Pain Science and Sensibility
54 episodes - English - Latest episode: over 2 years ago - ★★★★★ - 27 ratingsJoin co-hosts Sandy Hilton and Cory Blickenstaff, physical therapists who are "in the trenches" practicing in unique settings on opposite sides of United States, as they discuss current research and topics of pain science. Listen in on occasional interviews of the prominent figures of pain science. Focus will be on making the information meaningful to practice in the clinic.
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Episodes
053 Is Therapeutic Alliance a Bust?
October 27, 2021 02:13 - 32 minutes - 30.9 MBSandy and Cory discuss a recent paper that did not find an effect of providing education with therapeutic alliance in a chronic low back pain population. Does that settle the question of whether establishing a therapeutic alliance is worthwhile, or is there more to it? Of course there's more to it. Listen in on the conversation and see if you agree with our take. Education With Therapeutic Alliance Did Not Improve Symptoms in Patients With Chronic Low Back Pain and Low Risk of Poor Prognos...
052 Beyond the BPS Model?
February 27, 2021 05:23 - 1 hour - 59.8 MBIn this episode, Sandy and Cory take a look at this popular publication from 2019 proposing an "Enactive Approach" to pain. There's a lot to cover in this paper as it takes us through a history of pain science up to the Biopsychosocial model at which point it proceeds to point out some flaws in the model. GASP! Take a listen as the discussion unfolds. An enactive approach to pain: beyond the biopsychosocial model. Peter Stilwell & Katherine Harman. Phenomenology and the Cognitive Science...
2020 PT Podcast Network Holiday Extravaganza
December 14, 2020 18:00 - 59 minutes - 54.7 MBThe gang is all here (except Greg) for another festive dump of holiday cheer! Happy Holidays everyone!!!
050 Pain Flare-Up
November 16, 2020 23:28 - 43 minutes - 41.2 MBPain flare-ups are one of the most frustrating things for patients and clinicians alike. Are they normal? Who gets them? Why is it important to know their prevalence? What are Sandy and Cory's thoughts on dealing with them? All this and more in episode 50! Prevalence, Severity, and Correlates of Pain Flares in Response to a Repeated Sit-to-Stand Activity: A Cross-sectional Study of 14 902 Patients With Knee and Hip Osteoarthritis in Primary Care. Søren T Skou, Dorte T Grønne, Ewa M Roos....
049 Contemplating Possibilities and the Impermanence of Pain
August 25, 2020 13:00 - 54 minutes - 51.5 MBWe are joined in this episode by Professor Lorimer Moseley AO for a casual chat about pain. Lorimer gave us his thoughts on recent and future clinical research and the translation of the evidence into the clinic. Is there an expiration date for recovery from persistent pain? How can we enhance learning the things that matter? Was it a mistake to think that we could/should explain pain? Does Sandy work pelvic health examples into this conversation? Music by Kevin MacLeod - incompetech.com:...
048 The SI Joint Narrative
June 27, 2020 19:16 - 57 minutes - 54.1 MBDo you use SI joint tests? What type of information do the tests give you? Should you be using them? These are just a few of the questions that arise in the discussion of this recent perspective paper. Join us for episode 48! Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area. Palsson TS, Gibson W, Darlow B, et al. Phys Ther. 2019;99(11):1511-1519. doi:10.1093/ptj/pzz108 Due to copyright laws, unless the article is open source we cannot legally post ...
047 Is It Safe For Women To Lift Heavy Things?
May 08, 2020 17:18 - 50 minutes - 47.4 MBIs it safe to exercise and lift heavy things for people with pelvic organ prolapse symptoms? Or put more bluntly, will lifting heavy weights make your lady bits fall out? Is lifting weight asking for trouble? That is the question that our guest this month is seeking to answer and Sandy and Cory sit down to ask some questions about her recently published cross sectional study that is a start to this research. There are some important implications of this and potentially some misconceptions t...
046 Is There an Advantage to Pain Free Rehab?
March 13, 2020 21:42 - 43 minutes - 60.7 MBThese questions arise very frequently in rehabilitation. Should it hurt? Is it OK if it hurts? Will I set myself back if it hurts? Will I get better if it doesn't hurt? In this episode we examine a pair of articles that examine these questions. One article is an RCT that covers pain free vs. painful exercise in an acutely injured population, while the other is a systematic review and meta analysis of the approach in chronic pain populations. Pain-Free Versus Pain-Threshold Rehabilitation F...
