Occupational Therapy

Episode 24 - Occupational Therapy

[00:00:00] Dr. Eric Chehab: Welcome to IBJI's OrthoINFORM, where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoINFORM, our goal is to provide you with an in depth resource about common orthopedic services that we provide every day. Our guest today is Dr. Madison Smith.

who is an occupational therapist with Illinois Bone and Joint. Madison attended the University of Wisconsin Whitewater, where she received a bachelor's degree in psychology in 2016. She then pursued a doctorate in occupational therapy at Midwestern University in Downers Grove, Illinois. Her education equipped her with the knowledge to understand and address the various physical and psychological needs of patients.

who are pursuing their return to their meaningful daily activities. Upon completing her doctorate, Madison joined the team at Illinois Bone and Joint Institute as an occupational therapist in 2021. Here, she specializes in treating various upper extremity conditions, including ailments of the shoulder to the hand.

Additionally, she uses her supplementary training to cater to the workers compensation population, developing rigorous work conditioning programs that enable patients to transition back into the workforce effectively and safely. Alongside her role as an occupational therapist, Madison is also trained to perform functional capacity evaluations, which assess a patient's ability to meet the physical demands of their job.

This comprehensive approach to patient care allows Madison to ensure her patients are ready to return to work, thereby minimizing the risk of further injury. Her primary goal as an occupational therapist is not only to help patients return to work, but to help all patients regain their ability to perform their meaningful daily activities.

So Madison, welcome to OrthoInform, and thanks for being here today. Thanks. Thanks for having me. So occupational therapy, I'd love to hear, , your take on the definition of occupational therapy.

[00:01:52] Madison Smith-Osman: Yeah. So that's a hard one, but I think at the core of occupational therapy, it's getting back to your meaningful activities, whether that be hobbies or work, but also basic ADL such as dressing, bathing, all those, necessary activities.

[00:02:09] Dr. Eric Chehab: So, explain to me, for. So, in Illinois bone and joint, when I think of occupational therapy as a physician prescribing it, I'm generally thinking of it as, okay, how can we help a patient rehabilitate their shoulder, their elbow, their wrist,

their hand?

[00:02:22] Madison Smith-Osman: Yeah, that's exactly it at Illinois Bone and Joint.

That's what we focus on.

[00:02:25] Dr. Eric Chehab: Okay, and so why is that so meaningful for patients recovering their activities of daily living or their work related activity?

[00:02:33] Madison Smith-Osman: Right, so everything people do, it involves their upper extremity, right? Their arm, their hand, their elbow. And so, what we do is not only focus on getting them to return to those activities that are meaningful for them, but also using those meaningful activities in therapy, um, to get them to be able to use those fine motor skills or gross motor skills, um, that you have to do.

You know, think about anything you do throughout your day, you're always using your upper extremity.

[00:03:00] Dr. Eric Chehab: Yeah, I, I had a physician explain to me early on in my training that, that the shoulder and the elbow and the wrist exists to put your hand where you need it in space.

[00:03:09] Madison Smith-Osman: Yes, exactly.

[00:03:10] Dr. Eric Chehab: Exactly. And so that, that, that, that to me makes sense in terms of occupational therapy of being able to rehabilitate the shoulder, elbow, wrist, and hand so that people can do that.

And what are some of the Um, techniques that you're able to use to help patients recover, um, use of their upper extremity to, to pursue their hobbies, their activities, daily living, their work life.

[00:03:34] Madison Smith-Osman: Yeah, so, , when people first come in, typically it's a little bit of, manual stuff, so hands on massage, mobilization of tight muscles, things like that, , and once they kind of get past that, we work on the strength and how they can apply that to those specific activities.

[00:03:51] Dr. Eric Chehab: Okay. And so, when, when a patient presents to you and they've been told they need occupational therapy, what, what are some of the steps you go through in terms of the

[00:03:59] Madison Smith-Osman: evaluation? Yeah, so right off the bat, we ask, you know, how this happened, what happened, how are you feeling, um, what is affected by this injury, , and that's the important part because that's how we base our goals for them in therapy.

 Then we take, you know, range of motion measurements. strength measurements, um, sometimes some fine motor coordination tasks, and then, , we apply that and give them exercises for home.

[00:04:24] Dr. Eric Chehab: Okay. , once you do that initial assessment, then what are some of the So, what are some of the techniques that you have, some of the strategies and tactics that you have that, um, allow patients to progress through this process of occupational therapy?

