Dr. Graham Creasey reviews the current methods of management of the neurogenic bladder.
next we're going to be moving on to another subject. Energetic bladder. We have dr graham chrissy, dr creasy trained in Britain and Zimbabwe initially in trauma surgery and subsequently sub specialist in spinal cord injury. He is particularly interested in the restoration of function to the neurasthenic bladder and bowel using electrical stimulation after spinal cord injury. Um When uh when I was a resident in Ohio dr Creasy was one of my attendings and he helped educate the residents about neurasthenic bladder. Uh and much of what I know about neurasthenic bladder, I can attribute it to him. I don't know if doctor Christie was aware that I knew him when he agreed to participate in the conference, but I know the residents were disappointed when we found out that he was leaving for Palo alto because we were losing a good teacher. Um I didn't know at the time that I would be following him over to the west coast but uh I guess here we have built our in California. Um but uh I want to thank dr Creasy for for participating today and I'll let him get started. Thank you very much. Doctor. Thank you. Dr Jeffrey. It's good to see you again and it's interesting. We both moved west uh whether as young men or not. And uh thanks also to the organizers for inviting me to speak on this topic, which has a lot of bearing on the quality of life of people after a spinal cord injury and other neurological injuries, as well as the costs of their care, particularly when you consider lifetime of care. So the neurasthenic bladder is commonly uh described as one in which there is a bladder dysfunction associated with nerve damage or disease. But as you'll appreciate from the talk, we just heard patients with concussion and mild traumatic brain injury may not have any clearly defined structural lesion in the in the brain or the nervous system, but may have abnormal function, both physical and mental. So, uh both may be relevant even when we consider this traditional definition of the neurasthenic bladder. Now, we're not just talking about the bladder of course, but the lower urinary tract, which includes these sphincter mechanism and the urethra, as supposed to the upper urinary tract involving the kidneys and your ETTA's, which are less dependent on controlled by nerves and the functions of the lower urinary tract, of course, are in principle very straightforward. Uh it's essential to be able to empty the bladder completely or almost completely when desired in a safe manner and a socially appropriate time. That involves contraction of the smooth muscle of the wall of the bladder, the diffuser and relaxation of the sphincter mechanism and then that process alternates with storage for most of the time, Which requires urine to be maintained within the blood at a safe pressure without leakage. Which requires of course, the wall of the bladder to be relaxed and the sink to mechanism to maintain enough tone to keep the urine in at rest with occasional strong contractions of the externally ruthless thing to to cope with sneezing or coughing or laughing. So these principles are fairly straightforward, but not always easy to achieve. And they're dependent on multiple levels of the nervous system, of course, from the frontal lobes, determining whether it's socially appropriate to empty the bladder to the awareness of the patient as to whether their bladder is full or filling, awareness of whether they're passing urine. Yeah. And then they're voluntary control and decision as to when and where and how to pass urine and when to try not to do so if it's not socially appropriate. Now, the actual coordination between emptying a storage is organized by the ponds, which receives of course a sending signals from the bladder pelvic organs and the lower segments. And then can effectively switch between emptying and storage, sending signals down the descending tracts primarily to the sacral segments of the cord and thereby to the parasympathetic pre ganglion, like different nerves which travel out to the post ganglia, nick nerves causing contraction of the debt Russia and signals sent through the somatic different nerves to the striated muscle of the external urethral sphincter. There's some effect also, of course, from the historical lumber, sympathetic outflow and the hyper gastric plexus also affecting smooth muscle in the bladder wall and the uh huh bladder neck. Now, lesions of the brain, whether traumatic or non traumatic due to disease, can of course affect people's awareness of the social appropriateness. Uh and whether it's appropriate to the emptying the bladder or maintaining storage, as well as their awareness or bladder fullness awareness of incontinence and their voluntary uh control of it. But given that the intact neural system between palms downwards can result in safe avoiding, even though it may be unwanted times and unwanted frequencies. By contrast, when there are lesions between the ponds and the lower parts of the spinal cord and peripheral nervous system, then this produces hyper reflection not only of the