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Give Yourself a Hand
In this energetic and upbeat podcast, Dr. Gina Del Savio discusses the ways in which we are contributing to hand overuse syndromes. Our computer use and texting might just be culprits. She shares great information on treatments options and how to prevent them.
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Learn more about Gina Del Savio, MD
Gina Del Savio, MD
As Chief Medical Officer, Dr. Gina C. Del Savio is responsible for facilitating physician integration, development of service lines and providing clinical input for the development of organizational strategy. In addition, she is the director of the graduate student education programs working with Touro Medical College, NYCOM, Mount Saint Mary, Marist and others. Dr. Del Savio joined the Montefiore St. Luke's Cornwall community in 1996 as an orthopedic hand surgeon after completing the Robert E. Carroll Hand and Microsurgery Fellowship at Columbia-Presbyterian. She graduated from Brown University with a BA in Biology before attending the University of Vermont College of Medicine after which she was selected for the orthopedic residency program at New York Medical College. She has held many elected leadership positions on medical staff since 2000 including most recently the President of the Medical staff from 2011-2014. In 2015, Dr. Del Savio completed the American Association for Physician Leadership qualifying program, became a Certified Physician Executive and joined the administrative team at MSLC. She continues her clinical responsibilities as an Attending Orthopedic Hand Surgeon at MSLC with board certification in both Hand and Orthopedic surgery.Learn more about Gina Del Savio, MD
Transcription:
Melanie Cole (Host): If you’ve ever suffered overuse injury of the hand, wrist or elbow, as I have; you know how frustrating, painful and limiting it can be. It can be so frustrating. My guest today is Dr. Gina Del Savio. She’s an orthopedic surgeon and the Montefiore St. Luke’s Cornwall Chief Medical Officer. Dr. Del Savio, I’m so glad to have you back on with us today. This is a problem that’s affecting so many people in the country today for various reasons we will discuss. But what are some of the most common ergonomic repetitive strain injuries of the hand and wrist that you see?
Gina Del Savio, MD (Guest): Well, I’ll tell you as you said with all of us now on keyboards and manipulating our cell phones and our smart phones; we’re using our hands more and more for small manipulative type activities and of course, that is going to cause problems. Things like, carpal tunnel, which is a pinched nerve in your hand or trigger fingers which is a form of tendonitis. There’s a wrist tendonitis called DeQuervain’s tendonitis and even tennis elbow which is actually a tendonitis in the elbow from using your fingers repetitively.
Host: So, as you say, computers and we are all using our fingers repetitively and certainly texting, my goodness, I’m thinking all the teenagers are going to have so much arthritis in their thumbs and what is there; there’s something called texting thumbs or something, right?
Dr. Del Savio: Yeah, we’re starting to see these in younger folks now and again, it’s an inflammation around those ligaments and tendons that motor up your thumbs which in the past, unless you were an avid seamstress or perhaps a musician; you just didn’t do this on a repetitive everyday basis. So, again, as you pointed out; lots of different activities which can aggravate these things that are now part of our everyday life and that you can’t really stop doing.
Host: So, then what can we do? Before we get into some treatments or even diagnosis, if you are sitting at your desk and for me Dr. Del Savio, I started getting a lot of pain in my wrist and elbow and I changed my mouse to one of those penguins that sits upright, and I changed my biomechanics and I made it go away. What do you want us to know about setting up our work station or doing things that we can do that can hopefully prevent some of this?
Dr. Del Savio: Well, I think it’s really important for anybody who sits in any position all day long to remember that the tendons that move your fingers and the nerves that innervate your fingers are just simply rope, so it you think of all those toys when you had as a child where you pulled a rope and things moved, whether it was a crane or a Jacob’s ladder; that’s really what’s going on in your arm. And so, what you want to do is think about positioning yourself so that all those ropes are nice and lose and relaxed as you sit focused on your activities for the day.
So, first of all, that is going to mean that. Starting at your elbow, you don’t want to have your elbow bent really sharply like more than 90 degrees. You want to have it slightly less than 90 degrees, slightly straightened out. Then, if you move on down to your wrist; you want to think of your wrist the same way. You don’t want to have your wrist all cocked up so that it’s at that sharp angle and your forearm is now resting on your desk. And at the same time, you don’t want your workstation so low that your hand is dipped forward and squishing everything on the palm side of your hand.
