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June 15, 2022

Title: Fitting an Arthritis Appropriate Evidence-Based Intervention into Health Professional Education

Presenter: Julia Chevan, PT, DPT, PhD, MPH

Professor and Chair, Department of Physical Therapy, Springfield College

INTRODUCTION

(Katie Huffman): Hello, and welcome to the Osteoarthritis Action Alliance lunch and learn webinar for June 15, 2022.

Our presenter today is Julia Chevan. Dr Chevan is a professor of physical therapy and Chair of the Department of physical therapy at Springfield College school of health sciences. Dr Chevan has been instrumental in the development of a small clinic base in the program that offers community-based programs while giving students real time experiences with adults living with chronic conditions. She is also an active investigator publishing in the area of health services research. Dr Chevan is currently in Nepal on a Fulbright specialist award and because we were unsure of what her Internet connection would be like, Dr Chevan graciously prerecorded this presentation before she left the United States. It does look like she was able to join us today for the question and answer at the end of the recording, so we will look forward to hearing from her live in a little while.

Dr Chevan’s talk today is titled: Fitting Arthritis-Appropriate Evidence-Based Intervention into Health Professional Education.

PRESENTATION:

(Dr. Julia Chevan) Hi, good afternoon, as you were just told I’m Dr Julia Chevan and I just want to extend a thanks for the invitation to speak with you today. The title of my conversation with you is going to be called Fitting an Arthritis-Appropriate Evidence-Based Intervention into health professional education and really, what I want to do is share a story about how we managed to incorporate an AAEBI (Arthritis-Appropriate Evidence-Based Intervention) into our program and how some of the difficulties, some of the things we learned about it, and the big benefits that we’ve seen to our students and to our participants and how we’re managing to sustain this over the long term.

In advance of talking about this, I have to acknowledge that the way we got into this project was through a grant that was provided to us through the National Association of Chronic Disease Directors but was actually part of funding that they get from the CDC for work toward the Osteoarthritis Initiatives.

So let me set the stage and tell you a little bit about where I am employed. I’m faculty and actually I’m Program Director and Chair of the physical therapy program at Springfield college. We’re a small program and a small college in western Massachusetts, and our program is unusual in that although it’s a graduate program it’s by design, a contextual program that starts with an undergraduate degree that students complete in three years and ends with a graduate doctorate in physical therapy that students complete in the next three years, so they’re with us for a total of six years…three years of undergraduate coursework toward a bachelor of science and health science, and three years of graduate course work toward a doctor of physical therapy. Now, what makes our program unusual is that we actually have requirements in both the undergraduate coursework and the graduate coursework for students, while they’re taking their courses to engage in some types of, for lack of a better term, clinical activities or service-based interaction is what I call it here. The students in the undergraduate part of the program in their third year take a course on what’s called ‘profession’, the profession of physical therapy, where they put together a portfolio and reaffirm their choice of coming into graduate studies. It’s almost an equivalent of an application, except that we don’t require them to reapply.

One component of this affirmation is doing some service-based interactions with adults and in different times we’ve had them volunteer to be mobility aids at a hospital. They’ve done other kinds of interactions and, in this case, what I’m going to talk about is how they engaged with our program’s efforts on arthritis-appropriate evidence-based Programs. The DPT students, the graduate students in the second/third three years of the program also have clinical requirements embedded in the program, and they engage in something called integrated clinical experiences, which is a once-a-week activity requiring them to work in different settings with different ages across the lifespan and different conditions that are tied to their current clinical courses. So, it’s an opportunity each week to apply what they’ve learned in their courses. And, of course, the second part of setting the stage is what I had already mentioned, which was that we had received what was called a Walk with Ease Hub Grant from the National Association of Chronic Disease Directors, and this was a grant that we received to disseminate the Walk with Ease program across the State of Massachusetts, and as part of that grant, we wrote a goal to develop a process to incorporate Walk with Ease into a rehabilitation professions curriculum, so the concept was not just incorporated into the DPT program which we were a part of, but to actually spread that into our occupational therapy program and into some of the other programs that are tied to rehabilitation like therapeutic recreation and possibly even our physician assistants Program.

But we needed to start somewhere, and our starting point was what we knew and what we understood, and that was our physical therapy Program.

So, we came at this thinking that we really had a nice set of synergies and stakeholder needs our students needed to have some types of experiences and clinical experiences and interactions with people across the lifespan. And they needed different levels of interactions depending on what year they were. So, the undergraduate students needed one level of interactions, while students in the DPT program-either in year one or year two-needed higher levels of interactions.