bladder, but also are the Sington and this co contraction of the two, or at least the failure of the sphincter to relax when the bladder contracts produces this dangerous condition of the cruisers, think to dis energia which causes a lot of problems with super sacral spinal cord injury. Lower injuries to the communist metal aerosol according to corner, typically damage the peripheral nerves and there may be peripheral nerve damage independent of that, typically causing a reflex AEA of the bladder and of the sphincter mechanism. So they're depends essentially three types of neurasthenic bladder depending on the level of neural damage. Brain injury, typically causing hyper reflexive to of the bladder. So avoiding considerably coordinated by the ponds in a safe way but may occur urgently and frequently and lead to urge incontinence. With all the other complications that may follow from that, such as skin damage, pressure answers and the social consequences as well. So, a common feature of brain injury, but spinal cord injury, in its super sacred location produces this hyper reflexive, not only the tissues of it also this winter and the contraction of the sphincter. Of course impairs avoiding, which is often incomplete, leading to high post void residual. Uh The urine therefore is prone to become infected and to develop stones and avoiding may occur at high pressure because of the resistance of the sphincter, which can cause hypertrophy of the bladder. However, the hyper flex of the bladder itself can cause reflex incontinence when it overcomes the resistance of the sphincter. More importantly, the chronic contractions of the bladder cause high pressure storage of urine and that prolonged high pressure in the bladder during storage is what can be dangerous because it can hinder the flow of urine into the bladder from the kidneys can also cause reflux from the bladder up to the kidneys can cause hydro anthracis, which may be complicated by piling arthritis and kidney stones. Therefore renal damage and even renal failure. Then the lower damage to the sacral segments of the cord, the cord quieter or the peripheral nerves causes this reflects to which in which avoiding is impaired by poor bladder contractions. There may be dribbling, incontinence and stress incontinence and the uh consequences of that which can be difficult to manage. So of course the goals are possible to restore the normal functions of emptying and storage and to prevent these complications and improve the quality of life of the patient. And this is particularly appropriate for multidisciplinary management because it does involve taking account of mental ability, emmanuel ability of the patient and their mobility. So in rehabilitation and lifetime management, multidisciplinary teams need to work together to produce the best outcomes. And so many of the people attending today have a part to play in successful management the androgenic bladder. Whether that's psychology. Uh The occupational therapists, physical therapists, the social worker, the medical equipment manufacturers and so on. The methods of management often start with pharmacological methods and particularly addressing the innovation of the lower urinary tract. As I mentioned, the parasympathetic is uh stimulatory to the smooth muscle. The D. True sir. Uh There's some inhibitory action from the sympathetic. Usually not quite so strong. The other strong influences a somatic different or lower motor neurons to the external urethral sphincter, the pelvic floor in the origin. It'll diaphragm and then the sympathetic also has some influence on the smooth muscle in the blood and x. Sometimes known as the internal sphincter and typically the alpha sympathetic causing some contraction of that. And there's some evidence of parasympathetic can actually actively relax the bladder neck. Now on that basis the logical processes to start with antique allergic medication to oppose the activity of the parasympathetic. Specifically anti masker Rennick medication. But this is sometimes limited by side effects of these drugs than other body systems and that sometimes results in insufficient effect because the dosage is limited by these side effects. So there is a lot of competition to produce better uh pharmacological agents To control the bladder without these side effects. And in particular now the development of the 23 agonist drugs to try to produce more selective inhibition of the bladder, hyper reflexive to without these side effects. Also the use of toxins to address the bladder hyper reflexive to and the role of uh sympathetic agents on the internal sphincter. Mladic is relatively small, half agonists sometimes help with it in mild stress incontinence. Alfa block is used for prosthetic symptoms but not a very major role in the neurasthenic bladder. More importantly is addressing the hyper reflexive of the externally resource center. And sometimes botulinum toxin is used for this, injecting it directly into the sphincter, either at Sista Skopje or by a transparent he'll approach although still I think an off label use for botulinum more importantly uh which is used