Shoulder Pain Treatment

Pins and Needles

2008-08-18T15:05:00.000-07:00

Pins and needles is the common name for what the medical world call paresthesia. The feeling of tingling in the hands or feet is a symptom of nerve root irritation. This nerve irritation can be due to nerve pressure in the neck or the back - or it can be due to pressure on a nerve in a more peripheral part of the body, such as the wrist or the foot and ankle.

If a nerve root or peripheral nerve is subjected to sustained pressure then the feeling of pins and needles will develop in the skin supplied by that nerve. We are all familiar with this when we sit too long on a hard chair or bench and our foot "goes to sleep". When we get up and start to move again the pins and needles feeling starts in the limb and lasts for several minutes.

Nerve pressure or nerve root irritation will cause pins and needles, or pain, or weakness - and often all three will happen at the same time or within a few days of each other.

Carpal tunnel syndrome is the commonest example of peripheral nerve pressure when the median nerve is compressed as it passes through the carpal tunnel at the wrist. Pins and needles in the thumb and palm is the commonest symptom of carpal tunnel syndrome.

Shoulder and Back Pain

2008-08-18T14:34:00.000-07:00

Shoulder and back pain can be closely related - sometimes one leads to another and sometimes the two share a common source related to nerve entrapment.

The shoulder joint and all of its muscles and soft tissues are derived from the same part of the embryo as the fifth vertebra and nerve of the neck. This means that lower neck pain and shoulder area pain can be directly related.

Sometimes shoulder pain and back pain between the shoulder blades can also occur. Irritation of the lower segments of the neck will typically send pain down into the area between the shoulder blades - this pain is called referred pain. It is often dull and aching in quality and made worse by movements of the neck. This type of shoulder related back pain often causes trigger points to form in the muscles and these can be felt as acutely tender spots.

Carpal Tunnel Syndrome and Frozen Shoulder

2008-08-15T15:00:00.000-07:00

Carpal tunnel syndrome and frozen shoulder problems often seem to occur in the same patients - sometimes at the same time but sometimes many months apart.

Carpal tunnel syndrome is a problem with irritation of the median nerve - one of the main nerves that runs from the forearm into the hand.

The median nerve runs on the palm of the hand side of the forearm - entering the palm of the hand at almost exactly the mid point of your wrist crease. It supplies power to the muscles of the thumb and sensation to the skin of the thumb and the first three fingers - sometimes also to a bit of the fourth or ring finger too. To get into the hand the nerve has to pass through a tunnel of bones and gristle. This tunnel is called the carpal tunnel - so the problem of nerve entrapment there is called Carpal Tunnel Syndrome.

The commonest reason for carpal tunnel syndrome to develop is when the median nerve is squeezed in the tunnel. This often happens during pregnancy or in diabetic patients or in those with an under active thyroid gland. Often no cause is found at all - it just seems to start from nowhere and this is called Idiopathic carpal tunnel syndrome.

Sometimes however, carpal tunnel syndrome can arise as a later consequence of frozen shoulder. The median nerve arises from nerve roots that run in the armpit or axilla - just below the shoulder in other words. This group of nerve roots is called the brachial plexus and a good going frozen shoulder can affect the brachial plexus and thus eventually lead to carpal tunnel syndrome.

Frozen Shoulder Manipulation

2008-08-15T14:47:00.000-07:00

Does manipulation for frozen shoulder work?

Manipulation as a treatment for shoulder pain has been around for a long time. The word manipulation can be applied in several different ways.

When we think of shoulder pain in general then physiotherapists will use mobilisation or hands on type manipulation of the shoulder as a means of improving movement range in the joint and thus reducing the symptoms. Osteopaths or chiropractors will do much the same thing - and you might often find that your neck or back is treated at the same time. Not a bad idea actually since shoulder pain and neck pain or upper back pain often go hand in hand.

Manipulation for frozen shoulder is a slightly different issue however. Historically this has been a technique used when the patient is deeply asleep under a general anesthetic and the procedure is performed in an operating theater.

We know that frozen shoulder creates sticky adhesions inside the joint and we think that its these sticky areas that lead to the loss of movement. Manipulation of the shoulder under general anesthetic is a way of trying to force these adhesions apart - thus releasing the stuck shoulder and improving both pain and movement. This type of frozen shoulder manipulation seems to work but it's a very powerful - almost brutal technique - and there have been several reports in the past of arm bone fractures and other problems.

