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Kristin Nuckols, OT

Apr 18, 2024

Kristin Nuckols is an occupational therapist specializing in stroke rehab.  She is also the co-founder and chief clinical officer of Imago Rehab.  Join us as for a research packed discussion on what is really required to get tangible outcomes from therapy.  

Brennan Barber  0:31  

Welcome to the Theralinq podcast where we dive into the inspiring stories of individuals dedicated to reshaping the disability ecosystem. Join us as we explore the triumphs, challenges, and innovative solutions crafted by changemakers, striving to create a more inclusive world, from passionate advocates and trailblazing entrepreneurs, to the resilient individuals breaking down barriers. Each episode shines a light on the progress being made, and the work still to be done to create a more equitable society that enables every individual the chance to reach their full potential, get ready to be inspired, informed and uplifted as we hear from those who are reshaping the narrative around disability.

Bethany Darragh  1:21  

Today, on the podcast, we have Kristin Nuckels. She's an occupational therapist, Kristin, will you just start by telling us a little bit about yourself? 

Kristin Nuckols  1:29  

Sure. So as you mentioned, I'm an occupational therapist. And I have spent my whole career working on innovation in stroke recovery. So I spent first 10 years in the clinic and always just really pursuing technology based trainings and other clinical protocol trainings, and just really trying to understand this question of what do we do with people that helps them to get better. And then I had an opportunity to join a Harvard engineering lab, which was an unexpected twist in my clinical career.  But I've spent basically the last seven years involved with that group, and spent time working on soft robots in a Harvard engineering lab and then spinning out a startup based on wearable home technologies and telehealth for adults with stroke. And that's where I am now. And that's called a manga rehab, right? It's called a manga rehab. Yeah, the name Imago is a phase of metamorphosis. So it's when the creature takes off their exoskeleton, which is, we work with soft robots, which are called technically exosuits, to take off your Exosuit, and then you are something new. 

Bethany Darragh  2:44  

So Brennan, and I read your research from Boston University that kind of led you into the imago rehab company. And I had a few phrases that really stuck out to me as I was reading your research. And I would love to tell you what those are, and just hear you expound on those areas a little bit more. The first one was self management of stroke symptoms. 

Kristin Nuckols  3:08  

Yeah. And I really learned about self when I, when I came across the term self management, when I wrote that thesis that you're talking about, I did a post professional OTD, I had a Masters before. And so I a couple years ago, into the post professional OTD and had to write a thesis and really explore the literature and find out what it is that, you know, makes people with stroke get better, which is what I wanted to research. And this concept of self management of stroke emerged in the literature for me, and that really is about people taking control, taking the driver's seat of whatever it is, is it diabetes, is it stroke, is it depression, whatever it is their self management concept that runs through many, many impairments and conditions. But it's sort of changing, taking yourself out of the sick role, the patient role and turning yourself into the person in the driver's seat. You're making the decisions with the help of medical team, right, with the help of other therapy, or physicians or whoever it is counselors, but you're taking an active role, you're, you're doing some of the decision making, you're making the decision to to participate and to do things that are going to help you know, improve whatever your status is. So really going from having a back seat and have it feeling like things are happening to you to being the one in the lead that saying I'm going to make these choices I'm going to everything I do is a choice, and just having a different perspective. So that's kind of self management doesn't mean going rogue.  It's not the same thing as going rogue and saying I'm gonna do whatever the heck I feel like it's being empowered by knowledge. And the recommendations of the people that are that should be giving you recommendations, but it's really this idea of empowerment.

Bethany Darragh  5:02  

I really resonate with that a lot, I feel very passionate about not being the OT wizard who comes in and performs magic that no one can replicate at home. I want to empower people to know how to take the next step, and the next step, and give them that education and that knowledge and that power to own their current situation and the goals that they want to take the next step. The next phrase that I wanted to talk more about was the dedicated assessment of goal achievement.

