Transitioning To A Client-Centric Approach In Orthotics and Prosthetics. Dr. Chris Hovorka

people have multiple medical conditions.

They're receiving multiple medications or other types of overlapping treatments, some of which are counterproductive, and so the clinician today has to unravel that complexity to understand what are

Hello, I'm Catherine, your host of this variety show podcast.

Your positive imprint is transforming how we live today for a more sustainable tomorrow through education and information.

Your own positive actions inspire change.

Follow me on Facebook and Instagram, your positive imprint.

Connect with me on LinkedIn.

Visit my website, yourpositiveimprint.com and learn more about the podcast and sign up for email updates.

And thank you for listening on apple podcasts, Google podcasts, Spotify Podbean.

Well, your favorite podcast platform.

Music by the legendary and, talented Chris Nole.

Check out Chris and his awesome music at ChrisNole.com.

C H R I S N O L E Thank you again for listening and for your support of this podcast, your positive imprint.

What's your PI?

there is an estimated 30 million people worldwide who need prosthetic or orthotic devices.

Of the 30 million, it is estimated that about 75% of developing countries do not have a prosthetics, orthotics training program, which means patients are left without a means to better their quality of life.

The percentages change as more people worldwide become amputees due to traumatic occurrences.

These numbers that I just mentioned are estimates from the World Health Organization.

Well, my guest today, Dr.

Christopher Havorka, is advancing research on treatments using prosthesis to enhance the quality of life through better mobility.

Chris is also training rehabilitation medical professionals to enhance the lives of people with mobility challenges.

Chris is now working at Midwestern University in Arizona and is changing the statistics of the World Health Organization by developing a program, which he will talk more about.

And I'm excited to hear more about this program and to hear about all of his positive imprints.

Chris, welcome to the show.

It is so good to have you.

Well, thank you, Catherine.

It's a pleasure to be here today..

Oh, thank you.

And, and you have so much that you've given to our community worldwide.

You've worked in the United States, but everything you do is global and right now you're over in Arizona.

You really have given yourself to these programs and to, to the community.

And thank you for that.

Well, you're welcome.

It's a pleasure to be here today and I'm happy to share with your audience this area that we call orthotics and prosthetics.

It seems that it's becoming more understood today than ever before.

Well, what got you started?

Why did you wanna go this path?

Was there anything that, that was specific that occurred for you in your lifetime that you wanted to go in this direction?

Yes.

It's kind of a, a short story, but I actually was, an athlete back in my high school days and was very, Interested in improving my own capabilities physically to be a strong runner.

I was a track and cross-country athlete in high school.

I did pretty well in that area.

What occurs sometimes, which is natural for many athletes, particularly those that perform well, is some, like myself, gravitate towards, exercise science, , the science of

And so when I entered college and was supported to to pursue any kind of higher education degree, my first thought was to pursue exercise science, which I did.

And what I noticed when I came out of school and into the profession of exercise science.

I got into an area of cardiac rehabilitation.

And I worked in Albuquerque, New Mexico.

At that time, they had a multidisciplinary cardiac rehabilitation center, which is another way of saying they had exercise scientists, physicians, therapists, all working together as a

And my responsibility in that role was to work with people and help them using therapeutic exercise to achieve their goals.

You know, , they reached this debilitated state from a heart attack or stroke event.

And then my goal as a professional was to help them get back to their pre-morbid state, their pre-event state.

But here's the thing, which was really surprising to me.

is a number of my clients that I worked with, despite having what I would consider a life-changing event, a heart attack, a stroke, they were not motivated to exercise and to improve their condition.

I was stunned.

I I just made this presumption that people, when they have a, an event, a medical event, that they want to return back to their premorbid state.

And that wasn't the case in several instances.

There was a problem with compliance in getting people to understand what they needed to do and do it.

And so over time I became rather frustrated with that.

And one of the clients I worked with suffered a stroke and he had some paralysis of his lower limb and was wearing a brace.

And I thought that was rather interesting.

I said, what is that thing on your ankle and foot, which was designed to hold his foot up?

And how did you get that and who made it?

And he said, my Orthotist made it for me.

And I said, what's an orthotist?

Who's that?

? And then I talked to one of the other physicians there and he said, oh yeah, there's a whole profession called orthotics and prosthetics.

And my mind like went, Ooh, that's pretty cool, because this person said he relied on that device in order to function in his life.