045 A Review of Surgery for Rotator Cuff Tears
January 27, 2020 21:00 - 39 minutes - 38.1 MBA recent Cochrane review looked at studies of people with rotator cuff tears comparing those who had surgery with those who did not. What do you think they found? Did surgery provide benefit? Is it OK to go without surgery in these cases? Sandy and Cory discuss these findings and provide their clinical commentary in this episode of Pain Science and Sensibility. Surgery for rotator cuff tears. Karjalainen TV, Jain NB, Heikkinen J, Johnston RV, Page CM, Buchbinder R. Cochrane Database Syst...
044 Cognitive Functional Therapy Vs. Group Therapy Plus Education
November 20, 2019 14:00 - 52 minutes - 49.1 MBThis episode covers a recent paper that compares a popular and trending approach, Cognitive Functional Therapy, against a group treatment and exercise intervention. The primary outcomes were pain and disability. The results may surprise you. Join Sandy and Cory as they discuss the findings, what to make of them, and the clinical impact. Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain: a multicentre randomised controlled...
043 An Interview with Dr Henrik Vaegter
October 09, 2019 13:55 - 48 minutes - 45.9 MBIn the last episode (42) a systematic review was discussed regarding the value of pre-operative measures in predicting pain post-operatively. In this episode, Dr. Henrik Vaegter, an author of that review joins us to discuss that research as well as several other fascinating topics regarding exercise and pain. In this interview we discuss topics of Exercise Induced Hypoalgesia, Conditioned Pain Modulation, and Temporal Summation of Pain, all of which are among the focus of Dr. Vaegter's rese...
042 Does Preop Pain Predict Postop Pain?
August 30, 2019 19:50 - 44 minutes - 42.5 MBIn this episode Sandy and Cory discuss a systematic review which investigated what pre operative pain tells us about a person’s propensity for post operative pain. Is it predictive? If so, would changing it matter? The discussion gets into these topics and more. Are preoperative experimental pain assessments correlated with clinical pain outcomes after surgery? A systematic review. Sangesland A, Støren C, Vaegter HB. Scand J Pain. 2017 Apr;15:44-52. doi: 10.1016/j.sjpain.2016.12.002. Epu...
041 Bedtimes and Pain: Can You Sleep It Off?
June 12, 2019 21:36 - 54 minutes - 51.7 MBThis study looked at pain score associations between people with "typical" and "atypical" bedtimes. Sandy and Cory discuss the topic of sleep and pain broadly as well. So, perk up and see if you can make through this episode without dozing off. Does bedtime matter among patients with chronic pain? A longitudinal comparison study. McHugh RK, Edwards R, Ross E, Jamison R. PAIN Reports. May/June 2019 - Volume 4 - Issue 3 - p e747. doi: 10.1097/PR9.0000000000000747. We also discussed this p...
040 Does Activity Counteract Sitting?
May 13, 2019 17:32 - 41 minutes - 39.8 MBIn this month's episode we are examining more of a general health question. But it is one that is very relevant to people in pain. Much has been made of "Sitting is the new smoking" with some indications that the negative effects of sitting may not be able to be undone with exercise and activity. This study looked at that concept in particular. Join us for Episode 40. Sitting Time, Physical Activity, and Risk of Mortality in Adults. Stamatakis E, Gale J, Bauman A, Ekelund U, Hamer M, Ding...
039 Pain Education in Low Back Pain
April 01, 2019 22:19 - 56 minutes - 52.8 MBThis paper, with results that many find very surprising, has started a bit of a buzz in the PT world. What do we make of the results? Can we trust the results? What does this mean in clinical practice? We were able to discuss these topics and more with the researchers themselves as Adrian Traeger and James McAuley were kind enough to share their time and help us navigate these new findings. Don't miss this episode! Effect of Intensive Patient Education vs Placebo Patient Education on Outc...
038 Living Well with Chronic Pain
February 09, 2019 04:27 - 48 minutes - 46.2 MBResearch on chronic pain tends to aim at identifying factors that are in deficit, or are the so called "risk factors" for those who develops chronic pain. In this episode, we discuss a paper that takes a different angle in looking at what factors do those people who are successfully living well with chronic pain share. The primary author is friend of the show, Bronnie Thompson, who has made guest appearances in previous episodes. Living well with chronic pain: a classical grounded theory. ...