Kristin Nuckols  5:37  

I have to go back in the memory and figure out what I was talking about. But I'm at Imagorehab, we do a lot of assessments, which means we're not just guessing if people are getting better, what we do is judged by objective assessment, I think I'm on the right track, maybe not. Okay. So  in those 10 years, when I really worked with, you know, individuals with stroke in the clinic, a lot of times they would say, this is a lifelong chronic condition, right? And they would say, am I getting better? And if I didn't have objective assessment that I repeat, and can compare their function, they're kind of going off with my memory, you know, I think it's better I think it's better or I see a difference, can you see a difference. And so that's something that I really have focused on out of Imago. And we have a variety of ways to make sure that our clients know if things are better, because that drives the self management, if you can see yourself getting better that's motivating that nice trendline that shows you getting better, that's awesome. And people who are like, Good, I'm doing what I should be doing, it's making me better. Or if it's not getting better, then that's a moment of still self management, where you're going, okay? They're telling me what to do.  And you have those real conversations with people that's like, are you doing it? Are you doing this stuff? Or are you not? Are you not sure we're not giving you the right information? There's this really just open and honest conversation and those happen around objective assessment. 

Brennan Barber  7:16  

The Theralinq platform is really focused on pediatric therapy. But in reading your research, there seemed to exist some parallels between stroke patient recovery, and certain pediatric conditions when it comes to neuroplasticity and early intervention. Can you walk us through a timeline of maybe an ideal scenario of early intervention with a stroke patient?

Kristin Nuckols  7:40  

Sure. I'll sort of backup of stuff and start with, as soon as I became an OT, I was sent to the Taub clinic in Alabama, and trained in the constraint induced movement therapy approach. So everything I've done for the last close to 20 years has been sort of colored by that approach that says, you have to use your arm to make it better. So when we talk about things like cerebral palsy, we have these limbs that are not behaving the way we want them to behave. And part of what we understand about changing the brain through neuroplasticity is that to improve the patterns of moving, we have to use them. But that might be what's called forced use, where you put a cast around a child's arm, and then play with them on the floor. So they have that arm that support from the cast, to be able to use their arms and push themselves up and play games and things like that. So that's kind of step one is is figuring out what do you want someone to be able to do? It's kind of that that therapy, objective assessment, what's missing, what's not working properly, and then figuring out how the person is going to use it. And you talked about early intervention for for I've never done pediatric work in general. And I've so I've not done early intervention, the type of therapy called early intervention, but certainly, there's another neurologic principle that says that earlier is better, right? So time spent, not using that arm say is time spent, practicing not using your arm. And whatever we practice is what we get better at. So the longer that child goes without being able to engage in arm to prop up and play games, which is what children should do, or the longer an adult with a stroke, neglects their arm and leaves it hanging in their lap. The longer their brain goes without practicing those skills, and the longer they go getting worse. 

Bethany Darragh  9:46  

So I think that intrinsic motivation is one of the most integral but challenging parts of being a therapist. Because if you can light that fire, then the job is very easy. And I think I hear you saying that same thing when you talk about self management of stroke. Do you have any theories or strategies that you believe help light that fire and ignite and passion with your clients? Do you think that OTS really have anything to do with this? Or is it just all about following the client?

