Why Your Injuries Aren’t Healing Properly

injuryOveruse injuries are something I see in my practice on an almost daily basis.  Whether it’s low back pain from running, shoulder pain from lifting weights, or neck pain from being in the wrong position for too long, most of us have experienced an issue related to muscle pain.  Most of us have been told what to do when it comes to dealing with the immediate trauma-rest, ice, compression, elevation, etc.  But what about the majority of you who aren’t getting relief weeks, months, or sometimes years after the initial trauma?

What I’m finding is that the typical approach to soft tissue injuries (muscles, tendons, ligaments) is actually leading to further damage, and a long-term weakening of tissue.  Anti-inflammatory drugs and cortisone injections, the mainstay of treatment in conventional medicine, can help with short-term pain relief, but is rarely conducive to proper healing.  The whole point of the inflammatory response is to facilitate collagen repair, allowing tissue to fully heal, restoring it’s function back to normal.  Instead, our mainstream approaches to soft tissue healing are more degenerative in nature, setting people up for future pain and injuries.  So, what are the alternatives?

Acupuncture-While some people are afraid of it, acupuncture is actually one of the only therapies I know of that addresses pretty much every component of soft tissue healing.  Acupuncture not only works to diminish the perception of pain, but actually stimulates collagen repair through the release of platelet-derived growth factor (PDGF).  It also acts upon receptors in the central nervous system to create a sense of euphoria that will ultimately make people less prone to the psychological manifestation of chronic pain.

Proteolytic Enzymes-It’s possible that you’ve been told to eat pineapple after a dental surgery or procedure?  This is often due to the fact that pineapple is naturally high in bromelain.  Bromelain is one of several proteolytic enzymes that falls into the category of fibrinolytic agents.  Like nattokinase, serrapeptase, and other fibrinolytic agents, bromelain helps to speed up the healing response in areas of injury, getting rid of pain and swelling more quickly, all the while not interfering with the repair process.

Manganese-This trace mineral is extremely important in the tissue repair process.  Not only does it serve as an essential nutrient for laying down new collagen, but it also increases levels of superoxide dismutase (SOD), an antioxidant that helps to “clean up” chemicals in and around the area of injury that can lead to further tissue damage.

Herbs-There are a number of herbs out there that can help to minimize pain, without interfering with the healing response.  Some of the more commonly used examples include turmeric, ginger, and boswellia.  In addition to acting similarly to many of the commonly used NSAID drugs (without the side-effects!), these herbs also help to prevent platelet aggregation, allowing for a more rapid and complete healing response.  Plus, these herbs can usually be tolerated at high doses, without the kidney, stomach, and liver damage that can come with conventional anti-inflammatory and pain medications.

This list is by no means exhaustive, just a small sample of what can be done to both alleviate pain AND keep you from needing to revisit your doctor every few months with a recurring injury!  If you’ve been struggling with pain or a chronic injury, and felt like you had exhausted your treatment options, just know that there are other options out there for you to try that could be much more beneficial in the long run (literally)!

 

PMS? Oral Contraceptives Not The Only Option!

PMSPre-menstrual syndrome (PMS) is thought to affect about 90 per cent of women at some point in their lives, with a significant proportion of these suffering regularly from severe and debilitating symptoms.  PMS is typically the result of abnormal hormone fluctuations, such as elevated prolactin levels, or low progesterone during the second half of the menstrual cycle.  Another possibility is estrogen dominance, where the liver has a difficult time metabolizing estrogen, leading to a disproportionate amount of estrogen in the system.  And these are just a few of the possible scenarios that can lead to PMS.

So why, then, does conventional medicine treat virtually every person with PMS the same?  Oral contraceptives are prescribed almost exclusively to treat this issue, regardless of the cause.  While oral contraceptives may be a magic bullet in some instances, the list of potential side-effects is long, and includes an increased risk of breast cancer, cervical cancer, stroke, acne, yeast infections, and weight gain.  Therefore, why subject so many people to these side-effects, when there may be other, more natural cures that not only alleviate the symptoms, but address the root cause?

One of the most established natural treatments for PMS is an extract of an exotic fruit known as Agnus castus. Research from Germany shows that Agnus castus (also known as Chasteberry, Monk’s pepper and Vitex) can reduce prolactin levels and increase the production of progesterone. These effects help to correct the hormonal imbalances common in PMS, thereby helping to ease its symptoms.

