that um help carry out all of this exciting work that I'm so privileged to be a part of. Um And last but not least this is our our beautiful building on the star campus a number of years ago we graduated from a windowless basement clinic um to a beautiful building with lots of windows and lots of sunlight, which we haven't got to spend nearly enough time in lately, but um would really welcome any of you to come up and pay us a visit just up 95 from you guys in Newark Delaware and with that I am happy to take any questions. Mhm I don't know if um thank you. It was, I mean this was, it's great presentation and great work and I think maybe others will have questions about maybe prettier collecting question, I would suggest that the people want to jump in and ask directly or or some questions via the chat and I can read them while, while folks are thinking, I have a question for you darcy um since I'm talking, I'm just launching. So very interesting work about this idea of stratified people by the subgroups by all these categories and and it shows nicely, okay, you can classify folks into three different groups and then you go back and you understand that those different groups behave differently when you look at your as a little meter, the amount of walking now is very costly and time consuming to measure all those other things and it's much more cheaper than that may be accessible eventually to a person. So are you looking to do the reverse, which I know from the presentation we cannot infer that it's going to be the case. But are you looking to do the reverse where you say, okay, can I measure something in a very easy, cheaply manner accessible and then in for all these other elements that that can inform approaches for rehab? Yeah, I mean, I think that at this point. Yeah, we we just um we we we we definitely would like to do that. I think what you're really asking, Pablo is is there an easy biomarker, right, that we could measure that would help us understand better these subgroups? I think that what we and we don't know what I would like to suggest. Is that based on what we're seeing if you're and we don't know this because we have not done the reverse. But if you're patient is in a very low walking activity group, it appears from our data that the likelihood of them having low cognitive scores, low physical capacity, low self advocacy is pretty high. Right? And so until we get the answer, my clinical suggestion would be you might have access to their cognitive scores from speech therapy or whatever. You might not. But you probably have a pretty good idea from working with them. You know, whether they might have those issues. And and if it appears that they do, I think you better think about a comprehensive approach is addressing not just a physical capacity, but also these other other features as well. If you if you want to actually get them more physically active, does that answer your question? Yeah, No, absolutely. I think that makes sense. And clearly you're saying the big picture messages that doing simply, you know, more walking, more exercise is not gonna drive the drive the needle, you know, push the the ultimate goal of increasing physical capacity. The way I like to the way I like to frame it is it's a necessary but not sufficient intervention. So, you know, I I grew up my PhD in biomechanics and movement science, I grew up completely focused on the gate pattern, the characteristics of walking and what my my work over the last 10 years has really showed me is that that is necessary, right? People have to have the physical ability, but it's not sufficient for many people. And by the way, for the people in the higher category group, it might be sufficient, right? Those people with high physical activity um also had high physical capacity. So it might be that for some people if you can really get them to a high level of of walking ability, it might be sufficient. But certainly our work is suggesting for these people with lower levels of physical physical capacity. Just improving their physical capacity is not going to be enough. So necessary condition, but not necessary, but not sufficient condition. Does that I don't I would not want to give the impression that we should not be working on physical capacity because you know, that would be very bad for, for physical medicine and rehab should be working on it, but but it's it's not enough. Yeah, that's great darcy. Now, your classifications have been based on patients with chronic stroke, correct? Do you have any um you know, if it were a cohort of acute stroke, would your recommendations be any different or can you elaborate on that? I you know, I think the subgroups could be different because I think that um for example, really early on a physical capacity is really limited. It early on it made trump social environment, right? Or or some or physical environment. Um I don't know and I, you know, I'm at University of Delaware, we don't have a big medical system, we don't have a medical school, so I don't have great access to um to acute or sub acute stroke. But I know at Hopkins you certainly do. So, I mean, I think that's you know, really great food for thought and by the way, I think you collect a lot of this information in your medical record. So I think we don't know, we don't know how these factors change the weight of these factors change over time, but we could guess that they do and I think that is super important. Great. You know, we'll we'll be talking to you offline to sort of um see how we can synergize to answer that question with. Thank you. Um I know people in the audience must have a lot of questions because, you know, this is actually something that we are very involved