Scott Delp: Better gait, better life
Engineer Scott Delp first got interested in the details of human movement when he was injured in a skiing accident and spent five years trying to recover.
Back then, today’s powerful diagnostic tools, like MRI, weren’t generally available, and Delp experienced many roadblocks and false starts in his recovery.
Delp turned that challenging experience into a career studying and developing new approaches to motor dysfunction that he puts to use helping people with conditions like osteoarthritis and cerebral palsy to walk, run and move more easily and without pain. His multidisciplinary team includes surgeons, neurologists, roboticists, engineers and computer scientists who use sophisticated computer models to analyze movement dysfunction and to counteract them through surgery, robotics, neurostimulation and other techniques, including the use of Botox.
Delp’s latest focus is on discovering approaches that inspire patients to see better movement as key to better health and view physical rehab not merely as necessary, but actually enjoyable.
Join host Russ Altman and expert in the biomechanics of human movement Scott Delp for a “moving” discussion about the joys and the benefits of motion here on The Future of Everything radio show from Sirius XM.
Transcript
Russ Altman: Today on The Future of Everything, the future of biomechanics. Now, biomechanics is the study of the internal and external forces affecting the movement or structure of living organisms. Or so, that’s what the internet tells me. It enables us to understand fundamental activities of life, particularly relevant to movement. How do humans walk? How do the stay balanced? How can they be most efficient in their walking and their running? How do they coordinate their arms and their legs? How do they do all of this while concentrating on something else? What about these changes when we’re running, or we’re jumping, or we’re swimming?
Biomechanics has great value also in evolution as we compare the structure of different organisms and how they move. Cats versus tigers, apes versus humans, dinosaurs which we have never even seen, we can make inferences about how they may have moved.
And in the context of health care, it’s not just about curiosity, but it can be about important health care conditions. Children with muscular dystrophy, who might have trouble with walking gaited problems. People who have suffered a stroke. In these settings, we can appreciate the exquisite coordination of muscles, bones, ligaments and cartilage, and try to use this knowledge to help people with these challenges.
Dr. Scott Delp is a professor of bioengineering, mechanical engineering, and orthopedics at Stanford University. Scott, how did you become interested in biomechanics, and what have been the changes you’ve seen over the last 25 years in our understanding of biomechanics, and our capabilities?
Scott Delp: Yeah, thanks, Russ. It’s great to be here. I got interested in studying human movement because I had my own impairment in movement. I was skiing with some buddies during the winter as an undergraduate and I had a bad ski rack, and rip some muscles off of my pelvis. And following that, I really had difficulty walking for about five years. And it wasn’t clear what to do, or how to restore that.
I visited lots of great orthopedists and physical therapists, and so I kind of turned to my own engineering know how to try to sort out how to best recover muscle strength and your motion, coordination, and then ended up coming to Stanford and studying as a mechanical engineer interested in robotics, studying with a neuroscientist. That combination of dynamics, and robotics, and neuroscience, and computational methods really turned out to be a powerful approach.
Russ Altman: Yeah.
Scott Delp: So, when you think about movement, it’s really complicated. If you think about it, a robot, we would never try to design a robot or a satellite without engineering tools. But most of what we do or did in studying movement back when I was a graduate student, is watch people move and then try to just think about it and figure out what’s going on. It’s not possible to do that —
Russ Altman: Yeah, so there’s a lot going on under the hood —
Scott Delp: Exactly.
Russ Altman: That is difficult to believe?
Scott Delp: Yeah.
Russ Altman: So, just going back to your industry, your injury, did they know what was wrong —
Scott Delp: No.
Russ Altman: And not know how to treat it, or they didn’t even know what was wrong?
Scott Delp: No, they didn’t know. It wasn’t, I’m old as you know, and exactly your age.
Russ Altman: I think you’re perfectly good age.
Scott Delp: And back then, when you got hurt, there wasn’t routine MRI that you could do to assess what was going on. So, it was more just about physical examinations and your symptoms, and there was, there weren’t good diagnostic methods that were broadly used.
Russ Altman: Yes. So that actually is a great entry into, if you had that injury today, what are the kinds of things that would happen to give us a sense of how the field has moved forward?
