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The future of pediatric pain

An expert on pain explains why chronic pain in childhood is more common than believed and, if left untreated, it can lead to lifelong suffering. Fortunately, innovative behavioral health treatments offer hope.
Child patient's hand held by an adult in hospital.
About a quarter of young people suffer from chronic pain at some point in their childhood. | Chinnapong/Shutterstock

Laura Simons is a clinical psychologist and an authority on pain, particularly chronic pain in childhood, which is much more common than widely understood.

Most people don't even think chronic pain happens in children, says Simons. The consequences, however, are serious, ranging from learning gaps from missed school to social isolation and even depression. Better treatment begins with better understanding of the science of pain, as Simons tells host Russ Altman on this episode of Stanford Engineering’s The Future of Everything podcast.

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[00:00:00] Laura Simons: Many folks don't even recognize that chronic pain happens in children. There's about a quarter of young people who suffer with chronic pain at some point during their childhood. This can include the more common symptoms such as headache or abdominal pain. But many folks don't recognize that many kids have musculoskeletal pain, perhaps after an injury or surgery or an infection or illness. Um, and many of those folks go on to experience chronic pain in adulthood.

[00:00:35] Russ Altman: This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. If you're enjoying the podcast, please hit follow in the app that you're using. This will guarantee that you never miss an episode. 

[00:00:45] Today, Professor Laura Simons will tell us about childhood chronic pain. She'll tell us that kids experience pain, it's harder to diagnose, it can be harder to treat. But there's amazing new treatments coming out that do not involve medications that seem to be working. It's The Future of Childhood Chronic Pain. 

[00:01:05] Before we get started, please hit follow in the app that you're using to ensure that you get alerted to all of our new episodes, so you never miss the future of anything.

[00:01:20] You know, when we think about chronic pain, we usually think about adults. We think about adults, and we often think about adults who have back pain or musculoskeletal pain from arthritis. We think about how they're treated. We're trying not to use opioids because there's an epidemic going on. Other things can work.

[00:01:37] But what we don't think about is children. And you know what? 25% of children, we will learn, have chronic pain. And it's heartbreaking. They're young, they should be enjoying their childhood and their early adulthood. And instead, they're dealing with bone pain, body pain, headaches. Many of this is not related to things like cancer or infection that of course causes pain as well.

[00:02:00] So, Professor Laura Simons is an expert at childhood chronic pain. And she's an expert at how to diagnose it. She can tell you how difficult it is to explain what's happening to a young person. And she's an expert at the new treatments that are emerging to help these folks. There's virtual reality, there's sensory retraining, and there's short classes, as short as an hour and a half, that can have long term benefits to the patients. This is exciting, and this is the future of childhood pain.

[00:02:34] Laura, what is the scope of the problem of childhood pain? Help us understand where the pain is happening and why. 

[00:02:42] Laura Simons: Yeah, so, um, I want to start out by saying that many folks don't even recognize that chronic pain happens in children. There is about a quarter of young people who suffer with chronic pain at some point during their childhood. Um, this can include the more common symptoms such as headache or abdominal pain. Um, but many folks don't recognize that many kids have musculoskeletal pain, perhaps after an injury or surgery or an infection or illness.

[00:03:10] Um, and many of those folks go on to experience chronic pain in adulthood. So we have estimates now that two thirds of young people transition from adolescence into adulthood with persistent chronic pain. 

[00:03:22] Russ Altman: Wow. 

[00:03:23] Laura Simons: So the problem is pretty significant, um, and estimates from about ten years ago indicated that almost twenty billion dollars a year is spent, um, treating chronic pain in childhood. And we can just imagine how much that's, um, escalated over the past few years. 

[00:03:39] Russ Altman: Great. So, and in your response, you mentioned a couple of the causes. But I want to make sure that people have a sense of like where this pain comes from. Because I think people think, okay, kids with cancer must be having pain, kids who are athletes and break their, you know, break their leg or have a, uh, a cartilage injury. But I don't think people have a really good sense of exactly where that pain is coming from. And you mentioned things like infectious diseases and other things. So could you just expand for us a little bit, what kind of pain are we talking about? What are the sources? 

[00:04:09] Laura Simons: Well, interestingly, some of these estimates that I'm describing are actually young people with non-disease related pain. So this doesn't even include the scope of individuals who have cancer related pain, arthritis, and other rheumatoid conditions such as lupus.