Earlier this year, the British Medical Journal (BMJ) published a study which proved the effectiveness of this natural remedy in the treatment of PMS. Over half the women in this study had significant improvement in their symptoms, and the treatment was found to be safe and generally free of side-effects. This recent study is not the only evidence which supports the use of Agnus castus in PMS. Last year, the Journal of Women’s Health and Gender Based Medicine published a study which examined the effect of Agnus castus in more than 1600 women. The study lasted three months, after which time 93 per cent of the women reported an improvement in or elimination of their PMS symptoms. Four out of five women rated themselves as ‘much better’ or ‘very much better’.

Naturopathic doctors can also perform specialized hormone testing that can help to pinpoint specific imbalances, which in turn can be corrected with nutritional and herbal therapies.  This allows each case of PMS to be treated uniquely, rather than treating everyone the same.  If PMS is something you’ve been suffering from for years, and birth control isn’t the answer you’re seeking, seek out a qualified naturopathic physician who can help to get your symptoms under control.

Your Health and the Environment

chemicaltoxicityMost of us realize that the environment we live in isn’t exactly pristine.  From chemicals in our water supply to the ubiquitous use of plastics, we’re constantly challenging our body’s ability to handle environmental pollutants.  The incidence of chronic disease in this country has continued to grow, and most any chronic disease you can think of (diabetes, autoimmune disease, cancer, endocrine disorders, you name it!) is influenced by the chemicals that surround us.  However, when it comes to the relationship between exposure to environmental toxins and disease, conventional medicine pays little to no attention to this connection.

Let’s just consider the effects of one chemical on the body: PCBs.  The use of these industrial chemicals has been banned since the late 1970s, yet continues to show up in our soil and water supply.  According to the EPA, PCBs have been linked to cancer, reproductive disorders, immune system disorders, endocrine disease, and nervous system disorders, among others.  Now, consider this: More than 80,000 chemicals are registered for use in the United States, with 2,000 new chemicals being introduced each year.  That’s pretty scary!  The point of this article is not to induce fear, but to demonstrate how serious this problem truly is, and how little conventional medicine is paying attention to it.

Many of the chronic diseases we see today, whether it be asthma, allergies, or autoimmunity, were virtually non-existent before the 1900s.  So, despite the ongoing advancement of medications to treat these diseases, why have they continued to become more prevalent?  Largely because modern medicine continues to focus almost solely on symptom management, ignoring the underlying causes of chronic disease.  Of course, it’s not practical to test every patient for every chemical under the sun.  But, by being more conscious of how chemicals can promote disease, and having a better understanding of how our bodies deal with these chemicals, we can make a significant impact on the incidence of chronic disease in this country.

I like to use the analogy of our bodies being a bucket, with toxins being the water that fills it.  At some point, our bodies’ innate abilities to metabolize these toxins hits the tipping point, and organ systems begin to break down.  This, in turn, leads to the development of a number of chronic diseases that are often considered “incurable” by the medical profession.  But, we all have metabolic pathways in place that are programmed to help the body eliminate a number of the toxins we become exposed to.  These pathways can be enhanced and nurtured with proper diet and nutrient supplementation, lessening the toxic burden, and bringing the body back to a more balanced state.  The terms detoxification and cleansing are often thrown around loosely, but there are more definitive methods of testing that can isolate dysfunctional metabolic pathways, allowing them to be corrected accordingly with the appropriate nutritional interventions.

So, if you’re suffering from chronic disease, there are a number of things you can do to help lower your toxic burden.  One way to look at it as offense vs. defense.  Your doctor may be prescribing drugs to diminish pain or other debilitating symptoms, which is the defense, but you can play offense by providing your body with adequate nutrition and substrates to help enhance your body’s ability to eliminate disease-causing toxins.

Heartburn Drugs Typically Not Necessary

gerdProton Pump Inhibitors (PPIs) such as Nexium, Prevacid, and Protonix, are some of the most widely prescribed drugs in the U.S.  They are typically given to patients who complain of heartburn or reflux (GERD), who are then kept on the medication indefinitely.  In fact, it’s not uncommon for many of the patients I see to think of being on this medication almost as an afterthought, because it’s so common in our culture.  What they may not realize is that long-term use of these medications can lead to long-term complications, and may be doing more harm than good!