Without it, he couldn't do what he wanted to do.

And I thought, aha, that is interesting.

There's something there that this device that this person uses, he's adopted it and used it and, and become compliant with it.

which has improved his world.

And I thought, I wanna make a greater difference than what I'm doing now in training people to exercise.

I think I could do that and make a greater impact in a person's life.

So I said, I think I wanna be an orthotist, prosthetist, , . So then I went to the local Veterans Administration Center where they had an orthotics and prosthetics facility, and I saw these practitioners that

And these people were walking outta there with smiles on their faces and they, they, there was a lot of gratitude and happiness in the room.

And I thought, I'm hooked.

This is what I wanna do.

I re pivoted my career towards orthotics and prosthetics.

I essentially had to start over again with a lot of training, but I was, I was hooked.

And that was the start.

Chris, that is such an inspiring story, an inspiring happening in your life.

And yes, an absolute fabulous pivot on your journey and where it was taking you.

But not just you.

Look at what you've done for all of these people all over the world and the programs.

I am so glad that you had that experience with that one person.

You know, we go through life so often where we don't really recognize how somebody else affected us with their positive imprint and changed our path or changed our thought process or whatnot.

So thank you for sharing that, and that is a great opening to your positive imprints and you continued to work further and further and for years and years and years.

You've been on American Board for certification in orthotics and prosthetics.

You also went on to receive your PhD.

So then with that PhD, what was the research that you chose for your work?

Yes.

I, I think before I answer that question, I should give you a little bit more background cuz it'll, it'll make greater sense to answer the question about the PhD.

When I, when I pivoted into the profession of orthotics and prosthetics in the late eighties, early nineties the profession was still very device oriented, yet the technologies were not as advanced.

They were still rather crude.

, which is surprising given it was only 30 years ago.

And I trained at that time to become a clinical care provider.

They call that role an orthotist prosthetist.

And so in order to become a clinical care provider, obviously you have to get your entry level training in engineering sciences, medical sciences, how to be a care provider, how to, how to work with people.

A lot of skills and knowledge training, then you have to go through a period of, of intensive clinical training called residency.

Very similar to a physician medical doctor residency, but I'm not a medical doctor.

It just happens that our training follows a similar path.

And, and then after that period, , I entered practice for several years.

And here's now the answer to your question about the PhD.

As I engaged in clinical practice and treated a number of patients over many, many years , there becomes a sort of routine.

There are some persons with specific conditions have, have similar themes to their disabilities.

There are kind of stereotypical themes.

So a person who has a particular type of stroke may have a, a, a stereotypical pattern of disability, which over years of treatment can be easily di assessed and treated.

I'm not saying that that persons are not unique because every person has their own needs and goals.

But from a clinical care provider perspective, treating hundreds of patients, there was some routine to the procedure.

And it was this routine that to me, I lost a little bit of the challenge.

And I was, I was searching for additional challenges.

I wanted to continue to make an impact in people's lives, but I was wondering , whether I could have a broader impact and a more substantial impact in doing something else.

And this is the point of where I said I think I could have a better role as being a care provider if I could train others to do what I do.

And through that, through these others that I'm training that, that I could reach a broader number of people that need care and.

and that notion came to me over the period of several years where I became a bit frustrated with the type of training that I was receiving.

There were gaps in the types of training I felt it could be improved.

Rather than complaining about the system, why don't I take some action and try to participate in a solution?

So I said, okay, I think I need to go back to school and learn how to become an educator and a scientist in order to get the knowledge and skills to be an educator.

And to improve the body of knowledge where there were gaps.

So it was at that point in my clinical care days where I decided to pivot again and pursue a career in academia.

But to do that, I had to go back and get another master's degree, and then eventually a PhD.

So it was yet another journey of learning in order to make that enhanced positive imprint.

I'm just incredibly thrilled and definitely inspired because you were wanting to meet these challenges.

You also mentioned being the late eighties, the early nineties, even though it was just 30 years ago, that there wasn't a lot of improvement or advancement in the area of prosthetics and so on.

Dr.

Parks, Dr.

Bob Parks, he, you're smiling.

You might know who he is.

You do.

Okay.

Well, I had him on the podcast and thankfully he was a person who really pushed forward podiatry and Sports medicine.

So you also could consider yourself a pioneer in this area.

I think this is fantastic.

So now let's talk about your PhD and the research that you did.

