DME: BRACINGFOR CHANGEDurable Medical Equipment Helps Chronic Pain PatientsPAGE 9

TENS UNITA Drug-Free Alternative to Pain ReliefPAGE 7

November 2011

Brace by BREGwww.breg.com

PLUSAsk the Expert:Electromyography(EMG)

November Cooking

Pain Management:Ultrasound Technology

WELCOME

Paul Lynch, MD and Tory McJunkin, MD

Thank heavens! The weather

has cooled and we are f inal ly able to enjoy the beaut i fu l sur-

roundings we l ive in without

worry ing about dehydrat ion.

Cooler weather of ten means

increased act iv i ty. More fo lks

wi l l be hi t t ing the l inks, r id ing

thei r b ikes, taking walks and

spending t ime outs ide doing

whatever i t is they love.

With cooler c l imates can come

increased pain. I f you suffer

f rom arthr i t is or other jo int pain, i t may be aggravated

by both cool weather and

increased act iv i ty. I f you feel

more pain than usual , take

the t ime to rest , apply ice and

heat , consider an over- the-

counter ant i - inf lammatory and

make an appointment to v is i t

one of our specia l is ts . We can

make sure your achy jo ints are nothing more than the bi t ter-

sweet welcome of Fa l l .

This month’s issue of Ar izona

Pain Monthly is dedicated to

expectat ions. With the hol i -

days approaching, we expect many great meals , t ime with

f r iends and fami ly and t ime to

re lax. You’ l l f ind great autum-

nal rec ipes, a feature art ic le

on braces prescr ibed to help with pain, and informat ion

about ul t rasound technology

– one of the many we provide

at Ar izona Pain Specia l is ts . We

hope you are expect ing the

best th is month too!

From our fami l ies to yours,

Dr. Paul Lynch and

Dr. Tory McJunkin

Ar izona Pain Specia l is t

Founders

For I know the plans I have

for you, declares the! Lord,

plans for welfare and not for

evil, to give you a future and

a hope.

Jeremiah 29:11!

N o v e m b e r 2 0 1 12

CLINICAL EDITOR:

Tory McJunkin, M.D.

PUBLISHER: Nick Ryan

EDITOR/WRITER: Kelli Donley,

Kristen Wesley

LAYOUT: Addie Mirabella

CONTACT US

BOOST MEDICAL

9977 N 90TH STREET, SUITE 320

SCOTTSDALE, AZ 85258

Phone: 888-627-6121

Email: info@boostmedical.com

PRINT SUBSCRIPTION INFORMATION

888-627-6121

Publ ished monthly by

Boost Medica l

9977 N 90th Street , Sui te 320

Scottsdale , AZ 85258

Volume #20

Publ ished November, 2011

CONTENTS2WELCOME LETTER We welcome you to the November issue!

4ASK THE EXPERTWhat is Electromyography (EMG)?

6NOVEMBER COOKINGThese autumnal recipes use seasonal produce to flavor your holiday table. They are easy to prepare and great to share. We wish you a lovely Thanksgiving!

7TENS UNITA Drug-Free Alternative to Pain Relief By Dr. Chance Moore, DC

9DME: BRACING FOR CHANGE Durable Medical Equipment Helps Chronic Pain Patients By Kelli M. Donley, MPH

12PAIN Q&AUltrasound Technology: Diagnostics Fine Tuned By Ryan Cooper

15SUDOKUSudoku has a unique solution that can be reached logically without guessing.

N o v e m b e r 2 0 1 1 3

N o v e m b e r 2 0 1 14

G l e n H a l v o r s o n M . S . , M . D .

i s we l l k n own i n h i s f i e l d

f o r h i s e x t e n s i v e r e s e a r c h

a nd p r a c t i c e o f e l e c t r omy -o g r a ph y. B u t wha t e x a c t l y

i s a n EMG a nd wha t s h ou l d

p a t i e n t s k n ow a b ou t

t h i s d i a g n o s t i c t o o l ? D r.

H a l v o r s o n e x p l a i n s .

Q: What is an EMG?!