2018 PT Podcast Network Holiday Extravaganza
December 11, 2018 18:35 - 51 minutes - 48.8 MBThat's right everyone! It's that time of year again! All the PT Podcast Network voices (except for Adam) have gathered together to bring you some podcast holiday cheer! This very special episode is brought to you by My PT Insurance. Head on over to their website at myptins.com/ptinquest to be entered into a drawing for a $250 Amazon gift card (contest ends February 28, 2019). While you are there listeners can get a $20 discount off their already low price for a professional liability polic...
037 Brain Representations of Expectancy Violation
November 14, 2018 20:43 - 49 minutes - 46.8 MBThis episode covers a recent meta analysis looking at differences in brain patterns when an expectancy violation, thought to be important in effectiveness of exposure based therapies (see episodes 12, 15, and 31), occurs passively versus actively. Active expectancy violation is thought to be more likely to bring about a change in behavior. This research looked to see if there was a difference that could be identified in activated brain areas between the 2 conditions. Learning about Expecta...
036 Mechanism Based Pain Care
September 28, 2018 21:48 - 53 minutes - 50.6 MBIn this episode, Sandy and Cory discuss a recent paper proposing a "Mechanism Based approach to physical therapy management of pain." This paper proposes 5 mechanisms to consider when managing people in pain and how some common PT interventions may impact these mechanisms. The discussion goes into some of the details of these proposals as well as some of the criticisms that have been generated with regards to the paper. A Mechanism-Based Approach to Physical Therapist Management of Pain. ...
035 The Smallest Worthwhile Effect of Physiotherapy
August 17, 2018 17:55 - 52 minutes - 49.9 MBHow much of an improvement would you need to see in order to feel that physiotherapy was going to be worthwhile for your low back, neck, or shoulder pain? This is the question that this study examines and that is discussed in this episode. Also Sandy considers opening a steak restaurant. The smallest worthwhile effect of primary care physiotherapy did not differ across musculoskeletal pain sites. Christiansen DH, de Vos Andersen NB, Poulsen PH, Ostelo RW. J Clin Epidemiol. 2018 May 28. p...
034 How Well Do We Remember Past Pains?
July 05, 2018 01:28 - 1 hour - 58.1 MBIn this episode the topic of pain memory recall is explored. How well do we remember our past pains? Are there differences in recall between populations? What might account for the differences when they occur? All of these topics covered in episode in which Sandy and Cory discuss a recent research article on the topic. Hippocampal morphology mediates biased memories of chronic pain. Berger SE, Vachon-Presseau É, Abdullah TB, Baria AT, Schnitzer TJ, Apkarian AV. Neuroimage. 2018 Feb 1;166...
033 Reconsidering the IASP Definition of Pain
May 22, 2018 21:32 - 56 minutes - 52.9 MBIn episode 33, Sandy and Cory are joined once again by Pain Specialist Physician, Milton Cohen. Dr. Cohen and his group have submitted a new clinical definition of pain. In the discussion, we unpack the new definition term by term and discuss issues that Dr. Cohen and his group have spelled out regarding the current and famous IASP definition. Does the current definition have important shortcomings? Do you feel that patients would agree that the current definition fits with the experience of...
032 Are There Ethical Concerns With Mindfulness Approaches?
March 22, 2018 21:31 - 50 minutes - 48 MBA recent paper looks at the philosophical underpinnings of the practice of mindfulness and raises some concerns regarding the ethics of its use. In this episode, these concerns are discussed as well as the larger implications of informed consent and respect for patient values. Forgetting ourselves: epistemic costs and ethical concerns in mindfulness exercises. Ratnayake S, Merry D. J Med Ethics. 2018 Mar 9. pii: medethics-2017-104201. doi: 10.1136/medethics-2017-104201. [Epub ahead of pr...
031 Expectancy Violation Update
February 10, 2018 22:50 - 1 hour - 58.5 MBWe return to exposure based therapy and an update of the topic covered in the popular episodes 12 and 15, expectancy violation. This time we discuss a clinical commentary paper reviewing the state of the evidence related to the claims of Craske et al. How have the claims held up? What is the state of the science on the topic? This and more in episode 31. Exposure therapy augmentation: A review and extension of techniques informed by an inhibitory learning approach. Weisman JS, Rodebaugh T...