[00:04:38] Madison Smith-Osman: Yeah, so sometimes it's challenging. People come in, they're scared, they're not really sure what's happening, um, why they're feeling this way, right? So, it's a lot of education on why they feel this way and, um, what we can do for them. But, um, a lot of it is Starting out, telling them what happened, why it happened, maybe ways we can change the way that they're doing things to avoid some of these pains or symptoms that they're having, but also incorporating that, , making sure all the muscles are working as they should be.

Some aren't too tight, some aren't too loose, some aren't too strong, too weak, you know, kind of making that balance right for them.

[00:05:13] Dr. Eric Chehab: So educating the patients sounds like a very, very important part of beginning treatment and, and allowing patients to progress. Developing a knowledge of how the muscles work and which muscles seem to be working and which muscles aren't working as well.

Right. Exactly. Okay. Um, and so what are some of the special tools or techniques that you have that can be helpful for patients?

[00:05:37] Madison Smith-Osman: Yeah. So some of the, some of the supplementary stuff we use is things like kinesio tape, , that can help with some pain. Even some edema management, which is great, some swelling management, we use, instrument assisted soft tissue mobilization tools.

So it's these big scary tools that we use sometimes, but they just help get deeper into the tissues and really, really relax those muscles. So we use, um, we have a fluidotherapy machine, um, which patients absolutely love. I don't know if you've ever had the

[00:06:09] Dr. Eric Chehab: experience. I, I, I, it sounds like this. Fantastic massage of your arm and hand, but tell the listener more about it.

[00:06:16] Madison Smith-Osman: Sure. It's excellent, actually. It's kind of scary at first. It's a machine. You stick your hand in and it has this kind of, um, it's used to be corn husk, but now it's synthetic, right? It's warm and it blows around and it really helps people loosen up those tight muscles or people with arthritis love it. It really helps relax their muscles.

[00:06:36] Dr. Eric Chehab: So, kinesiotape is really helpful. You have some instruments that can help massage some of the swelling out and you have this um,,

[00:06:44] Madison Smith-Osman: fluid, fluidotherapy, fluidotherapy,

[00:06:47] Dr. Eric Chehab: thank you, um, that allows this sort of fantastic massage in this, in this machine that, um, uses this warm corn husk to get things going.

Um, are there some other techniques?

[00:06:57] Madison Smith-Osman: Yes, so we've been doing a little bit of cupping recently, which has been really, really successful. Um, and describe that. What's that? Yeah. So, you know, I always tell. Patients, it's like when Michael Phelps was in the Olympics, and he had these big red dots on his back, and people are like, what the heck is that?

That's cupping. So, you know, it's this, this plastic cup that we apply to the tissue that, that needs a little bit extra blood flow to the area, and we apply, pull on the skin. So it suctions their skin up a little bit. We hold it on there for a couple minutes, depending on the area and release it.

And sometimes you do have a little bit of a red mark on you, but that means that the tissue needed that area that needed that. So that blood flow to the area to promote some healing, but it can also help with, I had a patient with a nerve injury, again, canal injury. And I was able to use the cup. Right over that area to kind of mobilize it and his symptoms, uh, started fading away because he had more space in the area.

So,

[00:07:52] Dr. Eric Chehab: and so what, what are the tissues that you're specifically treating in occupational therapy?

[00:07:58] Madison Smith-Osman: Yeah. So that's a, that's a big one, right?

[00:08:01] Dr. Eric Chehab: Let's break it down then. Let's just go one by one. So, um, let's start with, we'll say muscles and tendons to begin with.

[00:08:07] Madison Smith-Osman: Yeah. So, um, a lot of the things that we see involve like The elbow when it comes to muscle and tendons.

So people who are weakened warriors might present with some tennis elbow, some golfer's elbow, things like that. Some just basic tendonitis. So we see that a lot especially at the elbow. Sometimes, I mean quite frequently, people at the shoulder are experiencing some overuse injuries there. So those are big ones we see.

[00:08:38] Dr. Eric Chehab: And then what about ligament? It's in the, in the hand, in the elbow and shoulder. Are those a big part of the practice or?

[00:08:45] Madison Smith-Osman: Yeah, I wouldn't say it's as big as, you know, like the, the tendons. However, it definitely is, um, some of those, um, in the hand, right? It's such these small ligaments, but they're so, so important.

