Stretching doesn’t work the way we think it does. At all. If you’ve ever spent your time gritting your teeth, pulling your arms or legs or (eek) neck into weird and wonderful positions to feel that pull, before noticing that a few hours later they’re back to where they were before, you’ll know that stretching doesn’t make your muscles stretchy. To understand why stretching isn’t the key to flexibility, we first have to understand a bit more about how and why our muscles stretch in the first place.
All humans have a reflex in our nervous system called the myotatic reflex. Believe it or not- you’ve probably had this tested without even knowing it. It’s the one we activate when we use a reflex hammer to hit just below your knee which makes your leg jump, or the one just above the elbow which does the same to your arm.
This reflex is the body’s pre-programmed response to a stretch stimulus in the muscle. When the muscle is stretched (as in when hit by the reflex hammer), an impulse is sent to the spinal cord to contract that muscle (and relax the muscle that works in opposition to it), causing the limb being tested to jump. These reflexes are what are called “monosynaptic” as there is only one junction for any signal to pass through before the body sends a response (the message going in->junction->message coming back happens in the spinal cord, bypassing the brain to make sure the response happens quickly) Think how rapidly your knee jumps when it’s hit by the reflex hammer- it’s usually just 1-2 milliseconds before the body responds.
We use these tests in clinic to check the integrity of your spinal cord and the peripheral nervous system, and they can be vital in helping us identify neuromuscular conditions. But that’s not what we’re talking about today. You might be wondering what purpose these reflexes have? Well, one of their most important functions is to prevent us from tearing our muscles/tendons/ligaments. Let’s look at the patella reflex to demonstrate this:
The patellar tendon is tapped just below the knee, which puts a rapid stretch into the tendon which attaches to your quadriceps muscle (the muscle in the front of your thigh). Muscle spindles (sensory receptors that pick up changes in the length of the muscle) pick up on this rapid increase in the length of the muscle, and very quickly send a message to contract your quadriceps in order to stop the muscle or tendon from over-stretching and causing damage. What happens when your quadricep contracts? Your lower leg comes flying up! If it doesn’t, it could indicate an underlying condition or disease affecting your muscles and nerves (which is why we always test them in clinic!)
What else do reflexes do? Well, they also stop us from falling over all the time. Stand up for a second. Now lean over. As far over to one side as you can go. What happens? The muscles on the opposite side to the lean become stretched, and that reflex is activated again, telling those muscles to contract in order to correct your posture and stop you toppling over. Now, this is a more obvious demonstration of how reflexes maintain our posture, and these postural corrections are generally carried out subconsciously (so we don’t spend all day feeling like we’re going to fall over!) It’s one of those things that we notice more when it stops working.
So what do reflexes have to do with stretching my tight muscles?
When we activate stretch receptors in the muscle, the message the body receives is to contract that muscle to prevent overstretch. So the usual static stretching that we do (for example when we bring our foot up behind us and grab on to it to stretch our quadriceps) puts our conscious and subconscious brain into war against each other. You’re consciously grabbing that foot to pull that muscle into a stretched position, and your stretch reflex (the subconscious brain) is automatically kicking in (as reflexes do) saying “No!” and tries to stop you from over-stretching and causing yourself an injury. What do we tend to do in this situation? Most people say “oooh that’s tight!” and promptly pull harder… Static stretching has actually been shown to decrease strength and athletic performance, while failing to reduce risk of injury to any significant degree.
Why does stretching feel so good then?
There are a few reasons why stretching might make you feel like you’re getting somewhere.
One: If you continually statically stretch your muscles, you can cause that stretch reflex to become less active. This can mean the muscles do lengthen, but only for a little while. Give it an hour or two for that reflex to go back to normal and the muscles will tighten back up again. This can cause problems for athletes- static stretching means the muscle is unable to contract properly because those muscle spindles aren’t functioning right. There’s plenty of research out there to show that static stretching before exercise can reduce your muscle strength, power, performance and joint stability.
Two: The more we stretch, the better we’re able to tolerate the sensation of “pulling” in our muscles. Yep, we’ve all said it “Ooooh, that’s a good stretch!” That temporary lengthening and release does feel good, but not for long.
Three: Pull a muscle or tendon enough, and you’ll begin to stretch your ligaments. Ligaments can, over time, then become stretched out to the point where they’re unable to function properly, resulting in joints that move too much, and are unstable. When ligaments get to this point, they might never regain their original length and strength.
