E51 | Nicole Surdyka: ACL Rehab & Ethical Return to Sport Decision Making

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Biography (In Nicole’s Words):

I grew up in a small town on the Jersey Shore, and have been around football (soccer) for as long as I can remember. Everything I did in my childhood and adolescence was aimed at becoming a Division-1 college soccer player. In my junior year of high school, I achieved my lifelong dream and verbally committed to play soccer at St. John’s University in Queens, NY. In November of my senior year of high school I fractured my tibia and fibula. I underwent Open Reduction Internal Fixation with an intramedullary nail in my tibia and three screws going from my tibia to my fibula, two distally at the medial malleolus and one proximally near the pes anserine, and then started physical therapy. 

If you haven’t already figured out how this story ends, my physical therapist not only helped me recover from my injury, she also gave me my dream back. She helped me reclaim my self-identity and led me on my eventual career path of becoming a physical therapist myself. I knew I would never be able to adequately repay her for all she had done for me, and I also knew that I wanted to dedicate my life to helping other soccer players achieve their dreams, especially when they might be feeling as hopeless as I had.  I ended up having an amazing experience at St. John’s, and then went on to Emory University in Atlanta, GA for physical therapy school where I met my husband, Marc. I currently see patients and clients for both physical therapy and performance training in person and remotely online in my cash based concierge style practice. When not working with clients or creating content, Marc and I try to spend as much time as possible outdoors in nature with our two dogs, Rosie and Kai.

Topics Covered:

1. Nicole’s physical therapy practice that blends sports rehabilitation with on field preparation and technical/tactical coaching
2. The open chain/closed chain debate in ACL rehabilitation
3. Why open chain exercises aren’t “dangerous”
4. How open chain exercises stack up against “acceptable” closed chain activities and activities of daily living in the research
5. Unique benefits of open chain exercises and what rehabilitation providers who avoid them are missing
6. What does “functional” and “specific” mean in the context of ACL rehabilitation
7. How Nicole progresses open chain exercises to maximize safety and effectiveness
8. Nicole’s “Ethical Return To Sport Decision Making” course
9. The ethics of risk aversion and harm in return to sport rehabilitation
10. Key stakeholders in the return to sport process
11. Ethics Case Studies: concussion in a high school athlete, is physical therapy “essential” during a pandemic, how many visits “should” insurance companies cover, what to do when physical and psychological readiness are at odds

Links of Interest:

• Nicole’s Website
• Nicole’s Courses
• Nicole’s Case For Open Chain Work in ACL Rehab
• Nicole’s Twitter
• Nicole’s Instagram
• Nicole’s Linkedin

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Episode Transcription: [00:00:00] Doug: Alright, Nicole, thank you so much for joining us. Would you please begin by talking a little bit about your clinical practice in physical therapy? I know it's unique in that you actually don't always work in a clinic or an office but sometimes your office, so to speak is on a soccer field, which I think is pretty cool. So would you mind getting into a little bit again on that clinical background and even your athletic background a little bit because I think there's a congruence between those two things. Nicole: Yeah, of course. Thanks for having me on. So basically I've always kind of been interested in the return to sport concept and the idea of taking someone from their injury and not just to being pain-free, that's not always been my goal as a clinician is to get someone pain-free but to functioning and performing. So I worked in a couple of different outpatient sports medicine orthopedic clinics since I've graduated and I just didn't no matter how good the setting might've [00:01:00] been, like my first job was in a sports performance center and I loved it there but it's still isn't, you still have limitations put on you by insurance companies mostly. So it's hard to really do everything that you know that athlete needs to return to how they should be performing in those types of systems. So I have my own cash based practice. I do nothing with insurance companies. I don't even supply a super bill because I purposely don't want to deal with any of it. Because I don't want; what I can foresee happening is if I start giving super bills, then someone someday is going to say, oh my insurance company isn't going to pay me back anymore. So I'm going to go somewhere else. It's like, if we just don't even set the expectation at all, then I've found that that's been better for me. Probably a little bit of the lazy way out because I hate insurance. Doug: I hear that 100%. Nicole: I just don't want any involvement. [00:02:00] and I just find that I have so much freedom in how I treat now. So like you said, some days that means I'm in a gym with an athlete some days that means I'm at someone's house, helping them after surgery, figure out how to go up and down their steps, in and out of the bathroom and sometimes I'm on a soccer field, which is great and I love that. It doesn't really feel like work or like an office and I'm there. So that's been the most fun for me and I mean, I was a college soccer player. I played at St. John's in Queens, New York and then I was a soccer coach. I wanted to be a college soccer coach or professional soccer coach and my college coach told me that I was too smart for that and that I should go do something else. So, he's the one who actually, kind of helped me see where I can bridge soccer and physical therapy and sports medicine. So that's what I try to do because I have a strong background in soccer, so that's just kind of what I lean towards, [00:03:00] but really any athlete, I love working with. Doug: Yeah and that's kind of how I encountered your work was just on social media, seeing some of the return to sport pieces that you wrote and the first one that really caught my attention was the article about ACL rehab and open chain exercises and that led me to your website, where I actually watched the ethics of return to sports. So I want to kind of get deep into both of those things, because they're both awesome resources, but I guess I want to begin by talking about the open chain exercise and ACL rehab because to me, it's one of those things where there's so many faux controversies in rehab and performance. It's like people have these endless, in my opinion, just completely wasteful debates about whether we should do single leg exercises or a double leg as if like you have to choose between one another. Close chain, agility drills versus open chain chaotic. It's like most co good coaches or what I would consider [00:04:00] competent coaches are always doing both of those things and there's an appropriate progression and appropriate time for all these different things. When it comes to the open chain thing and in ACL rehab, one of the kind of myths that you expose in your article is that it's dangerous to do open chain exercises, but you actually have some really good data and some studies that you cite where relative to other things, activities that have been quantified in terms of ACL stress that are deemed permissible in the early stages of ACL rehab, you found that those things are actually more quote, unquote dangerous than an open chain exercise. So can you get into why we should get over this thing about open chain exercises being dangerous, so to speak when it comes to even early ACL rehab? Nicole: Yeah. So, to your point, my argument is never like, oh, do open chain, but not close chain. We should do both and I think the argument [00:05:00] of we can only do close chain or that open chain is dangerous. That I was like, hang on, how do we know that? What makes it dangerous? So what the myth was or what the belief has been and what I was taught in school and what I'm sure many people were is that open chain exercises strain the ACL. So my first thought on that was, well, why is that a bad thing? Isn't that what we do right after a hip replacement, we get the person up and walking because we want to load, to help with healing. So, that was my first thought and then I was like, well, what are the things that we