More modern (and more gentle) approaches include using keyhole surgery to break up the sticky adhesions.

Rotator Cuff Injury

2008-08-13T17:02:00.000-07:00

The rotator cuff is the name given to the group of small muscles that stabilise the shoulder when it is in motion.

These rotator cuff muscles are vulnerable to injury and - if torn or if their tendons become inflamed can cause significant shoulder problems.

Treatment of rotator cuff injury can involve either medication, hands on treatment from a physiotherapist or sports therapist, injections or sometimes surgery.

Shoulder Nerve and Shoulder Nerve Pain

2008-08-13T13:24:00.000-07:00

Shoulder nerve pain is not common but it can arise for a number of reasons. The shoulder joint and all the muscles that surround it get their nerve supply from the same part of the spinal cord that supplies the fifth segment of the neck. This is called the C5 segment of the neck.

Pain from the C5 segment of the neck (or from the shoulder joint and the tissues that surround it) is felt from the top of the arm, down over the outer part of the elbow and towards the hand. This type of shoulder nerve pain is called referred pain.

The shoulder nerve is also called the suprascapular nerve - it runs above the spine of the shoulder blade bone - passing through a little notch - to supply the joint and its muscles.

Some specialist doctors can inject this suprascapular shoulder nerve as a treatment for chronic shoulder pain.

Read more about your shoulders by following the links on these pages

Shoulder Injury and Shoulder Injuries

2008-08-13T12:40:00.000-07:00

Shoulder Injuries are a common problem for those doctors who see athletes or sports men and women.

The shoulder is a very mobile joint and a shoulder injury can be sustained during a fall or during a throwing action or a tackle in football in rugby.

The challenge for the doctor or physical therapist is to figure out which part of the shoulder anatomy has been injured? The underlying problem might lie in the shoulder muscles, the tendons that join the muscles to the bone, the bursa or within the joint itself.

Injury to the shoulder can trigger a tear in the joint capsule or in the labrum - the tissue that deepens the socket that the head of the humerus sits in.

Read more about how injury can affect the shoulder by following the links on these pages

Shoulder Tendonitis

2008-08-13T12:22:00.001-07:00

Shoulder tendonitis is the name given to the condition where the tendons of the shoulder muscles become inflamed. The suffix "itis" means inflammation - think of tonsillitis, dermatitis, appendicitis and the likes. A tendon is the gristle that joins muscle flesh onto bone so "tendonitis" is inflammation in a tendon.

Shoulder tendonitis can be treated by physical therapy, by acupuncture, by exercises or stretches or sometimes by injection of a steroid.

Rarely tendonitis at the shoulder can progress or deteriorate into a rotator cuff tear.

Read more about your shoulders by following the links on this page

Shoulder Replacement

2008-08-13T11:47:00.000-07:00

Shoulder replacement is the name given to the surgical technique of inserting a new artificial shoulder joint into the body.

Shoulder replacement surgery is becoming more and more common and the success rate is now very good. Even though fewer shoulder joints are replaced compared to hips and knees the procedure is rising in popularity for two reasons. Firstly, arthritis in the shoulder is less common than it is in the lower limb joints - and, secondly, fewer surgeons are trained in shoulder replacement techniques at present. New techiques are changing things fast however and shoulder replacement operations are getting better and better all the time.

If you need help to deal with pain in your shoulders then follow the links on these pages.

Shoulder Exercises

2008-08-13T11:36:00.000-07:00

Shoulder exercises could help you deal better with your shoulder pain problems.

Exercises can help with a variety of shoulder conditions - from rotator cuff tendonitis to frozen shoulder.

If you think you need shoulder exercises for your painful shoulders or your neck and shoulder pain then you have the option of seeking input from a physical therapist or trying to learn the techniques for yourself from a book or a DVD. I would always recommend the former. Trying to learn to do shoulder exercises on your own is very difficult and you are likely to end up doing them wrongly.

Follow the links on these pages for more information about exercises for shoulder pains

Zocor Shoulder Pain

2007-06-30T03:08:00.000-07:00

Zocor and Shoulder Pain

Can treatment with the anti-cholesterol drug trigger shoulder pain. Zocor or simvastatin as it is sometimes known is one of the most commonly used cholesterol medications in the world.