We had the Walk with Ease Hub grant, and a stakeholder in the NACDD and the CDC really were interested in seeing how we could disseminate Walk with Ease as an arthritis appropriate intervention across the State of Massachusetts and what we had intended always was to use a variety of referral sources for the Walk with Ease Program. And those sources were focused on engaging clinics-physical therapy, occupational therapy, and medical clinics-in referring participants to the Walk with Ease program. So, the rehab clinics in the Community organizations, where our referral source and locally, they were yet another stakeholder and their final stakeholder where the communities of adults living with OA who needed physical activity.

Now what’s not on this synergy and stakeholder needs slide is the environment, and we got our grant in the fall of 2020 late fall 2020, and so we went into implementation in 2020 and the beginning of…sorry, in 2019, and everybody remembers about spring of 2020 was, so as we were implementing, we also went into shut down. And so, part of this synergy and stakeholder needs was that we had to figure out how to manage all of this during COVID. Our original intent was to incorporate it into the curriculum and have students going out and doing group activities for Walk with Ease, and we had to modify that and figure out how we could manage this during COVID. And it ended up that we met some additional needs of these communities of adults with osteoarthritis because many older adults who were living alone or in isolation had some need to engage with a human being, and it turns out, you’ll see that we met some of that need as well. So our first stage and trying to understand how to implement this in the program was to actually look at two things one was the actual curriculum, we had what types of courses, what types of content, and what types of activities we’re going to match to the delivery of an AAEBI (in this case Walk with Ease),and we identified content related to communication skills teaching students about concepts of population health, since what we’re talking about is the population of people living with osteoarthritis and engaging students and understanding what that means and how to manage the health of a population. We looked at content on motivational interviewing since we’re delivering a behavioral change program and then theories of behavior change, we’re all the types of content that we thought tied very well to the curriculum.

After we determined which course content and which activities were relevant, we actually went into each of our courses, where we thought this content existed and looked for objectives that could be met through developing a student delivered Walk with Ease program. So, it was a lot of curricular analysis it actually involved quite a bit of faculty. We have some faculty who are more cognizant of what happens in the undergraduate component of the curriculum and other faculty who were, primarily most of our faculty, who were primarily in the graduate part of the curriculum, and a particular set of faculties whose focus is on clinical education.

The second part of our analysis was to really look very carefully at the Walk with Ease program itself. As I said, our original intent had been delivered through the group program methodology. The downside to the group program methodology is that to do that every individual who’s delivering the program would have to be go through the certification process. Now all of our faculty went through the certification process and we’re ready to do some level of delivery and actually engage other clinicians in becoming certified. But the group program became untenable with COVID, and so we focused in on what’s called the self-directed program. The self-directed program for Walk with Ease is completed over a six-week period of time. Individuals in the program get the Walk with Ease guidebook which is published by the arthritis foundation. And they actually developed a self-directed enhanced program that had even more resources during COVID, so we were able to use that self-directed program context and some of the resources from the self-directed enhanced program side by side with what we wanted to do in our curriculum to come up with a full on program from this analysis that we were able to use with our students doing the delivery.

So, this is, I said there were a lot of faculties involved, this is actually our faculty team that was involved in developing our delivery of this content. I’m the person second to the left, I’m sort of the head of the grant. But the person to the far left, Dr. Pappas, was instrumental in guiding us on how we were going to implement it for the undergraduate part of our component. She is the program director for the undergraduate pre-physical therapy program. The two people on the far right are both our clinical education directors, and they were integral for the consideration of where to put curriculum analysis and objectives analysis for the graduate part of the Program. The person in the Center is really key to this entire team because another piece of our puzzle is that we actually have on the campus of physical therapy a community mobility clinic, and Dr Kaufman in the Center is the director of our community mobility clinic. This is a clinic that provides Community health, community health programming and it was the clinic that incorporated Walk with Ease as part of our community health programming. Through that clinic faculty provide services and, in some instances, student employees provide services.