Yes.

So when I was working in the clinic Treating persons who had limb loss and also who had their limbs intact, but suffered neurological or neuromuscular disorders where they needed a brace.

I, I noticed there was a theme while there are many themes, but there was an interesting nuance in what I did which was a bit unclear.

And that is that when a person is fit with an artificial limb or a brace, one of the goals of the care provider, like an orthotist prosthetist, is to use the

Essentially an orthotist prosthetist is mitigating forces to enable a person to move.

and those forces are transferred between the device and the person's body segment.

So if you wanna really make a fundamental philosophical approach to orthotics and prosthetics is my role is to mitigate forces to help a person move.

And I happened to use technology to achieve that goal.

The, the thing that I noticed when I entered the profession and over the next subsequent years is there was a lot of focus on the device.

Even given the limited technology at that time.

Orthotists and prosthetists were trained to focus on the device, which I did.

But as I matured as a clinical provider, I realized it's more than just the device.

The device is just a mechanism to help enable a person to do what they wanna do.

And I started to realize I need to pay more attention to the person and less attention to the device so that I'm informed well to create a, a treatment that's desired and helps the person achieve their goals.

So with all that being said, if you drill into the weeds of it a little bit, there's this notion what's called learned disuse.

And it's a challenge in rehabilitation medicine because particularly people that wear an orthosis or a prosthesis, because there's this balance between

so that they can move.

But sometimes there's a conflict where the device, and to achieve the mechanical goal, like for a person to have stability so that they don't fall over if they're using a lower

sometimes there's a trade-off where the device has to l lock up or limit other joints from moving.

So it's a difficult challenge in rehabilitation medicine and specifically in orthotics and prosthetics because many times the device has to lock up or limit

At the cost of learned disuse by locking up joints that don't allow muscles to move.

so there's this kind of interesting trade off in the, the area of neurological rehabilitation for people with like brain or nervous system disorders like cerebral pulsy.

Spinal cord injury, stroke.

There's this conundrum that after a person suffers , a neurological event, and they are less capable of moving that one of the rehabilitation strategies to improve their care

towards recovery is to get them up and moving, but in some cases when to do that may put a person at risk because their balance might be compromised and they may fall down.

Mm-hmm.

so.

The orthotic treatment for persons with these types of neurological disorders in many cases is to maximally constrain motion of a joint in order to provide stability

And there's been this reluctance by the other care providers, uh, physical medicine and rehabilitation doctors, physical therapists, occupational therapists.

There's been reluctance by those providers to recommend a device that restrains or maximally constrains joint motion for fear that the device through its

So there's this interesting trade-off between, providing stability and support for safety during walking, but perhaps at a cost of constraining movement.

And this notion of learned disuse.

So I began to explore that notion , through a couple of few studies by first examining does in fact, or, or how does the muscle actually behave when it's undergoing constraint during repeated activity, like walking.

And then from some of the preliminary findings that we identified, that it can now inform new approaches to care so that the stability, , issue can be

I probably need to explain that a little bit more because there's some important nuances that led now to the PhD.

Muscles, skeletal muscles that everyone has.

We have three types of muscles.

We have skeletal muscle, we have smooth muscle, we have cardiac muscle.

But of these three types of muscles, skeletal muscles are the most prevalent in our bodies and what we rely on every day to move.

But one thing that's interesting about skeletal muscles is their operation and their trigger for movement is dependent on length.

Muscles require changes in length to tell them whether to turn on.

or turn off.

So if you now come back to , that notion of length dependent activation for skeletal muscles, and you're designing myself as a, as a care provider, designing an orthosis

Now we have a conflict where the device might provide stability, but it may not create enough substantial length change in the muscle to activate it.

So this is the concept that we come back to, known as learned disuse by limiting joint motion, thus limiting length changes in a muscle.

And it becomes sort of this, if you don't use the joint, you lose the muscle function.

And so, What I encountered in the clinic when I would treat a patient that required a prosthesis or, or an orthosis, is sometimes the care provider would say, I'm a little reluctant for you to fit that

So this was an unresolved therapeutic conflict where I was trying to design a device to achieve stability at the cost of limiting motion.

My referral sources, physicians and therapists said, we want both stability and motion.

And I thought, wow, this is a really interesting conundrum.

I wonder if I can explore that further.

And that is what motivated my pursuit of the PhD was to examine the concept of learned disuse.