[00:04:24] Um, this is really individuals who have non-disease related pain conditions. Um, for example, migraine and headache, you know, we have, it's really interesting, actually, even from a developmental standpoint. Um, young people, you know, before adolescence there, we see equal numbers of females and males who have migraines. And then when we hit adolescence, that proportion shifts dramatically, and we see much more young females having persistent migraine and many of those migraines in young boys resolving. 

[00:04:58] Russ Altman: Ah. 

[00:04:59] Laura Simons: So we do see this kind of uneven distribution of about 75 to 80% of young people are females with chronic pain conditions. 

[00:05:08] Russ Altman: So, uh, you know, you hear about kids having some pain, musculoskeletal pain when they're growing up. In fact, people call it growing pains. I don't even know if that's a thing. So I'm guessing that the diagnosis of pain is much harder in children and even in like adolescence. Because they might not even have the vocabulary or the life experience to know what is not pain and what is pain. They haven't perhaps, they're early in their life, so their experience has been much more limited. So is it a diagnostic challenge? 

[00:05:39] Laura Simons: Very much so. Um, we actually have someone in our group who focuses on diagnostic uncertainty as it relates to, the non-disease related pain journey. Um, we see that, um, about 50% of young people and their parents aren't even clear on the diagnosis that's causing the chronic pain that they're experiencing. Um, so that contributes to a very complex treatment journey where they're seeing multiple providers, they're getting a lot of unanswered questions, um, and the treatment regimen then can result in a number of tests, procedures that can be potentially even traumatizing to the young people and their parents.

[00:06:22] Russ Altman: And of course, when you're talking about pediatrics, there's kind of three people in the room, so to speak. There's the physician, there's the patient, and then there's the parent. Appropriately. Um, but I'm guessing that that creates a dynamic. Are parents good at telling when their kids are having pain or do they, are they in denial about it because it's not part of what they're expecting as part of the parenting experience? Where do the parents play into all of this?

[00:06:46] Laura Simons: Oh, I mean, the parents are really critical to the whole journey. You know, it's so incredibly important to include the parents and assess like how they're coping with it. You know, oftentimes you have a parent who's highly concerned about their child who is experiencing persistent pain because the child's not able to attend school. They see them limited in their social interactions, in their participation, in their hobbies and sports activities. Um, so we see parents who are in a you know, a high level of distress trying to seek the appropriate level of care for their child. Some of the work that we've done, um, in the past few years has really suggested that they want treatments and they want behavioral treatments earlier in the process. They're seeing that these are being offered in tertiary care, Um, rather than frontline, um, in the pediatrician's office. Um, so I think we can do better in that realm as well. 

[00:07:38] Russ Altman: And I definitely want to get to treatment. But I'm still having fun finding out about the problem. So I'm, we're, I'm just going to ask you a few more questions. One of which is what is the impact of a chronic pain on a child? I can't even imagine because we, many of us know adults with chronic pain and it's just like a showstopper in some ways for their lives, right? They can't enjoy the things that they want to enjoy it has effects on work. It has effects on their personal relationships.

[00:08:03] What happens to children who are having chronic pain? If the pain is not adequately treated? 

[00:08:08] Laura Simons: And it can have huge impacts on their life trajectory. In fact, um, so we see kids who are missing significant amount of school, which develops into a vicious circle where the more school they miss, the more behind they get, the more difficult it is to re-enter, they become socially isolated. And we saw this profoundly impacted during the course of the pandemic, where initially there were kids with chronic pain that felt relief, um, from the demands of, you know, needing to wake up and get to school, but doing the remote learning. But then really struggling with re-entering, um, back into the school environment. Um, so the social isolation piece is tremendously impactful. Families are hugely impacted. Siblings, parents, family vacations get canceled. The regular activities that bond them and connect them, they're not able to engage in. So there's, you know, multiple ways that we see this, um, impacting the child, um, and, you know, it's pretty tremendous. 

[00:09:08] Russ Altman: Is it accompanied by an increased rate of diagnosis of mental health issue? I mean, pain in many ways is a mental health issue, right, itself. But do we see more depression and things like that because of the experience that they're having?