for the bladder. So the advantages of the oral drugs is of course the simplicity of giving them. But the disadvantage being that they aren't always sufficiently effective in controlling the bladder because the dose can be limited by these side effects of the dry mouth vision, constipation, possibly even uh cNS effects in the long term as well, botulinum toxin for the bladder has made a significant difference. The advantage being that it can last for around 18 months depending on the patient, shorter or longer. Uh injected assist Oscar P by multiple small injections into the wall of the debt cruiser. But of course this does require repeated test Oscar P and repeated injections possibly for life. And I think we don't know for sure what are the effects for life of putting these toxins into the bladder. But it has made a big impact on the control of bladder hyper reflexive to so the very active area of research and clinical treatment to try to control the hyper reflexive of the bladder for brain injury and other cNS injuries. Of course, we've long had mechanical assistance in managing the neurasthenic bladder, both for entering the bladder and collecting the europe and the history of capitals goes back a long way for emptying the bladder. The indwelling foley, of course, has the great advantage of convenience, but it has significant disadvantages in the presence of a foreign body in the bladder tends to cause chronic and recurrent infection and in crustacean of the foley can lead to bladder stones. Your actual damage either from catheterization or more importantly, is particularly the long term and particularly in women from traction on the catheter and traction on the balloon can stretch open the bladder neck, particularly in females and lead to intractable urinary incontinence which can require surgical correction. It would be difficult to treat in any other way. Risk of bladder carcinoma is not as great as it used to be with old style catheters, but still may be an issue with the long term or lifetime use of foley catheters. The use of intermittent catheterization. Of course it's an effective way of getting the turnout, but it may have to be combined with anti co emergence for other techniques for keeping the urine in. And it has the great advantage because there isn't a foreign body in the bladder all the time. It typically leads to reduced infection, even though the catheter may be inserted 4 to 6 times a day, the fact that the bladder is fairly thoroughly emptied each time. It means that when the urine comes out the bacteria come out and so usually there is reduced infection. And this technique provided the patient is taught good sterile or at least clean, intermittent catheterization techniques. But of course it does a fairly labor intensive technique and some patients, such as quadriplegics may not have the hand function to capitalize themselves may need an attendant or caregiver a family member to do it. In the case of females, they mean it need to get out of a wheelchair or back bed to do the catheterization and not everybody can do it on the toilet depending on their mobility in their hand function. And the cost of intermittent catheterization adds up over a lifetime. Both the cost of the devices and the cost of the labor. The some evidence that categorizing oneself for thousands of times over a lifetime can in time lead to urethral damage, particularly in males or with unskilled attendants who don't have the skill to do it. Well, reflex avoiding, sometimes to a fault method and this may produce emptying if the reflexes are just causing hyper reflexive to of the bladder. And so it has the advantage that, yes, if and sometimes there's a way of getting the run out. But at the cost of, uh, incontinence, uh, the storage of urine is usually impaired by the hyper reflexive of the bladder and if there's also hyper reflection, sphincter, as there may be in the supercycle spinal cord injury, then they're typically going to be high residuals, high pressure, avoiding, and the process of infection, stone and bladder and kidney damage that I mentioned before. So if this technique is used even as a default, it needs to be very frequently and carefully monitored, patients typically need repeat your dynamics to make sure that they're not developing kidney damaged or bladder damage. Surgical methods of managing the neurasthenic bladder are typically addressed towards the hyper reflexive to now. For the sphincter sphincter artemis used to be practiced either by direct cutting through a sister scope or later through laser. Think Terata me, which produced less bleeding and less scarring and it could be fairly precisely controlled, but because of the risks of incontinence and erectile dysfunction, things about me is much less frequently practiced. Nowadays, bladder augmentation still carried out in order to enlarge the blood and reduce its contract bility to allow it to store larger volumes at safer pressures, diversion of the urine to another part of the skin, such as the abdominal skin surface is perhaps more of a salvage procedure, but also a way of trying to main safety and protect