So, elbow at just a little less than 90 degrees, wrist in a neutral or flat posture and if you do that while sitting up in a chair that gives you good back support and again just holding up your back nice and straight with your feet firmly planted on the ground; that’s a good start. That’s a good start.
Host: That’s great advice. And something that is – I mean that’s ergonomics and people don’t really always think about that as they’re typing away and maybe their keyboard is up on an angle or they’re sitting not tall enough as you explained. So, all of these factors play in Dr. Del Savio. Let’s talk about carpal tunnel. People hear that term and they really don’t know what it even is.
Dr. Del Savio: Right and there is a lot of misperceptions about it. So, carpal tunnel is actually a pinched nerve physically in the palm of your hand. I say to my patients, remember, all nerves start up at the level of your neck. That nerves comes down your neck, it runs down you arm, actually on the palm side of your forearm. Not to get from your forearm into the tips of your fingers where it gives you your sensation; it has to pass under those big thick muscles that are at the bottom of your hand. So, I say, think of it like water under a bridge, that nerve has to pass underneath those muscles to get to the tips of your fingers so you can feel.
Well what happens is, that big fat wad of muscles now is sitting on top of your nerves and if you turn your wrist over, there’s a bunch of bones. Your nerve is literally between a rock and a hard place. And so, now anything you do that increases that pressure there; is going to pinch your nerve even more. So, any activity where you cock your wrist up, or you bend your wrist down and in either of those positions; moving your fingers repeatedly, repeatedly, repeatedly will make those tendons rub against your nerve in that tight spot and can irritate you and therefore give you carpal tunnel symptoms which is numbness. Numbness to your thumb, your index and your long finger and a little bit of your ring finger notably, your pinky finger should stay normal.
So, numbness to those fingers, pain perhaps in your wrist where the nerve is being pinched and often aggravated by any activities where your wrist is held in a hyper-flexed position, hyperextended position or repetitive finger motion.
Host: You’re a great educator Dr. Del Savio. You really are. What great information, so and you explain it so clearly, I can really see it. What are some of the treatments available and not just for carpal tunnel but for some of these other kinds of hand overuse injuries and we will get to arthritis separately.
Dr. Del Savio: Well again, carpal tunnel is a pinched nerve. You can also get pinched tendons just like your nerve has to pass underneath those muscles; there’s different tendons in the palm of your hand, the ones that bend your fingers into a fist that can get trapped in little tunnels that are at that bottom of your fingers in the palm. That’s what gives you a trigger finger. That is when you flex your muscles and squeeze those fingers into the palm of your hand; when you go to extend your fingers; that rope can’t quite get dragged through that tight spot and it will give you a sense of catching or triggering. And quite painful of course as you straighten out your finger.
There’s another overuse in your wrist. That the tendons that lift your thumb up and down. Same idea as I always say when you can see the tendons it’s not because they went away, it’s because they are stuck in a tunnel somewhere. And if they are stuck in a tunnel; there’s a potential for friction, there’s a potential for inflammation and obviously then a potential for pain and overuse.
So, what you want to do is figure out what are those activities which are aggravating you. So, for instance, in carpal tunnel. We know it’s squishing of that wrist into a bent position. So, one thing we tell folks is, wear a brace at night. A light brace. Something that keeps your wrist in sort of a neutral position as you sleep so you don’t curl it underneath your chin or cock it underneath your chin as you are sleeping and cause it to be irritated.
For things like the trigger finger, or this wrist DeQuervain’s tendonitis. Again, identifying the positions that aggravate the pain and doing your best to avoid those. And because this is all due to inflammation; anti-inflammatories, Advil, Aleve, over-the-counter anti-inflammatories, as long as of course they don’t interfere with your other medications can be helpful.
The brace for the carpal tunnel unfortunately is the only nonsurgical treatment. There are cortisone injections but unfortunately, they don’t treat the problem except for temporarily. Unlike tendonitis, where cortisone injections can actually cure the problem. So, carpal tunnel is bracing and if that doesn’t work, got to probably consider surgery. Trigger finger, DeQuervain’s tendonitis; those can actually be cured with things like bracing, anti-inflammatories, occupational therapy, and even cortisone injections. Of course, if all those things fail; there’s always a surgical option.