typically do early in ACL rehab and what types of strains do they put on the ACL? So there's some really good data out there. Some really good articles that show that things like body weight squats, walking, those are two of the things that we do first session with somebody is we do gait training and we have them do body [00:06:00] weight squats. So, the amount of strain on the ACL during those two tasks is really similar to an open chain knee extension exercise. So, Yeah, if that's the argument that it's dangerous because it's too much strain, well that doesn't hold water because you have no problem doing body weight squats and having them walk. So there should be no problem having them do open chain exercises. Now I will say, of course, that doesn't mean, that in the first week postop, I have them sit on a leg extension machine and go full range at max effort because that would be silly because nobody does any exercise max effort, right after surgery or the first time when they're deconditioned or they're a novice athlete or anything else. You always start at what their capacity is and then build it up. So same thing with open chain exercises, you find an entry [00:07:00] point, find what their capacity is and then build it up. Doug: Yeah. And that's one of those things where when people say, oh, it strains the ACL. Anytime a muscle contracts around the joint, it's going to put stress on that joint and that's kind of the point of rehab where I think the fundamental issue is it's like, are we putting so much strain that it's going to cause like a graph failure or some kind of a catastrophic failure and you make the point that like, even with something as simple as ambulation, the forces on the ACL are higher than what they would be with a very submaximal leg extension in a range of motion that's deemed safer. I mean, even, like I don't personally do full range of motion, leg extensions, early rehab either but because it's like, if something goes wrong, then you're obviously going to be deemed irresponsible. But at the same time after a surgery, there's so much inhibition anyway, that like is the nervous system going to allow such a high output that you're going to destroy your joint? Probably not, but [00:08:00] again, I think there's reasonable boundaries we can draw, we can get into the specifics of that later, but I think that the next point I want to kind of get into with you because you make us really well in the article is people talk about closed chain versus open chain as if, if you say that you do open chain exercises, it means you don't do close chain. I think that most people have this idea that closed chain exercises are kind of more functional or whatever that means. I think that functionalities become kind of a bastardized ambiguous word, because function is always contextual, but you make a case that there are actually very unique benefits to open chain exercises that you don't get with close chain and that's why we should do them. So can you get into, like, what are the unique benefits of open chain exercises that actually in the long run are ultimately going to improve function and presumably make them functional in the, in the long run. Nicole: Yeah, so absolutely like I'll still do closed chain exercises like [00:09:00] squats, dead lifts, lunges, all of those things, great to do, that should, that should be included in the rehab. But I would say that we need to include open chain because right now; now this may change with more research in the next couple of years, but right now as we stand the body of literature supports that the biggest predictive factor going on to have a second ACL injury is quad strength and so to me that makes that the priority in rehab is getting the quads really, really strong. Both of them because the contralateral side is just as much at risk as the ipsilateral side, sometimes more so. So having said that yes, we can strengthen the quads with close chain exercises. Sure, goblet squats, chat bar deadlifts, spanish squats, all of those things great for loading the quads. However, there's also some great research showing that after an [00:10:00] ACL reconstruction with athletes, what patients tend to do is subconsciously shift the load out of that surgical knee and we see this early on when we see the interlinked compensation. So if it's a right sided injury, they'll shift their weight on to the left side. We all see that as something we all, when we're working with this population, try to queue and correct and eventually it sorts itself out, we think. But what actually happens is that instead of an entire limb compensation, Susan Sigurd at USC and her research team, they found that around three to five months after surgery, there's a switch to an interim limb compensation. So now they're unloading that surgical knee and instead they're shifting that load into the hip and/or ankle. So we can't always see this, especially with something like a body weight squat, or a bilateral close chain task. We can't [00:11:00] see that happening, we can only see it if we have kinematic data at our disposal, which most of us probably don't. So since that shift occurs and they're not loading their knee appropriately, that means they're not exercises that we think are loading the quads aren't actually loading the quads as much as we would hope so. That's where something like a leg extension comes into play a knee extension machine, because there's no way to cheat that, you have to utilize your quads to perform that movement. That's the only thing that's going to do it. So, it's just a way to ensure that your doing everything you can to get this person back with a reduced risk of reinjury, because that's really the name of the game with ACL rehab is don't let it happen again, because they're at such high risk of a reinjury. So any way that we can do that, which right now it looks the best thing we can do is quad strength. [00:12:00] Then we have to include it. Doug: Yeah and I think that's like where people get all caught up in this functional training is the idea with functional training is that the body doesn't isolate muscles and it works as a unit, which is true but the confounding factor here is in a surgery, when you have inhibition at a specific joint, if you don't address that inhibition and isolate that individual joint early on now you've actually never sufficiently stressed that joint so that when the person goes back and plays in the field and they encounter stress that you can't account for in a training environment, now that joint is not ready and so have you seen even in things with a hop test, if you don't isolate the quad early on, a gifted athlete can learn to compensate and develop symmetrical readings on a hop test that maybe use more of like an ankle or a hip strategy to do it. So I don't know how do we get around that type of compensation unless we isolate the quad early on, and to your point, I [00:13:00] don't know how we do it unless we're doing a leg extension machine. What else do we do otherwise? Nicole: Yeah and that's exactly the point. Otherwise we're guessing, if you aren't sure, and you don't have like a valid way of measuring and assessing that, then you're guessing and I'd just rather not do that. I'd rather not just be guessing through someone's ACL rehab. But yeah, functional has come to mean so many different things. To me, it's going to be different person to person, functional is what does that person need to be able to do and for athletes, they need to be able to, especially the soccer players that I work with decelerate, accelerate, change direction, sprint, jump, land and they need strong quads for all of those things. It's not really beneficial for performance, let alone injury risk for what ends up happening is when they go back to sport and they are now on a quad that is weakened and [00:14:00] so they take the load out of that knee, like we talked about. So now they're going to go try to land and/or change direction and decelerate on a limb that's doing more of a hip strategy, so more of an extended knee trunk flection and then rotating and pivoting off of that and that's an ACL injury waiting to happen. The ACL tear is when your knee is at or near full extension. So if they're not loading that knee and getting good, strong quadriceps controlled centrally during those tasks, during deceleration and landing specifically, then they're going to utilize a hip strategy and then that's when we see valgus forces at the knees when they're in that more extended position, hip strategy, the quads not doing