Stretching- Will it get you out of pain?
In a nutshell, no. The nervous system rules the road. It’s totally in charge of everything that we do. If you’ve had treatment with me, you’ve probably heard me talk about the reasons why the brain can cause our joints to stiffen and feel like they’re “locked up”. It’s your brain’s way of stabilising an area that it perceives to be at risk of injury (whether that perception is founded in fact or fiction!) So on a very fundamental level, if your brain still perceives there’s an issue in that area, no amount of pulling on your muscles is going to change that. Equally,if the muscle is tight and sore because there’s a joint somewhere that’s misbehaving and preventing the muscle from functioning as it should, then stretching isn’t going to do much for that problem.
The process that tells us how tense our muscles should be at rest (known as “resting muscle tone”) is called the alpha-gamma feedback loop and it’s a lot more intelligent than we give it credit for when we’re yanking on our body to get it to stretch. In order to reset an over-enthusiastic resting muscle tone, we need slow, controlled movement which provides vital sensory feedback, allowing this system to reset itself. This makes it fairly clear that pulling our muscles into, or beyond, their stretch capacity does little other than provide a temporary increase in muscle length which then rebounds when those muscle spindles reset, giving you little more than temporary relief from pain and probably serving to prolong your discomfort by making your muscles tighter overall.
So how do we make muscles stretchy without stretching?
First we have to look at what’s causing the muscle tension in the first place. Let’s look at the hip joint as an example. It’s got anywhere between 170 to 200 degrees of flexion and 40-60 degrees of extension, so is well over the 180 degrees needed to do the splits. So aside from structural changes in the hip joint, is mainly restriction in the soft tissues that stops most of us from being able to pop the splits whenever we fancy. No amount of stretching or “bouncing” into the splits is going to get you there- for whatever reason, the muscles you need to do the splits are activating way before their supposed maximum load and your brain is telling those muscle spindles to stop before you hurt yourself.
We have to stop thinking that we can teach our muscles anything. Our muscles don’t call the shots- our brain does. If a muscle gets tight, it’s because the brain is telling it to contract. So if stretching isn’t the answer, what is?
Chiropractic care to correct the cause of the problem- We find, assess, diagnose and treat the underlying reason for the muscle tension. If you don’t know why they’re tight, how can you possibly get them better?
Foam rolling. It’s not just rolling about on the floor (although that helps!) Foam rolling activates a different receptor in the muscle (called the Golgi Tendon Organs) which sit at the junction between your muscles and tendons. When we foam roller correctly, we stimulate these GTO’s which encourage the muscle spindle activity to calm down, helping to decrease muscle tension, reduce pain and improve function.
Functional movement. Simply put, warm up based on movements you actually do in real life. How often do you actually grab your neck and pull it into a weird angle in real life? Not often. If you’re a runner, instead of doing straddle-stretches or the good old foot-behind-your-bum-and-pull stretch for the quads, try lunges, high knees and skipping instead to replicate the movement you’re going to do.
So there you have it. Stretching tight muscle tissue will only make it tighter. Find and correct the reason for the tension and enjoy super-supple muscles instead!
Below is a montage of the speedy renovation project that was conducted between Christmas and New Year 2016: including our new signage, new chiropractic bench fondly renamed Kermit for his bright green colour, painting, removing cupboards and replacing floors. Thank you to everybody whom has helped and been a part of the transition from award-winning chiropractic clinic to award-winning multidisciplinary clinic.
Take a tour through the transformation of 2 Palmer’s Road:
We’re not talking about the BBC PROMS, or in fact anything to do with music. We’re talking about Patient Reported Outcome Measures (PROMs), and they’re far more exciting than the BBC version (in our humble opinion).
Patient Reported Outcome Measures are the tools with which healthcare practitioners and clinicians can better understand the impact illnesses or conditions and treatment are having on our patients’ daily lives. At Acorn Health, we utilise Care Response, a system which gathers the data for us and is supported by the Royal College of Chiropractors.