, I've been seeing a lot of injuries from pickleball recently, people falling, falling from that. And yeah, so like at the thumb, there's ligaments that are really important to keep the thumb stable. Um, so yeah, we do see that. Okay.

[00:09:07] Dr. Eric Chehab: And then joints, the joint themselves.

[00:09:09] Madison Smith-Osman: Yeah., a biggie is the arthritis of the thumb, the CMC arthritis.

I think that's one of the most common things that we see.

[00:09:17] Dr. Eric Chehab: And how do you, how do you treat that?

[00:09:18] Madison Smith-Osman: Yeah. So there's multiple ways we can treat that. And it's a, it's a great way to collaborate with the physician we're working with, kind of seeing what their approach is and we can base our treatment off of that.

But, if someone comes in with, I'm not ready for a cortisone injection. I'm not ready for surgery, right? Um, we teach them, going back to education, on ways that they can properly use those joints to protect them and prevent them from getting more painful. But then we also teach them pain management techniques.

We, we teach them how to relax some of their muscles so they're not so tight. But also, um, how to Pinch things correctly and, you know, let's use scissors instead of our fingers to pull this Ziploc bag open. Things like that.

[00:10:00] Dr. Eric Chehab: Okay. So some adaptive strategies to help patients manage conditions such as arthritis, um, that can be helpful for the joints and then also sort of collaborating with the treating.

Physician, surgeon on what the goals of treatment are and how to achieve those, whether they're with therapeutic exercise alone or potentially with injections or potentially with surgery. Exactly. Okay. So what are some of the common conditions that you treat? We'll start with sort of the non operative conditions of the shoulder, the elbow, the wrist, and the hand.

So let's just start with the shoulder. What are some common conditions that you treat? And discuss

[00:10:42] Madison Smith-Osman: those a little bit. Sure. So at the shoulder, , the The typical impingement diagnosis we get often, um, which is just kind of a fancy word for your muscles aren't working correctly. Things aren't moving the way they should be.

 Arthritis often in the shoulder. Um, also some labral tears, which is some just instability of the shoulder. And we work on regaining that stability. But for all of those, you know, we're working on rebalancing those muscles. Kind of what we've been talking about this whole time is let's strengthen these.

Let's loosen up these. to get the shoulder moving like it needs to. And around the elbow? Yeah, so around the elbow, like I talked about that tennis elbow, that golfer's elbow those are biggies. I think that's one of the most, most common things

[00:11:25] Dr. Eric Chehab: that we see. And what are they? I mean, you hear about tennis elbow and golfer's elbow, what is it?

Sure,

[00:11:30] Madison Smith-Osman: so tennis elbow is pain at the outside of your elbow, , kind of right at that bony prominence that you have there. Um, people will have pain with gripping, lifting. Um, sometimes it can be pretty bad. They can't even straighten their elbows. And it's not always from tennis, right? People get it all the time.

Yeah, right. Exactly. And then golfer's elbow similar, but it's just the inside of the elbow. Um, which I would say isn't as common as tennis elbow, but it's still pretty prevalent. Um, uh, but it's those Big, you know, flexor muscles, the ones on the bottom of your forearm that get really tight and painful.

[00:12:05] Dr. Eric Chehab: And what are some of the techniques you do to help alleviate that?

[00:12:07] Madison Smith-Osman: Yeah. So when people come in, , we, we teach them how to, how to loosen up those tight muscles, you know, wrist stretches, things like that. Um, often we're kind of trying to strengthen those muscles in different ways to kind of heal the tissue. Um, but also we're looking at the shoulder a lot of the time because sometimes when your shoulder's weak, um, you know, So that puts more pressure on the elbow and you have to make up for that weakness at the shoulder.

So we'll go in and work on some scapular stability stuff, um, and go from there.

[00:12:38] Dr. Eric Chehab: So, so patients with a tennis or golfer's elbow, if they're getting their shoulder work done, shouldn't be surprised because it's part of the treatment. And then for the, for the wrist, um, what are some of the common conditions that

[00:12:49] Madison Smith-Osman: you see around the wrist?

Yeah. So for non operative, , a lot of the tendinitis, um, various, um, you know, It's areas of the wrist, um, sometimes and frequently it's called ulnar sided wrist pain. Um, that's a biggie and that's a, you know, who knows what's going on in the ulnar side of the wrist, you know, the, the pinky side of the wrist.