A : The l e t t e r s “EMG” s tand fo r

e l ec t romyog raphy. As opposed to an EKG, wh i ch i s an e lec t r i -

ca l t es t o f the hea r t , an EMG

i s an e lec t r i ca l t es t o f ske l -

e ta l musc le . The re a re two

aspec t s o f th i s t es t : the f i r s t

i s the musc le tes t , ca l l ed

the EMG. The second tes t s the ne rves – spec i f i ca l l y the

pe r iphe ra l moto r ne rves and

the senso ry ne rves . Th i s t es t

i s ca l l ed a Ne rve Conduc t i on

S tudy, o r NCS . When someone

re fe r s a pa t i en t fo r an EMG, common usage o f the te rm

inco rpo ra tes bo th tes t s . As

such , I don ’t pe rsona l l y use

“EMG.” When I wr i t e fo r such

tes t s , I use the te rm, “EDX”

wh i ch i s an e lec t rod iagnos -t i c exam. Th i s compr i ses bo th

ASK THE EXPERT: ELECTROMYOGRAPHY"EMG#

An EMG is an electr ical test of skeletal muscle.

N o v e m b e r 2 0 1 1 5

musc le and ne rve tes t ing .

Q. What should pat ients know

about EMGs?

A: Let ’s start with what the

test does. And EMG is a test

of normal vs . abnormal e lec-

t r ica l act iv i ty in the muscles

and nerves. I f you have pain,

numbness, burning, weakness or t ing l ing, symptoms of nerve

i r r i tat ion – these may come

from ei ther per iphera l nerve or

nerve root in jury.

When your nerves come out

o f the sp ina l cord , they are

ca l led nerve roots . F rom

there they d iv ide in to nerve branches that become per iph-

era l nerves . We t reat many

peop le wi th rad ia t ing nerve-

l ike pa in when s t ruc tura l

les ions o f the sp ine such as

hern ia ted d iscs , bone spurs , and/or degenerat ive a r thr i t i c

nar rowing cause pa in by

press ing on nerve roots . In

s imple te rms: i f a person has

a p inched nerve in the sp ine

or ex t remi ty, I can do a tes t to

determine where i t i s p inched,

how severe ly i t i s p inched and

i f there i s ev idence o f perma-nent or temporary damage. I

can a lso d is t ingu ish between

in jury to motor versus

sensory nerves as we l l as

d i f fe rent ia t ing nerve t rauma

f rom nerve d isease . The va lue

o f the tes t ing i s in t ry ing to

accurate ly determine loca-

t ion and sever i ty o f the in jury

and g ive the re fe r r ing/ t reat -

ing phys ic ian th is in format ion .

F rom there , the phys ic ian can best determine whether the

pat ient needs a procedure and

what k ind o f procedure .

Q: Are there s ide effects or any

issues pat ients should look for

fo l lowing an EMG?

A : No , an EMG i s a sa fe p ro -

cedure . The re i s some mi ld d i s comfo r t invo l ved . The tes t

shou ld take be tween 30 -90

minu tes depend ing on the

comp lex i t y o f the tes t and

number o f abnorma l f i nd -

ings . Pa t i en t s can take a l l

o f the i r med i ca t i ons p r i o r to t es t ing . The on ly res t r i c t i on

we requ i re i s no l o t i on , c ream

o r body o i l used p r i o r to the

tes t because we a re s t i ck -

ing e l ec t rodes on the sk in to

reco rd the ne rve responses .

F rom a p rac t i ca l pe rspec t i ve ,

i f you wear a sho r t s l eeve

sh i r t and sho r t s , pa t i en t s

p robab ly don ’t have to ge t

in to a gown .

Q: Is an EMG typica l ly covered by insurance?

A : Some insu rance do no t

requ i re p re -au tho r i za t i on

fo r in - c l i n i c p rocedures .

O the rs do . I t i s h i gh l y va r i -

ab le . Somet imes you can ge t

immed ia te au tho r i za t i on ove r

the phone , and fo r o the rs

i t m igh t be a f ew days to a

coup le o f weeks . Ev idence -

based gu ide l ines fo r who , wha t , and when to tes t a re

es tab l i shed by the AANEM.

Med i ca re gu ide l ines p re t t y much fo l l ow the AANEM gu ide -

l i nes ve rba t im , wh i ch have

been es tab l i shed by med i ca l

expe r t s in the f i e lds o f neu -

ro logy, who spec ia l i ze in e l ec -

t rod iagnos t i c med i c ine .