[00:09:22] Laura Simons: Um, yeah, I mean, we really view chronic pain as a biopsychosocial process and inherent in the definition of pain from the International Association for the Study of Pain is that it is a sensory and emotional experience. And oftentimes people forget about that second component and focus really only on the sensory and motor aspects.

[00:09:43] But we don't feel pain without feeling a negative emotion. If you stub your toe, it hurts, and you scream and you're not happy about it. And so that's incredibly important to think about that the normalization and the validation of having, um, you know, increased symptoms of maybe anxiety or depression that can show up when you've been living with pain. And so we see high comorbidity between the two. And it's important to note that it's not necessarily the cause of the pain, but a consequence of the pain. 

[00:10:15] Russ Altman: Right. Okay. And then my final, at least for now, question for background and for setting the table for our treatment discussions is, um, do kids who have chronic pain, do they turn into generally adults with chronic pain?

[00:10:28] Because I'm, I can imagine that this, that there's nothing magic that happens when you turn eighteen or when you turn twenty-one. And I'm just wondering if this becomes a very often a lifetime challenge, or if it very often resolves and they have different issues as adults. 

[00:10:44] Laura Simons: Well, both. 

[00:10:45] Russ Altman: Right. 

[00:10:45] Laura Simons: So we have a significant portion of young people, and we were still actually in the process of fully understanding the scope of the young people that go on to develop or to have chronic pain into adulthood. Um, and we're developing programming that's focused on, you know, um, the adolescent to young adult transition, um, because there is sort of the cliff that happens, um, where they transition into adult treatment and it's a very different model. It's a very, you know, I know we're not talking about treatment yet, but it's hard to not dip our toe in there. 

[00:11:20] Russ Altman: Please go for it. 

[00:11:22] Laura Simons: Yeah, but I mean, I think that, you know, most importantly is that we do see, um, this really critical piece of, um, young people who go on to have, you know, these chronic pain problems in adulthood. And there was an early study done about a decade ago that, um, demonstrated and young people with recurrent abdominal pain who go on to either have comorbid, um, or persistent mental health struggles continue to have conditions like irritable bowel syndrome and those who have kind of a sensitive or heightened sensitivity of their nervous system and how they process pain in the body. So for sure, these early experiences change our nervous system, um, if not treated adequately. 

[00:12:07] Russ Altman: Great. So now you said the magic word treatment, and of course you're an anesthesiologist and you're also a neuroscientist. So what's the approach to treatment? I mean, everybody knows about the opioid epidemic, so I'm sure everybody's very worried about throwing opioids at anyone and certainly at children. So where are we with the, um, I guess the array of options for treatments? 

[00:12:29] Laura Simons: Yeah. I mean, well, I will, you start out by saying I am in anesthesia. But I'm actually a pediatric pain psychologist. 

[00:12:37] Russ Altman: Okay.

[00:12:37] Laura Simons: Um, so my training, um, was actually in behavioral health interventions. Um, so that's kind of, and what we found is that's the bread and butter of what is effective in young people and in adults with chronic pain is the, um, behavioral interventions and the physical interventions. Like physical therapy, occupational therapy, um, those are really important for getting people kind of back on track. Um, and you're exactly right. Opioids are not something that are first line treatments in our non-disease related chronic pain syndromes. And what's interesting is that we're also taking a second look at those who have disease related pain, like cancer pain, sickle cell, and how we can limit the exposure to opioids in those populations because that's really, um, been problematic to not have adequate behavioral health treatments and physical treatments in those spaces and leaning more on the opioids, which we know have so many negative consequences.

[00:13:39] Russ Altman: So what are, and I know you've innovated in many areas in digital, even virtual reality things, peer groups, there's a lot we can talk about. But I guess what's the basic approach that you recommend to a newly diagnosed, like we finally have gotten help, the parents, the patient have come together, we've identified chronic pain as one of the main issues. What are the kinds of things that are done right off the bat to try to help these kids? 

[00:14:04] Laura Simons: Yeah, so the first thing is what we consider pain science education. So oftentimes we, you know, uh, folks come in and they haven't gotten adequate education about pain processing and how, you know, just that simple, uh, thing that I mentioned before about pain being a sensory and emotional experience, um, how it's processed in the brain, um, how we can modulate the pain processing using behavioral techniques. Um, and that's, you know, critical and, um, for kind of setting the stage and the foundation for the treatments going forward. So we kind of think of the pain science education as that sort of foundation. And then we build, we have building blocks on top of that.