Scott Delp: Yeah, if somebody walked in to one of our clinics now and had an injury like that, the first thing we do is get an MRI. We know exactly what was hurt, what the extent of the injury was, what the optimal rehabilitation would be. Back then the plan was immobilization. So they put me in a cast, which is absolutely the worst thing you can do for a soft tissue injury. So, you know —
Russ Altman: Great for a bone, right?
Scott Delp: Yeah, the bones healed, but my bones weren’t broke —
Russ Altman: Right.
Scott Delp: You take off the cast and your muscles are gone, and they’re all scarred down. So now, what you do when there’s a soft tissue injury, we keep it moving, gently moving with continuous passive motion so the soft tissue can recover but doesn’t get stiff and you don’t lose the strength of your muscles.
Russ Altman: Makes perfect sense. So, I know that as your career has progressed, one of the areas, and you’ve focused on many areas, and I’d love to hit as many of them as possible, but let’s go to the first one that I was aware of, was the use of these kinds of technologies and ways of thinking for looking at kids with muscular dystrophy. So, could you kinda, for people who are not familiar with the disease, could you characterize what’s the issue with the disease, what have been traditional ways to treat it, and how is biomechanical insights kind of revolutionizing the way we look at these children and help them?
Scott Delp: Yeah, so the area that I’ve began to focus and still work on, is cerebral palsy.
Russ Altman: Sorry, tell us about that disease.
Scott Delp: Yeah, in kids with cerebral palsy it’s quite common, about two in 1000 kids born have CP and it’s primarily a movement disorder that arises from damage to the developing brain. So, and gait impairments, impairments in walking are a primary problem. So kids wanna be able to walk, and run, and play with their peers, and if they are moving slowly or can’t walk at all, it’s really, holds them back. And so, their families come into the clinic, and they’re very concerned about how to optimize their performance. And that’s the way I frame this. It’s the way I frame all of biomechanics. We’re here to optimize people’s performance.
Russ Altman: Okay, great.
Scott Delp: So, if it’s a kid with cerebral palsy, we wanna get them able to walk, or walk at a higher speed, or if they’re already good at household ambulation, walking out into the community or running with their friends, so, for sure a physical exam by a doctor is important. But we also have them come through a motion capture lab. So we use cameras and characterize the motions that they can perform now, and then we use a detailed biomechanical model to see which muscles are causing what motion.
Russ Altman: So, this is a computational model?
Scott Delp: A computational model to —
Russ Altman: I see. And you try to replicate what you’re seeing in their walk to get, as we said, to look under the hood at how the muscles might be not optimally firing.
Scott Delp: Exactly, so we can measure the external motion, but we don’t know what’s happening inside. But we take a biomechanical model, we match it to that subject, we reproduce their dynamics, and then we know inside what’s happening. And then we could simulate surgery, we could simulate a Botox injection, we could put a brace on, and then we simulate a new movement, and then see what therapy is going to best restore motion.
Russ Altman: So, this sounds great, because in addition to getting all of this insight, you just listed a whole bunch of potential interventions to help the child. So, let’s just go through those. So, what kind of surgeries might you do that would help a patient with a walking dynamics problem?
Scott Delp: Yeah, so one of the common gait abnormality is walking down in a crouch. So, and it is thought frequently that the hamstrings muscles that cross behind your knee, are too tight, they’re firing too much, and lengthening those muscles surgically, I think a surgically assisted hamstring stretch.
Russ Altman: Yes.
Scott Delp: Could enable them to extend their knees and walk in a more erect posture. So, one of the things that we’ve been doing is to understand which patients are good candidates for that, which are not good candidates, and we find for these muscle lengthening surgeries, if we can identify good candidates, the outcome rate of surgery is much better —
Russ Altman: Interesting.
Scott Delp: Than we can do with, just watching them walk, or even with sophisticated gait analysis. We need that motion data with a biomechanical model to understand exactly what’s causing what, and what the intervention should be.
Russ Altman: This is The Future of Everything. I’m Russ Altman, I’m speaking with Dr. Scott Delp right now about cerebral palsy and helping plan surgeries. So, how enthusiastic are your physician surgeon collaborators about having you, you’re an engineer who comes in and makes pretty strong recommendations to what they should be doing. Is that a stressful interaction, or a positive one?