Dr. G len Halvorson is board cert i f ied in e lectrodiag-nosis with the American Associat ion of Neuromuscular and E lectrodiagnost ic Medic ine (AANEM). He is a former oral examiner for the nat ional EMG board and former Ar izona State physic ian representat ive to the AANEM for 10 years . He is a Qual i f ied Medical Examiner for the State of Cal i fornia. As medical d irector of a Medicare l icensed independent test ing fac i l i ty he has interpreted in the past three years over ten thousand nerve tests of pat ients with pr imar i ly d ia-bet ic neuropathy.

Ingredients:

• 1 tablespoon flour, (or corn starch,

to be gluten free)

• 1 tablespoon!unsalted butter• 1 1/2 cups!broth

• 1 tablespoon brown sugar

• 2 cups cooked sweet potatoes

• 1/4 teaspoon ground ginger

• 1/2 teaspoon all spice

• 1 cup milk• Dash of salt

Directions

In a Dutch oven, warm flour and

butter over medium heat, stir-

ring constantly until a light

caramel color. Add broth

and brown sugar. Bring to

a boil and then lower to simmer. Add potatoes!and

spices. With an immer-

sion blender, puree soup

until it is smooth. (This

can also be done in batch-

es in a blender.) Add milk and a dash of salt and

pepper last.

CROCKPOT TURKEY CHILE

These autumnal recipes use seasonal produce to flavor your holiday table. They are easy to prepare and great to share. We wish you a lovely Thanksgiving!

NOVEMBER COOKING

SWEET POTATO SOUP

Ingredients:

• Dash of olive oil

• 1!lb!ground turkey

• 1!cup onion, diced

• 2 cloves garlic, pressed

• 1!small can!chopped!chilies,

drained

• 1!small can!black beans, rinsed• 1!small can!kidney beans, rised

• 1 small can corn kernels

• 1 bag frozen squash or sweet

potatoes

• 1!large can!diced tomatoes, with

juice

• 1!small can!tomato paste

• 1 tablespoon!chili powder

• 1 tablespoon cumin

• 1 teaspoon kosher salt

Directions:In a cast iron skillet, warm a dash

of olive oil until bubbling. Add

garlic and onion. Lower heat

to medium. Add turkey. Cook

until no longer pink, then

drain cooking liquid. Add

to crockpot with remaining

ingredients, minus squash

and corn. Cook on high for 6

hours. Turn down to medium heat. Add frozen squash and

corn. Cook one more hour. Top

with sour cream, cheese or salsa.

N o v e m b e r 2 0 1 16

N o v e m b e r 2 0 1 1 7

TENS , o r t ranscutaneous e lec -

t r i ca l musc le s t imu la t ion , i s

a d rug - f ree a l te rna t i ve fo r

manag ing pa in . Fo r 30 years ,

pa t ien ts found sa fe , com-fo r t ing re l i e f in TENS t rea t -

ment . P lus , th i s FDA approved

too l i s re imbursab le by most

insurance p rov iders .

A TENS unit looks l ike a smal l

cel l phone and has one or two

sets of wire leads attached. The wire leads have a set of

sel f -adhering pads attached

to them. The TENS unit gener-

ates a gent le electr ical current

that travels through the lead

wires to the pads to the area

on the body being treated. The

TENS unit works to decrease

pain levels by electr ical ly

st imulat ing the local sensory

f ibers, overr iding the brain’s

abi l i ty to process the pain

messages from that area. A

good analogy is when you rub your knee when you hit i t

against something. The rubbing

sensat ion somewhat overr ides

the pain sensat ion and pro-

vides mild pain rel ief .

To ach ieve the bes t resu l t s

o f TENS therapy, i t i s impor-

tan t to remember th i s tech -

no logy mere ly ac t i va tes the

body ’s own pa in - f i gh t ing mechan isms . The e lec t rodes

shou ld be p laced d i rec t l y over

o r near the pa in fu l a rea . The

e lec t rodes w i l l de l i ve r a pa in -

b lock ing cur rent to the nerves

in th i s a rea . A l so , i t i s good

to va ry the p lacement o f the

e lec t rodes each t rea tment to avo id sk in i r r i t a t ion .

