Thankfully the action of the nerves that detect movement and pressure suppresses this pain at the spinal cord and you don’t feel it. However loss of movement of an area means the suppression is reduced and pain can start to be felt. Anyone who’s sat through a long film will know that. Your body is literally telling you to move so that you don’t damage it. The brain itself can also suppress pain from above if it is busy doing other tasks that are deemed more important, ie running away from danger or doing something more pleasurable.
Pain is felt when the impulses from those pain fibres actually manage to reach the sensory cortex of the brain. So you register pain in the head. To achieve this you must have increased excitation of the pain nerves. This can be down to an increase in stimulus or a lower threshold to fire the nerves. The chemistry of your body and level of electrolytes can influence pain generation. If your body is lacking in nutrients that are used for the building blocks of natural anti-inflammatories then you will generally be more likely to experience pain. Or if tissue is injured, chemicals released by the damaged cells lead to easier excitation of pain nerves and you feel pain.
It is possible to have a lot of wear and tear and have no pain at all. Similarly you can be in agony when there is very little damage showing. So if you have an x-ray or scan of a recently injured joint that was previously pain free and it shows degeneration or a tear of a structure don’t go straight for the surgical option. There is little correlation between tissue damage and pain. Think twice or even three times, seek an opinion of someone who isn’t a surgeon. You may be in pain simply because the pain nerves are more excited and the suppressive mechanisms aren’t working. If this is the case surgery won’t make any difference as the torn tendon might not have been the source of the pain. It could be coming from somewhere else entirely.
Surgery should always be a last resort, once it’s done it can’t be reversed. There are risks of infection and risks of further pain due to the inflammation and excitation of pain nerves from the surgery itself. In some cases this can trigger a complex pain syndrome that is self fulfilling and perpetuates.
The natural approach begins by activating the neurological mechanisms that suppress pain. Stimulation of these nerves anywhere in the body can help, the strength of the effect is variable depending on what area is stimulated and is related to the representation on the brain itself. Movement, mobilisation, manipulation, taping all help reduce pain. However they have to be applied correctly to ensure the balance of neurological activity is helping rather than hindering.
If the physical therapy approach you choose isn’t successful, try a practitioner in a different discipline such as Chiropractor or Osteopath, or vice versa. Or even two different practitioners within the same profession as they do work quite differently a lot of the time. After you’ve exhausted all options consider the surgery but remember the pain won’t just disappear after surgery, you will still have a period of 6-12 weeks of recovery and rehabilitation to go through.
Also you should look closely at your diet. Lack of fresh fruit, whole foods such as nuts, seeds, dark leafy green vegetables and oily fish can mean the body does not have the raw materials to create anti-inflammatory chemicals. Furthermore smoking and alcohol can aggravate inflammation.
The use of the painkiller Gabapentin alongside manipulation and stimulation can also be helpful to suppress the nerves so that treatment can be gently started in chronic pain syndromes. We do not recommend the use of Non Steroidal anti-inflammatories or paracetomol as the former is detrimental to gut, heart, liver and kidney health and the latter has no benefit long-term and will reduce your emotional as well as your pain sensation.
Recent National Pain Audit figures show a worrying trend. A staggering 20% of health expenditure in the UK is now spent on back pain services. Chronic pain affects 8-60% of the population depending on the definition of pain (1). Severe pain affects 11% of the population and 8% of children. Yes 8% of children, a group that are generally ignored as problems are put down to” growing pains”.
If more attention was put to diagnosing and recognising that young people start their journey to chronic pain young then maybe something could be done to redress the trend.
Severe chronic pain affects relationships, work status, sleep, mood, general ability to do daily tasks and all aspects of general health. Even more worryingly, daily back pain is linked with increased risk of a coronary event. This makes sense as less activity means reduced cardio-vascular fitness. Movement of the spine and joints also feeds activity into the brain and the resulting reflexes help to support and drive not only movement but also the autonomic responses that control body functions such as blood pressure and heart rhythm.
The simple reason is that as a population we are less active. People drive to work or school nowadays then many have sedentary roles that mean the body is held still for long periods. This will cause mild pain as your body will want you to move. That in itself is not a problem until it is repeated day after day for long periods. Gravity is a very strong force and even when you are not moving it exerts constant pressure. For example looking down at your smart phone will increase the weight of your head threefold. That’s a heavy load on your neck muscles and discs.