Scott Delp: No, it’s a very positive interaction. It’s a multidisciplinary team that includes a surgeon, a neurologist, a physical therapist, the gait analyst, and an unusually an engineer or two that meets to review these cases. And it’s pretty clear that we need all of us to make good decisions for every kid that that comes in. And so, the best labs, including the lab here at Stanford, and other leading children’s hospitals, all have an engineer on their team. And that those multidisciplinary teams also get together at national conferences so that engineers can share best practices —
Russ Altman: Yes.
Scott Delp: And we debate cases openly. People will bring their tough cases and we do it as a whole community.
Russ Altman: Kinda floating all boats?
Scott Delp: Yeah.
Russ Altman: So, the second intervention I think you mentioned, is Botox. So, I think a it’s a toxin, it’s causes paralysis if I’m not mistaken. Tell me where Botox might play a role in some therapy.
Scott Delp: Yeah, so in cerebral palsy, when issue is spasticity of muscles. So the muscles are overexcited. They’re excited in response to a stretch that normally we could move our joints and stretch muscles and they could stay relaxed. So, that occurs in stroke and spinal cord injury as well. Spasticity is a big problem. And one of the uses of Botox is to inject muscles that are spastic to try to reduce their activity. It’s just the way people inject Botox into their face to essentially —
Russ Altman: Yeah.
Scott Delp: Paralyze your face —
Russ Altman: So that you don’t have wrinkles.
Scott Delp: So that you don’t have wrinkles.
Russ Altman: I’ve lost that battle, sorry.
Scott Delp: So, you can inject skeletal muscles in the limbs to try to restore more normal range of motion and reduce spasticity.
Russ Altman: So, you mentioned in this discussion of treatments that this might also work for stroke. And as everybody knows, stroke is a huge burden on society. It causes great challenges for people who’ve suffered from strokes. I take it that in addition to helping these children, many of these technologies are also applicable to people who have lost, maybe half part of their right side or left side from a stroke. What are the current opportunities and achievements in that area?
Scott Delp: Yeah, so I’m glad you asked. It’s an area that I’ve been thinking about a lot, and we’re beginning to work on, and the way stroke rehab happens now, is again, we’re trying to optimize somebody’s performance. It may be a dad who wants to walk down the aisle with his daughter at a wedding and he’s unable to walk, so we’re trying to achieve those meaningful objectives. And the way it’s done now in clinic, patient will come in, meet with a physical therapist, the occupational therapist for 45 minutes and there’s an outpatient, for example. And they’ll work hard on those goals. The problem is, the dose of therapy is too small. We give them exercises to go home with, we don’t know if they do it.
Russ Altman: I recently got a prescription to do some exercises.
Scott Delp: Yeah, are you doing it?
Russ Altman: Six weeks ago, I haven’t done it once.
Scott Delp: Yeah, exactly. So, one of the things we wanna do is develop a program for ubiquitous rehabilitation so that we can monitor you to see if you’re doing your exercises. we can guide you through the exercises. If you’re, and the dose of therapy we could get, if somebody has a stroke, if they wanna recover, and you have a paretic limb, if you don’t use that limb, it will not recover.
Russ Altman: So what does paretic mean?
Scott Delp: So it’s paralyzed essentially.
Russ Altman: Paralyzed.
Scott Delp: So, in stroke, as you mentioned, one side of the brain is usually affected, and it’s the other side of the body that’s affected. And that affected side, we usually call it paretic side, or paretic limb.
Russ Altman: Gotcha.
Scott Delp: And you need to use that. The only therapy we really know that works, is if you take the unaffected side and you constrain it.
Russ Altman: Oh!
Scott Delp: Then people to use —
Russ Altman: So, force them to use the so called bad arm or bad limb?
Scott Delp: Yeah, exactly. So, the goal of Future Rehab, to do rehab everywhere, is to track people’s limbs, give them guidance, remind them that they need to use the limb so that they don’t get 45 minutes of therapy a week, they’re getting therapy every day all the time, and if we do that, they will recover more quickly and more robustly.
Russ Altman: This is The Future of Everything, I’m speaking with Dr. Scott Delp about stroke recovery and the importance of sustained rehab, and not just episodic rehab. Now, but you said something there that I wanted to catch on, which is, you said that we might be able to, for example, put on sensors and monitor how they’re doing. So, this all of a sudden becomes part of the kind of digital mobile health world. And of course, there’s also issues of privacy. Like, my doctor doesn’t know that I haven’t done any of the exercises that she prescribed six weeks ago, and in fact, if I happened to see —
Scott Delp: And you’ll probably lie to her, yeah.