S tud ies show i t takes an

average o f 30 minutes fo r

TENS t reatment to beg in to

re l ieve pa in . Some pat ients f ind hours o f pa in re l ie f f rom

shor t 30 - to -60 minute ses -

s ions . Others use the i r TENS

un i ts fo r severa l hours a day

or a l l day, depending on the

pa in generated by da i ly ac t iv -

i t ies . I t i s recommended TENS

not be used whi le s leep-

ing . Th is i s s imply because

movement dur ing s leep may

cause e lec t rodes to come off

o r be pressed in to the f lesh , caus ing sk in i r r i ta t ion .

Un l ike over- the -counte r o r

TENS UNIT:A DRUG$FREE ALTERNATIVE TO PAIN RELIEF

N o v e m b e r 2 0 1 18

presc r ip t ion med ica t ions , TENS

i s v i r tua l l y r i sk - f ree f rom

in ju ry, s ide e f fec ts o r add ic -

t ion . The low-vo l t e lec t r i ca l

cu r rent de l i ve red by the e lec -

t rodes on ly penet ra tes the

sk in to the leve l o f the nerve

f ibe rs . Th i s poses no danger

to most ind iv idua ls . However,

those w i th ca rd iac cond i -

t ions and/or pacemakers ,

and pregnant women, shou ld

consu l t the i r doc to rs be fo re

us ing TENS . Use caut ion when

you dr i ve o r opera te heavy

mach inery. Most impor tant l y,

a lways use TENS accord ing to your phys i c ian ’s d i rec t ions .

TENS, or transcutaneous electr ical muscle st imulat ion, is a drug-free alternative for managing pain.

N o v e m b e r 2 0 1 1 9

Durable medical equipment helpschronic pain patients .

DME:BRACINGFOR CHANGE

Wrist Brace by BREG

www.breg.com

“Conse rva t i ve ca re” i s a t e rm

o f ten hea rd a t pa in spec ia l -

i s t s ’ o f f i ces . I dea l l y, pa in

phys i c i ans want to be ab le

to t rea t the i r pa t i en t s and

e l im ina te a l l pa in in the mos t

m in ima l l y invas i ve method .

The re shou ld be no rush to

p rocedures , un less the pa in

i s acu te .

Most patients, however, have

chronic – or ongoing, nagging

pain. Conservative care plans for

such pain may include chang-

ing a patient’s diet, encouraging

N o v e m b e r 2 0 1 110

l ifestyle changes and chiroprac-

tic appointments. One of the

many tools chiropractors have

to help chronic pain patients is

DME – or durable medical equip-

ment. Think support braces for

the back.

“DME is designed to support

an area to reduce mechanica l

st ress, and promote heal ing,”

says Chance Moore, DC. “DME

can help muscle spasm, muscle tears , spinal d isc in ju-

r ies , knee l igament tears or

spra ins and a var iety of other

condit ions.”

Moore regular ly prescr ibes

DME to pat ients to help with

chronic pain.

“TENS and lumbar sp ine

brac ing are the most com-

monly prescr ibed DME for

pa in ,” says Moore . (See page X fo r more in format ion on

TENS un i ts . ) “We t reat many

condi t ions on any g iven day,

but the most f requent a rea we

t reat i s the lumbar sp ine – o r

lower back . When the s t ruc -

tures o f the lumbar sp ine are

in jured the bra in sends mes-

sages to the sur rounding mus-cu la ture to cont rac t . Th is

can resu l t in musc le spasm.

Brac ing o f the lumbar sp ine

suppor ts the area to reduce

DME can help muscle spasm, muscle tears , spinal disc injuries , knee l igament tears or sprains and a variety of other condit ions.”Knee Brace by BREG – www.breg.com

N o v e m b e r 2 0 1 1 11

musc le spasm and speed

hea l ing . TENS i s a g reat dev ice

that reduces the percept ion o f

pa in . TENS can be used a lmost

anywhere on the body.”

Whi le Moore has seen great

resu l ts f rom DME wi th

pat ients , K im Rowe, a DME

representat ive wi th Deser t

Medica l , says braces may

prov ide temporar i l y re l ie f but

not a cure .

“Many pat ients th ink that a

sp ine or knee brace wi l l com-

p le te ly hea l them and e l imi -nate the i r pa in ,” says Rowe.

“Th is i s fa r f rom the t ru th .