If you are also getting heavier then the forces become greater and the stress on structures and changes in posture results in a greater chance of back pain. If you are active you will generate reflexes and fire nerves that help to suppress pain, for more on this go here.
Nerves love to fire if they are healthy. If you fire them enough they will grow new and stronger connections and the result is healthier tissue and better faster, more accurate responses. If you don’t fire the body will remove the connections and the opposite occurs. You get less energy, less accuracy and tissues that are supplied become weaker.
However if you are already weakened, then firing too much can fatigue the nerve to the point that it can become so tired it will actually become very weak and eventually die. This is a process known as apoptosis. So if you are weak already or have nutritional compromise then you may overdo it and cause harm.
Firstly make sure you have the raw ingredients to support good nerve cell activity. A good healthy diet should give you this. So avoid fast food or ready meals with flavour enhancers. Monosodium glutamate will fatigue your cells very rapidly as it acts like a turbo, so will high sugar diets as nerve cells do not need insulin to absorb and use sugar. The result is like an engine over-revving, it will go pop at some point! Avoid too much caffeine, never drink energy drinks that is nerve cell suicide! Excessive alcohol and smoking are also highly detrimental to nerve health.
Leafy green veg is full of great nutrients to support cell health. Fish is a good source of protein and essential fatty acids, as are seeds, nuts and pulses. Magnesium is very supportive of energy release in cells and is found in dark leafy greens, nuts, seeds, fish, beans, whole grains,avocados, yoghurt, bananas, dried fruit, dark chocolate, and more.
Assuming your nutrition is good the next step is to start exercising your body and mind. If you are very weak start gently and build up incrementally at a round 5-10% increase in activity a week. If you feel very tired make a note of when that happened and only do 70% of that. Stay at that level for a few weeks and then start to increase activity. It may be a slow road but if it’s steady you will progress smoothly. If you try and jump activity too fast you may get more tired and / or injured.
Gradually you will start to feel a lot better. This isn’t easy though as the reason you got bad in the first place may be down to bad habits and these can be hard to break. So make gradual changes to your lifestyle and you will be more likely to keep on the straighter and narrower path.
Take a look in a full length mirror at yourself and see if the following applies to you.
A commonly seen aberrant posture in clinic is one where your foot is turned out, the arm on the same side is held slightly flexed at the elbow and is rotated inwards so that you can see more of the back of the hand than the other side when looking face on. The same shoulder will also be held forwards. Typically this is due to weakness of the anti-gravity muscles down one side of the body and is a milder presentation than Pyramidal Weakness found in some typical stroke patients.
The anti-gravity postural muscles hold the shoulder back and rotate the arm outwards. They also lift the leg and foot from the floor. Commonly this pattern of weakness leads to rotator cuff problems, tennis elbow, hip pain, shin splints etc. If you have had any of these problems or get them repeatedly despite having had treatment then you possibly have a functional weakness of a relay area in the brain called the Ponto-Medullary-Reticular-Formation or PMRF for short.
You can have as much Physiotherapy, Chiropractic, Osteopathy or whatever other therapy you like, but if the weakness is established the problem will keep recurring. Why? Because the brain will keep pulling you into the poor posture. If you are exercising and getting stronger you will have less symptoms, but push it hard and you’ll be likely to get your injury again. This is because the area in the brain will fatigue one side faster than the other and your control will diminish. The result, yet another injury. Just think how many sports people have struggled through their careers with hard to treat injuries. The list is endless.
By specifically treating to enhance function in this area we can help to restore normal function. If we combine this with visual exercises we can help to hard wire the pathways to strengthen them. This requires repeated stimulation over a short period to get the nerves to express genes that lead to growth of new connections. It won’t happen without repetition.
So if you’ve ever had a car accident or a whiplash type injury from sports such as horse riding, skiing, boarding and obviously boxing then you may be prone to these problems. If you’ve ever had a concussion or been knocked out the chances of this are significantly increased.
Make sure you find someone who can look at these patterns to help you for the longer term and not just a quick fix.
Last week (April 2015) a study was published in the British Medical Journal that got a lot of headlines. An analysis of 13 quality trials showed that Paracetomol is no better than a placebo for treating back pain, arthritic pain and disability. What’s more, those patients regularly taking Paracetomol for back pain or arthritis were 4 times as likely to have abnormal results on liver function tests. So taking this medication for your pain will make you less healthy.