Episode 30: I am a Placebo: An Interview With Dr. Nortin Hadler, MD
December 28, 2017 20:38 - 56 minutes - 53.5 MBOur guest in this episode is Dr. Nortin Hadler, a rheumatologist and professor of medicine at the University of North Carolina in Chapel Hill, who has spent decades right in the middle of several health care debates. Dr. Hadler, or as Sandy likes to call him "Quote Machine," spent an hour with us reflecting on a range of topics. What is medicalization and why is so important? What predicts poor health outcomes related to regional pain disorders most robustly? What is the difference between a...
029 Discussion of the book Meanings of Pain
November 25, 2017 22:15 - 59 minutes - 55.7 MBThis episode has Sandy and Cory discussing a recently released book, tilted Meanings of Pain. Can we measure pain? What is the impact when we try? How do the roles we assume impact the care we provide and how it is received? Listen in as our hosts consider these and other topics that have been raised by this very interesting and comprehensive book. Due to copyright laws, unless the article is open source we cannot legally post the PDF on the website for the world to download at will. That ...
028 Does Manual Therapy Suck?
October 28, 2017 16:58 - 40 minutes - 38.9 MBIn this episode of Pain Science and Sensibility, it’s another British Invasion! So, I guess that would make us the Ed Sullivan show? Special guest Adam Meakins, host of the NAF physio podcast, joins us for a discussion regarding his proclamation that “Manual Therapy Sucks.” His provocative stance has stirred a lot of attention and discussion. So, stepping away from our normal format of discussing a specific paper, in this episode we’re discussing the merit, or lack thereof, for manual therap...
027 Transverse Abdominals in Low Back Pain
September 19, 2017 17:53 - 55 minutes - 52.3 MBSandy and Cory discuss a popular topic in the treatment of low back pain; the role of the transverse abdominus. This paper examines the role in pregnancy related low back pain but the episode goes on to discuss the topic more broadly. Now suck in that naval and listen along! The transverse abdominal muscle is excessively active during active straight leg raising in pregnancy-related posterior pelvic girdle pain: an observational study. Mens JMA, Pool-Goudzwaard A. BMC Musculoskelet Disor...
026 Can We Predict Who's at Risk for Persistent Pain
August 18, 2017 16:25 - 54 minutes - 51.1 MBWhat is stratified care? Can we get the right patients to the right care at the right time? In this episode we look at a study examining some of the background required to answer these questions. Can we predict who is at risk for developing persistent pain? If we can then we might be better able to direct them to the right care. The findings may surprise you. The Value of Prognostic Screening for Patients With Low Back Pain in Secondary Care. Karran EL, Traeger AC, McAuley JH, Hillier SL,...
025 Comparing and Using Low Back Pain Clinical Guidelines
June 29, 2017 22:32 - 1 hour - 59.7 MBEpisode 25 has our hosts, and special guest Kelly Newman SPT discussing a recent review article comparing 3 of the major clinical guidelines for the treatment of low back pain. What is a clinical guideline? How are their recommendations established and why are there differences between them? What is "the burden of proof" and why is it relevant to this discussion? Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines. O'Conn...
024 Trigger Points, the "Third Space", and the Merit of Pain Theories with Dr. Milton Cohen
June 01, 2017 19:05 - 1 hour - 68.6 MBSpecial Guest Milton Cohen MD, Rheumatologist/Specialist Pain Physician, joins the show to discuss a variety of topics in this far ranging interview. Dr. Cohen and his research group has written extensively on topics ranging from critical appraisals of the biomedical and biopsychosocial framework to the nature of the therapeutic interaction. In the show we discuss these topics as well as the concept of the "Aporia" of pain. Additionally, his group's 2015 paper on the face validity of the tri...
023 Modeling Pain and Other Bayesian Topics
May 11, 2017 16:19 - 1 hour - 56.8 MBEpisode 23 has Sandy and Cory discussing a review article about modeling pain using a Bayesian statistical model. Fear not! You'll not need an abacus to follow along as the discussion moves from considering the model to potential use and problems with the "Bayesian Brain" concepts that are currently en vogue. What is the big deal with Bayes theorem? Why has it become so popular and why is it being applied to pain? Pain: A Statistical Account. Tabor A, Thacker MA, Moseley GL, Körding KP. ...