The idea beh ind brac ing a pa in

pat ient i s to he lp inc rease

the i r da i ly ac t iv i ty leve ls

whi le min imiz ing pa in . For example , i f wear ing a sp ine

brace can he lp a pat ient s i t o r

s tand longer wi thout hav ing

to take a pa in p i l l o r l i e

down, then i t i s success fu l . By wear ing a brace , your under-

ly ing prob lem is s t i l l there ,

the brace wi l l he lp suppor t

the in jured area whi le you are

undergo ing t reatment .”

Moore says whi le work ing wi th a pat ient on a t reatment p lan,

DME prov ides necessary l i te ra l

support . Many pat ients have

an improved qual i ty o f l i fe

thanks to these too ls .

“ I have seen great resul ts ,”

says Moore. “Some pat ients

come into the off ice unable to

stand due to the sever i ty of a muscle spasm. The immediate

support that a lumbar brace

can provide wi l l reduce the

muscle spasm and can a l low

the pat ient to walk out of the

off ice and perform their act iv i -

t ies of dai ly l iv ing.”

Rowe says as a brac ing consul -

tant , she enjoys working with

pat ients to f ind the r ight DME

to help with thei r pain.

“ I specia l ize in a l l types of

brac ing: spine, knee, shoul -

der, neck, ankle, h ip, etc . ,” she says. “Dai ly, I f i t or thope-

dic and pain pat ients for many di fferent a i lments and in jur ies .

Spine and knee braces are by

far most commonly prescr ibed

by physic ians and heal thcare

providers . But , i f you show me

where your pain is , I can f ind

a brace for i t !”

Dur ing such a meet ing with a

brac ing consul tant , pat ients

wi l l a lso learn how to wear,

remove and care for the brace. Pat ients should ask how long

they are to wear the brace and

what to look for i f the brace

isn’t working. Typica l ly, DME is

covered by insurance.

“Before fitting our patients for

a brace, we make sure to notify them of their remaining deduct-

ible amount and co-pay ben-

efits,” says Rowe. The patient

should know exactly what he/she

will owe before being fit.”

As with any t reatment, there

are r isks. However, Moore says

the r isks for in jury with DME

are minimal .

“ T EN S i s a g r e a t t r e a t -

men t a s l o n g a s t h e p a t i e n t

d o e s n o t h a v e a n y e l e c -

t r i c a l imp l a n t e d d e v i c e s , ”

s a y s Moo r e . “O v e r - r e l i a n c e o f b r a c i n g c a u s e s we a k -

n e s s a nd d ep enden c e o n

t h e b r a c e . I t i s impo r t a n t t o

n o t o v e r u s e t h e b r a c e a nd

when a pp r o p r i a t e e n g a g e i n a s up e r v i s e d s t r e t c h i n g a nd

s t r e n g t h en i n g p r o g r am .

I f a pa t ien t i s su ffe r ing f rom

chron ic back pa in and i s

in te res ted in f i r s t exhaus t ing a l l conserva t i ve ca re t rea t -

ment opt ions be fo re surge ry

– DME i s a smar t opt ion to

cons ider. Your pa in phys i -

c ian shou ld be ab le to d i scuss

DME opt ions and schedu le a

b rac ing consu l t .

N o v e m b e r 2 0 1 112

Ultrasound technology, or

u l t rasonography, refers to the

use of h igh f requency sound

waves, above the threshold of human hear ing, to perform a

task. In medic ine, u l t rasound

has two broad uses; u l t rasound

can be used as an imaging

modal i ty and diagnost ic a id to

v isual ize t issues and organs within the body, and a lso as

a therapeut ic modal i ty with a

var iety of appl icat ions1. Each

of these is d iscussed in deta i l .

As an imaging modal i ty and

diagnost ic a id, u l t rasound

technology ref lects short pulses of h igh- f requency

sound waves off of organs and

t issues to create an image

useful in ident i fy ing a var iety

of d iseases and pathologic

condit ions1, 2. D iagnost ic u l t ra-

sound offers severa l d ist inct

advantages over other medica l

imaging modal i t ies such as

MRI , CT, or X-Ray. These

inc lude1, 2, 6:

• Ultrasound captures images

in real-time, allowing internal

organs and blood flow to be visualized “live” in motion

• Ul t rasound has an excel lent

safety record; pat ients are

not exposed to potent ia l ly

harmful ioniz ing radiat ion

• Ul t rasound costs less than many imaging a l ternat ives,

part icular ly MRI

• With few except ions,

u l t rasound is typica l ly

non- invasive

• Ul t rasound is portable and

can be performed at the

bedside

Diagnostic ultrasound is com-

monly used to image blood f low

and vessels (a Doppler ultra-

sound), soft t issue, the heart

(an echocardiogram), and other

organs1. Diagnostic ultrasound

is also often used in obstetr ics

to est imate fetal age, screen

for potential complicat ions of

pregnancy such as ectopic preg-

nancies or uterine abnormali-

t ies and bleeding, and can be

used to guide needles during

procedures such as amniocen-

tesis4. Diagnostic ultrasound

is also often used in real-t ime

for more accurate needle place-

ment during biopsies and other

procedures1.

U l t rasound technology has

ULTRASOUND TECHNOLOGY: DIAGNOSTICS FINE TUNED

long been used for therapeut ic

appl icat ions, engaging long or

cont inuous pulses of h igh f re-

quency sound waves to induce

cel lu lar effects and bio logi -

ca l change3. A l though exact

mechanisms to systemat ica l ly

expla in the therapeut ic ben-

ef i ts of u l t rasound remain

unknown, the pr imary effect

of therapeut ic u l t rasound is

thought to be the generat ion

of heat within target t issues, which could have a number

of benef ic ia l effects such as

increasing blood f low. Another

potent ia l mechanism of ther-

apeut ic u l t rasound at h igher

intensi t ies involves cavita-t ion , or the creat ion of smal l

bubbles that can render tar-

geted t issue more porous, thus

a l lowing for the del ivery of medicat ions and gene therapy

through the skin3.

Therapeutic applications of

ultrasound technology are

dependent upon the intensity

used. Low power ultrasonogra-

phy can be used for treating soft

tissue injuries, hastening wound

and bone fracture healing, soft-ening scar tissue, and managing

swelling- particularly in joints3.

Higher intensity ultrasonogra-

phy can be used to destabilize

Ultrasound can be used as an imaging modal i ty and diagnostic aid to visual ize t issues and organs within the body, and also as a therapeutic modal i ty with a variety of appl icat ions.

N o v e m b e r 2 0 1 1 13

N o v e m b e r 2 0 1 114

cellular membranes, thus induc-

ing the cavitation necessary to

allow gene and drug delivery

through the skin. High intensity

ultrasound has also shown some

promise in targeting tumor cells

and other benign masses for cel-

lular destruction, in dissolving blood clots, and in sealing blood

vessels to prevent bleeding and

block blood and nutrition flow

to growing tumors3.

When undergoing treatment or

imaging with ultrasound tech-

nology, a device known as a

transducer is placed such that it

can aim sound waves at targeted tissue2. Water or water-based

gels are often used to buffer

and help transmit the sound

waves from the transducer to

the target surface3. Ultrasound

imaging and treatment are gen-

erally painless procedures done

over the skin; however some

procedures are more invasive in

that the transducer is inserted

within a natural opening in the

body for improved access or effect5. Depending on the loca-

tion and goal, an ultrasound

procedure can take anywhere

from a few minutes to an hour

to perform. In the case of diag-

nostic ultrasound, a radiologist interprets the image and will

report back to the patient and/

or referring doctor2.

The future of u l t rasound tech-

nology for physic ians is mon-i tor ing needle posi t ioning

dur ing surg ica l pain proce-

dures. With th is noninvasive imaging technique, physic ians

can fac i l i tate his/her needle

placement. This technique pro-

v ides a safe and effect ive way

to ass ist physic ians in del iver-

ing pain re l ie f .

References:

1 U.S. Food and Drug Administration. (2011)

Ultrasound Imaging. Available at http://

www.fda.gov/Radiation-EmittingProducts

RadiationEmittingProductsandProcedures/

MedicalImaging/ucm115357.htm. Accessed

October 5th, 2011

2 Mayo Clinic Staff. (2009) Ultrasound. Available

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sound/MY00308/METHOD=print&DSECTION=all.

Accessed October 5th, 2011

3 Haar, G. (2007) Therapeutic applications

of ultrasound. Progress in Biophysics and

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Ultrasound technology has long been used for therapeutic appl icat ions, engaging long or continuous pulses of high fre-quency sound waves to induce cel lular effects and biological change.

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