[00:14:49] Russ Altman: So let me ask you about that because I can imagine like a teenager, okay, they're going to get it. They, they're, uh, but what do you do with like a five- or seven-year-old? I mean, it's just amazing. It just boggles my mind how you could explain. I mean, it breaks my heart as well, that they would have chronic pain and that you would have tried to have to be explaining these things to them. But I'm sure there are best practices about the young kids with pain. Uh, what is the approach? If you can just give us a feeling for how it goes. 

[00:15:14] Laura Simons: Yeah. I mean, I will say that. the kind of peak age of onset of chronic pain in young people is adolescent. 

[00:15:22] Russ Altman: Ok. 

[00:15:22] Laura Simons: So we don't see a lot of, um, young kids. Like generally we don't see a lot of kids under the age of nine. 

[00:15:30] Russ Altman: Okay.

[00:15:30] Laura Simons: Maybe a few seven- or eight-year-olds. So in general, our kind of mass population is going to be our kind of young adolescent or mid adolescent. Um, but you know, there are some really innovative tools that have come out for pain science education, comic books, um, as well as board games. Um, I have a colleague in Australia who developed a series of books, um, that are focused on, um, targeting pain education in eight to twelve year old children. Um, so really there are some innovative tools that can help break it down into any more, um, friendly and kid friendly language. 

[00:16:06] Russ Altman: Okay, so you tolerated my interruption about that but go ahead. So the first thing is to kind of teach them kind of how we think about pain and perhaps how they should think about pain? Uh, and then what happens next? 

[00:16:17] Laura Simons: Yeah, I mean, I think depending on the diagnosis, oftentimes we're referring patients to physical therapy or occupational therapy, um, to get the body moving again, particularly our musculoskeletal kids. But even in abdominal pain and headache, um, there are some really particular targeted exercises that can enhance, um, your mobility, your activity and your pain management.

[00:16:42] And then, um, really the fundamental aspects of, you know, pain psychology or behavioral health interventions. Um, so this can come in many forms. Um, we keep innovating for, you know, additional forms that we can introduce it. Um, so we, there are now, you know, apps that folks can use that will walk them through kind of the fundamentals of pain management from a behavioral health lens. We offer and, um, uh, a class like a ninety-minute class that was developed, um, actually with adults. So it's been delivered, um, by Beth Darnall and the empowered relief class, um, to over ten thousand adults with chronic pain at this point. So we're like, we need to be able to do this for our young people. Um, so we're now launching that class in an adapted teen friendly form. Um, but that's kind of low-level intervention. 

[00:17:37] And then we have group based, um, workshops, individual, one to one, um, behavioral health coaching. Interdisciplinary interventions that involve psychology and PT working together with the patient, particularly if they're, um, feeling fear avoidant, um, or concerned about re-engaging in activities, getting that sort of multidisciplinary, in the moment approach can be really critical, um, for shifting, um, where they're at.

[00:18:05] And then we have even intensive interdisciplinary pain treatment programs, which is a mouthful. Um, but essentially that's where patients come in for five days a week, um, you know, several weeks, um, all day to get an intensive program that involves physical therapy, occupational therapy, um, pain psychology.

[00:18:25] And you know, early in my career, that's where I started. And it was like incredible. We'd see these kids come in in wheelchairs, crutches, um, and they would leave running. Um, and so it was really moving. They used to call me Dr. Tears, um, because we'd give like a graduation speech at the end and I'd be, you know, um, just really moved by seeing how much these kids have evolved and the parents, um, you know, they get their kids back. 

[00:18:52] Russ Altman: Yeah.

[00:18:52] Laura Simons: Um, and that can be incredibly moving as well. 

[00:18:56] Russ Altman: This is The Future of Everything with Russ Altman more with Laura Simons next.

[00:19:14] Welcome back to The Future of Everything. I'm Russ Altman and we're speaking with Professor Laura Simons from Stanford University. 

[00:19:19] In the last segment, Laura told us about chronic pain in children. How widespread it is, how difficult it is to diagnose, and some of the approaches to treatment. 

[00:19:29] In this segment, we're going to talk about a class that can markedly change their experience of pain. We're going to talk about the use of virtual reality, and we'll talk about how we can sensory retrain the experience of pain to help it make it more manageable.