Host: I’m sure that there is. Now tell us about arthritis. Because this can happen not necessarily from repetitive, but osteoarthritis of the hands can happen and swollen and painful and that’s not something that’s going to change, right? It’s just – you see people sometimes women with those clawed up hands when they are very old. I mean how painful must that be. What can we do if we start to notice we’re getting arthritis in our knuckles and really, I’m asking for a friend? Me.
Dr. Del Savio: Yeah. Well I’ll tell you, that’s the challenge. When patients present to me with arthritis in the office, I say really, there’s nothing that you can do to prevent arthritis. Remember, arthritis is from your grandma and grandpa, so unless you got a time machine and can go back and change up your parents; unfortunately, it is a genetic condition. Having said all that, although I have no way to cure somebody’s arthritis because remember, arthritis is a breakdown of that beautiful smooth Teflon coating called cartilage inside of your joint. And when that tissue begins to fray or wear away; what happens is you have cobblestones rubbing on each other inside your joints, rather than smooth Teflon coated layers.
But we do have tools to help you cope with those symptoms. So, again, what happens when you start to get breaking down inside of your joints is you get inflammation. There’s that mechanical grinding that goes on and that mechanical grinding also in turn causes inflammation. So, our treatment is around supporting the joints mechanically and then also diminishing the inflammation. Diminishing the inflammation again goes back to those tendonitis ideas. Oral anti-inflammatories, things in occupational therapy like ultrasound, deep heat, massage. Or getting a tad more aggressive, some joints respond well to cortisone, but just remember, cortisone can’t cure arthritis. It can cure tendonitis so that’s just some inflammation in an otherwise normal tendon. When you put cortisone in a joint; it can give you some relief; but it is temporary because unfortunately; nothing replaces that beautiful Teflon coating on the inside.
Host: Well certainly it doesn’t but what do you think Dr. Del Savio about like chondroitin or if people are using like the hot wax on their hands or that kind of things, a paraffin machine. Do any of those help?
Dr. Del Savio: Well, I’ll tell you. The paraffin bath is a great coping tool, but again, it’s not curing stuff, but you are 100% right. That is a terrific tool. I encourage my patients to go out there, get one and a trick I learned from one of my patients who had terrible rheumatoid was, she got a really good timer; she plugged it in in her bathroom and she had that darn bath heating up every night at 7 o’clock and then turn off automatically at 10 o’clock at night. So, she didn’t have to worry about remembering or forgetting to plug that in so she could dip her hands in every single night and if she fell asleep with the wax on her hands feeling all delicious and good; not a great big deal. It shut itself off.
So, paraffin baths are awesome. The chondroitin is a whole different animal. There are some people who swear by it. So, I’m not a naysayer. Listen, I believe in acupuncture no studies to support it. but the problem is that we don’t really know who specifically is going to be helped by chondroitin and we don’t have any studies that really support its utilization.
So, what I will say to patients is listen, it’s and over-the-counter tool. Try it. try it for three months and if it makes you feel better; terrific. Keep taking it. if on the other hand, after three months, you don’t really feel that it’s helping your type of arthritis; stop throwing good money after bad and try something different.
Host: That’s great information and so well put, so what do you want us to take from this episode Dr. Del Savio about hands and wrists and what we are doing to ourselves with our overuse and repetitive strain injuries. What can we do? Give us your best advice.
Dr. Del Savio: Well the first thing is just to be self-aware. Most people kind of know why they are getting a problem. They really, really think about it. if you stat getting aching and pain in your hands; did you start doing something new differently. Maybe you changed your work out routine in the gym. Maybe you changed your keyboard at the office. Maybe you changed how you sit in the car. Maybe you changed how you watch TV at night. So, really do sort of a deep dive. Those are the questions I’m going to ask in my office. What changed in your life?
Now if nothing really has changed in your life; then I’m going to start asking you about what do you do every day repeatedly and repeatedly and think about your positions and postures. And if you can adjust on your own; that’s the best way to treat these things. If you truly can’t adjust; come see a health hand professional. We’ll examine you. We can give you some advice around again, some anti-inflammatory medications, some modalities with our occupational therapists and the appropriate brace.
Just as a closer, please don’t go out and buy a brace on your own. I see so many people who spends tens of dollars or hundreds of dollars even on braces and they are the wrong braces. So, again before you spend money on braces, it’s probably worthwhile having someone take a good look at you, really evaluate what’s going on, both by x-ray, by physical exam, by history and then guide you into lifestyle changes, postural changes and then some other coping tools that they can offer you without wasting your time and money.
