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5 Causes of Sciatica

First, let us define what sciatica actually is and is not. Sciatica is, very specifically, pain along the sciatic nerve stemming from irritation of that nerve. The sciatic nerve is formed from a conglomeration of spinal nerves in the low back which binds together into one sheath. This nerve runs under the piriformis muscle in the pelvic area, then runs in between the two parts of the biceps femoris, also known as the hamstrings. It has become common to call any pain in the leg which is suspected to come from the back, sciatica. However, sciatica is a nerve pain which is the same feeling you get when you hit your “funny bone.” Most leg pain, and consequently what most people call sciatica, is actually referred pain. That is a different post. To be a true diagnosis of sciatica, it must be nerve pain that stems from the lumbar spine and runs into the buttock and/or down the backside and middle of the thigh. Now that we have that out of the way, let’s talk about what causes it!

  1. Disc Injury. Disc injuries are the most common back ailment. When a disc bulges or herniates, it can occupy the space where the spinal nerves exit from the vertebral column. If a disc bulges too far it can push against the nerve root causing pain to travel down the sciatic nerve and beyond. Sometimes, the bulge will hit the nerve and then pull back enough so that the sciatic pain is not constant. If the disc is in constant contact with the nerve, one can experience pain, numbness and tingling, weakness, and other symptoms. Chiropractic can help, but these can take a long time to heal and consistency makes the difference. Traction, rehabilitation exercises, physical therapy, and stretching can also help if done properly. If it comes to it, cortisone injections and surgery may be last resort options.
  2. Inflammation. With injury comes inflammation. Though the disc is the most common injury, there are several other structures in the area of the nerves that make the sciatic nerve that can be injured. Inflammation is toxic and can cause its own set of issues. Nerves are especially sensitive to inflammation. Icing, NSAIDs like ibuprofen, Chiropractic, and steroids can all help reduce inflammation. When the inflammation is in check, the back and sciatic pain will diminish. When the area with the sciatic nerve or nerve root is inflamed. The symptoms will remain constant.
  3. Sacro-Iliac (SI) Joint Dysfunction. The sciatic nerve crosses the SI Joint just after it forms the large nerve. If the pelvis shifts or is not working properly, it can irritate the Sciatic Nerve through direct pressure, inflammation, or by causing muscle tightness or spasms from the imbalance. Adjusting the SI joint will help reduce inflammation and muscle guarding, as well as move it away from contact with the nerve if that is the case. Chiropractic is by far the best thing for this case but a clever physical therapist can help, too. Exercise, stretching, and icing may help but can irritate it, as well.
  4. Piriformis Syndrome. This diagnosis has become pretty popular. I find that it is misdiagnosed more often than not. The piriformis is a little pear-shaped muscle (hence the name, piri means pear), that spans the SI joint. The Sciatic Nerve runs underneath it in most individuals. If this muscle tightens, it can compress the sciatic nerve and cause sciatica. The piriformis can tighten for various reasons including any of the above-mentioned maladies. Usually, I find the piriformis is a secondary issue. Sometimes, however, it can take on a life of its own after the other condition has resolved. If it is, truly, piriformis syndrome, the best thing to do is have a specialist perform a muscle release on it. Active release, myofascial release, Bowen, Rolfing, massage, etc. can all help if done right. Be aware that if it only helps for a little while, then there is probably another issue that is still causing the muscle to tighten or guard.
  5. Direct Contact. Because the Sciatic Nerve runs through the buttock and down the back of the leg, the way one sits can cause sciatica. The most common cause is a wallet in the back pocket. Additionally, a seat that curves upward along its lip can put pressure on the legs and irritate the nerve. Unfortunately, I have seen this most often in vehicles.  The solution for these is obvious. The trick is to figure it out before it causes problems more difficult to remedy.

There you have it. Probably not a comprehensive list but definitely the most common causes. Sciatica is actually rarer than it seems. When you have it, however, it is very painful and can be difficult to treat. If you are experiencing sciatica or any type of pain or other symptoms down the leg, chiropractic can help. And, like all conditions, being prompt and consistent makes for better and quicker healing.