Similarly taking Non Steroidal Anti-inflammatories (NSAIDs) such as Ibuprofen and Naproxen can lead to health problems related to gastro-intestinal inflammation. Interestingly Aspirin did not cause inflammation of the small intestine (2). This inflammation leads to increased permeability of the intestine. If you consider that the intestine is the barrier between you and your food, bacteria and powerful enzymes it’s good to keep it healthy.
If larger molecules cross the gut wall they can stimulate your immune system to attack them. Unfortunately, this reaction can then continue on similar molecules within you. Therefore increased gut permeability (caused by expression of a protein called Zonulin) contributes to the development of auto-immune diseases such as coeliac disease and diabetes type 1. (3) It has also been recently hypothesised that joint inflammation in relatively benign osteo-arthritis is also a product of this process. If that is the case then taking Nsaids could actually contribute to the cause of the problem you are taking it for.
The research paper from the BMJ recommended exercise and manipulation to help stay pain free. Manipulation stimulates the nerves that regulate muscle tone and also inhibits pain. Most people will have pain from either over doing things or not doing enough. So if you are not active start by taking walks and then think about swimming, cycling and general workouts. Build up slowly over time and you will soon start feeling better. If you are a weekend warrior make sure you do regular consistent exercise to build up your conditioning or you will get injured. If you do have pain don’t take painkillers and NSAIDS. Use Ice, get help from an expert who understands biomechanics, athletic training, neurology, anatomy, diagnosis in other words us!! Don’t pop a pill, it will make you less healthy in the long run. If something’s wrong find out what and why and do something constructive about it. Your liver, kidneys and gut will thank you for it.
So, when you consider all of the above it is crazy to take paracetomol and anti-inflammatories as part of your training. Pain is there to warn you. If you listen to it properly it can be your best friend as it will keep you healthy and aware of issues before they become established. If you ignore your warning systems you are heading for trouble.
Yes!! Studies have shown the efficacy of taking a concentrated turmeric formulation (4). Turmeric contains Curcumins which have been shown to reduce inflammatory cascades in the early phases of inflammation. It is not heat stable so cooking will nullify it’s effects. So a curry on the way home is not good practice. It won’t act instantly like a drug but is a useful supplement to help with a number of problems caused by inflammation if taken daily. We stock it as part of our holistic approach to improving musculo-skeletal health.
For more information on any of the above topics contact us on 01202 733355 or email us.
(1) Machado GC, Maher CG, Ferreira PH et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials.The BMJ 2015;350:h1225. doi:10.1136/bmj.h1225.
If I asked you what was the most important vitamin for fighting colds what would your answer be? Many people think it’s Vitamin C. It is certainly important in helping to mop up free radicals which cause damage through a process known as oxidative stress, but it’s not the most important. Vitamin D3 has been shown to boost immune function thereby helping you fight the invaders before they get a foot hold. To put it another way, Vitamin C helps you fight the effects of the chemicals released by inflammation, vitamin D3 helps to stop it in the first place.
Vitamin D3 is synthesized in the skin when exposed to sunlight. Vitamin D2 is found in plants. Vitamin D has long been known to support the absorption of calcium and formation of bone. A deficiency leads to softening of the bones and Ricketts (bandy legs). This disease is on the increase again, due to people covering up for cultural reasons and lack of sunlight in higher latitudes, especially for those of darker skin.
More recently Vitamin D3′s role in immune function regulation has been studied extensively and new research is confirming it’s importance as a vital supplement. Poor immune function obviously can leave you more susceptible to infections such as the common cold and flu. It can also reduce your ability to recognise and destroy cancerous cells, and can lead to the development of auto-immune disorders where your immune system actually attacks your own body. This process has been implicated in some inflammatory arthritis, multiple scerosis, systemic lupus. A correlation has been found between low levels of Vitamin D3 and all of these disease processes. In addition macular degeneration (blindness), hayfever, chronic rhinitis have all shown signs of being affected by low vitamin D3 levels.