We don’t collect PROMs purely for our own benefit, it’s also for yours. We want to understand how your pain or problem is affecting your daily life- are you able to wash and dress yourself without pain? Is it stopping you from having a social life? Is it preventing you from working? Not only that, but we want to know how you feel about your pain. Are you worried it’s never going to get any better? Perhaps you’re scared about whether being physically active is going to make it better or worse and had to duck out of that golf game you had lined up. These are all very common concerns (so don’t worry if you’re having them- we all do!) and by understanding what your concerns are and how your pain is affecting you, we can provide a more accurate and more appropriate course of treatment for you. The responses to these questions will also indicate to us whether you are at a low, medium, or high risk of the problem becoming chronic (lasting for a long time) and this can mean that we need to provide you with very specific advice and information in order to prevent this happening- and yes, it can be done!
PROMs are starting to sound really good, aren’t they?
Another fantastic thing about PROMs is that they can tell us whether the treatment plan we have together decided upon is having the effect we want or not. Often, when pain decreases it can be difficult to remember just how bad it was (Remember that saying about giving birth? If we remembered how bad childbirth was we’d never have more than one child!) That being said, PROMs give us a way to determine your response to treatment based on your original responses to the questionnaire.
The story of patient X: Utilising PROMs in clinical practice
So how do we put PROMs to use in clinical practice, and how do they help inform our decision making and improve the care we provide our patients? We’ve got a case study here to explain it.
A bit of background- this Patient (let’s call them Patient X… sounds all mysterious and technical doesn’t it!) Anyway, Patient X had sustained a lower back injury in a road traffic accident more than a decade ago and had suffered with recurring episodes of lower back pain which, as seen by the chart below, were having a significant impact on their ADL’s (activities of daily living- things like washing, doing housework and sleeping) as well as their social life (going out to see friends, going to the gym, playing sports), the pain was a 6/10 and it was also making them anxious, depressed, having quite a severe impact on their working day and they had very little ability to cope with, control or reduce the pain themselves. All in all, not a very pleasant situation to find yourself in, but these results are fairly common in the patients we see in clinic. So much so, in fact, that Philippa takes a special clinical interest in chronic pain management– but that’s a story for another time.
The questions on the initial form are part of a validated assessment tool called the Bournemouth Questionnaire, and the answers are scaled on a 0 – 10 linear scale, 0 being “the pain has no interference” and 10 being variations of responses such as “completely unable to carry on” or “extremely anxious/extremely depressed.” As you can see, this patient was also at medium risk of chronicity due to some concerns they had about their back pain and what it meant for them, as they were worrying about it a lot of the time and felt that it was never going to improve.
We normally complete an outcome questionnaire after 2 weeks but in this particular case it was after 4, and Patient X completed this questionnaire which asked how their pain has changed, and also assesses the impact this pain is having on their lives at that time. This is where we get a bit geeky and excited- bear with us while we explain why.
Yes, as you can see below, Patient X’s pain level had increased at the time they completed the outcome questionnaire because (by their own report) the “Sciatic nerve in left leg has been irritated since last weekend” after spending a weekend doing a lot of heavy work in the garden…. they knew it wasn’t the best idea (!) However, despite the fact that they’d been doing quite hard physical work and had a slight flare-up as a result, they still reported they were “much improved” as a result of treatment, and their Bournemouth Questionnaire (the one that tells us how the pain is impacting on your day-to-day life) had reduced from 52/100 to 34/100 (which is computed as a 34.62% improvement!)
How is it possible that the pain could actually have increased, but Patient X felt better? Well, as we do with all our patients, we had a lengthy chat with Patient X about their pain, and how it was impacting them, and how they could manage it more effectively, as well as what we could do to help. Studies have shown that in some specific cases, a pain management course is actually more helpful than physical treatment, so we always include pain management as part of our treatment programmes. The more control you have over your pain, the less pain you feel. So through understanding pain and knowing what’s going on, what the cause was (in this case a mechanical issue with how a joint in the lower back was moving) what it isn’t (lower back pain is very rarely serious) and what to do about it (treatment and active self-management), Patient X felt less pain as they were less threatened by it, understood what was going on, were less concerned by the pain and able to move more normally without fear of pain.
After speaking to Patient X to establish what they felt had changed, the overall message was “I know what’s happening now, and I know what to do about it.” Woohoo! This is why it’s absolutely critical that we convey the right messages to you and help you to understand your pain. As practitioners, we also know that pain in itself is a really unreliable indicator of the severity of the underlying issue. To use our favourite analogy- think how painful a papercut can be despite the fact it’s a fairly minor injury. Pain in itself is just a symptom and studies have shown it does not relate to the severity of the underlying problem- in fact, some studies show that pain related fear is more disabling than the pain itself!