That absolutely makes total sense.

I had a knee injury in high school from ballet, and one of the things when they put me into a brace, my hips hurt like crazy because I was walking differently,

It's kind of the same concept.

Anyway when my mother had her hip surgery, she wanted the second hip surgery right away.

She didn't wanna wait the three years or two years.

She wanted it, the next month and a half because she knew exactly what you're saying, The learned disuse.

She knew that she was going to be favoring the good hip.

Yes, yes.

With the human body and, and with a lot of things, nothing is free.

in other, in, in other words, if in, in the case that you brought up, if a, a person, like a family member or yourself has a, a joint problem at the knee or the hip and if a treatment to address that problem because

If you're limiting motion at one particular joint, other joints typically have to compensate through greater motion or, or unusual movement patterns to to accommodate the lost function of another joint.

. So, it's kind of like a pieces of a puzzle.

If you constrain or limit aspects of one area, there's a, a consequence to other areas of the body.

You don't get a, a free pass.

You have to adjust.

And sometimes that adjustment, by the way, can be unconscious.

You're not aware of a new movement pattern that you've adopted.

It, it just occurs.

It's an, it's inate or in other cases you, you consciously make the adjustment.

From a rehabilitation standpoint, it's really difficult to retrain a person to or to undo those unconscious compensatory movement behaviors.

So, yeah, it's a, it's a very, if you like, puzzles, which I do, it's exciting and fun but it's also a little complicated.

So you're wanting to also bring in education and learn how to appropriately train medical clinicians in rehab medicine in order to enhance mobility for people.

First of all, before we get to what you're doing, let's talk about the programs in United States.

Right.

So, the state of a, of of affairs, for orthotic prosthetic education in the United States I can benchmark this for you.

If you look at orthotic and prosthetic education in the United States and you compare it to the education and training of and the graduates' capabilities in schools in other

However, we, we maybe in part of this discussion, we can drill down to what does excellent education and training look like, but I would say generally speaking in the

However, there's a lot of room for improvement, and let me explain that a little bit more.

Part of the challenge in training a clinical care provider in orthotics and prosthetics is there's such a wide range of knowledge and skills that have to be taught.

Let me give you an example.

In order to provide care to a patient that requires a, a prosthesis or an orthosis, the person, like an orthotist or prosthetist needs to know about material science and engineering.

They need to know about gait and biomechanics and movement science.

They need to know about the clinical skills of how to in a friendly and engaging manner, interact with a person that will encourage them to communicate so

So there's this interprofessional or interpersonal skills and communication that's required.

In addition to all that, there's the medical knowledge, the pathophysiology of, of diseases and conditions, understanding the natural history of, of how people recover from injury.

So if you look at the spectrum of knowledge and skills that a person in orthotics and prosthetics needs to

have to practice it's, it's probably it spans almost half a dozen disciplines.

So that therein lies the first challenge of any educational programs is this wide breadth and scope of knowledge and skills that need to be taught within a limited amount of time.

On top of that there's this notion, and it's, it's remained in place for many years where care providers were, and in the schools in particular that trained the care providers, they were fairly device centric.

The focus for many, many years was on on more training on the engineering and the creation and production of the technology, the device rather than on the person themself.

So when I started, for instance 30 years ago, I would've probably defined myself more as a technician, where I was a really good designer and fabricator and I followed orders.

You know, a physician would say, make this particular device for this patient, and we know that you're a very skilled, crafts person and you'll, you'll make it fit really well.

And I did.

But as, as kind of time went by and what I noticed clinically, patients complained that sometimes the technology, the devices that they were provided, they didn't feel were correct.

They didn't feel that they would, that they were appropriate.

They could be better.

Like they, they didn't quite match the needs or goals that the person desired.

So, For many, many years what I'm trying to say is orthotic and prosthetic education was very device centric, and it wasn't client or patient centric.

And that's where we have room for improvement even up to today, is the schools could, I believe, benefit from more client , or patient-centric training.

Even today, we still see graduates of orthotic and prosthetic training programs being very well versed in the design and fabrication elements of the practice, but not as

and formulating an evidence-based plan of care.

And the reason for that is the educational standards still focus on device centralism and less so on patient client centered care.

So the opportunity that I've been proposing and evangelizing for a while is, Hey, why don't we as a profession, Have another closer look at how we're providing care through

And there's a couple of reasons.