Russ Altman: And I will totally lie to her —
Scott Delp: Exactly.
Russ Altman: And say, yeah, I’m still having the pain. Those exercises didn’t seem to work because I didn’t do them. So, is this now part of a bigger digital health movement? And I know you’ve worked in this area, what is the way to approach this so that you can gain the confidence and trust of the patients while helping them so they don’t say, uh-oh, now this is part of a big brother rehab routine. And now I’m feeling nervous that I’m gonna be judged by my doctor, I won’t be able to lie to my doctor, and so, this is all very problematic.
Scott Delp: Yeah. So, this is one of the big transformations of studying human movement. For me as a bio-mechanist, my students at I will historically do studies of 10 or 20, or maybe 50 subjects, they come into the lab. But now, everybody is equipped with an accelerometer, so —
Russ Altman: Like in your phone?
Scott Delp: Yeah, in your phone, your phone’s equipped with an accelerometer, and gyro that measures velocities, and that’s how the user interface works. For me as a bio-mechanist, I now have millions of subjects around the world that we can monitor and collect their data. So, your question was, how do we go about doing that in an ethical way?
Russ Altman: Helping people but also maintaining their trust.
Scott Delp: Exactly. So, people have to consent. So, they have to consent. And informed consent. So, we’re gonna do this, do you agree? And if they don’t agree, then we don’t have them participate. So most people, you know, they wanna get better. And so, the quantity of data we can get on people’s movement, you know, for the kids with CP, they may come cerebral palsy, they may come to the lab once a year. But we can take videotapes of them once a week and see how their gait is progressing. If they’re getting worse, if they’re getting better, how the therapy is going, and that level of monitoring is extremely valuable because the way we do it now is just super constrained based on expensive equipment.
Russ Altman: Yeah, so tell me. So, yeah, so it’s obvious to me not even being an expert, that there’s gonna be a difference in the quality of data you get when you bring somebody, I think you called it the gait lab or the instrumentation lab, where you watch them take movies, get a really good idea of every single muscle and how it’s moving versus the kind of data you might get from a watch, a Fitbit, or from a cell phone. So, clearly there’s a degradation in the quality of data that you’re getting. On the other hand as you said, this is for millions of people. So, how much information can you extract from my phone or from my Fitbit, about what my activity level is, and whether I’m optimized to use the word that you introduced before?
Scott Delp: Yeah, so we can get pretty good data from a video. So, we’ve been working on problems, and this is an area of tremendous growth, where from a video we extract meaningful biomechanical —
Russ Altman: And this is like a phone video?
Scott Delp: You just take a video with your phone. And from that we can use machine learning algorithms and fit a biomechanical model to your video data and get pretty high-quality data characterizing your motion sufficient to predict some clinical outcomes, so —
Russ Altman: So, that’s amazing.
Scott Delp: That’s exciting.
Russ Altman: This is something that used to be, I have to do it in the gait lab, and now at least for a subset of cases, a movie from iPhone or a Samsung might be enough.
Scott Delp: And you could just submit the video to a website anonymously, and you’d get a score and some biomechanical insights that we could essentially deliver for free. So, that’s opposed to expensive test when you come in the gait lab. From just the accelerometer on a phone or a Fitbit, you get different kinds of data. And it’s much lower resolution than that. But we still can figure out how someone’s using their arm, if they’ve had a stroke, for example, or just how much physical activity that you’re getting. And physical activity is super important. Without sufficient physical activity, we really suffer not just cardiovascular disease and diabetes, but four kinds of cancer, depression, anxiety —
Russ Altman: I think mood, yeah.
Scott Delp: Are profoundly affected by the lack of human movement. So, one of the big areas in biomechanics and the studies of human movement, is to motivate mobility. Only 20% of the people in US get sufficient physical activity to maintain their bodies and minds.
Russ Altman: This is The Future of Everything, I’m Russ Altman, more with Dr. Scott Delp, especially on this issue of mobility, its benefits and ways to encourage it. Next on Sirius XM Insight 121. Welcome back to The Future of Everything, I’m Russ Altman, I’m speaking with Dr. Scott Delp about biomechanics, but now also, mobility in general and it’s health importance and benefits. So at the end of the last segment, you kinda said something that’s amazing. You said that, it’s not just about your cardiovascular health, in terms of the importance of movement or daily functional activities, but this can have implications, I think you said for cancer, for mood disorders, psychiatric and neurologic, and many other parts of health. So, say a little bit more about that and say, what kind of ways can we bring technology and to help people know that they even have a problem that needs to be addressed in terms of their mobility?