Kristin Nuckols  10:18  

It's a really good question. And it's a complicated question. So I'll do my best.  Because it is this is talking about psychology. And it's so multifaceted. And while OTS have training in supporting mental health, and in helping to inspire intrinsic motivation, we are not psychologists or psychiatrists, or licensed mental health counselors, either. So we play this role of kind of like cheerleader coach, you know, medical professional, like, we have this interesting role where we do all of these things. Sometimes there are factors that are keeping someone from being able to engage in our therapy process, that's happened, you know, not very much for us, really.  But we've had one or two people who either maybe had depression that was too severe for them to be able to engage in what we do, because it is, so we are inspiring independence, right? So there's some people who just need more hand holding than we can provide. And so those people have said, I think I'm either gonna stop or I'm gonna go back to in, in clinic therapy, not telehealth, and that's fine. There's also folks who have more cognitive impairment, than then we than we thought when we screen them. And we get halfway through the, you know, our weeks of intervention, and we're going they're not carrying it over all the supports, we're given them to let you know, listen, we're working on an app, right? So we'd have this engaging environment and stuff that they're supposed to be doing, and they're not doing it.  That might not be based in motivation, it might be based in cognition. And that's can be hard to figure out which, which one is which. So there are objective assessments for cognition, right? So sometimes we have to evaluate our therapy process and see what is it that's the barrier. So some of that is screening, we do that initially, you know, we take a PHQ, nine for mental health, we can do a mocha or an MMSE, and check for, you know, cognitive abilities. So we try to know, what are the things that are going to be a barrier to this process? Sometimes we see that, you know, if it is like a mental health problem, that's the barrier.  Can we do we need to bring in more support, are people getting counseling? Are they on medication for depression or anxiety that's keeping them from being able to, to engage in a program the way they want to, so sometimes it's something else. So if it's not those things, and we're working, and we've got this person who's not particularly depressed, and has good enough cognition to participate, one of the things that we really focus on is ensuring that the therapy matters to the person, and that's in our OT training. So, you know, that's part of what we do is try to pick tasks that are important to people. But this is something that keeps coming up, as we're, you know, we're looking at sort of other other innovators that are creating home programs, because a lot of what we do is a home program. And there's other groups that have home programs, I won't name names, just because that's not the best idea. But you know, what you see out there on other platforms are exercise based home programs. And exercises don't necessarily make individuals with stroke get better.  Like we always ask when we talk to investors, and we talk to other industry partners, and we say, Have you ever had, you know, therapy for an injury? And they're like, Oh, yeah. And we're like, did they give you a list of exercises? And they're like, Oh, yeah. And we say, did you do them?  And like 97% of them were like, No.

Bethany Darragh  14:04  

This makes me think about the goal development process. To OTs, it's, it's very much of course, we're going to follow your leisure pursuits, your passion projects, we're going to develop these goals together. As a pediatric therapist, all of my clients have been brought to me by a parent, which may be the situation and in your clients as well, that someone's kind of urged them to, to get into therapy.  And when I do the goal writing process with my parents and homes, I get a little pushback when I say, Okay, let's write goals together. And they might feel a little surprised and say, Wait, aren't you supposed to tell us what to do? And it's, you know, maybe a little bit more natural when you're working with an adults to just include them in that process. But in pediatrics, it can be pretty challenging because what's motivating for a child and what a child may want to do is play and that's what they should do. But when an adult is going to want their child to do is dress themselves, feed themselves. So it's kind of this conversation of, well, let's see what we can do here, can we play and learn some skills through play that can help them dress themselves and feed themselves 

Kristin Nuckols  15:14  

That's another neurologic principle of transparent so you get the skill to do this thing like putting Legos together, which looks a lot like buttoning your pants. Right? So it's a check, you get one to do the other thing. There's, there's some of that in instruct recovery, too. This is one reason why I like working with adults, because you can just be like, Hey, I'm not gonna sugarcoat it. Like, if you want it, you know, this isn't really the conversation that we have. It's very straightforward. There's a lot of this back and forth interviewing. And they do ask us, Well, what am I supposed to be doing? And we asked them, well, what are you doing? And so it's very open, very direct, very honest, people are very satisfied. They like they really enjoy this, they stay a long time.  Because they find it effective. They they begin to understand, you know, they, we get quotes, like, no one's really asked me what I've done what I'm doing at home before, they're like five years post stroke, and you're like, you've done therapy five times, you know, you've gone like back and back to the clinic over and over. And they've given you the same stretches or exercises, but they've never helped you figure out how do you how do you get better at doing stuff that you need to do so? Interesting?

Brennan Barber  16:25  

Yeah, and when you talk about lack of execution in the home setting, in one of the phrases that you mentioned in part of your research, as well, was extra gaming. Can you describe what that means? What that looks like? 