But what we were trying to do was target all students to provide an evidence-based service through the clinic tied to the curriculum, so there are these multiple layers of pulling this together from the Department to the two programs, undergraduate and graduate and back to the physical therapy and Community mobility clinic. Now, part of all of this also means that we had a pretty robust infrastructure ready to take this on and a faculty who are all willing to do the work, because it really entailed quite a bit of work. And what the work was was developing what we called a student coaching manual, so we decided that we were going to have participants engage in the self-directed Walk with Ease program, that they would be coached by students, and so the first step was to write a coaching manual for the students. The coaching manual incorporated weekly scripts so that students knew week by week what they were going to be saying or guided scripts I would say is a better way to say it, saying with their participants and it provided a context of roles for the student coaches, so instead of a one-to-one coaching model. To me, we developed a team coaching model, and each team had a senior DPT student, so that would be someone who is a second year DPT student who had at least one first year DPT student and then most teams also had an undergraduate student who was involved in the in the coaching activity.

The teams, as I said, had these scripts, they had guidance in terms of understanding what was happening for the self-directed program for each of the participants. And they actually had a copy of the arthritis foundation book that they could refer to as they were working week by week with their participants. In addition to the scripts, we developed curricular content on the five areas that we analyze would fit well with Evidence based interventions in those areas. Again, we’re in the premises of health coaching and so we had students reading articles about health coaching and physical therapy, and we were doing this direction to physical therapy and gaining a better understanding of what health coaching is, looking at randomized clinical trials in which health coaching was used in the outcomes of those interventions.

We had them read all of the evidence that supports the Walk with Ease program from the initial evidence of its development to later evidence that looked at it as an effective and efficacious program as a self-directed model. We had them read and watch some videos on motivational interviewing and they didn’t do this all at once, each of these pieces of curricular content get introduced to the students over the six weeks that they’re doing the coaching. We had them read some articles and do some work on the transtheoretical model of behavior change and then, finally, we had them read some articles and engage in some work on communication skills.

So that was our curricular content and the way that we delivered this curricular content was through our learning management system which I’ve abbreviated here as LMS. In the LMS, each week that the students were engaged with coaching, they were required to write guided reflections and respond to discussion questions about the curriculum and about how the curriculum applied to the participant they were working with. Those discussion questions were tailored to the year of the student, so pre physical therapy students were asked different questions than first year physical therapy students and first year physical therapy students were asked different questions then second year physical therapy students, because the second-year students were really the so-called captain of the coaching team.

Overall, of the coaching teams, there were faculty supervisors. The faculty supervisors by way of an agreement that we had with the arthritis foundation, were the folks who were certified and Walk with Ease and who were responsible for ensuring that we had program fidelity and checking in on the students and, most importantly, responding to students’ questions.

So what we found over the course of the Semester was that the participants responded incredibly positively to having students doing the coaching and working with them, and they felt so comfortable with the students over time that they sometimes started to ask them questions that really weren’t within the realm of the Walk with Ease program or even within the realm of what a student was able to respond to, and so the students would go to their faculty guidance or their instructors actually for how to answer those issues or questions that came up.

I know when we’ve talked about this model before people have always asked us was it mandatory for every student to be involved in student coaching, and it was mandatory because it was embedded into the curriculum and all of these courses are required courses. So, for the undergraduate students in this required pre physical therapy course and for the graduate students, the DPT students, it is embedded in their integrated clinical experiences in each semester so fall and spring of year one and year two of the program it is preparatory work for these students before they go out on to their terminal internships where they’re full time in the clinic so they do it repeatedly and each time they do it, what happens is the curricular content gets modified a bit. They might read an additional article or respond to different prompts in the learning management system. Sometimes the hardest part actually has been recruiting participants. Now, in the original grant, our participant recruitment catchment was targeted to physical therapy clinics and we still work very closely with physical therapy clinics, to get participants for the program physical therapy clinics are really ideal for locations to find participants because it’s really, a typical discharge plan to ask a participant to engage in physical activity and what we provide is a structured physical activity program where the participants are, as I said, working with students in a coaching model. So, many of our participants are recruited from local physical therapy clinics, who will at discharge connect us with a prospective participant in the Program.

We also get participants from senior centers and Area Agencies on Aging and because we’ve actually been doing this program now through COVID and have developed systems for doing it that use phone coaching or videos zoom based coaching we’ve actually got folks who participate in our coaching model, who live hundreds of miles away, on the other side of Massachusetts.