In general terms zocor is a fairly straightforward drug for most of those who take it but it can trigger joint and muscle pains in some people. The pain caused by zocor is usually quite diffuse in nature but I've had several email questions recently from people with zocor related shoulder pain.

It may be that these people are making heavy use of their shoulder muscles and thus triggering discomfort which is aggravated by zocor. I'm really not sure of the true trigger for the situation.

You should be aware of this however:

Zocor triggers benign low grade joint and muscle pains in maybe around ten percent of those who take it. This includes zocor shoulder pain. These pains are usually transient and easy to cope with.

More rarely, zocor can cause a severe widespread muscle reaction that can lead quite quickly to serious ill health. Your doctor could pick up on this with a simple blood test. If you are concerned then please see your doctor at an early opportunity.

Artificial Oil for Creaky Joints

2007-06-26T05:36:00.000-07:00

The company who make Synvisc - a synovial fluid replacement product - have announced a new approach and a new version of their product.

Genzyme say that they are seeking approval to use a single treatment of Synvisc-One to treat osteoarthritis of the knee for up to six months. Synvisc treatment is currently approved to be given in three separate doses at once weekly intervals. Synvisc-One combines those doses in one treatment. This means that patients will need only one injection and not three as at present.

A number of companies make synovial fluid replacement products.
Synovial fluid is the natural "oil" that we all have in our joints. When osteoarthritis develops the supply of synovial fluid dries up and the joint becomes dry and stiff. The idea behind synvisc and related drugs is to replace the missing synovial fluid and thus to provide lubrication, better movement and pain relief.

At present synvisc and the other related drugs are mostly used for knee osteoarthritis but some doctors are beginning to experiment with their use in other joints.

Cherry Juice For Gout Pain

2007-06-25T16:53:00.000-07:00

We can all learn something new every day! And good doctors are constantly alert to learning from all of their patients. It takes a lot to surprise me after twenty years in medicine but - I hold my hand up - this is a new one!

I had never heard of cherry juice or fresh cherries being used to treat gout or for gout pain relief until I heard it recently from a patient (who had been told it by his pharmacist, who had heard it from a relative etc etc). Anyway - a quick search for the "treatment of gout" on google turned up one (rather ancient -1950) research paper and a whole stream of anecdotal reports about the positive effect of cherries and their juice. It seems that consuming about half a pound of fresh cherrys a day or half a litre of fresh cherry juice can significantly lessen the pain and swelling of gout.

I've never had gout and I hope you haven't either but I can tell you it's one of the most painful conditions known in medicine.

Our blood contains a salt called uric acid. It's there all the time in everyone but is normally fully dissolved in the way that sugar is fully disolved in a hot cup of tea. But ... if the tea cools down ... what happens to the sugar? It comes out of solution as little sharp edged crystals. Well, guess what - that's exactly what happens in an attack of gout pain.

A change in the blood chemistry allows the uric acid to crystalise out of solution and form little jaggy crystals (like bits of broken glass) in the joints. For some reason the first joint of the big toe is the most commonly affected - and the pain when walking is horrific. Quite literally "like walking on broken glass" as many of my patients describe it.

Anyhow - back to those cherries.

My patient swore that taking the cherry juice had made a big impact on his gout pain and had provided rapid gout pain relief. You might want to try this yourself if you have gout or you might want to recommend it to a friend or relative.I'm not clear whether tinned cherries can have the same effect.

The most commonly quoted explanation of the effect is that cherries contain flavonoid compounds that may lower uric acid and reduce inflammation. As I described above, uric acid is the body salt that triggers gout attacks.

I have found nothing published to suggest that taking regular cherry juice lessens the risk of you having an attack in the first place but if you suffer from gout regularly it may be worth a try. Cherry juice, cherry pie, ice cream with cherry sauce? Mmmm - sounds good to me!

Joint Pain and Diabetes

2007-06-25T11:20:00.000-07:00

It's long been known - and I've written extensively previously about it - that diabetic patients are more prone to frozen shoulder than the rest of the (non-diabetic) population.

A new study has shown however that it may not be only the shoulder that's affected. Indeed - the study seems to indicate that diabetics have increased stiffness in nearly all their joints - even if they are not aware of it and have no pain at the time.