[00:19:45] Laura, I want to key in on one thing you mentioned, which is this program called Empowered Relief. And you said it was initially, I think, developed for adults. But you've, you and others have modified it for kids. And that's just, and then I think you said ten thousand or something like that. So tell us more about what's the main idea behind that program and how does it work?

[00:20:06] Laura Simons: Yeah. So this is a tremendous program that was developed by Beth Darnall here at Stanford. And she, developed it as a brief class that could be delivered free of charge to patients as a first line treatment. It encompasses a pain science education component, as well as introducing three key skills. So, um, we have, there's like a relaxation, component where you learn how to kind of modulate your kind of physiology. There's a second component that involves identifying unhelpful mindsets related to pain. 

[00:20:44] Russ Altman: Ah.

[00:20:44] Laura Simons: And then the third piece is, and we, it in that you kind of think about your kind of best friend talk. Like, what would your best friend say to you if you're having this thought? And that can be really powerful and salient for folks because we talk to ourselves in a much more negative way than we would talk to our best friend.

[00:21:01] And then the third component being, um, kind of, um, engaging in activities that kind of bring us joy and nurture ourselves. So kind of wellness behaviors, um, you know, um, nurturing, um, our bodies and our minds. Um, so those are kind of really the fundamental components of what is the magic sauce behind Empowered Relief. And we've seen this, um, kind of really kind of make such an impact in so many spaces in the adult world, um, through Beth's leadership. And we thought it's time to bring this to teens where they can, um, also benefit from this kind of brief, um, kind of a fundamental course. Um, so we've adapted it to be ninety minutes, um, instead of two hours to be more team friendly.

[00:21:45] Russ Altman: I was going to say ninety minutes might be the longest amount of attention span that they're ever asked to do in their lives. 

[00:21:51] Laura Simons: Exactly, right. We have some breakout rooms. We try to make it interesting and engaging, you know, it's, you know, but, um, so far the feedback has been uniformly positive, um, from the teens and where we have parents sort of in the background listening in and they find it to be just, empowering, um, to get these tools and these skills that they can then kind of move forward with putting it into their pain management plan. Um, so it's been really well received, um, and we're excited. Um, myself, um, my colleagues, Lauren Harrison, Rashmi Bhandari have been working closely to kind of get this disseminated. And what's really beautiful is it's highly scalable. So it doesn't have to be just something we do within our, clinic. It can be something that can be developed, um, and distributed in community health centers and other spaces.

[00:22:42] It's been delivered remotely, um, so over Zoom, so it also, um, reduces a lot of the access barriers, um, with having to get, um, into the clinic or to get to a particular space. We've actually been working on translating into Spanish as well. Um, and we have, um, folks who are getting trained in delivering it in Spanish. So, we're really excited about, you know, from the get-go, making it more scalable and accessible and reducing some of the disparities and access. 

[00:23:07] Russ Altman: And it's quite remarkable that it's a single class. Do you have to do refreshers over time, or does that one class really seem to be sticky? 

[00:23:15] Laura Simons: TBD. You know, that's part of the research plus clinical piece is really determining, um, how that's going to shake out from the adult world. We can see that that one class has an impact and it's. And Dr. Darnall is actually run a study comparing this one class to eight weeks of cognitive behavioral therapy for pain and found equivalence in effects. 

[00:23:43] Russ Altman: Oh.

[00:23:43] Laura Simons: So that's pretty impactful. 

[00:23:45] Russ Altman: Yes. 

[00:23:46] Laura Simons: And certainly much more scalable. 

[00:23:48] Russ Altman: And just as a side comment, it sounds like a set of skills that we could all use actually for many different things other than pain, but that'll be a different podcast. I know you're doing work on virtual reality. You mentioned Zoom, but I bet you it goes beyond Zoom.

[00:24:02] Uh, tell me, what are the promises? I mean, I'm starting to see a lot of goggles and a lot of things that are coming out. Is, are those or things like them showing promise? 

[00:24:13] Laura Simons: Oh, yes. And you know, it's been really fascinating to kind of follow the virtual reality field, um, because it used to be just highly inaccessible and so niche to have, um, access to the headsets. But now you can get them for, you know, less than three hundred dollars. And there's even settings now where you can get a prescription for VR goggles... 