During COVID the other way that we recruited participants was actually through the Massachusetts libraries, the Massachusetts libraries themselves had a health grant that that was issued to provide health type programs to their clients. And we connected up with, I think, in the end, about five or six libraries, who sent us participants. And the image you see here is from the Plymouth public library, they were our first library to engage really heavily with the Program and they got a group of their clients who signed up to do Walk with Ease. This was during COVID, and it made the book delivery, because we provided the guidebooks to all the participants through the grant for free, it made the book delivery really simple. We sent it to the entire library system from our college library out to the Plymouth public library on a bus and then all the participants were able to go and pick up their books in a coven free touch rezone right outside the library, so it made everything really simple. And the library provided some of the resources the participants needed to have, connections Wi-Fi and video connections back to our students for the coaching, so the libraries end up being really lovely partners in this whole program. But, as I said, for participant recruitment, we really had three major partners are two major partners, I would say the clinics and the senior centers. And the libraries were something that just we added on during the time of COVID because they really made sense.

So, as I said, we’ve been doing this, since really the start of COVID, we have now done this program for the fall and spring semester five times. So, we’ve run a six-week program five times, and our participants rave about the experience. A year ago, we were asked by a local retirement community to offer it to the three campuses they have, so we did it for them. We are surprised, repeatedly surprised at how once word gets out and people here that there are students who are willing to share with participants an opportunity to engage in physical activity, how quickly they jump at it, and these are just these are some comments from our evaluations from our participants. One said, “without their coaching and giving me confidence, I wouldn’t have been walking I would recommend this program to anyone.”

And, and another of our participants, and again this was during COVID, said, “this program motivated me to get out and walk when I didn’t really feel like doing so.” And all of these, again, are participants who are living with osteoarthritis, and who may not have otherwise been engaged in physical activity.

We also do a survey with our participants, and these are our survey results from three different cycles of the Walk with Ease program. It’s as simple satisfaction survey, and I think what is most noticeable is that the Blue is where people are saying they strongly agree, and the Green is somewhat agree so for the most part. At least 90% across the board, our participants are agreeing with statements like they’re ‘satisfied with the Program’. Their coaching sessions were interesting, and the coaches presented the information well or kept them interested.

The coaching program fulfilled their expectations and they’re confident that they’ll continue to walk, they’ll continue to exercise, or they’ll become more active or recommended to family and friends. What was most interesting to us was that, after our first two cycles of doing this program, we started to have participants who asked if they could come back and do it again because they enjoyed having the student coaches so much. And we not only surveyed and looked at our participants for their enjoyment, or how worthwhile they felt the outcomes of the program where. We’ve also done some pre and post work with our students in terms of assessing how well we we’ve done at giving them some of the curricular content and also hearing a bit about their experience, and in fact, just this past weekend, one of our undergraduate students wrote a really lovely reflection on why being an undergraduate student working with graduate students already in the program was so beneficial to her through the Walk with Ease Program.

But here are some of the student comments:

 “I think, being part of such a small group allowed me to grow my professionalism and It made me speak out and be confident and ask questions behind because I had the space to do so, where I was not nervous of making a mistake,” and that was from us first year DPT student. Another student said, “this semester was beneficial and providing further practice and application of motivational interviewing and reflective listening techniques. Being a Walk with Ease leader pushed me to be confident in my communication skills and allowed me to develop skills and communicating with individuals about their health and personal goals.” Now that second statement was from a second year DPT student who was just preparing for her terminal clinical experiences, which are full time internships. And you can imagine that reading that reflection really made us see the importance of putting this into the curriculum because otherwise students go out onto these clinical experiences only coming out of the classroom or only having these cross sectional or minute experiences in the clinic as opposed to this long term opportunity to engage with one person over six weeks of a program, and to lead a team in the coaching experience. So, for our students it’s been a really robust and worthwhile experience and figuring out how to make it a part of the curriculum has really added a lot to our Program. But I will say it wasn’t easy, and so we have, many times, reflected on the lessons we’ve learned and what we would tell other programs if they were interested in embedding this into their curriculum.

First of all, what we learned from the start, was that to embed it into the curriculum really has to be done in an intentional manner so that you’re sure you have curricular objectives that can be met by having a coaching program. It shouldn’t just be laid on the curriculum, or you shouldn’t write objectives to meet the needs of the AAEBI. We were really careful in finding objectives and finding courses, where it linked, and initially we had looked at some other courses that we thought might link, and those courses fell off the map, because the objectives were just not consistent, you know? We had instructors, who said, ‘Oh yeah I have some course objectives that are tied to communication and motivational interviewing’ and when we looked really closely, the delivery of the AAEBI through coaching wouldn’t have been a match to that course so you have to be really intentional and really careful in analyzing your curriculum.