5 Things to Do When a Rib “Goes Out”

Rib pain can be miserable. I cannot tell you how many patients have come in to see me after visiting the Emergency Department because they suspected a heart attack or something serious. Pain in the chest, shortness of breath, radiating pain down the arm, nausea, etc. Sounds like a heart attack but all of the tests are negative. So what do you when the emergency docs send you home and tell you it is nothing? Most likely you are dealing with a rib that is either stuck or not moving in the way it is supposed to. Here are five things to do, and not to do, to help.

  1. Heat and Ice. One of the biggest complaints, when a rib is out, is muscle spasming. Heat will help you endure a muscle spasm. There is a caveat, however. Heat brings blood to an area and if that blood is not flushed out, it will cause more inflammation. So, use heat for 20 minutes and then walk around for a while or ice it. Ice drives away inflammation. Ice for 20 minutes maximum. Always end with icing. For more information on heating and icing, go here.
  2. Massage, but be careful. As mentioned, muscles are often tight when a rib is not functioning properly. massage can really help to calm down the muscles. Here again, a word of warning. Often times, the person giving the massage will feel a good sized bump and mistake what is really the head of the rib for a muscle knot. Rubbing this bump will not only be painful but can increase symptoms. Working on the areas around it can be quite helpful. Massaging after the rib is moving again is great.
  3. TENS or Electric Stimulation. A great, non-drug option for killing a spasm and managing pain is to use e-stim, TENS or something similar. These are basically devices that send electrical pulses through wires and patches over muscles. There are several options of machines and can be purchased at various locations or from Amazon. Price and quality range drastically but I have found that the inexpensive units work pretty well.
  4. Get it adjusted! At the end of the day, until the rib starts moving properly it will cause problems. Not all chiropractors are great at adjusting ribs as they can be difficult. Likewise, you really need to have the specific rib adjusted and not just do a general spine adjustment. Even after you get it adjusted it may still feel out. Remember that the muscles have most likely tightened around it and formed a knot. Symptoms can take a while to settle down.
  5. Mind your posture and quit trying to stretch it. Typically, ribs go out because of a forward head and shoulder posture. So, why do we always try and stretch that same way to get it to feel better? Likewise, stretching spasming muscles does not really work. It drives me crazy when I adjust a rib and the first things my patient does is check to see if stretching forward still hurts. That is like separating a wound to see if it has healed yet. If you keep doing it, it will never heal. Instead, look straight ahead and pull your shoulder blades down and back. Here is the vintage YouTube video I created to demonstrate. If you do this exercise and it is still really painful, chances are the rib is out again.

Ribs can definitely be tricky. Sometimes they stay in after one adjustment and sometimes they take several adjustments. Usually, the longer it is out the more adjustments it will take. The rib joints at the front where it connects to the sternum can go out, too. These are also very painful and can be adjusted, although it is a different method. Please remember that although rib pain is brutal, it is not that damaging. Stressing about it will only complicate the healing process. If you have pain to one side of the spine by the shoulder blades, in the front next to the sternum, radiating along the ribs, or all of the above, just come in and we can either help you or, at least, point you in the proper directions.

Decompression and Traction for the Intervertebral Discs

Life tends to be really hard on the discs between the vertebrae in our spines. Discs are made of a flexible cartilage with a thick fluid and a hard nucleus in the middle. Discs are designed to improve motion and provide shock absorption which makes them the most abused structure in the spine. When we bend forward, the disc bulges backward. This can cause weakness due to wear and tear on the inner posterior aspect of the disc. Likewise, placing too much strain on the top can make the disc bulge all the way around. This is seen when someone is overweight, does a lot of high impact exercises, or loads the body with too much weight like with squats.

Each time a disc bulges farther beyond its normal borders, micro-tearing occurs. Tears heal with scar tissue which is, by its nature, not as pliable and can tear again. It is possible to train scar tissue into flexibility and help it act like regular disc tissue but it takes time and training. Too often the more rigid scar tissue will tear and recreate the original problem. This is where traction or decompression comes in.

I may offend some docs who are big into decompression therapy but to me, it and traction are the same thing. I think they started using the fancier word “decompression” because they developed more sophisticated and expensive equipment and needed a word to match. I must confess, though, as a linguist, decompression does portray a clearer and more concise picture of what we are hoping to accomplish. But, I digress. With decompression or traction (and from here I will use the words interchangeably) the goal is to take away pressure from the disc. When pressure on the disc is lessened, the disc can reshape and heal.