022 Do Systematic Biases Impact Care?
April 11, 2017 16:58 - 59 minutes - 55.5 MBEpisode 22 has Sandy and Cory discussing a systematic review on whether biases are present in healthcare decisions and if so, do they have a negative impact. Are biases something that we need to worry about? Is Cory a robot? Also, Sandy coerces her DPT student Christa Wolf to join the show for an important perspective from the student side. Take a listen as the crew discusses these matters and their implications in matters such as the concept of N of 1. Cognitive biases associated with med...
21 Aerobic Exercise for Pain
March 07, 2017 04:23 - 1 hour - 58.6 MBIn this episode, Sandy and Cory are joined by special guest Roderick Henderson who is a physical therapist and strength coach. The group reviews a recent article on the impact of aerobic exercise on pain sensitivity and also goes on to talk about several topics concerning strength and conditioning aspects of care for people in pain. How much should we push our patients in pain? What constitutes "strength training?" Is Rod being attacked by a pack of wild dogs? Effects of aerobic exercise o...
020 Neuropathic Pain at the Pelvis
January 16, 2017 02:14 - 59 minutes - 56 MBIn episode 20 Sandy and Cory discuss an exploratory research paper on Sandy's area of expertise, pelvic pain. The presence or absence of neuropathic pain in this population is not well known and Sandy provides some insight into how this gap along with some common misconceptions play out in unfortunate ways for patients with these presentations. Cory's mettle is tested once again in another low front pain episode but he contributes a self report question that is sure to make you wink. There a...
Holiday Extravaganza 2016
December 11, 2016 03:01 - 57 minutes - 52.8 MBThe PT Podcast Network crew are here to spread some holiday cheer with the annual PT Podcast Network Extravaganza! They talk Jedis, rectums, Festivus, and horrible jet lag - all the holiday standards. Some say it's unlistenable...but you get to judge for yourself! Music for The PT Podcast Holiday Extravaganza: Kevin MacLeod - incompetech.com
018 What IS a Picture Worth
November 13, 2016 02:35 - 1 hour - 60.4 MBCory and Sandy continue their search for clinical excellence (and interesting new screening tools), including an in-depth look at the benefit of using pain drawings as part of clinical assessment. Can these drawings be used to indicate signs of central sensitization? If not, are they useful anyway? How excited is Cory about the Cubs in the World Series? Expanded Distribution of Pain as a Sign of Central Sensitization in Individuals With Symptomatic Knee Osteoarthritis. Di Lernia D, Serino...
017 Are There Ghosts in Your Machine
October 06, 2016 01:37 - 57 minutes - 54.4 MBIn episode 17, Sandy and Cory attempt to tackle a difficult theoretical paper (difficult for non-neuroscientists, at least) discussing some potential implications of interoception in chronic pain. The discussion wades into "embodied cognition" and "predictive processing" among many other models that this paper attempts to cover. Also, we uncover the real reason why Sandy is going to Japan. Ghosts in the Machine. Interoceptive Modeling for Chronic Pain Treatment. Di Lernia D, Serino S, Cip...
016_CBT_in_the_Workplace
August 28, 2016 12:55 - 1 hour - 57.7 MBIn this episode Sandy and Cory discuss a recent RCT in which a CBT approach was applied to the workplace. Cory works in the occupational setting and so is able to offer some insight into how this type of care might be provided. The discussion goes in some interesting directions as both of our co-hosts feel that there is application for these findings no matter the setting. Also, we find out that both Sandy and Cory are planning evil deeds for their cats. Early Workplace Communication and P...
015 Maximizing Exposure Therapy Revisited
July 28, 2016 18:55 - 1 hour - 80.6 MBIn this special episode of Pain Science and Sensibility we are co-releasing with the Naked Physio Podcast, joining up with Paul Lagerman and Bronnie Thompson (who you may remember was also a special guest on Episode 11) to revisit and expand thoughts on the Inhibitory Learning paper from Episode 12. Listen in as Sandy and Cory learn that their inventive pronunciation skills can also be applied to places in New Zealand.