One is I think there's a lot of room for improvement in the quality and outcomes of care that we're missing.

And the second is if we have reduced reimbursements that we need to find new and creative ways to deliver care that's less labor intensive.

and more efficient, we have to find efficiencies.

The practitioner of the future can spend more time with their client or patient in understanding their problem and needs in developing a plan of care that's well thought out and supported

So now you might say, okay, that's cool, but that's gonna take a lot of time to train a practitioner, to spend more time with the patient and to make really thoughtful evidence-based decisions.

And what I'm suggesting is that we flip the time so that we spend more of it with the patient and less of it fabricating a device

so that we can achieve a better outcome and we can use less time fabricating the device by exploiting, , digital technologies, particularly 3D shape capture and 3D printing.

Now, I'm not saying that there's no longer a place or a time for handcrafting because there are some technologies in 3D printing that are not possible.

Now, to be fair to the schools and my colleagues in academia , they're bound, all the schools are bound by accreditation standards.

These are the guidelines that inform a curriculum.

And so the educational standards, the accreditation standards have been very slow to evolve.

They're still somewhat device centric and not as client centric, as I believe is desired.

So, Over the years in my career when I developed the first master's degree training program in orthotics and prosthetics, our goal at the time was to improve the body of knowledge in science

that informed the engineering design and then informed the client's needs.

It's what we call today, but was very new at the time, 20 years ago, evidence-based practice where the clinician would use their own experience and knowledge to help inform

So how is physical therapy, or is it, does it have any rollover or crossover with device

centrism.

So, so this device, centrism is really only one of the two parts needed to be a care provider of orthotic and prosthetic services.

There's the device element, the engineering, the material science, the biomechanics, all of that.

But then there's the end user that's going to interface, uh, and adopt that device.

That's actually, I think, More important because the device is just an object of treatment, but the wearer, it's it that needs to satisfy the wearer's goals and, uh, needs in a safe and effective manner.

So the device centrism approach to delivering care, it's too narrow and, , it's very error prone, , not understanding

about, the patient or not enough about the patient.

Perhaps other, other medical conditions the individual may have, which are called comorbidities.

And by the way, in the United States, people with three or more comorbidities is very common.

So people today are more complex to treat.

And a person needs to be more knowledgeable of their unique conditions.

This device centrism approach, , really limits the knowledge and understanding of a care provider to, to know how to mitigate those multiple and complex problems of people in today's society.

, now to come back to your original question, with physical therapists, and how does their scope of practice enter into the field of orthotics and prosthetics?

Most physical therapists have very little to almost absent training in the field of orthotics and prosthetics.

At best, maybe one or two, three credit hour courses, that are usually a lecture, and that's about it.

So they have knowledge about show and tell, here's a device.

This is how theoretically it should work.

When you go out into practice

, hope you can learn more.

Now to be fair to the field of physical therapy, their board exams and the content on their board exams in the area of orthotics and prosthetics, it's less than 5%.

. So intuitively educational programs and physical therapy are not going to focus on orthotics and prosthetics, right?

Cuz it represents such a small component.

The point I'm trying to share with you, Catherine, is that the knowledge of, and skill of physical therapists in the area of orthotics and prosthetics and their device centric knowledge is pretty limited.

Now, the value of a physical therapist and their strengths, , they are specialists in movement.

They can diagnose and hopefully improve, uh, abnormal movement patterns and the abnormal movement patterns are very common in people that wear orthotic and prosthetic devices.

So what tends to work fairly well in the healthcare arena is when an orthotist and prosthetist can work collaboratively together with a physical therapist and

The prosthetist can address and or orthotist can address the needs of the device, whether it needs to be adjusted, maybe the fit is, uh, is causing some discomfort that's leading to an abnormal movement pattern.

The fit and function of the device and those, and anything related to that is kind of the scope of practice of a prosthetist orthotist.

The physical therapist, , is very knowledgeable and skilled at training the person how to relearn or improve movements, , maybe unlearn inappropriate movement patterns and adopt new strategies.

And sometimes, , that, that approach of, of, of collaborative, , work together through prosthetics, orthotics with physical therapy.

That's ideal.

, I'm trying to, kind of trying to, to paint a picture that both professionals are needed

to provide appropriate and optimal care for the patient that utilizes these orthotic prosthetic technologies.

It's not just one person in isolation.

.

and then that's refined by the existing information like through peer reviewed research.

