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Whether reading this blog, or reading the Neurology chapter in the Integrative and Lifestyle Medicine in Physical Therapy book, there are 2 main factors we want you to consider when using integrative medicine in neurological physical therapy care. How can we be more inclusive in our clinical settings? And how can we use the proper intensity to support an individual’s recovery from neurological injuries.
Now, those aren’t the only keys to maintaining a healthy nervous system, but they are a great place to start. Dr. LaVerene Garner, PT, DPT wrote the chapter, “Neurology” in the book, Integrative and Lifestyle Medicine in Physical Therapy. In this chapter, she mentions additional areas to address using integrative medicine in neurological physical therapy:
If you’ve been following our podcast blogs, you may be noticing a trend. There are many pillars of integrative and lifestyle medicine which overlap regardless of the patient population you are treating, or the health problems you may be experiencing. It turns out the same things that will keep your joints healthy, will also keep your nervous system healthy.
However, there are important considerations when it comes to each area of specialization.
The critical part to understand when treating your physical therapy patients with neurological conditions, is that some diseases or injuries require high-intensity exercise while others mandate a lower intensity in order to achieve the best outcomes and results.
The type of injury to the nervous system dictates the type of care required. Integrative medicine in neurological physical therapy indicates that we should be aware of these disease needs as well as individual needs. Someone who is recovering from concussive injuries, would require a lower intensity program. On the other end of the spectrum, an individual with Parkinson’s Disease responds best to a high intensity rehabilitation protocol.
A neurological injury can happen to anyone. Creating a space that is welcoming to anyone and everyone is critical to providing the best possible quality of physical therapy care. This is especially true for individuals with neurological injury. Our nervous systems are highly sensitive and requires a supportive environment to recover and heal.
This isn’t always easy, but “creating a safe space” is a message covered by nearly every author of the book, Integrative and Lifestyle Medicine in Physical Therapy.
Dr. Ginger Garner sat down to discuss this topic in greater detail with Dr. LaVarene Garner PT, DPT who is paving the way for practicing integrative and lifestyle medicine in neurological physical therapy care.
For those of you that prefer video, you can watch and listen to this discussion around the topic of practicing lifestyle medicine and integrative care in neurological physical therapy.
You can check out her chapter, “Neurology” in the book, Integrative and Lifestyle Medicine in Physical Therapy.
Dr. Garner is a board certified neurologic clinical specialist, and currently works as an assistant professor in the Department of Physical Therapy at Winston-Salem State University. Prior to her role as professor, Dr. Gardner developed the vestibular therapy, mindfulness and integrated health components of a concussion recovery clinic at Camp Lajune, where she treated individuals with chronic neurologic conditions.
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00:00 Dr. Ginger Garner: Hi everyone and welcome back. I am here with Dr. Lavarene Garner. I call her Lava, so… but I want to introduce her to you first. She wrote the neurology chapter in the book that Dr. Joe Tatta and myself edited and contributed to Integrative and Lifestyle Medicine in Physical Therapy.
And so, Dr. Garner is a board certified neurologic neurological clinical specialist and currently she’s an Assistant Professor in the Department of Physical Therapy at Winston Salem State University here in North Carolina. Prior to her role as professor, Dr. Garner developed the vestibular therapy mindfulness and integrated health components of a concussion recovery clinic at Camp Lejeune in North Carolina where she treated individuals with chronic neurologic conditions. And if I was saying it correctly I suppose it should be Camp Lejeune. I will correct myself on that.
Welcome Dr. Garner.
Dr. LaVerene Garner: Thanks it’s good to be with you.
01:12 Dr. Ginger Garner: Yeah, same here. As much as we know we’re not related, but we’re not sure.
Dr. LaVerene Garner: So that’s right. Yes, my husband’s from close to your family. So we figure we probably are in some way. Yeah maybe, distantly.
01:29 Dr. Ginger Garner: Yeah maybe distantly, because our families have been here in the same area of the state for a few hundred years. So yeah it’s probably highly likely. But speaking of that, speaking of family and history and such, tell me a little bit about yourself and what led you to PT.
01:49 Dr. LaVerene Garner: Yeah so I grew up I was born in ultra rural Kansas and then we moved to what I would consider rural Indiana when I was in first grade. And so I grew up in very rural communities where I didn’t really realize there were big problems with access to care until really much later in life. I just didn’t consider it. But that was a big part of my lived experience as a child was not having loads of access to really high quality care.