it so then it has to go to the glute and then it's too much for the glute to do and then we see knee valgus. So I think a lot of people take this idea of functional meaning it has to, [00:15:00] for whatever reason include an unstable surface and seven different colored bands and that doesn't happen on a field, that never happens on any field or court. So I think if we work under the definition of functional as being something that applies to what that person has to do, then we're a lot better off. Doug: Yeah and I think that it's, sometimes you have to constraint. It's like the whole part, whole training you have to constrain a drill or an exercise. So stress, whatever tissue is that you want to stress. So like, yeah, even when it comes to like change of direction, there's this whole, people are obsessed with the concept of self organization, but self-organization is contingent upon having options from which to self-organize and sometimes you have to isolate individual components of that system to make sure that you can call upon them to self-organize and to your point, if you don't have quad strength, now when [00:16:00] you go to change the direction, you're not going to be able to produce the right shin angles. You're not going to be able to load your knee effectively. You're going to have to rely on the hip strategy. So the only way to do that sometimes is to kind of, it's also like specificity. We're so obsessed with specificity. How do we mimic what goes on in the game but sometimes you need to isolate things and constrain things before you can get really specific. So in my opinion, sometimes the best way to be functional is to be as far away from specific as possible. Again, on a leg extension machine will strengthen your quad but when you say that it becomes just so polarizing. So I would encourage anybody to read your article on that because, it's not like you're saying do open chain and nothing else. You're saying like, there are unique benefits to open chain, here's why you should do them as part of a comprehensive rehab strategy. So that's a little bit abstract when it comes to like specific stuff, what's kind of your time, I know everyone's [00:17:00] somewhat unique, but your basic timeline and progression for like, what's the point at which you generally feel comfortable in ACL rehab, getting somebody to do a leg extension machine through a full range of motion how do you respect the arc of death and terminal knee extension early on? How are you getting from kind of day one postop to the point at which you feel comfortable loading that quad through a full range of motion with a lot of external load. Nicole: Yeah. So there is no strain on the ACL from like 90 to 60 degrees of knee flection. So immediately I'm comfortable with that range. Now what usually happens is that I'll have the person I'm working with right after surgery just do an isometric, if they can't get to 90 degrees of knee flection, which often they can't that early at 60, 70 or somewhere in that 90 to 60 range, I have them do isometrics, just pushing into my [00:18:00] hand. Just whatever amount of effort they feel comfortable putting in. I do tell them not a maximal effort, so I tell them so whatever their maximum is back off a little bit because there will occasionally be that one person who's like, all right, let's go for it, let's start this physical therapy program and push really hard and we don't necessarily need that day one. So I always start in at 90 to 60 range day one and I always start with isometrics because I find that to be a better way to start getting a good quad contraction than just quad sets. So I still will do quad sets, but I think it's a good idea to also get them in a different position. I'll do those manually resisted isometrics at different range, at a different angle. So at varying angles through that 90 to 60 range and then if they're comfortable, I just have them open and close 90 to 60 and I'll keep my hand there so that [00:19:00] they can't go past it. So immediately I'm comfortable with that 90 to 60 degree range because there's no strain on the ACL. So as long as they're comfortable doing it, I'm comfortable having them do it. After that then, usually for the first four, five, six, four to six weeks. I'll usually stay in 45 to 90 degrees and again, usually starting with varying manually resisted isometrics at varying angles throughout that range and then as they're comfortable producing an isometric contraction at those various angles, then I'll have them go through an isotonic contraction through that range. Doug: Like on the machine with some external load? Nicole: No, just their leg and then, because I just want them to be able to produce a quad contraction in that range. Now, if they're comfortable with that and that's fine, then yeah, I'll get them on the machine. Start off with an isometric. So this is all in the first four to six [00:20:00] weeks. I'll get them on the machine and they pushed into it as hard as they can, or I'll start off with 30 seconds, isometric contraction and I'll tell them to do between 50 and 70% of max effort and then rest for two minutes or so, because I want to work on getting a good, strong contraction. I don't really want to do that under fatigue just yet. So that's kind of the parameters I work with initially. At around six weeks, again, sometimes it's sooner, sometimes it's later, but around six weeks is when I have no problem opening up that full range. Often it's sooner, but there are times that either the athlete's not comfortable with it or I'm not comfortable with their amount of a quad contraction just yet, or their quad strength just yet, or they're having some discomfort or any other potential issue in the 90 to 45 degree range that I delay opening it up. One of those reasons that I delay opening it [00:21:00] up is if they've had an allograft or a hamstring autografted. So those take a little bit longer to heal. So for those, I'm definitely waiting for at least six weeks to open it up full chain, full range, in a full as 92 zero, because they're soft tissue attachments, the bone patella bone that has the bony plugs. So that's going to heal a little bit faster, whereas the soft tissue attachment of a semitendinosus or an allograft, I'm not sure as comfortable progressing fast with so you have to always respect biology. But that's kind of my general timeline of how I do it again, like you said, everyone's going to be a little bit different. I have someone right now who was able to do it super early and I had to kind of hold it back just because it was a hamstring autograft. Doug: Yeah. I like asking that to different therapists because it's just one of those, like there's some clinical judgment [00:22:00] involved in it and the consensus seems to be that, I mean, there are people that aren't touching open chain for like six months so like the quote, unquote riskier PTs, which would be someone like you, based on like the, I think probably how we look at things, but I think risky more in a good way and we'll talk about that with the ethics in a minute. I think people are saying like, all right, like, noone's really doing full range external load until like almost two months out open chain. So it's not like you're saying like, hey, it's day one, let's go get a leg extension and crank out full range of motion. You've got a progression, you're avoiding any kind of ACL stress and open chain for almost the first month to six weeks and then only at like maybe six to eight weeks you're even considering going through that full range there. So to me that's more responsible and prudent than risky. But I think because we've been so conditioned to think that open chain exercises are bad and dangerous, we're like, oh my God, we can't do them for six months. But the crazy thing about that is [00:23:00] people are running it three or four months, but not doing a leg extension until six. What do you think is really going to be more, more dangerous? I think we were a little bit distorted with some of that stuff, but I really going to post the link to that article you wrote in the notes and I hope this is going to be kind of a case closed type thing, because you really do a great job of hopefully putting it to bed. But I have a feeling that the controversies is going to persist because; what would we do if we're fighting over crazy things? Nicole: Exactly, because there's always going to be those people who are like, well, I haven't touched open chain in the 25 years I've been practicing and I'm doing well so... Doug: Again, it