Post Rehabilitation Training Series
Article 1: How injuries occur and Rehab Triangle

By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, C-IASTM

Introduction

The human body is a complex machine that consists of multiple parts engineered to work
and function synergistically. At the helm is the central and peripheral nervous system, which directs traffic in a sense, choreographing gross and precise movements of the musculoskeletal system. The degree of injury that someone sustains is dependent upon the magnitude, duration, and velocity of force-applied force to the body and underlying tissues involved. During an examination of a physical therapy patient, the mechanism of injury (MOI) is one of the most important pieces of information that a physical therapist acquires during the history taking. The mechanism gives the clinician a very strong indication of what tissues and structures may have been injured, how the injuries occurred and the potential severity of these injuries (Macgee et al 2007).

This information assists the physical therapist in treating all musculoskeletal injuries and movement dysfunctions. So how does all of this pertain to the 21^st century fitness professional? The human body breaks down because of injuries, surgeries and movement dysfunctions. Do you understand common injuries, post rehabilitation training, and program design to work with these types of clients? These series of three articles will the foundation science, functional assessments and application science of evidenced based movement science. This will help you, the fitness professional understand that having sound information in foundation science, will help your knowledge and understanding of helping all clients.

How common dysfunctions develop

There are several reasons a dysfunction (pathology) develops. It is important for the personal trainer to thoroughly understand all potential causes of how a dysfunction develops. Familiarizing yourself with these different causes will not only strengthen your knowledge and understanding to help the client, but will also assist in the communicating with other health care professionals as part of the Rehab Triangle. The rehab triangle is the communication between the client, personal trainer and physical therapist.

Do not diagnose or try and ‘figure’ out a client’s problem. If you have a client who has an injury or recently injured  himself or herself, the most prudent thing you can do is to refer to either a physician or physical therapist for help. A fitness professional is not a licensed professional, nor has the same educational level, clinical experience and rigorous training as a physical therapist does. It is important to know your boundaries and operate within it.

Listed below are several common causes on how dysfunctions develop:

1.  Degeneration due to overuse: Degeneration is simply defined as thinning of a tendon

due to micro tears or in essence or the breaking down of  a joint surface.  For example, a

postal worker who repeatedly uses one arm to file mail to one side for many months or even

longer, all of a sudden feel a  twinge in their medial deltoid for no reason. Another example

is a farmer who for years lifted hay a certain way and then starts to experience shoulder pain.                         

Both of these scenarios are examples of strain to a tendon (in this example, most commonly

the supraspinatus). Which most likely is tendonitis and if ignored, eventually progresses to

a tendinopathy.

2. Injury or trauma: There are several mechanisms or causes where tissue can be injured.
Someone who falls from a ladder will have a greater magnitude of force applied to the body, than someone who misjudges a step and falls. The forces can result in tissue overload that result from acceleration or deceleration injuries (i.e. sprains and strains), repetitive stress or overuse (i.e. repetitive stress injury),  compression or crushing (i.e. contusions) or transections (lacerations or surgical incisions). In addition, both static and dynamic movements (i.e. walking, sit to stand, etc.) made by the patient, provide the clinician with insight into the irritability and severity of the injury (Macgee et al 2007).

3. Surgery:

Like cars, Individuals down over time. Clinically, arthritis is common in both men and women, but tends to be more prevalent among those who work as tradesman, carpenters, plumbers, mechanics and similar fields. In these positions, individuals are consistently loading their spine, hips and knees. Whether someone is installing, building, or fixing,  the body receives compressive loads (forces) that stress the joint and surrounding tissues. Over time causes muscles to tighten, joint to break down, and eventually leading the onset of arthritis. The severity of the arthritis is diagnosed by an x-ray. Therefore, an individual’s type of work, lifestyle, injury(s) or all impact one’s daily function.

4. Sedentarism: Research is staggering about the United States and how obese we have become. In the next 2-5 years, the United States will lead the world as the most obese country. The consumption of a diet high in calories consisting of both fats and sugars, and lack of exercise

compounds this problem. This scenario stresses multiple systems such as the cardiovascular, musculoskeletal, neurologic systems. For example, there is a well established body of literature highlighting the relationship between lack of regular physical activity and hypokinetic diseases such as diabetes mellitus, cardiovascular disease and may also predispose and predisposing this individual to diabetes, early osteoarthritis to name a few. It is vital to educate your clients and their children about the importance of a healthy active lifestyle.