To understand more about pain and what causes pain, this should be your next bit of reading: Understanding Pain.
Let’s get back to Patient X, who today completed their final outcome assessment.
As you can see, the pain has dropped now to a 3/10. Those sections where Patient X reported were a 9/10 (ability to complete ADL’s and impact on social life) have dropped to a 3/10 and 2/10 respectively, impact on work was initially 7/10 and is now 0/10, anxiety and depression are both down from 7/10 to 1/10, and ability to cope with, control and reduce the pain was initially a 7/10 and is now a mere 2/10!
Whilst plenty of naysayers might say “Sure, but they’re not pain free and their Bournemouth Questionnaire isn’t zero.” If you had an illness or disease that lasted several years, would you take a few pills and expect it to be cured? No. Realistically, you’d hope that it would be better, as it is for this patient. Recovery takes time and is something that cannot be rushed. If you recall, Patient X’s problem had started over a decade ago, so we’re delighted that two months later the pain has improved this significantly. Not only that, but Patient X reports feeling “much improved” as well so we know they’re happy with how they’ve progressed- which gives us all sorts of warm fuzzy feelings. Hooray for job satisfaction!
So what happens now? At this stage, we’ll see a lot less of Patient X as they are formally discharged from care. The pain is now so minimal and intermittent that after discussing it with them, they’re happy to manage it themselves at home with stretches, exercises and lifestyle modifications (such as taking regular breaks from sitting whilst at work). We’ll check up on them in a few months to review their exercises, identify if there are any issues that have crept back on and this also gives us an opportunity to discuss their progress with them and if they have any further concerns. Of course, we’re always at the end of a phone or email, Facebook, Google+ or Twitter if they (or you) want to get in touch in the meantime!
We never guarantee 100% cure as nothing in medicine can. No pill, no operation, no treatment. There are no guarantees. What we do say at Acorn Health is that we will always give you the very best treatment and care, in accordance with the latest research guidelines and current evidence base. We can also say (thanks to another fancy PROMs questionnaire) that we have 100% satisfaction rates from every patient we’ve seen since we opened back in 2014, and that makes us very happy indeed.
So there’s a little overview and case study into how PROMs are put into use in clinical practice, and why we utilise them! If you’d like to know more, or would like to get in touch to book your own appointment, you can contact us using the form below.
They say money never sleeps, but in reality, it’s healthcare that never sleeps. Constant innovation, new technologies, new treatments, medications, therapies and more, healthcare is changing and developing fast enough to make your head spin.
With a New Year just hours away, we thought we’d take the opportunity to review the latest and greatest developments in healthcare throughout 2015, as well as popular healthcare articles that made headlines and our own most popular content.
One of the most widely-shared articles on the internet in 2015, this article from The Atlantic posed some interesting questions about how doctors interpret (or in fact, underestimate) women’s pain. In America, men wait an average of 49 minutes before receiving an analgesic for acute abdominal pain. Women wait an average of 65 minutes for the same thing. A harrowing and extreme example perhaps, but it highlights the ultimate need for all healthcare professionals to listen, understand and consider each person as an individual before making a clinical decision. There is no place for assumptions or generalisations in healthcare.
3. When the media gets it wrong
In a classic example of misinterpretation, a report from the American Journal of Cardiology caused quite a stir when it suggested that “strenuous jogging is as bad as no exercise at all.” The claims were quickly clarified by the NHS, as what the media failed to make clear here was the size of the demographic involved in the study- once the 1500 participants had been split into groups based on duration, frequency, and pace, some individual groups – particularly the most active groups – were (by research standards) too small to draw any real clinical significance from, with just 36 runners classified as “strenuous joggers.” As a result, the analyses conducted were less able to detect what, if any differences were present between the two groups. A classic example of needing to know the full picture when drawing a healthcare conclusion like this. (N.B. The biggest concern with exercise is not “overdoing” it. It’s not doing enough! If you’re thinking of taking up a new hobby in 2016, let’s keep you injury free.)