The second lesson we’ve learned is that biggest cost of embedding the program is faculty time. And we’ve put a lot of time into this…that time is focused on organizing the program, recruiting participants, providing participants with what we call a session zero where we orient them to the Walk with Ease program and to being engaged with participants and what they can expect or not expect from their coaching team. So, lots and lots of faculty time. And then the faculty time supervising students, monitoring learning management system, assessing the reflections and the content that the students are writing in the learning management system, and responding to students is another one of those costs.

And then, our third thing that we discovered about time is you sometimes need additional time to reorganize the teams, because we did have participant attrition. Most all of our participants got permission from a family physician to participate in the Walk with Ease program or referred from physical therapy clinics. But even with that, we occasionally had a participant who needed to drop out because the activity was too difficult or because they became ill with any number of illnesses from COVID to the flu, and so, sometimes we had coaching teams who had to take a week off and then come back. We built it around a curriculum that gave them enough time to get the six weeks in and did not run out of time with their participants. But not every student team was starting or finishing at the same time, and that became tricky.

I would say a final lesson that we learned was that it’s really important to do technology checks with the participants, so if the student coaching teams are going to be using zoom or facetime or any other use of technology to connect with their participants, you have to make sure that everybody knows how to use the technology and how to engage through technology and that everybody has their calendars synced and matched and that they’re ready to go. I didn’t say it already, but what our students did was they had a first meeting with their participants that was arranged through the faculty and then subsequent meetings were an arranged and agreed upon calendar between each participant in each coaching team.

So, we are really excited to actually share this as an idea for any type of an educational program, and again, this could be a physical therapy program, we’ve already shared it with about three programs that have the same model underway, or a similar model underway at their home institution. But we definitely see that this particular type of coaching model could be used by any type of health or rehabilitation Program.

We have modified our coaching manual, and it’s now up to version three, and we offer it for free on our website. I’ve given the URL there, it’s on our Walk with Ease website, and if you click on join as a DPT program to join the hub, you can download a copy of our student manual right on the website and send us an email, if you have questions about it, or if you feel like there are sections of it that you want to modify you just have to ask permission and we can help you out with that. So, if you want to contact us or in the least download the manual, this is the place to download it. If you want to get started with figuring out how this might work in your curriculum and getting it to work in your curriculum requires, as I said a lot of effort, a lot of teamwork, and we are really happy to consult with anybody who is thinking about this part of our work, how can we bring into our home Program, the best way to do that is probably contact me if you have directed questions or if you’ve downloaded the coaching manual and you want to use it. And this is my email address and I’m really open to questions or to contacts or to figuring out how we can assist other programs in bringing Walk with Ease or other Arthritis-Appropriate Evidence-Based Interventions to your Program.

I’d like to say that earlier, I had shown the team, and I said that we have a community-based mobility clinic. We now offer not only Walk with Ease, but we are offering some falls-based programming to adults with osteoarthritis, so we do a TAI Chi Program. It doesn’t use the coaching model, we have a different model for offering that with student employees that comes out of our clinic and then we have some pro-bono elements of our clinic where we’re also doing something called SAIL which is an exercise program also for falls prevention and again, we have number of adults with osteoarthritis who are engaged in that program. What’s interesting about offering a multitude of programs is that we have some participants now in this semester’s Walk with Ease program who are doing Walk with Ease with the student coaching group and then SAIL on the side twice or three times a week through our community clinic exercise group we haven’t yet ventured into offering these programs live and in person.

Most of them are offered through zoom or through some other type of technological feed to people. But we’re excited in the upcoming year to getting some coaching teams, hopefully working one on one or one on three with groups of adults live and in person.

So again, if you’re thinking about incorporating this into your curriculum, or you have any questions, really, please do contact me, I am I am open to talking with people about how to do it and providing guidance in any of the resources that we can offer. Again, I want to thank the Osteoarthritis Action Alliance for inviting me to talk about this and to share our experience.

QUESTION AND ANSWER:

QUESTION: That was such a great presentation. I loved hearing about the program and really appreciated Dr Chevan’s willingness to share their hard work, you know, by being willing to share the manuals and their experiences with others who may want to replicate this program. So, we do have a few minutes for questions and answers with Dr Chevan, she is on the chat so if we have any questions for her, she’ll unmute and answer those.