5. Systemic pain: Besides those mentioned above, another source of pain is know as “referred” pain. There are three sources of pain that someone may experience. The first is cutaneous pain  (related to the skin). Another is deep somatic pain, which is pain related to the wall of the  body. Lastly, visceral pain, is pain that includes all body organs of the respiratory, digestive, urogenital, endocrine, spleen, heart, etc. Pain is not well localized because innervation of the viscera which is connected via nerve endings.

Various organs such as gallbladder, spleen, appendix and others, have been shown by research to have distinct referral pain patterns. Listed below are some referral pain patterns for your review. However, as stated earlier, you as a fitness professional are not qualified, legally allowed or entitled to make a diagnose. Familiarizing yourself with this knowledge will help you become a better fitness expert, not a physical therapist or physician. When in doubt refer to a qualified heath provider.

Local and referred pain patterns systemic in nature(see below)

•          Gallbladder: Pain that is referred below the right pectoral region/right sub scapular area.

•          Spleen: Pain that is referred to left upper quadrant/shoulder pain.

•          Appendix: Pain that is referred to right lower quadrant along the right inner groin area.

•          Possible MI (myocardial infarction): Chest pain over left pectoral, left inner arm pain

and possible jaw pain. Pain is described as “elephant is sitting on my chest, or“heaviness.” Chest pain can also radiate to the right arm, neck and jaw and may not be reproducible.  Chest pain that resolves with rest immediately after activity should be assessed by a physician.

6. Repetitive stress injury (RSI): are injuries to the musculoskeletal and nervous systems that may be caused by repetitive tasks, forceful exertions, vibrations, mechanical compression, or sustained or awkward positions(www.osha.gov). Injuries come in all shapes and sizes, like computers, bicycles or house. Injuries are classified as either acute (0-7 days), subacute (7-21 days), or chronic (21 days post injury or surgery).

Rehab Triangle

Communication

The rehabilitation triangle is the synergistic connection between the client, personal trainer, and physical therapist (PT) I firmly believe that this relationship pseudo exists presently, however, should be more

pronounced. When evaluating a new patient for the first time, PTs are legally by insurance and Medicare standards, are required to contact and send a plan of care to a physician. This not only educates the physician with the thoughts’ of the PT, but how the PT will help the patient and why skilled

physical therapy is needed.  
                 Client 

Physical Therapist            Personal Trainer

A personal trainer and those with advanced training such as a Certified Post Rehabilitation Specialist are not  legally required to do something similar. However, if you receive a new client that comes from a physical therapist, professionally, contact the physical therapist and thank them! Why? Because no one is entitled to anything. If a physical therapist provides a thorough evaluation, personalized treatment that is evidenced  based, accompanied with great customer service, and listens to the patient, what will happen? That patient is going to tell other patients and most likely the physician. This is the cornerstone of word of mouth advertising.

Building relationships

Building relationships with allied health professionals such as physical therapists, massage therapists, chiropractors, physicians, and others is fundamental. This should be the cornerstone of marketing who you are, and how you can help their patients as the fitness professional. A strong referral network, provides greater exposure of your training services, branding and most importantly, how you can help clients achieve their fitness goals.

Marketing

According to the American Marketing Association, Marketing is the processes of creating, communicating, delivering, and exchanging offerings that have value for customers and clients. In other words, marketing is about satisfying the needs and wants of users or customers in a superior way than competitors.

The marketing mix (the 4 Ps)
Within marketing, there are four Ps, often referred to as the marketing mix The traditional marketing mix refers to four broad levels of marketing decision, namely: product, price, place and promotion.

1. Product

·         The product is something that is viewed as capable of satisfying a need or want. In

       other words, it is a bundle of positive attributes that a customer receives. I.e. Personal

       Training Services.

2. Price

·         This refers to the process of setting a price for a product, including discounts. The price is the cost that a consumer pays for a product--monetary or not.  I.e. Cost of a group or training sessions vs. the cost of one training session.

3. Place

·         This refers to how the product gets to the customer; the distribution channels used

such as wholesalers and retailers.  Helping customers to access products or services in a convenient manner. I.e. Conducting training at a gym or health club vs. at a clients home.