in darcy, just F. Y. I. Um and that's why we're so eager to have Maggie join us, we are planning to look at subgroups, prospective lee and um you know, look at how some of these factors actually inform their recovery and potentially intervene and, you know, while other people are coming up with their questions, I just wonder, have you experienced any major barriers? You know, I think it's using motivational interviewing techniques to sort of improve self efficacy is it's really fantastic, right? Because so many times we know what the patients need to do, but to get them to do it is a whole other matter. Um have you, you know, and I'm thinking, you know, if it were me, what kind of barriers might have, oh my knee hurts or you know, I'm too stiff and there's so many reasons or excuses if you will when you have a disability. And I'm just wondering, you know, were there any such barriers that you experienced? Um and how did you overcome them? Yeah. So I think, you know, the results of the pro box clinical trial will really tell us how effective we are in using these motivational interviewing techniques to help patients overcome their barriers. Um I we're, you know, we're hypothesizing based on this step activity monitoring programs. Being effective, we know that they've been effective in for example, um heart failure, patients with diabetes etcetera, but we don't know if they're effective in chronic stroke. What I will tell you is that we were when we started our early, so prior to pro box, when we did our feasibility study, one of the things that we were so surprised by is how difficult it was for patients to come up with ways to be more active. Um you know what, what we, the way I like to approach it is, you know, patient comes home from hopefully inpatient rehab right there may be getting home therapy, maybe getting outpatient therapy and very often they're not very mobile and so they kind of set up their lives to limit the amount of mobility they have to have and then as they continue to recover, they don't adjust that, right? And so, you know, the spouse that got accustomed to delivering the lunch on a tv tray continues to deliver the lunch on a tv trade, even though the person is fully capable of walking into the kitchen to have their lunch or the dining room or whatever. And what we were really surprised about was we had to really probe patients to say, okay, well let's stick back, you know, what was your day like before you had a stroke? What were things that you were doing and lo and behold, they would say, you know, I couldn't walk down to the mailbox and get the mail. My like my my spouse doesn't need to be doing that anymore, I could do that, but I just hadn't been and I didn't think of it right? And so we have found starting there with these small little bits of of the short walking bouts and that's why I emphasized that that data from the leaps trial, right? Getting it's very overwhelming to people to say I need you to go to the track and walk five laps around the track. I need you to mall walk or whatever where we are finding that it's much easier to get the patients to reflect on how they can improve their mobility just in and around their home and then build from there. Um So I don't know if that answers your question pretty but that's sort of what we've been finding in the implementation side of this. Thank you darcy. That was yeah. Um Mhm. You keep turning their cameras on, does that mean please speak up? I think I have a quick question. Um Nice to talk to you again and I got it right this time. Right. Yes, you did. Thanks. Um We a couple of years ago we had a like a C. V. A stroke support group while their own inpatient rehab and a big part of it was goal setting and um it was I like I like how you talked about, it's a huge struggle for people to talk about their own goals and to motivate themselves and with using like a fitness tracker with steps per day. I can know that you can have some data that they can reflect on. Um My question is how often did they have to see the data and have those m my motivation interviewing interventions to find it to be effective. But our goal setting was like once a week and I felt like it wasn't enough to to create change. Um So in that really very very small early stage that I showed you with 16 people where we just did the step activity monitoring program and nothing else. They were coming in once a week. Um and and they came in once a week for four weeks and we didn't really feel like that was that was sort of just a proof of concept and we didn't really feel like that was as effective as it needed to be. So in our our study that was a preliminary study to pro walks, we did three times a week because we thought that was more standard outpatient um like visiting. And so they did they got information three times a week. At that time we were using a research grade odometer which would not show them the data other than when they came in. So they were only getting information three times a week, which again we did not feel was ideal based on literature and other populations using step activity monitoring programs. Which is why we switched to the Fitbit so that they can see data, you know, they can see their their data just they use it just like you and I would use it right. Like we're like oh my God it's 12 o'clock and I've walked 1000 steps. This is an atrocity. I've got to get up and do something. The problem is for the Fitbit to be have reasonable accuracy in stroke, it's got to be worn on the non poetic ankle and they put on their socks or we give them a band that's a bit of a pain. You know if you're a stroke survivor to like get that ankle up there where you can see those little numbers on