Traction can be accomplished in a number of ways. The method I am asked about most is about home-unit to hang upside down. In this case, one straps their ankles into a clamp and then leans backward to a specified angle. Some units will allow a person to hang completely upside down. I recommend 45 degrees to start. That is usually enough to open the disc space without getting a head rush that will shorten the traction time.

There is a host of other traction devices. Most of them can be found on late night infomercials. All of have some legitimacy but some are definitely better than others. The one I have seen a lot recently has the person lying down with their heels resting on a moveable piece that pulls and moves the legs side to side. I am not sure how much traction is occurring but movement is always good. One of the better ones I have seen in the past looks like a big cushy loop that hangs in a doorway. The person is situated so that their upper back is on the ground and their pelvis and legs are parallel with the doorway. Again, the end result is the same and usually positive.

Some providers have very nice decompression machines that are extremely effective in separating the vertebrae thus decompressing the disc. With severe disc bulges and herniations, these machines can be lifesavers. The only downside is the expense which can be significant. In our office, we have available a more hands-on form of traction called flexion-distraction. The table we use flexes at the lumbar level and is spring loaded. The doctor puts one hand on the spine holding a specific level in place and uses the opposite hand to push the table down. The spine separates then accommodates as the spring pushes the table back up. If the chiropractor knows what they are doing, this a very effective form of traction and can make a big difference in the disc.

All of the forms of traction that I mentioned above address the low back. There are, however, various units for the neck, as well. There are three main types of cervical traction. One way uses a harness around the chin and base of the skull attached to a rope and pulley. These units either have a counter-weight, usually a water bag, or a tension spring. The other devices look like a collar between the shoulders and the chin/skull that expand when pumped full of air. Both are effective and mostly utilized at home. The third combines traction with an attempt to restore curvature. This unit is a wedge whereupon a person lies with their head hanging over the tall side of the wedge. Often times there is an elastic strap or a weight that pulls down from the forehead.

Whatever method you choose or whichever method is the most effective for you, the key to success, as with most things, is to apply it consistently over a significant length of time. I have a cervical traction unit that I use when my neck is hurting and I routinely have Dr. Wagnon adjust me on the flexion-distraction table. Discs, just like people, sometimes just need a break from the pressures of everyday life, traction or decompression is a great way to accomplish this.

Humpty Dumpty and Chiropractic

Humpty dumpty falling of the wall with the sky and clouds behind
Humpty dumpty falling of the wall with the sky and clouds behind

Recently, I had a patient ask me if I ever got stressed out about trying to put all of the Humpty Dumptys back together again. I joked that I am not all the king’s horses and all the king’s men so it is not my job to put Humpty Dumpty together again. This exchange brings up an interesting point, though. Several times a day people ask me to fix them. I understand what they want and I always do my best to help them, but somewhere in the back of my mind I am thinking that their expectations are mis-focused.

My job is to adjust the joints of the body. In doing so, the nervous system is stimulated which allows the body to communicate better. Better communication leads to better function. Better function leads to proper healing. Contrast helping the body function better with fixing something and you can appreciate why I am reluctant to claim that I fix or heal anything.

Bear with me while my BA in Linguistics drives the bus for a little while. If you take a very literal definition of the word fix, it means to “fasten (something) securely in a particular place or position.” That is the opposite of what I want to do. My aim is to help joints move. Likewise, it would be the height of hubris to think that I heal people. The body heals itself. Again, my job is to help the body function better so that it can heal properly and, hopefully, quicker.

Finally, giving me the burden of “fixing” someone is an impossible task no matter how willing the participants. That is like asking your exercise equipment to get you in shape. Sure the end goal is for you to get in shape but the responsibility is on you not on the equipment. Focus on improving function and not on getting fixed and you will find that not only are your expectations in line with your goals, but that your care will also be much more effective and productive.

 

The Art of Diagnosis

 

Full confession, I really do not like the word diagnosis. It is a little too limited, definitive, and stodgy for my tastes. I believe that we would be better served just identifying dysfunctional body parts than knowing fancy words that typically just describe symptoms. That saying, understanding symptoms and how they relate to dysfunctional body parts is extremely beneficial when coming up with treatment options. Understanding anatomy, biomechanics,  and physiology can make diagnosing musculo-skeletal injuries so easy it is a wonder why most doctors get it wrong most of the time.