[00:24:36] Russ Altman: Oh.

[00:24:36] Laura Simons: ...for treatment of low back pain in adults. We want to get there with kids. 

[00:24:40] Russ Altman: Prescription as in covered by insurance, perhaps? 

[00:24:43] Laura Simons: Covered by insurance, FDA approved. 

[00:24:45] Russ Altman: Wow, wow. 

[00:24:46] Laura Simons: Um, so that's been a huge breakthrough in, um, innovative treatments. Right now we're doing, um, VR enhanced physical therapy. Um, so this is really targeting young people who struggle with movement and re engagement and activities. And this kind of provides that kind of oomph to get over the hump, to increase their movement and physical activity. So we have some great stories and testimonials and visually we've seen these kids who really been unable to walk or put any weight on a particular foot and in VR, they're able to do so. And then they can translate that outside the headset into the physical therapy treatment that they're doing. 

[00:25:28] Russ Altman: That is just remarkable. And, uh, will make me look at those goggles with, uh, in a different way, uh, going forward. The other thing that you've published about is I think something called sensory retraining, uh, which sounds hard to me. Like I don't even know what it is, so maybe tell us what sensory retraining is and then how is it going with young people?

[00:25:49] Laura Simons: Yeah. So we know, um, this is a big piece of the work that occupational therapists do with young people with chronic pain is we see this sensory sensitivity, um, that happens, um, in a chronic pain state. Particularly with young people that have complex regional pain syndrome, um, where they can't tolerate the touch, they can't tolerate sheets, bed sheets, the wind can be, um, really difficult to tolerate. And so the sensory retraining involves being able to kind of progressively expose yourself to sensory stimuli. And we see a lot of young people even beyond CRPS who struggle with this. Um, so we're excited about a kind of pilot study that we're doing now with a group called TrainPain that involves a tool that allows you to flexibly attend to the sensory stimuli um, and trains that um, that aspect, um, and just in our initial, um, findings, the kids love it. 

[00:26:52] Russ Altman: So flexibly attend. I'm going to need you to define that for me because it sounds like a magic phrase. 

[00:26:57] Laura Simons: Yeah. So pain demands attention, right? 

[00:27:00] Russ Altman: Okay.

[00:27:01] Laura Simons: It steals the show. Um, when you're dealing with pain, it becomes the only thing that you can think about. And so this tool is something that allows you to attend not only to the pain, but away. 

[00:27:14] Russ Altman: Oh. 

[00:27:14] Laura Simons: Um, and it uses this kind of vibration. Um, so there are these little, pods that you place in different parts of your body. So the painful part and non-painful part, and it's really cool because there's like a game on your phone, um, that you play that you become more successful, the better you are able to attend to the stimuli that's being kind of the vibrations that are coming from the device. Um, so this allows you to flexibly attend to and from while you're succeeding in the game. Um, so what, the funny thing is that this, um, intervention has, was only been used with adults previously. And we're like, what? You guys are missing the boat because it's, uh, you know, it's a game. The kids are going to love it and, you know, we're exactly right. You know, this is the first time that I've done a study where we have, you know, kids participating in their treatment, uh, fifteen minutes a day. And they're doing it every day. Um, I've never. 

[00:28:14] Russ Altman: Right, right.

[00:28:15] Laura Simons: You know, usually adherence is up and down, but kids are loving this. Um, and they're finding it to be really beneficial for like managing their pain and feeling that they have a concrete tool that they can use. Um, so we're excited to see where this goes. And again, this is, you know, all can be done at home. So it provides kind of a greater accessibility. 

[00:28:36] Russ Altman: Well, this has been fantastic because we've had this conversation and we've hardly talked about drugs. I'm sure that medications play a role and that again that can be a discussion for another day. But the remarkable thing is we've just spent this time thinking about all of these other options that can be deployed. So that gives us gives me huge excitement.

[00:28:57] Thanks to Laura Simons. That was The Future of Childhood Chronic Pain. 

[00:29:01] Thanks for tuning into this episode with over 250 episodes in our archive you have instant access to an extensive array of discussions on a wide variety of everything. If you're enjoying the show or if it's helped you in any way, please consider rating and reviewing it to share your thoughts. You can connect with me on XR Twitter @RBAltman, and you can connect with Stanford engineering @StanfordENG.