the kidneys. Or sometimes dealing with intractable continent incontinence from the sphincter and urethral damage and rise. Artemis has sometimes been carried out particularly posterior sacred rites, taught me to cut the sensory nerves in the bladder and sphincter to the spinal cord and abolish the hyper flexion of both bladder and externally refill sphincter. But again, an irreversible procedure with side effects. Bladder augmentation typically involves taking a segment out of the bow and then reinvesting using the vowel and using that segment about tissue, often opened up into a flat piece of tissue, which can be then used as a patch on the dome of the bladder to enlarge the bladder. And it's not as contract. I'll as the hyper reflexive bladder and therefore allows storage of larger volumes at lower pressures. Using various different surgical techniques to enlarge or augment the bladder. In this way, it's also possible to meant the bladder simply by cutting the, the truth is the muscle of the bladder and that has. The lark may allow the mucosa and somebody koza layers of ladders to bulge into the abdominal cavity. Uh They may become adherent to the bows, Maybe some risk of perforating uh the mucosa with the catheterization that's typically added to bladder augmentation. Yeah, so augmentation has the advantage of producing low pressure and larger volume storage and thereby protecting the upper tracks. But it is significant surgery involving uh taking out part of the valve and uh it does commit the patient tibetan catheterization for life, surgical diversion, as I mentioned, is sometimes a salvage, but also a way of attempting to produce safe management. The simplest form of diversion is simply inserting super pubic catheter. The simple procedure that is essentially reversible and if the super pubic is typically the stonewall would close up, it has the same many of the same disadvantages as a the intra urethral catheter, of course of uh, infection and stone formation, but it does separate the bladder emptying from um sexual function via the penis and vagina, and sometimes it's easier for patients to manage than a free throw capita, particularly for changing it. In the case of females, as you know, William can be used to divert urine from the bladder to the abdominal wall. And sometimes the appendix is used as a convenient small tube for the same purpose. And there are various surgical techniques, of course, for this. The original ones were typically incontinent diversion and the conduit to the vulnerable. Therefore, of course, required the the bag to be attached to the skin of the abdomen. But other techniques tried to make this continent by using various types of surgical techniques to try to produce a valve both to avoid leaking through the skin or reflex up the irritants to the bladder, somewhat dependent on the skill of the surgeon to produce an adequate reservoir and still maintain continence and and if possible, avoid reflux to the kidneys. So surgical diversion has that potential advantage of producing continents. It's often easier for a female to categorize a uh, I'll uh, bladder then to categorize through the urethra can be done from a wheelchair instead of getting uh, bed or toilet. Uh But again, it's significant surgery and once again commits the person to either a bag on the skin or catheterization for the rest of life. Then there are some electrical methods of managing the neurasthenic bladder. Yeah, essentially there's been following the invention of the pacemaker, a variety of ways of producing electrical interfaces between the nervous system and the electronic system and electronic systems and computers. Because of course, the nervous system functions are on action potentials that rather resemble the digital pulses of digital electronic systems. And there are two main principles for this kind of interaction with the nervous system neuromodulation, which is intended to modify abnormal function of the nervous system and mainly applied in non Euro genic conditions. Um so it may benefit continents for people who have hyper reflexive because uh injection of electrical signals may modify reflexes, particularly the hyper reflexive of the bladder, can lead to urgency frequency and urging continents. By contrast, europe prosthesis are intended to replace missing structures, particularly in the nervous system and so it can be applied more to the neurasthenic ladder and are capable of restoring, avoiding after super sacred spinal cord injury, particularly in complete spinal cord injuries. So both of these may have some application to neurogenesis and Tony hygienic platters, neuromodulation. Typically, as you know, evolves electric stimulation of sensory nerves either in the periphery or in the spinal cord. And that sensory stimulation can often modify and inhibit reflexes, including the hyper reflexive to of the bladder. And this can be used in a couple of ways. The classic one by the medtronic Interest tim involves placing electrodes into the sacred parameter and after a test period with externalized leads. If it's effective, those leads can be connected to an implanted