This depends on your location, skin colour, diet and sun exposure. In the UK 90% of the population are below recommended levels. 75% of young adults are deemed deficient. 20-40% of young adults 19-24 years old, care home residents and children of British Asians have been found to have only a third of recommended levels. The amount needed varies according to who you read, the Endocrine Societies Clinical Practice Guidelines state from 400 iu to 800 iu as a daily requirement. With an optimum of 1000 iu to 1500 iu. In cases of deficiency 2000iu to 10000iu. You can read the guideline here. One thing is clear, if you are wrapped up for several months of the year in low sunlight you won’t be getting as much as in the summer.
Is this why you are more likely to have “bugs” in the winter? Is it also why cancers such as colo-rectal cancer are more common at higher lattitudes? There is also a possible link between latitude and multiple sclerosis and diabetes. Also have a look at this site which has a good deal more on the topic.
Natural food sources are oily fish, such as salmon and sardines and eggs. It is also in fortified cereals, spreads and powdered milk. The NHS site states that most people should have enough, but latest clinical guidelines dispute this. Supplementation should be 1000iu for babies and children (be aware that baby formula milk commonly contains vitamin D, so adjust accordingly). 1500-2000iu for adults 18+ years of age.
Generally because vitamin D deficiency is so widespread in the UK routine measurement is deemed unnecessary. A more cost-effective approach is routine supplementation with sensible sun exposure in the spring summer and autumn. High risk groups should be screened, these include people at high risk of inflammatory bowel disease, cystic fibrosis, gastric bypass patients and patients taking medication that effects vitamin D metabolism (anti-seizure meds, glucocorticoids, AIDS meds).
Historically there have been concerns as very high levels can be toxic and cause too high a level of calcium and phosphate in the blood leading to bone conditions. However it is now well established that toxicity is extremely rare. Doses of up to 10,000iu a day have been used for up to 5 months with no adverse effects, suggesting that only long-term over supplementation is an issue. However it is important to stick to the guidelines.
If you live in northern latitudes, are inside alot and use sunscreen extensively you won’t get enough from the sun. Especially with our weather!
There are many products on the market, I would recommend a natural food source variety and not a synthetic one. A quick search online should provide a wealth of information to help you choose.
It has long been a subject of hot debate between the medical profession and Chiropractors about the efficacy of longer term patient management programs. In a medico-socioeconomic model it has long been thought by the majority of the medical profession researchers that continual care for musculo-skeletal problems is not effective and that ongoing care is based purely on an economic basis for the benefit of the Chiropractor and not the patient.
This has on occasion put the professions at loggerheads when looking at care. It is important when considering this to question what is health? See previous post on this subject.
With the recent cold snap we were all left taking tentative steps, for some the result was a crash down to earth. I saw 2 people do it myself. A fall onto one’s derriere at speed causes damage to the ligaments of the sacro-iliac joint and lower lumbar vertebrae.
In fact cadaver studies(1) show that as many as 20% have sustained damage to the lumbar interspinous ligaments that support the lumbar vertebrae.
This leads to increased motion at those levels and eventually disc degeneration and facet joint hypertrophy due to increased stress on these structures. The result down the line is possible nerve impingement and sciatica or in long standing cases stenosis (a narrowing of the central canal that the nerves run through).
These conditions can require surgery to prevent nerve damage, but in most cases people just have to accept that they can only walk a hundred yards or so before needing to sit and rest due to the cramp like pains they get in the calfs. Stenosis can also lead to bladder and bowel problems in old age.
Do you know someone like this? Do you know someone who’s slipped on the ice? Help them achieve a better old age by pointing them in the right direction. Fix it now and these issues can be reduced.
1: Rissanen, P.M.(1960)The surgical anatomy and pathology of the supraspinous and interspinous ligaments of the lumbar spine with special reference to ligament ruptures. Acta Orthop Second, (Suppl.46)
Well not quite, but the infamous words of Noddy Holder have probably been ringing out for a while now on the high street, but I wouldn’t know about that. Instead of doing this a bit at a time, I join the usual rush of stressed out men looking for that last minute present. So how do I keep from getting knots and aches when out? Buy vouchers and be done with it I hear you cry! Certainly an idea, but believe it or not I do carry bags and this is how I avoid the pains and aches over the Christmas period right up to New Year.
But you said “I do it last minute”. That’s true, but I give myself time and before I shop, I mentally prepare myself by remembering that Christmas is about being festive. So while sauntering around and letting everyone else twist and duck and dive past I hum a carol or two and get in the spirit of things. How does this help? Stress will lead to increased tension and more likelihood of muscle strains. So relax and enjoy it.