When first approved by the FDA, the suggested use of PPIs was for 4-6 weeks, mainly for treating serious gastrointestinal issues, like ulcers and Barrett’s esophagus.  However, because these drugs are more effective for relieving symptoms of GERD than other medications, they became the treatment of choice for general complaints of “indigestion”.  While some doctors may be closely monitoring these medications, and weaning their patients appropriately, it’s more common for patients to be on PPIs for years without anyone questioning whether they still need them or not.  This is a serious problem, as a number of long-term risks have been associated with PPIs.  In 2012, the FDA issued warnings about Clostridium difficile-related diarrhea, which can be extremely challenging to treat, especially in the elderly population.  In 2011, the FDA warned doctors about the risk of magnesium deficiency with the use of PPIs, which can potentially lead to arrhythmia and seizures.  They even recommended that doctors screen their patients for low magnesium before prescribing PPIs.  In reality, how many doctors are actually following this protocol?  This doesn’t even include other documented risks of long-term PPI use, such as iron-deficiency anemia, vitamin B12 deficiency, increased fracture risk, and increased risk of pneumonia.

The guidelines established by the American Gastroenterological Association suggest that GERD or dsypepsia without any serious complications use PPIs for only 4-6 weeks, followed by the use of less potent acid blockers (ranitidine) as needed.  This greatly reduces the risk of long-term complications associated with these medications.  In my experience, there is typically an underlying cause for symptoms of GERD, whether it’s diet, stress, and/or medication side-effects.  Fortunately, it’s not impossible for you to wean off PPIs, it just takes patience to gradually taper the dosage, while simultaneously addressing underlying causes.  There are a number of natural agents, such as DGL, aloe vera, and D-limonene, that can help to heal irritated gastroesophageal tissue to make the transition of discontinuing the medication more tolerable.  Plus, these agents can be used for ongoing symptom management without having the harmful side-effects of PPIs.

Believe me, I’ve seen a number of patients who never thought in a million years that they would be able to stop their PPI medication, in fear of the reflux symptoms coming back with a vengeance.  But, with the proper guidance and attention to detail, it can be done!

 

IBS? It May Be Something Else . . .

SIBOPeople often come to my office saying they’ve been diagnosed with IBS.  They may complain of intestinal pain, constipation, diarrhea, or all of the above, yet all of their test results come back “normal”, so they are prescribed anti-spasmodic medications to manage their symptoms, and sent on their way.

In my experience, IBS is merely a symptom of other underlying causes, rather than  a definitive diagnosis.  Whether it’s food intolerances, poor eating habits, or restoring optimal production of stomach acid and digestive enzymes, naturopathic medicine has a lot to offer when it comes to identifying and treating the underlying cause of IBS.

One cause in particular that’s often overlooked is small intestine bacterial overgrowth (SIBO).  It’s thought that SIBO is responsible for over 50% of IBS cases, and possibly as much as 84%.  SIBO occurs when bacteria that normally live in the bowels (E. coli, Bacteroides, etc.) are allowed to replicate to excessive levels.  This can occur for a number of reasons, but poor gastric motility (especially due to the use of proton pump inhibitors) is usually the main underlying cause.  The main symptoms of SIBO include: Bloating, gas, abdominal pain, cramping, nausea, heartburn, joint pain, and/or fatigue.

Testing for SIBO can be easily performed using breath tests that detect abnormal levels of hydrogen or methane gas that are produced by excess levels of bacteria.  Once detected, it can be effectively treated with either naturopathic or pharmaceutical interventions.  Eradication of SIBO usually leads to a 75% reduction in IBS symptoms, and is even more effective when combined with dietary interventions (especially low carbohydrates) and motility agents.  Once treated effectively, preventive measures can be taken to reduce the risk of recurrence, which can be high if measures aren’t taken to correct the underlying imbalances that led to SIBO in the first place.

So, if you’ve suffered from IBS for years, see to it that your medical doctor or naturopath test for SIBO, especially since the testing is simple and affordable.  If there’s roughly a 75% chance of your symptoms resolving, your years of waiting for relief are hopefully over!