, and that's, that's a hard one, but that's a fun one.

[00:13:10] Dr. Eric Chehab: Okay. And then finally in the hand, what are some of the common conditions you're treating? Is it arthritis

[00:13:14] Madison Smith-Osman: of the hand or? I would say typically arthritis. Yeah. Okay.

[00:13:17] Dr. Eric Chehab: And what are some of the techniques to help with arthritis in the hand?

[00:13:21] Madison Smith-Osman: Um, like we had talked about, yeah, those adaptive equipment, um, heat is always a great one in educating.

You brought up paraffin in the past, in the, previously, and that's a big one. Patients love that. Um, and then, yeah, strengthening those, those weak muscles that kind of surround the joint because like we said, you can't really change arthritis, right? But we can kind of do some things to, um, stabilize the joint so it doesn't hurt as badly.

[00:13:46] Dr. Eric Chehab: And you mentioned some adaptive equipment. Explain some of those.

[00:13:49] Madison Smith-Osman: Yeah, so, , a lot of times people are like, oh man, I, I can't open this jar. It's so hard, right? So many different things. Amazon is great, right? Um, so under the cabinets, um, jar openers, we give away like those little, um, grippy, uh, tops for the top of the jar.

Um, but. Also, um, simple things. We try to make it simple, right? We're not saying, okay, go out and buy all these things for your kitchen, right? But scissors go a long way, right? Because every time you try to open a bag, you're putting too much load into that thumb. So cut things. Don't, don't pinch things. Um, you know, those choppers they have now, instead of chopping with a knife, you just put your vegetable in there and press down and then it chops it for you.

[00:14:29] Dr. Eric Chehab: I've got to get one of those. Okay. And then, um, what are some of the, uh, let's, let's change gears a little bit to some of the operative conditions that you'll end up treating. Sure. And we'll do sort of the same sequence, shoulder, elbow, wrist, hand. Um, so what are some of the common post operative conditions you treat in the shoulder?

[00:14:46] Madison Smith-Osman: Sure. So rotator cuff repairs are biggie, labral repairs, I think those are the two biggest ones that we see.

[00:14:53] Dr. Eric Chehab: And with rotator cuff and labral repair, a little bit different objectives in terms of The, the outcomes with, with rotator cuff surgery, it's a, it's a muscle surgery that we're repairing. And so obviously the outcome we want to get is.

It's regaining muscle strength and mobility. And labral surgery, we're stabilizing the shoulders, so we're trying to keep the shoulders stable while also recovering motion and strength. So what are some of the challenges in, in, in helping patients recover from those?

[00:15:20] Madison Smith-Osman: Yeah. So unfortunately, it's kind of a long process that they have to go through.

And so it's kind of talking them through it. It's okay. This takes time. You know, it gets a little, um, frustrating being in this big sling for so long and not being able to move and use their arm. So it's kind of navigating that balance of, okay, let's get you moving in therapy. Fortunately, at home, you might not be able to do too much, but it's giving them that confidence like, yes, your range of motion is coming back.

Your muscles are coming back. Everything's going okay.

[00:15:50] Dr. Eric Chehab: Yeah. I can see why your degree in psychology is so incredibly important at shepherding Patients through these tough recoveries.

[00:15:57] Madison Smith-Osman: Definitely. Yeah, these are big surgeries.

[00:15:59] Dr. Eric Chehab: Yeah. Yeah. And then around the elbow What are some of the common post operative conditions that you end up treating?

[00:16:04] Madison Smith-Osman: Yeah, so those are usually more like fractures at the elbow. So the bones at the elbow and oftentimes we People when they fall they might fall on their elbow And they might have to get some plates put in there So those are probably the most common Um, bony kind of surgeries we see.

[00:16:26] Dr. Eric Chehab: Okay. So, and then around the wrist, is it fractures?

[00:16:29] Madison Smith-Osman: Yeah. Again. Distal radius fractures.

[00:16:32] Dr. Eric Chehab: It's very, very common. So that sounds like it's like 90 percent of it. Oh

yeah. That's a big one. And then, so what happens when a patient fractures their wrist? I mean, we can treat wrist fractures both operatively and non operatively. Certainly there's been a role for So, an increased role for operative treatment of the wrist because we've developed implants that allow for the effective casting of the bone, essentially inside the skin instead of outside.

And, and so what are the advantages you see of patients who've had their wrist operatively treated versus non operatively treated?