works well, like how do we define that? It's not a controlled study relative to what you could have been doing. How do you know? Nicole: Exactly. Doug: It's a certain point where I guess you could just say your piece and then move on. Nicole: Exactly. And that's all you can really do, especially in social media. It's just like put out what you want to say, your objective statement and then back away. Doug: And that's why I appreciate your article, because like you can go back and [00:24:00] forth in these threads and they become, after a while, almost like more about fighting than about like getting to anything definitive. You wrote an article, it's like, if people want to abide by it, cool. If not, but it's like, you don't need to get involved in this mudslinging anymore. You put the effort into actually writing a well thought out article, which kind of segues into the next really, I thought, well thought out resource that you created, which was the ethics course. As you know in our field, especially in sports medicine, orthopedics, everything tends to be very exercise centric, manual therapy centric, programming centric and yet you created an ethics of return to sport course, which was really different than a lot of other resources that I've encountered for people that focus on the sports and performance side of things. But I mean it's two hours, but that could really be an entire semester long course in PT school. There are so many layers to it. [00:25:00] What inspired you to create that resource? Nicole: I guess a couple things. So the thing that really kind of made me do it was Matt Bobbin from South coast seminars. He was putting together; he was hosting Tim Gabbit for a training load workshop course and my husband and I were both attending it and Matt Bobbin reached out to me and was like, hey, I want to like put together an ethics course for PTs and athletic trainers. Would you be interested in doing it on return to sport? And I was just like sure, yeah, that sounds good. So that was kind of like the catalyst for me doing it, but it's something I've always been interested in and I can pinpoint like a few defining moments that have made me really interested in this side of things. The first is, we had; I went to Emory University for physical therapy school, My husband did as well that's where we met. We had an ethics course there and we had this professor, Dr. Bruce Greenfield, who's amazing. [00:26:00] He's a sports and orthopedic physical therapist, but now he just does ethics. So he's on like the ethics review board at Emory and I had never; kind of our semester long project was to write a term paper, so to speak and mine was on return to sport decision-making and then I just the way he made us think about things where I think a lot of times ethics, in California, for example, we have to take an ethics course every cycle I think and a lot of the ethics courses are just so dull and don't always apply. The first principle of like do no harm. That is not applying in sports. We are knowingly doing harm sometimes or knowingly risking harm, not doing harm, but putting athletes at risk of harm. So the very first thing that we're taught is do no harm principle just gets torn to shreds in sports. So, that just made me think a lot and then I have one of my college [00:27:00] teammates, Vaila, she plays professionally in Sweden right now and one of the first, I think it was her first year playing professionally. She was having some back pain and reached out to me. I was still a student in PT school and she said her MRI showed a herniated disc and whether or not that means anything clinically in her case. I don't know. But she said she had a game coming up where she was supposed to be playing against Marta. Who's one of the world's best soccer players who happens to be female and so it was a big deal, it was a big game. Vaila was trying to be seen by other professionals Scouts and national teams Scouts. So, this was a big deal for her to play in this game in mark one of the world's best players. So in my mind, I was like surely there are things in life and in sports that change the amount of risk you're willing to take. I can [00:28:00] say all day long, hey, you have a herniated disc. You shouldn't play soccer because it's contact sport and who knows what might happen. But then there are things that change that, there are things that say, hey, I'm willing to take more risk on this. So I thought that was a really cool concept to explore and try to utilize the ethical principles we do have within the APA code of ethics and our state practice acts and see maybe where they fall short or contradict each other sometimes. Doug: What's really cool is I think you do a good job of asking questions, but you also respect the complexity of some of these scenarios, and you're not saying like here's the best way to handle it because yeah, there are some situations that are from an ethical standpoint, like very clear and definitive as to what you should do and what you shouldn't, but part of what makes this so difficult is that you talk about like some of the stakeholders in the return to sport process and when you have more stakeholders you realize that [00:29:00] you've got kind of different interests. Sometimes they are aligned, sometimes they're conflicting, but if you look at all the stakeholders individually, you realize that they all kind of have legitimate things they're looking to achieve, but sometimes those things aren't always in the best interest of the medical outcomes. So can you talk a little bit about, before we even get into other stuff, who are the stakeholders in this return to sport process? Nicole: Yeah. And that's always going to depend on what level of competition you're in. So at a youth level, if we're working in an outpatient clinic, for example, we have the athlete, their parent, their coach, usually their gym teacher is somebody that we need to include as well; their friends, their teammates. So those are all people that we need. The referring physician of course, these are all the people that we need to consider in this process. At the professional level, we would have sports scientists, [00:30:00] sports medicine staff, sports performance staff, director of high performance coaching staff, the GM, the player's agent, the player's family still important here, the teammates, the fans, the media. So it gets a little bit more complex and what I think is really important is when it comes down to it, we're dealing with a human being and human beings are inherently complex systems. Working with an athlete, an athlete is not just an athlete. They're also a mother, a sister, a teammate, a friend. So there are a lot of layers, a lot of contextual layers each person needs to consider. So identifying the key stakeholders is important because it's important to recognize that our voice is not the only one being heard, nor should it be. There are a couple different people who have a say in what happens and have a say in how things should progress and as long as all of the stakeholders still keep the athlete [00:31:00] in the middle of this process and are still all coming from a place where the athlete's best interests are being kept at heart, then we can all move forward together. I think it's important for every stakeholder to recognize that we should all ultimately have the same goal and that's to have the best outcome possible for the individual athlete we're working with. We may all disagree on how to do that, but as long as we can agree on that being our end goal, then it's possible to move forward together and we need to hear everyone's perspective because that's what the athlete is hearing. Doug: Yeah. When you talk about these stakeholders, it's almost like you're teaching an emotional intelligence course because you have to have be so aware, hyper aware of how every party involved in the process, the lens through which they were going to look at the problem. It's difficult because it's not clear who decides whether the athlete plays or doesn't right. It's not like there's this [00:32:00] hierarchy where the GM can say he or she is playing or they're not ultimately kind of the athlete probably is going to make that decision, but the athlete also has a lot of people in his or her ear which makes it difficult. So from a medical standpoint, because as medical people, we like to think that we should probably be the gatekeepers to return to sport during a medical situation. But it's also like the athlete to your point might decide if they're willing to tolerate more