Lyme Disease Diagnosis is Clinical, Not Laboratory Based

tickI see it time and time again.  “My doctor said my Lyme antibody test was negative, so my symptoms can’t be due to Lyme disease.”  This is unfortunate, because many people in this area are becoming infected with Lyme disease, without being properly diagnosed.  Even worse, they give up searching for answers, because their doctors tell them everything is “normal”, allowing Lyme disease to progress into the more chronic stages, potentially causing serious, irreversible health consequences.

On their website, the Centers for Disease Control and Prevention (CDC) state that “Lyme disease is diagnosed based on signs and symptoms” and “a history of possible exposure to blacklegged ticks”.  They go on to say that “laboratory blood tests are helpful if used correctly . . .”  In my experience, most doctors don’t appear to be following these recommendations.  In fact, they seem to be completely ignoring symptoms and history, relying solely on laboratory evaluation.  Another problem is the reliance upon the characteristic “bull’s eye” rash, or the history of a known tick bite.  Have you ever seen how small a deer tick is in size?  The likelihood of knowing you’ve ever been bitten is quite low.  Plus, a 2010 study in the Journal of Emergency Medicine found that only a minority of cases (as little as 9%) exhibited the classic “bull’s eye” rash!  No wonder we’re dropping the ball when it comes to diagnosing this debilitating disease!  Adding to the confusion is the classic example of people visiting so-called Lyme “specialists” who will perform spinal taps or PCR tests on patients, telling them that a negative test is definitive for not having Lyme disease.  Quite frankly, these tests are like looking for a needle in a haystack.  The organisms responsible for Lyme burrow deeply into tissues, so the likelihood of identifying them in serum or cerebrospinal fluid is slim at best.

This doesn’t even take into account the co-infections that go along with Lyme disease, which can cause their own set of symptoms independently.  As a medical community, we need to put politics aside, and start paying more attention to what our patients are telling us.  Of course, you’ll have the occasional patient who swears that everything wrong with them is the result of Lyme, when it’s really not, but let’s not let that ruin for the people who truly are suffering from this disease!

We live in an area where Lyme is endemic, yet the number of healthcare providers who tend to recognize and treat this disease without relying solely on laboratory criteria are few and far between.  If you believe that you’ve been affected by Lyme or related tick-borne infections, don’t let doctors convince you that “everything is normal.”  Seek out a practitioner who has experience with diagnosing and treating this potentially chronic condition, as the sooner you can get help, the better!

Digestive Health In Early Life Linked To Allergies

dandelionAs a naturopathic physician, I’m always paying close attention to the connection between intestinal health and systemic complaints.  Allergies in particular are something that our profession has recognized as having strong ties to the digestive tract.  When people present to my office complaining of allergies, one of the first things I ask about is whether or not they’re having any digestive symptoms.  I also want to know about their history of antibiotic use, their diet, if they were breastfed as an infant, and whether or not they were born via Caesarean section.  So, what do these birth-related issues have to do with someone’s current allergy symptoms?  Well, we know that allergies are symptoms that result from antibody responses to antigens (dust mites, pollens, mold, etc.) that our body recognizes as foreign. But what your doctors don’t often discuss is why this occurs in the first place.

A recent study done at Henry Ford Health Center suggests that babies born by C-section are five times more likely to develop environmental allergies by age two than children who are born vaginally.  This mainly has to do with the bacterial exposure that occurs when babies pass through the birth canal, vs. if they’re removed via C-section.  Starting in the womb, the intestinal tract of babies is essentially sterile.  As they pass through the birth canal, they are exposed to the entire population of bacteria that resides within their mother’s vaginal and gastrointestinal tract.  This allows their immune system to learn the difference between “good” and “bad” bacteria.  A C-section prevents this critical exposure to bacteria, allowing the body to develop a sensitivity to allergens before the intestinal microbes have a chance to fully develop.

Of course, by the time most of us manifest allergy symptoms, it’s too late to do anything about how we were born!  However, there are still a number of intestinal-related factors that play a role in immune function, and how the immune system may recognize everyday substances as foreign.  But for expecting mothers, if you know you’ll be having a C-section, one of the best measures you can take to protect your child is by breastfeeding.  This will also help to pass on important bacteria that they won’t otherwise be exposed to with formula alone.  You can also supplement with probiotics, which are often formulated as powders with strains that are specific for infants.