pacemaker which provides chronic stimulation to the sacral nerves, particularly Afrikaans nerves, which may therefore inhibit or reduce the hyper reflexive bladder mostly being used actually in non allergenic bladders. N able bodied people, people who have overactive bladder or idiopathic uh urgency, frequency and urge incontinence. And the approval of this device was based on symptoms rather than disease categories. So it's it's being applied in a variety of different kind of diagnoses for patients, patients with frequency, urgency and urge incontinence. Latterly, this has been applied in a less invasive way through stimulating sacred vows of the ankle also uh sacral segments but stimulating Afrin nerves and the posterior tibial nerve, with a needle inserted through the skin and a return patch on the surfaces can also affect the overactive bladder. And there are some attempts to do this non invasively now that we're working on by contrast, prosthesis, as you know, are intended to replace missing or damaged structures. In addition to mechanical prosthesis, like artificial limbs, one can have neural prosthesis to replace neural tissue uh like a pacemaker like this with various leads and connections to nerves and muscles. And so typically these substitute for damaged nerves by stimulating motor nerves and producing results contraction of muscle and in particular for the patients with super secret spinal cord injury. It's possible to stimulate the sacral, parasympathetic and somatic nerves to restore function. This one would think would be counterproductive. If you stimulate both the parasympathetic and somatic, you would produce the co contraction that can be dangerous. But it was shown about 40 years ago brian Brindley in Britain, that intermittent stimulation separated by gaps of no stimulation um can produce summation of pressure in the bladder because the bladder muscle contracts and relaxes slowly with the externally. Rethink their contracts and relaxes rapidly. So there are gaps when the external thing too is relaxed and the blood is contracted and that can produce urine flow during those gaps. And this intermittent flow of urine, not typical of humans, but typical of other species site, can produce safe and effective uh empty. This shows a animation of that and the bladder and the spinal cord and sacred nerves to the bladder and sphincter here and the his nerves can interact with an implanted pacemaker or radio receiver, combined with the stimulator, which has leads under the skin, running two electrodes that are placed in contact with the sacred nerves, typically in the back of the sacred, and then an external transmitter operated by the patient can have an antenna, which transmits radio signals through the skin to the receiver. And the patient can then operate an external controllers such as this, switch it on, hold the antenna over the skin and the radio signals transmit power and control through the skin to the receiver, providing stimuli along the leads to the electrodes and then producing action potentials to the bladder and actually to the sphincter. And you can see here that the bladder contracts and intermittently the sphincter contracts but then relaxes again, allowing a flow of urine and repeated births like this can effectively empty the bladder with low residual volumes of urine and reduction of a lot of the symptoms. So that is good for getting you an out. But as far as keeping your in or storage, it's often been combined in the past with rise artemis or cutting the sensory nurse of the sacral segments to abolish the hyper reflexive bladder and sphincter. And So that combination of stimulation and rise Artemis, which has been used in three or 4000 patients now over number over many years has been shown that the electric stimulation can produce mix tradition on demand under control of the patient with the pacemaker and that can produce low residual volumes and therefore greatly reduced urine infection and not requiring capitals to get here and out the rise artemis restores the storage function of the bladder and that can reduce reflex and continents. And I mean that antico allergic are not required. And this also happens to reduce autonomic dis reflects here and the people who are prone to that. It also happens to benefit uh power function, which has a lot of the similar neural pathways and has been shown in several countries now to reduce the cost of care of the jura genic bladder and can greatly improve the quality of life of patients. However, there are still the disadvantages of the rise artemis in that it abolishes desirable reflexes like a reflex, erection, reflex, ejaculation. And although there are other methods of producing erection and ejaculation after spinal cord injury, which are often very effective, there's research in progress now to look for alternatives to the surgical rise artemis. Okay, so management, the neurasthenic ladder needs to be integrated with that of the bow, which has many similar features and similar neural pathways that about tends to respond more slowly than the bladder. It can also be emptied by pacemakers like