4. Kinesiology tape
Our most popular post of 2015 was “Kinesiotape during Pregnancy”, which to date has had a whopping 22,800 social shares. Kinesiotape is paradoxically gentle, yet strong, and depending on the way it is applied, it creates an effect on skin that improves circulation, relieves pain and supports muscles and joints which can be a huge help for mums to alleviate some of the postural aches and pains associated with a growing bump!
5. Back pain and paracetamol
An article published in the British Medical Journal back in March of 2015 confirmed what many of us have known for some time- that paracetamol is ineffective for back pain. With prescription of paracetamol being the most common approach to treatment used by general practitioners for spinal pain and osteoarthritis of the hip or knee, this has highlighted the need for a review and potential reconsideration of current recommendations that support the use of paracetamol for these groups. The current guidelines from the National Institute of Health and Clinical Excellence support the use of manual therapy for low back pain, alongside a structured exercise programme. Good news for Acorn Health patients who will know this is a fundamental part of our treatment programmes.
6. Our big news
2015 was a fantastic year for us as Philippa was accepted into the Royal College of Chiropractor’s specialist Pregnancy and Paediatric Faculty. These specialist faculties recognise chiropractors who have undertaken formal postgraduate studies and have specialist knowledge and expertise in their particular fields and Philippa was delighted to be welcome into the Paediatric Faculty in addition to her already acheiving Licenciate status with the specialist Pain Faculty. Not only that, but 2015 also saw Acorn Health pick up
it’s second national award with the Royal College of Chiropractors, the Clinical Managment Quality Mark, which is awarded to those clinics that demonstrate excellence in terms of operating within a structured and managed clinical environment. The clinics must demonstrate excellence in a range of areas including clinical audit, incident reporting and patient satisfaction.
We were also delighted this year to have been accepted as a Dementia Friendly Business with the Hampshire Dementia Action Alliance, part of the Dementia Friends group.
2015 brought sugar to the small screen in the form of the controversial Jamie’s Sugar Rush. One of our favourite pieces of the year was this article from the Huffington Post, showing what sugar does to your brain. In addition to being a key contributor to rising obesity levels, sugar is also known to impair memory, contribute to depression and anxiety and is linked to cognitive decline and dementia. 2015 was definitely the year that the UK began to combat the hidden sugars in our food, and began to make healthier dietary choices.
9. First Paracetamol, now Nurofen
The UK-based manufacturers of Nurofen, Reckitt-Benckiser were forced to defend their product after Australian courts ordered certain products off the shelves after finding each product, despite being marketed as able to treat specific pains, such as migraine, were identical to one another and contained the same active ingredient, ibuprofen lysine 342mg. Prices for these products also averaged around £3.49 for a box of 16 capsules. Why is it that snazzy packaging and good marketing so often tempts us in? We’ve said it once, we’ll say it again. Save your money and buy generic. (They’ll cost you about 30p instead!)
10. Paraplegic man walks again
An accident 5 years ago left a 26 year old American man paralysed from the waist down, unable to use his legs. This year, scientists successfully rerouted nerve signals from the man’s brain to electrodes on his knees, enabling him to become the first person with paraplegia caused by a spinal injury to walk without relying on robotic limbs that are controlled manually. Yes, our jaws dropped at this one too. Around 50,000 people in the UK live with paralysis, and whilst this treatment surely won’t be appropriate or possible for each of them, it was a truly groundbreaking achievement in science, and a step on the path to giving this young man back his independence.
Gosh- you see what we mean about how much takes place in a year? We know there’s been hundreds of new developments, too many to even mention, but we wanted to highlight a few of our favourites from 2015.
We have an exciting year lined up for us, with a new clinic opening at ActivHealth, Langstone Technology Park, Havant. We also have big plans for the introduction of new and improved online resources, new courses and workshops to be held and a few surprises we have in store for you (but aren’t quite ready to share yet!)
May we wish you all a very happy and healthy New Year!
Here it is, the oh-so-predictable New Year’s Resolution post about a “New Year, New You.” We’re going to bypass that this year in favour of something far more important. Whilst New Year’s Resolutions which centre around going to the gym, getting fitter or putting more of an emphasis on our health are fantastic, we want you to spare a thought for your joints before you start a new exercise regime. Search online for “getting fit quotes” and the words that pop up most frequently are “pain”, “hurt”, “sore”, “skinny” or “burn”. Whilst some pain is normal and to be expected, this has given rise to a worrying influx in the number of sport-related injuries we’ve seen from athletes “training through the pain”.