4. Promotion

·         This includes all traditional aspects of marketing communications; advertising, sales promotion

       including promotional avenues(print, radio, television) public relations, personal selling, product

       placement, branded entertainment, event marketing, trade shows and exhibitions.

Direct vs. Indirect Marketing
Direct marketing: Direct marketing think of it as an attempt to ask a customer to buy. Examples of direct marketing can be:

–Contacting physical therapists, physicians, chiropractors, massage therapists informing  
   them about who you are, and how you can help their patients. Be specific.
– In-person sales calls
– Print, radio or television advertisements
– Telephone sales calls
– Email advertisement campaigns
– Direct mail flyer or sales letters
– Promotedor paid advertising on social media(Facebook, LinkedIn, Instagram, Twitter)
– Creating videos about you, client testimonials using YouTube and other video platforms,
    and placing these on your website.
– A website informs potential clients about your educational background, qualifications,   
   experiences and skillset.

Indirect marketing: Is an approach to grow customer loyalty. Indirect marketing can be found in many forms:

– Offering an in-house presentation on a specific topic you are going to teach. Inviting
 members and outside members charging a nominal fee.
–Ne articles and press
– Useful blog posts
– Social media fan pages
– Product placements
– Word-of-mouth
– Referrals
– Online reviews

Summary:
Injuries are inevitable.  It is paramount to ensure that fitness professionals are qualified, skilled and representing themselves as professionals in this industry. The landscape of providing fitness services is changing drastically. The avenues for marketing and providing services have never been more robust and the ability to reach many markets is rapidly expanding with advancing technology.

A fitness professional who takes the time to advance their skill set with continued education or by obtaining specialty certifications, who develops professional relationships and delivers quality services informs prospect consumers and other professionals (e.g., physicians, PT, chiropractors) of their level of dedication, training and service quality. This, coupled with leveraging the marketing strategies described above, will help you experience success in this industry.

REFERENCES

Magee, D, et al, 2007, Scientific Foundations and Principles of Practice in Musculoskeletal Rehabilitation, Saunders, pp. 5-10, 25-32.

What is Insturment Assisted Soft Tissue Manipulation (IASTM)?

Instrument assisted soft tissue mobilization (IASTM) is a type of STM that uses rigid devices to deliver directed, targeted forces to specific tissue (Loghmani 2016). The history of IASTM has been traced back to ancient Greek and Roman baths, where small metal tools known as “strigils” were used to scrape dirt and sweat from the body (Hammer, WI 2008).

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"Understanding Human Movement, common injuries and MFR techniques" Two Day Course 14.5 CEUs For LMTs

"Understanding Human Movement, common injuries and MFR techniques" This two-day dynamic workshop will update your knowledge on how the human body works. Understand the anatomy, functional anatomy behind all movements, understand postural dysfunction and the biomechanics of movement. ELLICOTT CITY WELLNESS CENTER 3691 PARK AVE ELLICOTT CITY, MD 21043 10/ 22-10/23, 2016 9-5pm $300 14.5 CEUs - NCBTMB & MD Board of Massage Registration: 443-528-0527 www.pinnacle-tcs.com Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS

Working With The Older Client: Part 1

Working with the older client: Part 1 By Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS Introduction According to the 2012 Census, people over the age of 65 make up almost 14% of the US population. That means there are over 43 million seniors (adults 65 or older) today, with the numbers continuing to grow, reaching 70 million by 2030. This aging population creates a unique opportunity for the fitness professional to work with. In this article, we will review the effects of aging on the musculoskeletal system, learn simple functional assessments and understand benefits of strength strengthening. In part 2, strength training guidelines and programming for common aging conditions will be discussed. Effects of Aging on the Musculoskeletal System The aging process involves changes to various structures and numerous systems within the body. Research has shown that skeletal muscles change with age, specifically type II, where there is a decreased in these fibers, that atrophy over time, and decrease in size (Brunner et al. 2007). Research has consistently shown that muscle strength decreases with age(Lindle RS, Metter E. 1997). Physiologically it has been studied that maximal strength capacity reaches a peak sometime around the second or third decade of life, and by the fifth decade, begins a gradual decline(Peterson et al. 2010). The strength of people in their 80s is about 40% less than that of people in their 20s(Chiung-Ju Liu, 2011). The decline in muscle strength is associated with an increased risk of falls and physical disability in older adults. Functional assessments of older client Balance tests Assessing an older client’s balance needs to be objective and not guesswork. There are many tests available, but few are objective, measureable, and supported with research as the timed up and go test and the sit to stand test. 1)Timed Up and Go Test Use a standard armchair. Place the line ten feet from the chair. The score is the time taken in seconds to complete the task. The subject is encouraged to wear regular footwear and to use any customary walking aid. No physical assistance is given. Give the following instructions: • Rise from the chair • Walk to the line on the floor (10 feet) • Turn, return to the chair • Sit down again Figure 1. TUG test Scoring: Persons who take 10 seconds or less to complete this sequence of maneuvers are at low risk of falling. Persons who take >20 seconds to complete this sequence are at high risk of falling(Bohannon, RW., 2006). 2)Sit to stand test Have the client sit with their back against the back of the chair. Ask the client to stand from the seated positing, counting each stand aloud so that the client remains oriented. Stop the test when the patient achieves the standing position on the 5th repetition. Age Time(seconds) 60-69 11.4 70-79 12.6 80-89 14.8 Scoring-Age Norms: Figure 2. Sit to stand test 3) Functional squat The squat is a classic fundamental primal movement someone typically performs on a daily basis. Whether it is to perform to pick something up or move something. The squat is a movement that requires proper ankle and hip mobility, while stability is required at the knee and lumbar spine. Understanding the functional anatomy and muscle recruitment is fundamental when prescribing this exercise with any client. Figure 3. Squat picture Figure 4. Squat analysis Movement Analysis: As the body descends, the hip flexors concentrically contract with slight lumbar flexion, while the knees undergo flexion, glute maximus and hamstrings eccentrically contract. At the ankle, dorsiflexion occurs, where the anterior tibialis(concentrically contracts) while the gastrocnemius eccentrically contracts. Returning to an upright position(vertical), the opposite occurs. The hip flexors eccentrically contract, there is slight lumbar extension, while the knee transitions from flexion to extension. Hip extension occurs via the glute maximus, while the hamstrings concentrically contract. Ankle plantar flexion occurs with the concentric contraction of the gastrocnemius while there is eccentric contraction of anterior tibialis. Benefits of Strength Training for improving function in older adults Muscles behind the movement There are numerous benefits of strength training for older adults. However, it is important to understand the muscles behind everyday movement. Large muscle groups, including shoulders, arms, trunk, hips and legs, are important to perform activities of daily living(ADLs) and are susceptible to the aging process, training should targets these muscle groups. The latissimus dorsi muscle (assists with sit to stand). Glute maximus is a primary hip extensor muscle involved in walking and climbing stairs. The hamstring muscles are important in flexing the knee and extending the hip, which are involved in everyday activities such as walking, sit to stand, and negotiating stairs. Glute medius and minimus muscles are lateral stabilizers that are important for getting in and out of bed or car or stepping into a bathtub. Research: Benefits of Strength Training and Balance Strength training physiologically improves strength of bones and connective tissue, size of fast and slow-twitch fibers, reduces blood pressure, improves blood flow with many more benefits. Research has shown specifically that strength training improves gait mechanics(Persch et al. 2009), reduces the risk for falls in the elderly (Karlson, MK et al. 2013, Trombetti, A et al. 2011, Sherrington et al. 2008 & Zhen-Bo, Cao, et al 2006). Balance defined is defined as the ability to maintain an upright posture during both static and dynamic tasks(Benjuya, Melzer, & Kaplanski, 2004). Maintaining balance involves a complex interaction among the sensory, vestibular and visual systems. Aging dampens reaction time and muscle strength impairing, in some people, the ability to control a fall. In older adults, possessing lateral stability is a key contributor to maintaining balance control. Lateral stability is controlled by both the glute medius