risk and you bring up kind of that the athlete and the game center of the championship scenario where the athlete might have a soft tissue injury that predisposes them to something more catastrophic but if that athlete, if they play in game seven, they get to bond with their teammates. They're either going to get like a $2 million bonus for winning a championship, maybe it can solidify a legacy in terms of being a historically great player. [00:33:00] If I was in that situation and I'm not tall enough to ever be, I might risk tearing my ACL for all those things. So what is the job of the medical director in that scenario beyond just really providing the athlete and all the other stakeholders with information. What really more are we doing than saying here's what I think, here are the risks based on my analysis, but we're not really deciding are we? Nicole: I would say that that's our role is to educate and provide our objective perspective and say; and not just in the moment, because almost everyone else around the athlete is thinking in the moment. So I do think our unique role is to think long-term as well. How is this going to look for you when you're 70? Because that's really tough for athletes to do is to think about what their life will be like after they're not athletes anymore. So I think that that's a unique perspective that the medical staff, rehab stuff that we need to bring to the table. So I think that's our role to say [00:34:00] these are the risks I'm worried about this. I'm worried that because of this soft tissue injury; give it to them in terms they understand, when you land that you're not going to contract your quad hard enough and you might tear your ACL or I'm worried that your calf has been bothering you on and off for the past month. It's been getting a little bit worse recently. Your load has increased recently because we're in a championship series. I am worried that you're going to jump and tear your Achilles tendon. So if we give it to them in terms they understand and say, this is what I'm concerned about. Then at least we; do this simple teaching things, have them tell it back to you, ask them if they understand, what are the risks that you're willing to take? Are you willing to risk possibly missing next season? Having to undergo surgery that may or may not successful having a long, tedious, rehab process. Are you willing to [00:35:00] take on the risk of that for this game? Maybe they're early in their career and they're not willing to do that. Maybe they're planning on retiring soon anyway, so they are willing, or maybe this will, like you said, seal their legacy if they're going for 3P they're going to be written into the hall of fame, or if a contract year is coming up and it's up for a couple million more dollars. Who am I to tell the athlete, the $5 million isn't worth this injury. Maybe it is, I don't know that, I can't say that for that athlete. So yeah, I think our role is to provide a clear objective data, but I think maybe sometimes what we miss is making sure they understand what that means for them. Doug: Yeah. Yeah. And the hard part is everything that we're telling the athlete is still a hunch. We can't say with any kind of validity or reliability, well, you've got this percent chance of [00:36:00] an injury if you play because there has been people who've played hurt and nothing has happened and there are people who by every kind of metric, whether it's readiness, metric, HRV load management, they look good and they get hurt. I think you also talked about there's differences among various injuries, because somebody might say, okay, I am okay with tearing my ACL if that's like the worst possible scenario, but in a contact sport for someone who's had 10 concussions, where one more concussion could permanently disable them that's also a different kind of a calculation. You get into all those things in the course. When it comes to you and we talked about this earlier, the idea of like do no harm and I thought it was really cool when you talk about as rehab providers, we really can't abide totally buy that ethos because in order to prepare somebody for sport, there's some element of risk, the game is risky. The only way to prepare for the game is to systematically induce risk. So from like an ethical [00:37:00] standpoint, and I think because I think sometimes I've lost, would you say that complete risk aversion is unethical from the standpoint that you're basically, you're kind of trading the potential for harm in the present for the potential for harm in the future. Whereas if you like introduce some risks early on, maybe; and part of it is also the whole finger pointing. If you're not aggressive in your rehab, noone's going to get hurt on your watch, but then you could say okay, well it's the strength coaches fault or the head coaches fault, but maybe it actually was your fault because you didn't hand them off when they were actually ready for that stuff. So how do we reconcile the do no harm principle with ethically preparing that athlete for the rigors of the game? Nicole: Yeah. I liken it to you seeing free solo or people who do like the crazy rock climbing, they all take calculated risks and they'll say, in some, like in Meru, is that the one documentary? The one [00:38:00] movie on one of the...? Doug: Yeah, there is a climbing documentary. Nicole: Yeah. Yeah. So in there, they're in a tent and they're talking about I know that there's risk involved in this obviously, I'm hanging off the side of a mountain in a flimsy tent. But I also know what risks I'm not willing to take. I know what risks I'm ready for and I know which ones I'm not. So they're all calculated risks. I think that that applies to sports rehab as well in that if we are just completely risk averse and we just have them do simple exercises that aren't going to apply any type of stimulus that we need to cause adaptation that we're looking for but we're being safe, that's actually doing more harm than good because we're not actually preparing them for the things that they're going to go out there and do. On the other hand, if we do things that are too risky, so we have them do something that they're just clearly not ready for, we're having them do [00:39:00] single leg hopping and landing the first week post op that's probably a little too risky. So to me it's all about taking calculated and measured risks and figuring out what is an okay risk for the athlete to what they feel like is an okay risk. Do they feel comfortable with it? And then what in our objective data, what in our experience, what in the research tells us is an okay risk to take. Doug: Yeah. You go over a lot of case studies in your course and we don't have time to touch on all of them and we could do a whole episode on each of these scenarios, but I want to give people kind of an idea because you do a great job of kind of assessing what questions do we need to ask in each of these scenarios? You don't say here's the answer because there's so many contextual variables that that answer depends on and you give very simple scenarios because you'd have to ask, well, what about this? What about this? To really get to what's the right answer, [00:40:00] but I want to kind of go over some of them just so people can hear your thought process. And again, I encourage them to watch the course because you go into a lot more depth and this is really timely as a scenario. How do we, from an ethical standpoint or what questions do we ask to determine whether physical therapy, outpatient sports physical therapy should be considered essential in light of what's going on with COVID. I think that's a good place to start and you get into that in the course. Nicole: Yeah. So I created the course over a year ago, but I kind of revamped it, and recorded it in March. So just when everything was kind of like shelter at home. So it was, pretty, I thought we would be done with it by now, but hey.  