Most sporting injuries occur from what we call the Terrible Toos- doing too much, too soon. After not working out for months or years, people come in and try to run 5 miles or lift 200 lbs at their first session. Their deconditioned, unprepared muscles can’t cope with the action and so injury occurs. We then have to recover from the injury by which point our motivation for our New Year’s resolution is gone. You won’t become Batman (or Catwoman) in one workout session, so please please please train properly and spare a thought for injury prevention this year.
So how does injury occur?
Injury, particularly sports injury, occurs through direct or indirect trauma to muscles, ligaments, and joint capsules. Injury takes two forms- direct and indirect. Direct trauma or injury occurs through blunt trauma or a sudden overload- so dropping a weight on your foot would be a direct trauma (HINT: Don’t do it!)
Indirect trauma or injury occurs from repeated submaximal loading. (When we refer to joint loading, what we mean is the force that is put on a load-bearing or weight-bearing joint during exercise.) This could be therefore be repetitive injury to your elbows when lifting, or your knee when running. Indirect trauma can therefore occur through repetitive lifting of weights, running, or any activity that “loads” a joint.
Regardless of direct or indirect trauma, the end result is still the same- tissue dysfunction that is characterised through pain, inflammation, and internal tissue stress. This can lead to what is known as “functional disability”, where you’re able to go about your day-to-day life largely without issue, but your training or exercise regime is impaired. Not what you want when you’re motivated to get to the gym!
Why does injury occur?
Whilst some sports injury occurs through direct trauma- such as a rugby tackle, overuse injuries are more common in sports than acute injuries. These are subtle and occur over time, hence why early detection and diagnosis is key. Faulty movement patterns, joint restriction or muscle dysfunction can be detected by your chiropractor which can help to identify those who are at risk of an overuse injury and provide advice on injury prevention, modification of exercises, adaptations to technique or treatment if appropriate.
Researchers have reported that impact forces of up to 550% the normal force load are transmitted to our joints when running, with impact forces between 4 to 8 times higher than those during normal walking. Much as you wouldn’t lift a heavy weight without putting some thought into it first (if you even decided to lift it at all!) we need to put some thought into how well equipped our bodies are to cope with these additional stresses and strains before we hit the gym. This is why launching into a fitness regime without putting some thought into how you’re going to do it and how you’re going to protect yourself whilst doing it can be crucial.
Coping with this degree of stress can be challenging enough even for joints that are well-adapted to this degree of stress, but if you are starting a new exercise regime or perhaps picking up a new activity, your joints need some time to adapt to the new activity. They also need to be ready and able to cope with this degree of stress. This is where chiropractic comes in.
How does chiropractic help?
Chiropractors are primary healthcare professionals who are trained to diagnose, treat, manage and prevent disorders of the musculoskeletal system (bones, joints and muscles), as well as the effects these can have on the nervous system and general health.
Chiropractors are often thought to only “crack backs” and only treat back pain. Much like your GP wouldn’t prescribe the same pill for an ear infection as they would for high blood pressure, so a chiropractor doesn’t just perform spinal manipulation for a bad back. It entirely depends on the nature of the injury, the level of pain, and most importantly, your personal preferences (it all comes down to teamwork!) Chiropractors have a vast array of treatment options they can offer and chiropractic care can be crucial in injury prevention because chiropractic emphasises the correct functioning of all joints, muscles, tendons and ligaments in your body to ensure you are performing at your very best. Whether you are an elite athlete, a gym newbie, or perhaps a keen sportsperson returning from injury, chiropractic can be crucial in identifying dysfunction prior to an injury occurring.
A crucial part of treatment at Acorn Health is helping you to develop a firm understanding of how your body works, how pain and problems can occur and how to prevent it. We work with you to develop a new fitness routine and training programme with appropriate exercises that will enable you to strengthen and stabilise your joints whilst reducing your risk of picking up an injury.
So whilst you’re dusting off your trainers and wrangling your way into your sports kit, spare a thought for your joints, and spare a thought for injury prevention.
If you would like to receive our “Injury for Runners” resource, detailing the most common types of running injuries, the mechanism of injury, preventative measures and more useful information, please complete your details below.