and glute minimus muscles (Orr, R., et al. 2008). It has been shown there are several contributing factors that contribute to a person with falling. One major factor is leg weakness, particularly in hamstrings and glute maximus. Which has been commonly reported as an important fall-risk factor. Individuals exhibiting this sign have 4.9 times the risk of falling than people with normal strength (Bird, L. et al., 2009, & Rubenstein, 2006). Studies by (Nolan, M et al. 2010 and Ozcan et al. 2005 and Moreleand, JD 2004) identify that ankle mobility, specifically lack of dorsiflexion is another contributing factor for increased falls in seniors. Finally, several studies found that decreased plantar flexion strength is a contributing factor. (Menz et al. 2005) examined 171 men and women with a mean age 80.1, had their foot posture, range of motion, strength, and vision, sensation, strength, reaction time, and balance examined over a 12 month period. Results: seventy-one participants (41%) reported falling during the follow-up period. Those who fell exhibited decreased ankle flexibility, decreased plantar tactile sensitivity, and decreased plantarflexor strength. Additional factors including impaired proprioception (joint position sense), decreased flexibility and fear of falling (Visual Analogue Scale) as risk factors for falls per the research. Summary Aging is inevitable. Falls can be prevented. Arming yourself with more knowledge about the body will enable you to help your clients’ age gracefully reaching optimal health. A multi-component exercise intervention program that consists of strength, endurance, and balance training appears to be the best strategy for improving gait, balance, and strength, as well as reducing the rate of falls in elderly individuals(Cadore, E., 2013). Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS is the CEO of Pinnacle Training & Consulting Systems(PTCS). A continuing education company, that provides educational material in the forms of home study courses, live seminars, DVDs, webinars, articles and mentoring, teaching the foundation science, functional assessments and practical application behind human movement. Chris is both a dynamic physical therapist with 16 years experience, and a personal trainer with 20 experience, an experienced international fitness presenter, writes for various websites and international publications, consults and teaches seminars on human movement. For more information, please visit www.pinnacle-tcs.com. REFERENCES American Geriatrics Society and British Geriatrics Society. 2011. ‘Summary of the Updated American Geriatrics Society British Geriatrics Society Clinical Practice Guidelines for Preventions of Falls in Older Persons.’ Journal of American Geriatric Society, vol. 59., issue 1., pp.148-157. Benjuya, Melzer, & Kaplanski, 2004, ‘Aging-induced shifts from a reliance on sensory input to muscle cocontraction during balanced standing,’ ‘The Journals of Gerontology, Series A, Biological Sciences and Medical Sciences, vol. 59, issue 2, M166. Bird, L. et al., 2009, ‘Effects of Resistance and Flexibility Exercise Interventions on Balance and Related Measures in Older Adults,’ Journal of Aging and Physical Activity, vol. 17, pp. 444-454. Bohannon, RW., 2006, Reference values for the timed up and go test: a descriptive meta-analysis. Journal of Geriatric Physical Therapy, vol. 29, issue 2, pp.64-68. Brunner, F., et al. 2007, ‘Effect of Aging on Skeletal Muscles,’ Journal of Aging and Physical Activity, vol. 15., pp. 336-348. Buatois, S., et al. 2010, A simple clinical scale to stratify risk of recurrent falls in community dwelling adults aged 65 years and older. Journal of Physical Therapy 90, vol. 4, pp. 550-556. Cadore, E., 2013, ‘Effects of Different Exercise Interventions on Risk of Falls, Gait Ability, and Balance in Physically Frail Older Adults: A Systematic Review,’ Rejuvenation Research, Vol. 16, Number 2, pp. 105-115. Chiung-Ju Liu, 2011, ‘Can progressive resistance strength training reduce physical disability in older adults? A meta-analysis study,’ Disability and Rehabilitation, vol. 33, issue 2., pp. 87–8.9 Karlson, MK et al. 2013, ‘Prevention of falls in the elderly: A Review,’ Osteoporosis International vol. 24. pp. 747-762. Menz, et al. 2005, ‘Foot and Ankle Risk Factors for Falls in Older People: A Prospective Study,’ Journal of Gerontology: Biological Science, vol. 61, issue 8, pp. 866-870. REFERENCES CONTINUED Nolan, M. et al. 2010, The Aging Male, ‘Age-related changes in musculoskeletal function, balance and mobility measures in men aged 30–80 years,’ The Aging Male, vol. 13, issue 3, pp. 194-201. Orr, R., et al. 2008, Efficacy of Progressive Resistance Training on Balance Performance in Older Adults: A Systematic Review of Randomized Controlled Trial,’ Sports Medicine, vol. 38, issue 4, pp. 317-343. Ozcan, A, et al. 2005, ‘The relationship between risk factors for falling and the quality of life in older adults,’ BMC series, vol. 5, issue 90. Persch, L., et al. 2009, ‘Strength training improves fall-related gait kinematics in the elderly: A randomized controlled trial,’ Clinical Biomechanics, vol. 24, pp. 819–825. Peterson, 2010, ‘Resistance Exercise for Muscular Strength in Older Adults: A Meta-Analysis,’ Ageing Research, vol. 9, issue 3., pp. 226-237. Rubenstein, 2006, Falls in older people: Epidemiology, risk factors and strategies for prevention, Age and Ageing, vol. 35, supplement 2, pp. 37–41. Sherrington, C., et al. 2008, ‘Effective Exercise for the Prevention of Falls: A Systematic Review and Meta-Analysis,’ Journal of the American Geriatrics Society, vol. 56, Issue 12, pp. 2234-2243. Trombetti, A., 2011, ‘Effect of Music-Based Multitask Training on Gait, Balance, and Fall Risk in Elderly People A Randomized Controlled Trial,’ Archive Internal Medicine, vol. 6, pp. 525-533. Zhen-Bo, Cao, et al 2006, ‘The Effect of a 12-week Combined Exercise Intervention Program on Physical Performance and Gait Kinematics in Community-Dwelling Elderly Women,’ Journal of Physiology Anthropology, pp. 325-330.