The study compared the mobility of selected joints in diabetic and non-diabetics.

One hundred people comprising of 50 volunteer diabetics and 50 volunteer non-diabetics participated. The range of motion of the shoulder, elbow, wrist, fingers, hip and knee joins were measured.

The study revealed that there was a significant difference between joint mobility in the diabetic and non-diabetic subjects for all the joints measured - except the knee and elbow joints which showed no measurable differences.

There was also a slight but positive correlation between duration of diabetes and frequency of finger deformities.

The researchers concluded that reduced range of motion of some joints especially of the wrist, shoulder and hand could be seen as a complication of diabetes.

Frozen Shoulder - New Scientific Evidence

2007-06-19T01:13:00.000-07:00

The science behind frozen shoulder has always been somewhat mysterious.

Frozen shoulder experts often disagree on whether the problem is truly due to inflammation or not - some say that an auto immune reaction happens in the gristle around the shoulder.

Fibroblasts are cells that control wound healing and tissue repair. Some previous research has blamed overactive fibroblasts in the trigger of frozen shoulder.

A new study has looked at this in more detail. The aim of the study was to take fluid from the shoulder joint of patients with frozen shoulder and to see if this fluid affected fibroblast cells in a laboratory test tube. They also took fluid from patients without frozen shoulder for comparison.

The fluid from frozen shoulders caused a marked increase in the test tube fibroblast activity.

These findings demonstrate that fluid from shoulders with frozen shoulder contains chemicals or growth factors that influence fibroblast activity - and this may well be the basic trigger for the frozen shoulder process.

Back Pain and Tumour

2007-06-18T02:54:00.000-07:00

Back pain due to cancer is very rare - that's the good news - but it does happen and it's very important for both doctors and their patients to be aware of the warning signs.

A recent article published in the European Spine Journal highlights the most important issues.

The researchers looked at all published studies covering issues related to back pain and cancer.

Six studies evaluating 22 different clinical features and tests were identified.

Malignant cancer as a cause of back pain is rare - the scientists in this study foun rates between one in a thousand cases and, at most in some groups of patients, three in a hundred.

Features that acted as major warning signs or red flags for cancer were

A previous history of cancer
A high ESR blood test
A reduced hematocrit blood test
And overall clinician judgement

A combination of age more than 50 years, a previous history of cancer, unexplained weight loss, and failure to improve after 1 month were highly worrying features.

The authors emphasised that malignancy is rare as a cause of low back pain. The most useful features and tests are a previous history of cancer, elevated ESR, reduced hematocrit, and clinician judgement.

I'll say again here what I've said many, many times before .... if you are concerned about a persistent back ache then go see your doctor. Now please !

Shoulder Pain Talk

2007-06-17T04:47:00.000-07:00

I'm always on the look out for new high quality shoulder pain resources on the internet.

Dr Mike Carroll MD has created an extensive new blog site called Shoulder Pain Talk - it covers a wide range of different aspects relating to shoulder pain - including rotator cuff injury and shoulder replacement surgery.

Many other topics are also covered with up to date research and information explained in clear and easy terms.

Take a look at Mike's site - it's a good complement to the frozen shoulder information available in the Joint Enterprise site.

A New Way To Treat Frozen Shoulder

2007-06-04T07:05:00.000-07:00

Doctors are using synovial fluid replacement products to treat frozen shoulder pain and shoulder arthritis. Several synovial fluid replacement products exist but the commonest one used for shoulder pain is Hyalgan.

Hyalgan is mostly used for knee arthritis in patients who have not responded to simple treatment options.

However, a recent study presented at the American College of Rheumatology Annual Scientific Meeting suggested that Hyalgan may be beneficial for patients with arthritis pain in the shoulder.

More than 600 patients were studied. They suffered from moderate to severe shoulder pain due to arthritis, rotator cuff muscle pain and adhesive capsulitis or frozen shoulder.

The study showed that patients who received three or five weekly injections of Hyalgan over a six-month period had a statistically significant reduction in pain.

The results seem to show that Hyalgan relieves shoulder pain in most patients with osteoarthritis of the shoulder.

Other doctors recently have used hyalgan and other synovial fluid replacement products to treat chronic shoulder pain that has not responded to intraarticular steroid injections.