So that was in the time where there was kind of a lot going around on social media of why are you still seeing patients in your clinic? You shouldn't be doing that or people saying how can you close your business down you need to make money? And so [00:41:00] being a business owner and a clinician, I was like, I see both sides. I see the needs, hey, I need to pay my bills. I need to buy groceries and eat and contribute to my family. So I need to make money to live and that's okay. That's fine. That's essential. I also, like I said, the gym that I was utilizing closed, which it should, because I didn't really feel comfortable going into a gym anyway. I thought that was risk I wasn't willing to take for my health and my client's health. So luckily with my business model, I'm able to be flexible and adaptable and see people in their homes, take extra precautions. But I think that there's no one, there's very rarely one answer for every single person. There's never one thing that applies to everyone in a given scenario and I think that just kind of the threads [00:42:00] I was seeing on social media, how can you be open at a time like this? Doug: I saw that too and the majority of the people that said that were in academic positions where they were getting paid to teach virtual classes. So it's easy to be like, to be righteous when you're getting a paycheck. Nicole: Yeah. Doug: Not saying that was the only people that were saying that, but I think it was a big proportion of it. Nicole: Yeah. And I also see the side of hey, does every visit count as essential? Is that ankle sprained patient really an essential thing for you to be seeing? Is it so essential that you're willing to risk your health or the health of the people who come into your clinic? So I think that there's probably always a middle ground somewhere in the middle of that works for most people. Again, in the course, I said at the beginning of the course and you've mentioned it a couple of times, is that I try not to give any answers. I purposely tried not to give any answers in the course. [00:43:00] I just wanted to keep asking more questions and the way I do that is I kind of, this might make me sound crazy, but I always think of things with parallel universes. So, do you know those choose your own adventure books, the goosebumps series, when I was a kid was like pick your ending. If you can do 10 push-ups, go to page 37. I kind of always think of my decision like that. Like, okay. I can choose this, this will most likely leave me here, which will most likely cause this. If I choose this, this is the most likely outcome and I kind of try to look at all those alternate endings and decide on which one would be the best ending for me in that decision, and then choose that path. That doesn't mean that the other ones were wrong. They just weren't the one that led to the outcome that I thought was best suited for that scenario. So that's kind of little peek into how my brain works with these complex topics. But yeah I think that there's never one [00:44:00] solution with should clinics be open? I do think that probably there are times where it is essential for us to see people. My dad had had a knee replacement surgery in December, right before all this. I think there were times that he needed to be seeing someone. I think that there were also a lot of clinics still seeing 15-year-olds with ankle sprains that didn't necessarily need to be seen. Doug: Yeah. And it's tricky because there's kind of a bottom up and a top down way of looking at it. Even if the government said, look we'll let you guys decide what's going to be essential, for example, in New York City right now they allow outdoor seating. If tomorrow they wave the magic wand and said, you can eat indoors. I don't even think I would, even if I was legally allowed to and I think a lot of times the patients kind of self regulate. So there's an element like who determines what's essential? Is it a top down or a bottom up? And then beyond that, there's so many individual behaviors that you have to account for because if you see one patient for something [00:45:00] that you might deem essential, or if that patient is riding the subway and going to parties, that's different than if the patient is wearing a mask and living like a monk the rest of the time. So again, you do a really good job of kind of talking about like all the variables that can influence it, which is why you don't provide an answer. Another scenario that I thought was interesting was you talk about you have an athlete who based on kind of your objective and subjective analysis. You think that athlete's ready to return to play the athlete doesn't feel ready psychologically and then there's pressure from the coach and the GM, like hey, why isn't this person ready to play? And there's also, you have a selfish interest because the longer that person takes to get in the field, it kind of reflects poorly on you, like you're not doing your job. So how do you handle that? Because you feel like you've done your job, but the athlete doesn't feel psychologically ready and you'll hold this external pressure kind of what questions do you ask to navigate that? Nicole: Yeah. And that's something that's important because, well, first of all, I will say a little caveat to that is that [00:46:00] usually most of the time, of course, there's always outliers, most of the time though, if an athlete is physically ready, then psychologically, they feel ready too, they usually go hand in hand, but there is the very famous example of Derrick Rose, who by all accounts was physically prepared, enough time had passed, but he didn't feel prepared to step onto the court and that's really important. That's what as a clinician, we have to be really, we have to be curious and we have to be comfortable with that discomfort and the unknown and be able to say, I know that he's ready physically. I don't think him stepping on the court tomorrow, I don't think he's at an increased risk. So what is it that is making him feel like he's not, and then, like I said, just be curious and explore that. Why is it that he doesn't feel psychologically ready? Are you missing something physical? Doug: That's part of our [00:47:00] responsibility actually. Nicole: Yeah, it really is. If they don't feel, is it something that I'm missing from a physical perspective? Did I test this in a valid and reliable way? Was I on track with his progress throughout the rehab program? Or is this something that doesn't have anything to do with the physical side and I should have maybe refered him to a sports psychologist at this point. But I think what always rings true, is that without communication, this just ends up being a lingering problem and I think that's kind of like any of the examples I've given in the course, is communication is always going to be key. If I'm always communicating in an effective way with the athlete, develop a relationship with them and the coaching staff, the performance staff, the other medical rehab staff, if we're all staying open and [00:48:00] communicating effectively, then there shouldn't be surprises like that. I should be able to say to the head coach or to the performance coach, or any of the assistant coaches, hey, this is where we're at with the rehab and he's doing great. I'm a little concerned though about this and I think that if we take; and I know this is hard to do because the team is who's paying you and it's hard to get into pro sport and it's a job that doesn't have good job security, people get fired all the time and high performance. So I realized, I recognize that this is difficult to do, but I think that this is what makes people truly great at their jobs, is being a good people person and being able to effectively communicate and say, I'm a little concerned about this. I don't know why he doesn't feel ready. But it's important that we validate how he feels about it and explore why. I'll explore why from a physical perspective, is there a chance that we can refer to a sports psychologist [00:49:00] to get their perspective and I don't think that that reflects poorly on a clinician that I don't have an answer right now, but this is important and we need to explore it and I'm going to do my best on my end. Here's how the team can help on this end. I think that that reflects well on you, that you're willing to explore the unknown and willing to work with others on a challenging situation. Doug: Yeah, it's so interesting when you brought up the sports psychologist, because I've had patients where I felt like that was kind of the missing link, but even then from an ethical or an emotional intelligence standpoint, how do you raise that subject with an athlete? Because as soon as you do, there's a stigma associated with going to see a psychologist that you have to have to tread just so delicately to bring that up. But I think what's cool about that scenario is, it's one thing to be able to have the quad strength, pass some hop tests, do high velocity runs in your rehab. There's nothing that we can do [00:50:00] in an artificial environment to stimulate the stress of playing in front of 20,000 people, that emotional stress and then