It is important to understand location and type of symptoms to make a proper diagnosis. Location of symptoms does not necessarily indicate location of dysfunction. Many dysfunctional body parts refer symptoms to other parts of the body. Luckily, there are patterns which come is handy for those clever enough to recognize those patterns. The type of symptoms tell a good doctor what kind of structure is dysfunctional.

Embryologically speaking, there are three types of structures: bone, consisting of bones, joints, ligaments, discs, and cartilage; muscle, consisting of muscles, tendons, and organs; and nerve, which encompasses tissues of the brain, spinal cord, cranial nerves, autonomic nerves, nerve roots, and peripheral nerves. Bone symptoms are typically described as a deep dull ache and can refer to other bone-like structures. Muscle is also an ache but feels more like fatigue and soreness. Muscle is more superficial and usually stays within the same structure. Nerve symptoms are more electrical in nature; numbness and tingling, just numbness, burning, shooting, etc. Nerves stay in the network of nerves. Knowing this will get you pretty far.

Consultation is the first step. I ask for location and have the patient describe the symptoms. I also look for the mechanism of injury knowing that some structures are more likely to fail, depending on the stress placed on them, than others. With a good consultation, I have a fairly solid idea of what the problem is.

The second step is to do an exam. Bone structures cannot move themselves. For these tests, I do the movement on the patient checking for instability, pain, and altered movement. When I isolate joint movements, I can narrow down the location of dysfunction. Instability tests will suggest ligament issues (assuming we are not dumb enough to do a stability test on a complete fracture). X-ray is helpful to see fractures and degenerative changes. MRI is helpful to see disc bulges, ligament tears, and pathology. Repetitive movement works great for determining how to reform a bulged disc.

Muscles and tendons move bones. To test a muscle or tendon, resisting the muscle’s movement is an easy way to determine which muscle is injured. Why most doctors do not do this is baffling. Pain with resistance at the end of the muscle is usually tendon related and anywhere else is usually the muscle itself. If the type of pain is described as muscular but cannot be recreated with resisted movement, it could be an organ referring pain. Here again, repetitively resisting movement can really help determine how to help treat the injured structure.

Nerve symptoms require some specialized tests in the form of reflexes and sensation testing. True neurological injuries are very difficult to diagnose and to treat. In addition, any of the above can cause secondary and tertiary issues in other parts of the body, like muscles spasms or nerve pain due to encroachment with a disc herniation, for example.

Finally, one of the best ways to diagnose an issue is to treat the issue and see if it helps. Obviously you cannot do this with everything, but as a chiropractor, I can do this for most injuries. Even a surgeon will tell you that nothing is definitive until they open you up and see it in real life. The point being do not get too caught up with figuring out what something is before trying to treat it. Ruling out conditions is still valuable.

There you have it. Instead of plugging symptoms into WebMD to discover that you have a rare, incurable, terminal illness, just step back and look at the anatomy, physiology, and biomechanics of the body and go from there. Or, see your local chiropractor and let them help you through your issues or point you in the right direction. We spend a tremendous amount of time learning about all aspects of the human body.

 

Tennis Elbow? I Do Not Even Play Tennis!

tennis-elbow-pictureIn a world where we have so much access to information, I find that when it comes to diagnoses, there are some overly-simplified patterns. If there is pain in the foot, it is plantar fascitis, pain down the leg is labeled sciatica, and elbow pain is tennis elbow. Not that these conditions are not common; just not that common. Tennis elbow is particularly over-diagnosed. Pain in the elbow is common. Tennis elbow, however, is specifically pain resulting from injury to the extensor tendons which insert at the lateral epicondyle causing inflammation and dysfunction. Simply put, to be tennis elbow, the pain must be right around the little knob on the outside of the elbow and get worse when trying to extend the wrist with resistance. It is called tennis elbow presumably because repetitive backhand swings in tennis will cause such a condition. Incidentally, pain on the inner knob is known as golfers elbow.