Episode 14: Motor Control and Walking for Pain
June 19, 2016 20:18 - 1 hour - 63.9 MBIn episode 14, Sandy and Cory take on a Cochrane review looking at trunk motor control exercises for low back pain and another paper comparing specific exercise vs. just walking in low back pain. The findings may surprise you. As a special treat, guests Mike Stewart of "Know Pain Mike" fame, and Andrew Rothschild join in for the clinical application discussion. Sandy tries to keep Cory awake as he suffers from severe caffeine deficiency throughout the show.
013 Pelvic Floor Hyperalgesia
May 24, 2016 05:21 - 1 hour - 60.1 MBWe're talking about pelvises (or is it pelvi?) on episode 13! We discuss a specific paper that is both specific to pelvic pain and highlights some controversies that are more general in pain science. This is in Sandy's wheel house and she doesn't disappoint as she walks through some clinical applications while Cory tries to compensate for his discomfort with bad jokes.
012 Maximizing Exposure Therapy
April 03, 2016 19:55 - 56 minutes - 53.3 MBIn this episode of Pain Science and Sensibility Sandy and Cory dive into some specific applications of Graded Exposure some of which are very surprising and may have some astounding implications for what we do with our patients. Are we accidentally encouraging "safety behaviors" that may negatively impact progress? When is the best time to educate the patient in attempt to provide explanations or change cognitions? The answers, at least according to this approach, may shock you.
011 Function vs Activity
March 06, 2016 02:00 - 46 minutes - 44 MBIn Episode 11 Cory and Sandy get pedantic about the definition of "function" vs "activity" and are joined by a surprise guest when Dr. Bronwyn Thompson wanders by. Sandy learns another tool for helping her patients with sleep challenges and we get to nibble on a muffin and sip coffee while Bronnie teaches us some Kiwi words and a different perspective on activity and engagement.
010 Neurodynamics and Fibromyalgia
January 18, 2016 20:03 - 58 minutes - 55.4 MBIn this episode, Sandy and Cory discuss the popular treatment method of neurodynamics. While discussing a recent RCT which used the method in a group of patients with a fibromyalgia diagnosis the hosts also go in to some depth of how they use neurodynamics in the clinic. Also, Sandy's secret mission to convince Cory that he's a pelvic health therapist in denial continues.
Holiday Extravaganza
December 14, 2015 07:00 - 1 hour - 56.8 MBIt's that time of year again and the PT Podcast Network crew are in the holiday spirit! The gang got together, as best they can scattered across the world, to share a little eggnog and make fun of each other. So pour yourself a drink, sit by the fire (or pool in the Southern Hemisphere), and enjoy a little holiday cheer.
008 Pain: Of Mice and Men?
December 01, 2015 04:20 - 46 minutes - 44.5 MBHow do you know if a mouse feels pain? Not to spoil the surprise, but it involves being stuffed head first into a glove. What might this mean for us larger animals? In this episode, Sandy and Cory discuss an animal study article which examines the role of exercise and pain. Grab a beverage and pull up your hamster wheel for Episode 8!
007 CBT for Chronic Pain Delivered Through the Internet
November 01, 2015 20:00 - 55 minutes - 52.1 MBEpisode 7 explores two studies on the effects of a cognitive behavioral therapy program for chronic pain delivered through the internet. This is obviously the first step toward a post apocalyptic version of reality in which we are ruled by our computer/machine overlords. Or is it? The fate of world may depend on this episode! Also, Cory is a dumbass. These are among many probing topics in this episode of Pain Science and Sensibility.
006 To Exercise or Not to Exercise with Chronic Pain
October 08, 2015 19:00 - 53 minutes - 50.2 MBWhich patients with persistent pain will flare up with exercise? Should they exercise? In episode 6 Sandy and Cory discuss a paper that tackles these difficult questions while interjecting the normal clinical commentary of how they address these scenarios in their own practice settings. Also, Sandy cuts down the grandest tree in the forest with a herring. But will she get a shrubbery?
005 Follow-Up Discussion to the James McAuley Interview
September 15, 2015 03:37 - 36 minutes - 35.1 MBEpisode 5 is a short (30 min) follow up to Episode 4. James McAuley provided so much great information to consider that Sandy and Cory needed more time to discuss applications to the clinic.