For the rest of us, it’s still important to take steps to normalize the microbial environment of the intestines as much as possible when trying to minimize the body’s allergy response.  Ways to do this include consuming more sources of fermented foods, such as yogurt and kefir, and supplementing with mixed strains of probiotics (bifidobacter, lactobacillus, etc.).  You can also look at stool tests to measure the amount of healthy bacteria within your intestinal tract, along with making sure that unwanted microorganisms aren’t present.  The bottom line is that there is much more we can do when it comes to allergies than just loading up with anti-histamines and allergy shots.  The immune system is extremely intelligent and sophisticated, so let’s start giving it a little more credit!

Testosterone Lowers Male Heart Disease Risk

In the last couple of years, studies looking at the correlation between testosterone levels and heart disease in men have yielded mixed results.  However, if you look more closely at the data, most of the reports showing negative associations with testosterone failed to factor in other independent risk factors that can lead to heart disease.  The negative studies also used inaccurate laboratory methods and reference ranges to reach their conclusions, inflating the risks of testosterone.

A late 2011 study published in the Journal of the American College of Cardiology (JACC) demonstrated that men who had the highest levels of testosterone had a 30% lower risk of cardiovascular events.  Men with increasing levels of testosterone also had a decreased prevalence of diabetes, hypertension, and body fat mass.  One of the main reasons for testosterone’s beneficial effect on heart disease is it’s ability to boost HDL levels, and allow the liver to metabolize excess cholesterol more efficiently.  Testosterone also helps to dilate blood vessels and strengthen the muscles of the heart, further lowering the risk of hypertension, heart attacks, and heart failure.

So, with the link between testosterone and cardiovascular risk becoming more clear, why isn’t testosterone being tested routinely in men over the age of 50?  One of the main arguments has been the concern about inducing prostate cancer in men who are using supplemental testosterone.  However, contrary to popular belief, this fear has no basis.  In fact, in his book Testosterone For Life, Dr. Abraham Morgentaler demonstrated that men with low testosterone levels have an increased percentage of prostate cancer-positive biopsies.

Another factor interfering with more routine testing of testosterone levels is the belief that statin drugs are a cure-all for heart disease.  By only lowering cholesterol and ignoring the benefits of testosterone, as well as ignoring the effects of estrogen, insulin, and other hormones, it’s no wonder that heart attacks and strokes continue to be the leading causes of death in this country!  The fact is, if you’re a male over the age of 50, or you already have a history of heart disease, your doctor is doing you a gross disservice by not including testosterone as part of a routine screening for cardiovascular disease risk.

If you have low testosterone levels, this doesn’t necessarily mean you will need to supplement with testosterone injections or cream.  Your doctor should also look at other hormone levels to determine whether low testosterone levels are related to weight gain, insulin resistance, or lack of exercise, vs. a true deficiency.  Then, the appropriate underlying cause can be addressed, rather than just assuming that supplemental testosterone will correct everything.  Just as cholesterol is an important underlying clue when it comes to heart disease, looking at testosterone can be just as valuable, but we should never assume that one treatment is the answer for everything!

Light Therapy Not Just For Seasonal Affective Disorder

Since it was first described by psychiatric journals in 1984, artificial light therapy has been used successfully to treat seasonal affective disorder (SAD).  This therapy is meant to simulate exposure to sunlight in winter months, preventing people with SAD from suffering as much during periods where exposure to sunlight is more limited.  In the past few years, more evidence has suggested that light therapy may be beneficial for other types of depression as well.  In 2005, for example, a study in the American Journal of Psychiatry reported that the effects of light therapy are comparable to those found in many clinical studies of antidepressant drug therapy for mood disorders.

Since our bodies are programmed to be in sync with nature’s rhythms, this concept makes total sense.  If you’re suffering from depression, you will ideally want to make it a point to get outside on winter days for at least 15 minutes at a time.  Otherwise, you can acquire a light box that mimics the rays of the sun, and expose yourself to this light for 20 minutes or more every morning.  Dawn simulators are also a great tool, as you can program them to automatically turn on each morning, gradually getting brighter to replicate the rising of the sun.

Other tools to help get your body in sync with nature’s natural rhythms may also be helpful for depression, anxiety, and other mood disorders.  For example, taking physiological doses of melatonin (1 mg or less) at the onset of evening darkness can prepare your body for sleep (without being sedating).  Looking at cortisol and other hormonal fluctuations can also be helpful, as abnormalities in the diurnal output of these hormones can be corrected with natural interventions, making you less prone to mood changes that may be associated with these problems.