if it's like a really good, like the lead athlete where the entire franchise is depending on that person to come back and save them so to speak, you could see why people who maybe are physically ready, wouldn't feel emotionally ready to do it. You talk about how we can't judge, we have to validate it. We have to look deeper because maybe it's something that we missed and it's not just about the physical stuff. I think that the physical often kind of marries with the psychological, but it doesn't always, we've got to be prepared for those scenarios. Another scenario that I liked that you brought up because with a lot of this stuff, it comes down to like, for example, in this scenario, I'm going to talk about confidentiality, which we value part of the code of ethics versus privacy and safety. Sometimes these things are not complimentary, they can be at odds. The scenario [00:51:00] for this particular instance is, you brought up the high school football player. He comes to outpatient physical therapy for a concussion evaluation and because the athlete is a minor, the parents don't want you to disclose to the head coach or the athletic trainer that you may have found some concussion related symptoms because they want the athlete to play in the game regardless. So it comes down to like, well, the athlete is a minor, the athlete in the eyes of the law doesn't have agency to determine whether he or she shouldn't play or not. You want to value confidentiality because this is your patient, but at the same time, the athlete could be a danger if he goes into the field. So how do you navigate that scenario where you have parents, you've got confidentiality issues, privacy issues and you've got a minor where maybe the minor, if the parents weren't in the room would be telling you, look, I don't want to play, but the athlete's afraid to say it in front of the parents. Nicole: That happens a [00:52:00] lot actually. Doug: Yeah. I know. It's a lot of stuff. What questions do we ask, how do we like attack this problem? Nicole: Yeah. So that one is, I think the one underlying principle with that one is if you think the athlete is truly at risk of doing harm to themselves, you have to let the parents know that. There is a time and a place to employ scare tactics and this is one of those times. I have no problem saying this in front of the athletes sometimes, depending on how I think they'll take the information, but sometimes I'll say it to just the parents. Sometimes parents and athletes, I say this can affect their long-term health. This can affect their daily functioning. This can cause long-term brain damage. This can have early onset dementia and Alzheimer's and do you want to, when you're 25 start having these crazy mood swings and I'll bring up some of the famous examples from the NFL, former NFL players who've [00:53:00] gone on and committed suicide. Do you want these things because this is what you're setting yourself up for by making decisions like this and I think that there is a time and a place, like I said, for these scare tactics and this is one of those times. If you still are getting nowhere with the athlete; now this scenario specifically was somebody working in an outpatient clinic who's not affiliated with the high school. So if I was affiliated with the high school, it's different because then I can easily say to the head coach, because we're all working together for the case of this athlete. But if you're an outside member, and you don't know the head coach, you don't know the athletic trainer of this school and they've purposely gone to you to be outside of the school system. That's what makes it a little different. So if they explicitly say we want to get him evaluated, but we don't want you to tell his coach because we want to keep this private. You have to respect that but if there's anything that you think [00:54:00] he's inherently at risk for, or at a higher risk than you are willing to take, then do you call the head coach? Do you call this school? Do you just tell the parents, this is what he's at risk for and then let them make their day decision? I think that again, in these parallel universes and all these alternate endings, one path you can take is call the school and then what are the risks rewards of that? Next would be, do nothing, what are the risks rewards of that? Another path you could take is scare tactics with the parents. What are the risks rewards of that? And another one is you think that the child doesn't want to play, the athlete doesn't want to play in the parents are maybe forcing them, is that something where child services needs to be involved? So maybe that's an extreme scenario that maybe is an alternate path that you take as well. So all of these alternate journeys you can take, which [00:55:00] potential ending are you most comfortable with? And that's kind of what you have to ask yourself. Doug: Yeah, it's very subjective too, it's hard to say this is the best one. Then the last scenario, and this is mind of more systemic, you and I both don't have to deal with in network insurance, which will hopefully, it'll reduce our blood pressure and give us a couple more years on life. But one of the things that a lot of people that do deal with insurance are bothered by is this idea that I just had somebody tore an ACL and only got authorized 10 visits or 15 visits. But at the same time, an insurance company, they're a goal, it's a business they're trying to make money. So I kind of see it from both standpoints because if an insurance company said, okay, we're going to give you unlimited visits. We know most PT clinics would milk the crap out of that and meet people every single day and it is the burden on the insurance company to allow somebody to be seen every single day for the entire year. But at the same time the other extreme is they're authorized 10 visits for an ACL [00:56:00] that seems kind of low. Even in my career, I've never really, I've heard fellow therapists and colonies kind of complain about insurance companies, but no one talks about, if we're going to complain, what would you reasonably think from an ethical standpoint an insurance company should be willing to authorize in terms of number of visits? So maybe we don't come up with an exact number you and I, but how do we even go about from an ethical standpoint answering that question because if you take either extreme possession, you can see PTs taking advantage of the insurance company. Right now it's kind of the other way around, but what is an ethical kind of reasonable middle ground when it comes to that? Nicole: Well, I'd say there are two kind of topics that kind of spring off of this. Firstly, to just directly answer your question, I would say for a youth athlete, they're not going back to sport before nine to twelve months. So if we set, let's say 10 months, just to be somewhere in the middle. So 10 months and [00:57:00] then to be able to effectively strength train, do the proper conditioning, everything that they need to appropriately get them to where they need to be at the end of those 10 months, I would say probably on average, three times a week, there needs to be training. Maybe in some cases two, if they're doing something on their own, in some cases four if they're really far behind or whatever other reasons. So we'll say three, so three times a week for 10 months. That's how many, if we're just to give a straight up answer of ethically how many visits should somebody be seen for, for that, that's what it would be. Doug: That's, if my math is correct, a 120 visits? Nicole: Yeah. When I used to work in insurance, not an insurance, when I used to work in practices that accepted insurance, blue cross, blue shield, for example, would do like the initial 60 and then they would allow another 60. So that actually worked out really well. So now of course there needs to be some [00:58:00] kind of, and this is where I think insurance, the whole system falls flat is that there's always contextual factors. Somebody has a,Cyclops lesion and needs another surgery, somebody gets an infection, somebody is not psychologically ready and then they need an extra month. Whatever their timing of their season is it'd be better if they had an extra two months. So of course there's always gonna be contextual things that an insurance company, the system that we have in America is not set up to handle. But I think that this whole thing brings up a more profound issue that we have and actually the person who lays out this argument best is Eric Mira on his website, the