Kristin Nuckols  16:39  

Yeah, it's in very basic, making moving around more fun, right? So not just more fun, but keeps your mind off of the counting Bethany, in the in the clinic, you're like, This is something that OTs and PTs do that if if we tell someone to start doing these exercises, we're not going to count 

Bethany Darragh  17:01  

and they say, What number am I on and I say, I have no idea on

Kristin Nuckols  17:07  

They're like, I have no idea what number you're on, or you're on number one, and then they learn to count. But it's kind of like comical and evil. And we all think it's funny, but nobody really wants to do exercises that are the same movement over and over, I let me behind me in this room I'm sitting in, I have a rower that I haven't touched in, like a year.  And I have these weights that I use on occasion. But you know, I like to go out and walk my son to daycare and I like to go out and go on a family bike ride. But I don't really want to sit and lift weights in my, in this office room, I can't I could do that. There's just not that much fun. So extra gaming is the idea of taking your mind off of the movement and making it about something else. So we use a gaming platform that we're partnering with another research group.  And our users can utilize this gaming platform from their computer or from the phone or tablet. And they play games like dodging asteroids, and jumping up and down to pop the balloons that are coming by have the right color and doing a variety of other movements. And they're not thinking about, Okay, I'm gonna go lift my right arm 45 times, they're just kind of play the game and try to get a better score. So the idea of extra gaming is just getting your mind off of having to move. Typically, people will move more, if they're gaming versus not gaming, if you give them a exercise program versus giving them a gaming program, they tend to engage more minutes in the game more times per week. So just a little bit more fun you can make they can be competitive, two people can actually compete on a leaderboard, which some people like.  I think we'll get to the point where you can game at the same time as somebody else is a little hard because you know, people are in different time zones? And are they opening the game at the same time? But yeah, there's there's lots of ways to make things interactive, and also quantifiable, it's back to that idea of assessment, right? So maybe the first time they got 102. And you don't know what that means until you do it another time. The next time you get a worse score, you're like, Oh, what did you know? What was my problem? Should I have stretched further? Should I have had a different position I put my body and what was it different time of the day. And if you got you know 205 Next time, great, I moved more. So you can use that for for fun? And for for assessment and for kind of challenging yourself.

Brennan Barber  19:33  

And can you share with us to some details around your research into like frequency of back home exercise treatments, because I think that kind of relates to some of the extra gaming themes that you talked about and you know, what's needed?  I guess, with stroke in particular, you know, to effectively show improvement, you know if you can quantify that.

Kristin Nuckols  19:56  

Yeah, there's the numbers that kind of show up and literature are usually 300 to 400 300 400 What is a great question is, is lifting your arm up? One? Is it opening your hand? You know, what is it? It's a great question that I think that exact answer is not quite known, but several 100 what's called massed practice. So, group of practice, you know, just like if you were going to work out at home and you lifted a barbell once you know, la ti da that didn't do anything, but if you lifted it, you know, you did you exercise for half an hour, then you get a benefit, right. So it's the same idea, you need to do a decent amount, several 100 movements in order to really be firing up brain cells enough to stimulate growth. That's, that's kind of the magic number. And so in, in the thesis I talked about the, this is a paper kind of old now it's I think, 2009. But they watched therapy sessions to see how many times people moved. And the average number of times for the arm was about 30 times. So you need 300. But in the clinic, you got 30.  We're very nice. And we do a lot of chatting. And we're and we're also doing things like potentially talking about a home program or whatever it is, but in general therapy is typically not intense enough. So there's been a lot of research and push over the last 10 to 15 years about making therapy more intense. I think that is carrying over I think that is has been definitely shown to be possible that in clinic therapy or in home based therapies, you can make that hour intense, you can make intense therapy happen. There's lots of research protocols that show that it's possible 

Brennan Barber  21:49  

And from an intensity standpoint, both from a frequency within a given session. But also, when you look at, you know, therapy, like prolonged over multiple over multiple number of months, versus condensing that into a short period of time for an intensive type of program like is that where research is kind of directing it as well as seeing more impact during these condensed intensives? As opposed to, you know, weekly appointments over the course of a year, for instance? 