And so anyhow when I went to college my freshman year I was having headaches from studying and one of my friends worked on my neck. She did a suboccipital release and I thought it was so cool. And I didn’t know how she knew how to do it, but her mom was a PT and so her mom had taught her how.
And so I became really fascinated by just the technique she demonstrated or showed as a freshman in college I guess who’s untrained. And I decided I would go home and start volunteering so that I could learn more about physical therapy. And my mom was a nurse at the hospital so she got me set up and I started observing and I thought it was the coolest thing ever.
And so that really is what set me on my trajectory, I think, to become a PT.
03:06 Dr. Ginger Garner: Wow yeah well I mean of course I think PT is pretty cool and pretty fun as a career. And it takes on many different, PTs are working in all kinds of different forms now. Thankfully, we’re seeing PTs branch out into not just management or administration but things like public health. And what I am fascinated by since I come from the orthopedic sports medicine to orthopedic to pelvic health kind of journey. From my side is, neurology was never other than what you had to take in PT school, right?
When I did my neurological rotation it was never on you know on the forefront of my career path for me. So I’m wondering how you came to focus on neurology?
03:58 Dr. LaVerene Garner: Well I think it was a happy accident. I would say really I’m a generalist. I started out in an orthopedic, my first job was in orthopedics, but I got certified in Pilates.
And so that really led me to the breath which I’ll talk maybe more about later but when I first learned about the breath, I thought it was a bunch of mumbo jumbo. I was like I am never going to use this. Who knew? But that’s what the young 22 year old or 24 year old young girl like I was thought when I got out of PT school. So anyhow I ended up moving back to North Carolina and worked in a job setting where we rotated and I ended up in outpatient neuro and I loved it.
And then I moved to Jacksonville North Carolina and ended up being the only person in town that was really available to treat people with vestibular problems. And so all of these Marines started coming back from the war with an assundry of symptoms. And so I oftentimes was treating 18 injured Marines a day out in town and then eventually moved to Camp Lejeune to work.
So I think that I’m grateful for my background as a generalist because it gave me the ability to treat numerous impairments simultaneously which is necessary in that population of people. But it also really helps me that in my role now where I teach to be less siloed and to understand how beautiful health care can be when we understand the world or entertain a world outside of our own.
When we get out of our comfort zone and really start to learn more about orthopedics or even in the military population the pelvic floor is often a problem. Pelvic health is often an issue in the male Marines that I worked with at Camp Lejeune.
06:14 Dr. Ginger Garner: I think you said something that’s really important that I just want to draw out and that was your experience as a generalist really suiting you well to be able to actually ironically move into this clinical specialty because you have to look at everything.
One of the things that is important out of that is the fact that you really are a front-line care provider because when they come into you sure they may have vestibular issues or a non-contact brain injury or whatever it may be but there’s a lot of other things that actually come with that and that was one of the reasons that I felt it was important as well as Joe.
And all the authors that contributed that we really focus on the potential for all PT’s to be front-line care providers or primary care providers, if you will.
So I think that’s something that I love all new PT’s to hear is that they are and can be primary care providers out there on the front line like that and that generalist is not a bad word. It’s a very good word when we’re talking about being primary care providers.
07:35 Dr. LaVerene Garner: Yeah I think for me manual therapy is not my strongest suit, right? And I’m totally okay with that because if I have someone that I’m working on or working with who is post-concussion I have so many things to work on that I don’t really have time to treat their neck. So I really what I do need to be able to do is know when their neck is causing the symptoms and refer them to another PT.
Just like if a patient needs vision therapy, right? Maybe that’s not in your wheelhouse, right? But you can certainly send them to me and then I can help with that so I think it it helps instill a little bit of humility about the breadth of knowledge that we can have and learn to really work well and understand what another person is going to bring to the table, if we invite them.
08:39 Dr. Ginger Garner: Yeah that’s such a critical piece because it is so easy to let your ego get in the way and say oh I can treat that, I can treat that, I can treat that, but the best thing that we can do is to say, you know, is to admit whatever our limitation is and go “you know I know the person that is really good at that because it’s not me”. Yes you know and sometimes that’s the hardest.
That’s not the hard part for I think most clinicians perhaps unless they’re like brand new and still think they can they know everything and can do everything. I think the hard part is accessing other resources of knowing who is.. you know is that same therapist available ? Did they leave the practice? Did they you know did they move? Do I have a strong network of people that I can refer to I know in my private practice here in Greensboro?