Host: What a great tip. That was certainly well worth the whole episode, was that tip right there for sure. Thank you so much Dr. Del Savio for coming on. What great information and something that’s so usable right now listeners. You can take everything she said and do it right now. From her biomechanical tips to setting up your workstation to seeing a physician before you go out and spend money on a brace that may not do the job for you. And of course texting. We need to look at that for sure too.
Thank you again Doctor, for joining us. This is Doc Talk presented by Montefiore St. Luke’s Cornwall. For more information, please visit www.montefioreslc.org, that’s www.montefioreslc.org. I’m Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): If you’ve ever suffered overuse injury of the hand, wrist or elbow, as I have; you know how frustrating, painful and limiting it can be. It can be so frustrating. My guest today is Dr. Gina Del Savio. She’s an orthopedic surgeon and the Montefiore St. Luke’s Cornwall Chief Medical Officer. Dr. Del Savio, I’m so glad to have you back on with us today. This is a problem that’s affecting so many people in the country today for various reasons we will discuss. But what are some of the most common ergonomic repetitive strain injuries of the hand and wrist that you see?
Gina Del Savio, MD (Guest): Well, I’ll tell you as you said with all of us now on keyboards and manipulating our cell phones and our smart phones; we’re using our hands more and more for small manipulative type activities and of course, that is going to cause problems. Things like, carpal tunnel, which is a pinched nerve in your hand or trigger fingers which is a form of tendonitis. There’s a wrist tendonitis called DeQuervain’s tendonitis and even tennis elbow which is actually a tendonitis in the elbow from using your fingers repetitively.
Host: So, as you say, computers and we are all using our fingers repetitively and certainly texting, my goodness, I’m thinking all the teenagers are going to have so much arthritis in their thumbs and what is there; there’s something called texting thumbs or something, right?
Dr. Del Savio: Yeah, we’re starting to see these in younger folks now and again, it’s an inflammation around those ligaments and tendons that motor up your thumbs which in the past, unless you were an avid seamstress or perhaps a musician; you just didn’t do this on a repetitive everyday basis. So, again, as you pointed out; lots of different activities which can aggravate these things that are now part of our everyday life and that you can’t really stop doing.
Host: So, then what can we do? Before we get into some treatments or even diagnosis, if you are sitting at your desk and for me Dr. Del Savio, I started getting a lot of pain in my wrist and elbow and I changed my mouse to one of those penguins that sits upright, and I changed my biomechanics and I made it go away. What do you want us to know about setting up our work station or doing things that we can do that can hopefully prevent some of this?
Dr. Del Savio: Well, I think it’s really important for anybody who sits in any position all day long to remember that the tendons that move your fingers and the nerves that innervate your fingers are just simply rope, so it you think of all those toys when you had as a child where you pulled a rope and things moved, whether it was a crane or a Jacob’s ladder; that’s really what’s going on in your arm. And so, what you want to do is think about positioning yourself so that all those ropes are nice and lose and relaxed as you sit focused on your activities for the day.
So, first of all, that is going to mean that. Starting at your elbow, you don’t want to have your elbow bent really sharply like more than 90 degrees. You want to have it slightly less than 90 degrees, slightly straightened out. Then, if you move on down to your wrist; you want to think of your wrist the same way. You don’t want to have your wrist all cocked up so that it’s at that sharp angle and your forearm is now resting on your desk. And at the same time, you don’t want your workstation so low that your hand is dipped forward and squishing everything on the palm side of your hand.
So, elbow at just a little less than 90 degrees, wrist in a neutral or flat posture and if you do that while sitting up in a chair that gives you good back support and again just holding up your back nice and straight with your feet firmly planted on the ground; that’s a good start. That’s a good start.
Host: That’s great advice. And something that is – I mean that’s ergonomics and people don’t really always think about that as they’re typing away and maybe their keyboard is up on an angle or they’re sitting not tall enough as you explained. So, all of these factors play in Dr. Del Savio. Let’s talk about carpal tunnel. People hear that term and they really don’t know what it even is.