this. But we have to take account of sexual function and manage these three systems to get the best combination for the patient and giving patients uh good information to make an informed decision and choosing the management that suits them and improves their bladder, bowel and sexual function and optimizes all of these functions in the way the patient wants, which obviously depends on their their gender and their social situation made. And uh there preferences as men and women I mentioned of course, the need for multidisciplinary management because if a person is not aware of the need to avoid or aware they're incontinent or aware of when it's socially appropriate to avoid. That's a big factor in choosing the method of management that will not only be socially appropriate but will avoid incontinence and pressure ulcers and other complications. And then there are manual ability to dress or undress, manage their clothing, managed catheters during collection, bottles, bags and possibly categorize themselves uh depending their manual ability, depending, of course, on their on their mental ability and their hand function. If they have had a spinal cord injury and then mobility, can they get to the bathroom without falling? And are they using a wheelchair, which is sometimes called the third sphincter? Because just sitting on a firm wheelchair can itself in avoiding and require patients to move to the front of the wheelchair or have a cut out to the cushion to avoid compressing the male urethra. Also difficult for some females to categorize in the wheelchair, of course. So often the best management is done in specialist brain injury and spinal cord injury units, as you know sometimes called centers of Excellence where you can bring all these disciplines together to provide one stop shopping for the patient instead of the patients having to go around to a variety of different clinics for different body systems. And these units are often aggregated into networks of excellence which agree on common standards and guidelines and can collect data to determine what are the best practices and share these practices and who probably familiar with the system of brain injury care particularly expanded during recent wars and sometimes called poly trauma because of the multiple systems involved, they have long been the V. A. Spinal cord injury system of care, which grew up after the Second World War. And the network is finally units and primary care teams that work together to cover the country. Similarly, in the non V. A world, there are the model systems of care, both the brain injury and spinal cord injury and in addition other centers, uh many credited by Car, the commission on accreditation of rehab facilities, which again helps to maintain standards and guidelines for quality care. And there's been so much discussion in the last decade on how we can reform our health care and improve it. And these centers of excellence are one example of what was described in this article in the Harvard Business Review back in 2013 as integrated practice units units where you bring all the specialties together to revolve around the patient instead of the patient having to revolve around different clinics and specialties and physicians in different places. And so these integrated practice units are the building block of better care, and TBH and CNN's are a classic example. But then as this article discussed, there's a number of other features in which you can integrate care across these different facilities and expand them geographically around the country and develop the information needed to guide future care. Mhm. Because to really optimize health care and health, we have to take account of the quality not only of the care of course, but the quality of life of the patients. And we have to think not only of efficiency but also of effectiveness. There's no point of a surgeon using less suitors to be efficient if the suit has become undone and therefore ineffective. And then the value of care is the bottom line. Uh the relationship between costs and outcomes and this is value. That has to make sense for all parts of the supply chain and the individual physician, the hospital, the health care system. Health insurance, there's a whole ecology and each member of the ecology has to be able to see value in what is being done. And the value of course is not just monetary, but societal and ultimately the value is to patients. And we may all be patients sooner or later if we're not already very often, information about quality and patient safety and access is phrased in terms of how are we doing? And the surveys sent out to patients often ask the patient, how are we doing as a hospital system? But as one of the colleagues of that article I mentioned earlier, I'd like to say what we should really be saying to patients more often is how are you doing? That's the kind of question that we should really be asking patients. So I'll stop there and ask you as an audience how you're doing and whether you have any questions. Thank you dr creasy. I think that this is a very important topic. I mean when we're looking at patients