I’m constantly working on that spreadsheet you know of our providers so that we can actually make the appropriate referrals.
09:40 Dr. LaVerene Garner: Yeah that is challenging I know I do provide a lot of pro-bono care in my job where I work now and so I have to have people that provide free care typically to give the names to my patients. So I think that and know a various sundry of different charitable organizations that can help out when needed. So it is very much a challenge to keep abreast especially in the traditional health care setting. I worked in a clinic at Camp Lejuene. If I was working with a patient, and most of the people that I worked with they had a lot of mental health comorbidities: significant anxiety, depression or maybe PTSD.
So sometimes people are amenable to things like mental health care. Sometimes they’re not. So for me, I became pretty skilled at talking to people about mental health care and what that meant. So sometimes during my sessions they would be like, okay I’ll go talk and I will say, will you go talk with them now? So I could walk them straight down the hall to a mental health care provider’s room and they could start building rapport with someone.
So when they open the window you’ve got to have somebody to take them to and I think the more interdisciplinary clinics that we can have even as PTs. So I think, oftentimes, we think of our clinics as either being like a CrossFit based clinic or an outpatient neuro clinic or an outpatient orthopedic clinic, right? But in reality maybe we should just have clinics for human beings. So, there’s providers from different specialties that work together.
11:41 Dr. Ginger Garner: That was always my dream as a baby PT, to have that interdisciplinary interaction and that it’s accessible. I work in a relatively interdisciplinary situation now, which is good, but it can always be better.
And that kind of leads me into my next question. Part one, is you know how did you start, through Pilates I think was part of the answer on how you worked in and came to integrative and lifestyle medicine because Pilates is certainly a mind body function, but is there any other backstory on you know how you became interested in that and then I have kind of a follow-up question after that.
12:29 Dr. LaVerene Garner: Okay, well my story about how I really came to integrative health care is probably it’s a very personal story that I won’t go into sharing all of today. But I think for me I had to investigate my own humanness in very real ways that were not easy and when I did that it kind of opened me up I think to being more inquisitive or curious than I already was about the impact that thoughts and emotions have on the physical manifestation of disease or how they limit people’s lived ability to live their life the way they want to.
Or their willingness or ability to participate in life the way they want to. That’s really kind of what led me to yoga and then in working with people at Camp Lejeune, particularly Marines, I think they taught me more than I deserved to learn. I say they were great lessons and a privilege for me because I didn’t have to go through what they went through and they taught me so so much about the impact that trauma and the lived experience of trauma has on people’s well-being and so that’s where it started.
Now I work in historically black college and university and I’ve heard students share their racialized experiences of trauma and so that added another layer of privilege for me. Where I’m able to hear students of color talk about their lived experience in the world and what that’s like for them and how they carry that with them everywhere they go and everything they do.
14:33 Dr. Ginger Garner: Right you can’t just sit that down and you know tackle your Tuesday it’s always with you. Yes, for listeners that’s a little bit of our shared story for Lava and I because that’s how we met was through yoga and Camp Lejeune. Because I was actually at that time, living at the coast and teaching yoga as medicine or continuing education to health care providers and we got involved in what would go on to not happen because as you might imagine it’s hard to do research in the military but we started working on preliminarily a research study that would have been on yoga, and integrative and lifestyle medicine at that time. But that’s a little bit of our kind of intersection story of how we met each other.
So out of the I call it ILM for short (Integrative and Lifestyle Medicine). So out of ILM and we’ve talked about a lot of topics, so I have two or three questions kind of backed up against each other in my brain.
But the first one would be you’ve touched on your background and working with people with trauma, teaching students with trauma. We have concerns about health care access and health care justice. What would you say that you know, if you could bring out one important point or three important points however many you want to make from your chapter, what would it be? What would be the big salient points for people?
16:18 Dr. LaVerene Garner: Well, I think that okay I’m going to bring up two and have you remind me okay? So one would be inclusivity and the next would be intensity.
So two “I”s. Okay, so I’m going to start with intensity because I think it’s simpler. So intensity matters right that’s a principle that the neurology section of the APTA has blasted a lot and it’s really important but typically it’s spun more towards high intensity. High intensity exercise is appropriate in the most thoughtful and evidence-based prescription model for different populations.