your Fitbit. So that's the only thing that we found to be kind of problematic. But certainly the literature would support that just like for you and I the more they can get information about how much they're doing the better. And we that's even part of the motivational interviewing. We ask questions like well how often a day are you looking at your at your Fitbit and you know, do you think that's enough and well you know, again, back to this thing, we have patients with cognitive deficits and so we've worked with them to set alarms that you know they're gonna have these alarms three times a day and they're gonna check their Fitbit. and you know, what are they gonna do if their Fitbit is below a certain amount, you know, so it's it's that that back and forth. But to answer your question directly really I think the more the better that they can see how much they're doing and then right now we don't know if more than we don't know the results, but we're doing three times a week just because we thought that was feasible. Great, thank you very much. Dr Reisman if I could just offer a just a general thank you for making this presentation attainable for therapists like myself who are not specifically physical therapist. Um and I think thematically generalize a ble to what we all do. Um So thank you. Oh you're welcome. I hope. I hope so. So at least one person agreed. I think steven Wagner's Yeah, I put a little post up, they're on the chat. So I want to draw your attention to a key thing that we should take away from this. And that is you put up a slide before that showed your regression equation, right? And you put in the person's physical parameters which explains some of the variants, but about a third. And then what you ended up doing is you built a model of course that went to the unimportant, added the unimportant things last which of course accounted for more variants. Right? Of course this is, you know, nothing as I said in the post, there's nothing I like better than having excellent speakers from other disciplines talk about the primacy of behavioral principles and rehabilitation, right? And this is something that we all need to keep in mind is if you go back and you look at the papers Old literature, 2030 years old on spinal cord injury, the best predictor of someone's quality of life is not the level of injury. Yeah. Being a tetra or a para does not predict your quality of life, your life satisfaction or your level of depression, it's your social support, your self efficacy and always other categories, right? So, you know, we get often so caught up the principal obviously it's an important research questions here, but you know, in medicine we're always thinking what is the person's diagnosis and what's their physical parameters which of course are foundational but not determinant and you know, uh so nothing like, like I said nothing I like better than having an outstanding speaker, talking about how important behavioral and psychological principles are and we're always happy to be of service and feel free to use the stuff as much as you possibly can. Well, and I think you know, so thank you for that and I know I know Maggie is really excited to work with you because so we're you know, I always joke around, you know, for years as a physical therapist for years, I know how important the role of cognition for example is, but we're just like, oh yeah, yeah, cognition whatever and but we're gonna focus over here on their gate, right. You know, it gets to a point where you're like, this is this is ridiculous, We cannot ignore this. Because if ultimately our goal is to have these folks live the richest, most fulfilling life they can write which I think is all of everybody on this call, that would be their goal. It doesn't matter that my discipline is physical therapy, right? If that's our goal, we've got to bring together the information we have. I love the fact that um you guys are so lucky at Hopkins to have such an ability to work with amazing interdisciplinary folks. What I didn't point out in this talk and I am so remiss in not doing this and I really apologize and steve's comment made me realize it. We have several psychologists working with us on this. I am not an expert, I could not do this as a physical therapist by myself. We have a neuropsychologist who has been very instrumental as well as more general psychologist in sort of the cognitive domain has been very instrumental in helping us. But we are only scratching the surface right? I think there is so much more to be done with our colleagues from speech and language pathology, from our you know, our colleagues, colleagues in psychology, from our colleagues in behavioral health and nutrition, you know, there's lots of disciplines that we could be even doing a better job of all working together and bringing our knowledge. So thank you Stephen for pointing that out and that's why I start every talk with the huai Cf model, even though my students cringe, they're like, oh my God, could you stop with the who I cf. But it's so important. It just has to be the foundation I think for what we do other questions or other folks, I have one question, I'm David Mueller, a physical therapist. Um First off I just really appreciated your thoroughness with just how much all the different areas that you guys are looking into and it's super fun when you get to see those connections like you did with the amount of walking that people are doing. Um I was kind of curious with the environmental aspect and the walk ability score that you mentioned and just what factors into determining that. Like is it how busy the roads are? Is it city versus suburb? Just yeah along those. So for the for the A. D. I. Score