You know how it is, you’ve already got a load of bags and the shoulders are feeling sore, but you’ll just pop into M & S for a few more bits, then you come out looking like a sherpa on the Himalayas.
Disc Prolapse Here We Come!
Well don’t do it, when you’ve got a few things take them back to the car, lock them in the boot and feel the tension go as you stroll back to your next target. Better still, do it online! (it’s not the same though is it, you’ll miss the joy of seeing someone wrapped in tinsell after the office party).
Simple this one, if it’s freezing and windy you’ll immediately be more vulnerable to a muscle strain, wear a scarf and layers so if you get hot you can always take one off.
Why not do this after dropping off the first load in the car, then you won’t have someone standing on Mum’s new cardy in the cafe. Have a warming drink and a snack to recharge your batteries, if it’s caffeinated make sure you have water though so you don’t dehydrate. Muscles are more likely to strain if dehydrated. If you had a sneaky sherry or mulled wine somewhere this is even more important!
You’ve been out all day, hopefully not fed up and hungry, but full of joy as you don’t have to go back again for another year! You now have a boot full of presents, some wanted, some useless, but it’s the thought that counts. When you lift, pull things towards you and keep your lower back locked out. Don’t try and do it all at once if it’s heavy. The same goes for when you stuff it under the bed, at the top of the cupboard or in the loft, don’t twist and lift. Keep your back straight. We all know that one, but how often do you really take care when lifting?
I’m not expecting you to get on all fours, but there are a few exercises that you can do when stood in a queue that can really help your lower limb strength and stability. Firstly, as you’re wearing a big coat you can do buttock tenses and no one will be any the wiser as long as you remember to breath! Stand with legs shoulder width apart, and simply tense buttocks while gently pushing feet outwards while they stay firmly rooted to the floor, you can combine this by tensing the lower abs too. Remember to breathe!! Another is to stand feet shoulder apart, grip the floor with your feet, and lean forward slightly keeping your body rigidly straight. Do this until your heels just start to lift off the floor, think of Eddie “The Eagle” Edwards (ski jumper extraordinaire for those too young to remember). Hold both exercises for count of 5 and relax and repeat. If you spend an hour in a queue you’ll have had a great workout.
You don’t need to lean this far forward!
Self explanatory really, you’ve had a few sherries, eaten too much, got bored with being cooped in with all the relatives, so you commandere the sofa or armchair and settle down for an assault on the chocolates, while watching a film you’ve seen before. Well, before that military manouveure make sure you have a cushion behind you, and if its a particularly soft sofa, have one underneath your hips as well so that they are level with your knees. Make sure you regularly get up and move around, even better go for a walk and stretch those legs. You’ll feel much better for it and it’ll help the lunch go down. If you’re having to travel, get out now and again and walk about too. Don’t lift your heavy bags straight after arriving, stand up for a while first, see our travel tips.
There are occasions when this could be very beneficial, but best left to younger generations or students.
It’s pretty common to see a few self inflicted injuries due to overindulgence and temporary visual and reduced balance injuries! If your colleagues are dancing on the tables and you want to join them please make sure it’s sturdy, Limbo dancing is also best left to the professionals. Choose your dance partner wisely to avoid dislocated shoulders and whiplash.
Last and by no means least, if you’ve had problems before, have a check up so that you know you’re working better and not on the verge of an injury. Christmas time means less availability and it’s a time for enjoying yourself in the company of others. Don’t ruin it with a bad back or neck,pop in and make the most of it.
Have fun and enjoy it.
All the best
GPs are being advised to only use short courses of steroid injections to treat tendinopathies, after a systematic review found using them for longer can produce worse results than no treatment.
Instead they are being advised to use other methods of non-steroidal injections for treatment such as botulinum toxin and hyaluronic acid for conditions such as tennis elbow and other tendinopathies.
The extensive review – published in The Lancet – looked at 41 trials involving 2,672 patients and estimated the standardised mean differences between treatments and placebo.