And while we’re waiting for any questions to come in, Dr. Chevan I know that you alluded to this in the latter part of the presentation, about how much work it takes to put something like this together, and you know, the amount of coordination between faculty and then obviously the Community partners as well, but I’m curious to hear a little bit about kind of the early on discussions that you had with the other faculty and how you got by in knowing that this was going to be a lot of work for them.

ANSWER: Dr. Julia Chevan: Oh, that’s a great question. So we were in the process of developing that Community mobility clinic and part of what we knew we wanted to do through the clinic was to offer some evidence based programming that had a package and that we could deliver as opposed to the kind of therapy that you typically think of in a clinic where patient comes in and they get evaluated and we develop an individualized program. We wanted to do some population health-based programming, and so the buy in was there, because we had the idea for the clinic. We had been doing some programming, through it, but we did Walk with Ease was really our first evidence-based program that came out through the clinic.

And then, as I said on the video, since then we’ve added in TAI Chi and SAIL and at the moment, we’re actually looking at another program that we might bring in that’s going to focus on folks with Parkinson’s disease. So, my faculty liked it because a lot of the work is done for you already when you adapt and adopt an evidence-based program, it’s not that you’re creating the program it’s that you’re creating the curriculum around the Program. So that’s one way that we got buy-in the second way is that Doctor of Physical Therapy programs are required to do something called integrated clinical experiences and for us those clinical experiences with patients or participants happened during the Semester, and this so nicely met some of the objectives for our integrated clinical experiences. And our two faculty who focus only on clinical internships and clinical experiences were really excited to have something that’s based out of our home as opposed to reaching out to clinics, to get mentors in time. So, we were lucky, and it seems like the students get a lot out of it and that you know it’s kind of a finite amount of time and they really get to engage with participants and see them, you know, grow over the course of the Program. Yeah, it’s great and the other thing that we’re going to hopefully follow through with over time now is we’re going to start to do some surveys of our graduates, because what we’re interested in is: Do the graduates of our program when they go out to clinics not only provide direct one on one clinical care? And to start them thinking about could our clinic also offer this kind of a program, or should I make sure that I refer my patients who have osteoarthritis into an AAEBI somewhere, can I find out what those resources are in my community? So, we actually want to see if our students are more engaged in this kind of work after graduating because we had them in in the Program.

Students talk about the Walk with Ease program very often when they’re out in the clinic, we hear that from our clinical instructors, they ask, what is this Walk with Ease thing that you’re doing? So, we’re hopeful that you know the model extends itself. 

QUESTION: That’s great I’m so glad you mentioned that, when we were doing this presentation, a few months ago that comment you made was very exciting to me just thinking about sowing the seeds and having no idea of where these programs may embed in the future.

We have a couple of questions here with lots of comments from attendees about great presentation and great Program.

QUESTION: Do you think that health and wellness coaching students could be involved with the Walk with Ease program and a model, similar to the one you use with DPT students?

ANSWER: Dr. Julia Chevan: Oh definitely. You know, I think there is no limit to the training type program that the students could be in and do this kind of coaching health and wellness. Students are ideal because they already have some of the theoretical foundation or they’re studying the theoretical foundation that we’ve embedded into our student coaching manual, and the manual would have to be modified to pull out the physical therapy content but that’s easily done and it’s a really good experience. There is at least, I can think of one research article that is about actually health and wellness coaching students who are doing it. Those students are really ideal to do a coaching program. Again, you got to make sure you have the faculty oversight and the clarity for the students about what their limits are in terms of what they can do, we were really clear about that, with our DPT students. But, you know, I say go for it, whether it’s an OT program of PT program, health and wellness students, I could actually also see this happening through public health programs, there are all kinds of programs that could be doing this.

QUESTION: That’s great, and here’s another comment from Heather Murphy, love the sustainability focus by training students to take the Walk with Ease program with them in their professional work.

So, I don’t see any more questions, and I know it’s very late for Dr. Chevan where she is so we will let her go, but just thank you again, Dr Chevan for your presentation and for joining us today for a live question and answer and thank you to everyone in attendance for joining us today.

That does conclude our presentation. We just put a link in the chat to a survey that we’re doing about the lunch and learn program in general, trying to prepare for future programming…so if you have time to take the survey, it’s very brief, we would appreciate any ideas you have for us.

We do hope you’ll join in next month for our July 20^th lunch and learn featuring Bridget Graham, Vicky Duong and Belinda Lawford, who will present Developing an Effective Infographic for Policymakers, the Winning Submission from the OARSI/OAAA Infographic Competition.

Thank you everyone.