So for example people with Parkinson’s disease, moderate to high intensity exercise. The higher intensity the better is what is best for them, if they can successfully do it. For people post stroke high intensity stepping is really, really important once they’re stable.
But there are other populations where intensity has to go the opposite direction to start with or maybe for example concussion. So when people are post-concussion and they’re working back to return to sport we start with lower intensity exercise to let their nervous system kind of settle in again.
17:46 Dr. Ginger Garner: For the person post-concussion, what might that look like for them? When you say you’re backing it up and the intensity goes the other direction because I think for a lot of people this might be the first time that they’ve heard this. “Oh, I should do less in this population instead of more.” So what would that look like for that person?
18:00 Dr. LaVerene Garner: Yeah, so it depends on what their impairments are. If someone comes to me and they have a lot of oculomotor deficits, and maybe they have some cervical spine issues, and they also have exertional headaches. Then, I oftentimes will start them on the bike and we’ll have them maybe start at like 60/65-70 percent of their age-adjusted heart rate max. So that’s largely based upon the divbit guidelines, which is what I use a lot.
There’s also different, the buffalo concussion, tests that you can use to prescribe a more specific dosage, as well. And then you can kind of walk them up step by step. So once people’s oculomotor skills or their cervical spine gets better then we might move up to the elliptical and keep the heart rate range the same. So that we know if they have symptoms, whether it’s likely from the oculomotor system or the neck, as compared to an autonomic issue. So there’s kind of this piecing apart as they move up, but eventually we want them to get up to as high of an intensity as they can.
It just takes a little more time to walk them through it. And I think one of the things that I didn’t touch on in the chapter was this diagnosis called 3PV, which is kind of, I guess it stemmed from chronic subjective dizziness. Where essentially, I’m going to oversimplify this a lot, but the brain interprets an episode of traumatic dizziness, even bppv sometimes, in almost a traumatic way. And so, because dizziness is very alarming to adults, it’s a very alarming symptom.
So with that population, we want to especially if there’s trauma or mental health issues involved we want to kind of create a container where people feel safe to progress through these areas that have been hard for them. I think that’s one of the places that we can really be skillful. Thinking about how to really thoughtfully and intentionally prescribe physical activity and then also to carry the ILM further, understanding things that are outside factors that are limiting their ability to be physically active.
So those things might be, diet. They might be sleep, a really big one especially with the post-concussion and trauma folks. So understanding how those areas fit in and the need to either get people to the right provider or to make sure that you’re giving them strategies to help them sleep better at night or coaching them on things to eat to help control their headaches. Especially if they’re having migraines – can be beneficial and then I think go ahead ginger you look like you were gonna to ask something.
20:59 Dr. Ginger Garner: Oh, go ahead and finish your thought. I have a follow-up question.
21:06 Dr. LaVerene Garner: Yea, so I was gonna go next kind of into this inclusivity piece.
21:13 Dr. Ginger Garner: Yeah, yeah – I have a question on that because I think for a lot of people they might want to understand and know, especially if let’s just say you’re in the orthopedic space and you have someone come in. And you know people forget to put stuff on their intake. Oh yeah, I have a cervical fusion I forgot to tell you. You know, yes or I had a stroke last year just forgot to tell you or I had COVID and was in intensive car, forgot to tell you kind of thing. So if someone comes in with autonomic symptoms or oculomotor symptoms.
What is that going to look and present like to you? So that either pts or if you’re a person listening you know oh okay those are red flags that I should seek out care. For people with oculomotor problems, they may report problems reading. So maybe when they’re reading they may have problems like staying on the same line or maybe when they look at the page they see words kind of bouncing or things. It’s really hard for them to focus, or to use their focusing mechanism. So they see things kind of go in and out of focus a lot. I think especially with young people those might be things that would be telltale issues.
With older adults it could manifest in lots of ways. So it could look like balance and fall problems. It could look like, you know maybe, they feel like they’re not driving as well and I think it might be harder to find in an older adult population and some of this, I think they might be less likely to report it. So what I tell my student group is that if somebody has a cervical injury consider doing an oculomotor exam and seeing if they have symptoms with it.
If they do have symptoms with it then make sure that you’re pursuing appropriate care.