Dr. Del Savio: Right and there is a lot of misperceptions about it. So, carpal tunnel is actually a pinched nerve physically in the palm of your hand. I say to my patients, remember, all nerves start up at the level of your neck. That nerves comes down your neck, it runs down you arm, actually on the palm side of your forearm. Not to get from your forearm into the tips of your fingers where it gives you your sensation; it has to pass under those big thick muscles that are at the bottom of your hand. So, I say, think of it like water under a bridge, that nerve has to pass underneath those muscles to get to the tips of your fingers so you can feel.
Well what happens is, that big fat wad of muscles now is sitting on top of your nerves and if you turn your wrist over, there’s a bunch of bones. Your nerve is literally between a rock and a hard place. And so, now anything you do that increases that pressure there; is going to pinch your nerve even more. So, any activity where you cock your wrist up, or you bend your wrist down and in either of those positions; moving your fingers repeatedly, repeatedly, repeatedly will make those tendons rub against your nerve in that tight spot and can irritate you and therefore give you carpal tunnel symptoms which is numbness. Numbness to your thumb, your index and your long finger and a little bit of your ring finger notably, your pinky finger should stay normal.
So, numbness to those fingers, pain perhaps in your wrist where the nerve is being pinched and often aggravated by any activities where your wrist is held in a hyper-flexed position, hyperextended position or repetitive finger motion.
Host: You’re a great educator Dr. Del Savio. You really are. What great information, so and you explain it so clearly, I can really see it. What are some of the treatments available and not just for carpal tunnel but for some of these other kinds of hand overuse injuries and we will get to arthritis separately.
Dr. Del Savio: Well again, carpal tunnel is a pinched nerve. You can also get pinched tendons just like your nerve has to pass underneath those muscles; there’s different tendons in the palm of your hand, the ones that bend your fingers into a fist that can get trapped in little tunnels that are at that bottom of your fingers in the palm. That’s what gives you a trigger finger. That is when you flex your muscles and squeeze those fingers into the palm of your hand; when you go to extend your fingers; that rope can’t quite get dragged through that tight spot and it will give you a sense of catching or triggering. And quite painful of course as you straighten out your finger.
There’s another overuse in your wrist. That the tendons that lift your thumb up and down. Same idea as I always say when you can see the tendons it’s not because they went away, it’s because they are stuck in a tunnel somewhere. And if they are stuck in a tunnel; there’s a potential for friction, there’s a potential for inflammation and obviously then a potential for pain and overuse.
So, what you want to do is figure out what are those activities which are aggravating you. So, for instance, in carpal tunnel. We know it’s squishing of that wrist into a bent position. So, one thing we tell folks is, wear a brace at night. A light brace. Something that keeps your wrist in sort of a neutral position as you sleep so you don’t curl it underneath your chin or cock it underneath your chin as you are sleeping and cause it to be irritated.
For things like the trigger finger, or this wrist DeQuervain’s tendonitis. Again, identifying the positions that aggravate the pain and doing your best to avoid those. And because this is all due to inflammation; anti-inflammatories, Advil, Aleve, over-the-counter anti-inflammatories, as long as of course they don’t interfere with your other medications can be helpful.
The brace for the carpal tunnel unfortunately is the only nonsurgical treatment. There are cortisone injections but unfortunately, they don’t treat the problem except for temporarily. Unlike tendonitis, where cortisone injections can actually cure the problem. So, carpal tunnel is bracing and if that doesn’t work, got to probably consider surgery. Trigger finger, DeQuervain’s tendonitis; those can actually be cured with things like bracing, anti-inflammatories, occupational therapy, and even cortisone injections. Of course, if all those things fail; there’s always a surgical option.
Host: I’m sure that there is. Now tell us about arthritis. Because this can happen not necessarily from repetitive, but osteoarthritis of the hands can happen and swollen and painful and that’s not something that’s going to change, right? It’s just – you see people sometimes women with those clawed up hands when they are very old. I mean how painful must that be. What can we do if we start to notice we’re getting arthritis in our knuckles and really, I’m asking for a friend? Me.
Dr. Del Savio: Yeah. Well I’ll tell you, that’s the challenge. When patients present to me with arthritis in the office, I say really, there’s nothing that you can do to prevent arthritis. Remember, arthritis is from your grandma and grandpa, so unless you got a time machine and can go back and change up your parents; unfortunately, it is a genetic condition. Having said all that, although I have no way to cure somebody’s arthritis because remember, arthritis is a breakdown of that beautiful smooth Teflon coating called cartilage inside of your joint. And when that tissue begins to fray or wear away; what happens is you have cobblestones rubbing on each other inside your joints, rather than smooth Teflon coated layers.