The synovial fluid replacement products seem to work best for people who have an osteoarthritis element to their shoulder problem,

No one knows how hyalgan actually works inside the joint but recent research suggests that Hyalgan works inside the cartilage cells to block inflammation pathways.

New Concerns About Frozen Shoulder

2007-06-03T13:01:00.000-07:00

There is now serious concern amongst experts that cases of frozen shoulder are on the increase.

Doctors have different possible explanations for this but surgeons at the Mayo Clinic say that they think frozen shoulder is becoming more common because of the increase in obesity, diabetes, and an aging population.

Frozen shoulder is a condition in which the shoulder capsule contracts or becomes inflamed, causing adhesions and scarring that "freeze" the shoulder. Inactivity after even a minor injury can bring it on, though it usually begins spontaneously.

Symptoms include pain in the shoulder, especially when attempting to raise the arm. When raising an arm straight up, normal range of motion allows the arm to be raised as high as top of the head. A person with severe frozen shoulder can move a straight arm only waist high or lower. Orthopedists say that if patients and doctors understood the risks and symptoms, the disorder could be successfully treated by physical therapy.

Early diagnosis when the condition is still "freezing" is the key. Early therapy lessens the severity and lifespan of the disease.

Currently, about six million people in the U.S. suffer from the condition. About 10 percent to 20 percent of diabetics will have it at one time or another. And women are affected somewhat more often than men.

Shoulder ligaments are normally elastic and tighten when you reach up high. In a frozen shoulder, the joint gets smaller. Ligaments adhere to the shoulder or tighten at its resting position. Movement becomes painful and difficult, or even impossible.

Doctors have also found that a shot of cortisone into the shoulder may prevent a full-blown case of the disease. For severe cases, surgery is required. But for many with advanced frozen shoulder, full range of motion will not be achieved.

Sandals and Painful Feet

2007-06-03T12:49:00.000-07:00

Sandals and lightweight shoes may be comfortable in summer but in many cases they are bad for your feet and can trigger off quite troublesome foot and heel pain.

The most commom problem is a condition called plantar fasciitis.

Plantar fasciitis is an inflammation along the bottom surface of the foot of a band of tissue that connects from the ball of the foot to the heel. This band of tissue becomes strained and inflamed and causes pain on the sole of the foot near to the heel.

The strain occurs because your foot muscles are stressed trying to keep the shoes on. It's worse in shoes that are flexible, with no support in the midshaft, and in shoes that are perfectly flat, with no heel elevation.

There's good evidence that having a shoe with a slight heel can take some of the strain off the foot.

There are several different ways to treat plantar fasciitis - some specialists recommend foot stretches, some special insoles and some doctors use injections.

But the best advice for summer is to limit the amount of time you spend in flip-flops. Doctors say they're not good for long walks, or for exercise.

Whiplash Injury Treatment - New Evidence

2007-06-03T12:18:00.000-07:00

Whiplash Injury Treatment

How to treat acute whiplash neck injury

New research has confirmed what many involved in treating whiplash injury patients already know. If the initial treatment is too intensive or aggressive then recovery can be delayed not quickened. There may be something to be said for going back to an inital period of rest in a neck collar - something doctors, physiotherapists and chiropractors had moved away from recently.

The new research study was published in the May 25 Early View issue and June print issue of the journal Arthritis & Rheumatism.

"Although there are few effective treatments for curing whiplash, a growing body of evidence suggests that the delivery of intensive aggressive health care shortly after the injury may lead to a longer recovery period" said one of the researchers.

The study showed that those who simply attended their family doctor got better quicker than those who had early intensive hands on treatment from a chiropractor or a physiotherapist.

The results add to the body of evidence suggesting that early aggressive treatment of whiplash injuries does not promote faster recovery.

In particular, the combination of chiropractic and general practitioner care seemed to significantly reduce the rate of recovery

Surgery For Back Pain

2007-06-03T09:12:00.000-07:00

Surgery for Back Pain

Should you have an operation for chronic back pain?

The majority of those with chronic back pain will get better or find pain relief without surgery but new research shows that an operation may speed recovery for some

The New England Journal of Medicine have published new research to compare surgery with the simple passing of time for people with severe back pain. Those in the study mainly were known to have a slipped or herniated disc or sciatica

A spine specialist in Holland looked at 283 patients who had suffered from sciatica for at least six weeks before the study began. He found that 95 per cent of patients reported recovery after one year, whether or not they had surgery.