in acute rehab unit, one of the common reasons why they don't end up going home is because of um issues with bowel and bladder care. Um And I want to see one of the things that struck me being in some some different units is uh a difference in ah aggressiveness if you will with the urologist I've heard a number of times um move you know well let's not do anything right now things are gonna change. Have them follow up with me and clinton portfolio and and have them follow up with me in clinic. And also some of the reasons are the scopes that I have in the clinic are better. Uh I'm not able to do the your dynamic testing in the hospital things like that. Um But uh can you talk a little bit about the timing of doing the testing? Um You know I know used to uh you know back when I was in training you won doing the C. M. G. S. And uh on the spinal cord injury unit. So um okay the timing of the testing. How that certainly. Yes and I think that partly depends on physiology and partly just depends on the logistics of the care system in which the patient is found. Um Obviously after traumatic injury to brain or spinal cord there's some evolution of the symptoms and the physiology We heard earlier about the concussion lasting anything anywhere from 24 hours to six months and more severe injuries to bring lasting longer. And in the case of spinal injury, the function of the bladder tends to evolve over the first few months. So there's initially what's sometimes called spinal shock and a reflex to and then the reflexes return over a variable period of weeks to months. So doing your dynamics early sometimes just shows an a reflexive platter, but that's not necessarily the the long term situation. Uh Some of the recommendations, for example, in the V. A. System of care are the epidemic should be done before the patients first discharge from rehab. And certainly by six months because it's important to detect the hyper reflection and that it uses thing to dis synergies that may be developing. But it does depend on this uh system of care and whether the rehab towards are closely associated with acute wards and whether the urologist is just a visitor to the rehab unit or integral part of the team, whether the rehab units in an acute care hospital or a freestanding facility. I think the important thing is the relationship and the closeness of collaboration so that the urologist can be a close colleague at the fa scientists and a neurologist and can see the patients early before problems develop otherwise. As you said infection and other complications can just become a part of the patients. Experience from very early on in rehab and can delay rehab had had to cost duration length of stay. So I think close collaboration is the key. And uh accepting that your dynamics early may not give us the final answer. We need to maintain that close connection with the urologists and have him be interested in the patients, not just as candidates for one of his operations, but as people that he can manage conservatively as well as surgically and managed together with a multidisciplinary team taking account you know, the mental and manual the ability to the patients and so on. Um So another question is the Medtronic inter stem MRI compatible. I think the more recent versions are they used not to be? Uh Medtronic has been working to make its more recent systems compatible. And that's probably the best to consult with a company like Medtronic on which device and which which devices may be compatible with which MRI machines? Um because our MRI machines have been changing too. And the strength of the MRI machine affects the frequency of its signal. In the case of the Fintech Voelker device for example, the Currently MRI machines are compatible with the fine take Boko because they use a field strength at least 1.5 tesla or above. The very early machines with low field strength have frequencies in the range of the radio control of the implant. But current MRI machines are safe for the fine tech uh friendly system. Now with the with the vote care, I know that it's you know, not commercially available. But is there um do we have is there anything on the horizon? That's that's potentially yes that is going to be it's not commercially available currently in the U. S. A. It was the beginning part of the century but it remained commercial veil with other countries particularly europe and south America and the Far east. And what we're currently working on is research into alternatives to the rise artemis so that the vocal system could be brought back without resort to me and made available to more people. And so research in here in Cleveland and in europe is aimed to bring it back, make it commercially available in this country. Again without resort to me. Yeah. Well I think we're just about out of time. So I want to thank you again, Doctor Greasy for uh for your valuable extra and your and your time. And I think other questions come in. We'll move, move forward them to you. Yes. We are free to give my email address to people who have are questions and thank you for your sharing. It's good to see you again. Thank you.