sciencept.com, he has a blog about this. Where we really have to decide, are we a medically necessary profession or are we as service profession? And that's what makes the difference with insurance. Now for me and for you, working outside of that model, [00:59:00] if I do something that's, if I'm sitting down and educating the person for an hour, that's valuable, that's worth the money of the session, is an insurance company going to pay that? Probably not. So I think that we just have this deeper profound issue of are we medically necessary? And if we're going to say that we are, then we have to prove that what we do is effective. We have to prove that the modalities we use, that the interventions that we utilize, that they are effective in getting the outcome we want, and having a successful long-term outcome. I think that a lot of times in our profession, we do things and utilize things that make somebody feel good but aren't necessarily medically necessary and that's where we have a big problem, because if we're going to [01:00:00] continue to do that, why should the insurance companies pay for that? Because then I can say, and I'm not going to knock any specific modality that's not what I try to do. It's not what I'm here for, but let's say they are, I always hear the argument of, well, maybe it doesn't do anything more than placebo. And I know that maybe I know that it's placebo, but my patients really like it and they feel really good afterwards. Well then where is the line? Because I can easily say, okay, every time I go get a facial and massage, I feel phenomenal, I have no pain. Heck when I go get a haircut, I feel great. That's the best that I feel all month, all six months, I haven't had a haircut in a long time. Doug: You could open up a bar and charge health insurance for that. Nicole: Exactly. If that's the standard we're going on is, well, it makes my patients feel better, that's not medically necessary all the time and we can easily then push the [01:01:00] line either way. So I get insurance companies not paying for things like that. I get insurance companies saying I'm not going to cover this intervention modality, whatever, because it's not medically necessary and we haven't proven that it is. So I think that's the deeper issue, but yeah, just to be precise on the actual question you asked, we could say [Inaudible1:03:45]. Doug: Yeah, that's super helpful because it's very hard to be precise on it. I'm more interested in like your thought process. I mean, one thing that working in a cash base or at a network model where there's higher deductible plans is, I know that I can't really rely on that person coming in like three times a week. I'm not talking about like a post op, but for something that's a little bit more benign. And so, because ultimately healthcare costs somebody money. You might not see it if you're using your insurance, but it's costing somebody money, whether it's like collectively or individually, it's coming from somewhere. Because [01:02:00] if you're getting your health insurance from your employer, you're actually making less of a salary because of your health insurance. You can make a case if you put that money in the stock market, you'd be better off having buying your own health insurance if there was more competition and price transparency, that's a whole other tangent. But having to kind of be really cognizant of it's not cheap to go to an out of network PT for even one session. How can I maximize the value of that session? And I even worked with people who were postop, like ACL, where let's say they're like four months along, they've got their kind of range of motion and their MMT, but they're not like from a performance standpoint where they want to be and they're like, look, I can't really see you more than one or two times a month. It's forced me to figure out like, all right, well, under these constraints, can I still help this person? And sometimes like necessity is the mother of innovation. I think that there are ways to provide value at low costs with like we have like a YouTube channel, we have Excel spreadsheets with all the videos embedded into our programs. And so like, I can, it's not ideal [01:03:00] but I think I can see somebody one or two times a month and do that from like four to ten months post-op and do a pretty decent job. Again, not as well as I could if I saw them three days a week, but there are ways to do it and I think that with COVID, whether it's been like an education or in medicine, it's kind of forcing people to adapt a little bit more and not just rely on kind of being on this insurance based model and not being able to value people's time and money and I think that ultimately insurance, and there are reasons to take insurance because in our model we're kind of exclusive, there's certain people that we can't treat because the cost appears too high, even though we can make a case in the long-term you'll save money, but it's kind of a deterrent to say wow, I've got to pay this for one session. When in reality they might pay more if they went to somebody in network, it would just be over the course of a few weeks. But with that insurance system, it almost like homogenizes care because everyone's getting the exact same [01:04:00] reimbursement, they have the same business model. I think that like, as much as we want to stick together as a profession because other people are throwing stones at us. I think competing is going to make us better too and not relying on everybody getting compensated at the same way, but because the system is so homogenized nobody really has any incentive to what if we only had 10 sessions? What would we do? I think having that those constraints and those pressures could make the system better, but a lot of people don't really want that because they're comfortable. So the point of this whole spiel is that it's complex because we like to vilify the insurance companies and I think in certain cases they are the villain, but medical people are also responsible for the system lobbies and all these different things. So, it's really, really tricky and again, we don't have the answers, but we do a great job in your course of raising a lot of these questions and it's just really thought provoking. So, it's a great resource. Any kind of parting thoughts. I know you've [01:05:00] been really generous with your time before we kind of ask you about where we people can learn more about you? Nicole: No, I just say kind of like the running theme of the course and just kind of have our discussion. Be comfortable with asking yourself questions and always being curious and I always think that coming up with more questions is sometimes more valuable than coming up with answers because I don't think that we always can have an answer for everything and being comfortable with getting stuck in an issue and thinking about it, thinking about alternative pathways to solving that issue I think is often much more valuable. Doug: Yeah. Then where can people learn more about your course or resources and the kind of work that you do online? Nicole: Yeah. So I have a website it's nicolesurphysio.com and from there you can kind of find everything I do. I have a blog, I have Instagram andsocial media channels, some YouTube videos and then [01:06:00] I have some eBooks as well on my website. One of them is free. It's just kind of my underlying principles of rehab and performance training, kind of what I go into each case thinking about, and then, yeah my courses, I have the ethical return to support decision making course you can get to on my website. You can also get to it through Eric Ramirez website, thesciencept.com. It's on his website as well and I recommend his blog too and then my other of course is managing the uninjured soccer player and it's all about the injuries that are coming in soccer players, how to treat them, how to get them back to performance levels of soccer and how to potentially reduce their risk of recurrence and primary intervention as well. So, I was teaching that one in person, obviously I'm not right now, but I am going to be putting it online soon. I'm just kind of updating a couple of things in it. The problem with the science based field is it always [01:07:00] updates, so you can always update the work. But yeah, that's about it. Doug: Cool. Yeah. Thanks again for your time and we'll post all those links in the notes, and again, I encourage people to check out all those resources. So thank you again and enjoy the rest of your day. Nicole: Thanks so much. Doug: Alright. Thank you.