Kristin Nuckols  22:20  

Yeah, yeah, I think that that you're right, that more research is done in these sort of compressed stents, whether they're six weeks, 12 weeks, 18 weeks, 24 weeks that might be about as long as you ever see some kind of human, they might do longitudinal, you know, then they check you at six months, and they check you out a year, but they're not doing intensive intervention that whole time, because it's too demanding. On the research team, it gets too expensive to bring all these people in and manage these massive trials. So usually, research trials are done in sort of short stints. And then if we kind of translate that to the, to the real life therapy world, you know, let's say you have a commercial plan, and you have 60 visits would be a pretty good commercial plan. So if you go once a week, you could go all year. But we know that that kind of intensity is unlikely to stimulate change, right? So most people kind of pack them in to get that kind of intensity. Yeah, that's, you know, is that the right way, 

Brennan Barber  23:26  

especially when you receive multiple therapies? 60 visits don't go very far, very far.

Bethany Darragh  23:35  

So I have one last question for you, from my time in skilled nursing facilities, which I'll give a little background for people that aren't familiar with that whole therapy process. But someone may have an accident or an injury that puts them into an acute care hospital, just like you would think of a hospital. And there may be some extensive rehab that's needed after that, and those people can't go straight home. So they'll go to a skilled nursing facility to get some intensive rehab before they go straight home. So I spent time working in skilled nursing. And my favorite thing to do when people come from the hospital, is to get them in the shower. So they're in this weird place where they're pretty down, they're pretty traumatized. The hospital stay was a lot. And they're wondering what their life's gonna look like from here on out. And I would come in and say, Look, we're going to get a shower, we're going to get up, we're going to walk in, we're going to step in, we're going to slide in however we have to do to get under that spray of water and wash away that hospital stay in you can see your life will look more normal than you can picture it right now. And that moment was my favorite every single time that happened and in that moment afterwards where we could just reflect and celebrate that. This is something that client didn't think they were going to be able to do again. And they're doing it and just celebrating with them. So what I want to know from you is what is a recent celebration that you've been able to have with one of your among our we have clients?

Kristin Nuckols  25:15  

Yes. And when I worked in the hospital setting, I would chase down the doctors and be like, I need shower orders for this patient. We can't work with them until they've shot where we have to shower them. So I feel you showered everybody? Yeah, so in Umaga rehab, I am our Chief Clinical Officer, and I hire and train our therapy staff and train them to use the protocol that I wrote and kind of monitor that half help with pitching for investment help with lots of other things. So I don't treat very often, but are my therapist tells me lots of wonderful stories. And so a story I'm thinking of right now is a client that we that who came out a few months ago and is very, very impaired had, you know, the stroke was about five years ago, very tight arm, you know, it's even one of those moments where I'm thinking, I'm not so sure that we're going to be able to make a lot of change here because the impairments looks so static. And the therapist did the first reassessment. So 90 days later, and you're hoping for five to seven points of change on this assessment. And our average change is about 10 points, so about double what you're looking for. And this person changed 11 points. And I just was reminded that brains are plastic. And this person is, you know, five years post injury was unable to use the arm for anything. And now has, you know, a dozen or 15 different tasks that can they can use their arm for like scooping the dog's food and doing a bunch of different things. But you just, you know, you don't you don't get to write anybody off. That's something that I really love. We're able to just give people hope who have been pulled over and over that they're not going to get better. 

Bethany Darragh  27:04  

And like a true research or your celebration moment was database. I love it. Thank you so much for being on our podcast. Kristin. 

Kristin Nuckols  27:12  

Thank you for having me.

Brennan Barber  27:41  

Do you have questions for our guests? Send your questions to You can also find us at our and on our socials with a handle at Theralinq

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