Steroid administration was shown to be consistently effective over the short term but long term the benefit was unclear. For further information the full article can be found here, and the actual paper is here. Read more
“There is a high risk of poor long-term outcomes and higher recurrence rates with corticosteroid injections,” said lead author Bill Vicenzino, chair of sports physiotherapy in the School of Health and Rehabilitation Sciences at the University of Queensland.
“Other treatments, including exercise, some specific physiotherapy and possibly some other injections, should be used before corticosteroid injections,” Vicenzino said.
A critical review by L.Viola of the literature showed some evidence of increased effectiveness of medical acupuncture over steroid injection, however the study sample quoted was limited and further research is required with larger samples.
A study by Val Jones published in Shoulder and elbow concluded that Acupuncture is frequently used by Chiropractors, physiotherapists in the management of chronic tennis elbow . However, the very few acupuncture studies to date have failed to prove conclusively that the short term relief in pain seen gives rise to long term functional improvement. No trials to date have assessed, concentrated or commented on the potential adverse effects of this particular form of treatment. The most recentCochrane review concludes there is insufficient evidence to support or refute the use of acupuncture. Further trials utilizing appropriate methodology and adequate sample sizes are needed before firm conclusions can be drawn regarding this treatment modality.
In my opinion which is based solely on anecdotal cases, there is definitely a role for medical acupuncture in relieving short-term pain over general soft-tissue therapy alone. However it is likely that the combination of supportive taping, clasps, acupuncture, ice and heat therapy plus mobilisation and manipulation is probably the best route of care. This is due to the stimulation of repair, control of inflammation and restoration of accurate controlling reflexes.
From a personal view point just today I have been self administering acupuncture for a strain on my very own Tennis elbow, now I have to be disciplined and not play tennis tonight, pity as I was just starting to perfect my top-spin forehand, (probably wasn’t perfected, hence the injury). Physician heal thyself!!
This is a fundamentally important question when considering a “healthy” spine or body.
In the Western World health care is concerned mainly with getting you painfree, and unfortunately in general only lip service is paid to the preventative side of therapy. The commonest way of doing this is with medication until the pain goes, then you are healthy! This is fundamentally wrong and short-sighted.
Health is NOT an absence of symptoms, health is good function, everything working correctly, in a good environment, efficiently. Just focusing on being painfree will not result in good health.
In modern times we are all (well most of us) leading very busy lives, we are having to work harder, for longer, many of us travel ever increasing distances to work. We are under more pressure due to the cost of living, we have less time for ….
family and friends. There is an increase in the number of people being labeled as having behavioural disorders, ADHD, ADD etc and this is just a symptom of the environment that children are now being exposed to as a result of social changes that have taken place over the last 20 years.
All around the western world increasingly children are babysat with computer games or television, many complain of being bored in the holidays as many have reduced ability to partake in imaginative play.
There is a reason for this neurologically that relates to musculo-skeletal health, more on that in the next issue.
So what does western culture do about this growing epidemic? It gives it a name and medicalises what is essentially behavioural problems due to poor central nervous system stimulation. It prescribes drugs such as Prozac to make you “feel” better, but these drugs don’t make you better. Do you know that in the USA there is now a disease called shyness!! The cure? Prozac, but under a different name, how crazy is that?
Many of the serial killing gun sprees in America have been perpetrated by children who have been prescribed Serotonin re-uptake inhibitors SSRI’s. These affect the way the brain processes information and enhance the formation of repetitive patterns of activity, hence the multiple events. Consider also the relatively recent phenomenon of Fibromyalgia, how many people have you heard of that have been diagnosed with this condition. In my opinion this diagnosis should not be made as it labels individuals with a negative outlook that has detrimental effects on that persons prognosis, I’ll explain more on this subject in the next few entries.
I’m sorry if this is getting too morbid, but we really do have a health crisis on our hands if we don’t take steps to encourage children to explore imaginative play, exercise, challenging balance, eating well, communicating with friends and family, the same goes for adults too, although I’m not expecting you to get out the figurines from the attic if they are still there!
These are all positive feedback tasks that enhance and stimulate the central nervous system and lead to a sense of well-being.
Before I finish for now, ask yourself how you can make gentle, progressive and positive changes to your lifestyle that can help you feel better in general and also help you stay free of pain, both physical and emotional.
I’ll be covering the research on these subjects in the next few updates so do have a look soon. If you have children or are thinking of having them, this is information that you really should look at as a matter of utmost concern.
Until the next time.