Scott Delp: Yeah, so this is a huge public health need and really a great opportunity. Physical activity is really potent medicine. It works on lots of different things, in terms of disease prevention. As I mentioned, a number of different diseases that go well beyond what is traditionally known in cardiovascular health, and diabetes and obesity, but to many types of cancer, there’s a clear and statistically significant link between physical activity and cancer risk. And also, when you think about mood, the big two, depression and anxiety, physical activity is a potent antidepressant.
Russ Altman: Right.
Scott Delp: And an effective anti anxiety medicine. And the awesome thing here too is that, for sure, vigorous physical activity is important, but the medicine works even in small doses, and even in single doses, like going for a good long walk or a hike is you get benefit immediately.
Russ Altman: And it’s measurable and people have shown it.
Scott Delp: It’s absolutely measurable, there’s very clear evidence for this. And so, this is an opportunity because it is essentially free potent medicine that is effective across a broad class of diseases and disorders.
Russ Altman: So, I know that you lead a big national center trying to focus on mobility and mobilization, presumably with these kinds of goals in mind. So, tell me how technology and the kinds of expertise that you have can be deployed to help a much larger piece of the population, assess their own health and hopefully improve it.
Scott Delp: Yeah, so it’s a big data center funded by the NIH focused on human movement. And, so one of the things that we did was we use people’s cell phones to monitor their movement. So, we conducted the largest survey of physical activity in the world by a factor of 1000. So, instead of having hundreds or thousands, we had millions of subjects who were participating in this study.
Russ Altman: All with consent?
Scott Delp: They consented that through the use of the app —
Russ Altman: Amazing.
Scott Delp: It wasn’t —
Russ Altman: So you can do it at a large scale?
Scott Delp: You can do it at a large scale. And one of the amazing things we found was that the activity in a population is not distributed uniformly. And with that, it gives us really great insight. So, just like there’s income inequality, there’s activity inequality. So, there’s activity rich people and activity poor people, and a greater fraction of people who are activity poor are women. And where there are populations where women are activity poor, they lose life years. We also can figure out that if we’re gonna do an intervention where you wanna intervene, is with people who are activity poor because there at small dose will make a big difference to get people up to —
Russ Altman: Right, so somebody is regularly exercising, prescribing more exercise, they probably would do it but the —
Scott Delp: They’re fine.
Russ Altman: The incremental benefit might not be that great.
Scott Delp: If they wanna compete or something like that, they’re gonna need more exercise. But just to maintain physical and mental health where you can have the greatest effect.
Russ Altman: Yes.
Scott Delp: Is in individuals who are activity poor. So, a screening to identify in the population where there’s opportunity, is a great public health possibility.
Russ Altman: Do we have good knowledge about what to do when we’ve identified these individuals?
Scott Delp: It’s a great question, and we just started a project called the Catalyst project that brings together, that I’m leading, it brings together psychology and biology, and genetics, and even English department that relate it to narratives to get people engaged in stories so that the story, as the story progresses —
Russ Altman: Right.
Scott Delp: It only progresses, so, it’s a real challenge because behavior change —
Russ Altman: Behavior.
Scott Delp: Chart is very hard.
Russ Altman: Yes.
Scott Delp: And the only thing you can do to get people to really change things fundamentally over in a long term is if there’s some real meaningful value that’s deep within some emotional connection to —
Russ Altman: To motivate the ongoing change.
Scott Delp: To motivate an ongoing change, and the current way of just quantifying and giving people data, it doesn’t work. It works in a few people, people who were kind of —
Russ Altman: Compulsive.
Scott Delp: compulsive, it can kind of work. But for a lot of people, it can actually be discouraging, because they see their data, it’s compared to a norm, they’re below the norm, and they feel inadequate. And that’s a showstopper for lots of people. So, the way current apps are delivering those data, work for some people and don’t work for a lot of people. So, one of the things we’re trying to do is solve this master problem of how do you motivate physical activity? Knowledge isn’t enough. Everybody knows —
Russ Altman: Right.