As far as autonomics, I think it could go a lot of different ways. From a concussion perspective, people may get headaches with or dizziness with relatively low levels of exertion. They may also, people with Parkinson’s disease may report lightheadedness when they’re getting in and out of bed. So that can be another really common thing for older adults. So making sure that you’re checking vitals, I think is really important also.
If someone, I think the key is also to believe your patients. So when they tell you, I know as a new grad that was something that was hard for me and all the time, really. It’s something that I’ve really had to, because I have my areas of cognitive dissonance like everyone else, right? There I kind of just follow the path of least resistance and I think believing your patients and understanding that oftentimes it’s not their fault we just don’t know enough yet. And that’s okay, right? It’s okay as a provider to not know the answer and to kind of have to sit humbly in the space of discomfort and rely on other people and talk to other mentors that you have or colleagues and just get other ideas for things that you can do or even call the physician if they have a really great physician.
24:36 Dr. Ginger Garner: That’s such an important point to make. You know creating that safe space, it’s one of the softer aspects we don’t often think of as new graduates or new practicing PTs because you think I think you see things as black and white. You’re mostly worried about differential diagnosis, but oftentimes what you have to worry about the most is am I creating a safe space and really listening, deeply listening to patients and earning their trust? So that they’ll trust me, us?
You know as a profession that we are able to help them. And that maybe most important that we’re imparting to them that sense of control and self-efficacy that you know that they they can be better that they can get better.
25:24 Dr. LaVerene Garner: Yeah and I think that’s a great segue into inclusivity, right? Because that’s part of creating a safe space. So Ginger and I were talking, or Dr Garner, but we were talking before this and one of the things we were talking about is the need for inclusive clinical environments. So if I think about the majority of clinics that I’ve worked in very few clinics have bariatric equipment for like new steps or lower body ergometers for people to exercise on that are not maybe a normal body weight. So when people come into a clinic and that’s the space that they’re in they may be much less likely to return because just the space itself is not inclusive. Then if they don’t see people who look like them or that they feel like they can talk to receptively, that can be receptive to their medical concerns, then it makes it even worse.
So it’s important as we represent our companies, that were in our organizations, that we’re putting forth a multitude of face and body types that come from all kinds of backgrounds so that we’re really welcoming in all people. Because all people deserve access to health care.
When I think about where I work now, in East Winston, many people don’t have access to green areas or green spaces where they can engage in physical activity. They may not have the financial means to pay for a gym membership. So even for them getting in lifestyle physical activity of taking 10 000 steps a day could be a real challenge, for them to feel safe to do that. Where I grew up is farm country. There’s no sidewalks, right? I mean you can maybe get to a park, you might have to drive a long ways. And if you’ve ever walked down the side of a country road, it’s not typically that safe. Like you have to be willing to dive into a ditch pretty quickly and you may get chased by a dog or two. So anyhow I think having inclusive spaces and access to care is a really huge issue and then having diverse clinicians who can really meet the needs of the diverse population that is really important.
28:18 Dr. Ginger Garner: Yeah you know, as a white female we have a certain amount of privilege that if we don’t recognize it that makes us pretty tone deaf to what’s going on in the world. And then, as a mother of three I also realized that by and large women are often not listened to in health care. So there’s a certain, you know, saddling that we have to carry through our lives knowing if I end up at the ER, if I end up in an appointment, I very well may be medically gaslighted, ou know in some way.
So when we think about our own experiences, I think that’s one step is – what is your experience? Have you experienced discrimination? How how do you want your health care experience to look? And you know seeking providers out that will help with that or asking people – hey do you know someone, you know, is important.
I think the other part of that is and that’s part of, you know, this series is looking at and talking with doctors of physical therapy across realms that are willing to say, hey I know of a resource or or of someone who can help. Because I wish there was a simple solution to solving the health care affordability and access problem, but currently it’s us kind of in the trenches in our communities doing that outreach and saying ‘hey I do a free consult, doesn’t matter if you end up coming and seeing me, I can spend 10 minutes talking to you and pointing you in the right direction or to resources.’
And the second part of that too is when you’re looking for health care and imagining what you want your health care experience to be like. And everybody has a website now, right? Go to those websites and is there diversity, are different body types, and skin colors and everything represented? When you even go to a website, I would say oftentimes it isn’t. I think that you know I often feel convicted of that in many ways too. I want to look at my practices and what I’m doing and in my business and constantly reevaluate. Am I really being as inclusive as I think that I am or as I say that I am?