I have found that neither tennis elbow or golfers elbow are more common than just a regular subluxated elbow. As a hinge that rotates and pivots and is made up of three bones and two joints, dysfunction is easy to come by. Often, the radial head will get stuck farther back than it should be. This will cause a strain on the muscles that insert in that area and mimic or create tennis elbow. The good news is that with an adjustment or a few, the condition typically responds quickly. If it is, indeed, tennis elbow, the best thing to do is to make sure the elbow is adjusted and functioning properly, then focus on the tendons with ice, stretching, and myofascial massage or active release. So, the next time somebody complains of tennis elbow, tell them to see their local friendly chiropractor.

 

Chiropractic and the 3 Main Causes of Vertigo

vertigoIt could be the late cold season or a rampant allergy season, but I have had several patients come  in with vertigo this month. If you do not know what vertigo is, lucky you! If you have experienced the nauseating feeling of being on solid ground while your brain is telling you that the tilt-a-whirl is in full force, then you know that vertigo can seriously affect your life. Vertigo is described as a feeling of being stable while objects around you are spinning. The three systems that can cause vertigo, in order of most common to least, are the inner ear, the neck, and the brain stem.

  1. The Inner Ear has a complex system of tiny hairlike sensors, called cilia, that send information to the brain based on the movement of fluid through a maze of canals. When there is in an increase of fluid in the inner ear or the fluid gets too thick and mucousy, it affects the movement of the cilia, and can cause vertigo. This is common with inner ear infections, colds, flus, hay fever, and sinus infections. Drainage is critical to success in treating vertigo caused by inner ear congestion. Chiropractic adjustments help loosen the muscles in the neck which allows for freer lymph flow and better drainage. In addition, cranial adjustments can help pump the congested sinus and promote drainage. Drinking plenty of water will also help to thin the mucous which will help is drain.
  2. The Neck, especially the top two vertebrae called the atlas and the axis, respectively, have sensors in the joints called proprioceptors. Proprioceptors relay position to the brain.  They are found in all joints but the nerves in the neck are particularly sensitive to head movement. When these vertebrae do not move as they should, they send a mixed signal which can make the brain feel like the body is moving when it is not. Again, chiropractic adjustments will help reset proprioceptors which will restore the proper flow of position sense, thereby halting the vertigo.
  3. Brain Stem Dysfunction is by far the least treatable of the three. In general, brain injuries are extremely slow to heal. Depending on the nature of the injury, there is little hope of treatment save time and prayer. I have no empirical evidence, but I would imagine that hyperbaric therapy could be helpful. Chiropractic adjustments will not directly help but keeping the body and nervous system functioning well is always beneficial.

If you are suffering with vertigo, there are some easy, non-invasive tests to figure out which system is causing the symptoms. Treatment is effective and we usually see results pretty quickly in most cases.

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5 Things To Do When Your Back Goes Out

backpainHave you ever bent over to pick up something only to experience a pain like someone shoved a hot poker into your low back and then started pulling your muscles apart? Yeah, most of us have felt that at some point. Hopefully, it  never happens to you, too, but if it does, here is what you do.

  1. Stop and Breathe. You are probably feeling like your life is about to end. Most of what you are experiencing is muscle spasm. Your back muscles are trying to protect you but they have dramatically overreacted. If you can, stay where you are and do your best to let the muscles settle down. Deep breaths and relaxation will dramatically speed up the process. Have some water and wait it out.
  2. Stretch backwards. Typically, when a back goes “out” there is a disc inbetween the vertebrae that is stuck in a bulging position. Bending backwards will help squish that disc back to the center and will also shorten the spasmimg muscles. Go easy with this. Gently push into a cobra position if you are on the floor. Otherwise, brace yourself with your hands on your backside and carefully arch backwards. Do it several times in a row and often thereafter. Here is an old video for demonstration.
  3. Walk, Lie Down, Do NOT Sit. When the spasm has settled down, walk a bit. Movement will help get the blood moving which helps to settle the muscles and get the disc moving. You do not want to overdo this. Move a bit and then lie down on your back with the knees bent. The firmer the surface, the better. Sitting will be counterproductive. When you sit, you increase the pressure on the disc and stretch the muscles of the lower back.
  4. Ice. Icing helps reduce inflammation. Typically, when a back goes out, there is inflammation. The quicker you can get rid of the inflammation, the better. It is not completely out of the question to use heat. Heat will soften the spasming muscles and allow you to move. However, heat also brings more inflammation. If you decide you cannot move without heat, use it, but then move around for a while and then follow up with ice. Both heat and ice should only be used for a maximum of 20 minutes. For ice, the skin needs to get cold enough to go numb to be successful. Here are the stages of ice, so you know you are doing it right. 
  5. Go See Your Chiropractor. Once the spasms have settled down a bit, the inflammation is under control, and you are able to move, it is time to get the joints working properly and the disc back to a good shape. This is what chiropractors do best. An adjustment will get all of the joints in the area to move correctly which will allow the disc to heal properly. Get in as soon as possible before scar tissue makes that first adjustment a painful one.
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I Was Told I Have One Leg Longer Than the Other