Scott Delp: Moving around is good for you, but it doesn’t get people going.
Russ Altman: This is The Future of Everything, I’m Russ Altman, I’m speaking with Dr. Scott Delp. And now we’re talking about a little bit of behavioral science, but I wanna stay there for a minute because I think what you just said rings true for a lot of people. A lot of people have got a Fitbit, they have a great two months with it, and then either the battery goes out, or they take it off for some reason, and it never gets back on. And so, the behavior has not fundamentally changed. And I believe that you have even, I reviewed your papers, I think you have started to write a little bit about these motivational issues and people’s self image, and the importance of yourself image with respect to how much you might try hard or not try hard. So that, it was an exciting and surprising thing for me to see ’cause I thought, you know, okay, the guest is gonna be a bioengineer, but he looks like he cares about these motivational type issues. So, can you say a little bit more about what is thought to work, what doesn’t work and what we should be doing?
Scott Delp: Yeah, it’s kind of amazing. I’ll tell you two stories. One is about people who have osteoarthritis. So, in many instances, they think moving hurts, I shouldn’t move, it’s gonna make my disease worse. It’s actually the opposite is true. And so for them, the motivation is reducing their pain. People are very motivated to reduce their pain. If you hurt and you have a way out of it, that’s a pretty good fundamental motivation.
Russ Altman: Go for it, yes.
Scott Delp: So, for people with osteoarthritis, to view their disease as modifiable an opportunity to change, versus it’s just a sentence to sedentary behavior of pain for many years. So, you need to kind of flip that switch to get people going. So I’ve been working with Alia Crum, she’s a professor in psychology, studies mindset. And how information that you give people not only changes their behavior, but changes their physiology, so —
Russ Altman: So, what do you mean by, what is physiology mean in that setting?
Scott Delp: Yeah, so for example, we had people come into our lab in one of Allie’s experiments, and we did a genetic test on them, where people have high or low aerobic capacity. We measured their aerobic capacity in the human performance lab that I direct and measured their VO2 max, how much oxygen they can burn. It’s a measure of your fitness. We had them come back, so we know what their fitness is.
Russ Altman: Yes.
Scott Delp: We have them come back a week later, and then we randomize them to tell them whether they have higher low capacity. If you tell them they have low capacity, they work just as hard, but their physiology changes what the oxygen content, the CO2 content, things that you cannot voluntarily control, or change.
Russ Altman: We thought.
Scott Delp: Yeah, well, so it’s not really voluntary.
Russ Altman: Right, something is going on.
Scott Delp: It’s subconscious for sure, something is going on in physiological measures —
Russ Altman: Just telling —
Scott Delp: Just telling them —
Russ Altman: What their genetics showed —
Scott Delp: Absolutely.
Russ Altman: Change their physiological capability.
Scott Delp: Yes.
Russ Altman: Which is kind of mind blowing.
Scott Delp: Yes, so how you view exercise can also change how you respond to the exercise. So, it’s not just the amount but how you’re approaching it. And, if you’re approaching it as a burden, as medicine you have to take versus a social fun activity.
Russ Altman: Yes.
Scott Delp: These are the things that Allie’s teaching me that, we need to bring biomechanics —
Russ Altman: And then this needs to be folded in.
Scott Delp: Psychology together, yeah.
Russ Altman: Because with your surveillance capabilities, and I use that in a positive way, you might discover that there are people that you want to alert that your activity level is a danger to your health, but just telling them that is not enough, and now you’re beginning to get insights into how you might actually be able to advance their understanding to help them intervene.
Scott Delp: The other big thing that has to change is personalization. Currently, is kind of a one size fits all, but people respond differently to different stories, to different motivations, and we need to be able to understand what motivates individuals and personalize these interventions so that it works for you. And that what works for you is not gonna work for everybody. So, we need to really be able to discover that and deliver it.
Russ Altman: So, it’s great because early on you were saying that these tech interdisciplinary teams, and you mentioned doctors, and you mentioned engineers, but it’s very clear to me that the future of those teams is social scientists and behavioral scientists, psychologists who can go the final mile to help the patient make those intervention.
Scott Delp: Yeah, even storytellers.
Russ Altman: Thank you for listening to The Future of Everything, I’m Russ Altman. If you missed any of this episode, listen anytime on demand with the Sirius XM app.