One thing that came up for me because of your extensive experience and wisdom in the military health care setting is have any topics come up that you know in terms of inclusion? For I can give one example in the yoga community with military and that’s moving away from using Sanskrit and chanting towards maybe just a simple vocal toning because of some of the triggers that can happen with service members who have served overseas and, you know, using foreign language chanting could very much be a detriment or a trigger to them. So that’s one kind of point of accessibility and talking about military service members but are there others? And not even necessarily in the military surrounding inclusion, of you know, where you’ve experienced that and where you see there can be room for improvement?
31:38 Dr. LaVerene Garner: Yeah, so I know I have been talking in the military environment I never had I don’t think anyone who is actually concerned about practicing yoga from a like religious standpoint. I think that that has happened more in the civilian world interestingly. I, for me, I’m not sure where to go with this for me I think that the religious issues people have with yoga has been one of the most challenging and I just have to step back and say okay well this is not, I don’t need to go there. Or, I need to explain it in a very cut and dry scientific manner and so with the military population a lot of them have experienced some religious trauma, I would say or moral injury, we’ll call it moral injury. Where they are faced with decisions where there’s no real good choice which is actually really a problem related to many health care workers today post-covid. Right, this moral injury issue has been a real problem.
So I think that I have tried to make things as simple as I can. So, I often will liken yoga to just resource management. Which is I think a great approach for ILM. So when I worked with special operators they love the game Settlers of Katan so if there’s anyone who plays Settlers of Katan out there, this is oftentimes how I would explain it to them.
So instead of talking about the koshas which might be the way we would talk about it in a yoga environment, I will just talk about it ‘you know you come into every day with different resources. So maybe you had a great night’s sleep, and you feel like you can really get in a good workout, and a good day at work, and your relationship is going well with your significant other, and your bucket’s kind of full so we have these different resources of sleep, physical activity, and diet and nutrition, then family and relationships and you have to figure out these ways to manage all of these things and every day though it’s different.’
So if you don’t sleep as well, then maybe you have to take a break in the middle of your day and give yourself some time to go catch a nap. Sometimes for sleep hygiene napping can be bad, right, but maybe you have to take a breathing break. I taught them, in the military, Iris Yoga Nidra and maybe they take a break and they go do a pre-recorded yoga nidra session in their trucker car while they’re on lunch. That’s kind of the way I kind of worked to navigate away from talking about any kind of religious undertones. I would really steer away from that and just focus on it as a way to thoughtfully and mindfully gain some control over the resources that you have or don’t have on a daily basis.
35:06 Dr. Ginger Garner: I think that’s such a brilliant way of actually, just the nomenclature that you use just that vernacular of resource utilization. You know and you can put it in the bucket of all the integrative and lifestyle medicine stuff. So we have mindfulness which can be different than meditation. You have yoga which can be different from mindfulness. You have pilates or tai chi or qigong and then you’ve got sleep, nutrition, stress management, you know physical activity, environmental influences, all of those things.
And if we listed them all at once it can feel overwhelming, but when you talk about them in terms of what resource do you have available to you today? It makes it, it chunks it, it scaffolds it into something that’s realistic and doable. That’s really where it’s at, is behavior, you know, change and managing our own behavior. And saying, ‘I have five minutes, what resource will I choose today?’
36:10 Dr. LaVerene Garner: Yes, yes because in the end really I think what every person is after is living the fullest expression of their life it doesn’t matter what background you come from. And so regardless of my background, I can put my biases aside and say you know I am, it’s my privilege to walk with you on this journey to you being the best version of yourself that you can be. And so let’s just talk through how you might encounter obstacles in your day and then how you might think about the resources that you commonly have in place that you might use to overcome them.
36:48 Dr. Ginger Garner: That’s a perfect ending, I could not have summed that up any better. Yeah, thank you so much for spending this time talking about a lot of important things.
Neurology very much requires a holistic, whole person, integrative approach and you could make an argument in all kinds of populations, but you know when since the nervous system controls so much of who we are I think that just encapsulates you know it perfectly, so thank you.
37:30 Dr. LaVerene Garner: Yes, thank you.
37:34 Dr. Ginger Garner: All right guys until next time. Keep on keeping on. And whatever resource you’re going to pull from today whether it is good sleep, or grabbing a glass of water and staying well hydrated, or taking a mini break during your lunch just for mindfulness or to take a short walk and we will see you next time.
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