But we do have tools to help you cope with those symptoms. So, again, what happens when you start to get breaking down inside of your joints is you get inflammation. There’s that mechanical grinding that goes on and that mechanical grinding also in turn causes inflammation. So, our treatment is around supporting the joints mechanically and then also diminishing the inflammation. Diminishing the inflammation again goes back to those tendonitis ideas. Oral anti-inflammatories, things in occupational therapy like ultrasound, deep heat, massage. Or getting a tad more aggressive, some joints respond well to cortisone, but just remember, cortisone can’t cure arthritis. It can cure tendonitis so that’s just some inflammation in an otherwise normal tendon. When you put cortisone in a joint; it can give you some relief; but it is temporary because unfortunately; nothing replaces that beautiful Teflon coating on the inside.
Host: Well certainly it doesn’t but what do you think Dr. Del Savio about like chondroitin or if people are using like the hot wax on their hands or that kind of things, a paraffin machine. Do any of those help?
Dr. Del Savio: Well, I’ll tell you. The paraffin bath is a great coping tool, but again, it’s not curing stuff, but you are 100% right. That is a terrific tool. I encourage my patients to go out there, get one and a trick I learned from one of my patients who had terrible rheumatoid was, she got a really good timer; she plugged it in in her bathroom and she had that darn bath heating up every night at 7 o’clock and then turn off automatically at 10 o’clock at night. So, she didn’t have to worry about remembering or forgetting to plug that in so she could dip her hands in every single night and if she fell asleep with the wax on her hands feeling all delicious and good; not a great big deal. It shut itself off.
So, paraffin baths are awesome. The chondroitin is a whole different animal. There are some people who swear by it. So, I’m not a naysayer. Listen, I believe in acupuncture no studies to support it. but the problem is that we don’t really know who specifically is going to be helped by chondroitin and we don’t have any studies that really support its utilization.
So, what I will say to patients is listen, it’s and over-the-counter tool. Try it. try it for three months and if it makes you feel better; terrific. Keep taking it. if on the other hand, after three months, you don’t really feel that it’s helping your type of arthritis; stop throwing good money after bad and try something different.
Host: That’s great information and so well put, so what do you want us to take from this episode Dr. Del Savio about hands and wrists and what we are doing to ourselves with our overuse and repetitive strain injuries. What can we do? Give us your best advice.
Dr. Del Savio: Well the first thing is just to be self-aware. Most people kind of know why they are getting a problem. They really, really think about it. if you stat getting aching and pain in your hands; did you start doing something new differently. Maybe you changed your work out routine in the gym. Maybe you changed your keyboard at the office. Maybe you changed how you sit in the car. Maybe you changed how you watch TV at night. So, really do sort of a deep dive. Those are the questions I’m going to ask in my office. What changed in your life?
Now if nothing really has changed in your life; then I’m going to start asking you about what do you do every day repeatedly and repeatedly and think about your positions and postures. And if you can adjust on your own; that’s the best way to treat these things. If you truly can’t adjust; come see a health hand professional. We’ll examine you. We can give you some advice around again, some anti-inflammatory medications, some modalities with our occupational therapists and the appropriate brace.
Just as a closer, please don’t go out and buy a brace on your own. I see so many people who spends tens of dollars or hundreds of dollars even on braces and they are the wrong braces. So, again before you spend money on braces, it’s probably worthwhile having someone take a good look at you, really evaluate what’s going on, both by x-ray, by physical exam, by history and then guide you into lifestyle changes, postural changes and then some other coping tools that they can offer you without wasting your time and money.
Host: What a great tip. That was certainly well worth the whole episode, was that tip right there for sure. Thank you so much Dr. Del Savio for coming on. What great information and something that’s so usable right now listeners. You can take everything she said and do it right now. From her biomechanical tips to setting up your workstation to seeing a physician before you go out and spend money on a brace that may not do the job for you. And of course texting. We need to look at that for sure too.
Thank you again Doctor, for joining us. This is Doc Talk presented by Montefiore St. Luke’s Cornwall. For more information, please visit www.montefioreslc.org, that’s www.montefioreslc.org. I’m Melanie Cole. Thanks so much for listening.