But about 40 per cent of the participants assigned to conservative wait-and-see care also opted for surgery, which seemed to relieve symptoms more quickly than would otherwise have been expected.World recognised spine expert: Richard Deyo of the University of Washington in Seattle - said in a journal editorial

"For patients with persistent sciatica, there seems to be a reasonable choice between surgical and nonsurgical treatment, which may be influenced by aversion to surgical risks, the severity of symptoms, and willingness to wait for spontaneous healing,".

Most experts agree that surgery should only be considered an option if the pain has persisted for at least six weeks .

Shoulder Blade Pain

2007-06-03T06:26:00.001-07:00

Shoulder Blade Pain

What causes a pain in the Shoulder Blade area?

Interestingly, but importantly, shoulder blade pain only rarely arises due to a problem with the shoulder blade.

The shoulder blade is also called the scapula. True problems in the region of the scapula are rare and include bone disease such as infection or bone tumour. These causes account for no more than a tiny percentage of shouder blade pain problems.

Nearly every case of shoulder blade pain is due to a problems in the lower part of the neck or in the upper part of the back. This pattern of pain is known as referred pain. Referred pain from the neck is usually felt along the inner side of the shoulder blade - the side nearest the spine in other words.

How to diagnose Shoulder Blade Pain
Your doctor or therapist will begin the diagnosis of shoulder blade pain with a simple examination. They will examine your shoulder joint, muscles and the nerves of the upper arm. Your cervical spine (or neck) will also be examined - along with your upper back or thoracic spine.

If your shoulder blade pain is arising in the cervical spine then neck movements will trigger it or make it worse.

Your doctor may organise an x-ray of the neck or an MRI scan to confirm the diagnosis of a neck problem although this is not always required.

If your doctor suspects another reason for your shoulder blade pain then you may need blood tests, a chest x-ray or an MRI scan of the chest or thoracic region.

Severe shoulder blade pain of sudden onset can be an indication of serious heart or blood vessel problems. You should seek medical attention immediately if this occurs

How to treat Shoulder Blade Pain
The treatment of shoulder blade pain will in part depend on the cause that your doctor or therapist discovers. The commonest cause is related to the neck or cervical spine and treatment is usually best directed at this area.

Neck treatments for shoulder blade pain often result in a quick and full recovery.

Treatment options for shoulder blade pain include:

painkiller or anti-inflammation medication
physical therapy from a physiotherapist, chiropractor or osteopath
manipulation of the neck or thoracic spine
acupuncture

Gout Pain - Does Coffee Help Gout Pain?

2007-06-03T05:59:00.000-07:00

Can Coffee Drinking Help Gout?

Gout is triggered by high uric acid levels in the blood. Gout is the commonest inflammatory arthritis in adult men and is becoming more common in women.

Scientists have long thought that high intake of coffee and tea can reduce uric acid levels in the blood and thus reduce the risk of a gout attack and a new study published in the June 2007 issue of Arthritis Care & Research seems to support this - for coffee drinkers at least. Even decaffeinated coffee might help if you are a gout pain sufferer.

The researchers found that coffee consumption is associated with lower uric acid levels but this appears to be due to components in coffee other than caffeine.

The results of the research showed that levels of uric acid in the blood significantly decreased with increasing coffee intake, but not with tea intake.

Interestingly, there was an association between decaffeinated coffee consumption and uric acid levels. These findings back up the idea that components of coffee other than caffeine contribute to the observed association between coffee intake and uric acid levels.

The scientists emphasise that they do not really know how the connection between coffee, gout and uric acid works but they believe that the chemicals in coffee are affecting insulin levels and also producing powerful antioxidant chemicals within our body.

Shoulder Pain - Treating Rotator Cuff Pain

2007-01-05T07:19:00.000-08:00

The rotator cuff are the group of muscles that surround the shoulder and help to keep it stable and strong during movement.

These muscles can often become a source of pain - either due to inflammation or to tearing in the muscle fibres or in the muscle tendons that join the muscles to the bone.

Recovery from rotator cuff pain can be a long process - and you may receive a bewildering range of advice along the way.

Check out this great Guide to Rotator Cuff Injury - written by tennis pro Brent Abel. It's a comprehensive overview of the nature of the problem and of the available treatments.