[00:17:01] Madison Smith-Osman: Yeah. So, um, if someone comes in operatively, operatively treated, um, we can start moving them right away, which is fantastic. That's awesome. So, so early movement. Oh yeah. Yeah.

 They might be in their post op dressings for a little bit, but then they come to us and we fabricate a custom orthosis or a splint for them to wear, which they can take on and off too, which is, which is fantastic.

[00:17:22] Dr. Eric Chehab: And so what would you see with a patient who was treated with casting and non operative treatment of a wrist fracture?

[00:17:28] Madison Smith-Osman: So we would see them a lot. A lot later than we would see a, an operative case, um, and they're a little bit more stiff, right? Because they haven't been moving. Um, but they both typically do excellent.

[00:17:39] Dr. Eric Chehab: Okay. So good outcomes in the end, but stiffer and probably a longer recovery for the patients who are being treated with casting.

Has that been your experience? Definitely. Okay. And then for the hand, um, again, fractures or tendon tears or what are the things that you see in the hand that are common?

[00:17:54] Madison Smith-Osman: Yeah. Fractures. We see, um, where I work, we have a lot of workers compensation. Um, so we'll see some amputations, some crush injuries. So those are always some complicated cases.

[00:18:07] Dr. Eric Chehab: And then tendon lacerations. Boy, those must be, what's the challenge of when someone cuts a tendon and it gets sewn, what are some of the challenges that you face on the recovery side?

[00:18:18] Madison Smith-Osman: Yeah, so that's a hard one because at first we're like, don't move, like be really careful, right? But at the same time, why is that?

Why is that? Yeah. Cause it's so fragile. You have a high risk. Of, uh, re-injuring that or tearing that tendon again. Okay. , but then you have to fight the scar tissue, right? So we teach a lot of, , scar management, scar massage, things like that. Um, but also working through, yes, you can actually move it, but in this safe manner.

[00:18:41] Dr. Eric Chehab: Okay. Um, and then, you know. So, so we've gone through sort of the non operative conditions that are common in the upper extremity and then the operative conditions that are, are common. Um, but tell us a little bit about the psychological aspect of recovery because I know from my own personal experience, it's kind of devastating when you can't use your upper extremity, when you're unable to put your hand where you need it for whatever period of time.

So what, what are some of the things that you help patients, what are some of the techniques you use to help patients cope with their injury? And their recovery and giving them the hope and the optimism that they're going to get back to where they need to be.

[00:19:18] Madison Smith-Osman: Yeah, definitely. I mean, my favorite thing to do is, you know, after, after their first evaluation, we give them exercises.

Um, I remind them of what their range of motion measurements were and I say, okay, let's remeasure. I'm like, wow, you increased this by 20 degrees. That's amazing. You know, it's sometimes hard to see the, the changes you make cause you're with your hand or elbow or shoulder all day, every day, right? Right, right.

For me, I'm like, wow, that's fantastic. So. So really showing them the objective, um, gains that they're making is, is huge. But also, you know, when I was talking about we do a lot of that soft tissue mobilization, the massaging, that's a time where we really talk and connect. I think that's a unique thing about occupational therapy.

We're just so close to our patients, um, when we're working on them and that's when we talk about the things that are hard for them. Maybe we could try this instead in trying to, um, you know, a lot of people want to get back to work. They want to get back to doing their hobbies because that's what makes them happy, right?

And that's, that's our goal. Um, well, let's try it this way and see if that works better for you. And oftentimes it does and they come back and that, that frustration or sadness kind of slowly goes away.

[00:20:23] Dr. Eric Chehab: So, we've talked about the patient who comes in with stiffness and, and again, or some injury and education being a critical part of their recovery and then regaining motion and then regaining strength.

But there are some times where immobilization is. So, tell us some of the things that you're able to do to help patients be adequately protected but still having use of their arm or hand.

[00:20:53] Madison Smith-Osman: So, we, , are trained in fabricating these custom splints, right? And what's nice is that they're custom, right?

They're made just for you, um, and they immobilize only the joints that need to be immobilized, right? Only the joints that have to be limited. You know, we're not going to go all the way up your elbow if it's just your wrist, right? And the splints that we make are actually very comfortable and can be easily removed.

, so big things like showering and washing your hands, especially with COVID that was a hard thing, right? People wanted to be able to do that. So, you know, with fractures like we had talked about, it's necessary for them to wear these, these splints almost all the time unless they were in therapy.