Short LegI see it everyday. For some patients it is a major concern. They tell me their previous chiropractor diagnosed them with it. I tighten my lips and lower my eyebrows with an empathetic look. On the inside my eyes are rolling. I can tell the patient needs me to understand that this is a serious chronic issue. This is obvious learned behavior from their previous doctors. I wonder if I am the only one that thinks this is no big deal. I try not to be condescending and to acknowledge their concern. The truth is that it is another temporary sign. I am talking, of course, about having a “short leg.” 

The truth is that perfect symmetry in nature is rare. I am sure everyone has one leg a little shorter than the other if you start measuring in millimeters. This begs the question as to why one leg can look so much longer than the other? The answer is found in the mechanics of the body. 

Most movements in the body have a coupled movement to help maintain balance and flexibility. Side to side bending and rotation go together. In the low back, when a disc bulges and causes the vertebrae to bend to one side, it is accompanied by roation. Rotation, in turn, contracts the muscles on the same side pulling the leg toward the trunk of the body. When lying face down, this leg will appear short because it contracts up. 

I will not get into the mechanics and how it looks when standing up. In addition, if the pelvis is rotated it can cause a different scenario. Suffice it to say that no matter what, a “short leg” is usually temporary and correctable, if not very manageable. No reason get alarmed and go out to find the perfect sized lift or to change all of your shoes. After one chiropractic adjustment, balance is restored. Now, how long that balance will last is anyone’s guess. It may take a series of adjustments before the legs become or stay relatively the same length. However long it takes, just remember, a “short leg” is not the end of the world. 

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Chiropractic and the Law of the Club

In Jack London’s Call of the Wild, the main character, a dog named Buck, finds himself face to face with a man who has a club in his hand. Buck attacks that man in an attempt to escape his abduction, only to be hit painfully on the head nearly unconscious. He attacks again with the same result. Buck is a large and powerful dog and honestly feels he can beat this man. However, after several more attempts, he finally submits believing that if he continues, he will end up dead. He reasons that the man with the club in his hand is too persistent and strong and therefore must be obeyed.

Switching perspectives to the man with the club, there has to be some trepidation when confronted by a large animal with sharp teeth. Safety only comes from using the club effectively. Not using the club at the right time or the right way can be disastrous. It is likely there is a fear that the dog may be to big or too fast. Finally, not being prepared or ready to use the club again, at all times around the dog could also be fatal. Each animal has a different temperament. Some are more predictable than others but none are truly controlled.

This scenario is like an injury. Sometimes, after one or two adjustments the injury heals and is never a problem again. Other times it is good for a while but comes back again. Some injuries take several adjustments before healing and some never heal completely and need continuous work. There are injuries that will never get better. The best we can hope for, sometimes, is that we slow down the progression of an injury. The worst are injuries for which we cannot help.

Often times, in the healing process, we believe we have healed and disontinue care too early. When this happens, healing momentum is lost and can prolong the overall healing time. The question I get more often than not is how many adjustments it will take. As much as I would love to give an answer, I do not know. I can give general outlines and recommendations. Average injuries generally take about three months to heal with consistent treatment. There are so many factors that can decrease or increase the healing time. Factors such as age, degenerative change, weight, etc. can significantly change a prognosis.

The healing plan for chiropractic is the same as the law of the club. We keep hitting or adjusting the incoopertive joint until it decides to submit to the proper movement and heal appropriately. Some joints and injuries are going to respond quicker and easier than others and some are not going to respond at all. We do not always know how the healing process is going to respond without consistent care over a significant period of time.

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