What is spinal stenosis?

Background: A narrowing within the vertebral canal coupled with hypertrophy of the spinal lamina and ligamentum flavum or facets as the result of age related degenerative process. Contributing factors: Posture, prior job or lifestyle(sat for numerous hours), an individual who runs frequently, sits for excessive hours, and doesn’t regular stretch. Presentation: Client presents in posterior pelvic tilt, creating shortened and tight hamstrings with tight lumbar extensors. Evidenced training recommendations: Important to avoid end of range extension based exercises should be avoided as they close the neural foramen(ie. cobra press-up). Focus: Perform flexion based exercises such as; knee to chest, prayer stretch and reverse abdominal crunch. Lower extremity stretching should focus stretching the inflexible hamstrings, hip flexors and quadriceps, which are commonly tight in stenotic individuals. Yoga and pilates can also be effective to improve a client’s flexibility and core stability. Progressive resistance training exercises such as lat pull-down, seated mid row, seated reverse flyes, and horizontal leg press are all-safe to teach a client with lumbar stenosis based on science. www.pinnacle-tcs.com "Teaching The Science Behind The Movement"

Have clients with history of shoulder impingement?

Background: Shoulder impingement is a common condition affecting men> women(2:1) where someone complains of anteromedial pain that has gradually developed. Contributing factors: History of individual working out predominantly shoulder press, chest press, anterior raises and front of body. Muscle imbalances, type of work and lifestyle. Two types: Primary(Mechanical) impingement: Is caused by a mechanical dysfunction such as bursa, AC joint, acromion, humerus or rotator cuff/supraspinatus tendon beneath the coracromial arch. This is a mechanical problem that may result from sub acromial crowding. Secondary(Structural) impingement: Is caused by a relative decrease in sub acromial space caused by instability of the glenohumeral joint, tight posterior capsule and weakness of scapulothoracic musculature. Evidenced training recommendations: Emphasis is to create scapular stability/balance the shoulder muscles dynamically. • Posterior capsule stretching • Chest stretching • Scapular protraction(strengthening serratus anterior/upper trapezius/low trapezius biomechanically, together all cause an upward rotation of the scapula to maintain the sub acromial space above 90 degrees of shoulder elevation. • Scapular retraction via mid row with tubing or cable (decreases load to front of the shoulder). • External rotation strengthening: ideal is side lying which is more isolative for teres minor and infraspinatus recruitment(decreases the load to the anterior shoulder). Prevention: Keep stretching pectorals and posterior capsule. Avoidance of shoulder press or military press, avoidance of anterior raises and client engaging in regular “balanced “ workout. Targeting weaker phasic muscles(rhomboids, low trapezius, external rotators, scapular depressors).