However, people with some of the tendinitis , the tennis elbow, golfer's elbow, or even carpal tunnel, for example, , they benefit from splinting, too, and, , for the carpal tunnel, what's nice about what we do is we actually bring it up a little bit, on their fingers, um, which you can't necessarily get over the counter, you know, at the Walgreens or CVS, , and that way people might notice actually a better benefit than what they got previously.

[00:21:56] Dr. Eric Chehab: And that's like for night splinting for carpal tunnel? Exactly. So you can custom mold it, but it'll be different than anything they can buy over the counter? Yes, exactly. Wow, that sounds great and comfortable, particularly for sleeping. Okay. And then, um, and so you're mentioning the splints that immobilize, but there are other splints that help.

Aid and mobilizing the joint, is that correct?

[00:22:14] Madison Smith-Osman: Yeah, definitely. So describe some of those. Sure. So, um, I actually just made one last week. It was great. Okay. Um, it was for the wrist. Someone's just a little stiff after surgery, right. So we created this splint that went on his forearm, but then a separate piece actually that went on the hand and we're able to use, , actually, , fishing line.

to pull down on the splint and allow for that wrist to move a little bit longer, but then stay in that position for longer, which helps over time, the muscles relax and the tissue to stay in that position that we want it to be in. And what's that type of splint called? Yeah, so there's a, it's a static progressive splint.

[00:22:53] Dr. Eric Chehab: Static progressive splint. And then what are some of the other?

[00:22:57] Madison Smith-Osman: Yeah, so there's like the, the dynamic progressive splints, which are really fun.

[00:23:02] Dr. Eric Chehab: What are those about? Where do you see those?

[00:23:04] Madison Smith-Osman: Yeah, so,, when people have a rare, , complication, sometimes of breaking their arm, um, like a radial nerve breakdown.

palsy, , like their wrist just bends forward, they can't extend it at all, we'll make a splint that actually holds them in that position, but they can still move their fingers and then the splint actually brings them back up into the position.

[00:23:24] Dr. Eric Chehab: So someone with a nerve injury who can't bring their hand straight and it kind of flops down, the splint can bring it straight for them, but it doesn't hold them straight, it allows them to use their hand.

Like it's meant to which is to grip things. Exactly. And then to open the grip the splint assists in that opening the grip. Yep. Yeah, those are those are cool splints and very elaborate and Incredibly helpful for the patient as they recover from some of these injuries. For sure. So Madison, what are some of the pearls that you would like your patients to know as they enter occupational therapy as they Progress through occupational therapy and then as they graduate from occupational therapy.

[00:24:03] Madison Smith-Osman: Sure, yeah. So, , as we talked about the education piece, right? So we are, are there to give you the tools. We want you to be able to take those tools and apply them to your daily life. So, we're kind of there at first with a lot of help. Right? But then slowly, we're going to let you kind of take the reins a little bit.

And then by the time that you're done with therapy and you're ready to discharge, , we'll, we'll provide you with some exercises to keep doing, but also, you know, remind you, , of the tools that we learned along the way and how to keep applying those to your life. Because often, you know, you'll have to keep up with that for a little bit after therapy.

[00:24:38] Dr. Eric Chehab: So and when you say tools, it's not just Physical tools, all those tools that you mentioned on Amazon. It's also skills that you're teaching patients in terms of mobilization, strength, and techniques to, um, basically give them an advantage to overcome and improvise and adapt to any of the shortcomings that they may have from an injury or a condition that's developed.

[00:25:02] Madison Smith-Osman: Yeah, exactly. You know, um, how they modified the way that they were playing tennis, for example, or how they modified the way that they were lifting at work. Um, those are all the tools, you know, I would say, make sure your butt's down when you're lifting. You know, they're going to replay that in their head when they're, when they return to work.

[00:25:18] Dr. Eric Chehab: Right. So, um, I, I always say to my patients that, um, Patients who engage with an occupational therapist will be engaging with some of the nicest people in the world and some of the most ambitious people in the world because you're so kind to people and you want to get them all better. And that's the kindness and the ambition.

And certainly you fit the bill. So I'd like to again thank Dr. Madison Smith. She's our guest today on IBGI's OrthoInform. So thank you so much for being here today.

[00:25:47] Madison Smith-Osman: Thanks. It was great.