So those three pieces kind of come together and are mashed up to inform the plan of care.

That was very new 20 years ago, and that was the model that we that we espoused at Georgia Tech when we started that program.

But now as I've matured, as the profession has matured, I'm now looking at a slightly new model that we're adopting at Midwestern University, where I'm at in Arizona.

And that's to infuse more skills and knowledge in the client-centered domain, the patient client-centered domain.

That's the piece where we have, I believe, even more opportunity for improvement.

And that's been informed by frustrations by clients that have received very expensive devices that didn't work to their desires.

It's been informed by by errors in clinical practice, if you will.

And there are many, many examples I could provide to you for that.

But there's another side of it as well, besides improving the, the, the care delivery and meeting the person's goals through a client-centric training model.

There's also a, a monetary aspect to this.

A lot of these technologies that we provide, orthoses and prosthesis, they're really expensive, particularly in developed nations like the United States.

. There are some particularly lower and upper limb prosthesis that have these mechanical, externally power driven designs.

The, the costs for these technologies in some cases can be in the tens of thousands of dollars.

In some cases, a hundred thousand dollars.

So if a person that's deciding on these technologies to be utilized for a patient, if they're not really engaged in understanding the patient's needs and desires and physical

restraint limitations.

If they don't know those, those sets of factors, they're not gonna match the technology to meet the goal.

And so it can also be a loss not only in not achieving the patient's goals, but a loss in charging too much money into an already overburdened healthcare system.

We, myself and a group of , a handful of others, developed an entry level master's degree model.

It's a master of science in the early two thousands.

And we launched that model at Georgia Tech.

At that time in the field of orthotics and prosthetics the entry level degree was a back bachelor of science, and we proposed to do better.

We proposed very, the very first time an entry level master of science.

It wasn't required, but we decided that we would infuse more science and more methods on, on training this evidence-based practice approach because at the time clinicians were more like technicians.

and they weren't really taught well to think systematically.

And so this, this new model was to address those shortcomings through more systematic processes of thinking, assessment and treatment formulation.

And that was 20 years ago.

So see you, you are a pioneer of this and you're bringing it forward.

I'm glad that you mentioned assessment because oftentimes I think that that is still missing today when anybody goes to visit the doctor

or medical provider.

As a patient, we must advocate for ourselves.

Here we have the World Health Organization saying that 75%, 75% of developing countries don't have a prosthetics and orthotics training program, which then means

Your work and the work of your colleagues and your peer reviewed materials, I think are moving things forward.

We might see that 75% start to drop as your model is adopted throughout the world.

I think I read 57 million amputee amputees in the world.

Your research has been important.

Yes.

Well, I remain very positive.

So Chris, you have been transforming the way we live, the way people with prosthetics, orthotics live to bettering the quality of life for them through the

affects many worldwide.

So thank you for that.

. you have been inspiring, what are your last inspiring words

Well, I think perhaps one of the, the things I'd like to share with your listeners is it, it takes a community.

To, to, to achieve your goals.

If you have a particular thing you wanna do, don't forget about the people along the way that got you to where you are.

And, and don't forget them.

Acknowledge them.

Be grateful to them.

And I think you'd be more inspired by having that kind of reflecting back to know that if you wanna get to where you, to a particular level, you need to

So a little gratitude, a little reflection, and keep moving forward.

Chris, thank you for continuing to moving forward and thank you for your gratitude and I applaud you.

And thank you so much for sharing your positive imprints here on the.

It was fun.

Catherine, looking forward to our next discussion.

Absolutely, Chris.

Thank you.

Well, that has been amazing information.

Well, next week, join Chris and me for part two, influencing change in healthcare, guiding the transition to client centric, training something we definitely need is more client-centric healthcare.

Well, Dr.

Chris Hovorka next week.

Learn more about Chris and his research by going to Midwestern.E D U.

And to find his other peer reviewed research or articles just Google Chris Hovorka C H R I S H O V O R K a.

And don't forget to follow, subscribe or download this podcast.

This is a free podcast, but if you'd like to donate to the production of this variety show, You may do so by going to paypal.me/yourpositiveimprint.

. I also have my shop with lots of fun shirts and hats, which you can access from yourpositiveimprint.com.

And don't forget to leave positive reviews from your favorite podcast platform.

Thank you so much for the support and thank you for listening.

See you next week and safe journeys, your positive imprint.