and I would encourage you guys, this is such an easy thing to do and maybe some of you are already doing it. You know, basically you just have to have their street address and then there is a nationally available calculator. I think it's based originally out of the University of Wisconsin. Um for the A. D. I. But basically for the A. D. I. They're really looking at a lot of factors that have to sort of do with what you might think of as socioeconomic. They're looking at like the cost of housing, the average income and they're looking at things like the availability of you know um certain kinds of of um resources like health care and banks and you know those kind of things. The A. D. I. That's the A. D. I. The walk ability score is particularly interested in the walk ability of your neighborhood things. Like are there are there control crosswalks, what you know what are are there sidewalks um what are the other parks and areas to walk in your name with those kind of things. So um you know it's interesting because I gave this talk at Christiana care health system which is a big health system here in Delaware. And there was several diabetes people who do research and diabetes and they've been using the A. D. I. And they're also finding that when it comes to physical activity, the A. D. I. Is a very significant predictor in patients with diabetes um with how much how active they are. So this may be this A. D. I. And this um walk ability score maybe something that kind of transcend um specific diagnoses. Yeah where my mind was kind of going with, it was like one of it was kind of like based off of that and then to thinking about how like a lot of those things like parks and just like the infrastructure is kind of based off of like tax dollars and just even how much people are making in the community to have things contribute to that and how like some organizations are kind of taking note of those inequities and doing a lot of advocacy wise with that or just even connecting this data with that to just prove the health part of it as well. I think that's exactly right. And those pieces are, so this is why how socioeconomic status, this advantage of the neighborhood kind of plays in. Mhm. Yeah. On the flip side, can I just quickly say one more thing? I know we're going to run out of time, but there is some literature to suggest however, that in very urban environments where the walk ability might be low if there's public transportation that it actually can lead to higher activity because people are utilizing public transportation which by nature ends up causing them to walk more. So there could be. Again, these are, you know, when you're looking at the whole person, there's a lot of really interesting complex interactions. I mentioned that because I think of Baltimore yeah. Yeah, that's great. And and yes, some, some people here hope you have access to this A. B. I so if you're interested, I know, you know, some of the folks who do a lot of this health disparities research and so on. the use of this A. B i as variable to control for for for different elements. So there folks, I'm gonna help connect with those who have access to that directly so we can take a look at that. That was a nice question in the chat put there. I mean, I love, thank you. So, so you can take a look at that. But one question, I'm sure you're gonna say yes, is asking taken referred questions to your studies. Oh my goodness, please please please please do um that absolutely, we would love, we would love to have anybody that you think might might be interested. And the best way, I think at this point is just um feel free to give them my email address. Great, do they need to be local or to Delaware or could be from from, they can, they can be from anywhere. And surprisingly we do get people, so a lot of people come to you guys are kind of from that central Maryland area, that's not actually so far to come to Newark. So, um, yeah, they can, I mean, we're not, we're not at this point, we're not housing people. I think if that's your question at this point, we're not housing people, but as long as they can get here. Okay. But I think that's gonna be helpful for for folks. Uh um, I don't know, pretty or others other questions. Yeah, I'm darcy, can I request you to put your email on the chat? People would have it. Thanks. Well, you know, I just want to say that we had, um, over 100 and 15 people on this, um, listening to you darcy from, you know, all the various disciplines. So your talk really address sort of the comprehensive nature of rehabilitation and there was something for everyone. So really thank you very much. Um, I think there's, you've given us a lot of food for thought, you know, and I think it's touching pretty much what everybody's working on, you know, from some angle or from one angle or another. So I really couldn't have wanted more. So really thank you very much for this very engaging talk. And thank you for also visiting the posters at the expo um, and I hope this will be the seed for more discussions on how we can collaborate on some of these questions. I would love that. And it was so great to see so many familiar faces shout out to Mark Hopkins, jen Keller Michael Schubert, Ryan Ramesh. I don't know. I'm sure there's other people I know whose names I just didn't get to see. So thanks so much for inviting me. Hi Ryan. Thanks so much for inviting me. I always love you guys have such a great group and I would, I would love to um, work with you all more. Right. Right, excellent. Thank you Darcy. Thank you. Thank you everyone for joining us today and happy holidays for anybody who knows how. Okay. Bye. Hi. Created by
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