Does this mean that if you’re taking antidepressants, you can just go outside for a few minutes every day and be cured? Absolutely not!  You will need to work with your doctor to start implementing light therapy and some of the other recommended changes, and hopefully with time, be able to cut back on your medication.  I think the take home message is that more and more evidence is demonstrating how a disconnection with nature and it’s rhythms can have a profound effect on our mood and overall health.

 

Does Arthritis Originate in the Gut?

I see quite a few patients with rheumatoid arthritis, and other autoimmune arthropathies, and what is the first thing I do?  Give them anti-inflammatory medications?  Give them immune-modulaters?  No!  Chances are, their rheumatologists have already done this.  The first thing I will always do with patients in this category is address their digestive health.  What does digestion have to do with systemic inflammation?  Everything!

If you think about it, the intestines are really the main barrier that separate us from the outside world.  They have to be extremely selective about what they let in and what they keep out.  Immune cells constantly patrol the intestinal barrier, attempting to keep foreign invaders from entering the circulation.  Enzymes and microbes help to break down foods, assuring that only the nutrients we need are allowed to pass through.  We take this whole process for granted, but the level of intricacy at which everything must stay in check is astounding!

When it comes to rheumatoid arthritis, our biggest concern with respect to intestinal health is an increase in permeability (“intestinal hyperpermeability” or “leaky-gut syndrome”).  The causes of this are numerous, but can include stress, food allergies, intestinal inflammation, medications, genetic influences, and exposure to environmental toxins.  Normally, your intestinal cells are bound by “tight junctions”, which are meant to prevent undigested foods from passing through the intestines into the bloodstream.  So, when your body is exposed to substances that are pro-inflammatory, the intestines can usually limit any negative effects with a localized immune response.  However, when various factors (as mentioned above) affect intestinal permeability, antigens are able to bypass the intestinal immune response, allowing them to mobilize throughout the body, causing a systemic inflammatory response.  The body then begins to attack itself because it’s primary defense (the intestinal barrier) has been compromised, forcing other parts of the immune system to become overactive.  Thus, it’s not surprising that a wide range of gastrointestinal and systemic disorders are associated with abnormal intestinal permeability.  According to a 2003 article in the Journal of Gastroenterology and Hepatology, systemic lupus (SLE), juvenile arthritis, eczema, sarcoidosis, psoriasis, inflammatory bowel disease, and a number of other chronic disorders can be linked to intestinal hyperpermeability.

So, what do most doctors instruct their patients with auto-immune disease to do?  Take NSAID medications.  What do these medications do?  Increase intestinal permeability!  They may temporarily relieve the pain, but the approach of using NSAIDs and immune suppressants is not sustainable, and is most likely worsening the long-term prognosis of auto-immune arthropathies.  While a number of respected journals have discussed the link between intestinal hyperpermeability and systemic inflammation, this concept is largely ignored by conventional rheumatologists.  Repairing the gut needs to be the first line of defense when dealing with auto-immune disease.  Otherwise, as long as antigens continue to be able to “slip past” the intestines, it will be impossible for the immune system to regain control of itself.

What should you do if you have an auto-immune disease, or if leaky gut is a potential concern?  If you want a more definitive assessment, there are tests that can be performed to measure the severity of intestinal permeability.  Comprehensive stool testing can also be performed to evaluate the bacterial environment of the intestines, including the overgrowth of any foreign microorganisms that may need to be dealt with.  A doctor who has experience with treating leaky gut will then need to determine which factors are contributing the most, whether it be food allergies, stress, or medications.  Once these underlying obstacles are removed, nutritional interventions which help to initiate intestinal healing can then be implemented.

The concept of a “leaky gut” is not new to naturopathic medicine.  Even though it has begun to gain traction in conventional medical journals over the last 10 years, it’s certainly far from being the “standard of care” in rheumatology practices.  If you are suffering from any form of auto-immune inflammation, whether it be inflammatory bowel disease, rheumatoid arthritis, or psoriasis, you seriously need to address the underlying causes that may be affecting your digestive health.  While the connection may not seem obvious at first, healing the gut will be the most important step you can take towards stabilizing any systemic form of inflammation.